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Recent outrage about the number of toddlers being treated for ADHD is warranted. American Academy of Pediatric guidelines which pushed the lower age limit for evaluation and treatment of ADHD down to 4 years (from the earlier guideline of 6 years) was already a bit of a stretch for many of us. But to learn that thousands of American children between the ages of 2 and 3 are being treated for the condition was a shock to many commentators, perhaps especially in light of the fact that children from lower-income families are more likely to fall in that group.
And my thoughts are immediately drawn to how these babies (don't you call a 2-year old a baby?) were identified as "having" ADHD. It's easy enough to imagine a parent endorsing - on a checklist or in an interview - 6 or more features of inattention, distractibility, and restlessness. I mean they're babies, right? But how did the examining doctors identify functional impairment? And how did they identify that impairment in two or more domains? What could even constitute a "domain" of impairment for a putative ADHD diagnosis in a toddler?
In my own clinical evaluation of attentional and executive functioning in children, I seek out collateral information - like a phone interview with a teacher. Can you imagine such a phone call in the evaluation of a 2 year old? "Hi, Mr. Stephens, in your experience there in the day care setting do you find that my client is more or less able to sustain focus and concentration, follow instructions, and resist impulses than her peers? Her 2-year old peers?"
Another typical component of a neuropsychologist's evaluation of ADHD is a continuous performance test (CPT). The mental image of a toddler being administered the CPT is as adorable as those photos of babies with neckties and big glassses while holding an accounting spreadsheet or something.
As outrageous as it is to consider "treating" ADHD in toddlers, it's even more irritating to me that our clinical evaluation of the condition is so sloppy, so cursory, so neglectful, that we could even get to the point of considering "treatment."
So this conversation about toddlers and ADHD is a chance for us to remind ourselves once again what constitutes proper evaluation. Appropriate evaluation of ADHD in children or adults requires a thorough history, mental status examination, review of records, collateral interviews, and - in many cases - selected standardized testing. We can't examine for these developmental variations in patients who are intoxicated, comatose, or otherwise noncompliant with evaluation. Can we possibly perform such evaluaitons on toddlers?
I'd love to hear your thoughts on this topic, especially if you're a parent or teacher or early intervention specialist. Thanks!
image: Flickr
