Preschool ADHD: The next critical public health concern

The numbers are staggering. In every preschool classroom, there’s a strong possibility that at least one child will be diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).

And the prospects for that preschool child with ADHD don’t look bright. That’s because 40 percent of children who show signs of ADHD are suspended from preschool. Sixteen percent are eventually expelled.

A quiet alarm in the education community is ringing, bringing attention to a disorder that is actually quite common. Estimates show that seven percent of all preschool children show signs of having the lifelong—and incurable—disorder. How well they and their families adapt to their situation is yet another question.

For the College of Education’s George DuPaul, professor of school psychology, and Lee Kern, Iacocca professor of special education, preschool ADHD has long been a cause for concern. Very little research has been conducted that helps to prevent academic, behavioral and social problems related to ADHD at such an early age.

But that’s about to change. In collaboration with John Van Brakle, chairperson of the department of pediatrics at Lehigh Valley Hospital, DuPaul and Kern studied the disorder in the preschool and home environments of 135 children between the ages of three and five. They talk about their findings and their impact on the ADHD community in a special series of podcasts at the Lehigh news center.

	George DuPaul: Too often, families rely on medicine to treat ADHD when other options, like interventions, are proven alternatives.
	Project Achieve demonstrates how non-medicinal interventions are effective in treating ADHD symptoms in early childhood.
	Lee Kern: Education researchers are now better able to analyze ADHD-related symptoms among preschool-aged children.
	Project Achieve studied the impact of two types of interventions and their impact on behavioral, academic and social skills.

A proven alternative

Common ADHD treatments at that age include the use of medication, an approach that can be helpful under certain circumstances. The problem is that these psychotropic treatments are becoming more popular while other non-medicinal solutions have yet to be fully studied, let alone implemented.

That may no longer be the case. DuPaul, Kern and their colleagues have just ended Project Achieve, a five-year study that argues that interventions are successful when treating the disorder at such an early age.

The study was funded by the National Institute of Mental Health (NIMH) and is the largest study ever of its kind involving children between the ages of three and five who are at-risk for ADHD. Results of the study are outlined in the most recent School Psychology Review journal’s special series on ADHD. Published by the National Association of School Psychologists, it is the world’s second largest peer-reviewed psychology journal.

“Early identification and intervention is essential, but there has been a lack of research on how to identify and intervene effectively with these children during their preschool years,” explained Thomas J. Power, editor of the journal and program director with the Center for Management of ADHD at The Children’s Hospital of Philadelphia. “The investigation by Kern, DuPaul, and their colleagues is the most ambitious study of non-pharmacological, psychosocial interventions for young children with ADHD ever conducted.”

Over the course of 70 months, the researchers charted the progress of 135 students with symptoms of ADHD. They evaluated how effective early intervention techniques were in helping children decrease their levels of defiant behavior and aggression, while enhancing their academic and social skills.

Assessing early intervention

Early intervention techniques include highly individualized programs that often rely on positive supports to reinforce behavior. For example, in consultation with parents and preschool teachers, Project Achieve researchers modified the environments in home and school (such as altering tasks and activities in the classroom to accommodate for ADHD students), in an effort to improve behavior. The highly-interactive techniques were presented as alternatives to medicine.

“Medication may address the symptoms, but it does not necessarily improve children's academic and social skills. And because this is a lifelong disorder, without any cure, it’s important that we start understanding what tools and strategies are effective for children with ADHD at such an early age,” says DuPaul.

“There’s simply a lack of understanding about the type of non-medicinal services that are available to preschool children and their families. Our goal is to address behavior and academic issues before they become more problematic in elementary school,” he added

The results were significant. Using a variety of early intervention strategies, parents reported, on average, a 17% decrease in aggression and 21% improvement in their children’s social skills. Teachers saw similarly strong results; in the classroom, there was a 28% improvement in both categories. Early literacy skills improved up to three times their baseline status.

Positive results

The study suggests that a multi-tiered approach to intervention, whereby a more traditional approach to intervention is offered to children who are at-risk and more intensive services are provided to those children in greatest need, may be the most practical and cost effective strategy in helping preschoolers tackle behavioral and academic challenges.

“While parents of children with ADHD usually trace the characteristic behaviors back to the preschool years, pediatricians have long questioned whether such children can accurately be identified given the overlap with normal behaviors in young children. And if so, whether any intervention that does not involve medicine can be of value,” Van Brakle explains. “Project Achieve suggests that with careful assessment, such children can be accurately identified and appropriate behavioral interventions are an important part of the treatment plan.”

Research conducted by Lehigh University plays a prominent role in the issue. The special series also featured the results of Project PASS, an ADHD study organized by DuPaul and Asha Jitendra of the College of Education. DuPaul also contributed the forward for the issue titled, “School-Based Interventions for Students With Attention Deficit Hyperactivity Disorder: Current Status and Future Directions.”

--Tom Yencho