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In younger children, their usual demanding behaviour and any existing specific and global deficits, especially in language, make it more difficult to determine what is "developmentally inappropriate". As preschool children learn, their mobility and curiosity is demanding and parents often complain of "hyperactivity". Palfrey, Levine, Walker et al (1985) followed a cohort of children from birth to second year at school in a study which also emphasised personalised education and guidance of the child and parents. Of 174 children, 41 per cent had some attentional concern; this peaked at 42 months and was often minor or transient. Thirteen per cent were judged worthy of intervention, 8 per cent had definite problems which abated before kindergarten and 5 per cent had definite and persistent problems with attention. Persistent attention problems were associated with preschool socialöemotional concerns, developmental lags, and single parent families. By second year at school, 45 per cent had reading problems (compared with 13 per cent with normal attention), 37 per cent had poor work output, and used support teaching and language therapy twice as often. Communication disorders Communication disorders have a strong and persistent association with behavioural dysfunction. In a group of 3 year-olds with expressive language delay 59 per cent (compared to 14 per cent of controls) had behaviour problems and significant persistence to age eight years (Stevenson, Richman and Graham 1985). ADHD is a common diagnosis when speech and language problems are found in both clinic patients (16 per cent) (Baker and Cantwell 1987) and in population samples (30 per cent) (Beitchman, Wilson, Brownlie et al 1996b; Cohen, Davine, Horodesky et al 1993). Benasich, Curtiss and Tallal (1993) question this specific association with ADHD, though did not specifically study it. Genetic associations between ADHD and speech, language and literacy problems are evident in the Australian twin study (Levy, Hay, McLaughlin et al 1996). ADHD populations at school demonstrate language dysfunction with academic and social impact (Tannock, Purvis and Schachar 1993; Sandler, Hooper, Watson et al 1993). It is crucial in the diagnosis and management of ADHD in young children to thoroughly assess and manage communication disorders. Persistence into adolescence Both Campbell's review (1995) and the Dunedin cohort study (McGee, Partridge, Williams et al 1991) document the persistence of preschool hyperactivity and difficult behaviour into adolescence. Satterfield, Swanson, Schell et al (1994) re-examined their cohort from two decades earlier and demonstrate that defiance, not only aggression, in preschoolers has a poorer outcome. Preschoolers, in general, already disapprove of aggressive, hyperactive peers as shown by Milich, Landau, Kilby et al (1982). Management of ADHD in preschoolers Logically, treatment, including stimulant medication, might allow children with moderate to severe problems to achieve more successful behaviour, learning, social acceptance and self-esteem before school entry. Stimulants have been used in young children for twenty years (Schleifereifler, Weiss and Cohen 1975) and act similarly as in older children, although dosage, benefits and side-effects need more careful evaluation. Mayes, Crites, Bixler et al (1994) conducted a realistic standardised blinded trial of three daily methylphenidate doses with 69 children aged 22 months to 13 years, with IQs between 23 and 136. Of preschool children with ADHD alone, 88 per cent improved with methylphenidate, with no increased side-effects. Behavioural management of all preschoolers is challenging. While severe ADHD may be less common in very young children, it does exist, often with strong effects on parental psychopathology. In some children, complex developmental, social and family adversity combine to produce severe problems in spite of all support services being engaged and high-dose or multiple medications being used. Such cases tax the control procedures for the prescription of stimulants, which demand clinical thoroughness and, in very young children, second opinions from appropriate professionals. With ADHD, particularly with defiantöaggressive behaviour, immediate tangible and structured rewards are essential, and parents require close support (Strayhorn and Weidman 1989). There is no published controlled study of combined medication and behavioural management in very young children. There is no controlled scientific support for the efficacy and safety of other medications, such as clonidine, antidepressants or thioridazine, but these are often used to avoid the bureaucratic complexities of stimulant monitoring. The management of ADHD, including that of medication, in preschool children is of growing significance in trying to deflect the poor outcome of moderate/severe ADHD with the developmental, emotional and family problems which accompany it. Complex interaction between intrinsic traits in, and environmental influences on, the child and parent (as discussed in Section 4.6.4 and 8.1) may result in a preschool child presenting with symptoms of ADHD, defiant and aggressive behaviour (Satterfield, Swanson, Schell et al 1994). Management of ADHD in preschoolers demands careful consideration of the interactive effects of severe child behaviour disturbance and parental responses, major relationships and evaluation of practical and emotional safety of the child. Parents require support in relation to behaviour management therapy for the developmental problems of their child/ren, especially that of communication. Alternative or respite care is also required. The use of medication in children under three years is rare and is only indicated for severe symptoms. It demands comprehensive, intensive and integrated expertise. Medication is only used in infants under two years of age in extreme circumstances that are likely to be associated with significant brain impairment, major developmental problems and/or severe environmental disruption. Monitoring of medication for ADHD must be very thorough for such young children. This should particularly apply to the use of medications other than stimulants, as there is little scientific data on their efficacy and safety and no statutory guidance and monitoring. Recommendation The diagnosis of ADHD in toddlers and preschoolers is complicated by normal developmental changes and environmental factors. Behaviour management and parent guidance is essential, and medication should be used with caution. Adolescence and ADHD Management of ADHD during adolescence must be considered in the context of the behaviour, learning and social characteristics of normal adolescent development, persistence of dysfunction from early childhood and into adulthood, co-morbidity (especially conduct disorders), the need for specialised approaches to adolescents and the shortage of services which promote adolescent wellbeing.
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