Ear­lier this month, the Amer­ican Academy of Pedi­atrics expanded the guide­lines for diag­nosing and treating chil­dren with atten­tion deficit hyper­ac­tivity dis­order (ADHD), low­ering the age to include kids as young as 4 years old. We asked Robert Volpe, asso­ciate pro­fessor in the Bouvé Col­lege of Health Sci­ences, whose research involves assessing the aca­d­emic prob­lems chil­dren with ADHD expe­ri­ence, to ana­lyze the new guide­lines — and dis­cuss how research in this area has evolved in recent years.

Why did the pre­vious guide­lines need to be changed?

Most of what we know about ADHD we have learned from studies of school-​​aged chil­dren. There­fore, we remain at the early stages of under­standing how the dis­order is first evi­denced in early child­hood. Since the last guide­lines were pub­lished in 2000, sev­eral impor­tant find­ings have emerged that should to be trans­lated into prac­tice. For example, we now have a better under­standing of the sta­bility of ADHD symp­toms in preschool chil­dren, and large-​​scale studies have been con­ducted focusing on both psy­choso­cial and med­ical inter­ven­tions with young chil­dren. One change in the new guide­lines is the rec­om­men­da­tion that psy­choso­cial inter­ven­tions be the first line of treat­ment for chil­dren meeting diag­nostic cri­teria for the dis­order. This is an encour­aging devel­op­ment because some chil­dren respond quite well to easily admin­is­tered psy­choso­cial inter­ven­tions; and even those chil­dren who do not demon­strate an ade­quate response from psy­choso­cial inter­ven­tions in iso­la­tion often require lower doses of med­ica­tion than they would had they been receiving med­ica­tion alone.

Is 4 years old an appro­priate age to diag­nose and treat a child that shows symp­toms of ADHD? Could normal tod­dler behavior be mis­taken as ADHD?

The sta­bility of ADHD symp­toms increases as chil­dren age. That is, a child diag­nosed with ADHD at age 5 is much more likely to con­tinue to meet diag­nostic cri­teria than a child who was diag­nosed at age 3. Sev­eral studies have shown that accept­able sta­bility can be achieved for older preschoolers, which sup­ports the down­ward exten­sion of the guide­line from age 6. For example, some chil­dren who meet diag­nostic cri­teria at this young age might not still have suf­fi­cient dif­fi­cul­ties to meet cri­teria two years later. How­ever, given the social and aca­d­emic impair­ments that are part of ADHD, one would not want to with­hold treat­ment from a young child who was expe­ri­encing sig­nif­i­cant symp­toms and impairments.

How has ADHD research grown in recent years and how has this affected your per­sonal research?

Research on the treat­ment of ADHD has moved from a focus on the core symp­toms of the dis­order to an increased focus on areas of impair­ment. The over­whelming majority of stu­dents with ADHD expe­ri­ence aca­d­emic under­achieve­ment in one of the basic skill areas. My pro­gram of research in this area cen­ters upon under­standing why chil­dren with ADHD have aca­d­emic prob­lems and how best to help them reach their full aca­d­emic poten­tial. Essen­tially, there have been two gen­er­a­tions of research directed toward improving the aca­d­emic func­tioning of stu­dents with ADHD.

In the first gen­er­a­tion, inter­ven­tions typ­i­cally tar­geted spe­cific behavior prob­lems in the belief that reduc­tions in dis­rup­tive behavior would lead to increases in aca­d­emic per­for­mance. Although med­ical and con­tin­gency man­age­ment inter­ven­tion strate­gies have been found to enhance rates of aca­d­emic pro­duc­tivity and accu­racy, these treat­ments do not com­pre­hen­sively address all of the aca­d­emic deficits that may be exhib­ited by stu­dents with ADHD. One expla­na­tion for these find­ings is that the treat­ments may increase levels of aca­d­emic engage­ment, but do nothing to impact the quality of instruction.

In the second gen­er­a­tion of studies, rather than tar­geting the symp­toms of ADHD, inves­ti­ga­tors tar­geted aca­d­emic skills deficits directly. Although aca­d­emic inter­ven­tions are designed to increase prac­tice of key aca­d­emic skills, such prac­tice can only take place if stu­dents are paying atten­tion and not engaging in dis­rup­tive class­room behavior. Focusing on early lit­eracy skills in chil­dren at risk for ADHD and reading failure, I have begun a series of third-​​generation studies in which class­room behavior and aca­d­emic skills deficits are both tar­gets for inter­ven­tion. Ini­tial results have been quite promising and point to the addi­tive ben­efit of tar­geting both aca­d­emic and behav­ioral domains simultaneously.