Early intervention for ADHD
By Dylan S. T. Voris and John S. Carlson
Research on preschool-age children at risk for ADHD has received limited attention within the literature. This despite an increased focus within the field of school psychology on early intervention and prevention designed to correct problems before they become pervasive or to prevent problems altogether (Merrell, Ervin, & Gimple, 2006). Further, the research on school-aged children may not fully inform intervention programs for preschool-aged children given the significant developmental differences between these age groups. As Ken Robinson (2010) sarcastically commented on treating age groups similarly, “A three year- old is not half a six-year-old. They’re three.” That is to say, preschool-aged children may differ in important ways from older children, and the best practices for older children with ADHD may not translate well to preschool children. Differential treatment recommendations for children with ADHD based on age have recently been recommended by the American Academy of Pediatrics (2011).
The book Young Children with ADHD: Early Identification and Intervention (DuPaul & Kern, 2011) adds substantially to the preschool mental health literature. It provides readers with a detailed look at an empirically supported psychosocial intervention specifically designed for treating preschool children experiencing symptoms of inattention, hyperactivity, and impulsivity. The need for such interventions has been clearly established (American Psychological Association, 2006) and given increased importance due to the increasing trend in off-label stimulant usage for preschoolers (Kollins & Greenhill, 2006). This increase in prescriptions has emerged despite the exaggerated side-effects (e.g. appetite reduction, sleep disturbances, growth suppression) reported within this young population (American Psychological Association, 2006).
This book review provides a critical examination of Young Children. Specific attention is given to the implications of this book on the field of school psychology including (a) assessments for ADHD in preschoolers, (b) the intervention model used (c) and the outcome data presented. Finally, the review concludes with a close look at the limitations of this book and the significance of this work on future practice and research with ADHD in preschoolers.
Young Children targets an audience of, “Mental health and education professionals who work with young children” (p. viii). The organization of the book parallels an article by the same authors appearing in the literature a few years ago (Kern et al., 2007). First, the problem is framed through a literature review. Then the authors present an argument supporting their methods for identifying preschoolers with ADHD. Next, and the majority of the book, is a detailed description of the methods in their combined school and home-based intervention. Interspersed throughout this section is practical advice and problem-solving strategies for practicing professionals who are working with this client base and/or student population. This book concludes with a review of their methodology, results of their investigation, and a lengthy discussion featuring future directions for research.
One important issue addressed within Young Children is the feasibility and reality of diagnosing preschoolers as having ADHD. Given that the majority of diagnoses of ADHD occur during the school years (Richters et al., 1995), the ADHD label for preschool children may be problematic for a number of reasons. As DuPaul and Kern (2011) point out, “the behaviors that attentiondeficit/ hyperactivity disorder (ADHD) compromises…are relatively common among preschool children (p.23).” Young Children provides an overview of the assessments that should be used to determine the ADHD status of preschool children. First, the authors point to the importance of screening for other potential mental health diagnoses. They suggest screening for autism, which precludes a child from an ADHD label, as well as screening for disorders that may better define the child’s behavior or that may be comorbid with ADHD (e.g. oppositional defiant disorder, generalized anxiety disorder, separation anxiety disorder, or major depression). From there, the authors also suggest the cross-setting use of diagnostic interviews, behavior rating scales and direct observations of behavior. Further, using objective rather than subjective measures and evaluating social, preacademic, and family functioning are said to enhance the accuracy of an ADHD diagnosis. In short, an ADHD diagnosis in preschoolaged children is not a straightforward matter even with the helpful suggestions and guidance found within this book. Consistent with DuPaul and Kern, The American Academy of Pediatrics (2011) also concludes that reliable ADHD diagnoses are possible for this age group.
Throughout their book, DuPaul and Kern make reference to Response to Intervention (RtI) and School-Wide Positive Behavioral Support (SWPBS). These notations are potentially confusing because the authors use different identification procedures and nomenclature from current RtI and SWPBS processes. RtI and SWPBS start with universal prevention or intervention and increase the intensity of services for children identified as not responsive to less intensive services. DuPaul and Kern’s approach identifies children who have problematic behavior before implementing a tiered approach. In RtI and SWPBS children are not identified as having problematic behavior until universal and/ or targeted interventions prove ineffective. DuPaul and Kern’s tier one services are not universal because they have already identified children with problematic behavior. Their tier one is similar to the tier two typically discussed within RtI and SWPBS. However, the classwide tier one services of the school-based intervention described in Young Children are similar in practice to RtI and SWPBS despite the fact that children are preidentified. The home-based intervention is also markedly different from RtI and SWPBS in that there is no universal component and children are pre-identified. DuPaul and Kern’s home-based intervention certainly has demonstrated success, however a home-based prevention program such as universal parenting classes may go even further and likely have more beneficial results. Young Children is an important step towards early intervention and prevention efforts for this young population. However, as the model used by DuPaul and Kern translates similar work and traditions with school-aged children to examine its efficacy with preschool children, it also brings similar limitations.
In an APA working group report (2006) several general limitations of ADHD research are highlighted that apply to the psychosocial intervention reviewed in Young Children. Namely, this work group asserts that interventions should be sufficient for all children, and there should be evidence of long-term efficacy. The former is true for nearly all psychological interventions. DuPaul and Kern attempt to resolve the later issue though tracking. In the reported data, there are promising trends over the two-year period with reduced ADHD symptoms, reduced pharmacological usage, reduced delinquent behavior increased social skills ratings, and increased early literacy skills.
The next, and perhaps more pressing, problem facing ADHD research is an almost exclusive focus on symptom reduction; an issue discussed in the conclusion of Young Children. Given that an emphasis of the methods in this book was on academic interventions, and the author’s previous findings with academic improvements for children with ADHD (Kern et al., 2007), it would have been refreshing to see a more thorough discussion and description of the academic outcome measures. An important non-symptomatic outcome that was given considerable attention in Young Children was the decreased use of psychotropic medications for children receiving the combined home and school intervention. There are a host of known side effects of stimulant medications use with young children (APA, 2006).
Additionally, The American Academy of Pediatrics (2011) recommends parent and/ or teacher-based treatment for preschoolage children before considering stimulant medication. Even so, DuPaul and Kern note that stimulant medications are still frequently given to young children before exhausting non-psychotropic options. DuPaul and Kern’s combined home- and school-based intervention results in impressive results in this area by nearly cutting in half the number of preschool students receiving psychotropic medications at a two-year follow up compared to a control group. This finding is even more salient considering evidence from the APA report (2006) that medication treatment does not produce long-term improvements compared to large-impact psychosocial interventions, such as DuPaul and Kern’s.
A general limitation arises from the National Institute of Mental Health funding DuPaul and Kern received. It is important to keep in mind the challenges associated with disseminating interventions that emerge from federally-funded sources. This level of funding is not available to all communities or schools that may wish to use DuPaul and Kern’s approach. Dissemination of the program may require only partial utilization of their methods due to resource constraints or access to well-trained professionals who can carry out this intervention with integrity. Interestingly though, there is support within the study findings that only receiving some of the intervention (i.e., a limited number of parent education sessions) still imparts meaningful change (Kern et al., 2007). Overall, Young Children provides a thorough description of a multiple component intervention designed for preschool-aged children exhibiting the symptoms of ADHD with a focus on a three-tiered approach. It provides professionals with a better understanding of what works for young children with ADHD while reporting promising results to support their conclusions. In the end, this book demonstrates the possibility of fostering positive change for young children with ADHD and underscores the need for school psychologists to focus beyond symptom reduction.
The American Academy of Pediatrics (2011). ADHD : Clinical practice guideline for the diagnosis, evaluation, and treatment of Attention-Deficit/Hyperactivity Disorder in children and adolescents. Pediatrics, 128, 1007-1022. doi: 10.1542/peds.2011-2654.
American Psychological Association. (2006). Report for the working group on psychotropic medication for children and adolescents: Psychopharmacological psychosocial, and combined interventions for childhood disorders: Evidence base, contextual factors, and future directions. Washington, D.C. : American Psychological Association.
DuPaul, G. J., & Kern, L. (2011). Young Children with ADHD: Early Identification and Intervention. Washington, D.C. : American Psychological Association.
Kern, L., DuPaul, G. J., Volpe, R. J., Sokol, N. G., Lutza, G., Arbolino, L. A., Pipan, M., & VanBrakle, J. D. (2007). Multisetting assessment-based internvetion for young children at risk for attention deficit hyperactivity disorder: Initial effects on academic and behavioral functioning. School Psychology Review, 36, 237-255.
Kollins, S. H., & Greenhill, L. (2006). Evidence base for the use of stimulant medication in preschool children with ADHD . Infants & Young Children, 19, 132-141. Merrell, K., Ervin, R. A., & Gimpel, G. (2006). School Psychology for the 21st century. New York: Guilford.
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Robinson, K. (2010). Bring on the learning revolution. TED talks.