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.