Can ADHD be Prevented in Early Intervention?

Almost all of the work I have seen in helping children with ADHD focuses on providing effective treatment after the disorder has  been diagnosed.  Studies on the possible prevention of ADHD, in contrast, are few and far between.  Is it possible that early intervention in children showing signs of being at risk for the development of ADHD could prevent the development of the condition when they are older?  This is an extremely interesting and important question.

A study that appeared in Israeli Journal of Psychiatry and Related Science provides an interesting initial look at this question (Rappaport, G.C., Ornoy, A., & Tenenbaum, A. (1998). Is early intervention effective in preventing ADHD? Israeli Journal of Psychiatry and Related Science, 35, 271-279).  The authors of this study note that ADHD is usually not diagnosed until after a child begins school, even though evidence of ADHD symptoms is often present at a much earlier age.  Clinicians are often reluctant to diagnose ADHD in preschool age children - and rightly so, in my opinion - because of the difficulty involved in differentiating between normal and deviant behavior in children this young.

On the other hand, some studies have shown a significant continuity of ADHD symptoms from a very early age.  Thus, one research has reported that 33% of children who were hyperactive at age 3 were diagnosed as having ADHD at age 11.  The authors of the current study had found in prior work that among 2-4 year old children who showed signs of inattention, hyperactivity, and speech delay, approximately 80% were diagnosed as having ADHD upon reaching school age.  Based on these earlier results, the authors reasoned that such symptoms in young children might serve as early signs of ADHD, and wondered whether early intervention by non-pharmacologic methods might be effective in reducing the number of children showing these early signs who go on to develop ADHD.

In this study, the authors identified 77 children between the ages of 2-4.5 who were showing problems with inattention, and who showed evidence of speech and/or motor delay.  All of the children identified were offered treatment, which consisted of occupational therapy and speech therapy.  These treatments were individually administered at least once a week over a period of at least 6 months.  The authors hypothesized that improving children's speech and motor functioning would also enhance their attention and concentration abilities, and that this would reduce the incidence of ADHD in those children receiving treatment.  About 60% of parents elected to provide their children with the recommended treatment while about 40% did not.

Children were followed up an average of 5.5 years later when they were 8-10 years old.  Fifty-one of the original 77 children were able to be contacted, and a comprehensive evaluation of ADHD was performed at this time.  Of the children who were evaluated  for ADHD, 31 had received the early speech and occupational therapy evaluation and 20 had not.  Did the rates of ADHD differ in these two groups?

Of the 21 children who had not received the early intervention, 10 (48%) were diagnosed with ADHD at the follow up assessment. (These follow up evaluations were done by examiners who were not aware of whether or not the child had received prior treatment.) In contrast, only 33% of children who had received the early Intervention were diagnosed with ADHD at this time.  These results are in the expected direction, but were not statistically significant.  This means that differences of this magnitude could have occurred by chance reasons alone.

When looking at children according to whether or not there was a family history of ADHD, however, the results are more striking. Every child who was from a family where another member had ADHD and who did not  receive the intervention, was diagnosed with ADHD at follow up.  In contrast, only 37% of children who had the same family history but who received the early intervention developed ADHD.  The differences between these rates was statistically significant, meaning that they were unlikely to reflect chance factors alone. When there was not any family history of ADHD, whether or not a child received early intervention services was not related to whether or not he/she developed ADHD.

These results need to be considered cautiously, as they were obtained with a small sample of children and certainly require replication with a larger sample.  Even so, I think they are quite intriguing.  What they suggest is that for children who are showing early signs of ADHD, and who have a family member who has this disorder,  early intervention may be effective in reducing the odds of their developing ADHD later on. Perhaps other types of intervention, or similar interventions applied for a longer  time, might prove

similarly helpful for children showing early signs of ADHD but do not have a positive family history.

In terms of the practical application of these results, I think the most important message is that when a young child is showing signs of difficulty, efforts should be made to determine the best ways to address that difficulty.  I have been involved in many situations where a parent felt certain that their child was not developing in ways that they felt comfortable with, but were told that the child was too young to diagnose and would probably just grow out of the trouble.

Although I agree that diagnosing a 2 year-old with ADHD is not appropriate, that does not mean that treatment/assistance should not be provided to a child that age who is showing problems in their development.  The important thing, I think, is to provide a young child with the assistance he or she may need to help get their development back on a healthy trajectory.  When the difficulties really are interfering with their developing the skills and abilities they need, then waiting until they "outgrow" them, or not providing any assistance because they are too young to diagnose with ADHD, does not seem like a particularly helpful position to take.

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