A new outlook on treatments for preschool-age children with ADHD

Michael Whaby
June 18, 2021
Angela C. LaRosa, M.D. plays with Freddie Taylor, a young patient with ADHD, at a recent doctor's visit.
Dr. Angela LaRosa plays with Freddie Taylor, a young patient with ADHD, at a recent doctor's visit. Photo by Sarah Pack.

MUSC Children’s Health developmental pediatrician Angela LaRosa, M.D., recently led the MUSC site of the largest study to date of treatments for attention deficit hyperactivity disorder (ADHD) in preschool-age children.

One out of every 50 preschool-age children is diagnosed with ADHD, according to LaRosa. If left untreated, ADHD can put children at increased risk for poor academic achievement and make it more difficult for them to mature emotionally and socially.

"This study is the largest retrospective review of treatment efficacy and side effects for the most common medications currently prescribed.(...)
I think that our findings set the stage for a prospective trial, examining the two therapies head-to-head."

-- Dr. Angela LaRosa

The study, sponsored by the Developmental Behavioral Pediatrics Network (DBPNet) and led by investigators at Children's Hospital of Philadelphia and Boston Children’s Hospital, compared the records of nearly 500 preschoolers who had been treated with either the stimulant methylphenidate or alpha-2 adrenergic agonists. The team found that both treatments had good efficacy, but the alpha-2 agonists had a better side-effect profile. The team’s findings are published in the April issue of the Journal of the American Medical Association.

“The literature on the treatment of ADHD in preschool children has been limited, and this study is the largest retrospective review of treatment efficacy and side effects for the most common medications currently prescribed,” said LaRosa. “It provides data to support the efficacy of the alpha-2 agonists and stimulant medications in this population.”

The stimulant methylphenidate is the preferred treatment for ADHD when behavioral therapy fails, but it can cause side effects such as irritability, which can also lead to problems both at school and home. Some pediatricians instead prescribe alpha-2 adrenergic agonists “off label” in children of this age.

“We know that the stimulant methylphenidate is what is actually recommended for the treatment of ADHD in children within this specific age group,” said LaRosa. “But you still see a decent number of children being prescribed the alpha-2 adrenergic agonists instead.”

Angela C. LaRosa, M.D. listens to Freddie Taylor's heart, while his mom, Joanne Taylor, holds him at a recent doctor's visit.  
Dr. Angela LaRosa listens to Freddie Taylor's heart, while his mom, Joanne Taylor, holds him at a recent doctor's visit. Photo by Sarah Pack.

In fact, a Kentucky Medicaid claims study found that the prescribed use of alpha-2 adrenergic agonists in preschool-age children with ADHD had increased by 13% from 2012 to 2017. And while there are studies that looked at the use of alpha-2 adrenergic agonists in older children and adolescents, data on the use of these medications in younger populations is extremely limited. 

"Children [in the study] were less irritable on the alpha-2 adrenergic agonists.”

-- Dr. Angela LaRosa

The DBPNet study found that ADHD symptoms improved in more than half of the patients treated with either the alpha-2 agonists (66%) or the stimulants (78%). These findings suggest that both treatments are effective at treating preschool-age children.

However, the side effect profile for the alpha-2 agonists was less severe overall than that of stimulants in this age group. Daytime sleepiness was the only adverse effect that was reported more with alpha-2 adrenergic treatment (38%) than treatment with stimulants (3%).  By contrast, treatment with stimulants led to more frequent moodiness/irritability (50% vs 29%), appetite suppression (38% vs 7%) and difficulty sleeping (21% vs 11%).

“The side effect that is most common with the alpha-2 adrenergic agonists is sleepiness during the day,” said LaRosa. “But when you look at the irritability, which is the main side effect of stimulants, children were less irritable on the alpha-2 adrenergic agonists.”

The team’s findings point to the need for a trial that would provide a more definitive answer as to which of the treatments would be most appropriate for preschool-age children.

“I think that our findings set the stage for a prospective trial, examining the two therapies head-to-head,” said LaRosa.

About the Author

Michael Whaby
Michael Whaby is a second-year PhD student in the College of Graduate Studies, who is researching RAS GTPases and cancer in the O’Bryan Lab at Hollings Cancer Center. He is also a CGS communications intern.