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Assessing ADHD in Preschool Children

Assessing ADHD in Preschool Children


Childhood ADHD is a major public health problem with prevalence estimates of over 5 million children in the US alone. Of particular concern is the progressive increase in diagnosis. For example, in 2013, the National Center for Health Statistics estimated that 9.5% of children in the US aged 4 to 17 years (13.3% of boys, 5.6% of girls) have been diagnosed with ADHD.1 Moreover, nearly 2% of children aged 3 to 4 years had been diagnosed with ADHD—an almost 4-fold increase from 0.5% in 1997.2

The need to identify ADHD earlier
Recently, a leading ADHD researcher, Stephen Hinshaw,3 warned that the movement toward universal pre-kindergarten might inadvertently lead to an “epidemic” of preschool children wrongly identified as having ADHD. This is largely due to the mismatch between biological readiness and earlier academic demands.3

Increased prevalence of ADHD is of great concern because the disorder is associated with extraordinary societal costs. In 2011, for example, it was estimated that the annual incremental cost of illness for ADHD in the US was $143 to $266 billion,4 driven largely by high rates of psychiatric and learning disorders, injury, and mortality associated with the disorder.5

An especially alarming trend is the identification of adverse outcomes among preschool children with ADHD.6 Even when children with ADHD are identified and treated in the preschool years, symptoms and functional difficulties continue throughout the elementary school years.7 A recent prospective study from the UK found that adults who were rated as hyperactive at aged 3 years incurred 17.6 times higher annual health care costs than concomitantly studied cohort of adults who had not been identified as hyperactive at aged 3 years.8

The costly toll that ADHD takes on individual adjustment, family life, schools, health care, and social services underscores the importance of earlier identification and treatment. Biomarkers of ADHD, including neuroanatomic and functional anomalies, are associated with chronic cognitive and behavioral dysfunction.9 These brain-based changes develop early in life (even before formal diagnosis) and include delayed brain maturation (delay from to 2 to 5 years) by the time children with ADHD reach middle school age.10


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