Preschoolers and ADHD

Preschoolers and ADHD

At times preschoolers may have difficulty paying attention, following directions, and waiting or taking their turn. These behaviors can be common and age appropriate or they may indicate the need for an Attention-Deficit/Hyperactivity Disorder (ADHD) evaluation. As a parent, you might wonder whether your preschooler has ADHD or is just being rambunctious and acting typical for his or her age. This fact sheet will tell you more about ADHD in preschoolers and what to do if you are concerned about your child.

Can preschoolers have or be diagnosed with ADHD?

Yes. Children as young as age 4 can be diagnosed with ADHD. According to the 2010-2011 National Survey of Children’s Health, approximately 194,000 preschoolers (2-5 years of age) had a current ADHD diagnosis. Some children outgrow the symptoms, but others may not. Research shows that 3-year-olds who show symptoms of ADHD are much more likely to meet the diagnostic criteria for ADHD by age 13.

How can I tell if my preschooler has ADHD?

Preschoolers with ADHD are more likely to be suspended from school or daycare because of their disruptive behavior. These kids have more trouble learning concepts at school, and many get special education placements at a very young age when compared to children without ADHD.

As a parent, you will want to know where your child’s behaviors fit along a range of behaviors that are typical of kids the same age. Ask yourself, “When compared with other preschoolers of the same age, where does my child’s behavior fall”? Talking with your preschooler’s teachers and/or childcare providers can let you know what are common behaviors in young children and not related to a disorder and what is of more serious concern.

What is involved in having my preschooler evaluated for ADHD?

To be diagnosed with ADHD, a child must have a specified number of symptoms for at least 6 months that show up in more than one area of life. For example, if your child has behaviors at home that may look like ADHD but does not have these behaviors in situations outside the home, there may be another explanation. If you suspect that your preschooler has ADHD, you will want to talk to a professional who is trained to diagnose and treat ADHD such as your child’s pediatrician, a child psychiatrist, psychologist, clinical social worker or other qualified mental health clinician. It is also important to have your child checked for other conditions such as vision, hearing, or sleep problems because sometimes the symptoms look like ADHD.

Evaluations for preschoolers should be thorough and follow the guidelines outlined by The Diagnostic and Statistical Manual of Mental Disorders (DSM 5), the American Academy of Pediatrics (AAP), and the American Academy of Child and Adolescent Psychiatry (AACAP). These guidelines recommend a detailed interview with you to determine how long the symptoms have been going on, how severe they are, how often they occur and in what settings. You and your child’s teachers or child care providers will be asked to complete questionnaires with rating scales to evaluate your child’s behavior. The ADHD professional will conduct a detailed review of your preschooler’s school and medical records, talk with and observe your child directly, and check for other conditions your child may have along with ADHD. The professional may also suggest other psychological tests to help understand your preschooler’s strengths and weaknesses in learning and thinking skills and screen for learning disabilities.

What are the symptoms of ADHD in children?

A diagnosis of ADHD is based on The Diagnostic and Statistical Manual of Mental Disorders (DSM 5). The manual lists three presentations of ADHD–Inattentive, Hyperactive-Impulsive and Combined and the symptoms for each.

Inattentive

• Fails to give close attention to details or makes careless mistakes
• Has difficulty sustaining attention
• Does not appear to listen
• Struggles to follow through on instructions
• Has difficulty with organization
• Avoids or dislikes tasks requiring a lot of thinking
• Loses things
• Is easily distracted
• Is forgetful in daily activities

Hyperactive Impulsive

• Fidgets with hands or feet or squirms in chair
• Has difficulty remaining seated
• Runs about or climbs excessively in children; extreme restlessness in adults
• Difficulty engaging in activities quietly
• Acts as if driven by a motor; adults will often feel inside like they were driven by a motor
• Talks excessively
• Blurts out answers before questions have been completed
• Difficulty waiting or taking turns
• Interrupts or intrudes upon others

Combined, Inattentive & Hyperactive-impulsive

• Has symptoms from both of the above lists

These symptoms can change over time, so children may fit different presentations as they age.

What are the causes of ADHD?

Research has yet to determine the exact causes of ADHD. However, scientists have discovered a strong genetic link since ADHD can run in families. Other factors in the environment may increase the likelihood of having ADHD:

• mother smoking cigarettes or drinking alcohol while pregnant
• exposure to lead or pesticides in early childhood
• premature birth or low birth weight
• brain injury

Scientists continue to study the exact relationship of ADHD to environmental factors, but point out that there is no single cause that explains all cases of ADHD and that many factors may play a part.

The following factors are NOT known causes, but can make ADHD symptoms worse for some children:

• watching too much television
• eating sugar
• family stress (poverty, family trauma)

Why is it important to address ADHD in my preschooler at an early age?

Preschoolers with ADHD are more likely to have difficulties in daycare or school, including problems with peer relationships, learning, and a higher risk of injuries. An early diagnosis is important so that your child can get the needed help to minimize these problems.

Even for the preschooler who might have some symptoms but does not have ADHD, these early years are the time when significant brain development occurs. This is an optimal time for children to learn positive behaviors, and for you to know how to effectively help your child learn. It’s best to address problematic behaviors sooner rather than later.

How should ADHD be treated in preschoolers?

When it comes to treatment for preschool and kindergarten-aged children, the AAP calls for behavioral treatments first and medication only when needed. Behavioral therapy from child and adolescent therapists who specialize in ADHD will provide both the parents and the children techniques to teach and reinforce positive behaviors and skills. This will help a preschooler with ADHD to successfully function at home and school.

When medication is prescribed, the AAP recommends starting children ages 4-5 on a methylphenidate medication trial beginning with a low dose. Because children respond differently to medication, what may work for one child may not work for another. The health care professional can adjust the dose to determine if it is helping, if a different medication is needed or if any side effects are present. Treating ADHD is complex, and it is important to continually monitor children to see if the treatment is working. This includes periodically repeating the rating scale assessments to make sure the medication and behavioral therapy are having the desired effect. Additionally, the AACAP Preschool Pharmacology Working Group recommends that preschoolers who are taking ADHD medication have their medication stopped (under the prescribing doctor’s direction) after 6 months to reassess the symptoms and to consider whether the medication should be continued.

What is parent behavioral training and how can it benefit me and my child?

Children who have ADHD may not have the skills and behaviors that result in their receiving positive attention. Often they tend to misbehave and are in situations where they are punished more frequently than other children. This can have a negative effect on their self-image and cause them to increase their problem behaviors. Parents and caregivers (daycare providers, preschool teachers, and other caretakers) can learn to manage the behavior of preschoolers who have ADHD by becoming educated about the disorder and by receiving parent training in how to use behavioral techniques.

Parent training programs taught by trained therapists can give caretakers the tools and strategies to help children who have ADHD. A 2010 review by the Agency for Healthcare Research and Quality (AHRQ) found that effective programs:

• help parents develop a positive relationship with their child
• teach them about how children develop
• help them manage negative behavior and increase positive behavior with positive discipline

Parent behavioral training programs for parents of preschool-aged children that currently have enough research evidence to be described as effective:

• Triple P (Positive Parenting Program)
• Incredible Years Parenting Program
• Parent-Child Interaction Therapy

Other programs that focus on the same elements may also be helpful.

Parents and caregivers who wish to learn more about ADHD and ways to help their child may wish to enroll in Parent to Parent: Family Training on ADHD offered through CHADD.

Are preschoolers receiving the recommended treatments?

The Centers for Disease Control and Prevention (CDC) reports that 1 in 2 preschoolers do not receive recommended behavioral treatment. The rates of preschool-aged children taking medication for ADHD has doubled in the last four years, and 1 in 4 receive only medication treatment, which should be the last resort.

There is a movement within the field of ADHD to increase access to behavior therapy for young children, particularly to behavioral parenting therapy that is considered evidence-based and effective. The hope is to decrease the rates of preschool and kindergarten-aged children taking medication for ADHD as a first line of treatment.

For More Information

http://www.cdc.gov/ncbddd/adhd/treatment.html

http://pediatrics.aappublications.org/content/128/5/1007.full
The information provided in this sheet is supported by Cooperative Agreement Number IU84DD001049-2 from the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. Permission is granted to photocopy and freely distribute this factsheet for non-commercial, educational purposes only, provided that this document is reproduced in its entirety, including the CHADD and NRC names, logos, and all contact information. Permission to distribute this material electronically without express written permission is denied.