Preschool ADHD: Is That a Thing and What Do I Do About It?

ADHD can technically be diagnosed as young as three years old. At Kids BRAIN we like to wait a little longer and get closer to 5 years old before full diagnosis is considered. But, if they are diagnosed with ADHD at 5, or 6, or 10, they were still preschoolers who struggled with attention problems, hyperactivity, impulsivity, or some combination of all of these. We expect all preschoolers to be active and to love to run around more than they consent to sit still. We expect them to be impulsive and prone to doing things without thinking about the consequences. But some kids are extremely active like they are “bouncing off the walls” and so impulsive they’re extraordinarily difficult to manage.

These children may have ADHD, and early diagnosis and treatment can help them better control themselves and help their parents to be better able to manage them with less effort. Treatment for ADHD in young children is NOT the same as treatment in older children. ADHD experts and the American Academy of Pediatrics agree that behavioral therapy is the preferred treatment for preschoolers with ADHD, and that stimulant medication should be considered only if behavioral therapy isn’t available or hasn’t worked. It can also be considered if the child or the family is at risk of serious harm.

It is usually hyperactive and impulsive behavior that leads to an ADHD diagnosis in preschoolers. The attention part is “quieter,” so it does not often come up as a major issue until school age. Young children later diagnosed with ADHD may have been kicked out of preschool or banned from playdates. Their parents may worry constantly that they will run into the street or hurt themselves in some other impulsive way. Preschoolers will only have the symptoms consistent with an ADHD diagnosis about 2 to 6 % of the time, and boys are twice as likely as girls to be diagnosed. Often, the struggles with parenting, discipline, and compliance are what lead parents to psychologists like me. A typical child will listen and follow directions about 80% of the time. Preschoolers with ADHD symptoms are far less capable when it comes to following instructions.

A lot of times, an early diagnosis ADHD will be made at the physician’s office. But, observing a child’s behavior in the doctor’s office is not sufficient for a diagnosis, as symptoms may not be present in that environment. Pediatricians are encouraged to collect screening questionnaires filled out not only by a parent but by at least one other adult who spends time with the child. Symptoms must be present in more than one setting, like at home, at preschool or daycare, with relatives or family friends. From there, it is highly recommended that your child undergoes an actual developmental assessment. I am biased, because this is what I do for a living, but the most important part of testing with children in this age range is determining what they DON’T have. The symptoms of ADHD can be observed in lots of diagnoses that are not ADHD. Specifically, developmental delays in language and motor functions, sensory processing differences, early indications of mental health issues, sleep deprivation, temperamental factors, poor diet, early learning differences, and autism could be present instead.

Parent training for behavioral management techniques is the front line recommended treatment for preschoolers with ADHD. Through these programs, parents learn how to more effectively shape the behavior of young children, and the children usually show marked improvement in their ability to comply with direction and become more aware of ways to reduce problem behaviors. Some parents will seek out the assistance of a play therapist. This is a fine method for supporting children with emotional regulation issues but is not necessarily the most “bang for your buck” with ADHD kids. I know that stinks. Most parents would love for a therapist to chip away at their child’s struggles while they keep doing what they are doing. While it’s the child who has the “problem,” what we want to do is change the environment so we can set the child up for success. That typically involves working with parents and teachers so that a plan can be put in place to offer the structure and support needed for the ADHD child to thrive. These programs teach parents how to use praise, or positive reinforcement, to promote the behaviors they want to encourage. Parents are also taught to deliver consistent consequences when kids don’t comply. The result is that kids learn to modulate their behavior to meet expectations and the family conflict can be reduced, sometimes dramatically. One of the best things about parent training is that it helps kids whether or not they have an ADHD diagnosis, so there is no downside to trying it if kids are having behavior problems. It helps the child, helps the parents, and it will help the other kids in the family, too. There are a number of programs that can be used as a “package deal.” See below. Other times, elements of all of these will be merged to work with a family.

Parent-Child Interaction Therapy (PCIT)

Parent Management Training (PMT)

Positive Parenting Program (Triple P)

The Incredible Years

In general, stimulant medication should be considered only for preschoolers who haven’t been helped by behavior therapy, or whose behavior is so severe that it’s dangerous or it’s severely impacting their lives, and their families’ lives. My rule of thumb is when the family is starting to erode to the point that there is little meaningful connection and no patience left that medication may be a consideration. However, I also include elements to address nutrition, sleep, and general wellness like physical activity, limiting screen time, increasing educational opportunities, and fostering sibling connections. One reason to try behavior therapy first is that while stimulant meds are very effective for most school-aged children, with a rate of more than 70 percent, the preschooler the response rate drops to 50 percent. This is not an ideal response rate, but there are some circumstances when medication may be a valid consideration for treatment planning.

Behavior therapy has been consistently provided but has been unsuccessful

Significant risk of injury to the child is present due to high levels of hyperactivity/impulsivity

Significant risk of injury to other children or caregivers

Ejection from preschool or daycare and struggles to remain consistently enrolled

Strong family history of ADHD (when ADHD diagnosis becomes more likely)

Neurological issues like prematurity, prenatal alcohol or cocaine exposure, or lead poisoning

ADHD symptoms interfere with other needed therapy, such as speech/language, OT, PT

Significant parent-child or spousal conflict that is interfering with family connectedness

If your child is under the age of 5 and have one or more of the above factors in play, consider a consultation with a neuropsychologist. If you are in the Dallas, Texas area, call us at Kids BRAIN. We would be happy to help!

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