Preschoolers and ADHD

ADHD is most often diagnosed in school-aged children; it can be diagnosed in children as young as three-four years

Of course, we expect all preschoolers to be active — more inclined to run around and constantly move than to sit still. And we expect preschoolers to be impulsive —  to do things without thinking about the consequences. But some kids are incredibly active — parents typically describe them as “bouncing off the walls” — and they’re so impulsive that they need constant monitoring and instructions to function at home and school.

These children may have ADHD, and early diagnosis and treatment can help them control impulsive behaviour causing problems for them, their families, and teachers. They can get along better with other kids and be able to participate in activities appropriate for their age. But it’s important to know that the recommended first-line treatment for preschoolers with ADHD is different from what’s recommended for older kids.

ADHD experts and the American Academy of Pediatrics agree that behavioural therapy is the preferred treatment for preschoolers with ADHD and that stimulant medication should be considered only if behavioural 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.

How is ADHD diagnosed in preschoolers?

Usually, hyperactive and impulsive behaviour leads to an ADHD diagnosis in preschoolers. They may have been expelled or excluded from preschool or banned from playdates. Their parents constantly worry that they will run into the street or hurt themselves in some other impulsive way.

2 to 6 per cent of preschoolers are estimated to have the disorder. Boys are twice as likely as girls to be diagnosed.

Behavioural problems are usually what cause parents to bring preschoolers in for evaluation. One of the screening questions, “How many times do your child obey an instruction within five seconds?” By age four, it should be 7 out of ten. In my patients, it’s 10 per cent.

Diagnosing ADHD at this age should be done with great care since all preschool children exhibit some hyperactivity, impulsivity and inattention, the key symptoms of ADHD. 

Diagnosing ADHD should not be “quick and easy.”

Observing a child’s behaviour in the doctor’s office is insufficient for a diagnosis, as symptoms may not be present in that environment. 

It is the specialist’s job to rule out other conditions that look like ADHD. “There are medical mimics, like hypothyroidism, poor sleep problems, and medication effects. And there are psychiatric mimics, like having autism or r anxiety.”

Behavioural treatment for ADHD

Parent training for behavioural management techniques is the recommended treatment for preschoolers with ADHD. Through these programs, parents learn how to shape the behaviour of young children more effectively, and the children usually show marked improvement in their ability to comply with directions and rein in their impulsivity.

Why is parent training rather than therapy delivered directly to the child? Children are often referred for play therapy, but this is not a very helpful intervention for ADHD. “At its worst, it’s like an expensive play date. At its best,t, it’s a well-intentioned intervention with the support.” What families should be pursuing is parent training in behaviour management techniques.

“Intuitively, one would think that if the child has the problem, the therapy should be focused on the child. The reality is that, while the child has the problem, we want to change the environment so we can set the child up for success. And that typically involves working with parents and teachers,” he explains. “If a child has allergies — the problem is with the child, but the solution is working with the environment. You might get rid of the carpet or the drapes or find a new home for the cat. We can do things with the environment to help kids behave better.”

These programs teach parents how to use praise, or positive reinforcement, to promote the behaviours they want to encourage. And parents are taught to deliver consistent consequences when kids don’t comply. The result is that kids learn to modulate their behaviour to meet expectations, and the family conflict can be reduced, sometimes dramatically.

Programs that have shown evidence of effectiveness include:

  • Parent-Child Interaction Therapy (PCIT)
  • Parent Management Training (PMT)
  • Positive Parenting Program (Triple P)
  • The Incredible Years

When is the best time to manage ADHD? “I always tell a parent that now is the ideal time. You don’t want to be dealing with a non-compliant 15- or 16-year-old.”

When kids have behaviour problems, parents often take them out of preschool, but they need to get them more in.

If children can’t behave well enough for a mainstream preschool, there are special preschools for children with behavioural problems. “The idea is to not run away from structure but to get more intensive services. The parents need the respite, and the kids need to learn to be socialised.”

When should medication be considered?

In general, stimulant medication should be considered only for preschoolers who haven’t been helped by behaviour therapy or whose behaviour is so severe that it’s dangerous or severely impacting their lives and their families.

Based on recommendations of the AAP, of situations in which medication might be an appropriate choice:

  • Behaviour therapy has been unsuccessful
  • Significant risk of injury to the child
  • Significant risk of injury to other children or caregivers
  • Ejection from preschool or daycare
  • Threatened ejection from preschool or daycare
  • Strong family history of ADHD
  • Possible central nervous system injuries, such as prematurity, prenatal alcohol or cocaine exposure, or lead poisoning
  • ADHD symptoms interfere with other needed therapy, such as speech/language, OT, Physio
  • Parent or guardian on the verge of a “mental breakdown” because of the child’s behaviour
  • Marriage on the verge of divorce or separation because of the child’s behaviour

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