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ADHD and Preschoolers – Child-sized Bundles of Energy

Close your eyes and imagine.

You’re at a park. You’re surrounded by children, and their screams and giggles are filling your ears. To your left, there is a boy jumping off some playground equipment. To your right, there’s a herd of children hollering as they chase after and tackle one another. In front of you, a girl is hanging upside down, even though she probably shouldn’t be. You are surrounded by child-sized bundles of energy and, well, chaos.

If I told you that these kids were in late-elementary school or early-junior high, you’d probably suspect that they had ADHD. After all, when people think of children with ADHD, they tend to picture a child who is full of energy, absolutely cannot stop moving, and is all over the place. Perhaps, they are even in to everything. And they probably don’t like the word ‘no’ (although, most kids don’t).

But what if I told you that you’d just walked in on a preschool class at recess? Some people might argue that it had to be a class full of kids with ADHD, while others would say the scene is absolutely normal. So, which is it?

This is the challenge. Can you diagnose ADHD in preschoolers? Should you be diagnosing it? And, what do you do for preschoolers with ADHD?

Simply put, yes, you can diagnose ADHD in preschoolers. The most recent diagnostic guidelines released by the American Academy of Pediatrics have indicated that any child between 4-18 years old should be assessed if there are behavioural concerns. This assessment should be used to determine whether these concerns are part of normal child development or if they could be associated with a medical condition, like ADHD.

This is where the challenge comes in, and why professionals are needed to make the diagnosis of ADHD. What is normal child development and behaviour?

As it turns out, preschoolers are supposed to be into everything. That’s part of normal development. Does ‘the terrible 2’s’ sound familiar?

The typical preschooler is inattentive, impulsive, and has high energy levels – all of which are diagnostic criteria for ADHD. But all preschoolers do NOT have ADHD. Preschool-aged children are only just beginning to develop the capacity to sustain attention and inhibit impulses.

The typical preschooler does not like the word ‘no’. In fact, resistance to following directions and rules is normal. While some people might believe it has to do with difficulty listening and following instructions – both associated with ADHD – it’s actually part of normal development. The preschool-age is when children first start to experience a desire for more independence, along with developing a sense of self-awareness, and beginning to engage in more goal directed behaviour.

In summary, the mere presence of inattention and hyperactivity does NOT equal a diagnosis of ADHD in preschoolers.

So, if there are concerns about a preschooler’s behaviour, professionals usually look at the extent to which the child is into everything. In other words, whether or not their behaviour can be considered outside of typical development. But remember, development and growth is a spectrum, and it’s normal for some children to develop – and thus outgrow the typical preschooler impulsivity and hyperactivity – quicker than other children.

Typically, when evaluating a preschooler for ADHD, a pattern is noticed.

Because preschoolers aren’t usually placed in situations were high-levels of attention is required, most of the symptoms they present with have to do with hyperactivity and impulsivity. And, because of the degree to which they are experiencing hyperactivity and impulsivity, studies have found higher rates of reported accidents, unintentional injuries and visits to the emergency department. Some examples of the behaviours that have been reported and documented are:

  • Falling off furniture after excessive climbing.
  • Leaning, falling, or jumping out of windows.
  • Running into traffic-filled streets.
  • Turning on stoves and reaching across burners.
  • Unbuckling restraints and standing up in cars and strollers.

However, it’s not just risky behaviour that could result in broken bones, concussions and physical injuries. Studies have also found that preschoolers with ADHD are more likely to be suspended or expelled from preschool. This, in turn, forces parents to find alternative means of childcare, or take time off work to look after their child themselves. There have even been reports of parents losing their jobs because of how many times they’ve had to go to the school to deal with their child’s inappropriate behaviour or take time off work to care for their child after they had been suspended/expelled.

This is why it is so important to properly diagnosis ADHD in preschoolers. One, if identified, the ADHD and its symptoms can be managed. This means that preschool issues, ER visits, injuries and even parental job issues all decrease. Two, studies among people with ADHD have shown that the earlier the condition is diagnosed and treated, the better the outcome. And, as it turns out, ADHD in preschoolers is quite stable, with >60% of children still meeting diagnostic criteria at age 7.

Now, as every pediatrician will tell you, kids aren’t just mini adults. Because of all of the growth and development preschoolers are going through, they don’t respond to medical treatments the same way that older children and adults do. This means that their ADHD treatment has to be customized to them.

For a long time, people were hesitant about prescribing preschoolers with medication because of the potential side effects. And this is understandable – because children are still growing and developing, they tend to be more sensitive to medications and their side effects. Plus, we have yet to discover a drug that doesn’t have any side effects. Consequently, there were few studies looking into the use of ADHD medication in preschoolers. Today, there still isn’t a lot of data, but we do have one high-quality study which has become the foundation for our most recent guidelines about ADHD in preschoolers.

Here’s what’s been found.

Stimulant medication is effective among preschoolers. However, the impact on ADHD symptoms is not as large as that seen in school-aged children. And, preschool children tend to experience more side effects when taking stimulant medication. Some of the reported side effects included:

  • Decreased appetite.
  • Decreased growth (seen in both a decrease rate of weight gain and a decreased height).
  • Increased difficulties falling asleep.
  • Increased mood swings.

In fact, as the study reported, these side effects were so severe that 11% of the children had to stop taking the medication.

Additionally, we don’t currently have any long-term (years to decades in the future) data on the side effects of using stimulant medication in preschoolers.

Because of all of this, parent behaviour therapy has been proposed as an alternative to stimulant medication, and is actually considered first-line in the preschool population.

Parent behaviour therapy helps parents learn the skills necessary for having a child with ADHD or attention problems. Its focus is on promoting positive parent-child interactions, strategies for setting age-appropriate limits and expectations, and managing negative behaviours. And, it’s been shown to be very effective. As was reported, after undergoing 10 weeks of parent behaviour therapy, 7.2% of study participants had improved to the point that they were no longer eligible for medical treatment of their ADHD. Additionally, 6.9% of study participants met criteria for stimulant use, but the parents declined medication based on how much their child’s symptoms had improved with only parent behaviour therapy. And, when medication was necessary, combining it with parent behaviour therapy allowed for lower doses of stimulants to be used.

So, what are some of the key points and recommendations to take away from this?

  1. Be patient – both with your child and yourself. Raising kids is hard. Period. Having a child with ADHD, especially a preschooler who is naturally supposed to be hyperactive and impulsive, brings with it an extra set of challenges.
  2. Get help if you have concerns. Just because hyperactivity and impulsivity are normal parts of development, doesn’t mean that what you and your child are experiencing is normal. If you have concerns, speak with your child’s doctor. In this case, it’s better to be overly cautious, go to the doctor and find out if your child’s behaviour is developmentally normal, as opposed to ignoring your concerns and delaying your child getting diagnosed and appropriately treated.
  3. Give parent behaviour therapy a try. Just because parent behaviour therapy has been recommended does NOT mean that you are a bad parent. Parent behaviour therapy is not training parents to be better parents, but helping them learn to work with the special needs of their child. If you need to, think of it this way. Preschoolers are too young to attend a behaviour therapy course and learn anything. But, mom and dad can. And (most of the time) children look up to their parents and listen to them. Think ‘monkey see, monkey do.’ As an added bonus, even if your preschooler’s hyperactivity and impulsivity doesn’t meet criteria for ADHD, it’s been suggested that parent behaviour therapy can still help in managing these traits.
  4. Remember, you and your child aren’t alone. Having a preschooler diagnosed with ADHD can be intimidating and scary. Especially when you consider that ADHD tends to be a chronic condition. But, you and your child aren’t alone. The medical professionals who work with you and your child are not just there to provide medication refills – they are your support team. Their goal is to help you and your child in whatever way they can, so that your journey with ADHD is as smooth as possible. There’s no such thing as a dumb question. Just ask, and they will be more than happy to help.

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Amanda Marchak, BSc Materials Engineering, MD Candidate (Class of 2019)
Amanda Marchak completed a Bachelors of Science in Materials Engineering at the University of Alberta, with a special interest in biomedical applications. After realizing that her interests were more clinical-based as opposed to research-based, she began pursuing a medical degree at the University of Calgary. Amanda is set to graduate in 2019, and hopes to pursue a career in pediatrics. As a volunteer at the the CanLearn Society in Calgary, Alberta, she works in collaboration with a team of psychologists and physicians to help provide information to individuals, and their families, about ADHD and Learning Disabilities.