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.

Want to know more? There is a podcast for that!

Listen to the podcast now.

You can also subscribe to Inside ADHD on iTunes.

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.

Mindfulness Meditation and ADHD

“Om….Om….Om….”

For those of you familiar with meditation, you might recognize the mantra written above.  Then again, if you are familiar with the concepts of meditation – including its use of mantras – there’s a chance that you wouldn’t be reading this blog.Continue reading

Unlocking Potential Fund – Affordable Assessments

Meet Max and Angie and learn how an assessment can help!
Angie and her seven-year-old son Max were referred to CanLearn from a women’s shelter. Angie, a mother of two boys, was constantly moving to avoid her abusive former partner. Angie could see that Max was struggling emotionally and academically, and felt uncertain and anxious about how to best support her son. She was not sure if his difficulties at school were the result of emotional trauma or a learning disability.

When Max came to CanLearn for a psycho-educational assessment, many areas of strength were noted, including emotional resiliency. At the same time, a significant learning disability was identified that was hampering his progress in reading and writing. Because the family moved so frequently, school personnel had not identified his learning needs. The assessment at CanLearn provided both Angie and the school with strategies to help Max.

Now Angie has a clear understanding of Max’s learning struggles and the tools to advocate for Max at any school. Angie is pleased to report that Max‘s literacy skills have improved and that she is actively employing the strategies provided by CanLearn to help with reading and writing at home. Angie is extremely grateful for both the support and the reassurance that despite the family’s struggles, Max will now be able to achieve learning success at school. Angie also expressed appreciation that her financial challenges did not keep Max from obtaining the support he needed.

Our greatest reward is seeing individuals like Max unlock their potential and achieve success. Each year hundreds of children, youth and adults come through our doors and about 30% of them live in poverty.  Last year alone, our Unlocking Potential Fund helped to change the lives of 76 families. Donate Now!

If you are interested in our services click here!

Too Much of a Good Thing: Video Game Addiction and ADHD

Video games have always been promoted as amazing sources of entertainment. But not much is said about the impact they have on a gamer’s health.

Back in 1980, when the big, jumbo-sized arcade games first came out, some gamers developed Pac Man’s elbow – a tendonitis caused by spending too much time manipulating the gaming joystick. Today, this trend has continued and we have Nintendonitis, or Nintendo thumb. Along with the notion that video games can have a negative impact on a player’s health.Continue reading

You, Your ADHD, and Marijuana

Everyone knows that the brain is complicated. Yet, even with all of the scientific and medical advances that have been made, we still don’t know everything there is to know about the brain. What we do know, is that it is responsible for nearly everything we do. The brain is always on, processing a constant stream of information. Then, based on this information, it tells the body how to react. However, something so complex doesn’t just develop and start operating perfectly overnight. Like the rest of the body, the brain has to undergo puberty to develop and reach its “adult” state. This starts in adolescence, but doesn’t stop until the mid-20s. (Yes, this means that you can vote, buy a car, get a loan, and are even considered an adult in the eyes of society before your brain has fully matured.)

So, what is puberty for the human brain?

Scientifically, puberty for the brain is a time when it undergoes growth and refinement, also known as neuromaturation. In other words, the brain is remodelling itself to ensure more efficient communication takes place between its different regions. This is done through an increase in white matter and a decrease in grey matter.

However, as any teenager can attest to, it’s also a time of increased vulnerability. Especially if something unexpected or foreign is added to the mix, and you have no idea how to handle it.

The active ingredient in marijuana is tetrahydrocannabinol (THC), and it is a foreign substance in both the body and brain.
In animals, studies have shown that the adolescent brain is particularly vulnerable to the effects of THC, and that exposure can result in permanent structural changes with persistent cognitive and behavioural changes.

In humans, current research has shown similar trends.

Structurally, imaging studies of the brains of marijuana users have shown disordered white matter. And, a greater degree of disorder was found with a greater use of high potency – high THC level – marijuana. However, because of how the studies were designed, it is not possible to prove whether the white matter changes in the brain occurred because of marijuana use, or if the white matter changes in the brain are what lead people to use marijuana.

Now, while the extent to which marijuana effects the structure of the brain has not been 100% proven, marijuana use does effect behaviour and cognition.

Among adolescents, issues with memory, learning, problem-solving, attention and impulsivity were observed. Further, these issues didn’t just disappear after the adolescents stopped using marijuana – some actually remained after weeks of abstinence. And, it’s not just adolescents experiencing behaviour and cognition deficits. In adults, numerous studies have reported impairment in inhibition, decision making, and executive control.

One thing to note is that these issues are similar to the symptoms experienced by people with ADHD. So, does this mean that there is a relation between ADHD and marijuana use?

Multiple studies have shown that, compared to the general population, ADHD youth begin using substances earlier and are at greater risk of developing a substance use disorder (SUD). And, it’s not just youths. In general, people with ADHD are approximately two-times as likely to develop a SUD. Plus, if they do develop a SUD, they become addicted at a much younger age, use more substances, and are hospitalized more often than people without ADHD.

But why?

One hypothesis is that risky substance use may be due to the difficulties people with ADHD have around regulating their consumption – aka impulsivity issues. However, research has suggested that this may also be due to how the brain is structured. Dopamine imbalance in the brain has been shown to play a role in both ADHD and SUD. Additionally, this might be why there is also an over-representation of ADHD among people with SUD, with approximately one in four people with SUD meeting criteria for ADHD.

So if this is the case, and people with ADHD are more likely to develop SUD, why are they using marijuana?

An analysis of a forum about marijuana use and ADHD found that, despite a lack of clinical recommendations or research suggesting beneficial effects of marijuana for ADHD, most people were using marijuana because they believed that it would help with their ADHD symptoms, or help them better manage side effects. In other words, subjectively, they felt less anxious, more in control and, overall, better when they used marijuana.

Additionally, it was found that the course, rather than the severity, of ADHD symptoms impacted future substance use. In other words, adolescents with worsening ADHD symptoms predicted higher levels of early adult substance use. In contrast, adolescents with improving, or even stable, ADHD symptoms predicted lower levels of early adult substance use. And, in other research, it has been found that treating ADHD actually decreases substance use among people with ADHD.

But what happens when people with ADHD use marijuana?

Initially, the hypothesis was that people who use marijuana and have ADHD would experience a worsening of their ADHD symptoms, because marijuana has been shown to mimic symptoms of ADHD in non-ADHD people.

One study examined the impact of ADHD and marijuana use on executive functioning in young adults. This study found that the ADHD group performed worse than the control subjects in areas of verbal memory, processing speed, cognitive interference, decision-making, working memory, and response inhibition. However, this is typical of people with ADHD when compared to the general population. The key finding of the study was that, when marijuana was added, there was no significant impact on executive functioning among marijuana users with ADHD. In other words, people with ADHD who used marijuana did NOT improve, but they also did not get worse.

In general, when people with ADHD have reported an improvement when using marijuana, this is because of the anti-anxiety effects of the drug. Objectively, marijuana does not improve ADHD symptoms. However, subjectively, people report an improvement because they experience less stress about having ADHD as their overall anxiety decreases.

So, this raises the alternative hypothesis: if people with ADHD (subjectively) feel better, they might be using marijuana as a form of self-medication. This hypothesis is supported by some ADHD teens who say that marijuana helps them cope, as well as one small study discussed below.

Now, the study did have some faults, and the results were not statistically significant. So, the results need to be interpreted with caution, and further research into this topic is still needed. However, the study does provide some early evidence supporting the self-medication theory of marijuana use in ADHD. As the study noted, there were minor improvements in ADHD symptoms among the people using the cannabinoid spray as opposed to the placebo.

Additionally, while the study did not report any negative cognitive effects, the authors proposed two explanations for their findings that are worth mentioning. The first, is that the duration of the study was too short and the study group small. This means, marijuana use could still have been harmful and worsened ADHD symptoms, but it was just too early/the duration of marijuana use too short to be able to tell. The second is that the spray used in the study had a 1:1 of cannabinoidiol (CBD)-to-THC. This 1:1 ratio is NOT typical of what is being bought on the streets. Commonly purchased marijuana has been found to have much higher levels of THC, and these levels are not balanced with CBD. This is important, because previous studies have suggested that THC is responsible for the cognitive issues caused by marijuana use, while CBD is likely to protect against these impairments.

Now, the decision to use marijuana is a personal decision. Hopefully, this blog will help you make an informed decision about whether marijuana use is right for you. So, if moving forward you choose to use marijuana, here are 10 recommendations, based on medical research, for lower-risk marijuana use:

  1. The most effective way to avoid marijuana-use related health issues is to abstain from use.
  2. Avoid using marijuana at a young age (<16yrs).
  3. Choose low potency THC or a balanced THC-to-CBD marijuana products.
  4. Abstain from using synthetic cannabinoids (which have been found to have 80-90% more THC).
  5. Avoid smoking marijuana and give preference to non-smoking methods.
  6. Avoid deep or other risky inhalation practices.
  7. Avoid high frequency (e.g., daily or near daily) marijuana use.
  8. Abstain from marijuana-impaired driving.
  9. Populations at higher risk for marijuana-related health problems (pregnant women, adolescents and children, etc.) should avoid use altogether.
  10. Avoid combining previously mentioned risky behaviours (e.g., early inhalation and high-frequency use).
  11. Speak to your doctor about any health concerns you may have related to marijuana use.

Want to know more? There’s a podcast for that!

This podcast episode is an audio recording of a blog that can be read at www.adhdfamilies.ca.

Listen to podcast.

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.