Diagnosis

Is 4 Too Young?!

Revised guidelines give doctors the go-ahead to diagnose and treat ADHD in preschool children, but are parents comfortable evaluating kids under five years old?

A preschooler with ADHD, running around a field
Boy with ADHD diagnosis playing with model airplane on lawn outside

Ann Marie Morrison suspected that her son had ADHD when he was three — barely a preschooler.

“John’s temper tantrums were more intense than those of other three-year-olds, and they came out of nowhere,” says Morrison, of Absecon, New Jersey. “It took forever to get him out the door. He had to dress in the hallway, where there were no pictures or toys to distract him. He couldn’t sit still, and he tore apart every toy. I carried gift cards in my purse, so that when he destroyed a toy at a friend’s house, I could hand the mom a gift card to replace it.”

When Morrison discussed John’s hyperactivity and impulsive behavior with his doctors, her concerns were dismissed. “He’s just an active boy,” they said. “One pediatrician said, ‘Even if he has ADHD, there’s nothing we can do until he’s at least five years old,'” recalls Morrison. “That’s like saying, ‘Your son has a serious illness, but we can’t treat it for another two years.’ What was I supposed to do in the meantime?”

The family moved to another part of the state when John was five years old, and, by chance, their new pediatrician was an expert in ADHD. She had been diagnosed with ADHD herself and had raised a son with the condition.

“At John’s checkup, she was taking a medical history and John was, as always, unable to sit still. She stopped and asked, ‘Have you had him tested for ADHD?’ I started to cry. I thought, ‘Oh, thank God. Someone else sees it,'” says Morrison. “After years of being told by relatives that I needed to discipline him more, after years of feeling physically and mentally exhausted, and thinking I was a horrible parent, someone realized what we were dealing with.”

A thorough evaluation of John, which included input from John’s teachers and family, led to a diagnosis of ADHD. Soon afterward, he was put on medication, which has helped him focus and improved his impulse control. Treatment has changed John’s and his family’s life.

“If John had been diagnosed earlier, it would have helped a lot,” says Morrison. “I don’t know if we would have given him medication when he was three or four, but I would have learned techniques for getting him organized, disciplining him, and helping him establish a routine, without having to figure it out by myself. If I had known earlier that he had ADHD, I would have taken better care of myself, too. I wasn’t prepared. It’s not just the child who’s affected by ADHD. It’s the whole family.”

Today, it’s likely that children like John will be diagnosed and helped earlier in life, thanks to new guidelines from the American Academy of Pediatrics (AAP). The findings include recommendations for evaluating and treating preschool children and adolescents ages 4 through 18 years. Earlier guidelines, released in 2001, covered children ages six through 12.

“The AAP committee reviewed the research on ADHD done over the last 10 years, and concluded that there are benefits to diagnosing and treating ADHD in children younger than age six,” says Michael Reiff, M.D., professor of pediatrics at the University of Minnesota, who served on the committee that developed the new guidelines.

The new AAP guidelines specify that diagnoses should rule out other causes of the behaviors while assessing for coexisting conditions — anxiety, mood disorder, conduct disorder, or oppositional defiant disorder. The diagnosis should include input from people in the child’s life — teachers, care providers, and the immediate family — to be sure that the symptoms of ADHD are present in more than one setting. When a child has been diagnosed with ADHD, based on criteria in the Diagnostic and Statistical Manual of Mental Disorders (V), the AAP offers these age-specific treatment recommendations:

> For children ages four to five, the first line of treatment should be behavior therapy. If such interventions are not available, or are ineffective, the physician should carefully weigh the risks of drug therapy at an early age against those associated with delayed diagnosis and treatment.

> For children ages six to 11, medication and behavior therapy are recommended to treat ADHD, along with school interventions to accommodate the child’s special needs. Evidence strongly indicates that kids in this age group benefit from taking stimulants.

> For adolescents ages 12 to 18, doctors should prescribe ADHD medication with the teen’s consent, preferably in combination with behavior therapy.

While some experts and parents welcome the news of earlier diagnoses and treatment, others are concerned. Many parents believe that children are already overdiagnosed and overmedicated. Won’t expanding the guidelines only exacerbate the problem?

“The goal of the new guidelines is not more diagnoses, it is more accurate diagnoses,” says Ari Tuckman, Ph.D., a psychologist and author of Understand Your Brain, Get More Done: The ADHD Executive Functions Workbook. Still, some parents hesitate to have their children evaluated before they are school-age. Here are four common reasons why they wait:

“I’m afraid to medicate my four-year-old”

The new AAP guidelines say that when a preschool-aged child has been diagnosed, the first line of treatment should not be medication but behavior therapy. The guidelines do not mandate using medication. They merely inform families and clinicians that using medication in younger groups has been shown to be helpful and safe. If behavior therapy has been tried (usually in an eight- to 12-week program) and found not to work, only then should a doctor consider putting a four- or five-year-old on medication.

“Medication, at any age, is never a magic bullet,” says Reiff. “However, if your child exhibits dangerous behaviors that significantly impair his daily living, it seems reasonable to consider the possibility of medication management.”

“Parents should ask, ‘Would it be helpful to my child to explore what medications have to offer?'” says William Dodson, M.D., head of the ADHD Treatment Center, in Denver, Colorado. “As one pediatrician said, ‘We’re not talking about a tattoo on your child’s face. We are going to see what medication has to offer and then decide, based on knowledge rather than fear.'”

“Behavior therapy doesn’t work”

“Behavior therapy won’t change the wiring of a child’s brain,” says Tuckman. “It can, however, minimize distractions and change the tone of the interactions between a child and parents or teachers. Behavior therapy enables a child with ADHD to function better, as changing the way a diabetic’s diet can help him feel and function better without changing his ability to process sugar.”

“I don’t want my child to be labeled”

Your child will be less likely to be labeled a “troublemaker,” a “bad kid,” or a “daydreamer” if you address his ADHD early. “One study showed that a child with untreated ADHD received 20,000 negative messages in the first 10 years of life,” says Dodson. “If a child mostly hears, ‘You’re a little monster, you’re impossible to deal with,’ it affects how the child thinks about himself. Treating ADHD can help your child function and behave better, and will most likely build his self-esteem.”

“It’s normal for preschoolers to be hyperactive and have short attention spans.”

Preschoolers are naturally active and usually can’t focus as long as older children can, but there are differences between kids with ADHD and those without it. “Preschoolers with ADHD run out into the street without thinking,” says Patricia Quinn, M.D., a developmental pediatrician in Washington, D.C. “Very young children with ADHD have more broken bones, more stitches, and more emergency room visits than children who don’t have the condition.”

Another difference is something Quinn calls “up and away activity.” “Say the preschool teacher asks the students to glue cotton balls to paper to create clouds. The child without ADHD may glue on 10 cotton balls. Children with ADHD may glue on two and get up and walk away. Or they’ll pull out a toy, touch it, and walk away. There is a lack of purpose to their activity. They’re the kids who spin around in a chair incessantly or jump up and down on a sofa. Having your child diagnosed and treated in preschool will help her manage symptoms and will likely keep her safe and sound.”

As a speech therapist who works with children, Joe’L Farrar, of Wilburton, Oklahoma, recognized symptoms of ADHD in her daughter, Carey, at age one and had her diagnosed at age three. Because Farrar was already using many behavior therapy strategies, Carey’s doctor suggested a trial of medication when she was four. It didn’t go well.

“The side effects were too much for Carey,” says Farrar. “We took her off medication and focused on behavioral modifications for a couple of years — and put her back on meds at six.” Now 10, Carey takes Strattera, which Farrar says is helpful in managing Carey’s hyperactivity and inattentiveness, but less effective in improving her impulsivity.

Despite mixed success with medication in Carey’s early years, Farrar is glad she had her daughter diagnosed at three. She was able to get accommodations Carey needed at school. “When her kindergarten teacher said that Carey didn’t like to take naps, we arranged for the special-ed teacher to take her to another room during naptime to do calm activities together.”

Carey has done well in school, as well as in cheerleading and choir. Farrar has also put a positive spin on her daughter’s ADHD. “I explained to her that there were chemicals missing in her brain that made it harder for her to sit still in a chair like other kids did,” says Farrar, “but that didn’t mean she wasn’t as smart as they were.”

“The earlier parents intervene, the greater the chance that we can make a difference,” says Quinn. “Earlier diagnoses may increase the chances that young children with ADHD will make friends and do well in school. The new AAP guidelines can prevent a lot of pain and suffering in the lives of individuals who have ADHD.”


How Young Is Too Young for Diagnosis and Treatment?

ADDitude readers on getting their young children diagnosed and treated with medication.

“My son took ADHD medication at six. If a child needs glasses, you get them. If a child needs insulin, you give it to him.” -Andi, Illinois

“As a psychologist, I am cautious about diagnosing a child at three or four. Many children at this age have behaviors that mimic the symptoms of ADHD.” -An ADDitude Reader

“My son was diagnosed with ADHD at four years old. He is now 11, and I am grateful for the early diagnosis. We have been through years of family and individual counseling and have tried different medications to help my son thrive.” -Deidra, Utah

“Putting very young children on medication? I’m not so sure. It depends on a lot of things, but, most important, a child should be treated by a doctor who has experience with ADHD. My son started his meds in fourth grade. They helped a little.” -Diane, Virginia

“My son is now eight years old, and he displayed symptoms of ADHD at an early age. We have not put him on medication, and he is doing well without it. We will medicate if things change for him.” -F. Chery, Connecticut

“Children who have severe ADHD symptoms may be treated at age four. Why would you wait for a child to fail at school, if you know something can help?” -Heather, Michigan

“ADHD can be accurately diagnosed at age four, but giving a child medication at that age seems unnecessary, unless the problems are severe.” -Kristen, Connecticut

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