Q&A: Could My Toddler Really Have ADHD? How Can I Tell?
ADHD in toddlers manifests through extreme behaviors, emotions, and reactions as well as typical ADHD symptoms such as hyperactivity and inattentiveness. Learn more about how ADHD is evaluated in young children and what treatment options exist.
Standard clinical guidance suggests that children younger than 4 shouldn’t be diagnosed with attention deficit hyperactivity disorder (ADHD or ADD). However, symptoms of ADHD — especially in the form of behavioral deficits — can be clearly present in children as young as 2. Learn about the tell-tale signs of ADHD in toddlers (including the ones you’re most likely to miss) and more in this Q&A session with Caroline Buzanko, Ph.D.
Q: How can normal toddler behavior and emotions be distinguished from ADHD, or something else?
Emotional dysregulation, while not a symptom delineated in the DSM-5, is actually one of the hallmarks of ADHD for adults, children, and even toddlers. Emotional dysregulation includes negative emotionality, low frustration tolerance, and trouble with transitions. In toddlers, these can manifest as:
- constant crying
- quickness to anger
- poor self-soothing abilities
Emotional dysregulation often looks like excess emotion. Neurotypical toddlers, for example, typically experience up to three tantrums a week, each one lasting less than 15 minutes. Toddlers with ADHD, on the other hand, typically have more than three tantrums a week, each one lasting more than 15 minutes.
Excess emotion isn’t always negative. Tell a toddler with ADHD that they’re going to the park, and they may become jubilant, as if they just heard they’re going to Disneyland.
Q: Can emotional dysregulation include being “overly dramatic?”
Yes – again, this symptom just means an excess response to everything. It can look like oversensitivity when something doesn’t go their way, or when they’re getting corrective feedback, or if a friend doesn’t want to play with them. Anything outside of their expectations often leads to a rise in emotions. It can even be sensitivity to smells and sounds.
Q: Is emotional dysregulation all a clinician would look for, then, to diagnose a toddler with ADHD?
Emotional dysregulation is one huge piece of the diagnostic process that is often overlooked. That said, an ADHD diagnosis for a toddler, as is also the case with older children and adults, really comes down to detecting the core symptoms of inattentiveness and hyperactivity or impulsivity. These symptoms include:
- Not paying attention when spoken to
- Easily distracted
- Shy and quiet
- Trouble focusing
Hyperactivity or Impulsivity
- Extreme squirminess
- Constant noises; plays loudly
- Runs or climbs when not supposed to
- “Repeat offenders” – rewards don’t work
- Mishears directions
Q: What constitutes a proper ADHD evaluation for a toddler? And what should families look for in a clinician?
Evaluating for ADHD is a complex process, given how different ADHD can look from one toddler to another, as well as overlapping conditions that look like ADHD. A good ADHD clinician should be well versed in ADHD, its comorbidities, and normal child development. They should also assess the child as a whole.
As with older children and adults, we’re looking for core symptoms of inattentiveness and hyperactivity that persist for at least six months in more than one context. With toddlers, however, we’re also taking a close look at behavioral deficits (impairments to meet societal expectations) and assessing whether these behaviors are more severe than those of neurotypical children.
A thorough emotional, social, behavioral, and developmental assessment is also needed to rule out other conditions and to consider what else the toddler is experiencing (like stress at home). In my practice, that requires listening to families and their stories, and asking appropriate questions that can lead to clues: What was your child’s temperament like as a baby? Any difficulties with eating or sleeping? Did your child have trouble learning how to ride a bike? Did they have chronic ear infections?
Q: Is there a connection between ear infections and ADHD in toddlers?
There is indeed a high correlation between chronic severe ear infections and ADHD. Science is still working to determine what’s behind the link (like whether it’s tied to auditory processing difficulties, which makes it hard for them to pick up on verbal cues and process information they hear, and how the sensory impairment creates changes in the brain that lead to behavioral problems). There’s also a high correlation between ADHD and having an induced labor in pregnancy, which is another question I ask families during evaluation, though there are mixed results and may be due to other associated factors (like the mom’s risk of labor induction) rather than the oxytocin used to induce labor itself.
Q: How is ADHD in toddlers treated? What if comorbidities are present?
ADHD treatment for toddlers should include pursuing family support and maintaining healthy habits (nutrition, sleep, exercise, and play, etc.). Behavior modification — or behavioral therapy — forms a critical component of symptom management. This intervention targets problem behaviors in the child, but also focuses in part on parent training, which teaches parents how to regulate themselves to interact in positive ways with their child and how to understand unwanted behaviors.
A lot of my work, actually, is with parents and helping them with their own emotion- and self-regulation skills. Oftentimes, when a parent is butting heads with their child, it’s because their own executive functioning skills – the same skills their child has difficulties with – are still developing. Putting all the pressure and demands on the child to self-regulate is unrealistic and ineffective, which is why parental support is so important.
Even if the child is showing early symptoms of a comorbid condition like autism spectrum disorder (ASD) or oppositional defiant disorder (ODD), the primary treatment is still behavioral therapy at this age. As the child reaches an age where additional impairments come to light, it becomes even more important to evaluate them properly for comorbidities and to consider treatment beyond behavior therapy.
ADHD in Toddlers: Next Steps
- Guide: When Toddler Tantrums Are Actually ADHD – Early Signs of ADD and Emotional Dysregulation
- Blog: “My Child Was Diagnosed at Age 3 — and Thank God She Was.”
- Read: 4 Bad Reasons to Delay an ADHD Evaluation
The content for this article was derived from the ADDitude Expert Webinar “How to Distinguish ADHD Warning Signs from Typical Toddler and Preschooler Behavior” by Caroline Buzanko, Ph.D., (podcast episode #325), which was broadcast live on September 24, 2020.
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Updated on November 16, 2020