ADHD in Toddlers: Signs, Symptoms, and Treatment
Though no medical guidelines exist for diagnosing ADHD in toddlers, preschool-aged children may be evaluated and treated for attention deficit disorder. Learn the telltale signs of ADHD in preschoolers, and research available and appropriate treatments for this young age group.
Can Toddlers Have ADHD?
Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood.1 A 2016 national survey found that 9.4% of children in the United States have ever had an ADHD diagnosis, including 2.4% of children between 2 and 5 years of age 1
For many years, only children between ages 6 and 12 were covered under the American Academy of Pediatrics’ (AAP) guidelines for diagnosis and treatment of ADHD. That all changed in 2011, when the AAP expanded its guidelines to cover preschoolers and teens — ages 4 through 18.
Though no clinical guidelines exist for diagnosing ADHD in toddlers under the age of 4, a growing number of studies suggest that ADHD symptoms first show up during these early years.2 And, while uncommon, some children do receive an ADHD diagnosis before the age of 4.
What are the Signs of ADHD in Toddlers and Preschoolers?
Hyperactivity and impulsivity — core symptoms of ADHD — are developmentally appropriate for toddlers, which makes it all the more difficult to determine if ADHD is present in that age group.
In preschoolers ages 4 to 5, though, the most common ADHD symptom is hyperactivity, according to the National Institute of Mental Health (NIMH).3 DSM-5 criteria can be applied to diagnose preschool-aged children for ADHD. The following symptoms of hyperactivity, impulsivity, and inattention must be present for at least six months to merit a diagnosis:
- Trouble holding attention on tasks or play activities
- Fidgeting, squirming, unable to sit still
- Often does not seem to listen when spoken to directly
- Blurting out answers or has trouble waiting their turn
- Often does not follow through on instructions (gets sidetracked or loses focus)
- Forgetful in daily activities
- Seeming to be always on the go
These symptoms also apply to children over the age of 5 when considering an ADHD diagnosis. For preschoolers, the key is to figure out if your child’s behavior is developmentally age-appropriate.
Dr. Mark Mahone, director of the department of neuropsychology at the Kennedy Krieger Institute in Baltimore, Maryland, recommends that parents look for these additional signs of ADHD in pre-school aged children4:
- Frequently aggressive with playmates
- Cannot hop on one foot by age 4
- Loses interest after engaging in an activity for a few moments
- Has been injured because of running or otherwise moving when told not to do so
Dr. Tanya E. Froehlich, a developmental-behavioral pediatrician at the Cincinnati Children’s Hospital Medical Center, recommends taking note of the following to tell if a preschooler is showing signs of ADHD 5:
- Any comments about the child’s behavior in their preschool or daycare
- Your child’s ability to follow one or two-step directions without getting distracted (i.e. hang up your coat and put away your shoes)
- Your child’s difficulty with “circle time” and other group activities
- Whether you have avoided taking your child out in public, even to family-friendly places, because of his or her behavior
How is ADHD Diagnosed in Toddlers and Preschoolers?
An ADHD diagnosis in children is made in part by asking teachers and other caregivers about the child’s behavior in different settings — for example, at home and at school.
The AAP, however, signals some challenges in identifying ADHD symptoms in preschoolers:
- Preschoolers are not likely to have a dedicated observer if they attend certain preschools or childcare programs
- Preschool and/or daycare staff might be less knowledgeable about ADHD symptoms than are elementary school teachers
Parents may be asked by clinicians to complete a parent-training program or to place their child in a qualified preschool program before confirming an ADHD diagnosis. Both environments could be appropriate settings for identifying ADHD symptoms in preschoolers.
Even then, some ADHD-like symptoms may actually be indicative of other conditions. A child’s inability to follow directions, for example, may be due to a hearing problem or a learning disability. Behavioral problems in children can also emerge after experiencing stressors, like parental separation or illness. A full ADHD evaluation will rule out any other conditions.
How is ADHD Treated in Toddlers and Preschoolers? Is ADHD Medication Safe?
For preschool-aged children under age 6, the AAP recommends:
- Behavior therapy as the first line of treatment.
- Methylphenidate if behavioral therapy is ineffective and serious problems persist
Behavioral training can be implemented by parents or teachers, and involves therapists working with both groups to teach them skills that help the child better manage symptoms of ADHD. The Preschool ADHD Treatment Study (PATS), a 2006 landmark study on children ages 3 to 5.5 with ADHD, found that behavior therapy alone drastically improves ADHD symptoms in preschool-aged children.6
The same study also found that methylphenidate can effectively reduce ADHD symptoms for children in this age group. The caveat, however, is that the participants in the study all had moderate to severe dysfunction. The AAP, therefore, recommends that clinicians prescribe the stimulant only if behavioral therapy doesn’t work and the child continues to experience significant problems.
This recommendation does seem to be followed in the United States. According to a 2016 national parent survey, 18% of children with ADHD in the 2 to 5 age group were currently taking ADHD medication, while 60% received behavioral treatment in the past 12 months.1 Still, 2014 data from the Centers for Disease Control and Prevention revealed that more than 10,000 toddlers 2 or 3 years old were being medicated for ADHD — outside of pediatric guidelines.7
It’s important to weigh the risks of starting medication at an early age. Children under 6 are more likely than older children to experience side effects from ADHD medication, like increased heart rate, trouble sleeping, and loss of appetite.8
ADHD in preschoolers may be managed with the following natural strategies as well:
- Finding activities that soothe and settle (avoiding busy areas like shopping malls or crowded parks).
- Engaging in physical activities to help burn off energy prior to attending public events.
- Using a leash or harness to keep the child safe.
1 Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol. 2018;47(2):199–212. https://doi.org/10.1080/15374416.2017.1417860
2 Hallie R. Brown & Elizabeth A. Harvey (2019) Psychometric Properties of ADHD Symptoms in Toddlers, Journal of Clinical Child & Adolescent Psychology, 48:3, 423-439, DOI: 10.1080/15374416.2018.1485105
3 Attention-Deficit/Hyperactivity Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
4 Is it ADHD or Typical Toddler Behavior? Ten Early Signs of ADHD Risk in Preschool Age Children. Retrieved from https://www.kennedykrieger.org/stories/Is-it-adhd-or-typical-toddler-behavior-ten-early-signs-adhd-risk-preschool-age-children
5 Froehlich, T. (2017, Oct. 3). 9 Questions to Ask When You Suspect Your Preschooler May Have ADHD. Retrieved from https://blog.cincinnatichildrens.org/healthy-living/child-development-and-behavior/9-questions-suspect-preschooler-adhd
6 Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–1293. DOI: https://doi.org/10.1097/01.chi.0000235077.32661.61
7 Schwarz, A. (2014, May 16). Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries. The New York Times. Retrieved from: https://www.nytimes.com/2014/05/17/us/among-experts-scrutiny-of-attention-disorder-diagnoses-in-2-and-3-year-olds.html
8 Behavior Therapy First for Young Children with ADHD. Retrieved from: https://www.cdc.gov/ncbddd/adhd/features/adhd-awareness.html