Is Preschool Too Early to Diagnose ADHD?
ADHD is traditionally diagnosed after age 6. But if your preschool student is abnormally hyperactive or impulsive, new evidence suggests you might consider an ADD evaluation at 5 years old.
Medically reviewed by ADDitude’s ADHD Medical Review Panel
Ann Marie Morrison suspected that her son had attention deficit disorder (ADHD or ADD) when he was three. “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 for ADHD in children under 5,'” 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.”
Mary K., of Hillside, New Jersey, suspected that her young son, Brandon, should be diagnosed with attention deficit disorder, too. At home, life was difficult — as it is for many families with children with ADHD.
“Brandon drew on the walls and didn’t listen to anything we said. He threw pictures or silverware across the room when he was frustrated, which was all the time. We lived and died by Brandon’s moods. If he was in a good mood, everyone in the house was in a good mood, and vice versa. I had a three-year-old running my household,” says Mary.
At first, Mary and her husband ascribed Brandon’s high activity level to ‘boys being boys’. But when the preschool he attended asked the three-year-old to leave because of concerns about his aggressive and impulsive behaviors, she began to suspect an ADHD diagnosis was needed.
After Brandon was asked to leave a second preschool — he’d chased a girl around the playground with a plastic knife, saying he would “cut her up” — Mary booked an appointment with her son’s pediatrician to ask about diagnosing the preschooler with attention deficit disorder. Her doctor’s response, however, was that Brandon was much too young for an ADHD diagnosis.
The bottom line: This is simply not true. In extreme cases like these, an ADHD diagnosis in preschool is entirely appropriate — and often critical.
New ADHD Diagnosis and Treatment Guidelines
Today, children like John and Brandon are being diagnosed and helped earlier in life, thanks to new guidelines from the American Academy of Pediatrics (AAP). The AAP now recommends evaluating and treating children for ADHD beginning at age 4. Earlier guidelines, released way back in 2001, covered children ages 6 through 12. The new guidelines, which extend through age 18, also recommend behavioral interventions, especially for younger children.
“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 6,” says Michael Reiff, M.D., professor of pediatrics at the University of Minnesota, who served on the committee that developed the new guidelines.
The updated AAP guidelines1 specify that diagnoses should rule out other causes of problem behaviors while assessing for coexisting conditions like anxiety, mood disorder, conduct disorder, or oppositional defiant disorder. A thorough 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 4 to 5, 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 6 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.
Diagnosing ADHD in Preschoolers
But can a doctor truly differentiate symptoms of ADHD from normal preschool behaviors in a patient who is only 4 years old? Yes, however the tipping point in diagnosis is usually a matter of degree.
“A child with ADHD is much more extreme than the average three-year-old,” says Alan Rosenblatt, M.D., a specialist in neurodevelopmental pediatrics. “It’s not just that a child with ADHD can’t sit still. It’s that he can’t focus on any activity, even one that’s pleasurable, for any length of time.”
Larry Silver, M.D., a psychiatrist at Georgetown University School of Medicine, says that an experienced teacher, one with a baseline of appropriate three-year-old behavior, can be a tremendous help. “You have to look at whether the behaviors are consistent in more than one environment,” he notes.
But experts caution that, even with “red flags,” early diagnosis of ADHD can be difficult. “You have to delve deep into the root of certain behaviors,” Silver says. “A child might have separation anxiety, his fine motor skills or sensory problems could be making it hard for him to behave, or it could be evolving autism spectrum disorder,” he says.
Nonetheless, Laurence Greenhill, M.D., of Columbia University/New York State Psychiatric Institute (http://nyspi.org/), points to two behavioral patterns that often predict an ADHD diagnosis later in life. The first, preschool expulsion, is usually caused by aggressive behavior, refusal to participate in school activities, and failure to respect other children’s property or boundaries. The second, peer rejection, is one that parents can easily identify. Children with extreme behaviors are avoided by their classmates and shunned on the playground. Other children are often “busy” whenever parents try to arrange playdates.
In these extreme cases, a parent should take her preschooler to a pediatrician for referral, or straight to a child psychiatrist. Diagnosis of ADHD should involve a thorough medical and developmental history, observation of social and emotional circumstances at home, and feedback from teachers and health professionals who have contact with the child. In many cases, neuropsychological testing may be needed to rule out conditions whose symptoms might overlap with ADHD, including anxiety disorder, language-processing disorders, oppositional-defiant disorders, autism spectrum disorder, and sensory integration problems.
Treatment Options for ADD
If your preschool child is diagnosed with ADHD, what is the next step? Both the American Psychological Association and the American Academy of Child and Adolescent Psychiatry advise that ADHD treatment in children proceed according to the severity of the symptoms. For children who play well with others and who have healthy self-esteem, Carol Brady, Ph.D., a child psychologist in Houston, says that environmental changes can help. “A smaller classroom, with less stimulation, and a strong routine often make a tremendous difference in improving ADHD symptoms in preschoolers.”
In most cases, parent effectiveness training or behavior therapy is the next course of action. There is increasing evidence that treating ADHD symptoms in preschoolers with behavior therapy can be extremely effective, even for children with a high degree of ADD-related impairment.
But what if your child with ADHD doesn’t respond to behavioral interventions? Is medication the answer? A low dose of methylphenidate (brand names include Ritalin, Concerta, Quillivant, and others) is the American Academy of Pediatrics’ (AAP) recommendation to treat preschool-age children diagnosed with ADHD, when behavior therapy is tried first and unsuccessful. However, methylphenidate is not approved by the Food and Drug Administration (FDA) for use in children younger than six. While doctors can prescribe them for children under 6, insurance companies can refuse coverage for prescriptions not covered for a specific child’s current age. As a result, some doctors prescribe amphetamine-based stimulant medications approved to treat ADHD in kids ages 3 to 5, such as Adderall, Dexedrine, Evekeo, and Vyvanse.
The Preschool ADHD Treatment Study, or PATS, conducted by the National Institute of Mental Health (NIMH), is the first long-term study designed to evaluate the effectiveness of treating preschoolers with ADHD with behavioral therapy, and then, in some cases, low doses of methylphenidate. In the first stage, the children (303 preschoolers with severe ADHD, between the ages of 3 and 5) and their parents participated in a 10-week behavioral therapy course. For one third of the children, ADHD symptoms improved so dramatically with behavior therapy alone that the families did not progress to the ADHD medication phase of the study.
Preliminary data were released in late 2006. “PATS provides us with the best information to date about treating very young children diagnosed with ADHD,” says NIMH director Thomas R. Insel, M.D. “The results show that preschoolers may benefit from low doses of medication, when closely monitored.”
Profiles in Diagnosis
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 at home, 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.”
Robin S., of Englewood, Colorado, wishes she had done things differently when she suspected her son, Jacob, now eight, had ADHD. “I wish I had trusted my gut,” she says. “I was always making excuses for Jacob’s behavior. I was ineffective as a parent. If I’d had a ‘real’ diagnosis, I could have advocated more effectively for my son.”
Thanks to the changes in the DSM-V allowing kids as young as four to be formally diagnosed with ADHD, a growing number of health professionals realize the benefits of early diagnosis and treatment. Peter Jensen, M.D., Ruane Professor of child psychiatry at the Center for Advancement of Children’s Mental Health in New York City, maintains that parents should intervene before major damage is done to a child’s self-esteem. “You should avoid letting it get to the point that your child dislikes school or feels like a failure or is always in trouble. That can set the stage for a child to expect failure and act in self-protective ways (e.g., becoming the class clown or resorting to aggression) that, in turn, promote more negative feedback.
“Youngsters who are carefully diagnosed by competent professionals show great benefits from early intervention,” says Brady. “They are more relaxed, more successful, and able to enjoy their childhoods.”
For Mary and her husband, a chance meeting at the neighborhood pool when Brandon was 4 years old made all the difference. “I was trying to talk Brandon through yet another tantrum when a mom walked over to say that Brandon reminded her of her son, now 9. She gestured toward a boy sitting on a towel, quietly playing cards with a couple of other boys. Her son, as it turned out, suffered from severe ADHD. She gave me her psychiatrist’s name and phone number and I called right there, from the pool, and made an appointment.”
After a thorough evaluation, the psychiatrist diagnosed Brandon with ADHD and started him on a low dose of medication just before he turned five. Mary and her husband enrolled in a structured behavior modification program and joined a local parent group for extra support. “I can’t say that life is perfect, but it is certainly light years ahead of where we were,” she says. “Had I seen a different pediatrician earlier on, or known that ADHD could be diagnosed and treated at a younger age, I could have spared our family a lot of heartache.”
The Preschool ADHD Treatment Study (PATS): What You Need to Know
Sponsored by the National Institute of Mental Health, and conducted by a consortium of researchers at six sites, PATS is the first long-term, comprehensive study of treating preschoolers with ADHD. The study included more than 300 three- to five-year-olds with severe ADHD (hyperactive, inattentive, or combined type). Most exhibited a history of early school expulsion and extreme peer rejection.
Stage 1: Parent Training
Ten-week parent training course in behavior modification techniques, such as offering consistent praise, ignoring negative behavior, and using time-outs. Result: More than a third of the children (114) were treated successfully with behavior modification and did not proceed to the medication stage of the study.
Stage 2: Medication
Children with extreme ADHD symptoms who did not improve with behavior therapy (189) participated in a double-blind study comparing low doses of methylphenidate (Ritalin) with a placebo. Result: Methylphenidate treatment resulted in significant reduction in ADHD symptoms, as measured by standard rating forms and observations at home and at school.
- Lower doses of medication were required to reduce ADHD symptoms in preschoolers, compared to elementary school children.
- Eleven percent ultimately stopped treatment, despite improvements in ADHD symptoms, due to moderate to severe side effects, such as appetite reduction, difficulty sleeping, and anxiety. Preschoolers appear to be more prone to side effects than elementary schoolers.
- Medication appeared to slow preschooler growth rates.Children in the study grew half an inch less and weighed three pounds less than expected. A five-year follow-up study is looking at long-term growth rate changes. Look for preliminary results in 2009.
Preschoolers with severe ADHD experience marked reduction in symptoms when treated with behavior modification only (one third of those in the study) or a combination of behavior modification and low doses of methylphenidate (two thirds of those in the study). Although medication was found to be generally effective and safe, close monitoring for side effects is recommended.
For more information on the Preschool ADHD Treatment Study: Journal of the American Academy of Child and Adolescent Psychiatry, November 2006. (jaacap.com), National Institute of Mental Health, (nimh.nih.org).
Updated on July 1, 2019