Rates of ADHD among preschoolers range from 2-5%. While preschool-aged children with ADHD show similar patterns of symptoms and impairments as school-aged children with ADHD, symptoms in children this age are associated with significant behavioral, social, and emotional difficulties compared to their peers. Specifically, they are significantly more overactive and impulsive, more likely to demonstrate emotional distress, and often have difficulty behaving appropriately in home, day-care, and preschool environments. These symptoms are generally stable over time, meaning that children diagnosed with ADHD in preschool typically continue to demonstrate symptoms as school-aged children and can predict later behavioral difficulties.
Impairment in Preschool-Aged Children With ADHD
Preschool-aged children with ADHD are at significant risk for current and long-term academic, behavioral, social, and emotional impairment.
Preschool aged children with ADHD are often somewhat delayed in developing pre-academic skills.
Children diagnosed with ADHD in preschool are more likely to develop academic impairment and be placed in special education programs upon reaching elementary school.
A diagnosis of ADHD in preschool is associated with aggression, disruptive behavior, and social difficulties both currently and over the course of childhood.
Preschool-aged children with ADHD demonstrate more frequent and intense emotional distress, and are more likely to develop mood disorders such as depression.
ADHD symptoms in preschoolers are also correlated with an increased risk of serious injury throughout childhood.
Evaluating ADHD in Preschool
Much like evaluating ADHD in older children, a multi-informant evaluation is crucial. An evaluation should consist of:
General psychiatric evaluation.
Interviews with parents.
Information from school or preschool teachers.
Monitoring of the child in more than one setting.
Ruling out of developmental disorders, medical ailments, or abuse at home. Abuse at home or parental neglect can cause preschool aged children to exhibit ADHD-like symptoms.
It is important to consider developmental norms when evaluating ADHD in preschool-aged children. While preschool-aged children are typically more active, impulsive, and inattentive than older children, preschoolers with ADHD will be more hyperactive, impulsive, and inattentive than other typical preschoolers. While all preschoolers are somewhat impulsive, preschoolers with ADHD may demonstrate extreme impulsivity by frequently getting themselves into dangerous situations like running into traffic, climbing a very tall tree, playing with fire or matches, pulling or pushing objects frequently and inappropriately. Similarly, while all preschoolers are overactive at times, preschoolers with ADHD may be so hyperactive that they are unable to sit for even very brief moments. They may frequently "bounce" between activities. They may be unable to play quietly or independently. They may run off in public.
Treatment
Similar to treatment of school-aged children, preschoolers with ADHD may be treated with either stimulant medication, psychosocial intervention, or a combination of both. However, for preschool-aged children with ADHD, best practice recommendations typically suggest that psychosocial treatment be initiated prior to use of medication. Medication is typically recommended only in cases where children continue to demonstrate symptoms following psychosocial treatment.
Medication
An estimated 1% of preschool aged children have been treated with stimulant medication.Methylphenidate is the most frequently prescribed medication used to treat preschool-aged children with ADHD, however, no medication has currently received FDA approval for treatment of ADHD in children under 6 years of age.The Preschool ADHD Treatment Study (PATS) was a recent NIMH-funded multisite study examined the safety and efficacy of methylphenidate in preschool aged children with ADHD. PATS included careful diagnosis, behavior management groups for parents, randomization into different doses of methylphenidate and intensive follow-up evaluation. The PATS study found:
85% of children receiving methylphenidate showed improvement on ratings of ADHD symptoms.
Methylphenidate was more effective than placebo in reducing ADHD symptoms.
The average dose of methylphenidate was about half of what is normally prescribed older children. Average best total dose was 14 mg/day.
Approximately 1/3 of children demonstrated significant side effects. However, only 8.7% of children experienced side effects severe enough to require discontinuation of medication treatment.
Common side effects included irritability, decreased appetite, sleep difficulties, and emotional outbursts.
The most common long-term side-effect was reduced growth. Children receiving methylphenidate gained approximately 22% less height and 55% less weight than national norms for their age.
Psychosocial Treatment
Psychosocial treatment is typically the primary treatment method for preschool-aged children with ADHD. Parenting styles greatly impact the behavioral outcomes of preschool aged children with ADHD. High rates of family conflict and negative and inconsistent parenting are correlated with behavioral problems in children. For this reason, treatment of ADHD in young children focus on parenting and the parent-child relationship. Two treatments that are well-researched and commonly used are Behavioral Parent Training and Parent-Child Interaction Therapy (PCIT).
Behavioral Parent Training aims to reduce hyperactive and impulsive behaviors in children by teaching parents how to appropriately respond to the behaviors. This treatment may be administered individually or in groups. Parents are taught skills to manage preschool-aged children with ADHD. Some topics covered in parent training typically include:
Giving effective instructions
Setting appropriate limits
Consistent use of rewards and consequences to reduce problem behavior.
Education about developmentally appropriate behavior
Parent-Child Interaction Therapy (PCIT), on the other hand, is a special form of behavior management that trains parents to manage their child's behavior by coaching them as they interact with their child. Parents are trained to consistently use positive attention, ignoring, and consequences to reinforce positive behavior and reduce negative behavior. Studies have demonstrated that both forms of treatment are effective at reducing behavior problems and improving parent-child relationships for preschool-aged children with ADHD.
Controversy
There is significant controversy in the field about the diagnosis of ADHD in young children. In some cases, these children may be misdiagnosed with ADHD. This occurs most commonly when:
The ADHD diagnosis may be misapplied to children who demonstrate impulsivity, overactivity, inattention, and/or behavior problems due to developmental delays or uneven patterns of development rather than ADHD.
Difficulties in situations where unreasonable and developmentally inappropriate demands are regularly placed a preschool-aged child resulting in impairment. For example, some children demonstrate difficulty in day-care based on inappropriate developmental demands. Some daycares may expect young children to be able to sit still, play quietly, and follow rules more independently than the child is able to developmentally.
However, studies have indicated that ADHD is actually underdiagnosed in preschool-aged children with ADHD. One study reported that only 23% of preschool-aged children who were suspected to have ADHD were referred for further evaluations. Further, preschool-aged children with ADHD often do not receive treatment. One community study found that only 19% of preschool-aged children who had been diagnosed with ADHD were receiving any form of psychological or psychiatric treatment. Many physicians are reluctant to treat ADHD in young children, as data supporting treatment for preschool aged children with ADHD is limited.
