In childhood, rates of ADHD among preschoolers range from 2-5%. ADHD is a stable, life-long disorder meaning children diagnosed with ADHD in preschool typically continue to demonstrate symptoms as school-aged children. In preschool aged children, ADHD symptoms are linked to significant behavioral, social, and emotional difficulties, and may predict future behavioral difficulties. Research on symptoms and impairment related to ADHD suggest similar patterns in preschool-aged children with ADHD as in school-aged children with ADHD. Specifically:
Preschoolers with ADHD are significantly more overactive and impulsive than their peers,
Preschoolers with ADHD are more likely to demonstrate emotional distress than their peers.
Preschool aged children with ADHD often have difficulty behaving appropriately in home, day-care, and preschool environment
However, there are a number of impairments linked to ADHD in preschool aged children, such as:
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.
Due to their young age, diagnosis and treatment may look a little bit different. Determining what is normal behavior and normal limits for attention in young children has to be considered during this process. Yet, it is important to seek diagnosis and treatment early in order to prevent future impairment.
Much like with evaluating 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 also important that these procedures are conducted with developmental norms in mind. 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. For example:
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.
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.
Much like with diagnosis, treatment of preschoolers with ADHD is treated similarly to that of older 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
An estimated 1% of preschool aged children have been treated with stimulant medication, however no medication has currently received FDA approval for treatment of ADHD in children under 6 years of age. One study, 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. Methylphenidate, also known by the brand names of Concerta and Daytrana, is the most commonly used medication used with this population. The PATS included careful diagnosis, behavior management groups for parents, randomization into different doses of methylphenidate and intensive follow-up evaluation. This results of this study indicated:
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.
Results of PATS were published in The Journal of the American Academy of Child and Adolescent Psychiatry (2006).
Psychosocial treatment is typically the primary treatment method for preschool-aged children with ADHD. Much like in older children, treatment is conducted with the family and teachers to improve the child's attention and behavior. This occurs for a number of reasons. Parenting styles can greatly impact the behavioral outcomes of preschool aged children with ADHD. As such, high rates of family conflict and negative and inconsistent parenting are correlated with behavioral problems in children. Treatments that are generally used with young children include 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. Parent training may be administered individually or in groups, depending on the needs of the family. 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) 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. Additionally, parents spend 5 minutes a day alone with the child using positive attending techniques. This helps to strengthen the parent-child relationship and teach both the parent how to utilize positive attending to encourage positive 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.
Controversies Regarding ADHD in Preschool Aged Children
Diagnosing very young children with ADHD is not an easy task, and one that is hotly debated in the mental health field. Many worry that 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. Similarly, difficulties in situations where unreasonable and developmentally inappropriate demands are regularly placed a preschool-aged child may be misdiagnosed as ADHD. 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 under-diagnosed in preschool-aged children with ADHD, with one study reporting that only 23% preschool-aged children who were suspected to have ADHD were referred for further evaluations. Without a proper diagnosis, children in need to not receive treatment. In fact, one study found that only 19% of preschool-aged children who had been diagnosed with ADHD were receiving any form of psychological or psychiatric treatment. Data supporting treatment for preschool aged children with ADHD is limited. This may be a reason that many physicians are reluctant to treat ADHD in young children. However, it is important that diagnosis and treatment is sought out early to prevent future impairment and promote long-term emotional, social, and behavioral health.