I routinely receive questions from parents concerned about their preschool child. A parent might ask, "My child is so hyperactive, but is only 3 years old. Can he be diagnosed with ADHD?" or "My child is consistently getting into trouble in preschool for not following the rules and is always getting up and walking around, even during story time. Could he have ADHD?"
While it is certainly impossible to know whether either of these children, or any child, has ADHD based on a short description and without an evaluation by a medical professional, it is possible for children as young as three or four years old to be diagnosed with ADHD. In 2011, the American Academy of Pediatrics (AAP), released a report indicating that guidelines for diagnosing ADHD have expanded to include children as young as four years old and up to 18 years of age. Their previous guidelines addressed children between the ages of 6 and 12 years old.
One of the difficulties in diagnosing young children with ADHD is that the diagnostic criteria, as outlined in the Diagnostic and Statistical Manual, Fifth Edition, lists a number of behaviors and examples typical in school age children, such as "Often leaves seat in situations when remaining seated is expected," or "Often loses things necessary for tasks and activities (e.g. school materials"). These types of descriptions sometimes make it hard for parents and doctors to envision what the symptoms would look like when a child is not in school.
Another difficulty is that children, at the age of three and four years old, are notoriously inattentive, impulsive and hyperactive. According to Stephen Hinshaw, Ph.D, "It's hard to know if you're seeing the signs of a disorder or just the signs of a young kid." But Hinshaw believes, with a thorough evaluation, children as young as three years old, can reliably be diagnosed with ADHD.
According to the AAP report, the DSM criteria can be used to diagnose children as young as four years old, however, doctors might have trouble getting accurate observations from day-care providers, who may not have the same level of experience with ADHD checklists as a elementary school teacher, or a child might not yet attend a day-care or preschool. In these situations, the AAP suggests parents consider enrolling their child in a preschool program and/or attending a parent training program. These steps can help a doctor better identify problem behaviors and ADHD symptoms.
Whether a young child or a school-age child, the diagnostic process is the same. A diagnosis of ADHD is based on thorough evaluation that includes: parent completed rating scales, teacher or caregiver completed checklists, doctor observation, consultation with the parents and a physical evaluation to rule out any physical causes of the symptoms.
Treating ADHD in Young Children
Along with recommendations for diagnosing ADHD in young children, the AAP also recommends that medication not be the first line of treatment at this age. Although methylphenidate seems to work, side effects and concerns over slowed growth make other options a better place to start. The AAP recommends parent training and school based interventions for young children. In one study, parents were provided 20 training sessions in behavior problems, math and language skills and child safety. The children showed "marked improvement" in ADHD symptoms. Behavior programs,such as using a token reward system and praising children for desired behaviors also helped in managing ADHD symptoms in young children. If these strategies don't bring about any reductions of symptoms, or if symptoms are still causing dysfunction in everyday life, medication can be considered.
While three and four year old children can be diagnosed with ADHD, the process can be a little more involved than when diagnosing school age children. Treatments also need to be tailored to the child's age, with medication being a last resort.