Diagnosis and Management of ADHD in Young Children

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child’s behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child’s day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child’s ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child’s suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child’s style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn’t know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won’t hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on.

That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn’t happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don’t understand the disorder, to say:

"Don’t do that!"

"Put that down!"

"Come back here!"

"I just bought you this – why don’t you want to play with it?"

"Why can’t you play like your friend Johnny does?"

"Why can’t you sit still for a minute while Mommy fixes dinner?"

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD.

My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny, and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it’s hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self esteem.

Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

If these children do sit down to work, and you know they only have 10 minutes in them, you may want to help them succeed within those 10 minutes, rather than having them flounder and then criticize them at 12 or 14 minutes for not getting the task done.

We don’t have the same expectations for every 4-year-old or 6-year-old. We tailor expectations to who they are. One child might be able to stay on task for 20 minutes, but another for only 3 minutes. Is it fair to expect them both to do something for 20 minutes?

One example might be going to church, where children with ADHD will find it very hard to sit through a sermon they don’t understand. It may be a religious family, but is it reasonable to expect these children to last through church? Also, is it reasonable to criticize them six times during a sermon because they can’t sit still?

So try to turn whatever they’ve got into a success rather than have expectations they can’t meet.

Think about what style of behavior you want to reinforce and what you may not want to encourage. Explain to parents that they may want to reward behavior that is in the right direction.

You can recommend that when the child is impulsive and interrupts, the parent may want to ignore this behavior. Or suggest that if a child grabs the mother’s shirt to ask for something, the parent should say, "That is not going to work." On the other hand, if they say "Mom, can I have a glass of milk?" get them that milk in a very responsive way.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don’t do very well in the outfield of T-ball because they are distracted. They don’t stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I’ve seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the "belt" system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child’s functioning and self-esteem often outweigh these risks.

Pediatricians will see and diagnose, and will be the primary treaters for, many young children with ADHD. One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly.

Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child’s self-esteem, advising on the child’s day-to-day functioning, and supporting the overall care with appropriate use of medications.

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child’s behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child’s day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child’s ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child’s suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child’s style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn’t know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won’t hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on.

That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn’t happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don’t understand the disorder, to say:

"Don’t do that!"

"Put that down!"

"Come back here!"

"I just bought you this – why don’t you want to play with it?"

"Why can’t you play like your friend Johnny does?"

"Why can’t you sit still for a minute while Mommy fixes dinner?"

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD.

My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny, and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it’s hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self esteem.

Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

If these children do sit down to work, and you know they only have 10 minutes in them, you may want to help them succeed within those 10 minutes, rather than having them flounder and then criticize them at 12 or 14 minutes for not getting the task done.

We don’t have the same expectations for every 4-year-old or 6-year-old. We tailor expectations to who they are. One child might be able to stay on task for 20 minutes, but another for only 3 minutes. Is it fair to expect them both to do something for 20 minutes?

One example might be going to church, where children with ADHD will find it very hard to sit through a sermon they don’t understand. It may be a religious family, but is it reasonable to expect these children to last through church? Also, is it reasonable to criticize them six times during a sermon because they can’t sit still?

So try to turn whatever they’ve got into a success rather than have expectations they can’t meet.

Think about what style of behavior you want to reinforce and what you may not want to encourage. Explain to parents that they may want to reward behavior that is in the right direction.

You can recommend that when the child is impulsive and interrupts, the parent may want to ignore this behavior. Or suggest that if a child grabs the mother’s shirt to ask for something, the parent should say, "That is not going to work." On the other hand, if they say "Mom, can I have a glass of milk?" get them that milk in a very responsive way.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don’t do very well in the outfield of T-ball because they are distracted. They don’t stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I’ve seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the "belt" system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child’s functioning and self-esteem often outweigh these risks.

Pediatricians will see and diagnose, and will be the primary treaters for, many young children with ADHD. One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly.

Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child’s self-esteem, advising on the child’s day-to-day functioning, and supporting the overall care with appropriate use of medications.

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child’s behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child’s day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child’s ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child’s suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child’s style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn’t know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won’t hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on.

That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn’t happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don’t understand the disorder, to say:

"Don’t do that!"

"Put that down!"

"Come back here!"

"I just bought you this – why don’t you want to play with it?"

"Why can’t you play like your friend Johnny does?"

"Why can’t you sit still for a minute while Mommy fixes dinner?"

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD.

My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny, and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it’s hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self esteem.

Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

If these children do sit down to work, and you know they only have 10 minutes in them, you may want to help them succeed within those 10 minutes, rather than having them flounder and then criticize them at 12 or 14 minutes for not getting the task done.

We don’t have the same expectations for every 4-year-old or 6-year-old. We tailor expectations to who they are. One child might be able to stay on task for 20 minutes, but another for only 3 minutes. Is it fair to expect them both to do something for 20 minutes?

One example might be going to church, where children with ADHD will find it very hard to sit through a sermon they don’t understand. It may be a religious family, but is it reasonable to expect these children to last through church? Also, is it reasonable to criticize them six times during a sermon because they can’t sit still?

So try to turn whatever they’ve got into a success rather than have expectations they can’t meet.

Think about what style of behavior you want to reinforce and what you may not want to encourage. Explain to parents that they may want to reward behavior that is in the right direction.

You can recommend that when the child is impulsive and interrupts, the parent may want to ignore this behavior. Or suggest that if a child grabs the mother’s shirt to ask for something, the parent should say, "That is not going to work." On the other hand, if they say "Mom, can I have a glass of milk?" get them that milk in a very responsive way.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don’t do very well in the outfield of T-ball because they are distracted. They don’t stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I’ve seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the "belt" system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child’s functioning and self-esteem often outweigh these risks.

Pediatricians will see and diagnose, and will be the primary treaters for, many young children with ADHD. One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly.

Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child’s self-esteem, advising on the child’s day-to-day functioning, and supporting the overall care with appropriate use of medications.