Young children with adhd

Preschoolers and ADHD - CHADD

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At times preschoolers may have difficulty paying attention, following directions, and waiting or taking their turn. These behaviors can be common and age appropriate or they may indicate the need for an Attention-Deficit/Hyperactivity Disorder (ADHD) evaluation. As a parent, you might wonder whether your preschooler has ADHD or is just being rambunctious and acting typical for his or her age. This fact sheet will tell you more about ADHD in preschoolers and what to do if you are concerned about your child.

Can preschoolers have or be diagnosed with ADHD

Yes. Children as young as age 4 can be diagnosed with ADHD. According to the 2010-2011 National Survey of Children’s Health, approximately 194,000 preschoolers (2-5 years of age) had a current ADHD diagnosis. Some children outgrow the symptoms, but others may not. Research shows that 3-year-olds who show symptoms of ADHD are much more likely to meet the diagnostic criteria for ADHD by age 13.

How can I tell if my preschooler has ADHD

Preschoolers with ADHD are more likely to be suspended from school or daycare because of their disruptive behavior. These kids have more trouble learning concepts at school, and many get special education placements at a very young age when compared to children without ADHD.

As a parent, you will want to know where your child’s behaviors fit along a range of behaviors that are typical of kids the same age. Ask yourself, “When compared with other preschoolers of the same age, where does my child’s behavior fall” Talking with your preschooler’s teachers and/or childcare providers can let you know what are common behaviors in young children and not related to a disorder and what is of more serious concern.

What is involved in having my preschooler evaluated for ADHD

To be diagnosed with ADHD, a child must have a specified number of symptoms for at least 6 months that show up in more than one area of life. For example, if your child has behaviors at home that may look like ADHD but does not have these behaviors in situations outside the home, there may be another explanation. If you suspect that your preschooler has ADHD, you will want to talk to a professional who is trained to diagnose and treat ADHD such as your child’s pediatrician, a child psychiatrist, psychologist, clinical social worker or other qualified mental health clinician. It is also important to have your child checked for other conditions such as vision, hearing, or sleep problems because sometimes the symptoms look like ADHD.

Evaluations for preschoolers should be thorough and follow the guidelines outlined by the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP). These guidelines recommend a detailed interview with you to determine how long the symptoms have been going on, how severe they are, how often they occur and in what settings. You and your child’s teachers or child care providers will be asked to complete questionnaires with rating scales to evaluate your child’s behavior. The ADHD professional will conduct a detailed review of your preschooler’s school and medical records, talk with and observe your child directly, and check for other conditions your child may have along with ADHD. The professional may also suggest other psychological tests to help understand your preschooler’s strengths and weaknesses in learning and thinking skills and screen for learning disabilities.

What are the symptoms of ADHD in children

A diagnosis of ADHD is based on The Diagnostic and Statistical Manual of Mental Disorders (DSM 5). The manual lists three presentations of ADHD–Inattentive, Hyperactive-Impulsive and Combined and the symptoms for each.


  • Fails to give close attention to details or makes careless mistakes
  • Has difficulty sustaining attention
  • Does not appear to listen
  • Struggles to follow through on instructions
  • Has difficulty with organization
  • Avoids or dislikes tasks requiring a lot of thinking
  • Loses things
  • Is easily distracted
  • Is forgetful in daily activities

Hyperactive Impulsive

  • Fidgets with hands or feet or squirms in chair
  • Has difficulty remaining seated
  • Runs about or climbs excessively in children; extreme restlessness in adults
  • Difficulty engaging in activities quietly
  • Acts as if driven by a motor; adults will often feel inside like they were driven by a motor
  • Talks excessively
  • Blurts out answers before questions have been completed
  • Difficulty waiting or taking turns
  • Interrupts or intrudes upon others

Combined, Inattentive & Hyperactive-impulsive

  • Has symptoms from both of the above lists

These symptoms can change over time, so children may fit different presentations as they age.

What are the causes of ADHD

Research has yet to determine the exact causes of ADHD. However, scientists have discovered a strong genetic link since ADHD can run in families. Other factors in the environment may increase the likelihood of having ADHD:

  • mother smoking cigarettes or drinking alcohol while pregnant
  • exposure to lead or pesticides in early childhood
  • premature birth or low birth weight
  • brain injury

Scientists continue to study the exact relationship of ADHD to environmental factors, but point out that there is no single cause that explains all cases of ADHD and that many factors may play a part.

The following factors are NOT known causes, but can make ADHD symptoms worse for some children:

  • watching too much television
  • eating sugar
  • family stress (poverty, family trauma)

Why is it important to address ADHD in my preschooler at an early age

Preschoolers with ADHD are more likely to have difficulties in daycare or school, including problems with peer relationships, learning, and a higher risk of injuries. An early diagnosis is important so that your child can get the needed help to minimize these problems.

Even for the preschooler who might have some symptoms but does not have ADHD, these early years are the time when significant brain development occurs. This is an optimal time for children to learn positive behaviors, and for you to know how to effectively help your child learn. It’s best to address problematic behaviors sooner rather than later.

How should ADHD be treated in preschoolers

When it comes to treatment for preschool and kindergarten-aged children, the AAP calls for behavioral treatments first and medication only when needed. Behavioral therapy from child and adolescent therapists who specialize in ADHD will provide both the parents and the children techniques to teach and reinforce positive behaviors and skills. This will help a preschooler with ADHD to successfully function at home and school.

When medication is prescribed, the AAP recommends starting children ages 4-5 on a methylphenidate medication trial beginning with a low dose. Because children respond differently to medication, what may work for one child may not work for another. The health care professional can adjust the dose to determine if it is helping, if a different medication is needed or if any side effects are present. Treating ADHD is complex, and it is important to continually monitor children to see if the treatment is working. This includes periodically repeating the rating scale assessments to make sure the medication and behavioral therapy are having the desired effect. Additionally, the AACAP Preschool Pharmacology Working Group recommends that preschoolers who are taking ADHD medication have their medication stopped (under the prescribing doctor’s direction) after 6 months to reassess the symptoms and to consider whether the medication should be continued.

What is parent behavioral training and how can it benefit me and my child

Children who have ADHD may not have the skills and behaviors that result in their receiving positive attention. Often they tend to misbehave and are in situations where they are punished more frequently than other children. This can have a negative effect on their self-image and cause them to increase their problem behaviors. Parents and caregivers (daycare providers, preschool teachers, and other caretakers) can learn to manage the behavior of preschoolers who have ADHD by becoming educated about the disorder and by receiving parent training in how to use behavioral techniques.

Parent training programs taught by trained therapists can give caretakers the tools and strategies to help children who have ADHD. A 2010 review by the Agency for Healthcare Research and Quality (AHRQ) found that effective programs:

  • help parents develop a positive relationship with their child
  • teach them about how children develop
  • help them manage negative behavior and increase positive behavior with positive discipline

Parent behavioral training programs for parents of preschool-aged children that currently have enough research evidence to be described as effective:

  • Triple P (Positive Parenting Program)
  • Incredible Years Parenting Program
  • Parent-Child Interaction Therapy

Other programs that focus on the same elements may also be helpful.

Parents and caregivers who wish to learn more about ADHD and ways to help their child may wish to enroll in Parent to Parent: Family Training on ADHD offered through CHADD.

Are preschoolers receiving the recommended treatments

The Centers for Disease Control and Prevention (CDC) reports that 1 in 2 preschoolers do not receive recommended behavioral treatment. The rates of preschool-aged children taking medication for ADHD has doubled in the last four years, and 1 in 4 receive only medication treatment, which should be the last resort.

There is a movement within the field of ADHD to increase access to behavior therapy for young children, particularly to behavioral parenting therapy that is considered evidence-based and effective. The hope is to decrease the rates of preschool and kindergarten-aged children taking medication for ADHD as a first line of treatment.

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Preschoolers and ADHD - Child Mind Institute

While ADHD is most often diagnosed in school-aged children, it can be diagnosed in children as young as three.

Of course we expect all preschoolers to be active — more inclined to run around than to sit still. And we expect them to be impulsive — prone to doing things without thinking about the consequences. But some kids are extemely active — parents typically describe them as “bouncing off the walls” — and they’re so impulsive they’re extraordinarily difficult to manage.

These children may have ADHD, and early diagnosis and treatment can help them rein in impulsive behavior that’s causing problems for them, and their families. They can get along better with other kids and be able to participate in activities appropriate for their age. But it’s important to know that the recommended first-line treatment for preschoolers with ADHD is different from what’s recommended for older kids.

ADHD experts and the American Academy of Pediatrics agree that behavioral therapy is the preferred treatment for preschoolers with ADHD, and that stimulant medication should be considered only if behavioral therapy isn’t available or hasn’t worked. It can also also be considered if the child or the family is at risk of serious harm.

How is ADHD diagnosed in preschoolers?

It is usually hyperactive and impulsive behavior that leads to an ADHD diagnosis in preschoolers. They may have been kicked out of preschool or banned from playdates. Their parents worry constantly that they will run into the street or hurt themselves in some other impulsive way.

From 2 to 6 percent of preschoolers are estimated to have the disorder — a much lower percentage than school age kids. Boys are twice as likely as girls to be diagnosed.

Mark Stein, PhD, the director of the ADHD and Related Disorders Program (PEARL Clinic) at Seattle Children’s Hospital, explains that behavioral problems are usually what cause parents to bring preschoolers in for evaluation. He notes that one of the screening questions he uses when taking a child’s history is “What percentage of the time, when you give your child a command, do they obey you within five seconds?” By age four, he says, it should be 75 to 80 percent. “In my patients it’s like 10 percent.”

But Dr. Stein, who is also a professor of psychiatry and behavioral science at the University of Washington, emphasizes that diagnosing ADHD at this age should be done with great care, since all preschool children exhibit some hyperactivity, impulsivity and inattention, the key symptoms of ADHD.

Observing a child’s behavior in the doctor’s office is not sufficient for a diagnosis, as symptoms may not be present in that environment. Pediatricians are encouraged to collect screening questionnaires filled out not only by a parent but by at least one other adult who spends time with the child. Symptoms must be present in more than one setting — ie at home, at preschool or daycare, with relatives or family friends.

As Dr. Stein notes, it’s harder to evaluate children who are not yet in a structured environment like preschool, where their behavior is easier to observe and compare to that of other kids.

Andrew Adesman, MD, a pediatrician who is Chief of Developmental & Behavioral Pediatrics at Cohen Children’s Medical Center of New York, adds that for kids who have been kept at home, if parents are frustrated with their behavior and suspect ADHD, sending them to preschool or daycare can be a good way to get some validation, as well as some respite. “Parents know their child best, but they don’t have the training, experience and perspective on what’s typical at a certain age,” he explains.

Dr. Stein notes that it’s the diagnostician’s job to rule out other conditions that look like ADHD. “There are medical mimics, like hypothyroidism, and poor sleep problems and medication effects. And there are psychiatric mimics, like having autism or depression or anxiety.”

Behavioral treatment for ADHD

Parent training for behavioral management techniques is the recommended treatment for preschoolers with ADHD. Through these programs, parents learn how to more effectively shape the behavior of young children, and the children usually show marked improvement in their ability to comply with direction and rein in their impulsivity.

Why parent training, rather than therapy delivered directly to the child? Dr. Adesman explains that children are often referred for play therapy, but this is not a very helpful intervention for ADHD. “At its worst it’s like an expensive play date. At its best it’s a well-intentioned intervention that doesn’t have any evidence to support it.” What families should be pursuing is parent training in behavior management techniques.

“Intuitively one would think that if the child has the problem, the therapy should be focued on the child. The reality is that, while it’s the child who has the problem, what we want to do is change the environment so we can set the child up for success. And that typically involves working with parents and teachers,” he explains. “If a child has allergies — the problem is with the child but the solution is in working with the environment. You might get rid of the carpet or the drapes or find a new home for the cat. We can do things with the environment to help kids behave better.”

These programs teach parents how to use praise, or positive reinforcement, to promote the behaviors they want to encourage. And parents are taught to deliver consistent consequences when kids don’t comply. The result is that kids learn to modulate their behavior to meet expectations and the family conflict can be reduced, sometimes dramatically.

Programs that have shown evidence of effectiveness include:

  • Parent-Child Interaction Therapy (PCIT)
  • Parent Management Training (PMT)
  • Positive Parenting Program (Triple P)
  • The Incredible Years

Dr. Stein notes that the preschool years are the “sweet spot” for parent training, when evidence shows that it can have the most effect. “I always tell parents, you know, now is the ideal time. You don’t want to be dealing with a noncompliant 15- or 16-year-old.

Dr. Stein also recommends that parents of preschoolers with ADHD get them into a structured school setting. When kids have behavior problems, parents often take them out of preschool, but they really need to get them more in.

If children can’t behave well enough for a mainstream preschool, there are special preschools for children with behavioral problems. “The idea is to not run away from structure, but to get more intensive services. The parents need the respite, and the kids need to learn to be socialized.”

Dr. Adesman adds that it’s especially important that these children have some experience of meeting expectations in a structured setting before they go to kindergarten.

When should medication be considered?

In general, stimulant medication should be considered only for preschoolers who haven’t been helped by behavior therapy, or whose behavior is so severe that it’s dangerous or it’s severely impacting their lives, and their families’ lives.

One reason to try behavior therapy first is that while stimulant meds are very effective for most school-aged children — the response rate is more than 70 percent — Dr. Adesman notes that in preschoolers the response rate drops to 50 percent.

Dr. Adesman offers this list, based on recommendations of the AAP, of situations in which medication might be an appropriate choice:

  • Behavior therapy has been unsuccessful
  • Significant risk of injury to the child
  • Significant risk of injury to other children or caregivers
  • Ejection from preschool or daycare
  • Threatened ejection from preschool or daycare
  • Strong family history of ADHD
  • Possible central nervous system injury, such as prematurity, prenatal alcohol or cocaine exposure, or lead poisoning
  • ADHD symptoms interfere with other needed therapy, such as speech/language, OT, PT
  • Parent or guardian on the verge of a “mental breakdown” because of the child’s behavior
  • Marriage on the verge of divorce or separation because of the child’s behavior

Prescribing to preschoolers can be confusing because there is a discrepancy between what is approved by the FDA and what is recommended by the AAP.

Of the two types of stimulant medication — those based on methylphenidate and those based on amphetamine — the FDA has approved only short-acting amphetamine-based medications (Dexedrine and Adderall) for children 3-5. The AAP, on the other hand, based on the results of the Preschool ADHD Treatment Study (PATS) that used mepthylphenidate, recommends methylphenidate-based medications for children 4-5.

A reasonable approach, Dr. Adesman adds, would be to use a methlyphenedate medication first, and if it’s not working, try amphetamine-based.

What everyone agrees on is that if medication is used it should be an extremely low dose. And the good news here is that there are new formulations for preschoolers that not only don’t require swallowing a pill, but they can deliver very small doses — “liquids that can be titrated down, or a patch that can be cut in half,” he explained.

Behavior training for preschoolers

But Dr. Adesman stresses that medication should be considered only if parent training isn’t working well enough, or if the situation is extreme.

“Children don’t have ADHD because their parents are ineffective. But they can definitely be part of the solution,” he said.

And one of the best things about parent training is that it helps kids whether or not they have an ADHD diagnosis, so there is no downside to trying it if kids are having behavior problems. “If there are behavioral challenges, with or without an ADHD diagnosis, parents should get training,” he said. “It will help the child, it will help the parents, and it will help the other kids in the family, too.“

Child hyperactivity | Children's City Hospital

There is a playground where my 4-year-old daughter and I go to play, one boy, Alyosha. He's 5. To say that he is very active is an understatement.

Just for the almost 2 years that we have been going there, I have never seen him calmly play in the sandbox, swing on a swing or just sit next to his mother for at least 2 minutes. This is a hurricane, a whirlwind, a tornado - such comparisons can be made. He doesn't walk, he runs. And always. Spinning, spinning, stumbling, falling, pushing, throwing, with anything, in the end, he is exhausted, and departs home with his mother in hysterics ...

When we see Alyosha on the playground, we try to wait for him to leave. Other mothers said to each other that Alyosha had already been taken to a psychiatrist and diagnosed with hyperactivity...

What is Attention Deficit Hyperactivity Disorder?

There are generally two different options. This, in fact, is a painful condition in which the help of a specialist is necessary, and features of the character, temperament and upbringing of the child.

The disease is called Attention Deficit Hyperactivity Disorder (ADHD) and has distinct features:

  • unable to maintain attention during play and tasks;
  • often "does not hear" what they say to him, and has no hearing problems;
  • does not finish what he started;
  • often loses things that are needed every day - toys, school supplies;
  • finds it difficult to do anything on his own; easily distracted;
  • forgetful in familiar everyday situations;
  • constantly on the move, even while eating;
  • always does everything with noise; makes aimless movements;
  • talks a lot; answers questions without hesitation;
  • interferes with others, interferes with games and conversations;
  • can't wait, stand in line.

If there are more than six of these signs and they are observed for six or more months in a row, it is highly likely that this is not a character and temperament, but a painful condition that requires the help of specialists.

In addition, children with ADHD simply cannot control themselves, cannot stop and calm down on their own, do not respond to prohibitions and remarks, are often impulsive and aggressive, do not finish anything, are quickly distracted and exhausted, speak quickly and a lot , ask millions of questions, but do not listen to the answers, are clumsy (dropping, breaking things), sleep poorly, they often have intestinal disorders and enuresis.

How to distinguish a simply active child from a hyperactive one

There is a simple way: if a child behaves the same EVERYWHERE - both at home, and at a party, and on the street, and in an unfamiliar environment, and in a children's team - this requires the help of specialists ( child neurologist, psychologist, psychiatrist). Consult, then either calm down and properly educate (more on this below), or confirm your doubts and be treated according to the recommendations of doctors.

If a child is only noisy, restless and active at home, and sits “like a mouse” at a party, these are rather features of the character of such a child. This is exactly what happened to me with my child. The neurologist consulted, said that this is not a disease, but such a temperament; psychologist gave advice.

Why does this condition occur? Is it related to upbringing?

These are the questions that all parents worry about when a child is diagnosed. The number of children with ADHD, unfortunately, is growing every year. And now, according to various experts, they are from 3 to 10%. Boys among them are five times more than girls.

The causes of this condition are not fully known, but:

  • environmental degradation;
  • infectious diseases of the mother during pregnancy;
  • abnormal delivery;
  • birth injuries

. .. ... play an important role in the development of this condition.

It is not connected with insufficiently tough upbringing (as some parents think, the child is not just “indulging” and “not obeying”), tougher penalties only worsen the situation with behavior.

“If you scold me and say that I am bad, then you will know how bad I can be!” - this is the result.

What is the main problem of children with ADHD and what to do about it?

The main problem is that such children cannot adapt to society. Due to their impulsiveness, uncontrolled aggression, such children ignore the generally accepted rules of behavior, harming themselves and others. Which inevitably leads to problems. With development, study, communication.

And one more thing. According to statistics, 80% of people who are in prison were hyperactive children. Think about it and do not delay treatment. It won't go away on its own!

How can parents help such a child?

Dealing with Hyperactivity in a Child I have a very active child myself. This, thank God, is just such a temperament, but it is also suitable for children diagnosed with ADHD. And the psychologist taught us how to properly handle it, in order to live a little more ourselves.

  • Try to establish contact with the child before demanding anything from the child. Touch, hold hands.
  • Look into his eyes and then talk to him. Why do it? Because when a child is busy with something, passionate, playing - he is all there, in his experiences, and does not hear you. It really helps - I take my daughter by the hand, look into her eyes, tell her what I need her to do, and in most cases it helps.
  • Set permanent rules. Stick to it strictly. The rules for the child should be clear and simple. For example, if today you can’t eat sweets before meals, touch someone else’s dog, jump from a swing, be rude to your grandmother, open a gas valve, then tomorrow it’s impossible.
  • It is important to follow the sequence of actions, break complex tasks into several simple ones - this will make it easier for the child to cope. How do I apply it? I say: “Let's clean the children's room. First we make the bed. To do this, we straighten the sheets, pillows, cover with a bedspread. Then we collect toys. Cars - in a box, dolls - on a doll table, cubes - in a box. And so on, until we remove everything.
  • Always observe the regime in everything. Literally by the hour, get up, eat, walk, go to bed. Always, any day of the week. It really helps. And adults too.
  • Praise. But wisely. Something done well - praise. Listened - praise. Find something that your child is best at and praise for it. My daughter, for example, loves to help prepare her dad's breakfast. And literally melts with pleasure when I praise her for it. And the mood is good for half a day.
  • Try to spend excess energy. Excess energy goes away - the child becomes calmer. Checked on myself. It is important not just to run, but to “put energy in the right direction” - dancing, acrobatics, athletics, swimming pool ...
  • If you are going somewhere (travel, guests, shop), prepare in advance. Discuss with your child where you are going, what you will do there and how you should behave.
  • Use every opportunity to relax - entrust grandparents, aunts and uncles to play, walk with the child, in general, those to whom you can entrust the child, without forgetting to give them detailed instructions. Otherwise, all efforts will go down the drain.

Your child needs adequate parents, right? Then think a little about yourself.

Health and patience to you and your children!

Children with Attention Deficit Hyperactivity Disorder: Epidemiology, Comorbidity and Diagnosis

Elis Charach, MSc, MD
Hospital for Sick Children, Canada
(English). Translation: November 2015

PDF Document

Epidemiology of ADHD

Children with Attention Deficit Hyperactivity Disorder (ADHD), which is characterized by age-appropriate levels of inattention, hyperactivity and impulsivity, are most often identified and treated in primary school. Studies around the world have identified an ADHD prevalence rate equivalent to 5.29% (95% confidence interval: 5.01-5.56) among children and adolescents. 1 Rates are higher for boys than for girls and for children under 12 years of age compared to adolescents. 1.2 Estimates of prevalence depend on the method of determination, the diagnostic criteria used, and whether criteria for assessing functional disorders are included. 1 In general, rates are almost the same across countries, with the exception of countries in Africa and the Middle East, where prevalence rates are lower than in North America and Europe. 1

Typically, the symptoms cause functional difficulties with behavior and schoolwork, and often disrupt family and peer relationships. 3.4 Children with ADHD are more likely to seek health care services and have an increased percentage of injuries compared to children without the condition. 5.6 While symptoms of hyperactivity decrease during adolescence, most children with ADHD continue to show some cognitive impairment (eg, executive function deficits, working memory impairment) compared to their peers in adolescence and adulthood. 7.8 Research has found lower high school completion rates, earlier initiation of alcohol and illicit substance use, higher rates of cigarette smoking and car accidents among adolescents with ADHD. 9-14 Hyperactivity in childhood is also associated with the subsequent onset of other psychiatric disorders, including anxiety, behavioral disorders, affective disorders, suicidal behavior, and antisocial personality disorder. 13.15-18 Adults with a childhood history of ADHD have higher than expected rates of injuries and accidents, marital and work difficulties, teenage pregnancies, and children born out of wedlock. 15,17,19-21 ADHD is an important public health issue, not only because of the long-term hardship faced by individuals and families, but also because of the heavy burden placed on the educational, health care, and criminal justice systems. 22-24

Population studies have found that child inattention and hyperactivity are more common in single-parent families, as well as in families with low parental education, parental unemployment and low income. 17,25,26 Data from family studies suggest that ADHD symptoms are highly heritable, 27 however, early environmental factors also play a role. Smoking and maternal alcohol consumption in the prenatal (antenatal) period, low birth weight, and developmental problems are associated with high levels of inattention and hyperactivity. 26.28 More recently, a review of longitudinal data from The Canadian National Longitudinal Survey of Children and Youth found that approximately 7% of children show persistently high levels of parental inherited hyperactivity from two years of age to the first grades of primary schools. 29 Maternal smoking during the prenatal period, maternal depression, poor parenting practices, and living in a disadvantaged neighborhood in the early years are all associated with later childhood behavior problems, including inattention and hyperactivity 4 years later. 29-31

Clinical detection and treatment of ADHD in North America may vary geographically, presumably reflecting differences in community practices or access to services. 32-34 Treatment of symptoms of inattention and hyperactivity with stimulant drugs has increased in frequency since the early to mid-1990s and likely reflects longer periods of use with continued treatment into adolescence, as well as an increase in the number of girls diagnosed and treated disease. 35-38

Comorbid (or comorbid) disorders

Half to two-thirds of children diagnosed with ADHD also have comorbid psychiatric and developmental disorders, including rebelliousness and aggressive behavior, anxiety, low self-esteem, tic disorders, disorders motility, learning disabilities and speech disorders. 39-46 Sleep problems, including enuresis (bedwetting), are common, along with disturbed sleep breathing, which is a potentially modifiable cause for increased inattention. 47.48 The global decline in well-being in children with ADHD increases with the number of comorbidities. 13.49 Concomitant diagnoses also increase the likelihood of additional difficulties for children as they progress into adolescence and adulthood. 10,15,16,50-55

Neurocognitive difficulties are an important source of deterioration in well-being in children with ADHD. Areas of executive functioning and working memory, as well as specific speech and learning disorders, are common in the clinical group. 56.57-64 Approximately one third of children referred for psychiatric, often behavioral, problems may have previously undiagnosed speech problems. 65 Potential cognitive problems should be diagnosed whenever possible to ensure appropriate correction in educational settings.

ADHD in preschool children

Attention deficit hyperactivity disorder (ADHD) usually begins before the child enters school. However, in preschool children, ADHD is characterized not only by attention deficits, excessive impulsivity, and hyperactivity, but is often accompanied by violent outbursts of anger, demanding, confrontational behavior, and aggressiveness, which can interfere with attendance at daycare centers or lead to avoidance of family gatherings, and also represent a heavy burden of care for the family and contribute to distress. 66,67,68 These disruptive behaviors are often a concern for parents, many of which are 66 diagnosed as oppositional defiant disorder. Early identification of the disorder can be helpful in addressing a number of developmental issues that children with ADHD may have.

Assessment of ADHD in school-aged children

In elementary school, teachers often bring to the attention of parents their concerns about the learning style and behavioral difficulties of their children. Educators generally expect kindergarten and first grade children to be able to follow classroom routines, follow simple directions, play cooperatively with peers, and stay focused for 15 to 20 minutes during classwork. The issues raised by educators, especially experienced educators, are a source of important information about the child's academic and social functioning.

The formal diagnosis of ADHD reflects pervasive and damaging levels of inattention, distractibility, hyperactivity, and impulsivity. The child's symptoms should be beyond the normal age range and cause impairment of functioning, most commonly in academic or social skills, relationships with peers, and family. Difficulties are usually present in the preschool years, although they are not always diagnosed. The harassing behavior recurs in more than one context - in the family, at school, or in public places, such as on a trip to the park or at the grocery store.

There are two sets of formal diagnostic rules used in Canada, DSM IV TR (Diagnostic and Stratistical Manual, Fourth Edition, Text Revised; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised) and ICD-10 (International Classification of Disorders , Tenth Edition; International Classification of Diseases, Tenth Edition). The DSM IV diagnosis of attention deficit/hyperactivity disorder (ADHD) largely reflects the consensus understanding of the diagnosis in the United States. There are three types of ADHD (see Table 1 for diagnostic symptoms).

Type I - predominantly inattentive type, the child exhibits 6 of the 9 symptoms of inattention described;

type II - predominantly hyperactive-impulsive type, the child has 6 out of 9 hyperactive-impulsive symptoms;

type III - combined type, where the child shows high levels of development of symptoms of both types (see diagnostic symptoms in Table 1).

The ICD-10 diagnosis of hyperkinetic disorder is most commonly used by physicians who practice outside of North America. The theoretical underpinnings of ADHD and hyperkinetic disorder overlap to a large extent: the MCD-10 diagnosis of hyperkinetic disorder covers a narrower group of children who must meet both criteria - both hyperactivity and inattention and distractibility. However, when considering aspects of the overall clinical picture, children with ADHD, especially of the combined type, show similar impairments in functioning and need intervention in the same way as children with hyperkinetic disorder. 69

Clinical diagnosis of a child with ADHD is best done by professionals trained in child mental health and psychosocial development tests. Because young children often respond to stressful situations with increased levels of activity and distractibility, and have learning and social difficulties, identification of alternative explanations for these complicating symptoms requires diagnostic evaluation of the child's age, family, and social contexts. Physical symptoms such as poor sleep or chronic illness should also be considered as potential causes or contributing factors to a child's difficulty. Ideally, the doctor should obtain information about the child's social and school life from more than one informant who has the opportunity to observe him in various situations, for example, this may be the child's parent and his teacher. Self-report surveys of parents and educators are widely used to obtain information about the behavior of a particular child at home or in the school environment, respectively. 4 In addition, it is essential to conduct detailed clinical interviews with parents of young children and, for older children, with the child or adolescent himself. Reviewing school records over several years is also useful for getting a longitudinal view of a child from multiple educators. The identification of comorbid disorders is one of the important aspects of the diagnostic evaluation, including the learning and speech disorders discussed in the last section. In addition, psychosocial problems and age-related difficulties should be identified, as they can complicate the treatment of ADHD and affect the long-term prognosis.

Table 1: DSM IV TR Criteria for Attention Deficit Hyperactivity Disorder

A. Choice of option (1) or (2):

(1) Six or more of the following symptoms persist during inattention6 months, are expressed to the degree of inadequacy and do not correspond to the age level:


    1. often does not pay close attention to details or makes careless mistakes
    2. often has difficulty maintaining attention during tasks or play activities
    3. often the child does not seem to listen when spoken to directly
    4. often unable to follow directions and complete lessons, homework, or chores (not due to disobedience or inability to understand directions)
    5. often has difficulty organizing assignments and other activities
    6. often avoids, dislikes, or does not want to participate in tasks that require prolonged mental effort
    7. often loses items needed at school and at home (eg toys, school supplies, pencils, books, work tools)
    8. easily distracted by extraneous stimuli
    9. forgetful in everyday situations

(2) Six or more of the following symptoms of hyperactivity and impulsivity persist for 6 months, are severe to the degree of inadequacy, and do not correspond to the age norm:


    1. frequent restless movements in the hands and feet, fidgeting in a chair
    2. often gets up from his seat in the classroom during lessons or in other situations in which you need to stay in place.
    3. often runs or climbs things beyond measure in situations where this is unacceptable
    4. unable to play quietly and engage in leisure activities
    5. is often in constant motion or behaves as if "it has a motor attached to it"
    6. often talkative


    1. often answers questions without thinking or listening to the end
    2. usually has difficulty waiting in line
    3. often interferes with or pesters others (for example, interferes in conversations or games)

B. Some symptoms of hyperactivity-impulsivity or inattention that worsen well-being were present in a child under the age of 7 years.

C. Problems associated with these symptoms occur in two or more areas of life (e.g., school and home)

D. There must be clear evidence of clinically significant impairment in social life, academic activities, or studies associated with acquiring a profession.

E. Symptoms do not completely overlap with pervasive developmental disorder, schizophrenia, or other psychotic disorder, and cannot be explained by other mental disorders (eg, mood disorder, anxiety disorder, dissociative disorder, or personality disorder).


  1. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American Journal of Psychiatry 2007;164(6):942-948.
  2. Waddell C, Offord DR, Shepherd CA, Hua JM, McEwan K. Child psychiatric epidemiology and Canadian public policy-making: the state of the science and the art of the possible. Canadian Journal of Psychiatry 2002;47(9):825-832.
  3. American Academy of Pediatrics. Subcommittee on Attention-Deficit/ Hyperactivity Disorder and Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108(4):1033-1044.
  4. Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry 2007;46(7):894-921.
  5. Bruce B, Kirkland S, Waschbusch D. The relationship between childhood behavioral disorders and unintentional injury events. Pediatrics & Child Health 2007;12(9):749-754.
  6. Leibson CL, Katusic SK, Barbaresi WJ, Ransom J, O'Brien PC. Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder. JAMA-Journal of the American Medical Association 2001;285(1):60-66.
  7. Brassett-Harknett A, Butler N. Attention-deficit/hyperactivity disorder: an overview of the etiology and a review of the literature relating to the correlates and lifecourse outcomes for men and women. Clinical Psychology Review 2007;27(2):188-210.
  8. Spencer TJ, Biederman J, Mick E. Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Journal of Pediatric Psychology 2007;32(6):631-642.
  9. Barkley RA, Fischer M, Edelbrock C, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria III. Mother-child interactions, family conflicts and maternal psychopathology. Journal of Child Psychology and Psychiatry 1991;32(2):233-255.
  10. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry 1990;29(4):546-557.
  11. Biederman J, Faraone S, Milberger S, Guite J, Mick E, Chen L, Mennin D, Marrs A, Ouellette C, Moore P, Spencer T, Norman D, Wilens T, Kraus I, Perrin J. A prospective 4- year follow-up study of attention-deficit hyperactivity and related disorders. Archives of General Psychiatry 1996;53(5):437-446.
  12. Mannuzza S, Klein RG, Konig PH, Giampino TL. Hyperactive boys almost grown up. IV. Criminality and its relationship to psychiatric status. Archives of General Psychiatry 1989;46(12):1073-1079.
  13. Fergusson DM, Horwood LJ. Early onset cannabis use and psychosocial adjustment in young adults. Addiction 1997;92(3):279-296.
  14. Barkley RA, Guevremont DC, Anastopoulos AD, DuPaul GJ, Shelton TL. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey. Pediatrics 1993;92(2):212-218.
  15. Fergusson DM, Horwood LJ, Ridder EM. Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal of Child Psychology and Psychiatry 2005;46(8):837-849.
  16. Copeland WE, Miller-Johnson S, Keeler G, Angold A, Costello EJ. Childhood psychiatric disorders and young adult crime: a prospective, population-based study. American Journal of Psychiatry 2007;164(11):1668-1675.
  17. Fergusson DM, Boden JM, Horwood LJ. Exposure to single parenthood in childhood and later mental health, educational, economic, and criminal behavior outcomes. Archives of General Psychiatry 2007;64(9):1089-1095.
  18. Woodward LJ, Fergusson DM, Horwood LJ. Driving outcomes of young people with attentional difficulties in adolescence. Journal of the American Academy of Child & Adolescent Psychiatry 2000;39(5):627-634.
  19. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Archives of General Psychiatry 1993;50(7):565-576.
  20. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult psychiatric status of hyperactive boys grown up. American Journal of Psychiatry 1998;155(4):493-498.
  21. Biederman J, Petty CR, Fried R, Kaiser R, Dolan CR, Schoenfeld S, Doyle AE, Seidman LJ, Faraone SV. Educational and occupational underattainment in adults with attention-deficit/hyperactivity disorder: a controlled study. Journal of Clinical Psychiatry 2008;69(8):1217-1222.
  22. Birnbaum HG, Kessler RC, Lowe SW, Secnik K, Greenberg PE, Leong SA, Swensen AR. Costs of attention deficit-hyperactivity disorder (ADHD) in the US: excess costs of persons with ADHD and their family members in 2000. Current Medical Research & Opinion 2005;21(2):195-206.
  23. Leibson CL, Long KH. Economic implications of attention-deficit hyperactivity disorder for healthcare systems. Pharmacoeconomics 2003;21(17):1239-1262.
  24. Secnik K, Swensen A, Lage MJ. Comorbidities and costs of adult patients diagnosed with attention-deficit hyperactivity disorder. Pharmacoeconomics 2005;23(1):93-102.
  25. St Sauver JL, Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Jacobsen SJ. Early life risk factors for attention-deficit/hyperactivity disorder: a population-based cohort study. Mayo Clinic Proceedings 2004;79(9):1124-1131.
  26. Szatmari P, Offord DR, Boyle MH. Correlates, associated impairments and patterns of service utilization of children with attention deficit disorder: findings from the Ontario Child Health Study. Journal of Child Psychology and Psychiatry 1989;30(2):205-217.
  27. Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry 2005;57(11):1313-1323.
  28. Fergusson DM, Woodward LJ, Horwood LJ. Maternal smoking during pregnancy and psychiatric adjustment in late adolescence. Archives of General Psychiatry 1998;55(8):721-727.
  29. Romano E, Tremblay RE, Farhat A, Cote S. Development and prediction of hyperactive symptoms from 2 to 7 years in a population-based sample. Pediatrics 2006;117(6):2101-2110.
  30. Elgar FJ, Curtis LJ, McGrath PJ, Waschbusch DA, Stewart SH. Antecedent-consequence conditions in maternal mood and child adjustment: a four-year cross-lagged study. Journal of Clinical Child & Adolescent Psychology 2003;32(3):362-374.
  31. Kohen DE, Brooks-Gunn J, Leventhal T, Hertzman C. Neighborhood income and physical and social disorder in Canada: associations with young children's competencies. Child Development 2002;73(6):1844-1860.
  32. Brownell MD, Yogendran MS. Attention-deficit hyperactivity disorder in Manitoba children: medical diagnosis and psychostimulant treatment rates. Canadian Journal of Psychiatry 2001;46(3):264-272.
  33. Rappley MD, Gardiner JC, Jetton JR, Houang RT. The use of methylphenidate in Michigan. Archives of Pediatrics & Adolescent Medicine 1995;149(6):675-679.
  34. Jensen PS, Kettle L, Roper MT, Sloan MT, Dulcan MK, Hoven C, Bird HR, Bauermeister JJ, Payne JD. Are stimulants overprescribed? Treatment of ADHD in four U.S. communities. Journal of the American Academy of Child & Adolescent Psychiatry 1999;38(7):797-804.
  35. Charach A, Cao H, Schachar R, To T. Correlates of methylphenidate use in Canadian children: a cross-sectional study. Canadian Journal of Psychiatry 2006;51(1):17-26.
  36. Miller AR, Lalonde CE, McGrail KM, Armstrong RW. Prescription of methylphenidate to children and youth, 1990-1996. CMAJ ̶ Canadian Medical Association Journal 2001;165(11):1489-1494.
  37. Robison LM, Sclar DA, Skaer TL, Galin RS. National trends in the prevalence of attention-deficit/hyperactivity disorder and the prescribing of methylphenidate among school-age children: 1990-1995. Clinical Pediatrics 1999;38(4):209-217.
  38. Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics 1996;98(6 Pt 1):1084-1088.
  39. Fliers E, Vermeulen S, Rijsdijk F, Altink M, Buschgens C, Rommelse N, Faraone S, Sergeant J, Buitelaar J, Franke B. ADHD and Poor Motor Performance From a Family Genetic Perspective. Journal of the American Academy of Child & Adolescent Psychiatry 2009;48(1):25-34.
  40. Drabick D, Gadow K, Sprafkin J. Co-occurrence of conduct disorder and depression in a clinic-based sample of boys with ADHD. Journal of Child Psychology and Psychiatry 2006;47(8):766-774.
  41. Baeyens D, Roeyers H, Van Erdeghem S, Hoebeke P, Vande Walle J. The prevalence of attention deficit-hyperactivity disorder in children with nonmonosymptomatic nocturnal enuresis: a 4-year followup study. Journal of Urology 2007;178(6):2616-2620.
  42. Angold A, Costello EJ, Erkanli A. Comorbidity. Journal of Child Psychology and Psychiatry 1999;40(1):57-87.
  43. Corkum P, Moldofsky H, Hogg-Johnson S, Humphries T, Tannock R. Sleep problems in children with attention-deficit/hyperactivity disorder: impact of subtype, comorbidity, and stimulant medication. Journal of the American Academy of Child & Adolescent Psychiatry 1999;38(10):1285-1293.
  44. Kadesjo B, Gillberg C. The comorbidity of ADHD in the general population of Swedish school-age children. Journal of Child Psychology and Psychiatry 2001;42(4):487-492.
  45. Shreeram S, He JP, Kalaydjian A, Brothers S, Merikangas KR. Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among U.S. children: results from a nationally representative study. Journal of the American Academy of Child & Adolescent Psychiatry 2009;48(1):35-41.
  46. Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry 1991;148(5):564-77.
  47. Corkum P, Tannock R, Moldofsky H. Sleep disturbances in children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry 1998;37(6):637-646.
  48. Owens JA, Maxim R, Nobile C, McGuinn M, Msall M. Parental and self-report of sleep in children with attention-deficit/hyperactivity disorder. Archives of Pediatrics & Adolescent Medicine 2000;154(6):549-555.
  49. Biederman J, Milberger S, Faraone SV, Kiely K, Guite J, Mick E, Ablon JS, Warburton R, Reed E, Davis SG. Impact of adversity on functioning and comorbidity in children with attention-deficit hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry 1995;34(11):1495-1503.
  50. Fischer M, Barkley RA, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: II. Academic, attentional, and neuropsychological status. Journal of Consulting & Clinical Psychology 1990;58(5):580-588.
  51. Fischer M, Barkley RA, Fletcher KE, Smallish L. The adolescent outcome of hyperactive children: predictors of psychiatric, academic, social, and emotional adjustment. Journal of the American Academy of Child & Adolescent Psychiatry 1993;32(2):324-332.
  52. Fergusson DM, Horwood LJ. Early conduct problems and later life opportunities. Journal of Child Psychology and Psychiatry 1998;39(8):1097-1108.
  53. Fergusson DM, Horwood LJ, Lynskey MT. The effects of unemployment on psychiatric illness during young adulthood. Psychological Medicine 1997;27(2):371-381.
  54. Biederman J, Monuteaux MC, Mick E, Spencer T, Wilens TE, Klein KL, Price JE, Faraone SV. Psychopathology in females with attention-deficit/hyperactivity disorder: a controlled, five-year prospective study. Biological Psychiatry 2006;60(10):1098-1105.
  55. Costello EJ, Erkanli A, Federman E, Angold A. Development of psychiatric comorbidity with substance abuse in adolescents: effects of timing and sex. Journal of Clinical Child Psychology 1999;28(3):298-311.
  56. Solanto MV, Gilbert SN, Raj A, Zhu J, Pope-Boyd S, Stepak B, Vail L, Newcorn JH. Neurocognitive functioning in AD/HD, predominantly inattentive and combined subtypes. Journal of Abnormal Child Psychology 2007;35(5):729-744.
  57. Hinshaw SP, Carte ET, Fan C, Jassy JS, Owens EB. Neuropsychological functioning of girls with attention-deficit/hyperactivity disorder followed prospectively into adolescence: evidence for continuing deficits? Neuropsychology 2007;21(2):263-273.
  58. Thorell LB, Wahlstedt C. Executive functioning deficits in relation to symptoms of ADHD and/or ODD in preschool children. Infant and Child Development 2006;15(5):503-518.
  59. Loo SK, Humphrey LA, Tapio T, Moilanen IK, McGough JJ, McCracken JT, Yang MH, Dang J, Taanila A, Ebeling H, Jarvelin MR, Smalley SL.. Executive functioning among Finnish adolescents with attention-deficit/hyperactivity disorder . Journal of the American Academy of Child & Adolescent Psychiatry 2007;46(12):1594-1604.
  60. Barkley RA, Edwards G, Laneri M, Fletcher K, Metevia L. Executive functioning, temporal discounting, and sense of time in adolescents with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Journal of Abnormal Child Psychology 2001;29(6):541-556.
  61. Beitchman JH, Brownlie EB, Inglis A, Wild J, Ferguson B, Schachter D, Lancee W, Wilson B, Mathews R. Seven-year follow-up of speech/language impaired and control children: psychiatric outcome. Journal of Child Psychology and Psychiatry 1996;37(8):961-970.
  62. Clark C, Prior M, Kinsella G. The relationship between executive function abilities, adaptive behavior, and academic achievement in children with externalising behavior problems. Journal of Child Psychology and Psychiatry 2002;43(6):785-796.
  63. Calhoun SL, Dickerson Mayes S. Processing speed in children with clinical disorders. Psychology in the Schools 2005; 42(4):333-343 .
  64. Rabiner D, Coie JD, Conduct Problems Prevention Research Group. Early attention problems and children's reading achievement: a longitudinal investigation. Journal of the American Academy of Child & Adolescent Psychiatry 2000;39(7):859-867.
  65. Cohen NJ, Davine M, Horodezky N, Lipsett L, Isaacson L. Unsuspected language impairment in psychiatrically disturbed children: prevalence and language and behavioral characteristics. Journal of the American Academy of Child & Adolescent Psychiatry 1993;32(3):595-603.
  66. Cunningham CE, Boyle MH. Preschoolers at risk for attention-deficit hyperactivity disorder and oppositional defiant disorder: family, parenting, and behavioral correlates. Journal of Abnormal Child Psychology 2002;30(6):555-569.
  67. Keown LJ, Woodward LJ. Early parent-child relations and family functioning of preschool boys with pervasive hyperactivity. Journal of Abnormal Child Psychology 2002;30(6):541-553.
  68. Greenhill LL, Posner K, Vaughan BS, Kratochvil CJ. Attention deficit hyperactivity disorder in preschool children.

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