Can ADHD Be Diagnosed in Children as Young as Pre-School Age?
ADHD is defined as a neurodevelopmental disorder that is first evident in early childhood. Thus, it is common for children with ADHD to first be identified by pre-school teachers, daycare center staff, and the family pediatrician. Take the example of four-year-old Jack. His teacher says he is unable to sit at the table and do “desk work” tasks alongside the other children such as coloring, putting together puzzles, and copying alphabet letters. He often grabs crayons from the other children rather than wait his turn to get the crayon he needs. His behavior is often disruptive in class; he doesn’t obey class rules such as standing in line quietly before walking to lunch, but bumps and touches other children while swinging his lunchbox around. Story time is a problem because Jack is restless, talking and play-wrestling with other children, or simply getting up and leaving the mat. When made to comply with rules, such as coming in from the playground, he often refuses and descends into a tantrum. Once he ran out of the playground and into the street.
Because these children are young, we cannot make firm predictions about the next few years for them. Some fathers will say, “He’s all boy. He needs to move around more! Let him play and work off steam!” The teacher may say, “He’s immature. He needs to repeat pre-school (or kindergarten) to catch up with his peers.” Pediatricians, having seen thousands of children, may opt with, “Children grow at different rates. Let’s wait a year and see if he grows out of it.”
How is a clinician to make a judgment about whether we should take this problem seriously, make a medical diagnosis of ADHD, and initiate treatment? Aren’t all four-year-old children boisterous? Don’t they all have short attention spans? We start with getting information from the pre-school teacher or daycare director. If they bring to the parent’s attention the fact that this child is the only child, or one of only two children, in a classroom of 20, who are displaying such severely disruptive behavior, then we know that this child’s behavior is in the upper 5% to 10% level of severity. (Statistical studies in the U.S. estimate the rate of ADHD in children to be somewhere between 5 and 10 per cent). If the child has been expelled from the pre-school or daycare because of his disruptive, impulsive, and sometimes aggressive behavior, this is further confirmation that the behavior problems are severe. In Kindergarten, often the parent calls for an evaluation because the child’s behavior has caused him to be suspended from school for a period of time.
The psychologist or pediatrician may give the teacher a questionnaire to complete where she will rate a list of ADHD symptoms on a scale from “not at all” to “very often.” If the child’s score on the checklist is above the 90th percentile, then we have more confirmation that this child’s behavior is far above the norm for his age in his current classroom.
The parent is a good informant as well. The father, or mother, or both may complete questionnaires rating the child on a list of problematic, disruptive behaviors in the home. If the scores are above the 90th percentile, and are in agreement with the teacher or daycare staff, we again have confirmation that the child’s behavior is well out of the range of what we would see as typical for this age. Sometimes, the parents’ scores are in the mild to moderate range. This suggests that in the home, where there is less structure and fewer rules, the child’s behavior might not be so problematic. The parent may give the report that, “I have three children, and this child is definitely harder to manage that the other two.” Grandmother may weigh in with the observation that, “He’s just like your (dad) at this age. That’s when you were diagnosed with ADHD.”
How does the psychologist/mental health clinician evaluate a four-year-old for ADHD? Is there a test? The answer is no. The psychologist will want to interview the parents in depth, getting the parents’ childhood history as well as the child’s history. Does ADHD run in the family? They will gather information, records, documentation from the pre-school (behavior charts, Friday folders, etc.), as well as the questionnaires, then review them to see if they suggest a pattern of hyperactivity, impulsivity, and inability to attend to and comply with instructions in an age-appropriate manner. The timeline is very important—behavioral problems that began as early as age two or three and have been worsening suggest ADHD, especially if they worsened when the child was put in group child-care and had to conform to structure. Children who display behavior problems as a consequence of a significant life event, such as the parents’ divorce, or physical/emotional abuse, or living in overcrowded, poverty conditions, would be diagnosed with what is called an Adjustment Disorder but not ADHD.
How does the psychologist evaluate the child in the office setting? Largely through observation. Does the child grab interesting items in the office? Or ask permission to handle them? Does the child listen to instructions? Or does the clinician have to give instructions repeatedly? Does she finally have to hold the child by the shoulders, touch their chin, ask for eye contact, and then give instructions? Can the child sit still long enough to print his name? draw a stick figure? Assemble a six to 10 piece puzzle? Can the child play a simple interactive board game or card game, following the rules? If the child is allowed to play freely with toys in the office, the clinician will note how long he stays with each toy. Does he play with it for 5 to 10 minutes, exploring it fully, using it in different ways, then putting it back on the shelf? Or does he pick it up, manipulate it roughly for a minute or less, then drop it, and move on to the next toy? The clinician will make detailed observations, then compare those with what the pre-school teacher is seeing in the classroom and what the parent is reporting in the home. In the final report, the clinician will follow the guidelines for diagnosing ADHD in children according to industry standards—the child is displaying 6 out of 9 symptoms of hyperactivity and 6 out of 9 symptoms of inattention. The symptoms have been present for at least 6 months, they occur in two settings (usually home and school), and they clearly interfere with the child’s functioning, academically, socially, and with day-to-day tasks.
Why render a diagnosis of ADHD to a four-year-old? After all, it is possible that the child may grow out of it, simply mature. Or the child may have fewer behavior problems if moved to a pre-school that has fewer rules and more outside play time.
Studies show that 79% to 80% of children who are diagnosed with ADHD at age four will continue to have significant behavior problems in school and at home at age five, six, and seven and older. This is especially true if they are also diagnosed with oppositional defiant disorder—a pattern of stubbornness, inflexibility, argumentativeness, and resistance toward authority. Early intervention with appropriate treatment can make all the difference, enabling a child to be more successful academically and not come to view school as a battleground and a place of failure. Social success on the playground and a harmonious relationship with parents and siblings are also more likely with early intervention.
References
Childress, A. 2018. Diagnosis and Treatment of ADHD in Pre-School-Aged Children. J. of Child & Adolescent Psychopharmacology, 28 (9), 606-614.
Dreyer, B. 2006. The Diagnosis and Management of ADHD in Preschool Children. Curr. Probl. Pedtr. Adolesc. Health Care, 36, 6-30.