ADHD in the Preschool Years: What to Look For at Ages 3 to 5

A three-year-old who will not stay in one place, who does not focus on anything for more than five minutes and who touches everything: we read this as "just his age." And most of the time we are right.

But some families sense that something else is going on even in this age group. Notes come from kindergarten one after another, the child drops away from the group, daily chores at home turn into a battle. Then the question changes: what is "normal" at this age, and when should one start to look?

Activity is expected in the preschool years

Skills such as attention span, impulse control and waiting for a turn develop rapidly in the preschool period, and there is a large difference between children. For this reason, looking at a list of symptoms and saying "our child has these" is easily misleading at this age. Even the DSM-5 criteria require the symptoms to be at a level "inconsistent with developmental level."

The list in the article on symptoms of ADHD in children was written for school age. In the preschool years the following distinction helps: not what the child does, but how often, how intensely and how everywhere she does it compared with her peers.

Signs the physician pays attention to

In the preschool years there are a few situations that raise suspicion. None of them is a diagnosis on its own; they draw attention when seen together and persistently:

• unlike peers, being unable to finish even a short activity, moving constantly from one thing to another
• activity that does not take danger into account and leads to frequent accidents or injuries
• being unable to wait for a turn in group activities at all, being unable to follow instructions
• showing the same picture in more than one setting, such as home and kindergarten
• because of these behaviors, getting frequent warnings from kindergarten, being unable to make friends, disruption of the family's daily functioning

Anxiety disorders, sleep problems, hearing or speech delays and recent major changes can look similar too. For this reason the physician first separates these out. For the diagnostic process you can look at the article on how ADHD is diagnosed in children.

From what age can it be diagnosed

The 2019 guideline of the American Academy of Pediatrics makes its recommendations for the diagnosis and treatment of ADHD for ages 4 to 18. Because symptoms are very variable in younger children, physicians often choose the path of monitoring and support instead of making a diagnosis immediately. This is not neglect; it is a deliberate caution.

The first step is not medication but parent training

This is perhaps the most important part of this heading. The guidelines say that in the 4 to 5 age group the first treatment is behavioral parent training. The reason is this: at this age the routine the parent builds with the child, the rewards and limits used, are the area that has the greatest effect on the course of the symptoms. Medication comes onto the agenda only if there has not been enough progress with this work and the symptoms disrupt function at a moderate-to-severe level.

I explained how parent training works in the article on parent training programs.

What can be done at home now

Even while waiting for a diagnosis or remaining in doubt, there are a few things that help. All of them are generally useful for child development:

• Short, one-step instructions. "Put on your shoes" instead of "go to your room, find your shoes, put them on." When that is done, the second step.
• A predictable daily routine. Let sleep, meals and play happen at about the same times. A picture plan works for a child who cannot yet read as well.
• Giving notice before transitions. Saying "in five minutes we will pick up the toys" reduces the conflict that comes from a sudden interruption.
• Noticing good behavior. Rather than punishment, concrete praise given at the moment the wanted behavior happens teaches the child what is expected. The details are in the article on reward systems.
• Plenty of movement. Being able to run freely outdoors every day reduces suppressed activity breaking out as a problem.

Working together with the kindergarten

Talking regularly with the teacher both provides the second-setting information needed for diagnosis and makes the child's day easier. The article on talking with the teacher will be useful in preparing for the meeting.

In the meeting, instead of being accusatory, the most productive thing to ask is often this: "At which moments of the day does she struggle most, and at which moments does it go well?" The moments when it goes well are the clue to the solution.

Waiting or looking

The sentence "she'll grow out of it" is true for some children and not for others. We cannot know beforehand which it is. If your concern persists and the symptoms disrupt daily life, consulting a specialist does not give you a label; it opens the way to finding the right support for your child.

This article is for information; the decision on diagnosis and treatment for your child belongs to the physician who examines her.