Attention Deficit/Hyperactivity Disorder, Ages 3 to 6

What is attention deficit/hyperactivity disorder?

ADHD (commonly known as ADD) is a behavioral disorder. Basically, children with ADHD have difficulty concentrating and are excessively active, or both. The American Psychiatric Association calls the distinct types "inattentive" and "hyperactive-impulsivity." Some kids with attention deficit disorder repeatedly fail to finish tasks, get distracted easily, and seem not to listen. Others fidget and squirm constantly and can't wait their turn. Still others have both kinds of problems.

Don't be alarmed if those behaviors seem familiar: Your child may get overexcited or lost in his own thoughts from time to time -- those are normal passing moods for any youngster. A child with ADHD will be inattentive or frenetic with greater frequency (though, unless he has a severe case, you wouldn't be able to pick him out from a group of kids watching TV).

The ADHD diagnosis is highly controversial for two reasons: Researchers aren't sure precisely what causes it, and family physicians, pediatricians, other medical experts, and parents all tend to have strong opinions on the use of drugs to treat it in children.

A minority of medical experts have argued that the ADHD diagnosis is overused for children who simply have difficulty adjusting to the structure of classroom life. This is given more credence by the experience of children in Sweden: The schools give children ample time to play outdoors and in nature, and they have a much lower rate of ADHD. If you're the parent of a child who feels too constricted in the classroom, your child may not need medical treatment. You may just need to exercise more patience and take responsibility for creating the right environment for your child to prosper in school, experts say.

How common is ADHD, and why do kids develop it?

According to the American Academy of Pediatrics, ADHD affects 4 to 12 percent of US schoolchildren. Signs usually appear before the age of 7. Studies indicate that more boys than girls are diagnosed with ADHD, and there is often a strong family history of other males with the condition.

Boys may be more often diagnosed than girls is because they tend to be disruptive in school and attract the attention of teachers and parents. Girls are less likely to be noticed because the ADHD usually shows up in poor academic performance.

Most researchers and ADHD experts believe the disorder has a neurological cause. Researchers are exploring the possibility that these kids inherit a physical inability to regulate levels of neurotransmitters (substances that transmit signals in the brain), such as dopamine. Less plausible explanations include drug or alcohol abuse by the mother during pregnancy or psychological trauma early in the child's life. But these hypotheses don't account for the vast majority of children with ADHD whose mothers didn't use harmful substances and who didn't go through hard times as babies and toddlers.

What are the symptoms?

To be diagnosed with inattentive ADHD, your child must exhibit six of the following symptoms for at least six months:

• Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities
• Often has trouble sustaining attention in tasks or play
• Often doesn't seem to listen to what's being said to him
• Often doesn't follow through on instructions and fails to finish schoolwork or chores (not out of rebellion or failure to understand)
• Often has difficulty organizing tasks and other activities
• Avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort
• Often loses things necessary for tasks or activities (such as toys, school assignments, pencils, and books)
• Is easily distracted by the world around him
• Is often forgetful

To be diagnosed with hyperactive-impulsivity ADHD, your child must exhibit at least four of the following symptoms for at least six months:

• Often fidgets or squirms
• Leaves his seat in the classroom or in other situations in which remaining seated is expected
• Often runs about or climbs in situations where it is inappropriate
• Often has difficulty playing quietly
• Often blurts out answers before the whole question has been stated
• Often has difficulty waiting in lines or awaiting his turn in group play
• Often interrupts

For your pediatrician to diagnose ADHD, your child must have started showing these symptoms by age 7 and the behaviors must be taking place in more than one situation (at school and at home, for example). Also, your child's difficulties must be intense enough to significantly harm his social interactions or academic performance. And of course the symptoms shouldn't be due to a physical problem such as hearing loss or poor vision.

When should I seek help?

Make an appointment with your pediatrician if your child's unmindful or impetuous behavior becomes frequent, severe, or begins to affect his ability to get along at home or at school. If his daycare provider or teacher tells you there's a problem -- that your child can't get halfway through a project or sit still for a story -- don't take this as a diagnosis of ADHD. A physical or emotional problem could be making him unable to focus or excitable. Or he could have a learning disability such as dyslexia or a neurodevelopmental disorder that makes it hard for him to remember things or acquire language. (However, many kids with ADHD also have learning disabilities.) Your pediatrician can make a preliminary identification of such problems and refer you to someone who will thoroughly assess your child's condition.

What will my pediatrician do?

She'll perform a physical exam of your child and review your medical and social history. She may ask you about your pregnancy, other family members who have been diagnosed with ADHD, and any emotional difficulties your child has gone through.

Your doctor may order tests of your child's vision and hearing to rule out these physical problems. She might order an IQ test, too; ADHD doesn't directly affect IQ, so a child with it will have an IQ in the normal range (unless the ADHD has an environmental cause such as lead poisoning). But the result of the test can be useful in the light of results from tests measuring memory, problem-solving, and listening skills. Your doctor will most likely refer you to a child psychologist, who will administer a battery of tests in addition to the IQ evaluation. The psychologist will also ask you or your child's teacher to fill out one of the many rating scale forms, which present such questions as "How often does your child pay attention in class?" and ask for a numerical rating on a five-point scale between "never" and "always."

In addition, your doctor or the psychologist will assess your child for the behaviors associated with ADHD. Either may want you to ask your child's teacher to write a letter describing the behavior he's observed, since even a child who's lost in the clouds much of the time may focus in during an office visit.

Together, your pediatrician and the child psychologist (or other mental health professional) can make a definitive diagnosis.

What are the treatment options?

There are three: family therapy, behavioral therapy, and medication. However, the Centers for Disease Control and Prevention (CDC) has warned that young children are being overmedicated for ADHD and urge all doctors and parents to try "behavior therapy" before using any medications on preschoolers. Through family therapy or "parent training," you can learn more about ADHD and adjust your expectations for your child. You can also learn to deal with your own frustration and how to parent consistently and positively. Behavioral therapy can teach you how to structure situations at home and school so that your child doesn't become unnecessarily stimulated or distracted.

Some medical experts feel that family counseling and behavioral therapy are enough to treat ADHD. Kathleen Holton of American University has written in the Journal of Attention Disorders that a "healthy lifestyle" could be used in place of medication to combat ADHD. Her "prescription" includes 1) no more than an hour a day of screen time; 2) getting enough sleep (9 to 11 hours); 3) drinking 7 to 10 cups of water a day; 4) getting at least an hour of exercise each day.

Other experts have suggested using "nature therapy" -- that is, walking or playing with children in parks and other natural settings -- to manage symptoms of ADHD. One study found children were able to concentrate better ("shockingly better," as one researcher put it) after taking a walk in the park rather than suburban streets.

If behavioral therapy, nature therapy, and a healthy lifestyle don't work and a drug is part of the treatment plan for your child, you'll have to work with your child's pediatrician or psychiatrist to find the right dosage.

Ironically, the drugs most often prescribed are stimulants, including methylphenidate (better known by its brand name, Ritalin) and dextroamphetamine (Dexedrine). But the current drug of choice for ADHD is Adderall, an amphetamine; it may have fewer side effects than Ritalin, and its slow-release formulation means kids don't have to take a second dose while they're at daycare or school.

The FDA has issued an advisory on atomoxetine (Strattera), a non-stimulant ADHD medication, warning of an "increased risk of suicidal thinking" in children and teenagers taking this drug. However, it is still on the market, and has a host of other serious side effects.

The FDA directed the manufacturers of all ADHD drugs like Adderall, Dexedrine, or Ritalin to include a medication guide with their products. The guide warns of the risk of cardiovascular complications and psychiatric problems -- such as hearing voices and paranoia -- in patients with no history of them. Patients or parents of children taking these drugs should talk to their doctors before altering or discontinuing treatment.

Researchers believe these medications help modulate levels of neurotransmitters in the brain. Side effects can include loss of appetite, stomach pain, insomnia, and rapid heartbeat. You might also consider that stimulants such as Ritalin have been found to significantly suppress growth, according to a study presented at a Pediatric Academic Societies Meeting. Your doctor should monitor your child carefully if she prescribes these medications.

As far as your child's schooling is concerned, you should know that he is eligible for special education services. Under federal law, public schools must evaluate children with ADHD to determine their particular needs and then make reasonable efforts to meet those needs.

One last point to keep in mind is that ADHD is a relatively new term and the condition has received a lot of media attention in recent years. Researchers are still trying to determine the best ways to treat it, and as new studies appear in the press, your friends and family may give you an earful on what you should do. The best solution to the confusion and anxiety you naturally feel is to work closely with your pediatrician and your child's therapist, focusing on the solutions that seem to work for your child.

What can I do?

The first thing you should do is accept that your child has a behavioral disorder and adjust your expectations. Many kids with ADHD are terrifically bright and creative. Your child may well grow up to be an eminent scientist or film director. But you'll need to rethink the way you parent him as well as the type of environment you establish for him at home and school. Here's how to begin:

• Sign everybody up. Now that you have a diagnosis, tell family, close friends, teachers, and anybody else who can offer your child support. Don't let the idea of a stigma silence you; your child will need all the help he can get in the months and years ahead, and so will you.
• Change the scene. Eliminate sources of overstimulation and distraction in your child's environment. At home, make sure his room is tidy, stashing extra toys or books where they won't catch his eye. At daycare or school, ask the teacher to place your child near her, where she can keep an eye on him, or to move him away from kids and objects that tend to draw his attention.
• Structure your day. All children respond well to routines, no kid more than one with ADHD. A regular schedule extinguishes much of the anxiety and tension your child feels when he doesn't know what's going to happen next. You don't have to be rigid; just make sure that he knows when and where he'll have his meals, naps, baths, and so on. This also helps him focus on important tasks, instead of the mundane details of living.
• Start rewarding instead of punishing. You've probably already discovered how useless it is to try to punish your child when he's running around or tuning you out. But you may not know how well kids with ADHD respond to simple rewards. Praise good behavior immediately ("You brushed your teeth, just like I asked you to! Thanks so much!"), and give your child some little token that pleases him -- a gold star, a funny rubber stamp, or an extra bedtime story. (The reward should be something he can enjoy right away; kids with ADHD don't want to wait.)

Getting a tangible show of appreciation will make your child feel good, and he'll be inclined to repeat the behavior that made him feel that way. Over time he'll internalize the positive connection and you'll no longer have to give him external rewards; the good feeling will come from inside.

What should I tell my child?

First, that he's physically fine -- healthy and strong. Going to the doctor and having your hearing, vision, and intelligence checked is enough to rattle anyone.

Second, tell your child that he does have a problem with being attentive or staying still. This won't be news to him, but now you can explain why: He has a problem that's been getting in the way.

Depending on your child's age, you may want to tell him what ADHD stands for and explain the words: "Attention means listening and concentrating on what people say or do; hyperactivity means getting up, jumping around, and climbing things when it's not a good time for those activities." Don't waste much energy on disorder or deficit; better to discuss the words he already at least partly understands.

Third, talk to your child about what's going to happen, whether it's trips to a new doctor or therapist, a special medication, or both. Children with ADHD need to know what's ahead. Make sure he knows that none of this is to punish him.

Finally, talk to your child about the changes you're making at home, for example, placing his toys out of sight when he's not playing with them or rewarding him with gold-star stickers when he puts away his shoes or brushes his teeth. Reassure him that his home routine will stay the same in many ways and that your love is constant.

References

Cha, Ariana Eunjung. CDC Warns That Americans May Be Overmedicating Youngest Children with ADHD. https://www.washingtonpost.com/news/to-your-health/wp/2016/05/03/cdc-warns-that-americans-may-be-overmedicating-two-to-five-year-olds-with-adhd/?tid=a_inl&utm_term=.a6faea1eb097

Nature Therapy and ADHD. Healthy Parks, Healthy People. www.hphpcentral.com/article/nature-therapy-and-adhd

Attention deficit hyperactivity disorder, Scientific American, Russell A. Barkley.

FDA Statement on Adderall, http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements

Childrens Hospital Boston. Childrens Hospital Boston presents at the 2006 Pediatric Academic Societies Annual Meeting. http://www.childrenshospital.org/newsroom/Site1339/mainpageS1339P1sublevel213.html

US Food and Drug Administration. Cardiovascular and Psychiatric Risks with ADHD Drugs. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/printer.cfm?id=519

National Institute of Mental Health. Attention Deficit Hyperactivity Disorder (ADHD). http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

FDA. Adderall and Adderall XR (amphetamines) Information.http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111441.htm

FDA. FDA Asks Attention-Deficit Hyperactivity Disorder (ADHD) Drug Manufacturers to Develop Patient Medication Guides. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm107918.htm

American Academy of Pediatrics, HealthyChildren.org. Understanding ADHD. http://www.healthychildren.org/English/health-issues/conditions/adhd/pages/Understanding-ADHD.aspx

National Institute of Mental Health. What medications are used to treat ADHD? http://www.nimh.nih.gov/health/publications/mental-health-medications/what-medications-are-used-to-treat-adhd.shtml

US Food and Drug Administration. Safety Alerts for Human Medical Products. Strattera (atomoxetine) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm152628.htm