Diagnosis and Management of ADHD in Young Children

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.