Should ADHD Be Diagnosed In Toddlers?

The American Academy of Pediatrics (AAP) has issued new guidelines on ADHD: it is now suggested that kids as young as 4 years old should be evaluated, diagnosed and treated. I don’t agree. Stick with me here as I lead up to telling you why I feel this way.

Diagnosing ADHD is a tricky business at any age – there are no benchmark biological indicators that tell you “yes or no.” Experienced clinicians have to rule out a host of factors (biological, psychological, social) that could contribute to a child showing the key constellation of symptoms that go into making an ADHD diagnosis. In addition, practitioners have to consider age as a relevant factor, since many of the symptoms of ADHD are extreme versions of age-appropriate behavior. As kids enter the normative years for traditional schooling (say by 7 years of age), there is some calibration in a classroom and a reasonable metric of comparison with other kids – so a kid who’s behavior is extreme compared to other kids the same age and gender might have what we label clinically as ADHD. Keep in mind that to make a thoughtful diagnosis of ADHD, it’s important to see that the behavior is not limited to one context (e.g., you need to see it at home and at school). So the school years provide a few key reference points for differential diagnosis: some clear comparisons with relevant peer groups, an opportunity to assess behavior outside the home, and some opportunity to observe barriers to learning. 

My issue with lowering the age bracket for screening and diagnosing ADHD is that we really shouldn’t expect 4- and 5-year old kids to behave like 1st graders – even if they are in preschool or kindergarten. We expect them to observe some rules, and to dip into the academic readiness pond – but let’s face it, if we apply the expectations of formal schooling to toddlers we are going to be labeling lots of normative behavior as pathological. And the consequence of that could be starting medication regimens with toddlers without having a solid platform to know that they will need this – and in many cases take on the risks for a number of side effects without knowing that there will be meaningful benefits. A quick case in point is dyslexia – although you can observe the early signs of this in toddlers, diagnosis is typically not applied until the school years because it’s only then that you can gather sufficient developmental evidence for it (you need to let kids get through the developmental window of opportunity for learning to read before you can really know that they have an underlying problem with it).

Look, it’s quite possible to observe behaviors in 4-year-olds that can be improved. The preschool years are an important time for parents (and teachers) to socialize kids, and set up some expectations for behavior that are age-appropriate. There could be lots of reasons why toddlers are showing acting out and disruptive behaviors. Addressing these behaviors and sharing with parents good behavioral techniques and parenting strategies to promote more regulated behavior is a fine goal that would help kids and parents alike. But applying diagnostic labels that may promote immediate prescription drugs for toddlers seems to pull us away from what we should be doing: focusing on best practices for socialization at an age where youngsters should be youngsters. And the reality is as kids get older, there will be much better opportunities to properly identify the small percentage who may profit from more intensive intervention.

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  1. by Dianne

    On October 19, 2011 at 7:10 am

    How about checking these kids for STREP? A common sign of P.A.N.D.A.S. (pediatric autoimmune neuropsychiatric disorder associated with STREP) is attention deficits. Along with attention issues kids with PANDAS can also display sudden behavioral changes such as anxiety, irrationality, tics, ocd, confusion and can suffer handwriting and cognitive declines especially in math Many times these kids do not display the usual signs of STREP infection such as sore throat or fever/headache. Rule out PANDAS with a simple throat culture or blood test. A dose of antibiotics will usually resolve the symptoms.

  2. by Tanya

    On October 27, 2011 at 7:47 am

    As a medical office receptionist in a pediatric practice, I see a disproportionate amount of vanderbilt assessment forms going home with parents of very young children, some whose preschool teachers want them evaluated as young as 3 (!). More often than not, the parents are requesting the forms of their own volition, not at the behest of the physician. It so happens that these parents oftentimes have perfectly normal children, and in a few cases are simply lazy in disciplining their children. They allow the kids to run sound the office, move chairs, climb up the front of my counter, or all three. Meanwhile, the parent is generally on the phone, or sitting in a chair half-heartedly saying “johnny, stop that” without ever making a move to actually stop the behavior. These are usually the parents who get upset that our office will nut even consider evaluating a child for adhd unless they are at least 5 AND in kindergarten. It’s crazy to me that they are suggesting that children younger than that can be expected to sit still and focus all day long! Add to that the fact that most parents don’t even know the actual symptoms of adhd (or combinations of disorders), and we are seeing a generation of kids being raised on drugs. Sad.

  3. by jacques

    On April 12, 2013 at 1:19 pm

    Although as a teacher I do agree that ADHD should be identified as soon as possible to give the child a better chance for his/her future, I also believe that before over reacting, parents need to go through fundamental steps, like making sure the toddlers are eating a good diet, sleeping properly, trying to keep the same sleeping patterns, not over exposing the toddler to the television. Some toddlers can work Iphones or Ipad – is it a good thing?