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Is ADHD a Valid Diagnosis is Young Children?
The younger children are, the more likely they are to seem overactive, impulsive, and inattentive. Just compare the attention span and activity level of your typical 4 year old with a typical 10 year old. For this reason, it can be more difficult to make the diagnosis of ADHD in younger children and some professionals have even questioned whether it makes sense to make this diagnosis in preschoolers. I’m sure that some of you may have experienced this first hand when your initial concerns expressed to physicians were responded to with "He’s just an active boy."
Professionals have become particularly concerned with this question because the current diagnostic criteria set forth in DSM-IV permits children who display no inattentive symptoms and only hyperactive-impulsive symptoms to be given the diagnosis (i.e. such a child would be diagnosed ADHD, Predominantly Hyperactive/Impulsive Type). Many of these children would not have been diagnosed with ADHD using the prior set of guidelines and concern has been expressed that this might increase the diagnosis being given to active but otherwise unimpaired preschool and primary school children.
A study which appears in the July 1998 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (pages 695 -702) takes a careful look at this important question. In this study 126 3-7 year old children who met current diagnostic criteria for ADHD were compared with 126 same age children who did not. The authors were interested in determining how these children were functioning in important life areas such as peer relations, behavior at school, impairment reported by parents, and early academic functioning.
Please note that these areas are not specific symptoms of ADHD, but are life areas that children with ADHD often have trouble in. The logic of the study was to determine if even at a young age, children who show the primary symptoms of ADHD (i.e. inattention, impulsivity, and overactivity) are also showing early signs of struggle in these important areas. If they are, it would indicate that ADHD is a valid diagnosis in young children because it is associated with significant impairment in important life areas. If, however, the children who showed the primary ADHD symptoms were not having trouble in these areas, it would suggest that the diagnosis of ADHD in young children is problematic. After all, if a child is doing fine socially, academically, and behaviorally, what sense does it make to say that he or she has a disorder?
The results were striking and clear cut. Even after controlling for other psychiatric symptoms (i.e oppositional defiant disorder (ODD), conduct disorder (CD), depression, and anxiety) the children with ADHD were faring less well than their counterparts at an early age. Children who met criteria for each subtype of ADHD were rated by teachers as being liked by fewer classmates and ignored by more classmates than comparison children. They were also rated by teachers as being less prosocial and less assertive. Mirroring the teachers’ reports, the children themselves indicated that they were experiencing friendship difficulties, and this was true regardless of which subtype (i.e. hyperactive/impulsive, inattentive, or combined) the child had been diagnosed with. (Note: for a complete discussion of current diagnostic criteria you can click here .
Academically, young children with ADHD were already showing signs of difficulty. This was assessed by determining the difference between children’s IQ results and their achievement test results. In general, achievement test scores and IQ scores should be roughly equivalent - when they are it indicates that a child is learning about as well as he/she should based on how smart they are. When achievement test scores start dropping significantly below a child’s IQ score, it indicates that the child is not learning at a level that is consistent with his potential. In math, children with ADHD had significantly lower math scores relative to their intelligence than did control children. A similar trend was found for reading, but the results were not quite as strong. Finally, even at this young age, children with ADHD (at least those who had started school) were already more likely to be in special education classes for learning and/or behavior problems.
These are very compelling results and clearly indicate that ADHD - when it is diagnosed properly - is a very real and important condition in preschool and beginning elementary school children. As was clearly demonstrated, young children who are carefully diagnosed with ADHD are not just children who are a bit more active and inattentive than their peers. Rather, they are already having trouble making friends, behaving prosocially, and achieving at a level that is consistent with their potential.
The implications of these results are equally clear. It is just not appropriate to do nothing for a young child whose symptoms are consistent with an ADHD diagnosis. It is still fairly common practice for treatment to be withheld until a child begins school in the hope that he or she will "grow out of it." In other cases, the concerns expressed by parents are dismissed as reflecting their inability to manage and discipline their child. Many children this will not "outgrow" their symptoms, however, and in the meantime, months and years are passing where a child is really struggling without any help. The longer a child’s struggles go unaddressed, and the further he or she falls behind in the social and academic arenas, the more difficulty it generally is to get back on track.
Understandably, many physicians are reluctant to prescribe medication to preschool children, and parents of young children displaying these problems are then often left with nothing to do. It is essential to be aware that there are alternative psychological and behavioral approaches to help with the difficulties that preschoolers with ADHD display and the decision not to treat with medication does not need to mean a decision not to treat at all. Even if one is reluctant to label a child as having ADHD at a very young age (personally, I do not feel comfortable making this diagnosis prior to kindergarten) that does not mean that help can and should not be provided to parents and children who are having a difficult time.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.