CCPR: How common is ADHD in young children? 

Dr. Pon: About 2%–5.7% of children ages 3–6 meet criteria for ADHD using the DC:0–5: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (from birth to 5 years old). But the distribution is 3:1 boys to girls vs 50:50 in adolescence. Girls tend toward the inattentive subtype and are diagnosed later. They may just be less active or partly influenced by cultural pressure to suppress overactivity. 

CCPR: Do these diagnostic criteria differ from the DSM-5-TR?

Dr. Pon: The DC:0-5 focuses on inattention during play/activities rather than schoolwork. And while the DSM-5-TR requires “more than one setting,” the DC:0-5 phrases it as “more than one relationship.” Both consider the context of culture and family. For example, if a child enters their first structured environment, they may seem overactive because they’ve never needed to sit quietly. 

CCPR: Aren’t all young children active? 

Dr. Pon: Typical preschoolers are in constant motion, have short attention spans, and lose interest or move rapidly from toy to toy. Parents of preschoolers with ADHD tend to seek care in more extreme circumstances, such as expulsion from day care or preschool due to aggression, dangerous situations, or injuries. 

CCPR: What are your thoughts about the characterization of ADHD as neurodiversity, with goals of acceptance and facilitating function, instead of a disorder?

Dr. Pon: I favor neurodiversity. Parents don’t want their children hearing the label ADHD. And children with ADHD get so much negative feedback. There are great children’s books—My Whirling Twirling Motor, My Wandering Dreaming Mind, My Brain is a Racecar—that frame the child’s experience in a positive way, highlighting strengths like creativity, adventure, or willingness to take risks. Everybody’s brain has different strengths, and some brains must work harder on some things than others. A strengths-based approach is helpful, especially for young kids, because while we want to validate the parents’ concerns and challenges, we don’t want parents to feel their child is doomed. Kids’ brains are developing, and treatment and early intervention can help.

CCPR: How do you assess for ADHD symptoms in preschoolers?

Dr. Pon: Look at the whole picture, including the parents’ upbringing, parenting style, and expectations. Assess the child’s sleep, diet, physical outlets, and sensory sensitivities, including their response to stooling. Some kids are hyperactive when constipated or withholding stool, and symptoms remit after they defecate. Diet matters too: Malnutrition and high sugar in the diet are associated with ADHD symptoms (Pinto S et al, Nutrients 2022;14(20):4332). In utero exposure to drugs, alcohol, or tobacco increases risk of ADHD. Other confounders include anxiety, trauma, and maternal depression. It’s hard for families to talk about trauma and easier to report the child is touching everything, hitting, or not listening. We do preschool observations, see parents and children together, see the child alone, and compare these observations. I see the child at least twice plus a preschool observation. I use videotapes or telehealth to see how structured the child’s natural environment is.

CCPR: How do autism and related conditions fit into the differential diagnosis of ADHD in young children?

Dr. Pon: Children with ADHD struggle to read the room because they are moving so fast. If they can pause, they can think and utilize social cues. Autistic children may not know what to do with these social cues even when there is a pause. They may also have more trouble with joint attention (eg, they might not look at people to share enjoyment).

CCPR: How do bipolar disorder and anxiety in young children compare with ADHD?

Dr. Pon: Parents may describe their child as “bipolar.” However, the rate of early childhood bipolar disorder is so low that, without a significant family history and mood symptoms, that is low on my list. On the other hand, 10%–20% of preschoolers have anxiety disorders and can be hyperactive and/or inattentive due to anxiety (Whalen DJ et al, Child Adolesc Psychiatr Clin N Am 2017;26(3):503–522). Also, children with ADHD often develop anxiety because they are constantly corrected, worried about making mistakes, or becoming anxious after getting into dangerous situations. Anxious children may fidget or talk too much. A pediatrician’s office or an unstructured preschool is a stressful environment for a 3- or 4-year-old, and as a result the child may show ADHD features, resulting in a referral. This is why it’s crucial to evaluate the child across multiple settings and relationships. 

CCPR: What is the role of sleep when assessing ADHD in young children?

Dr. Pon: Poor sleep creates ADHD symptoms, and ADHD affects sleep. Sleep symptoms are also common with mood disorders or anxiety. The structure around bedtime can also affect sleep. Other reasons for preschool sleep issues include obstructive sleep apnea, restless legs, and medication side effects (eg, asthma, allergy medications). We help caregivers implement a consistent, structured, and developmentally appropriate bedtime routine for at least two to four weeks before other interventions.

CCPR: Is there a link between nutrition or metabolic problems and ADHD symptoms in preschoolers? 

Dr. Pon: Red food dye and lead can exacerbate ADHD symptoms. Thyroid testing may be important if there are other symptoms consistent with thyroid problems. But avoid traumatizing the child with too many blood draws. 

CCPR: How do culture or race influence diagnosis of ADHD in young children?

Dr. Pon: Studies are mixed. The Early Childhood Longitudinal Study Birth Cohort tracked US kids through age 5; secondary analysis found that kindergarten teacher–reported classroom behavior had no difference in frequency for ADHD symptoms across ethnic groups, but Black children were 70% less likely to be diagnosed with ADHD than White children (Morgan PL et al, J Child Psychol Psychitar 2014;55:905–913). Hispanic children seemed underdiagnosed; however, that difference was nonsignificant after controlling for whether English was the primary language at home. Other studies show that Black children are more likely to be diagnosed with ADHD (www.tinyurl.com/5n8j9ctk). 

CCPR: What resources can we use to help make the diagnosis?

Dr. Pon: The DC:0–5 can help practitioners clarify symptoms in that age group. The Child Behavioral Checklist 0–5 is a good general assessment for all psychiatric conditions. ADHD-specific scales, like the Vanderbilt, work better in latency-age children. For preschoolers, I usually use the ADHD Rating Scale IV–Preschool Version (www.tinyurl.com/2s3r3rf3). The BRIEF-Preschool and the Conners Early Childhood are typically used by assessment psychologists. For tracking progress, I like the Eyberg Child Behavior, which captures in detail “problematic behaviors” that parents report.

CCPR: Tell us about treatment. 

Dr. Pon: Behavior management is the first line for young children. It’s easier for 3- to 5-year-olds to learn to work with us than older children. These programs train parents to scaffold their child’s regulation, then help their child learn independent self-regulation: Parent Management Training (PMT), Positive Parenting Program, Incredible Years, and ­Parent-Child Interaction Therapy (PCIT). For ages 2–7, I favor PCIT, because sessions include both parent and child, using live coaching to help the parent practice skills to use outside of sessions.

CCPR: How do you explain therapy to the parent?

Dr. Pon: I tell parents these skills will help all their children—understanding age-appropriate behaviors, setting expectations, using positive-labeled behavior praises to get more of the behaviors they want, and delivering developmentally appropriate, consistent, natural consequences. PCIT improves the child’s social behavior, fosters parent-child attachment, and teaches parent behavior management skills. Therapy distinguishes behaviors from feelings, so parents can model support and validation rather than consequences for negative emotions.

CCPR: Which professionals do PMT? 

Dr. Pon: Some child psychiatrists do PMT, but psychologists, licensed marriage and family therapists, and licensed clinical social workers deliver these treatments. This is different from parent coaching—this isn’t “how to be a better parent.” These are specialized skills to address ADHD. For example, transitions are often extremely difficult for young children with ADHD. The tendency to hyperfocus, time blindness, difficulty with initiation, and emotional dysregulation impair a child’s ability to move from one task to another throughout the day. We train parents to scaffold their child with visual timers, transition prompts, brief effective commands, and positive reinforcement to support transitions. We also help parents organize their day to manage common points of dysregulation (moving from preferred to unpreferred tasks) with movement/activity or rewards. We also train parents on how to give effective commands to their young child with ADHD. These need to be brief, single-step, specific, and immediate; we may recommend the parent pairs the command with physical touch (like a hand on the back), or a visual cue (like a transition card) to optimize listening as children with ADHD often cannot follow auditory directions alone.

CCPR: Is it difficult to find therapists who do these therapies? 

Dr. Pon: If you self-pay, there are many providers. It is hard to find insurance-based providers who work with 3- to 5-year-olds and have the experience to tailor techniques and developmentally appropriate expectations. Parents should ask: “Do you have a lot of experience with young children?” 

CCPR: How is therapy with a young child different from therapy with older children? 

Dr. Pon: We nurture relationships through play before any commands or consequences. Young children learn and navigate the world through play, and we support child-directed play where the parent utilizes verbal reflections and behavior descriptions while minimizing commands, questions, and critical statements. Without that positive nurturing, the young child is unlikely to listen despite any consequences. Children with ADHD are told all day what to do and not to do, so the parent directing play can increase the child’s anxiety and elicit oppositionality. 

CCPR: What’s the problem with asking questions? 

Dr. Pon: Adults naturally communicate through questions; however, young children experience questions as intrusive and a command to answer. If you observe young children and their parents, you will notice they ignore a lot of questions from the parents (and possibly the provider). We want to help parents utilize child-centered language and decrease unnecessary questions so they don’t inadvertently create or reinforce a cycle of “not listening.” I see many young children improve behaviorally with just this positive time and these skills with the parent. 

CCPR: Are there differences in how you reinforce behavior in young children vs latency-age children? 

Dr. Pon: A token economy is a common behavioral intervention that we teach parents. Latency-age children might earn stars and spend them on a screen time privilege. A 3-year-old child cannot wait and save up stars for even a day. They need a developmentally appropriate tighter reinforcement schedule—a third of the day or at most half of the day. 

CCPR: What is the role of medication in the treatment of ADHD in young children?

Dr. Pon: Consider methylphenidate if there are safety concerns or severe impairment. The Preschool ADHD Treatment Study (PATS) showed that methylphenidate reduces symptoms of ADHD in preschool children. Up to 30% of young children are likely to experience adverse side effects, including emotional outbursts, irritability, sleep difficulties, decreased appetite, and weight loss. Parents in the PATS discontinued medication more often compared to older children because of adverse side effects. So start low and go slow. For medication-naive patients on the younger side, consider starting at 0.3 mg/kg/dose of methylphenidate as the PATS showed an average of 0.7 +/- 0.4 mg/kg/day. Another study used 0.3 mg/kg/dose and 0.5 mg/kg/dose with BID dosing, though I usually start with once daily to evaluate tolerability. Also consider whether the child still needs naps (Musten LM et al, J Am Acad Child Adolesc Psychiatry 1997;36(10):1407–1415). The FDA has also approved short-acting amphetamines for treating ADHD in 3- to 5-year-olds, but they tend to produce even more side effects (Childress AC and Stark JG, J Child Adolesc Psychopharmacol 2018;28(9):606–614).

CCPR: Do the side effects have to do with CNS development?

Dr. Pon: Absolutely. Young children lack myelination and development of the prefrontal cortical tracts, and we think that this is the cause of the side effects and reduced efficacy of stimulant medications in this population. By 7, 8, or 9, children do beautifully, with the response that we would expect. Counsel parents about this difference so that they modulate their expectations. 

CCPR: How do medications fit into the bigger plan?

Dr. Pon: Preschool children may have a hard time at dinner or bedtime, but these are bad times to give stimulants. I talk with parents about behavior therapy, structure, and setting limits (eg, safety rules, limits on electronics, and bedtime) in combination with medications during the day. This scaffolding helps the child develop self-regulation even at times with no medication.

CCPR: Do you use central alpha-agonists like clonidine or guanfacine in the evening?

Dr. Pon: Clonidine and guanfacine are helpful off-label for young children, especially children with comorbid anxiety or sleep issues. Alpha-agonists reduce hyperactive-impulsive symptoms in young children, which at this age often are more problematic than “inattentive” symptoms. There are no randomized controlled trials of alpha-agonists in the preschool population, but about 25% of young children with ADHD are prescribed an alpha-agonist vs 35% who are prescribed stimulants. The efficacy of alpha-agonists for ADHD in young children seems lower than for stimulants but with fewer side effects. Young children can become irritable or have sleep disturbances on alpha-agonists. 

CCPR: Is there a role for supplements? 

Dr. Pon: Many of my patients take melatonin, but parents need to know to dose it 1.5–2 hours before the target bedtime. I start with 1–3 mg and give it 10–14 days to see if it works (Gleason MM et al, J Am Acad Child Adolesc Psychiatry 2007;46(12):1532–1572). Magnesium can help sleep, constipation, and stooling issues. I usually recommend “Calm” gummies with 81 mg, no more than 200 mg for a young child, and monitor their stools. 

CCPR: Are there other therapies that you typically recommend for young children with ADHD?

Dr. Pon: We mentioned sleep. Also think about increasing exercise. I refer young children with ADHD to occupational therapists (OTs) and social executive functioning skills groups. Skilled OTs can teach young children body-based regulation strategies, especially when the child is hyperactive, impulsive, sensory-seeking, or avoiding. OT programs such as Zones of Regulation address both emotional and physical self-regulation. Social executive functioning skills groups differ from traditional social skills groups for children with autism, which tend to be more basic. ADHD symptoms affect friendships (eg, when a child dominates play, is too rough or intrusive, makes unfiltered statements that alienate peers, or struggles to maintain friendships). Groups are usually led by a speech therapist with two to four children and focus on scaffolding play, slowing things down, and practicing prosocial interactions. This can improve frustration tolerance, perspective-taking, and flexibility with play.

CCPR: How do you talk with parents about the course of ADHD?

Dr. Pon: ADHD is a lifelong condition, with different challenges at different developmental stages. Inattention often becomes obvious when the child begins formal education, and overactivity may abate in young adulthood. Empower parents to learn skills now that they’ll use for 20 years. Help parents understand how constantly correcting a child, telling them “don’t do that,” or getting into trouble affects self-esteem. Help parents monitor their children for mood and anxiety symptoms over the years even if the child doesn’t have those symptoms early on.

CCPR: Thank you for your time, Dr. Pon.