ADHD

Dr. Greene, how long should a toddler be expected to pay attention to one thing? My 3-year-old just can’t sit still. Could he have ADHD?
Kate – New York, New York

ADHD

Dr. Greene’s Answer:

After a long day in the office, when I would be ready to wind down with a quiet evening, my youngest son, almost 3, is switching on his turbo jets! Together, as Batman and Robin, we race around the house chasing imaginary villains. We catch up with them, tie them up, untie them, and sprint again more times than I can count. Sometimes we get tied up, and Mommy rescues us. In between we jump on Casper, his broomstick Bat Horse, and gallop around the town to say “Hi!” to the pirates. When we pass the basketball hoop, we pause ever so briefly to play a game of basketball, before zipping outside to hit some baseballs and run. A dash to the front yard to throw rocks and play hockey, then back inside for Batman and Robin to make a tunnel and hide, vibrating with excitement, for Mommy to find.

Where does he get that boundless energy?

When a toddler enters that stage of zest and fascination, it’s almost a parental rite of passage to discover this force of nature, as if for the first time, and remark, “If only we could bottle that energy and sell it, we would be rich!” or “I could sure use a transfusion of his energy (and he could stand a little less),” or “Youth is wasted on the young!”

A three-year-old’s normal fountain of energy delights and exhausts, and sometimes frustrates and worries, modern-day parents. Perhaps our world doesn’t accommodate this explosion of energy as well as the pioneer or farming days of old might have. Today, we hear about the medical condition called Attention Deficit Hyperactivity Disorder (ADD or ADHD), and wonder if our children might be hyperactive. By age 4, about 40 percent of children act in a way that makes their parents and teachers concerned about ADD (Developmental and Behavioral Pediatrics, 6, 339-348, 1985).

Some people are very tall, some are short, but most are of average height or close to it. As with most things in life, something of a bell-shaped curve also applies when it comes to toddler energy levels. There is a normal, average period of extreme energy that lasts about a year and often includes the 3rd birthday. This phase in normal children actually fits the official definition of ADHD.

There are several good, “official” definitions of ADHD, but I find the definition in the DSM-IV the most useful (Diagnostic and Statistical Manual of Mental Disorders, 4th edition). This definition differentiates symptoms into two categories: “Inattention” and “Hyperactivity-Impulsivity.” Children with a diagnosis of ADHD should meet A-E of the criteria below:

A. Either 1 or 2:

1. Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

  • a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • b. Often has difficulty sustaining attention in tasks or play activities
  • c. Often does not seem to listen when spoken to directly
  • d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
  • e. Often has difficulty organizing tasks and activities
  • f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as homework)
  • g. Often loses things necessary for tasks or activities (toys, school assignments, pencils, books, or tools)
  • h. Is often easily distracted by extraneous stimuli
  • i. Is often forgetful in daily activities

2. Six or more of the following symptoms of hyperactivity- impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity

  • a. Often fidgets with hands or feet or squirms in seat
  • b. Often leaves seat in classroom or in other situations in which remaining seated is expected
  • c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
  • d. Often has difficulty playing or engaging in leisure activities quietly
  • e. Is often “on the go” or often acts as if “driven by a motor”
  • f. Often talks excessively
    Impulsivity
  • g. Often blurts out answers before questions have been completed
  • h. Often has difficulty awaiting turn
  • i. Often interrupts or intrudes on others (such as butting into conversations or games)

B. Some hyperactive, impulsive, or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (such as in school or work and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or another psychotic disorder and are not better accounted for by another mental disorder (such as a mood, anxiety, dissociative, or personality disorder).

Children meet the criteria for “ADHD, Predominantly Inattentive Type” when they have met inattention criteria (section A1) for the past 6 months. They meet criteria for “ADHD, Predominantly Hyperactive-Impulsive Type” when they have met hyperactive-impulsive criteria (section A2) for the past 6 months. When a child meets criteria for both section A1 and A2 for the past six months, he/she meets the criteria for “ADHD, Combined Type.” Now, parents who have tried to take a 3-year-old out for a leisurely dinner in a quiet restaurant (especially with other adults whose opinions they value) can quickly learn that normal children at this age can exhibit all of these behaviors.

Perhaps a good way to tell whether a child’s development is normal would be to ask his daycare providers, preschool teachers, or religious teachers. These adults see at close range a larger sampling of children. If your child is more active, more restless, less attentive, and more impulsive than the rest of the class, then he might have ADHD. However, ADHD is a very difficult diagnosis to make in children younger than school-age.

Less than half of those actually diagnosed with ADHD at age three, and only 10 percent of those who concern their early teachers, will be the ones who turn out to have ADHD in the long run (Journal of Child Psychology and Psychiatry, Sep 1990). The toddler full-tilt exuberance usually gives way to the dawning self-control of a preschooler at about age four. Different children go through this energetic stage at different ages. Those who still fit the criteria for ADHD at age 4, though, have a greater chance of truly having ADHD.

There is still no reliable way to make the diagnosis of ADHD in a 3-year-old. Researchers are only now beginning to look into how to properly make the diagnosis in these younger children (Journal of Developmental and Behavioral Pediatrics: Feb 2002, 23(0), S1-S9)

Thus, I would be more concerned about problems of social interactions with peers than with a short attention span, more concerned with those for whom it is difficult to obtain a babysitter than with those who are always on the go, and more concerned with those who consistently disrupt other children’s play than with those who fail to listen.

This afternoon, we took our almost 3-year-old son to a community theater production of Big River. He sat fairly still and fairly quietly through the first act. His whole body danced with each musical number on stage. During intermission, several friendly onlookers commented on his energy and enthusiasm. He charmed them with his smile. By the end of intermission, though, it became clear that the time to end his first theater experience on a positive note had arrived. So we went outside for a walk and to play golf on the sidewalk. As much energy as it takes to keep up with him, I shall dearly miss these days when they are over.

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Dr. Alan Greene

Dr. Greene is the founder of DrGreene.com (cited by the AMA as “the pioneer physician Web site”), a practicing pediatrician, father of four, & author of Raising Baby Green & Feeding Baby Green. He appears frequently in the media including such venues as the The New York Times, the TODAY Show, Good Morning America, & the Dr. Oz Show.

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