Q&A -- Does My Child Have ADHD?

We recently received this question from Erin:

My son is 2 1/2 years old.  He's cute, sweet, and smart, has a great vocabulary, and is actively participating in potty-training.  My Husband and I, however, are concerned he might have ADHD. 

He is very active in class and is constantly aggressive at home and at school.  He's in a preschool class with approximately 20 children and 3 adults.  He bites the other children frequently, often several times per day.  He knows this behavior is wrong and always apologizes immediately and remorsefully.  He agrees not to bite again and says, "I don't want to bite," yet he can't seem to stop himself.  Often, he bites the children without any provocation at all.  He bounces around the class without seeming to be able to focus on one activity for any length of time.  He often takes toys from several children at a time, quickly moving from one to another, until the teacher notices that several children are crying because of him.  For several months, we have talked to him about his behavior, while just considering it age appropriate and agreeing he is a rambunctious little boy, a challenge.  At a recent conference with his teacher, she admitted that his general behavior is definitely different from the other children. 

Other behaviors include:

Biting
Throwing
Pinching
Hitting
Pushing
Aggressive behavior (taking toys, etc.)
Refusal to sit during meal times, throwing food, spilling drinks, etc.
Refusal to sit during circle time

At home he acts the same way, minus the biting. His has an older sister that he loves very much, but he is aggressive to her as well. Is this just the terrible twos, or is it something more that we should be concerned about?  I’ve made an appointment to have him tested for ADHD, but the soonest he can be seen is 6 months from now.

First, according to the DSM IV, it's really difficult to make the diagnosis in children younger than 4 or 5 years old.  Thus, should the examining neurologist give your son this diagnosis, I would absolutely get a second, even third, opinion.  In the end, there is no absolute objective test for ADHD.  Most clinicians make the diagnosis based on behavioral criteria and use checklists completed by the parents and teachers -- clearly and nonobjective method.  A neurologist will most likely examine the brain since certain regions have been found to be smaller in children diagnosed with ADHD.  While this method may seem to be the most objective, there is still some concern since studies examining the brains of children with ADHD generally only include those who have been medicated (Krain & Castellanos, 2006).  Finding unmedicated diagnosed children is very difficult.  Thus, the question becomes: are the smaller brain regions due to the medication or ADHD? 

In the end, just be cautious and get as much information from a variety of sources as possible should you decide to get your son tested.

With that said, I, obviously, have not personally observed your son, so I can't say for sure whether or not he has ADHD.  What I can tell you, however, is that based on your description of his behavior, including further descriptions you supplied to me in private email communications, it sounds like your son has a very active temperament.  This does not mean, however, he has ADHD.  One can have an active temperament and still be able to focus for a period of time.  However, your son is still very young, so I don't really expect him to focus for too long. 

Additionally, the aggressive behaviors you describe, sound very much like normal toddler behavior -- especially since he started displaying them around 18 months of age (according to your email), which is when the "terrible twos" begin for a lot of kids (mine included!).  I know his teacher claims his behavior is "different" from the the other children, but it's not that different from what I've seen at other preschools or even at my neighborhood playgroup.

Before having him checked out for ADHD, I would use some behavioral modification techniques.  For instance, when he takes another kid's toy, show him, step-by-step, the proper way to handle this interaction.  Give him the words (which I know you do), AND give him the behavior.  Guide him through the interaction, cuing him to take the toy from Susie once she offers it to him. 

When he bites or hits, remove him from the situation immediately.  After giving him two minutes by himself (since I know you use time-outs), try to find out what he wanted.  Did he want the child's attention?  Your attention?  If possible, find out why he bit or hit.  This may be difficult, and he may not be able to articulate why, but since he's very verbal, I would give it a try without being too interrogative.  Whatever his response, teach him what to do instead of biting or hitting.  But keep it simple!  No lecturing!

If he gets up and walks around at mealtime (which is normal!), then I would tell him very clearly, "If you get up, mealtime is over."  You may have to take his food away a few times, but he'll get the idea.  Once he does get the idea, you'll still have to remind him, and he may stand-up instead of sitting (he is active, after all!), but he'll be far less likely to walk away from the table.

As far as getting up at circle time, honestly, I don't have a problem with this.  For a 2 1/2 year-old with an active temperament, I'm not surprised he wants to do something other than sit and listen to his teacher.  At some schools, children this age not required to sit at circle time.  Instead, they're given the option to do something quietly by themselves.  A program such as this may better suit his temperament.

Basically, you and his teacher should be very clear and consistent with your expectations, limits and boundaries.  And be sure to do it in a way that doesn't make him feel like he's "bad" or there's something "wrong" with him.  This is especially important because the behaviors have been going on for some time, so it's easy for everyone -- parents and teachers -- to feel exasperated and to show that exasperation to him through their own behavior.  Sometimes, if a child feels like he's "bad" he'll just keep misbehaving because "Why not? I'm bad anyway," or because he doesn't know what to do instead.  (I'm not saying that that is what's happening here -- I just think it's something to be aware of.)

If you don't see any positive change in his behavior after a couple of months (and be sure to keep a record of it), then I would keep the appointment with the neurologist and have him examined. 

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Krain, A. L., Castellanos, X. (2006).  Brain development and ADHD.  Clinical Psychology Review, Vol., 26(4), 433-444.

Comments

[Kat O+]

I've had a few relatives suspected and diagnosed with ADHD but I agree, the diagnostic methods seem a little subjective to me. Another thing Erin might like to try is to experiment with her child's diet. He might be sensitive to certain types of food, which might be aggravating his behaviour. There are lots of diet camps out there - low GI, low dairy, etc. - so maybe just play around with his food, try different things and see if they make a difference or if any specific food items help/make it worse.

Oh, and maybe make sure he's getting enough sleep. Overtiredness might be a contributing factor.

Just some ideas. Good luck, Erin!

[Laura S.]

Good suggestions, Kat!

[ktjrdn]

I agree. A friend of mine has a daughter that was driving her nuts. After dealing with it for quite a while, they finally found that she had an allergy to soy. Now that they manage her diet, she is much more agreeable.

[candace]

I have to add: don't EVER take your child to a psychiatrist/psychologist/specialst to be tested for a specific thing (unless, of course, other tests have shown that the child has some specific thing and you're getting a second opinion). It's VERY easy to "find" ADHD in pretty much any kid, if you're looking for it. If it's at all possible, simply make the appointment by saying that something about your child's behavior is troubling you and you'd like to get some help. You can certainly explain those behaviors that are a problem without saying, "I'm wondering if my child has ADHD."

[honey]

Good advice. Diet affects so many people in different ways and not just ADHD.

[texasgal]

I would consider an evaluation by an occupational therapist. He sounds just like my son and mine has been diagnosed with both ADHD and SPD (sensory processing disorder). My son started showing obvious signs at the same age and we ended up getting him help through the early childhood intervention program through the local school district when he was 3. My son is in Kindergarten now and because of the ADHD diagnosis, he qualifies for special education services in a mainstream class. We have ARDs to discuss his IEP and BIP and he gets "sensory breaks" in school.