Child Behavior

American Academy of Pediatrics

Attention-Deficit/Hyperactivity Disorder—Behavioral Issues in Child Care and Schools

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ICD10

  • R45.87

  • R41.840

  • R46.3

  • F90

  • Z55

How can children with attention- deficit/hyperactivity disorder be identified?

  • Children with attention-deficit/hyperactivity disorder (ADHD) have higher levels of impulsivity and hyperactivity and/or inattention than other children their age.

  • Not every child who has disorganized or impulsive behaviors has ADHD. The most important step is to look for other causes, especially exposure to traumatic events or stressors, developmental delays, and mood and anxiety problems.

  • These symptoms are chronic, lasting at least 6 months and generally longer.

  • Young children with ADHD are often identified because they have trouble following rules, and sometimes adults think children aren’t trying hard enough or are intentionally breaking rules. Sometimes children with ADHD are identified because they get frustrated or angry, often because even though they are trying to do their best, their symptoms get in the way of them being successful.

How common is it?

  • About 2% to 3% of preschoolers and 8% of older children have ADHD.

  • It is more common in children

    • Born preterm

    • With other brain conditions, such as seizures, head injuries, or learning problems

    • With specific genetic conditions, such as fragile X syndrome

    • With a history of lead exposure

    • Exposed to significant adversity or challenges, including poverty, food insecurity, and violence

    • With siblings or parents who have ADHD

  • In young children, girls and boys have ADHD at the same rates, but in older children, boys with ADHD tend to be identified more frequently than girls.

  • There is some research to suggest that white children receive diagnoses of ADHD more than children of other races, even though they are not actually more likely to have ADHD.

What are the behaviors usually seen?

  • Very young children with ADHD may have trouble with

    • Keeping their body still and not fidgeting

    • Staying seated when they are expected to be sitting (and when other children are sitting)

    • Not running and climbing on furniture or objects outdoors

    • Playing quietly

    • Moving slowly and/or having a plan for their actions

    • Being overly talkative

    • Calling out in class or circle time

    • Waiting their turn in conversations and play

  • Inattention problems are less common in younger children but can include problems with

    • Careless mistakes

    • Paying attention

    • Listening when people are talking

    • Following directions, especially when directions have more than one step

    • Organizing their belongings

    • Focusing on reading or puzzles

    • Keeping track of things they need to have (eg, shoes, backpacks)

    • Getting distracted by other people talking, other noises, or objects

    • Losing track of basic activities

  • While many young children have some of these patterns, children with ADHD have at least 6 impulsive/hyperactive symptoms and/or at least 6 inattentive symptoms and have trouble functioning in 2 parts of their lives (eg, home and school).

  • It is important to note that there are many reasons why a child may be impulsive, hyperactive, or inattentive and that the diagnosis requires careful assessment by a pediatrician or developmental or mental health professional. Other reasons for similar patterns of behavior include

    • Typical development

    • Being the youngest in the classroom

    • Sleep problems

    • Vision or hearing problems

    • Developmental delays

    • Anxiety disorders

    • Autism spectrum disorder

    • Trauma exposure

    • Exposure to caregivers with depression or other mental health problems

    • Caregiver depression or low frustration tolerance

When should a more concerning issue be suspected?

  • Children with ADHD may have trouble

    • Participating in organized activities that require sitting or focus, including circle time, desk work, or quiet play centers

    • Interacting with others in situations that require taking turns or having patience

    • Following multistep directions

  • Children with ADHD may show their difficulties by

    • Not participating in activities

    • Not being able to stay on task

    • Talking out of turn (interrupting)

    • Showing aggression toward others when they are frustrated

    • Making lots of careless mistakes

    • Running, climbing, and sometimes getting hurt because of careless physical play

  • If these patterns persist, even with structured approaches to promoting positive behaviors, caregivers may encourage families to seek out support from the child’s pediatrician or other primary care pediatric clinician, a developmental specialist, or a mental health professional who has training in early childhood.

What are typical management strategies in the behavioral support plan?

  • Children with ADHD benefit from even more structured approaches to positive behavioral strategies.

  • Specifically, adults can help children with ADHD practice on-task behaviors by

    • Providing positive attention for on-task behaviors such as

      • Following directions

      • Sitting quietly (even for just a bit longer than usual)

      • Waiting their turn to talk or participate

      • Staying engaged in an activity such as reading

    • Providing positive attention in the form of

      • Praise that is specific for the behavior— a quick “Good job waiting!” or “Thank you for using your inside voice!”

      • Describing what you see the child doing— “I see Joey sitting on his circle spot.”

      • Repeating what the child says—when the child says “I’m drawing a circle,” responding with, “Yes! You are drawing a circle!”

    • Not giving attention to ADHD symptoms that are not unsafe and only somewhat distracting to other children, such as a child with ADHD twirling her fingers during story time or wiggling her feet.

    • Using clear, consistent consequences for unsafe, inappropriate behaviors, such as aggression, in the form of time-out or removal of a privilege for a brief period. Children with ADHD will succeed best if they know how they can work to earn back the privilege.

  • Adults can also help young children with ADHD be successful by giving them approved opportunities to move around the room and use some energy. Examples include being a helper who brings needed items to the teacher or who helps move nap time mats with the adults.

  • Children with ADHD may have more difficulty settling down for nap time. They may need a quieter space and may not sleep. Adults may need to be flexible and let them look at books quietly if they cannot sleep.

When should I ask for additional support?

  • A mental health consultant can help tailor expectations for children with ADHD and develop appropriate behavioral plans.

  • Young children who appear to have ADHD should undergo a full assessment by a pediatrician or developmental or mental health professional who has expertise in working with young children.

  • Children with ADHD should undergo behavioral therapy based on the same principles as those described previously for classroom behavioral plans. These behavioral treatments are often called parent management training because caregivers are taught the same skills therapists use to help a child practice on-task behaviors.

  • Medications are not the first-line treatment for ADHD in preschoolers, but they may be considered if children do not show improvement with therapy. There is little research, but it does show that ADHD medications are less effective in preschoolers than in older children and have more side effects. In children older than 6 years with ADHD, stimulant medications are the first-line treatment.

  • Children’s therapists, pediatricians, or clinicians who are treating ADHD may ask teachers to complete questionnaires that ask about a child’s symptoms. Questionnaires aid in assessment and help track the effects of treatments. It is helpful to add written comments to expand on questionnaire responses. Responses can be returned to families without any formal, specific consent process and can be sent directly to the pediatrician or other clinician with the parent’s consent. Direct communication with a treating clinician can be invaluable. The more information that is made available to the child’s therapist, the more specific the treatment plan can be.

What training and/or policies may be needed?

  • Training child care and early education staff members in positive behavioral management techniques can help children with ADHD be more successful.

  • Medication administration policies may apply in the small number of children who take medications for ADHD and who may have to take a dose at lunchtime.

Where can I find additional resources?

  • Children and Adults with Attention-Deficit/ Hyperactivity Disorder: Preschoolers and ADHD (https://chadd.org/for-parents/preschoolers-and-adhd)

  • Green RW. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children. New York, NY: HarperCollins Publishers; 2014

Adapted from Managing Behavioral Issues in Child Care and Schools: A Quick Reference Guide.

Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

© 2020 American Academy of Pediatrics. All rights reserved.

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