Is Four Too Young For an ADHD Diagnosis?
Are we in danger of medicating away youthful exuberance?
The American Association of Pediatrics has released new guidelines that drop the recommended starting age for evaluating children for Attention Deficit and Hyperactivity Disorder from six to four years old, raising concerns about medicating children so young and that diagnoses will become even more widespread.
Per the Chicago Tribune, “There is now enough evidence to address this broader age range,” says Dr. Mark Wolraich, the lead author of the report that was released last weekend, “We know that identifying and treating kids at a young age is important … because the earlier we can provide treatment, the better chance of success.”
As a mother of a son who was diagnosed with ADHD at five and started medication just shy of six, even I am alarmed when I hear that four-year-olds are being diagnosed and labeled as ADHD. I am well aware of the fact that ADHD manifests itself in many ways and feel for any parent of a “difficult” child, but it just seems like a bad idea to open this up and invite irresponsible doctors to prescribe medication to children that are barely out of their toddlerhood.
The guidelines recommend starting behavioral therapy and parental training as the first method of treatment for diagnosed four-year-olds, noting the importance of instructing parents on how to build the structured environment that ADHD children need to help control their impulsivity, hyperactivity and inattentiveness (while hopefully NOT make everyone else in the family crazy in the process).
But how many families fail at creating such an environment and quickly turn to medication? I am sure that they are well-intentioned, but can’t help but imagine the exhaustion level of these parents (many of whom suffer from varying levels of ADD, as well). The promise of medication to make the calls from the preschool stop, to help restore order to their days, and/or to just make life easier is difficult to resist.
According to the U.S. Center for Disease Control, ADHD is now being diagnosed in almost 1 out of every 10 American children, and is the most widespread neurological disorder in children. It can have devastating long-term effects from the low self-esteem that comes from constantly being told that something is wrong with them, to a higher rate of dropping out of school (32% compared to the average of 16% among other students), to problems with substance abuse later in life.
I believe strongly, from personal experience, that medication can make a world of difference for ADHD kids. I can tell you about that February evening when, after our son’s first day on a low dose of Ritalin, his kindergarten teacher called to tell us that he had played in the “home life” area of the classroom that day for the first time and had said to her, “This is so much fun!! When did you put these toys here??” because he had never even noticed that part of the classroom before. I can also tell you about the times before and how my heart would break every time he would cry after school while telling me that nobody would talk to him at school and that “everybody hates me.” And then I will tell you how the medication enabled him to slow down long enough to take the time to make friends with those same children.
I can also tell you, with hesitation and not a little humiliation, that before we started the medication, I was an absolute mess. My husband and I had tried our best to manage our three children (all under the age of seven) with Raising Your Spirited Child and Parenting With Love and Logic as my guides, but it was not enough. Our evenings were chaotic and whatever progress I might make with the one, would be erased by another’s regression. Add marital discord over whether or not to medicate and how to deal with the increasing disorder in our household and you can see how I would be profoundly grateful that medication ended up taking away at least one of the stresses in our lives … but more importantly, and to the point, it eased almost ALL the stress that our son was experiencing at school.
So, while I agree with Dr. Wolraich and the study that treatment is vital for children with ADHD, I just can’t get behind anything but behavioral counseling at so young an age.
Why do I draw a distinction between four and five? Because preschool is not SCHOOL.
Because children at four are expected to run around. Because even though your little tyrant might be making you crazy, he is still just a vulnerable, tiny four-year-old that, at the end of the day, just needs to be loved by his parents and accepted for who he is no matter what.
Consider your time spent defending your child from advice to medicate as training to become your child’s advocate — a role you will have to take up quite vigorously when they enter the school system.
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I’m with you Amy. Ryan is in 2nd grade and he’s had his medicine for only 3 weeks. We’re seeing a huge improvement in this short amount of time. And I will say without any uncertainty at all that he was experiencing the same disorganization and lack of focus as he is today back in Pre-K. And we saw it again in Kindergarten…and 1st grade and now finally we explored this option. I am hoping for the best. So far, so good.
Amy – your story is almost the exact same as mine — my little guy (now 6) HATED kindergarden and cried every day — other kids called him the “bad kid”. After low dose ritalin, things completely turned around. It was also necessary for me to learn more about ADHD, how to give him direction – and how to tailor my expectations. At three and four when other kids are dressing themselves I had a hard time keeping my guy in clothes at all! He was (and still is) messy when he eats, loses things, and can be tough to deal with. I think one of the greatest gifts his diagnosis has given me is the realization that I wasn’t failing as a parent – that he was not “just a boy” – and that there was help out there for us. Early intervention is key — maybe not early meds – but just knowing there is a problem can be a relief and can help calm the storm.
My 8 year old just started Ritalin a few weeks ago. We pushed against accusations of ADHD for years longer than we should have because of the stigma against meds. We have a well worn copy of How To Raise Your Spirited Child, Scream Free Parenting (even did the online course), a bunch of Coloroso books, Positive Discipline. I went through years of scrips for Lexapro and Prozac (never worked, my depression was extreme stress). I put on 100lbs (yes, that’s right, 100lbs) due to severe stress, lack of sleep, emotional eating. I almost ruined my marriage because I because the biggest a&&hole around. The very first day on meds, my son came home and happily did homework with me and commented, “this is hard but fun!” and I cried. I wrote about it on my blog: http://momcast.blogspot.com/2011/09/writing-on-wall.html But to address the question whether 4 is too young: we start Junior Kindergarten at age 4 here. In my experience, the kids with the issues who go on to get a diagnosis and require and respond well to meds show very clear signs as young as 4. We had communication books with every single teacher starting in JK due to my son’s “issues”. I made special visual charts that outlined how to come in from recess! He bit a kid on the face – which was the worst physical thing he did, be physical aggression was one of the ways he expressed his frustration with the world. If there wasn’t such a stigma around meds and the ADHD diagnosis, I would have enthusiastically pursued meds at that age and not gone through years of heartache watching him be socially isolated, unhappy, unable to learn in a school environment all the way to ultimately starting to discuss suicide this summer (yes, my 8 year old expressed the wish to die and spoke of self harming urges). I got two comments and phone calls from his teachers (he is in French Immersion, so he gets a French teacher and an English teacher) and both wanted to let me know my son has had a 100% improvement in behaviour, work habits, attitude and actual participation (the last two years he had to have aides to do his handwriting for him because he was unable to write more than a few words). Again, I wept after hearing this. I wish he’d gotten the needed intervention years earlier and I’m positive he wouldn’t have had his self esteem eroded and developed a number of scary psychological problems. I do believe that a great deal of caution must accompany such a diagnosis, especially when the chosen therapy is medication. We had to do a number of tests and interviews before it was determined that ADHD was the root problem for our son. (Our other son definitely does not exhibit any of the same signs at age 4 as his brother did, just for contrast.)
@Leeanne I’m so sorry you went through all those years of stress! ADHD is so very difficult because it is misunderstood by a vast amount of people and the stigma is horrendous. (We lived in the UK for the last two years and most people there think it is a figment of lazy American parents’ imagination!)
We were fortunate in that our son went to a Montessori school until he started Kindergarten that was suited perfectly to his tendencies to hyper-focus on things and desire to move around the room independently. Our home life was chaotic, but until he was labeled by his kindergarten teacher, and subsequently diagnosed, we had no idea that the root of the chaos was his inability to follow-through on any directives given. We were also lucky that his teacher had two ADHD sons of her own and spotted the signs so quickly (she told us about her fears less than three months after starting school) — which saved us from having to suffer through years of not knowing what the issue was.
Good luck to you and your family!
As an adult female who has thrived with ADD, I think it’s great that the AAP has lowered the diagnosis age to allow for early interventions and behavioral modifications. Kids with ADHD need structure, boundaries, clear limits, lots and lots of physical activity and, above all, parental understanding. I think, often times, medicine is introduced too soon and I’m not sure its wise to start a 4 year old on concerta prior to finding a sport that they may be interested in. However, a dose of medicine here or there while learning the fundamentals may not be so bad either. These kids are so amazing and smart that it’s a shame that they are made to feel like the ‘bad kid’ or the ‘trouble maker’ or anything less than super smart, highly energetic and curious. Teachers should also adopt varied teaching styles and allow these kids lots of hands on opportunities and chance for movement.
My son who is 4 1/2 years old was diagnosed with ADHD and Aspergers this past summer. The center that diagnosed him recommended medicine but we feel that he’s too young. We instead send him to a really great school for kids with behavioral issues and Occupational Therapy plus have made changes to our home life. The school put him on a detailed behavioral plan that all of his caregivers follow. Since we started all of these early intervention measures we’ve seen a huge improvement in his behavior to the point where we’re considering mainstreaming him for kindergarten.
Hi Amy,
This story is so poignant and I admire your courage in telling it. And I love how you conclude that four year olds are supposed to be wild and crazy. Kids do need time to play. They’ll be sitting down the rest of their lives.
Amy
A few things come to mind:
1) your experience is totally valid but it’s just your experience. The recommendation is made based on 1000s (if not more)
2) parents still can chose whether to take meds and if things are really bad, maybe it’s better to take meds than ‘get thru it’. Because what’s to say that the effects of active ADHD or a chaotic household on a child’s brain is better than the meds on a 4 year old brain?
3) some people have to send their children at 4 to preschools which are sit down places. If their child cannot function in that environment without meds to treat their disease, why is it ok?
All that being said, I think that ADHD is probably over-diagnosed because it has a medication treatment as opposed to many of the possible diagonoses or other issues which can mimic it.
It feels good to all involved be able to treat something in a (seemingly) succinct way.
I think the greatest pitfall is not taking away being 4 from 4 year olds but missing more complex diagnoses.
And let me guess – almost all the little people being drugged into submission are little boys. Who are just being little boys. But rather than change the environment to allow them to be who they are, you pour dangerous drugs that alter their brain chemistry into them, and then applaud when the lobotomoy ensues. How incredibly, horribly sad. This is a war on boys, and it will come back to haunt us. These boys are the thinkers and doers and innovators and dreamers who drive our futures. And they’re being drugged into orderly surrender. Good thing Steve Jobs didn’t have any of you as a mother. Or Bill Gates. Or Einstein or Newton or Gould.
I’m of two minds on this..
Some kids are seriously out of control, and no amount of behavioural therapy will help. For them, you’ve really gotta give the drugs, for their own sakes as well as the parents and teachers. But for others, many really are just young boys being young boys. My energetic son is six, and although the teachers aren’t suggesting ritalin just yet, I’m sure it will come at some point. But the thing is, his teacher says he works really hard and focuses on his work, he’s doing fine academically, and he’s extremely popular. His friends love him. His teachers don’t. He gets in trouble for his inability to sit still, his propensity for blurting things out rather than putting up his hand, and his silly behaviour. He very likely has mild ADHD, I admit, but it’s only really impairing him in the fact that he’s difficult (but not impossible) for his teacher to handle. I’m not going to put my son on drugs for the school system’s benefit.
@Joan, just a quick note to say that you might want to expore the idea that your son has Sensory Processing Disorder, and not mild ADHD. I don’t want to derail this conversation, but I agree with Alex (above) when s/he says that there are other issues that can present in ways very similar to ADHD. This might be worth exploring for you. My son is seven and has/had many of the issues your son seems to be experiencing. When I read the SPD checklist, I had the biggest ‘Ah-ha’ moment of my life. Hope this is helpful.
Our brains are made up of chemicals right? The food that children are being feed these days are FULL of chemicals right? If you listened in Science class you’d all know… certain chemicals react!!! Diet has EVERYTHING to do with it! A chemical reaction that happens and then doctors quite happily hand out drug prescriptions and place these false labels on children
If your child is “out of control”…. take a good hard look at what chemicals are going into his or her brain. Even so call “healthy foods” like saltanas, bananas etc can cause negative reactions in some people! I have a friend who’s daughter you would seriously commit if you saw her after dried raisins. Off them and a few other things that act like rocket fuel in her brain… she’s a completely normal child. She’s a very lucky girl that her mum was smart enough to not listen to a doctor who’s been brain washed by pharmaceutical reps into handing out drug scripts at the speed of lightning. This is a must watch for ALL parents: http://www.youtube.com/watch?v=xehHwkPpevk