A conversation with Julia S. Feldman, Ph.D., about taking impairment and context into consideration when diagnosing preschoolers with ADHD

Preschoolers may be written off as “just energetic,” but emerging research suggests that, for some children, these early behaviors may be early signs of attention-deficit/hyperactivity disorder (ADHD). In a new review, Julia S. Feldman, Ph.D., a postdoctoral fellow in the Department of Psychiatry at the University of Pittsburgh and her team, analyzed ADHD-related behaviors in children ages 3 to 5 across multiple U.S. cohorts to understand which symptoms are most strongly linked to a current or future ADHD diagnosis. Their findings challenge the notion that young children are “too young” to meaningfully assess for ADHD and underscore the importance of listening closely when parents raise concerns about their child’s behavior.

This conversation has been edited for length and clarity.

MHE: Can you start by giving an overview of the study?

Feldman: This study used secondary data analysis from a large consortium of studies across the United States. The National Institutes of Health Environmental influences on Child Health Outcomes (ECHO) Program groups together studies that all are generally on child development with some element of health outcomes. The nice thing is, because there are all these studies that are studying slightly different things, we can bring all that data together to look at bigger questions. We were interested in understanding more about how ADHD symptoms show up in the preschool period and how meaningful they are for current or future diagnosis. To do that, we looked at all these studies from across the United States that included similar questions about ADHD symptoms in kids ages 3 to 5 and included some indication of whether or not that child either at that time or later on in development was diagnosed with ADHD.

MHE: What were the 10 ADHD symptoms that you looked at, and how did you narrow the list down to 10?

Feldman: There are four inattentive symptoms: difficulty focusing, not seeming to be listening when being spoken to, difficulty with following through on instructions or activities and being easily distracted. Then there were six hyperactive impulsive symptoms that we looked at: fidgeting, restlessness, which in early childhood is often climbing, jumping when you're not supposed to, being “unusually loud,” so being louder than other people when maybe you're not supposed to be so loud, being constantly on the go or acting as if driven by a motor, having difficulty waiting, and interrupting or intruding on others, kind of jumping into other people's business. Now, there are 18 symptoms of ADHD. These 10 symptoms were selected because out of the five questionnaires that were used across all these studies that we brought together, these were the only 10 symptoms that were covered. So, some of these early childhood questionnaires didn't talk about other symptoms of ADHD, so we weren't able to include them.

MHE: What symptoms were the most related to ADHD and why?

Feldman: The symptoms that were most related to ADHD fell within the hyperactive-impulsive area of ADHD. The top two were being on the go or acting as if driven by a motor and interrupting or intruding on others. I think in general, the hyperactive-impulsive symptoms were more predictive of a current or future ADHD diagnosis. There are several reasons, but two I can highlight are one, they're just much more observable. It's hard to tell if a little kid is having trouble focusing. If they are daydreaming but look like they're focusing on playing, for example. So, parents might have been a little more able to pick up more accurately when their kids were having these symptoms. Another one is that these symptoms are also more likely to be picked up early on; this kid might be getting in trouble a lot in class and/or disrupting peers, whereas the more inattentive ones might stay hidden for longer in the school setting.

MHE: What made you want to study ADHD symptoms in kids ages 3 to 5, specifically?

Feldman: This is my favorite question! So, it's a common misconception that little kids can't have ADHD because all children look like they have ADHD. That's a myth. Yes, kids are maybe a little more impulsive generally, maybe a little more active than grown-ups, but there are preschool-aged children who either are already able to be diagnosed with ADHD in the preschool period or are clearly well on their way to a diagnosis. What we wanted to better understand was when we diagnose ADHD at any age, we want to think about if these symptoms are inconsistent with development. So if they're not typical for a child their age, and how these symptoms are showing up early on, how they might predict later diagnoses. We were interested in breaking past that myth that these symptoms can be inconsistent with development and also figuring out how we can better understand when a kid comes to their pediatrician and the parents expressing concerns and what we can do, instead of simply saying, ‘Oh, kids will be kids at that age.’ We can actually take it seriously and figure out how concerned to be. Should we do some further monitoring? Should we do some further questioning to figure out a diagnosis?

MHE: Why is it important to identify and diagnose ADHD in children sooner rather than later?

Feldman: The preschool period is an exciting period for thinking about this, because not all kids are in school at that time. Even if they are in preschool, the demands are not as high as when a child transitions to kindergarten. As adults, we don't give kids enough credit for how hard that transition is. All of a sudden, they're expected to sit in their seat and pay attention to their lessons and get along with peers and all these things that are somewhat new and can be pretty challenging for any kid, especially a kid who might be developing ADHD. And so, if we can identify kids before they're getting in trouble for getting out of their seat in class all the time or interrupting the teacher, which is great for self-esteem, we're catching it earlier, so we can do things earlier, like help support caregivers in managing their child's emerging symptoms to help set them up for success as they transition into the kindergarten years and continue to go forward with their schooling.

MHE: How can parents support their kids during this time?

Feldman: A big thing is supporting the parents, actually. At this age, the first-line treatment for a young child with ADHD is their parents, rather than medication or individual focus. I think helping parents have a predictable routine and structure and teaching them how to set their child up for success with following through on an instruction the first time it's given, even if it's hard for that kid to keep track of what they're supposed to be doing or they really don't want to stop the fun thing they're doing right now. Also encouraging parents to have good communication with their school as the child's transitioning. Every school is different. Some schools will be quick to tell parents concerns about a child, but others might not. Being in the loop and knowing how that transition's going when you're not seeing how your child's doing in this new environment is important.

What are the next steps for this research?

Feldman: This was a bird's-eye view of which symptoms are more or less predictive of ADHD diagnosis in this period. I think it'd be really important next to look at if this is different for boys versus girls. Is it different based on, for example, how they're diagnosed or when they're diagnosed? It's likely that there are differences in different subgroups of kids.

MHE: What is the main message you want clinicians to take away from this?

Feldman: What we found from this was that every symptom we looked at was associated with a higher likelihood of developing or being diagnosed with ADHD. The main message is if parents are bringing up concerns about these symptoms, listen, take them seriously and ask more questions. I'm not saying that if a child is fidgeting a lot, automatically diagnose them. We know that's not how diagnosis works, but maybe you give them a screener to complete. Maybe if they're in preschool, you give the preschool teacher a screener. Explore more and figure out, is this child already showing elevated symptoms? Take those concerns seriously instead of saying, 'Little kids are always like that,’ because what we learned from this is little kids aren't always like that. In this discussion, Julia S. Feldman, Ph.D., a postdoctoral fellow in the Department of Psychiatry at the University of Pittsburgh, explains that ADHD symptoms in preschoolers can be meaningfully linked to current or future ADHD diagnoses, underscoring the importance of taking parents’ early concerns seriously.