While that was an easy question to answer, I do get more difficult questions about young children with hyperactivity.

In order to start this conversation, it is important to remember the core ADHD symptoms: inattention, impulsivity and hyperactivity.

Based on appropriate diagnostic criteria, you cannot diagnose ADHD until age 4. It is also difficult to diagnose children until they are in school because the diagnosis requires that symptoms be present in more than one environment.

As with any type of behavioral problem, the degrees of severity present a wide spectrum of the various symptoms of ADHD.

Inattention-Some children can focus for hours at a time but some jump from one activity to the next very quickly, seeming to never really focus on one thing for a significant amount of time.

Impulsivity-Some children are very cautious and don’t do anything dangerous, while others jump from my exam table across the room to the chairs on the other side.

Hyperactivity-Some children can sit still for long periods of time, while others are constantly fidgeting and restless.

So, how does this look in a 3-4 year old child?

All 3 and 4 year olds show signs of inattention. There are a select few children in this age group who can maintain focus for extended periods of time. Because of this, it’s hard to get too excited about concerns about a 3 year old’s attention span.

I have definitely seen varying levels of impulsivity in this age group. Those that are highly impulsive, in my experience, often go on to meet criteria for ADHD as they get older. Remember, however, that talking back and aggression are not necessarily impulsivity.

The most common symptom that parents interpret as ADHD is hyperactivity. There is definitely a difference between the general restlessness of a typical 3 year old and a child that truly becomes ADHD in the future.

Children at this age are often described by parents who report, “Their motor is just always running” or “They just go non-stop from the moment they wake up.” Because I see so many children of this age group every day, I also have some subjective sense of what is normal or abnormal for the age group and this can help my assessment over time. However, I never make snap judgments because any child can act like they have ADHD on a particular day.

So, what if you are concerned that your young child may be showing some signs of hyperactivity? A great place to start is here: ADHD Behavioral Treatment-8 Tips.

Here are some basic things to remember:

1. Try to stay patient.

Because so many of these young children will outgrow these symptoms, it is important to stay patient with them.

2. Try to stay calm.

Anxiety only makes hyperactivity worse. Yelling at a kid to sit down and shut up will most likely just make your problems worse.

3. Try to stay consistent.

Children with hyperactivity do their best with structure and clearly defined boundaries. If these children don’t know what to expect from minute to minute, they cannot adjust as easily as most kids. If they are not disciplined consistently, they do not know where the boundaries lie. With any behavior problem, I ask my families to pick out what 1 or maybe 2 behaviors that they want to extinguish and be consistent in the their punishment for those. It is not feasible to fix all of your child’s problems at once.

Also remember to praise them when they do the proper behavior. If a child is only getting negative reinforcement, they will often choose that over positive reinforcement.

If you have a child with ADHD and have chosen to go for a non-medical route, more power to you, and if it is working well for you, that is awesome. However, I also have families that have stressed for years because of something they have heard in the media or from their friends and they and their child suffered because they didn't want to place their child on medicine for whatever reason.

Won't They Get Addicted to the Medicine?

Children on ADHD medicines are not addicted and are not more likely to have addictions later in life.

Here is the definition of addiction: "compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly  : persistent compulsive use of a substance known by the user to be harmful."

ADHD medicine do not form compulsions in children who actually need them and they are not habit forming. Just like any other medicine, parents and kids will forget from time to time and the only effect they see from missing a dose is that their child's behavior is not as good that day. There are no other side effects.

Tolerance is the effect where a person develops a bigger and bigger need for a substance in order to develop the desired effect. While there are times when I do have to increase a dose of medicine it is typically more related to the size of the child increasing and the changing stressors (increasing difficulty, etc) at school that require the increase. Changes are often necessary around puberty as well.

Finally, there are no withdrawal symptoms when a person comes off their stimulant ADHD medicines. In fact, the child “comes off” their medicine every night and can take weekends or summers off without developing symptoms (other than being more hyperactive). By definition, this means that there is no withdrawal.

So, without compulsion and habit, tolerance or withdrawal, there is no single characteristic about these medicines that make them addictive.

As for the question about children with ADHD going on to have more addictions later in life, it seems that this is more related to the ADHD than the medicine and adequate treatment may actually help prevent some of these later behaviors.

I Don't Want Them to Act Like a Zombie!

I hear this complaint or concern with just about every consult that I see. Understandably, parents don't want their children to act differently or have a change in personality because they are on medication. Guess what? Me neither. If I were to see personality changes in my patients, I would change their medicine or come up with other treatment strategies. However, this is a very uncommon complaint when families actually start medication. In my 6 years of practice, I have heard this complaint only twice and both of the parents were extremely worried about it prior to starting medicines, which makes me wonder if they weren't looking too hard for it in the first place.

It is my opinion, this was a bigger problem before with the short acting medicines (like Ritalin). Because they needed to be dosed more twice in the day, the children may have experienced the change in their blood level throughout the day which led to more drastic behavior changes.

Will This Stunt My Child's Growth?

While there have been some studies showing a slight decrease in weight and height growth over the first year of starting a medicine, these differences disappear when you recheck the children at 2 and 3 years out from starting medicine.

What are the Common Side Effects?

The most common side effects I see from the ADHD medication (primarily stimulants) are loss of appetite and difficulty going to sleep.

Loss of appetite-We usually see this problem just after starting medication and it certainly can improve over time. The child usually has the biggest problem with lunch time as that is the when the medicine is at its highest level in the blood stream. Usually, you can make up for this problem by making sure the child eats a good breakfast and dinner and eats what they can at lunch. I follow my patients’ weights closely especially when there is a concern about the child's appetite.

Difficulty with sleep-Occasionally, we will have a child who has a difficult time going to sleep. Like appetite, this is most common right after starting the medication. My first treatment for this is to make sure that are taking care of doing the right things to help themselves go to sleep: no food or drink with 1-2 hours of bed time, no screens on in the room 1 hour prior to bed time, etc. If that doesn't work we can do a trial of melatonin. Other options are available if this doesn't work.

Some more rare side effects that I want to discuss are mood instability and tics.

Some of the medicines are worse that others about this but we will sometimes have a child who is very emotional and tearful when first starting the medicines. This typically happens in the afternoon or evening as the medication is wearing off. Usually, with just a period of observation, this will improve after about 1 week on the medicine so I first have my families continue trying for a bit and monitoring closely to see what happens.

Tics are involuntary movement disorders that result in a short jerking of the head, lip smacking or some other short, quick motion. These medicines do not cause tics, but in a child who is already predisposed to them for some reason can cause them to become much more obvious and frequent. If the tics are disruptive or concerning, we will usually need to switch medicine to something else as this does not usually improve over time.

Summary

1. Children do not become addicts because of ADHD medicines.
2. Children do not become zombies because of ADHD medicines.
3. Children do not become short because of ADHD medicines.
4. Children should be watched closely for loss of appetite or difficulty sleeping when starting ADHD medicines.

For more information

Visit our Checkup newsroom resource page to learn more about ADHD. 

New research published this week in the Journal of Clinical Psychiatry may challenge that stereotype or at least require us to broaden what we think ADHD “looks like.”

The research looked at the overall rate of ADHD comparing surveys of parents completed in 2003 and 2011. It might not surprise you to learn that the overall diagnosis of ADHD increased during that time. But you may not have heard that increases were found across all racial/ethnic groups, with the largest increase in Hispanics (83 percent). Perhaps another surprise was the fact that the increase in girls was greater than the increase in boys (55 vs. 40 percent).

Symptoms of ADHD can include difficulty paying attention, hyperactivity and impulsivity. Diagnosis is based upon a conversation you can have with your pediatrician or a psychologist and usually involves a screening questionnaire to be completed by a parent and teacher. Treatment starts with behavioral and parenting strategies to help children cope with symptoms but can require medication when these are not successful.

The study showing this increasing number of children diagnosed with ADHD certainly grabbed my attention. As someone who generally does not like medication for kids, I worry that this means the number of children on medications for ADHD is also increasing. As with all medications (and more than most), treatments for ADHD do not come without risk.

I do have some theories as to why the number of children diagnosed is increasing:

Theory No. 1 - Parents and teachers are more aware of the signs of ADHD.

Many hyperactive and impulsive children were previously labeled as trouble-makers and ended up spending lots of time in detention and in school suspension. Many inattentive children slowly started to have more trouble as classes got harder and parents and teachers eventually gave up on them as someone who just “wasn’t made for school.” Now we are realizing that those hyperactive/impulsive kids can’t simply “just sit still” and that those kids who were previously doing well shouldn’t be failing just because they can’t listen to lectures or get their paperwork turned in on time.

This particularly accounts for the increased rates of diagnosis in children of Hispanic and African-American descent. Previously, the stigma associated with all mental health conditions (including ADHD) prevented parents from seeking help. Also, because many girls are inattentive, rather than hyperactive and always in trouble, they could also go undiagnosed.

Theory No. 2 - Physicians are increasingly giving in to parent demand to “fix” their child.

This is by far my least favorite, but I just believe it is something we should at least consider. In a world where the expectation is that a pill can cure just about anything right now, parents increasingly want something today that will resolve their child’s behavior problems. Long term treatment plans that involve behavioral techniques and maybe even counseling aren’t as popular for all parents. However, we should fight against this as the diagnosis of ADHD and decision to start treatment should not be based on demand from a parent.

Theory No. 3 – The expectations and demands on children are changing.

Children are learning to read and do more intense math earlier and earlier. Homework was virtually non-existent when I was growing up until second or third grade. This is not necessarily the schools or teachers fault so don’t call up and gripe at your child’s teacher. Many of the requirements for what they teach and when they teach it come from above them. The simple fact is that, in trying to keep up with the success of other countries, we have decided to accelerate curriculum and to challenge students. It’s not always a bad thing, but it can be if you have a hard time sitting still for long periods or can’t keep yourself organized.

Theory No. 4 - New medications with less side effects have made parents more likely to seek treatment.

No one wants to see their child “turn into a zombie.” It’s still the number one concern I hear when starting treatment for ADHD. Fortunately, with newer medications, the side effects are much less severe and much less common. Loss of appetite and difficulty falling asleep are now the most common side effects I see, even those are not that frequent.

Keep in mind, each of these things are theories based on my experience. We will need to continue investigating why we are seeing this increase in the rate of ADHD. We all need to be observing our children for signs and symptoms, particularly if they are struggling with school but parents and teachers need to be careful not to attribute all school struggles to ADHD.

For more information, read: 

The first line of treatment for children with ADHD are behavioral options. I never ask (or let) a family jump first to medication if they haven't first tried some of the techniques I’m going to describe below.

What are the goals of treatment?

1. Improved interaction with parents, teacher, classmates and siblings

2. Improved grades

In my opinion, the goals are simple and should be taken in that order. It is important to consider these goals and re-evaluate them frequently during the treatment course. Perfection should not be the goal.

I recommend these behavioral techniques before medication for all children, especially those who are young or who have milder ADHD:

1. Make a schedule daily. All kids have difficulty and waste time with transitions. Children with ADHD do this to the 1000th degree. If these transitions are scheduled and the child knows what comes next it might speed up the transition. Things that should be included on the schedule are homework time, daily chores and self-care items (shower, brushing teeth, etc).

2. Make separate areas in the house for necessary tasks. Keep toys and video games out of the space where homework needs to be completed. This helps limit the child’s distractions so that they can finish the task at hand.

3. Set small goals that are attainable. Don’t ask the child who is failing to make the A honor roll in the next six weeks. Start with turning all assignments in and that they are complete, then slight increases in grades, etc.

4. Use charts and checklists. Children with ADHD are often very visual and concrete. If you can put a list in front of them that can be checked off, they are much more likely to complete what needs to be done. I find this to be helpful for me as well ...

5. Keep choices to a minimum. Don’t tell them to go to the closet in the morning and pick out something to wear. This is a sure way to start a huge fight as they stand in front of the closet for hours while you are trying to wrestle them out the door. Pick out two options ahead of time for them to choose from.

6. Don’t discipline them impulsively. Remember that one of their biggest problems is that they don’t stop to think about consequences before they act. If your discipline follows the same pattern, how can we expect them to learn to act differently? Plan out your discipline plan in advance and be consistent. As tempting as it may be, corporal punishment is rarely effective. I’m not going to get into a spank your child or not debate here, but timeouts and restriction of privileges seem to be more effective for children with ADHD.

7. Help your child with organizational skills. Developing a system that helps them keep track of all the papers is a way to keep them from getting thrown away, having them sit in the floorboard of the car or (more infamously) avoiding having the dog eat them. If you need some help establishing this system, check out this amazing book called That Crumpled Paper Was Due Last Week.

8. Get help. Raising a child with ADHD can be very frustrating and quite exhausting. There will be lots of times when you will feel like there is nothing left to do to help. If your child continues to struggle, talk with your pediatrician about options for treatment, including medication options. Find a family counselor that can work with your child but, maybe even more importantly, that can help you develop a plan for your child and help you cope with the struggles you will face.

I hope that you find these tips helpful as you begin to think about how you can help your child with ADHD.

As you walk through the process keep in mind that your goal should be function, not perfection.

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

According to a lawsuit filed by the American Civil Liberties Union (ACLU) on Monday, the deputy violated the rights of two children when he shackled the kids around their biceps in the fall of 2014. The boy and a 9-year-old girl had both been diagnosed with attention deficit hyperactivity disorder (ADHD). The lawsuit alleges that both children were being punished for behavior related to their disabilities.

ADHD is a common challenge in classrooms across the country. So what should parents and teachers do to prevent a child from becoming too unruly to handle? Lena Zettler, director of Psychology at Cook Children’s, suggests the following:

• Have a plan
• Have a team
• Have an advocate

“What are the steps that will be taken and who are the key people involved? These things should be understood before an emergency happens,” Zettler said. She says it’s important to remember that kids with ADHD most likely aren’t acting up for attention.

“Education is the first step for treatment for ADHD. It’s is a neuro-developmental disorder. It is not a disorder of bad parenting,” says Zettler.

Students with disabilities make up 12 percent of the student population nationally. According to the U.S. Department of Education, they account for 75 percent of the students who are physically restrained by adults in their schools. To prevent such drastic measures from being taken, parents who have a child with ADHD should have a conversation with their child’s teacher about the condition before the school year begins.

Together, parents and school officials need to put a team in place to assist in the child’s education and plan out what will happen when the child acts out.

Parents and school officials also need to designate an advocate, someone the child can turn to for help. The advocate could be an assistant teacher, a counselor or even a principal. By putting a team together and a plan in place, parents can help ensure ADHD children and their classmates get the most out of the school year.

“Taking these steps will not only benefit a child with ADHD, they will help the entire class,” says Zettler.