Are there other signs of ADHD besides the ones traditionally used to establish the diagnosis?

ADHD can show up in children in many ways besides those defined by established criteria in DSM-IV-TR. Social-skill issues may be the presenting symptoms at home and at school. Children may display isolated aggressive behavior in preschool and early elementary school, because of their impulsivity and poor attention to verbal and visual cues. Because their disruptive behavior often results in conflicts with peers, siblings, and authority figures, such children stand out from their classmates. Consequently, they tend to be rejected by their peers. Children with ADHD may also be quite messy and disorganized. Parents frequently describe bedrooms in complete disarray, backpacks with papers falling out, and poor eating habits. General academic difficulties are also common. Children forget their assignments, do not appear to be listening in class, and get poor grades. In addition, they may have what are usually called executive functioning problems: difficulties with planning, starting tasks, shifting from one activity to another, controlling responses, and staying interested and motivated.

Do the symptoms of ADHD change as children mature?

Yes. Although some symptoms persist, many symptoms of ADHD change with development. For example, hyperactivity diminishes in some children after elementary school. Many people think that the hormonal changes of puberty are responsible for this, although we do not understand the mechanism. Older children may have either outgrown their hyperactivity or found ways in which to channel it. A sense of inner restlessness may replace the hyperactivity. In the preteen and adolescent years, poor grades, inability to sustain attention, difficulties in maintaining social relationships, disorganization, and risk-taking behavior may surface as primary symptoms. At school, ADHD may show up more as written work becomes increasingly complex and a teenager is required to plan ahead for long-term assignments. Socially, the range of accepted behavior in many ways is narrowed by the unwritten rules of a teenager’s peer group. The difficulties with emotional self-control and interpersonal communication common in ADHD makes these teenagers appear more immature and clumsy among their peers. Their impulsivity may cause them to blurt out answers inappropriately or to interrupt conversations. They can become disruptive in the classroom or even be perceived as the “class clown.” This can result in peer rejection and subsequent distress in ADHD children.

At what age might I begin to worry about whether my child has ADHD? Can ADHD be diagnosed in a preschooler?

ADHD can be diagnosed in a child as young as 3 years of age. Signs of ADHD in preschoolers may include a noticeably high activity level, inability to persist with tasks, problems in following group instructions, poor behavior modulation, difficulties with social interactions, unending curiosity, excessive aggression or destructive play, silliness, bossiness, and impulsivity. Preschoolers with ADHD may have sleep problems, such as restless or decreased sleep. In addition, argumentative behavior and temper tantrums may be more common in preschoolers with ADHD. These children may also be quite immature, frequently demonstrating off-task or inappropriate behaviors. All of this can contribute to conflicts within the family, ranging from battles with siblings and parents to difficulties in keeping baby-sitters.

Could the many ear infections my child had as a toddler be the cause of his ADHD?

Some studies, although not all, have found that children with a history of frequent bilateral ear infections had lower language and speech scores, lower reading scores, and more behavior and attention problems during elementary school. Investigators have suggested that children who suffer from intermittent hearing impairments from ear infections do not get enough “practice” in paying attention. This does not mean that your child will have problems in these areas if he has frequent ear infections, but parents and teachers do need to be vigilant about this problem. It is very unlikely that ADHD is caused by ear infections.

My child with iron-deficiency anemia is hyperactive rather than tired. Is that common?

Anemia, although commonly thought to decrease energy, can be a cause of inattention and hyperactivity during early childhood. Pediatricians routinely monitor for anemia, which is most often caused by iron deficiency. Iron replacement corrects both the anemia and the inattention and hyperactivity fairly quickly.

Are children born prematurely at increased risk for ADHD?

The frequency of ADHD in children born prematurely is fairly high. One study compared children who had been born prematurely with children who were from the same social class but had been born at full-term. When the children were evaluated at age 7 years, approximately 20% of those in the premature group had ADHD as compared to about 10% of the other group.Many of the premature children who had ADHD also had additional cognitive, neurological, or academic disabilities (e.g., dyslexia and developmental language disorders).

The rapid advances in medical technology have greatly increased the number of children who survive premature birth. However, as more premature babies survive, there is growing evidence that suggests that there are long term repercussions: many of these children—especially the very small ones—develop major neurological problems. These children appear to be at special risk for ADHD because their frontostriatal circuitry is particularly vulnerable to injury owing to its immaturity at the time of birth. It is wise to carefully monitor children who are born premature.

Can a significant head injury or a minor concussion cause ADHD?

Behavior problems from significant traumatic brain injury include irritability, fatigue, impulsiveness, decreased anger control, disinhibition, decreased motivation, decreased frustration tolerance, decreased initiative, aggressiveness, decreased attention, and hypo- or hyperactivity. This is due at least in part to the fact that a closed-head injury is likely to damage the frontal lobes of the brain. A physician must carefully and indefinitely monitor the classroom attention of a child who has sustained a significant head injury. In contrast, concussions, which are associated with only a brief loss of consciousness, are considered very minor head injuries. Nonetheless, children may have trouble concentrating and focusing for several weeks after a concussion. The effects are transient, but can temporarily affect school performance. Paying attention to the problem will minimize it.