Is it ADHD or NOT ???
ADHD only occurs in about 5% of the population, so the majority of parents who assume their toddler "must have" ADHD do not actually have a child with ADHD : The child may be experiencing normal varitions of temperament. Children in this young age-range have a very wide range of what is considered normal (maybe not always acceptable, but "within normal limits"). There are also some instances parents need to lower their expectations of what a toddler can or should be able to do. Should a two-year-old be able to sit still for 15 minutes, even with toys in front of him? No, and to quote my editor, Kathryn Robyn, "That is a blessing by design." It's a blessing because movement is crucial for brain development, especially in the toddler years, so it needs to be encouraged!
There are also other instances that mimic symptoms of ADHD- for instance, sleep issues can produce sympotms that are similar to ADHD. If someone who is only suffering from lack of sleep (and not actually ADHD) takes traditional ADHD medication, this might actually worsen their sleep condition. In my book, I also talk about kids with ADHD and their sleep patterns or issues that may accompany ADHD. Confusing? Yes! I also talk about many other things that mimic symptoms of ADHD.
If the child does have a mental health condition, ADHD actually has symptoms that overlap with other disorders. In toddlers, ADHD symptoms seem to be most frequently confused with juvenile-onset bipolar disorder, oppositional defiant disorder, anxiety, depression, and autism spectrum disorders. Toddlers & ADHD describes some common similarities among these disorders as well as key differences. For example, excessive temper tantrums are common in ADHD and these other disorders. However, the tantrums'
origins typically differ, in addition to the length of the tantrum, depending on the diagnosis. It is also possible that a child has a comorbid (more than one) diagnosis, and ADHD is in fact a common comorbid diagnosis with all of these other diagnoses listed.
ADHD is a neurodevelopmental disorder that hinders the ability to self-regulate. It presents with hyperactivity, impulsivity, inattentiveness, irritability, and/or aggression. Due to the fact that all toddlers demonstrate some "ADHD behavior," it can be challenging to discern if the child’s behavior falls within normal limits or if the child is actually demonstrating clinically significant behavior. This can be confusing for parents, teachers, and even clinicians, and it makes it challenging to conduct an accurate assessment on a toddler, and subsequently to accurately diagnose during these early years. Toddlers & ADHD is meant to help clarify this distinction, although it is not to be used to formulate a diagnosis or rule out a diagnosis.
ADHD is widely overdiagosed, and its important for parents not to assume their toddler has ADHD becausd they "always run around" or are "always so loud." I discus reasons why it'is important to let the toddler be a bit crazy at times; It doesn't mean the child has a disorder. As clinicians, we do not want kids medicated who do not actually have ADHD.
What Age Can ADHD Be Diagnosed?
Previously, it was not considered standard practice of care to diagnose a child with ADHD until at least age 6, which was for many valid reasons. These reasons will be covered in Toddlers & ADHD. However, in the last few years, diganosing ADHD in the preschool years has become endorsed. This is because of a lot of reserach-based evidence, which came from a push from the National Institute of Mental Health and was backed by the Ameican Academy of Pediatrics. ADHD can have an onset as late as age 12, but most in most cases, the age of onset is prior to age 4.
1-5 Year-Olds with Clinically Significant Symptoms
Reserach shows that ADHD most commonly has an onset prior to the age of 4, but ADHD does not magically turn on at a certain age. There are certian signs to watch for in toddlers, such as dangerous play or chaotic play. Depending on age, the child will not actually realize that some play is dangerous, but if not modified with typical parenting strategis, that is a concern. By the time the toddler is older and does realize it's very dangerous to them, that is a big concern. Another common symptom is the demonstration of excessive tantrums, which stem from cognitive, emotional, and behavioral impulsivity associated with ADHD. (Toddlers & ADHD gives information on what determines "normal" verses "excessive" tantrums, depending on "proportion to the event" and intensity of the tantrum). Learn how to control these tantrums (wihtout giving in). Many toddlers go through a "no" phase where it may seem like that's the only word out of their mouths, but when you read Toddlers & ADHD, you will see why that may actually be good because it could mean they are developing appropriately! However, when the "no" talk becomes excessive or aggressive, it may be a sign of ADHD. There are many other signs and symptoms to be covered as well!
Guide for Clinicians and Teachers
There are some symptoms that will not show up in every setting, depending on the situation, so ADHD can be confusing! For instance, a child at preschool may be able to focus intently in music class but struggle to maintain himself during circle time. The child may do okay in academic situations but struggle during unstructured settings such as recess or lunch. Or, a child with the hyperactive presentation of ADHD may not seem hyperactive or impulsive in school at all! In addition, it is well-known that children with this disorder will usually struggle more at home than school with certain symptoms. There are many factors at play in the brain which showcase why this is, and these factors are explored in the book
As for special services provided by the public school, I discus that a 504 plan is considered before an IEP, and I let parents know that a child may not qualify for special services just because he has an ADHD diagnosis. However, the positive effects of medication alone cannot rule out special services for the child. In Toddlers & ADHD, I give examples of accommodations at school. (Many preschool teachers will try a reward/incentive sticker system or token economy system with these children, and I describe in detail why these may not work (for this age range with ADHD) due to the biology of the ADHD brain). Daycare, preschool, or kindergarten teachers may try time-outs for this age range, and I discus why, with this disorder, they are not as effective as with kids without ADHD until these kids with ADHD get older. In addition to examples of interventions and accommodations, I give examples of IEP goals that are timely, measurable, and challenging, yet attainable for preschoolers and kindergartners with this diagnosis.
I also discus the possibility that there can be other factors at play in the brain of a toddler with ADHD: It is well-known that children with ADHD may also experience a combined speech delay, learning disabilitiy, motor delay, potty-training delay, or have a sensory processing disorder. If any of these hold true for the child, in Toddlers & ADHD, I have reasons as to why, in addition to discusing some of the school services available for these issues as well.
It's also possible that the child does not have ADHD but is rather displaying normal variation of temperament, which is the most common misdiagnosis for ADHD in this age range. It'salso possible the child has medical, hearing, or speech issue, or is externalizing stressors from difficult life situations. As for other mental health conditions that mimc some symptoms of ADHD, these include but are not limited to: juvenile onset bipolar disorder, autism spectrum disorder, oppositional defiant disorder, anxiety, or depression. In the book, I discus the overlapping symptoms of these disorders, but also the key differences.
Causes: ADHD and the Brain
ADHD is a neurodevelopmental disorder- meaning it affects the brain. According to MRIs and EEGs, there appears to be less activity or stimulation within the brain, and the brain appears less mature. People respond by sensory seeking and novelty seeking, and they act in hyperactive ways to stimulate their brains to get themselves to a baseline level of arousal- which helps them emotionally feel well and alos helps them focus. Usually, these behaviors can come across as disruptive, chaotic, or dangerous. They can present as hyperverbal with constant movement and display intrusive behavior, aggressive behavior, and distractibility.
*Neurotransmitters: The brain is not producing enough, retaining enough, or transporting them efficiently (specifically dopamine and norepinephrine)
-Dopamine is the main focus neurotransmitter and our main "feel good" neurotransmitter. When this is stimulated, people with ADHD can sometimes "hyperfocus," meaning they will intently pay attnetion to something they are really interested in and won't notice other things around them.
-Norepinephrine helps people pay attention to things that are either boring or challenging, in addition to being involved in sleep cycle.This is why students in school with ADHD find it easiery to pay attention to the subjects they like, and therefore, it may not look like ADHD in those classes- so teachers may assume they are "defiant" in their other classes when they really do have ADHD- same thing at home:)
*Brain Waves: People with ADHD produce more theta waves (slow waves) while in awake states than their typically developing peers. These are most pronouncd during reading or listening tasks, leading people to become unfocussed, bored, or drowsy.
*Grey Matter/White Matter: Patients with ADHD can have up to 24% more grey matter in their brain than their typically developing peers. This makes transportation of their neurotransmitters less efficient.
*Frontal Lobe/Prefrontal Cortex: There are 17 subregions to the frontal lobe, and the prefrontal cortex is like the "conductor of the orchestra" for the frontal lobe. These areas are where the executive functions exist- planning, organization, task initation, task completion, time estimation, time management, self regulation, social behavior, short term memory, working memory, motivation, impulse control, intentionality, purposefulness, and transitioning. The frontal lobe/prefrontal cortex areas are less developed in ADHD patients than their typically developing peers and also have less blood flow to thes areas. Due to this, these patients struggle with these executive functions associated with ADHD. They also will seem emotionally immature becaues of this as well.
*Limbic System: The "ADHD neurotransmitters" prominently connect to the limbic system (the emotion center of the brain), so when there's interference here, you will see an ADHD patient with emotional reactions disproportionate to the event- both posiitvely overreacting and negatively overreacting.
*Caudate Nucleus: This is smaller in the ADHD patient. It also has less blood flow to it and is heavily innervated by dopamine neurons. This structure is important in learning, memory, social behavior, voluntary movement, and sleep.
*Amygdala: This is typically overractive in people with ADHD. It regluates the "fight, flight, freeze" responses.
*Cerebral Volume: This tends to be less in patients with ADHD.
Chapter 1: Do You Ever Hear Parents Say?
Chapter 2: What is ADHD? Is it a Real Condition?
Chapter 3: What Causes ADHD
Chapter 4: What Mimics ADHD
Chapter 5: The Issues that Delay an ADHD Diagnosis
Chapter 6: Typical Toddler Development in Comparison to Clinically Significant Behavior
Chapter 7: Early Intervention Services (Birth-35 Months Old)
Chapter 8: School Based Services and Special Education Law
Chapter 9: Therapeutic Services (Interpersonal Modes of Therapy and Holistic Approaches)
Chapter 10: How a Clinician or a Physician Diagnoses ADHD
Chapter 11: ADHD Medication
Chapter 12: Parenting Tips for a Calmer for the Family Unit
Chapter 13: Parenting Strategies to Increase Cooperation
Chapter 14: Maneuvering Effectively Out in Public
Chapter 15: What Strangers Might Say to You (About Your Child or Your Parenting), & How You Can Respond
Chapter 16: Coping Skills for Parents
Chapter 17: Your Child Might Be Meant to Swim
Relief for Parents
I have five full chapters dedicated to offering hope and relief for parents. ADHD is an illness that, if emerges in toddlerhood, can be debilitating to the entire family. A toddler will struggle with self-regulation even more so than an older child with ADHD becuase this age range is supposed to struggle in self-reguation anyway! They are so young that they lack information processing skills to be able to effectively self-monitor and implment strategies to help themselves. A toddler with ADHD will usually not respond well to typical behavior modification techniques at home (like sticker reward systems or time-outs), so these chapters will also be helpful in aligning parenting strategies targeted toward ADHD.
It's well documented that children with ADHD struggle even more outside of home and school. Therefore, through Toddlers & ADHD, parents will learn how to effetively maneuver through typical family events out in public: grocery shopping, Easter egg hunts, restaurants, etc. As an example, a simple tip for a succeful restaurant visit is to order the food in advance so it's ready when you get there. For an Easter egg hunt, have the child go with the next age group up. While out in public, parents of children with ADHD are judged negatively by others. That's why there is an entire chapter about the comedy that is my life with things strangers have said to me...."What? You're choosing to have another baby?" (on an airplane when I was 6 months pregnant with 2 ADHD toddlers running around the aisles of the plane). These five chapters will be crucial for parents to read to gain a sense of universaility, that they are not alone in the world with these issues, as well as help keep things in perspective!
Through these five chapters, parents will be taught how to teach coping skills to their toddler, plus utilize their own coping skills to be able to maintain their much-needed self-control. Parents will be given reasons why reward-incentive learning does not seem effective for their toddler and why time-outs may not seem effective in changing future behavior, but when they need to be used. Parents will learn simple things to do around the house to help manage hyperactivity, impulsivity, or distraction, such as a way to organize toys and organize play. The book offers other examples, such as an indoor swing for when it's below zero outside, and it talks about why investing in a sandbox or a water table may be soothing and calming for children with ADHD, among many other tips and the research that backs them.
Treatment Options & Holistic Measures
Treatment for a toddler with ADHD can include medication, although it does not have to. There are several factors, that if significant in a toddler, are reasons medication should be strongly recommended in conjuction with therapy (and not just starting with therapy alone). These reasons will be discussed in Toddlers & ADHD. However, there is currently only one FDA approved first line treatment medication for ADHD (in the stimulant category). The other stimulants can be prescribed off label, but there is not a lot of research on the long term effects on the brain in this age range. The pros/cons of medication (and what classifications of medication) will have to be discussed with the psychiatrist.
Infants/toddlers (0-3) can seek out Early Intervention services provided by the Department of Human Services at their county health department. These services will offer social-emotional assistance to the child (and helpful tips for the parents), and these services are offered on a sliding scale! Once the toddler turns 3, she is no longer eligible for EI services, so she can possibly transfer into the public school system as a preschooler, and receive free preschool and "curb to curb" transportation.
"Outside services" (servies provided outside of school) are also recommended for some toddlers with ADHD. A child will not comprehend the full nature of "traditional talk therapy" until around age 7, so there are other interpersonal modes of therapy that can be equally as effective at this younger age. This includes, play therapy and teaching parenting strategies, which may focus on any number of researched techniques including, but not limited to, Ross Greene's Collaborative Problem Solving Model and Sheila Eyberg's Parent Child Interaction Therapy.
Recreation therapy, music therapy, art therapy, dance-movement therapy, and animal-assisted therapy are all therapeutic approaches attempt to work on the same concepts: self-awareness, self-management, interpersonal/social skills, and decision-making skills. Clearly, a child with ADHD needs help in all of these areas! The toddler will think she is just at any of these types of therapy to "have fun," but really, so much more is happening! In Toddlers & ADHD, I go thoroughly go through each therapeutic mode and discuss the research behind why each mode can benefit ADHD.
In Toddlers & ADHD, I also discus many other holisitc approaches, but they are not to be a substitute for interpersonal therapy; this is because these other holistic methods attempt to work on the biology of ADHD and not the child's social-emotional factors. Some of these holistic measures include chiropractic care, craniosacral therapy, acupuncture, vestibular input such as swinging (as seen in this picture), heavy-work/proprioceptive input (activities that involve resistance), sensory stimulation, such as water tables, sand tables, beanbag chairs, and weighted vests/blankets. Also, nature-based activies, playing in the dark, cardio-vascular exercise & movement, mindfulness (sensory stimulation combined with deep breathing or guided visualization), music, art, animals, and balance-based activities, such as gymnastics, martial arts, scooter, bicycle, or yoga. Another holistic area is nutrition- is the child getting enough protein, zinc, vitamin C, omega 3's, and magnesium to promote neurotransmitter health. The research and reasons behind these holistic ideas are disucssed in the book.
Interpersonal therapy. holistic approaches, in combination with specific ADHD parenting interventions at home, day care, and preschool/kindergarten may produce enough positive effects that the child may not need medication. (The specific parenting strategies for this disorder are also discussed in the book).