What’s the difference between an energetic child and one with ADHD?

Mom of preschooler

Our Quick Take

• For preschool age children, there are two main things we found in our research when it comes to diagnosing ADHD:
  
  
  • An ADHD diagnosis often includes not just hyperactivity, but also impulsivity. And that means not just bouncing off the walls, but things like frequently interrupting, having difficulty taking turns, calling out answers before the question is complete, etc.
    
    
  • The diagnosis is often made in conjunction with multiple people and the behavior has to be frequently observed in multiple locations over an extended period of time. For example, a pediatrician would also rely on observations from your child’s teacher/caretaker, who ideally has a baseline understanding of how a preschool-aged child acts.
    
    
• This is definitely a question that is worth discussing with your pediatrician.

Jump To…

• The Details
• What Parents Say
• What Experts Say
• More Reading
• Methodology
• Maternie Manifesto
  

The Details

The American Academy of Pediatrics put it succinctly: “There is no single test for ADHD. The process requires several steps and involves gathering a lot of information from multiple sources. You, your child, your child’s school, and other caregivers should be involved in assessing your child’s behavior.“

That being said, they do offer guidance on symptoms that can help clarify what behavior goes beyond the norm. 

The symptoms must occur in two settings, and must “cause some impairment,” or in other words, make life difficult on a regular basis. For children under 17, the AAP says 6 or more symptoms above must be identified.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) also says the symptoms must persist for at least six months and “occur often.” 

In 2019, the AAP recommended evaluating and treating children for ADHD starting at 4 years old. Earlier guidelines started evaluations at 6 years old. But as you’ll see in the Experts section, several practitioners recommend earlier evaluations so children can get behavioral help early on to prevent negative associations with school or making friends. 

There are two ratings systems–the Conners Comprehensive Behavior Rating Scale and the ADHD Rating Scale IV–that have been shown to effectively evaluate preschool-aged children for the disorder.

And every source we researched emphasized the importance of having multiple people evaluate the child’s behavior for ADHD. It is typically not a diagnosis that can be made by a doctor alone. 

What Parents Say

From ADHD in Preschoolers: What AAP Guidelines Say (additudemag.com)

Ann Marie Morrison suspected that her son had attention deficit disorder (ADHD or ADD) when he was three. “John’s temper tantrums were more intense than those of other three-year olds, and they came out of nowhere,” says Morrison, of Absecon, New Jersey. “It took forever to get him out the door. He had to dress in the hallway, where there were no pictures or toys to distract him. He couldn’t sit still, and he tore apart every toy. I carried gift cards in my purse, so that when he destroyed a toy at a friend’s house, I could hand the mom a gift card to replace it.”

When Morrison discussed John’s hyperactivity and impulsive behavior with his doctors, her concerns were dismissed. “He’s just an active boy,” they said.

“One pediatrician said, ‘Even if he has ADHD, there’s nothing we can do for ADHD in children under 5,’” recalls Morrison. “That’s like saying, ‘Your son has a serious illness, but we can’t treat it for another two years.’ What was I supposed to do in the meantime?” The family moved to another part of the state when John was five years old, and, by chance, their new pediatrician was an expert in ADHD. She had been diagnosed with ADHD herself and had raised a son with the condition.

“At John’s checkup, she was taking a medical history and John was, as always, unable to sit still. She stopped and asked, ‘Have you had him tested for ADHD?’ I started to cry. I thought, ‘Oh, thank God. Someone else sees it,’” says Morrison. “After years of being told by relatives that I needed to discipline him more, after years of feeling physically and mentally exhausted, and thinking I was a horrible parent, someone realized what we were dealing with.”

…

For Mary and her husband, a chance meeting at the neighborhood pool when Brandon was 4 years old made all the difference. “I was trying to talk Brandon through yet another tantrum when a mom walked over to say that Brandon reminded her of her son, now 9. She gestured toward a boy sitting on a towel, quietly playing cards with a couple of other boys. Her son, as it turned out, suffered from severe ADHD. She gave me her psychiatrist’s name and phone number and I called right there, from the pool, and made an appointment.”

After a thorough evaluation, the psychiatrist diagnosed Brandon with ADHD and started him on a low dose of medication just before he turned five. Mary and her husband enrolled in a structured behavior modification program and joined a local parent group for extra support. “I can’t say that life is perfect, but it is certainly light years ahead of where we were,” she says. “Had I seen a different pediatrician earlier on, or known that ADHD could be diagnosed and treated at a younger age, I could have spared our family a lot of heartache.”

What Experts Say

On diagnosis

Dr. Alan Rosenblatt,  a specialist in neurodevelopmental pediatrics (ADDitude Magazine):

“A child with ADHD is much more extreme than the average three-year-old…It’s not just that a child with ADHD can’t sit still. It’s that he can’t focus on any activity, even one that’s pleasurable, for any length of time.”

Dr. Larry Silver, psychiatrist at Georgetown University School of Medicine (ADDitude Magazine):

“You have to look at whether the behaviors are consistent in more than one environment…You have to delve deep into the root of certain behaviors. …A child might have separation anxiety, his fine motor skills or sensory problems could be making it hard for him to behave, or it could be evolving autism spectrum disorder.” 

Dr. Laurence Greenhill, Columbia University/New York State Psychiatric Institute (ADDitude Magazine):

Identifies two behavioral patterns that can often predict ADHD diagnosis: 

1) Preschool expulsion, caused by aggressive behavior, refusal to participate, failure to respect other children’s boundaries or property

2) Peer rejection, avoided by classmates and shunned on the playground

Dr. James Perris, pediatrics professor at Harvard Medical School (WebMD):

“Young kids with ADHD are incredibly active all the time. …Most 4-year-olds are very active in general, but they settle down — take naps, sit for meals. A child with ADHD is on the go all the time.”

Dr. George DuPaul, professor of school psychology at Lehigh University (WebMD):

“What sets these kids apart is the degree and frequency with which they are hyper and impulsive …These kids are literally plowing through activities and people at a high pace.”

Dr. Nathan Blum, the chief of developmental and behavioral pediatrics at the Children’s Hospital of Philadelphia (New York Times):

“The kids are starting to feel that they’re not liked, that they’re bad, other kids are being turned off by them because they can’t pay attention or because they’re impulsive, can’t wait their turn.”

On treatment

Dr. Peter Jensen, professor of child psychiatry at the Center for Advancement of Children’s Mental Health (ADDitude Magazine): 

“You should avoid letting it get to the point that your child dislikes school or feels like a failure or is always in trouble. That can set the stage for a child to expect failure and act in self-protective ways (e.g., becoming the class clown or resorting to aggression) that, in turn, promote more negative feedback.”

Dr. Carol Brady, child psychologist in Houston (ADDitude Magazine):

“A smaller classroom, with less stimulation, and a strong routine often make a tremendous difference in improving ADHD symptoms in preschoolers. …Youngsters who are carefully diagnosed by competent professionals show great benefits from early intervention. …They are more relaxed, more successful, and able to enjoy their childhoods.”

Dr. Mark Wolraich, chief of developmental behavioral pediatrics at the University of Oklahoma Health Sciences Center (New York Times):

“If your child does have A.D.H.D., then you have to be a lot more consistent than most parents need to be in managing your child. …Having a coach is really helping to empower the parents to be more effective.”

Dr. Nathan Blum, the chief of developmental and behavioral pediatrics at the Children’s Hospital of Philadelphia (New York Times):

“I think it’s really important for parents to understand they’re struggling because of their child’s behavior, but they’re still the agent of change and so we have to work with them.”

Methodology / Sources

We started researching this question in several medical and scientific research sources and journals, including PubMed, the American Academy of Pediatrics, and UpToDate.  We then used a structured Google search to find trustworthy media sources, including the New York Times and Additude Magazine, to gather additional information and parse what both experts and parents had to say on this question.

For more reading:

• ADHD in Preschoolers: What AAP Guidelines Say (additudemag.com)
• ADHD Child vs. Non-ADHD Child Interview – YouTube
• Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Preschool-Aged Children – PubMed (nih.gov)
• NICHQ | Caring for Children with ADHD: A Resource Toolkit for Clinicians
• Structured PubMed Search Results
• Why Parents and Doctors Should Think About A.D.H.D. in Preschool – The New York Times (nytimes.com)

Maternie Manifesto

Our mission is to get parents the best information out there on the many important questions they encounter when raising children.

Sometimes there are clear cut answers to these questions and how to proceed. But often there is no perfect answer, and what works for one child will not work for another. Experts can have differing opinions, and parents will have different experiences.

That contradictory information can create stress and make an already difficult decision even harder. That’s where we come in. 

We do the research for you, not only getting you science and evidenced-based information but explaining where there is consensus among experts and parents, and where things might diverge.

Our greatest hope is that this information will give you greater confidence in your parenting journey, saving you time and some sanity along the way 🙂