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Ask Dr. Doug: Typical Toddler Behavior or ADHD?

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Q: We have a very rambunctious 3-year-old. I know that’s pretty normal for this age, but he doesn’t seem able to really focus on things, even bedtime stories. I’m wondering whether there are any early warning signs for ADHD that I should know about — should I have him tested at this age? What can we do to support him besides medication if he does have ADHD? Would behavior therapy help?

A: Three is exhausting, isn’t it? In addition to all that energy, 3-year-olds add a dose of independence and negativity. “No!” enters their vocabulary more and more. Attention spans are short and tantrums can get more intense. The behavior you’re describing sounds developmentally normal to me (which I know doesn’t make the tough days easier!), but I would encourage you to meet with your pediatrician to discuss your concerns and think of some helpful supports.

ADHD is a specific grouping of behavioral symptoms that includes impulsivity, hyperactivity, and inattention — often with big emotional responses and trouble shifting from one thing to the next. Think of ADHD as less “not able to pay attention” and more “trouble regulating attention and emotion.” Kids with ADHD can even get “hyperfocused” on engaging activities, but often have a hard time showing regulation in other situations.

At the same time, I often worry we’re too quick to label behavior a “disease.” Children demonstrate a remarkable level of neurodiversity. That means developmental differences exist along a spectrum and, in many cases with the right supports, can function as strengths in life. In my practice, I approach behavioral concerns by considering whether it is causing impairment or distress. What usually matters more than labels is supporting families to ensure a child’s highest level of functioning with a growth mindset. This means considering a child’s history, environment, nutrition, and sleep when thinking about treatment. Evidence-based therapies, such as parent-child interaction therapy, can be very helpful. Medication may play an important role, but should never be a knee-jerk response.

A few other thoughts: Kids are not robots, so normal behaviors vary considerably based on age and gender. I often see kindergarteners with summer birthdays get mislabeled as “problem kids” when really they just need a bit more time to develop. And keep in mind, the behaviors we see in children with ADHD overlap substantially with anxiety, learning disabilities, trauma, and mood disorders, requiring a thoughtful approach to diagnosis and treatment.

At Metropolitan Pediatrics, I’m lucky to practice with an integrated behavioral health team that includes a psychologist, social worker, and care manager, which allows us to support preschoolers with tantrums and toileting issues all the way up to teens with anxiety, depression, and ADHD. And if your 3-year-old is bouncing off the walls and melting down within minutes of waking up, remember you’re not alone (and maybe put that second pot of coffee on)!