ADHD in Toddlers: Signs, Diagnosis, & Treatments

Is it Possible to Diagnose ADHD in Toddlers?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not include a minimum age necessary for diagnosis of attention deficit/hyperactivity disorder (ADHD), meaning it is possible to diagnose ADHD in toddlers. It simply requires that criteria are met for at least 6 months and have been occurring before age twelve.³ However, ADHD diagnosis in toddlers should be limited to include only professionals trained in the early identification of neurodevelopmental disorders.

Specific criteria used to make an ADHD diagnosis in early childhood are the same ones used for older children. Specifically, toddlers with ADHD experience significant hyperactivity and impulsivity, difficulty with sustaining attention to certain tasks, or both.³ Other related signs may include emotional dysregulation, including frequent and intense tantrums. Importantly, these symptoms must be occurring to a greater degree of frequency and/or intensity than same-aged peers, and must be occurring in multiple settings.

Diagnostic Process for Toddlers with ADHD

The evaluation process for pre-school aged children suspected of having ADHD is slightly more complex than for older children, due to developmental and physical considerations for toddlers.⁴ The use of a careful evaluation and behavioral observations by a trained provider like a developmental pediatrician or pediatric psychologist is typically necessary before a diagnosis will be provided. Specific areas of focus during an evaluation may involve family history of ADHD, language and/or motor delays, and overall growth rate from birth to 18 months.¹

Overdiagnosis of ADHD in Young Children

The issue of over-diagnosis of ADHD, particularly among young boys, has been raised in both the media and scientific literature.⁵ While there may be several reasons why a particular disorder is diagnosed, some contributing factors may be stereotypes related to young boys’ behavior,⁵ and inexperienced clinicians who are not adhering to established clinical guidelines.⁶

Is Labeling a Toddler With ADHD Helpful or Harmful?

The question of whether early identification of a neurodevelopmental disability is helpful has been well-established across medical disciplines:⁴ early identification increases opportunities for early intervention, which is instrumental in teaching skills to affected children and their caregivers. It has been increasingly demonstrated that early screening for and identification of ADHD symptoms can help reduce the negative present and future impact of the disorder.²

However, labeling a toddler with ADHD absent the consultation of an expert professional and without appropriate early intervention can indeed be harmful. Specifically, loosely using the term ADHD to describe an overactive or disruptive child may create undue hardship or stigmatization on that child. In addition, inappropriate use of clinical terminology minimizes the experience of children and families navigating the condition.

Early Signs of ADHD in Toddlers

Many researchers have sought to identify early markers for an eventual ADHD diagnosis in children.¹

Findings seen in some toddlers with ADHD in addition to the required symptoms of hyperactivity and inattention may include:

• Head circumference percentile: Young children ages 9 and 18 months with ADHD have been found to have smaller head circumferences than their neurotypical peers. While often comparable during 1-month well visits, these differences become increasingly apparent as children approach age 2.
• Motor development: Delays in motor development (e.g., crawling, standing, or gross motor tasks that require balance) have been noted in young children who are diagnosed with ADHD.
• Speech and language development: Children with ADHD may develop words and use complex sentences later in development than their peers.
• Sleep difficulties: Children with ADHD are more likely to have difficulty initiating sleep or achieving consistent sleep patterns.
• Feeding difficulties: Children with ADHD have been described as more likely to be picky eaters or engage in inappropriate mealtime behavior.
• Behavior problems: ADHD is often associated with behavioral difficulties, which include being slow to warm, tantruming, and difficulties with emotion regulation.

How to Know the Difference Between Typical Toddler Behavior & ADHD in Toddlers

Knowing what’s “normal” can often be hard to discern, even for seasoned caregivers. In truth, typical development occurs on a continuum – there is often no one-size-fits all way to capture what a child should be doing at a given time. Specifically, challenging behavior, over-activity, inattention, and impulsivity are all expected components of typical child development. Key distinctions involve the degree of impairment and the number of settings where symptoms occur.

Some examples of significant functional impairment might include:

• Missed or rescheduled parts of the day due to avoidance of triggering contexts or management of dysregulated behavior
• Feelings of helplessness or distress from caregivers due to their child’s inability to engage in activities that their same-aged peers do
• Observations that frontline strategies like redirection or praise are ineffective in helping a child to stay on task or remain calm

If It’s Not ADHD, What Is Your Toddler Struggling With?

Parenting a child, particularly during their preschool years, can be challenging. In fact, many of the signs and symptoms of impulse and disruptive behavior disorders in older children (e.g fidgeting, excessive running or climbing, difficulty with waiting, frequent interrupting) are expected behaviors of children under age five.⁶ Prior to pursuing any kind of treatment for symptoms of ADHD, parents and caregivers should strongly consider a comprehensive medical evaluation to rule out any potential biological explanations for their child’s behavior.

Common challenges in early childhood that may contribute to increased behavioral challenges:

Sleep Difficulties

Poor sleep is one of the most important risk factors for emotional and behavioral problems in childhood.⁷ Different types of sleep problems have been linked to different types of behavior issues; for instance, sleep anxiety, night waking, and insufficient sleep have been linked to irritability and anxiety. On the other hand, certain types of parasomnias (e.g., sleep walking, sleep talking, etc.) or sleep disordered-breathing have been linked to oppositional and defiant-type behaviors.

Hearing Problems

Although it is standard practice for babies to be screened for hearing loss, these problems can sometimes be missed or develop later in childhood. Some signs of hearing problems that might mask as ADHD symptoms can include learning difficulties, difficulty with attention, delayed or impaired speech, or not responding when their name is called.

Red Dye 40

Artificial food colors (AFCs), of which Red#40 is included, and has been implicated in changes in child behavior, including increasing hyperactivity and the likelihood of learning problems.⁸ Ultimately through more than 40 years of research, AFCs have been determined to have a small but not insignificant impact on child behavior. Food additives may have different levels of impact for different children, with more consequential effects for children predisposed to behavioral or attention problems.

Learning Disabilities

Learning disabilities involve difficulties in specific areas of learning, with overall intellectual functioning being unaffected. Examples of learning disabilities may include difficulties understanding concepts related to time, challenges with writing or drawing, or difficulty remembering things that were just said. These challenges can increase a child’s frustration in academic settings leading to acting out behavior. While there may be considerable overlap between learning disabilities and ADHD, the use of targeted educational assessments by a child’s school team can help identify these areas of skill deficit.

Emotional Distress

Symptoms of ADHD can also overlap or be misdiagnosed with other mood or emotional disorders. Anxiety disorders occur in approximately 8% of all preschool children and up to 30% of children with co-occurring ADHD.⁹ These children may be more likely to have poor social skills, inattention, and refuse to participate in specific activities.

Impact of ADHD on a Toddler’s Development

ADHD is a complex neurodevelopmental disability that may impact a variety of different areas of childhood development. Specific areas of impact include problems with learning and education, difficulties with peer and familial relationships, and increased risks for accidents and injuries. These problems are often chronic, with approximately 50% of children with ADHD continuing to meet criteria for the diagnosis into adulthood.¹⁰ Parents and caregivers often require specialized support and training for toddlers with ADHD, as traditional parenting strategies can often lead to increased frustration for the child and those around them.

Early Treatment for ADHD in Toddlers

Once ADHD is diagnosed in a toddler or preschool-aged child, it is important to consider which areas of growth might benefit from targeted therapy. While typically developing children often acquire these skills on their own, children with ADHD may need more explicit instruction to stay on track with their peers. It is important to note that a diagnosis of ADHD does not always require therapy in every skill domain; working with your child’s pediatrician or health provider will be helpful in identifying specific areas of weakness.

Physical Therapy for Toddlers With ADHD

Sometimes children with ADHD have significant areas of weakness in their motor functioning. Delays in motor skills can look like challenges with coordination, gross motor movements (e.g., running, balance), or low muscle tone. Physical therapists are specialists who are trained to diagnose and address these issues using targeted exercises and movement therapy. Identifying a physical therapist with experience working with toddlers and young children is particularly useful while trying to build these early skills.

Behavior Therapy for Toddlers With ADHD

ADHD is diagnosed through the observation of very specific behaviors occurring across settings. Thus, cognitive behavior therapy for ADHD is often a critical component of support for children with ADHD and their families. Critical skills can be taught using behavioral approaches, which can increase a child’s appropriate behavior while decreasing problematic or maladaptive ones. Behavioral therapies are often considered “front-line” interventions, as they are supported by research and are generally effective.

Most of these approaches focus on teaching caregivers how to support their children and increase their likelihood of success. Specific approaches range in their time commitment and targets for therapy vary by model. Possible programs include group-based parent training,¹¹ caregiver-directed interventions such as parent child interaction therapy,¹² or combined child and caregiver training programs such as applied behavior analysis.¹³

Is Medication Ever Prescribed for Toddlers With ADHD?

Yes, medication can be prescribed for toddlers with ADHD, but typically behavioral therapies are the frontline-treatment. The second-line treatment recommendation by the American Academy of Pediatrics for symptom management of ADHD in toddlers is methylphenidate (common brand names include Ritalin, Concerta, and Quillivant) ADHD medication.⁴ However, it is important to note that there is a risk of adverse side effects for young children who are taking stimulant medication, which include decreased appetite, irritability, and insomnia.

How to Support a Toddler With ADHD Symptoms

Regardless of whether they meet criteria for ADHD, children who are hyperactive, impulsive, or who have difficulty maintaining attention often need support from those around them. While it might look like these children are deliberately disobeying or trying to frustrate their caregivers, their behaviors are often the product of skill deficits (for instance, difficulty tolerating frustration or challenges with waiting or sitting still).

Here are some general tips on supporting a child with ADHD:

1. Create a Structured Environment

Generally, children are most successful with consistency and predictability. While we don’t always realize it, even very young children benefit from understanding the patterns in their environment and when to expect the things they care about. Caregivers can support this preference by developing routines around key parts of the day, such as bedtime and wake time, mealtimes, and playtimes. Creating structured, predictable environments does not require overbooking or rigid adherence to a minute-by-minute schedule; rather, having the same general approach to each day will serve these youngsters well.

2. Using Positive Reinforcement

Recognizing and acknowledging even small successes can be a remarkably effective intervention strategy for supporting a young child with ADHD. Each child is unique in the things in the environment that motivate them; however, many are receptive to attention and praise from their caregivers. Helping to motivate a child to make good choices is both supportive and nurturing; it also has an added benefit of reducing familial stress – when children are doing the right thing they can’t be doing the wrong thing.

3. Focus on Simple Communication

Adults are typically accustomed to using a lot of words to convey their expectations of others. However, hearing instructions from others may not be the best way for young children to learn and process information. Similarly, when children are frustrated or overwhelmed, they may have difficulty expressing why they are upset. When it comes to communication around challenging things, often less is more. Caregivers often find success with using and expecting the least number of words necessary to communicate wants and needs. 

4. Manage Sensory Overload

While not all children with ADHD have sensory problems, considering the impact of a noisy or chaotic environment can be extremely helpful in setting a child up for success. Creating or identifying spaces that are quiet and predictable can be useful in helping a child to focus and/or manage their emotions. However, it is important to use these environments as a way to prevent a sense of overwhelm rather than in response to disruptive behavior.

5. Seek Professional Support

Parents and caregivers are often experts in their children; they understand their child’s wants and needs in ways many others cannot. However, parenting a child with ADHD can often feel difficult, even for caregivers who have a lot of experience with neurotypical children. Specialty programs that focus on developing the unique parenting skills necessary for helping children with ADHD can be useful in reducing stress and improving parent-child relationships.

6. Encourage Outdoor Play

Sometimes children just need to run and play. Providing spaces for physical activity can be extremely useful to help children expend excess energy safely. This, in turn, can help them regulate during other parts of the day where they are not permitted to freely access the environment, such as at school. However, it is equally important to ensure that outdoor time is supervised, as children with ADHD can be more likely to engage in risk-taking behavior.

Advocating for a Toddler With ADHD Symptoms at Daycare

Unfortunately, not all daycares are equipped to support children who are highly active and/or impulsive. Often, daycare staff will reach out to caregivers for solutions for behavior problems associated with a child’s ADHD symptoms, leaving families feeling frustrated and helpless. It is important to emphasize providing consistent, predictable environments where expectations are clear. Caregivers should resist the urge to go into daycares to provide support themselves, unless their schedule is flexible enough to do so without a significant negative impact (e.g., financial issues related to missed work). Instead, caregivers should advocate for their child to receive the support necessary to help their child to be successful within the structure and staffing of the program itself.

Resources for Toddlers With ADHD Symptoms

In addition to guidance from mental health professionals, there is a great deal of information available to caregivers and family members about supporting their young child with ADHD.

Some helpful resources for family members include:

• Support groups and organizations: Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) is a national organization that provides up-to-date information around research, education, and related services for children and families.
• Healthcare resources: Several national and state organizations provide information about best practice guidelines, advocating for educational services, and identifying local professionals with the experience and expertise to treat young children.
• Books and blogs: While information included in books about ADHD or blogs about ADHD can be very subjective, it can also be very useful to learn about others’ experiences and perspectives.

Questions to Ask a Pediatrician About ADHD in Toddlers

Caregivers often arrive at their pediatrician with a great deal of concern and uncertainty around their child’s symptoms. To that end, it can be useful to develop a list of questions that might help with next steps in providing care and future monitoring.

The questions below are just a sample of relevant questions that could prove useful to families as they make that initial visit to their child’s pediatrician:

• How can I differentiate between ADHD and normal toddler behavior?
• What is the process for diagnosing ADHD in toddlers?
• What documentation from the toddler’s teachers/sitters would be helpful?
• What are the potential impacts of ADHD on a child’s development?
• Are there lifestyle or dietary changes that can help manage symptoms?
• What resources are available for families dealing with ADHD?
• How can I monitor and evaluate my child’s progress?

How to Find Professional Support

There are a variety of different types of providers that can provide relevant services to a child suspected of having ADHD. Often, obtaining a diagnosis is just the beginning of that process, and many caregivers are interested in finding a neurodiverse-affirming therapist in their area. It can be useful to start with the child’s insurance provider’s webpage or directory, as finding a provider that is covered in-network can alleviate much of the financial burden around support services. In addition, many online therapist directories or online therapy platforms allow users to search by insurance type to help families minimize their out-of-pocket expenses.