nieman: difficulty in diagnosing adhd in preschoolers

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making an accurate diagnosis of adhd in patients between the ages of four and six years is not only challenging, but often draws intense criticism.

by dr. peter nieman, calgary herald

published may 26, 2025

4 minute read

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4 minute read

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many preschool-aged children will experience adhd-like symptoms, and these children need to be followed closely by parents, teachers and doctors until it becomes clear that the behaviour impairs day-to-day functioning. getty images

making an accurate diagnosis of adhd in patients between the ages of four and six years is not only challenging, but often draws intense criticism. experts in the field agree that there are certain patterns of behaviour, unique to that age range, which make an accurate diagnosis more difficult.

ideally, doctors follow strict diagnostic criteria for making the diagnosis of adhd at a young age. the american academy of pediatrics (aap) recommends behavioural interventions as the frontline treatment in children ages four to six.

the canadian adhd resource alliance also weighs in with their recommendations, based on peer-reviewed research. practically, though, it is not uncommon to navigate the following situations:

parents who cannot agree whether there is a problem or not. this disagreement frequently leads to accusations of one parent being an incompetent parent. the latter may be compounded in situations of strife, divorce, or custody battles.
preschoolers, by nature, are rambunctious, curious, rarely consistently attentive or regulated; they often have intense energy, demand attention, interrupt parents easily, and struggle to follow adult-led activities for long periods.
a family history of adhd in one of the parents can be helpful. but adhd is not always diagnosed in childhood. there may then be a sense that the preschooler is simply following the pattern of behaviour of one parent, who has undiagnosed and untreated adhd, and that the preschooler is “normal.”

a number of single parents find it hard, both physically and emotionally, to deal with a very busy preschooler all on their own, with very little support. they are exhausted, as one would expect, by the relentless need to supervise and guide a child safely through an average day. it can be overwhelming. on top of all these demands, one can only imagine how hurtful it must be for a single parent, who does his or her best, to be accused of being an incompetent caregiver.

parents, doctors and teachers who are dubious about the diagnosis of adhd in preschoolers often raise these questions as the root of the child’s behaviour: can it be that preschoolers are allowed too much screen time? does it have anything to do with poor nutritional choices? could there be any connection between a child’s misbehaviour and the exposure to cannabis or other neurotoxins while in the mother’s womb? could it be related to inflation, unaffordable living, lack of housing opportunities, bigger classes in even preschools or a higher divorce rate?

in addition, are doctors overzealous in making the diagnosis and prescribing medication?

with the above as the background, when can one assume that a preschooler has early adhd features, and when is it indeed just normal behaviour for that age range?

what do we do when a preschooler runs from wall to wall in an exam room and schools, climbs over furniture, fails to attend to any activity for even three minutes, cannot wait his turn, talks loudly and excessively, bolts across a busy street, impulsively, with no fear of danger, despite being told to hold the adult’s hand? what to say about a preschooler who requires very little sleep and simply exhausts a parent who, inappropriately, engages in self-recrimination regarding their parenting skills. what should we do if we get two very different stories about a child from parents who cannot get along?

as a general rule, and following the protocols of the aap and the canadian pediatric society, i rarely make a diagnosis after one visit and rarely suggest any medication.

behavioural interventions are the ideal approach at this age, but how realistic is that?

the majority of single parents are not in a position financially to seek input from psychologists on how to parent busy and energetic preschoolers. when psychologists are not an option, i have found online resources to be extremely helpful, at least as a starting point for raising awareness.

one such resource is available at www.additudemag.com. a webinar on aug. 8, 2024, can be found as a replay and as podcast #516. two experts, both psychologists, drs. alexis bancroft and cynthia martin did an excellent job explaining how hard it is to manage preschoolers who may just be a busy boy or girl or have adhd.

i also suggest a book, the better brain, which takes a deep dive into how a child’s brain may be fueled properly via healthy nutrition.

dr. nieman is the founder of centre 70 pediatrics and the past president of the alberta chapter of the american academy of pediatrics. he has written monthly columns for the herald since 1999.

this article was originally published in the calgary herald on may 24, 2025.