Is my 4-year-old hyper?

Dear Mamas,

I recently got a call from my 4-year-old son’s preschool teacher that left me with mouth wide open.

She began by explaining that while Keegan is a charming and “spirited” little boy, she anticipates some problems when he gets to kindergarten next year and wanted to discuss it. It seems my guy is more energetic than the average child and is very “squirmy” (that’s the word she used – squirmy) when asked to sit at his desk to practice writing his letters and numbers. She’s concerned that he may be showing early signs of an attention disorder, and recommended that I have him evaluated for possible medication.

My neighbor’s 8-year-old has been diagnosed with ADHD and I’ve heard her talk about some of the symptoms, so I asked if Keegan disturbs other children, or if he has difficulty interacting with others in the class. She said, no, not at all. He’s well-liked and is always in a happy group when they play outside, but  only has difficulty sitting still when it’s lesson time.

Is it just me, or is 4 too young to be labeling him with ADHD? I’m still in shock.


Dear Callie,

My mouth would be hanging open right next to yours, but this has become so commonplace that I can no longer be shocked. Instead I have steam coming out of my ears. My bias (and it is a bias) is that children, particularly boys, in preschool are not developmentally equipped to sit still at a desk and perform repetitive tasks. That readiness comes later — often not until well into first grade.

In my opinion, preschool kiddos should be running around getting their ya-yas out, playing make believe, and using their vivid imaginations, not sitting at a desk practicing letters and numbers. It is a disservice to our children to expect otherwise. But this is a controversial topic, and if you ask five developmental pediatricians you’re likely to get five different answers. While there isn’t a whole lot of reliable information on ADHD in very young children, there are some areas of agreement.

Experts describe two behavioral patterns that may predict ADHD diagnosis later in childhood. The first is preschool expulsion, which is usually caused by aggressive behavior, refusal to participate in group activities, and failure to respect other children’s boundaries. The second is peer rejection, easily recognized by parents. Children with behaviors outside the norm are avoided by their classmates and shunned on the playground. Other kids tend to be “busy” whenever parents try to arrange playdates.

Red flags for these little ones aren’t limited to fidgeting or extra energy when asked to sit quietly, they include aggression, isolation and avoidance by the group. This doesn’t sound like the behaviors Keegan is demonstrating.

Diagnosis of ADHD in any child should involve a thorough developmental history, observation of the social and emotional environment, and feedback from health professionals who know the child well. In most cases, neuropsychological testing is needed to rule out other conditions with similar symptoms.

Treatment must include counseling and behavior therapy.  ADHD medication can have severe side effects in the very young, including poor appetite, insomnia, and anxiety. Preschoolers appear to be more prone to side effects than school-age children.

For more information, take a look at what and the American Academy of Pediatrics have to say on the topic.

If I had to guess, I’d say that Keegan is a typical 4-year-old boy. Less focused than the girls (as little guys are), soaked in a brine of kiddo testosterone, and feeling the energy of his wild, age-appropriate oats. But don’t take it from me, talk to his pediatrician and other professionals you trust. And you may want to reconsider your choice of preschool.

Good luck!

~ The Mamas






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Rachel Zahn, MD is a pediatrician turned health writer who had three kids during medical school and pediatric training—crazy, huh?

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