ADHD: Leave the diagnosis to the doctor
Ms. Estelle looks up from reading
to her 4-year-olds.
“The caterpillar ate three plums and was still hungry,” she says. “How
could he do that?”
“I ate three bowls of cereal,” says Jenny. Other children recount
At the back of the circle, Josh is twisting and pulling fibers
in the rug. Without warning, he blurts out: “I have a new
Ms. Estelle pauses. “Wow, that’s great, Josh.” She
turns to the group: “We’ll finish the story this
afternoon. Let’s stand up and stretch for a few minutes.”
During nap time, she writes notes about the children’s
behaviors. On the page for Josh, she records his unrelated comment
during story time. She also notes that he gave up working a puzzle,
dumped blocks on the floor, and then tried to pry safety plugs
out of an electrical outlet.
“He seems unusually restless today,” she thinks. “Is he angry
or anxious about something? Am I seeing a pattern of behavior
that might be ADHD? Do I need to be concerned?”
It would be hard for anyone to interpret Josh’s behavior.
In early childhood, most children have trouble paying attention,
sitting still, finishing a task, and focusing on a topic.
Some might characterize Josh as “hyperactive.” But
that characterization is misguided for two reasons. First, only
a physician can diagnose the condition known as attention deficit/hyperactivity
disorder, or ADHD. Second, a child’s behavior before age
6 can be challenging and still fall within a normal range.
What is ADHD?
ADHD is defined by the American Psychiatric Association as “developmentally
inappropriate attention and/or hyperactivity and impulsivity
so pervasive and persistent as to significantly interfere with
a child’s daily life” (Reiff 2004).
Scientific evidence suggests that ADHD is a biologically based
condition in the brain. The cause is unknown, but the condition
seems to run in families. Unfortunately, there is no brain scan,
X-ray, blood test, or other medical procedure that can establish
that a child has ADHD. Instead, a diagnosis is based on reports
about a child’s behavior and functioning.
For many children, ADHD is a combination of inattention and hyperactivity/impulsivity.
Some children, however, have problems mostly with one or the
In evaluating a child, a physician will conduct a physical examination,
take a family medical history, and consider whether symptoms
might indicate another disorder. Observing a child for a few
minutes in a medical office cannot produce a diagnosis. Instead,
the physician will pore over information about the child’s
behavior collected from parents and teachers and will often consult
a psychologist or neuropsychologist who specializes in testing
The testing specialist will usually perform a battery to tests
to augment the information collected from teachers and the parents.
The specialist will attempt to answer specific diagnostic questions,
Is the child really inattentive, hyperactive, and impulsive?
Are there family or social stresses that are causing anxiety
and therefore inattention?
Does the child have learning problems that are causing the
inattention, hyperactivity, and impulsivity?
The younger the child, the harder it is to establish a diagnosis
of ADHD with certainty. Similarly, it is hard to be certain of
learning disabilities until the child is in elementary school.
The range of what is age-appropriate behavior in young children
is wide. For that reason, most physicians resist making a diagnosis
of ADHD before a child is 7 years old.
For a diagnosis of ADHD, a child must have symptoms for longer
than six months, and some symptoms must have existed before age
7. The symptoms must interfere with the child’s functioning
in two or more settings, such as home and school, and be more
pronounced than for most children at the same level of development.
What’s the teacher’s role?
A caregiver or teacher is responsible for knowing the strengths
and needs of every child in the group and accommodating those
needs in the day home or classroom. If Tanya is allergic to
peanuts, for example, the caregiver will modify menus to eliminate
peanut products. If parents cannot afford books to read to
their children, the teacher may set up a lending library so
families can take books home for short periods.
Discerning the strengths and needs of each child requires a knowledge
of child development and experience with children. It requires
communicating with parents, observing a child over time, and
documenting the child’s behavior using written notes, checklists,
and other tools.
Documentation must be objective; that is, it reports facts, not
judgments or opinions. “He was hyperactive again today” is
an opinion. “During story time, Josh sat at the back of
the circle and fidgeted with the rug for 3 to 4 minutes” is
an observable fact.
Documentation must also be consistent and methodical. A teacher
observes and jots notes about the behavior of all the children.
She takes notes at regular intervals, dates them, and keeps them
in a confidential file.
If a pattern of problem behavior appears, the teacher first analyzes
the schedule and environment. Perhaps she is expecting Josh to
do tasks for which he is not developmentally ready. She might
try adding simpler puzzles to the manipulatives center, offering
calming materials like play dough and sand, and reading with
him one-on-one, for example.
All the while, the teacher stays in regular communication with
parents about what’s happening at school and any changes
at home that might affect his behavior. Under no circumstances
does a teacher label the child or make a judgment about the child’s
In many cases, the parents also may have concerns or questions
about their child’s behavior. At that point, it’s
helpful to schedule a parent-teacher conference. The teacher
can review her notes about the child and refer the parents to
a physician or an Early Childhood Intervention (ECI) program
for a screening.
While a child is under evaluation, the parents may give permission
for the teacher to share her notes with the physician’s
office or ECI staff.
A screening may reveal a problem or group of problems other than
ADHD. The child may have a hearing impairment, an auditory processing
impairment, an anxiety disorder, or an overactive thyroid, for
example. A screening may indicate some behaviors that fit ADHD
but not enough to warrant a diagnosis, particularly if the child
is younger than 6.
If a child is eventually diagnosed with ADHD, the treatment may
include medication, behavioral therapy, parent education, and
other services. The caregiver or teacher may be invited to participate
in the treatment team, particularly in helping the child improve
behavior and learning in the classroom environment.
It’s important to realize that parents may already feel
overwhelmed and even guilty about their child’s behavior.
It is not the teacher’s role to criticize the parents’ child-rearing
practices, suggest a particular diet, or urge the use of a medication
or vitamin supplement. Treatment is the physician’s responsibility.
A number of alternative treatments for ADHD exist, but their
effectiveness remains to be proven. In the absence of medical
evidence, the American Academy of Pediatrics recommends a best-practice
approach. Best practices are based on the consensus of what experts
consider the best advice for dealing with the disorder.
How to deal with overly active behavior
Regardless of a screening outcome, caregivers and teachers can
respond to the overly active behavior of children of any age.
Focus on the child’s strengths and interests. The more
a child experiences success, the more the child will feel confident
and ready to learn. If Josh is interested in soccer, for example,
provide books about soccer and offer physical games with a soccer
Talk with the parents about what the child likes and does well
at home. Offer a variety of activities until you discover those
that are enjoyable in a classroom setting.
the environment. Many children feel overstimulated
by the noise and activity of daily life—TV, video games,
traffic snarls, blaring music on the radio, flashing billboards.
Identify things that distract children, remembering that the
distractions may be different for individual children. You may
consider muffling noise and softening lights, for example. Or
you may rethink the number of activities in each learning center
and change centers less often.
the environment. Set clear boundaries for learning
centers, and keep traffic paths open. Limit the number of children
in each center, and provide enough toys and learning materials
to avoid squabbles. Have specific places for storing materials
and children’s belongings.
predictable routines. A consistent schedule is important
for all children and essential for those who are overly active.
Knowing that the day always begins with free play, circle time,
and snack, for example, helps children feel secure.
realistic about your expectations. Notice when a child seems
to lose interest, even with ordinarily pleasant, enjoyable activities
and interactions. You may need to shorten circle time, break
up a task into smaller chunks, and avoid activities that require
waiting or watching.
ways to accommodate the child’s high activity level. Set aside a space indoors for intensive movement and energy release.
But avoid self-esteem damaging signals that broadcast the child
as different or troubled.
Give active children assignments that require movement like passing
out supplies or arranging floor mats for circle time.
activities so you can provide close supervision. Instead of a cooking activity for the whole class, divide children
into small groups. At circle time, encourage an overly active
child to sit near you and away from distractions such as windows
and hallways. Your proximity gives you the ability to respond
quickly to redirect or refocus a child who is distracted.
charts and checklists. Children often need reminders about
rules and routines. To help a child learn the procedure for washing
hands, for example, make a chart with pictures that show wetting
the hands, applying soap, scrubbing long enough to sing “Twinkle,
Twinkle Little Star,” rinsing, drying with a paper towel,
and tossing the towel into the trash.
clear directions. Call the child’s name to get attention,
and make eye contact. A clear direction is a statement (“Lie
down on the cot”), not a question (“Would you like
to lie down on the cot now?”)
directions simple and brief. “Put the paper towel
in the trash can under the sink.” It may help to have the
child repeat the direction to ensure hearing and understanding.
Remember to squat or kneel to get to the child’s eye level
before you give the direction.
If the child interrupts or is distracted, you may need to shorten
the direction: “Towel in the trash.” To regain attention,
touch the child’s arm or take a hand. Say only what needs
to be said.
on effort, not outcome. “You worked hard in fitting
those puzzle pieces together.” “You listened carefully
when I read how the train chugged up the mountain.”
as few rules as possible. Instead of 30 classroom rules,
have two: “We treat everyone kindly, and we keep the room
clean and neat.” Explain the rules and point out examples. “When
Damian gave Elyse a turn on the tricycle, he was treating her
positive behavior immediately. “Thanks for
putting away the paint pots.” A smile, a pat on the back,
or a thumbs-up can work equally well. A reward system in which
children earn stars or stickers is sometimes useful.
If only part of a behavior is positive, focus on that. “You
dried your hands with the paper towel. Great! Now put the wet
towel in this trash can.”
negative behavior if it’s not dangerous and you
can tolerate it. Negative behavior is sometimes a bid for attention.
When you encourage the positive and ignore the negative, children
will discontinue the negative because the positive is more pleasant.
Of course, the negative may increase for a time until children
see that you are consistent.
dangerous behavior immediately. If a child is about to
poke a pencil into someone’s eye, grab the child’s
hand and remove the pencil. Explain what you’re doing. “If
you poke a pencil into Ben’s eye, we’d have to take
him to the hospital. It would hurt him a lot. I won’t let
you hurt anybody.”
you see unacceptable behavior, respond immediately with clear
directions that tell the child what to do. “Josh,
freeze! Blocks are not for throwing. Use the blocks for building.
Can you build a barn for these farm animals?” A child may
hear and understand what’s expected but may not be able
to think ahead and plan actions accordingly. Children learn through
experience and can often modify their behavior to avoid unpleasant
One effective consequence for overly active preschoolers and
school-agers is a time-out or cooling-off period. Some teachers
have the child sit in a chair facing a corner with no distractions.
Some programs encourage teachers to sit with the child and talk
through the behavior, brainstorming appropriate solutions to
The maximum time for time-out is one minute per year of age.
A 4-year-old would be in time-out no longer than four minutes,
for example. Remember that young children cannot comprehend time,
so set a timer. “Take a few minutes to calm down and rest.
The timer is set for four minutes. Think about what activity
you’d like to do when you rejoin the group.”
Another effective consequence, particularly for school-age children,
is loss of privilege. For Josh, it might be playing with materials
other than blocks for part of the morning. Always make consequences
logical—related to the undesired activity or behavior—and
immediate. Denying Josh the privilege of playing soccer in the
late afternoon isn’t a logical or immediate consequence
to his morning block throwing.
Make consequences clear and give a warning before imposing the
stated consequence: “Blocks are for building. If you continue
to throw the blocks you’ll have to give up your turn in
the construction area.” If the behavior stops, acknowledge
the child affirmatively with a simple nod. If it doesn’t,
carry through with the stated consequence.
stating rules and warnings, speak calmly and firmly. Avoid
looking or sounding angry. Help children understand that rules
enable us to live in harmony and that breaking a rule is the
that children’s behavior changes as they get
older. Even children who are eventually diagnosed with ADHD can
learn to manage their behavior with the support of informed,
Provide a safe and friendly environment
ADHD is surrounded by a great deal of confusion and controversy.
As responsible caregivers and teachers, we do not use terms
like “hyperactive” and “ADHD” lightly.
Our job is to recognize the strengths and challenges of every
child in our care and respond in ways that can best help children
grow and learn.
American Academy of Pediatrics. “Children’s Health
Topics: ADHD.” www.aap.org/healthtopics/adhd.cfm.
Reiff, Michael I., M.D., ed., with Sherill Tippins. 2004. . Elk Grove Village, Ill.:
American Academy of Pediatrics.
Editor’s note: Thanks to Walter B. Kuhl, MD, and Julia
Kirby, Sharon Stone, and Rachel Moyer-Trimyer at ECI who reviewed