Early ADHD Signs in Preschoolers: Key Indicators for Parents

In 2022, approximately 7 million children in the US aged 3-17 had been diagnosed with ADHD at some point. When it comes to preschoolers, spotting ADHD symptoms can be tricky. Things like short attention spans or high energy often seem pretty normal for their age, making it tough to tell if there’s something more going on.

But here’s the thing—missing those early signs could make life harder down the road. It might lead to struggles in school, challenges with making friends, and low self-esteem. In fact, a 2024 study found that about 4.4% of kids with ADHD had been expelled from preschool, with boys experiencing higher rates compared to girls.

As a parent or caregiver, being aware of potential ADHD signs early on can make a big difference. It opens the door to early support, guidance, and even intervention if needed. In this article, we’ll walk you through the early ADHD signs in preschoolers, tips on distinguishing it from normal preschool behavior, and information on available treatment options.

Diagnostic Criteria for ADHD According to DSM-V

Given the symptom variability in ADHD, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) categorizes it into separate subtypes:

At least six specific symptoms need to be present for kids 16 and younger. For teens 17 and older, it’s five or more. These symptoms have to persist for at least six months and shouldn’t align with what’s typical for their developmental stage.

These signs should also be noticeable before the age of 12, and they need to show up in at least two places—like at home, school, or work. This helps rule out situations where behaviors might only happen in a specific environment.

It’s also important that these symptoms significantly affect day-to-day life, whether socially, academically, or professionally. Lastly, they can’t be better explained by another condition, such as anxiety, a mood disorder, or something else entirely. It’s a detailed process, but understanding these criteria can help clarify what ADHD really looks like.

ADHD Presentations

ADHD is classified into three main presentations based on the types of symptoms that are most prominent in the individual. These are:

• Predominantly Inattentive Presentation: People with this presentation might seem distracted, forgetful, or have a hard time staying organized. There’s usually little to no hyperactivity or impulsivity involved. You might recognize this as what used to be called ADD (Attention Deficit Disorder).
• Predominantly Hyperactive-Impulsive Presentation: In this case, hyperactivity and impulsiveness take the spotlight. Think of constant fidgeting, difficulty staying still, or acting on impulse without much thought.
• Combined Presentation: This one’s the most common. It’s a mix of both inattention and hyperactive-impulsive symptoms. To fall under this category, someone needs to show at least six symptoms from both groups for six months or more.

Keep in mind that these presentations aren’t set in stone. As kids grow, the way ADHD manifests can shift, too—some symptoms might fade while others become more noticeable.

Early ADHD Signs in Preschoolers

Hyperactivity often takes center stage among the ADHD symptoms in kids. In fact, a 2022 study found that 58% of preschool-aged kids with ADHD showed a hyperactive-impulsive presentation. This makes sense because kids aren’t typically expected to focus for long periods at this age, so signs of inattention can easily fly under the radar.

Now, let’s be real–most preschoolers have their moments of high energy or occasional tantrums. But with ADHD, these behaviors tend to be much more intense and frequent. Here are some early signs of ADHD in kids:

• Intense and uncontrolled emotions: They react intensely to both positive and negative emotions. For instance, they may scream with excitement over small rewards or react aggressively when something is taken away.
• Frustration and low tolerance for delays: Minor issues often feel overwhelming and lead to meltdowns over small disappointments. These children often want things immediately to gain immediate satisfaction.
• Sensitivity to feedback and difficulty with transitions: They may react with anger or frustration to simple requests, such as putting on a coat. Transitions and feedback can also trigger intense responses.
• Frequent and severe tantrums: These aren’t your average tantrums. They can come out of nowhere, last 20 minutes or more, and leave the child unable to calm themselves down.
• Aggression and controlling behavior: In group settings like preschool, they might push peers or act out emotionally when things don’t go their way. This can lead to repeated disruptions and challenges with social interactions.

ADHD Symptoms Observed in a Case Report

The symptoms listed above match the behaviors identified in a case report of a 4-year-old boy with ADHD who visited the National Homoeopathy Research Institute in Mental Health (NHRIMH). His parents had reported a two-year history of symptoms, including:

• Anger when contradicted
• Frequently asking trivial questions
• Handling his genitals
• Harming insects
• Exhibiting constant restlessness
• Running around and being unable to sit quietly, even for short periods
• A brief attention span, often unable to stay focused while playing or speaking
• Appearing uninterested in listening to others and frequently getting distracted
• Often losing or dropping belongings wherever he played
• Rarely obeying instructions
• Being highly stubborn and often doing the opposite of what he was told
• Disturbing or hurting others to get his way
• Having a tendency to break his toys
• Biting his nails
• Quickly moving from one activity to another, leaving tasks unfinished

The child’s symptoms were first noticed when he began attending a daycare center. His teachers reported that he rarely sat still, frequently disrupted other children, and often pushed or bit them.

Soon, he began displaying similar behaviors at home. He would ask questions like how birds fly, why snails move slowly, or how bubbles are trapped inside a glass paperweight. As these behaviors became more intense and disruptive at school, at home, and in public settings, his parents decided to seek help and brought him to the institute.

ADHD Symptoms Observed by Practitioners

Clinical observations of ADHD in preschoolers reflect similar patterns, especially in their difficulty following commands or instructions. In an interview with Child Mind Institute, Dr. Mark Stein, director of the ADHD and Related Disorders Program at Seattle Children’s Hospital, shared a key screening question he uses when assessing ADHD in preschoolers:

“What percentage of the time, when you give your child a command, do they obey you within five seconds?”

According to him, children without attention or behavioral issues typically comply with commands about 75-80% of the time by age four. However, Dr. Stein notes that in many of his young patients with ADHD symptoms, compliance is closer to 10%.

Note that a lack of hyperactivity doesn’t mean a child doesn’t have ADHD. Inattention is a frequently overlooked symptom. These children often exhibit what are known as “dreamy” symptoms. Parents of preschoolers with inattentive symptoms report signs such as:

• Constant daydreaming and lack of responsiveness
• Frequently losing personal items
• Difficulty following multi-step directions
• Struggles with retaining information learned in school
• Viewed as "spacey," "underachieving," or "random" by teachers

Early recognition of these symptoms is important, given that 60–80% of preschool ADHD cases persist into school age.

Differentiating ADHD from Normal Behavior

It can be challenging to distinguish early ADHD signs in preschoolers from normal behavior, as many young children are naturally energetic and impulsive. To clarify the differences, here’s a comparison of typical behavior and behaviors that may indicate ADHD:

Tantrums

Neurotypical children generally experience tantrums 2-3 times per week, with each episode lasting less than 15 minutes. Over six months, the frequency and intensity tend to decrease as the child develops more emotional regulation skills.

In contrast, those with possible ADHD may have tantrums 3 or more times per week, with each episode lasting over 15 minutes. These tantrums remain frequent and intense for six months or longer, which indicates challenges with self-regulation.

Aggressive Behaviors (e.g., biting)

When a preschooler bites, it could be a reaction to something at home or in their childcare environment that is making them feel upset, frustrated, confused, or scared. Biting may also be a way for them to seek attention or to defend themselves.

In children with possible ADHD, aggressive behaviors happen more frequently, especially during tantrums. This behavior may continue even if they have developed good language skills, suggesting an underlying difficulty with impulse control.

Self-injury (e.g., biting or hitting oneself)

Self-injury behaviors, such as biting, hitting oneself, or head-banging, are generally uncommon in neurotypical children and are rarely observed. However, children suspected of having ADHD may exhibit these behaviors at any time, suggesting a higher level of frustration or challenges with emotional regulation.

This behavior is especially concerning. A 10-year follow-up study on girls diagnosed with ADHD between ages 6 and 12 found significantly higher rates of suicide attempts and self-injury. Both inattentive and combined subtypes displayed similar patterns, though the combined subtype showed a higher concentration of these cases.

Treatment Approaches for ADHD in Preschoolers

The American Academy of Pediatrics (AAP) recommends behavioral Parent Training in Behavior Management (PTBM) and/or classroom behavioral interventions as the primary treatment for preschool-aged children with ADHD.

This is a grade A recommendation, meaning it’s supported by strong evidence from high-quality studies, with a “strong recommendation” label indicating that clinicians should follow this guidance closely.

Nonpharmacological Therapies

PTBM is a structured program to teach parents effective techniques for managing behavioral challenges in children with ADHD. A recent study found that children whose parents received training showed lower scores in attention deficit, hyperactivity, and impulsivity on the ADHD Rating Scale compared to the control group.

Programs available for PTBM targeting preschool children include:

1. Parent-Child Interaction Therapy (PCIT)

PCIT involves coaching sessions where the parent and child are in a playroom while the therapist observes from an adjoining room, using a one-way mirror or live video feed. The parent wears an ear device to allow the therapist to provide real-time coaching on behavioral management skills.

This program is divided into two treatment phases:

• First phase: Emphasizes building warmth in the parent-child relationship.
• Second phase: Focuses on teaching parents how to handle their child’s most challenging behaviors.

2. Incredible Years Parent Training

This program includes 14 weekly group sessions where parents learn techniques on:

• Relationship-building
• Positive reinforcement
• Non-violent discipline

These techniques guide parents to shift their focus from negative to positive child behavior, helping them avoid coercive interactions and increase positive interactions.

3. Positive Parenting Program (Triple P)

Triple P is a multi-level parent training program with increasing intensity, targeting children from birth to age 12:

• Level 1: General parenting information available through media to raise community awareness and promote program participation.
• Level 2: One or two sessions offering guidance for parents of children with mild behavior issues, supported by tip sheets and videos.
• Level 3: Four sessions focused on active skills training for parents of children with mild to moderate behavioral challenges.
• Level 4: An intensive program for parents managing more severe behavioral difficulties in children.
• Level 5: Enhanced interventions for parents dealing with additional issues, such as relationship conflicts, depression, or high stress.

4. New Forest Parenting Programme (NFPP)

This is a specialized parenting program designed specifically to help manage ADHD in preschool children. NFPP incorporates games and activities to improve self-regulation and attention skills.

NFPP is delivered by a single practitioner through eight weekly sessions held in the family’s home. Each session lasts about 90 minutes, with five sessions dedicated to the parent alone and three involving both the parent and child together.

Pharmacological Therapies

If behavioral interventions alone do not significantly improve symptoms and the child continues to face moderate-to-severe impairments, methylphenidate (a stimulant medication) is the preferred first-line pharmacologic treatment for preschool-aged children.

Situations where medication may be appropriate include:

• Behavior therapy has been unsuccessful
• Symptoms have persisted for at least 9 months
• Risk of injury to the child, other children, or caregivers
• Threatened or actual expulsion from preschool or daycare
• Strong family history of ADHD
• Possible central nervous system injury (e.g., prematurity, prenatal alcohol exposure, or lead poisoning)
• ADHD symptoms interfere with other therapies (e.g., speech, occupational, or physical therapy)
• Parental stress reaching a critical level, or marriage is strained due to the child’s behavior

FDA vs. AAP Recommendations

Treatment guidelines for preschoolers are complex because FDA approvals don’t fully align with AAP recommendations. While methylphenidate is the AAP’s recommended first-line medication treatment, it is FDA-approved only for children ages 6 and older, making its use in preschoolers “off-label.”

The AAP’s latest guidelines suggest that methylphenidate has the strongest evidence for safety and effectiveness in children ages 3 to 5 (preschoolers). However, the FDA has approved amphetamine, not methylphenidate, for children ages 3 to 16. The AAP notes that amphetamine received approval under less rigorous standards, with insufficient evidence to support its use as a first-line treatment for ADHD in preschool-aged children.

Dr. Andrew Adesman, Chief of Developmental & Behavioral Pediatrics at Long Island Jewish Medical Center, advises starting with a methylphenidate-based medication for preschoolers. If it proves ineffective, he suggests trying an amphetamine-based option as a secondary approach.

Takeaway

Hyperactivity and impulsivity might sit at the top of the checklist for ADHD symptoms in children, while signs of inattention may appear more subtly as the child grows. Differentiating these symptoms from typical behavior can be complicated, as young children naturally exhibit energetic and impulsive tendencies.

Behavioral treatments, such as PTBM, are generally recommended first. In more severe cases, medications like methylphenidate may be considered, although its use in this age group is off-label. The varying recommendations between the AAP and FDA for ADHD treatment reflect the ongoing complexities in managing ADHD in preschoolers.

Consulting a healthcare provider is the most important step for parents and caregivers concerned about a child's behavior. Early intervention can significantly improve the child’s development and well-being.

FAQs about the Early ADHD Signs in Preschoolers

Are certain foods, like sugary snacks, linked to ADHD symptoms in young children?

There’s no solid evidence that sugar or specific foods affect ADHD symptoms directly. A 2010 study found a correlation between a Western diet (high in fat, calories, and sugar) and higher ADHD rates in children, but it didn’t establish a cause. Research on sugar's impact on hyperactivity is also mixed, with some studies noting a slight increase in hyperactivity and others finding no effect.

Are boys more likely than girls to show early ADHD signs?

Males with ADHD often display more disruptive behaviors, making their symptoms more noticeable and reinforcing the stereotype of ADHD as a "boy’s condition." In contrast, females with ADHD are usually less disruptive, often showing symptoms like daydreaming rather than interrupting or hyperactivity, so their struggles are less visible. Even when females have similar symptoms to males, ADHD may be overlooked or downplayed because they don't match the common image of a child with ADHD.

Are there any risk factors that increase the likelihood of ADHD in preschoolers?

Yes. Scientists have found a strong genetic link to ADHD, meaning it can often run in families. Certain environmental factors may also increase the risk. These include the mother smoking or drinking alcohol during pregnancy, early exposure to lead or pesticides, premature birth or low birth weight, and brain injuries.