No, but you should realize that at this age few children are perfect angels, and that misbehavior and hyperactivity are relatively common and usually no cause for alarm. However, while most children are not brought for diagnosis until they are of school age, earlier diagnosis may offer help that might prevent later problems from developing.A doctor should be consulted if the child’s behavior is causing serious problems at home, in school, or in other social situations. If you feel your baby does have severe difficulties in calming down, or if your toddler seems especially hyperactive, inattentive, or very difficult to soothe, you should consult with your pediatrician, and perhaps ask for a referral to a child psychiatrist. Similarly if your child has not begun babbling during the first year, or is not speaking words during the second year, or if your child seems to not relate to you, it would be advisable to seek a consultation.I will illustrate the picture of ADHD in a preschooler, by describing Peter, who already exhibited severe symptoms of ADHD by the age of four.
Peter, a four-year-old preschoolerPeter was first brought to see me when he was four years old, a few months after beginning pre-kindergarten. His teachers had told his parents that he never communicated with them or other children, did not play with his peers, and never joined in group activities. He either kept to himself in a corner with books, or he careened around the room in an unrelated, hyperactive state. He could only tolerate an hour or two a day before becoming disruptive and demanding to go home. At times he became babyish, for example, crawling around the classroom and mouthing toys.His parents said these were also long-standing problems at home. While Peter had a large vocabulary and fund of knowledge, he rarely spoke to them directly about his needs or feelings and they felt he did not listen to them. He seemed to tune them out when they tried to speak to him, particularly when they asked him to do something. He spoke incessantly, but rarely about any real events or interactions. His speech was irrelevant and filled with fantasy. He reacted with increased hyperactivity and uncontrollable behavior whenever a change of situation was required, such as when leaving the house or having to end an activity or go to bed.Peter was his parents’ first child, a second having arrived when he was three. His mother’s pregnancy with Peter was normal but the labor lasted three days, and monitoring of the baby’s heartbeat in the birth canal showed there was some fetal distress during the end stages. However, he seemed healthy at birth and went home with his mother on schedule. She remembered that he was colicky and very difficult to soothe, often requiring prolonged carrying. Now, at age four, he still became uncontrollably distressed when upset or over-stimulated, had tantrums and banged his head on the wall. He still seemed unresponsive to his parents’ attempts to soothe him or to control or punish him.A further troubling symptom was that he had never achieved full bowel training. He would retain his feces, and then have repeated accidents in his clothing (encopresis). Sometimes he would actually disrobe and defecate on the floor, but he very rarely defecated in the toilet. He preferred to wear diapers and, though not wearing them to preschool, was continuing to wear them at night. His pediatrician found no physical abnormality to account for this encopresis and, in fact, found him in excellent health except for his recurrent ear infections. These infections may well have interfered with his hearing at various times during his infancy. His speech development had been delayed, and he did not start speaking in full sentences until after three years of age.When I first met Peter, he came bursting into my office enthusiastically, his mother at his side. I invited her to stay in the room, and he proceeded to explore hectically, talking continually with an immature articulation at times difficult to understand. Sometimes he spoke about the toys and asked me about broken things and missing pieces, but often his streams of speech seemed irrelevant to the situation at hand, and were just another medium of motor discharge. Suddenly, after about ten minutes, his activity stopped, and he went and stood by his mother and stared at me, as though he had only just realized I was a stranger and he needed to take stock of the situation.I easily engaged him again, and found I had to keep my own energy level very high to keep up with him, following him around the room, talking, answering his questions. He was not rough with the toys, however, and worked with great perseverance to carefully free a stuck car from a garage elevator. When I suggested that his mother could wait in the waiting room while he and I continued, he said that she would have nothing to do there. When she went anyway, saying she had lots to do, he seemed not to respond, and went on playing.In her absence, Peter’s activity level increased even further. He went to the cold woodstove and started to rub his hands in the ashes. He wanted to open my drawers, in addition to other activities that I had to prohibit. He clearly was now reacting to his mother’s absence with some anxiety. He couldn’t express it or acknowledge it; rather, he just became more disorganized, distracted, and hyperactive. I felt that he wasn’t listening or couldn’t really focus on what I said. When I asked him to draw, however, it became clear he had heard me because he immediately said he was no good at drawing. He began to gather paper and tape it together into a long strip because he wanted me to draw a six-foot-high picture of a volcano. It was to be Mount Vesuvius, and as he became more excited and paced around, he spoke rapidly, loudly, and in great detail about the volcano, its massive eruption, the burying of Pompeii, and his voluminous instructions for my drawing.*19\173\2*
