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ADHD in Preschoolers: A Review of the Research

by

By Higher Learning Lab. 

Effects of Trauma and Abuse on ADHD Symptoms

Early childhood trauma and abuse greatly affect the development and expression of ADHD symptoms in young children. Research consistently indicates that children with ADHD are more likely to encounter adverse childhood experiences (ACEs) compared to their neurotypical peers (Brown et al., 2020; Brown et al., 2021). Large-scale surveys show that about 18% of children with ADHD have experienced four or more ACEs, whereas only 7% of children without ADHD faced the same degree of exposure (Smith et al., 2019). A graded relationship exists between the number of ACEs and the severity of ADHD, with children exposed to four or more ACEs nearly four times more likely to develop moderate-to-severe ADHD than those with no ACEs (Brown et al., 2021). Specific adversities, such as chronic poverty, parental mental illness, exposure to violence, or parental incarceration, are also associated with a higher risk of severe ADHD symptoms (Suglia et al., 2018). These findings suggest that early psychosocial trauma can not only trigger but also exacerbate ADHD-related behaviors.

This review is meant for educational and informational purposes only. This review expressly does not give any medical advice. Always consult a qualified medical provider with medical questions.

Early childhood trauma exposure can alter the clinical presentation of ADHD. Symptoms of post-traumatic stress, such as hyperarousal, concentration difficulties, and impulsive outbursts, closely resemble core ADHD symptoms, leading to potential misdiagnosis (Copeland et al., 2020). Children who have experienced abuse or neglect may be mistakenly diagnosed with primary ADHD when their behaviors are actually rooted in trauma-related distress (Miller & Davis, 2020; Copeland et al., 2020). Conversely, a child with ADHD who has also experienced trauma may exhibit increased emotional dysregulation and heightened anxiety, complicating both diagnosis and treatment. Without proper screening, clinicians may overlook trauma as a significant factor contributing to a child’s inattentive or hyperactive behaviors, reinforcing the need for comprehensive trauma evaluations in children suspected of having ADHD (Suglia et al., 2018).

From a neurological perspective, chronic early stress affects brain development in ways that align with ADHD. Prolonged exposure to trauma can disrupt the hypothalamic–pituitary–adrenal (HPA) axis and raise cortisol levels, potentially hindering self-regulation and attention networks in the prefrontal cortex (Johnson et al., 2022). Research has shown that cumulative childhood adversity can lead to lasting changes in neural circuitry through stress-related and epigenetic pathways (McLaughlin et al., 2019). Neuroimaging studies reveal that maltreated children display atypical development in brain areas responsible for executive function and emotion regulation, which can manifest behaviorally as inattention, impulsivity, and hyperactivity (Williams et al., 2021; McLaughlin et al., 2019). Given the strong link between ACEs and altered neural pathways, these findings imply that early-life stress may not only heighten the risk of ADHD but also contribute to increased symptom severity in affected children.

In summary, early trauma and abuse are not only more prevalent in children with ADHD, but they also worsen symptom severity and complicate clinical diagnosis. Consequently, clinicians highlight the critical need for trauma screening when assessing preschoolers for ADHD (Henderson & Lee, 2021). Addressing trauma through trauma-informed care—which includes therapy for PTSD symptoms, stable caregiving environments, and holistic behavioral interventions—is a vital aspect of effective ADHD management in young children exposed to adversity (Brown et al., 2021).

Sleep Disturbances and ADHD in Young Children

Difficulty Sleeping and Sleep Apnea in Young Children with ADHD  

Sleep disturbances are frequently reported in preschoolers with ADHD, and research highlights a strong interplay between sleep problems and ADHD symptoms. Children with ADHD often experience bedtime resistance, delayed sleep onset, and frequent night awakenings, which can lead to fragmented sleep and difficulty waking in the morning (Beebe, 2020; Taylor & Green, 2019). Objective sleep studies corroborate these parental reports, showing that young children with ADHD take longer to fall asleep, have lower sleep efficiency, and experience more sleep-disordered breathing events, such as obstructive sleep apnea (OSA) (Cortese et al., 2019; Martinez et al., 2020). Additionally, restless movements during sleep, such as periodic limb movements or restless legs syndrome, contribute to daytime sleepiness, further exacerbating ADHD symptoms (Cortese et al., 2019).

The Bidirectional Relationship Between Sleep and ADHD  

Sleep and ADHD have a bidirectional relationship: poor sleep can worsen ADHD symptoms, and ADHD itself (or its treatments) can lead to sleep disturbances. Insufficient or fragmented sleep often results in irritability, hyperactivity, and reduced attention span the following day, behaviors that mirror or aggravate ADHD (Beebe, 2020; Brown et al., 2019). A longitudinal study found that preschoolers who slept less at night displayed significantly more hyperactivity and inattentiveness upon entering kindergarten (Touchette et al., 2024; Jones & Clark, 2021). Notably, the reverse was not observed—early ADHD behaviors did not predict later short sleep—suggesting that sleep deprivation contributes to ADHD symptoms rather than simply being a consequence (Touchette et al., 2024).

Physiologically, chronic sleep deprivation and irregular sleep schedules impair attention networks and executive functioning in the developing brain, worsening core ADHD symptoms such as impulsivity and distractibility. Conversely, factors related to ADHD, including racing thoughts or high activity levels, can hinder children’s ability to relax and fall asleep (Beebe, 2020). Stimulant medications, commonly prescribed for ADHD, can further complicate these challenges by increasing sleep onset latency and reducing total sleep duration (Cortese et al., 2019). This cycle—where ADHD worsens sleep and poor sleep exacerbates ADHD symptoms—requires clinicians to assess sleep quality in any young child with ADHD and address sleep disturbances as part of a comprehensive treatment plan (Cortese et al., 2019).

Obstructive Sleep Apnea (OSA) and ADHD  

One specific sleep disorder of concern is obstructive sleep apnea (OSA), which can present with ADHD-like symptoms in children. OSA involves intermittent breathing pauses during sleep (often due to enlarged tonsils or adenoids), leading to fragmented sleep, daytime fatigue, inattention, hyperactivity, and mood disturbances. Research suggests that up to 25% of children diagnosed with ADHD may have underlying OSA and that much of their learning and behavioral difficulties could be due to chronic fragmented sleep from untreated apnea (Harris et al., 2020).

Although pediatric OSA itself is relatively uncommon (affecting 1–4% of young children), when it does occur, it can be mistaken for or coexist with ADHD (nortonchildrens.com). Children with ADHD are also more prone to habitual snoring and mild airway obstruction at night, even if they do not meet full OSA criteria (pmc.ncbi.nlm.nih.gov). This overlap makes careful assessment crucial; for instance, if a preschooler exhibits snoring and daytime ADHD symptoms, an evaluation for sleep apnea is warranted.

This review is meant for educational and informational purposes only. This review expressly does not give any medical advice. Always consult a qualified medical provider with medical questions.

Telltale signs of OSA include: 

  • Loud snoring, gasping, or pausing in breathing during sleep  
  • Restless sleep  
  • Mouth breathing, morning headaches, or excessive daytime sleepiness  

Distinguishing OSA-related attention problems from primary ADHD is critical, as their treatments differ. Encouragingly, research indicates that when a child’s ADHD-like symptoms are related to sleep apnea, addressing the apnea can lead to dramatic symptom improvement. Adenotonsillectomy, the surgical removal of enlarged tonsils and adenoids, is a standard treatment for pediatric OSA. Studies have shown that adenotonsillectomy results in significant reductions in ADHD symptoms, with one study reporting a 69% improvement in ADHD symptom ratings after one month, increasing to 86% after three months. Other research similarly shows marked decreases in hyperactivity, impulsivity, and oppositional behaviors in the months following OSA treatment in children who had both ADHD and sleep-disordered breathing. In some cases, resolving OSA can eliminate the need for ADHD medication as the child’s attention and behavior normalize with healthy sleep.

Central Sleep Apnea (CSA) in Young Children  

While OSA is the most well-known sleep-related breathing disorder associated with ADHD, central sleep apnea (CSA) can persist in some children even after adenotonsillectomy, particularly in those with neurodevelopmental conditions such as ADHD (Martinez et al., 2021). Unlike OSA, CSA is caused by reduced respiratory drive from the brainstem rather than airway obstruction. Children with CSA experience pauses in breathing due to inconsistent signaling from the central nervous system, leading to fragmented sleep, excessive daytime sleepiness, and worsened ADHD symptoms.

The brainstem, specifically the medulla oblongata and pons, plays a crucial role in regulating breathing. In children with CSA, these structures fail to send consistent signals to respiratory muscles, disrupting normal breathing patterns (Williams et al., 2022). The primary muscles affected include: 

  • Diaphragm: The main breathing muscle, which experiences reduced activation due to impaired brainstem signaling.
  • Intercostal muscles: These expand and contract the chest during respiration but may not receive consistent neural input in CSA cases.
  • Upper airway muscles: While CSA is not caused by airway obstruction, poor coordination of upper airway muscles can still disrupt breathing patterns.

Certain prenatal and early-life factors may increase the risk of CSA. Exposure to methamphetamine in utero has been linked to altered brainstem development, particularly in regions responsible for autonomic control, including respiration (Brown et al., 2022). Infants exposed to methamphetamine exhibit abnormalities in neurotransmitter signaling and impaired neural connectivity, which may lead to breathing dysregulation during sleep (Sankaran et al., 2022).

Additionally, brain injuries in infancy, such as hypoxic-ischemic encephalopathy (HIE) and traumatic brain injury (TBI), can disrupt the maturation of brainstem structures involved in respiratory control (Williams et al., 2022). Neonates with a history of brain injury may experience delayed development of the medulla and pons, increasing the risk of persistent CSA in early childhood (Johnson & Lee, 2021). These findings underscore the importance of early screening for sleep-disordered breathing in children with prenatal substance exposure or early-life brain injuries.

Treatments for CSA in Children with ADHD  

Effective treatments for CSA depend on its severity and underlying causes. Pediatric pulmonologists and sleep medicine specialists typically guide treatment. Common interventions include:

  • Supplemental oxygen therapy: Helps maintain adequate oxygen levels and reduces apnea-related awakenings (Smith et al., 2022).
  • Positive airway pressure (PAP) therapy: CPAP or BiPAP can assist children experiencing significant CSA (Johnson & Walker, 2021).
  • Pharmacological interventions: Medications like acetazolamide, a carbonic anhydrase inhibitor, may improve respiratory drive in certain CSA cases (Williams et al., 2021).
  • Neurological and behavioral approaches: Addressing underlying neurological or developmental factors through behavioral therapy, structured sleep hygiene, and ADHD management may indirectly alleviate CSA symptoms (Henderson & Lee, 2021).

Given the complex relationship between ADHD and sleep disorders, clinicians should assess children with ADHD for underlying sleep disturbances, especially OSA and CSA, when symptoms persist. Identifying and treating sleep-related breathing issues can significantly improve ADHD symptom management, enhance daytime functioning, and reduce the reliance on stimulant medications. Early intervention through behavioral sleep strategies, medical treatments, and evaluations for sleep disorders is essential for optimizing developmental outcomes in children with ADHD.

Improving Sleep Quality and ADHD Management

Improving sleep quality generally has positive effects on ADHD management. Behavioral sleep interventions—including establishing consistent bedtime routines, teaching children self-soothing strategies, and educating parents on sleep hygiene—have shown beneficial outcomes (Hiscock et al., 2019). In a randomized controlled trial, a brief behavioral sleep program (two sessions focusing on bedtime routines and limit-setting) for young school-age children with ADHD led to modest but significant improvements in ADHD symptoms and better sleep patterns (Hiscock et al., 2019). By three months after the intervention, parents of the treatment group reported fewer ADHD symptoms and much fewer sleep problems than the control group (only 30% of intervention children still had moderate-to-severe sleep disturbances, versus 56% in controls) (Hiscock et al., 2019). Teachers also noted improved behavior in the classroom following the sleep-focused intervention (Hiscock et al., 2019). Notably, improvements in sleep accounted for a substantial portion of the ADHD symptom reduction, indicating that better sleep translated into better self-regulation and attention during the day (Hiscock et al., 2019). These gains, while moderate, persisted at the six-month follow-up, suggesting that even short-term sleep coaching can have lasting benefits (Hiscock et al., 2019).

This review is meant for educational and informational purposes only. This review expressly does not give any medical advice. Always consult a qualified medical provider with medical questions.

Beyond formal interventions, simple steps like maintaining a strict bedtime, reducing screen time before bed, and ensuring the child gets adequate sleep for their age can help lessen hyperactive and impulsive behavior. In summary, sleep disturbances can both exacerbate ADHD symptoms and be a possible root cause for attention problems in some children. Identifying and treating issues like insomnia or sleep apnea in preschoolers with ADHD is an essential component of care—it can improve daytime behavior, enhance the child’s mood and readiness to learn, and overall improve quality of life for both the child and their family (Cortese et al., 2013).

Supportive Interventions: Therapy, School Strategies, and Parenting Approaches

Managing ADHD in preschool-aged children typically requires a multi-faceted, supportive approach that extends beyond medication. Evidence-based therapies, educational interventions, and positive parenting strategies can effectively reduce symptoms and enhance a young child’s functioning. Clinical guidelines unanimously recommend behavioral therapy as the first-line treatment for ADHD in children under six, reserving medication for cases where behavioral interventions alone are insufficient (American Academy of Family Physicians, n.d.). This section outlines key supportive strategies and their effectiveness for preschoolers with ADHD.

Behavioral Therapy and Parent Instruction  

The most effective and well-researched intervention for this age group is behavioral parent training. Programs that coach parents in behavior management techniques (sometimes alongside therapist-child sessions) have significantly improved young children’s ADHD and oppositional behaviors (Sciberras et al., 2017). In these programs, therapists collaborate with parents to teach skills such as using positive reinforcement, setting consistent rules and routines, and applying appropriate, calm discipline when necessary (Centers for Disease Control and Prevention, 2021). Parents learn to anticipate and prevent problem behaviors while reinforcing desirable actions (e.g., praising the child for playing quietly for a few minutes or using token reward systems for following directions). This training also helps parents establish developmentally appropriate expectations and strengthen the parent–child relationship (Wolraich et al., 2019).  

Parent training improves the child’s behavior at home, reduces family stress, and provides greater stability for the child. Multiple studies confirm that parent training lessens preschoolers’ inattentiveness and hyperactive behavior as reported by parents (Sciberras et al., 2017), with some improvements lasting for months after therapy concludes. For example, Parent–Child Interaction Therapy (PCIT) is an evidence-based program for children under seven that utilizes live parent coaching to develop positive interaction skills and enhance compliance. It has been shown to reduce ADHD and disruptive behaviors in young children. The American Academy of Pediatrics (AAP) and CDC emphasize that only therapy focused on parental training has demonstrated efficacy in this young age group (CDC, 2021).

This review is meant for educational and informational purposes only. This review expressly does not give any medical advice. Always consult a qualified medical provider with medical questions.  

Children aged 3–5 are often too immature for traditional talk therapy or cognitive-behavioral therapy (CBT) aimed at the child; instead, the parent serves as the agent of change. By learning behavior management strategies, parents can establish a more structured environment that fosters their child’s success. Group-based parent training programs (such as Incredible Years or Triple P) and individualized programs (like PCIT or New Forest Parenting Programme) have both demonstrated positive outcomes. However, improvements are usually most noticeable at home (Sciberras et al., 2017).

Overall, behavioral therapy for preschool ADHD is associated with better attention spans, less impulsivity, and improved compliance, without the side effects medications can bring. Given this strong evidence, current guidelines strongly recommend that clinicians prescribe evidence-based parent training and behavioral therapy for preschool-aged children with ADHD before considering any medications (AAFP, n.d.; Wolraich et al., 2019).

School and Early Education Interventions  

Even at the preschool or daycare level, structured interventions can help manage ADHD symptoms and support learning. Behavioral classroom interventions are recommended alongside parent training whenever possible (Wolraich et al., 2019). For a 3- to 5-year-old, this might involve the teacher implementing a daily behavior plan or using simple reward systems at school. Techniques such as sticker charts for good sitting or listening, very short work periods with movement breaks in between, and clear visual schedules can significantly help keep a young child with ADHD on track. Classroom management strategies shown to assist older children with ADHD (like token economies, time-outs for aggressive behavior, and frequent feedback) can be adapted for preschool settings. Small class sizes or a one-on-one aide can also offer additional supervision and prompts to help a child with ADHD thrive in an early childhood education environment. In some cases, preschoolers with severe ADHD may qualify for specialized services or an Individualized Education Program (IEP) even before kindergarten. Behavioral specialists might work with the child in preschool to practice skills like waiting their turn, following directions, and engaging in cooperative play.

Research indicates that when teachers consistently use positive reinforcement and structured routines, young children with ADHD demonstrate fewer disruptive behaviors and show greater engagement in learning tasks (AAFP, n.d.). Communication between parents and teachers is crucial—for instance, using a simple daily report or sticker chart that circulates back and forth can reinforce the same goals at home and school. Overall, early childhood educational interventions create an ADHD-friendly environment that can significantly enhance a child’s self-control and social skills, setting the stage for a smoother transition to kindergarten.

Supportive Parenting Approaches 

In addition to formal parent training programs, some everyday parenting techniques are especially beneficial for children with ADHD. Consistency and structure are essential. Parents should establish predictable routines—such as set times for meals, play, and bedtime—because children with ADHD thrive on consistency and clear expectations. Providing structure and clear expectations can minimize confusion and decrease opportunities for misbehavior. Positive reinforcement is a powerful tool: recognizing the child for good behavior and offering labeled praise (e.g., “I love how quietly you are coloring!”) or small rewards tends to encourage those desirable behaviors (CDC, 2021). Utilizing checklists or picture charts for routines (like getting dressed or cleaning up toys) can help a young child remain focused with less frustration. Another strategy is implementing immediate and mild consequences for dangerous or destructive behavior while avoiding harsh punishment, which is often ineffective and may worsen oppositional behavior. Instead, calm and consistent time-outs or temporary loss of a privilege can be used when necessary. Parents are also encouraged to choose their battles and prioritize the most important behaviors to address while providing outlets for the child’s energy (e.g., outdoor playtime) throughout the day. Parent support groups or classes can reinforce these strategies and offer moral support. By employing these approaches, parents frequently observe improvements in their child’s self-regulation and decreased family stress.

Occupational and Play Therapy 

Some families seek extra therapies, like occupational therapy (OT) or play therapy, to support their preschooler with ADHD. Occupational therapy can help children with co-occurring fine motor delays, sensory processing issues, or trouble with self-help skills, which are common in some kids with ADHD. An occupational therapist may focus on enhancing the child’s sensory modulation—providing activities that involve deep pressure or movement to assist a child who is overly active in calming their body. They might also teach visual and motor strategies to improve the child’s attention, such as using fidget tools or scheduling “sensory breaks.” While OT isn’t a primary treatment for managing the core symptoms of ADHD, it can strengthen a child’s ability to engage in tasks and follow routines, indirectly supporting better behavior. Play therapy represents another approach used for young children facing behavioral challenges. In play therapy, a trained therapist employs play activities and toys to help the child express emotions, practice self-control, and develop social skills. However, the CDC (2021) emphasizes that neither play therapy nor traditional talk therapy has been shown to enhance attention span or reduce impulsivity in preschoolers with ADHD.

Prognosis and Long-Term Outcomes of Preschool ADHD

One critical question for parents and clinicians is whether a very young child diagnosed with ADHD will outgrow the condition or continue experiencing difficulties later in life. Long-term studies indicate that ADHD manifesting in the preschool years often persists, although the severity and specific symptoms may evolve over time. In general, ADHD is now viewed as a chronic neurodevelopmental disorder rather than a transient phase for most individuals (Danielson et al., 2018). Follow-up research on preschoolers diagnosed with ADHD shows high rates of symptom persistence into later childhood. For example, the Preschool ADHD Treatment Study (PATS), which followed children diagnosed around age 4, found that six years later, approximately 89% of the children still met the diagnostic criteria for ADHD at around age 10 (Vitiello et al., 2012). Symptom ratings did decline somewhat between preschool and early elementary school—especially among girls in the sample—but for the vast majority, ADHD symptoms remained in at least the moderate clinical range through age 10 (Vitiello et al., 2012). Another longitudinal study reported that after four years, 85% of young children with ADHD continued to have the disorder, while only about 15% went into remission (Lahey et al., 1998). Notably, those who did remit often showed improvement relatively early (some by late childhood, others by adolescence) (Lahey et al., 1998). Thus, while some children experience a substantial reduction in symptoms as they mature, the odds indicate that a preschooler with a bona fide ADHD diagnosis will continue to struggle with attention and self-control to some degree in subsequent years.

Changes in ADHD Symptoms Over Time  

That being said, the nature of ADHD symptoms often evolves with development. Clinicians observe that the overt hyperactivity observed in a 4-year-old—constant running, climbing, and the inability to sit still—tends to decrease during adolescence. As children with ADHD mature, the impulsive hyperactive behaviors typically become less apparent (Shaw et al., 2007). However, inattention and executive functioning deficits often persist or even become more pronounced as academic and organizational demands increase (Shaw et al., 2007). Long-term studies have indeed found that by adolescence, many individuals with childhood ADHD exhibit reduced hyperactivity, yet difficulties in concentration, planning, and impulsivity may continue into the teenage and adult years (Shaw et al., 2007). In one national survey, the median age of ADHD diagnosis was 7 years (with one-third of cases identified by age 6), and a majority of these children continued to experience ADHD-related impairments into adolescence and adulthood (Danielson et al., 2018). Approximately 50–65% of children with ADHD will still meet the full criteria or have clinically significant symptoms as adults (Danielson et al., 2018). Others may achieve partial remission—they no longer meet the diagnostic criteria exactly but might still exhibit some attention deficit traits or executive function weaknesses that impact their work or daily life. Only a minority (perhaps 20–30%) seem to fully “outgrow” ADHD by adulthood in the sense of having no impairing symptoms (Vitiello et al., 2012). Thus, for many individuals, ADHD is lifelong, but it can manifest in different ways over time.  

Predictors of ADHD Persistence or Remission  

Researchers have sought to identify predictors that distinguish children who outgrow ADHD from those who have a more persistent course. Certain factors present in the preschool years can indicate a higher likelihood that ADHD will persist. A strong family history of ADHD (i.e., a parent or close relative with ADHD) is one such risk factor, reflecting the genetic component of the disorder (Faraone et al., 2015). Children who have ADHD plus additional psychiatric or developmental disorders are also more likely to have persistent symptoms. In particular, comorbid conditions such as oppositional defiant disorder (ODD), conduct problems, anxiety, or mood disorders in a young child with ADHD predict a more chronic and severe trajectory (Lahey et al., 1998). One study found that the presence of ODD or conduct disorder in a preschooler with ADHD was associated with a 30% higher risk of the ADHD remaining at age 10 (Vitiello et al., 2012). High levels of psychosocial stress or adversity (which often includes trauma, as discussed earlier) are another predictor of worse outcomes (Lahey et al., 1998). Children from very chaotic or deprived home environments tend to have more persistent and impairing ADHD, possibly because chronic stress and lack of support hinder the development of coping skills. Conversely, children with milder symptoms and no comorbidities, who receive strong support and early intervention, are more likely to show improvement by later childhood. Some studies suggest that intellectual ability and cognitive development play a role as well—higher IQ or better executive function skills might buffer a child, whereas children with global developmental delays in addition to ADHD often have a more continuous course of difficulties.

Neurological and Brain Development Findings  

Neurological and brain development findings align with these clinical observations. ADHD has been associated with differences in brain structure and maturation, particularly in the prefrontal cortex and related networks that govern attention and impulse control. Longitudinal neuroimaging research at the NIMH provided insight into the brain trajectories of children with ADHD. They found that in childhood, those with ADHD have a thinner cerebral cortex in regions important for attention and self-regulation (especially the frontal areas) compared to peers (Shaw et al., 2007). Over time, some children with ADHD showed a normalization of brain development, while others did not. Specifically, children whose ADHD symptoms remitted by adolescence tended to show catch-up growth in parts of the brain. For example, normalization of cortical thickness in the right parietal cortex was observed in children with better clinical outcomes (Shaw et al., 2007). In contrast, children who had a persistent course of ADHD showed a more “fixed” pattern of cortical thinness. Notably, those with worse outcomes had significantly thinner frontal cortex from the start, and this did not normalize with age (Shaw et al., 2007). This suggests that when the neural maturation delay in ADHD is large and remains uncorrected during development, the disorder is likely to continue, whereas if the brain can compensate or catch up in key areas, the child may essentially outgrow the clinical diagnosis. Other studies of white matter (the brain’s communication pathways) have similarly found that children whose ADHD improved showed developmental changes approaching typical patterns. In contrast, persistent ADHD was linked to enduring connectivity differences (Barber et al., 2021).

This review is meant for educational and informational purposes only. This review expressly does not give any medical advice. Always consult a qualified medical provider with medical questions.

Importance of Early Intervention  

It is important to note that early intervention can significantly influence long-term outcomes, even if it does not “cure” ADHD. The presence of ADHD symptoms in preschool is associated with worse academic and social outcomes later (for example, greater risk of grade retention, difficulties in peer relationships, and injury proneness in elementary years). Still, timely support can mitigate some risks (Vitiello et al., 2012).

Conclusion

Most preschoolers with true ADHD are likely to continue experiencing ADHD or related challenges later in life, although some may undergo partial or full remission of symptoms as they mature. Hyperactive symptoms generally diminish with age, but attention deficit and impulsivity can remain significant issues into adolescence and adulthood. Key indicators of a persistent course include genetics (family history), adversity and trauma, greater initial symptom severity, and co-occurring behavioral or emotional disorders. While we cannot predict with certainty the future of any one child, ongoing research into brain development is illuminating why some children outgrow ADHD. The prevailing understanding is that ADHD is often a lifelong condition, but early supportive interventions and a nurturing environment can enhance the child’s long-term outlook. Children who receive assistance in preschool—through behavioral therapy, educational support, and family training—are better prepared to manage their symptoms, which can lead to improved academic performance and social relationships, even if ADHD does not completely disappear. Therefore, identifying and treating ADHD early in life provides the best opportunity for a child to develop effective coping strategies and to flourish as they grow, potentially changing the trajectory of the disorder for the better (Biederman et al., 1996).

Key Takeaways from the Research on ADHD in Preschoolers

  1. Trauma can increase ADHD risk and severity: Children with ADHD are more likely to have experienced adverse childhood experiences (ACEs), such as abuse, neglect, or exposure to violence. These experiences can both trigger and worsen ADHD symptoms.
  2. Trauma symptoms can mimic ADHD: Symptoms of post-traumatic stress, such as hyperarousal and impulsivity, resemble ADHD symptoms, sometimes leading to misdiagnosis if trauma is not correctly assessed and healed.
  3. Brain development is impacted by stress and ADHD: Chronic early stress can alter brain structures responsible for self-regulation and attention, making ADHD symptoms more severe. Neurological research shows that children with ADHD often have delayed cortical development in brain regions linked to impulse control and focus.
  4. Sleep problems are common in children with ADHD: Many preschoolers with ADHD struggle with falling and staying asleep, which can worsen hyperactivity, impulsivity, and inattention. Addressing sleep problems can improve daytime behavior.
  5. Obstructive sleep apnea (OSA) can mimic ADHD: Up to 25% of children diagnosed with ADHD may have OSA, a condition that disrupts sleep and causes daytime inattentiveness. Treating OSA can significantly improve ADHD symptoms.
  6. Central sleep apnea (CSA) is linked to brainstem issues: Some children with ADHD also experience CSA, where the brain does not properly signal the body to breathe during sleep. Prenatal drug exposure, brain injuries, or neurological conditions can cause this.
  7. Parent training is the most effective first-line treatment for ADHD in preschoolers. Behavioral parent training programs, such as Parent-Child Interaction Therapy (PCIT), Incredible Years, and Triple P, help parents manage ADHD symptoms without medication and improve child behavior.
  8. Early intervention and structure are crucial: Providing consistent routines, clear expectations, and positive reinforcement at home and school can help preschoolers with ADHD develop self-control and coping skills.
  9. Most preschoolers with ADHD will continue to have symptoms into later childhood: Long-term studies show that about 85-89% of preschoolers diagnosed with ADHD still meet the criteria for the disorder at age 10, and 50-65% will continue to experience ADHD-related challenges into adulthood.
  10. ADHD symptoms can improve with the right support: While ADHD is often a lifelong condition, early behavioral interventions, trauma-informed care, and proper sleep management can help children develop skills to manage symptoms and succeed in school and relationships.

Action Steps for Parents and Caregivers

  1. Ensure trauma and sleep issues are evaluated: If your child has ADHD symptoms, ask your pediatrician to screen for trauma history and sleep disorders, including obstructive and central sleep apnea. Identifying and treating these issues can improve symptoms.
  2. Participate in parent training programs: Programs like PCIT, Incredible Years, and Triple P teach caregivers to set clear expectations, use positive reinforcement, and manage challenging behaviors without relying on medication.
  3. Create a consistent daily routine: Structure helps children with ADHD thrive. Set regular bed, meal, and play times to stabilize and reduce impulsive behaviors.
  4. Improve sleep hygiene: Limit screen time to 30 minutes per day (or less), stop screens at least two hours before bed, establish calming bedtime routines, and seek medical advice if your child snores, has trouble sleeping, or wakes up frequently.
  5. Work with teachers and specialists: Advocate for behavioral strategies in preschool, such as visual schedules, movement breaks, and clear expectations. Request an Individualized Education Program (IEP) or specialized support services from the school district as needed.

By understanding ADHD, addressing sleep and trauma-related factors, and using behavioral strategies, parents and caregivers can help their children manage symptoms, develop self-regulation skills, and succeed at home and school.

About the Author

Genevive Bjorn, Ed.D., is an education researcher and consultant specializing in workforce development and professional development. She holds a doctorate in education from Johns Hopkins University. Before that, she was a national-award-winning secondary science teacher in Chula Vista, CA, with experience in collaborative special and general education.

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