Attention Deficit-hyperactivity Disorder (ADHD) in Preschool
Nur Faizah Romadona
Universitas Pendidikan Indonesia, Jl. Dr. Setiabudhi No. 229, Bandung, Indonesia.
Keywords: Attention Deficit-Hyperactivity Disorder, Preschool Children.
Abstract: Attention Deficit-Hyperactivity Disorder is now known as a lifetime developmental disorder. The symptoms
vary, depending on the age of the affected children. Preschool age children with symptoms of Attention
Deficit-Hyperactivity Disorder (ADHD) are at risk from rejection by their peers and expulsion from the school
setting due to disruptive and noncompliance behavior. Removal from preschool will limit a child’s exposure
to preacademic instruction and socialization. Despite the diagnosing difficulties, it has been estimated that
2% of the preschool age children suffer from ADHD. Knowledge about ADHD is a necessity for both parents
and teachers in instruction for them to be able to deal with preschool age children with ADHD symptoms.
Without early intervention, the symptom will remain and often escalate at the school-age. The early
interventions include medications, parent-training, behavior-management interventions, and combination
interventions.
1 INTRODUCTION
Attention Deficit-Hyperactivity Disorder (ADHD) is
the most commonly diagnosed neurobiological
disorder of children and three symptoms: inattention
(short attention span), hyperactivity, and impulsivity.
The latest data show that 3-5% of preschool and
school age children are diagnosed with ADHD
(McGoey et al., 2002). It is acknowledged that
ADHD is a developmental disorder that tends to
persist a lifetime. ADHD is frequently noticed at the
age range of 2-4 (Connor, 2002), causing significant
problems for children, teachers and caregivers
(McGoey et al., 2002). These problems may include
accidents, rejection by peers and relatives, high
dependence on others, school expulsion, and so on.
Generally, ADHD preschool children are also
associated with physical and mental comorbidity.
Some longitudinal studies reveal that ADHD
symptoms in preschool children will continue into
school age and can lead to more severe problems. The
increasing use of drugs by ADHD preschool age
children (2-4) in the United States, tripling from
1990, can be construed as an increased prevalence of
ADHD preschool children in the population (Connor,
2002). Posner et al. reported that approximately 70%
of preschool age children were diagnosed with
comorbidities including behavioral disorders by
52.1%, communication disorders by 24.7%, and
anxiety by 17.7% (Schmidt and Petermann, 2008).
Without early intervention, ADHD symptoms that
affect preschool age children will continue into
school age and can cause other problems such as
behavioral disorders, impulsivity, aggression, and
socialization disorders. ADHD symptoms in
preschool children persisted even until they were 6
years old, 33% of them were diagnosed with ADHD
when they are entering the primary school age
(McGoey, 2002). ADHD preschool children are at
risk from school expulsion. As a result, they become
restricted from pre-academic education, socialization,
and classroom environment (Schmidt and Petermann,
2008).
2 LITERATURE REVIEW
2.1 Prevalence
To date, there have been few data on the prevalence
of ADHD in preschool children internationally. The
prevalence of ADHD in preschool children is
estimated to reach 2%, other data say 6%, and some
other say 18% based samples of parents and teachers
of children of 3-5 age group. It was reported to reach
about 6% in the US (Schmidt and Petermann, 2008),
5.2% in India, and 9.6% in Germany (Connor, 2002).
The work of Hebrani et al. (2007) reveals that the
Romadona, N.
Attention Deficit-hyperactivity Disorder (ADHD) in Preschool.
In Proceedings of the 1st International Conference on Educational Sciences (ICES 2017) - Volume 1, pages 243-247
ISBN: 978-989-758-314-8
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
243

prevalence of ADHD in preschool children in Iran
reached 12.3%. A study on 104 preschool children
from low income family in the US found that 5.7% of
them met the DSM-IV diagnostic criteria. As many as
47 out of 79 (59.5%) children aged 2-5 years who
were admitted to psychiatric clinics met the DSM-IV
diagnostic criteria (Connor, 2002).
There have been no definitive data yet on the
prevalence of preschool children with ADHD in
Indonesia. Suharmini (2005) study reveals that 1.76%
of 3,233 kindergarten students all around Yogyakarta
met the ADHD category. The actual prevalence rate
is estimated to be higher, especially in big cities.
2.2 Neurobiology and Causes of ADHD
Many studies have revealed a change in neurobiology
of the central nervous system as a cause or etiology
of ADHD. Studies on molecular biology, molecular
neuropharmacology, and neuroimaging of the central
nervous system (MRI) have successfully revealed the
presence of neurobiological disorders in ADHD.
Neuropharmacology data support the hypothesis of
dopamine/norepinephrine regulatory disorder; i.e.,
inhibitory disturbance in the dominant noradrenergic
prefrontal cortical area and subcortical area, which is
predominantly dopaminergic. Stimulant drugs that
serves as central nervous system noradrenergic and
dopamine such as guanfacine, clonidine, bupropion,
and atomoxetine, are quite helpful for those with
ADHD (Connor, 2002).
Hereditary factors in ADHD have also long been
known. Studies on twin children suggest that the
heritability rate of ADHD ranges from 0.60 to 0.95.
This figure means that as many as 60 to 95% of the
variance of ADHD cases are caused by genetic
factors rather than environmental factors (Hudzia et
al., 1998). Nevertheless, the heritability rate of
ADHD is always estimated to be lower than 1.0. This
means that the cause of ADHD cannot be explained
solely because of genetic factors, but environmental
factors or interactions of genetic and environmental
factors also play an important role in the etiology
(causal factors) of ADHD (Connor, 2002). About a
third of father of hyperactive children also suffer from
the same disorders as that of their children in their
childhood. The risk of ADHD in parents and close
relatives of children with ADHD is increased 2–8
times. The risk of ADHD in monozygotic twins is
also higher than in dizygotic twins (Judarwanto,
2009).
The role of genes and chromosomes as the
etiology of ADHD is still not known for certain.
Some of the genes associated with dopamine receptor
codes and serotonin production, including DRD4,
DAT, DRD5, DBH, 5-HTT, and 5-HTR1B, have
been frequently associated with ADHD (Judarwanto,
2009). The presynaptic dopamine transporter protein
(DAT-1) and the post-synaptic dopamine D4 receptor
(DRD-4) have been well recognized as the site of
action of the stimulant drugs. Various studies have
found that deviations or polymorphisms in these
genes lead to abnormalities in the structure of the
child or adult brain with ADHD (Connor, 2002).
Studies using magnetic resonance imaging (MRI)
found structural brain abnormalities. The prefrontal
areas, basal ganglia, and vermix cerebellum of
children with ADHD are smaller by 5-10% than those
without ADHD. MRI also found lack of blood flow
in the prefrontal cortex, anterior cingulatus, and
striatum of both children and adults with ADHD
(Connor, 2002).
2.3 Symptoms
Inattention, hyperactivity, and impulsivity are the
characteristics of normal development of preschool
age children (Harpin, 2005). However, preschool
children with ADHD often exhibit more extreme
behavioral problems than their peers. They appear
less attentive, less organized, difficult to remain
seated, and abusive, both verbally and physically,
towards their peers. Nearly 30-60% of preschool
children with ADHD (especially boys) often give
noncompliant responses to instructions and authority
figures. Thus, preschool children with ADHD are less
able to cooperate and less productive in school
(McGoey, 2002).
The parents of school-aged children with ADHD
generally reveal that the ADHD symptoms have
appeared before their children enter school. They are
aware of something different about their children or
indicative symptoms of ADHD from the earliest
months or years (toddler). However, some children
who show these symptoms grow as normal children
and never get a diagnosis of ADHD (Schmidt and
Petermann, 2008).
Bailey (2002) lists some of the common
characteristics of children diagnosed with ADHD
upon entering school age as follows:
 Baby (0-12 month):
 To be restless or to stretch often;
 To be not fond of holding;
 To be less patient and easily frustrated;
 To need paying attention to more than
other babies;
 To sleep less.
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 Toddler (1-3 years):
 To be inattentive;
 To be continuously disturbed by the
surrounding lights and noises;
 To find it difficult to keep eye contact;
 To be compulsive of fun things like video
games or fond of playing outdoor that
requires high energy;
 To be overactive;
 To be not fond of holding or activities that
does not require movements and high
energy;
 To find it difficult to calm down after
doing activities;
 To be very impulsive: jumping onto chairs,
jumping out of windows, or running out to
busy streets.
 Preschool age:
 To find it difficult to remain seated;
 To be not fond of holding or activities that
does not require movements like listening
to stories;
 To less attentive;
 To be overactive;
 To be talkative;
 To be badly behaved;
 To be clumsy;
 To like to snatch toys from other children;
 To not like waiting for a turn;
 To aggressively behave.
2.4 Diagnosis
ADHD diagnosis can only be carried out on children
at their school age; i.e., around 7, using the DSM IV-
TR (American Psychiatric Association, 2000). This is
due to the fact that during preschool age, the
characteristics of ADHD can hardly have
distinguished from those of normal development
(McGoey, 2002). Nevertheless, based on the criteria
of DSM IV-TR, the prevalence of preschool-aged
children with ADHD is estimated to reach 2%
(Lavigne et al., 1996), with inattention as the most
commonly noticed symptom (McGoey, 2002).
Prospective studies have also identified that the peak
age of onset of ADHD is between the ages of 3-4
years (Connor, 2002).
In preschool age groups, ADHD is usually
assessed using scales and behavioral observation. The
ADHD-Rating Scale IV is now a standard assessment
for preschool children, assessing the following
symptoms (Schmidt and Petermann, 2008):
 To be less attentive;
 To get easily distracted;
 To be overactive;
 To exhibit noncompliant behaviour;
 To be unable to remain seated for 3-4 minutes.
2.5 Early interventions
The intervention for preschool-aged ADHD children
can be broadly divided into: (1) pharmacological
intervention and non-pharmacological/psychosocial
intervention.
2.5.1 Pharmacological Interventions
The use of stimulant drugs to treat ADHD symptoms
in preschool children is a subject of controversy with
regard to drug side effects. In the US, the FDA (Food
and Drug Administration) forbids the use of stimulant
drugs for children under the age of 6. The most
frequently used stimulant drug (90%) by preschool
children is methylphenidate. Many studies have
suggested that the use stimulant drugs to treat ADHD
symptoms, based on data obtained from teachers and
parents, yields in positive results such as: increased
on-task behavior, decreased
hyperactivity/impulsivity, increased attention span,
increased compliance with instructions, increased
social skills, and improved parent-child interaction.
The study also noted the side effects of stimulant
drug use in pre-schoolers, including decreased social
interactions, loss of appetite, and dysphoric mood
(McGoey, 2002). A study by Firestone et al. (1998)
in 32 preschool children with ADHD showed that the
use of methylphenidate stimulant drugs had more
severe side effects on preschool children than on
school-aged children.
2.5.2 Parent-Training Interventions
Some studies suggest the effectiveness of parent-
trainings to deal with preschool children with ADHD.
These trainings have yielded positive results such as
increased compliant of ADHD children with
instructions, the ability of parents to make appropriate
instructions, and the acquisition knowledge of
appropriate parenting techniques by the parents.
Parent-trainings provide knowledge of specific
management skills to improve parent-child
interaction skills, which will further improve the
child's behavior (McGoey, 2002).
Attention Deficit-hyperactivity Disorder (ADHD) in Preschool
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2.5.3 Behavioral-Management Interventions
Effective behavioral management for preschool-aged
children with ADHD including: appropriate rewards,
effective instruction and request, self-control
teaching, and consistent use of discipline methods.
However, self-instruction training using cognitive-
behavioral methods yielded in unsatisfactory results.
On the contrary, a single subject study on a preschool
child with ADHD using daily report card system and
self-monitoring package brought about positive
results. Study on an ADHD child aged 5 yielded in a
dramatic results: increased on-task behavior from
57% to 85%, decreased disruptive behavior from
29% to 7%, and decreased activities from 8 to 2
activities. Nevertheless, most studies were conducted
in a laboratory setting, not a school setting and hence
less generalizable. In addition, most of these studies
also used small sample size and low integrity
treatment and did not have any follow-up action after
the research. Thus, despite promising results, these
studies are less consistent and less conclusive, so
further investigation and a more comprehensive
replication need to be carried out.
2.5.4 Combination Interventions
Henry’s (1987) study using combination
interventions including pharmacological
interventions, symbolic modeling, and parent training
interventions to improve behavior during 14 weeks
showed satisfactory results. In symbolic modeling,
the children were shown a video game on how a child
should comply with instructions of a teacher/parents
for 5 minutes The combination of these three
interventions were found more effective than a
combination of pharmacological interventions and
symbolic modeling, a symbolic modeling only, or a
pharmacological intervention only. It was also
revealed that parent trainings about positive
behavioral management was more effective than
symbolic modeling and that a combination of parent
trainings about reductive behavioral management
(e.g., time-out) was more effective than positive
behavioral management (e.g., behavioral
reinforcement through rewards).
2.5.5 Prognosis
The severity of inattention and hyperactivity in
preschool aged children does not have a prognostic
value of that they will develop similar problems when
entering the school age. However, the impairment
seems to have prognostic utility value. One of the
measurements that can be used to measure
impairment levels of ADHD in preschool children is
Children's Problem Checklist (CPC). The CPC avoids
asking questions related to academic matters because
they are not appropriate for their development. The
CPC consists of several common behaviors that
indicate the presence of disorders in preschool
children with ADHD such as: disruptive behavior,
difficulty in relationships with peers and adults, low
self-esteem, difficulty falling asleep, and often having
an accident. In the following table are the CPC items
that parents and teachers need to fill in:
Table 1: Children’s Problem Checklist (CPC) Items
Questions for Parents
Questions for Teachers
Does your child:
1. disrupt family life?
2. have difficulties in
relationships with
siblings?
3. have difficulties in
relationships with peers?
4. have difficulties in
relationships with adults?
5. feel something wrong
with himself?
6. have difficulties falling
asleep?
7. often have accidents like:
trip, bumping, etc.?
Does the child:
1. disrupt others in the
classroom?
2. have difficulties in
relationships with peers
at school?
3. have difficulties making
friends with others?
4. have difficulties in
relationships with
teachers or other adults?
5. feel something wrong
with himself?
6. often have accidents
like: trip, bumping, etc.?
Source: Healey et al. (2008).
2.5.6 Strategy for Children with ADHD-
Like Behavioral Disorders
If you notice any ADHD symptoms in preschool
children, you can employ the following strategies
(Bailey, 2002; Snuggs, 2008):
 Simplify instructions for them. Arrange the
instruction in a direct single sentence. ADHD
children are forgetful. Arranged a well-
structured schedule of children's daily
activities. Breakfast, lunch, dinner, and break
snacks should be at the same time every day;
 Give them enough time to release energy; e.g.,
by running around the park or backyard. If
outdoor activities are not possible, use radio or
music CD for them to dance to;
 Provide them with toys appropriate for their
development ad to enhance their intelligence.
ADHD children have an unstable emotion;
 Use integrative interactive learning techniques
so they can learn fast. Use as many sensory
functions as possible to teach them a new skill.
When teaching colors, use objects perceptible
by touch, smell, taste, or sight;
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 Foster a supportive environment. Accept that
ADHD children are prone to accidents. Provide
drawers with a picture tag to help them
remember what’s in them;
 Use behavioral management techniques that
can immediately be functioning. Give them
rewards for behaving well as soon as possible.
Otherwise, they will find it hard to see a
relationship between action and consequence;
 Get ready for an unpleasant situation. When
having to stay seated for a relatively long time
period, provide them with small activities,
snacks, and beverage so that they feel
comfortable;
 To help them remember objects, use songs or
music. Let them choose the song of their choice
to help them remember;
 Make an effort to figure out their potentials.
Provide them with objects that can enhance
their potentials;
 Be consistent. Consistency is the most
important part of behavioral management of
ADHD children.
3 CONCLUSIONS
Early interventions are badly needed for preschool
children. Although ADHD diagnosis can be carried
out when they are 7 years old, early interventions are
expected to prevent the symptoms to continue into
adulthood. Interventions for ADHD symptoms in
preschool children are expected to raise awareness of
parents and teachers so as to enable early
interventions. Appropriate early interventions are
expected to reduce the ADHD symptoms in preschool
children and stress level in the family and prevent the
symptoms to persist until children enter the school
age.
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