ATTENTION-DEFICIT DISORDER AND PRESCHOOLERS: WITNESSING CHANGE
I am an early-childhood specialist and public-school administrator charged with sorting, serving, and documenting the early histories of children with suspected or verified developmental needs. I have worked with families and schools concerning the care of children under school age for more than 25 years, and I am not tired yet. I cannot imagine another job that offers as much challenge, interest, and hope.
Years of experience have taught me that predicting long-term outcomes of developmentally at-risk children is dubious, regardless of the presenting problem or diagnosis. Speech problems persist or evaporate, wild children calm down, little geniuses turn out to be literate but socially helpless.
I remember teaching a course in special education in the late 1970s. A slim column of newsprint was our only usable reference on “hyperactivity.” Most of my colleagues had been led to understand that children could not be labeled hyperactive until they reached school age. By the mid-1980s, professionals were armed with sheaves of articles about “minimal brain dysfunction.” One mother, confronted with this label by one of my team psychologists, dissolved into tears over the implication that her child was brain damaged. This mother feared that her son would spend his life behind bars because he had slipped from her arms as an infant. (He was last heard from at Stanford!) Just 5 years later, parents complained fiercely when they found that attention-deficit disorder with or without hyperactivity (AD/HD) was not recognized as a special education need and the diagnosis did not automatically qualify a child for special education.
It is encouraging to consider the remarkable changes in the professional and popular views of this condition. Improvements in recognition and treatment have meant that for at least a decade children with AD/HD have had the benefit of a more hopeful perspective. However, not all parents, physicians, or schools have seen or currently see young children with AD/HD profiles through the same lens. It may be instructive to recount stories of some of the children affected—or not affected—by the developments of the recent era.
Jason, late-born son in a family of teenage girls, was dangerously hyperactive and slow in all areas. His parents saw him as “active,” and his sisters played with him and taught him and boasted of his antics. Jason did well in parochial school and junior college. Now, he is a father and hockey player and still a delight to his family.
Barbara danced her way through two preschools and spent an evening in an empty parking lot looking for pennies. She was removed from her grandmother’s home and adopted by cousins who provided medication and appropriate opportunities. Barbara was enrolled in figure-skating classes to channel her abundant energy. She now skates with her own toddlers and has a job and bachelor’s degree.
Matthews by the half-dozen with AD/HD went undiagnosed in preschool. They were seen as “busy” and their teachers walked them through the days. These boys did well in elementary school with committed teachers and poorly with those distracted by their needs and noise.
The medical questions for this collection of papers—What is the minimum age children can be diagnosed? What is the minimum age children can be medicated? With how young a child can we feel safe and confident in our handling of this disorder?—are somehow tangential to the questions that are faced by those of us who care for these preschoolers every day.
Most young children attend preschool now. Well before school age, 90% of 2 to 5 year olds, including the Jasons, Barbaras, and Matthews, present themselves to caregivers in a vast and unstandardized collection of programs.
Our questions in early childhood are necessarily more practical than those of researchers and physicians. We ask, What is this? Will it last? What happens if we try some behavior management? Will this school take this child? Will it be safe? Will this plan give this mom enough relief and support? Will this teacher be discouraged or delighted? Is this child’s problem holding the class back? Is this child struggling and are the AD/HD symptoms evidence of the struggle? Is this how the child behaves everywhere? How angry are Dad, Mom, and the day-care provider? Is medication in the cards? Do we agree that it should be tried? Can this child and school survive without it? How do we support Mom and Dad? How do we react to their experiments with diets, herbs, and chiropractors? Our questions go on and on for 2 or 3 years for some children.
I have worked for 24 years to “broker” services and placements for children with suspected or identified special needs. We have kept most children with special needs in community programs and used special-education classes only for those children with severe disabilities. Attention problems have become an increasing focus of our work as the percentage of children in group care and in preschool has increased. Medication has been prescribed for 2, 3, and 4 year olds—with equivocal results—only recently. Although attention-deficit disorder with or without hyperactivity (AD/HD), per se, is not a bona fide special-education need, the child with this profile presents more compelling needs than many of our truly disabled children.
Identifying and Serving Children
Public school and early intervention agencies have well-established practices related to the identification of special needs and disabilities. They can also offer families a variety of services designed to address a broad range of needs. There are ongoing struggles to ensure that services offered in different districts are appropriate or equivalent. There are, of course, discrepancies and varying interpretations of eligibility standards. For example, in some districts, children with speech difficulties are treated routinely, whereas in other districts, they are treated only if their difficulties relate to a defined disability.
Although outsiders often cite funding as a determinant of service availability, it is rarely, in my experience, a key factor. The boundary separating special from regular education has been so permeable that districts struggle periodically to protect the overall integrity of educationally relevant special services as medical providers and regular education administrators abdicate more and more responsibility for needs that fall outside of the absolute norm. AD/HD is one of the few disabilities that need not impair educational functioning in otherwise healthy children. It is most frequently addressed through “accommodations” within the regular education arena.
For the child with AD/HD, behavioral, psychopharmacological, and educational treatments are generally seen to help the school-aged child. Younger children are usually offered similar interventions, especially if additional disabilities qualify them for special education.
Georgia DeGangi, 1 whose work in sensory integration has complemented Stanley Greenspan’s popular research and treatment, lists many possible interventions for the child with attention problems. In my experience, most children receive one or two interventions during the early years; only when they reach school age do families and schools try several strategies.
RESEARCH AND PRACTICE
This paper does not pretend to describe a classic research effort. Similar to most educators, early-childhood specialists are very practical, concrete, and narrowly focused. Although some have training and experience in research, most providers and administrators are fans of “best practice” manuals and conferences that give tips, lists, and case descriptions. There are more toys than textbooks at early-childhood conferences. We can hope that our best practices come from considering the findings of research in light of the wisdom of experience. Some of the following opinions about managing attention-deficit disorder with or without hyperactivity (AD/HD) in very young children may, indeed, represent applications of practical and scientifically sound care.
Dr. Bernard Arons, President Clinton’s mental health czar, said in his keynote address at the December 15, 2000, Wellchild Conference, “Practice is not driven by research. It is driven by something else.” I am included here, I suspect, to represent the “something else.”
Obtaining Views of Other Preschool Specialists
For this examination of AD/HD in preschool, I reviewed records related to early-childhood program caseloads from 1979 to 2000 and conducted 41 brief interviews with colleagues.
The interviewees represented two groups: The first group was composed of members of a regional coordinators’ network, a group of approximately 20 public-school administrators that has met since 1986. The second group was composed of members of our local Early Childhood Association, a group of approximately 20 program directors and service providers that was formed in 1978. The two groups have in common the responsibility for day-to-day care and education of preschool-aged children.
All interviews began with an explanation, “I need to prepare for a conference…,” followed by the leading question, “What is the most important thing that comes to mind about programming for young children with AD/HD?” Additional probes were used such as, “What have you done…? Why do you say that? How did that work?” and “Could you say more?”
Respondents from Public School Versus Community Programs
When asked “What is the most important thing that comes to mind in programming for children with AD/HD?” public-school coordinators were nearly unanimous in responding, “Structure!” The community-based group of program directors did respond unanimously: Essentially they all said, “Depends on the kid.”
Members of each group eventually mentioned the other group’s theory. There was, however, a notable difference in their emphasis that appeared to reflect the groups’ respective roles. Special educators and public-school administrators see only those children who need special attention (remediation). Community early-childhood educators are responsible for all children and are usually not moved to scrutinize a child unless there is a compelling problem in caring for the child.
The ramifications of these differences are readily apparent in the treatment and care of young children with AD/HD profiles. Special-education models have become more prescriptive and intense of late, despite the universal mandate that all early-childhood programs be “developmentally appropriate.” (This term means that programs should provide ample resources for play, exploration, and hands-on activity for children on a continuum of development.) State and federal laws now require that children have defined disabilities to receive services.
Community-based early-childhood programs are mandated to prove their developmental appropriateness and are further expected to accommodate a range of learning styles, personalities, and abilities. They must also accommodate the personalities and preferences of parents. Community-based programs have, in recent years, been forced to abandon practices such as requiring toilet training for entry or “promotion” to preschool classes—this is in response to parent feedback and a parental reluctance to push training. Programs are, at the same time, under pressure from parents to provide early computer training and to follow personalized feeding and care plans demanded by parents
It is not surprising, then, that public-school special-education professionals serving a discrete population would see a prescriptive solution to AD/HD as a problem, whereas those directing community programs would see AD/HD more pragmatically and not necessarily frame the condition as a problem. This difference in point of view and practice is illustrated by the following case examples.
Case Examples: The Impact of Program Goals on Children
Several years ago, I visited two schools serving 4-year-old boys with very similar presentations. The first, a traditional nursery school with a play-based, social skills-oriented curriculum, was “sorting out” the needs of Thaddeus, who was having difficulty with formal activities, sharing, and following simple rules. At a staff meeting, the director listened to several “tales of Thaddeus”—the scissors in the water table, the scattered snack cups, the impulsive journeys he made to soak towels in the toilet, and so on. The director asked for ideas about assigning Thaddeus to a small story group. “Ah, Thaddeus! He’s a rogue!” laughed a veteran teacher. “I want first dibs!”
Two weeks later, I sat in as the staff in a special public preschool discussed David, a child with very similar behaviors. “Oh, he’s coming along,” said one teacher. “He’s all boy, really. Today, he sat for almost 5 minutes at speech, and he helped me set up lunch. He didn’t run out of the room to the bus. I think he’ll be fine.” Her director raised a forefinger and shook it gently at the teacher. “I think we’ll move David to Skills Class.” She raised her voice, “This child has special needs, and your denial is not doing him any good!”
During the following September, I was able to observe Thaddeus “reading” to his kindergarten class from a newly purchased Big Book. His teacher said he was “a delight,” although she’d love to see him have “a little bit of medication before first grade.”
I had to revisit the special program to observe David, who was struggling to meet the strict demands of his latest behavior checklist sticker chart. Now he seemed angry. His teacher complained that he was having “way too much trouble for a child so bright.”
Thaddeus did well in grade school despite the fact that his assessments revealed many more learning problems than David had. David today carries a reputation for being “difficult,” and he has had many special services, many medications, and a complex individualized education program. David has a vigilant, loving family, and he has always tested within normal limits.
The above cases are admittedly simplistic, but they clearly capture one major element in fostering successful development and later achievement in children with AD/HD. Expectations make a difference.
Factors Associated with Success
From the records review and provider interviews, five factors emerged that are associated with successful outcomes for children with AD/HD profiles.
In contrast with the special-education image of rigid adult-directed classrooms, structure that is child-friendly seems more helpful. Routines, clear behavioral expectations, and the availability of a benign “organizing ego” function are elements of useful structure. Adults ready to cue or encourage desired behavior seem to help more than overt behavior-management tools. Helpful structure is not seen as embodied in an individual instructional aide or “shadow.”
2. Gross Motor and/or Sensory Diet Facilities
Children who attend schools with available large motor rooms, adjacent playgrounds, and/or well-used clinical facilities do better.
3. Awareness of Comorbid Conditions
Children whose attention difficulties are seen as personality traits, as their “only” problem, or as related to known special needs seem to do better. One director said, “If my staff see a child as a behavior problem, it is the kiss of death. If a child is seen as busy or also has learning issues, they do okay.”
4. Family Intactness/Integrity
Because there are few families fitting post-World War II stereotypes and there are many children raised by choice or chance by single women, the “integrity/intactness” factor bears explanation. The term is used here to connote functionality on behalf of the child. Preoccupied and/or unavailable parents, families in the throes of dissolution, families with negligible boundaries, and families with poor guidance skills are often not able to provide important support.
Fully half of children initially suspected of having AD/HD, or even diagnosed early with either disorder, are found to be living in families with serious adult problems. Several dozen children with this diagnosis or suspected diagnosis proved in later years to have been living with domestic violence or sexual abuse, or both.
Children with unavailable or preoccupied parents were seen to do less well than those with relatively functional families. One child was “cured” in second grade when his father left the home. Another was described as not responding to any medication or behavior plan until his mother began to take Prozac. In sum, children with difficulties at home were less likely to be seen or recalled as having done well.
I would also mention the importance of a careful diagnosis. Many children are symptomatic when depressed or stressed. Other conditions look like AD/HD in early life. Many children have underlying developmental disabilities, and their poor attention is only part of a fundamental problem. Several preschool directors mentioned that medications given for asthma and respiratory problems were likely to make children inattentive, hyperactive, and/or irritable. This is corroborated by Russell Barkley who states that half of children diagnosed with AD/HD as preschoolers will lose the diagnosis in later years. 2
A half-dozen records described children who had mothers with breast cancer histories; four of these children were diagnosed with AD/HD before their mothers were found to have ultimately fatal recurrences of cancer. Only one of the six children now carries the diagnosis in grade school. Several recent case records revealed AD/HD diagnoses made during fertility quests by the children’s parents. Twelve cases were renamed depression, many children were later seen to have posttraumatic stress disorder, and many cases resolved substantially with changed living circumstances or changes in school or grade placement.
Early-childhood specialists are newly resigned to the probability that some children will be treated for AD/HD because their families have problems or poor parenting skills. This contrasts with the conventional wisdom common among caregivers in earlier times. Most of the program directors I interviewed were open to medicating children under 5 years of age and said that they formerly rejected the idea.
5. General and Thorough Acceptance of the Child
From the David and Thaddeus examples, it is obvious that teacher acceptance plays a critical role in the success of individual children. Our referral records suggest that children in preschools who ask for help did better than those whose schools asked for alternative placement. In their interviews, several directors said that parents who wanted their child “fixed” or “the problem taken care of” were dreaded. “Those kids never do well,” said one veteran day-care director.
Troublesome Trends and Practices
The local and regional colleagues I interviewed urged me to discuss several cultural trends that they believe complicate the identification and treatment of children with AD/HD. No child grows in a vacuum. No parent or school raises a child without influence from some of the following five cultural phenomena.
1. Multiple Caregivers and Interruptions in Care During the First 30 Months of Life
It is not unusual for 2 year olds entering group care to have had a half-dozen nannies or caregivers. Children adopted after early infancy seem to be overrepresented in the AD/HD population. Whereas many are seen to have postadoption syndromes or special needs related to their heritage or prenatal history, adopted children are likely to have had several tandem caregivers and adjustments before preschool.
Directors pointed out that it is now typical for very young children to be left for weeks at a time by parents who travel for business or pleasure. Child-care center staff often care overnight for infants and toddlers while parents vacation alone.
2. Limited Understanding of “Developmental Appropriateness” by Parents and Caregivers
This may lead to physical, emotional, and sensory neglect. Sensory problems often display themselves as attentional symptoms. Young children are exposed routinely now to adult entertainment, to adult activities, and to recreational experiences beyond their interest or abilities. Children are fixtures in restaurants late at night, are left alone “to practice” on bunny ski slopes, and are even encouraged to roam airplanes as parents sleep. Computer software is available and plentiful for children as young as 18 months of age.
In preschools, computers and videos are easily abused as phantom staff, and curriculum pitched for older children may be used because of its appeal to parents. For example, there are currently curriculum materials for preschoolers on such topics as international culture, rainforest preservation, and fine art. These do not reflect or address the needs of very young children.
The young child with attention difficulties needs concrete and consistent experiences and much adult supervision. Ill-chosen or undersupervised activities do not provide these and may actually put the child at risk for injury and neglect.
3. Failure to Foster Self-Soothing, Adaptive Mastery, and the Ability to Delay Gratification in Mainstream Child-Rearing
Directors from both groups were vocal on this topic. The use of the “family bed” by default when parents could not manage bedtime routines was mentioned by 20 directors. Use of pacifiers, covered cups, and “comfort” nursing were all seen as serving to “hold children back” and to foster the anxiety they are supposed to relieve. Many child-care program personnel reported that they must rub children’s backs or rock them to help them get to sleep on a daily basis right into kindergarten.
Children with AD/HD often have regulatory difficulties, and children with regulatory problems are often mistaken for those with AD/HD. A culture that does not help children with self-regulation cannot be good for children with AD/HD.
Children with AD/HD are seen by both groups interviewed to need more help from staff than other children. Staff overwhelmed by the increased needs of typical children are not likely to be available to provide that help.
4. Overstimulation and Underresting
It is very common for parents and schools to overschedule children, even on weekends, to ensure that children are not “bored” or undereducated. Child-care facilities themselves promote after-hours events and hold parent conferences on weekends with child care available. These practices both reflect and model overscheduling. Directors both mentioned after-hours activities and bemoaned them.
It is also common for parents to insist to child-care program personnel that their child must be prevented from sleeping at school in the mistaken belief that daytime napping causes bedtime problems. Several directors said something such as, “They’re all exhausted.” Sleep deprivation was mentioned many times with respect to both parents and children.
Respondents from public schools talked about family schedules so overbooked that a major office task is to try to squeeze in therapies demanded by parents.
Children with AD/HD are likely to have magnified problems when overtired or overstimulated. Sleep-hungry parents are not likely to address their needs well either.
5. Delegated Parenting and the Expectation of Perfection
Child-care professionals and special-education staff often see themselves as surrogates for parents, especially when children spend long days out of their homes.
To borrow Garrison Keillor’s phrase about a community in which “all the children are above average” is to reflect current beliefs that wholeness and even perfection are to be expected. Those charged with caring for young children often complain that parents expect them to ensure optimal development in their children.
Programs try to meet the expectations of their consumers, in this case, parents. Some now offer gymnastics, dance, and even therapy for children. There are programs that send caregivers to pediatric visits, to special-education sessions, and to dental and dancing school appointments. Directors listed recent parent requests: for staff to perform physical therapy exercises that are prescribed for bath time, for staff to complete toilet training during a marathon weekend at school, and for staff to be on call for overnight child care when parents are “too stressed to deal.”
Public-school administrators mentioned a common expectation that therapy will correct early-childhood speech and motor problems. In reality, therapy is effective only if modeled strategies are carried over into daily life. Many parents in all of our communities now demand extra therapy because they themselves cannot follow through at home.
For the child with AD/HD, having a parent who expects an easy “fix,” an out-of-home fix, or, indeed, any fix at all probably predicts a rocky course. Current programming for autistic children illustrates this principle: In response to parent demands, schools often provide 30 to 50 hours of weekly treatment by parent surrogates, often without parents present. There are practitioners and parents who sincerely expect “recovery” from autism via this route. When children do not recover, parents seek more of such treatment. One father asked his town to provide 62 hours of training in the belief that progress is just out of reach.
A result of this and similar perceptions is that parents and caregivers do not feel competent or powerful in the face of specific disabilities. Children, who do not need adults to convey insecurity about their care, suffer doubly—from the disability and from adult weakness.
Children with AD/HD need matter-of-fact and consistent care. Children with anxiety masquerading as AD/HD probably need adult confidence and steadiness even more.
I am encouraged that physicians and other scientists are taking seriously the reality that very young children are expected to function in out-of-home care. It is also encouraging to imagine that caregivers and teachers will benefit from scientific efforts to help children with attention challenges.
From this informal investigation of young children and the early-childhood educators and program administrators, I am gratified to see that our clinical practice often involves principles substantiated in the scientific literature.
I am most encouraged, though, to consider the immediate progress and surprising wisdom of actual children. Just weeks ago, I heard a 4 year old chirp delightedly to his preschool teacher, “I never didn’t do it before! This day, I didn’t do it, right? I told my body, ‘stay in the circle,’ and I didn’t run away!” Luckily, he—and his teacher—knew exactly what he was talking about!
Years ago I watched a talented teacher handle wiggly 3 year olds in a group activity. A child with clear AD/HD was not able to contain himself when the discussion sparked his interest. He stood up, jigged around his spot on the floor, flapped his hands, and tried to get the teacher’s attention. She said whimsically, “Harrison, do you have a bee in your bonnet?” One of Harrison’s peers, a sage 4 year old, said, “No, teacher, but he sure has a buzz in his behind!”
The teacher, the sage, and Harrison are all doing just fine.