Next steps for 4 year old with ADHD
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Anonymous
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After a recent visit to KKI, we were told that my almost 4 year old son is virtually certain to receive an ADHD diagnosis in the next year or so. His diagnosis is "hyperactive impulsive", and not combined or inattentive. He also clearly does not have oppositional defiance disorder, as he is an extremely happy kid. So what does this look like on a daily basis? At home, he is happy, bouncey and nonstop movement (i.e., literally can't stop bouncing his legs even if you offer him a cookie to stay still for five seconds), but generally follows orders without defiance - getting dressed, putting things away, etc. So long as he is given an activity, he has exceptional focus - he can focus on trains, puzzles, drawing, tv, eating, baking with me, having a bath, cleaning up etc for literally hours. That's why he received a "hyperactive" diagnosis and not the inattentive diagnosis. He does get too touchy at home, with the occasional slapping of his hands on us if he's bored, good-natured head butt etc. We have used good strategies since toddlerhood, and these physical issues have greatly dissapated at home but are still there.
In public, he is extremely busy, touching and a bit difficult to reign in compared to other kids, but we've adapted some strategies so we don't really have any problems with the grocery store, etc. Mostly just need to keep our eyes on him. His main issues are at preschool, where he is inappropriately physical with other kids. In his ideal world, he would just go off by himself and play trains for hours. But school requires circle time, dancing time, play time at the park, and my son gets overexcited and will randomly run up to kids and hit them, bump them, hug way too tight, squeeze their face (he does this one because he know he hugs too tight, so I think it's his attempt at reigning in his behavior). During circle time, he is unable to sit quietly like other kids, and rolls around, flails his legs (and kicks other kids), somersaults, etc. He likes other kids, but he is definitely off socially with his peers because he wants to interact through inappropriate physical behavior instead of talking. As mentioned, he probably prefers to be alone at school, but this is on par with several boys in his class. His speech is not great, but pretty on par with several of the other boys in his class (who also don't use speech unless quiet and controlled). School is really the only place where we have behavior that is consistently a problem. His school has been awesome, supportive, creative and patient, but the problems are still there. He is always a very happy kid, no tantrums, no defiance. Just busy, touchy, physical. We are doing the DCPS early intervention thing to coordinate some accommodations with his private preschool and then start a paper trail for when he goes to DCPS for a 504. KKI said that, based on the hyperactive-only issue, no inattention issues, a good personality, no defiance issues and family history of highly gifted people with similar adhd symptoms, he's likely to age out of most of the problems by age 10 or so, but may still prefer to be on meds after that. KKI said meds weren't recommended at this age given that he and others aren't at major risk of injury (even though I said he's constantly hurting other kids), said that meds will almost certainly be indicated in a couple years, but in the mean time the recommended course is intensive therapy. We looked into this and the options are inconvenient (times and locations) and extremely expensive ($800 for initial analysis, plus $300 a week for therapy). We have also read about therapy for 3 year olds without defiance, and we're not sure that this would have much impact on our son (esp given the above description). I feel like this was recommended to us not because it will necessarily help, but because the guidelines say that doctors are supposed to recommend behavior modification before they suggest medication next year. I've read several books and lots of stuff on the internet, and feel like we're already implementing good parenting techniques at home - hence a lot of his behavior at home has improved. There's not much need for a reward system, because he pretty much does everything he is supposed to do at home, and is it appropriate to reward a kid for, say, not bouncing their leg anymore? What else should we be doing? Would a social skills group help at this age? Do you think we're crazy for passing on therapy? Anything else for an almost-4-year old who's only issues are touching/hyperactivity/social issues in a school setting? |
Anonymous
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Your kid sounds like mine. Read the Kazdin Method and I recommend seeing a behavioral therapist. KKI's outpatient clinic in Columbia MD is good. Get routines to follow at home. (As my kid got older, he got more defiant for activities he didn't want to do.) Getting lots of physical activity is great too.
It's great that he is amiable at home, however, the reality is that he will need to participate in circle time and appropriately interact with his classmates. An OT that follows a "zone" program, e.g., red, yellow, blue or "how is your engine running?" can be helpful b/c your kid can learn how to regulate himself is he's getting to revved up. Many OTs or STs do social skills groups which would be helpful as well. |
Anonymous
| How's it going, OP? |
Anonymous
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OP here. It's only been two weeks! So we've had literally no progress. Having talked to a few psychologists who specialize in kids with ADHD (one of whom even has a son with the exact same profile as mine, only older) the psychologists all indicated that therapy isn't likely to help much - because at this age he will lack the maturity to transfer the skills over to a classroom setting. A couple of them (and some people on this site) recommended social skills groups as something that might help - so we've been trying to track down a group that is offering a group for preschoolers - and that works on our schedule/geography (we're in the district and I work - so outside the beltway during rushhour just isn't viable). No luck yet.
He started his new year of preschool yesterday, and this morning I got the "we're working with him on his hitting and pushing" from his teachers.... argh. |
Anonymous
| Hmmm. My son is almost 4 and definitely has the hyperactive profile, as well as inattention issues, but for now does not push and hit at school (we shall see). I am meeting with the dev ped tomorrow to talk about what to do, and will update. Our recommendations might be different b/c of the attention issues, but it still might be helpful. I would really do OT for the pushing/hitting, and look into maybe a wiggle seat. |
Anonymous
| We tried OT last fall and did not find that it was helpful. He was well behaved in the sessions and basically it was me paying for an hour of fun playground type activity. The issue is that he can't carryover his learned-positive behaviors into a busy classroom setting. One on one with another kid -- he's fine. Twelve kids in a room and it goes to sh*t. The pushing isn't aggressive or frustrated - he just lacks body control. He'll literally just grab someones face and squeeze because he's over-stimulated. I may try the wiggle seat, but to be honest, all the various OT gizmos we've tried just go to die a quick death when we figure out they don't make any difference. I was talking to a well-respected psychologist (as mentioned above) whose son is the same profile, and she was like "listen, you can try some of these things, I'm happy to come to your school to help implement some stuff, but you're probably going to find that the only stuff that really makes a difference is age and medication." I thought it was an honest and helpful response and has taken some pressure off me. I have all along been feeling like I have to keep investing so much time and energy until I get this issue under control - but maybe I just need to let it go and recognize for now that there's not much to do. Nonetheless I'd be interested in the feedback you get. |
Anonymous
Btw, if my son wasn't hitting and pushing, I wouldn't be sweating it at all about the hyperactive profile! I'm of the mindset that who cares if he won't sit still for circle time, because maybe he'll be ready when he starts K in 2 years. Also, on the inattentive issues, my son looks somewhat inattentive (looking all around, moving when you are trying to talk to him, avoiding eye contact) but it became clear to the dev ped that he was hearing and retaining everything we said (she had him read back a few long strings of numbers, so he was clearly registering info). |
Anonymous
I get this, a lot, but why are you paying? you should not be - if he is clearly going to have an ADHD diagnosis, OT should be covered. And it should be less about "gym" time, and more regulation - like playing red light, green light, figuring out alternative ways to get what he needs to settle down (my son has to be on the swing to totally focus), etc. They should be able to come up with some plans to get him to settle down that you can work on with the school. |
Anonymous
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A weighted vest and a wiggle seat might help.
A smaller class and hours and hours of physical activity might help. Other than that, there's nothing you can do. IMO. I think expensive therapy would be a huge waste here. |
Anonymous
We were doing that stuff at OT - he was good in therapy, and even the therapist said it wasn't really helping because they couldn't replicate the classroom chaos. This was in another state where early childhood stuff was not free unless you were in school or low income. And are you saying it should be free because it's part of Early Stages? Or because insurance should cover it? If the latter, we're on a high deductible plan so the first $5800 is on us.... |
Anonymous
Shoot, yeah, I meant insurance would cover it. I completely understand where you are coming from because I find OT minimally useful, and would not do it unless it was covered. It sounds like he just needs more warnings at school, like in five minutes x, some calm down time, and maybe some more exercise in the morning. Can you get a mini trampoline or go swimming super early? |
Anonymous
We tried a weighted vest - no effect whatsoever (though his teachers called in a panic - thought he had a major body injury that he had to wear a body cast for!) I'm going to try the wiggle seat. Would love a smaller class but we don't have any options where we are. I've also looked into co-ops, home care with a small group of kids - literally nothing unless I quit my job to drive out to the suburbs in the morning. The crisis isn't that bad yet. The funny thing is that we do not notice any difference in his behavior between no activity days and hours and hours of activity days. We live in the city and walk and scooter everywhere, and the kid never stops moving in any event. School takes him to the park every day for 2 hours, I usually take him back to the park after school. He runs around the house. Never stops. He's still a maniac at school. Then some days he'll watch tv for 5 hours (rarely, but happens, e.g. on a school holiday where the babysitter cancels and I have to work from home) and once he gets up from the tv his behavior is the same as the days when he was running around for 6 hours. We've also noticed no difference in days with sugar versus days with only healthy stuff. Or days with dairy versus days without. Or days when he takes an allergy pill versus days without. The reality is that this is just a core part of his brain. |
Anonymous
| OP, if you are in the district, is he in DCPS or a charter? If so have you requested an eval, to lead to an IEP and services at school? These may include fidgets, movement breaks etc. can you walk or scoot to school? Do you do social stories? My kid was quite similar in PreK and K, at risk for ADHD diagnosis, much better now. |
Anonymous
We are in DC, at a private preschool. We are starting the ball rolling on the Early Stages eval, at the gentle suggestion of his school  Two of the teachers in his room have experience in special needs, and came up with some great strategies (like fidgets, and all the kids sit in chairs during circle time now, going to the park every day). His whole day is a movement break - because they don't really force him to sit at circle time (which I fully support, otherwise he's prone to causing trouble). We scoot to and from school every day, they walk a couple blocks to the park every day. He has a lot of movement in his day. So that's not what's missing....
What are social stories? |
Anonymous
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My son was very much the same. One thing that may help is a quiet space at school where he can go to calm down--maybe they could set up some bookcases to block off a corner with some cushions and he could go there with a book or quiet toy when he is over-stimulated? That's the only thing that really helped with mine. At home we sent him to his room and he'd come back 20 minutes later just fine. At preschool they often sent him to sit in the office, which he enjoyed because he got to sit and look at books.
I don't use the "engine running" metaphor because my son's view is that engines should be fast, fast, fast. I tell him his train is running off the tracks and he needs to slow down go get them back on the tracks or his train will just get stuck. He's played with enough train sets that metaphor makes sense to him. Also, it makes more sense to me than the engine...once he is off track, it usually just gets worse until we can get him back on track. You might also try a book like Personal Space Camp. Also, maybe the teachers can give him more physical touch? I know I today's world a lot of teachers feel like they are not allowed to touch the kids--if you affirmatively ask them to give your child more pats, back rubs, hugs, etc., it might help calm him. My son needs about 3x as much hugging as the ordinary kid. He's old enough now that he knows that when he needs a squeeze, he comes to mama, not another kid. |