For a year, a kitchen timer went everywhere 3-year-old Eddie Fitzgerald did — home, playground, day care.
Counting down the time before he had to switch activities, fun ones or not so fun, helped the Pennsylvania youngster control outbursts spurred by attention deficit hyperactivity disorder, known as ADHD.
New research suggests simple techniques that give more structure to a preschooler's day can offer a nondrug alternative to help the tiniest sufferers of ADHD.
The research highlights a poorly understood problem. Yes, frazzled parents know it's normal for preschoolers to be hyperactive, impulsive and have problems paying attention. But some are too hyperactive, too impulsive, and too inattentive — they can develop hallmark ADHD symptoms that young.
"We looked at the preschool years as an important window of time in the development of these children," says Lehigh University psychologist George DuPaul, who co-authored the work.
"We know ADHD carries long-term risks," including difficulty in school and making friends, he said. "Wouldn't it make sense to intervene as early as possible?"
Between 3 percent and 5 percent of school-age children are thought to have ADHD; for preschoolers, fuzzier estimates range from 1 percent to 4 percent.
Identifying the littlest patients is difficult.
"Do not be too quick to jump on the bandwagon in making early diagnoses," says Dr. Louis Kraus, child psychiatry chief at Chicago's Rush University Hospital. He cautions that even when a preschooler's unruliness really is abnormal, other causes must be ruled out.
Kicked out of preschool
This is not routine temper tantrums or a fidgety 4-year-old. To be diagnosed with ADHD, a preschooler must have extreme symptoms when compared with youngsters of the same age. These are kids so out of control they may be kicked out of preschool.
"Lots of young kids don't listen and drive their families crazy," says ADHD specialist Stephen Hinshaw of the University of California, Berkeley. "But when they're booted out of preschool, cause head injuries because they're running in front of cars or falling off kitchen appliances ... this condition is going to get this kid in serious trouble."
ADHD drugs are not formally approved for use in preschoolers, and while they may help some, side effects are more common in younger children, including a worrisome slowing of growth.
Thus Lehigh's hunt for alternatives is sparking interest. The five-year study, paid for by the National Institutes of Health, provided a range of behavioral-only therapies to 135 preschoolers with severe ADHD.
After a year, aggression and other problem behaviors had dropped, and learning improved, by about 30 percent, the researchers report this month in a journal of the National Association of School Psychologists.
"This work is critically important," says Berkeley's Hinshaw.
Consistent rules and routines
What helped? Stressing consistent rules and routines, and more praise for good behavior than punishment for bad. Surprisingly, both groups fared equally well, raising questions about how to tell which children need more intense aid.
Preschoolers with ADHD learn more through repeated practice than through observing social cues like other youngsters, DuPaul says. So the study stressed role-playing things like how to ask to share a toy.
Channel extra energy to avert misbehavior, adds study co-author Lee Kern, a Lehigh special education professor. For example, kids who couldn't sit still for circle time were handed an instrument to play while their classmates sang.
Parents were taught to reserve stronger punishments for worst cases, and to try reward systems where children gain or lose "points" for behavior instead. Even the time-out standby was to be used sparingly.
"If they end up in time-out a lot of time, they're not learning social skills," Kern says. "We want parents and teachers to implement strategies that prevent the behavior and teach children skills."
Predictability turned out to be what Eddie Fitzgerald's mother calls her magic bullet. Sheree Fitzgerald, of Macungie, Pa., was skeptical when Lehigh researchers suggested a kitchen timer.
First, she used it to ease Eddie out of fun activities: "Five minutes until we leave the playground... now four minutes..."
Then Eddie was praised for sticking through boring activities — cleanup or, when he reached kindergarten, homework — that he gradually learned didn't last long.
Now 6, Eddie starts first grade this week, and Fitzgerald is confident he'll do well.
"It really made a difference, I think, that we started it early," she says. Now, "he strives for that positive recognition."