Marvin, 4 years old, has just been expelled from preschool for aggressive behavior. Carolyn, 2.5 years old, is so motorically wound up that she takes no naps, finally falls asleep at 11:00 pm, and awakens at 6:00 am. Leah, 3 years old, cannot be trusted to play unsupervised. She has been to the emergency department three times for toxic ingestions and pushed the new puppy off the bed, dislocating its hind limb. Two weeks after his second birthday, Kelly's longed-for toys are already broken. Rarely did his interest in any one of them last for more than a few minutes.

The parents of these young children are exasperated, tired, embarrassed, and sometimes fearful. At these ages they are most likely to turn to their child's primary care physician for help. Some parents already have a specific agenda: they want medication to control the hyperactivity and impulsiveness, regardless of the child's age. Others are more open, perhaps naive initially, and seek a better understanding of their child's behavior as well as various options for management.

Each of these children might warrant a diagnosis of attention-deficit/hyperactivity disorder (ADHD). However, their behaviors are also consistent with a variety of other diagnoses, including normal behavior for age or developmental level. Distinguishing between the possibilities and making the medically and ethically correct decisions are exceedingly challenging in early childhood.

The purpose of this article is to review the literature regarding the diagnosis and management of ADHD in preschool-aged children and to offer specific strategies for approaching this formidable challenge in pediatric practice based on this review, personal experience, and the experience of colleagues.