Identifying ADHD Risk in the First Years of Life

Heather M. Joseph, DO, is associate professor, psychiatry and pediatrics, University of Pittsburgh School of Medicine. Dr. Joseph’s clinical and research focus is on the earliest detectable signs of attention-deficit/hyperactivity disorder (ADHD) and the parent and family factors that may influence its development and clinical course. Dr. Joseph leads a program that follows infants and toddlers born to parents with and without ADHD, with the goal of identifying high-risk phenotypes before symptoms reach a diagnostic threshold and intervening early enough to change developmental trajectories. She leads the Attention in Babies and Children’s Lab at the Youth and Family Research Program. Dr. Joseph’s clinical work with patients is at UPMC Children’s Hospital of Pittsburgh as part of the Behavioral Health Consultation Liaison team.

“The goal of my research is to allow clinicians to intervene with children who are at high risk so we can improve outcomes and maybe reduce the prevalence of ADHD and the impairments associated with it.”

Dr. Joseph’s research is part of a small but growing international effort to push back the timeline on identification of children at risk for ADHD and in need of preventive interventions. Dr. Joseph is a contributing investigator in the Early ADHD Consortium, a group of researchers focused on the field’s emerging questions, with whom she coauthored a paper outlining the current state of early-risk research and priorities for future work.

Dr. Joseph earned her medical degree from Ohio University Heritage College of Osteopathic Medicine.  She then completed residency in psychiatry and a fellowship in child and adolescent psychiatry at UPMC Western Psychiatric Hospital. Dr. Joseph participated in the Department of Psychiatry’s research pathway as a resident and fellow, training with Brooke Molina, PhD, professor of psychiatry, pediatrics, and psychology at the University of Pittsburgh School of Medicine, whose work on the long-term outcomes of childhood ADHD provided the foundation for Dr. Joseph’s focus on intervening earlier in the developmental course.

ADHD Is a Common Condition

ADHD is the most common neurodevelopmental disorder of childhood and one of the primary reasons children present to primary care and pediatric psychiatry for behavioral health issues. The typical presentation, with inattention, hyperactivity, impulsivity, and emotion dysregulation, generally surfaces in the early elementary school years, between ages 7 and 9, after academic and behavioral problems become apparent in the classroom. Comorbid conditions, including learning disorders and autism spectrum disorders, depression, anxiety, and substance use disorders in adolescence and adulthood, are common.

“ADHD is one of the most heritable psychiatric conditions, and there are studies that suggest that about 80% of parents with ADHD will have at least one child with ADHD,” Dr. Joseph says. “The mechanisms driving this are not clear, but it is likely a mixture of genetic and environmental factors at a minimum.”

If high-risk infants and toddlers can be identified before problems develop, Dr. Joseph and colleagues hypothesize, evidence-based behavioral interventions for parents and families could be deployed during a developmental window in which the brain’s attention networks are still actively forming. The downstream rationale of this approach extends beyond working to mitigate the ADHD itself, but also other issues that are common co-occurrences.

“If we can intervene earlier and reduce the negative consequences of ADHD, we may also be able to prevent or dramatically decrease the incidence depression and anxiety that many of these individuals also are dealing with over time,” Dr. Joseph says.

What an Early ADHD Signal Looks Like

Identifying ADHD risk in a nonverbal infant or a high-energy toddler is, by definition, a difficult task. Some level of inattention, activity, and impulsivity is normal at these ages.

“In the toddler and preschool age range, we expect some ADHD symptoms to be normative, and which children will grow out of. They’re learning how to attend for longer periods of time, they’re learning emotion regulation and inhibitory control,” Dr. Joseph says. “It is hard to look at a single child at these early ages and know for sure who will develop ADHD and who won’t.”

Diagnosis of ADHD at any developmental stage is made relative to same-age peers, and the variability in early childhood is wide. Dr. Joseph’s approach combines several lines of measurement designed to detect signs across a heterogeneous population. Infant temperament has been studied across the field as a candidate early marker; in a systematic review and meta-analysis published in the Journal of Child Psychology and Psychiatry, Dr. Joseph and colleagues found that activity level, attention, and negative emotionality in infancy and toddlerhood were significant predictors of later childhood ADHD diagnosis and symptoms.

“There are stable temperament traits that start at about age four months that we can hypothesize make up someone’s temperament and likely will continue on through their life in some form,” Dr. Joseph says. “So, that may be a precursor to different developmental outcomes like internalizing disorders, depression, anxiety, and same with ADHD.”

Beyond parent-reported temperament, Dr. Joseph’s research uses infant attention tasks adapted from cognitive psychology, including looking-time and habituation paradigms in which an infant’s eye gaze and time-to-novelty are used to infer attentional engagement and learning.

“Looking time can equate to attention in infants. There are tasks that look at eye gaze to tell how attentive infants are, how quickly they learn about a stimulus, and when they become interested in something else,” Dr. Joseph says. “Infants crave new stimuli, and once something is familiar, they look for something new. So, looking behavior can tell us things about attention and learning in infants.”

Dr. Joseph’s research also incorporates the NICU Network Neurobehavioral Scale (NNNS), an extended neurological assessment that captures tone, reflexes, soothability, and attention to faces and sounds, administered in the home at 4 weeks of age by neurodevelopmental specialists from UPMC Children’s and UPMC Magee-Womens Hospital.

More recently, Dr. Joseph’s research has added functional near-infrared spectroscopy (fNIRS), a noninvasive neuroimaging technique used to measure activity in the frontal and parietal cortices, the anatomic locations in the brain of attention networks. The hypothesis being studied is that connectivity in these networks is delayed in children at elevated risk for ADHD.

“What we are seeing are delays in brain development,” Dr. Joseph says. “That’s what I’m looking at: Is the attention network delayed in its connectivity and not functioning as well for kids who are at risk for ADHD?”

Moving from Observation to Intervention

Prior research by Dr. Joseph, conducted through the Pittsburgh ADHD Risk in Infancy Study (PARIS) and its follow-up cohorts, was designed to examine the development of attention in infants and toddlers at high and low risk for ADHD. What the studies also have revealed, and what has driven a substantial portion of her published work to date, is the picture of the parents of children with ADHD.

“Parents in families with parental ADHD report greater parenting stress. They have worse sleep, even if it’s the other person, their partner, that has ADHD,” Dr. Joseph says. “Both of them are more stressed and both of them have poor sleep.”

Rates of depression and anxiety in the postpartum period, for mothers and fathers, are three to five times higher than in families without parental ADHD. Differences in mother-infant attachment have also been observed. The family environment in which a high-risk infant is being raised, is itself often a high-stress one with consequences that can affect the entire family unit.

These findings have shaped Dr. Joseph’s research around intervention. The clinical logic is straightforward as most evidence-based behavioral treatments for young children with ADHD, including parent-child interaction therapy and parent management training, are delivered through the parent.

“If you’re trying to teach the parents how to work with their children to improve positive behavior and reduce negative behaviors, the parent has to be able to participate and then implement the skills,” Dr. Joseph says. “And if they have ADHD, that can be really challenging.”

Dr. Joseph’s current work includes two clinical trials designed with that consideration in mind. The Moms Managing ADHD (MomMA) study developed and is testing a cognitive behavioral therapy-based intervention with organizational skills training and cognitive behavioral therapy for expectant mothers with ADHD. The intervention’s aims include reducing maternal ADHD symptoms, preventing postpartum depression, and improving parent-child outcomes.

The Optimizing Attention and Sleep Intervention Study (OASIS) trial tests a sleep-focused parent behavioral intervention for preschool-aged children, ages 3 to 5, who present with ADHD symptoms and sleep difficulties. Sessions are delivered in the pediatrician’s office by behavioral health therapists. The aim is to reduce ADHD symptoms and improve sleep, potentially before a formal diagnosis is made.

Her newest study, Attention, Hyperactivity, and Early Neurodevelopment Study (AtHENS), uses fNIRS during parent-child interactions to ask a question that bridges the observational and interventional sides of her work.

“Could we identify specific types of parent behavior that could help strengthen the developing brain?” Dr. Joseph says. “Are there parenting behaviors that might increase attention and tap into the child’s attention network in a way that we can strengthen neuroconnectivity? That is a future goal.”

Recent Recognitions and Awards

In the fall of 2025, Dr. Joseph was named a Richard King Mellon Institute for Pediatric Research scholar. The program supports early-career investigators conducting cutting-edge pediatric research and connects them with mentorship, pilot funding, and a community of peers across disciplines. Dr. Joseph has also received the inaugural YourMomCares Brilliance in Research Award, which provided funding to support the MomMA study. Dr. Joseph was named a Distinguished Fellow of the American Academy of Child and Adolescent Psychiatry (AACAP).

Further Reading

Below is a selection of published research from Dr. Joseph about her ADHD research.

• Joseph HM, Lorenzo NE, Fisher N, Novick DR, Gibson C, Rothenberger SD, Foust JE, Chronis-Tuscano A. Research review: A systematic review and meta-analysis of infant and toddler temperament as predictors of childhood attention-deficit/hyperactivity disorder. J Child Psychol Psychiatry. 2023; 64(5): 715-735.
• Joseph HM, Santosa H, Fisher N, Huppert T, Morgan JK. Greater frontoparietal connectivity during task engagement among toddlers with parent-reported inattention. Dev Psychobiol. 2024; 66: e22546.
• Mark E, Molina BSG, Wilson MA, Zeanah CH, Joseph HM. Differential impacts of parental attention deficit/hyperactivity disorder on early maternal-infant attachment. JCPP Adv. 2026; 6: e70029.
• Joseph HM, Wilson MA, Diaz J, Salisbury A, Lorenzi-Quigley L, Vecchiarelli J, Coughlin C, Iverson JM, Molina BSG. Neonatal neurobehavior and infant temperament amongst offspring born to parents with and without ADHD. Infant Behav Dev. 2025; 79: 102066.
• Joseph HM, Khetarpal SK, Wilson MA, Molina BSG. Parent ADHD is associated with greater parenting distress in the first year postpartum. J Atten Disord. 2022; 26(9): 1257-1268.
• Miller M, Arnett AB, Shephard E, Charman T, Gustafsson HC, Joseph HM, Karalunas S, Nigg JT, Polanczyk GV, Sullivan EL, Jones EJH. Delineating early developmental pathways to ADHD: Setting an international research agenda. JCPP Adv. 2023; e12144.