Children aged 4 and 5 diagnosed with attention deficit/hyperactivity disorder frequently start medication right after their diagnosis, going against established guidelines from the American Academy of Pediatrics, according to a study spearheaded by Stanford Medicine researchers.
This key observation, detailed in a publication dated August 29 in JAMA Network Open, points to significant shortcomings in the healthcare provided to preschoolers with ADHD. The official guidelines urge that these young patients and their families first engage in six months of behavioral therapy prior to initiating any ADHD medications.
However, many pediatricians opt to prescribe drugs immediately following the diagnosis, as revealed through an examination of medical records from almost 10,000 preschool-aged children with ADHD treated across eight pediatric health networks throughout the United States.
‘Our research indicates that a substantial number of these young children receive medication prescriptions shortly after their ADHD diagnosis is recorded in their files,’ explained Yair Bannett, MD, the lead author and an assistant professor of pediatrics. ‘This trend is worrisome since evidence clearly shows that launching ADHD management with behavioral strategies yields substantial benefits for both the child and the entire family dynamic.’
Moreover, stimulant medications commonly used for ADHD tend to produce more adverse effects in younger patients compared to older ones, Bannett noted. In children under 6 years old, their developing bodies do not process these drugs as efficiently.
‘We aren’t worried about the inherent toxicity of these medications in 4- and 5-year-olds, but there is a strong chance of discontinuation because families often find the side effects more burdensome than the therapeutic gains,’ he added. Such stimulants can heighten irritability, emotional volatility, and aggressive tendencies in preschoolers.
ADHD represents a neurodevelopmental condition marked by excessive hyperactivity, challenges in maintaining attention, and impulsive actions.
‘Detecting it at an early stage is crucial because these children face elevated risks of academic struggles and incomplete education,’ Bannett emphasized. Prompt recognition paired with appropriate interventions can enhance school performance in children with ADHD. Studies further demonstrate that effective management supports long-term outcomes, including job stability, healthy interpersonal relationships, and reduced encounters with legal issues.
Complementary Treatment Approaches
The primary pillars of ADHD management—behavioral therapy and pharmacological interventions—serve distinct roles in addressing the disorder.
‘Behavioral interventions focus on modifying the child’s environment, including parental behaviors and daily routines,’ Bannett described. These therapies equip parents and children with essential skills and routines tailored to the unique wiring of the ADHD brain.
The American Academy of Pediatrics endorses a specific evidence-backed program known as parent training in behavior management. This approach assists parents in cultivating robust, affirming bonds with their children; provides strategies for reinforcing positive actions while disregarding undesirable ones; and introduces practical aids like visual timetables to promote organization in kids with ADHD.
On the other hand, medications work to alleviate core symptoms like hyperactivity and inattention, though their benefits diminish as the body metabolizes each dose.
For the majority of children with ADHD, integrating both modalities is essential for optimal results. Yet, prior investigations involving preschoolers diagnosed at ages 4 or 5 consistently advocate beginning with a full six months of behavioral therapy before introducing medications.
Trends in Rapid Medication Prescribing
The research team reviewed electronic health records from children treated at primary care facilities linked to eight prominent U.S. academic medical centers. They started with a dataset encompassing 712,478 records of children aged 3, 4, or 5 who had at least two visits with their primary care provider spanning a minimum of six months, covering the years 2016 to 2023.
Narrowing down the data, they pinpointed 9,708 children diagnosed with ADHD, accounting for 1.4% of the original cohort. Strikingly, 42.2% of these—over 4,000 individuals—received medication prescriptions within just one month of their diagnosis. In contrast, only 14.1% began medication more than six months post-diagnosis. Although the dataset lacked specifics on behavioral therapy referrals, given the guideline mandating six months of standalone therapy before drugs, those medicated earlier were undoubtedly deviating from recommended protocols. A prior smaller-scale study from 2021 on therapy adherence reported that merely 11% of families followed guidelines appropriately.
Children receiving an initial formal ADHD diagnosis showed a higher propensity for medication within the first 30 days compared to those whose records first documented ADHD-like symptoms with a delayed formal label. Nevertheless, even among preschoolers not fully qualifying for diagnosis initially, 22.9% were prescribed drugs within 30 days.
Challenges Hindering Behavioral Therapy Adoption
Since the investigation relied solely on electronic medical record analysis, the team could not directly query physicians on their prescribing rationales. That said, Bannett’s group engaged in casual discussions with doctors beyond the formal study framework to explore these decisions.
‘A recurring theme in these talks is the limited availability of behavioral therapy options,’ Bannett shared. In certain areas, qualified therapists are scarce or nonexistent, and insurance coverage may be inadequate. ‘Physicians frequently explain, “We lack local resources to refer families for behavioral training, so after balancing pros and cons, we deem medication preferable to leaving them without any intervention.”‘
Bannett aims to empower primary care pediatricians with knowledge to overcome these obstacles. For instance, numerous free or affordable online platforms exist to teach parents the fundamentals of behavioral strategies.
Although this research centered on the most junior ADHD cases, behavioral management proves valuable for older children as well.
‘For children aged 6 and up, guidelines endorse combining both therapies, as behavioral training imparts enduring skills to the child and family for lifelong success,’ Bannett stated. ‘Medications alone cannot achieve this, so they should never be viewed as a standalone remedy for ADHD.’
Collaborators on the study hailed from institutions including the Children’s Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Texas Children’s Hospital, Baylor College of Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, the University of Colorado, and Nemours Children’s Hospital.
Funding for this research came from the Stanford Medicine Maternal and Child Health Research Institute; the National Institute of Mental Health under grant K23MH128455; and the National Heart, Lung, and Blood Institute via grant K23HL157615. The analysis utilized PEDSnet, a national pediatric clinical research network established with support from the Patient-Centered Outcomes Research Institute.
