ADHD drugs are being prescribed too quickly to preschoolers

In contrast, medication relieves ADHD symptoms such as hyperactivity and inattentiveness, with effects that wear off as the body breaks down each dose of the drug.

Both approaches are needed for most kids with ADHD to do well. But previous studies of preschoolers diagnosed at age 4 or 5 show that it’s best to start with six months of behavioral treatment before prescribing any medication.

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Rapid prescriptions

The researchers analyzed data from electronic health records for children seen at primary care practices affiliated with eight U.S. academic medical centers. They began with 712,478 records from children who were 3, 4 or 5 years old and were seen by their primary care physician at least twice, over a period of at least six months, between 2016 and 2023.

From these records, the scientists identified 9,708 children who received an ADHD diagnosis, representing 1.4% of the children in the initial sample. They found that 42.2% of these children — more than 4,000 kids — were prescribed medication within a month of their ADHD diagnosis. Only 14.1% of children with ADHD first received medication more than six months after diagnosis. The researchers did not have access to data on referrals to behavioral therapy, but since young children are supposed to try the therapy alone for six months before receiving medication, any who were prescribed medication sooner were likely not being treated according to academy guidelines. A smaller study of recommendations for behavior therapy, published in 2021, found only 11% of families got the therapy in line with guidelines.

Children who were initially given a formal diagnosis of ADHD were more likely to get medication within the first 30 days than those whose medical charts initially noted some ADHD symptoms, with a diagnosis at a later time. But even among preschoolers who did not initially meet full criteria for the condition, 22.9% received medication within 30 days.

Barriers to behavioral treatment?

Because the study was based on an analysis of electronic medical records, the researchers could not ask why physicians made the treatment decisions they did. However, Bannett’s team had informal conversations with physicians, outside the scope of the study, in which they asked why they prescribed medication.

“One important point that always comes up is access to behavioral treatment,” Bannett said. Some locales have few or no therapists who offer the treatment, or patients’ insurance may not cover it. “Doctors tell us, ‘We don’t have anywhere to send these families for behavioral management training, so, weighing the benefits and risks, we think it’s better to give medication than not to offer any treatment at all.’”

Bannett said he hopes to educate primary care pediatricians on how to bridge this gap. For example, free or low-cost online resources are available for parents who want to learn principles of the behavioral approach.

And while the study focused on the youngest ADHD patients, behavioral management therapy also helps older children with the diagnosis.

“For kids 6 and above, the recommendation is both treatments, because behavioral therapy teaches the child and family long-term skills that will help them in life,” Bannett said. “Medication will not do that, so we never think of medication as the only solution for ADHD.”

Researchers contributed to the study from 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, Children’s Hospital of Philadelphia, the University of Colorado, and Nemours Children’s Hospital. `

This work was supported by the Stanford Medicine Maternal and Child Health Research Institute; the National Institute of Mental Health (grant K23MH128455); and the National Heart, Lung, and Blood Institute (grant K23HL157615). The study was conducted using PEDSnet, A Pediatric Clinical Research Network. PEDSnet was developed with funding from the Patient-Centered Outcomes Research Institute.