A recent study led by Stanford Medicine has found that many preschool-aged children diagnosed with attention deficit/hyperactivity disorder (ADHD) are being prescribed medication immediately after diagnosis, rather than first receiving behavioral therapy as recommended by treatment guidelines. The research was published on August 29 in JAMA Network Open.
The American Academy of Pediatrics advises that children aged 4 and 5 with ADHD should begin treatment with six months of behavior therapy before starting medication. However, the analysis of nearly 10,000 young patients across eight pediatric health networks in the United States revealed that this guidance is often not followed.
“We found that many young children are being prescribed medications very soon after their diagnosis of ADHD is documented,” said Yair Bannett, MD, assistant professor of pediatrics at Stanford and lead author of the study. “That’s concerning, because we know starting ADHD treatment with a behavioral approach is beneficial; it has a big positive effect on the child as well as on the family.”
Bannett also noted that stimulant medications tend to cause more side effects in younger children compared to older ones. He explained, “We don’t have concerns about the toxicity of the medications for 4- and 5-year-olds, but we do know that there is a high likelihood of treatment failure, because many families decide the side effects outweigh the benefits.” According to Bannett, these side effects can include increased irritability, emotional responses, and aggression.
ADHD is characterized by hyperactivity, difficulty paying attention, and impulsive behavior. Early identification and effective management are important for improving academic outcomes and preparing individuals for adulthood.
“It’s important to catch it early because we know these kids are at higher risk for having academic problems and not completing school,” Bannett said. He added that proper treatment helps improve performance in school and later life skills such as employment and relationships.
Behavioral therapy focuses on modifying the child’s environment through changes in parental actions and daily routines. “Behavioral treatment works on the child’s surroundings: the parents’ actions and the routine the child has,” Bannett said.
The specific behavioral intervention recommended by pediatric guidelines is called parent training in behavior management. This method teaches parents how to build strong relationships with their children, reward positive behaviors, ignore negative ones, and use organizational tools like visual schedules.
Medication addresses symptoms such as hyperactivity or inattentiveness but does not provide lasting skills once its effects wear off. Both approaches may be needed for most children with ADHD; however, previous studies suggest beginning with behavioral therapy yields better results for preschoolers.
Researchers reviewed electronic health records from over 712,000 children ages three to five who had seen their primary care physician at least twice between 2016 and 2023. Of those diagnosed with ADHD (1.4% or 9,708 children), more than 42% were prescribed medication within one month of diagnosis while only about 14% received medication more than six months after diagnosis.
The study did not include data on referrals to behavioral therapy but inferred from prescription patterns that many patients likely did not receive guideline-recommended care. A smaller prior study indicated only about one in ten families accessed appropriate behavioral therapy following recommendations.
Children formally diagnosed were more likely to receive immediate prescriptions compared to those initially identified only by symptoms. Even among those without an initial full diagnosis, nearly a quarter received medication within a month.
Since researchers relied on medical records rather than direct interviews with physicians or families, they could not determine exact reasons behind prescribing decisions. However, informal discussions suggested limited access to qualified therapists or insurance coverage often influenced choices made by doctors.
“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 hopes primary care pediatricians will learn how to address this gap using available resources including free or low-cost online programs teaching principles of behavioral management for parents.
He emphasized that while this research focused on preschoolers newly diagnosed with ADHD, similar strategies benefit older children as well: “For kids 6 and above, the recommendation is both treatments because behavioral therapy teaches long-term skills… Medication will not do that so we never think of medication as the only solution for ADHD.”
Collaborators included researchers from several institutions such as Children’s Hospital of Philadelphia; Perelman School of Medicine at 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 & Robert H. Lurie Children’s Hospital of Chicago; University of Colorado; Nemours Children’s Hospital; among others.
Funding came from sources including Stanford Medicine Maternal & Child Health Research Institute; National Institute of Mental Health (grant K23MH128455); National Heart Lung & Blood Institute (grant K23HL157615); Patient-Centered Outcomes Research Institute via PEDSnet Pediatric Clinical Research Network.
