Nearly half of all American pre-scholars with ADHD are prescribed medication too soon – within 30 days of diagnosis – according to a retrospective analysis by researchers at Stanford University.
They said this was contrary to guidelines that recommend six months of behaviour therapy before pharmaceutical interventions.
Medpage Today reports that among children diagnosed with ADHD at age four or five, 42.2% were prescribed medications within 30 days of their first diagnosis (range across institutions 26%-49%), compared with 14.1% who got those prescriptions more than six months after initial diagnosis, wrote the researchers, led by Yair Bannett, MD, MS, of Stanford University School of Medicine in California.
Overall, 68.2% were prescribed ADHD drugs before the age of seven, Bannett and colleagues reported in JAMA Network Open.
They found that some subgroups were more likely to be prescribed medication early. White patients were more likely than Asian (adjusted hazard ratio [aHR] 0.51, 95% CI 0.38-0.68), Hispanic (aHR 0.75, 95% CI 0.70-0.81), and black patients (aHR 0.88, 95% CI 0.83-0.94) to be prescribed medications early.
Others include:
• Boys vs girls: adjusted hazard ratio (aHR) 1.17 (95% CI 1.11-1.25)
• Older vs younger kids: aHR 1.62 (95% CI 1.55-1.69)
• Those on public vs private insurance: aHR 1.09 (95% CI 1.03-1.15)
The findings that so many young children were being prescribed medications soon after their diagnosis was concerning, said Bennett. “We know starting ADHD treatment with a behavioural approach is beneficial; it has a big positive effect on the child as well as on the family.”
About 10% of youngsters in the United States have ADHD, which is increasingly being diagnosed before they even start school. Most children at this age are diagnosed in primary care, though few studies have assessed how these physicians manage ADHD among pre-schoolers.
In 2011, an American Academy of Paediatrics subcommittee published updated, evidence-based clinical practice guidelines for primary care management of ADHD, which was reaffirmed in 2019.
They specified that for children aged four to five, parent-training in behaviour management should be the first step, with medication as possible second-line treatment.
James Waxmonsky, MD, of Penn State University and Penn State Health, in Hershey, noted that this study adds potential insight into why so many young children are prescribed ADHD drugs before therapy.
Waxmonsky, who was not involved in the research, said that “meds are prescribed shortly after diagnosis, limiting the options for therapy to occur, suggesting delaying medication onset could promote therapy uptake”.
Some of his own research has found that parents who opt for medications are less likely to engage in behavioural therapy, which supports the importance of discussing therapy early on.
Waxmonsky said this new study raises several questions, including whether parents and doctors choose the first treatment option presented, or if there is something about medication that makes them choose it more often; and whether primary care offices have integrated therapy or not influences outcomes.
The cohort study assessed rates of ADHD identification and timing of medication prescriptions for children in primary care settings across eight large paediatric health systems from 1 January 2016 to 31 December 2023. Children who were seen ≥2 times and had at least six months of follow-up were included.
Overall, about 1.4% of the 712 478 children seen in primary care between the ages of three and five years received an ADHD-related diagnosis at four or five, with a median age at first diagnosis of 5.31 years. Most were male (76.4%), while 39% were non-Hispanic white, 31% were non-Hispanic black, 18.1% were Hispanic, 1.3% were non-Hispanic Asian, 4.9% were non-Hispanic multiracial, 1.5% were non-Hispanic other, and for 4.1%, race and ethnicity was unknown.
Study limitations included the reliance on diagnostic codes, which carry the potential for misclassification. Also, the first diagnosis may not be the first time ADHD-related concerns were raised.
Additionally, some non-stimulant medications may have been prescribed for sleep issues, not ADHD. The authors said that information about first-line behavioural treatment was not available, so they couldn’t determine if behavioural treatment wasn’t available in certain cases.
Future research should extract information from the clinical notes to capture and assess this information, Bannett and colleagues advised.
Study details
ADHD Diagnosis and Timing of Medication Initiation Among Children Aged 3 to 5 Years
Yair Bannett, Ingrid Luo, Rodrigo Azuero-Dajud, et al.
Published in JAMA Network Open on 29 August 2025
Abstract
Importance
Early identification and treatment of attention-deficit/hyperactivity disorder (ADHD) symptoms in pre-school-age children is important for mitigating social, emotional, and academic problems. Clinical practice guidelines recommend first-line behaviour intervention before considering medication treatment for children aged 4 to 5 years.
Objective
To assess variation in rates of ADHD identification and rates and timing of medication initiation in children aged three to five years in primary care settings across 8 US paediatric health systems and to identify patient factors associated with the time from diagnosis to prescription.
Design, Setting, and Participants
This retrospective cohort study used electronic health records from primary care clinics affiliated with eight academic institutions participating in the PEDSnet Clinical Research Network. Participants were children aged 3 to 5 years seen between 2016 to 2023. Data were extracted from the PEDSnet database on April 18, 2025.
Exposure
ADHD diagnosis at age four to five years.
Main Outcomes and Measures
The primary outcomes were (1) rate of ADHD diagnosis, (2) rate of stimulant and non-stimulant prescription after diagnosis before age 7 years, and (3) time from first ADHD-related diagnosis (including symptom-level diagnoses) to medication prescription. Independent variables included institution, year of diagnosis, patient age, sex, race and ethnicity, medical insurance, and presence of comorbidities. Multivariable Cox proportional hazards models were used to estimate associations between clinical and demographic variables and time from diagnosis to prescription.
Results
Of 712 478 children seen in primary care at three to five years, 9708 (1.4%) received an ADHD diagnosis at age four to five years (range across institutions, 0.5%-3.1%; median [IQR] age at first ADHD-related diagnosis, 5.31 [4.86-5.66] years). Of those with ADHD, 7414 (76.4%) were male, 1762 (18.1%) were Hispanic, 122 (1.3%) were non-Hispanic Asian, 3014 (31.0%) were non-Hispanic Black, 479 (4.9%) were non-Hispanic multiracial, 3782 (39.0%) were non-Hispanic white, 148 (1.5%) were non-Hispanic other, and 401 (4.1%) were of unknown race and ethnicity. Of 9708 preschool-age children with ADHD, 6624 (68.2%) were prescribed ADHD medications before age seven, and 4092 (42.2%) were prescribed medications within 30 days of the first documentation of an ADHD-related diagnosis (range across institutions, 26.0%-49.0%). Asian (adjusted hazard ratio [aHR], 0.51; 95% CI, 0.38-0.68), Hispanic (aHR, 0.75; 95% CI, 0.70-0.81), and Black (aHR, 0.88; 95% CI, 0.83-0.94) children with ADHD were less likely to be prescribed medication early compared with white children. Older vs younger patients (aHR, 1.62; 95% CI, 1.55-1.69), male vs female patients (aHR, 1.17; 95% CI, 1.11-1.25), and publicly insured vs privately insured patients (aHR, 1.09; 95% CI, 1.03-1.15) were more likely to be prescribed medication early.
Conclusion and Relevance
In this retrospective cohort study of preschool-age children with ADHD seen in primary care in eight large paediatric health systems, many children were prescribed medications at or shortly after the first documented diagnosis. Analysis of clinical documentation is needed to understand early prescription patterns.
Medpage Today article – Preschoolers Are Prescribed ADHD Meds Too Soon, Study Suggests (Open access)
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ADHD drug benefits outweigh health risks – global study