What’s the Hurry to Treat ADHD?

Source: Bannett Y, Luo I, Azuero-Dajud R, et al. ADHD diagnosis and timing of medication initiation among children aged 3 to 5 years. JAMA Netw Open. 2025;8;(8):e2529610; doi: 10.1001/jamanetworkopen.2025.29610.Investigators from multiple institutions conducted a retrospective study to evaluate rates of diagnosis of attention-deficit/hyperactivity disorder (ADHD) in children 3–5 years old in primary care clinics and rates and timing of use of stimulant and non-stimulant medication in these children. For the study, they reviewed electronic health record (EHR) data of patients 3–5 years old, seen in primary care clinics affiliated with 8 large medical centers in the US between 2016 and 2023. Specific diagnosis codes were used to identify patients with ADHD, and variation in rates of diagnosis across different health care systems were calculated. Rates of stimulant and non-stimulant medication prescriptions for ADHD before the age of 7 years in these children were determined. The timing from first diagnosis of ADHD to first medication prescription also was evaluated and categorized as 0–30 days, 1–6 months, or >6 months after diagnosis. Cox proportional hazards model regression was used to assess the association between specific demographic characteristics and early (0–30 days) medication prescription for children diagnosed with ADHD. The association between behavioral comorbid conditions and medication prescription also was evaluated.Among a total of 712,478 children 3–5 years old seen at the primary care sites, 9,708 (1.4%) had a diagnosis of ADHD. The median age of first diagnosis of ADHD was 5.31 years, and 76.4% of patients were male. Rates of ADHD diagnosis varied from 0.5% to 3.1% across the 8 health care systems. ADHD medications were prescribed to 6,624 children (68.2%), including 5,131 prescribed stimulant medications (77.5%), 1,108 prescribed non-stimulants (16.7%), and 385 prescribed both (5.8%). Overall, 4,092 (42.2%) patients diagnosed with ADHD when they were 3–5 years old were prescribed medications within 30 days of diagnosis. The median time from diagnosis to first medication prescription was 390.5 days for children 3 years old, 28.0 for those 4 years old, and 0 days for 5-year-olds. In the multivariate model that included multiple covariates, compared to non-Hispanic White children, those who were Asian (adjusted hazard ratio [aHR], 0.51; 95% confidence interval [CI], 0.38, 0.68), Hispanic (aHR, 0.75; 95% CI, 0.70, 0.81), or Black (aHR, 0.88; 95% CI, 0.83, 0.94) were significantly less likely to be prescribed medications within 30 days of initial ADHD diagnosis. Older (vs younger) patients, males, and publicly insured (vs privately insured) children were significantly more likely to be prescribed medications within 30 days. Behavioral comorbid conditions associated with early prescription of ADHD medication included sleep problems (aHR, 1.23; 95% CI, 1.16, 1.31) and disruptive behavioral disorders (aHR, 1.21; 95% CI, 1.14, 1.29).The authors conclude that children diagnosed with ADHD when they were 3–5 years old were frequently prescribed ADHD medications within 30 days of diagnosis.Dr Badawi has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Pediatric guidelines for treatment of ADHD in children younger than 6 years consistently recommend parent training in behavioral management and environmental accommodations prior to initiation of medication.1,2 Children younger than 4 years presenting with symptoms of ADHD represent a complex population, based on the Society for Developmental and Behavioral Pediatrics ADHD treatment guidelines.2 In keeping with these guidelines, the current authors found only 5% of children were diagnosed at younger than 4 years of age, and these children did not begin medication for at least a year after diagnosis.The current study finding that many 4-year-olds began medication before the recommended 6-month trial of behavioral intervention is not surprising. Previous work has documented the limited and very variable receipt of behavioral therapy for preschool children with ADHD.3 There are multiple barriers to receipt of such therapy, including availability of in-network providers who see young children, parent work schedules, and transportation. Research is needed to identify how to make parent training in behavioral management accessible in a timely manner to all parents.The current authors found that non-Hispanic White children were more likely to receive medication prescriptions within 30 days of diagnosis than children of other races/ethnicities. More research clearly is needed to identify reasons for this difference, though trust in the pediatric provider may be relevant.4 Children with comorbid sleep and disruptive behavioral concerns were more likely to receive prescriptions shortly after diagnosis. Sleep problems can be exhausting for families and result in desperate pleas for rapid intervention. Disruptive behaviors often threaten day care and preschool placement.Guidelines for management of preschool ADHD are not being followed consistently; many children are prescribed medications shortly after diagnosis. (See AAP Grand Rounds. 2025;53[3]:30.)5