Although the American Academy of Pediatrics clinical practice guidelines recommend parent training in behavior management as first-line therapy for preschoolers with attention-deficit/hyperactivity disorder, many children in primary care began pharmacologic treatment shortly after the first ADHD-related diagnosis (including symptom-level codes), according to a recent study.
The multisite cohort study by Yair Bannett, MD, MS, Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, and colleagues analyzed 712,478 children aged 3 to 5 years in US primary care. Of these, 1% were diagnosed with ADHD at ages 4 to 5 years, with prevalence ranging from 0.5% to 3% across health systems. Among diagnosed children, 68% were prescribed medication before age 7 years, and 42% initiated treatment within 30 days of the first ADHD-related diagnosis. Median age at first ADHD-related diagnosis was 5.31 years. Stimulants accounted for 78% of initial prescriptions, nonstimulants for 17%, and both for 6%.
The retrospective analysis used 2016–2023 electronic health record data from eight pediatric health systems in the PEDSnet network, requiring at least two visits and six months of follow-up. ADHD-related encounters included disorder-level and symptom-level diagnoses. Cox proportional hazards models, adjusted for year of diagnosis, primary care utilization, institution, initial diagnosis type, and comorbidities, assessed associations between demographics and time to first prescription.
Variation and disparities in prescribing were observed. Compared with non-Hispanic White children, Asian (aHR, 0.51), Hispanic (aHR, 0.75), and Black (aHR, 0.88) children were less likely to receive medication within 30 days. Early prescribing was more likely among older patients (aHR, 1.62), males (aHR, 1.17), and publicly insured children (aHR, 1.09). Comorbidities were documented in 65% of cases, including language delay/disorder (33%), sleep problems (19%), and disruptive behavior disorders (19%). Among medicated patients, 40% had an ADHD-related follow-up within 60 days.
In sensitivity analyses, early prescription rates decreased to 28% when nonspecific behavioral concerns were included as the first encounter. Children with symptom-level initial diagnoses were less likely to receive rapid treatment (23% vs 48% for disorder-level diagnoses).
Limitations included reliance on diagnostic codes, absence of documentation on behavioral therapy recommendations, and possible misclassification of prescriptions written for sleep or behavioral concerns. Bannett and colleagues suggested future studies use natural language processing of clinical notes to capture behavioral treatment recommendations, prescribing rationale, and subspecialist involvement.
Full disclosures can be found in the published study.
Source: JAMA Network Open