Treating preschoolers with ADHD: 90 percent of pediatric specialists not following clinical guidelines

Some prescribe medication too soon; others not even as a second-line treatment

A recent study by pediatricians from the Cohen Children's Medical Center of New York examined to what extent pediatric physicians adhere to American Academy of Pediatrics (AAP) clinical guidelines regarding pharmacotherapy in treating young patients with Attention Deficit Hyperactivity Disorder (ADHD). The results showed that more than 90 percent of medical specialists who diagnose and manage ADHD in preschoolers do not follow treatment guidelines recently published by the AAP.

"It is unclear why so many physicians who specialize in the management of ADHD -- child neurologists, psychiatrists and developmental pediatricians -- fail to comply with recently published treatment guidelines," said Andrew Adesman, MD, senior investigator and chief of developmental and behavioral pediatrics at Cohen Children's Medical Center in New Hyde Park. "With the AAP now extending its diagnosis and treatment guidelines down to preschoolers, it is likely that more young children will be diagnosed with ADHD even before entering kindergarten. Primary care physicians and pediatric specialists should recommend behavior therapy as the first line treatment."

Current clinical guidelines for pediatricians and child psychiatrists associated with the American Academy of Child & Adolescent Psychiatry (AACAP) recommend that behavior therapy be the initial treatment approach for preschoolers with ADHD, and that treatment with medication should only be pursued when counseling in behavior management is not successful.

The study also found that more than one-in-five specialists who diagnose and manage ADHD in preschoolers recommend pharmacotherapy as a first-line treatment alone or in conjunction with behavior therapy. Although the AAP recommends that pediatricians prescribe methylphenidate when medication is indicated, more than one-third of specialists who prescribe medication for preschool ADHD said they 'often' or 'very often' choose a medication other than methylphenidate initially (19.4 percent amphetamines; 18.9 percent non-stimulants).

"Although the AAP's new ADHD guidelines were developed for primary care pediatricians, it is clear that many medical subspecialists who care for young children with ADHD fail to follow recently published guidelines," said Jaeah Chung, MD, the study's principal investigator who also practices at Cohen Children's. "At a time when there are public and professional concerns about over-medication of young children with ADHD, it seems that many medical specialists are recommending medication as part of their initial treatment plan for these children."