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In A Nutshell
- 42% of preschoolers with ADHD were prescribed medication within 30 days of diagnosis, despite guidelines recommending behavioral therapy first.
- 68% received medication before age 7.
- Significant disparities: White and multiracial children, as well as those with public insurance, were more likely to receive early prescriptions.
- System barriers, such as limited therapy access, insurance constraints, and resource shortages push doctors toward medication as the default.
STANFORD, Calif. — A major new study reveals that nearly half of young children diagnosed with ADHD receive medication within just one month of diagnosis, even though pediatric guidelines recommend starting with behavioral therapy first for this age group.
The largest study of its kind examined electronic health records from more than 712,000 children seen at eight major pediatric health systems across the United States between 2016 and 2023. Among the 9,708 children who received an ADHD diagnosis between ages 4 and 5, over two-thirds were ultimately prescribed medication before turning 7.
Why Guidelines Recommend Therapy First
ADHD affects an estimated 10% of American children, and diagnoses in preschoolers are becoming more common. A 2022 national survey found that 2.4% of children aged 3 to 5 had an ADHD diagnosis.
Current American Academy of Pediatrics (AAP) guidelines, reaffirmed in 2019, recommend that children aged 4 to 5 first receive evidence-based parent training in behavior management before considering medication. Medication should be considered only if these interventions prove insufficient or if symptoms cause substantial disruption.
Yet across the eight health systems studied, between 26% and 49% of preschoolers were prescribed medication within a month of diagnosis, often leaving little or no time for behavioral treatments to take effect.
The AAP recommendations exist because preschoolers’ brains are still rapidly developing, and the evidence base for behavioral interventions is stronger in this age group than for medication. Parent training helps caregivers manage challenging behaviors, establish routines, and create structured environments that can meaningfully reduce ADHD symptoms.
For children who were prescribed medication within 30 days, there often wasn’t enough time to properly implement or assess these therapies, which typically require weeks or months to show benefit.
Racial and Insurance Disparities in ADHD Treatment
The study revealed clear disparities. Asian children with ADHD were least likely to receive early medication, with only 28.6% prescribed within 30 days, compared to 43.9% of White children. Hispanic children were at 35.8%, Black children 41.8%, and multiracial children the highest at 47.7%.
These gaps persisted two years after diagnosis. White children had prescription rates of 78.2%, while Asian children had substantially lower rates at 55.6%.
Publicly insured children were more likely to receive early prescriptions than privately insured peers. Families on Medicaid often face barriers accessing behavioral therapy, making medication the more immediate option. Prior research suggests that minority families may have greater hesitancy toward ADHD medication, but also encounter obstacles to behavioral care.
Preschool ADHD Care Varies Widely
Prescription rates varied dramatically across the eight health systems, from 44.1% to 74.1%. This suggests that treatment decisions may depend as much on geography and local resources as on clinical guidelines.
Older preschoolers were more likely to receive medication quickly. The median time to prescription was zero days for 5-year-olds, compared to nearly 400 days for 3-year-olds.
Comorbidities played a role too. Children with sleep problems or disruptive behavior disorders were more likely to get early medication. About 65% of children had a documented additional condition, such as language delays or learning difficulties.
Follow-up care was inconsistent. Only about 40% of children prescribed medication had a documented follow-up within two months, though the true number may be higher since many doctors use phone calls or secure messaging not captured in records.
A System Under Strain
The study exposes how practical realities often drive treatment. Behavioral therapies require trained providers, multiple sessions, and significant family commitment. In many communities, especially for families with public insurance, such resources are scarce.
Primary care doctors face heavy caseloads and limited access to mental health specialists. Writing a prescription takes minutes, while arranging therapy can take hours, with no guarantee that services are available.
The results don’t mean early prescriptions are always inappropriate. Some children may genuinely need immediate medication, especially with severe symptoms or multiple conditions. But the scale of early prescribing points to a startling gap between recommended best practice and what families actually experience.
Until health systems reduce barriers to behavioral interventions, many preschoolers may continue receiving medication without first having the chance to benefit from therapy — the very path pediatric guidelines were designed to encourage.
Disclaimer: This article is for informational purposes only and is not a substitute for professional medical advice. Parents should consult their child’s healthcare provider for individualized recommendations about ADHD diagnosis and treatment.
Paper Summary
Methodology
Researchers conducted a retrospective study using electronic health records from eight major pediatric health systems participating in the PEDSnet Clinical Research Network. They analyzed data from 712,478 children aged 3 to 5 years seen between 2016 and 2023, identifying 9,708 children who received an ADHD diagnosis between ages 4 and 5. The study measured rates of ADHD diagnosis, medication prescription rates, and timing from diagnosis to prescription. Researchers used statistical models to examine associations between patient characteristics (race, ethnicity, insurance type, age, sex) and treatment patterns while adjusting for factors like year of diagnosis and healthcare utilization.
Results
Among preschoolers diagnosed with ADHD, 68.2% were prescribed medication before age 7, with 42.2% receiving prescriptions within 30 days of diagnosis. Medication prescription rates varied widely across institutions (44.1% to 74.1%). Notable disparities emerged by race and ethnicity: Asian children were least likely to receive early medication (28.6% within 30 days), followed by Hispanic children (35.8%), while White children had higher rates (43.9%). Publicly insured children were more likely to receive early prescriptions than privately insured children. Only 40.5% of children prescribed medication had documented follow-up visits within 60 days.
Limitations
The study relied on diagnostic codes from electronic health records, which may not capture the complete clinical picture. Researchers couldn’t determine whether doctors recommended behavioral therapy that wasn’t accessible to families, or identify cases where early medication might have been clinically appropriate due to symptom severity. Information about actual behavioral treatment recommendations, typically documented in clinical notes rather than diagnostic codes, wasn’t available. The study also couldn’t track follow-up care provided through phone calls or secure messaging.
Funding and Disclosures
This research was supported by the Stanford Maternal and Child Health Research Institute and the National Institute of Mental Health (grant K23MH128455). Additional funding came from various National Institutes of Health grants supporting individual researchers. The study used data from PEDSnet, funded by the Patient-Centered Outcomes Research Institute. Most authors reported no conflicts of interest, though some disclosed consulting relationships and research support from pharmaceutical companies unrelated to this study.
Publication Information
This study was published in JAMA Network Open on August 29, 2025, titled “ADHD Diagnosis and Timing of Medication Initiation Among Children Aged 3 to 5 Years.” The lead author is Dr. Yair Bannett from Stanford University School of Medicine’s Division of Developmental-Behavioral Pediatrics. The research involved collaboration among multiple institutions including Children’s Hospital of Philadelphia, Cincinnati Children’s Hospital, and Texas Children’s Hospital, among others.
