Treatment Guidelines for Preschoolers With ADHD Rarely Followed

A survey of pediatric subspecialists found that 9 in 10 do not follow guidelines from the American Academy of Pediatrics for treating preschoolers with ADHD.

The “overwhelming majority” of pediatric subspecialists do not comply with guidelines for treating preschoolers with attention-deficit/hyperactivity disorder (ADHD), according to the results of a survey presented on May 4, 2013, at the Pediatric Academic Societies Annual Meeting in Washington, DC. The survey was carried out by researchers from the Cohen Children’s Medical Center of New York.

According to guidelines from the American Academy of Pediatrics (AAP), preschoolers with ADHD should be treated first with behavioral modification. If this fails, the guidelines call for using methylphenidate as a first-line medication. To determine how well these guidelines are being followed, the researchers sent a questionnaire to a random sample of 3000 US pediatric subspecialists asking how often they recommend behavioral modification training for parents, how often they recommend medication as first- or second-line treatment, and which medication type they tend to prescribe first.

The researchers received 714 surveys and limited their analysis to 560 board certified subspecialists who diagnose ADHD in preschoolers. These included 322 developmental-behavioral pediatricians, 170 child psychiatrists, and 68 child neurologists. Among those included in the analysis, 21% said they use medication as a first-line treatment often or very often, and 69.5% said they use medication as a second-line treatment often or very often. (Local availability of behavioral modification therapy was not associated with the decision whether to use medication as a first-line treatment.)

Among those who said they prescribe medication for preschoolers with ADHD, 38.3% said they generally prescribe an initial medication other than methylphenidate—19.4% prescribe amphetamines and 18.9% prescribe non-stimulants. However, 90.7% of those in the analysis said they recommend behavioral modification often or very often, even when there is limited local availability. There were no variations by subspecialty in terms of whether to initiate medication or medication selection.

With adherence to AAP guidelines defined as initial treatment with behavioral modification and pharmacotherapy with methylphenidate in particular as second-line treatment, the survey found that just 12% of child psychiatrists, 8% of developmental-behavioral pediatricians, and 9% of child neurologists were in compliance.