A new multisite US study, published in JAMA Network Open (Bannett et al., 2025), caught my attention this week. It looked at more than 700,000 children aged 3 to 5. The study asked a simple but pressing question: how often are very young children diagnosed with ADHD, and how quickly are they started on medication? Earlier research showed that 1 out of 9 children in the US gets this diagnosis.

What the guidelines say

The guidelines are clear. For children aged 4–5, the American Academy of Paediatrics recommends that physicians first try behavioural parent training before considering medication. Methylphenidate may be appropriate, but only when symptoms are severe or behavioural approaches fail. Reality, however, looks quite different.

What the study found

The study found that of the nearly 10,000 preschoolers diagnosed with ADHD, more than two-thirds received medication before age 7. Strikingly, 42% were prescribed within 30 days of their first documented diagnosis. That’s not much time for any meaningful behavioural intervention. In fact, many children were on medication at or almost immediately after diagnosis.

The variation between institutions was considerable (from 44% to 74% medicated), and the disparities by race and ethnicity were equally telling. White children and those with public insurance were more likely to receive early prescriptions. Asian, Hispanic, and Black children were less likely to start medication quickly. This raises familiar but uncomfortable questions about inequities in healthcare access and attitudes toward ADHD treatment.

The bigger picture

What does this mean in practice? On the one hand, clinicians and parents are often working under intense pressure: families struggle, schools demand quick solutions, and access to evidence-based behavioural interventions is patchy at best. In such contexts, a prescription can feel like the only available option. On the other hand, the speed and scale of early prescribing suggest that guidelines are not being effectively translated into practice. This indicates that the barriers to nonpharmacological care are substantial.

Why it matters

We should be cautious not to frame this as a simple story of over- or under-medication. For some children, early treatment might indeed be necessary and beneficial. But when nearly half of preschoolers with ADHD receive medication within a month of diagnosis, it tells us something about systemic gaps. There is a lack of time, resources, and access to behavioural support for families.

The authors call for

• A deeper analysis of clinical notes,
• What recommendations are actually given,
• How severe the symptoms are,
• And what options are available to families.

Until then, this study serves as a reminder: guidelines can be excellent on paper, but the realities of primary care, insurance systems, and family circumstances often render them ineffective.

Abstract of the study:

Importance  Early identification and treatment of attention-deficit/hyperactivity disorder (ADHD) symptoms in preschool-age children is important for mitigating social, emotional, and academic problems. Clinical practice guidelines recommend first-line behavior intervention before considering medication treatment for children aged 4 to 5 years.

Objective  To assess variation in rates of ADHD identification and rates and timing of medication initiation in children aged 3 to 5 years in primary care settings across 8 US pediatric health systems and to identify patient factors associated with the time from diagnosis to prescription.

Design, Setting, and Participants  This retrospective cohort study used electronic health records from primary care clinics affiliated with 8 academic institutions participating in the PEDSnet Clinical Research Network. Participants were children aged 3 to 5 years seen between 2016 to 2023. Data were extracted from the PEDSnet database on April 18, 2025.

Exposure  ADHD diagnosis at age 4 to 5 years.

Main Outcomes and Measures  The primary outcomes were (1) rate of ADHD diagnosis, (2) rate of stimulant and nonstimulant prescription after diagnosis before age 7 years, and (3) time from first ADHD-related diagnosis (including symptom-level diagnoses) to medication prescription. Independent variables included institution, year of diagnosis, patient age, sex, race and ethnicity, medical insurance, and presence of comorbidities. Multivariable Cox proportional hazards models were used to estimate associations between clinical and demographic variables and time from diagnosis to prescription.

Results  Of 712 478 children seen in primary care at age 3 to 5 years, 9708 (1.4%) received an ADHD diagnosis at age 4 to 5 years (range across institutions, 0.5%-3.1%; median [IQR] age at first ADHD-related diagnosis, 5.31 [4.86-5.66] years). Of those with ADHD, 7414 (76.4%) were male, 1762 (18.1%) were Hispanic, 122 (1.3%) were non-Hispanic Asian, 3014 (31.0%) were non-Hispanic Black, 479 (4.9%) were non-Hispanic multiracial, 3782 (39.0%) were non-Hispanic White, 148 (1.5%) were non-Hispanic other, and 401 (4.1%) were of unknown race and ethnicity. Of 9708 preschool-age children with ADHD, 6624 (68.2%) were prescribed ADHD medications before age 7 years, and 4092 (42.2%) were prescribed medications within 30 days of the first documentation of an ADHD-related diagnosis (range across institutions, 26.0%-49.0%). Asian (adjusted hazard ratio [aHR], 0.51; 95% CI, 0.38-0.68), Hispanic (aHR, 0.75; 95% CI, 0.70-0.81), and Black (aHR, 0.88; 95% CI, 0.83-0.94) children with ADHD were less likely to be prescribed medication early compared with White children. Older vs younger patients (aHR, 1.62; 95% CI, 1.55-1.69), male vs female patients (aHR, 1.17; 95% CI, 1.11-1.25), and publicly insured vs privately insured patients (aHR, 1.09; 95% CI, 1.03-1.15) were more likely to be prescribed medication early.

Conclusion and Relevance  In this retrospective cohort study of preschool-age children with ADHD seen in primary care in 8 large pediatric health systems, many children were prescribed medications at or shortly after the first documented diagnosis. Analysis of clinical documentation is needed to understand early prescription patterns.

Image: https://commons.wikimedia.org/wiki/File:ADHD_Thought_Bubble.svg