More than 90% of pediatric specialists who diagnose and manage attention-deficit/hyperactivity disorder (ADHD) in preschoolers do not follow the American Academy of Pediatrics (AAP) clinical-treatment guidelines.
That’s the conclusion of researchers from the Cohen Children’s Medical Center of New York, which sent the Preschool ADHD Treatment Questionnaire to a random sample of 3,000 physicians who specialize in diagnosing and treating neurobehavioral conditions nationwide. The doctors reported on how often they recommended strategies such as training parents in behavioral management of ADHD, how often they relied on medication as a first- or second-line treatment, as well as which drugs they prescribed most often.
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In 2011, the AAP released revised guidelines for diagnosing kids with ADHD. “Those guidelines were important in that they extended down from age 6 down to age 4. For the first time pediatricians were given guidance in how to approach the management of ADHD in preschoolers,” says the study’s lead author Dr. Andrew Adesman, the chief of developmental and behavioral pediatrics at Cohen Children’s Medical Center in New Hyde Park.
Along with the expansion of the population that could be diagnosed with the condition came advice for how to treat the youngest patients. Adesman says, in general, pediatricians have been especially uncomfortable with diagnosing ADHD in very young children, so they have turned to medical specialists like child neurologists, child psychiatrists and developmental-behavior pediatricians to make the call. “When we undertook this study, we were interested in seeing what the specialists in the field were doing, since pediatricians turned to them and parents turned to them,” says Adesman. “Actually, the AAP in their guidelines specifically state that if a pediatrician is not comfortable with evaluating children — especially young children — for ADHD, then they should turn to these medical specialists.”
Currently, the AAP recommends that behavioral therapy should be the first type of treatment offered to preschoolers with ADHD, followed by medication only if the behavior interventions are unsuccessful.
However, the results of the study show that more than 1 in 5 specialists who diagnose and recommend treatment for ADHD in preschoolers recommend pharmacotherapy as a first-line treatment, either alone or with behavior therapy. These specialists are also not adhering to advice on which drugs should be used; the AAP recommends that when medication is needed, pediatricians should prescribe methylphenidate, but over one-third of specialists who medicate preschoolers for ADHD reported that they “often” or “very often” pick medication other than methylphenidate first.
Why the discrepancy? For one, say the authors, behavior management and counseling strategies are not always easily accessible to many families. And if they are available, in some cases they may be financially out of reach if insurers don’t cover services provided by professionals in the local community.
However, Adesman says when his investigators asked the doctors whether their decision to prescribe medication for first-line treatment was influenced by the availability of behavior therapy for their patients, he did not find evidence of a trend. “So as much as I would like to think that doctors are prescribing medicine first line because behavior therapy is not available, that does not seem to be the case,” he says.
It’s also possible that doctors are turning to medication because the long-term commitment that repeated behavioral-therapy sessions require may be onerous for parents. Adesman says clinicians may also be paying attention to some studies in school-age children that have shown that medicine can be more effective than behavioral therapy. Yet he argues this still does not justify its use in preschoolers. “There is an important distinction, and that is that even if medication has been shown to be more effective in the short term than behavior therapy in school-age children, medication does not work quite as well or consistently in preschool kids. So a head-to-head comparison in school-age children may not necessarily be appropriate to extrapolate down to the preschool kids,” he says.
The AAP guidelines were meant for primary-care pediatricians who may need guidance and assurance in making decisions about diagnosing and treating preschoolers with ADHD. And these physicians may indeed be following the guidelines, although the current study did not include them. “Still, certainly it would seem that pediatricians and specialists should increasingly look to behavioral interventions as a first-line treatment,” says Adesman. “I think parents also should seek at behavioral treatments as first line, and in general, medication should be reserved for cases where either behavioral therapy is not effective or where it is not available.”
The study was presented at the Pediatric Academic Societies in Washington, D.C.