Why Meds Aren’t the Gold Standard for Helping Kids With ADHD

In 2011 and 2019, the American Academy of Pediatrics (AAP) published clinical guidelines that recommended parent training in behavior management (PTBM) as the first-line treatment for preschool-aged children with attention-deficit/hyperactivity disorder (ADHD).

A new first-of-its-kind study (Bannett et al., 2021) by a team of researchers at Stanford University analyzed electronic health records from a community-based pediatric health care network in San Francisco, California.

This study's objective was to assess how many primary care professionals and pediatricians actually recommend PTBM as a first-line treatment for 4- to 5-year-olds who'd received an ADHD diagnosis or displayed symptoms of hyperactivity or impulsivity. These peer-reviewed findings were published on October 18 in JAMA Pediatrics.

PTBM Therapy Is the Gold Standard for Treating Kids' ADHD

Of 22,714 children in this large cohort study, only about 192 (1%) were given an ADHD diagnosis or had ADHD symptoms. Of these patients, 141 (73%) were male and 32 (17%) were prescribed ADHD medications such as methylphenidate (i.e., Concerta, Ritalin LA). Stimulants comprised 88% of these prescriptions. Only 21 (11%) of these 192 patients received referrals for PTBM therapy during their ADHD-related clinical visits.

"The most common [behavioral therapy] treatment recommendation was not PTBM but rather routine/habit modifications—including dietary modifications (e.g., reduced sugar intake) and supplements (e.g., ω-3 fatty acids), sleep hygiene, and limited screen time—for 79 patients (41%)," the authors explain.

Interestingly, using multivariable logistic regression models, Bannett et al. found that ADHD patients with public insurance were less likely to receive a PTBM recommendation when compared to those who had private insurance (Table 2). The authors sum up their findings:

"The results of this cohort study suggest that within a large community-based health care network, most preschool-aged children with primary care professional (PCP) diagnosed ADHD or ADHD symptoms were not offered first-line, evidence-based behavioral treatment. Rates of PTBM recommendation were especially low among publicly insured patients, underscoring the need to identify barriers that drive disparities in recommended treatments."

PTBM Is Only Recommended to 11% of Kids With a Recent ADHD Diagnosis

According to an October 2021 news release about this study: "More preschoolers were prescribed ADHD medications than were referred for PTBM therapy, even though AAP guidelines say drugs should be considered only if behavior therapy doesn't provide significant improvement."

"The reason [PTBM] is recommended is based on evidence. There's more evidence for its effectiveness when we compare it to medications," first author Yair Bannett, an instructor of developmental-behavioral pediatrics at Stanford University School of Medicine, noted.

"Really, there is more need for training on this topic, for providing available resources for pediatricians. A lot of times they're just not aware of what's available for each community, for each child with a specific insurance coverage. It just gets pretty complicated," he added.

Medication Is a Quick Fix, but Pills Don't Give Us Real-World Skills

Training parents to help their kids with ADHD may be more time-consuming than the quick fix of prescribing a pill, but in the long run, parent training in behavior management is widely considered the best first-line treatment.

"Americans want an instant fix. They don't want to spend the time with behavior management strategies. Some people, they say 'give me a pill and make it better,'" Max Wiznitzer, co-chair of the professional advisory board for CHADD, an ADHD patient advocacy group, said in the news release.

In Wiznitzer's opinion, ADHD drugs shouldn't be prescribed to preschoolers by a pediatrician but rather by behavioral specialists for kids that age.

"If these kids end up with a specialist who has determined that even at that young age they've got ADHD, then judicious use of medication in conjunction with the behavioral programming may be appropriate," Wiznitzer said in the news release. "I do not want a general pediatrician to do that for fear they might misdiagnose."

For example, if someone with a generalized anxiety disorder is misdiagnosed with ADHD and given a stimulant, it could exacerbate their anxiousness or trigger panic attacks.

"[With PTBM] you're providing both the parents and the child with skills that are going to be long-lasting and really have an actual effect on how the child and the parents manage in the real world," Bannett concluded. "The medication route is very effective and does reduce some of the symptoms, but it is in a way a temporary fix. It's not really giving the child or the parents any skills moving forward."