Timing of Medication Treatment in Children 3-5-Years-old with ADHD: A PEDSnet Study

ImportanceEarly 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 4-5-years-old. ObjectiveTo assess variation in rates of ADHD identification and rates and timing of medication treatment in children 3-5-years-old in primary care settings across eight US pediatric health systems and to identify patient factors associated with the time from diagnosis to prescription. DesignRetrospective cohort study of electronic health records. SettingPrimary care clinics affiliated with eight academic institutions participating in the PEDSnet Clinical Research Network. ParticipantsChildren 3-5-years-old seen in primary care between 2016-2023. ExposureADHD diagnosis at age 4-5 years. Main Outcomes and MeasuresOutcomes: (1) rate of ADHD diagnosis; (2) rate of stimulant and non-stimulant prescription after diagnosis before age 7, (3) time from first ADHD-related diagnosis (including symptom-level diagnoses) to medication prescription. Independent variables: institution, year of diagnosis, patient age, sex, race/ethnicity, medical insurance, and presence of comorbidities. ResultsOf 712,478 children seen in primary care at ages 3-5 years, 9,708 (1.4%) received an ADHD diagnosis at age 4-5 years (range 0.5-3.1% across institutions). Of those with ADHD, 76.4% (n=7414) were male, 39.0% (n=3782) were White. Of 9,708 preschool-age children with ADHD, 68.2% (6624) were prescribed ADHD medications before age 7, 42.2% (n=4092) were prescribed medications within 30 days of the first documentation of an ADHD-related diagnosis (range 26.0-49.0% across institution). Asian (aHR 0.50, CI 0.38-0.65), Hispanic (aHR 0.75, CI 0.70-0.81), and Black (aHR 0.90, CI 0.85-0.96) children with ADHD were less likely to be prescribed medication early compared to White children. Older (aHR 1.64, CI 1.57-1.72), male (aHR 1.74, CI 1.11-1.24) and publicly insured (aHR 1.10, CI 1.04-1.17) patients were more likely to be prescribed medication early compared to younger, female and privately insured patients, respectively. Conclusion and RelevanceMany preschool-age children with ADHD seen in primary care in 8 large pediatric health systems were prescribed medications at or shortly after the first documented diagnosis. Future analysis of clinical documentation is needed to understand the reasoning behind early prescription patterns.