Timing of Medication Treatment in Children 3-5-Years-old with ADHD: A PEDSnet Study
Yair Bannett1, Ingrid Luo2, Rodrigo Azuero-Dajud3
1Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
Insights
Early ADHD diagnosis in preschoolers is crucial. Many young children diagnosed with ADHD in primary care receive medication shortly after diagnosis, with variations based on race and insurance.
Area of Science:
- Pediatric Health
- Neurodevelopmental Disorders
- Clinical Practice
Background:
- Early identification and treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in preschoolers is vital for addressing social-emotional and academic challenges.
- Clinical guidelines advocate for behavioral interventions as the primary treatment for 4-5-year-olds before considering medication.
Purpose of the Study:
- To examine the rates of ADHD identification and medication prescription among children aged 3-5 years in US primary care settings.
- To analyze the timing of medication treatment following ADHD diagnosis and identify patient-specific factors influencing this timeline.
Main Methods:
- A retrospective cohort study utilizing electronic health records from eight academic pediatric health systems within the PEDSnet Clinical Research Network.
- Analysis included children aged 3-5 years between 2016-2023, focusing on those diagnosed with ADHD at ages 4-5 years.
Main Results:
- Approximately 1.4% of children aged 3-5 years received an ADHD diagnosis at ages 4-5 years, with significant institutional variation.
- 68.2% of diagnosed preschoolers were prescribed ADHD medication before age 7, and 42.2% received it within 30 days of diagnosis.
- Racial and ethnic disparities were observed, with Asian, Hispanic, and Black children less likely to receive early medication compared to White children. Older age, male sex, and public insurance were associated with earlier prescription.
Conclusions:
- A substantial proportion of preschoolers diagnosed with ADHD in primary care settings receive medication relatively soon after diagnosis.
- Significant variations in early medication prescription exist, influenced by patient demographics such as race, age, sex, and insurance status.
- Further investigation into clinical documentation is necessary to understand the rationale behind these early prescription patterns.
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 4-5-years-old.
Objective:
To 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.
Design:
Retrospective cohort study of electronic health records.
Setting:
Primary care clinics affiliated with eight academic institutions participating in the PEDSnet Clinical Research Network.
Participants:
Children 3-5-years-old seen in primary care between 2016-2023.
Exposure:
ADHD diagnosis at age 4-5 years.
Main Outcomes And Measures:
Outcomes: (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.
Results:
Of 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 Relevance:
Many 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.
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