Preschoolers with attention deficit hyperactivity disorder (ADHD) rarely receive the gold-standard treatment recommended by the American Academy of Pediatrics (AAP) for their condition, a new study reports.
The AAP recommends a behavioral therapy technique called "parent training in behavior management," or PTBM, as first-line treatment for ADHD kids ages 4 and 5.
But only 1 of every 10 children in that age group with an ADHD diagnosis or ADHD-like symptoms actually receive a referral for PTBM therapy, according to findings published online Oct. 18 in the journal JAMA Pediatrics.
Instead, parents often are given general advice that wouldn't be out of place in any well-child visit -- cut back on sugar, establish good sleep habits and limit screen time.
In fact, 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," said lead researcher Dr. Yair Bannett, an instructor of developmental-behavioral pediatrics at Stanford University School of Medicine.
PTBM therapy focuses on parents, rather than their child with ADHD.
Parents undergo training that teaches them skills and strategies in positive reinforcement, structure and consistent discipline, as well as positive ways to interact and communicate with their child, according to the U.S. Centers for Disease Control and Prevention.
"You're providing both the parents and the child with skills that are going to be long-lasting and really have an actual effect how the child and the parents manage in the real world," Bannett said.
Train the parent to help the child
"On the other hand, the medication route is very effective and does reduce some of the symptoms, but it is in a way a temporary fix," Bannett continued. "It's not really giving the child or the parents any skills moving forward."
The point of PTBM therapy "is that little kids learn better from positive reinforcement than from punishment," said Dr. Max Wiznitzer, co-chair of the professional advisory board for CHADD, an ADHD patient advocacy group. "If we encourage the behavior we want them to do, the unwanted behavior tends to fade."
For this study, Bannett and his colleagues reviewed medical records for more than 22,700 4- and 5-year-olds treated by primary care doctors with the Packard Children's Health Alliance, a pediatric care network in the San Francisco area. Of those kids, about 1% (192) had an ADHD diagnosis or symptoms.
About 41% of the time, parents of a child with signs of ADHD were given routine advice involving diet, sleep and screen time, researchers found.
"We're happy these healthy habits are recommended, but on the other hand there really is no evidence they alleviate any of the symptoms of ADHD that we're talking about," Bannett said.
Only 21 kids received a referral for PTBM therapy, while 32 were prescribed ADHD medications.
Many pediatricians likely don't know enough about PTBM to offer it as a treatment option, Bannett said.
"Really, there is more need for training on this topic, for providing available resources for pediatricians," Bannett said. "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."
Many docs may not know about parent therapy
Kids with ADHD were about 13% less likely to be referred for PTBM if they were covered by Medicaid as opposed to private insurance, the study found.
Even if the doctor knows about PTBM therapy, there's still a good chance such training isn't easily available to parents, Wiznitzer added.
"The behavioral therapy resources, they're not as available as we'd like them to be," Wiznitzer said. "To me, that's the rate-limiting step -- getting someone who really knows how to work with a preschooler like this and can help them. It's better now, but there are still backlogs. There are waiting lists."
Finally, PTBM involves a lot of work on the part of parents, and some just aren't up for the challenge, Bannett and Wiznitzer said.
"Sometimes families do feel like this is too much work, they're not able to handle this with their daily schedule, it's a little bit too much," Bannett said. "It's in a way sometimes easier to give a medication to a child than learning these skills and practicing these type of parenting skills that are more demanding."
"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," Wiznitzer said.
Medication can be a good option for preschoolers with ADHD, but they need to be prescribed judiciously, Wiznitzer said. These young and developing brains are more susceptible to side effects from the drugs, and it can be hard to find the appropriate dose.
ADHD drugs should only be prescribed by behavioral specialists for kids that age, and not by pediatricians, in Wiznitzer's opinion.
"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. "I do not want a general pediatrician to do that for fear they might misdiagnose."
Wiznitzer gave the example of a child who appears to have ADHD symptoms but actually is suffering from anxiety.
"You put them on a stimulant, all you do is aggravate the anxiety disorder," Wiznitzer said.
The U.S. Centers for Disease Control and Prevention has more about parent training in behavior management.
SOURCES: Yair Bannett, MD, instructor, developmental-behavioral pediatrics, Stanford University School of Medicine, California; Max Wiznitzer, MD, co-chair, professional advisory board, CHADD; JAMA Pediatrics, Oct. 18, 2021, online