A recent study by the U.S. Centers for Disease Control (CDC) found that in 2015, 75 percent of children aged two to five years with a diagnosis of Attention Deficit-Hyperactivity Disorder (ADHD) were receiving medication-based treatment, and only 50 percent received some form of behavioral therapy. This was true regardless of insurance type; that is, it was equally true for children covered by Medicaid as it was for children on private insurance.
The study raises concerns on many levels.
The data on treating older children are fairly clear regarding the benefits and risks of medication treatment for ADHD. The landmark trial showed better outcomes in those treated with medication and behavioral therapy as opposed to behavioral therapy alone, and side effects were infrequent and readily manageable or reversible. Similar high-quality, multi-center, blinded scientific studies in younger children have not been done.
A child’s brain undergoes significant and rapid changes between the ages of two and five years. Considering this, and the possibility that medications which alter neurotransmitters may have different effects at different ages, providers should be cautious about going straight to medication. Given the chronic nature of ADHD treatment, one cannot simply assume that what is safe and effective at an older age is safe and effective at a young age, because there is the added potential of cumulative effects on a developing brain.
Moreover, major organizations involved in the health of children, including the American Academy of Pediatrics (AAP) and the CDC, strongly suggest behavioral therapy should be the first line of treatment for younger children. Behavioral therapy for ADHD often includes the techniques of Cognitive Behavioral Therapy (CBT). CBT employs various means of supporting and encouraging the development of desired behaviors, and helping children learn to control less desirable behaviors.
Overcoming the obstacles: Beyond insurance
Across the spectrum of health insurance policies, behavioral therapy is not covered as much as medication-based therapies, which may be driving the apparent physician preference for the latter.
But the CDC authors also note a troublesome shortage of well-trained therapists who can work with younger children showing signs and symptoms of ADHD.
In some ways, this may be a self-fulfilling set of circumstances — if behavioral therapy is not well-covered or compensated by insurance carriers, there will be little incentive for more people to train in this field, and also little incentive for those already trained to take on the care of younger children.
The CDC report also emphasizes that there is room for improvement in our approach to diagnosing ADHD. No lab test can accurately diagnose the condition; it is up to the clinician’s individual skill.
Providers should use well-established and validated tools that can assist in medical diagnosis and treatment decision-making, such as the AAP ADHD Tool Kit. Boston Children’s Hospital also has a collaborative working group from the Developmental Medicine Center, the Department of Neurology and the Department of Psychiatry that is developing decision-support tools specific to various clinical settings with children suspected of having ADHD.
Clinicians must advocate on behalf of their patients and families. Since there is no literature clearly proving the safety and efficacy of medication as treatment for younger children with ADHD, clinicians should follow the current practice guideline from both the AAP and the CDC and use behavioral therapy as the first line of treatment.
David K. Urion, M.D., FAAN, is the director of Behavioral Neurology Clinics and Programs in the Department of Neurology, where he has served for 35 years. He has a large clinical practice and cares for many children with ADHD.
Learn more about the Department of Neurology