Despite clear medical guidelines urging behavioral therapy as the first step in treating preschoolers with attention deficit hyperactivity disorder (ADHD), a new study reveals that most children in the United States are prescribed stimulant medications almost immediately after diagnosis.

The American Academy of Pediatrics (AAP) recommends that children between the ages of 3 and 5 begin with six months of behavioral therapy before doctors consider medication. But researchers at Stanford Medicine found that this guideline was followed in only 14.1% of cases.

“We found that many young children are being prescribed medications very soon after their diagnosis of ADHD is documented,” said lead author Dr. Yair Bannett, assistant professor of pediatrics at Stanford Medicine. “That’s concerning, because we know starting ADHD treatment with a behavioral approach is beneficial; it has a big positive effect on the child as well as on the family.”

The findings, published August 29 in JAMA Network Open, tracked more than 9,700 preschoolers diagnosed with ADHD across eight academic medical centers. Within a month of diagnosis, more than 42% had already received a prescription for medications such as Adderall or Ritalin—drugs that come with higher risks for younger children, since their bodies metabolize them less efficiently.

While these medications can be effective, the side effects—including aggression and irritability—often discourage families from continuing treatment. “We don’t have concerns about the toxicity of the medications for 4- and 5-year-olds, but we do know that there is a high likelihood of treatment failure, because many families decide the side effects outweigh the benefits,” Bannett explained.

Behavioral therapy, on the other hand, focuses on building positive routines, strengthening parent-child relationships, and rewarding good behaviors while ignoring bad ones. Known as “parent training in behavior management,” it equips children with coping tools—like visual schedules—that align with how their brains function.

Yet, access to behavioral therapy remains a major barrier. In many communities, trained therapists are scarce, and insurance coverage is inconsistent. As a result, physicians may feel compelled to prescribe medication as the only immediate option.

“Doctors tell us, ‘We don’t have anywhere to send these families for behavioral management training, so, weighing the benefits and risks, we think it’s better to give medication than not to offer any treatment at all,’” Bannett said.

He noted, however, that parents can access online resources to learn the fundamentals of behavioral therapy, with pediatricians guiding them toward reliable tools. Ideally, Bannett said, a combined approach works best as children grow older.

“For kids 6 and above, the recommendation is both treatments, because behavioral therapy teaches the child and family long-term skills that will help them in life. Medication will not do that, so we never think of medication as the only solution.”

Early diagnosis, experts emphasize, remains critical. Children with untreated ADHD are at higher risk of academic struggles and school dropout. Guideline-led treatment, Bannett said, can make a lasting difference—not only boosting grades and social relationships but also improving long-term prospects into adulthood.