Pediatrician Russell Saunders asks us to imagine two children with similar behaviors and different diagnoses:

Both of them are little bundles of seemingly ceaseless energy. When they come for medical appointments, both of them are constantly getting into things around my exam room. Both have nerve-wracked parents who tell them to sit still every 30 seconds, to no avail. At the end of their visits, I feel a little tired and nerve-wracked myself.

One of these children has attention deficit hyperactivity disorder (ADHD). The other is a normal toddler.

Know how to tell them apart? Me neither.

The difficulty is that behaviors that would indicate ADHD in a 9-year-old are completely normal in a 2-year-old.


A recent report from the CDC finds that at least 10,000 American children under the age of four are receiving prescriptions for stimulant medications to treat attention deficit and hyperactivity disorder (A.D.H.D.).  The report also states that a majority of families whose children receive these prescriptions receive health insurance through Medicaid.

Through its clinical practice guidelines, the American Academy of Pediatrics (AAP) makes it clear that the under-four age group is too young to establish a diagnosis of A.D.H.D.:

The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.


For a child to be diagnosed with A.D.H.D., according to the AAP guidelines, there needs to be “documentation of impairment in more than 1 major setting.”  Pediatricians rely on reports from parents and teachers, therapists and other providers, report cards and progress reports, as well as regular well-child checkups evaluating each child’s overall growth and development, physical and emotional health, and family involvement and support.  Because A.D.H.D. can include co-existing learning disabilities and behavioral and emotional issues, other evaluations from school psychologists and neuropsychologists (especially to establish a diagnosis of learning disability), private psychologists, pediatric psychiatrists, developmental pediatricians, and therapists are often added to provide more context as to why a child might be bombing in school, or whether they may also have anxiety and/or depression, oppositional/defiant or conduct disorders, or significant and sometimes-dangerous-always-disruptive impulsivity behaviors.  Finally, reports may also be requested from pediatric physicians such as allergists/asthma specialists, endocrinologists, cardiologists, neurologists, and ENT’s regarding a child’s chronic medical conditions (asthma, diabetes, congenital heart disease, epilepsy, and chronic snoring are some examples for the specialists listed).  Even though children seem to be entering day care and preschool programs at earlier ages (creating the second “major setting”, with the home environment as the first), one would think it would take time — at least four years — to amass and analyze all the other data required for a pediatrician to make an informed diagnosis of A.D.H.D.

Dr. Saunders is “appalled” at the findings that young children — especially poor children —  are being prescribed A.D.H.D. medications at such an early age, and he’s not in a forgiving mood:

We owe it to our young and vulnerable patients to use these medications sparingly and judiciously. Anytime there is evidence that drugs are being given to children when they ought not to be, I am given a depressing reminder of how common substandard care is. That the numbers in the CDC report were derived from Medicaid records indicates how often this substandard care hits those who are already suffering from a lack of resources. I am saddened but not shocked to learn that parents on the financial margins would be stuck with medical providers who don’t know what they’re doing.

Let us hope that this report will generate enough attention that physicians who are doling out Adderall to inappropriately young patients will revise their practices. Every child deserves a medical provider who knows what comprises normal behavior and who doesn’t try to medicate it away.

And parents who come to the end of their ropes shouldn’t find a prescription bottle tied there.


Read the AAP’s Clinical Practice Guidelines for A.D.H.D. here.

More PediaBlog on A.D.H.D. here.