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Today, we’re tackling a big question: How young is too young to treat children with medication for ADHD?
Published On: 05/12/2025
Duration: 14 minutes, 36 seconds
Transcript:
MARA GOVERMAN: Today, we're tackling a big question: How young is too young to treat children with medication for ADHD?
JOSH FEDER: I'm Dr. Josh Feder, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Factbook for Psychiatric Practice, second edition 2023, and our other book, Prescribing Psychotropics.
MARA GOVERMAN: And I'm Mara Goverman, a licensed Clinical Social Worker in Southern California, with a private practice, and an avid reader of the Carlat Psychiatry Reports. ADHD in preschoolers is a hot topic, and in our practice, we see the struggle parents face when non-pharmacological strategies aren't enough.
JOSH FEDER: Absolutely, Mara. ADHD medications are FDA-approved for marketing to kids as young as three, but guidelines still recommend starting with non-pharmacological interventions, and when that doesn't work, many parents and providers hesitate before turning to stimulants.
MARA GOVERMAN: Right, and that caution makes a lot of sense. Current research also helps to paint a better picture of these interactions. A recent meta-analysis that looked at nine clinical trials with over 500 kids under seven showed that stimulants had a medium to large effect size on parent and teacher ADHD ratings, but only a small effect on inattention.
JOSH FEDER: Let's look at that distinction.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Hyperactivity and impulsivity seem to improve more than inattention, but this is what concerns me. The neuropsychological tests showed no improvement with stimulants, and that makes me wonder if the medication is just kind of masking outward behaviors rather than addressing underlying challenges, whether it's cognitive or sensory motor, or all those different things that we think about when we're trying to help these kids. So, for instance, I've got a little kid who I've been seeing fairly recently, and of course, off the walls, right? I mean, just bouncing around, and we try to think, okay, so what is it that's creating these difficulties? And if you haven't heard it yet. I did an interview with Dr. Jeff Rowe.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Where we were unpacking all these different things that happen in little kids and trying to figure out, well, what is it that makes them have these surface behavioral symptoms? And it could be all kinds of things, and if you go back to our biopsychosocial model, right? I like to reverse and say social psycho bio, because I think the social things are sometimes the biggest things you think about what's happening in the family. What disruptions have occurred? Is there something else that is happening, like at school, that may be upsetting the child, you know, who knows. Right? And then psychologically, how does this child perceive and understand the world, right?
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: I mean, how do they think about things? And there certainly can be the basic distractibility of ADHD that makes it so that they're not sure always what's going on around them. Their internal level of arousal is heightened. They will often misperceive even neutral kinds of things as threatening. So a kid comes up to them to play and they may react in some fashion, runoff or, or even become angry, because they're not reading the reality of the situation itself, and you know, yada, yada, yada, there's much more about that, and also connected to the fact that kids with ADHD are often doing things for which the people around them are saying, No, you're wrong. You're wrong. So, part of that's the social part, but part of that is in the ages where you're trying to develop your sense of self and self-esteem. You end up feeling pretty badly about yourself. Okay, and then the biological part. Yeah, yeah, yeah. You know, we can talk about prefrontal cortex not developed very much at all at those ages.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: That's right. But we also need to think about sensory-motor function.
MARA GOVERMAN: Sensory motor function, and processing, right?
JOSH FEDER: Yeah, yeah, yeah. So, you could have a kid who's, you know, maybe very sensitive to the temperature in the room.
MARA GOVERMAN: Or to the light, or by the window, or not in front of the teacher.
JOSH FEDER: And sounds. Oh, and their tummies. Right? So, they're internal interceptive sensations. They may be reacting to those. So, you just have to unpack all that. And you mentioned processing, so we talked a little bit about misreading cues.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: But also, just sometimes, the slower processing of the things around them. So, back to the teacher. The teacher says, What's the answer, Johnny? And Johnny's like, Uh, it takes Johnny time. Teacher isn't waiting, moves on to somebody else, and it's a fail for Johnny, who feels bad about it, they may react.
MARA GOVERMAN: It's a vicious cycle.
JOSH FEDER: Right. So, there's all these things that could be involved, and coming back to where we started, which was if medication is just making someone slow down and not addressing all those underlying challenges, well, what are we really doing for the child and the family?
MARA GOVERMAN: As well as wouldn't it be great if you can get someone to go in and visit the classroom and see what it's like for the child and teaching methodology, and whether it's a match? And let's talk about the side effects of medication at this age group. The study found decreased appetite as the main adverse effect. It didn't show increased irritability, sleep issues, or anxiety. Still, the longest trial lasted only six weeks. That's not long enough to assess long-term effects like growth suppression, which we see in the preschool ADHD treatment study.
JOSH FEDER: Exactly, over a period of three years, the famous PAT study found significant reductions in growth and weight gain with stimulant use in children. Plus, the symptom improvement wasn't as strong as what we'd hoped for. Right, and that's why I'm cautious. If we do start a preschooler on medication, we need to monitor them closely using growth charts and vital signs and symptom changes, and looking at sleep and appetite, and ticks, and you know, all the other side effects.
MARA GOVERMAN: As well as supporting the parents and extended family, because it's really uncomfortable when your child is not eating.
JOSH FEDER: Oh, my goodness, right? I mean, the care of kids who have ADHD who are young is comprehensive care. I mean, think about it. Most of what we do in mental health is chronic care, like people have these things that are gonna be with them for a very long time, and that includes monitoring medications and growth, and working really closely,
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: With parents to help manage some of those concerns. So, part of it is helping parents to feel more comfortable and competent in working with their children to help them do what they need to be doing without having to yell at the child, things like that. Including about eating,
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: When you're giving them medication, if it's stimulant medication, that reduces their appetite. And the thing is that it doesn't have to be rocket science to do it all, you just have to remember these things, talk about them, and then do some problem-solving around them. And it may be as simple sometimes as giving a child a high-calorie, delicious breakfast that they're willing to eat because that gets great calories in them, and it works out pretty well, and it's okay. Now, in a world where we're worried about obesity, among our entire population, you have to think that through carefully. But, even so, for a skinny little kid on a stimulant, we want them to be able to grow, and so maybe, in this case, we're giving them something that's tastier for breakfast.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Right.
MARA GOVERMAN: We can't forget that ADHD looks different in young children. A preschooler who struggles with attention and impulse control might just need more structure than medication and more support as well. But if a child is at risk for injuries, social struggles, or family distress, then medication might be a reasonable option.
JOSH FEDER: And that's the tipping point, right? So, we're basically, you know, for everything we do with medication at Carlat Child Psychiatry Report, we always think, Okay, do we really need to use medication? Can we do other things first? Do we really understand what's going on, and are there other kinds of supports or interventions that we can use, but you got to kind of call it when things are getting dangerous in particular, or it's just unmanageable? Well, then medications can make a good plan work better. Now, if you don't have that good plan in place, if you haven't looked at those things, and you're just giving medication, things probably won't get all that better. Medication doesn't make up for an incomplete or bad plan. But it can sure make a good enough plan actually work well enough, right?
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: So, a medicine that slows the kid down enough to process the things that we're doing to try to support them, and then it can be, you know, really successful. It's really all about having this comprehensive picture of the child so that we're integrating and coordinating everything we do non-pharmacological first, and often it works out really well, but if a child isn't improving, is really struggling, then we have to weigh the risks and benefits of giving medication. I always emphasize an informed decision-making process with parents. So, talking about their child and their family, their family values, their culture, their goals for the child, reviewing the available research, and then looking at the different options there are for care and what a package looks like. I mean these are complex situations, which usually require multiple kinds of approaches to work together and then, managing our expectations in an ongoing, developing picture.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Meaning the child is growing, medicine may help a lot, but you know, it might not, there may be some side effects that we really have to address, and so when you give a medication, sometimes parents and teachers will have expectations. Well, the medicine is gonna fix all this, and it's really not true. And the other problem that happens is sometimes you start using medicine, and all your conversations can be about the medication instead of remembering to talk about all the other things. So, you have to really remember to think about the child comprehensively, to think about the medication as a part of that plan, and to pay attention to all those different factors as you move forward.
MARA GOVERMAN: I also just wanted to highlight that, if possible, collaborating with their interdisciplinary team is really supportive for a strong treatment plan.
JOSH FEDER: What does that mean?
MARA GOVERMAN: That means being able to communicate with teachers, with after school, with parents, with extended family makes a big difference in the outcome.
JOSH FEDER: And you know what? I know what you're thinking. That takes time, and we don't get reimbursed for it a lot of times.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Some of us do, but usually we don't. Right?
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: So, we're putting in this extra effort. It's not exactly pajama time because we're not doing it after hours necessarily, or at least not late at night. But you know, you think about we need to do these things, we need to coordinate care.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: To try to deliver good care so that kids do well and we can feel good about it at the same time, not burning ourselves out.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: So, there's a real balance there as well. I'll tell you; I like to work with other professionals who will answer my calls, who are able to work by email asynchronously. Teachers who will be responsive. Not everybody's like that.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: And frankly, we're not always like that. I just had this from another colleague yesterday who called me, and we were talking about a patient. She's doing the therapy, I'm doing the medication, and she said, I've never had a doctor actually call me to talk. And I was thinking, Oh my God. I mean, we lose so much. We lose so much when we're not in contact with the people who are caring for our patients makes a difference to try to stay in touch. Preserve yourself to a degree, but think about it this way, if your kids come back and they're doing better because you had some of that connection, which, by the way, is less isolating when you're actually talking to the rest of the team, it's much more fulfilling than if you're sitting looking at kids writing scripts and maybe doing vital signs, if you do that, I do them, and you're more isolated. So, there is a real value for the child, for yourself, and for therapy, and also for the field, for the reputation of our field. So, just a commercial for staying in touch with the other colleagues in your purview.
MARA GOVERMAN: Hear, hear! Parents need to know that starting medication is just a part of a comprehensive treatment care plan. We can assess a just doses or even stop treatment slowly. In the meantime, all the other interventions should continue. Dr. Earth Hasassri's article in our October/November/December 2024 newsletter is the inspiration for today's podcast, and it contains additional insights on using stimulants in preschool-aged children, and if you found this episode valuable, which we hope you did, please share it with others who need to hear this message.
JOSH FEDER: Everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry.
MARA GOVERMAN: The newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding. That helps us to bring you unbiased information that you can trust.
JOSH FEDER: Thanks to all of you for tuning into this episode. Again, like Mara said, if you found this discussion helpful, subscribe to more episodes on mental health and psychiatric care, and tell your friends. Until next time, take care.
JOSH FEDER: I'm Dr. Josh Feder, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Factbook for Psychiatric Practice, second edition 2023, and our other book, Prescribing Psychotropics.
MARA GOVERMAN: And I'm Mara Goverman, a licensed Clinical Social Worker in Southern California, with a private practice, and an avid reader of the Carlat Psychiatry Reports. ADHD in preschoolers is a hot topic, and in our practice, we see the struggle parents face when non-pharmacological strategies aren't enough.
JOSH FEDER: Absolutely, Mara. ADHD medications are FDA-approved for marketing to kids as young as three, but guidelines still recommend starting with non-pharmacological interventions, and when that doesn't work, many parents and providers hesitate before turning to stimulants.
MARA GOVERMAN: Right, and that caution makes a lot of sense. Current research also helps to paint a better picture of these interactions. A recent meta-analysis that looked at nine clinical trials with over 500 kids under seven showed that stimulants had a medium to large effect size on parent and teacher ADHD ratings, but only a small effect on inattention.
JOSH FEDER: Let's look at that distinction.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Hyperactivity and impulsivity seem to improve more than inattention, but this is what concerns me. The neuropsychological tests showed no improvement with stimulants, and that makes me wonder if the medication is just kind of masking outward behaviors rather than addressing underlying challenges, whether it's cognitive or sensory motor, or all those different things that we think about when we're trying to help these kids. So, for instance, I've got a little kid who I've been seeing fairly recently, and of course, off the walls, right? I mean, just bouncing around, and we try to think, okay, so what is it that's creating these difficulties? And if you haven't heard it yet. I did an interview with Dr. Jeff Rowe.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Where we were unpacking all these different things that happen in little kids and trying to figure out, well, what is it that makes them have these surface behavioral symptoms? And it could be all kinds of things, and if you go back to our biopsychosocial model, right? I like to reverse and say social psycho bio, because I think the social things are sometimes the biggest things you think about what's happening in the family. What disruptions have occurred? Is there something else that is happening, like at school, that may be upsetting the child, you know, who knows. Right? And then psychologically, how does this child perceive and understand the world, right?
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: I mean, how do they think about things? And there certainly can be the basic distractibility of ADHD that makes it so that they're not sure always what's going on around them. Their internal level of arousal is heightened. They will often misperceive even neutral kinds of things as threatening. So a kid comes up to them to play and they may react in some fashion, runoff or, or even become angry, because they're not reading the reality of the situation itself, and you know, yada, yada, yada, there's much more about that, and also connected to the fact that kids with ADHD are often doing things for which the people around them are saying, No, you're wrong. You're wrong. So, part of that's the social part, but part of that is in the ages where you're trying to develop your sense of self and self-esteem. You end up feeling pretty badly about yourself. Okay, and then the biological part. Yeah, yeah, yeah. You know, we can talk about prefrontal cortex not developed very much at all at those ages.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: That's right. But we also need to think about sensory-motor function.
MARA GOVERMAN: Sensory motor function, and processing, right?
JOSH FEDER: Yeah, yeah, yeah. So, you could have a kid who's, you know, maybe very sensitive to the temperature in the room.
MARA GOVERMAN: Or to the light, or by the window, or not in front of the teacher.
JOSH FEDER: And sounds. Oh, and their tummies. Right? So, they're internal interceptive sensations. They may be reacting to those. So, you just have to unpack all that. And you mentioned processing, so we talked a little bit about misreading cues.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: But also, just sometimes, the slower processing of the things around them. So, back to the teacher. The teacher says, What's the answer, Johnny? And Johnny's like, Uh, it takes Johnny time. Teacher isn't waiting, moves on to somebody else, and it's a fail for Johnny, who feels bad about it, they may react.
MARA GOVERMAN: It's a vicious cycle.
JOSH FEDER: Right. So, there's all these things that could be involved, and coming back to where we started, which was if medication is just making someone slow down and not addressing all those underlying challenges, well, what are we really doing for the child and the family?
MARA GOVERMAN: As well as wouldn't it be great if you can get someone to go in and visit the classroom and see what it's like for the child and teaching methodology, and whether it's a match? And let's talk about the side effects of medication at this age group. The study found decreased appetite as the main adverse effect. It didn't show increased irritability, sleep issues, or anxiety. Still, the longest trial lasted only six weeks. That's not long enough to assess long-term effects like growth suppression, which we see in the preschool ADHD treatment study.
JOSH FEDER: Exactly, over a period of three years, the famous PAT study found significant reductions in growth and weight gain with stimulant use in children. Plus, the symptom improvement wasn't as strong as what we'd hoped for. Right, and that's why I'm cautious. If we do start a preschooler on medication, we need to monitor them closely using growth charts and vital signs and symptom changes, and looking at sleep and appetite, and ticks, and you know, all the other side effects.
MARA GOVERMAN: As well as supporting the parents and extended family, because it's really uncomfortable when your child is not eating.
JOSH FEDER: Oh, my goodness, right? I mean, the care of kids who have ADHD who are young is comprehensive care. I mean, think about it. Most of what we do in mental health is chronic care, like people have these things that are gonna be with them for a very long time, and that includes monitoring medications and growth, and working really closely,
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: With parents to help manage some of those concerns. So, part of it is helping parents to feel more comfortable and competent in working with their children to help them do what they need to be doing without having to yell at the child, things like that. Including about eating,
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: When you're giving them medication, if it's stimulant medication, that reduces their appetite. And the thing is that it doesn't have to be rocket science to do it all, you just have to remember these things, talk about them, and then do some problem-solving around them. And it may be as simple sometimes as giving a child a high-calorie, delicious breakfast that they're willing to eat because that gets great calories in them, and it works out pretty well, and it's okay. Now, in a world where we're worried about obesity, among our entire population, you have to think that through carefully. But, even so, for a skinny little kid on a stimulant, we want them to be able to grow, and so maybe, in this case, we're giving them something that's tastier for breakfast.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Right.
MARA GOVERMAN: We can't forget that ADHD looks different in young children. A preschooler who struggles with attention and impulse control might just need more structure than medication and more support as well. But if a child is at risk for injuries, social struggles, or family distress, then medication might be a reasonable option.
JOSH FEDER: And that's the tipping point, right? So, we're basically, you know, for everything we do with medication at Carlat Child Psychiatry Report, we always think, Okay, do we really need to use medication? Can we do other things first? Do we really understand what's going on, and are there other kinds of supports or interventions that we can use, but you got to kind of call it when things are getting dangerous in particular, or it's just unmanageable? Well, then medications can make a good plan work better. Now, if you don't have that good plan in place, if you haven't looked at those things, and you're just giving medication, things probably won't get all that better. Medication doesn't make up for an incomplete or bad plan. But it can sure make a good enough plan actually work well enough, right?
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: So, a medicine that slows the kid down enough to process the things that we're doing to try to support them, and then it can be, you know, really successful. It's really all about having this comprehensive picture of the child so that we're integrating and coordinating everything we do non-pharmacological first, and often it works out really well, but if a child isn't improving, is really struggling, then we have to weigh the risks and benefits of giving medication. I always emphasize an informed decision-making process with parents. So, talking about their child and their family, their family values, their culture, their goals for the child, reviewing the available research, and then looking at the different options there are for care and what a package looks like. I mean these are complex situations, which usually require multiple kinds of approaches to work together and then, managing our expectations in an ongoing, developing picture.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Meaning the child is growing, medicine may help a lot, but you know, it might not, there may be some side effects that we really have to address, and so when you give a medication, sometimes parents and teachers will have expectations. Well, the medicine is gonna fix all this, and it's really not true. And the other problem that happens is sometimes you start using medicine, and all your conversations can be about the medication instead of remembering to talk about all the other things. So, you have to really remember to think about the child comprehensively, to think about the medication as a part of that plan, and to pay attention to all those different factors as you move forward.
MARA GOVERMAN: I also just wanted to highlight that, if possible, collaborating with their interdisciplinary team is really supportive for a strong treatment plan.
JOSH FEDER: What does that mean?
MARA GOVERMAN: That means being able to communicate with teachers, with after school, with parents, with extended family makes a big difference in the outcome.
JOSH FEDER: And you know what? I know what you're thinking. That takes time, and we don't get reimbursed for it a lot of times.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: Some of us do, but usually we don't. Right?
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: So, we're putting in this extra effort. It's not exactly pajama time because we're not doing it after hours necessarily, or at least not late at night. But you know, you think about we need to do these things, we need to coordinate care.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: To try to deliver good care so that kids do well and we can feel good about it at the same time, not burning ourselves out.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: So, there's a real balance there as well. I'll tell you; I like to work with other professionals who will answer my calls, who are able to work by email asynchronously. Teachers who will be responsive. Not everybody's like that.
MARA GOVERMAN: Mm-hmm.
JOSH FEDER: And frankly, we're not always like that. I just had this from another colleague yesterday who called me, and we were talking about a patient. She's doing the therapy, I'm doing the medication, and she said, I've never had a doctor actually call me to talk. And I was thinking, Oh my God. I mean, we lose so much. We lose so much when we're not in contact with the people who are caring for our patients makes a difference to try to stay in touch. Preserve yourself to a degree, but think about it this way, if your kids come back and they're doing better because you had some of that connection, which, by the way, is less isolating when you're actually talking to the rest of the team, it's much more fulfilling than if you're sitting looking at kids writing scripts and maybe doing vital signs, if you do that, I do them, and you're more isolated. So, there is a real value for the child, for yourself, and for therapy, and also for the field, for the reputation of our field. So, just a commercial for staying in touch with the other colleagues in your purview.
MARA GOVERMAN: Hear, hear! Parents need to know that starting medication is just a part of a comprehensive treatment care plan. We can assess a just doses or even stop treatment slowly. In the meantime, all the other interventions should continue. Dr. Earth Hasassri's article in our October/November/December 2024 newsletter is the inspiration for today's podcast, and it contains additional insights on using stimulants in preschool-aged children, and if you found this episode valuable, which we hope you did, please share it with others who need to hear this message.
JOSH FEDER: Everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry.
MARA GOVERMAN: The newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding. That helps us to bring you unbiased information that you can trust.
JOSH FEDER: Thanks to all of you for tuning into this episode. Again, like Mara said, if you found this discussion helpful, subscribe to more episodes on mental health and psychiatric care, and tell your friends. Until next time, take care.
__________
The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 CreditsTM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.
