When pediatricians diagnose preschoolers with attention deficit hyperactivity disorder, there are clear steps they are supposed to take.

Families should first be referred to behavior therapy, which teaches caregivers how to better support their children and manage challenging behaviors that may be related to ADHD. If therapy isn’t making a significant difference, the American Academy of Pediatrics advises, pediatricians can then consider medication.

Nationwide, this process — behavior therapy, then medication if needed — isn’t being followed as often as it should, according to a study recently released by Stanford Medicine and published in JAMA Network Open. Instead, more than 42 percent of 3- to 5-year-olds with ADHD were prescribed medication within a month of their diagnosis.

Missing out on behavior therapy has worrisome implications for children and families, said Dr. Yair Bannett, assistant professor of pediatrics at Stanford Medicine and lead author of the study. Behavioral management training for parents over the course of several months has been found to reduce children’s ADHD symptoms and behavioral problems, and improve parent skills and their relationships with their children. 

Without that support, families may be left facing additional challenges. Behavioral training “reduces the chaos in the house and can improve the quality of life for the parents and the child,” Bannett said. 

There are several reasons families may be missing this intervention. Some pediatricians aren’t familiar with the purpose of behavior therapy, Bannett added, which is specifically aimed at the adults who support children with ADHD, not the children. “It’s really more of an advanced type of parenting course,” he said. Families also may have trouble finding affordable local therapists.

Bannett said parents should use three key practices to support young children with ADHD. (These strategies also work well for teachers, he added.)

Focus on building a strong, positive relationship: Having a strong attachment between the child and parent or teacher is an important first step to managing behavior, Bannett said. That means spending quality one-on-one time with the child. “That’s the child’s motivation, they want to please you,” he added. “Without that first piece, none of this will work.”

Use positive reinforcement: Rather than punishing a child’s negative behavior, Bannett said, parents and teachers will see more success if they praise good behaviors and develop reward systems to encourage them.  

Adjust the child’s environment: Children with ADHD may thrive with simple environmental changes, such as “visual schedules” — charts that use pictures to show a child daily activities or tasks — and a consistent, structured routine.

Parents who can’t find in-person therapists can substitute online therapy, Bannett said. The training is also useful for families even after their children are prescribed medication. 

To make sure more families have access to helpful strategies, Bannett would like to see more education for doctors and clinicians on these best practices. 

“The pediatricians could also counsel families in the office about these techniques,” Bannett said. “Some written materials and resources could be enough” to at least introduce these practices, he added. “That’s what I’m hoping could make a change.”

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This story about children with ADHD was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.