KAS 5a: For preschool-aged children (age 4 years to the sixth birthday) with ADHD, the PCC should prescribe evidence-based behavioral PTBM and/or behavioral classroom interventions as the first line of treatment, if available (grade A: strong recommendation). Methylphenidate may be considered if these behavioral interventions do not provide significant improvement and there is moderate-to-severe continued disturbance in the 4- through 5-year-old child’s functioning. In areas in which evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication before the age of 6 years against the harm of delaying treatment (grade B: strong recommendation).

Aggregate evidence qualityGrade A for PTBM; Grade B for methylphenidate
BenefitsGiven the risks of untreated ADHD, the benefits outweigh the risks.
Risks, harm, costBoth therapies increase the cost of care; PTBM requires a high level of family involvement, whereas methylphenidate has some potential adverse effects.
Benefit-harm assessmentBoth PTBM and methylphenidate have relatively low risks; initiating treatment at an early age, before children experience repeated failure, has additional benefits. Thus, the benefits outweigh the risks.
Intentional vaguenessNone.
Role of patient preferencesFamily preference is essential in determining the treatment plan.
StrengthStrong recommendation.
Key referencesGreenhill et al83; Evans et al25