When it comes to treating attention-deficit hyperactivity disorder (ADHD) a lot of kids are getting the meds they need—but they may be missing out on other treatments. Despite clinical guidelines that urge that behavioral therapy always be used alongside medication, less than half of the children with ADHD received therapy as part of treatment in 2009 and 2010, according to the first nationally representative study of ADHD treatment in U.S. children.

The findings, published online March 31 in The Journal of Pediatrics, come from data collected during that period on 9,459 children, aged four to 17, with diagnosed ADHD—just before the American Academy of Pediatrics (AAP) issued its clinical practice guidelines on treatments of the condition in 2011. They provide a baseline for comparison when the next report is issued in 2017. Medication alone was the most common treatment for children with ADHD: 74 percent had taken medication in the previous week whereas 44 percent had received behavioral therapy in the past year. Just under a third of children of all ages had received both medication and behavioral therapy, the AAP-recommended treatment for all ages. “It’s not at all surprising that medication is the most common treatment,” says Heidi Feldman, a professor of developmental and behavioral pediatrics at Stanford University School of Medicine who served on the AAP clinical practice guidelines committee. “It works very effectively to reduce the core symptoms of the condition,” she adds, “and stimulants are relatively safe if used properly. The limitation of stimulant medications for ADHD is that studies do not show a long-term functional benefit from medication use.”

For children aged four and five, in particular, the AAP only recommends medication if behavioral therapy is insufficient and the condition continues to significantly interrupt the child’s ability to function—but nearly half were on medication. “We know so little about the possible effects of medications on preschoolers that we tend to avoid using them when possible,” says Glen Elliott, chief psychiatrist and medical director of the Children's Health Council in Palo Alto, Calif. “The sparse data we do have strongly suggest that preschoolers are both less responsive at least to methylphenidate than are older children and more likely to experience unacceptable side effects.” Those side effects can include lethargy, appetite problems, sleeping difficulties and irritability.

The preschoolers most likely to receive behavioral therapy were blacks, Hispanics and lower income children on public health insurance, a surprising finding given the historically reduced access to mental health care in these groups. “That’s an interesting pattern we hadn’t seen before,” says lead author Susanna Visser, a researcher at the National Center on Birth Defects and Developmental Disabilities at the U.S. Centers for Disease Control and Prevention. “It’s consistent with research about differences in the cultural perception of both mental and behavioral disorders among minorities and also a preference toward behavioral therapy and alternative therapies for treatment of these disorders.”

The findings for black and Hispanic children with ADHD indicated that both cultural factors and potentially reduced access to medication playing a role in the treatment minority children receive. White children were still more likely to get some kind of treatment and more likely to get medication, but among those receiving treatment, black and Hispanic children were more apt to receive behavioral therapy treatment, as recommended according to the AAP guidelines. The type of behavioral treatment children received was not specified in the report. Eleven percent of white, 16 percent of black and 13.5 percent of Hispanic children received neither medication nor therapy. Medication rates were 78 percent for whites, 67 percent for blacks and 70 percent for Hispanics. “The reasons children may not be on medication include lack of access to a prescribing physician, financial burden of medication, untoward side effects of medication and parents who are often not interested in medication management of ADHD,” Feldman says. If the lower rate indicates poor access to insurance to pay for medications, that’s bad news, she says. “If the caution to diagnose in underrepresented minority populations results in greater care and less overdiagnosed [children], that finding would be positive,” Feldman adds.

The findings regarding therapy, however, are certainly positive for minority children, especially the younger ones, says Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children’s Hospital in Houston. “It was really refreshing to me to see that black and Hispanic children, especially poor black and Hispanic children, were receiving behavioral therapy at higher rates than other demographics of kids,” Spinks-Franklin says. The results showed 17 percent each of blacks and Hispanics received only behavioral therapy and a third of each group received therapy and medication. Among whites only 11 percent received therapy alone and 30 percent received both therapy and medication. Typically, if children are receiving behavioral therapy, their parents may be more likely to receive training in strategies for managing their children’s needs as well. “We know mental health treatment access is much lower among black and Hispanic populations generally,” Spinks Franklin says. “Often, mental health problems and seeking treatment is seen as a white folks’ problem, so the fact that they agreed to seek mental health help for their children is fabulous.” The reasons minority parents opt for therapy over medication may stem from the historical mistrust of the health care system that minorities, particularly blacks, have in the U.S. “These reasons go back centuries—it’s not just the Tuskegee experiment,” Spinks-Franklin says, adding that slaves’ bodies were the first cadavers in U.S. medical schools and that slaves were frequently subjected to medical experimentation without anesthesia.

Another reason black and Hispanic children may receive therapy at higher rates is that they may have more overlapping problems that go along with ADHD and need earlier or more comprehensive attention, says Lawrence Brown, associate professor of neurology and pediatrics at The Children’s Hospital of Philadelphia and one of the AAP committee members. “There may be fewer resources within the family and the community so that they need outside help,” he says.

Regardless of the reasons, experts hope to see the rates of behavioral therapy increase across all the surveyed groups. Those with ADHD face greater long-term difficulties, including lower employment and educational attainment, higher high school dropout, divorce and severe car accident rates as well as more involvement with the criminal justice system. “Medicine is important to address the biological component of the disorder but it doesn’t teach a person how to manage their own symptoms and behavior, and it is that lack of self-management that leads to these really poor outcomes as adults,” Spinks-Franklin says. “Pills don’t teach you social skills, coping strategies and self-control. Behavior therapy does.”