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Off-label prescribing is described by the US Food and Drug Administration (FDA) as the “unapproved use of an approved drug for a disease or a medical condition.” 11 When a new medication is approved, the FDA-approved labeling is based on the indication and age group treated during clinical trials conducted for the approval process. 9 Both on-label and off-label prescribing patterns among Oregon nurse practitioner prescribers and physicians (the most prevalent type of prescribers for children on Medicaid) are similar for the treatment of ADHD, 10 and their ability to prescribe controlled substances is similar on a state level in scope and breadth. The Oregon Medicaid formulary system uses a preferred drug list for ADHD medications but does not require prior authorization for non-preferred mental health medications. 6–8 Oregon Medicaid, unlike other state programs, funds mental health medications as a carve-out, which allows for individualized prescribing. Medicaid claims data have been used to examine prescribing patterns for children with ADHD in multiple studies. For young children who are not successfully maintained on methylphenidate, treatment alternatives used in practice include other stimulants, the alpha agonists, and atomoxetine. Since ADHD is a condition that often manifests most prominently in the young, it is recommended that children be frequently monitored when initiating therapy and be evaluated at least twice a year once maintained. 4 Methylphenidate should be initiated at a small dose and titrated up slowly. 5 If medication is indicated, methylphenidate is the treatment of choice for young children. 4 The American Academy of Child and Adolescent Psychiatry recommends behavioral therapy as required adjunctive therapy in children 3 to 5 years of age. The American Academy of Pediatrics (AAP) guidelines recommend behavioral therapy as first-line treatment for preschool-aged 4- to 5-year-old children. 3 Also in 2011, over half of preschool-aged children diagnosed with ADHD were not receiving behavioral therapy even though there is significant evidence demonstrating its effectiveness for the treatment of ADHD symptoms. 2 By contrast, in 2011, there were 103,562 children 2 to 5 years old on medication and 49,839 diagnosed and not receiving medication, a ratio of approximately 3:1 in favor of taking medication for ADHD. In 2007, a total of 97,583 children ages 2 to 5 years diagnosed with ADHD were identified as being untreated or treated without medication, while 51,409 children were identified as taking an ADHD medication, a ratio of approximately 2:1 in favor of not using medication. 2 Practices changed significantly within the last decade to favor pharmacologic treatment in very young children, despite a consensus in guidelines recommending non-pharmacologic therapy as the primary treatment approach. 1 From 2007 to 2011 the number of children ages 2 to 5 years taking medication to treat ADHD increased by 2-fold. Attention-deficit/hyperactivity disorder (ADHD) is currently diagnosed in approximately 11% of United States children ages 4 to 17 years.