For children under the age of 7 with ADHD who continue to have significant impairment with behavioral interventions, how do you decide between starting with a stimulant vs. starting with an alpha agonist?  

Accurate diagnosis is the critical first step in treating ADHD in young children, though it can be particularly challenging in this age group. ADHD remains a clinical diagnosis without a definitive test, and its symptoms often overlap with other conditions such as anxiety, depression, and PTSD. Alth...

If the ADHD symptoms are still impairing despite being treated with behavioral interventions, pharmacotherapy is indicated. First-line pharmacotherapy for ADHD, even in elementary school age or younger, is stimulants. I would treat them with stimulants unless there is a contraindication or a reason ...

1) I agree with first of all a good evaluation with the developmental history, and the chronology of symptoms onset.  Comorbid diagnoses are important to address also. Typically I agree with the recommendation of starting with stimulant first line, and then add or change to low dose clonidine ...