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Psychotropic medications are increasingly used for very young children. Patterns of use in a well-described group of children 3 years and younger with a diagnostic label of attention-deficit hyperactivity disorder (ADHD) reveal both reasons to use such medications and concerns about how these medications are used. Of 223 children with ADHD, more than half (n = 127) received psychotropic medications in an idiosyncratic manner, both in the specific medication and in use over time. Almost half of the children who were medicated did not have opportunities for monitoring as often as every 3 months, despite the fact that more than half received psychotropic medications for 6 months or longer. Children with comorbid mental health conditions and chronic health conditions were at greater risk for receiving psychotropic medications. These patterns of use demonstrate a compelling need for guidance in psychopharmacological treatment of very young children.