The American Academy of Pediatrics (AAP) published guidelines for the diagnosis and treatment of ADHD, which include using DSM-IV criteria to evaluate ADHD, using rating scales from multiple sources to assist in making the diagnosis and monitoring for treatment effects and side effects and inclusion of psychosocial treatment paradigms in treatment recommendations (American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158–1170. http://dx.doi.org/10.1542/peds.105.5.1158.) This just published study by Epstein and colleagues examined the rates of evidence based care and potential sources of clinician and patient centered variability in a chart review of over 1500 patients, 188 pediatricians in 50 different practice settings in Ohio since the publication of the AAP guidelines for ADHD. The authors found:
- Diagnosis: There was an underutilization of parent and teacher rating scales in making the ADHD diagnosis (occurring in slightly over 55% of the sample); about 30% of the patients did not fulfill DSM-IV criteria for ADHD.
- Treatment Initiation: Medications were used in the vast majority of cases (93.4%); psychosocial treatments were not commonly recommended or used (13% of the time). Less than ½ the sample had a visit or a phone call with the pediatrician’s office within the first month of starting treatment.
- Monitoring Treatment: Only 10% and 8% of the charts indicated that parent or teacher rating scales, respectively, were used to assess treatment response or side effect. The average time to collection of these scales was quite long – over a year from the time of treatment initiation.
- Practice Variables: Urban and rural practices used psychosocial treatments more commonly than suburban ones, while suburban practices had shorter times for follow up visits after starting treatment than urban practices.
The authors concluded that there is a need to improve the quality of ADHD care in the pediatric practices they surveyed. Advances could be achieved in applying DSM criteria for ADHD, using rating scales from parents and teachers and using psychosocial treatments. They suggest that improvements could be made in terms of education and the use of technology in the practice and patient level.
Even though this study was of pediatric PCPs (pediatricians), it has significant implications for the treatment of adults with ADHD by PCPs. As there are no US practice guidelines for adults with ADHD, there is a clear need to educate PCPs about the appropriate use of the DSM for diagnosis and rating scales to monitor ADHD adults during treatment. The above study does not address the issue of whether the cost of potential psychosocial treatments might create a barrier to their use, which could also be the case for adult ADHD (along with a smaller network of providers of these treatments for adults as compared to children). The study did not assess the consequences of failing to document and monitor treatment efficacy and side effects. The need for ongoing monitoring of patients with ADHD is certainly important when using stimulant and non-stimulant medications.
Variability in ADHD Care in Community-Based Pediatrics, Jeffery N. Epstein, Kelly J. Kelleher, Rebecca Baum, William B. Brinkman, James Peugh, William Gardner, Phil Lichtenstein and Joshua Langberg. Pediatrics; originally published online November 3, 2014; DOI: 10.1542/peds.2014-1500.