March 2006 | Back to Table of Contents
Clinical and Health Affairs
Assessment and Diagnosis of Attention-Deficit/Hyperactivity Disorder by Family Physicians
By Mary E. Daly, D.O., Norman H. Rasmussen, Ed.D., David C. Agerter, M.D., and Stephen S. Cha
Abstract
In this study, our aim was to determine the extent to which family physicians in Minnesota follow the American Academy of Pediatrics (AAP) guideline in the assessment and diagnosis of attention-deficit/hyperactivity disorder (ADHD) in school-aged children and to identify barriers to using the guideline. We surveyed 1,000 randomly chosen members of the Minnesota Academy of Family Physicians. Of 303 respondents, 36% always referred children for a diagnosis and 99.7% referred children for a diagnosis of ADHD some of the time. Fifty-four percent were unaware of the AAP guideline. However, among those who said they evaluate children for ADHD, most followed the criteria in the AAP guideline. For example, most family physicians (97%) used a child’s response to stimulant medication in their assessment. Respondents also said that barriers to ADHD assessment included lack of reimbursement and training.
Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder in the United States.1,2 The condition impairs academic, social, and emotional functioning. It also affects family dynamics. Although ADHD has generally been estimated to affect 3% to 5% of school-aged children, wider ranges have been reported.1-4 In a population-based cohort in Rochester, Minnesota, Barbaresi et al. found a cumulative incidence of ADHD ranging from 1.7% to 16%, with an incidence of 7.5% when using diagnostic criteria similar to those specified by the American Academy of Pediatrics (AAP) practice guideline.2
Prevalence and incidence rates of ADHD are affected by multiple factors including comorbidities, age, sex, and the diagnostic criteria used. Diagnosis is complicated by the occurrence of comorbid conditions such as oppositional defiant disorder, conduct disorder, mood disorders, anxiety, and learning disabilities.5-7
Public concern about overdiagnosis of ADHD and a fear that too many children are being treated with stimulants and other psychotropic medications emphasize the importance of accurate diagnosis. However, assessment and diagnostic procedures vary widely among clinicians.8 This lack of consistency in the criteria used to diagnose ADHD in children has led to both overdiagnosis and underdiagnosis of the disorder and has been identified as a major public health problem by the National Institutes of Health.3,9,10
Limited information is available on children presenting initially to primary care offices, where a detailed evaluation can be challenging. The evaluation of behaviors that define ADHD is a subjective process that requires the use of multiple methods and multiple sources of information.8,11 Physicians must identify behavior patterns from multiple settings and collect information from sources not immediately available to them.4 Also, use of clinical judgment is required when applying the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).12-14
Evidence is mounting that comprehensive, multimodal assessments are essential to the assessment and diagnosis of ADHD. With such a comprehensive evaluation, however, questions may arise about time constraints, cost effectiveness, and insurance coverage. Another concern voiced by primary care physicians is difficulty of accessing certain tests if they are indicated in the evaluation.8
The AAP clinical practice guideline provides evidence-based recommendations for the assessment and diagnosis of school-aged children with ADHD in primary care settings. It is based on extensive review of the medical, psychological, and educational literature. The guideline is an attempt to integrate scientific evidence from randomized controlled studies, and the AAP’s reason for creating it is to change practice patterns to reflect evidence-based medicine. Physicians need to keep in mind that the guideline is a framework for diagnostic decision making and is not intended to replace clinical judgment.9,11,12
Given the prevalence of ADHD among school-aged children, family physicians should be prepared to identify children with this disorder. They may be the first health care professionals to have contact with these children. Because they have detailed information about the children and their families, family physicians are also in an ideal position to diagnose and treat ADHD.5,14 However, very little research related to ADHD has focused specifically on family physicians. Most studies have examined the assessment of children and diagnosis of ADHD in a psychiatric setting. It is unclear whether the findings from these studies can be generalized to a primary care setting.
Our study focused on the extent to which family physicians followed AAP recommendations in the assessment and diagnosis of ADHD in school-aged children. It sought to determine 1) awareness of the AAP guideline for the assessment and diagnosis of school-aged children with ADHD, 2) adherence to the criteria outlined in the guideline, 3) use of the DSM-IV criteria in making a diagnosis of ADHD, and 4) perceived barriers to the use of the AAP guideline by practicing family physicians in Minnesota.
Subjects and Methods
A self-designed survey consisting of 18 questions was mailed to 1,000 family physicians. We used simple random sampling to select from the membership list of the Minnesota Academy of Family Physicians. A second survey was mailed to physicians who did not reply to the initial mailing. The proportion and the 95% exact binomial confidence interval for the proportion were used to describe the data.
Results
♦ Sample
Of the 1,000 physicians in the sample, 321 returned the survey after 2 mailings, yielding a response rate of 32%. Eighteen surveys were excluded from the analysis for various reasons, including not working in clinical practice, not working in primary care, being retired, having no pediatric patients, and being a co-investigator for this study. The demographics of the 303 eligible respondents are shown in Table 1.
♦ Assessment and Diagnostic Practices
Virtually all family physicians (99.7%) who responded to the survey reported that they referred children to other professionals for evaluation of ADHD. Of those, 66% referred always or most of the time (Figure 1). In addition, a large percentage (97%)of those who reported that they evaluate children for ADHD used a child’s response to stimulant medication in their assessment (Figure 2).
♦ Reported Adherence to Criteria in AAP Guideline
More than half of the family physicians (54%; n=165) were not aware of the AAP guideline for the assessment and diagnosis of ADHD in children in the primary care setting. However, as shown in a summary of the reported adherence to individual criteria of the AAP guideline, the majority of respondents followed the individual criteria: initiating an evaluation of a child, ensuring that the child meets DSM-IV criteria, obtaining evidence directly from parents or caregivers, obtaining evidence directly from a teacher or school personnel, and evaluating for co-existing conditions to establish a diagnosis of ADHD. In particular, 90% reported using the diagnostic criteria outlined in the DSM-IV, with 61% using DSM-IV criteria always or most of the time (Figure 3). However, physicians reported that they did selectively use other tests, including lead screening, CT, MRI, and other laboratory tests in making an ADHD diagnosis (Table 2).
♦ Perceived Barriers
The surveyed family physicians reported barriers to using the AAP guideline and to assessing a child for ADHD. The most frequently cited barriers to using the AAP guideline were not being aware of the guideline and perceiving the guideline as being inaccessible, too lengthy, and difficult to use. The reasons reported most often for not assessing a child for ADHD were problems with reimbursement, lack of training and education, time constraints, and diagnostic complexity.
Discussion
Our results indicate that more than half of the family physicians surveyed reported that they were unaware of the AAP guideline for the assessment and diagnosis of ADHD in school-aged children, yet many of the physicians did follow the criteria in the guideline. It is not unexpected that family physicians were unaware of the guideline. In a study of primary care providers in Michigan, Rushton et al. found that pediatricians were more likely than family physicians to be familiar with the AAP guideline (91.5% versus 59.8%).15
Previous surveys have shown that physicians are more likely to report familiarity with and have greater confidence in guidelines developed by their own specialty organizations.15,16
The AAP guideline is only one of the guidelines available to family physicians for diagnosing and assessing ADHD in children. Other guidelines Minnesota family physicians said they were aware of or familiar with included those developed by the Institute for Clinical Systems Integration and the American Academy of Child and Adolescent Psychiatry. The criteria in each of these guidelines also focus on the DSM-IV criteria. For that reason, the particular guideline used may not be important. Physician adherence to guidelines may be influenced by a multitude of factors including their effects on clinical autonomy, lack of awareness of the guideline, lack of familiarity with the guideline, lack of agreement among different guidelines, reluctance on the part of the practice to use the guideline, health care costs, and satisfaction with clinical practice.16,17 Studies have shown that despite their limited use, evidence-based guidelines may contribute to the improvement of medical care and patient outcomes.16-18
Multiple barriers to using guidelines were reported by survey respondents. In addition to a lack of awareness and familiarity, the guidelines were perceived to be inaccessible and lengthy. An unexpectedly high percentage of respondents (99.7%) said they referred children to other professionals, including psychologists, child psychiatrists, developmental pediatricians, and pediatricians, for a diagnosis of ADHD. Reasons for referral included lack of training and education on the part of the family physician, diagnostic complexity, time constraints, and reimbursement issues. Similar reasons for referral have been found by other investigators.8,19-21 In a study of pediatric residents, Stancin et al. found that 75% referred children to specialists for diagnosis and treatment of ADHD.20 In another Minnesota study, Evink et al. found that more family physicians than pediatricians reported that they would refer their patients to another specialty.21 Similar results were reported in an Australian study of general practice physicians.19
Ninety-seven percent of respondents reported using a child’s response to stimulant medication in their assessment, although this is not a criterion specified in any guideline. Use of this criterion is not specific to family physicians; it has also been reported in the pediatric literature.14,22
One limitation of our study is that self-report measures may not reflect actual diagnostic practices. Studies have shown discrepancies between reported and observed physician behaviors.14,22 Whether self reports reflect actual physician behavior and practices could be validated by observation or a chart review. A second limitation is a flaw in the design of the survey that led to a large amount of missing data secondary to respondents being directed to skip questions if 1) they always refer a child for the diagnosis of ADHD or 2) they never conduct an evaluation of a child for ADHD. Still another limitation is that the sample included only family physicians in Minnesota, and the results may not generalize to other regions of the country.
Conclusion
Our results suggest that the majority of family physicians in Minnesota are not aware of the AAP guideline for the assessment and diagnosis of ADHD in school-aged children. In addition, a large percentage of those physicians refer their patients to specialists for the diagnosis of ADHD. Several noteworthy barriers to performing an initial evaluation were identified in this study, including diagnostic complexity, insufficient training and education, time constraints, and a lack of reimbursement. Future research directions include exploring further the reasons why family physicians refer children for the diagnosis of ADHD, determining whether the results from Minnesota family physicians generalize to a broader geographic sample, and determining the effects of specialized training and reimbursement issues on family physician behavior and practices. There is evidence that the use of American College of Cardiology/American Heart Association evidence-based guidelines for cardiovascular care substantially contributes to the improvement of medical care and patient outcomes. It has not yet been demonstrated, though, that the same holds true in the use of guidelines for assessment and diagnosis of ADHD in children. MM
Mary Daly is currently a family physician at the Wabasha Clinic. Norman Rasmussen is a consultant in the departments of psychiatry and psychology and family medicine, David Agerter is is a consultant in the department of family medicine, and Stephen Cha is a statistician in the division of biostatistics at Mayo Clinic in Rochester.
References
1. Agerter DC, Rasmussen NH. Diagnosing and treating ADHD in children. Minn Med. 2000;83(6):51-4.
2. Barbaresi WJ, Katusic SK, Colligan RC, et al. How common is attention-deficit/hyperactivity disorder? Incidence in a population-based birth cohort in Rochester, Minn. Arch Pediatr Adolesc Med. 2002;156(3):217-24.
3. Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). NIH Consens Statement, 1998 Nov 16-18;16(2):1-37.
4. Taylor MA. Attention-deficit hyperactivity disorder on the frontlines: management in the primary care office. Compr Ther. 1999;25(6-7):313-25.
5. Barbaresi WJ. Primary-care approach to the diagnosis and management of attention-deficit hyperactivity disorder. Mayo Clin Proc. 1996;71(5):463-71.
6. Brown RT, Freeman WS, Perrin JM, et al. Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings. Pediatrics. 2001;107(3):E43.
7. Hechtman L. Assessment and diagnosis of attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am. 2000;9(3):481-98.
8. Shaw KA, Mitchell GK, Wagner IJ, Eastwood HL. Attitudes and practices of general practitioners in the diagnosis and management of attention-deficit/hyperactivity disorder. J Paediatr Child Health. 2002;38(5):481-6.
9. Waldron T. ADHD: improving diagnosis in primary care. Behav Healthc Tomorrow. 2000;9:40-43.
10. Wender EH. Attention-deficit/hyperactivity disorder: is it common? Is it overtreated? Arch Pediatr Adolesc Med. 2002;156(4):209-10.
11. Stein MT. The role of attention-deficit/hyperactivity disorder diagnostic and treatment guidelines in changing physician practices. Pediatr Ann. 2002;31(8):496-504.
12. American Academy of Pediatrics Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158-70.
13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:78-85.
14. Copeland L, Wolraich M, Lindgren S, Milich R, Woolson R. Pediatricians’ reported practices in the assessment and treatment of attention deficit disorders. J Dev Behav Pediatr. 1987;8(4):191-7.
15. Rushton JL, Fant KE, Clark SJ. Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder. Pediatrics. 2004;114(1):e23-8.
16. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-65.
17. Brindis RG, Sennett C. Physician adherence to clinical practice guidelines: does it really matter? Am Heart J. 2003;145(1):13-5.
18. Sinuff T, Cook DJ. Guidelines in the intensive care unit. Clin Chest Med. 2003;24(4):739-49.
19. Shaw K, Wagner I, Eastwood H, Mitchell G. A qualitative study of Australian GPs’ attitudes and practices in the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD). Fam Pract. 2003;20(2):129-34.
20. Stancin T, Christopher N, Coury D. Reported practices of pediatric residents in the management of attention-deficit hyperactivity disorder. Am J Dis Child. 1990;144(12):1329-33.
21.Evink B, Crouse BJ, Elliott BA. Diagnosing childhood attention-deficit/hyperactivity disorder: do family practitioners and pediatricians make the same call? Minn Med. 2000;83(6):57-62.
22. Leslie LK, Weckerly J, Plemmons D, Landsverk J, Eastman S. Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings. Pediatrics. 2004;114(1):129-40.