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PCPs make most ADHD diagnoses
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Most children in the United States with attention-deficit/hyperactivity disorder were diagnosed by their primary care providers, regardless of age at diagnosis, according to a CDC report.
“Describing the diagnostic experiences of a representative sample of U.S. children with ADHD is an important step toward understanding how children are diagnosed with ADHD … and helps to inform efforts that seek to ensure that best practices are used in the evaluation and diagnosis of the disorder,” Susanna N. Visser, DrPH, of the National Center on Birth Defects and Developmental Disabilities at the CDC, and colleagues wrote.
To study the ADHD diagnostic experience, the investigators gathered data from the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome. Parents of children aged 2 to 15 years diagnosed with ADHD were contacted to participate in the survey. Almost 3,000 questionnaire sessions were completed by parents of children with ADHD during the study.
Overall, parents reported that their children were diagnosed by a variety of health care workers, with 53.1% diagnosed by a PCP, 18% by a psychiatrist, 14.2% by a psychologist outside of school, 4.9% by a neurologist and 9.7% reporting diagnosis by “other,” such as a school professional.
Other findings included:
- More than 75% of children were diagnosed with ADHD before age 9 years;
- The median age at which children were diagnosed with ADHD was 7 years;
- Children aged younger than 6 years were more likely to be diagnosed by a psychiatrist;
- Children aged 6 years or older were more likely to be diagnosed by a psychologist;
- The initial concern of ADHD was reported by a family member in 64.7% of cases;
- The initial concern of ADHD was reported by a school professional in 30.1% of cases; and,
- Only a family member provided information to a health care worker during the ADHD diagnosis process in 18.1% of cases.
“These findings may be used to inform assessments of the alignment between clinical practice and the 2011 AAP clinical practice guidelines for ADHD,” Visser and colleagues wrote. – by David Costill
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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L. Eugene Arnold, MD, MEd
This article summarizes some statistics from a nationally representative sample of families —there were no great surprises. The median age at diagnosis was 7, coinciding with late first grade, early second grade, when many children with ADHD have “hit the brick wall.” In preschool, kindergarten, and first grade many children were able to get by with the expectation that they would mature; however, by end of first grade it becomes obvious that they will not outgrow the problem. The chart illustrates well the individual variability among children in being able to ‘get by’ without diagnosis, probably related to the interaction of intelligence (able to ‘get by’ longer) and symptom severity (cannot ‘get by’ as long). Almost one-sixth of children with ADHD are diagnosed each year from age 4 to 8 years, but almost one-fourth were diagnosed after age 9 —probably those who are brighter with less severe symptoms.
Perspective
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Carol Vidal, MD, MPH
ADHD can be impairing and lead to negative outcomes if untreated. However, its diagnosis in the U.S. has increased by 42% over the past decade, igniting discussions among researchers and clinicians about the socio-cultural aspects of a society that may lead to over-diagnosis and over-prescription – for example, using stimulants to calm children or help them perform better in a demanding school environment. Other researchers, however, think this is a sign of improved diagnosis and treatment. This increase raises questions about the validity of the diagnosis and the CDC is looking to find a balance so that children are appropriately screened but not overly diagnosed.
As a first step to better understand how the diagnosis is made, the new report titled “Diagnostic Experiences of Children with Attention Deficit/Hyperactivity disorder” describes the experiences of the parents of a sample of 2,976 American children diagnosed with ADHD, in an attempt to understand if providers are adhering to the AAP diagnostic guidelines. The report also compares experiences for children diagnosed before and after the age they enter school (age 6).
The study is based on the 2014 National Survey of the Diagnosis and treatment of ADHD and Tourette syndrome, a follow-up phone survey of parents who, during the National Survey of Children’s Health phone survey conducted in 2011-2012, reported having been told by a provider that their child had a diagnosis of ADHD. Besides some methodological limitations — the parents were subject to recall bias and the data were not validated against medical records — the study provides valid information about current practices and opportunities for improvement.
A sign of good adherence to the guidelines is the finding that behavior rating scales were used for 9 out of 10 children of the group age diagnosed before and after 6 years of age. However, there is room for improvement at younger ages. One out of three diagnoses of ADHD are made in children aged younger than 6 years. Child health care providers are involved in 39.3% of the diagnoses of ADHD made at that age, whereas 82.4% of school staff and teachers are involved in the group of children diagnosed after age 6. Having informants from a setting in which the child interacts with peers, and is expected to follow directions and learn, is important as it can better predict their future ability to function. Furthermore, clinical recommendations require impairment in at least two settings, but one in five providers relied on data collected exclusively from family members. This suggests that there could be better adherence to guidelines in children diagnosed at younger ages.
Not explored in this study, but for future consideration, is the risk of confusing developmentally-appropriate behaviors with pathological behavior in younger children. Many of the DSM criteria are focused on academic functioning, which may be difficult to measure in pre-school children. Additionally, the interference or reduced quality “social, academic, or occupational functioning” criterion can also have a wide range of interpretation: the same child may be seen as functionally impaired by one care provider but not by another. This is a necessary study and a first step in the extensive work needed to correctly diagnose and treat children’s mental health disorders.
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