Who Is Diagnosing All These Kids With ADHD?

Diagnostic Experiences of Children With Attention-Deficit/Hyperactivity Disorder

Visser SN, Zablotsky B, Holbrook JR, Danielson ML, Bitsko RH
Natl Health Stat Report. 2015;3:1-7

Study Summary

Approximately 11% of US children receive a diagnosis of attention-deficit/hyperactivity disorder (ADHD), and the prevalence of the condition has been increasing in recent decades. Although professional organization guidelines^[1] exist and outline specific criteria that should be met to make the diagnosis of ADHD, the extent to which diagnostic criteria are followed and who diagnoses ADHD in children are not clear.

The investigators present data from a 2014 nationally representative survey that was sponsored by the Centers for Disease Control and Prevention's National Center for Health Statistics. Households providing data for this report all had children aged 2-15 years. Data on the epidemiology of the diagnosis, the presence of other disorders, and the types of medication or behavioral treatment the child received were collected, as well as information about the types of symptoms present at diagnosis.

Children were included if the respondent answered "yes" to a question of whether a provider had ever diagnosed the child with ADHD or attention-deficit disorder. There were 2976 children with a diagnosis of ADHD in the analysis. The median age of the children at the time of diagnosis was 7 years, but approximately 31% received a diagnosis before age 6 years, and 76% of the diagnoses were made before age 9 years.

Family members were overwhelmingly the first individuals who had been concerned about whether the child might have ADHD. However, for approximately one third of the children who received a diagnosis after age 6 years, someone at school or daycare was the first to raise concern.

Pediatricians diagnosed ADHD in 39% of the children, with another 14.1% of cases being diagnosed by other primary care physicians. Psychologists diagnosed approximately 14% of cases among all children, psychiatrists diagnosed 18%, and neurologists diagnosed approximately 5%. The remaining children received the diagnosis from other types of providers.

For children in the youngest group (age 0-5 years), the proportions were relatively similar, with the exception of a slightly larger percentage of cases diagnosed by psychiatrists (23.7%) and relatively fewer diagnosed by psychologists. Pediatricians and other primary care physicians still diagnosed 37.4% and 12.2%, respectively, of the cases among children who received a diagnosis before age 6.

Parents reported that in 89.9% of the cases, behavior rating scales or checklists were used for diagnosis. Neuropsychological testing was used for 68% of all children, and 30% had neurologic imaging or other neurologic laboratory tests. Neuropsychological testing as well as imaging and laboratory testing were more likely to be used in children with ADHD diagnosed before age 6 years. Finally, in 81.9% of all cases, the providers obtained information from adults outside of the child's immediate family during some aspect of the evaluation process.

The investigators conclude that physicians, particularly pediatricians, make most ADHD diagnoses regardless of child age. They also emphasize that for approximately 18% of children who receive a diagnosis, no adult outside of the immediate family provided information as part of the evaluation process.

Viewpoint

These data are certainly eyebrow-raising, even though the findings are probably not greatly surprising to pediatric providers. I was surprised that even for children younger than 6 years, primary care physicians provide the bulk of the diagnoses. I definitely expected greater emphasis on testing and evaluation by psychologists or psychiatrists among children younger than 6. Children who received an ADHD diagnosis before 6 years of age were slightly more likely to have neurocognitive testing as well as other neurologic evaluation, including imaging, but large proportions of children, including young preschoolers, are still receiving a diagnosis on the basis of behavior rating scales and input from one or two adults.

One must be a little careful in interpreting these data, in that the analyses rely on parental report. It could be that parents either over- or underestimate the complexity of the evaluation that the providers undertook. Nonetheless, the survey points out the need for pediatric providers to make sure that they try to adhere to an organized and evidence-based approach when evaluating children for ADHD, particularly for children younger than 6 years, for whom school performance data as well as data from other adults who might interact with the child are less available.

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