Preschool ADHD Diagnoses Stabilize After Guideline

Diana Phillips

November 15, 2016

The increasing rate of attention-deficit/hyperactivity disorder (ADHD) diagnoses in preschool-aged children stabilized after release of the American Academy of Pediatrics' practice guideline in 2011, a new study shows. Meanwhile, the overall rate of stimulant prescriptions, which had declined before the guideline release, remained the same.

"These are reassuring results given that a standardized approach to diagnosis was recommended and stimulant treatment is not recommended as first-line therapy for this age group," Alexander G. Fiks, MD, MSCE, associate director of the Center for Pediatric Clinical Effectiveness at Children's Hospital of Philadelphia, Pennsylvania, and colleagues report in an article published online November 15 in Pediatrics.

To examine the rates of ADHD diagnosis and stimulant prescribing among preschool aged children, the researchers reviewed electronic health record (EHR) data from 63 primary care practices in the Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER2) Consortium, extracting preventative health evaluation visits by children aged from 48 to less than 72 months between January 1, 2008, and June 30, 2014. The final study sample included 21, 558 visits from 143,881 children at 63 primary care practices.

The American Academy of Pediatrics released the practice guideline on October 1, 2011; therefore, the study periods of interest were January 1, 2008, to September 30, 2011 (preguideline) and October 1, 2011, to June 30, 2014 (postguideline). The preguideline period included 118,957 visits among 87,067 children, and the postguideline period included 92,601 visits among 56,814 children.

In the preguideline period, children had an ADHD diagnosis at 0.7% of visits compared with 0.9% in the postguideline period.

"These rates of preschool ADHD are lower than those found in the epidemiologic surveys of community samples that report between 2% and 4% of preschool children affected but, as expected, higher than rates found among 2- to 5-year-olds using claim data (0.5%–0.6%)," the authors report.

Although the mechanism behind the observed pattern would require a detailed chart review of the diagnostic processes used by individual clinicians, "our findings indicate that the standardization provided by the guideline did not trigger increases in diagnosis."

The rate of stimulant prescribing in the current study was stable across periods, at 0.4%, the authors report. "An examination of these rates is particularly important because behavior therapy, not stimulant medication treatment, is first-line management for ADHD in this age group, and previous investigations have found that nearly 80% of preschool children with ADHD received medication, compared with only slightly more than half receiving behavior therapy," they write.

Of note, the likelihood of receiving medication given a diagnosis of ADHD significantly decreased before the release of the 2011 guideline, but stabilized after. "This pattern of decreasing medication use given a diagnosis of ADHD over time may have been driven by the Preschool ADHD Treatment Study, published in 2006, which found that the effect size of stimulant treatment in preschool-aged children is lower than in school-aged children."

It is also possible that, as the proportion of all preschoolers diagnosed with ADHD increased, the severity of the condition across the population decreased, resulting in decreased stimulant prescribing, the authors hypothesize.

The researchers also observed significant variation across practice sites in the proportion of visits with an ADHD diagnosis or stimulant prescription from before to after guideline release. Specifically, the rates of diagnoses and stimulant prescribing, respectively, increased in 41% and 22% of practices, remained stable in 19% and 21% of practices, and decreased in 24% and 41% of practices.

"Because guidelines standardize care, we expected to see decreased variation across sites after guideline release. However, we found varying responses of sites to the guideline, and the interquartile range across practices for both diagnosis and stimulant prescribing did not narrow," the authors write. "These findings indicate that although the overall results of our study are reassuring, practices may be responding differently to the guideline both for diagnosis and prescribing, and standardization of ADHD practice may be difficult to achieve."

Further research is warranted "to understand whether these patterns reflect local changes in the population under care, varying demand for evaluation of preschool ADHD, or known differences in how clinicians respond to guidelines," the authors stress.

The current study is also notable because it demonstrates the feasibility of using multisite EHR data to measure practice change associated with the publication of clinical practice guidelines, the authors write. The systematic measurement of practice change in this way "could provide an opportunity to assess in what circumstances and contexts guidelines demonstrate the greatest impact, where there might be unintended consequences, and when additional practice supports are needed to better achieve guideline-based care."

This approach "is an innovative process that can provide more rigorous information about moving evidence into practice," Mark L. Wolraich, MD, from the University of Oklahoma Health Sciences Center, Oklahoma City, writes in an accompanying commentary.

As a tool to enhance the management of ADHD in preschool-aged children, however, the EHR "still has a long way to go," Dr Wolraich states. For example, although the current study showed that the release of recommended criteria for the use of stimulant medications did not increase its use in this age group, the frequency of behavioral parent training, the first-line recommended treatment, could not be ascertained from the EHR analyses, he notes.

Policy and technology improvements are needed to facilitate better communication across stakeholders, Dr Wolraich explains. Such improvements could include enhanced communication through patient and community portals and the electronic availability of behavior-rating scales, which "can be completed and reviewed by the providers and families on an ongoing basis," he says.

Further, "there needs to be greater standardization of assessment and treatment modalities so that we can better examine the outcomes of changes in treatment," Dr Wolraich stresses.

"[I]t truly will take a full-service integrated village to optimize ADHD care across the life span."

Dr Fiks disclosed receiving an Independent Research Grant from Pfizer for work on ADHD unrelated to this project. The other authors and Dr Wolraich have disclosed no relevant financial relationships.

Pediatrics. Article abstract, Commentary extract

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