In the Journals

ADHD diagnosis among preschoolers stabilizes after publication of AAP guidelines

The release of the 2011 AAP practice guidelines for attention-deficit/hyperactivity disorder was associated with an end to an increasing trend in diagnosis of preschoolers, according to data recently published in Pediatrics. Rates of prescribing stimulants remained steady.

However, rates of diagnosis and stimulant prescribing varied among clinics nationwide.

“Still, given the possibility of overlap between normal behavior and behaviors associated with ADHD and the relative lack of trials in the age group, pediatricians and the public have been concerned about the potential for excessive diagnosis and medication treatment of preschool-aged children,” Alexander G. Fiks, MD, MSCE, from the Center for Pediatric Clinical Effectiveness at Children’s Hospital of Philadelphia, and colleagues wrote. “Before 2011, no [AAP] guideline existed to help pediatricians diagnose or treat ADHD among preschoolers.”

To identify patterns of diagnosis and treatment of preschool-aged children after publication of the 2011 AAP guideline, the researchers culled electronic health record data from 63 primary care practices within the Comparative Research Through Collaborative Electronic Reporting Consortium. Data included 211,558 visits by 143,881 children aged 4 to 5 years between January 2008 and July 2014. The researchers compared trends in ADHD diagnosis and stimulant prescribing prior to and after guideline implementation using logistic regression analysis with a spline and cluster method.

Before guideline publication, the diagnosis rate of ADHD among preschoolers was 0.7% (n= 87,067; 118,957 visits; 95% CI, 0.7-0.8). After publication, the diagnosis rate was 0.9% (n = 56,814; 92,601 visits; 95% CI, 0.8-0.9). Children were prescribed stimulants at 0.4% (95% CI, 0.4-0.4) of visits during both periods. Children were also diagnosed with comorbidities and polypharmacy was identified at the same rates during both periods.

However, the number of children with an ADHD diagnosis who received stimulants decreased significantly prior to 2011 (P < .001).

“These findings indicated 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,” the researchers wrote. “Additional investigation is needed to understand whether these patterns reflect local changes in the population under care, varying demand for evaluation of preschool ADHD, or unknown differences in how clinicians respond to guidelines.” – by Kate Sherrer

Disclosure: Fiks reports an independent research grant from Pfizer for work on ADHD unrelated to this study. All other researchers report no relevant financial disclosures.

The release of the 2011 AAP practice guidelines for attention-deficit/hyperactivity disorder was associated with an end to an increasing trend in diagnosis of preschoolers, according to data recently published in Pediatrics. Rates of prescribing stimulants remained steady.

However, rates of diagnosis and stimulant prescribing varied among clinics nationwide.

“Still, given the possibility of overlap between normal behavior and behaviors associated with ADHD and the relative lack of trials in the age group, pediatricians and the public have been concerned about the potential for excessive diagnosis and medication treatment of preschool-aged children,” Alexander G. Fiks, MD, MSCE, from the Center for Pediatric Clinical Effectiveness at Children’s Hospital of Philadelphia, and colleagues wrote. “Before 2011, no [AAP] guideline existed to help pediatricians diagnose or treat ADHD among preschoolers.”

To identify patterns of diagnosis and treatment of preschool-aged children after publication of the 2011 AAP guideline, the researchers culled electronic health record data from 63 primary care practices within the Comparative Research Through Collaborative Electronic Reporting Consortium. Data included 211,558 visits by 143,881 children aged 4 to 5 years between January 2008 and July 2014. The researchers compared trends in ADHD diagnosis and stimulant prescribing prior to and after guideline implementation using logistic regression analysis with a spline and cluster method.

Before guideline publication, the diagnosis rate of ADHD among preschoolers was 0.7% (n= 87,067; 118,957 visits; 95% CI, 0.7-0.8). After publication, the diagnosis rate was 0.9% (n = 56,814; 92,601 visits; 95% CI, 0.8-0.9). Children were prescribed stimulants at 0.4% (95% CI, 0.4-0.4) of visits during both periods. Children were also diagnosed with comorbidities and polypharmacy was identified at the same rates during both periods.

However, the number of children with an ADHD diagnosis who received stimulants decreased significantly prior to 2011 (P < .001).

“These findings indicated 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,” the researchers wrote. “Additional investigation is needed to understand whether these patterns reflect local changes in the population under care, varying demand for evaluation of preschool ADHD, or unknown differences in how clinicians respond to guidelines.” – by Kate Sherrer

Disclosure: Fiks reports an independent research grant from Pfizer for work on ADHD unrelated to this study. All other researchers report no relevant financial disclosures.