Abstract
This cohort study investigates the rate of pediatrician recommendations for behavioral treatment for preschoolers with an attention-deficit/hyperactivity disorder diagnosis or symptoms.
Primary care professionals (PCPs) diagnose and treat most US preschool-aged children with attention-deficit/hyperactivity disorder (ADHD).1 The American Academy of Pediatrics (AAP) published clinical practice guidelines for PCPs in 2011 and again in 2019,2 emphasizing parent training in behavior management (PTBM) as the first-line treatment for children aged 4 to 5 years with an ADHD diagnosis or ADHD symptoms (eg, hyperactivity/impulsivity) given stronger evidence for PTBM vs ADHD medications such as methylphenidate.3 To our knowledge, the extent to which PCPs follow this AAP clinical practice guideline has not yet been studied. We analyzed PCP documentation from electronic health records (EHRs) to assess the rates of pediatrician PTBM recommendations for 4- to 5-year-olds who had an ADHD diagnosis or ADHD symptoms or were prescribed ADHD medications.
Methods
For this cohort study, we reviewed EHRs for children aged 48 to 71 months with 2 or more visits (from October 1, 2015, to December 31, 2019) at 1 of 10 primary care practices within the Packard Children’s Health Alliance, a community-based pediatric health care network in the San Francisco, California, area, as previously described.4 Patients with 1 or more ADHD-related visits, defined as a visit with International Classification of Disease, Tenth Revision ADHD diagnosis codes or symptom-level diagnosis codes (eg, hyperactivity), were included. Patients with an autism diagnosis were excluded. The Stanford University School of Medicine Institutional Review Board approved the study and granted an informed consent waiver. Informed consent was waived because the study involved no more than minimal risk to the patients and precautions were taken to ensure that confidentiality was maintained.
Two pediatricians (Y.B. and other) performed independent medical record reviews and annotated clinical notes (eMethods in the Supplement). They validated that ADHD-related visits included a discussion of ADHD and noted subspecialist involvement (eg, a developmental pediatrician). Two types of PTBM mentions were annotated: (1) the PCP referred families to professionals for PTBM and (2) the PCP counseled families and/or provided handouts on PTBM. Of 277 independently annotated clinical notes, the annotators reconciled 21 disagreements in PTBM annotation (8%). When agreement was not reached for 4 mentions, a third pediatrician (L.C.H.) made the final decision.
Multivariable logistic regression models were fit, accounting for practice affiliation. Adjusted relative risks with 95% CIs were calculated for patient factors associated with PTBM recommendations, including sex, insurance type, comorbid condition(s), ADHD medications prescribed (stimulants, α-2 agonists, or atomoxetine), ADHD diagnosis type (disorder or symptoms), and subspecialist involvement. Patient age was not included in the models because of low variability with regard to age in our cohort, which included only children aged 4 to 5 years. Self-reported race and ethnicity data, as documented in the EHR, were not included in the model because of missing data (ie, for 27 patients [35.5%] who received a recommendation for PTBM and 42 [36.2%] who did not). A sensitivity analysis that included imputed race and ethnicity data did not change the model results (data not shown). Analyses were conducted using R software (version 3.5.2). This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Results
Of 22 714 children in this study, 192 (1%) had an ADHD diagnosis or ADHD symptoms. Of these patients, 141 (73%) were male, 123 (64%) were privately insured, 108 (56%) had subspecialists involved, and 32 (17%) were prescribed ADHD medications (stimulants comprised 88%) by PCPs (Table 1). The most common treatment recommendation was not PTBM but rather routine/habit modifications—including dietary modifications (eg, reduced sugar intake) and supplements (eg, ω-3 fatty acids), sleep hygiene, and limited screen time—for 79 patients (41%). Of the 192 patients, only 21 (11%) received referrals for PTBM in ADHD-related visits. Another 55 patients (29%) had mention of PCP-provided counseling on PTBM, including handouts. Of 32 patients for whom the PCP prescribed ADHD medications, 9 (28%) had PTBM recommendations documented; for 4 patients (13%), the PCP recommended PTBM before prescribing the first medication. In multivariable logistic regression models, patients with public insurance were less likely to receive a PTBM recommendation (adjusted relative risk, 0.87; 95% CI, 0.78-0.98) compared with those with private insurance (Table 2).
Table 1. Characteristics of 192 Patients With an ADHD Diagnosis or ADHD Symptoms.
| Characteristic | Behavioral treatment recommended, No. (%) | Absolute standardized differencea | |
|---|---|---|---|
| No (n = 116) | Yes (n = 76) | ||
| Behavioral treatment | |||
| Referral | NA | 21 (27.6) | NA |
| Counsel | NA | 55 (72.4) | NA |
| Sex | |||
| Male | 81 (69.8) | 60 (78.9) | 0.21 |
| Female | 35 (30.2) | 16 (21.1) | |
| Age, mean (SD), mob | 62.6 (6.6) | 61.1 (6.7) | 0.23 |
| Insurance | 0.30 | ||
| Private | 71 (61.2) | 52 (68.4) | |
| Public | 33 (28.4) | 14 (18.4) | |
| Military | 9 (7.8) | 5 (6.6) | |
| Unknown | 3 (2.6) | 5 (6.6) | |
| Race and ethnicityc | 0.35 | ||
| Asian | 13 (11.2) | 7 (9.2) | |
| Black | 7 (6.0) | 2 (2.6) | |
| Hispanic | 17 (14.7) | 6 (7.9) | |
| White | 29 (25.0) | 25 (32.9) | |
| Other | 8 (6.9) | 9 (11.8) | |
| Unknown | 42 (36.2) | 27 (35.5) | |
| ADHD disorder diagnosis | 52 (44.8) | 25 (32.9) | 0.25 |
| Subspecialist involvement in diagnosis and/or treatment | 66 (56.9) | 42 (55.3) | 0.03 |
| Medication prescribed | 23 (19.8) | 9 (11.8) | 0.22 |
| No. of comorbid conditionsd | 0.33 | ||
| 0 | 49 (42.2) | 38 (50.0) | |
| 1 | 54 (46.6) | 24 (31.6) | |
| ≥2 | 13 (11.2) | 14 (18.4) | |
| No. of ADHD-related visits, mean (SD)e | 1.43 (1.1) | 1.53 (1.3) | 0.08 |
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; NA, not applicable.
Absolute standardized difference values of 0.2, 0.5, and 0.8 correspond to small, moderate, and large differences, respectively.
Age at first ADHD-related visit. Mean (SD) values are displayed for continuous variables, including age and ADHD visits.
Race and ethnicity data were documented separately in the electronic health record. Here we combined data into race and ethnicity variables, including Asian (non-Hispanic Asian), Black (non-Hispanic Black), Hispanic (irrespective of the value in the race category), White (non-Hispanic White), and other (non-Hispanic other).
Includes behavioral problems (eg, oppositional defiant disorder), emotional problems (eg, anxiety, depression), language delay or disorder, learning problem or disability, developmental delay or disability, and sleep problems.
Number of ADHD-related visits when the patient was aged 4 to 5 years.
Table 2. Results of Multivariable Logistic Regression Models for Likelihood of Receiving PTBM Recommendation and Patient Factors, Adjusting for Practice Affiliation.
| Patient factor | aRR (95% CI) | P value |
|---|---|---|
| Male sex | 1.09 (0.98-1.20) | .12 |
| Insurance | ||
| Private | 1 [Reference] | NA |
| Public | 0.87 (0.78-0.98) | .02 |
| Military | 1.03 (0.86-1.20) | .75 |
| Disorder diagnosis | 0.98 (0.89-1.06) | .41 |
| Subspecialist involvement in diagnosis and/or treatment | 0.99 (0.91-1.08) | .87 |
| Medication prescribed | 0.93 (0.81-1.06) | .26 |
| No. of comorbid conditions | ||
| 0 | 1 [Reference] | NA |
| 1 | 0.96 (0.88-1.04) | .35 |
| ≥2 | 1.07 (0.95-1.20) | .26 |
Abbreviations: aRR, adjusted relative risk; NA, not applicable; PTBM, parent training in behavior management.
Discussion
The results of this cohort study suggest that within a large community-based health care network, most preschool-aged children with PCP-diagnosed ADHD or ADHD symptoms were not offered first-line, evidence-based behavioral treatment. Rates of PTBM recommendation were especially low among publicly insured patients, underscoring the need to identify barriers that drive disparities in recommended treatments. These objective data on PCP practices complement previous survey-based and claims-based studies reporting that about half of young children with ADHD received behavioral treatment.5,6
The limitations of this study include relying on PCP documentation in the study period and limiting medical record review to visits with diagnostic codes for ADHD or related symptoms. These findings must be replicated beyond the examined health care system to assess generalizability.
These study findings offer an opportunity for quality improvement initiatives to increase PCP adherence to clinical practice guidelines—thus establishing early access to behavioral treatment for patients with an ADHD diagnosis or ADHD symptoms—with the goal of mitigating long-term morbidity.
eMethods. Annotation Guidelines
References
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Associated Data
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Supplementary Materials
eMethods. Annotation Guidelines