Lower Rate of Preschool ADHD Diagnosis Since 2011 Practice Guideline
By Will Boggs MD
NEW YORK - The rate of attention-deficit/hyperactivity disorder (ADHD) diagnoses in preschoolers stopped rising after release of the 2011 American Academy of Pediatrics (AAP) guideline aimed at standardizing diagnosis and care of ADHD, but the rate of stimulant prescribing remained constant.
"I find it highly reassuring that the increasing trend in diagnosis of preschoolers with ADHD ended after the guidelines were released," Dr. Alexander G. Fiks from Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania told Reuters Health by email. "Pediatricians would be concerned if the release of the guidelines triggered accelerated growth in ADHD diagnosis or medication treatment, especially because typical behavior in preschoolers often includes at least some hyperactivity and inattentiveness."
The 2011 guideline advised primary care clinicians to "initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity."
For treatment, it specified, "For preschool-aged children (4-5 years of age), the primary care clinician should: 1) prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and 2) may prescribe methylphenidate if the behavioral interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child's function."
Dr. Fiks and colleagues examined changes in rates of ADHD diagnosis and stimulant prescribing to children ages 48 months to 72 months after publication of the 2011 ADHD practice guideline, as well as variability in the patterns of change across 63 primary care practices.
During the 45 months before the guideline was issued, the trajectory of ADHD diagnosis increased slightly but significantly across practices. The rate of ADHD diagnosis no longer increased significantly during the 33 months after release of the guideline.
The rate of stimulant prescribing was stable across periods (0.4%), as were the rates of comorbid diagnoses and polypharmacy, according to the November 15th Pediatrics online report.
The proportion of children with an ADHD diagnosis who received stimulants had already decreased significantly before guideline release, and after release that proportion did not change significantly over time.
There was considerable variability across primary care practices. The rate of preschool ADHD diagnosis increased in 41% of practices, did not change in 19% of practices, and decreased in 24% of practices after release of the guideline.
Rates of stimulant prescribing increased for 22% of practices, held steady for 21%, and decreased for 41% of practices.
"Pediatricians should be reassured that the publication of a standardized approach to diagnosis and treatment of ADHD in preschoolers did not trigger an epidemic," Dr. Fiks said. "Parents should be aware that pediatricians can be a very helpful resource for thinking about behavior problems in preschoolers broadly, as well as whether such behaviors might meet criteria for ADHD."
"Both the profession and public should be reminded that preschool ADHD is a very real condition, albeit one that should be diagnosed with caution and ideally treated with behavior therapy (first-line)," Dr. Fiks concluded.
Dr. Mark L. Wolraich from the University of Oklahoma Health Sciences Center in Oklahoma City, who wrote an editorial related to this report, told Reuters Health by email, "The main point I wanted to make in the commentary is that diagnosing and treating a child appropriately for ADHD requires more than the traditional pattern of diagnosing the condition by history of the parent/patient, physical exam, and laboratory tests and that treatment requires more than just prescribing medication. Input from teachers, social workers, and psychologists is very frequently required to appropriately diagnose these children."
He added, "When we first published the guidelines, we were criticized in the popular press for increasing the use of stimulant medication in young children. The reality was that this was being done already and the provision of what should be done before prescribing the medication, namely making a diagnosis based on DSM-5 criteria and first trying a behavioral information, has improved based on the results of this study."
Dr. Rudolph Uher from Dalhousie University, Halifax, Nova Scotia, Canada, who last year reported that five of eight youth who had taken stimulants experienced psychotic symptoms, told Reuters Health by email, "I have different views about diagnosis and stimulant prescribing. There may be advantages in early diagnosis if it is carried out in an objective and reliable way, especially if it opens opportunities for less invasive interventions."
"Based on our prior findings that stimulants cause distressing symptoms to some children, I am concerned about the increased rates of stimulant prescribing in children who are that young," he concluded. "Even if the increasing trend has slowed down, the rate of prescribing stimulants to preschoolers has not gone down."
SOURCE: https://bit.ly/2gdsMO3 and https://bit.ly/2gdEIjU
Pediatrics 2016.
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