ADHD Treatment Varies with Practice Specialty

Primary care physicians (PCPs), who treat the majority of children and adolescents with attention-deficit/hyperactivity disorder (ADHD), are more likely than child psychiatrists to prescribe medication in the initial visit, and less likely to diagnose comorbid conditions or refer for consults.

The research team lead by Hua Chen, MD, PhD, College of Pharmacy, University of Houston, Texas, examined electronic medical records for the period between 1995 and 2010 to identify over 100,000 children and adolescents (hereafter referred to as children) who had been prescribed a stimulant medication or atomoxetine (Strattera, Eli Lilly) after receiving a new diagnosis of ADHD.

The final study cohort included 66,719 children who had received some follow-up within one-year of the initial diagnosis.

“To improve the quality of care for children with ADHD, it is necessary to understand the differences between practice of PCPs and child psychiatrists,” said Chen. “However, little relevant information exists in the literature. Therefore, we compared the current practice of diagnosis, treatment, and monitoring.”

The population that had ever been diagnosed with ADHD comprised approximately 5% of the almost 4 million children in the GE Centricity database, coinciding with other estimates of the prevalence of the disorder. The retrospective cohort study distinguished between those receiving the index diagnosis of ADHD from a PCP or child psychiatrist. The 2 groups were then compared on several measures: diagnosis of comorbid psychiatric disorder; follow-up care, including collaborative referral for consult; time to prescribing ADHD medication after index diagnosis; and use of a single or of multiple psychotropic medications.

The researchers noted that although children with ADHD have increased risk for comorbid conditions such as depression, anxiety, and conduct or oppositional disorder, these were less likely to be diagnosed by PCPs than child psychiatrists. In this population, the PCP diagnosed 2.2% with comorbid depression compared to 3.5% diagnosed by the child psychiatrist; 1.8% with anxiety versus 4.4%; 2.2%with conduct or oppositional disorder versus 3.5%.

Chen and colleagues cited previous research findings that PCPs were likely to miss comorbid mental illness in their patients with major depression. "Given the increasingly important role of PCPs as gatekeepers for ADHD identification and treatment among children, it is critical to develop collaborative approaches that involve PCPs and specialists in the diagnostic process," they indicate.

The number of follow-up visits within 10 months after an initial medication prescription was similar in both groups, with PCPs having a slightly lower mean of 6.56 visits compared to 7.26 with child psychiatrists. There was a substantial difference in referrals after the index diagnostic visit; however, with PCPs referring 0.9% for consult, compared to 84.6% referred by child psychiatrists for follow-up specialty care.

The groups were also distinctly different in the time period before prescribing medication, with 59% of PCPs providing a prescription immediately upon diagnosis, compared to 43% of child psychiatrists. Chen and colleagues speculated that the difference reflected a preference of child psychiatrists for a "period of watchful waiting". In prescribing medication; however, the child psychiatrists — more likely to diagnose comorbid psychiatric conditions – were also more likely than the PCP to add other psychiatric medications to the prescription for ADHD.

The comparison of care and prescribing practice for ADHD by PCPs and child psychiatrists, “Care Provision and Prescribing Practices of Physicians Treating Children and Adolescents with ADHD,” was posted on-line February 15 in Psychiatric Services.

Related Coverage:

80 Percent of Children's Doctor Visits for ADHD Result in Stimulant Medication

Youngest in Class Most Likely to Receive ADHD Medication

Girls with ADHD Often Have Comorbid Behavioral Disorders