Original Article

Clinical Management of ADHD in a Family Medicine Residency Program: Comparison with AAP Guidelines

Authors: Jessica W. Skelley, PharmD, BCACP, P. Chase Carpenter, PharmD, M. Shawn Morehead, MD, MPH, Patrick L. Murphy, MD


Objectives: Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder. Research has shown that even with the growing incidence of children diagnosed as having ADHD, physicians may find providing optimal care to these patients challenging. Our objective was to contrast existing clinical management of ADHD in a family medicine setting with published American Academy of Pediatrics guidelines and review the literature pertinent to differences.

Methods: A report was generated for all visits with “ADHD” or “ADD” (attention-deficit disorder) as a current or past medical problem that had been addressed at the family medicine clinic from July 2012 to June 2014. A total of 60 pediatric patients were identified. A retrospective chart review of clinical practice and management patterns for these patients was completed using a standardized data collection form based on the 2011 ADHD treatment guidelines set by the American Academy of Pediatrics.

Results: Fifty-seven (95%) patients had documentation of at least one core symptom of ADHD, and 27 (45%) patients had documentation of these symptoms in more than one setting (clinic/school/home). Only 30 (50%) patients were assessed at the initial ADHD visit for coexisting conditions. Coexisting conditions were found to be present in 20 (33.3%) patients. Of these 20 patients, coexisting conditions were not addressed during the visit in 12 (60%) patients before drug therapy for ADHD was initially prescribed. Behavioral therapy was initiated as first-line monotherapy in one of the nine preschool-age patients (4–5 years old). Fifty-two (86.7%) patients received a preferred initial medication as identified by guidelines, and 41 (78.8%) of those patients received an appropriate initial dose. Fifty-one (85%) patients were assessed for improvement of symptoms, and 39 (65%) were assessed for adverse events. Of 62 documented medication adjustments, 54 (87.1%) adjustments coincided with current practice guidelines. Sixteen (26.7%) patients were referred to mental health specialists.

Conclusions: This retrospective review identified areas of strength and weakness for attending physicians and medical residents in the diagnosis, evaluation, and treatment of children with ADHD. A significant need was identified for more physician-focused education on the evaluation of coexisting conditions and long-term management associated with ADHD therapy. Further training in the initiation of behavioral therapy as a first-line treatment above drug therapy and proper medication selection in children aged 4 to 5 years also are recommended.

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1. Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics 2011;128:1007-1022.
2. Centers for Disease Control and Prevention. Attention-deficit/hyperactivity disorder (ADHD). Data and statistics. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed September 30, 2014.
3. Arndorfer RE, Allen KD, Aljazireh L. Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: implications for behavioral psychologists. Behav Ther 1999;30:137-148.
4. Hoagwood K, Kelleher KJ, Feil M, et al. Treatment services for children with ADHD: a national perspective. J Am Acad Child Adolesc Psychiatry 2000;39:198-206.
5. Barbaresi WJ, Katusic SK, Colligan RC, et al. How common is attention-deficit/hyperactivity disorder? Incidence in a population-based birth cohort in Rochester, Minn. Arch Pediatr Adolesc Med 2002;156:217-224.
6. Shaywitz BA, Shaywitz SE. Comorbidity: a critical issue in attention deficit disorder. J Child Neurol 1991;6(Suppl):S13-S22.
7. Polaha J, Cooper SL, Meadows T, et al. The assessment of attention-deficit/hyperactivity disorder in rural primary care: the portability of the American Academy of Pediatrics guidelines to the ‘‘real world.’’ Pediatrics 2005;115:e120-e126.
8. Jensen PS, Kettle L, Roper MT, et al. Are stimulants overprescribed? Treatment of ADHD in four U.S. communities. J Am Acad Child Adolesc Psychiatry 1999;38:797-804.
9. Daly ME, Rasmussen NH, Agerter DC, et al. Assessment and diagnosis of attention-deficit/hyperactivity disorder by family physicians. Minn Med 2006;89:40-43.
10. Hirfanoglu T, Soysal AS, Gucuyener K, et al. A study of perceptions, attitudes, and level of knowledge among pediatricians towards attention-deficit/hyperactivity disorder. Turk J Pediatr 2008;50:160-166.
11. American Academy of Pediatrics, Task Force on Mental Health. Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit [CD-ROM]. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
12. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children With ADHD. Arch Gen Psychiatry 1999;56:1073-1086.
13. Jensen PS, Hinshaw SP, Swanson JM, et al. Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr 2001;22:60-73.
14. Pelham WE Jr, Fabiano GA. Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 2008;37:184-214.
15. Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry 2006;45:1284-1293.
16. American Academy of Pediatrics. Implementing the key action statements: an algorithm and explanation for process of care for the evaluation, diagnosis, treatment, and monitoring of ADHD in children and adolescents. http://pediatrics.aappublications.org/content/suppl/2011/10/11/peds.2011-2654.DC1/zpe611117822p.pdf. Accessed March 29, 2016.
17. National Collaborating Centre for Mental Health. Attention Deficit Hyperactivity Disorder. Diagnosis and Management of ADHD in Children, Young People and Adults. London: National Institute for Health and Clinical Excellence (NICE); 2008.
18. Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007;46:894-921.
19. Copeland L, Wolraich M, Lindgren S, et al. Pediatricians’ reported practices in the assessment and treatment of attention deficit disorders. J Dev Behav Pediatr 1987;8:191-197.
20. Leslie LK, Weckerly J, Plemmons D, et al. Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings. Pediatrics 2004;114:129-140.