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The introduction of the 2011 American Academy of Pediatrics practice guidelines on attention-deficit/hyperactivity disorder was associated with a leveling off in the number of diagnoses in preschool children.
“In the preguideline period, the trajectory of ADHD diagnosis increased slightly but significantly across practices,” Alexander G. Fiks, MD, from the Children’s Hospital of Philadelphia, and his coinvestigators wrote. “However, the rate of ADHD diagnosis no longer increased significantly after guideline release.”
They found that the rate of ADHD diagnoses was 0.7% before the release of the 2011 guidelines and 0.9% after, while the rate of stimulant prescriptions remained constant at 0.4% across the entire study period (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2025).
While the levels of stimulants prescribed remained the same across the period of the analysis, the proportion of children diagnosed with ADHD who were prescribed stimulants had already been in significant decline before the release of the guidelines. After the guidelines, this rate also plateaued, signifying that before – but not after – the guidelines, children were becoming less likely to be prescribed stimulant medication following an ADHD diagnosis.
Commenting on the change in diagnostic and prescribing patterns, the investigators noted that the primary goal of practice guidelines was to standardize care.
“In the case of preschool ADHD, such standardization might have resulted in an increasing trajectory in diagnosis of preschool children if pediatric clinicians had not previously been evaluating ADHD when an evaluation was warranted,” they wrote. “Alternatively, a decrease in diagnosis could have occurred if clinicians were applying more rigorous standards to the diagnosis and therefore excluding certain children who might have previously been diagnosed or no change if a combination of these two patterns was occurring or if there was no change in the standard used.”
They suggested that the observation of a decreasing likelihood of stimulant prescriptions for ADHD before the guidelines may have been driven by the results of the 2006 Preschool ADHD Treatment Study, which showed a lower effect size of stimulant medication in preschool-aged children, compared with school-aged children.
“Alternatively, findings may have resulted from a decrease in the severity of preschool children diagnosed with ADHD as the proportion of all preschoolers diagnosed with ADHD increased,” they wrote.
The study was supported by the U.S. Department of Health & Human Services. Dr. Fiks reported receiving a research grant from Pfizer for work on ADHD unrelated to this study. The other investigators reported having no financial disclosures.
It is encouraging for those of us who worked on crafting the revised guidelines to find some evidence about the impact of those recommendations. However, as the investigators point out, although they were able to find out that, in preschool-aged children with ADHD, recommended criteria for the use of stimulant medications, specifically methylphenidate, did not result in an increase in its use in this age group, the frequency of behavioral parent training, the first-line recommended treatment, could not be determined.
In addition, to address the issue that was the focus of this study, examining the implementation of evidence into practice, there needs to be greater standardization of assessment and treatment modalities so that we can better examine the outcomes of changes in treatment. Studies of prevalence and treatments of children with ADHD have indicated wide variations across the country. Clarifying those differences will require the improved ability to examine the various factors responsible for these variations, particularly across the systems of care that go beyond just medication use.
Mark L. Wolraich, MD, is from the University of Oklahoma Health Sciences Center, Oklahoma City. These comments are adapted from an accompanying editorial (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2928). He reported having no financial disclosures.
It is encouraging for those of us who worked on crafting the revised guidelines to find some evidence about the impact of those recommendations. However, as the investigators point out, although they were able to find out that, in preschool-aged children with ADHD, recommended criteria for the use of stimulant medications, specifically methylphenidate, did not result in an increase in its use in this age group, the frequency of behavioral parent training, the first-line recommended treatment, could not be determined.
In addition, to address the issue that was the focus of this study, examining the implementation of evidence into practice, there needs to be greater standardization of assessment and treatment modalities so that we can better examine the outcomes of changes in treatment. Studies of prevalence and treatments of children with ADHD have indicated wide variations across the country. Clarifying those differences will require the improved ability to examine the various factors responsible for these variations, particularly across the systems of care that go beyond just medication use.
Mark L. Wolraich, MD, is from the University of Oklahoma Health Sciences Center, Oklahoma City. These comments are adapted from an accompanying editorial (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2928). He reported having no financial disclosures.
It is encouraging for those of us who worked on crafting the revised guidelines to find some evidence about the impact of those recommendations. However, as the investigators point out, although they were able to find out that, in preschool-aged children with ADHD, recommended criteria for the use of stimulant medications, specifically methylphenidate, did not result in an increase in its use in this age group, the frequency of behavioral parent training, the first-line recommended treatment, could not be determined.
In addition, to address the issue that was the focus of this study, examining the implementation of evidence into practice, there needs to be greater standardization of assessment and treatment modalities so that we can better examine the outcomes of changes in treatment. Studies of prevalence and treatments of children with ADHD have indicated wide variations across the country. Clarifying those differences will require the improved ability to examine the various factors responsible for these variations, particularly across the systems of care that go beyond just medication use.
Mark L. Wolraich, MD, is from the University of Oklahoma Health Sciences Center, Oklahoma City. These comments are adapted from an accompanying editorial (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2928). He reported having no financial disclosures.
The introduction of the 2011 American Academy of Pediatrics practice guidelines on attention-deficit/hyperactivity disorder was associated with a leveling off in the number of diagnoses in preschool children.
“In the preguideline period, the trajectory of ADHD diagnosis increased slightly but significantly across practices,” Alexander G. Fiks, MD, from the Children’s Hospital of Philadelphia, and his coinvestigators wrote. “However, the rate of ADHD diagnosis no longer increased significantly after guideline release.”
They found that the rate of ADHD diagnoses was 0.7% before the release of the 2011 guidelines and 0.9% after, while the rate of stimulant prescriptions remained constant at 0.4% across the entire study period (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2025).
While the levels of stimulants prescribed remained the same across the period of the analysis, the proportion of children diagnosed with ADHD who were prescribed stimulants had already been in significant decline before the release of the guidelines. After the guidelines, this rate also plateaued, signifying that before – but not after – the guidelines, children were becoming less likely to be prescribed stimulant medication following an ADHD diagnosis.
Commenting on the change in diagnostic and prescribing patterns, the investigators noted that the primary goal of practice guidelines was to standardize care.
“In the case of preschool ADHD, such standardization might have resulted in an increasing trajectory in diagnosis of preschool children if pediatric clinicians had not previously been evaluating ADHD when an evaluation was warranted,” they wrote. “Alternatively, a decrease in diagnosis could have occurred if clinicians were applying more rigorous standards to the diagnosis and therefore excluding certain children who might have previously been diagnosed or no change if a combination of these two patterns was occurring or if there was no change in the standard used.”
They suggested that the observation of a decreasing likelihood of stimulant prescriptions for ADHD before the guidelines may have been driven by the results of the 2006 Preschool ADHD Treatment Study, which showed a lower effect size of stimulant medication in preschool-aged children, compared with school-aged children.
“Alternatively, findings may have resulted from a decrease in the severity of preschool children diagnosed with ADHD as the proportion of all preschoolers diagnosed with ADHD increased,” they wrote.
The study was supported by the U.S. Department of Health & Human Services. Dr. Fiks reported receiving a research grant from Pfizer for work on ADHD unrelated to this study. The other investigators reported having no financial disclosures.
The introduction of the 2011 American Academy of Pediatrics practice guidelines on attention-deficit/hyperactivity disorder was associated with a leveling off in the number of diagnoses in preschool children.
“In the preguideline period, the trajectory of ADHD diagnosis increased slightly but significantly across practices,” Alexander G. Fiks, MD, from the Children’s Hospital of Philadelphia, and his coinvestigators wrote. “However, the rate of ADHD diagnosis no longer increased significantly after guideline release.”
They found that the rate of ADHD diagnoses was 0.7% before the release of the 2011 guidelines and 0.9% after, while the rate of stimulant prescriptions remained constant at 0.4% across the entire study period (Pediatrics. 2016 Nov 15. doi: 10.1542/peds.2016-2025).
While the levels of stimulants prescribed remained the same across the period of the analysis, the proportion of children diagnosed with ADHD who were prescribed stimulants had already been in significant decline before the release of the guidelines. After the guidelines, this rate also plateaued, signifying that before – but not after – the guidelines, children were becoming less likely to be prescribed stimulant medication following an ADHD diagnosis.
Commenting on the change in diagnostic and prescribing patterns, the investigators noted that the primary goal of practice guidelines was to standardize care.
“In the case of preschool ADHD, such standardization might have resulted in an increasing trajectory in diagnosis of preschool children if pediatric clinicians had not previously been evaluating ADHD when an evaluation was warranted,” they wrote. “Alternatively, a decrease in diagnosis could have occurred if clinicians were applying more rigorous standards to the diagnosis and therefore excluding certain children who might have previously been diagnosed or no change if a combination of these two patterns was occurring or if there was no change in the standard used.”
They suggested that the observation of a decreasing likelihood of stimulant prescriptions for ADHD before the guidelines may have been driven by the results of the 2006 Preschool ADHD Treatment Study, which showed a lower effect size of stimulant medication in preschool-aged children, compared with school-aged children.
“Alternatively, findings may have resulted from a decrease in the severity of preschool children diagnosed with ADHD as the proportion of all preschoolers diagnosed with ADHD increased,” they wrote.
The study was supported by the U.S. Department of Health & Human Services. Dr. Fiks reported receiving a research grant from Pfizer for work on ADHD unrelated to this study. The other investigators reported having no financial disclosures.
Key clinical point:
Major finding: The rate of ADHD diagnoses was 0.7% before the guidelines and 0.9% after, while stimulant prescriptions remained constant at 0.4% across the study period.
Data source: An analysis of electronic health record data from 143,881 children across 63 primary care practice from January 2008 to July 2014.
Disclosures: The study was supported by the U.S. Department of Health & Human Services. Dr. Fiks reported receiving a research grant from Pfizer for work on ADHD unrelated to this study. The other investigators reported having no financial disclosures.