Trends in the Diagnosis and Management of ADHD
Trends in the Diagnosis and Management of ADHD
Garfield CF, Dorsey ER, Zhu S, et al
Acad Pediatr. 2012;12:110-116
The 2000s saw several changes in the clinical approach to diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). To begin with, practice guidelines were issued in 2000 and 2001 (and updated in 2011) in an effort to improve diagnosis and assessment of ADHD. In addition, many pharmaceutical options were introduced during that period, expanding the number and type of drugs approved for treating ADHD in children. Finally, concerns about the safety of some medications prompted advisories that may have affected use of certain pharmacotherapies for ADHD.
Garfield and colleagues used the National Disease and Therapeutic Index, a nationally representative survey of more than 4000 physicians, to assess how ADHD diagnosis, medication treatments, and other practices changed during 2000-2010. The participating physicians provided data on all patient contacts during a consecutive 2-day period once every 3 months. The investigators identified children younger than 18 years of age with ADHD using appropriate ICD-9 codes. They divided the therapeutic drugs into:
Overall, the number of visits at which ADHD was a diagnosis increased significantly during the study decade. Boys accounted for over 70% of all visits. Of note, no trend toward increased in visits in younger children was observed over the 10-year period. The percentage of visits for children aged 0-6 years, for example, fluctuated between 8% and 11% across the decade, with very little year-to-year change. The percentage of cases rated as severe also fluctuated little, 7%-12%, with no clear trend over the study period.
Pharmacotherapy changed markedly over the study years. Although the percentage of visits at which a child received a medication remained in the range of 93%-96%, the types of medications prescribed changed significantly. The percentage of patients who received stimulants declined overall, from 96%-98% at the beginning of the decade to 87%-92% by the later years. Atomoxetine experienced a surge in use in 2003-2006 but then drifted down to 6% by the end of the decade.
In 2000, 14% of the stimulants prescribed were long-acting preparations and 86% were short-acting. However, by 2010, the percentages were almost exactly reversed, with long-acting stimulants accounting for 87% of prescriptions. In fact, long-acting stimulants have represented most of the stimulants prescribed since 2002.
Prescription of alternative medications (clonidine, guanfacine, or bupropion) changed relatively little across most of the decade, then spiked to 13% in 2010, coincident with the release of a long-acting guanfacine preparation. Across the study decade, the number of children prescribed a stimulant who received either amphetamine-based or methylphenidate-based preparations remained essentially 50%. A slight trend toward methylphenidate or methylphenidate-based preparations in recent years was revealed.
The overwhelming majority of visits for patients on stimulants, 82%-87% depending on the year, were for children who were receiving only stimulants. The percentages who received stimulants plus other potential medications changed little.
A trend toward fewer total visits to pediatricians was seen throughout the decade, decreasing from 54% to 47%. Visits to family medicine or internal medicine physicians remained constant, at 9%-10%. Visits to psychiatrists increased from 25% to 37%. Garfield and colleagues concluded that during the decade studied, ambulatory visits during which ADHD was diagnosed increased and more of these children were seen by psychiatrists.
ADHD, as one of the most prevalent pediatric chronic conditions in childhood, is certainly a part of daily practice for virtually every pediatric provider. The data in Garfield and colleagues' study cover such a large period that it is difficult to know exactly what has influenced the changes in practice. Diagnostic and regulatory changes, as well as changes in pharmacotherapeutic options and marketing, have all probably had an influence on diagnosis and prescribing during the study years.
It does seem clear that providers have made a wholesale switch to use of long-acting preparations, but it is hard to know whether that was based on quality of evidence, quality of marketing, or both of these factors. Certainly, the published guidelines increased awareness of making a systematic diagnosis of ADHD, but it would be very interesting to see a study that evaluated the appropriateness of diagnoses over the same study years to determine how well we have done in not only increasing the number of children diagnosed but in making appropriate diagnoses.
Abstract
Trends in Attention Deficit Hyperactivity Disorder Ambulatory Diagnosis and Medical Treatment in the United States, 2000-2010
Garfield CF, Dorsey ER, Zhu S, et al
Acad Pediatr. 2012;12:110-116
Study Summary
The 2000s saw several changes in the clinical approach to diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). To begin with, practice guidelines were issued in 2000 and 2001 (and updated in 2011) in an effort to improve diagnosis and assessment of ADHD. In addition, many pharmaceutical options were introduced during that period, expanding the number and type of drugs approved for treating ADHD in children. Finally, concerns about the safety of some medications prompted advisories that may have affected use of certain pharmacotherapies for ADHD.
Garfield and colleagues used the National Disease and Therapeutic Index, a nationally representative survey of more than 4000 physicians, to assess how ADHD diagnosis, medication treatments, and other practices changed during 2000-2010. The participating physicians provided data on all patient contacts during a consecutive 2-day period once every 3 months. The investigators identified children younger than 18 years of age with ADHD using appropriate ICD-9 codes. They divided the therapeutic drugs into:
stimulants;
atomoxetine;
alternative medications, such as clonidine, guanfacine, and bupropion; and
antipsychotics.
Overall, the number of visits at which ADHD was a diagnosis increased significantly during the study decade. Boys accounted for over 70% of all visits. Of note, no trend toward increased in visits in younger children was observed over the 10-year period. The percentage of visits for children aged 0-6 years, for example, fluctuated between 8% and 11% across the decade, with very little year-to-year change. The percentage of cases rated as severe also fluctuated little, 7%-12%, with no clear trend over the study period.
Pharmacotherapy changed markedly over the study years. Although the percentage of visits at which a child received a medication remained in the range of 93%-96%, the types of medications prescribed changed significantly. The percentage of patients who received stimulants declined overall, from 96%-98% at the beginning of the decade to 87%-92% by the later years. Atomoxetine experienced a surge in use in 2003-2006 but then drifted down to 6% by the end of the decade.
In 2000, 14% of the stimulants prescribed were long-acting preparations and 86% were short-acting. However, by 2010, the percentages were almost exactly reversed, with long-acting stimulants accounting for 87% of prescriptions. In fact, long-acting stimulants have represented most of the stimulants prescribed since 2002.
Prescription of alternative medications (clonidine, guanfacine, or bupropion) changed relatively little across most of the decade, then spiked to 13% in 2010, coincident with the release of a long-acting guanfacine preparation. Across the study decade, the number of children prescribed a stimulant who received either amphetamine-based or methylphenidate-based preparations remained essentially 50%. A slight trend toward methylphenidate or methylphenidate-based preparations in recent years was revealed.
The overwhelming majority of visits for patients on stimulants, 82%-87% depending on the year, were for children who were receiving only stimulants. The percentages who received stimulants plus other potential medications changed little.
A trend toward fewer total visits to pediatricians was seen throughout the decade, decreasing from 54% to 47%. Visits to family medicine or internal medicine physicians remained constant, at 9%-10%. Visits to psychiatrists increased from 25% to 37%. Garfield and colleagues concluded that during the decade studied, ambulatory visits during which ADHD was diagnosed increased and more of these children were seen by psychiatrists.
Viewpoint
ADHD, as one of the most prevalent pediatric chronic conditions in childhood, is certainly a part of daily practice for virtually every pediatric provider. The data in Garfield and colleagues' study cover such a large period that it is difficult to know exactly what has influenced the changes in practice. Diagnostic and regulatory changes, as well as changes in pharmacotherapeutic options and marketing, have all probably had an influence on diagnosis and prescribing during the study years.
It does seem clear that providers have made a wholesale switch to use of long-acting preparations, but it is hard to know whether that was based on quality of evidence, quality of marketing, or both of these factors. Certainly, the published guidelines increased awareness of making a systematic diagnosis of ADHD, but it would be very interesting to see a study that evaluated the appropriateness of diagnoses over the same study years to determine how well we have done in not only increasing the number of children diagnosed but in making appropriate diagnoses.
Abstract