Study analyzes ADHD diagnosis, stimulant use after guideline released
from the AAP Department of Research
Diagnosis of attention-deficit/hyperactivity disorder (ADHD) stopped increasing and
stimulant use remained constant among U.S preschool children after the 2011 release
of the AAP clinical practice guideline on the diagnosis and treatment of ADHD (http://bit.ly/2p0JpNW).
These findings are detailed in a recently published study involving the AAP Pediatric
Research in Office Settings (PROS) network (Fiks AG, et al. Pediatrics. 2016;138:e20162025, http://bit.ly/2qpeWtY).
The 2011 guideline provided the first evidence-based recommendations for the diagnosis
and treatment of ADHD in preschool-age children. However, the limited research before
and after release of the guideline left pediatricians and parents concerned about
possible over-diagnosis and medication treatment in this age group.
Researchers used a large national database of electronic health record data to compare
rates of diagnosis and stimulant use among U.S. children 48-72 months of age before
and after release of the guideline.
Data from 63 primary care practices were analyzed, including 211,558 preventive care
visits by 143,881 children. In the pre-guideline period (from Jan. 1, 2008, through
Sept. 30, 2011), 87,067 children had 118,957 visits. In the post-guideline period
(from Oct. 1, 2011, through June 30, 2014), 56,814 children had 92,601 visits. ADHD
was identified by International Classification of Diseases, Ninth Revision codes 314.0-314.9.
ADHD diagnoses and stimulant prescribing were more common among boys than in girls
and in children 61-72 months old relative to children ages 48-60 months before and
after release of the guideline.
Analyses compared the proportion of preventive care visits in the pre- and post-guideline
periods during which children had a diagnosis of ADHD or received a prescription for
stimulants. In the pre-guideline period, children had an ADHD diagnosis at 848 of
118,957 visits (0.7%) and received a stimulant prescription at 467 visits (0.4%).
In the post-guideline period, children had an ADHD diagnosis at 796 of 92,601 visits
(0.9%) and received a stimulant prescription at 326 visits (0.4%).
Regression analyses were performed to compare trajectories of diagnosis and prescribing
in the 45 months before vs. the 33 months after release of the guideline. The previously
increasing rate of diagnosis leveled off after release of the guideline, and stimulant
prescribing remained consistent across both periods (see figure).
Although analyses could not determine causality, they did account for trajectories
in diagnosis and prescribing over time. This study highlights the power of large datasets
to examine questions about uncommon conditions or conditions with infrequent treatment.
Because of the large cohort, researchers could detect the small percentage of children
who were diagnosed with and receiving medication treatment for ADHD.
This study involved collaboration among pediatric practices from the AAP PROS network;
the AAP Comparative Effectiveness Research through Collaborative Electronic Reporting
(CER2) Consortium research team; and researchers from the MetroHealth System and Case Western
Reserve in Cleveland, The Children’s Hospital of Philadelphia (CHOP), University of
Pennsylvania, University of Vermont and the Academy.
The project was supported in part by the Health Resources and Services Administration
(HRSA) of the U.S. Department of Health and Human Services (HHS) with the National
Institutes of Child Health and Human Development under grants R40MC24943, UB5MC20286
and UA6MC15585; CHOP and the Academy.
This content and conclusions are those of the authors and should not be construed
as the official position or policy of, nor should any endorsements be inferred by
HRSA, HHS or the U.S. government.