Attention-deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed childhood neurodevelopmental disorders. Children with ADHD experience a persistent pattern of inattention and/or hyperactivity, which significantly interferes with their functioning and/or development.1 According to the National Survey of Children's Health, approximately 9.4% of US school-aged children received a diagnosis of ADHD in 2018.2 This accounts for approximately 6.1 million children, or 1 in 5 school-aged boys and 1 in 11 girls, and the rate of diagnosis continues to rise by 5% each year.3 Based on this prevalence, it is likely that most individuals will experience the direct or indirect consequences of poorly managed ADHD during their lifetime. Poorly managed ADHD, characterized by emotional dysregulation, externalizing behaviors, poor school performance, and family disruption, often have profoundly negative effects on the patient, family, and community.4
The significance of poorly managed ADHD is amplified by its negative impact on multiple domains of the child's life. Core symptoms of inattention, hyperactivity, impulsivity, and aggression create persistent difficulties with peers and increase the child's risk for frequent injuries, adolescent pregnancy, school dropout, substance use disorder, and entry into the juvenile justice system.5 At least 25% of inmates in the US have untreated ADHD, and of those, two-thirds will experience frequent recidivism.6 Young and colleagues indicate that living with undiagnosed or poorly managed ADHD doubles a person's risk for substance use, especially tobacco, cocaine, and marijuana.6 van Emmerik-van Oortmerssen and colleagues found that adolescents living with ADHD not only have increased rates of substance use, but initiate substance use at an earlier age, and relapse more often after drug rehabilitation than those living without the disorder.7 Families are not excluded from the consequences of ADHD, and are likely to bear a substantial impact from living with an affected child. These families experience high rates of negative parent-child relationships, marital discord, dysfunctional parenting, and increased parental stress and depression.8 On a societal level, poorly managed ADHD creates a significant economic burden. Fisher estimates that the annual societal cost of illness for ADHD ranges from $38 billion to $72 billion.9
Recognizing the need for appropriate management of ADHD, the American Academy of Pediatrics (AAP) published an evidence-based practice guideline for diagnosis in 2000 and a treatment guideline in 2001. These guidelines were subsequently updated in 2011. Treatment guidelines were based on randomized control trials, which highlighted medication efficacy and indicated that the benefits of treatment strongly outweigh the risks. In addition, the trials revealed that a lack of proper treatment significantly increases the risk of poor patient outcomes.10 These facts should motivate clinicians to adhere to AAP guidelines for the diagnosis and treatment of childhood ADHD. Unfortunately, several studies identify poor adherence, including a study by Langberg and colleagues, which found that only 27% of physicians reported adhering to the AAP guidelines.11 Given the similarity of patient populations managed by primary care physicians and NPs, these results can be extrapolated to hypothesize that NPs also lack guideline adherence. Therefore, this study surveyed Upstate New York NPs and examined their use of the AAP guideline.
The literature includes very few studies on clinician use of childhood ADHD diagnosis and treatment guidelines, and no exclusive studies of NPs. There is a wide variation in study setting and sample size, and the literature is overwhelmingly limited to convenience samples of community-based pediatric physicians. In addition, there are no recent studies on this topic. Only two studies included family physicians, and only one study compared practice behaviors between physician groups.12,13 Most studies found that although a majority of clinicians followed at least some of the AAP guideline, adherence to all components was low. Several studies also found that many physicians used diagnostic methods contrary to current AAP guidelines, such as neuroimaging and lab tests.13,14 The majority of studies were limited to descriptive analysis. However, a study by Rushton, Fant, and Clark found statistically significant differences between family (39%) and pediatric (78.1%) physicians for guideline use.13 In addition, McElligott showed differences in practice behavior between academic and private practice physicians, as well as between urban and rural practice locations.14
This study replicated the McElligott study. Permission was obtained from McElliogott to use the survey and adapt it for NPs.14 The study was deemed exempt by the SUNY Upstate Medical University Institutional Review Board. A convenience sample of 422 NPs listed as members of the nursing alumni association at an Upstate NY College of Nursing as well as NPs from three large Upstate NY practice groups were emailed an invitation to participate in the study. Of these, 124 were returned because of email address errors, 14 opted out, and 89 responded. McElligott and colleagues investigated pediatricians' use of the AAP guideline.14 Because the original survey was developed for physicians, it was modified to represent NPs in this study. The McElligott survey consisted of 21 questions and 5 demographic questions. The survey included three sections: Screening/Diagnosis, Follow-up/Reassessment, and Treatment/Intervention. The McElligott survey was amended to include 16 Likert scale questions and 8 demographic questions. The third section, Treatment/Intervention, was not included because it was not as relevant to the purpose of the study and would have made the survey too long.
McElligott's survey consisted of multiple-choice questions, although the NP survey questions included both multiple choice and a dichotomous scale (1 = low or rare response, and 2 = high or frequent questions). The survey questions assessed self-reported practice behaviors for diagnosis and treatment based on the 2011 AAP guideline for ADHD.10 Seven questions described provider demographics. Three questions directly referencing the guideline were added to the Screening/Diagnosis section:
- How likely are you to initiate an ADHD evaluation for a child between the ages of 4 and 18 who presents with academic or behavioral problems?
- How often do you use DSM-5 criteria to diagnose ADHD?
- How long should symptoms be present before making a diagnosis of ADHD?
Data were collected from Survey Monkey between May 13 and August 31, 2015. The IP addresses were disabled to keep the survey anonymous. Survey data were analyzed using SPSS version 23 for descriptive statistics for response frequency and distribution. Anticipating a larger sample, a five-point Likert scale was used to measure continuous data. However, given the imbalance between the number of family NPs (FNPs), 51 (59%), and pediatric NPs (PNPs), 15 (17%), crosstabs were misleading and Likert scales were converted from five to two categories—1.) rare and low; and 2.) likely, high and frequent—to better analyze the data.
A total of 89 surveys were returned. Of note, only NPs who treated children were surveyed. Of these, 51 were FNPs, 15 were PNPs, and 21 described themselves as other. The “other” group consisted of adult or psychiatric-mental health NPs (PMHNPs). In New York, adult NPs treat children over age 12 and PMHNPs can treat children of all ages. Two survey respondents did not answer the NP-type question. Most had been in practice for fewer than 5 years and graduated between 2012 and 2015. (See Survey respondent demographics.) At least 50% of respondents followed most of the AAP guideline for both diagnosis and treatment. (See Survey results: Diagnostic criteria and Survey results: Treatment criteria.) Adherence to recommended diagnosis guidelines was lowest in the category for diagnosing ADHD. A high percentage (76%) of respondents, correctly, did not obtain diagnostic medical tests to diagnose ADHD. All other correct responses for diagnosis criteria ranged from 51% to 69%. Adherence to treatment criteria was lowest for using behavior therapy first line for 4- to 5-year-olds, 27 (31%), and prescribing a stimulant medication as first-line treatment in 6- to 11-year-olds, 32 (37%). Not using stimulant medication as first-line treatment for 4- to 5-year-olds had the highest percentage of adherence, 73 (85%). Overall, 9 out of 14 criteria were followed by at least 50% of respondents.
Two questions not directly pertaining to AAP guidelines were included in the survey to help make inferences about NP practice behaviors. The first question assessed the youngest age group the respondent was comfortable diagnosing with ADHD. A large portion of PNPs (7 [29%]) and other NPs (10 [42%]) indicated they were comfortable treating children as young as 4 or 5 years old, and FNPs were most comfortable treating ADHD in the 6- to 10-year-old range (22 [44%]). The AAP guideline includes diagnostic and treatment criteria for children starting at age 4. The second question assessed whether respondents felt that childhood ADHD is underdiagnosed, overdiagnosed, or neither. Most NPs felt it was overdiagnosed (55 [63%]).
When diagnosing, a higher percentage of PNPs (6 [40%]) than FNPs (11 [(22%]) indicated they were very likely to initiate an evaluation for 4- to 18-year-olds who present with academic or behavioral problems. A majority of each type of surveyed NP recognized criteria for predominately inattentive (22 FNPs [46%]; 11 PNPs [73%]; and 14 Other/PMHNPs [82%]) and hyperactive/impulsive (26 FNPs [53%]; 13 PNPs [87%]; and 13 Other/PMHNPs [77%]) type ADHD. The majority also indicated that they use guidelines to diagnose whether symptoms are present in at least two settings (29 FNPs [60%]; 14 PNPs [93%]; and 12 Other/PMHNPs [71%]). However, a majority of FNPs (29 [62%]) and Other/PMHNPs (9 [53%]) chose 1 year, instead of 6 months, as the minimum length of time symptoms should be present to meet diagnostic criteria.
No medical test can diagnose ADHD. The question, How often do you obtain ferritin levels, lead levels, neuroimaging, or thyroid stimulating hormone (TSH) levels when considering the diagnosis of ADHD? should have been answered, “Never.” Of the respondents that would order medical tests, PNPs were less likely than FNPs and other NPs to order a TSH level, lead level, or ferritin test to help diagnose ADHD. Neuroimaging was the least-ordered diagnostic test among all types of NP respondents. (See Number of NPs very likely to order diagnostic tests.) Although all NPs were likely to consult with the child's parents and teachers when treating a child with ADHD, FNPs (32 [64%]) were more likely to consult the school psychologist than either PNPs (4 [27%]) or other NPs (6 [33%]). More than half of PNPs (8 [53%]) follow the AAP guideline for using behavior therapy as first-line treatment in 4- to 5-year-olds compared with FNPs, who are less likely to do so (12 [24%]). A comparable number of FNPs also use behavior therapy as first-line treatment for 6- to 11-year-olds (10 [20%]) and all ages (12 [24%]). In addition, a large portion of FNPs (15 [30%]) stated they do not use behavior therapy for any age in ADHD treatment. Most practitioners (73 [85%]) would correctly avoid prescribing stimulants first line to 4- to 5-year-olds, or nonstimulants to 6- to 11-year-olds (63 [73%]). However, 54 (63%) respondents reported that they would also, incorrectly, not prescribe stimulant medication as first-line treatment for 6- to 11-year-olds.
This study adds data specific to NP practice behavior for both the diagnosis and treatment of childhood ADHD to the literature. Interestingly, this study found that most NPs might be opposed to prescribing any ADHD medication to children. The perception that childhood ADHD is overdiagnosed (63%) could represent provider stigma, which might generate reluctance to prescribe medication. Of the FNP respondents, 32 (64%) reported being more likely than PNPs (4 [27%]) to consult the school psychologist as part of their treatment plan. This may be because of the likelihood that PNPs have greater access to pediatricians for collaboration and therefore felt less need for input from the school psychologist.
This study has several limitations. It is a self-reported survey study and therefore dependent on subjective data. The small sample size and participant characteristics limited this study to a descriptive analysis. Respondents categorized as being other than FNP or PNP could not be identified by their certification, which may influence their use of the AAP guideline. For instance, adult NPs would presumably have little exposure to childhood ADHD. This made it difficult to compare responses between groups. The sample, however, was representative of the New York population of FNPs (40%) and PNPs (10%).15
This study is a first step toward describing NPs' use of the AAP guideline and practice behaviors for both diagnosis and treatment of childhood ADHD. Future research should include a larger sample size that is not limited to primary care FNPs and PNPs. The sample numbers should also be balanced between the two groups so that cross-tabulations are not misleading and possible demographic influence on clinician behavior can be identified.
The results of this study indicate that most NPs use the AAP guideline for diagnosing childhood ADHD. However, the percentage of adherence for individual criteria, as well as for all criteria, is less than adequate. The AAP recommendations are based on evidence that children with ADHD benefit from proper diagnosis and the use of treatment criteria contained in their guidelines. Improving NP adherence to practice guidelines will help ensure that children with ADHD receive the much-needed benefits of evidence-based practice.
2. Data Resource Center for Child & Adolescent Health: The Child and Adolescent Health Measurement Initiative. National Survey of Children's Health. 2017. https://childhealthdata.org/learn/NSCH
3. Visser SN, Danielson ML, Bitsko RH, et al Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry
4. Tsai C-J, Chen Y-L, Lin H-Y, Shur-Fen Gau S. One-year trajectory analysis for ADHD symptoms and its associated factors in community-based children and adolescents in Taiwan. Child Adolesc Psychiatry Ment Health
5. Nigg JT. Attention-deficit/hyperactivity disorder and adverse health outcomes. Clin Psychol Rev
6. Young S, González RA, Fridman M, Hodgkins P, Kim K, Gudjonsson GH. The economic consequences of attention-deficit hyperactivity disorder in the Scottish prison system. BMC Psychiatry
7. van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W, et al Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug Alcohol Depend
8. Okado I, Mueller CW. The relationship between child-reported positive affect and parent-reported emotional and behavioral problems in ADHD youth. J Child Fam Stud
9. Fisher G. Recently published economic analysis highlights the financial impact of attention-deficit/hyperactivity disorder (ADHD) in the United States (US): loss of workplace productivity and income contribute 70 percent to 80 percent of overall excess costs in adults with ADHD and adult family members of patients with ADHD. PR Newswire
10. Wolraich M, Brown L, Brown RT, et al ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics
11. Langberg JM, Brinkman WB, Lichtenstein PK, Epstein JN. Interventions to promote the evidence-based care of children with ADHD in primary-care settings. Expert Rev Neurother
12. Daly ME, Rasmussen NH, Agerter DC, Cha SS. Assessment and diagnosis of attention-deficit/hyperactivity disorder by family physicians. Minn Med
13. Rushton JL, Fant KE, Clark SJ. Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder. Pediatrics
14. McElligott JT, Lemay JR, O'Brien ES, Roland VA, Basco WT Jr, Roberts JR. Practice patterns and guideline adherence in the management of attention deficit/hyperactivity disorder. Clin Pediatr (Phila)
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
American Academy of Pediatrics (AAP); attention-deficit hyperactivity disorder (ADHD); behavior therapy; diagnostic tests; evidence-based practice; stimulant medication