Cardiac Screening Prior to Stimulant Treatment of ADHD: A Survey of US-Based Pediatricians

Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
PEDIATRICS (Impact Factor: 5.3). 02/2012; 129(2):222-30. DOI: 10.1542/peds.2011-1574
Source: PubMed

ABSTRACT To determine pediatricians' attitudes, barriers, and practices regarding cardiac screening before initiating treatment with stimulants for attention-deficit/hyperactivity disorder.
A survey of 1600 randomly selected, practicing US pediatricians with American Academy of Pediatrics membership was conducted. Multivariate models were created for 3 screening practices: (1) performing an in-depth cardiac history and physical (H & P) examination, (2) discussing potential stimulant-related cardiac risks, and (3) ordering an electrocardiogram (ECG).
Of 817 respondents (51%), 525 (64%) met eligibility criteria. Regarding attitudes, pediatricians agreed that both the risk for sudden cardiac death (SCD) (24%) and legal liability (30%) were sufficiently high to warrant cardiac assessment; 75% agreed that physicians were responsible for informing families about SCD risk. When identifying cardiac disorders, few (18%) recognized performing an in-depth cardiac H & P as a barrier; in contrast, 71% recognized interpreting a pediatric ECG as a barrier. When asked about cardiac screening practices before initiating stimulant treatment for a recent patient, 93% completed a routine H & P, 48% completed an in-depth cardiac H & P, and 15% ordered an ECG. Almost half (46%) reported discussing stimulant-related cardiac risks. Multivariate modeling indicated that ≥1 of these screening practices were associated with physicians' attitudes about SCD risk, legal liability, their responsibility to inform about risk, their ability to perform an in-depth cardiac H & P, and family concerns about risk.
Variable pediatrician attitudes and cardiac screening practices reflect the limited evidence base and conflicting guidelines regarding cardiac screening. Barriers to identifying cardiac disorders influence practice.

Download full-text


Available from: Susan K Parsons, May 09, 2014
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background:  Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well-tolerated, there are common, although less severe, as well as rare but severe AEs during treatment with ADHD drugs. The aim of this review is to provide evidence- and expert-based guidance concerning the management of adverse events (AEs) with medications for ADHD. Methods:  For ease of use by practitioners and clinicians, the article is organized in a simple question and answer format regarding the prevalence and management of the most common AEs. Answers were based on empirical evidence from studies (preferably meta-analyses or systematic reviews) retrieved in PubMed, Ovid, EMBASE and Web of Knowledge through 30 June 2012. When no empirical evidence was available, expert consensus of the members of the European ADHD Guidelines Group is provided. The evidence-level of the management recommendations was based on the SIGN grading system. Results:  The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviours and psychotic symptoms. Conclusion:  Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment.
    Journal of Child Psychology and Psychiatry 01/2013; 54(3). DOI:10.1111/jcpp.12036 · 5.67 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background. Current data are limited on compliance with guidelines for the treatment of attention deficit/hyperactivity disorder (ADHD). Methods. A survey assessing compliance with ADHD guidelines for diagnosis and management was distributed to pediatricians in a practice research network. Comparisons were made by practitioner characteristics. Results. In all, 42/76 surveys were returned (55%). Respondents largely adhered to American Academy of Pediatrics (AAP) guidelines. A lower percentage reported compliance for rescreening with a standardized tool (80%), use of electrocardiograms (78% rarely use), and the use of routine additional testing (80% rarely use). Academic practitioners were more likely to rescreen (100% vs 79%, P < .05). Private practitioners more often used newer therapeutic agents (7% vs 44%, P < .01). Older graduates were more comfortable diagnosing at a young age (93% vs 56%, P < .01) and were more comfortable using sleep agents (60% vs 15%, P < .01). Conclusion. Pediatricians largely adhered to AAP guidelines. These findings support changes made to the guidelines in 2011. Differences in practice patterns exist by practitioner experience, location, and practice type.
    Clinical Pediatrics 06/2014; 53(10). DOI:10.1177/0009922814540985 · 1.26 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: The objective of this study was to test whether physicians' attitudes regarding the impact of ADHD on healthrelated quality of life (HRQL) explain differences in practices for prescribing psychostimulants in children. Method: In a cross-sectional survey, U.S.-based pediatricians and psychiatrists ("physicians") used the Paper-Standard Gamble-a widely used preference-based assessment of HRQL-to rate four vignettes describing ADHD health states of varying severity. Associations between standard gamble scores and questions about prescribing practices were analyzed using ordinal logistic regression. Results: Surveys were mailed to 291 physicians; 127 (44%) returned complete forms. Lower standard gamble scores were associated with more emphasis on children's ADHD symptoms (p = .03) and less emphasis on parents' concerns about stimulant side effects (p = .03) when prescribing psychostimulants. Conclusion: Differences in physician perceptions of the severity of ADHD symptoms and in their emphasis on parental concerns about side effects may help explain variations in ADHD psychostimulant prescription patterns. (J. of Att. Dis. 2012; XX(X) 1-XX).
    Journal of Attention Disorders 11/2012; DOI:10.1177/1087054712461689 · 2.40 Impact Factor