To examine the implementation of a protocol for the assessment of attention-deficit/hyperactivity disorder (ADHD) in rural pediatric practices. The protocol was designed to provide an efficient means for pediatricians to learn and use the ADHD guidelines put forth by the American Academy of Pediatrics (AAP).
Primary care staff (physicians, nurses, etc) from 2 rural pediatric practices were trained to use the ADHD-assessment protocol. Medical records for 101 patients were reviewed from 1 to 2 years before the introduction of the protocol and for 86 patients during the subsequent 2 to 3 years to assess compliance with the AAP guidelines. In addition, 34% of the scales scored by the staff were rescored to check for scoring accuracy.
Before the availability of the AAP guidelines and the implementation of the assessment protocol, neither primary care site was consistently collecting the comprehensive information that is now recommended for an ADHD assessment. Parent and/or teacher rating scales were collected for only 0% to 21% of assessments across sites. When provided with brief training and supporting materials, medical records reflected significant improvement in the ascertainment of clinically necessary ADHD information, with parent and teacher rating scales present 88% to 100% of the time. Staff demonstrated an ability to score rating scales with a high degree of accuracy. The integrity of protocol collection and management was maintained 2 to 3 years after training.
An efficient system for conducting ADHD assessments according to AAP guidelines in rural pediatrics clinics can be initiated and maintained with integrity. Additional research is needed to determine if this system improves diagnostic decision-making and patient outcomes.
"Several recommendations along these lines may be made based upon the current study. First, further development and evolution of guidelines for the diagnosis and treatment of ADHD [16,22,27,55,56] need to incorporate a) explicit statements regarding an emphasis on impairment and, to a lesser extent, upon symptom presence, and b) explicit statements directing physicians to avoid relying upon socioeconomic or racial characteristics when conducting evaluations. Future studies may implicate the need to include gender in this list. "
[Show abstract][Hide abstract] ABSTRACT: Attention Deficit Hyperactivity Disorder (ADHD) is a costly and prevalent disorder in the U.S., especially among youth. However, significant disparities in diagnosis and treatment appear to be predicted by the race and insurance status of patients.
This study employed a web-based factorial survey with four ADHD cases derived from an ADHD clinic, two diagnosed with ADHD in actual evaluation, and two not. Randomized measures included race and insurance status of the patients. Participants N = (187) included clinician members of regional and national practice-based research networks and the U.S. clinical membership of the Society of Teachers of Family Medicine. The main outcomes were decisions to 1) diagnose and 2) treat the cases, based upon the information presented, analyzed via binary logistic regression of the randomized factors and case indicators on diagnosis and treatment.
ADHD-positive cases were 8 times more likely to be diagnosed and 12 times more likely to be treated, and the male ADHD positive case was more likely to be diagnosed and treated than the female ADHD positive case. Uninsured cases were significantly more likely to be treated overall, but male cases that were uninsured were about half as likely to be diagnosed and treated with ADHD. Additionally, African-American race appears to increase the likelihood of medicinal treatment for ADHD and being both African-American and uninsured appears to cut the odds of medicinal treatment in half, but not significantly.
Family physicians were competent at discerning between near-threshold ADHD-negative and ADHD positive cases. However, insurance status and race, as well as gender, appear to affect the likelihood of diagnosis and treatment for ADHD in Family Medicine settings.
BMC Family Practice 02/2010; 11(1):11. DOI:10.1186/1471-2296-11-11 · 1.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a previous article, we provided a review of the literature pertaining to the potential misdi-lagnosis of giftedness as ADHD, as well as a smail-scale study to illustrate this potential misdiagnosis. In this issue of Roeper Review, Mika provides several criticisms of that paper. In this article, we provide responses to her arguments by discussing the "symptoms" of giftedness; the relationship between ADHD, giftedness, and overexcitabilities; and the diagnosis of ADHD. Jason Nelson is an assistant professor of psychology in the School Psychology Program at Eastern Illinois University. He recently com-pleted an American Psychological Association-accredited internship at the Department of Psychological Services of Virginia Beach City Public Schools, where he worked in a middle school for gifted students. His research inter-ests include the prevention of reading disabili-ties, assessment of phonological processing, affective and motivational characteristics of students with reading disabilities, and internal-izing psychopathology in children.
[Show abstract][Hide abstract] ABSTRACT: This study was designed to investigate the perceptions of primary care providers about their roles and the challenges of managing attention-deficit/hyperactivity disorder and to evaluate differences between providers who serve families primarily from urban versus suburban settings.
The ADHD Questionnaire was developed to assess primary care provider views about the extent to which clinical activities that are involved in the management of attention-deficit/hyperactivity disorder are appropriate and feasible in primary care. Participants were asked to rate each of 24 items of the questionnaire twice: first to indicate the appropriateness of the activity given sufficient time and resources and second to indicate feasibility in their actual practice. Informants used a 4-point scale to rate each item for appropriateness and feasibility.
An exploratory factor analysis of primary care provider ratings of the appropriateness of clinical activities for managing attention-deficit/hyperactivity disorder identified 4 factors of clinical practice: factor 1, assessing attention-deficit/hyperactivity disorder; factor 2, providing mental health care; factor 3, recommending and monitoring approved medications; and factor 4, recommending nonapproved medications. On a 4-point scale (1 = not appropriate to 4 = very appropriate), mean ratings for items on factor 1, factor 2, and factor 3 were high, indicating that the corresponding domains of practice were viewed as highly appropriate. Feasibility challenges were identified on all factors, but particularly factors 1 and 2. A significant interaction effect, indicating differences between appropriateness and feasibility as a function of setting (urban versus suburban), was identified on factor 1. The challenges of assessing attention-deficit/hyperactivity disorder were greater for urban than for suburban primary care providers.
Primary care providers believe that it is highly appropriate for them to have a role in the management of attention-deficit/hyperactivity disorder. Feasibility issues were particularly salient related to assessing attention-deficit/hyperactivity disorder and providing mental health care. The findings highlight the need not only for additional training of primary care providers but also for practice-based resources to assist with school communication and collaboration with mental health agencies, especially in urban practices.
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