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Attention-Deficit/Hyperactivity Disorder in 2- to 5-Year-Olds: A Primary Care Network Experience
Yair Bannett1, Heidi M Feldman1, Rebecca M Gardner2
1Division of Developmental-Behavioral Pediatrics, Stanford University School of Medicine (Y Bannett, HM Feldman, and LC Huffman), Stanford, Calif.
Insights
Primary care providers diagnosed attention-deficit/hyperactivity disorder (ADHD) in young children at low rates, with disparities by insurance type. While guideline adherence for diagnosis and medication was noted, follow-up care was insufficient.
Area of Science:
- Pediatrics
- Neurodevelopmental Disorders
- Healthcare Delivery Research
Background:
- Attention-deficit/hyperactivity disorder (ADHD) diagnosis and management in young children (2-5 years) present unique challenges in primary care settings.
- Understanding primary care provider (PCP) practices and adherence to clinical guidelines is crucial for optimizing early intervention.
Purpose of the Study:
- To evaluate PCP diagnosis rates of ADHD in young children.
- To assess PCP adherence to ADHD clinical practice guidelines regarding diagnosis, comorbidity documentation, medication, and follow-up.
- To identify patient factors associated with variations in ADHD diagnosis and management by PCPs.
Main Methods:
- A retrospective cohort study analyzed electronic health records of children aged 2 to 5 years from 2015 to 2019.
- Outcomes included ADHD diagnosis, comorbidity documentation, medication choice, and follow-up visit frequency.
- Logistic regression models examined associations between patient characteristics and study outcomes.
Main Results:
- ADHD diagnoses were identified in 0.7% of 29,408 eligible children, with 56% receiving symptom-level diagnoses.
- ADHD medication was prescribed to 21% of diagnosed children (4-5 year olds), primarily stimulants (85%).
- Children with public or military insurance had higher odds of ADHD diagnosis, while older children had lower odds of comorbidity documentation.
Conclusions:
- Primary care providers frequently used symptom-level ADHD diagnoses in young children, and overall diagnosis rates were below estimated population prevalence, indicating potential sociodemographic disparities.
- PCPs demonstrated guideline-consistent comorbidity documentation and stimulant medication choices, but timely follow-up rates for medicated patients were low.
- The findings highlight the need for improved diagnostic practices and follow-up care for young children with ADHD in primary care settings.
Objective:
To assess 1) rates of primary care provider (PCP) diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young children, 2) documented PCP adherence to ADHD clinical practice guidelines, and 3) patient factors influencing PCP variation in diagnosis and management.
Methods:
Retrospective cohort study of electronic health records from all office visits of children aged 2 to 5 years, seen ≥2 times between 2015 and 2019, in 10 practices of a community-based primary health care network. Outcomes included ADHD diagnosis (symptom or disorder), and adherence to guidelines in 1) comorbidity documentation at or after ADHD diagnosis, 2) ADHD medication choice, and 3) follow-up of medicated patients. Logistic regressions assessed associations between outcomes and patient characteristics.
Results:
Of 29,408 eligible children, 195 (0.7%) had ADHD diagnoses. Of those, 56% had solely symptom-level diagnoses (eg, hyperactivity); 54% had documented comorbidities. ADHD medications were prescribed only to 4- to 5-year olds (40 of 195 [21%]); 85% received stimulants as first-line medication; 48% had follow-up visits within 2 months. Likelihood of ADHD diagnosis was higher for children with public or military insurance (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.40-2.66; OR 3.17; 95% CI 1.93-4.96). Likelihood of comorbidity documentation was lower for older ADHD patients (OR 0.48; 95% CI 0.32-0.71) and higher for those with military insurance (OR 3.11; 95% CI 1.13-9.58).
Conclusion:
PCPs in this network frequently used symptom-level ADHD diagnoses in 2- to 5-year olds; ADHD diagnosis rates were below estimated population prevalence, with evidence for sociodemographic disparities. PCP comorbidity documentation and choice of stimulant medications were consistent with guidelines. Rates of timely follow-up were low.
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