Feasibility of an Emergency Department-Based Two-Step ADHD Screening Pathway in Primary School-Age Children...

Background/Objectives: Emergency department (ED) visits for pediatric home accidents may provide an opportunity to identify children who warrant evaluation for attention-deficit/hyperactivity disorder (ADHD). This study primarily evaluated the feasibility of a two-step ED-based ADHD screening and Child and Adolescent Psychiatry referral pathway. A secondary exploratory objective was to compare the frequency of confirmed ADHD between children presenting with home accidents and non-injured ED controls. Methods: This prospective, two-center case-control study was conducted in two emergency departments in Denizli, Turkey, between October 2022 and June 2023. Children aged 5-11 years were enrolled as home-accident cases or non-injured controls. Parents or guardians completed the Turkish-validated Turgay DSM-IV Disruptive Behavior Disorders Rating Scale (DDDRS). Screen-positive children and those with prior documented ADHD were referred for DSM-5-based diagnostic confirmation or record verification by Child and Adolescent Psychiatry specialists blinded to group allocation. Feasibility outcomes included completion of ED screening, referral threshold positivity, and attendance at specialist assessment. Results: The study included 139 home-accident cases and 139 controls. Among 267 children eligible for ED screening, all completed the DDDRS. Forty-nine children (18.4%) met the referral threshold, and 40 of 49 (81.6%) attended the Child and Adolescent Psychiatry assessment. Overall, ADHD was confirmed in 21 cases (15.1%) and 9 controls (6.5%) (unadjusted odds ratio [OR], 2.57; 95% confidence interval [CI], 1.13-5.83; p = 0.020). In an exploratory multivariable logistic regression model adjusted for sex, age, and school grade, confirmed ADHD remained associated with home-accident case status (adjusted OR, 2.45; 95% CI, 1.06-5.65; p = 0.035). However, a sensitivity analysis restricted to children without prior treated ADHD showed a non-significant difference in newly diagnosed ADHD (12/130 vs. 7/137; OR, 1.89; 95% CI, 0.72-4.96; p = 0.190). Conclusions: A two-step ED screening and specialist referral pathway for ADHD after pediatric home-accident presentation was operationally feasible in this two-center sample. The higher overall frequency of confirmed ADHD among home-accident cases should be interpreted as a secondary exploratory finding because it was partly influenced by imbalance in pre-existing ADHD and was not confirmed in the newly diagnosed-only analysis. Larger studies with center-level data, broader confounder measurement, and longitudinal follow-up are needed.