VARIATIONS IN DIAGNOSTIC PRACTICES FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER: A NATIONAL SURVEY OF PRIMARY CARE PHYSICIANS Eugenia Chan, Marianne Hopkins, James M. Perrin, Carla Herrerias, Charles J. Homer Division of General Pediatrics, Children's Hospital, Boston, MA; American Academy of Pediatrics, Elk Grove Village, IL; Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston, MA; National Initiative for Children's Healthcare Quality, Institute for Healthcare Improvement, Boston, MA

BACKGROUND: The new American Academy of Pediatrics (AAP) clinical practice guideline emphasizes evidence-based treatment of Attention Deficit Hyperactivity Disorder (ADHD) in school-aged children. Although previous studies have shown wide variation in how physicians treat ADHD, more are needed to assess the guidelines' impact on practice.

OBJECTIVE: To describe the practice patterns of primary care physicians treating school-aged children with ADHD.

DESIGN/METHODS: We conducted a national, cross-sectional survey of 2000 primary care pediatricians and family physicians in 1999-2000 regarding attitudes, beliefs, and current practices on the management of children with ADHD. Questions were included on issues of how the diagnosis of ADHD is made, modalities of treatment, as well as ongoing monitoring.

RESULTS: 1076 surveys (54%) were returned, with 905 (84%) meeting data quality criteria. We tabulated frequencies for each survey item, and used chi-square analysis to examine whether coexisting conditions changed physicians? decisions. Most primary care physicians (72%) reported managing a child with uncomplicated ADHD on their own. Most (74%) would initiate medication therapy, with methylphenidate as the first choice medication for 93%. Nearly half would refer to a subspecialist if there were no response to medication. In contrast, only 20% of physicians reported managing the child with ADHD and a coexisting condition on their own. Only one-third would begin medication therapy, and 81% would refer if there were no response to initial treatment. Physicians reported using other treatment strategies for both complicated and uncomplicated ADHD, including classroom modifications (66%), parent and child counseling (64%), behavior modification (51%), and parent training (50%). When monitoring patients, physicians relied more on narratives from parents (75%) and teachers (61%) than on rating scales (57-58%).

CONCLUSIONS: Primary care physicians? evaluation practices for school-aged children with ADHD vary widely and differ from recent AAP guidelines for management strategies and systematic monitoring. These data help identify areas needing improvement and provide a baseline from which to assess the impact of new practice guidelines.