Attention-Deficit Hyperactivity Disorder (ADHD) is the most common pediatric neurobehavioral disorder with a prevalence of approximately 7%-10% in school-age children. ADHD significantly affects functioning throughout life including academic achievement, social and family relationships and occupational success, predisposing individuals to secondary psychopathology, substance use, justice system involvement and suicide. Fortunately, ADHD is treatable, most effectively with a combination of medication, behavioral therapy and school-based supports. Unfortunately, many children with ADHD go undiagnosed and untreated for years, and sometimes for life, putting those children most at risk for problematic outcomes.
Universal screening for ADHD in pediatrics could improve early identification and treatment of ADHD. Many pediatric practices have successfully implemented universal behavioral health screening with the Pediatric Symptom Checklist (PSC-17) across populations and languages. However, strategies to optimize use of the Attention Subscale of the PSC-17 in primary care pediatrics have not been described.
Researchers at Boston University Chobanian & Avedisian School of Medicine describe a quality improvement initiative to improve screening for ADHD in the primary care pediatric clinic at Boston Medical Center, the largest safety net hospital in New England. “In our clinic, we found that many children who screened positive for attention problems were not receiving a diagnostic evaluation for ADHD,” explained first author Mona S. Doss Roberts, DO, assistant professor of pediatrics at the school. “Despite the fact that delayed and underdiagnosis of ADHD is common, particularly among lower income and racial and ethnic minority youth, to our knowledge this is the first published report of a quality improvement effort specifically to improve screening for ADHD in pediatric primary care,” she said.
The ADHD Detection Quality Improvement (ADQI) initiative was a multicomponent program including 1) developing and teaching a provider decision-making algorithm; 2) adjusting clinic operational/workflow; and 3) optimizing features in our electronic medical record to flag positive screens and facilitate next steps for evaluation. With their initiative, the researchers showed improvement in recognition of positive Attention Subscale scores on the PSC-17 and evaluation for ADHD with a follow up diagnostic evaluation tool.
According to the researchers, their initiative led to improved clinician recognition of positive screens for attention problems and follow up evaluation for ADHD by distributing diagnostic rating scales to these families. Thus, even in a clinic that had excellent rates of universal behavioral health screening in primary care, were able to optimize use of the tool as a screener for ADHD, improving the likelihood that providers would recognize and document the positive attention problems score as an indication of possible ADHD.
“Despite our initial success, additional interventions are needed to improve the completion of ADHD evaluations in primary care to ensure that children are appropriately identified and offered evidence-based care,” added Roberts, who also is a pediatrician at Boston Medical Center.
These findings appear online in the Journal of Developmental & Behavioral Pediatrics.
Last author Andrea Spencer, MD,currently receives grant funding from the Klingenstein Third Generation Foundation, the Charles H. Hood Foundation, and the National Institute of Mental Health. Other authors report no conflicts of interest.