PHILADELPHIA — It's appropriate for primary care physicians to evaluate and treat children with attention-deficit hyperactivity disorder, but in many cases it isn't feasible, according to a survey of such physicians.
The survey results show that primary care physicians working in urban practices report the greatest challenges in delivering ADHD services, Thomas J. Power, Ph.D., said at the annual meeting of the Society for Developmental and Behavioral Pediatrics.
Understanding what types of clinical services primary care physicians can provide is crucial because primary care physicians are often the first-line care providers for children with ADHD, said Dr. Power, program director for the Center for Management of ADHD at the Children's Hospital of Philadelphia. “The primary responsibility for managing ADHD is really in the hands of primary care physicians and school professionals,” he said.
Dr. Power and his colleagues developed a 24-item questionnaire looking at the appropriateness and feasibility of a number of clinical activities surrounding ADHD treatment. The questionnaire asked physicians to evaluate each activity twice based, first, on whether the activity was appropriate assuming that they had adequate time and resources, and then based on the feasibility of providing that service in their own practice.
Each of the 24 items was evaluated on a 4-point scale ranging from “not at all” to “very much.” For example, one of the items asked physicians to assess whether it was appropriate and feasible to obtain behavior ratings from teachers for an initial assessment of ADHD.
The questionnaire was administered to 181 physicians affiliated with the Children's Hospital primary care network. Of the 181 physicians who were asked to participate, 119 completed the questionnaire. The physicians represented 31 primary care practices, including 27 suburban practices and 4 urban practices. The investigators did not specify the specialty of the physicians.
The racial and socioeconomic makeup of the practices was vastly different between the urban and suburban settings. For example, patients in suburban practices were 70% white and only 10% were eligible for Medicaid. In the urban practices, 85% of patients were African American and about 66% had Medicaid as their primary insurance.
Primary care physicians surveyed viewed a number of clinical activities as being highly appropriate, Dr. Power said. Those activities included assessing ADHD, providing mental health services, determining whether the child has comorbidities, educating families about behavioral treatment strategies, and recommending and monitoring medications that have been approved for ADHD by the Food and Drug Administration.
Recommending medications that have not been approved by the FDA for ADHD was not viewed as a very acceptable practice by primary care physicians in the survey, Dr. Power said.
But while the physicians viewed many clinical activities as appropriate for the primary care setting, the ratings fell for feasibility. The average item ratings show significant differences between appropriateness and feasibility in all major areas, with the most challenges being reported by physicians working in urban settings, Dr. Power said.
For example, when asked about obtaining information from schools about ADHD, suburban physicians rated the activity as appropriate with an average 3.09 rating on the 4-point scale. Urban physicians rated it similarly at 3.02. But when asked about the feasibility, suburban physicians rated it as 2.51, with urban physicians dropping to 2.14 on the scale.
“The urban physicians experienced a lot more trouble getting information about ADHD,” Dr. Power said.
The researchers found similar trends related to recommending and monitoring FDA-approved medications. Urban physicians rated this activity as 3.10 in terms of appropriateness, but 2.61 for feasibility in their own practice. Among suburban physicians, the appropriateness was 3.43, while the feasibility was 3.16.
The findings suggest that primary care physicians need more support in providing ADHD services, Dr. Power said, including additional training and resources.