Treatment of Attention-Deficit/Hyperactivity Disorder in Preschool-Age Children: Child and Adolescent Psychiatrists' Adherence to Clinical Practice Guidelines

Abstract

Objectives:

To compare child and adolescent psychiatrists' (CAPs) practices in the treatment of preschool children with attention-deficit/hyperactivity disorder (P-ADHD) with published guidelines, and to determine which clinical factors most influence physicians' decisions to initiate pharmacotherapy for P-ADHD.

Methods:

We developed and mailed the Preschool ADHD Treatment Questionnaire (PATQ) to a randomly selected national sample of ∼2200 CAPs trained in the management of ADHD. The PATQ asked CAPs about their approach to clinical management of children ages 4–5 years with ADHD—specifically, how often they recommend parent training in behavior management, medication as a first- or second-line treatment, and which medication they typically choose first. CAPs also rated the perceived importance of 19 different clinical factors in their decision to initiate pharmacotherapy. These 19 factors reflected five child-centered areas of concern: ADHD risk factors, education concerns, social issues (SI), emotional stress, and physical safety (PS). The physicians were asked to rate each factor on a 4-point Likert scale from “not important” to “very important.”

Results:

The final sample consisted of 339 board-certified CAPs. When adherence to the Academy of Child and Adolescent Psychiatry (AACAP) guidelines was defined as initial treatment with behavior management (not medication) and pharmacotherapy specifically with methylphenidate as second-line treatment, only 7.4% of CAPs followed clinical guidelines. Most physicians identified PS as an important or very important factor when initiating pharmacotherapy for P-ADHD (93.4%), followed by educational concerns (EC) (79.9%), emotional stress (69.6%), SI (52.8%), and the presence of risk factors for ADHD (32.7%).

Conclusions:

The overwhelming majority of CAPs do not follow current AACAP guidelines for treatment of P-ADHD, especially regarding medication initiation and selection. When deciding whether to prescribe medication for P-ADHD, safety and EC were the most important and historical risk factors for ADHD were the least important clinical factors.