This Article
Right arrow Full Text
Right arrow Full Text (PDF)
Right arrow P3Rs: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when P3Rs are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via ISI Web of Science (24)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Leslie, L. K.
Right arrow Articles by Eastman, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Leslie, L. K.
Right arrow Articles by Eastman, S.
Related Collections
Right arrow Office Practice
PEDIATRICS Vol. 114 No. 1 July 2004, pp. 129-140

Implementing the American Academy of Pediatrics Attention-Deficit/Hyperactivity Disorder Diagnostic Guidelines in Primary Care Settings

Laurel K. Leslie, MD*,{ddagger},||, Jill Weckerly, PhD*,§, Dena Plemmons, PhD*, John Landsverk, PhD*,¶ and Sarita Eastman, MD#

* Child and Adolescent Services Research Center, Children’s Hospital, San Diego, California; Departments of
{ddagger} Pediatrics
§ Psychiatry, University of California, San Diego, California
|| School of Public Health
School of Social Work, San Diego State University, San Diego, California
# San Diego County, California

Objectives. To evaluate the feasibility of the San Diego Attention-Deficit/Hyperactivity Disorder Project (SANDAP) protocol, a pediatric community-initiated quality improvement effort to foster implementation of the American Academy of Pediatrics (AAP) attention-deficit/hyperactivity disorder (ADHD) diagnostic guidelines, and to identify any additional barriers to providing evidence-based ADHD evaluative care.

Methods. Seven research-naïve primary care offices in the San Diego area were recruited to participate. Offices were trained in the SANDAP protocol, which included 1) physician education, 2) a standardized assessment packet for parents and teachers, 3) an ADHD coordinator to assist in collection and collation of the assessment packet components, 4) educational materials for clinicians, parents, and teachers, in the form of handouts and a website, and 5) flowcharts delineating local paths for referral to medical subspecialists, mental health practitioners, and school-based professionals. The assessment packet included the parent and teacher versions of the Vanderbilt ADHD Diagnostic Rating Scales. In this study, we chose a conservative interpretation of the AAP ADHD guidelines for diagnosing ADHD, requiring that a child met criteria for ADHD on both the parent and teacher rating scales. A mixed-method analytic strategy was used to address feasibility and barriers, including quantitative surveys with parents and teachers and qualitative debriefing sessions conducted an average of 3 times per year with pediatricians and office staff members.

Results. Between December 2000 and April 2003, 159 children were consecutively enrolled for evaluation of school and/or behavioral problems. Clinically, only 44% of the children met criteria for ADHD on both the parent and teacher scales, and 73.5% of those children were categorized as having the combined subtype. More than 40% of the subjects demonstrated discrepant results on the Vanderbilt scales, with only the parent or teacher endorsing sufficient symptoms to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Other mental health and learning problems were common in the sample; 58.5% of subjects met screening criteria for oppositional defiant disorder/conduct disorder, 32.7% met screening criteria for anxiety/depression, and approximately one-third had an active individualized education program in place or had received an individualized education program in the past. On evaluation, the SANDAP protocol was acceptable and feasible for all stakeholders. However, additional barriers to implementing the AAP ADHD guidelines were identified, including 1) limited information in the guidelines regarding the use of specific ADHD rating scales, the evaluation and treatment of children with discrepant and/or negative results, and the indications for psychologic evaluation of learning problems, 2) families’ need for education regarding ADHD and support, 3) characteristics of physical health and mental health plans that limited care for children with ADHD, and 4) limited knowledge and use of potential community resources.

Conclusions. Our results indicate that children presenting for evaluation of possible ADHD in primary care offices have complex clinical characteristics. Providers need mechanisms for implementing the ADHD diagnostic guidelines that address the physician education and delivery system design aspects of care that were developed in the SANDAP protocol. Additional barriers were also identified. Careful attention to these factors will be necessary to ensure the sustained provision of quality care for children with ADHD in primary care settings.

Key Words: pediatrics • primary care • attention-deficit/hyperactivity disorder • guidelines

Abbreviations: DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th ed • AAP, American Academy of Pediatrics • ADHD, attention-deficit/hyperactivity disorder • NICHQ, National Initiative for Children’s Healthcare Quality • PCP, primary care provider • SANDAP, San Diego ADHD Project • AC, ADHD coordinator • ODD, oppositional defiant disorder • CD, conduct disorder

Received for publication Sep 4, 2003; Accepted Jan 5, 2004.




This article has been cited by other articles:


Home page
 PediatricsHome page
J. N. Epstein, J. M. Langberg, P. K. Lichtenstein, B. A. Mainwaring, C. P. Luzader, and L. J. Stark
Community-wide Intervention to Improve the Attention-Deficit/Hyperactivity Disorder Assessment and Treatment Practices of Community Physicians
Pediatrics, July 1, 2008; 122(1): 19 - 27.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
T. J. Power, J. A. Mautone, P. H. Manz, L. Frye, and N. J. Blum
Managing Attention-Deficit/Hyperactivity Disorder in Primary Care: A Systematic Analysis of Roles and Challenges
Pediatrics, January 1, 2008; 121(1): e65 - e72.
[Abstract] [Full Text] [PDF]

Home page
 The Annals of PharmacotherapyHome page
A. G Winterstein, T. Gerhard, J. Shuster, J. Zito, M. Johnson, H. Liu, and A. Saidi
Utilization of Pharmacologic Treatment in Youths with Attention Deficit/Hyperactivity Disorder in Medicaid Database
Ann. Pharmacother., January 1, 2008; 42(1): 24 - 31.
[Abstract] [Full Text] [PDF]

Home page
 EDUCATION AND PRACTICEHome page
E. A. Livesey and J M. Noon
Implementing guidelines: what works
Arch. Dis. Child. Ed. Pract., October 1, 2007; 92(5): ep129 - ep134.
[Full Text] [PDF]

Home page
 Arch Pediatr Adolesc MedHome page
J. N. Epstein, D. Rabiner, D. E. Johnson, D. P. FitzGerald, A. Chrisman, A. Erkanli, K. K. Sullivan, J. S. March, P. Margolis, E. C. Norton, et al.
Improving Attention-Deficit/Hyperactivity Disorder Treatment Outcomes Through Use of a Collaborative Consultation Treatment Service by Community-Based Pediatricians: A Cluster Randomized Trial
Arch Pediatr Adolesc Med, September 1, 2007; 161(9): 835 - 840.
[Abstract] [Full Text] [PDF]

Home page
 J Pediatr PsycholHome page
L. K. Leslie and M. L. Wolraich
ADHD Service Use Patterns in Youth
J. Pediatr. Psychol., July 1, 2007; 32(6): 695 - 710.
[Abstract] [Full Text] [PDF]

Home page
 J Atten DisordHome page
A. Bener, R. A. Qahtani, and I. Abdelaal
The prevalence of ADHD among primary school children in an arabian society.
J Atten Disord, August 1, 2006; 10(1): 77 - 82.
[Abstract] [PDF]

Home page
 J Pediatr PsycholHome page
K. A. Bailey, D. A. Chavira, M. T. Stein, and M. B. Stein
Brief Measures to Screen for Social Phobia in Primary Care Pediatrics
J. Pediatr. Psychol., June 1, 2006; 31(5): 512 - 521.
[Abstract] [Full Text] [PDF]

Home page
 PediatricsHome page
J. P. Guevara, C. Feudtner, D. Romer, T. Power, R. Eiraldi, S. Nihtianova, A. Rosales, J. Ohene-Frempong, and D. F. Schwarz
Fragmented Care for Inner-City Minority Children With Attention-Deficit/Hyperactivity Disorder
Pediatrics, October 1, 2005; 116(4): e512 - e517.
[Abstract] [Full Text] [PDF]

Home page
 JAMAHome page
A. Joffe
Pharmacotherapy for Adolescent Obesity: A Weighty Issue
JAMA, June 15, 2005; 293(23): 2932 - 2934.
[Full Text] [PDF]