Attention-Deficit Hyperactivity condition (ADHD) is the most common pediatric neurobehavioral condition, affecting 7% to 10% of school-age children. ADHD has a substantial impact on functioning throughout life, including academic achievement, social and familial connections, and occupational success, predisposing individuals to subsequent psychopathology, substance abuse, engagement with the criminal system, and suicide. Fortunately, ADHD is treatable, and the most successful treatment is a combination of medication, behavioral therapy, and school-based support. Unfortunately, many children with ADHD go misdiagnosed and untreated for years, if not their whole lives, putting them at the highest risk of negative consequences.
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.
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.
Mona S. Doss Roberts
Researchers from Boston University’s Chobanian & Avedisian School of Medicine present a quality improvement project to increase ADHD screening in the primary care pediatric clinic at Boston Medical Center, New England’s biggest safety-net hospital. “In our clinic, we found that many children who screened positive for attention problems were not receiving a diagnostic evaluation for ADHD,” noted 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,” according to her.
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 approach resulted in increased clinician awareness of positive screens for attention issues and follow-up evaluation for ADHD by providing diagnostic rating scales to families. Thus, even in a clinic with excellent rates of universal behavioral health screening in primary care, we were able to optimize the tool’s use as an ADHD screener, increasing the likelihood that providers would recognize and document a 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.
