SPECIAL COMMUNICATION
Treatment Services for Children With ADHD: A National Perspective

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ABSTRACT

Objective

To summarize knowledge on treatment services for children and adolescents with attention-deficit hyperactivity disorder (ADHD), trends in services from 1989 to 1996, types of services provided, service mix, and barriers to care.

Method

A review of the literature and analyses from 2 national surveys of physician practices are presented.

Results

Major shifts have occurred in stimulant prescriptions since 1989, with prescriptions now comprising three fourths of all visits to physicians by children with ADHD. Between 1989 and 1996, related services, such as health counseling, for children with ADHD increased 10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from 40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more than 90% of visits to only 75%. Family practitioners were more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or recommend follow-up care. About 50% of children with identified ADHD seen in real-world practice settings receive care that corresponds to guidelines of the American Academy of Child and Adolescent Psychiatry. Physicians reported significant barriers to service provision for these children, including lack of pediatric specialists, insurance obstacles, and lengthy waiting lists.

Conclusions

The trends in treatment services and physician variations in service delivery point to major gaps between the research base and clinical practice. Clinical variations may reflect training differences, unevenness in the availability of specialists and location of services, and changes in health care incentives.

Section snippets

Research Review

Trends in Prescription Practices. Safer et al. (Safer, 1997; Safer and Krager, 1988, 1994; Safer et al., 1996) studied levels of methylphenidate use over time and found increased levels of prescribing for all ages of children. The rate of medication treatment for elementary school students increased from 1.07% in 1971 to 5.96% in 1987; for middle school students, it increased from 0.59% in 1975 to 2.98% in 1993; and for high school students, it increased from 0.22% in 1983 to 0.70% in 1993.

METHOD

NAMCS, a survey conducted by the NCHS, uses a multistage probability design of samples of medical practices within primary sampling units and patient visits within practices. The basic sampling unit is the visit to medical practices engaged in office-based patient care. For these analyses, a sample was constructed of all children aged 0 to 17 seen by either a pediatrician, family practice physician, or psychiatrist and coded with an ICD-9 diagnosis of ADHD. All analyses of NAMCS data refer to

Trends in Identification of ADHD From 1989 to 1996 (NAMCS)

Analyses from NAMCS indicate that the percentage of visits to physicians where ADHD was identified has risen from less than 1% in 1989 (0.74%) to almost 2% (1.9%) in 1996. The percentage of mental health problem visits where ADHD was specifically identified has risen as well. In 1989, 40.91% of all visits to physicians by children where a mental health problem was identified as the primary reason for the visit included attentional problems. In 1996, the percentage of mental health problem

DISCUSSION

It is clear that patterns of services for children with ADHD have changed. Since 1989, prescriptions of stimulants have risen from about one half of all visits to three fourths of all visits. During the same period, prescriptions of other medications have dropped. Children with ADHD who are seen by physicians now are more likely to receive diagnostic services, mental health counseling, and general health counseling than they were in 1989. These children, however, are less likely to receive

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    The opinions and assertions contained in this paper are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Health and Human Services or the National Institute of Mental Health.

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