Stimulant Medication Use by Primary Care Physicians in the Treatment of Attention Deficit Hyperactivity Disorder

Treatment of attention deficit hyperactivity disorder (ADHD), one of the most common behavioral disorders in children in the United States, remains controversial because of concern about stimulant medication use. Extending a previous study of pediatricians, the present study surveyed a random national sample of family practitioners and then directly screened 457 patients of 10 pediatricians and family practitioners in two small midwestern cities. Responses to the national survey indicated that stimulant medication remains the main treatment prescribed by primary care physicians for children with ADHD. In the direct patient screening, the prevalence of ADHD diagnoses was 5.3% (pediatricians) and 4.2% (family practitioners) of all elementary-schoolaged children screened. Eighty-eight percent of these children were treated with methyiphenidate. Although medication was considered an effective treatment by the parents of 85% of the children given the medication, efficacy was unrelated to the accuracy of diagnosis. When explicit DSM-III-R criteria were used, only 72% of those assigned a diagnosis of ADHD by the physicians would have received that diagnosis based on a structured psychiatric interview with the parents and only 53% received that diagnosis based on teacher report of symptoms, even when the child was not receiving medication. Although the majority of physicians (in both the surveys and the direct screenings) reported using at least some behavioral treatments with their patients, parents reported infrequent use of nonpharmacologic forms of therapy, such as behavior modification. These data thus indicate a relatively modest rate of stimulant medication use for ADHD, but a serious underuse of systematic behavioral treatments in primary care.