Diagnosing and treating attentional difficulties: a nationwide survey
- 1Glen Acre House Child and Family Service, 21 Acre House Avenue, Lindley, Huddersfield HD3 3BB, UK
- 2Cringlebar House, 415 Bradford Road, Leeds LS28 7HQ, UK
- Correspondence to:
Cringlebar House, 415 Bradford Road, Leeds LS28 7HQ, UK;
- Accepted 4 March 2004
Aims: To ascertain from paediatricians and child psychiatrists their views regarding the aetiology, assessment, and diagnosis of attentional difficulties in children, and the prescribing of stimulant medication for such difficulties.
Methods: Using a questionnaire devised by the authors, 465 paediatricians and 444 child psychiatrists were surveyed.
Results: The overall response rate was 73%. Some 94% of child psychiatrists and 29% of paediatricians routinely dealt with attentional difficulties. Views on aetiology, classification, and diagnosis were varied. More than 60% of both groups were prepared to prescribe stimulant medication without a formal diagnosis being made. Comorbid conduct disorder and the views of other professionals and of parents have an impact on practice.
Conclusions: This survey demonstrates that there is a range of approaches to attentional difficulties by both paediatricians and child psychiatrists.
- ADHD, attention deficit/hyperactivity disorder
- DSM, Diagnostic and Statistical Manual of Mental Disorders
- ICD, International Classification of Diseases
- NICE, National Institute for Clinical Excellence
- SM, stimulant medication
- attention deficit hyperactivity disorder
- hyperkinetic disorder
- prescribing practice
- professional attitudes
Inattention, hyperactivity, and impulsivity are commonly reported symptoms in children and provide the basis for a number of diagnoses described in formal classification systems. The expectations and demands on clinicians to make a diagnosis and to prescribe for children with these symptoms have increased in the last decade. However, the validity of such diagnoses and the utility of pharmacological treatments have been the subject of considerable debate in both professional and public arenas.1,2
Other related issues should be considered. Both biological and environmental aetiological mechanisms leading to attentional difficulties have been suggested and there is unlikely to be one single causative factor.2–,5 Various guidelines have been developed as to how assessments should be carried out. An emerging consensus is the importance of collecting information from a number of sources including school, although assessment processes still vary.6–,9 Comorbidity has been shown to be important when considering treatment options.10 The availability of information (especially on the internet) means that parents are more, although not necessarily better, informed, and may have a specific agenda when seeking medical help.
Few large scale studies have been conducted in the UK looking at assessment and treatment, and the two that have been published in the last 5 years did not examine practitioner beliefs underlying their practice.11,12 The publication of National Institute for Clinical Excellence (NICE) guidelines on the use of methylphenidate13 has pushed for greater standardisation although it has been argued that variation in practice needs to be better understood.14 Recent community surveys in Australia and the USA suggest a substantial proportion of children taking stimulant medication (SM) do not have a diagnosis of attention deficit/hyperactivity disorder (ADHD).15 We conducted a nationwide survey of child psychiatrists and paediatricians in an attempt to establish the current range of views on aetiology, classification, treatment thresholds, and user/referrer expectations.
In this paper, we use the term “attentional difficulties” throughout to encompass the symptoms of inattention, hyperactivity, and impulsivity as well as formal diagnoses made from either the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM)16 or the World Health Organisation’s International Classification of Diseases (ICD).17
The reference population for this study was all child psychiatrists and all paediatricians in Great Britain and Northern Ireland. Child psychiatrists were identified via the Royal College of Psychiatrists Faculty of Child and Adolescent Psychiatry mailing list (n = 460). An equivalent sized group of paediatricians was identified by selecting a one in three sample from a national medical register using computer generated random numbers (n = 490). If the questionnaire was returned with information indicating that the addressee had moved away (with no forwarding address), retired, or died, the index subject was excluded from the study.
The questionnaire was designed by the authors to examine professional approaches and attitudes to attentional difficulties using a “forced choice” format with space for free text comments. Four areas were covered, namely aetiology, diagnosis, assessment, and prescribing. Participants were asked to reflect on their usual practice. We piloted the questionnaire using local clinicians and incorporated any feedback into the final version. A preliminary question ascertained if the clinician routinely dealt with attentional difficulties and it was made clear that even if this were not the case, the questionnaire should be returned. The questionnaire is available as a supplemental file from http://adc.bmjjournals.com/supplemental.
Ethical approval was sought and granted for this study. Questionnaires were sent with a reply paid envelope and a covering letter explaining the purpose of the study. If no reply had been received within 2 months a repeat questionnaire was sent.
This study was essentially descriptive and the statistics used reflect this. Pearson’s χ2 analyses were conducted where dependent variables were dichotomous in order to compare the practice of paediatricians and child psychiatrists.
A total of 665 completed questionnaires were returned: 323/465 (69%) from paediatricians and 342/444 (77%) from child psychiatrists. A further 41 responses indicated that the recipient had either moved away (with no forwarding address provided), retired, or died.
Some 29% (93/323) of paediatricians who responded indicated that they are routinely involved in the assessment and treatment of children with attentional difficulties, while 94% (323/342) of child psychiatrists indicated likewise. The following results refer solely to those respondents who routinely manage children with attentional difficulties.
Aetiology and classification
Most paediatricians (70%) and child psychiatrists (56%) consider that both biological and environmental factors contribute to the aetiology of attentional difficulties (table 1⇓). More child psychiatrists than paediatricians think a biological cause is most likely, while very few of either group see environmental aetiology as being of primary importance.
Nearly half of both groups claim to use solely DSM terms such as “ADHD”, “ADDH”, and “ADD” when describing attentional difficulties in children, while a similar proportion use a mixture of terms taken from different classification systems.
Approximately one third of both groups use DSM criteria to make a diagnosis. ICD criteria are used by half the child psychiatrists but less than a quarter of the paediatricians. More than a quarter of paediatricians do not use a formal classification system as opposed to 4% of child psychiatrists. Child psychiatrists are significantly more likely than paediatricians to apply diagnostic criteria tightly (41% v 13%; χ2 = 25.20; p = <0.01).
More than 90% of both groups routinely obtain assessment information from schools, although child psychiatrists are more likely than paediatricians (χ2 = 15.62; p<0.01) to do so (table 2⇓). More than two thirds of each group perform baseline physical investigations. Paediatricians are more likely to collect psychometric testing information (χ2 = 9.17; p<0.01).
Use of stimulant medication
Almost all paediatricians and child psychiatrists indicated that they prescribe SM at least sometimes and the majority are prepared to prescribe on occasion without a diagnosis being made (table 3⇓). More than half the paediatricians and a third of child psychiatrists indicated that their decision to prescribe SM would be affected if both attentional difficulties and conduct disorder were present in children. Most would prescribe less readily although a sizeable minority would prescribe more readily.
Expectations of families and referrers
Responses from both paediatricians and child psychiatrists showed that parents often had preconceived ideas that their child had ADHD (or similar) (table 4⇓). Furthermore, both groups frequently perceived pressure to prescribe from parents as well as education professionals. Such pressure was less evident from social services, but was more likely to be encountered from this source by child psychiatrists than paediatricians (χ2 = 11.39; p<0.01). Under this perceived pressure, more than a quarter of both groups were influenced in the direction of prescribing.
This nationwide survey of paediatricians and child psychiatrists looked at their views regarding the aetiology, assessment, and diagnosis of attentional difficulties in children, and the subsequent prescribing of SM. The response rate (73%) indicates that the findings are broadly representative. The results show that despite very similar assessment procedures there is variation between practitioners in terms of diagnosis and treatment. The influence of professional background is relatively minor.
The majority of respondents use diagnostic criteria from formal classification systems (ICD, DSM), but by their own admission do not necessarily apply these “tightly”. In addition, some use ICD classification systems to make a diagnosis but DSM terminology to describe the condition they have diagnosed. The use of SM is almost universal. A majority of clinicians indicated a willingness to prescribe without a definite diagnosis having been made, although a substantial minority did not. Comorbid conduct disorder may make some clinicians less likely (and others more likely) to prescribe. Furthermore, clinicians may take into account the views of parents and other agencies.
The current NICE guidance on the use of methylphenidate for ADHD states that assessment should be comprehensive, including information from both home and school. Our results indicate that this recommendation is being followed. The guidance also includes prescriptive advice about diagnostic criteria, implying an expectation of precision in their application. In this study, a number of respondents use no formal classificatory system at all, and of those that do, the majority do not apply criteria tightly. Although the guidance recommends that methylphenidate is indicated where a firm diagnosis has been made, it is also possible to prescribe it when this is not the case but where children are “experiencing severe problems due to inattention or hyperactivity/impulsiveness”. We have found that the majority of our respondents do this at least sometimes, suggesting that this is indeed common practice.
Our findings suggest that diagnoses made by one clinician will not necessarily be those that would be made by another despite very similar assessment procedures. The use of DSM and ICD together is likely to lead to even less diagnostic reliability as the two classification systems do not use co-terminus criteria. One explanation for this seemingly curious finding may be that while the ICD classification system is most commonly used in this country by professionals, it is DSM terminology that predominates in the media, and that families are most familiar with.
It is good clinical practice to make decisions about the management of any condition collaboratively. In this study, practitioners report that they perceive not only parents, but also social services and education as having an influence on their prescribing practice. This may go some way to explaining the variation in practice this study has highlighted, and is an inherent difficulty in producing categorical guidelines.
The study has some limitations. Questionnaire methodology may not necessarily reflect real practice to the same extent as chart reviews or the use of vignettes. The initial sampling produced two groups of comparable size, although when the clinicians who did not routinely see this group of children were excluded (a previously unknown number), the resulting groups remained of reasonable, but not equivalent, sizes. As nearly all child psychiatrists report seeing children with attentional difficulties, the findings of this study describe child psychiatrists in general. In contrast, only paediatricians who routinely manage attentional difficulties are represented in the findings (although probably this is the group that matters). Some of the differences in the responses between the two professional groups could be explained by referral bias or other possible confounding variables. Referrals made to each may differ, for example child psychiatrists seeing children referred on by paediatricians and paediatricians seeing a younger group in whom hyperactivity is more prominent than inattention. There was no indication from the respondents that the use of the term “attentional difficulties” limited their answers to a particular group of children.
This study was designed to investigate professional attitudes (and differing practices) regarding the diagnosis and treatment of attentional difficulties in children. Diagnostic practice varies between clinicians as shown by their use of classification systems and terminology. Treatment thresholds also vary. However, this is not explained by professional background as the differences between paediatricians and child psychiatrists are not marked. Attentional difficulties and their treatment exemplify issues commonly raised in paediatrics and child mental health about the utility of diagnosis, and the relative influences of parents, clinicians, and other agencies on how a child’s problems are labelled and treated.
The authors are grateful to the clinicians who took part in this study.
This research was supported by a project grant from the Association for Child Psychology and Psychiatry.
Conflict of interest: none declared.