Variability in ADHD care in community-based pediatrics

Pediatrics. 2014 Dec;134(6):1136-43. doi: 10.1542/peds.2014-1500. Epub 2014 Nov 3.


Background: Although many efforts have been made to improve the quality of care delivered to children with attention-deficit/hyperactivity disorder (ADHD) in community-based pediatric settings, little is known about typical ADHD care in these settings other than rates garnered through pediatrician self-report.

Methods: Rates of evidence-based ADHD care and sources of variability (practice-level, pediatrician-level, patient-level) were determined by chart reviews of a random sample of 1594 patient charts across 188 pediatricians at 50 different practices. In addition, the associations of Medicaid-status and practice setting (ie, urban, suburban, and rural) with the quality of ADHD care were examined.

Results: Parent- and teacher-rating scales were used during ADHD assessment with approximately half of patients. The use of Diagnostic and Statistical Manual of Mental Disorders criteria was documented in 70.4% of patients. The vast majority (93.4%) of patients with ADHD were receiving medication and only 13.0% were receiving psychosocial treatment. Parent- and teacher-ratings were rarely collected to monitor treatment response or side effects. Further, fewer than half (47.4%) of children prescribed medication had contact with their pediatrician within the first month of prescribing. Most variability in pediatrician-delivered ADHD care was accounted for at the patient level; however, pediatricians and practices also accounted for significant variability on specific ADHD care behaviors.

Conclusions: There is great need to improve the quality of ADHD care received by children in community-based pediatric settings. Improvements will likely require systematic interventions at the practice and policy levels to promote change.

Keywords: attention deficit and disruptive behavior disorders; behavioral medicine; guidelines; pediatrics; quality.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Attention Deficit Disorder with Hyperactivity / therapy*
  • Central Nervous System Stimulants / therapeutic use
  • Child
  • Community Mental Health Services*
  • Education, Nonprofessional
  • Evidence-Based Medicine
  • Female
  • Humans
  • Male
  • Medicaid
  • Pediatrics*
  • Physician-Patient Relations
  • Practice Patterns, Physicians'
  • Psychotherapy
  • Quality Assurance, Health Care
  • Quality Improvement*
  • Retrospective Studies
  • Rural Health Services
  • Suburban Health Services
  • United States
  • Urban Health Services


  • Central Nervous System Stimulants