ADHD is recognised as a chronic disorder that requires ongoing care and changes in service delivery as individuals advance through life. Yet, there is limited research on how services for children with ADHD change through preadolescence and adolescence. This was a retrospective, longitudinal cohort study of individuals diagnosed with ADHD before the age of 10 that collated and analysed primary care providers’ assessment and treatment practices for children with ADHD from preadolescence through to adolescence. In particular, the investigators studied:
- The frequency with which ADHD care is offered to children by primary care providers;
- The range of concerns assessed during encounters with children with ADHD;
- Treatments implemented or recommended.
Children with ADHD were identified from a larger research study that investigated the association between ADHD and driving outcomes in individuals from three primary care practices across six sites in the USA (Curry AE et al, 2017). To be included in the study, individuals had to be born between 1996 and 1997 and diagnosed with ADHD before the age of 10 years. All children were under primary care for their ADHD, with ≥1 visit between the ages of 15 and 18 years. For each child enrolled in the study, data were collected on their demographics and psychiatric comorbidities. Information on each hospital visit and factors relevant to the assessment and treatment of ADHD from preadolescence through to late adolescence (aged 15–18 years) was also collated. Data were compared among study participants and grouped into three age ranges: preadolescence (aged 9–11 years); early adolescence (12–14 years); and late adolescence (aged 15–18 years).
In total, 262 children with ADHD (78.2% male; 65.5% non-Hispanic White) were included in the study; the majority (96.2%) had private health insurance. The median age of ADHD diagnosis was 7 years (interquartile range [IQR] 6–8 years). As the children got older, the median (IQR) primary care visits for ADHD decreased (preadolescence, 12 [7–18]; early adolescence, 7 [5–11]; late adolescence, 7 [4–11]; p < 0.001). The percentage of children and adolescents with ADHD visiting their primary care provider at least once per age period and having an assessment of their ADHD symptoms also decreased over time (preadolescence, 63.0% and 59.5%; early adolescence, 53.8% and 48.1%; late adolescence, 40.8% and 38.2%, respectively; p < 0.001). The number of children and adolescents using psychotropic (p = 0.005) and stimulant (p = 0.007) medication also significantly decreased from preadolescence (70.2% and 90.8%) through early adolescence (66.0% and 86.1%) and late adolescence (56.9% and 78.5%). The percentage of children and adolescents receiving school interventions was significantly different been age groups (preadolescence, 36.3%; early adolescence, 15.6%; late adolescence, 17.6%; p < 0.001) but was generally similar for behavioural interventions (preadolescence, 14.9%; early adolescence, 13.0%; late adolescence, 20.6%; p = 0.05).
As children and adolescents with ADHD got older, primary care providers monitored depression, suicide and substance abuse more frequently; however, monitoring for sexual activity occurred in only about half of adolescents aged 15‒18 years:
- Depression: 37.4% (preadolescence), 93.9% (early adolescence) and 89.3% (late adolescence); p < 0.001.
- Suicide: 34.7% (preadolescence), 93.5% (early adolescence) and 89.7% (late adolescence); p < 0.001.
- Substance abuse: 24.0% (preadolescence), 94.3% (early adolescence) and 91.2% (late adolescence); p < 0.001.
- Sexual activity: 0.0% (preadolescence), 9.2% (early adolescence) and 46.6% (late adolescence); p < 0.001.
The authors noted several limitations to this study. Assessment and treatment practices were assessed using the notes from the primary care physicians and may not capture the information discussed comprehensively and uniformly, and subspecialists with experience of complex ADHD did not participate. Diagnosis of ADHD was sometimes made without using best practices for assessing the disorder (e.g. obtaining rating scales) and individuals were diagnosed during childhood so the results may not apply to those diagnosed with ADHD at ≥9 years of age. There were also a limited number of practices in this study and the participants were of a particular demographic, which may limit the generalisability of these findings.
The authors concluded that these findings may raise concerns about the management of children with ADHD in primary care as they mature into adolescents. The authors emphasised that the needs of these children may change as they mature from preadolescents into adolescents and that they need to be managed during this crucial phase of their development.
Curry AE, Metzger KB, Pfeiffer MR, et al. Motor vehicle crash risk among adolescents and young adults with ADHD. JAMA Pediatr 2017; 171: 756-763.
Moss CM, Metzger KB, Carey ME, et al. Chronic care for attention-deficit/hyperactivity disorder: clinical management from childhood through adolescence. J Dev Behav Pediatr 2020; 41(Suppl 2S): S99-S104.