Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatr. Mar 22, 2016; 6(1): 118-127
Published online Mar 22, 2016. doi: 10.5498/wjp.v6.i1.118
How does a real-world child psychiatric clinic diagnose and treat attention deficit hyperactivity disorder?
Kumi Yuki, Jyoti Bhagia, David Mrazek, Peter S Jensen
Kumi Yuki, Peter S Jensen, REACH Institute, New York, NY 10018, United States
Jyoti Bhagia, David Mrazek, Division of Child and Adolescent Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, United States
Peter S Jensen, Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
Author contributions: Yuki K designed and performed the research, collected and analyzed the data, and wrote the paper; Bhagia J provided clinical advices for the research; Mrazek D designed the research and provided an initial supervision on the research; Jensen PS supervised the research design and the research process, analyzed the data, and revised the paper.
Institutional review board statement: This naturalistic study is a part of the original study entitled “Pharmacogenetics and the Care of Child and Adolescent Patients”, which was reviewed and approved by the Mayo Clinic Institutional Review Board (IRB).
Informed consent statement: Because this study is a chart review and the research is exempt, a waiver of informed consent was allowed. Study subjects have given authorization for use of their Mayo Clinic electronic medical record for research purposes.
Conflict-of-interest statement: Drs. Yuki and Bhagia have no conflicts to declare. Dr. Jensen has received research funding from NIMH, AHRQ, Marriott Foundation, Mayo Foundation, and REACH Institute (non-profit) and gained book royalties from Civic Research Institute, Guilford, APPI, Oxford, Free Spirit Publishing, and Random House. Dr. Jensen owns a stock in CATCH Services, Inc. Dr. Jensen has received charitable gifts from Shire, Inc.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Kumi Yuki, MD, Research Scientist, REACH Institute, 485 7th Ave #1510, New York, NY 10018, United States. kumiyuki1026@gmail.com
Telephone: +1-507-3161166
Received: May 29, 2015
Peer-review started: June 1, 2015
First decision: September 30, 2015
Revised: December 6, 2015
Accepted: December 18, 2015
Article in press: January 4, 2015
Published online: March 22, 2016
Abstract

AIM: To investigate child and adolescent psychiatrists’ (CAPs) attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) diagnoses and treatments in real-world clinical practice.

METHODS: The medical records of 69 ADHD children (mean age = 9.5 years), newly referred to the ADHD clinic, were reviewed for their scores of parent- and teacher-reported Vanderbilt ADHD Diagnostic Rating Scales (VADRSs), CAPs’ diagnoses of ADHD and ODD, and CAPs’ treatment recommendations. Among 63 ADHD subjects who completed both parent and teacher VADRSs, we examined the agreement of the parent and teacher VADRSs. We also examined the concurrent validity of CAPs’ ODD diagnoses against the results from the VADRSs. In addition, we compared CAPs’ treatment recommendations against established ADHD and ODD guidelines.

RESULTS: Among 63 ADHD subjects, the majority of the subjects (92%) met full ADHD diagnostic criteria at least in one setting (parent or teacher) on the VADRSs. Nearly half of the patients met full ADHD diagnostic criteria in two settings (parent and teacher). Relatively low agreement between the parent and teacher VADRSs were found (95%CI: -0.33 to 0.14). For 29 children who scored positive for ODD on the rating scales, CAPs confirmed the ODD diagnosis in only 12 of these case-positives, which is considered as a fair agreement between CAPs and VADRSs (95%CI: 0.10-0.53). For 27 children with no ODD diagnosis made by either CAP or VADRS, more than half of them were recommended for medication only. In contrast, where CAPs made the diagnosis of ODD, or where the parent or teacher VADRS was positive for ODD, almost all of the patients received recommendations for medication and behavior therapy.

CONCLUSION: CAPs’ ADHD diagnoses have strong concurrent validity against valid rating scales, but ADHD’s most common comorbid condition - ODD - may be under-recognized.

Keywords: Attention deficit hyperactivity disorder, Oppositional defiant disorder, Vanderbilt attention deficit hyperactivity disorder Diagnostic Rating Scale, Quality assessment, Clinical practice

Core tip: Given the concerns about possible attention deficit hyperactivity disorder (ADHD) over-diagnosis and over-treatment, within a newly diagnosed sample of consecutive ADHD patients, we examined the concurrent validity of child and adolescent psychiatrists’ (CAPs) ADHD and oppositional defiant disorder (ODD) diagnoses against the results from the Vanderbilt ADHD Diagnostic Rating Scales. We also evaluated CAPs’ ADHD and ODD treatment recommendations and discussed clinical implementations of the established treatment guidelines into CAPs’ practice. In our samples, CAPs diagnosed ADHD strongly agreeing with the rating scales, but given our results showing the relatively low prevalence rates of ODD diagnosis within ADHD, ODD may be under-recognized.