The Retrospective Diagnosis of Attention-Deficit/Hyperactivity Disorder in Adolescents: Family Physicians' Challenges

The primary purpose of the study was to identify current retrospective practices used by family physicians in the diagnosis of Attention-Deficit-Hyperactivity Disorder (ADHD) in adolescents and young adults. In other words, do physicians adhere to best practices and examine information from childhood in order to diagnose ADHD in adolescents and young adults? In addition, this study aimed to examine the information physicians request for ADHD diagnosis, types of treatments they recommend, the type of information they use to assess treatment outcomes, and professional attitudes regarding the nature of ADHD. Participants completed a questionnaire designed to answer the research questions. Participants included a random sample of members of the American Academy of Family Physicians (AAFP, N= 143) and a convenience sample (N= 84). Results indicated discrepancies between participating physicians' current practices and best diagnostic practices, while these physicians generally reported treatment recommendations consistent with evidence-based practice. Reports of adherence to retrospective diagnostic practices and treatment outcome evaluation were limited, suggesting the need for training as well as collaboration with school professionals. Limitations of the current study and implications for future research are discussed. Retrospective Diagnosis of ADHD 7 The Retrospective Diagnosis of Attention-Deficit/Hyperactivity Disorder in Adolescents: Family Physicians' Challenges Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic and pervasive neurobiological and behavioral disorder that is commonly associated with young children. However, these symptoms typically persist well into adolescence and adulthood, but many individuals with ADHD are not diagnosed during childhood. Further, while family physicians have emerged as first responders for mental illness; there has been no standard of practice for the assessment and treatment of ADHD, especially for adolescents and young adults. Therefore, it is necessary to assess the type and amount of diagnostic information currently used by physicians in order to improve treatment outcomes for adolescent patients. The purpose ofthis study was to identify current retrospective practices used by family physicians in the diagnosis and treatment of ADHD in adolescents and young adults. ADHD is one of the most common childhood neurobiological and behavioral disorder, and it is characterized by symptoms of inattention, impulsivity, hyperactivity, and functional impairments in multiple domains (American Psychiatric Association, 2013). Diagnostics for ADHD in adolescents do not, however, appear to be straight forward. Some researchers have suggested that adolescents present significant and unique challenges. For example, ADHD symptoms can be easily faked (Harrison, Edwards, & Parker, 2007; Booksh, Lee, Pella, Singh, & Drew Gouvier, 2010), and adolescents and college students may fake ADHD symptoms in order to gain access to additional academic accommodations (e.g., more time for taking tests) as well as stimulant medications (Harrison et al., 2007). A comprehensive and accurate Retrospective Diagnosis of ADHD 8 retrospective diagnosis can remediate these concerns. In this study, retrospective diagnosis describes the process of identifying a medical condition originating in a previous period of time. During this process, physicians must rely on archeological data to determine if symptoms of ADHD continue to be present in order to make diagnostic decisions. As children enter adolescence and young adulthood, the detection of ADHD can become complicated due to increasingly complex biological, environmental and social factors (Sibley et al., 2012; Bruchmuller et al., 2012; Langberg et al., 2008). Therefore, it is especially critical for physicians to gather sufficient information for ADHD diagnosis when working with adolescent clients (Bruchmuller et al., 2012). For example, while the Diagnostic and Statistical Manual5th Edition (DSMJI) explicitly requires symptoms to be apparent prior to age 12, it is currently unknown how and if physicians are confirming this age of onset criterion (American Psychiatric Association, 2013). The current study attempted to assess the sources of information currently utilized by physicians for conducting a retrospective diagnosis of ADHD in adolescents as well as patterns of differences in treatment practices based on the preferred sources of assessment information utilized. For example, it would be beneficial to determine whether family physicians are more or less likely to prescribe stimulant medication, behavioral intervention, or a combination, stimulant medication and behavioral intervention, to adolescents based on various methods of assessment (e.g., behavior rating scales, comprehensive interview, and school records). Finally, this study sought to examine family physicians' attitudes regarding the nature of ADHD (e.g., "ADHD cannot be effectively treated without medication.") as well as how and if such attitudes are related Retrospective Diagnosis of ADHD 9 to diagnostic and treatment preferences. It is important to assess the type and amount of diagnostic information currently used by physicians in order to protect against potential misdiagnosis, false positive or false negative, which both have negative outcomes for patients, and to improve continuing education efforts, if indicated. The study targeted adolescents because if ADHD symptoms were not recognized in childhood, they are more likely to be diagnosed during adolescence as social and academic demands mount and the symptoms become more evident. In this study, adolescence is defined as the ages between 11 and 24 years old. Because of the qualitative developmental difference adolescence presents, the American Academy of Child and Adolescent Psychiatry (as cited in the U.S. Department of Health and Human Services, 2013) identified three substages: early adolescence (11-13 years old), middle adolescence (14-18 years old), and late adolescence (19-24 years old). These ages straddle late middle school and the college years. This study also focused on family physicians because of their emerging role as mental health service providers. It appears that family physicians are typically the first health care professionals that people contact when they have a problem (Faghri, Boisvert & Faghri, 2010). The Nature of ADHD, Diagnostic Criteria, and Prevalence Nature of ADHD. ADHD has been recognized for a hundred years, although by different names, such as minimal brain syndrome, hyperkinetic, and impulse disorder. More recently the disorder was separated into two symptom domains, inattention and hyperactivity/impulsivity, and three classifications (Predominantly Inattentive Type, Predominantly Hyperactive/Impulsive Type, and Combined Type) in the DSM-VI, and it was named Attention Deficit Hyperactivity Disorder (Barkley, 2013 ). Despite significant Retrospective Diagnosis of ADHD 10 advancements being made in the topography and discriminate diagnosis of this common childhood disorder, the cause of ADHD continues to challenge researchers. In fact, to date, no definitive etiological factors have been identified (Weyandt, Swentosky, & Gudmundsdottir, 2013). However, technological advancements have enabled researchers to identify genetic, neurological, and environmental factors which could affect (either directly or indirectly) the development of ADHD symptoms. For example, genetic studies, such as adoption and twin studies (Barkley, 2013, & Willcutt, 2005) and neurological studies, such as those involving magnetic resonance imaging (MRI) (Konrad, Neufang, Hanisch, Fink, & Herpertz-Dahlmann, 2006; Weyandt et al., 2013) have contributed useful knowledge regarding potential genetic and neurological factors of ADHD. More specifically, if one twin is diagnosed with ADHD, there is a greater likelihood that the other one will have the disorder as well. In addition, brain imaging studies have illustrated differences in brain activity between those individuals with and without an ADHD diagnosis (Barkley, 2013). Barkley further suggested that examination of executive functioning may help to better explain both the nature and etiology of ADHD. Although not yet conclusive, the theory suggests that executive :functioning involves working memory (nonverbal), internalization of speech (verbal working memory), and self-regulation of affect, motivation, and arousal. These areas are related to inhibition, working memory, planning, self-monitoring, verbal regulation, motor control, maintaining and changing mental set, and emotional regulation (Barkley, 1997, 2013). Regarding environmental factors that are suspected to predispose a child for ADHD, low birth weight, fetal distress, and substance use (Willcutt, 2005) top the list. Retrospective Diagnosis of ADHD 11 In sum, although significant advancements have been made in understanding the nature and scope of the disorder, the etiology of ADHD remains essentially unknown. Diagnosis. The same criteria are currently used for diagnosing ADHD in children, adolescents, and adults in the current medical field, with several distinct differences established for adolescents and adults in particular. The core symptoms of ADHD are inattention, impulsivity, and hyperactivity. The American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders V (5th ed.) criteria stipulate that symptoms should occur in two or more settings of an individual's life and be present for more than 6 months (APA, 2013). There are presently four ADHD subtypes: ADHD-combined presentation characterized by inattentive, hyperactive, and impulsive symptoms; AD HD-predominately inattentive presentation; ADHDpredominately hyperactive/impulsive presentation; and other specified ADHD, and unspecifiedADHD (APA, 2013). The DSM-Voutlines five criteria for a diagnosis of ADHD: (1) number and sev