Parental Influence and the Diagnosis of ADHD in Pediatric

Patients

Michael Weaver

History of ADHD

Let me see if Philip canBe a little gentleman;

Let me see if he is able To sit still for once at table.(“Fidgety Philip” 1-4, 1844)

History of ADHD

• Sir Alexander Crichton• An inquiry into the nature and origin of mental derangement: comprehending a concise system of the physiology and pathology of the human mind and a history of the passions and their effects.

•Section On Attention and its Diseases•"Sensibility of the Nerves"

• Diagnosed First Probable Case in 1878

What is ADHD?

• DSM-5 Diagnosis–" A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development."

–Symptoms Present before Age 12–Symptoms from 1 of 2 Categories–Presence of Symptoms in 2 Settings–Symptoms not Associated with Other Disorder

DSM-5 Diagnosis

• Inattention• Difficulty Organizing Tasks and Activities• Often Forgetful in Daily Activities

• Hyperactive• Often Talks Escessively• Often Fidgets with or Taps Hands or Feet or Squirms in Seat

What is ADHD?

• ICD-10–Symptoms from each of 3 Categories–Presence of Symptoms in Multiple Settings–Noted Impairment due to Symptoms –Called 'Hyperkinetic Disorder'

ADHD Diagnosis Increase

(Connor, 2011; Voelker, 2014)

0

2

4

6

8

10

12

1970 1975 1980 1985 1990 1995 2000 2005 2010

Year

Chi

ldre

n D

iagn

osed

with

AD

HD

(%)

Potential Problems

• 58% of Physicians use Formal Diagnostic Procedures

• <30% used DSM-IV(Chan, Hopkins, Perrin, Herrerias & Homer, 2005)

• European Physicians 14% Adherence to ICD-10(Kovshoff et al. 2012)

AAP Guidelines

• 91.5% Familiar with Guidelines 25.8% Reported Using(Rushton, Fant & Clark, 2004)

• <10% Adherence(Chung, Sunday, Meryash, Gutman & Adesman, 2013)

AAP Guidelines

• To be used with DSM-IV• Notes Failure to Diagnose Accurately can lead to Inappropriate Labeling

AAP Guidelines

• Stresses Importance of Impairment in Multiple Settings

• Encourages Uncomfortable Physicians Not to Diagnose

• Nonspecialsit Physicians more likely to Diagnose ADHD and Prescribe Psychotropics(Kelwalkar & Nayak, 2010)

Subjectivity of ADHD

• Measuring Adult's Frustration? (Stoeltzer, 2007)

• Lack of Stable Reference in DSM Guidelines

• Lack of Clarity Among Those Involved(Taylor, 2009)

Parents

• Feel more Knowledgeable than Physicians (Lloyd & Norris, 1999)

• Can be 'Difficult Patients' (Steinmetz & Tabenkin, 2001)

•Violent•Rude•Aggressive•Demanding•Seeking Secondary Gain

Reasons to Seek Diagnosis

• School (ACT, 2013; CollegeBoard, 2012; DESE, 2012; Vickers, 2010;Schnoes, Reid, Wagner & Marder, 2006)

• Financial (Social Security Administration)

• Reduce Stress (Janicke & Finney, 2003)

Problems with Incorrect Diagnosis

• Diffusion of Responsibility (Henley, Algozzine & Ramsey, 2008; Schneider & Eisenberg, 2006)

• Labeling Stigma from Others (O’Driscoll, Heary, Hennessy & McKeague, 2012; Martin, Pescosolido, Bernice, Olafsdottir & McLeod, 2007)

• Self Labeling (Link, Yang, Phelan & Collins, 2004; Wiener, Malone, Varma, Markel, Biondic et al., 2012)

Problems with Incorrect Diagnosis

• Methylphenidate–Reduction of Growth (Wagner, 2007; Hotlkamp, Peters-Wallraf,

Wüller, Pfäaffle & Herpertz-Dahlmann, 2002)

–Loss of Sleep and Appetite Suppression (Sonuga-Barke, Coghill, Wigal, DeBacker, & Swanson, 2009)

–Suppression of Social Play Behavior (Vanderschuren, Trezza, Griffioen-roose, Schiepers, Van Leeuwen, et al., 2008)

Methodology

• Freeman Health System• 19 question Survey

–Paired Questions–Unpaired Questions

Analysis

• Paired Questions–2-Tailed Student's Paired T-Test

• Unpaired Questions–ANOVA–Linear Regression–2-Tailed Student's Unpaired T-Test

Results

• Demographics–33% Male (6); 50% Female (9); 3 Unknown–83% Pediatrics (15); 17% Psychiatry (3)–M: 19 years of Practice

Results

• General Diagnostic Accuracy–Self More Accurate than Others–t(17) = 4.80, p < .001

• Accuracy of ADHD Diagnosis Trained vs Untrained

–Trained More Accurate than Others–t(17) = 3.36, p = .004

Results

• ADHD Diagnostic Accuracy, Self versus Trained

–No Significant Difference–t(17) = 1.09, p = .29

ADHD Diagnosit Accuracy, Self versus Untrained

–Self More Accurate than Untrained–t(17) = 2.40, p = .028

Results

• ADHD Diagnostic Accuracy versus Other Diagnoses

–Approched Significance with ADHD Accuracy slightly lower

–t(17) = 1.66, p = .028

Results

• Following Up on the Suggestion of a Parent

–No Significant Difference–t(17) = 1.80, p = .09

• Following Up on the Suggestion of ADHD by a Parent

–Self Less Likely than Others–t(17) = 2.42, p = .026

Results

• Diagnose at the Suggestion of a Parent even if Unsure

–Self Less Likely than Others–t(17) = 3.95, p < .001

• Diagnose ADHD at the Suggestion of a Parent even if Unsure

–Self Less Likely than Others–t(17) = 4.19, p < .001

Results

• Parents Attempting to Convince ADHD–No Significant Difference–t(17) = 0.07, p = .95

• Parents Continuing to Ask–Self Less Likely than Others,–t(17) = 2.18, p = .04

Results

• Objectivity rating of ADHD Diagnosis–1 Completely Subjective to –10 Completely Objective–M = 6.44, SD = 1.62

Results

0123456789

10

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Percent Office Composition

Obj

ectiv

ity S

core

r = .4757 , n = 18, p = 0.046

Results

• Parents attempt to convince the physician that their child has ADHD

–p = .95• Parents Continue to insist upon a Diagnosis of ADHD

–p < .05

Results

0

2

4

6

8

10

12

0 5 10 15 20 25 30 35 40

Physician's Years of Practice

Pare

nt's

Atte

mpt

to C

onvi

nce

r = -.8490 , n = 18, p = 0.00000837

Results

0123456789

10

0 5 10 15 20 25 30 35 40

Physician's Years of Practice

Pare

nts

Con

tinue

to In

sist

r = -.5672 , n = 18, p = .0141

Discussion

• Humanity of Physicians

Discussion

• Problem of Young Physicians

Conclusion

• Parents are Attempting to Secure a Diagnosis of ADHD for their Children

Acknowledgments

Dr. Laura WeaverDr. Casey Cole

Dr. Karen KostanDr. James Jackson

Freeman Health SystemMSSU Honor's Program

Questions?