The assessment of attention-deficit/hyperactivity disorder in rural primary care: The portability of the American Academy of Pediatrics guidelines to the "real world"

Objective. To examine the implementation of a protocol for the assessment of attention-deficit/hyperactivity disorder (ADHD) in rural pediatric practices. The protocol was designed to provide an efficient means for pediatricians to learn and use the ADHD guidelines put forth by the American Academy of Pediatrics (AAP). Methods. Primary care staff (physicians, nurses, etc) from 2 rural pediatric practices were trained to use the ADHD-assessment protocol. Medical records for 101 patients were reviewed from 1 to 2 years before the introduction of the protocol and for 86 patients during the subsequent 2 to 3 years to assess compliance with the AAP guidelines. In addition, 34% of the scales scored by the staff were rescored to check for scoring accuracy. Results. Before the availability of the AAP guidelines and the implementation of the assessment protocol, neither primary care site was consistently collecting the comprehensive information that is now recommended for an ADHD assessment. Parent and/or teacher rating scales were collected for only 0% to 21% of assessments across sites. When provided with brief training and supporting materials, medical records reflected significant improvement in the ascertainment of clinically necessary ADHD information, with parent and teacher rating scales present 88% to 100% of the time. Staff demonstrated an ability to score rating scales with a high degree of accuracy. The integrity of protocol collection and management was maintained 2 to 3 years after training. Conclusions. An efficient system for conducting ADHD assessments according to AAP guidelines in rural pediatrics clinics can be initiated and maintained with integrity. Additional research is needed to determine if this system improves diagnostic decision-making and patient outcomes.