Purpose: ADHD is one of the most common psychiatric disorders in childhood. Despite availability of effective treatment options, adherence to therapeutic regimens is poor. Little is known about how ADHD treatment decisions are made and to what extent parents/patients share in the process. As a first step, we sought to better understand the physician perspective.

Method: A qualitative study was conducted among primary care physicians who treat children/adolescents with ADHD. We purposely sampled from a large children's hospital's referral database, obtaining a balance of urban and suburban practices in three strata: 1) pediatrician practices, 2) family practices, and 3) pediatric practices participating in an ADHD quality improvement collaborative. Within each stratum, physicians were randomly selected. Semi-structured interviews were conducted employing an interview guide with questions regarding decision-making, information sharing, and sources of conflict and uncertainty. Interviews were audio taped and transcribed verbatim. Thematic analysis was performed by three collaborating investigators. Differences in coding were resolved by consensus.

Results: Eighteen physicians (mean=46 years old, 61% male, 72% Caucasian) participated in an interview (~45 minute duration). Physicians perceived that most families whose child had been diagnosed with ADHD had a strong desire to initiate a medication. Few physicians described explicitly asking families to choose between medication, behavioral therapy, or combined treatment. All physicians reported sharing at least some information about treatment options. Occasionally, physicians reported not recommending a modality they believed a family would not be receptive to, compliant with, or be able to access. Physician approaches were mediated by these primary factors: family access to mental health services, parental conflict about diagnosis or treatment, and parental beliefs, expectations, or fears about medication. To address concerns, many physicians described advocating a medication trial as a way to demonstrate that the child could experience benefit without undue harm, yet none reported using within-patient, randomized, double blind, placebo-controlled crossover trials. Physician-perceived challenges included communicating effectively with schools/teachers, providing education within office visit time constraints, communicating risk information, engaging children/adolescents with ADHD, diagnosing and treating co-morbid conditions, and obtaining adherence.

Conclusions: ADHD treatment decisions were largely driven by the physician's perception that families want pharmacologic treatment. Our findings identify barriers to the sharing of ADHD treatment decisions with families. We plan to obtain parent/patient perspectives to further inform this work.