The use of stimulant medication by primary care physicians in treatment of attention deficit hyperactivity disorder was evaluated by a random national survey of family practitioners and direct screening of 457 patients in midwestern cities and is reported from the Division of Developmental Disabilities, Departments of Pediatrics and Preventive Medicine University of Iowa, Iowa City and Department of Psychology, University of Kentucky, Lexington. In the national survey, methylphenidate was used by 85% of pediatricians, dextroamphetamine 11%, and pemoline 23%. Pediatricians used stimulant medication in preschool children and adolescents as well as children between 6 and 16 years of age. Drug holidays were employed by more than 2/3rds of physicians, but placebo trials were rarely used. Height and weight were monitored by three-quarters of the physicians. Timed or sustained release forms of methylphenidate were used by less than 50%. The Feingold diet and sugar restricted diets were employed by 10 and 15%, respectively, and behavior modification by 77%. In the direct patient screening, the prevalence of ADHD diagnosis was 5.3% of all elementary school aged children screened, and 88% were treated with methylphenidate. Medication was considered effective by the parents of 85% of children and efficacy was unrelated to the accuracy of the diagnosis. When DSM-III-R criteria were used, only 72% of those assigned a diagnosis of ADHD by physicians would qualify on a psychiatric interview of the parents and only 53% on a teacher report of symptoms. Although physicians reported the use of behavioral treatments, parents reported infrequent use of behavior modification. 
COMMENT: The authors concluded that systematic behavioral treatments were underused compared to medications and the accurate diagnosis of ADHD needs clarification by identification of subtypes.