Deficiencies in Attention Deficit Hyperactivity Disorder Diagnostic Assessment, Evaluation of Stimulant Medication Risks, and Policy Guidance

The VA Office of Inspector General (OIG) evaluated the Veterans Health Administration’s (VHA’s) attention deficit hyperactivity disorder (ADHD) diagnostic assessment practices, stimulant medication (stimulant) prescribing practices, training expectations, and policies. A diagnosis of ADHD must be established by a qualified provider based on diagnostic criteria. Stimulants are approved to treat ADHD and classified as controlled substances because of the risk for abuse. ADHD diagnoses and stimulant prescribing to treat adult ADHD have increased in recent decades. Prescribers insufficiently documented support for ADHD diagnoses corresponding to new stimulant prescriptions. Additionally, most electronic health records included documentation of a diagnostic interview, while fewer documented other assessment methods. The OIG found that prescribers inadequately assessed the risks and contraindications of stimulants prescribing, such as cardiac risks and urine toxicology testing. Prescribers assessed risks through the prescription drug monitoring program queries consistent with VHA expectations of 75 percent for new and 95 percent for active controlled substance prescriptions. The OIG would expect the query goal for new controlled substance prescriptions to meet or exceed the goal established for active prescriptions. The OIG found deficiencies in prescribers’ reported ADHD diagnostic and stimulant-prescribing training and knowledge. Among survey respondents, 13 percent of mental health and 65 percent of primary care respondents reported being somewhat or not knowledgeable about prescribing stimulant medication for the treatment of ADHD. The OIG determined that VHA has no established policies or clinical practice guidance related to ADHD assessment, diagnosis, and treatment. The lack of ADHD-related policies may contribute to limited awareness of clinical expectations and resources. The OIG made five recommendations to the Under Secretary for Health related to diagnostic assessment, assessment of risks and contraindications, prescription drug monitoring program goals, the referral process for complex mental health conditions, and ADHD policy and clinical practice guidance.