Pediatricians and ADHD

For most families, pediatricians are the go-to professionals when it comes to ADHD and other psychiatric and behavioral concerns. In a survey for the Child Mind Institute, over 80 percent of parents with worries about a child’s mental health talked about it with their pediatrician.

Between 2000 and 2010, the number of office visits to a doctor in which ADHD was diagnosed increased by 66 percent, according to a study in Academic Pediatrics. The vast majority of those visits (96 percent in 2000 and 87 percent in 2010) resulted in prescriptions for stimulant medications. Most of those prescriptions were written by primary care doctors, though the balance has shifted towards specialists. In 2000 psychiatrists accounted for 24 percent of all office visits for ADHD. Ten years later, their share of office visits increased to 36 percent.

Driven by concerns about shotgun diagnosis and overmedication, parents are going to greater lengths to find specialized care for their children. Some, like Julissa Viana, a public relations director living in a suburb of New York City, spend months in the search. Viana, the mother of twin eight-year-old boys, says that their pediatrician wasn’t interested in being part of ADHD treatment.

“It never occurred to me to use another pediatrician. I wanted someone with expertise,” Viana says. She and her husband finally settled on a two-member team, a child psychiatrist and a behavioral therapist.

Outside major metropolitan areas, however, parents’ options are more limited. Child psychiatrists are scarce across the country, with acute shortages in states like Alabama, which has only 20. With many children living 100 miles from the nearest psychiatrist — and many more for whom a specialist may be financially out of reach — it’s important for parents and caregivers to find a pediatrician who can give a child with ADHD good care.

“There are pediatricians out there who are very skilled and practiced with ADHD, and they treat it as well as anyone else in the universe,” says Ron Steingard, a veteran child psychiatrist. “But it is also true that there are no uniform criteria for measuring competence or quality.”

In the absence of any external rating system, experts recommend that parents look for signs that their pediatrician is giving quality care, including:

• Use of a formal assessment to diagnose ADHD: In assessing your child for ADHD, clinicians should use rating scales based on DSM-IV criteria. There are a variety of rating scales that attempt to capture the child’s levels of hyperactivity, impulsivity, and inattention. Ask your clinician to show you the scale they are using and explain how they arrived at a diagnosis.
• Communication with child’s school: One of the hallmarks of ADHD is its presence across multiple settings-the child will show inattentiveness and hyperactivity whether at school or at home. Is the pediatrician asking about school performance and seeking reports from teachers during both diagnosis and treatment?
• Informed Consent: Does your pediatrician educate you about the various medications and their effects? Do they cite recent studies and take the time to discuss behavioral treatment and other non-medical interventions that can improve behavior and reduce frustration and conflict for kids with ADHD?
• Active Treatment: Frequency of visits changes as children pass through the initiation, stabilization, and maintenance phases of their care. Does your pediatrician closely monitor your child whenever medications are changed, and continue to use rating scales to learn how the medication is affecting their behavior at home and at school?

Medication management is where the doctor’s knowledge and experience come into full play. Most children who are diagnosed with ADHD — 80 percent, according to studies — respond to stimulant medications, and half of them will respond equally well to two different classes of ADHD medications, methylphenidate (Ritalin and other brands) or amphetamine (Adderall and other brands). The other half will do better on either methylphenidate or amphetamine, explains Dr. Roy Boorady, a senior child psychiatrist at the Child Mind Institute. So it’s critical that a doctor has the experience and patience to try a different medication if the first isn’t effective, or has unacceptable side effects.

It’s also important to recognize that children respond to different medications at different ages — what doesn’t work at 7 or 8 may be very successful for a child at 13. There are also different release formulas that need to be selected, and perhaps combined, to be effective for a particular child over the course of a day. This, too, is an ongoing process that changes as the child grows and responds to different demands in school, in extracurricular activities, and at home.

“If you’re engaging in treatment — and this is what all evidence-based treatment-purveyors do — you’ve got to see if it’s working,” said Dr. Stephen Hinshaw in a recent lecture on ADHD medications. “You can’t diagnose on the basis of a 10-minute chat with a pediatrician and you can’t just rely on a six-month follow-up visit in which the doctor asks, ‘How’re things going?’ Regular monitoring of the child’s behavior, regular monitoring of the parents’ improvements, consultation with schools — these are needed whether you’re giving medication or doing behavior modification in a school setting.”

A good generalist also recognizes the limits of what they can do. If your child shows signs of other conditions in addition to ADHD, such as tics, anxiety, or defiance, the perspective of a specialist is likely needed. Some states have telepsychiatry programs that allow primary care doctors to consult with experts when making a diagnosis or modifying medication.

Parents looking for a skilled, experienced primary care provider have to dig deep and network widely. Basic psychopharmacology and ADHD management have been part of medical training for at least 15 years, says Martin Stein, professor of pediatrics at UC-San Diego. Theoretically, any pediatrician should be able to manage ADHD, especially if there are no co-occurring diagnoses.

However, many general practitioners are uncomfortable treating brain disorders. Julissa Viana’s experience, in which her child’s primary care provider expressed reluctance to diagnose or treat ADHD, is common.

“ADHD is not something most pediatricians deal with every day,” says Stein. “Their bread and butter is physical medicine — sprained ankles, pneumonia, meningitis. Many practices are not set up to handle children with behavioral and school issues.”

Here are a few tips for finding a primary care practice in your area that can provide evidence-based treatment for ADHD:

• CHADD (Children and Adults with ADHD): This nationwide support network has over 200 local chapters and an online directory of ADHD professionals.
• Developmental-Behavioral Pediatricians: These general practitioners receive post-residency training in evaluating and treating a wide range of mental health needs in children. You can search for DB-pediatricians in your area on the healthychildren.org website.
• Word of Mouth: Other parents, your school nurse, or your current pediatrician may be able to give you ideas on where to find local primary care providers who treat ADHD. Or you can reach out to other parents and advocacy groups via social networks.