Pediatric Help for ADHD
Up to 9 percent of children ages 6 to 12 in the United States suffer from attention deficit hyperactivity disorder (ADHD), according to estimates from the American Academy of Pediatrics (AAP). In hard numbers, the Centers for Disease Control and Prevention estimates that ADHD affects almost four million children ages 3 through 17.
These numbers translate to thousands of parents and children who may have to endure months of waiting to see a specialist – child psychiatrists, neurologists and developmental/behavioral physicians – for diagnosis or treatment. Many of these specialists are in short supply, especially in more rural areas, so there's a considerable backlog of children waiting to get the help they need.
That's why in recent years, hospitals and pediatricians have stepped in to help alleviate this growing need. According to Dr. Harlan R. Gephart, a behavioral pediatrician and ADHD specialist in Seattle, Wash., and one of the online community advocacy leaders for ADHDbalance.net, this push began roughly five years ago with the National Initiative for Children's Healthcare Quality and the Robert Wood Johnson Foundation project. Dr. Gephart helped assemble guidelines and tools for pediatricians to help correctly diagnose and treat ADHD.
Dr. Gephart reports that there was a lot of variability in how doctors were approaching ADHD, and the initiative sought to establish clear guidelines for the diagnoses and treatment of the disorder. A collaborative of 35 practices was formed, he says, and helpful tools such as parental handouts and behavioral rating scales were developed.
"There are over 50,000 practicing pediatricians in the USA, most of whom are trained and comfortable diagnosing ADHD," Dr. Gephart says. "By and large one could have their child evaluated by a pediatrician within a reasonable time period. The American Academy of Pediatrics has developed excellent resources, including the ADHD Toolkit, to help pediatricians in this process."
A New Kind of Training
But helpful tools are really only the first step in ensuring that doctors are properly equipped to diagnose and treat ADHD. Experts say pediatricians need continuing education specifically aimed at helping them unlock the intricacies of a child's mind.
One of Dr. Gephart's trainees, Dr. Philip Lichtenstein from the Cincinnati Children's Hospital Medical Center in Ohio, has sought to do just that. Dr. Lichtenstein directs the hospital's ADHD Collaborative Training Project and trains more than 360 local physicians to diagnose and assess ADHD in children.
"Historically, primary care physicians haven't been adequately trained to practice behavioral health," Dr. Lichtenstein says. "There's always been a dichotomy in medical training – a split between those who study physical disease systems and those who study mental or psychiatric disorders. The dichotomization has been so firmly drawn that medical trainees didn't get well grounded in mental health issues. Even in the pediatric and internal medicine residencies, physicians were learning to take care of classic physical conditions. Any training that had to do with diseases of the mind, such as ADHD or depression, was cordoned off to be mastered by another group of trainees in psychiatry."
This division didn't go unnoticed by residency directors, specialty boards and state and national legislatures and became an increasing area of concern, Dr. Lichtenstein says. Essentially, there was a shortage of help equipped to handle both the physical and the mental side of medicine. But, according to Dr. Lichtenstein, there has been a renewed focus on including training mental health issues in primary care physicians' training.
"There's been a tremendous effort nationally to refocus training and to put more emphasis in mental and behavioral health issues, with the long-term prospect of making primary care physicians collaborators in and equal participants in the triaging of patients with mental health care problems," Dr. Lichtenstein says.
Dr. Lichtenstein's role in Cincinnati is to work with physicians who are already out in the field. "We focus on familiarizing doctors with the diagnostic guidelines, the tools available for making the ADHD diagnosis and how to use those treatments optimally," he says. "The format for doing this is a direct adaptation of the methodologies introduced in Dr. Gephart's national collaborative project five years ago."
Hospitals Offer Training Programs
And Cincinnati is only one of many cities looking to help. Among the hospitals that have gotten on board and started offering similar training are Children's Mercy Hospitals and Clinics in Kansas City, Mo. The entire idea originated from area physicians in a focus group, says Kevin W. Turner, the ADHD education coordinator in the Health Management Department.
"Through questionnaires and reviewing the literature, we identified the major problems that created barriers to primary care physicians diagnosing and treating ADHD in their clinics," Turner says. "Based on this information we began developing tools and processes that would make managing ADHD in the primary care environment more efficient and effective. We have since taken these tools into a large metropolitan clinic and have had excellent response by the physicians, staff and patients to the program."
The program began in May and is in the developmental stage with a local area pediatric practice in Kansas City testing educational materials and making recommendations about processes. The full pilot program is slated to run in September or October of 2006.
"The doctors and their staffs receive eight training modules with updated information about the diagnosis and treatment of ADHD," Turner says. "The content is based on the American Academy of Pediatrics guidelines for the diagnosis and treatment of ADHD. In addition to these training modules, we provide 'shadow time,' which involves a trained ADHD community educator working with doctors in the clinic to provide assistance with patient education, forms utilizations and referrals."
Given that so many hospitals and pediatricians are stepping up to the plate, how can parents determine if their child's doctor has had the appropriate training?
"My experience is that most family practitioners don't feel so comfortable diagnosing ADHD, though it depends on whether they've had some extra training," Dr. Gephart says. "Any pediatrician trained in recent years should have some training in seeing ADHD, and there are plenty of resources available from the American Academy of Pediatrics."
According to Dr. Gephart, one of the best ways to find out if your child's pediatrician is comfortable diagnosing ADHD is to ask. "To find out whether a doctor is equipped to handle a diagnosis, simply ask them whether they'd feel comfortable doing this," he says. "Most would be honest and say if they do or don't."
A Positive Response
"While we're only in the developmental phase, the majority of doctors in the clinic in which we're working have been receptive to incorporating forms and procedures that document that they're following recommended guidelines," Turner says. "They've also expressed appreciation for our help with referring those patients who need second opinions on diagnosis and treatment or more extensive mental health services, evaluations or interventions."
Turner says there's no doubt that they've developed a program that will have a significant, positive effect on the quality of care provided for the children and families in the community. "Feedback from patients and physicians we're currently working with, the success [of] our asthma program, which uses a similar primary care model, and the success of similar programs around the country all indicate that this program can have a powerful impact on the care of these special children."
Dr. Lichtenstein reports that through their program, they've worked with about 90 doctors and the response has been striking. "There were 15 doctors who've decided they're not ready to do this," he says. "But over 80 percent are ready, and the results have been phenomenal."
Dr. Lichtenstein says participants in the program had a baseline chart review performed that involves looking at the charts of 10 children who've been diagnosed with ADHD in the preceding two years. These charts were reviewed to see how close the physicians were to complying with the guidelines of the AAP.
"We've done extensive data collection on all patients who've been newly diagnosed with ADHD in these practices following our training intervention," Dr. Lichtenstein says. "And we've been very pleased to find good, substantial improvement after the intervention. We're not quite at the targeted outcome yet and we're in ongoing dialogue with the offices, but we're finding that not only are most offices maintaining their improvement, but [they] are continuing to improve over time."
And an even better sign? Dr. Lichtenstein says patients appear to be more satisfied with the results.
"They like the increased attention, the shortened time frame to get things diagnosed, and they like the fact that there's a rigorous plan to get things accomplished using input from both parents and teachers," he says. "There's good evidence that kids seen more frequently by their doctor end up staying on medication longer, their parents are less afraid of the long-term side effects of the medications and the behavior in the home and in schools is more consistently improved."
And that's welcome news for children, parents and doctors alike.