Pediatric Annals

FROM THE GUEST EDITOR 

Attention-Deficit/Hyperactivity Disorder: Issues for the Pediatric Office

Mark L Wolraich, MD

Abstract

Attention- deficit/ hyperactivity disorder (ADHD) has the distinction of being both the most extensively studied mental disorder, and the most controversial. With services for children with ADHD spanning the general medical, mental health, and educational sectors of a community and including both constitutional and environmental issues, it is not surprising that there are differences of opinion about the condition and its treatment. For the past few years, the extensive use or overuse of stimulant medication has been the most publicized concern. Much of the treatment with stimulant medication takes place in primary care with primary care pediatricians, in particular, providing the majority of the prescriptions.1,2,3,4 Most of the patients are treated by primary care clinicians and not referred for mental health services. A schoolbased sample by Bussing, Zima, and Belin4 found that, of the children receiving services for the diagnosis of ADHD, 74% were receiving those services from their primary care providers and, of the 74%, more than two thirds had no contact with mental health specialists. A study of psychiatrists reported that only 14% of their referrals for ADHD came from non-psychiatric physicians.5

Although primary care physicians play a key role in the diagnosis and treatment of children with ADHD, it is not clear that primary care physicians have employed the best practices in diagnosing and treating those children. Two studies6-7 of actual diagnostic practices found that primary care physicians under diagnose ADHD and conditions such as conduct or oppositional defiant disorder.

Another study of a community-based sample8 found that only 1 in 8 children with the diagnosis of ADHD was being treated with stimulant medication, but of those treated with stimulant medication, only half met the criteria for the diagnosis of ADHD.

Further, a study examining primary care physician accuracy in diagnosing ADHD found only moderate sensitivities and specificities,9 and the Bussing et al.4 study found that those receiving services from their primary care providers had fewer sessions, less time with their providers, and less use of multimodality therapies. The deficiencies may be one of the reasons children treated in the multimodality treatment of ADHD study10 found that those children treated with a rigorous medication protocol did significantly better than those treated with medication in the community.

To address the problems in pediatrie practice relating to ADHD, the American Academy of Pediatrics has developed both diagnostic and treatment guidelines11·12 and is in the process of developing and providing a toolkit and training on the subject. The same process has occurred in the child psychiatry community.13'14 The purpose of this issue of Pediatrie Annals is to inform the pediatrician about the American Academy of Pediatrics guidelines, how they were developed, and how they impact practice. It also updates physicians about the recent expansion in the number of new medication formulations, and, because school is such an important contributor to the situation, provides information about educational interventions and regulations regarding services for children with ADHD. Lastly, there is an article about identifying and managing adolescents with ADHD because it has become quite clear that the condition does not disappear for many of the children with ADHD when they become adolescents.

1. Sherman M, Hertzig ME. Prescribing practices of Ritalin: The Suffolk County, New York study. In: Greenhill L, Osman B, eds., Ritalin Theory and Patient Management. New York, NY: MA. Liebert; 1991.

2. Rappley MD, Gardiner JC, Jetton JR, Houang RT. The use of methylphenidate in Michigan. Arch Pediatr Adolesc Med. 1995;149:675-679.

3. Ruel JM, Hickey P. Are too many children being treated with methylphenidate? Can J Psychiatry. 1992;37:570-572.

4. Bussing R, Zima BT, Belin TR. Differential access to care…

Attention- deficit/ hyperactivity disorder (ADHD) has the distinction of being both the most extensively studied mental disorder, and the most controversial. With services for children with ADHD spanning the general medical, mental health, and educational sectors of a community and including both constitutional and environmental issues, it is not surprising that there are differences of opinion about the condition and its treatment. For the past few years, the extensive use or overuse of stimulant medication has been the most publicized concern. Much of the treatment with stimulant medication takes place in primary care with primary care pediatricians, in particular, providing the majority of the prescriptions.1,2,3,4 Most of the patients are treated by primary care clinicians and not referred for mental health services. A schoolbased sample by Bussing, Zima, and Belin4 found that, of the children receiving services for the diagnosis of ADHD, 74% were receiving those services from their primary care providers and, of the 74%, more than two thirds had no contact with mental health specialists. A study of psychiatrists reported that only 14% of their referrals for ADHD came from non-psychiatric physicians.5

Although primary care physicians play a key role in the diagnosis and treatment of children with ADHD, it is not clear that primary care physicians have employed the best practices in diagnosing and treating those children. Two studies6-7 of actual diagnostic practices found that primary care physicians under diagnose ADHD and conditions such as conduct or oppositional defiant disorder.

Another study of a community-based sample8 found that only 1 in 8 children with the diagnosis of ADHD was being treated with stimulant medication, but of those treated with stimulant medication, only half met the criteria for the diagnosis of ADHD.

Further, a study examining primary care physician accuracy in diagnosing ADHD found only moderate sensitivities and specificities,9 and the Bussing et al.4 study found that those receiving services from their primary care providers had fewer sessions, less time with their providers, and less use of multimodality therapies. The deficiencies may be one of the reasons children treated in the multimodality treatment of ADHD study10 found that those children treated with a rigorous medication protocol did significantly better than those treated with medication in the community.

To address the problems in pediatrie practice relating to ADHD, the American Academy of Pediatrics has developed both diagnostic and treatment guidelines11·12 and is in the process of developing and providing a toolkit and training on the subject. The same process has occurred in the child psychiatry community.13'14 The purpose of this issue of Pediatrie Annals is to inform the pediatrician about the American Academy of Pediatrics guidelines, how they were developed, and how they impact practice. It also updates physicians about the recent expansion in the number of new medication formulations, and, because school is such an important contributor to the situation, provides information about educational interventions and regulations regarding services for children with ADHD. Lastly, there is an article about identifying and managing adolescents with ADHD because it has become quite clear that the condition does not disappear for many of the children with ADHD when they become adolescents.

REFERENCES

1. Sherman M, Hertzig ME. Prescribing practices of Ritalin: The Suffolk County, New York study. In: Greenhill L, Osman B, eds., Ritalin Theory and Patient Management. New York, NY: MA. Liebert; 1991.

2. Rappley MD, Gardiner JC, Jetton JR, Houang RT. The use of methylphenidate in Michigan. Arch Pediatr Adolesc Med. 1995;149:675-679.

3. Ruel JM, Hickey P. Are too many children being treated with methylphenidate? Can J Psychiatry. 1992;37:570-572.

4. Bussing R, Zima BT, Belin TR. Differential access to care for children with ADHD in special education programs. Psychiatric Serv. 1998;9:1226-1129.

5. Zarin D, Suarez AP, Pincus HA, Kupersanin E, Zito JM. Clinical and treatment characteristics of children with Attention-Deficit / Hyperactivity Disorder (ADHD) in pyschiatric practice. / Am Acad Child Adolesc Psychiatry. 1998;37:1262-1270.

6. Costello EJ, Edelbrock Q Costello AJ, Dulcan MK, Barne BJ, Brent D. Psychopathology in pediatrie primary care: the new hidden morbidity. Pediatrics. 1988;81:415-424.

7. Lindgren, S, Koeppl GG. Assessing child behavior problems in a medical setting: development of the Pediatrie Behavior Scale. In: Prinz RJ, ed., Advances in Behavioral Assessment of Children and Families. Greenwich, CT: JAI Press; 1987:57-90.

8. Jensen P, Kettle L, Roper MT, Sloan MT, Dulcan MK, Hoven C, et al. Are stimulants overprescribed? Treatment of ADHD in four communities. J Am Acad Child Adolesc Psychiatry. 1999^8:797-804.

9. Lindgren S, Wolraich ML, Stromquist A, Davis C, Milich R, Watson D. Diagnostic heterogeneity in attention deficit hyperactivity disorder. In: The Fourth Annual NIMH International Research Conference on the Classification and Treatment of Mental Disorders in General Medical Settings. Bethesda, MD: National Institute of Mental Health; 1990.

10. Jensen P, Hinshaw SP, Swanson JM, Greenhill LL, Conners CK, Arnold LE, et al. Findings from the NIMH multimodal treatment study of ADHD (MTA): implications and applications for primary care providers. / Oev Behav Pediatr. 2001;22:60-73.

11. Perrin J, Stein MT, Amler RW, Blondis TB, Feldman HM, Meyer BP, et al. Diagnosis and evaluation of the child with AttentionDeficit/Hyperactivity Disorder. Pediatrics. 2000;105: 1158-1170.

12. Perrin J, Stein MT, Amler RW, Blondis TB, Feldman HM, Meyer BP, et al. Climical practice guideline: treatment of the school-aged child with Attention-Deficit/Hyperactivity Disorder. Pediatrics. 2001;108:1033-1044.

13. Dulcan, M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/ hyperactivity disorder. American Academy of Child and Adolescent Psychiatry / Am Acad Child Adolesc Psychiatry. 1997^36:15-375.

14. Greenhill L, Pliszka S, Dulcan M. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. / Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S.

10.3928/0090-4481-20020801-06

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