Q: The most recent American Academy of Pediatrics (AAP) guidelines1 on the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD) ask the primary care clinician (PCC) to collaborate with the school to follow and manage the care of children and youth who are diagnosed with ADHD. What are some strategies that practices can use to effectively do this?
A: The AAP guidelines include collaboration with the school for both diagnosis and ongoing follow-up. “The procedures recommended in this guideline necessitate spending more time with patients and families, developing a system of contacts with school and other personnel, and providing continuous, coordinated care, all of which is time demanding.” Prior to diagnosis, the PCC is expected to gather information from the school to include: concerns from the classroom teacher, a validated rating scale from the teacher, any evaluation of co-existing learning issues, a report of function indicating strengths and weaknesses, academic records, and any disciplinary reports. The PCC is also to collaborate management with the family and school.
It is, indeed, a challenge for the individual PCC or practice to initiate a process to accomplish these steps with each individual patient. Therefore, it is advisable for the practice to develop a standardized process that facilitates care for this population of patients. As the guideline states, pre-visit planning is necessary. Pre-visit planning also increases both family and PCC satisfaction with the care process. Practice readiness for accomplishing the recommendations includes agreeing on a standard process that encompasses the role of the medical home to:
- Identify a contact person(s) at the practice to receive information and communicate with the school.
- Allow pre-visit review of the medical and developmental history, particularly developmental concerns and school data.
- Confirm the diagnosis, if indicated.
- Provide prescription and medication follow-up, if indicated.
- Make referrals, if indicated.
- Send completed ADHD report with recommendations to school.
- Provide regular follow-up visits, with updates from the teacher.
Standardized communication with the school is needed for the practice to manage this population. Building communication and relationships with the school is the essence of implementing the chronic care model with this population and is a crucial part of working with the patient and family. Therefore, for practice readiness it is advisable to meet with the lead psychologist or an equivalent administrator for the local school system to establish exchange of information and communication expectations/roles prior to implementation of new practice procedures.
Considerations for standard communication between the school and primary care medical home should include the following items for diagnosis and for follow-up.
Diagnosis Components, Standard Elements
School to PCC
- Summary of concerns (include strengths and weaknesses).
- Validated rating scale.
- Any previous evaluations.
- Academic records.
- Two-way consent.
- Feedback regarding intervention plans (eg, classroom accommodations, 504 Plan, individualized education plan as appropriate).
PCC to School
- Written report of ADHD diagnosis.
Follow-Up Components, Standard Elements
- PCC to parent and teacher.
- Request / release of information and rating scale.
- Teacher / school to PCC.
- Rating scale(s) and any updates.
- Parent / adolescent to PCC.
- Rating scale(s).
- PCC to parent and school.
- Summary of visit: to include any medication change and/or new issues identified at visit.
Of course, such systems change can be even more far reaching if a group of practices from the community, or even the state AAP chapter, could participate in conversations with the school system. One such successful community effort has been described.2: The process would vary based on state infrastructures, but involving the chapter would greatly reduce the burden at the individual practice level. If a practice is championing this effort, engaging the AAP Chapter for assistance is recommended.
- Wolraich M, Brown L, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management et al. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011;128(5):1007–1022. doi:10.1542/peds.2011-2654 [CrossRef]
- Foy J, Earls M. A process for developing community consensus regarding the diagnosis and management of attention deficit hyperactivity disorder. Pediatrics. 2005;115:97–104.