We know from several QI projects in the Chapters that with the right help and support pediatricians can do assessment, diagnosis and treatment for ADHD in the pediatric office. And they can get paid for the services they perform. The following details on ADHD will provide you with the basics if you have never engaged in this work, or will provide additional information if you have only done it a few times. It is hoped that for those of you fully engaged in offering comprehensive ADHD services in your practices it will strengthen and further support your ADHD affects 5-7% of the school age population.
It is considered a neurodevelopmental disorder with a strong genetic influence. The symptom picture encompasses the trifecta of inattention, impulsivity and hyperactivity. Treatment has its own trifecta of stimulant medication, parent behavioral management training, and where necessary, school accommodations. Diagnosis is based on clinical history aided by the use of Rating Scales such as the Vanderbilt, typically completed by both classroom teacher and parent, and of course the physician’s own clinical assessment. EEG, MRI or psychological testing are not necessary for diagnosis. However, ADHD frequently co-occurs with Oppositional Defiant Disorder, Learning Disabilities, Anxiety and Depression. Psychological testing is necessary where there is suspicion for a co-occurring learning disability. Pre-prescribing warrants a thorough physical examination, but does not require any blood work unless specifically indicated.
An EKG is not necessary unless the patient or 1st degree relatives have a history of structural cardiac disease. Medicine can be titrated rapidly to the place of optimal clinical response using rating scale data from home and school for monitoring purposes. The clinician must determine effectiveness at any given dose as well as duration of action (morning dosing may not last long enough). The condition may present in the pre-school years. Current AAP guidelines emphasize the primacy of psychosocial interventions first in this age group. Implied in this stance is acknowledgement of the neurodevelopmental trajectory towards increasing maturity in these early years.
Stimulant medication and its positive impact on ADHD is one of the most robust findings in all of medicine. The stimulants belong to 2 families: methylphenidate derivatives and amphetamine derivatives. Existing preparations vary only in their delivery systems and duration of action. Failure to respond to one class warrants switching to the other. Second line medicines include the alpha 2 agonists, short acting Guanfacine (Tenex) or Clonidine (Catapres), or their longer acting versions Guanfacine (Intuniv) and Clonidine (Kapvay). Strattera is another option for those who cannot tolerate stimulants or where stimulants exacerbate tics. Lastly, Wellbutrin (Bupropion) has moderate effects on ADHD symptoms. It is not FDA approved for this indication.
A child with ADHD is invariably embedded in a family, school and larger community all of which may be helpful or hurtful in a given circumstance. Referral to the C.H.A.D.D organization is helpful for parents to learn more about the condition. Some parents will do well in studying for themselves an extensive literature on managing the ADHD child. Others will benefit from more formal parent behavioral management training groups, others will require one-on-one family work. Accommodations may be necessary in the school setting.
The primary care physician has a strong advocacy role to play in requesting such accommodations, most commonly extra time on tests in a quiet location, preferential classroom seating, assistance with note taking, etc. Treating ADHD in the primary care practice is often very rewarding to the clinician and most certainly contributes significantly to the well-being of affected children and families.
