Introduction to Caring for Children with ADHD: A Resource Toolkit for Clinicians, 2nd Edition

 

Pediatric Primary Care Clinicians Play an Important Role in the Care of Children and Youth With Attention/Deficit-Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children.1 The American Academy of Pediatrics (AAP) recently revised its previous guidelines for diagnosis, evaluation, and treatment of ADHD.2,3 The high prevalence rate of ADHD makes it impossible for many children to receive care from mental health clinicians. Pediatric primary care clinicians have unique access to children and families and thus are uniquely situated to diagnose and treat children with this condition. In addition to providing their own guidance, primary care clinicians play an important role in advocating for and linking families to resources and school programs, all of which may positively influence the social-emotional health of children.


Unique Strengths of Primary Care Clinicians

The AAP recognizes the unique strengths of primary care clinicians and opportunities inherent in the pediatric primary care setting—“the primary care advantage.”4

    1. A longitudinal, trusting, and empowering therapeutic relationship with children and family members
    2. The family-centeredness of the medical home5–12
    3. Unique opportunities to promote healthy lifestyles, reinforce strengths in children and families, recognize adverse childhood experiences and stressors associated with social-emotional problems, and offer anticipatory guidance13–15
    4. Understanding of common social, emotional, and educational problems in the context of a child’s development and environment13
    5. Experience working with specialists in the care of children with special health care needs and serving as coordinators and case managers through the medical home
    6. Familiarity with chronic care principles and practice improvement methods

 

Barriers to Primary Care Change

Yet primary care clinicians experience many barriers to providing services for children with ADHD, including discomfort with their knowledge and skills, time constraints, poor payment, limited access to mental health consultation and referral resources, and administrative issues with insurance plans.16,17 Also concerning is the compelling perspective of parents of children with mental health concerns. At a focus group in 2006, parents expressed a variety of concerns about the care their children received in primary care settings, including a delay in identification of their child’s mental health problem, lack of referral for needed specialty services, inadequate information about mental health resources, and lack of empathy and emotional support. Most of the participants pointed to institutional barriers between the medical and mental health communities as a core problem; the medical community has not fully integrated mental health into its culture, creating and perpetuating a division between the 2 communities.

Caring for Children With ADHD: A Resource Toolkit for Clinicians, 2nd Edition, is designed to provide tools and materials to implement and document the procedures as outlined in the “Overview of the ADHD Care Process” algorithm that complements the revised guideline recommendations.18 The number of diagnostic assessment tools in the kit has expanded, particularly those to help clinicians better evaluate possible comorbid conditions. There are also materials to cover a broader age range, such as a behavioral contract that families can use with their teenagers. Decision support materials that clinicians can use with families have been updated and expanded. With the guideline revisions, development of a more detailed practice algorithm, expanded number of tools, and AAP Quality Improvement Innovation Network members using these tools in practice to test for feasibility, we have enhanced the ability of primary care clinicians to provide exemplary services to patients with ADHD and their families.


References

1. Visser SN, Lesesne CA, Perou R. National estimates and factors associated with medication treatment for childhood attention-deficit/hyperactivity disorder. Pediatrics. 2007;119(Suppl 1):S99–S106
2. American Academy of Pediatrics Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158–1170
3. American Academy of Pediatrics Subcommittee on Attention-Deficit/Hyperactivity Disorder, Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108(4):1033–1044
4. Harris M. Rural private pediatric practice ownership and management of a mental health practice [teleconference audio file]. Elk Grove Village, IL: American Academy of Pediatrics; October 25, 2006
5. American Academy of Pediatrics. Family pediatrics: report of the Task Force on the Family. Pediatrics. 2003;111(Suppl 2):1541–1571
6. Wertlieb D. Converging trends in family research and pediatrics: recent findings for the American Academy of Pediatrics Task Force on the Family. Pediatrics. 2003;111(Suppl 2):1572–1587
7. Blanchard LT, Gurka MJ, Blackman JA. Emotional, developmental, and behavioral health of American children and their families: a report from the 2003 National Survey of Children's Health. Pediatrics. 2006;117(6):e1202–e1212
8. Kim HK, Viner-Brown SI, Garcia J. Children’s mental health and family functioning in Rhode Island. Pediatrics. 2007;119(Suppl):S22–S28
9. Beardslee WR, Gladstone TRG, Wright EJ, Cooper AB. A family-based approach to the prevention of depressive symptoms in children at risk: evidence of parental and child change. Pediatrics. 2003;112(2):e119–e131
10. Allmond BW, Tanner JL, Gofman HF. The Family Is the Patient: Using Family Interviews in Children’s Medical Care. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999
11. Coleman WL, Howard BJ. Family-focused behavioral pediatrics: clinical techniques for primary care. Pediatr Rev. 1995;16(12):448–455
12. Coleman WL. Family-focused pediatrics: solution-oriented techniques for behavioral problems. Contemp Pediatr. 1997;14(7):121–134
13. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008
14. Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project. Pediatrics. 2007;120(3):547–558
15. Ginsburg KR, American Academy of Pediatrics Committee on Communications and Committee on Psychosocial Aspects of Child and Family Health. The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics. 2007;119(1):182–191
16. Horwitz SM, Kelleher KJ, Stein REK, et al. Barriers to the identification and management of psychosocial issues in children and maternal depression. Pediatrics. 2007;119(1):e208–e218
17. American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics, American Academy of Pediatrics Task Force on Mental Health. Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics. 2009;123(4):1248–1251
18. American Academy of Pediatrics Steering Committee on Quality Improvement and Management, Subcommittee on Attention-Deficit Hyperactivity Disorder. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. In press