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C
H A M P
AN ASSOCIATION WITH A MULTIDISCIPLINARY
APPROACH
TO CHILDREN WITH DEVELOPMENTAL PROBLEM
ATTENTION DEFICIT HYPERACTIVITY DISORDER
WHAT IS ADHD
ADHD is a common disorder of childhood. One review of 19 studies conducted during the past 2
decades estimates the prevalence of ADHD to be 5% to 10% in school-aged children. In spite of
media alerts about an "epidemic" of ADHD, these rates have been stable over time.
RECOGNIZING ADHD
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How is your child doing in school?
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Are there problems with learning that you or the teacher has seen?
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Is your child happy in school?
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Are you concerned with any behavioral problems in school, at home, or when your child
is playing with friends?
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Is your child having problems completing class work or homework?
When parents themselves raise concerns about ADHD, their suspicions often prove to be
accurate. Sometimes, the problem presents as a crisis, ranging from grade retention,
suspensions, or even problems with the law.
Screening can turn up problems other than ADHD, such as learning disabilities, depression,
anxiety disorders, or other psychiatric disorders.
Family or environmental problems are often only disclosed after the child's problem has been
identified.
Importance of Multiple Informants
There is a strong consensus that the diagnosis of ADHD requires information from multiple informants regarding
the child's or adolescent's behavior in several settings, usually at home and in school. Formal and informal
observations, anecdotal reports, semi-structured clinical interviews, and behavioral checklists are all options.
Individuals with ADHD tend to be poor reporters about their own function. In cases of divorce or separation,
reports from noncustodial parents are important.
Classroom observation and interviews of teachers, coaches, and other informants is usually not practical, so most
clinicians rely on checklists and notes from teachers, supplemented by parent and child interview.
Impairment of Function
School function is almost always affected in ADHD. A child who is felt to be able to do grade-level work, but
whose work is highly inconsistent may be more likely to have ADHD than a specific learning disability. If grades
swing between As and Bs, and Ds and Fs, it is helpful to look more carefully at the D and F work. If this is due to
work being turned in late or not at all, forgetting to bring materials to class, or incomplete assignments, then
ADHD is more likely.
It is also important to document function at home, with peers, and occupationally.
Sometimes adolescents are more concerned about how well they perform their job, and may have already experienced consequences of
ADHD.
Comorbidity
Diagnoses include oppositional defiant disorder (ODD), specific learning disability (LD), conduct disorder (CD),
anxiety disorders, and depression. Tourette's syndrome can also be seen in patients with ADHD. Adjustment
disorders are also common in children and can coexist with ADHD. Bipolar disorder is very rare in young children,
as is schizophrenia. Substance abuse may complicate the course of ADHD, particularly
in children with a history of conduct disorder.
Autism and mental retardation are both less common than ADHD. Autism and other pervasive developmental
disorders may include problems with attention and self-control, as well as serious problems with organization,
planning, mental flexibility, and emotional regulation (often called Executive Functions).
The DSM-IV specifically excludes the diagnosis of ADHD in children with pervasive
developmental disorders.
Clinical Approaches to ADHD
Based on the new guidelines , there are a number of approaches to ADHD in the primary care setting. The main
approaches are outlined below.
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Immediate mental health referral
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Crisis situation
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Conduct disorder suspected
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Suicidality suspected
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Substance abuse
· Other dangerous situation
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Conduct a further history and physical, gather parent and teacher questionnaires and anecdotal reports,
review psychoeducational testing at a psychologist.
In cases in which the child is referred specifically because of ADHD and there is a low likelihood of
comorbidity, but no previous evaluation.
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Brief interview and physical (if not done within previous 12 months)
Have parents obtain standard questionnaires from teacher and complete rating forms .
Obtain anecdotal reports about schoolwork, and review available report cards and achievement test
data. Schedule a longer follow-up visit.
Most cases of ADHD can be managed relatively simply when no significant learning or psychiatric
problems are suspected or present.
Treatment and referral decisions can be made at follow-up visit.
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Clinical trial of psychostimulant
After the child has been thoroughly evaluated by a team at school or independently and
shows strong evidence of ADHD.
Use a baseline measure such as the Clinical Attention Problem scale[18] with weekly
teacher reports.
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Neurodiagnostic assessment (EEG, MRI)
Electroencephalography (EEG) and magnetic resonance imaging (MRI) are appropriate only when
there is a strong index of suspicion (not as a routine).
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Laboratory tests (Lead bloodlevels, Full Blood Count, Thyroid function.)
Appropriate only when there is a strong index of suspicion (not as a routine). Electrocardiogram
(EKG) may be appropriate with some medications .
Liver function tests are not required with methylphenidate and dextroamphetamine.
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Multidisciplinary evaluation
This approach is used for children who have problems performing in school, but their behavior is not
considered to be the primary cause of underperformance.
Useful for children with established ADHD who are having problems despite treatment.
Evaluation can be targeted to answer clinical questions.
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Parent referral for counseling or training
Initial approach for parents with young children and when parent-child interaction problems or
temperament difficulties are suspected rather than a disorder.[19]
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Developmental-behavioral surveillance
This is the usual strategy when no problem is suspected or identified. It is a proactive
approach that
recognizes problems may present late or subtly.
SUMMARY
ADHD is a common diagnosis that is frequently lifelong and is often associated with significant comorbid
condition(s). The most serious type of comorbidity is conduct disorder. Primary care clinicians will frequently be
asked to evaluate children with suspected ADHD. Primary care evaluation and treatment is feasible, but it does
require a systematic approach and a moderate time commitment -- at least an hour for children and adolescents
with straightforward presentations and good supporting documentation, and up to several hours for more
complex presentations. Even in children who have been referred to specialists (eg, developmental-behavioral
pediatricians, child and adolescent psychiatrists, or child neurologists), the primary care clinician still plays a
role in monitoring and quality assurance.
Primary care physicians need to work together with subspecialists and other partners in the community to make
sure that the complex needs of children with ADHD are met. This includes advocacy at the individual level for
accommodations in school and eligibility for special education services and funding, and advocacy at the
community level. The medical community needs to promote the development of adequate systems of
psychosocial and mental health care that are effective, accessible, and high quality. It is also necessary to help
community agencies (including those in the juvenile justice system) and promote family
support services.
Advocacy is as important as proper medical diagnosis and treatment for good outcomes. Physicians need to insist
that they get adequate documentation of evaluation and treatment from the mental health system, just as they
would expect from any other consultant.
SAMPLE CASES >>
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