ABSTRACT: The majority of children with attention-deficit/hyperactivity disorder (ADHD) are assessed and treated by primary care pediatricians. However, the services of others are frequently needed to provide optimal care for children with ADHD; one of the pediatrician’s most important roles is to serve as coordinator of the treatment team. A child’s parents are the most important members of the ADHD treatment team. Education of parents by professionals is the cornerstone of any treatment plan for a child with ADHD. Schools are a major provider of services for children with ADHD. Schoolbased evaluations and interventions are often provided under the Individuals with Disabilities Education Act. In cases complicated by comorbid diagnoses, medication treatment resistance, or complex family and psychosocial dynamics, child psychologists and psychiatrists can provide invaluable assistance with diagnosis and treatment. Other professionals, such as speech therapists, occupational therapists, psychiatric social workers, and nurse practitioners can also provide valuable services. Developing technology is creating new avenues of collaboration, including telepsychiatry and phone or Internet consultation.
Attention-deficit/hyperactivity disorder (ADHD) is the most common mental health disorder treated by pediatricians.1 Some pediatricians may not have the training, clinical experience, or time to adequately evaluate and treat children with ADHD—and most may feel their skills are insufficient in children with medication treatment resistance, comorbid psychiatric illnesses, or complex family dynamics.
In addition, pediatricians who treat children with ADHD often encounter complex systems issues that are beyond their usual scope of practice.
Because most children with ADHD—and especially those with comorbidities— display symptoms in multiple environments and require multimodal treatment (academic, family, individual, and medical interventions), a team of professionals is often required to provide comprehensive treatment. In such instances, the pediatrician may become the focal point for facilitating collaborations between parents, schools, and other evaluating and treating clinicians.
In this article, we describe the roles of the possible members of a comprehensive treatment team. We also offer advice on how pediatricians can facilitate and make the most of these collaborative relationships in order to optimize the treatment of their patients with ADHD.
PEDIATRICIANS’ MANY ROLES IN ADHD TREATMENT
Despite formidable barriers to pediatricians’ caring for children with ADHD, both pediatricians and child psychiatrists agree that pediatricians should treat the disorder.2 Pediatricians play many roles in the treatment of ADHD. In the assessment phase, they determine whether ADHD is present or whether a comprehensive mental health evaluation by a specialist is needed. After a child has received a diagnosis of ADHD, pediatricians serve as educators, counselors, and primary health care providers.
In addition to prescribing medication, they frequently provide detailed ADHD information and parenting advice to parents. For special education plans, schools require the help of a treating clinician to verify the presence of a qualifying medical illness. For many children with ADHD, their pediatrician serves as primary organizer and consultant for their comprehensive treatment plan. In more complex or treatment-resistant cases, pediatricians assist parents in connecting with needed specialists, such as child psychologists, child psychiatrists, psychotherapists, or skills trainers.
PARENTS Keys to obtaining a good family history.
History gathered from a child’s adult caregivers is crucial in ruling out psychosocial or environmental causes of secondary ADHD symptoms. If these causes are not ruled out, disruptive children may receive unnecessary psychotropic medications.
Clearly, ADHD and learning disorders are potentially familial conditions. Thus, it is important to inquire about any family history of these problems.
It is also critical to ask families about routines that involve food and sleep. Children who are not provided breakfast or lunch are likely to focus on their hunger rather than their schoolwork—and to suffer the physiological and cognitive effects of not eating. Although sugary foods have not been shown to cause ADHD, the metabolic effects of glucose fluctuation following boluses of simple carbohydrates may lead to shifts in energy and concentration.
Lack of sufficient sleep is a prevalent cause of academic and behavioral struggles. Thus, it is important to rule out poor regulation of access to computers and television as well as sleep disorders, such as sleep apnea, when evaluating a child with suspected ADHD.
Children may also have difficulty in paying attention at school if they are the target of bullying. Children with ADHD are often socially awkward and reluctant to tell others when they are victimized; thus, parents may need to be coached to query teachers and educational staff if they suspect bullying at school, despite a child’s denial. Bullying may also occur at home between siblings or between a child and a parent, resulting in disruptive behaviors and poor school performance.
Finally, keep in mind that hyperactivity, impulsivity, and inattention symptoms may be the cause of greatly impaired bonding and joy in a family; however, these symptoms may also be the outcome of family turmoil, parental depression, or family trauma. Good family relationships are crucial to a favorable treatment outcome, and left ignored will result in unsuccessful interventions.
Importance of parenting education. A child’s parents or guardians are the most important members of the ADHD treatment team. Education of parents by professionals is the cornerstone of any treatment plan for a child with ADHD. A thorough understanding of ADHD and its treatment enables them to provide an optimal environment at home and to advocate for their child’s educational needs at school. Pediatricians can help dispel common misconceptions, such as the belief that ADHD is caused by eating too much sugar, the concern that drugs used to treat ADHD can have catastrophic long-term consequences, or a lack of awareness of the connection between disruptive behaviors and parenting methods.
Parents as case coordinators. When it comes to the treatment of ADHD, parents and guardians are usually the de facto case coordinators for their child’s care. They must know what their child’s special needs are.
When services at school are needed, parents must know how to request an assessment for an Individualized Education Plan (IEP) or 504 accommodation plan. Parents may also need to coordinate other treatment modalities, such as speech and language therapy, tutoring, occupational therapy, and social skills training. Pediatricians can help parents add appropriate members to a comprehensive treatment team.