New Attention for ADHD
ADHD – attention deficit hyperactivity disorder – isn't just for specialists to treat anymore, nor is treatment simply a matter of taking one of several widely prescribed pills.
Affecting more than one in 20 children and nearly one in 10 boys, attention deficit hyperactivity disorder is by far the most common childhood behavior disorder. Its prevalence increasingly is driving diagnosis and treatment outside the realm of child psychiatrists and psychologists and into pediatricians' offices, says Helmut Roehrig, PhD, pediatric psychologist with Cincinnati Children's Hospital Medical Center.
"Psychologists and psychiatrists do first-line assessment of ADHD, but the wait time is extensive," Dr. Roehrig says. "There simply aren't enough psychologists or psychiatrists out there. The pediatricians are capable of doing wonderful jobs with the diagnosis and medication treatment plans."
More Training for Pediatricians
Cincinnati Children's has led an effort in the region in the past year to step up training for pediatricians in assessment and treatment of ADHD. Despite what might sometimes appear to be an epidemic, ADHD has fairly consistently affected about 9 percent of elementary-school boys and 3 percent of girls over several decades.
Today, pediatricians commonly will include questions about behavior and school performance in annual physicals in an effort to assess a child's functioning, Dr. Roehrig says. This information may indicate a need to evaluate the child for ADHD. The pediatrician also can prescribe what research indicates is an effective treatment for the disorder – psychoactive stimulants – and help parents develop behavior management plans to use at home and school, he says.
Though regular screening sometimes helps identify the need for an evaluation, parents usually seek medical advice after they, relatives or teachers note signs of ADHD, including problems with academic performance, disruptive behavior or peer relations, Dr Roehrig says. Though ADHD is first identified most frequently in elementary-school-age children, the condition persists well into the middleand
high-school years and even into adulthood in many cases, he says.
Making the Diagnosis
Diagnosis is made according to the DSM-IV, or fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, which provides criteria and a checklist of symptoms for making the call. Cincinnati Children's has conducted extensive
training with a pilot group of pediatricians to help them diagnose and treat the condition. Screening for ADHD includes a physical exam and teachers and parents filling out standardized checklists with questions about children's academic and behavioral performance.
Misdiagnosis has occurred at times, as such conditions as learning disorders, non-ADHD behavior problems, and the increasingly recognized juvenile onset of such mood disorders as depression and bipolar disorder can be confused with or exist alongside ADHD, Dr. Roehrig says. "But I believe missed diagnoses may be as common as misdiagnoses," he adds.
Though medication remains the standard for treatment of ADHD, research supports the use of behavior management strategies and parent training, which are important parts of ensuring the best outcome for affected children and their families, he says.
The Division of Behavioral Medicine and Clinical Psychology at Cincinnati Children's has increased the availability of parent training at sites throughout the area, conducting sessions in a group-therapy format where parents of children with ADHD can learn about behavior-management strategies and how to use them.
Changing Behaviors
"We're not really targeting symptoms of ADHD," Dr. Roehrig says. "We target behaviors that, if changed, would help a child improve in academic, social and family functioning."
Among behaviors targeted by behavioral treatment are:
- Compliance with requests from parents
- Playing better with siblings
- Completing chores and homework
- Following classroom rules
- Improving accuracy of work
- Peer relationships – avoiding bossiness and fostering cooperation
The focus is on teaching parents how to give children effective commands and instructions, shaping behavior through positive attention for desirable behaviors, setting gradual goals for improvement and using reward systems and timeouts.
Pediatricians can refer parents to training sessions through Cincinnati Children's and help in development of care-management plans that include targeted improvement in problem behaviors, Dr. Roehrig says. "Sometimes there's reluctance [to take these steps] because the medication is working well," he says. But he believes, and research supports, that a combination of parent training with medication and behavior therapy helps improve outcomes.
