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Caring for children with attention-deficit/hyperactivity disorder (ADHD) in a busy pediatric practice is possible, Joseph F. Hagan Jr. M.D., FAAP, said during a session at the AAP Virtual National Conference.
Dr. Hagan not only provided those encouraging words, he also outlined the process he uses in his practice in Burlington, Vt.
Dr. Hagan served as chair of the AAP Committee on Psychosocial Aspects of Child and Family Health, is a co-author of the 2019 AAP Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents and is co-editor of ADHD: What Every Parent Needs to Know, 3rd Edition.
Working with experts on those and other projects “led me to feel very comfortable and relatively proficient at how I provide this care,” he said.
Dr. Hagan began the session “Adopting AAP ADHD Clinical Guidelines in Your Practice” by reviewing prevalence estimates for ADHD, common comorbid conditions and key action statements in the guideline for diagnosing, treating and managing the condition.
He then addressed the elephant in the (virtual) room — the myriad barriers all pediatricians face in providing comprehensive care.
“Let me tell you four things you already know so that we can all whine together,” Dr. Hagan said as he enumerated the following systemic barriers to care:
- Inadequate training for pediatricians and shortages of specialists.
- Inadequate payment for services and payer coverage limitations for medications.
- Challenges in practice workflow and staffing.
- Fragmentation of care and communication barriers between the pediatrician and families, mental health providers and school staff.
“On the other hand,” he added, “there are things we can do about this, and we need to think to the future to change this.”
Dr. Hagan encouraged pediatricians to use the process of care algorithm in the guideline to implement the key action statements. “The barriers are there,” he said. “The algorithm is a way to weave your way through the barriers.”
He described how he uses the algorithm when a family expresses concerns about their child’s inattention or struggles in school.
First, he has his staff give questionnaires to the family, school and sometimes the patient. While he typically uses the Vanderbilt assessment scales, he urged pediatricians “to find a couple that you are comfortable with and use them.”
Next, he reviews completed questionnaires and bills for that service. He then schedules a conference with the parents to find out what they have observed, what they are worried about and what they and the school have tried so far.
“Why not include the child? This is an information-gathering discussion,” he said. “… And remember, these parents think their child is hyperactive. Have you ever had a parent conference go well with a hyperactive child in the room? I’ve yet to have it go well.”
He also gets family and social histories from the parents, which can illuminate issues like bullying or conditions such as depression or anxiety that mimic ADHD.
After that, he reviews with parents the questionnaire findings, criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, his assessment of whether the child has ADHD and next steps.
If the child has ADHD, he provides parents with resources to learn more about the condition.
Later, he meets with the patient to confirm the diagnosis, explain what ADHD is in an age-appropriate way and lay out the treatment plan.
“We’re not telling them that they will never learn. We’re not telling them they’re not smart,” he said. “We’re telling them that they don’t pay attention like the average (child) and that we can help them with that attention in certain ways.”
He ends by seeking patients’ willingness to engage in treatment by asking if they understand how he is going to be working with them and how the medication can help.
Finally, he plans follow-up by phone, patient portal or in the office.
Dr. Hagan ended by inviting pediatricians to email him at firstname.lastname@example.org if they have questions.
Registered attendees can access the session through Jan. 31 at https://www.eventscribe.net/2020/AAPexperience/.