ADHD: Strategies for Developing a Further Dialogue - Episode 3
Key opinion leaders consider the collaborative role of pediatricians and child psychiatrists in managing young patients with ADHD (attention deficit hyperactivity disorder).
Tim Wilens, MD: Harlan, I was wondering if you happen to know who’s making the diagnosis? Is it pediatricians, is it a child psychiatrist? What factors determine who goes to whom? What does it look like out there?
Harlan R. Gephart, MD:It’s a very interesting question. For years we’ve said it’s probably 50/50 with child psychiatrists and pediatricians. In recent years, due to wonderful educational efforts that you at Massachusetts General Hospital and the [American Academy of Pediatrics] have developed…uncomplicated ADHD [attention-deficit/hyperactivity disorder] is good meat for a general pediatrician to diagnose. So we certainly don’t want to take up the time of a child psychiatrist doing that. But certainly, we need you because uncomplicated ADHD is only about 25% or 30% of the kids, and probably 70% or 75% of kids diagnosed with ADHD have a comorbid or a coexisting problem.
As Bob mentioned, these are all the way from mental health issues like anxiety, depression, or developmental issues like autistic spectrum disorder, family issues, divorce, parents’ separation, death of a parent, all those kinds of things. In the book I wrote, I listed 30 or 40 conditions that not only would look like ADHD, but would give you a positive Vanderbilt ADHD Diagnostic Rating Scale score. So you have to be careful because all of these other conditions can either look like ADHD or they can accompany ADHD. As I said, anxiety and depression can give you a positive Vanderbilt rating scale, can make you inattentive and distractable. That all has to be sorted out.
I’ve been teaching residents now for 50 years maybe. As a matter of fact, we didn’t call it ADHD when I started. My first year I ran a clinic called a minimal brain dysfunction clinic, and you all probably read about that. Just to show you that it was not a minimal problem…it did have something to do with the brain not working well, but at any rate, we chuckle when we think about that.
General pediatricians, the ones I see now graduating from residency, are capable of diagnosing uncomplicated ADHD. Now they're getting better, and our effort in recent years is to try to teach them some of the comorbidities. Certainly, learning disabilities exist in about 30% or so of kids with ADHD, and that’s one that the schools hopefully can help you work out.
One of the things that Mark has showed me over the years, and it works very well, is the Vanderbilt rating scale for ADHD, the teacher form, is a really good screen for learning disabilities. So you kill 2 birds with 1 stone with that instrument.
Tim Wilens, MD: Harlan, I was wondering if I could bring Bob into this. As you may or may not know, Bob is also a pediatrician and a child psychiatrist, and I’m trying to get a sense of how do pediatricians and child psychiatrists work together? Should it be with any comorbidity? Should it be when first-line treatment doesn’t work that child psychiatry gets called in? What's your sense? Bob, what’s your sense about that? You're right next to pediatrics, you’ve worked with pediatrics your whole life, you are a pediatrician. What do you think is reasonable in terms of handoffs?
Robert L. Findling, MD, MBA: The important part more than anything else is that you put the child at the center of the treatment plan, though it sounds a little glib. As we’ve talked about, the capacity for pediatricians to assess and treat ADHD has changed over the last several years. Different folks have different comfort levels and capacities. The word is collaboration, but the good news is one of the privileges of being a psychiatrist is you have nice long appointments. A lot of pediatricians just don’t, and they can’t. In many ways there are still some practical exigencies of it. If a youngster has ADHD and is being effectively treated, you’ll know. It’s not that challenging when you’ve hit the nail on the head. But if they're not doing well, it never hurts to get a second pair of eyes, and oftentimes the care can continue with the pediatrician. And the other treatment providers might not even necessarily, as Harlan said, it could be a psychiatrist, it could be the school, could be a behavioral health counselor, or a social worker, or psychologist, or nurse…. What’s nice is there's a whole group of people who are getting ever more familiar with this, and sometimes it just takes a bunch of people working together, putting the kid right in the center.
-Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Afecta, Akili, Alkermes, Allergan, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Emelex, Gedeon Richter, Genentech, Idorsia, Intra-Cellular Therapies, Kempharm, Luminopia, Lundbeck, MedAvante-ProPhase, Merck, MJH Life Sciences,NIH, Neurim, Otsuka, PaxMedica, PCORI, Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, and Validus.
-Dr Gephart is retired from the practice of medicine. He is on the faculty of the REACH Institute for a course entitled “Patient Centered Mental Health in Primary Care.” He receives a stipend for serving as a virtual consultant to Course graduates who call in and present difficult cases. He has no other financial contracts to report.
-Dr Childress reports receipt of research or writing support, participation on advisory boards, and service as a consultant or speaker for Adlon Therapeutics, Aevi Genomic Medicine, Akili Interactive, Allergan, Arbor Pharmaceuticals, Cingulate Therapeutics, Emalex Biosciences, Ironshore Pharmaceuticals, Jazz Pharmaceuticals, KemPharm, Lundbeck, Neos Therapeutics, Neurovance, NLS Pharma, Otsuka, Pearson, Pfizer, Purdue Pharma, Rhodes Pharmaceuticals, Sunovion, Supernus Pharmaceuticals, Takeda, and Tris Pharma.
-Dr Wolraich is professor emeritus from the University of Oklahoma Health Sciences Center. He is on the steering committee and a faculty member of the REACH Institute, a non-profit organization providing CME training on mental health to primary care physicians. He has no affiliations or investments where he receives any compensation, and he is no longer in any clinical practice.
-Dr Wilens is Chief, Division of Child and Adolescent Psychiatry and Co-Director of the Center for Addiction Medicine at Massachusetts General Hospital. He receives or has received grant support from NIH(NIDA). He is or has been a consultant for Arbor, Otsuka, Ironshore, KemPharm and Vallon. He is the author of Straight Talk About Psychiatric Medications for Kids (Guilford Press). He is co-editor of ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier); and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). He is co-owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire) and has a licensing agreement with Ironshore (BSFQ Questionnaire). He serves as a clinical consultant to the US National Football League (ERM Associates), U.S. Minor/Major League Baseball; Gavin Foundation and Bay Cove Human Services.