Majority of Doctors Do Not Follow Treatment Guidelines for ADHD

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More than 90% of pediatric specialists who diagnose and manage attention-deficit/hyperactivity disorder (ADHD) in preschoolers do not follow the American Academy of Pediatrics (AAP) clinical-treatment guidelines.

That’s the conclusion of researchers from the Cohen Children’s Medical Center of New York, which sent the Preschool ADHD Treatment Questionnaire to a random sample of 3,000 physicians who specialize in diagnosing and treating neurobehavioral conditions nationwide. The doctors reported on how often they recommended strategies such as training parents in behavioral management of ADHD, how often they relied on medication as a first- or second-line treatment, as well as which drugs they prescribed most often.

(MORE: ADHD Diagnoses Continue to Climb)

In 2011, the AAP released revised guidelines for diagnosing kids with ADHD. “Those guidelines were important in that they extended down from age 6 down to age 4. For the first time pediatricians were given guidance in how to approach the management of ADHD in preschoolers,” says the study’s lead author Dr. Andrew Adesman, the chief of developmental and behavioral pediatrics at Cohen Children’s Medical Center in New Hyde Park.

Along with the expansion of the population that could be diagnosed with the condition came advice for how to treat the youngest patients. Adesman says, in general, pediatricians have been especially uncomfortable with diagnosing ADHD in very young children, so they have turned to medical specialists like child neurologists, child psychiatrists and developmental-behavior pediatricians to make the call. “When we undertook this study, we were interested in seeing what the specialists in the field were doing, since pediatricians turned to them and parents turned to them,” says Adesman. “Actually, the AAP in their guidelines specifically state that if a pediatrician is not comfortable with evaluating children — especially young children — for ADHD, then they should turn to these medical specialists.”

Currently, the AAP recommends that behavioral therapy should be the first type of treatment offered to preschoolers with ADHD, followed by medication only if the behavior interventions are unsuccessful.

(MORE: ADHD Medications Improve Decisionmaking, but Are They Being Overused?)

However, the results of the study show that more than 1 in 5 specialists who diagnose and recommend treatment for ADHD in preschoolers recommend pharmacotherapy as a first-line treatment, either alone or with behavior therapy. These specialists are also not adhering to advice on which drugs should be used; the AAP recommends that when medication is needed, pediatricians should prescribe methylphenidate, but over one-third of specialists who medicate preschoolers for ADHD reported that they “often” or “very often” pick medication other than methylphenidate first.

Why the discrepancy? For one, say the authors, behavior management and counseling strategies are not always easily accessible to many families. And if they are available, in some cases they may be financially out of reach if insurers don’t cover services provided by professionals in the local community.

However, Adesman says when his investigators asked the doctors whether their decision to prescribe medication for first-line treatment was influenced by the availability of behavior therapy for their patients, he did not find evidence of a trend. “So as much as I would like to think that doctors are prescribing medicine first line because behavior therapy is not available, that does not seem to be the case,” he says.

(MORE: Can Anesthesia Raise the Risk of ADHD?)

It’s also possible that doctors are turning to medication because the long-term commitment that repeated behavioral-therapy sessions require may be onerous for parents. Adesman says clinicians may also be paying attention to some studies in school-age children that have shown that medicine can be more effective than behavioral therapy. Yet he argues this still does not justify its use in preschoolers. “There is an important distinction, and that is that even if medication has been shown to be more effective in the short term than behavior therapy in school-age children, medication does not work quite as well or consistently in preschool kids. So a head-to-head comparison in school-age children may not necessarily be appropriate to extrapolate down to the preschool kids,” he says.

The AAP guidelines were meant for primary-care pediatricians who may need guidance and assurance in making decisions about diagnosing and treating preschoolers with ADHD. And these physicians may indeed be following the guidelines, although the current study did not include them. “Still, certainly it would seem that pediatricians and specialists should increasingly look to behavioral interventions as a first-line treatment,” says Adesman. “I think parents also should seek at behavioral treatments as first line, and in general, medication should be reserved for cases where either behavioral therapy is not effective or where it is not available.”

The study was presented at the Pediatric Academic Societies in Washington, D.C.

19 comments
edwardfruitman
edwardfruitman

These guidelines are very helpful for dealing with ADHD. One essential thing to remember is that you must avoid the use of drugs as much as possible. Sessions with a psychiatrist on a regular basis can be very helpful in treating ADHD as well as other mental disorders. 

edwardfruitman
edwardfruitman

It isn’t a surprise that most doctors prefer not to follow the basic treatment. Most believe that ADHD is just a sham and used for selling prescription drugs and medicines. Many have realized that psychotherapy is the best solution.

NOpharma
NOpharma

Diagnosing drugs to a young developing brain for this so-called condition is simply legalized pushing of narcotics, plain and simple. And no, SheeterParmaDingBat, it's not a case of someone hiking up their ego. It's a case of someone sticking up for those who can't stick up for themselves ie kids. Does it occur to you-at all- that when millions are "afflicted" with this, that in point of fact the likelihood that a child would be inattentive (aka daydream) might be an evolutionary response on the part of the brain? Our species has survived literally thousands of years of war, famine and disease, often on a catastrophic scale. How crazy then is it, that we would have developed a coping mechanism, particularly evident in the young (always the hardest hit in such times) that now our privileged prima donnas would hope to medicate away as they find it annoying. 

The flip side of this annoyance is young developing brains having amphetamines introduced to them so that depression, suicidal thoughts and oh by the way, a big fat label, courtesy of the school system on their back. Think they won't be belittled by their peers-- their instructors? Think again. You're worried about them acting up a little now, just wait till the system marks them as an ADHD kid- you just guaranteed them years of humiliation and feeling like they are always lesser than their peers, I promise you.

You ALSO might want to take them in to get their hearing checked. It might surprise you to learn that some kids experience a critical delay between when sound reaches their ears and the information is actually retained in our short term memory. That's why our kind learn through repetition. Recording their lesson and playing it back for them, flashcards, having them read their material while being recorded, then listening to it- all of these things can absolutely help them. Remember that guy, Abraham Lincoln? Guess what schools in his day were called? "Blab" schools. Why? Kids did nothing but recite their lessons all day long. Do we need anything today so extreme? No, but repetition works and beats hopscotching through subjects.

Step up to the plate and be a parent. Sign them up for sports, read to them, hug them, play games with them. Understand they will NOT be like some artificial standard you read about. You count far more than a pill ever could. Yes we grow up and yes we do just fine- and to those working in the pharmacological industries- you should hang your head for doing this to kids to make a buck.

sandersasylum
sandersasylum

Lemon balm(Melissa officinalis) and milky oats (Avena sativa, A. fatua) are known to be an effective remedy for calming hyperactive children. 

 

PaulRandall
PaulRandall

ADD is real but doctors don't always investigate the possibility of other problems that have similar symptoms, Anything that causes sleep deprivation like, sleep apnea, will look a lot like ADD. Give someone who is sleep deprived a stimulant and what are the chances they will preform better.

SigmundDerman
SigmundDerman

Guidelines are closer to suggestions than to absolute requirements. Good physicians treat the individual patient in front of them based on the evidence they feel applies in the particular case. I would be scared to have a physician who relied entirely on guidelines. On seeks an expert in cases in which guidelines may not apply. As a physician I would be ashamed if it were shown that I followed guidelines the majority of the time. In the case of ADHD, many family do not have the time or the money to drive their children to constant behavioral therapy appointments. If it is not a practical alternative (and if it is a particular serious case), medications would be the first line of treatment.

PeterSharma
PeterSharma

ADHD is a false flag diagnosis designed to generate profits for therapists, MDs, and Big Pharma. A gigantic, violently assaultive scam perpetrated upon the people.

NellyCardinale
NellyCardinale

Unfortunately, even if doctors were to follow these guidelines, there aren't enough child psychologists in the  United States to treat all of the children who are ADHD.