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.

16 comments
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.

DeniseBadger
DeniseBadger

Doctor, have you ever considered the fact that these children might have an underlying medical issue?Have you ever conducted IgG and IgE panels for food allergies on a hyperactive child?If not, why?How can you, as a medical professional, justify medicating a child not suffering from a life-threatening illness with a drug consumed daily? What about their livers, their kidneys, the potential for lifelong drug addiction?Please, doctor, explain the big picture on the root cause of attention deficit hyperactivity and how damaging a child's internal organs for life takes precedence over some simple tests that might display food allergies and food sensitivities?What happens to the Hippocratic oath when you prescribe the equivalent of meth to a 4 year old?

DeniseBadger
DeniseBadger

Doctor, have you ever considered the fact that these children might have an underlying medical issue?

Have you ever conducted IgG and IgE panels for food allergies on a hyperactive child?

If not, why?

How can you, as a medical professional, justify medicating a child not suffering from a life-threatening illness with a drug consumed daily? What about their livers, their kidneys, the potential for lifelong drug addiction?

Please, doctor, explain the big picture on the root cause of attention deficit hyperactivity and how damaging a child's internal organs for life takes precedence over some simple tests that might display food allergies and food sensitivities?

What happens to the Hippocratic oath when you prescribe the equivalent of meth to a 4 year old?

knut
knut

@PeterSharma 

I am very glad that you shared this opinion with us. It is not an easy diagnose too deal with in every day living. Especily when sympthomps of "disorder/dysfunction" , continue to be cover by CHEAP chemicals like Metylphenidate ( Ritalin, Concerta osv). It is not an easy way in order too provide better care options for those of us who has to listen too doctor`s that only give preciptions recepies   , and not any kind of scientificly tested alternative too treatment, as eks. therapeutic cognitive training and nutrition, food supl. etc.

I have had very good experience by eating fat fish, omega 3, MultiVitamin B injections and Vitamin B 12 injections. ( I think many people forget / do not know that it is not everybody that are taking those Vitamin up into the metabolic.syst. And if they can`t add those vitamins, then they won`t be able add C - Vit. ).

Maybe it will work for you. It make me feel better, and it seems like it also might have similar  results at my belowed wife......she has such a happy smile ,afther finish each injections of Multi B Vitamins and Vitamin B 12 injections.

Thank you for wice opinion.

knut


SheeterParmaDingBat
SheeterParmaDingBat

@PeterSharma you're a frigging trouble maker who is out to feed your ego at the expense of those who suffer from this disorder.

SheeterParmaDingBat
SheeterParmaDingBat

@NellyCardinale um, if parents were to take responsibility doing their job, kids would be taught to manage this condition. It is not easy and the first line of help is teaching the kids what's going on with ongoing therapy and light meds. many adults who suffer from this disorder have learned to lead successful and productive lives with the right treatment regimen.

silentwolf13
silentwolf13

@DeniseBadger  My eldest, now 16, was diagnosed 10 years ago.  Before putting him on meds, I requested that he be tested for allergies.  I made sure they did a full workup on him.  After everything came back normal, I tried behavior modification first.  The 1st med we tried was non-amphetamine based.  We ended up having to put him on methylphenidate, though.  Since going on that, he has been calmer and done better in school.  He still has his issues but it would be MUCH worse without the meds.  That being said, we don't rely on the meds solely.  He has rules he has to follow, chores to do and consequences when they aren't.  We don't allow him to use his ADHD (which is severe in his case) as an excuse.

PeterSharma
PeterSharma

@knut @PeterSharma I am fortunate to not have this diagnosis. Had my childhood occurred in the 90s or since rather than in the 60s, I feel certain I'd have been diagnosed as ADHD simply because I found the redundant nature of school lessons boring and usually found other ways to involve myself while still achieving straight-'A' averages.

Boneheaded, lazy parents and educators who choose to medicate rather than dealing with the more rambunctious and differently interested than most ought to get out of the parenting game and the education game. DOn't tell your kid to stay off drugs while making them pop psychotropic drugs on a daily basis.

PeterSharma
PeterSharma

@SheeterParmaDingBat @PeterSharma You, Sheeter, are either a fool or a marketing victim. I have plenty of empathy for those genuinely afflicted. This diagnosis is, indeed a false flag for the vast majority of those diagnosed who would be better aided by cognitive behavioural therapy WITHOUT DRUGS.

I do not troll. I do know whereof I speak.

silentwolf13
silentwolf13

@PeterSharma My 16yo has ADHD and takes meds for it.  We limit his tv, computer and video game time and homework comes first.  I help him with his math homework and my mother (who lives with us) helps with English.  He has chores and rules.  He also has consequences for breaking rules.  He's active at church, participates in Special Olympics.  He loves bowling, basketball and skiing.   Med were not our first choice.  Behavior modification alone just wasn't working.  I tried changing his diet.  It helped some but not enough.  The meds allow him to function day to day.  He still will be lucky if he graduates high school.  Most likely he won't even be able to live on his own.