A colleague of mine published an op-ed in the New York Times on February 1, 2016 “Diagnosis is Key to Helping Kids with ADHD.” As Dr. Froelich states, even though there is strong scientific evidence that ADHD has a biologic basis, there is always concern whether a child truly has ADHD and if it is misdiagnosed or over diagnosed. The issue is that there are currently no medical or laboratory tests that is inexpensive, non-invasive and has good test characteristics to reliably be used as part of every day practice. We must rely upon a careful behavioral history that includes asking about the home, family and school, collect parent- or teacher-report on behaviors and functioning and think through this while taking into account behavioral observations.
We still have a long way to go to improve upon the decision making process regarding behavioral conditions. There is not the equivalent of a “swab” or laboratory test to tell the pediatrician, parent or teacher that a child definitely has ADHD. This is, in part, because behaviors are the equivalent of symptoms of any medical condition. Behaviors are what the parents or teachers see and observe. However, not being able to sit still, daydreaming or being forgetful can represent other things about the child (like chronic untreated allergies, anxiety, learning disabilities, poor sleep, or just plain having an “off” day) or may be a reflection of something else going on in the home environment. This is why it is important to explore the the context around the child and understand how the behaviors impact the child’s functioning in the home and school. It takes understanding the patterns and paying attention to the environment in which the child is in to truly begin to understand the “why” of a behavior.
This is why general pediatricians or family practitioners find behavioral conditions so challenging. However, having only 15-20 minutes to address these complex issues and still cover other topics, do a physical exam and give vaccinations is less than optimal. That is why it is important to examine innovative ways to automate some of the screening processes and use health information technology to remind pediatricians of key information. This is also why we have been working towards developing a new model to improve care in busy pediatric clinics. By restructuring the typical brief visit for individuals into an hour long group visit for up to 6 families, pediatric providers not only get to educate and explore these issues with families, but also observe children with others.
There is so much work to do to improve upon diagnosis and ongoing management of pediatric behavioral conditions. Over the next several posts I will be sharing materials we have developed for our group visits (curriculum, handouts and just lessons learned). The group visit is one option that at our institution has led to increased satisfaction for providers and families, despite the systems-level challenges this model requires. Yet, the group visit model may not be for everyone and is not always feasible. Explaining this to families is important and acknowledging the imperfect methods we have to identify behavioral conditions. It requires being flexible and re-evaluating if a child’s behavior or functioning does not improve. Also, being open to going back to the drawing board and thinking about other conditions that can mimic ADHD. It means partnering with teachers and educators, and other family members to get their impressions on how a child is doing. Primary care providers are able to develop long-standing relationships over time and build a working partnership with each and every one of their families. This is also why primary care providers are still best equipped to make the initial diagnosis.
I cannot discount the importance of reaching out to the schools and talking to teachers and daycare providers about their concerns. This step is so important, but can be overlooked at times. Input from schools (whether it be through asking educators to complete screening forms or picking up the phone to ask for their opinions) is a vital part of the process, not just to make the diagnosis but also as part of ongoing management. We are all part of the family’s team: doctors, teachers, behavioral therapists, tutors, with the family at the center.
There is still so much work to be done. Together we can share solutions, brainstorm additional methods or ways that may help decrease the time to diagnosis or ensure the diagnosis a child receives is correct.