Establishing Community Protocols for Treating ADHD

IN THE 1990S, OFFICE VISIT FOR STIMULANT PHARMACOTHERAPY INCREASED 5 FOLD. WHAT HAS BEEN THE RESPONSE FROM THE PUBLIC AND FROM INSTITUTIONS?

You are listening to ReachMD XM157, The Channel for Medical Professionals. In a recent tape our guest today reminds us that ADHD holds the distinction of being the most extensively studied pediatric psychiatric disorder and one of the most controversial. In the 1990s, office visit for stimulant pharmacotherapy increased 5 fold. What has been the response from the public and from institutions? Welcome to the Clinicians Roundtable. I am Dr. Leslie Lundt and with me today is Dr. Rick Mayes. Dr. Mayes is an associate professor of Public Policy at the University of Richmond's Department of Political Science and a faculty research fellow at the Petris Center on Healthcare Markets and Consumer Welfare at UC Berkley. His newest work is called Medicating Children ADHD and Pediatric Health.

DR. LESLIE LUNDT:

Welcome to ReachMD, Rick.

DR. RICK MAYES:

Thank you. Happy to be here.

DR. LESLIE LUNDT:

So Rick, why all the controversy about ADHD?

DR. RICK MAYES:

Oh, I think ADHD is much more controversial than for example say ODD, oppositional defiant disorder, because I think of 3 basic reasons. The first one is that the diagnosis has a really strong educational contact. In other words it is hard to even imagine ADHD existing without schools and teachers. The vast majority of childhood diagnoses originate with teacher observations and interestingly enough there is a huge surge every year in October and November in ADHD diagnoses and stimulant prescriptions in the research, but what we have done informally is that it coincides very well with the first round of parent-teacher conferences. Most children who have ADHD and/or diagnosed with it do not show enough symptoms in a clinician's office to warrant diagnosis. It is the kind of disorder that is so strongly tied to schools in a way that say depression is not that it often arouse a suspicion by people who see other modems and efforts by people to make be make their lives easier, in this case teachers. Another reason is that the primary most effective treatment for the disorder stimulants is very different from the drug treatment per se, depression and bipolar disorder. I will give you another interesting example. At my college, University of Richmond and other colleges and universities there is a not insignificant black market for stimulants every semester that peaks usually during mid terms and final exams. These are times when students are really struggling to maintain their attention span and energy level. There is no equivalent black market for antipsychotics or antidepressants, so this is another unique aspect of the diagnosis and the treatment. And the last reason, I think that makes it so controversial is that when the average person reads the list of symptoms that are used as the behavioral criteria for ADHD things like often does not seem to listen or spoken to directly, often has trouble organizing activities, is often usually distracted, is often forgetful, frigid with hands or feet or <_____>. Those symptoms do not see all that intense, bizarre or extremely seem like a lot of things all of which wrestle with more or less in day to day during boring lectures or church sermons or business meetings. When people look at it they say, this does not seem like a really unique diagnosis and it does not seem like when I think of mental disorder, this is not what I think of, but for those who work in the field and deal with people who do have the disorder they can tell you very precisely that there is about 3% to 5% of the population for whom their frigidness and their lack of attentiveness and their hyperactivity are so beyond the average person that it really makes their life difficult and for that reason it is a real disorder, because all of us have some sort of passing similarity or familiarity with the symptoms, lot of us do not realize for many people it is a severe stumbling block.

DR. LESLIE LUNDT:

Tell us what had happened in North Carolina to develop community protocols to treat ADHD?

DR. RICK MAYES:

Ya, I think this might be of particular interest to your audience. I think a lot of the people who are listening to you will sympathize with what these physicians were facing and may be like to do the same thing as they did. About 10 years ago, a group of about 42 primary care physicians, most of whom were pediatricians, who were practicing in 2 rural North Carolina Counties, decided that they could find a better way to treat their patient population of children with behavior disorders. They were really dissatisfied with the fact there was nothing standardized that children sometimes came to their office with a whole ________ of information from the parents and teachers that was helpful but sometimes there was almost too much information and it was not in the form that they could use it. On the other hand they get the next child into their office with no documentation and they were just been asked to find someway to help this child and they have to go out and collect all the information. A lot of the parents from the community felt like that they were the very last one in the process to have a say in this that a nurse or teacher contacted the doctor and then eventually they got the parent involved. So lot of parents felt like they were not involved in the very beginning. And a lot of schools, particularly nurses were constantly in the awkward position of trying to answer teacher questions about medications when they had no communication with the doctors and so we could not say anything and it just seemed like if you could get everybody in the room together and get them all talking about let us find some standardized protocol for information every year at about the same time in the same format to come from the school to the parents and to the clinicians in format that both of them could understand and use in their practices and then you could everybody more or less on the same page that is what these 42 primary care physicians did. They got everybody in the room who had a say in this and they said lets' come up with a protocol. Let us come up with a standardized screening method and time and this way we will get the information the way we needed and we can make individual diagnoses and treatment recommendations based on the best medical practices. Some kids will get prescription medication, some kids will get family therapy, and if it is more along the non medication route, there were other people in the community social workers who were also incorporated into these discussions and so when the treatment regimen was more directed at using non medication there were other people in the community who could do a better job of that and actually free-up the physician's time and they could actually focus more on the things that they do well and actually in this I am sure listening audience will appreciate physicians have to be mindful of what things they get paid for and what things they do not get paid for, especially primary care physicians and so developing these protocols allow the physician to focus more on the things they excelled in and the things for which their valuable time is reimbursed sufficiently.

DR. LESLIE LUNDT:

So who actually did the work?

DR. RICK MAYES:

In the beginning it was the doctors who came together and they were the catalysts for this whole formulation of the community protocol that is for a variety of reasons not the least which is they are the ones _________ prescribe medications which will allow the children, the ultimate route that they go. But they also have significant amount of influence in their community. There are people who are very greatly looked up to and are pillars of their community, so when they made a few phone calls and they led the way everyone else very quickly followed, because they all realized that they were going to benefit as well and it was valuable for all the people involved to say, "Wow let me tell you from our perspective and from the teacher's perspective how this looks" and then the physician could say they were great and now we had a better understanding of what things you face. Here is what happens when it comes to our office and here is where it works and here it where it does not work, so at the end of this even though it did involve some more time of upfront to get them by on the same page it benefits quickly accrued every single part of the community. I am not saying that the researcher's who did this research are not saying that everything went from haphazard and sloppy to nirvana and you know it is not the case, but everyone involved were significantly more satisfied with the process after they established the protocols because the protocol.

DICTATION ENDS ABRUPTLY.