January 1st, 2012

New AAP guidelines recommend collaboration

New American Academy of Pediatrics (AAP) guidelines recommend primary care physicians initiate an evaluation/treatment for ADHD for children ages four to 18 who present with symptoms of inattention, hyperactivity or impulsivity.

The previous AAP guidelines covered children six to 12, but AAP says emerging evidence makes it possible to diagnose and manage children as young as four and the organization wants to stress that ADHD is a “chronic” condition, and therefore, consider children with ADHD as having special health care needs.

Area psychologists see pros and cons to these new guidelines.

“Mostly, I think it’s a positive change,” says Rachel Brown-Chidsey, Ph.D., a psychologist, AAP associate member and faculty member at the University of Southern Maine. “I think the new guidelines are far more inclusive and recognize that kids present with these symptoms beyond the scope of the prior age range. My biggest concern is pediatricians may not reach out to psychologists as often as they should.”

According to the AAP guidelines, in preschool children (ages 4 and 5) with ADHD, doctors should first try behavioral interventions. Such interventions are well within the scope of psychologists, Brown-Chidsey says. “My concern is will they actually reach out to us so we can work collaboratively? Part of me thinks the academy is expecting pediatricians to know and do everything, rather than recognizing the limits of their expertise and when they need to refer or collaborate with others.”

“The language says the right thing in terms of collaborating, but I’m not sure what the reality is going to be, particularly in regard to the real young ones, the preschool population,” she says. “We know kids present with (ADHD symptoms) at very young ages. There are really effective interventions that can be put into place. My question is, how well prepared is a primary care physician at knowing those interventions and getting access to them? The good news is the new guidelines suggest more collaboration with psychologists; the question is, what will that look like?”

Jannette Rey, Ph.D., clinical child psychologist and co-founder of the Providence Behavioral Health Associates in R.I., says there are pros and cons to the new guidelines.

Rey says. “The earlier we can identify and provide interventions, the better the prognosis for kids as they move into school age. So that’s a benefit.”

“If they were identified accurately and that identification was thorough, that could be a good thing,” Rey says.

But four and five year olds are still experiencing developmental variations. “We want to be approaching it in the most developmentally appropriate way,” Rey says.

“Some of the cautions are – determining the need for medication at that age, because there still are so many developmental factors that may be at play for some kids who may not formally meet the threshold for diagnosis,” she adds.

The AAP guidelines suggest Methylphenidate may be considered for preschool children with moderate to severe symptoms who do not see significant improvement following behavior therapy.

Some four and five-year-olds may just be on a bit of a delayed trajectory, building better self-control and psychological skills, Rey says. “I think I would find it hard to find colleagues, at least in our field, that would find (medication) to be the best step.”

Rey is hoping the guidelines mark the beginning of larger system changes.

“Collaboration is key,” Rey says. “With young kids, certainly, (parents) are so used to the pediatrician being the first call. But it would be lovely if they were supported in an integrated collaborative,” featuring mental health specialists.

Rey hopes the recognition of ADHD as a “chronic” condition may lead to enhanced supports for parents in terms of health insurance benefits.

Brown-Chidsey says the recognition of ADHD as a chronic condition is long overdue. “I have seen for years how it’s clear it’s not something that is outgrown and there’s a need to differentiate treatment.”

She says as a child grows older, it’s important to come up with a treatment plan that appreciates the child’s voice and that needs to last over a lifetime.

By Pamela Berard

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