New research on ADHD

[ADHD RESEARCH UPDATE]

-------------------------------------------------------------------
This mailing is being sent to over 16,000 parents and professionals
interested in keeping up with new research on ADHD.

If you are no longer wish to receive this information, just
mailto:[EMAIL PROTECTED] and type unsubscribe preview in
the body of your message. Please do not simply reply to this
message as it will not remove you from the list.
------------------------------------------------------------------

Greetings:

Below is an article that appeared in a prior issue of ADHD
RESEARCH UPDATE. The article summarizes an interesting study
in which the researchers examined changes in the treatment of
children with ADHD over the past 10-15 years. I think this is an
interesting and important study and I hope that you enjoy the
summary below.

Please feel free to forward this article to others you know
who may be interested in it. If this has been forwarded to you by
a friend, and you would like to begin receiving these mailings
directly, go to http://www.helpforadd.com/nresearch.htm to sign up.

Sincerely,

David Rabiner, Ph.D.
Duke University

P.S. Are you a health care professional? I have started a second
list to better meet your needs. To switch to this new list, just
mailto:[EMAIL PROTECTED] and I will make the change.
=================================================================

** SUBSCRIBE TO ADHD RESEARCH UPDATE **

Interested in keeping up with the latest research on ADHD? If
so, you'll receive even more information by becoming a regular
subscriber to ADHD RESEARCH UPDATE.

You can learn about subscribing at:

https://www.helpforadd.com/subscribe.htm.

==================================================================


* A NATIONAL PERSPECTIVE ON TREATMENT
SERVICES FOR ADHD

What have been the important trends during the past decade
in the type of care that children with ADHD typically receive
in community settings? As you can imagine, this is a difficult
and complicated question to address. The answer to this
question is enormously important, however, for it will inform
us about critical gaps in the provision of appropriate care that
parents need to be aware of and that professionals and
policy makers need to address.

A recent article from the Journal of the American Academy of
Child and Adolescent Psychiatry (JAACP) provides the most
comprehensive information yet available on this issue
(Hoagwood, K. et al., (2000). Treatment services for children
with ADHD: A national perspective. JAACP, 39, 198-206).
There is a tremendous amount of interesting data presented in
this paper, and I will try to highlight what seem to be the key
findings below.

Data for this study come from two large national data bases
that were established in the 1980s and updated annually since
then. These data bases include representative samples of
pediatricians, family physicians, and psychiatrists who provide
records of patient visits, diagnoses, and services provided
at each visit. (All information that could potentially identify
any patient is removed so that records remain anonymous.)
By comparing the kinds of services provided to children who
had been identified as having a diagnosis of ADHD, and
noting the types of services that these children received,
trends in service provision over the recent past can be
identified. This is because these data are based on thousands
of community physicians who treated thousands of children
and teens for ADHD. Even though the exact same physicians
did not provide data in different years, the sample is large
enough, and representative enough, to provide a good
picture of what is actually going on.

RESULTS

The results of this study are fascinating. Here are some of the
key findings:

* ADHD is being identified at a greater rate

The percentage of visits where ADHD was identified has risen
from .74% in 1989 to 1.9% in 1996. In addition, for physician
visits where a mental health problem was identified as the primary
reason for the visit, the percentage of children identified as
having important attentional problems increased from 41% to
60% during this same period.

Note: Although these data indicate that ADHD is being identified
at an increased rate, 2 points are important to keep in mind.
First, these data tells us nothing about the accuracy of the
diagnoses being made. Second, the 1.9% rate for physician-
identified ADHD in 1996 is still substantially below actual
prevalence rates that have been determined from a number of
different studies. Overall, therefore, it may be that many
instances of ADHD continue to go undiagnosed and untreated.

* Important changes are occurring in medication
management

The percentage of visits for children with ADHD during which
stimulants were prescribed increased from about 55% in 1989
to about 75% in 1996. During that time, there was a corresponding
decline in the prescription of other medications to treat ADHD -
from about 15% in 1989 to about 7.5% in 1996.

Note: Because stimulant medication has been shown to be an
effective treatment for most children with ADHD, the fact that
more children are receiving it may reflect physicians' greater use
of an empirically validated treatment approach. Unfortunately,
no data is available on the quality and care of the medication
treatment being practiced. As you may recall from the results
of the MTA study (gttp://www.helpforadd.com/mta.htm)(i.e. the
largest and most comprehensive treatment study of ADHD conducted
to date) there is good reason to believe that children treated
with medication in the community typically do not derive as much benefit
as they might were careful and systematic procedures followed.

I think it is encouraging that the rate of prescribing non-stimulant
medications for children with ADHD has been cut dramatically.
These reason for this is that non-stimulant meds are typically
less effective and less is known about their long-term safety.
In the MTA study, however, almost none of the children with
ADHD required medications other than stimulants to effectively
manage their symptoms. This suggests that in many cases where
other meds are prescribed, it may be because careful efforts to
obtain the greatest possible benefits from stimulant medications
were not used. Thus, the 7.5% figure may still reflect a greater
use of alternative medications than is really necessary.

* There has been an important decline in important
follow-up care for children with ADHD

Between 1989 and 1996, the percentage of visits where
follow-up care was recommended declined from 91%
to 75%. Thus, as recently as 1996, 25% of children
identified as having ADHD are not scheduled for any
follow-up care.

Note: I am very concerned about this finding. Because
ADHD typically effects children over many years, one of
the most important aspects of treatment is carefully monitoring
a child's development over time. Just because a child's
symptoms are being managed effectively at one point in
time does not, unfortunately, mean that this will persist.
Difficulties often emerge and require that adjustments to
a child's treatment be made. It is virtually inconceivable
that effective care could be provided in the absence of
regular and periodic follow-ups. (I've developed a simple
tool called the ADHD Monitoring System that can be very helpful
for this purpose. You can learn about this tool, and order it
online if you wish, at https://www.helpforadd.com/monitor1.htm).

The authors also examined how the type of services that
children with ADHD received varied according to whether
the provider was a pediatrician, family physician, or
psychiatrist. These results are based on the most recently
available data, which was from 1996.

The major findings here are that family physicians are more
likely than the other providers to prescribe stimulant
medication for treating ADHD (i.e. 95% vs. about 75%
for pediatricians and psychiatrists). Conversely, family
physicians were less likely to utilize any type of formalized
diagnostic services in their visits with children identified
as having ADHD (i.e. 33% vs. 64% for pediatricians and
about 80% for psychiatrists). Family physicians were also
less likely to recommend specific follow-up care (i.e. 46%
vs. 79% for pediatricians and 89% for psychiatrists).
Family physicians were also far less likely to provide any
type of mental health/behavioral counseling services during
visits - only 7% of the time - than were pediatricians
(44%) or psychiatrists (67%).

Note: Although this study does not include any data that
enables one to determine the appropriateness of services
being provided, it does appear that the care a child receives
depends greatly on the type of physician doing the treatment.
In particular, although family physicians were more likely
to prescribe stimulant medication, they were less likely to
use any formalized diagnostic services, to provide any
type of counseling, or to even recommend follow-up
care. Even among pediatricians and psychiatrists, follow-
up care often failed to be recommended, and it seems
highly unlikely that this was because no such care would
have been needed.

Overall, the authors conclude that in at least 50%
of the cases, guidelines for care that have been
recommended by the American Academy of Child
and Adolescent Psychiatry for the treatment of
ADHD are not being followed. This is not good
news.

BARRIERS TO CARE

The final issue examined in this study concerned what
primary care physicians (i.e. pediatricians and family
physicians) perceived as the major obstacles to making
mental health referrals they may have felt were needed
for their patients with ADHD. Listed below are some of
the barriers they identified along with the % of the physicians
surveyed who reported each barrier:

Barriers % reporting

Lack of specialists 64%

Difficulty getting appt. 64%

Restrictions on who could be 48%
referred to because of insurance
company

Authorization procedures 39%

Financial disincentives 35%

Burdensome paperwork 30%



The two most commonly reported barriers, mentioned by
nearly two-thirds of participating physicians, reflect the
perceived lack of clinicians who are specially trained to
work with child behavior problems (e.g. child psychiatrists,
child psychologists, developmental pediatricians). The
other commonly reported barriers to care appear to be
direct outgrowths of the restrictions placed on mental
health treatment by many of today's health maintenance
organizations. It is particularly striking to me that
over one-third of the physicians surveyed reported that
financial disincentives limited the number of mental
health referrals they made for children. Although these
data do not provide direct evidence that the quality of care
that children receive as a result of HMO regulations has been
compromised, it is certainly consistent with this hypothesis.

SUMMARY AND IMPLICATIONS

The most important implication of this study according to
the authors is as follows:

"Although at least 2 professional associations have
written guidelines or parameters of practice with these
children (American Academy of Child and Adolescent
Psychiatry and American Academy of Pediatrics), and
though evidence-based reviews have been completed,
these guidelines are not yet influencing care as delivered
in real-world practices."

To this conclusion I would add that these data strongly suggest
that changes in the insurance industry and the restrictions these
changes have placed on many physicians is likely to be having
a negative effect on the quality of care that many children with
ADHD - as well as children with other types of emotional and
behavioral problems - receive.

To me, this highlights how important it is for parents to be as
informed as possible about how ADHD can affect children's
development and what are the best ways to promote the
long-term success of children with ADHD. I truly hope that
your subscription to ADHD RESEARCH UPDATE is
being helpful to you in this regard.


______________________________________________________________________

"ADHD RESEARCH UPDATE WILL PROVIDE YOU WITH
CONVENIENT, RELIABLE ACCESS TO THE LATEST
RESEARCH BASED KNOWLEDGE FOR UNDERSTANDING
AND HELPING CHILDREN WITH ADHD."

(You can subscribe at https://www.helpforadd.com/subscribe.htm or
review the benefits of subscribing outlined below.)

Dear Parent:

I hope you enjoyed the article presented above. It is an
example of the comprehensive and objective summaries of
research on ADHD that you will receive by subscribing to
ADHD RESEARCH UPDATE. By becoming a subscriber, however,
the amount of information on important new studies that
you receive will be far greater.

"IF YOU CAN SPARE ABOUT AN HOUR A MONTH, ADHD
RESEARCH UPDATE IS GUARANTEED TO MAKE AN
IMPORTANT DIFFERENCE FOR YOU AND YOUR CHILD."

By spending about 45-60 minutes each month reading the
newsletter, you will gain access to information that can
make an important difference for you and your child. The
studies I review are published in the world's leading
medical and psychology journals that are typically only
available in university and medical school libraries.

What you can expect from subscribing is to gain substantial
knowledge about promoting your child's healthy development
that you can put to immediate and meaningful use.

You will not find this comprehensive discussion of new
research information on ADHD anywhere else on the internet.


"WHY NOT HAVE THE BENEFIT OF THE LATEST RESEARCH INFORMATION
FOR UNDERSTANDING ADHD AND HELPING CHILDREN WITH ADHD TO
SUCCEED?"

You can find complete details on subscribing at:

https://www.helpforadd.com/subscribe.htm

The more you know about ADHD the more confident and effective
you can be in promoting your child's healthy development. By
subscribing, you will be assuring yourself of receiving the
knowledge and information you need to assist you in this
important task.

Sincerely,

David Rabiner, Ph.D.
Licensed Psychologist
Duke University

















----------------------------------------- To unsubscribe send an email to: [EMAIL PROTECTED] with UNSUBSCRIBE PREVIEW in the BODY of the message.