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Diagnosis and Treatment of ADHD: Interview with Harlan Gephart, MD

Harlan Gephart, MD

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. -- Harlan Gephart, MD We are pleased to welcome Harlan Gephart, MD, Past Chair of the American Board of Pediatrics and an ADHD expert, who talks about the diagnosis and treatment of attention deficit / hyperactivity disorder. Dr. Gephart, former director of the Group Health ADHD Clinic, is the ADHD consultant at Pediatric Associates in Bellevue, Washington, and a Clinical Professor of Pediatrics at the University of Washington Medical School in Seattle. He is a member of the editorial boards of Contemporary Pediatrics and Journal Watch - Pediatric and Adolescent Medicine. Dr. Gephart has also served as the pediatric delegate to the American Board of Medical Specialists and as a member of the Future of Pediatric Education II Project (FOPE II), the national joint task force of pediatric societies studying pediatric practice and education into the 21st century. How did you become interested in ADHD?

Dr. Gephart: I completed a pediatric residency at the University of Washington and particularly enjoyed the behavioral side of pediatrics. I considered taking a residency in child psychiatry, but the Viet Nam war intervened, and after I completed a tour of duty with the Air Force, I decided to take additional training in behavioral pediatrics. I returned to the University of Washington as chief resident in pediatrics and spent much of that year at what is now called the Center for Human Development and Disability, working with Dr. Michael Rothenberg, a nationally-known pediatrician / child psychiatrist.

Following my fellowship, I joined Group Health as a general pediatrician. My interest in ADHD and behavioral pediatrics was fueled by my work as physician for one of the local school districts and the significant number of ADHD patients that I was seeing in my practice. How did the Center for Attention Deficit Disorders at Group Health come into being?

Dr. Gephart: Another physician, Dr. Connie McDonald, who was a fully trained developmental pediatrician, and I established the clinic in 1989.

It was becoming increasingly difficult for primary care physicians to carve out the block of time necessary to do a complete assessment for ADHD, and we were receiving a large number of these kinds of referrals. We needed a place where we could facilitate the assessment and management of children with the disorder. When Dr. McDonald retired in 1990, I became medical director of the center, and for a number of years I practiced half time in the center and half time in general pediatrics. Today, I limit my practice to half time, but devote 100% of my practice time to assessments, medication management, supervision, teaching, and administration at the center. How many patients have been assessed at the center?

Dr. Gephart: We have assessed or managed between 5,000 - 6,000 young people. How are patients referred to the center?

Dr. Gephart: We receive around 40 - 50 referrals each month. The majority of our referrals come from within the Group Health system, but about 10% - 15% of the kids are private patients referred to our center from outside of Group Health. About two-thirds to three-quarters of our referrals come from family doctors, and the rest generally come from pediatricians or mental health care providers. Why aren't these patients assessed for ADHD by their own health care providers?

Dr. Gephart: The family physician may not have time to conduct a comprehensive evaluation, or his/her clinical expertise may lie elsewhere. Some clinicians do not feel comfortable diagnosing ADHD, but they are able to manage the treatment of the child once the diagnosis is made.

The referrals we receive from pediatricians are often the more complex cases not easily managed in a general pediatric practice. Mental health care providers may refer to the center for an assessment and then rely on us for medication management. What is the prevalence of ADHD?

Dr. Gephart: Prevalence estimates vary, but among school-aged children the prevalence is estimated to be between 6% - 10%. Why is it important to treat ADHD?

Dr. Gephart: Attention deficit/hyperactivity disorder is the most common behavioral disorder of childhood. Children with ADHD exhibit symptoms of inattention, hyperactivity, and impulsivity, and as a result, they frequently experience school problems, have difficulty with peers and family members, and show poor psychosocial development. They are at higher risk for teen pregnancy, substance abuse, and other comorbid conditions, and they are more likely to drop out of school at an early age. Virtually all children with ADHD suffer from low self-esteem.

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. If we let an ADHD child go untreated, we may well be handing that child a life sentence of academic and social failure. What is being done to improve the diagnosis and treatment of ADHD?

Dr. Gephart: In recent years a significant effort has been made to develop evidence-based guidelines that standardize the diagnosis and treatment of the disorder. For example, the American Academy of Pediatrics (AAP) recently published guidelines for the diagnosis and treatment of ADHD in children 6 to 12 years of age. The American Academy of Child and Adolescent Psychiatry has published similar guidelines.

The next important step is developing effective programs that teach physicians, nurses, mental health providers, school staff, and other members of the treatment team how to apply the guidelines. How do you conduct an ADHD assessment?

Dr. Gephart: ADHD assessments require a considerable amount of time and effort. At the center we plan about four hours for an initial assessment.

The diagnosis of ADHD requires that a child meet the criteria set forth in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). A complete assessment includes the following:

  • A complete history from the child's parent or caretaker, including information about the child's inattention, hyperactivity, and impulsivity, the age of onset of the symptoms, and the extent of the child's academic and social impairment;
  • Behavior and academic reports, including report cards and samples of school work, from the child's school. It is also helpful to gather information from other collateral resources such as counselors, day care providers, or coaches if they have significant contact with the child.
  • Use of ADHD-specific behavior rating scales and questionnaires. Scales are used in an attempt to quantify the level of the child's impairment. All kids have some characteristics of ADHD. However, if a child has ADHD, the symptoms will be clinically significant for longer than 6 months and will manifest themselves in at least two environments, typically at home and at school. The scales also assist us in establishing a baseline so that once the condition is treated, we have something against which we can measure improvement.

    The AAP guidelines recommend several parent and teacher rating scales, including:

    • CPRS-R:L-ADHD Index (Conners Parent Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
    • CTRS-R:L-ADHD Index (Conners Teacher Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
    • CPRS-R:L-DSM-IV Symptoms (Conners Parent Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale); and
    • CTRS-R:L-DSM-IV Symptoms (Conners Teacher Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale).
  • A complete physical examination, including a neurological examination if indicated, to determine if there is a physical reason for the problem, such as a visual or hearing impairment or a genetic disorder;
  • An interview with the child separate from the physical examination;
  • An assessment for co-existing conditions. There are a number of look alike and/or co-occurring disorders associated with ADHD - depression, anxiety, substance abuse, learning disorders, conduct disorder, oppositional defiant disorder (ODD), and Tourette syndrome to name a few.

    It is not uncommon for an ADHD child to have a co-existing condition. In patients with ADHD about fifty percent (50%) fulfill the criteria for ODD and about twenty-five percent (25%) fulfill the criteria for conduct disorder.

    Learning disorders are two times more common in children with ADHD. If an ADHD child is performing below grade level in school, the clinician should recommend that the school conduct a psychoeducational evaluation. What causes ADHD and can it be cured?

    Dr. Gephart: We don't have a complete answer for what causes ADHD, but we certainly understand a great deal more than we did. We now know that:

    • ADHD doesn't occur because the parent is a bad parent or because the child is a bad kid;
    • ADHD runs in families;
    • ADHD may, at least in part, be caused by neurotransmitter deficits;
    • Although chronic, ADHD is a highly treatable medical condition.

    We used to say that ADHD kids would eventually outgrow the disorder. Today, we know that inattention and lack of organization can persist into adulthood - although hyperactivity and impulsivity tend to diminish with age.

    School is a burden for kids with ADHD. In adults, it isn't that the disorder goes away, it's that school goes away, and therefore, the focus on the symptoms and the resultant impairment is often reduced. What about girls with ADHD?

    Dr. Gephart: I would say that ADHD is under-diagnosed in girls. This may be, in part, because girls with ADHD tend to be more inattentive than hyperactive, and therefore, draw less attention to themselves. In recent years we have come to recognize that this disorder has a significant impact on girls, too.

    For example, it was previously thought that ADHD was ten times more common in boys than in girls. However, recent studies indicate that the ratio is much lower than that, i.e., ADHD is four times more common in boys than in girls. As patients get older, the ratios are reduced. In adults, the ratio between males and females with ADHD is 1:1.

    In our clinic we see two definite referral spikes related to age and gender:

    The first referral spike occurs around the first grade where we see a large influx of hyperactive boys, ages 5 - 7.

    The second referral spike occurs around the sixth grade, and girls are predominate in this referral group. Often, these are previously well-liked girls who, once they reach middle school, are overwhelmed by classroom changes, increased assignments, and large class sizes. They begin to fall further behind academically, and they start to struggle socially.

    The DSM-IV criteria are somewhat limited with regard to diagnosing ADHD in girls. Prior to reaching middle school, the inattentive girl may not exhibit all of the symptoms required by the DSM-IV, and as a result, the diagnosis may be missed. Is the evaluation and treatment for boys different than for girls?

    Dr. Gephart: The assessment and the treatment are the same. However, if the patient is a hyperactive, impulsive child, that child will require more intervention. And, since boys tend to be more hyperactive than girls, boys will often require more intense intervention than girls. Do you treat children differently than you treat teenagers?

    Dr. Gephart: No. Teenagers respond to stimulant medication and behavioral treatment approaches in the same ways that younger children do. However, teenagers have more control over how they participate in treatment, and therefore, adolescents present a different set of compliance issues than children do. How is ADHD treated?

    Dr. Gephart: There are two proven treatments:

  • Stimulant medication such as Ritalin, Dexedrine, and Adderall, and
  • Behavioral therapy such as parent training, social skills programs, and the daily report card.

    The best treatment involves the use of both approaches.

    In parent training classes parents learn how to work with their kids on a daily basis. These programs focus on teaching parents how to deal with the child's social and academic problems - when to use time-outs, how to give clear, concise instructions to the child, how to set up a system of rewards and consequences. It is important to keep in mind that many ADHD kids have ADHD parents. The parents, therefore, may forget to give the child his/her medication or be disorganized in their approach to the child. These programs teach parents how to be more successful in dealing with the child.

    Many ADHD children exhibit socially inappropriate behavior and have problems getting along with siblings and peers. Social skills programs, particularly camping programs that provide intense intervention, group work, and a lot of one-on-one assistance, can help these kids learn skills in problem solving, working with others, and anger management. ADHD kids need to experience success, and when a child learns how to interact appropriately with others, this can be an important self-esteem builder.

    The daily report card is a tool used by the school to give more immediate feedback to the parent (and the clinician) about the child's progress. The report card focuses both on behavior and academics, and a system of rewards and consequences can be designed to reinforce the performance goals. We hear a lot in the media that ADHD is over-diagnosed and that kids are over-medicated. Can you comment on this?

    Dr. Gephart: People are certainly more aware of the disorder. Although there may be evidence of over-prescribing in some communities, one recent study concluded that, in fact, ADHD is actually under-diagnosed in the U.S., that only 50% of children with ADHD are actually being treated with stimulant medication (despite its proven effectiveness), and that for a significant number of children who are taking stimulant medication, the treatment is inadequate.

    In addition, it is possible that prescribing variations could be attributed to such wide-ranging factors as inconsistent care, affluent neighborhoods where families have more resources to cover the costs of diagnosis and treatment, or a greater number of child psychiatrists and other clinicians in a community who are trained to make the diagnosis. What do you do if parents are resistant to giving their child medication?

    Dr. Gephart: I think the key is to spend a lot of time conducting a careful assessment before ever talking to parents about medication and other treatment options. Most parents are eager for help, but they want to be certain that their child has been properly evaluated, and they may be resistant to certain treatments if they feel their child has not received a complete evaluation. Also, practitioners need to spend time giving parents information about the pluses and minuses of each intervention and educating families about how to manage the disorder.

    In our clinic we schedule a separate appointment to discuss treatment options. For parents who don't want to use medication, we recommend parent groups, skills training, and other educational interventions.

    With regard to medication, a more common problem is the ADHD teen that refuses to take his/her medication. In such situations adherence to the treatment plan is disrupted, and we have to develop strategies that encourage the teen to participate in the treatment. Is there any concern about the risk of increased substance abuse for kids taking ADHD medication?

    Dr. Gephart: ADHD kids are at increased risk for substance abuse, but research indicates that ADHD kids who are on stimulant medication are not more prone to substance abuse. In fact, early treatment reduces the risk of substance abuse.

    We do talk to kids about the possibility of adverse drug reactions if they use alcohol or other substances while taking their medications. Unfortunately, this doesn't necessarily mean that they refrain from the use of alcohol or drugs. The more likely result is that they may not take their medication when they are drinking. Do you find that kids share their medications with other students?

    Dr. Gephart: Generally, this has not been a problem in my practice. Kids know that the medication helps them, and even though they may not like to take it, they recognize that there are benefits when they do take it. How important is it to work with the school and others who have significant contact with the child?

    Dr. Gephart: It is very important. Treating an ADHD child is a team effort. Parents, teachers, nursing staff, mental health professionals, case managers, and others are essential members of the team and are critical to the success of the treatment. We also need to remember that building a therapeutic alliance with the child is an important component.

    In treating ADHD we use a chronic illness treatment model as opposed to an acute illness treatment model. Consequently, treatment is usually a long-term proposition that requires the implementation of a medication schedule as well as education and behavioral interventions at home, in day care, at school, and wherever else the child spends time. Earlier you mentioned the importance of obtaining a learning assessment. Can you comment further on that?

    Dr. Gephart: It is essential to determine if the child has a comorbid learning disorder. ADHD kids slowly fall behind in school. They may have normal IQs, but they frequently perform below grade level.

    These kids daydream and are easily distracted. They find it hard to process language, organize their materials, and pay attention to details - tasks that are required in all educational settings. If a child is not paying attention for one-third of the day, that child is essentially missing every third day of school.

    The parent or the clinician can initiate a request for a learning assessment. There are at least two federal statues that apply to children with disabilities:

  • The Individuals with Disabilities Education Act (IDEA) and
  • Section 504 of the Rehabilitation Act of 1973.

    IDEA governs special education, and Section 504 provides for reasonable accommodations for children with disabilities. It is difficult to get kids into special education, but ADHD kids can receive certain accommodations such as extra time for tests, preferential seating, taking tests in a quiet room, and so on. Parents can be a great deal of help in advocating for the child on these kinds of issues. In 1999 you wrote an article entitled, The ADHD History: 42 Questions to Ask Parents (Contemporary Pediatrics 1999;10:127-128, 130-136), in which you described a list of questions that you use when evaluating a child for ADHD. Describe some of those questions.

    Dr. Gephart: In my initial interview with the parents I try to ask such questions as: Does your child have a history of accidents or injuries? How does your child react to schedule changes? Does your child sit quietly when watching TV? Does anyone in the family have ADHD or learning problems? Does your child have friends? Does your child interrupt others when they are talking? What are your child's strengths? Does your child obey you? How would you describe your child's self-esteem?

    These questions are not all inclusive nor are they meant to be used as a checklist for diagnosing ADHD. Rather, they are designed to flesh-out the DSM-IV criteria. For example, if I ask a parent if the child is fidgety, the parent may say, "No." However, if I ask if the child is able to sit through dinner in a restaurant, the parent may give a very different response. These more specific responses often provide information that is pertinent to the diagnosis. Do you consider one or two of the questions to be more important than the others?

    Dr. Gephart: No. All of the questions used in the parent interview are important to learning about the child. However, if you really pressed me to choose a question that seems to describe a significant percentage of ADHD kids, it would be: Does your child do his/her homework and forget to turn it in? Describe how you treat a child with ADHD.

    Dr. Gephart: Once the diagnosis is made, we develop a child-specific treatment plan that includes goals, methods of treatment, patient education, a system for monitoring progress, and plans for follow-up. What do you do if the child does not respond to treatment?

    Dr. Gephart: If the target outcomes are not met and the child is not responsive to treatment, we re-group and try to find out why. This means reassessing the original diagnosis, evaluating the selection of medications, looking to see if all appropriate treatments have been tried, examining compliance issues, and determining if there is a co-occurring condition that we may have missed. Does the presence of ADHD in a child pose particular problems for other members of the family?

    Dr. Gephart: Parents of ADHD children have a higher incidence of depression and alcohol-related disorders and are at greater risk for marital problems. Dealing with an ADHD child can place a considerable amount of stress on a family, particularly if the child's symptoms are severe. If sibling relationships are poor (and they often are), the strain on the family is increased. It is not uncommon for more than one child in a family to have the disorder.

    Because ADHD is a chronic condition, families who have an ADHD child may be in for a long haul, and they have to develop long-term coping skills. Single parents are particularly hard hit since they are alone on the front line.

    In addition, the disorder places a financial burden on families. Evaluation and treatment can be costly, and work schedules and careers sometimes have to be adjusted to meet the child's needs. What are some of the most significant developments in the treatment of ADHD in recent years?

    Dr. Gephart:

    • Despite it's limitations, the development of the DSM-IV criteria for diagnosing ADHD;
    • The development of practice guidelines that help us do a better job of assessing and treating ADHD; and
    • The introduction of longer-acting medications. For example, once-a-day medications help reduce the social stigma associated with ADHD because they eliminate the need to interrupt after-school activities or single out the child for a trip to the nurse's office to receive his/her medication. Are there areas that still need improvement?

    Dr. Gephart: Always. We need to develop a better understanding of ADHD in girls. Additional research needs to be done with regard to the diagnosis and treatment of ADHD in adolescents. Also, there is very little information in the literature on ADHD and multicultural issues, and I hope to see some research generated in this area. Thank you for taking time to share your expertise with us.

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    Page last modified or reviewed by on February 3, 2014