Starting ADHD medication in children

[SpongeBob DoctorPants]

There isn't necessarily one right way to do this, but I'm curious which approach some of you would take in this scenario: Imagine you are seeing a child for the first time in clinic, and you suspect ADHD as a diagnosis. You discuss stimulants as a possible treatment option, but decide to wait on starting a stimulant until after receiving a completed Vanderbilt from the school teacher.

Do you...
- call the parent after receiving the form, discuss the results over the phone, and prescribe medication prior to seeing the child again?
- have the parent and child return to clinic after receiving the form, discuss the results in person, and prescribe medication then?
- do something different than either of the above? (If so, please explain.)

Bonus question:
What do you do in the above scenario when school is out for the summer?

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[VA Hopeful Dr]

There isn't necessarily one right way to do this, but I'm curious which approach some of you would take in this scenario: Imagine you are seeing a child for the first time in clinic, and you suspect ADHD as a diagnosis. You discuss stimulants as a possible treatment option, but decide to wait on starting a stimulant until after receiving a completed Vanderbilt from the school teacher.

Do you...
- call the parent after receiving the form, discuss the results over the phone, and prescribe medication prior to seeing the child again?
- have the parent and child return to clinic after receiving the form, discuss the results in person, and prescribe medication then?
- do something different than either of the above? (If so, please explain.)

Bonus question:
What do you do in the above scenario when school is out for the summer?

Option B.

I don't diagnose in the summer given how many times I've had the parent Vanderbilt be pan positive and the teacher one be pan negative.

 

[calvnandhobbs68]

Option B.

I don't diagnose in the summer given how many times I've had the parent Vanderbilt be pan positive and the teacher one be pan negative.

Agree. Sometimes the parent changes their mind about if they wants meds and if they will be okay with a stimulant or not too. I’m also of the opinion that starting long term meds is best initiated in person, you’re not just prescribing antibiotics for a week or a steroid burst.

Also agree about the Vanderbilt. There’s a reason you do school and parent forms.

 

[TexasPhysician]

Why wait for a teacher report form to start medication at all? A clinical interview diagnosing ADHD would prompt treatment from me regardless of what the teach sees

 

[VA Hopeful Dr]

Why wait for a teacher report form to start medication at all? A clinical interview diagnosing ADHD would prompt treatment from me regardless of what the teach sees

So the kid behaves perfectly in class, doesn't struggle with school work, and generally has no problems and that wouldn't concern you?

 

[TexasPhysician]

So the kid behaves perfectly in class, doesn't struggle with school work, and generally has no problems and that wouldn't concern you?

A 1:1 clinical evaluation would more effectively rule out adhd. Teachers are not clinicians. Teachers have 20+ kids to keep up with at any moment and no formal adhd training. Teachers are asked to do plenty of unpaid work, and another form is often not a top priority for their attention unless on a top problem student. The odds that a teacher could effectively tease out every child with inattentive type adhd is very low. Just like some parents over-report symptoms, some teachers under-report.

I am currently treating a child with excellent initial teacher reports as everyone else including me saw the dysfunction/inattention. She is very polite, quiet, and high IQ so the teacher loves her. On the flip side, she is quite inattentive, forgetful, etc. Her teacher later admitted that she has seen significant positive change after treatment of symptoms she didn’t recognize.

Teacher reports are more beneficial to track changes over time (they all rate differently) and possibly to reinforce the lack of adhd in a clinical interview although I’ve met teachers that have admitted to over-reporting symptoms to appease an irritated parent.

For me: If I diagnose ADHD and there are no contra-indications to treatment, delaying treatment for a teacher report makes no sense.

If I’m on the fence, teacher reports are only 1 of multiple further data points to increase my level of certainty.

 

[calvnandhobbs68]

A 1:1 clinical evaluation would more effectively rule out adhd. Teachers are not clinicians. Teachers have 20+ kids to keep up with at any moment and no formal adhd training. Teachers are asked to do plenty of unpaid work, and another form is often not a top priority for their attention unless on a top problem student. The odds that a teacher could effectively tease out every child with inattentive type adhd is very low. Just like some parents over-report symptoms, some teachers under-report.

I am currently treating a child with excellent initial teacher reports as everyone else including me saw the dysfunction/inattention. She is very polite, quiet, and high IQ so the teacher loves her. On the flip side, she is quite inattentive, forgetful, etc. Her teacher later admitted that she has seen significant positive change after treatment of symptoms she didn’t recognize.

Teacher reports are more beneficial to track changes over time (they all rate differently) and possibly to reinforce the lack of adhd in a clinical interview although I’ve met teachers that have admitted to over-reporting symptoms to appease an irritated parent.

For me: If I diagnose ADHD and there are no contra-indications to treatment, delaying treatment for a teacher report makes no sense.

If I’m on the fence, teacher reports are only 1 of multiple further data points to increase my level of certainty.

I think the fact that part of the diagnostic criteria is that the symptoms persist across 2 or more settings make some people more inclined to try to gather collateral to make sure that’s the case prior to starting stimulants.

 

[TexasPhysician]

I think the fact that part of the diagnostic criteria is that the symptoms persist across 2 or more settings make some people more inclined to try to gather collateral to make sure that’s the case prior to starting stimulants.

Gathering collateral is fine, but you don’t need verification from any specific one person. The lack of teacher acknowledgement doesn’t mean dysfunction isn’t there.

 

[PikminOC]

Unpaid work?
Teacher Pensions Sweeter Than They Would Like You to Think

 

[hamstergang]

Gathering collateral is fine, but you don’t need verification from any specific one person.

Have you gotten collateral from anyone other than a teacher wrt ADHD?

I have initiated ADHD treatment without teacher input when I've been able to gather data from the parent and kid that already support the diagnosis. Sometimes, they can describe symptoms experienced in school which fit the parent report of home or other settings behaviors.

 

[TexasPhysician]

Have you gotten collateral from anyone other than a teacher wrt ADHD?

I have initiated ADHD treatment without teacher input when I've been able to gather data from the parent and kid that already support the diagnosis. Sometimes, they can describe symptoms experienced in school which fit the parent report of home or other settings behaviors.

Sure. Some kids get speech therapy or see a counselor for other issues. I’ve even had a principal weight in. Patients can often express problems from school themselves.

 

[birchswing]

Teachers may not have training in diagnosing ADHD, but they would know at least some about developmental psychology. And they might notice the types of things a social worker would that parents would not be forthcoming about that could negatively impact their children—deaths in the family, parents dating new people, not being picked up from school, parents neglecting to attend meetings/sign forms, etc.

Parents have a motive not to implicate themselves as sources of trouble for their children. And teachers have a bird's eye view into those lives.

They know which ones are worried about deportation (another thing parents would have a motive not to bring up but which affects children's nerves), which ones have 14 people living in one house with two bedrooms, etc.

 

[SpongeBob DoctorPants]

I appreciate everyone's input and I'm glad to see some differences of opinion. This may explain why there wasn't any sort of required approach to starting stimulants in my fellowship training. Some prefer to get collateral information from teachers first, while others are comfortable prescribing during the initial visit, or at any time without getting teacher input. I think it's also worth mentioning that some physicians don't even always require an ADHD diagnosis; for example, in my fellowship training I saw a patient who only had an ODD diagnosis, and my attending at the time recommended starting a stimulant.

Personally, if I evaluate a patient and I think they will benefit from a stimulant, I'll prescribe it without getting a teacher's input. Generally, I am most comfortable doing this when there are clear signs of ADHD during the evaluation, such as the kid who interrupts nonstop, or the kid who needs everything repeated because their mind is on something else.

My main question, of course, had to do with when to start medication when I am unsure of the diagnosis and am seeking a teacher's input. The reason I ask this question is because I typically spend time at the end of the initial visit discussing treatment options and potential side effects, and sometimes I feel like it's a waste of the parent's time and money to make another clinic visit just so I can tell them, "Well, it turns out the teacher's observations are consistent with a diagnosis of ADHD, so we are going to start the medication we talked about last time. " Perhaps I am getting ahead of myself, and should wait until the second visit to discuss treatment in this scenario.

Regarding those whom I see in the summer, while I might prefer having a teacher Vanderbilt I also try to consider things from the parent's perspective. The child might have done very poorly in school the preceding year, and the parents want to get medications figured out during the summer so the child can have a greater chance for starting school successfully in the fall. Telling them to wait a few months so we can get information from a teacher may not be in the child's best interest.

 

[TexasPhysician]

My main question, of course, had to do with when to start medication when I am unsure of the diagnosis and am seeking a teacher's input. The reason I ask this question is because I typically spend time at the end of the initial visit discussing treatment options and potential side effects, and sometimes I feel like it's a waste of the parent's time and money to make another clinic visit just so I can tell them, "Well, it turns out the teacher's observations are consistent with a diagnosis of ADHD, so we are going to start the medication we talked about last time. " Perhaps I am getting ahead of myself, and should wait until the second visit to discuss treatment in this scenario.

My opinion is that you put too much stock in the teacher report. If you see an 18 y/o who arrived at your college clinic to continue adhd meds, are you going to consult professors? Will you consult the roommate to confirm dorm setting dysfunction? The diagnostic criteria requires symptoms by age 12. Will you call the mother to verify or ask his elementary school to send a transcript? Most young children can discuss school concerns in their own way.

If the child doesn’t demonstrate symptoms during an in-depth clinical interview, I wouldn’t change my mind because 1 teacher claims symptoms are there.

If the history and interview are significantly opposed, I would want more in-depth testing, not less (teacher screening). Neuropsych testing, OT evaluation, and I’d argue something like Quotient testing is much more objective than a teacher report.

 

[SpongeBob DoctorPants]

My opinion is that you put too much stock in the teacher report. If you see an 18 y/o who arrived at your college clinic to continue adhd meds, are you going to consult professors? Will you consult the roommate to confirm dorm setting dysfunction? The diagnostic criteria requires symptoms by age 12. Will you call the mother to verify or ask his elementary school to send a transcript? Most young children can discuss school concerns in their own way.

If the child doesn’t demonstrate symptoms during an in-depth clinical interview, I wouldn’t change my mind because 1 teacher claims symptoms are there.

If the history and interview are significantly opposed, I would want more in-depth testing, not less (teacher screening). Neuropsych testing, OT evaluation, and I’d argue something like Quotient testing is much more objective than a teacher report.

I appreciate your input and you bring up another scenario I have wondered about... the adult patient with ADHD. (This may be a topic for another thread.) The vast majority of my experience in treating ADHD came from my child fellowship training. In my general psychiatry residency it was almost as if ADHD didn't exist in adults, and there were a lot of drug-seeking patients in our community so that was probably why. But of course, ADHD does not magically stop at age 18.

I see mostly children and adolescents in my practice, but I also see young adults, and several of them I treat for ADHD. Generally, I do like to have some sort of input from another source, such as previous medical records documenting a past diagnosis of ADHD. When this is not available, I have actually spoken with parents sometimes, whom I feel I can rely on somewhat when I have a college-age patient coming to my office wanting to get put on Adderall. I have referred some patients to receive neuropsychological testing but so very few actually complete the testing due to cost, and some of these drop out of care.