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News & Articles > A Clinician’s Guide to Diagnosing and Treating ADHD and Its Comorbidities

By Harlan R. Gephart, MD

In 2013 the American Academy of Pediatrics (AAP) surveyed its membership of over 70,000 Pediatricians regarding their comfort in diagnosing and treating children and adolescents with mental health concerns.  Sixty-five percent of practicing pediatricians felt they lacked the necessary skills to do so. Forty-five percent felt they lacked the diagnostic skills, and greater than fifty percent felt they lacked the necessary treatment skills.

Some experts have suggested it will “take a whole new generation of Pediatricians to rise to this challenge.” With 70 million children and adolescents in the United States, it is estimated that 20% of them (approximately 14 million) need mental health services and with only 8700 Child Psychiatrists in the United States, who can step up and help address the problem if Primary Care Clinicians (Pediatrics, Family Medicine, and General Internal Medicine) don’t do so?   

As a group, the ADHD population of children and adolescents are loaded with other comorbid diagnoses. The numbers vary in different studies but overall, we know that roughly two-thirds to three-fourths of ADHD children/adolescents fulfill criteria for another DSM-5 diagnosis in addition to the ADHD. For example, Specific Learning Disorders in 25-30%, Anxiety Disorders in 20%, Depressive Disorder Major or Minor (Dysthymia) in 5% to 50%, Oppositional Defiant Disorder in 40-50%, and Conduct Disorder in 20%.  We also know ADHD adolescents are 3 to 4 times more likely to have car accidents or traffic violations and are much more prone to other risk behaviors, such as teenage pregnancy, substance abuse, smoking or alcohol abuse, compared to their non-ADHD peers. 

Our experience suggested that the risk behaviors and the ability to modify or lessen them were a major determinant in the success of treating the ADHD adolescent. We received pushback from primary care clinicians to receive these patients back from us after stabilization, mostly I believe from the statement made in the first paragraph: greater than fifty percent of practicing pediatricians felt they lacked the skills to treat mental health concerns. Hence, the stimulus for the writing of my new book: to help primary care clinicians to feel more comfortable following (and eventually diagnosing and treating) children and adolescents with mental health concerns.

I am Harlan R. Gephart, MD FAAP, a general pediatrician with extra training in behavioral pediatrics, who recently published a book with Elsevier entitled ADHD Complex:  Practicing Mental Health in Primary Care. I practiced general and behavioral pediatrics for 50 years in the Seattle area, where in 1990 I organized and directed a clinic called the “Center for ADHD.”  Over the next 14 years the clinic diagnosed, treated, and followed several thousand children and adolescents with this disorder, utilizing a multi-modality treatment approach consisting of parental/child education about ADHD, parent training in behavioral therapy, school accommodations, and medication. The clinic became a national model for the treatment of ADHD and its comorbidities.

My direct motivation to write the book came from two colleagues. The first is Dr. Peter Jensen, eminent child psychiatrist, author of the classic MTA study regarding the treatment of ADHD, and currently the CEO of the REACH (Resource for Advancing Children’s Health) Institute in New York, where I am a faculty member for their intensive 3-day PPP Course (Patient-Centered Mental Health in Primary Care) offered to Primary Care clinicians. The other encourager, who almost “insisted” I write a book, was Paul Miles, MD, VP of the American Board of Pediatrics for Quality Improvement, who like me had spent over 25 years in the trenches of rural Idaho as a general pediatrician. Paul recognized the breadth of experience we had obtained over many years with literally thousands of patients and the value of that experience for pediatricians. Our experience was unique and practical and worth sharing because it was different in some ways from the more academic information about ADHD.

The book is not an academic treatise about ADHD.  It is a “do it yourself handbook,” not only for ADHD, but all the mental health conditions seen in children and adolescents with or without ADHD, such as Specific Learning Disorders, Anxiety, Depression, Tics/Tourette Syndrome, Aggression, Oppositional Defiant Disorder, Conduct Disorder, and more. Using case vignettes, clinical “pearls,” rules to follow, and pitfalls to avoid, the diagnosis and management of mental health conditions are simplified and clarified. The abundant resources listed provide ample support for clinicians, patients, and their families.

A quick perusal of the chapter headings will give the prospective reader the realization that all the major comorbidities of ADHD are covered. The chapters are all presented in a similar format, including case vignettes, signs and symptoms, screening tools, differential diagnosis, evidence-based treatments, resources, rules to follow, and errors to avoid. What does not show up in the Table of Contents are all the subtopics included in each chapter, such as:

Chapter 1.  Rating Scales

  • Over a dozen tools to measure ADHD, anxiety, aggression etc. and how to access them for free online
  • A questionnaire for use in history taking (developed by our clinic)

Chapter 2.  Learning Disorders

  • What is an SLD, an IEP, a 504 Plan?
  • What does Response to Intervention (RTI) mean?

Chapter 3.  ADHD

  • What are 30 plus medical, developmental, behavioral, and educational conditions that mimic or may accompany ADHD?
  • What are common errors in diagnosis and treatment?
  • How does one decide which medication to use?
  • How about alternative/complementary treatments?

Chapter 9.  Anxiety

  • How does one do a Mental Health Interview?

All the above and more are provided in a clear, succinct and easy to grasp format. The book is published both in print as well as electronically as both an eBook and on Elsevier’s broad reaching ScienceDirect Platform, thus making its information readily available to the clinician via phone or laptop.  Interestingly, though written primarily for clinicians, reviewers in non-clinical areas, such as counseling, psychology, and special education, have recognized its resource value in those disciplines as well. Additionally, feedback to me from concerned parents of children and adolescents with ADHD and/or other mental health issues have also shared that they find this resource to be very helpful, further demonstrating the book’s broad reach and usability across the many groups of stakeholders involved in the treatment of child and adolescents with ADHD and other comorbid mental health disorders.

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