Follow-up care received by children with attention deficit hyperactivity disorder (ÅDHD) by primary care clinicians (PCCs) was evaluated by questionnaires completed by parents at an index visit and at six months, in a study at Ohio State University, Columbus, OH and several research networks. Each clinician enrolled a consecutive sample of 55 children, 4 to 15 years of age, and 976 children identified with ÅDHD were selected for follow-up. Surveys were returned by 659 (68%) families, and the outcome measure was the number of office visits during the 6 months. Medications (94% stimulants) were prescribed at the index visit in 52% children with ADHD, and 78% were medicated at 6 months. A median of one visit was made to the PCC in 6 months, and the number of visits was the same for those taking psychotropic medication as those not on medication. Follow-up visits were more frequent to PCCs who had completed a fellowship in mental health training. Children seeing a mental health specialist (26%) were more often black, on Medicaid, or had higher levels of internalizing symptoms. Follow-up care by PCCs for ADHD falls below that recommended in the 2000-1 AAP Guidelines. [1]

COMMENT. Follow-up of children with ADHD requiring medication monitoring is time consuming, and optimal management should include both parent and teacher reports regarding educational and behavioral progress, provided monthly. A psychological evaluation is essential in patients whose academic achievement falls short of that expected. A single clinician visit each 6 months is generally insufficient, and collaboration with a mental health or neurology specialist can optimize results of therapy.

A current clinical practice review and guidelines for diagnosis and management of ADHD, as followed in the Department of Pediatrics and Human Development, Michigan State University, East Lansing, MI, recommends visits every 3 to 4 months, once a stable dose of medication is established [2]. An opportunity to monitor medication between quarterly visits is also afforded by parental telephone requests for prescription renewal at monthly intervals.

Recent warnings regarding rare but serious adverse events with Adderall XR and Strattera (atomoxetine) have emphasized the importance of close medication monitoring to avoid toxicity: patients with a history or signs of cardiac problems should not be treated with Adderall, and patients receiving Strattera should be monitored for symptoms or signs of liver dysfunction.

The physician’s role in the collaborative community care of ADHD is outlined in a report of a consensus developed among health care providers and educators in North Carolina Counties [3]. The MD’s role includes close collaboration with school personnel, and use of communication forms to share diagnostic and medication information with school and family. Large discrepancies were identified between pediatricians’ practice patterns and AAP guidelines, and 50% of children with ADHD were unidentified and untreated.