Attention Deficit Hyperactivity Disorder (ADHD) is considered one of the most widespread childhood behavioral complaints that physicians address.¹ The symptoms of ADHD can impact multiple areas related to children’s performance in their everyday activities at school, home or in the community. There is some concern about over-diagnosis of ADHD and increase in stimulant use for treatment of ADHD. It has been shown that stimulant medication can increase the capacity for the patient to stay on task and follow rules, and can decrease emotional outbreaks. The American Academy of Child and Adolescent Psychiatry (AACAP) has recommendations for the care of children with ADHD.² Their recommendations include:

• Providers should institute management programs to treat ADHD as a chronic condition.
• Treatment evaluation should include the patient, family, teachers and other adults in the patient’s life.
• Environmental and behavioral techniques should be included with drug therapy.
• Follow-up with the patient to target outcomes and decrease side effects.

Follow-up care for ADHD includes:

• Should be instituted the month after medications are initiated.³
• Follow-up office visits at periodic time intervals after the patient is stabilized on an appropriate dose. This number should be individualized to the patient’s clinical needs.⁴

A retrospective study of Medi-Cal Fee-For-Service (FFS) recipients was conducted that measured the extent that recipients had medical follow-up visits after initiating ADHD medication therapy. It is recognized that physician phone follow up cannot be tracked through administrative claims and, therefore, could not be identified in this analysis. Recipients who were continuously eligible throughout the January 2006 to March 2007 period and started ADHD drug therapy between July 2006 through September 2006 were included in the study.

1,247 Medi-Cal recipients under age 17 had claims for ADHD drugs during the study period and met the continuous eligibility criteria.
		–	Over 39 percent of the recipients between 0 – 5 years old had follow-up care within 180 days after starting drug therapy, though less than 18 percent had follow-up care within 30 days as recommended by the AACAP
		–	Overall, follow-up care within 180 days after initiating ADHD drug therapy decreased in older age groups, as 33 percent of recipients between 6 – 12 and only 18 percent of recipients between 13 – 16 had follow-up doctor visits after initiating ADHD drug therapy
		–	Median number of days before the first follow-up visit was 37 days for the recipients seen within 180 days of initiating ADHD drug therapy

Overall, pediatric patients are getting follow-up care when diagnosed with ADHD and receiving medication to treat the condition. The percentage of patients receiving follow-up within AACAP recommendations could be improved upon. Medi-Cal recommends:

• Providers follow current AACAP recommendations for treatment and follow-up for patients with an ADHD diagnosis
• Schedule follow-up visits at periodic intervals
• Providers obtain information on the efficacy of the medication from multiple caregivers, including family, teachers and the community
• Pharmacists inquire when patients pick up medications that a follow-up visit has been scheduled and are always available to discuss the advantages and side effects of ADHD medications

References

1. Rushton JL, Fant KE, Clark SJ. Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder. Pediatrics 2004; 114(1):e23-e28.


2. American Academy of Child and Adolescent Psychiatry. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf 2007.
   
3. Harpaz-Rotem I, Rosenheck RA. Prescribing practices of psychiatrists and primary care physicians caring for children with mental illness. Child Care Health Dev 2006; 32(2):225-237.
   
4. American Academy of Child and Adolescent Psychiatry. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf 2007.