Blue Care Network Best Practices

Attention deficit hyperactivity disorder

Brighton pediatrician shares treatment of patients with attention deficit hyperactivity disorder

Angela Browning, medical assistant, and Mo El-Fouly, M.D.

The Centers for Disease Control and Prevention estimates that 9.5 percent, or 5.4 million children 4 to 17 years, have been diagnosed with attention deficit hyperactivity disorder as of 2007. Rates of ADHD increased an average of 3 percent a year from 1997 to 2006 and 5.5 percent per year from 2003 to 2007. As of 2007, 2.7 million children ages 4 to 17 were receiving medication treatment for the disorder.

Because ADHD is the most commonly treated childhood neurobehavioral disorder and because medications can cause serious side effects, careful follow-up is indicated, according to NCQA's report, "The State of Health Care Quality 2010: HEDIS Measures of Care."

Dr. El-Fouly and his patient, Joe Barton IV

Mo El-Fouly, M.D., Ph.D. is a primary care physician in Brighton who has developed a personalized system for following up with his ADHD patients and their families. ADHD patients account for between 5 and 10 percent of his pediatric practice, Dr. Mo Pediatric Center.

Dr. El-Fouly refers to his treatment as individualized and patient-centered.

"After the diagnosis has been established, I go through a comprehensive pre-treatment counseling with the patients and their parents to gather information on their social circumstances, home environment and school performance," he says.

Depending on the patient's age, Dr. El-Fouly likes to involve the child in his or her own management plan and explains to the parents that positive feedback is important in helping their children reach their potential.

Treatment is multi-faceted and includes a pharmaceutical approach, counseling and the involvement of the parents, grandparents (if appropriate) and the child's teachers.

"Once the diagnosis has been established, I start the patient on a low dose of medication based on age and weight," says Dr. El-Fouly. He insists on regular communication and feedback from parents and teachers. For the first follow-up, "If the feedback indicates that the benefits of medication heavily outweigh any side effects, we proceed and adjust the dose according to the child's needs. If the feedback is negative, I sometimes have to reconsider a lower dosage, an alternative medication or change the patient's individual management plan," he says.

Dr. El-Fouly sees some patients anywhere from three to five times in the first six months instead of the recommended two visits between four weeks and nine months.

"This is crucial especially in newly diagnosed patients because some parents may have trepidation about their medication and its potential side effects. They have to feel confident that the doctor is interested in helping their child."

Counseling and parent support are important parts of Dr. El-Fouly's treatment of ADHD patients. He often has extended office visits and, when necessary, extensive phone conversations with parents.

Parent education is also an important part of the treatment.

"I take the parents step by step through slides and diagrams showing how the neurotransmitters function and I keep a model of the brain in my office to demonstrate how brain circuits work," Dr. El-Fouly says.

Part of the individualized plan includes behavior management.

"It's essential to manage the structure of the child's day," says Dr. El-Fouly. "I give parents strategies tailored to each individual child. That requires the doctor to have some experience in managing these patients."

Giving the parents strategies in simple and realistic terms works best, he says. For older teens (16 to 18 years old) the follow-up visits include discussions about friends and any risky behaviors they may be engaged in, including illicit drug use.

An on-site clinic called the Mind and Spirit Institute is another resource for counseling ADHD and other patients. Dr. El-Fouly runs the clinic with Judy Lewis, an on-staff counselor.

Outcomes

Tracking outcomes is important to make sure patients with ADHD adapt to medication and improve their school performance. Dr. El-Fouly monitors both the home and school environments to make sure that the medication and behavioral therapy are working.

"If a patient has no hyperactivity and impulsivity and it's just a matter of deficient focus, they can eventually go off the medication. In my experience, if they have mild to moderate ADD without hyperactivity, those patients may ultimately develop a positive reference point of mental processing and achievement. If I take them off medication, they can then use their reference point to realize what they can accomplish," he says.

"I also explore any therapy failure further," says Dr. El-Fouly. "Sometimes there's more to it than ADHD, including psychiatric conditions or illicit drug habits. Those patients may require further assistance and specialized care."

"I have built-in great patient advocates," says Dr. El-Fouly. "They are parents who saw a positive transformation in their child's condition and became vocal about offering to talk to my other patients and their parents who may be hesitant to start on medication, a support group of sorts. Most ADHD cases can be managed successfully in the primary care setting — at their regular doctor's office. For that to be achieved, the provider would require processing a quad core of essential qualifications: knowledge, communication skills, passion and time."

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