Attention Magazine October 2019

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WHERE SHOULD THESE PEOPLE TURN for the best expertise in treatment for their ADHD, including medications? It’s not as simple as finding a cardiologist for a heart problem or an obstetrician to deliver a baby. What kind of practitioner specializes in ADHD? The variety of specialists who treat ADHD can be dizzying.

Psychiatrists

Psychiatrists are traditionally the specialists we should assume will specialize in ADHD. Many, but not all, adult psychiatrists are trained to treat ADHD. Adult ADHD was not widely recognized by psychiatrists until the 1990s, and it took many years for psychiatry residencies to develop and train faculty to teach adult ADHD care to residents. Recent psychiatric residency graduates are thoroughly trained in ADHD care, and most prior graduates have learned about it through professional accreditation and continuing education programs.

Most psychiatrists treat a significant number of patients with ADHD, although this cannot be assumed. Psychiatrists have extensive training in differential diagnosis and are usually the best specialists to seek when ADHD is comorbid with depression, severe anxiety, bipolar disorder, aggressive disorders, or other serious psychiatric conditions.

Child and adolescent psychiatrists are extensively trained in ADHD care of children. Some have extended their scope of practice to include adults in locations where adult ADHD specialists are not available.

In the field of psychiatry, HIPAA regulations are often interpreted to limit a psychiatrist from caring for more than one member of a family. HIPAA regulations do not spell this out specifically, but this is a common interpretation of the law in psychiatry.

Primary care providers

Family practitioners, pediatricians, internists, some ob-gyns, nurse practitioners, and physician assistants in primary care practices are typically the first point of contact for when adults with ADHD need care. Some will determine and monitor treatment, some will continue treatment after a specialist determines it, and some refer all ADHD care.

Many group practices have one caregiver who acts as an internal consultant, managing ADHD patients for all the other providers. Pediatric practices are increasingly employing nurse specialists who coordinate care for all ADHD patients in their practices, and the concept is spreading to large primary care groups as well.

The advantage of obtaining ADHD care at a setting in which you are already known is obvious. Because ADHD in one person affects everyone in the home, family-oriented medical practices are sometimes more attuned to family dynamics than specialty offices. Family care providers have different methods for providing privacy under HIPAA guidelines, and they are often willing to provide mental health care for all members of a family as needed.

Primary care doctors can prescribe all psychiatric medications. Some will not initiate care, but will provide continuing care once a specialist has determined the correct dosage. They will often consult a psychiatrist if ADHD is accompanied by bipolar disorder, severe depression, and/or anxiety disorders, or if treatment response is not typical.

Nurse practitioners (NPs) and physician assistants (PAs)

NPs and PAs may work within a larger physician group, but increasingly more are working in independent practice settings. Some specialize in mental health broadly, while others specialize in ADHD or depression and anxiety specifically. Their practices may be especially suited to mental health care. Studies have shown, for example, that nurse practitioners spend more time with their patients, give patients more information, and follow-up more frequently than physicians do. NPs and PAs prescribe medications including controlled substances in every state.

Psychologists

Psychologists can prescribe mental health-related medications in Idaho, Illinois, Iowa, Louisiana, New Mexico, and the Territory of Guam, as well as in the Public Health Service, the Indian Health Service, and throughout the US Armed Services. In other states, psychologists typically consult with a patient’s primary care physician, who writes the recommended prescriptions.

Neurologists and physiatrists (rehab specialists)

Doctors who treat injuries to the brain are often knowledgeable regarding ADHD. The majority of these specialists in diseases and injuries of the brain don’t treat developmental disorders such as ADHD, but their background is sufficient if they develop an interest.

 

Network to find a specialist

If you are lucky enough to know an ADHD specialist already, your next step is a phone call to schedule a first visit. If you don’t know one, finding one will require some sleuthing. Here are some suggestions.

1. If you are seeing a coach or therapist for ADHD, ask for recommendations.
2. If you know someone with ADHD, ask them who they have seen.
3. The director of your local CHADD chapter (https://chadd.org/affiliate-locator/) often knows providers in your area who have worked with chapter members.
4. Your primary care provider might prescribe ADHD medications. If not, he or she will often refer you to someone who does.
5. University medical centers have health centers that provide mental health services. Many have specialized ADHD clinics or behavioral health clinics. If not, there will be a be an outpatient mental health clinic where ADHD patients are seen.
6. Consider asking your pastor, the principal of your child’s school, the president of your PTA, or other community leaders who know who’s who in your locale.
7. Search provider databases at chadd.org, www.add.org or www.additudemag.com. All providers in these databases specialize in ADHD.
8. The provider referral service at psychologytoday.com has a robust database. Narrow the search with the selections on the left of the page: select ‘ADHD’ in the Issues category and ‘Psychiatrists’ in the ‘See Nearest’ selector at the bottom. Your search results will include psychiatrists, NPs, and PAs.
9. And last, but not least, there’s Google. Try “ADHD doctor near me” or “ADHD specialist.”

Check out potential practices

After you locate a candidate or two, you will want to dig a little deeper.

1. Check the practice website. Most doctors who concentrate in ADHD will let you know that quite prominently on their personal page.
2. Don’t assume that all mental health specialists are experienced at treating ADHD or that primary care providers are not. Some adult psychiatrists finished residency without any training in ADHD, while some family doctors and internists find a special interest and become very experienced at diagnosing and treating ADHD.
3. In many large practices, nurse practitioners and physician assistants do the bulk of the mental health patient visits and prescriptions. Some of the best listening and smartest prescribing happens in their offices.

The most revealing questions you can ask

You probably cannot call and interview a physician, but you can often speak to a nurse at a prospective practice. The top two questions I would ask are:

1. How many patients with ADHD do you currently treat?
2. Do you (or does your doctor or your practice) like treating ADHD?

The first question is a good indicator of expertise. It’s hard to have up-to-date expertise without actively managing a panel of at least 50-100 patients. This is not a precise number, as it is entirely possible to churn through a high number of patients using rote treatment formulas.

The second question is odd, and not all answers are helpful. If the person stammers or asks what you mean, that is not a deal-breaker, but an answer such as, “Dr. Goodheart has family members with ADHD and considers it a special part of her mission,” suggests that you may have found the right place.

ADHD specialty clinics

A growing number of medical practices specialize in ADHD, and they are often a good choice if you can find one in your locality. When everyone in a practice focuses on ADHD, office personnel can offer rich advice and support. You can be assured that a practice named “ADHD Clinic” has expertise and “likes” treating ADHD.

In my personal practice, my staff and I manage over a thousand ADHD patients. We have diagnosed more than five thousand individuals since we began in 2001. When my office nurse is asked whether we like treating ADHD, she has been heard to say, “Why people with ADHD are literally the reason we open our doors in the morning!”

Practical questions

There are other questions that may help you evaluate a practice. Check the practice website first, particularly the FAQ section if there is one. It is usually quicker to do this than to sit on hold waiting to talk to office staff, since their time is often overwhelmed by the needs of patients already sitting in the office. Look for answers to the following suggested questions.

1. What is the cost of an evaluation?
2. What is the wait time for a new evaluation?
3. What are the costs of follow-up visits?
4. What is the standard follow up for typical patients after treatment is established? This typically varies from two to twelve visits per year.
5. What insurance does this practice accept?
6. Are televisits available (if you live a considerable distance from the practice)?
7. Does this practice offer ancillary services—psychotherapists, social workers, coaches, educational specialists, nutritionists, care coordinators, etc.? If not, are referrals available?

Selecting a practice

ADHD specialists are unfortunately uncommon relative to the number of people with ADHD needing treatment. You are fortunate if you have more than one or two practices from which to choose.

All the research in the world cannot help you find the perfect practice, since there is no such thing. In the end, the best practice is not the one with the prettiest office or the nicest doctor. It is the one under whose care the person with ADHD finds symptom relief and successful life progress. That result will develop over time, but careful research now improves your chance of that success.

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Oren W. Mason, MD, is a family physician and an assistant professor at Michigan State University College of Human Medicine. Since 2000, he has specialized exclusively in the diagnosis and treatment of children and adults with attention disorders. In 2008, he founded Attention MD and currently treats over 1000 patients with ADD/ADHD, executive function impairments, and accompanying comorbid conditions. He has published research on combination therapy for ADHD, ADHD management in a primary care setting, and stimulant prescription abuse. He has also authored educational programs for physicians who treat ADHD. Dr. Mason speaks internationally to professional and lay audiences about ADHD, and he is the author of Reaching for A New Potential: A Life Guide for Adults with ADD from a Fellow Traveler. Dr. Mason lives in Grand Rapids, Michigan, with his wife, Christine, who is also a family physician. Two sons were born in 1992 and 1995, and in 2001 they expanded their family to include five Sudanese teenagers orphaned by the civil war in South Sudan. They maintain a personal interest in the education and medical care of the poor in the developing world.