EDITORIAL
Evaluating the Quality of Community Care
for Attention-Deficit/Hyperactivity Disorder
Mark Olfson, M.D., M.P.H.
R
ational reform of the mental health system
resembles good clinical care in that it starts
with a careful assessment and an accurate
diagnosis. Although it has been known for many
years that the treatment of attention-deficit/hy-
peractivity disorder (ADHD) is often shallow
and uneven, the portrait of community care that
emerges from the study by Zima et al.1 in this
issue of the Journal is considerably more detailed
and stark than previous assessments. In an ele-
gant set of longitudinal analyses drawn from
Medicaid service and pharmacy claims data,
parent interviews, and school records, the inves-
tigators characterize the mental health care and
clinical course of children with ADHD in a
managed-care Medicaid program. The results
reveal a failure to allocate specialty services to
those in greatest clinical need, widespread defi-
ciencies in pharmacologic treatment, high rates
of treatment disengagement, and unacceptably
poor clinical and academic outcomes. Perhaps
the only bright spot in this otherwise unrelent-
ingly bleak report is the remarkably favorable
parent perceptions of treatment. Even here, it
might be argued that favorable parent views of
treatment could slow consumer-driven efforts
to push for sorely needed mental health care
reform to improve the quality of care.
The new report offers a window into funda-
mental differences between the nature of ADHD
care provided in primary care and specialty
mental health care within a large Medicaid managed-
care program. Although all children in specialty
mental health clinics received at least some
psychosocial treatment and only a minority
filled stimulant prescriptions, children treated
in primary care were far more likely to receive
stimulants than psychosocial treatment. Even
in primary care, however, the rate and persis-
tence of stimulant treatment fell far below
national monitoring and treatment standards.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 49 NUMBER 12 DECEMBER 2010
Neither setting appeared to offer an acceptable
level of care.
The reasons for the low level of stimulant
treatment, which was especially evident in spe-
cialty mental health clinics, remain unclear. As
the authors suggest, it is possible that non-
medically trained mental health professionals may
determine that most children with ADHD do not
warrant a medication evaluation. Inadequate
clinical assessments, knowledge deficits concern-
ing the safety and efficacy of stimulants for
ADHD, pressures to meet administrative case-
load expectations, and concerns over parent re-
sponses to a referral for medication evaluation
may further impede appropriate referrals. A
scarcity of child and adolescent psychiatrists,
especially in settings that serve Medicaid popu-
lations, may also constrain referrals for medica-
tion management.2
Parent preferences may also contribute to low
rates of stimulant treatment. Most Americans are
not well informed about ADHD and its treat-
ment. Although a majority support a combina-
tion of counseling and medication, many more
support counseling alone than medication
alone.3 More specifically, parents of children di-
agnosed with ADHD are often initially hesitant
to have their child started on stimulants4 and
usually report that the diagnosis and treatment
stigmatizes and socially isolates their child.5 In the
African-
American community, there appears to be partic-
ularly high levels of skepticism and mistrust
about psychotropic medications for child mental
health problems.6 Clinicians should be taught to
approach this delicate and important topic in a
flexible and open-minded manner that commu-
nicates to parents and their children that their
doubts and concerns are heard and respected.
The physician who recommends starting stimu-
lants for ADHD should recognize that his or her
www.jaacap.org 1183
OLFSON
views will likely be weighed against prevailing
cultural norms and the influence of friends,
teachers, and the popular media.
In children who received stimulants, Zima et
al.1 found that medication trials were often quite
brief. Although it is not possible to determine the
intended duration of treatment, it is likely that
stimulant treatment nonadherence was common.
Widespread early treatment termination under-
scores the central importance of developing clin-
ical strategies to enhance treatment continuity.
Parent and child knowledge and beliefs about the
need for ongoing stimulant treatment likely
play key roles in treatment acceptance. Con-
certed efforts to implement guideline-based
medication algorithms for ADHD have demon-
strated some success. In one implementation of
a medication algorithm for ADHD within pub-
lic community mental health centers, psychia-
trists were successful in implementing major
aspects of the algorithm and decreasing polyp-
harmacy, although some parents declined stim-
ulant dose titration once they observed im-
provement in their child’s behavior with an
initial stimulant dose.7
In recent years, substantial progress has been
made in developing the evidence base for behav-
ioral parent training, behavior contingency man-
agement, and behavioral peer interventions for
child and adolescent ADHD.8 A limitation of the
study by Zima et al.1 is their inability to specify
the content of psychosocial treatments received
by the children in their study. Regrettably,
most social work and clinical psychology train-
ing programs do not require training in any
evidence-based psychotherapies9 and efforts to dis-
seminate behavioral interventions for ADHD are
inchoate. Without a strong foundation in the
clinical skills necessary to deliver evidence-
based interventions, initiatives to improve the
quality of psychosocial treatment for ADHD
are likely to falter and the option of an evidence-
based alternative to medications will remain un-
common.
The clinical severity of children treated in
primary care clinics in the study by Zima and
colleagues1 closely resembled those seen in spe-
cialty mental health clinics. A more efficient
allocation would redistribute more severely ill
children to specialty settings. Several factors in-
cluding a dearth of locally available specialized
services, stigmatization of specialty mental
health care, inadequate coordination of referrals,
JOURNAL
1184 www.jaacap.org
and tensions over professional roles may impede
the flow of more severely ill children into spe-
cialty care. Despite widespread agreement that
pediatricians should play a key role in identify-
ing ADHD, pediatricians and child and adoles-
cent psychiatrists hold sharply different views
regarding referral and treatment. Although child
and adolescent psychiatrists tend to believe pe-
diatricians should refer rather than treat children
with ADHD, most pediatricians view themselves
as capable of treating ADHD.10 A shared under-
standing of the respective roles of each profes-
sional group might provide a stronger founda-
tion for improved communication, collaboration,
and patient allocation between primary and spe-
cialty care.
Few children in the study by Zima and col-
leagues1 received primary care and specialty
mental health treatment. Colocation of primary
care physicians and mental health professionals
within the same building may increase profes-
sional interaction and opportunities for coman-
agement. Improving access to specialty mental
health services within pediatric primary care,
however, may require relatively complex system
level restructuring and identification of funding
streams to support shared care.
The report by Zima and colleagues1 adds
renewed urgency to the call for reform of
Medicaid-financed community care of children with
ADHD. Closer clinical monitoring with more
frequent follow-up contact may be needed to
increase continuity of care. Improvements are
also needed in medication management, espe-
cially in specialty mental health clinics. Greater
attention should also be devoted to assessment
and referral procedures to ensure that children
with the most complex clinical needs receive
specialty care. Sustained progress in each of these
key areas will likely require interventions at the
patient, parent, clinician, and system levels.
The next few years will bring substantial change
to Medicaid-financed mental health services. After
enactment of the Patient Protection and Affordable
Care Act of 2010, Medicaid benefits will be ex-
tended to large numbers of previously uninsured
individuals. During this transitional period, al-
ready strained community services and resources
will be further stretched. In this challenging envi-
ronment, it will be critically important to maintain
focus on the quality of care provided to children
and adolescents in the Medicaid program who
have ADHD. &
OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 49 NUMBER 12 DECEMBER 2010

Accepted September 1, 2010.
Dr. Olfson is with the New York State Psychiatric Institute and the
College of Physicians and Surgeons of Columbia University.
Work on this editorial was supported by award U18-HS016097 from
the Agency for Healthcare Research and Quality (Center for Education
and Research on Mental Health Therapeutics).
Disclosure: Dr. Olfson has received research grants to Columbia
University from Eli Lilly and Company and Bristol-Myers Squibb.
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JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 49 NUMBER 12 DECEMBER 2010
EDITORIAL
Correspondence to Mark Olfson, M.D., M.P.H., New York State
Psychiatric Institute/Department of Psychiatry, College of Physicians
and Surgeons of Columbia University, 1051 Riverside Drive, New
York, NY 10032; e-mail: mo49@columbia.edu
0890-8567/$36.00/©2010 American Academy of Child and
Adolescent Psychiatry
DOI: 10.1016/j.jaac.2010.09.005
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