It Takes a Village to Treat ADHD: Community and Clinical Collaborations

October 6, 2009

Attention-deficit/hyperactivity disorder (ADHD) is the most common mental health disorder treated by pediatricians.1 Some pediatricians may not have the training, clinical experience, or time to adequately evaluate and treat children with ADHD-and most may feel their skills are insufficient in children with medication treatment resistance, comorbid psychiatric illnesses, or complex family dynamics.

ABSTRACT: The majority of children with attention-deficit/hyperactivity disorder (ADHD) are assessed and treated by primary care pediatricians. However, the services of others are frequently needed to provide optimal care for children with ADHD; one of the pediatrician’s most important roles is to serve as coordinator of the treatment team. A child’s parents are the most important members of the ADHD treatment team. Education of parents by professionals is the cornerstone of any treatment plan for a child with ADHD. Schools are a major provider of services for children with ADHD. Schoolbased evaluations and interventions are often provided under the Individuals with Disabilities Education Act. In cases complicated by comorbid diagnoses, medication treatment resistance, or complex family and psychosocial dynamics, child psychologists and psychiatrists can provide invaluable assistance with diagnosis and treatment. Other professionals, such as speech therapists, occupational therapists, psychiatric social workers, and nurse practitioners can also provide valuable services. Developing technology is creating new avenues of collaboration, including telepsychiatry and phone or Internet consultation.

Attention-deficit/hyperactivity disorder (ADHD) is the most common mental health disorder treated by pediatricians.1 Some pediatricians may not have the training, clinical experience, or time to adequately evaluate and treat children with ADHD-and most may feel their skills are insufficient in children with medication treatment resistance, comorbid psychiatric illnesses, or complex family dynamics.

In addition, pediatricians who treat children with ADHD often encounter complex systems issues that are beyond their usual scope of practice.

Because most children with ADHD-and especially those with comorbidities- display symptoms in multiple environments and require multimodal treatment (academic, family, individual, and medical interventions), a team of professionals is often required to provide comprehensive treatment. In such instances, the pediatrician may become the focal point for facilitating collaborations between parents, schools, and other evaluating and treating clinicians.

In this article, we describe the roles of the possible members of a comprehensive treatment team. We also offer advice on how pediatricians can facilitate and make the most of these collaborative relationships in order to optimize the treatment of their patients with ADHD.

PEDIATRICIANS’ MANY ROLES IN ADHD TREATMENT
Despite formidable barriers to pediatricians’ caring for children with ADHD, both pediatricians and child psychiatrists agree that pediatricians should treat the disorder.2 Pediatricians play many roles in the treatment of ADHD. In the assessment phase, they determine whether ADHD is present or whether a comprehensive mental health evaluation by a specialist is needed. After a child has received a diagnosis of ADHD, pediatricians serve as educators, counselors, and primary health care providers.

In addition to prescribing medication, they frequently provide detailed ADHD information and parenting advice to parents. For special education plans, schools require the help of a treating clinician to verify the presence of a qualifying medical illness. For many children with ADHD, their pediatrician serves as primary organizer and consultant for their comprehensive treatment plan. In more complex or treatment-resistant cases, pediatricians assist parents in connecting with needed specialists, such as child psychologists, child psychiatrists, psychotherapists, or skills trainers.

PARENTS Keys to obtaining a good family history.
History gathered from a child’s adult caregivers is crucial in ruling out psychosocial or environmental causes of secondary ADHD symptoms. If these causes are not ruled out, disruptive children may receive unnecessary psychotropic medications.

Clearly, ADHD and learning disorders are potentially familial conditions. Thus, it is important to inquire about any family history of these problems.

It is also critical to ask families about routines that involve food and sleep. Children who are not provided breakfast or lunch are likely to focus on their hunger rather than their schoolwork-and to suffer the physiological and cognitive effects of not eating. Although sugary foods have not been shown to cause ADHD, the metabolic effects of glucose fluctuation following boluses of simple carbohydrates may lead to shifts in energy and concentration.

Lack of sufficient sleep is a prevalent cause of academic and behavioral struggles. Thus, it is important to rule out poor regulation of access to computers and television as well as sleep disorders, such as sleep apnea, when evaluating a child with suspected ADHD.

Children may also have difficulty in paying attention at school if they are the target of bullying. Children with ADHD are often socially awkward and reluctant to tell others when they are victimized; thus, parents may need to be coached to query teachers and educational staff if they suspect bullying at school, despite a child’s denial. Bullying may also occur at home between siblings or between a child and a parent, resulting in disruptive behaviors and poor school performance.

Finally, keep in mind that hyperactivity, impulsivity, and inattention symptoms may be the cause of greatly impaired bonding and joy in a family; however, these symptoms may also be the outcome of family turmoil, parental depression, or family trauma. Good family relationships are crucial to a favorable treatment outcome, and left ignored will result in unsuccessful interventions.

Importance of parenting education. A child’s parents or guardians are the most important members of the ADHD treatment team. Education of parents by professionals is the cornerstone of any treatment plan for a child with ADHD. A thorough understanding of ADHD and its treatment enables them to provide an optimal environment at home and to advocate for their child’s educational needs at school. Pediatricians can help dispel common misconceptions, such as the belief that ADHD is caused by eating too much sugar, the concern that drugs used to treat ADHD can have catastrophic long-term consequences, or a lack of awareness of the connection between disruptive behaviors and parenting methods.

Parents as case coordinators. When it comes to the treatment of ADHD, parents and guardians are usually the de facto case coordinators for their child’s care. They must know what their child’s special needs are.

When services at school are needed, parents must know how to request an assessment for an Individualized Education Plan (IEP) or 504 accommodation plan. Parents may also need to coordinate other treatment modalities, such as speech and language therapy, tutoring, occupational therapy, and social skills training. Pediatricians can help parents add appropriate members to a comprehensive treatment team.

TEACHERS AND SCHOOLS

How teacher evaluations help.
A comprehensive ADHD evaluation should include behavioral and academic information from a child’s school. This data may take the form of a completed ADHD rating scale, a phone conversation with school staff, or written notes from the teacher. Information provided by a child’s teacher or school can help in making an accurate diagnosis and in titrating medication dosages.

Although parental history is usually confirmed by observational data from a teacher, this is not always the case. Children with ADHD often perform poorly academically. However, it is not uncommon for a child who is reported to be totally out of control at home to be doing well in school. This may be related to the child’s ability to thrive when provided with appropriate structure-which he or she receives in the classroom but not at home. Conversely, a school may be pressuring a parent to seek an ADHD evaluation because of disruptive behavior in the classroom that a parent does not witness at home. This may represent a situation in which a child with a learning disability exhibits behavioral problems only in the school setting because of the obvious frustration of not being able to follow the process and content of classroom lessons. In cases such as these, it is important to sort out the differences in behavior and assess the role of parental or teaching styles or other factors that may explain them. Obtaining services for children with comorbid learning and language disorders. Comorbid learning and language disorders are found in up to one-third of children with ADHD.

Speech and language disorders and other communication disorders engender low self-esteem, anxiety, and depression. Resulting impairment in social and vocational adaptations is not uncommon and is considered pervasive in this population. The vast majority of pediatric and psychiatric settings do not feature language evaluation services for children and adolescents, and these services are not routinely covered by medical insurance.

The Individuals with Disabilities Education Act (IDEA), which serves infants, children, and adolescents with special needs, is a public law providing a federal statutory structure that distributes federal money to educate children with disabilities through state and local educational agencies. Evaluations and interventions provided under IDEA by default must come under the purview of schools. Schools have thus become a major provider of mental health services for children with ADHD and learning disorders.

Children with ADHD who do poorly in school can access special education services through IDEA, whether or not they have a comorbid learning disorder.3 An IEP for a child with ADHD may include an instructional aide, token economies, social skills training, a class with fewer students, or a self-contained classroom. A child with a 504 accommodation plan usually does not receive extra services but is allowed to take more time to finish tests or projects, is assigned fewer math problems for homework, or is given additional breaks during class when restless.

Pediatricians can assist families with children who have ADHD by providing some basic education regarding IDEA and by providing letters supporting the request for an IEP assessment. Pediatricians may also be asked to complete a checklist form to document the disability or illness that qualifies the child for special services. Pediatricians should coach parents to create a paper trail of IEP evaluation requests and other records documenting school responses.

PSYCHOLOGISTS

Psychologists can assist pediatricians in both the assessment and treatment of children with ADHD.
It is important for referring pediatricians to have knowledge of a psychologist’s training in child psychology. Comprehensive postdoctoral subspecialty training in child psychology is elective. Even though general programs in clinical psychology may expose trainees to cases involving children, full training is preferable, since there are many evaluation and treatment issues that are unique to children and their families.

Role of psychologists in assessment. While no single psychological test is diagnostic for the presence of ADHD, a comprehensive psychological assessment can prove invaluable in creating a comprehensive treatment plan and in advocating for an IEP. A psychologist can help clarify the diagnosis in a child with disruptive behaviors and suspected ADHD. Psychologists are able to detect the presence of co-occurring psychiatric disorders such as oppositional defiant disorder, conduct disorder, anxiety disorders, and mood disorders. In addition, educational psychologists should be able to diagnose the presence of learning disabilities, including auditory and visual information processing disorders, speech and language disorders, disorders of written language, math and reading disorders, and dyslexia.

Psychological testing should be performed if a child’s history suggests low general cognitive ability or low achievement in language and math relative to his or her intellectual ability.4 Pediatricians may use screening instruments to determine whether a child in whom a learning disability is suspected is likely to meet criteria for special education services. Below-average scores on these screening inventories are a firm indicator for comprehensive psychological testing. These screening tests can be used to obtain authorization for psychological testing from insurance companies that require objective data (rather than clinical suspicion).

It is important for children with ADHD symptoms to be assessed for comorbid learning disabilities to ensure that their treatment plan is comprehensive and ultimately effective. Psychologists are able to assess for these special needs and specify which interventions should be part of a comprehensive education plan.

How psychologists can help with treatment. Child psychologists are trained to provide individual therapy for children and adolescents. Individual psychotherapy may be particularly helpful in children with comorbid anxiety or depressive disorders. Successful behavioral interventions in anxious children may obviate the need for medication interventions.

Child psychologists are also expert in providing parental guidance and counseling and family therapy. Providing parent skills training may be the most important role a psychologist fills in the care of an ADHD child. Parents are frequently baffled by the inconsistent behavior of their child with ADHD and may need to learn effective parenting techniques. When basic parent skills training does not result in improved communication patterns and less disruptive behavior, family therapy may be indicated.

Psychologists and pharmacotherapy. There is controversy regarding whether psychologists should make medication recommendations to pediatricians. Although the diagnostic skills of child psychologists are probably greater than those of most pediatricians in the domain of psychiatric disorders, the ability to make specific medication recommendations is in most cases beyond their scope of practice. At the time of this writing, with the exception of those practicing in New Mexico and Louisiana, psychologists in the United States do not have prescription privileges. Although feedback from psychologists about the efficacy of a medication trial is often extremely helpful, medication treatment recommendations should generally not be solicited from them.

Innovative models of psychologist- pediatrician collaboration. Because of the national shortage of child psychiatrists, collaboration between pediatricians and child psychologists is needed in many communities.

The traditional model of a pediatrician referring a patient to a psychologist in another office is associated with many barriers to coordinated care. A current National Institute of Mental Health study5 notes that if a pediatrician wishes to refer a patient with ADHD to a child mental health specialist, many obstacles- including but not limited to stigma, insurance issues, and long waiting lists-often interfere with the patient’s actually receiving services.

This study is examining an innovative model of care in which a child psychologist is located on the premises of a pediatrician’s office and is available to share with the pediatrician the care of patients who have ADHD. Inviting a psychologist into a pediatrician’s office for a consultation day-or an actual office-sharing arrangement- might also be a good solution that could solidify pediatrician- psychologist collaboration.

CHILD PSYCHIATRISTS

Like child psychologists, child psychiatrists can provide diagnostic clarification, diagnosis of comorbid psychiatric disorders, and identification of environmental, psychosocial, and family factors that play significant roles in the clinical presentation of a child with ADHD. In addition, their medical training allows for an integrated consideration of biological factors that may also influence the child’s presentation. This capacity for a “biopsychosocial” view is unique to this subspecialty.

Child psychiatrists can provide the principal ADHD interventions of medication management, skills training for both parents and children, and individual and family therapy. They can be particularly helpful with the treatment of children who are resistant to the usual first-line ADHD medications and who may require treatment with non–FDA-approved agents. For patients with ADHD, seeing a child psychiatrist for treatment has the advantage of obviating the need to see multiple clinicians.

When to enlist a child psychiatrist’s help with diagnosis. Child psychiatrists may assist pediatricians in confirming the diagnosis of ADHD in more ambiguous cases. For example, ADHD without hyperactivity- particularly in girls-is often harder to identify because of the absence of disruptive behaviors. ADHD in teenagers is also sometimes missed, because the level of hypermotor and hyperactive behaviors diminishes as a child gets older.

The identification of environmental and psychodynamic factors that aggravate or stabilize ADHD symptoms is also an integral and important part of a child psychiatric evaluation of hyperactivity and inattention. A child psychiatrist can assess such factors as the amount of structure provided in the home and school (often a critical factor in the level of dysfunction displayed by affected children), whether expectations of the child in the home are realistic, the relationship between the child with ADHD and other siblings, and how the child is treated in school (eg, is he being bullied or excluded?).

Pediatricians are encouraged to seek child psychiatric consultation if a child who initially appeared to have a straightforward case of ADHD does not progress or worsens with medication. In addition, the onset of ADHD symptoms after the age of 5 is suggestive of a confounding primary medical, environmental, or psychological influence. If medical issues have been ruled out, consider a psychiatric consultation.

While there are cases of simple ADHD, ADHD is often comorbid with another psychiatric diagnosis. According to Spencer and colleagues,6 Wilens and colleagues,7 and Faraone and Kunwar,8 it is more common to find children with ADHD and a co-occurring psychiatric disorder than children with ADHD alone. The diagnosis of disorders that are comorbid with ADHD can be difficult because of overlap between the symptoms of ADHD and those of other disorders. For example, impulsivity, hypermotor behavior, and the inability to sustain attention and control behavioral outbursts in response to strong emotions are just a few of the signs and symptoms that are present in both ADHD and mania (bipolar disorder).9

Diagnosing any co-occurring mental illnesses or learning disabilities is a major part of a comprehensive psychiatric evaluation, and pediatricians do well to refer to a child psychiatrist any patient with ADHD in whom they suspect a psychiatric comorbidity.

How child psychiatrists can help with treatment. Most pediatricians feel comfortable with the use of stimulants and atomoxetine, which are considered the first-line treatments for ADHD in various medication algorithms. Pediatricians are usually less confident, however, when other medications are required, and they may want to consult with or refer their patient to a child psychiatrist in such instances. One example of a situation in which a non–FDAapproved medication is required would be that of a child with treatment- resistant ADHD. In such a case, a child psychiatrist would select from a variety of off-label regimens with which he or she was familiar.

Children with ADHD and comorbid diagnoses often need to be treated with more than one psychotropic medication. Child psychiatrists commonly use combinations of stimulants, antidepressants, and antipsychotics in children with multiple co-occurring diagnoses or severe medication resistance, and they are comfortable with the practice. Because of the dearth of research data supporting such “polypharmacy,” this type of treatment is more of an art than a science. When complex medication regimens are needed, an experienced child psychiatrist can prove indispensable.

When children and adolescents with ADHD are in need of hospital or residential levels of psychiatric care, it is important to enlist the help of a child psychiatrist. In addition to providing psychiatric evaluations, medication management, and psychotherapy sessions, child psychiatrists can provide leadership and guidance for the inpatient treatment teams. Common indications for inpatient treatment of children with ADHD include self-injurious behaviors, dangerous physical aggression, and failed outpatient treatment.

Child psychiatrists versus general psychiatrists. Although child psychiatrists are preferred over general psychiatrists for consultation purposes in pediatric populations, general psychiatrists do have some child psychiatry experience. The Accreditation Council for Graduate Medical Education program requirements for residency training specify that residents in psychiatry should have a supervised clinical experience in the assessment, diagnosis, and treatment of child/adolescent outpatients. The American Academy of Child and Adolescent Psychiatry (AACAP) also notes that it is not inappropriate for adolescents 14 years and older to be seen by qualified psychiatrists who do not have child fellowship training. Thus, in the absence of a child psychiatrist, adult psychiatrists may be available who are comfortable receiving referrals of older adolescents from primary care clinicians.

OTHER COLLABORATORS

In addition to psychologists and psychiatrists, other clinicians may also play a role in the assessment and treatment of ADHD.
Psychiatric social workers, master’s level therapists, and bachelor’s level skills trainers can often be invaluable in providing treatment for children with ADHD. These clinicians can provide many evidence-based psychosocial therapies10 that have been shown to be successful in the treatment of ADHD. In many county and community mental health programs, they will make visits to the home when treatment in traditional office settings has not been effective. They can provide parenting skills training for parents and behavior skills training for children and teens with ADHD. In more complex cases, in which skills training has proved unsuccessful, social workers and therapists are often able to help sort out family dynamics that are preventing the child with ADHD from improving. Family therapy is often the key to making progress in such cases.

Speech and language therapists. With as many as 35% of children with ADHD also having a specific learning disorder, collaboration with a speech and language therapist is frequently indicated. Since many children with ADHD tend to have academic difficulties, a concomitant learning disability only contributes to the risk of school failure. Therefore, early intervention should be the goal in any hyperactive preschooler who shows signs of delayed language acquisition. A referral from a child’s pediatrician can speed up the scheduling of an assessment and referral for treatment.

Occupational therapists.
These specialists offer some treatments for ADHD that are not considered standard but that are beginning to show evidence of effectiveness based on case studies. Many children with pervasive developmental disorders and ADHD also have other neurodevelopmental issues. When sensory sensitivities, rigidity, and inflexibility are prominent among these, sensory motor treatment provided by occupational therapists may prove beneficial, reducing the child’s reactivity to environmental stimuli.

Sleep specialists.
In children with attentional problems, sleep apnea or another sleep disorder may be the cause of ADHD-like symptoms.11 Sleep disorders can prevent children from obtaining proper amounts of rest; as a result, their ability to concentrate and pay attention in school may be greatly compromised. Young children, who are at particular risk for adenotonsillar hypertrophy, may present with symptoms that suggest ADHD. Indications for a sleep study in inattentive children include large tonsils, which obstruct the airway in the nasopharynx and can result in loud snoring, and childhood obesity, which may also interfere with normal respiratory function. Sleep disorder specialists are continuing to collect more data regarding these phenomena.

Nurse practitioners.
It is increasingly common for nurse practitioners with special training in psychiatry to meet the needs of communities without enough child psychiatrists. In a recent survey study done in New York by Kaye and colleagues,12 it was found that about half of all mental health agencies surveyed employed nurse practitioners with advanced certification in child and adolescent psychiatry. Most of these agencies had identified a shortage of child and adolescent psychiatrists in their communities, and nurse practitioners were used to improve access to care. This is viewed as a promising strategy for improving access to care in other areas with a shortage of child psychiatrists.

WHEN THERE ARE NO NEARBY COLLABORATORS

For clinicians who like using the Internet and “cyber bulletin boards,” the “Child-Pharm” Google interest group provides an informal place to discuss difficult and challenging cases with sometimes nationally renowned experts in the field. Currently, the Child-Pharm group boasts several hundred members. Primary care clinicians with questions and an interest in pediatric psychopharmacology will find the discussions here salient to their practices.

The Internet also has resources for parents and patients. For example, Children and Adults with Attention- Deficit/Hyperactivity Disorder (CHADD) is a national non-profit organization that provides education, advocacy, and support for persons with ADHD. In addition to maintaining an informative Web site, CHADD also publishes a variety of printed materials to keep members and professionals current on ADHD research advances, medications, and treatments. Other helpful Web sites are listed in the Box.

In addition to Web sites and cyber consultation groups, technology has also made another intervention available in areas where there is a shortage of psychiatrists. For several years it has been possible to increase access to health care through interactive televideo communications. Myers13 and Cain, with the AACAP Work Group on Quality Issues, helped develop a practice parameter for telepsychiatry with children and adolescents; this was published in December 2008. Because psychiatry relies predominantly on conversation and observational skills, telepsychiatry provides a reasonable alternative to the traditional office visit for children and families who cannot readily access psychiatric care. In rural communities across the country where neither child psychologists nor child psychiatrists can be found, telepsychiatry-based treatment programs are being used. The states of Massachusetts, Washington, and Oregon have or are developing collaboration projects to support primary care providers via phone consultation and timely face-to-face evaluations by child psychiatrists. Many programs are showing promise in providing support and training for primary care clinicians at a time of severe shortages in available child mental health services across the country.

Web Sites for Pediatricians and Parents of Children With ADHD

 

Wrights Law (http://www.wrightslaw.com): For parents, educators, advocates, and attorneys; this site provides accurate, reliable information on special education law, education law, and advocacy for children with disabilities.

Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) (http://www.chadd.org): A national non-profit organization working to improve the lives of people affected by ADHD through education, advocacy, and support. (For parents and families.) Children’s Medication Algorithm Project (CMAP) (http://www.dshs.state.tx.us/mhprograms/adhdpage.shtm): Public domain medication algorithms for ADHD with and without comorbid conditions-provided by the State of Texas Department of Health Services.

Child-Pharm Bulletin Board (http://groups.google.com/group/ Child-Pharm?lnk=srg): Child and adolescent psychopharmacology and psychotherapy group for professionals; membership includes child psychiatrists, pediatric neurologists, developmental and behavioral pediatricians, child psychologists, psychiatric nurse practitioners, social workers, and members of related professions.

The REACH Institute (http://www.reachinstitute.net/REACH_training): Founded by CEO Peter Jensen, MD, a world-renowned child psychiatrist and ADHD expert, the REACH Institute has created numerous training opportunities (such as the Mini-Fellowship in Primary Pediatric Psychopharmacology) to help primary care providers reduce inappropriate or unsafe prescribing practices and increase their use of safe and effective approaches to the treatment of psychiatric disorders.

American Academy of Child and Adolescent Psychiatry (http://www.aacap.org/cs/root/facts_for_families/facts_for_families_key word_alphabetical): This Web site offers “Facts for Families”- information on ADHD in both English and Spanish.

University of Buffalo (http://ccf.buffalo.edu/pdf/Medication_Info_Sheet%202008.pdf): A 3-page handout for parents providing detailed descriptions of ADHD medications, including information on lisdexamfetamine and the methylphenidate transdermal system.

References:

REFERENCES: 1. Stein RE, Horwitz SM, Storfer-Isser A, et al. Attention-deficit/hyperactivity disorder: how much responsibility are pediatricians taking? Pediatrics.2009;123:248-255.

2. Heneghan A, Garner AS, Storfer-Isser A, et al. Pediatricians’ role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree? J Dev Behav Pediatr. 2008;29:262-269.

3. Childers A. The Individuals with Disabilities Education Act serving infants, children, and adolescents with special needs. In: Cheng K, Myers K, eds. Child and Adolescent Psychiatry: The Essentials. Baltimore: Lippincott Williams & Wilkins; 2005.

4. Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/ hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46:894-921.

5. Weill Medical College of Cornell University. Pilot Study of Shared Care of ADHD in a Pediatric Clinic: Colocation of a Psychologist as an ADHD Care Manager. NIH Clinical Trials Web site. http://clinicaltrials.gov/ct2/show/NCT00644566. Last updated March 25, 2008. Accessed July 6, 2009.

6. Spencer T, Biederman J, Wilens T. Attention-- deficit/hyperactivity disorder and comorbidity. Pediatr Clin North Am. 1999;46:915-927.

7. Wilens TE, Biederman J, Brown S, et al. Psychiatric comorbidity and functioning in clinically referred preschool children and school-age youths with ADHD. J Am Acad Child Adolesc Psychiatry. 2002;41:262-268.

8. Faraone SV, Kunwar AR. ADHD in Children with Comorbid Conditions: Diagnosis, Misdiagnosis, and Keeping Tabs on Both. Medscape CME Web site. http://cme.medscape.com/viewarticle/555748. Published May 3, 2007. Accessed July 6, 2009.

9. Masi G, Perugi G, Toni C, et al. Attention-deficit hyperactivity disorder-bipolar comorbidity in children and adolescents. Bipolar Disord. 2006;8:373-381.

10. Pelham WE Jr, Fabiano GA. Evidence-based psychosocial treatments for attention-deficit hyperactivity disorder. J Clin Child Adolesc Psychol. 2008; 37:184-214.

11. O’Brien LM, Holbrook CR, Mervis CB, et al. Sleep and neurobehavioral characteristics of 5- to 7- year-old children with parentally reported symptoms of attention-deficit/hyperactivity disorder. Pediatrics. 2003;111:554-563.

12. Kaye L, Warner LA, Lewandowski CA, et al. The role of nurse practitioners in meeting the need for child and adolescent psychiatric services: a statewide survey. J Psychosoc Nurs Ment Health Serv. 2009;47(3):34-40.

13. Myers KM, Valentine JM, Melzer SM. Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents. Psychiatr Serv. 2007; 58:1493-1496.