ADHD Parent-Pediatrician Letters to the School: A Family-Centered Medical Home Tool to Improve Collaboration, Grades, and Behavior.

Introduction

Between 15% and 35% of children and adolescents with attention deficit hyperactivity disorder (ADHD) have learning disabilities or behavior disorders as coexisting conditions.[1] Stimulant medication alone will fail to produce optimal improvement at home and school unless combined with academic and behavioral therapies. Parents as well as pediatricians may lack the expertise necessary to successfully advocate for the ADHD child or patient to receive psychological or academic testing and appropriate classroom accommodations. Despite their legal eligibility based on Section 504 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA), students with ADHD may not receive the educational services essential for them to achieve their potential.

Earlier studies have addressed this issue by describing methods to improve interaction between physicians and schools.[2] Subsequent research has suggested an extensive multidisciplinary process to develop community consensus for the accurate diagnosis and comprehensive treatment of ADHD.[3] The recent American Academy of Pediatrics (AAP) classification of ADHD as a chronic condition recommends that the medical home guiding principle of family-centeredness should be followed to promote strong family–school partnerships.[4] Although both the AAP and the National Dissemination Center for Children with Disabilities have endorsed a strategy of letters to the school from the pediatrician and parent to improve collaboration with the school, the format and effectiveness has not been studied.[5,6]

Materials and Methods

A multidisciplinary group of parents, pediatricians, and educators at our institution developed a sequence of 3 letters to the school written by the pediatrician and signed by parent. This first letter provided parental permission to the school to share information with medical personnel, requested completion of an attached Conners 3-Teacher Questionnaire and Academic Rating Scale, and suggested that a student assistance team meeting (SAT) be held as soon as possible (Figure 1). The second letter formally documented the diagnosis of ADHD and requested psychometric testing and appropriate classroom modifications based on educational rights defined by Section 504 or IDEA (Figure 2). A third letter restated the diagnosis and specified a 15-day deadline after which the school board would be notified and legal action taken. All patients referred to our center for evaluation of ADHD from January 2008 through December 2010 participated in the study. Parents were surveyed by telephone at the end of project to assess the effectiveness of the ADHD letter sequence.

Figure 1.

Pediatrician–parent letter to the school: school information/consent form.

Figure 2.

Pediatrician–parent letter to the school: ADHD diagnosis documentation and request for services.

Results

Over the 24-month period, 160 first letters were sent to parents with instructions for completion by the school prior to their child’s first office visit. The teachers of all patients completed the Conners 3-Teacher Questionnaire and Academic Rating Scale but no data were obtained concerning compliance with the request for a SAT meeting. The second letter was given to 84 patients (53%) after stimulant treatment was begun for delivery to the principal and discussion with the teacher. The parents of 41 of the 84 patients (48%) receiving the second letter were contacted by telephone for follow-up information after 4 to 6 months of treatment. There were 35 males (89%) and 6 females (15%), with 20 (49%) in high school, 14 (34%) in middle school, and 7 (17%) in elementary school. The third letter was requested by only 2 parents who were unavailable for follow-up.

Of the 41 parents interviewed, 71% reported improved communication and collaboration with the school while 29% noted no change. Seventy-six percent of respondents had a face-to-face meeting with school personnel, including the school counselor or psychologist in 46%. Fifty-six percent received a classroom change, resulting in an improvement in grades or behavior. Modifications obtained included adding resource teachers, aides, or tutors; providing organizational strategies, extra time, or study breaks; and allowing for seating adjustments, oral tests or retesting, exercise periods, and an extra set of books at home.

Discussion

The difficulties inherent in physician–parent–school communication and collaboration have been recognized as one of the major barriers limiting the implementation of the AAP published ADHD diagnostic and treatment guidelines for primary care providers.[7] The 2011 revised clinical practice guidelines for ADHD recommend that the principles of the medical home model be followed to provide care that is accessible, continuous, coordinated, family centered, comprehensive, compassionate, and culturally competent.[8] One study has demonstrated that children with ADHD who receive treatment in a parent-centered medical home have fewer missed days and decreased school initiated contact with parents for behavior or academic problems.[9]

The AAP guidelines further state that schools can and should provide classroom adaptations and coordinate behavior therapy programs for children with ADHD under the “other health impairment” of the IDEA or Section 504 when the condition substantially limits “reading, concentration, thinking, or communication with others.” The process of obtaining these critical resources is initiated when the physician, with the approval from the family, informs the school of the diagnosis and treatment.

Shared decision-making is a key medical home component to build productive interactions between motivated, informed families and prepared proactive physicians.[10] Written communication is the most common strategy described in the limited research on improving physicians–parent–school collaboration. The ADHD Resource Toolkit for Clinicians in 2002 provided templates adapted from the San Diego Learning Disabilities Association of 2 sample letters from the parent to the school signed by the doctor requesting assessment for educational services. Curiously, these letters were not included in the 2012 2nd Edition Toolkit.

We developed a 2-part ADHD parent–pediatrician letter to request information, document the diagnosis, and suggest academic and behavior accommodations. The majority of respondents obtained a meeting with key school personnel and received a classroom adaptation that resulted in an improvement in grades and behavior. The letters continue to be in daily use and are particularly valuable at the start of a new school year, transition to a different school, or when modifications are ineffective or nonexistent. Parents are encouraged to individualize their letters by adding their specific requests for modifications for review with administrators and teachers. The letters are useful addition to the toolbox for implementation of the AAP ADHD clinical practice guidelines promoting shared decision making in the patient-centered medical home model.