How to Find the Right Psychiatrist for your Anxious ADHD Child

One of the most important decisions in supporting a child with ADHD (Attention Deficit Hyperactivity Disorder) and/or anxiety is selecting your child’s psychiatrist. Just as ADHD and anxiety presentations vary, so do capabilities of doctors who treat them. The right psychiatrist can make the difference between success and struggle.

As a preliminary, it helps to gauge the seriousness of your child’s condition. Here are some basic examples:

• ADHD is diagnosed, but interventions such as psychotherapy and school supports without medicine may be sufficient.
• Medicine is needed and your child is responsive to first line medications without unmanageable side effects.
• Medicine is needed, but your child is unresponsive to and/or has side effects from first line medications.
• Medicine is needed, but severity and/or comorbidity of your child’s conditions complicate treatment, and first and second line medications have been ineffective or produce unsustainable side effects.

As a corollary to the different kinds of ADHD/anxiety cases, here are some kinds of prescribers who may treat your child:

• Child psychiatrists and other caregivers such as pediatricians and nurse practitioners who are able to prescribe long-established first line medications such as Ritalin (Methylphenidate), Adderall (Amphetamine/dextroamphetamine), and Intuniv (Guanfacine)—I am using the non-generic brand names first since they may sound more familiar.
• Child psychiatrists specializing in ADHD/anxiety who are familiar with and comfortable prescribing newer and more specialized stimulant and non-stimulant ADHD medications, first-line pediatric anxiety medications such as SSRI’s, as well as some drugs that are used “off label.” “Off label” means they are approved by the U.S. Federal Drug Administration (FDA), but not for the condition they are being prescribed for. Physicians may prescribe off label when research shows that the medication may help the patient.
• Child psychiatrists specializing in the most challenging ADHD/anxiety cases, including treatment resistance to first and second line medications, or presenting with other mental health and behavioral issues. These doctors should have experience prescribing medications from the full range of medicine classes potentially benefiting the patient, including antipsychotics, tricyclic anti-depressants, anti-convulsants, and benzodiazepines. These medications may be third, fourth, or even fifth-line interventions for the underlying conditions, some of which have significant risks such as severe weight gain (anti-psychotics and tricyclic antidepressants) or addiction (benzodiazepines). Doctors at this proficiency level identify cases where the potential reward of these medications justifies the risks, and follow best practices for prescribing them. Children who may benefit for this level of treatment include cases that have deteriorated to where the child can no longer normally attend school, or behavioral implications of treatment resistance jeopardize the child’s ability to live safely at home.

This is not a comprehensive list—there are other kinds of prescribers such as developmental pediatricians who specialize in treating ADHD, anxiety, and other conditions—but it gives a sense of the range of specialities in play. With that, here are traits that are desirable, compared with traits that may be red flags:

• Psychiatrists who give parents a balanced read on the degree to which using medication is warranted, as opposed to doctors who too hastily prescribe in mild or borderline cases before non-prescription interventions such as psychotherapy and school supports are tried.
• Psychiatrists who make therapeutic recommendations but ultimately respect parents’ choices for related treatments, such as choice of therapists. This is as opposed to doctors who overreach in pressing for a therapist with a certain level or expertise or reputation, even to the point of slow-rolling or declining to move forward on trying different medications until the family has made a change.
• Psychiatrists who may make useful educational suggestions but ultimately respect parents’ school choice, including respecting financial, logistical, or other practical limitations. This is as opposed to doctors who pressure families to enroll their child in a particular school, or offer biased general admonitions like a child will benefit from private school. While doctors may have useful insight into local schools through their practice, doctors are not educational consultants or financial advisors.
• Psychiatrists who will straightforwardly advise a family if the level of care may be beyond their ability because they lack experience or training to prescribe medications the patient may need, so that a new provider should be sought for a second opinion or to take over the case. This is opposed to doctors who will not acknowledge their limitations and decline to provide further options. The latter may surface as undue pressure to the family to make other changes, such as replacing the therapist or changing schools.

Now with more of a sense of the kind of doctor who would be the right fit, how do you find that practitioner? Families often find new doctors through referrals, though that is not always successful. Here are some ways to dig deeper:

• Ask other professionals you use to support your child, such as your educational consultant or education lawyer, who may be able to provide feedback on a psychiatrist you are considering, or who may be a good fit for you.
• Request a brief 15 minute uncharged call with a prospective provider to get a mutual sense of whether the case could be a good fit or not.
• Ask direct questions to ascertain whether the doctor can provide the level of care you believe your child may need. For example, if you have been doing your own research and read a medical journal article indicating that a child with a presentation like yours may benefit from a particular class of medication, ask the doctor if they would be able to prescribe that kind of medication in an appropriate case. A reply that they would never prescribe that medication, or that they would refer the family to another doctor for the prescription, may indicate limitations in their ability to help your child.
• Arrange an initial evaluation with two psychiatrists over the same period. This will give you greater assurance in asking direct questions since you already have a potential back up plan. It will also make you more comfortable monitoring for red flags, such as doctors with rigid expectations like expecting the family will consider transferring the child to particular private schools.
• Ask your health insurance company. Insurance companies may have case managers for complex cases, including mental health. Whatever issues you may have had with your insurance company, there are strong business reasons for insurance companies to held their insured families. If a case declines to a point where the child needs major care, such as psychiatric hospitalization or residential placement, the insurance company can also end up paying big time, so the company has an incentive for the family to find effective outpatient treatment. Case managers for major insurance companies who see the most complex cases may have considerable insight into various local providers, including psychiatrists, therapists, intensive outpatient programs, schools, and alternative therapies, both in and out of network. It may help to call your insurance company’s customer service and ask them if there is a mental health case manager you can speak with for help finding a provider.

The last point intersects with an important practical question families often face: whether to use an in or out of network doctor. The degree to which insurance will reimburse for using an out-of-network doctor—if at all—varies widely by policy, and out-of-network fees vary considerably by locality and provider. In addressing this question, it is vital to stick to facts, e.g., who is the best doctor for your child and what is the real cost difference. Families may hear biased admonitions like “all the best mental health providers are out of network.” This kind of generalization ignores that there are many reasons unconnected with care quality why a fitting practitioner may be found in network. Optimally, a family will be able to afford the doctor who turns out to be the best fit for their child regardless of insurance status. Some families may even want to schedule initial evaluations with both an in and out of network provider, which due to low in-network insurance co-pays may be only marginally more than doing a single out of network evaluation. But a family who can’t afford to go out of network doctor shouldn’t assume they won’t find a great doctor—that will ultimately turn on the strength of their insurance carrier’s local network and the family’s resourcefulness in searching.

This may sound like a lot to do to hire a single doctor, but when you think about what’s at stake for your child’s future it can be well worth the effort.