Medical Record Review
Staying Focused: Documenting the Management of a Child Who Has an Attentional Disorder
Editors: Lawrence F. Nazarian, MD.
The Guide for Record Review prepared by the American Board of Pediatrics that accompanies this issue of Pediatrics in Review deals with attention deficit hyperactivity disorder.
The emphasis of the guidebook and of this section of the journal is on the proper recording in the medical record of the steps taken by the pediatrician to diagnose and treat patients who have this disorder. Comprehensive reviews of attentional disorders are available (PIR. 1993;14:455-464; PIR. 1994;15:5-14.)
The terms attentional disorder (AD) and attention deficit disorder (ADD) are used to describe children whose problems revolve around paying attention, focusing, and staying on task. If there is an element of hyperactivity, as is the case in the majority of these patients, the term attention deficit hyperactivity disorder (ADHD) is used. Formal criteria for making these diagnoses are found in the guidebook and the references. Many children who have AD will have a concomitant learning disability (LD). A significant number of these patients will have emotional problems, often as a result of the academic and social failure resulting from AD and LD.
The pediatrician helping a child suspected of having AD must define, as precisely as possible, what that child's problems are and whether he or she fulfills the criteria for inclusion in any of the categories of this constellation of disorders.
