Not every community has adequate resources to provide assessment and treatment of ADD syndrome for children; most do not yet have any resources for treating adolescents and adults with this disorder. For most families in developing countries and for many even in the more developed countries, access to medical care is extremely limited. Many do not have access to adequately trained physicians for life-threatening medical conditions, let alone services for mental health. Even in communities where psychologists and physicians are available, patients are often put on waiting lists for many months or even years. Moreover, even when accessible, these caregivers may or may not be familiar with current understandings of ADD and its appropriate treatment.
Clinicians tend to interpret each patient's presenting complaints within the framework of diagnoses they know well. If they have been trained to recognize and treat depression and anxiety, but lack adequate training to identify and treat ADHD, clinicians are likely to interpret pa tients' presenting complaints about impaired short-term memory, inattention, disorganization, underachievement, and so on as signs of anxiety or depressive problems. They also are likely to provide treatments appropriate for those disorders without even considering the possibility that these may be symptoms of ADHD, with or without comorbid anxiety or depression.
Even in those communities where physicians and medications are available, such services and medications remain inaccessible to many because of cost. If family members are struggling to pay rent and to put food on the table each day, they are not likely to be able to afford visits to a doctor or medications, especially for a disorder that does not present any immediate, obvious threat to physical health or to life. Even if a family wants very much to provide appropriate treatment for a member with impairments of ADD, the costs may be prohibitive and insurance often does not cover them. Medication costs, especially for the newer, longer-acting formulations, are significant. The expense of consultations with psychologists and physicians for assessment and ongoing treatment can also be substantial. Many families simply cannot afford to begin—or to continue—treatment for ADD syndrome.
When behavioral treatments are added to medication, the costs increase substantially. Peter Jensen (2003) showed that the cost of alleviating impairments of children with ADHD to the point of "normalization" using MTA behavioral treatment alone or in combination with medication management was four times the cost of typical community care. In that study, the most cost-effective treatment for ADHD was careful medication management. (Combined behavioral and medication management treatments were somewhat more cost-effective for children with ADHD and comorbid disorders.)
Many are quick to argue that every patient with ADHD should receive all relevant treatments. Such an outlook makes sense only to those who hold unrealistic views of what professional and financial resources are actually available to most of the world's families. The unfortunate truth is that in many parts of the world at this time, only the most fortunate are likely to have access to appropriate assessment and treatments for ADD.
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