adhd assessment and treatment in primary care
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ADHD Assessment and Treatment in Primary Care. Jodi Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute University of Nebraska Medical Center. Overview. Current State of Affairs Information and Education for Physicians Role of Behavioral Health Specialist Assessment - PowerPoint PPT PresentationTRANSCRIPT
ADHD Assessment and Treatment in Primary Care
Jodi Polaha, Ph.D.Assistant Professor, Pediatrics
Munroe-Meyer InstituteUniversity of Nebraska Medical Center
Overview
• Current State of Affairs• Information and Education for Physicians• Role of Behavioral Health Specialist
– Assessment – Treatment
• Research Questions
Current Affairs
• Majority of health care visits for mental health are to primary care (60%).
Current Affairs
• Majority of health care visits for mental health are to primary care (60%).
• “Attentional problems” greatest increase of all mental health problems in PC since 1979.
Current Affairs
• Majority of health care visits for mental health are to primary care (60%).
• “Attentional problems” greatest increase of all mental health problems in PC since 1979.
• ADHD diagnosis a 2.3-fold increase in population-adjusted rate from 1990-95.
Current Affairs
• Majority of health care visits for mental health are to primary care (60%).
• “Attentional problems” greatest increase of all mental health problems in PC since 1979.
• ADHD diagnosis a 2.3-fold increase in population-adjusted rate from 1990-95.
• Children with ADHD use primary care more, cost more.
Current Affairs Copeland, Wolraich, Lindgren, Milich, & Woolson, 1987
How is diagnosis made?• 79% “activity in office” • 47% “neurologic soft signs”• 33% “aggressive/antisocial activity”• 58% parent rating scales, 62% teacher rating scales• 77% stimulant response
Current Affairs Copeland, Wolraich, Lindgren, Milich, & Woolson, 1987
What treatment recommendations are made?• 84% use stimulants moderately - frequently
– 73% get parent report for periodic re-evaluation– 56% get teacher ratings for periodic re-evaluation– 33% treat preschoolers
• 70% behavior modification • other therapies rarely recommended• 26% never refer to mental health clinics
Current Affairs What treatment recommendations are made?• In pediatric visits, when meds prescribed, counseling
offered in 68% cases.– Hoagwood, Jensen, Feil, Vitiello, & Bhatara, 2000
• 50% physicians surveyed referred to mental health professionals.– Jensen, Xenakis, Shervette, & Bain, 1989.
• In children with ADHD under 3y.o., 57% received stimulants, but fewer psych services.– Rappley, et. al (1999)
Current Affairs
What treatment recommendations are made?• No indication that ADHD is overdiagnosed or that stimulant
medications are overprescribed (Safer, Zito, & Fine, 1996)• Goldman et al. (1998): review of literature shows % prescribed
ritalin at lower end of prevalence range.• Jensen et al. (1999): epidemiological study showed 12.5% of
those meeting criteria were treated with medication in last 12 mos.
Information for PhysiciansWhat information is available?• NIH Consensus Statement on ADHD• AAP Clinical Practice Guidelines
– Prevalence and Assessment– Diagnosis and Evaluation– Treatment
• AACAP Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with ADHD.
Information for PhysiciansNational Institutes of Health
Consensus Statement• Developed in 1998• 13-member panel with expertise in wide
variety of disciplines.• 31 speakers all “experts” on different
topics, 30 minutes to present.• Some opportunity for public debate of
consensus draft.
Information for PhysiciansNational Institutes of Health
Consensus StatementPros• Points out lack of data for alternative treatments
(including CBT) and support for drug and behavior therapy (p. 11).
• Describes limits to medication therapy (p. 13).• Discusses difficulties of making accurate
diagnosis/referral to mental health in primary care settings and why that’s a problem (p. 15).
Information for PhysiciansNational Institutes of Health
Consensus StatementCons• Long.• Non-specific and at times “says nothing.”• On the verge of being out-dated.
Information for PhysiciansAAP Clinical Practice Guidelines
• Diagnosis and Evaluation• Treatment
Information for PhysiciansAAP Clinical Practice Guidelines
Diagnosis and Evaluation1. Kids who present with symptoms should
be evaluated for ADHD (strength of evidence: good; strength of recommendation: strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Diagnosis and Evaluation1. Kids who present with symptoms should be evaluated for ADHD.
2. The diagnosis of ADHD requires that a child meet DSM-IV criteria (strength of evidence: good; strength of recommendation, strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Diagnosis and Evaluation1. Kids who present with symptoms should be evaluated for ADHD.2. The diagnosis of ADHD requires that a child meet DSM-IV criteria.
3. Assessment requires direct evidence from parents regarding core symptoms, duration, and degree of impairment (evidence: good; recommendation, strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Diagnosis and Evaluation1. Kids who present with symptoms should be evaluated for ADHD.2. The diagnosis of ADHD requires that a child meet DSM-IV criteria.3. Assessment requires direct evidence from parents regarding core
symptoms, duration, and degree of impairment.
4. Assessment requires direct evidence from teachers as above plus a review of school records (evidence: good, recommendation: strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Diagnosis and Evaluation1. Kids who present with symptoms should be evaluated for ADHD.2. The diagnosis of ADHD requires that a child meet DSM-IV criteria.3. Assessment requires direct evidence from parents regarding core
symptoms, duration, and degree of impairment.4. Assessment requires direct evidence from teachers as above plus a
review of school records.
5. Assess for coexisting conditions (evidence: strong, recommendation: strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Diagnosis and Evaluation1. Kids who present with symptoms should be evaluated for ADHD.2. The diagnosis of ADHD requires that a child meet DSM-IV criteria.3. Assessment requires direct evidence from parents regarding core symptoms,
duration, and degree of impairment.4. Assessment requires direct evidence from teachers as above plus a review of
school records.5. Assess for coexisting conditions.
6. Other diagnostic tests not indicated to establish diagnosis (evidence: strong, recommendation: strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Treatment1. Establish management program
recognizing ADHD as chronic condition (evidence: good; recommendation, strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Treatment1. Establish management program recognizing ADHD as chronic
condition.
2. Treating clinician, parents, child and school should specify appropriate target outcomes to guide treatment (evidence: good; recommendation: strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Treatment1. Establish management program recognizing ADHD as chronic
condition.2. Treating clinician, parents, child and school should specify appropriate
target outcomes to guide treatment.
3. Clinician should recommend medication (evidence: good) and /or behavior therapy (evidence: fair) to improve outcomes (recommendation: strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Treatment1. Establish management program recognizing ADHD as chronic condition.2. Treating clinician, parents, child and school should specify appropriate
target outcomes to guide treatment.3. Clinician should recommend medication and /or behavior therapy to
improve outcomes.
4. When outcome has not met targeted goal, clinician should re-evaluate diagnosis, treatments, adherence,and coexisting problems (evidence: weak; recommendation: strong).
Information for PhysiciansAAP Clinical Practice Guidelines
Treatment1. Establish management program recognizing ADHD as chronic condition.2. Treating clinician, parents, child and school should specify appropriate target
outcomes to guide treatment.3. Clinician should recommend medication and /or behavior therapy to improve
outcomes.4. When outcome has not met targeted goal, clinician should re-evaluate
diagnosis, treatments, adherence,and coexisting problems.
5. Clinician should systematically follow-up with parents, teacher and child (evidence: fair; recommendation, strong).
Role of Behavioral Health Specialist: Assessment
• Educate.• Familiarize with norm-referenced,
empirically-supported rating scales and encourage use.
• Take on ADHD assessment cases, OR, set up protocol for practice.
• Provide consultative assistance.
Role of Behavioral Health Specialist: Assessment: The BHC Protocol
Parent Ratings• BASC• Conners• ADHD-IV/DBD
Checklist• Measure of adaptive
functioning• ECBI
Teacher Ratings• BASC• Conners• ADHD-IV/DBD
Checklist• Measure of adaptive
functioning
Role of Behavioral Health Specialist: Assessment: The BHC Protocol
• Clinical interview.• School records.
Role of Behavioral Health Specialist:Treatment
• In-house behavioral interventions with family.
• School-based consultation and behavioral intervention development.
• Assessment of progress toward goals including response to drug therapy and behavioral interventions.
Research Questions:Assessment
• What are actual current practices? How are they in line with AAP Guidelines?
• Can a protocol be developed for assessment of ADHD in primary care that is effective but efficient? How does it improve accuracy of diagnoses?
• What is the smallest protocol that can be used?
Research Questions:Treatment
• What are actual current practices? How are they in line with AAP Guidelines?
• What is the best, most practical way of providing feedback re: medication effectiveness for titration?
• How does in-house behavioral services and collaboration with schools improve care?