ADHD Assessment and Treatment in Primary Care

BHC Outreach Meeting

December 10, 2004

Overview

• Current State of Affairs

• Information and Education for Physicians

• Role of Behavioral Health Specialist– Assessment – Treatment

• Current Research on Implementation

• Future 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

• American Academy of Pediatrics Resource Toolkit for Clinicians

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 Statement

Pros

• 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 Statement

Cons

• 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 Evaluation

1. 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

Treatment

1. 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).

AAP Resource Toolkit for Clinicians

• Developed by AAP to assist clinicians in providing care for children with ADHD

• Rooted in the evidence-based AAP guidelines for diagnosis and treatment of ADHD

• Goal: encourage multidisciplinary collaboration

AAP Resource Toolkit for Clinicians

Contents

1) Diagnostic tools– NICHQ ADHD Primary Care Initial

Evaluation form– The NICHQ Vanderbilt Parent and Teacher

Assessments Scales– Cover Letter to Teachers

AAP Resource Toolkit for Clinicians

Contents

2) Treatment – ADHD Management Plan– Establish a Home School Note– Stimulant Medication Management Information

AAP Resource Toolkit for Clinicians

Contents

3) Parent Information and Support– Handouts for Parents

• E.g., Does my child have ADHD?, Homework Tips for Parents, Educational Rights for children with ADHD

AAP Resource Toolkit for Clinicians

Contents

4) Resources– ADHD Coding Fact Sheet for Primary Care

Physicians– ADHD Encounter Form– Documentation for Reimbursement– ADHD Resources Available on the Internet

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?

Implementation of an ADHD Assessment Protocol

Polaha, Cooper, Meadows, & Kratochvil (in press)

• Purpose– To implement an assessment protocol for

diagnosing ADHD in rural primary care– Provide an efficient way for pediatricians to use

the AAP guidelines for ADHD

Implementation of an ADHD Assessment Protocol

Polaha, Cooper, Meadows, & Kratochvil (in press)• Method

– Primary care staff at two sites were trained to use the ADHD assessment protocol (e.g., physicians nurses, etc.)

– Medical records examined for use of ADHD procedures 1-2 years prior to study

– Medical records examined after induction of assessment protocol to determine compliance with AAP guidelines

– 1/3 of all assessment measures were recoded for accuracy of scoring

Assessment Protocol

Parent Ratings• Child Behavior

Checklist (CBCL)• Conners• ADHD-IV/DBD

Checklist• ECBI

Teacher Ratings• Teacher Report Form

(TRF)• Conners• ADHD-IV/DBD

Checklist

Implementation of an ADHD Assessment Protocol

Polaha, Cooper, Meadows, & Kratochvil (in press)

• Results (Prior to implementation)– Neither site used comprehensive assessment

collection prior to implementation of AAP guidelines and the assessment protocol

– Parent and/or teacher data collected on 0-21% of all cases

Implementation of an ADHD Assessment Protocol

Polaha, Cooper, Meadows, & Kratochvil (in press)• Results (After protocol implementation)

– After provided with training and appropriate assessment materials, collection of assessment data increased dramatically

– Parent and/or teacher data was collected 88-100% of the time

– Accuracy in scoring measures

– Use of the protocol was maintained at 2-3 years

Implementation of an ADHD Assessment Protocol

Polaha, Cooper, Meadows, & Kratochvil (in press)

• Conclusions– Effective and efficient systematic way to collect

ADHD information in both rural pediatric practices

– Reliability of scoring high

Implementation of an ADHD Assessment Protocol

Polaha, Cooper, Meadows, & Kratochvil (in press)

• Research still needed– Diagnostic decision making– Patient outcomes

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?