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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.

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Adhd assessment and treatment in primary care

ADHD Assessment and Treatment in Primary Care

BHC Outreach Meeting

December 10, 2004


Overview
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
Current Affairs

  • Majority of health care visits for mental health are to primary care (60%).


Current affairs1
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 affairs2
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 affairs3
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
Current AffairsCopeland, 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 19871
Current AffairsCopeland, 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 affairs4
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 affairs5
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 physicians
Information for Physicians

What 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 physicians national institutes of health consensus statement
Information for PhysiciansNational Institutes of HealthConsensus 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 physicians national institutes of health consensus statement1
Information for PhysiciansNational Institutes of HealthConsensus 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 physicians national institutes of health consensus statement2
Information for PhysiciansNational Institutes of HealthConsensus Statement

Cons

  • Long.

  • Non-specific and at times “says nothing.”

  • On the verge of being out-dated.


Information for physicians aap clinical practice guidelines
Information for PhysiciansAAP Clinical Practice Guidelines

  • Diagnosis and Evaluation

  • Treatment


Information for physicians aap clinical practice guidelines1
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 physicians aap clinical practice guidelines2
Information for PhysiciansAAP Clinical Practice Guidelines

Diagnosis and Evaluation

1. 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 physicians aap clinical practice guidelines3
Information for PhysiciansAAP Clinical Practice Guidelines

Diagnosis and Evaluation

1. 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 physicians aap clinical practice guidelines4
Information for PhysiciansAAP Clinical Practice Guidelines

Diagnosis and Evaluation

1. 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 physicians aap clinical practice guidelines5
Information for PhysiciansAAP Clinical Practice Guidelines

Diagnosis and Evaluation

1. 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 physicians aap clinical practice guidelines6
Information for PhysiciansAAP Clinical Practice Guidelines

Diagnosis and Evaluation

1. 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 physicians aap clinical practice guidelines7
Information for PhysiciansAAP Clinical Practice Guidelines

Treatment

1. Establish management program recognizing ADHD as chronic condition (evidence: good; recommendation, strong).


Information for physicians aap clinical practice guidelines8
Information for PhysiciansAAP Clinical Practice Guidelines

Treatment

1. 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 physicians aap clinical practice guidelines9
Information for PhysiciansAAP Clinical Practice Guidelines

Treatment

1. 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 physicians aap clinical practice guidelines10
Information for PhysiciansAAP Clinical Practice Guidelines

Treatment

1. 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 physicians aap clinical practice guidelines11
Information for PhysiciansAAP Clinical Practice Guidelines

Treatment

1. 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
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 clinicians1
AAP Resource Toolkit for Clinicians

Contents

  • 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 clinicians2
AAP Resource Toolkit for Clinicians

Contents

2) Treatment

  • ADHD Management Plan

  • Establish a Home School Note

  • Stimulant Medication Management Information


Aap resource toolkit for clinicians3
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 clinicians4
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
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


Role of behavioral health specialist assessment the bhc protocol1
Role of Behavioral Health Specialist:Assessment: The BHC Protocol

  • Clinical interview.

  • School records.


Role of behavioral health specialist treatment
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
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
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 protocol1
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

Assessment Protocol


Implementation of an adhd assessment protocol2
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 protocol3
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 protocol4
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 protocol5
Implementation of an ADHD Assessment Protocol

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

  • Research still needed

    • Diagnostic decision making

    • Patient outcomes


Research questions treatment
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?


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