Transcript ADHD Assessment and Treatment in Primary Care

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?
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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 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
• 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 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 Statement
Cons
• Long.
• Non-specific and at times “says nothing.”
• On the verge of being out-dated.
Information for Physicians
AAP Clinical Practice Guidelines
• Diagnosis and Evaluation
• Treatment
Information for Physicians
AAP 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 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 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 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 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 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 Guidelines
Treatment
1. Establish management program
recognizing ADHD as chronic condition
(evidence: good; recommendation, strong).
Information for Physicians
AAP 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 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 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 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
• 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
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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?