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ADHD Assessment and Treatment in Primary Care: Overview, Current State, and Future Research

This outreach meeting highlights the current state of ADHD assessment and treatment in primary care, including information and education for physicians, the role of behavioral health specialists, assessment methods, treatment recommendations, and research on implementation. The meeting also identifies future research questions and discusses the major increase in attentional problems in primary care since 1979.

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ADHD Assessment and Treatment in Primary Care: Overview, Current State, and Future Research

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  1. ADHD Assessment and Treatment in Primary Care BHC Outreach Meeting December 10, 2004

  2. Overview • Current State of Affairs • Information and Education for Physicians • Role of Behavioral Health Specialist • Assessment • Treatment • Current Research on Implementation • Future Research Questions

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

  4. 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.

  5. 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.

  6. 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.

  7. 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

  8. 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

  9. 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)

  10. 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.

  11. 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

  12. 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.

  13. 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).

  14. Information for PhysiciansNational Institutes of HealthConsensus Statement Cons • Long. • Non-specific and at times “says nothing.” • On the verge of being out-dated.

  15. Information for PhysiciansAAP Clinical Practice Guidelines • Diagnosis and Evaluation • Treatment

  16. 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).

  17. 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).

  18. 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).

  19. 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).

  20. 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).

  21. 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).

  22. Information for PhysiciansAAP Clinical Practice Guidelines Treatment 1. Establish management program recognizing ADHD as chronic condition (evidence: good; recommendation, strong).

  23. 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).

  24. 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).

  25. 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).

  26. 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).

  27. 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

  28. 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

  29. AAP Resource Toolkit for Clinicians Contents 2) Treatment • ADHD Management Plan • Establish a Home School Note • Stimulant Medication Management Information

  30. 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

  31. 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

  32. 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.

  33. 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

  34. Role of Behavioral Health Specialist:Assessment: The BHC Protocol • Clinical interview. • School records.

  35. 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.

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