ADHD Assessment and Treatment in Primary Care

1
ADHD Assessment and Treatment in Primary Care

• Jodi Polaha, Ph.D.
• Assistant Professor, Pediatrics
• Munroe-Meyer Institute
• University of Nebraska Medical Center

2
Overview

• Current State of Affairs
• Information and Education for Physicians
• Role of Behavioral Health Specialist
• Assessment
• Treatment
• 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 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

8
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

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.

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 thats 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
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.

28
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

29
Role of Behavioral Health Specialist Assessment
The BHC Protocol

• Clinical interview.
• School records.

30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
Role of Behavioral Health SpecialistTreatment

• 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.

44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
Research QuestionsAssessment

• 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?

49
Research QuestionsTreatment

• 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?