Article

Sharing of ADHD Information between Parents and Teachers Using an EHR-Linked Application

Authors:
  • The Children's Hospital of Philadelphia
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Background Appropriate management of attention-deficit/hyperactivity disorder (ADHD) involves parents, clinicians, and teachers. Fragmentation of interventions between different settings can lead to suboptimal care and outcomes. Electronic systems can bridge gaps across settings. Our institution developed an email-based software to collect ADHD information from parents and teachers, which delivered data directly to the clinician within the electronic health record (EHR). Objective We sought to adapt our institution's existing EHR-linked system for ADHD symptom monitoring to support communication between parents and teachers and then to assess child characteristics associated with sharing of ADHD information. Methods We updated our software to support automated sharing of ADHD information between parents and teachers. Sharing was optional for parents but obligatory for teachers. We conducted a retrospective cohort study involving 590 patients at 31 primary care sites to evaluate a system for sharing of ADHD-specific health information between parents and teachers. We used multivariable logistic regression to estimate associations between child characteristics and parental sharing. We further investigated the association between child characteristics and viewing of survey results delivered through the electronic communication system. Results Most parents (64%) elected to share survey results with teachers at the first opportunity and the vast majority (80%) elected to share all possible information. Parents who elected to share usually continue sharing at subsequent opportunities (89%). Younger child age and performance impairments were associated with increased likelihood of sharing. However, parents viewed only 16% of teacher submitted surveys and teachers only viewed 30% of surveys shared by parents. Conclusion This study demonstrates that electronic systems to capture ADHD information from parents and teachers can be adapted to support communication between them, and that parents are amenable to sharing ADHD information with teachers. However, strategies are needed to encourage viewing of shared information.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Although professionals from both health care and education are central to the treatment of children and youth with ADHD, there has been surprisingly limited communication and collaboration between professionals in the two systems (Guevara et al., 2005;Power et al., 2013). This pattern persists despite the finding that health care providers, parents, and teachers willingly share information about a given child's care when they have a method for doing so (Michel et al., 2018). In fact, there remain persistent barriers to effective collaboration among professionals from the education and health care systems, including (a) administrative and fiscal barriers, including time for collaboration, (b) conceptual and linguistic differences between professionals' training and practice, (c) differences in expectations for collaboration held by health care providers and educators, (d) limitations to collaboration associated with one's role in a given system, (e) absence of specific processes to coordinate care, (f) barriers associated with privacy laws in health care (Health Information Portability and Accountability Act, HIPAA) and education (Family Educational Rights and Privacy Act, FERPA), (g) lack of continuity in care for youth from year to year, and (h) lack of resources in some low-income communities and schools (Power et al., 2013). ...
... This allows family members to become team members in the management of a child's ADHD. To improve communication and collaboration between professionals in health care and education and facilitate the use of evidencebased assessment and intervention across home and school contexts, Power and colleagues developed and refined the ADHD Care Assistant (Michel et al., 2018;Power et al., 2016). Other electronic systems exist, but they are not directly linked to the health care electronic system (Epstein et al., 2013). ...
... The ADHD Care Assistant has four distinct features: (a) an electronic survey designed to collect data from parents and teachers, (b) a module visible to providers and integrated into the electronic health record (EHR) system, (c) a web service design to facilitate communication between the shared data and the EHR, and (d) an e-mail-based platform for sharing data between parents and teachers (Michel et al., 2018;Power et al., 2016). One of the particular benefits of the ADHD Care Assistant is the opportunity it affords parents to select preferred treatments for the child, including medication and/or behavior therapy, and to share data among members of the health care team and with the child's teachers. ...
Article
Full-text available
Attention Deficit Hyperactivity Disorder (ADHD) is among the most commonly diagnosed disorders of children and youth. Young people receive their ADHD diagnoses and medical treatment in primary health care settings and can experience a range of behavioral and educational disabilities treated in the clinic, at home, and at school. We propose a Team-Based Collaborative Care Model (TBCCM) to foster communication and collaboration among health care and education teams, embedding implementation science methods to promote and sustain evidence-based practices for youth with ADHD. Key features of the model include: (a) effective leadership and teamwork within the two universal systems of education and health care; (b) use of data from multiple informants who describe and monitor student behavior within and across contexts; and (c) adoption and adaptation of evidence-based practices. We expect that these efforts to embed implementation science methods within a collaborative team structure will improve the uptake of evidence by intervention teams in the two systems, and thus optimize outcomes for children and youth with ADHD.
... This intervention improved open sharing of information www.jaacap.com/content/connect between involved parties regarding children's ADHD symptoms and overall functioning. 11 Barriers to integrated school services are similar to those limiting access to child psychiatry services at large. The ongoing national shortage of child psychiatrists and therapists makes it difficult to find providers to staff integrated programs for both in-person and telepsychiatry services. ...
... Even if families provide dual consent for release of information between schools and mental health providers under HIPAA and FERPA (as was done in the CHOP EHR-school communication tool study), large-scale collaboration between the educational and mental health systems may only be possible if elements of HIPAA and FERPA are legally revised to facilitate easier sharing of health care records and educational records without compromising patient and student privacy. 11,13 The interface of these two legal frameworks has produced communication barriers at the K-12 and higher education levels and remains an ongoing challenge for educators, administrators and health care professionals. ...
Article
Full-text available
As former public school teachers now in child psychiatry training and practice, we continue to be struck by the disconnect between the K-12 education system and psychiatric care. As teachers, we often felt unsupported by the medical community, and now as physicians we struggle to negotiate appropriate roles as collaborators with schools. Constraints on funding, time, and privacy often limit the expansion of mental health competency training for teachers and clinical services in schools. Under-resourced communities are particularly vulnerable to these barriers to mental health care. As local experts, psychiatrists can partner with schools to improve teacher competence and strengthen referral networks.
... Previous research also highlights the importance of engaging rural parents and school stakeholders when assessment tools for ADHD are incorporated into the EHR because findings suggest even when these tools are available and used to complete behavior ratings, parents and teachers may not view them often without additional implementation strategies in place. 37 We also identified factors to consider when planning and implementing research and quality improvement efforts with the pediatric ADHD population in this health system; these are summarized corresponding to the PRISM 23 in Figure 2. The high proportion of engagement from clinics and providers eligible to participate in the broader study indicates potential for high levels of engagement with intervention efforts and suggests high potential for broad reach of the innovations to be tested if targeted appropriately on constraining factors to high-quality care. PCC reasons to improve adherence to evidence-based guidelines for assessment and treatment of pediatric ADHD were broadly related to beliefs that ADHD is a chronic neurodevelopmental disorder for which evidence-based treatments exist and are best implemented throughout childhood and adolescence with coordination between PCCs, BHPs, families, and schools. ...
Article
Objective: Despite efficacious treatments, evidence-based guidelines, and increased availability of integrated behavioral health care, youth coping with attention-deficit/hyperactivity disorder (ADHD) receive suboptimal care. More research is needed to understand and address care gaps, particularly within rural health systems that face unique challenges. We conducted a qualitative study within a predominantly rural health system with a pediatric-integrated behavioral health care program to address research gaps and prepare for quality improvement initiatives, including primary care clinician (PCC) trainings and clinical decision support tools in the electronic health record (EHR). Method: Semistructured interviews were conducted with 26 PCCs representing clinics within the health system. Interview guides were based on the Practical Robust Implementation and Sustainability Model to elicit PCC views regarding determinants of current practices and suggestions to guide quality improvement efforts. We used thematic analysis to identify patterns of responding that were common across participants. Results: PCCs identified several internal and external contextual factors as determinants of current practices. Of note, PCCs recommended increased access to continuing education trainings held in clinic over lunch and delivered in less than 30 minutes. Suggested improvements to the EHR included incorporating parent and teacher versions of the Vanderbilt Rating Scale into the EHR, documentation templates aligned with evidence-based guidelines, and alerts and suggestions to aid medication management during appointments. Conclusion: Future research to identify implementation strategies to help rural PCCs adopt innovations are needed given the increased responsibility for managing ADHD care and intractable gaps in access to behavioral health care in rural regions.
... olves collecting information on these domains from stakeholders (see Langer & Jensen Doss, 2018). In fact, in services research for ADHD, we know that the majority of parent informants willingly share data related to ADHD symptoms with teachers, and that many parents will review teacher-reported ADHD symptom data when provided with the opportunity (Michel et. al., 2018). We see the Needs-to-Goals Gap framework as distinct from these therapeutic literatures in several important ways. Specifically, whereas the alliance and shared decisionmaking literatures focus on issues directly relevant to the therapeutic bonds built in therapy, the Needs-to-Goals Gap framework adds a complementary insight by drawing ...
Article
Over 60 years of research reveal that informants who observe youth in clinically relevant contexts (e.g., home, school)―typically parents, teachers, and youth clients themselves―often hold discrepant views about that client’s needs for mental health services (i.e., informant discrepancies). The last 10 years of research reveal that these discrepancies reflect the reality that (a) youth clients’ needs may vary within and across contexts and (b) informants may vary in their expertise for observing youth clients within specific contexts. Accordingly, collecting and interpreting multi-informant data comprise “best practices” in research and clinical care. Yet, professionals across settings (e.g., health, mental health, school) vary in their use of multi-informant data. Specifically, professionals differ in how or to what degree they leverage multi-informant data to determine the goals of services designed to meet youth clients’ needs. Further, even when professionals have access to multiple informants’ reports, their clinical decisions often signal reliance on one informant’s report, thereby omitting reports from other informants. Together, these issues highlight an understudied research-to-practice gap that limits the quality of services for youth. We advance a framework―the Needs-to-Goals Gap―to characterize the role of informant discrepancies in identifying youth clients’ needs and the goals of services to meet those needs. This framework connects the utility of multi-informant data with the reality that services often target an array of needs within and across contexts, and that making decisions without accurately integrating multiple informants’ reports may result in suboptimal care. We review evidence supporting the framework and outline directions for future research.
... 15 To date, there are few studies of integrated remote symptom monitoring interventions: most have targeted oncology and surgical patients on a standardized care pathway or clinical protocol. 16 Attention deficit hyperactivity disorder 17 and use of PROMIS measures in the ambulatory pediatric settings 18 have also been studied. Furthermore, to be effective and scalable for patients with chronic conditions, clinically integrated interventions require more than summative evaluations: attention to rigorous design based on the real-world needs of patients, caregivers, and providers is paramount. ...
Article
Objective To determine user and electronic health records (EHR) integration requirements for a scalable remote symptom monitoring intervention for asthma patients and their providers. Methods Guided by the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, we conducted a user-centered design process involving English- and Spanish-speaking patients and providers affiliated with an academic medical center. We conducted a secondary analysis of interview transcripts from our prior study, new design sessions with patients and primary care providers (PCPs), and a survey of PCPs. We determined EHR integration requirements as part of the asthma app design and development process. Results Analysis of 26 transcripts (21 patients, 5 providers) from the prior study, 21 new design sessions (15 patients, 6 providers), and survey responses from 55 PCPs (71% of 78) identified requirements. Patient-facing requirements included: 1- or 5-item symptom questionnaires each week, depending on asthma control; option to request a callback; ability to enter notes, triggers, and peak flows; and tips pushed via the app prior to a clinic visit. PCP-facing requirements included a clinician-facing dashboard accessible from the EHR and an EHR inbox message preceding the visit. PCP preferences diverged regarding graphical presentations of patient-reported outcomes (PROs). Nurse-facing requirements included callback requests sent as an EHR inbox message. Requirements were consistent for English- and Spanish-speaking patients. EHR integration required use of custom application programming interfaces (APIs). Conclusion Using the NASSS framework to guide our user-centered design process, we identified patient and provider requirements for scaling an EHR-integrated remote symptom monitoring intervention in primary care. These requirements met the needs of patients and providers. Additional standards for PRO displays and EHR inbox APIs are needed to facilitate spread.
... Parents were provided an opportunity to view teacher reports, and teachers could view parent-submitted reports with parental consent. 20 The frequency of e-mails from the portal varied from biweekly to every 3 months at the discretion of the clinician in consultation with the family. Parent and teacher usage of the ADHD Care Assistant during study participation was extracted from the EHR. ...
Article
Objectives: To compare the effectiveness of care management combined with a patient portal versus a portal alone for communication among children with attention-deficit/hyperactivity disorder (ADHD). Methods: Randomized controlled trial conducted at 11 primary care practices. Children aged 5 to 12 years old with ADHD were randomly assigned to care management + portal or portal alone. The portal included parent-reported treatment preferences and goals, medication side effects, and parent- and teacher-reported ADHD symptom scales. Care managers provided education to families; communicated quarterly with parents, teachers, and clinicians; and coordinated care. The main outcome, changes in the Vanderbilt Parent Rating Scale (VPRS) score as a measure of ADHD symptoms, was assessed using intention-to-treat analysis. Results: A total of 303 eligible children (69% male; 46% Black) were randomly assigned, and 273 (90%) completed the study. During the 9-month study, parents in the care management + portal arm communicated inconsistently with care managers (mean 2.2; range 0-6) but similarly used the portal (mean 2.3 vs 2.2) as parents in the portal alone arm. In multivariate models, VPRS scores decreased over time (Adjusted β = -.015; 95% confidence interval -0.023 to -0.07) in both groups, but there were no intervention-by-time effects (Adjusted β = .000; 95% confidence interval -0.011 to 0.012) between groups. Children who received ≥2 care management sessions had greater reductions in VPRS scores than those with fewer sessions. Conclusions: Results did not provide evidence that care management combined with a patient portal was different from portal use alone among children with ADHD. Both groups demonstrated similar reductions in ADHD symptoms. Those families with greater care management engagement demonstrated greater reductions than those with less engagement.
... Previous research also highlights the importance of engaging rural parents and school stakeholders when assessment tools for ADHD are incorporated into the EHR because findings suggest even when these tools are available and used to complete behavior ratings, parents and teachers may not view them often without additional implementation strategies in place. 37 We also identified factors to consider when planning and implementing research and quality improvement efforts with the pediatric ADHD population in this health system; these are summarized corresponding to the PRISM 23 in Figure 2. The high proportion of engagement from clinics and providers eligible to participate in the broader study indicates potential for high levels of engagement with intervention efforts and suggests high potential for broad reach of the innovations to be tested if targeted appropriately on constraining factors to high-quality care. PCC reasons to improve adherence to evidence-based guidelines for assessment and treatment of pediatric ADHD were broadly related to beliefs that ADHD is a chronic neurodevelopmental disorder for which evidence-based treatments exist and are best implemented throughout childhood and adolescence with coordination between PCCs, BHPs, families, and schools. ...
Preprint
Background and Objectives: Despite efficacious treatments and evidence-based guidelines, youth coping with attention deficit hyperactivity disorder (ADHD) receive suboptimal care. Primary care clinicians (PCCs) are frontline providers of ADHD care; however, little is known about PCC perspectives regarding this care gap and how to effectively address it within health systems. We investigated PCC perspectives on determinants of pediatric ADHD care and considerations for improving adherence to evidence-based guidelines. Methods: Semi-structured qualitative interviews were conducted with 26 PCCs representing clinics within a health system on improving adherence to treatment guidelines for pediatric ADHD. Interview guides were based on the Pragmatic Robust Implementation and Sustainability Model (PRISM) to elicit PCC views regarding determinants of current practices and suggestions to guide improvement efforts. We used thematic analysis to identify patterns of responding that were common across participants.Results: We identified 12 themes categorized into two broad domains: Status Quo of Pediatric ADHD Care and Supporting and Constraining Factors for Improvement Initiatives. PCCs identified several internal and external contextual factors as determinants of current practices. Of note, PCCs reported they face challenges at multiple steps in the care process, including mental health stigma, coordinating care across settings, clinical productivity pressures, access to behavioral health care, and insurance mandates regarding medications. PCCs recommended efficient continuing education trainings accompanied by improvements to the electronic health record to include validated screening tools and documentation templates.Conclusions: Future research triangulating these findings may help to more efficiently improve the quality of pediatric ADHD care in health systems.
... Also as discussed previously, electronic systems have been developed to facilitate cross-setting (i.e., primary care offices, schools, and home) communication to enhance access to evidencebased assessment and treatment practices (e.g., Epstein et al., 2011). A promising system embedded in the EHR is the ADHD Care Assistant (see Power et al., 2016) which was designed to promote (a) shared decision-making between family and provider by identifying family goals and preferences for treatment (Fiks et al., 2012) and assessing goal attainment; and (b) the sharing of information among parents, educators, and health providers (Michel et al., 2018). Expanded development and evaluation of electronic systems such as the ADHD Care Assistant in the context of pediatric primary care holds the promise of facilitating access to screening, assessment, and early detection of ADHD. ...
Article
Multiple psychosocial interventions are efficacious for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) including behavioral parent training, behavioral classroom management, behavioral peer interventions, and organization training programs. Unfortunately, there is a significant gap between research and practice such that evidence-based treatments often are not implemented in community and school settings. Using a life course model for ADHD treatment implementation, we discuss future research directions that support movement from the current, fragmented system of care to a more comprehensive, integrated, and multisystemic approach. Specifically, we offer six recommendations for future research. Within the realm of treatment development and evaluation, we recommend (1) identifying and leveraging mechanisms of change, (2) examining impact of youth development on treatment mechanisms and outcomes, and (3) designing intervention research in the context of a life course model. Within the realm of implementation and dissemination, we recommend investigating strategies to (4) enhance access to evidence-based treatment, (5) optimize implementation fidelity, and (6) examine and optimize costs and cost-effectiveness of psychosocial interventions. Our field needs to go beyond short-term, efficacy trials to reduce symptomatic behaviors conducted under ideal controlled conditions and successfully address the research-to-practice gap by advancing development, evaluation, implementation, and dissemination of evidence-based treatment strategies to ameliorate ADHD-related impairment that can be used with fidelity by parents, teachers, and community health providers.
Article
Objectives: Randomized controlled trials (RCTs) have shown that attention-deficit/hyperactivity disorder (ADHD) medications significantly reduce symptomatology at a group level, but individual response to ADHD medication is variable. Thus, developing prediction models to stratify treatment according to individual baseline clinicodemographic characteristics is crucial to support clinical practice. A potential valuable source of data to develop accurate prediction models is real-world clinical data extracted from electronic healthcare records (EHRs). Yet, systematic information regarding EHR data on ADHD is lacking. Methods: We conducted a comprehensive review of studies that included EHR reporting data regarding individuals with ADHD, with a specific focus on treatment-related data. Relevant studies were identified from PubMed, Ovid, and Web of Science databases up to February 24, 2024. Results: We identified 103 studies reporting EHR data for individuals with ADHD. Among these, 83 studies provided information on the type of prescribed medication. However, dosage, duration of treatment, and ADHD symptom ratings before and after treatment initiation were only reported by a minority of studies. Conclusion: This review supports the potential use of EHRs to develop treatment response prediction models but emphasizes the need for more comprehensive reporting of treatment-related data, such as changes in ADHD symptom ratings and other possible baseline clinical predictors of treatment response.
Article
The neoliberal and biomedical ‘good caregiver’ discourse neglects the many facets of everyday information work that parents of children with special needs are required to do as they seek, receive and share information concerning their children’s health and wellbeing. Along with time and skills, one such neglected facet is emotion work, the management of feelings in relation to societal norms. The purpose of this article is to explore emotion work, as a facet in parental health information work in the care and education sector, among mothers of neurodivergent children. Our analysis draws on interviews with 50 Swedish mothers of neurodivergent children. We present three primary insights. 1. Emotion work, on the self as well as on others, is pivotal to the information work that the mothers carry out in the education and care sector as they strive to ameliorate their children’s situation. 2. Contested diagnoses, such as diagnoses associated with neurodivergent conditions, result in intense parental information and emotion work. 3. Fragmented and complex education and care systems, alongside traditional gender structures, compel mothers to undertake extensive information and emotion work.
Article
Primary care physicians (PCPs) have an important role in the identification and management of Attention Deficit Hyperactivity Disorder (ADHD). There is a paucity of research on PCPs' practices related to the discussion of educational interventions. We conducted a retrospective chart review using Natural Language Processing to extract data on how often PCPs in an outpatient clinic: 1) discuss educational support with patients and caregivers; and 2) obtain educational records. About three-quarters of patients had at least one term related to educational support included in at least one note, but only 13 percent of patients had at least one educational record uploaded into the electronic health record (EHR). There was no association between having an educational document uploaded into the EHR and inclusion of a term related to educational support in a note. Almost half (48 percent) of these records were unclearly labeled. Further education of PCPs is warranted to increase discussions of educational support and obtaining educational records, as is collaboration with health information management professionals around labeling.
Article
Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral condition in children. Current guidelines recommend that Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) criteria be met before diagnosing ADHD. However, 14-49% of providers are not documenting the use of DSM-V criteria in screening and diagnosis. The use of a standardized electronic health record (EHR) ADHD template is a potential option to assist providers with documenting the DSM-V criteria. The aim for this project was to provide a 1-hour educational in-service on the use of the DSM-V criteria, Vanderbilt rating scale, and a revised EHR ADHD template, and to assess provider use pre and post intervention. Results showed that few providers (n = 1; 2%) document using DSM-V criteria preintervention and post intervention with only a modest increase in template use (n = 3; 5%). However, there were statistical differences between provider type with advanced practice registered nurses and physician assistants screening more frequently using the EHR DSM-V ADHD template compared with physicians (p = .009). Future studies are needed to evaluate barriers to use, including practice preference, openness to change, and other factors that may affect provider workflow.
Article
Commercial electronic health records (EHRs) were first developed to automate business processes. As EHRs developed, design principles focused on transferring existing paper-based documentation to comparable electronic forms. In addition, a strong industry focus on adult healthcare settings and quality measures has limited attention and resources for high priority EHR functionality needed for the unique health care of children. The objective of this paper is to provide a review of innovation in the EHR, that includes a variety of established and emerging technologies that may help realize a more effective EHR in child health settings. A more effective EHR would serve as an electronic hub. Existing EHR infrastructure could provide the foundation upon which new technologies and approaches branch and extend, enabling more rapid and customizable innovation to better meet shifting stakeholder and end-user needs. Among many areas for improvement, key goals of innovation could include technology that relieves ambulatory primary care clinician documentation burden, identifies needs, and supports improved care coordination and outcomes, focused on the following key areas: identification of child and family care needs, decision support, documentation, care coordination, and family communication.
Article
Objective To identify challenges to the use of Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric measures in the ambulatory pediatric setting and possible solutions to these challenges. Study design 18 semi-structured telephone interviews of health system leaders, measurement implementers, and ambulatory pediatric clinicians were conducted. Five coders used Applied Thematic Analysis to iteratively identify and refine themes in interview data. Results Most interviewees had roles in leadership or the implementation of patient-centered outcomes; 39% were clinicians. Some had experience using PROMIS clinically (44%) and 6% were considering this use. Analyses yielded six themes: 1) selection of PROMIS measures, 2) method of administration, 3) use of PROMIS Parent Proxy measures, 4) privacy and confidentiality of PROMIS responses, 5) interpretation of PROMIS scores, and 6) using PROMIS scores clinically. Within the themes, interviewees illuminated specific unique considerations for using PROMIS with children, including care transitions and privacy. Conclusions Real world challenges continue to hamper PROMIS use. Ongoing efforts to disseminate information about the integration of PROMIS measures in clinical care is critical to impacting the health of children.
Article
Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (∼76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication can improve monitoring of ADHD symptoms and functional performance. The American Academy of Pediatrics ADHD guidelines were initially developed to help primary care clinicians address the needs of their patients with ADHD and were further refined with the second revision in 2019.
Article
Full-text available
Objective: To evaluate a distance-learning, quality improvement intervention to improve pediatric primary care provider use of attention-deficit/hyperactivity disorder (ADHD) rating scales. Methods: Primary care practices were cluster randomized to a 3-part distance-learning, quality improvement intervention (web-based education, collaborative consultation with ADHD experts, and performance feedback reports/calls), qualifying for Maintenance of Certification (MOC) Part IV credit, or wait-list control. We compared changes relative to a baseline period in rating scale use by study arm using logistic regression clustered by practice (primary analysis) and examined effect modification by level of clinician participation. An electronic health record-linked system for gathering ADHD rating scales from parents and teachers was implemented before the intervention period at all sites. Rating scale use was ascertained by manual chart review. Results: One hundred five clinicians at 19 sites participated. Differences between arms were not significant. From the baseline to intervention period and after implementation of the electronic system, clinicians in both study arms were significantly more likely to administer and receive parent and teacher rating scales. Among intervention clinicians, those who participated in at least 1 feedback call or qualified for MOC credit were more likely to give parents rating scales with differences of 14.2 (95% confidence interval [CI], 0.6-27.7) and 18.8 (95% CI, 1.9-35.7) percentage points, respectively. Conclusion: A 3-part clinician-focused distance-learning, quality improvement intervention did not improve rating scale use. Complementary strategies that support workflows and more fully engage clinicians may be needed to bolster care. Electronic systems that gather rating scales may help achieve this goal. Index terms: ADHD, primary care, quality improvement, clinical decision support.
Article
Full-text available
Objective: Care provision and prescribing practices of physicians treating children with attention-deficit hyperactivity disorder (ADHD) were compared. Methods: A retrospective cohort study was conducted with the 1995-2010 General Electric Centricity Electronic Medical Record database. The sample included children (≤18 years) with newly diagnosed ADHD (ICD-9-CM code 314.XX) who received a prescription for a stimulant or atomoxetine. Identification of comorbid psychiatric disorders, duration from initial ADHD diagnosis to treatment, prescription of other psychotropic medications, and follow-up care during the ten months after the ADHD treatment initiation were compared across provider type (primary care physicians [PCPs], child psychiatrists, and physicians with an unknown specialty). The associations between provider type and practice variations were further determined by multivariate logistic regression accounting for patient demographic characteristics, region, insurance type, and prior mental health care utilizations. Results: Of the 66,719 children identified, 75.8% were diagnosed by PCPs, 2.6% by child psychiatrists, and 21.6% by physicians whose specialty was unknown. Child psychiatrists were less likely than PCPs to initiate ADHD medication immediately after the diagnosis. However, once the ADHD treatment was initiated, they were more likely to prescribe psychotropic polytherapy even after analyses accounted for the comorbid psychiatric disorders identified. Only one-third of ADHD cases identified by both PCPs and child psychiatrists have met the HEDIS quality measure for ADHD medication-related follow-up visits. Conclusions: Differences were found by physician type in care of children with ADHD. Additional studies are needed to understand clinical consequences of these differences and the implications for care coordination across provider specialties.
Article
Full-text available
Collaborative care (CC) is an innovative approach to integrated mental health service delivery that focuses on reducing access barriers, improving service quality and lowering health care expenditures. A large body of evidence supports the effectiveness of CC models with adults and, increasingly, for youth. Although existing studies examining these models for youth have focused exclusively on primary care, the education sector is also an appropriate analogue for the accessibility that primary care offers to adults. CC aligns closely with the practical realities of the education sector and may represent a strategy to achieve some of the objectives of increasingly popular multi-tiered systems of supports frameworks. Unfortunately, no resources exist to guide the application of CC models in schools. Based on the existing evidence for CC models, the current paper (1) provides a rationale for the adaptation of CC models to improve mental health service accessibility and effectiveness in the education sector; (2) presents a preliminary CC model for use in schools; and (3) describes avenues for research surrounding school-based CC, including the currently funded Accessible, Collaborative Care for Effective School-based Services project.
Article
Full-text available
Background: The quality of care for children with attention-deficit/hyperactivity disorder (ADHD) delivered in community-based pediatric settings is often poor. Interventions have been developed to improve community-based ADHD care but have not demonstrated that better care results in improved patient outcomes. The objective of this study was to determine whether an ADHD quality improvement (QI) intervention for community-based pediatric practices improves patient outcomes. Methods: A cluster randomized controlled trial was conducted in which 50 community-based pediatric primary care practices (213 providers) were randomized either to receive a technology-assisted QI intervention or to a control condition. The intervention consisted of 4 training sessions, office flow modification, guided QI, and an ADHD Internet portal to assist with treatment monitoring. ADHD treatment processes and parent- and teacher-rated ADHD symptoms over the first year of treatment were collected for 577 patients. Results: Intent-to-treat analyses examining outcomes of all children assessed for ADHD were not significant (b = -1.97, P = .08). However, among the 373 children prescribed ADHD medication, there was a significant intervention effect (b = -2.42, P = .04) indicating greater reductions in parent ratings of ADHD symptoms after treatment among patients treated by intervention physicians compared with patients treated at control practices. There were no group differences on teacher ratings of ADHD symptoms. ADHD treatment care around medication was significantly better at intervention practices compared with control practices. Conclusions: A technology-assisted QI intervention improved some ADHD care quality and resulted in additional reductions in parent-rated ADHD symptoms among patients prescribed ADHD medications.
Article
Full-text available
Background: Parent training is recommended as the first-line treatment for attention-deficit/hyperactivity disorder (ADHD) in preschool children. The New Forest Parenting Programme (NFPP) is an evidence-based parenting program developed specifically to target preschool ADHD. Objective: The objective of this trial is to investigate whether the NFPP can be effectively delivered for children referred through official community pathways in everyday clinical practice. Methods: A multicenter randomized controlled parallel arm trial design is employed. There are two treatment arms, NFPP and treatment as usual. NFPP consists of eight individually delivered parenting sessions, where the child attends during three of the sessions. Outcomes are examined at three time points (T1, T2, T3): T1 (baseline), T2 (week 12, post intervention), and T3 (6 month follow/up). 140 children between the ages of 3-7, with a clinical diagnosis of ADHD, informed by the Development and Well Being Assessment, and recruited from three child and adolescent psychiatry departments in Denmark will take part. Randomization is on a 1:1 basis, stratified for age and gender. Results: The primary endpoint is change in ADHD symptoms as measured by the Preschool ADHD-Rating Scale (ADHD-RS) by T2. Secondary outcome measures include: effects on this measure at T3 and T2 and T3 measures of teacher reported Preschool ADHD-RS scores, parent and teacher rated scores on the Strength & Difficulties Questionnaire, direct observation of ADHD behaviors during Child's Solo Play, observation of parent-child interaction, parent sense of competence, and family stress. Results will be reported using the standards set out in the Consolidated Standards of Reporting Trials Statement for Randomized Controlled Trials of nonpharmacological treatments. Conclusions: The trial will provide evidence as to whether NFPP is a more effective treatment for preschool ADHD than the treatment usually offered in everyday clinical practice. Trial registration: ClinicalTrials.gov NCT01684644; https://clinicaltrials.gov/ct2/show/NCT01684644?term= NCT01684644&rank=1 (Archived by WebCite at http://www.webcitation/6eOOAe8Qe).
Article
Full-text available
We describe the user-centered development of an electronic medical record-based portal, "MyAsthma," designed to facilitate shared decision making in pediatric asthma. Interviews and focus groups with 7 parents of children with asthma and 51 clinical team members elicited 2 overarching requirements: that the portal should support sustained communication and ensure patient safety. Parents and clinicians prioritized features including collecting parent and child concerns and goals; symptom, side effect, and medication adherence tracking with decision support; and accessible educational materials. Iterative usability testing refined the system. MyAsthma provides a model for using technology to foster shared decision making in ambulatory care settings.
Article
Full-text available
Previous studies have identified significant variability in attention-deficit / hyperactivity disorder (ADHD) prevalence estimates worldwide, largely explained by methodological procedures. However, increasing rates of ADHD diagnosis and treatment throughout the past few decades have fuelled concerns about whether the true prevalence of the disorder has increased over time. We updated the two most comprehensive systematic reviews on ADHD prevalence available in the literature. Meta-regression analyses were conducted to test the effect of year of study in the context of both methodological variables that determined variability in ADHD prevalence (diagnostic criteria, impairment criterion and source of information), and the geographical location of studies. We identified 154 original studies and included 135 in the multivariate analysis. Methodological procedures investigated were significantly associated with heterogeneity of studies. Geographical location and year of study were not associated with variability in ADHD prevalence estimates. Confirming previous findings, variability in ADHD prevalence estimates is mostly explained by methodological characteristics of the studies. In the past three decades, there has been no evidence to suggest an increase in the number of children in the community who meet criteria for ADHD when standardized diagnostic procedures are followed.
Article
Full-text available
Though the American Academy of Pediatrics has developed and disseminated clear evidence-based guidelines for ADHD care, community-based pediatricians often have difficulty implementing these guidelines. New strategies are needed to improve the quality of care received by children with ADHD and to improve utilization of the AAP consensus guidelines by pediatricians. An evidence-based quality improvement intervention has been developed that effectively improves the quality of ADHD care delivered by community-based pediatricians. In order to facilitative widespread dissemination of this intervention model, the entire intervention has been modified for online delivery. The intervention is called the myADHDportal.com Improvement Program. The full functionality of this online intervention is described including the collection of online ADHD rating scales from parents and teachers and online communication between parents, teachers, and physicians. In addition, the web portal integrates several innovative quality improvement features including an online wizard for mapping ADHD patient flow, an online report card for monitoring quality of care, and an online wizard for guiding practices through the Plan-Do-Study-Act (PDSA) cycle process. The combination of clinical utility and quality improvement tools facilitates delivery of quality ADHD care and reduces several of the obstacles to implementing AAP-recommended practice behaviors. Initial results with this intervention model are reviewed and goals for dissemination are described.
Article
Full-text available
Objectives: To describe the association between parents' attention-deficit/hyperactivity disorder (ADHD) treatment preferences and goals and treatment initiation. Methods: Parents/guardians of children aged 6 to 12 years diagnosed with ADHD in the past 18 months and not currently receiving combined treatment (both medication and behavior therapy [BT]) were recruited from 8 primary care sites and an ADHD treatment center. Parents completed the ADHD Preference and Goal Instrument, a validated measure, and reported treatment receipt at 6 months. Logistic regression was used to analyze the association of baseline preferences and goals with treatment initiation. Using linear regression, we compared the change in preferences and goals over 6 months for children who initiated treatment versus others. Results: The study included 148 parents/guardians. Baseline medication and BT preference were associated with treatment initiation (odds ratio [OR]: 2.6 [95% confidence interval (CI):1.2-5.5] and 2.2 [95% CI: 1.0-5.1], respectively). The goal of academic achievement was associated with medication initiation (OR: 2.1 [95% CI: 1.3-3.4]) and the goal of behavioral compliance with initiation of BT (OR: 1.6 [95% CI: 1.1-2.4]). At 6 months, parents whose children initiated medication or BT compared with others had decreased academic and behavioral goals, suggesting their goals were attained. However, only those initiating BT had diminished interpersonal relationship goals. Conclusions: Parental treatment preferences were associated with treatment initiation, and those with distinct goals selected different treatments. Results support the formal measurement of preferences and goals in practice as prioritized in recent national guidelines for ADHD management.
Article
Full-text available
Objective: To examine the effect of a shared decision-making intervention with parents of children newly diagnosed with attention-deficit/hyperactivity disorder. Methods: Seven pediatricians participated in a pre/post open trial of decision aids for use before and during the office visit to discuss diagnosis and develop a treatment plan. Encounters pre- (n=21, control group) and post-intervention implementation (n=33, intervention group) were compared. We video-recorded encounters and surveyed parents. Results: Compared to controls, intervention group parents were more involved in shared decision-making (31.2 vs. 43.8 on OPTION score, p<0.01), more knowledgeable (6.4 vs. 8.1 questions correct, p<0.01), and less conflicted about treatment options (16.2 vs. 10.7 on decisional conflict total score, p=0.06). Visit duration was unchanged (41.0 vs. 41.6min, p=0.75). There were no significant differences in the median number of follow-up visits (0 vs. 1 visits, p=0.08), or the proportion of children with medication titration (62% vs. 76%, p=0.28), or parent-completed behavior rating scale to assess treatment response (24% vs. 39%, p=0.36). Conclusions: Our intervention increased shared decision-making with parents. Parents were better informed about treatment options without increasing visit duration. Practice implications: Interventions are available to prepare parents for visits and enable physicians to elicit parent preferences and involvement in decision-making.
Article
Full-text available
There is a significant research to practice gap in the area of mental health practices and interventions in schools. Understanding the teacher perspective can provide important information about contextual influences that can be used to bridge the research to practice gap in school-based mental health practices. The purpose of this study was to examine teachers' perceptions of current mental health needs in their schools; their knowledge, skills, training experiences and training needs; their roles for supporting children's mental health; and barriers to supporting mental health needs in their school settings. Participants included 292 teachers from 5 school districts. Teachers reported viewing school psychologists as having a primary role in most aspects of mental health service delivery in the school including conducting screening and behavioral assessments, monitoring student progress, and referring children to school-based or community services. Teachers perceived themselves as having primary responsibility for implementing classroom-based behavioral interventions but believed school psychologists had a greater role in teaching social emotional lessons. Teachers also reported a global lack of experience and training for supporting children's mental health needs. Implications of the findings are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Full-text available
This Clinical Practice Guideline was revised. See https://doi.org/10.1542/peds.2019-2528 Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001.
Article
Full-text available
Background: Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour. Objectives: To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention. Search methods: We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research. Selection criteria: Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome. Data collection and analysis: Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies. Main results: We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm. Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD. Authors' conclusions: Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.
Article
Full-text available
To determine the effectiveness of a quality improvement program to improve pediatricians' adherence to existing, evidence-based, attention-deficit/hyperactivity disorder (ADHD) practice guidelines. Forty-nine community-based pediatricians at 8 practices participated in a cluster-randomized trial. Practices were matched according to the numbers of pediatricians and the proportions of patients receiving Medicaid. The medical charts for a random sample of patients with ADHD for each of the participating pediatricians were examined at baseline and 6 months. All practices participated in 4 sessions of training, including didactic lectures and office flow modification workshops. Practices were then given access to an ADHD Internet portal that allowed parents, teachers, and pediatricians to input information (eg, rating scales) about patients, after which information was scored, interpreted, and formatted in a report style that was helpful for assessment and treatment of patients with ADHD. Physicians evaluated their practice behaviors quarterly and addressed underperforming areas. Pediatricians in the intervention group, compared with those in the control group, demonstrated significantly higher rates of many American Academy of Pediatrics-recommended ADHD care practices, including collection of parent (Cohen's d = 0.69) and teacher (d = 0.68) rating scales for assessment of children with ADHD, use of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria (d = 0.85), and use of teacher rating scales to monitor treatment responses (d = 1.01). A quality improvement intervention that can be widely disseminated by using Internet-based information technology significantly improved the quality of ADHD care in community-based pediatric settings.
Article
Full-text available
To identify systematic problems in coordinating care for inner-city minority youths with attention-deficit/hyperactivity disorder. We recruited participants from inner-city minority communities in a single metropolitan area for a focus group study. We held separate meetings for pediatricians, mental health therapists, school staff, and parents (both black and Latino). We audiotaped and transcribed the meetings. We identified themes by consensus and used root cause analysis as a conceptual framework to guide our analysis. We held 13 focus group meetings. Participants uniformly perceived insufficient communication and coordination of care. Five themes representing system and human factors that contributed to this fragmentation in care emerged: (1) a lack of consensus about who should oversee care; (2) changes in health care providers or teachers; (3) uncertainty in the diagnosis, insufficient training, and few resources; (4) distrust and blame that emerged when relationships among people who care for the child were absent or otherwise inadequate; and (5) lack of support from employers, friends, and family to engage in collaborative care. Using a root cause analysis framework, we identified system- and human-level factors that were perceived to impede communication and coordination of care for this population of children with attention-deficit/hyperactivity disorder. These results suggest that better organizational policies that define provider responsibilities and accountability, support the coordination of care, bridge relationships between agencies, and provide additional education and resources may improve collaboration. Additional study is needed to assess the generalizability of these finding to other settings.
Article
Full-text available
This study examines interventions designed to improve communication between individuals who take care of children with ADHD. A teacher rating of 6,171 elementary school children identifies 1,573 children with ADHD or with high risk for ADHD. Parent interviews and information from teachers are collected on 243 children who are randomized into treatment and control conditions and followed for 39 months. The interventions consisted of group workshops and single one-on-one tutorials with parents, teachers, and providers about the evaluation and treatment of ADHD that stressed the need for communication between the three parties. There are few significant effects on communication that are short lived. Results suggest that the interventions are insufficient to cause significant increase in communication. Future attempts to improve parent-teacher-provider coordination should be continuing rather than single-session interventions.
Article
Full-text available
Despite a significant increase in the number of children and adolescents who receive clinical services for attention deficit hyperactivity disorder (ADHD), there is still a considerable level of unmet need. Children of ethnic minority status continue to lag well behind their non-minority counterparts in the rate of diagnosis and treatment for the disorder. Racial/ethnic disparities in service use are the result of a combination of access barriers and individual, cultural, and societal factors. The ADHD Help-Seeking Behavior Model is proposed as a framework for understanding factors that may be predictive of service use. Variables specific to ADHD and ethnic-minority populations are integrated within the framework of a four-stage pathway model encompassing problem recognition, decision to seek help, service selection, and service use. The authors argue that by systematically addressing factors related to service use for each ethnic minority group, more effective intervention initiatives can be developed to improve identification and treatment for ADHD among underserved children.
Article
Full-text available
• Despite the high prevalence of mental health problems and disorders that develop in adolescence and early adulthood, young people tend to not seek professional help. Young men and young people from Indigenous and ethnic minority groups tend to be those most reluctant to seek help. • Young people are more inclined to seek help for mental health problems if they: • have some knowledge about mental health issues and sources of help; • feel emotionally competent to express their feelings; and • have established and trusted relationships with potential help providers. • Young people are less likely to seek help if they: • are experiencing suicidal thoughts and depressive symptoms; • hold negative attitudes toward seeking help or have had negative past experiences with sources of help; or • hold beliefs that they should be able to sort out their own mental health problems on their own. • Young people may seek help through talking to their family and friends, with family being more important for younger adolescents, and friends and partners becoming more influential later on. • The professionals most likely to act as gatekeepers to mental health services for young people are school counsellors, general practitioners, and youth workers. • Increasingly, Internet‐based information and interventions are being used to engage young people in the help‐seeking process.
Article
Full-text available
s To determine the psychometric properties of the Vanderbilt Attention Deficit/Hyperactivity Disorder Parent Rating Scale (VADPRS), which utilizes information based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV). The VADPRS was created to collect uniform patient data and minimize the time burden of lengthy interviews. Participant data (N = 243) was used from the first 2 years of a longitudinal study on communication among physicians, teachers, and parents in diagnosing, treating, and managing children with attention deficit/hyperactivity disorder (ADHD). The reliability, factor structure, and concurrent validity of the VADPRS were evaluated and compared with ratings of children in clinical and nonclinical samples on the Vanderbilt ADHD Teacher Rating Scale and the Computerized Diagnostic Interview Schedule for Children-IV, Parent version. The internal consistency and factor structure of the VADPRS are acceptable and consistent with DSM-IV and other accepted measures of ADHD. The VADPRS is a reliable, cost-effective assessment for ADHD in clinical and research settings.
Article
Implementing enterprise systems (ES) suffers from a high failure rate despite their promised benefits. A commonly cited reason for ES implementation failures in the context of mandatory use is end users’ unwillingness to adopt or use systems or their sabotage thereof. Considering that expectations toward using newly implemented systems may promote positive user behavior, we examine the effects of outcome expectations on information systems (IS) use activity from the viewpoint of social cognitive theory. In addition, we propose a new surrogate variable for IS use activity in the mandatory use context, conative IS use, which is conceptualized as a second-order aggregate construct comprising three dimensions: immersion, reinvention, and learning. Conative IS use here refers to IS use that is proactively motivated by intentional and personal causes. The empirical results, based on data collected from 208 ES users, are found to support the conceptualization of the proposed variable. They also reveal that conative IS use is positively affected by outcome expectations. The findings of this study thus imply that the appropriate management of expectations may promote IS use behavior in the mandatory use context.
Article
Background: Palivizumab is effective at reducing hospitalizations due to respiratory syncytial virus among high-risk children, but is indicated for a small population. Identification of patients eligible to receive palivizumab is labor-intensive and error-prone. To support patient identification we developed Clinical Decision Support (CDS) based on published recommendations in 2012. This CDS was developed using a systematic process, which directly linked computer code to a recommendation’s narrative text. In 2014, updated recommendations were published, which changed several key criteria used to determine eligible patients. Objective: Assess the effort required to update CDS in response to new palivizumab recommendations and identify factors that impacted these efforts. Methods: We reviewed the updated American Academy of Pediatrics (AAP) policy statement from Aug 2014 and identified areas of divergence from the prior publication. We modified the CDS to account for each difference. We recorded time spent on each activity to approximate the total effort required to update the CDS. Results: Of the 15 recommendations in the initial policy statement, 7 required updating. The CDS update was completed in 11 person-hours. Comparison of old and new recommendations was facilitated by the AAP policy statement structure and required 3 hours. Validation of the revised logic required 2 hours by a clinical domain expert. An informaticist required 3 hours to update and test the CDS. This included adding 24 lines and deleting 37 lines of code. Updating relevant data queries took an additional 3 hours and involved 10 edits. Conclusion: We quickly adapted CDS in response to changes in recommendations for palivizumab administration. The consistent AAP policy statement structure and the link we developed between these statements and the CDS rules facilitated our efforts. We recommend that CDS implementers establish linkages between published narrative recommendations and their executable rules to facilitate maintenance efforts. Citation: Michel J, Utidjian LH, Karavite D, Hogan A, Ramos MJ, Miller J, Shiffman RN, Grundmeier RW. Rapid adjustment of clinical decision support in response to updated recommendations for palivizumab eligibility. Appl Clin Inform 2017; 8: 581–592 https://doi.org/10.4338/ACI-2016-10-RA-0173
Article
Introduction: New-age technologies are ubiquitous in the lives of adolescents. Recent trends in media use suggest that adolescents are spending more time than ever engaging with technologies, and are able to do so in virtually all settings at any time. Given that new-age technologies are so heavily integrated within the daily life of adolescents, the health risks and benefits they offer must be closely examined. Evidence acquisition: In this systematic review, we present recent literature related to the implications of new-age technologies on adolescent health. A total of 94 articles published since 2006 were collected using PubMed and Google Scholar on the most popular new-age technologies among adolescents: the internet, television, cell phones, and video games. Evidence synthesis: The current body of research highlights several health risks related to these technologies. Nearly all have the potential for addiction, which can result in other symptoms and impair one's daily life. Excessive use can affect several components of health, such as quality of sleep, body composition, and mental well-being, and certain practices (viewing pornography, sexting) can lead to risky sexual behaviors. However, the technologies discussed in the present review also have tremendous potential to promote adolescent health. Conclusions: Pediatricians must educate parents and patients on how to safely use technology to minimize the potentially harmful outcomes.
Article
Perhaps the two principal venues for the delivery of mental health services are schools and primary care practices. Unfortunately, these systems of care are poorly connected, which may result in care that is fragmented and suboptimal. This article describes the development and implementation of an electronic health record portal, known as the ADHD Care Assistant, to facilitate the sharing of information between schools and primary care offices to promote the use of evidence-based practices for managing children with behavioral health conditions. A feasibility study was conducted across 19 diverse primary care practices with 105 participating providers. Across the practices, 67% of providers activated the system for at least one patient and 32% activated it for five or more cases. Care Assistant use was lower in practices with a relatively high percentage of Medicaid patients (≥25%). The article discusses challenges that have arisen among primary care providers, parents, and schools in using the Care Assistant, potential strategies for addressing the challenges, and directions for future research and practice.
Article
For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial. Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic® EHR. All sites implementing EHR-based CDS built the rules by using the vendor’s CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider entered prediction rule data. One central site developed and tested the intervention package to be exported to other sites. The intervention package included a clinical trial alert, an electronic data collection form, the CDS rules and the format for recommendations. The original PECARN head trauma prediction rules were derived from physician documentation while this pragmatic trial led each site to customize their workflows and allow multiple different providers to complete the head trauma assessments. These differences in workflows led to varying completion rates across sites as well as differences in the types of providers completing the electronic data form. Site variation in internal change management processes made it challenging to maintain the same rigor across all sites. This led to downstream effects when data reports were developed. The process of a centralized build and export of a CDS system in one commercial EHR system successfully supported a multicenter clinical trial.
Article
Objectives: 'Habit' is a process whereby situational cues generate behaviour automatically, via activation of learned cue-behaviour associations. This article presents a conceptual and empirical rationale for distinguishing between two manifestations of habit in health behaviour, triggering selection and initiation of an action ('habitual instigation'), or automating progression through subactions required to complete action ('habitual execution'). We propose that habitual instigation accounts for habit-action relationships, and is the manifestation captured by the Self-Report Habit Index (SRHI), the dominant measure in health psychology. Design: Conceptual analysis and prospective survey. Methods: Student participants (N = 229) completed measures of intentions, the original, non-specific SRHI, an instigation-specific SRHI variant, an execution-specific variant, and, 1 week later, behaviour, in three health domains (flossing, snacking, and breakfast consumption). Effects of habitual instigation and execution on behaviour were modelled using regression analyses, with simple slope analysis to test habit-intention interactions. Relationships between instigation, execution, and non-specific SRHI variants were assessed via correlations and factor analyses. Results: The instigation-SRHI was uniformly more predictive of behaviour frequency than the execution-SRHI and corresponded more closely with the original SRHI in correlation and factor analyses. Conclusions: Further, experimental work is needed to separate the impact of the two habit manifestations more rigorously. Nonetheless, findings qualify calls for habit-based interventions by suggesting that behaviour maintenance may be better served by habitual instigation and that disrupting habitual behaviour may depend on overriding habits of instigation. Greater precision of measurement may help to minimize confusion between habitual instigation and execution. Statement of contribution What is already known on this subject? Habit is often used to understand, explain, and change health behaviour. Making behaviour habitual has been proposed as a means of maintaining behaviour change. Concerns have been raised about the extent to which health behaviour can be habitual. What does this study add? A conceptual and empirical rationale for discerning habitually instigated and habitually executed behaviour. Results show habit-behaviour effects are mostly attributable to habitual instigation, not execution. The most common habit measure, the Self-Report Habit Index, measures habitual instigation, not execution.
Article
Context: The Child Behavior Checklist-Attention Problem (CBCL-AP) scale and Conners Rating Scale-Revised (CRS-R) are commonly used behavioral rating scales for diagnosing attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. Objective: To evaluate and compare the diagnostic performance of CBCL-AP and CRS-R in diagnosing ADHD in children and adolescents. Data sources: PubMed, Ovid Medline, and other relevant electronic databases were searched for articles published up to May 2015. Study selection: We included studies evaluating the diagnostic performance of either CBCL-AP scale or CRS-R for diagnosing ADHD in pediatric populations in comparison with a defined reference standard. Data extraction: Bivariate random effects models were used for pooling and comparing diagnostic performance. Results: We identified and evaluated 14 and 11 articles on CBCL-AP and CRS-R, respectively. The results revealed pooled sensitivities of 0.77, 0.75, 0.72, and 0.83 and pooled specificities of 0.73, 0.75, 0.84, and 0.84 for CBCL-AP, Conners Parent Rating Scale-Revised, Conners Teacher Rating Scale-Revised, and Conners Abbreviated Symptom Questionnaire (ASQ), respectively. No difference was observed in the diagnostic performance of the various scales. Study location, age of participants, and percentage of female participants explained the heterogeneity in the specificity of the CBCL-AP. Conclusions: CBCL-AP and CRS-R both yielded moderate sensitivity and specificity in diagnosing ADHD. According to the comparable diagnostic performance of all examined scales, ASQ may be the most effective diagnostic tool in assessing ADHD because of its brevity and high diagnostic accuracy. CBCL is recommended for more comprehensive assessments.
Article
Pediatric nurse practitioners take a lead role in diagnosing and coordinating the care of children with attention deficit hyperactivity disorder (ADHD). School nurses offer rich insight into the child's health and social and academic functioning in the school setting. School nurses develop individualized health care plans, administer and monitor medications, provide valuable input on Individualized Education Plans and Section 504 Accommodation Plans, and serve as the point person in communicating with the medical provider. Pediatric nurse practitioners can enhance the collaboration with school nurses by establishing communication parameters, streamlining medication regimens, and facilitating development of educational curricula for school nurses regarding evidence-based ADHD management. Optimizing partnerships with school nurses will provide better surveillance of treatment efficacy and can facilitate improved health and academic and social outcomes for children with ADHD.
Article
Electronic health record (EHR)-linked patient portals are a promising approach to facilitate shared decision-making between families of children with chronic conditions and pediatricians. This study evaluated the feasibility, acceptability, and impact of MyAsthma, an EHR-linked patient portal supporting shared decision-making for pediatric asthma. We conducted a 6-month randomized controlled trial of MyAsthma at 3 primary care practices. Families were randomized to MyAsthma, which tracks families' asthma treatment concerns and goals, children's asthma symptoms, medication side effects and adherence, and provides decision support, or to standard care. Outcomes included the feasibility and acceptability of MyAsthma for families, child health care utilization and asthma control, and the number of days of missed school (child) and work (parent). Descriptive statistics and longitudinal regression models assessed differences in outcomes between study arms. We enrolled 60 families, 30 in each study arm (mean age 8.3 years); 57% of parents in the intervention group used MyAsthma during at least 5 of the 6 study months. Parents of children with moderate to severe persistent asthma used the portal more than others; 92% were satisfied with MyAsthma. Parents reported that use improved their communication with the office, ability to manage asthma, and awareness of the importance of ongoing attention to treatment. Parents in the intervention group reported that children had a lower frequency of asthma flares and intervention parents missed fewer days of work due to asthma. Use of an EHR-linked asthma portal was feasible and acceptable to families and improved clinically meaningful outcomes. Copyright © 2015 by the American Academy of Pediatrics.
Article
Patient preferences are an important topic of study with respect to attention-deficit hyperactivity disorder (ADHD) interventions, as there are multiple treatment choices available, multiple developmental levels to consider, and multiple potential individuals involved in treatment (children, parents, and adults with ADHD). Stated preference methods such as discrete choice experiment (DCE), best-worst scaling (BWS), and other utility value methods such as standard gamble interview (SGI) and time trade-off (TTO) are becoming more common in research addressing preferences for ADHD treatments. A synthesis of this research may facilitate improved patient-centered and family-centered treatment for ADHD. The purpose of this review was to synthesize reports across existing DCE, BWS, TTO, and SGI studies to assess which aspects of ADHD treatment are most studied as well as most preferred and influential in treatment decisions. MEDLINE, PsycINFO. A total of 41 studies referring to preferences for ADHD treatment were identified through the initial search and contact with researchers. Of these, 13 reported ADHD treatment preference data from a study using DCE, BWS, or SGI methods. No TTO studies were identified that met inclusion criteria. Methods and designs varied considerably across studies. Relatively few studies focused on preferences among children, adolescents, and adults compared with those that focused on the preferences of parents of children with ADHD. The majority of studies focused primarily on medication treatments, with many fewer focused on psychosocial treatments. Some studies indicated that parents of children with ADHD prefer to avoid stimulant medications in favor of behavioral or psychosocial interventions. Others report that parents see medication as a preferred treatment. Treatment outcome is a particularly salient attribute for treatment decisions for many informants. Potential outcomes of various treatments play a proximal role in patients' and families' decisions for ADHD treatment. Because the majority of studies focus on medication treatments for children with ADHD, more research is necessary to understand preferences related to behavioral and other psychosocial treatments both as stand-alone interventions and used in combination with medication. Additional research is also needed to assess the treatment preferences of adults with ADHD. In general, DCE, BWS, and SGI methods allow measurement of patient preferences in a manner that approximates the uncertainty and trade-offs inherent in real-world treatment decision making and provides valuable information to inform patient-centered and family-centered treatment.
Article
Objective Substantial investment in electronic health records (EHRs) has provided an unprecedented opportunity to use clinical decision support (CDS) to increase guideline adherence. To inform efforts to maximize adoption, we characterized the adoption of an otitis media (OM) CDS system, the impact of performance feedback on adoption, and the effects of adoption on guideline adherence.Study SettingA total of 41,391 OM visits with 108 clinicians at 16 pediatric practices between February 2009 and August 2010.Study DesignProspective cohort study of EHR-based CDS adoption during OM visits, comparing clinicians receiving performance feedback to none. CDS was available to all physicians; use was voluntary.Data CollectionExtraction from a common EHR.Principal FindingsClinicians and practices used the CDS system for a mean of 21 percent (range: 0–85 percent) and 17 percent (0–51 percent) of eligible OM visits, respectively. Clinicians who received performance feedback reports summarizing CDS use and guideline adherence had a relative increase in CDS use of 9.0 percentage points compared to others (p = .001). CDS adoption was associated with increased OM guideline adherence. Effects were greatest among clinicians with the lowest adherence prior to the study.Conclusions Performance feedback increased CDS adoption, but additional strategies are needed to integrate CDS into primary care workflows.
Article
Children with attention-deficit/hyperactivity disorder (ADHD) experience significant difficulties with behavior, social functioning, and academic performance in elementary school classrooms. Although psychotropic medication may enhance classroom behavior, pharmacologic treatment is rarely sufficient in addressing the many challenges encountered by individuals with ADHD in school settings. This article describes 3 evidence-based strategies including behavioral, academic, and self-regulation interventions. Future directions for research on school-based interventions are discussed.
Article
A number of evidence-based treatments are available for attention-deficit/hyperactivity disorder (ADHD), including pharmacological, psychosocial, or a combination of the two treatments. For a significant number of children diagnosed with ADHD, however, these treatments are not utilized or adhered to for the recommended time period. Given that adherence to treatment regimens is necessary for reducing the symptoms of ADHD, it is crucial to develop a comprehensive understanding of why adherence rates are so low. The current review examines the literature to date that has directly explored utilization and adherence issues related to the treatment of ADHD in order to identify the key barriers to treatment. This review focused on four main factors that could account for the poor rates of treatment utilization and adherence: personal characteristics (socio-demographic characteristics and diagnostic issues), structural barriers, barriers related to the perception of ADHD, and barriers related to perceptions of treatment for ADHD. This review included 63 papers and covered a variety of barriers to treatment that have been found in research to have an impact on treatment adherence. Based on this review, we conclude that there are complex and interactive relationships among a variety of factors that influence treatment utilization and adherence. Four main gaps in the literature were identified: (1) there is limited information about barriers to psychosocial interventions, compared to pharmacological interventions; (2) there is a limited variety of research methodology being utilized; (3) treatment barrier knowledge is mostly from parents' perspectives; and (4) treatment utilization and treatment adherence are often studied jointly. Information from this review can help practitioners to identify potential barriers to their clients being adherent to treatment recommendations.
Article
Abstract Developing collaborations between families and schools to promote academic success has a long-standing basis in research and is the focus of numerous programs and policies. We outline some of the mechanisms through which parental school involvement affects achievement and identify how patterns and amounts of involvement vary across cultural, economic, and community contexts and across developmental levels. We propose next steps for research, focusing on the importance of considering students' developmental stages, the context in which involvement takes place, and the multiple perspectives through which involvement may be assessed. Finally, we discuss enhancing involvement in diverse situations.
Article
Electronic reminders are increasingly used to improve patient adherence to chronic medication in clinical practice. We conducted a meta-analysis of randomized controlled trials (RCTs) up to January 2014 to evaluate effects of electronic reminders on patient adherence to medication in chronic disease care. A random-effects meta-analysis method was used to pool outcome data. Subgroup analyses were performed to examine a set of moderators. Data from 20 studies, representing 22 RCTs, were synthesized. Thirteen trials utilized short message service (SMS) reminders, three used pager reminders, and six employed electronic alarm device-triggered reminders. The meta-analysis showed that the use of electronic reminders was associated with statistically significant, yet small, improvement in patient adherence to medication (pooled Cohen’s d = 0.29, 95% confidence interval (CI) = 0.18 - 0.41; p < 0.001). The effect was sensitive to sample size, type of disease, and intervention duration. The frequency and type of electronic reminders appeared to have no moderating effect on medication adherence. The use of electronic reminders seems to be a simple and potentially effective way to improve patient adherence to chronic medication. Future studies should give high priority to research concerning innovative electronic reminders in an effort to augment their effectiveness.
Article
To review the pathophysiology, etiology, and treatment of attention-deficit hyperactivity disorder (ADHD). A literature search was conducted in PubMed and EMBASE using the terms attention deficit hyperactive disorder, ADHD, pathophysiology, etiology, and neurobiology. Limits applied were the following: published in the past 10 years (January 2003 to August 2013), humans, review, meta-analysis, and English language. These yielded 63 articles in PubMed and 74 in EMBASE. After removing duplicate/irrelevant articles, 86 articles and their relevant reference citations were reviewed. ADHD is a neurological disorder that affects children, but symptoms may persist into adulthood. Individuals suffering from this disorder exhibit hyperactivity, inattention, impulsivity, and problems in social interaction and academic performance. Medications used to treat ADHD such as methylphenidate, amphetamine, and atomoxetine indicate a dopamine/norepinephrine deficit as the neurochemical basis of ADHD, but the etiology is more complex. Moreover, these agents have poor adverse effect profiles and a multitude of drug interactions. Because these drugs are also dispensed to adults who may have concomitant conditions or medications, a pharmacist needs to be aware of these adverse events and drug interactions. This review, therefore, focuses on the pathophysiology, etiology, and treatment of ADHD and details the adverse effects and drug interaction profiles of the drugs used to treat it. Published research shows the benefit of drug therapy for ADHD in children, but given the poor adverse effect and drug interaction profiles, these must be dispensed with caution.
Article
The concepts of healthcare reform and population health are shifting the emphasis from traditional, volume-based care to a model in which value, or quality, predominates. High quality care will be increasingly rewarded, with financial consequences for poor performance. This shift will be accelerated by the use of healthcare technology, a rapidly growing industry with tools ranging from electronic health records to smart phones and web portals. In this article we highlight pertinent legislative reforms followed by a review of technologies that may play a role in the implementation of these reforms. Pediatric Attention Deficit Hyperactivity Disorder is used as an example given the large number of proposed tools for this condition. While the evidence base is weak for some technologies, research regarding web portals is better developed and will be presented as an example of a technology that may allow practitioners and organizations to improve healthcare quality in several dimensions.
Article
Although primary care practices and schools are major venues for the delivery of mental health services to children, these systems are disconnected, contributing to fragmentation in service delivery. This paper describes barriers to collaboration across the primary care and school systems, including administrative and fiscal pressures, conceptual and linguistic differences between healthcare and educational professionals, role restrictions among professionals, and privacy laws. Strategies for overcoming these barriers that can be applied in both primary care and school settings are described. The paper has a primary focus on children with ADHD, but the principles and strategies described are applicable to children with a range of mental health and health conditions.
Article
To describe the development and validation of an instrument to measure parents' attention deficit-hyperactivity disorder (ADHD) treatment preferences and goals. Parents of children 6 to 12 years of age diagnosed with ADHD in the past 18 months were recruited from 8 primary care sites and an ADHD treatment center (autism excluded). A 16-item medication, 15-item behavior therapy preference scale and a 23-item goal scale, were developed after a review of the literature, 90 parent and clinician semistructured interviews, and input from parent advocates and professional experts were administered to parents. Parent cognitive interviews confirmed item readability, clarity, content, and response range. We conducted an exploratory factor analysis and assessed internal consistency and test-retest reliability and construct and concurrent validity. We recruited 237 parents (mean child age 8.1 years, 51% black, 59% from primary care, 61% of children medication naive). Factor analyses identified 4 medication preference subscales (treatment acceptability, feasibility, stigma, and adverse effects, Cronbach's α 0.74-0.87); 3 behavior therapy subscales (treatment acceptability, feasibility, and adverse effects, α 0.76-0.83); and 3 goal subscales (academic achievement, behavioral compliance, and interpersonal relationships, α 0.83-0.86). The most strongly endorsed goal was academic achievement. The scales demonstrated construct validity, concurrent validity (r = 0.3-0.6) compared with the Treatment Acceptability Questionnaire and Impairment Rating Scale and moderate to excellent test-retest reliability (intraclass coefficient = 0.7-0.9). We developed a valid and reliable instrument for measuring preferences and goals for ADHD treatment, which may help clinicians more easily comply with new national treatment guidelines for ADHD that emphasize shared decision making.
Article
Strategies that are most effective in both prevention and management of chronic disease consider factors such as age, ethnicity, community, and technology. Most behavioral change strategies derive their components from application of the health belief model, the theory of reasoned action/theory of planned behavior, transtheoretical model, and social cognitive theory. Many tools such as the readiness ruler and personalized action plan form are available to assist health care teams to facilitate healthy behavior change. Primary care providers can support behavior changes by providing venues for peer interventions and family meetings and by making new partnerships with community organizations.
Article
Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral condition that impairs functioning throughout childhood and adolescence. Evidence-based guidelines for the treatment of ADHD recommend recognizing ADHD as a chronic condition. The chronic care model for child health emphasizes the need for productive interactions between an informed, activated family and a prepared, proactive practice team. Key parent-physician interactions in the treatment of a child with ADHD include: family education, treatment goal setting, treatment plan formation, cardiovascular screening, medication titration and ongoing monitoring and treatment plan revision. Most care for children/adolescents with ADHD is provided in community-based primary care settings where there are significant barriers to delivering high-quality care to children with chronic conditions. This article reviews recommended physician-parent interactions, examines current practice patterns and identifies facilitators and barriers to the implementation of recommended practices for ADHD care.
Article
This study examines the psychometric properties of the Vanderbilt AD/HD Diagnostic Teacher Rating Scale (VADTRS) and provides preliminary normative data from a large, geographically defined population. The VADTRS consists of the complete list of DSM-IV AD/HD symptoms, a screen for other disruptive behavior disorders, anxiety and depression, and ratings of academic and classroom behavior performance. Teachers in one suburban county completed the scale for their students during 2 consecutive years. Statistical methods included (a) exploratory and confirmatory latent variable analyses of item data, (b) evaluation of the internal consistency of the latent dimensions, (c) evaluation of latent structure concordance between school year samples, and (d) preliminary evaluation of criterion-related validity. The instrument comprises four behavioral dimensions and two performance dimensions. The behavioral dimensions were concordant between school years and were consistent with a priori DSM-IV diagnostic criteria. Correlations between latent dimensions and relevant, known disorders or problems varied from .25 to .66.
Article
To summarize knowledge on treatment services for children and adolescents with attention-deficit hyperactivity disorder (ADHD), trends in services from 1989 to 1996, types of services provided, service mix, and barriers to care. A review of the literature and analyses from 2 national surveys of physician practices are presented. Major shifts have occurred in stimulant prescriptions since 1989, with prescriptions now comprising three fourths of all visits to physicians by children with ADHD. Between 1989 and 1996, related services, such as health counseling, for children with ADHD increased 10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from 40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more than 90% of visits to only 75%. Family practitioners were more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or recommend follow-up care. About 50% of children with identified ADHD seen in real-world practice settings receive care that corresponds to guidelines of the American Academy of Child and Adolescent Psychiatry. Physicians reported significant barriers to service provision for these children, including lack of pediatric specialists, insurance obstacles, and lengthy waiting lists. The trends in treatment services and physician variations in service delivery point to major gaps between the research base and clinical practice. Clinical variations may reflect training differences, unevenness in the availability of specialists and location of services, and changes in health care incentives.
Article
Effective chronic illness interventions generally rely on multidisciplinary care teams. Successful teams often include nurses and pharmacists with clinical and behavioural skills. Such teams ensure that critical elements of care that doctors may not have the training or time to do well are competently performed. These elements include population management, protocol based regulation of medication, self management support, and intensive follow up. The participation of medical specialists in consultative and educational roles outside conventional referrals may contribute to better outcomes.
Article
This study describes 4 help-seeking steps among children at high risk for attention deficit hyperactivity disorder (ADHD), and identifies barriers to ADHD symptom detection and treatment. Using a district-wide stratified random sample of 1615 elementary school students screened for ADHD risk, predictors of 4 help-seeking steps among a high-risk group (n = 389) and parent-identified barriers to care among children with unmet need for ADHD care (n = 91) were assessed. Study findings indicate that although 88% of children were recognized as having a problem, only 39% had been evaluated, 32% received an ADHD diagnosis, and 23% received current treatment. Older children and those with more severe behavior problems were more likely to be perceived by their parents as having a problem. Additionally, gender and ethnic disparities in the subsequent help-seeking process emerged. Boys had over 5 times the odds than girls of receiving an evaluation, an ADHD diagnosis, and treatment. Compared to African American youth, Caucasian children had twice the odds of taking these help-seeking steps. For those children with unmet need for ADHD care, poverty predicted lower treatment rates and was associated with the most pervasive barriers. The gap between parental problem recognition and seeking services suggests that thresholds for parental recognition of a child behavior problem and for seeking ADHD services may be different. Future research examining the help-seeking process for ADHD should include a qualitative component to explore the potential mechanisms for gender and ethnic differences.
Article
To explore the application of the original Charles et al. model of shared treatment decision-making [Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44:681-92; Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999;49:651-61] in the context of general practice, and to determine whether the model needs tailoring for use in this clinical context. Conceptual paper, presenting the defining characteristics of general practice compared to the original clinical context for which the model was developed (i.e. life threatening disease with different treatment options), and exploring how the model can be tailored for use in the context of general practice. We identify two areas where the original model requires tailoring: sharing the decision-making around agreeing on an agenda for each consultation; and adapting the information transfer component of the model to acknowledge that doctors may not be the only, or even the main, source of technical information for patients. Finally, we explore the importance of shared decision-making in the context of chronic disease. The Charles et al. model can be tailored for use in general practice. Tailoring the model for use in general practice has implications for research, in terms of identifying the additional physician competencies needed for implementation. Policy makers who wish to promote shared decision-making need to ensure that incentives which prioritize access and health outcomes do not militate against shared decision-making in general practice.
Article
The objective of the present paper was to determine the association between parent-provider communication and parent ratings of satisfaction and quality of care for a group of parents of children identified with a psychosocial problem. A sample of 804 parents of children with psychosocial concerns enrolled in the Child Behavior Study (CBS) was used for the present analyses. As part of the CBS, parents of children with psychosocial problems answered questions that assessed parent-provider communication and parent ratings of satisfaction and quality of care. Overall, parents reported good communication with their child's provider. Eighty-two percent of parents were very satisfied with the care received and 68% reported a very high quality of care. Parent-provider communication (e.g., collaboration and mutual understanding) was strongly related to parental reports of both satisfaction and quality of care. Parent-provider communication is an important correlate of parental report of satisfaction and quality of care. Involvement of parents in the treatment planning process was particularly important in determining satisfaction and quality ratings within this sample. When working with families with identified psychosocial concerns, the use of collaboration and an empathic style by providers may enhance the quality of care parents report receiving from their primary care clinicians.
Article
The objective of this study was to test the hypothesis that clinical alerts for routine pediatric vaccinations within an electronic health record would reduce missed opportunities for vaccination and improve immunization rates for young children in an inner-city population. A 1-year intervention study (September 1, 2004, to August 31, 2005) with historical controls was conducted in 4 urban primary care centers affiliated with an academic medical center. All children who were younger than 24 months were enrolled. Electronic health record-based clinical reminders for routine childhood vaccinations were programmed to appear prominently at every patient encounter with vaccines due. The main outcome measures were rates of captured immunization opportunities and overall immunization rates at 24 months of age. Immunization alerts appeared at 15,928 visits during the intervention. Alert implementation was associated with increases in captured immunization opportunities from 78.2% to 90.3% at well visits and from 11.3% to 32.0% at sick visits. Adjusted up-to-date immunization rates at 24 months of age increased from 81.7% to 90.1% from the control to intervention period. Children in the intervention group also became up-to-date earlier than control patients. Patient characteristics were stable throughout the study. An electronic health record-based clinical alert intervention was associated with increases in captured opportunities for vaccination at both sick and well visits and significant improvements in immunization rates at 2 years of age. As electronic health records become more common in medical practice, such systems may transform immunization delivery to children.
ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis
  • G V Polanczyk
  • E G Willcutt
  • G A Salum
  • C Kieling
  • L A Rohde
Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol 2014;43 (02):434-442