July 8, 2008 An innovative program is helping busy primary care physicians improve the care they provide for school-aged children with Attention-Deficit/Hyperactivity Disorder (ADHD), according to a study led by researchers at Cincinnati Children's Hospital Medical Center and published in the July edition of Pediatrics.
The study is the first to intervene with an entire community of primary care physicians and help them more accurately diagnose and effectively monitor treatment response of their patients with ADHD, said Jeff Epstein, Ph.D., director of the Center for ADHD at Cincinnati Children's and lead author of the study. Although community practitioners are the first point of contact for children with ADHD, the use of standardized evidence-based diagnosis and treatment guidelines established by the American Academy of Pediatrics (AAP) was infrequent at most of the participating pediatric practices before the study began.
The intervention consisted of an innovative training program developed by Cincinnati Children's on how to implement AAP diagnosis and treatment guidelines. The training focused on modifying office systems to accommodate the AAP guidelines, said Dr. Epstein. This included building in the use of parent and teacher ADHD rating scales into the evaluation and treatment monitoring process.
After 84 Cincinnati-area community physicians finished training and implemented AAP guidelines at their practices, the use of ADHD child assessment rating scales by parents and teachers soared from 55 percent and 52 respectively to nearly 100 percent, the research team reported. This led to more accurate diagnosis of prospective patients and fewer children being started on medication inappropriately. Systematic monitoring of patient medication response improved from a baseline of 9 percent to over 40 percent. For patients who were being monitored systematically, most had documentation of significant symptom reduction during their first several months of treatment
"An additional benefit of the intervention is it appears that as a result of participating in the intervention, physicians in the community are now better equipped to recommend alternatives to medication -- such as behavioral therapy -- engage families in setting treatment goals, and more effectively coordinate care with the child's school.," said Dr. Epstein.
ADHD is the most commonly diagnosed behavioral disorder in childhood, with prevalence rates among grade-schoolers children estimated at 3 to 8 percent. ADHD is characterized by developmentally inappropriate symptoms of inattention, hyperactivity and impulsivity. These symptoms produce significant impairment in school performance, social interactions with peers and family, daily self-management activities and self-esteem.
Although ADHD is classified as a mental disorder, the majority of children with ADHD are evaluated and treated by primary care physicians rather than by mental health specialists. The AAP has encouraged its members to become more knowledgeable about best-practice standards for ADHD diagnosis and management and in 2001 published an evidence-based guideline for pediatricians to follow.
"A significant problem, both locally and nationally, is that guidelines, once published, rarely find their way quickly into clinical usage," Dr. Epstein said. "A large part of the problem is that no means exists for systematically exposing physicians to the guidelines and teaching them how to adapt them for use in their busy practices. This was the case in the Cincinnati-area practices with the ADHD guidelines."
The research team consisted of an interdisciplinary group of doctors from the divisions of General and Community Pediatrics, Behavioral Medicine and Clinical Psychology, Child and Adolescent Psychiatry and Developmental Disabilities at Cincinnati Children's Hospital Medical Center. Funding support was provided by a grant from the Patient Innovation Fund at Cincinnati Children's.
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