Improving Attention-Deficit/Hyperactivity Disorder Treatment Outcomes Through Use of a Collaborative Consultation Treatment Service by Community-Based Pediatricians

Using session recordings to understand the content of community-based treatment for childhood anxiety disorders and response to technology-based training

OBJECTIVE

The goal of the current study is to advance efforts to increase the quality of care for childhood anxiety disorder (CADs) through (1) detailing the content of community-based treatment sessions, (2) exploring the validity of therapist surveys, (3) examining the influence of setting differences, and (4) testing the effects of a technology-based training on use of nonexposure strategies.

METHODS

Thirteen therapists were randomly assigned to technology-based training in the use of exposure therapy or treatment as usual (TAU) for CADs. Therapeutic techniques were coded from 125 community-based treatment sessions.

RESULTS

Consistent with survey responses community therapists spent the majority of session time reviewing symptoms (34% of session time), implementing nonexposure cognitive behavioral therapy (CBT; 36%), and rarely engaged in exposure (3%). An integrated behavioral health setting was associated with greater endorsement of exposure on survey, p < 0.05, although this difference was not significant in session recordings, p = 0.14. Multilevel models indicated that technology-based training that has been shown to increase exposure, also decreased use of nonexposure CBT techniques (2% vs. 29%, p < 0.001).

CONCLUSION

The study supports the validity of survey-based findings that community-based care for CADs consists of non-exposure CBT techniques. Efforts should be invested in dissemination of within-session exposure.

Carer perspectives of a transition to adult care model for adolescents with an intellectual disability and/or autism spectrum disorder with mental health comorbidities

BACKGROUND

Transition to adult care for adolescents with an intellectual disability and/or autism spectrum disorder with coexisting mental health disorders, often termed 'dual disability', is complex. It requires a family-centred approach, with collaboration among health, disability and social services and early planning.

AIM

To describe carer perspectives of transition to adult care and the outcomes of a transition support intervention, Fearless, Tearless Transition, for adolescents with dual disabilities piloted at a tertiary children's hospital.

METHODS

Carers of adolescents with a dual disability were invited to complete a survey at the commencement of their participation in the Fearless, Tearless Transition model, and again at the conclusion of the project. Within this intervention, carers and adolescents were encouraged to attend dedicated transition clinics and participate in a shared care general practitioner (GP) and paediatrician process.

RESULTS

One hundred and fifty-one carers of adolescents with dual disabilities were included in Fearless, Tearless Transition. Of this cohort, 138 adolescents and their carers received support in a dedicated transition clinic with 99 carers completing the initial survey at the commencement of the model. Eighty-two per cent of carers reported moderate to high levels of anxiety about transitioning from paediatric to adult care with 39% feeling 'unprepared' about transition. Eighty-one per cent reported having inadequate access to respite care with 47% reporting a lack of access to services in the community and 56% expressing dissatisfaction with their GPs. One hundred and two families participated in the shared care process with 80 GPs and 33 paediatricians. Twenty-two carers completed the second survey reporting a modest but significant improvement in preparedness for transition to adult care.

CONCLUSION

This study highlights the potential to improve transition outcomes for adolescents with dual disabilities and their carers through early, centralized transition planning, consistent methods of assessing adolescent and carer needs and shared care.

Dose titration of osmotic release oral system methylphenidate in children and adolescents with attention-deficit hyperactivity disorder: a retrospective cohort study

BACKGROUND

Osmotic release oral system methylphenidate (OROS-MPH) is one of the most commonly used medication for attention-deficit hyperactivity disorder (ADHD), however, real-world knowledge on OROS-MPH dose titration has been limited. This study aims to summarize and visualise the OROS-MPH titration patterns in children and adolescents with ADHD in the United States (US) and Japan.

METHODS

This retrospective cohort study used the US IBM® MarketScan® Commercial Claims and Encounters database from 2000 to 2019 and the Japan Medical Data Centre database from 2008 to 2019. New OROS-MPH users with ADHD were identified and split into child (6 to < 13 years) and adolescent (13 to < 18 years) groups according to age at OROS-MPH initiation/reinitiation. Patient characteristics and OROS-MPH treatment patterns were described. OROS-MPH dose titration pathways were visualised by Sankey diagrams.

RESULTS

We included 98,973 children and 62,002 adolescents in the US cohort, and 4595 children and 1508 adolescents in the Japanese cohort. In Japanese cohort, 91.9% of children and 77.9% of adolescents initiated OROS-MPH at the lowest dose (18 mg/day), whereas US patients had a broader distribution of initial doses (e.g., 18-54 mg/day). The US patients had higher daily dose of OROS-MPH than Japanese patients. Overall, a minority (< 40%) of the OROS-MPH users underwent dose titration, and different titration patterns were observed between the US and Japanese patients.

CONCLUSIONS

Different treatment and titration patterns of OROS-MPH were observed in the two countries. Additional real-world studies about clinical reasoning underlying dose selection are needed to support clinical decision-making.

Clinical decision support methods for children and youths with mental health disorders in primary care

BACKGROUND

Mental health disorders among children and youths are common and often have negative consequences for children, youths, and families if unrecognized and untreated. With the goal of early recognition, primary care physicians (PCPs) play a significant role in the detection and referral of mental disorders. However, PCPs report several barriers related to confidence, knowledge, and interdisciplinary collaboration. Therefore, initiatives have been taken to assist PCPs in their clinical decision-making through clinical decision support methods (CDSMs).

OBJECTIVES

This review aimed to identify CDSMs in the literature and describe their functionalities and quality.

METHODS

In this review, a search strategy was performed to access all available studies in PubMed, PsychINFO, Embase, Web of Science, and COCHRANE using keywords. Studies that involved CDSMs for PCP clinical decision-making regarding psychosocial or psychiatric problems among children and youths (0-24 years old) were included. The search was conducted according to PRISMA-Protocols.

RESULTS

Of 1,294 studies identified, 25 were eligible for inclusion and varied in quality. Eighteen CDSMs were described. Fourteen studies described computer-based methods with decision support, focusing on self-help, probable diagnosis, and treatment suggestions. Nine studies described telecommunication methods, which offered support through interdisciplinary (video) calls. Two studies described CDSMs with a combination of components related to the two CDSM categories.

CONCLUSION

Easy-to-use CDSMs of good quality are valuable for advising PCPs on the detection and referral of children and youths with mental health disorders. However, valid multicentre research on a combination of computer-based methods and telecommunication is still needed.

Guideline adherence in German routine care of children and adolescents with ADHD: an observational study

Although guidelines for the assessment and treatment of mental disorders in childhood and adolescence have been available in Germany for several years, there are barely any data on adherence to guidelines in national routine care. Therefore, the study aimed at a nationwide evaluation of guideline adherence (GA) for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) in German routine care in various groups of health care providers (HCPs). Besides a detailed description of GA, the study focused on examining possible differences between professional groups. Furthermore, data based on global self-reports of clinicians were compared with ratings of documented care in individual patients. Protocols of 73 clinicians regarding their handling of ADHD in routine care for 167 patients were rated according to German guideline recommendations for ADHD care. GA was measured as the proportion of components fulfilled in each individual patient as documented by the HCP. The results were compared to a preceding interview with clinicians regarding their GA. Multilevel models were constructed to detect differences in GA between professional groups. Based on mandatory guideline components, adherence rates of 38.9-72.7% were found and classified as moderate (33.3% < GA ≤ 66.6%) to high (GA > 66.6%). The comparison of the GA between the professional groups generally yielded only small differences. Correlations between GA reported globally by the HCPs and GA documented and rated for individual cases were low. Overall, most rates of GA for ADHD in German routine care lay within a moderate range. Targets for enhancement of GA may be the involvement of teachers and schools in the treatment process, the implementation of psychoeducational methods in general, as well as a careful examination of patients, including monitoring of treatment effects during titration trials. The development of further strategies to monitor the quality of ADHD routine care is needed.

Effects of Collaborative Care for Comorbid Attention Deficit Hyperactivity Disorder Among Children With Behavior Problems in Pediatric Primary Care

This study evaluates the impact of a 6-month care management intervention for 206 children diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) from a sample of 321 five- to 12-year-old children recruited for treatment of behavior problems in 8 pediatric primary care offices. Practices were cluster-randomized to Doctor Office Collaboration Care (DOCC) or Enhanced Usual Care (EUC). Chart reviews documented higher rates of service delivery, prescription of medication for ADHD, and titration in DOCC (vs EUC). Based on complex conditional models, DOCC showed greater acute improvement in individualized ADHD treatment goals and follow-up improvements in quality of life and ADHD and oppositional defiant disorder goals. Medication use had a significant effect on acute and follow-up ADHD symptom reduction and quality of life. Medication continuity was associated with some long-term gains. A collaborative care intervention for behavior problems that incorporated treatment guidelines for ADHD in primary care was more effective than psychoeducation and facilitated referral to community treatment.

Key Components of Effective Pediatric Integrated Mental Health Care Models: A Systematic Review

IMPORTANCE

Emerging evidence suggests that integrated care models are associated with improved mental health care access and outcomes for youths (children ≤12 years and adolescents 12-21 years) served in pediatric primary care settings. However, the key components of these complex models remain unexamined.

OBJECTIVE

To identify and describe the key components of effective pediatric integrated mental health care models.

EVIDENCE REVIEW

The PubMed, Embase, PsycINFO, and Cochrane Controlled Register of Trials electronic databases were searched for relevant peer-reviewed articles published between January 1, 1985, and April 30, 2019. Articles were restricted to those published in the English language. Eligible articles reported original data on youths 17 years or younger, implemented an integrated mental health care model in a pediatric primary care setting, and assessed the model's association with primary outcomes (eg, mental health symptom severity) and secondary outcomes (eg, functional impairment and patient satisfaction). Articles that specified some degree of systematic coordination or collaboration between primary care and mental health professionals were included in the final review. Two independent reviewers extracted data on study design, model type, model components, level of integration, and outcomes. Study quality was assessed using the Jadad scale. Data were analyzed between January 1, 2018, and May 31, 2019.

FINDINGS

Eleven randomized clinical trials involving 2190 participants were included. Three studies focused on youths with depression, 3 on youths with attention-deficit/hyperactivity disorder, and 5 on youths with behavioral disorders. Most studies (9 of 11) implemented either the collaborative care model (n = 3), a slightly modified version of the collaborative care model (n = 2), or colocated care (n = 4). The most commonly reported components of effective pediatric integrated mental health care models were population-based care, measurement-based care, and delivery of evidence-based mental health services; all 3 components were present in studies reporting clinical improvement of mental health symptoms. Other model components, such as treatment-to-target or team-based care, were common in studies reporting specific outcomes, such as functional impairment.

CONCLUSIONS AND RELEVANCE

This review is the first to date to systematically search and qualitatively synthesize information on the key components of effective pediatric integrated mental health care models. This knowledge may be especially useful for pediatric primary care administrators in the selection of an integrated care model for their setting.

Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population

OBJECTIVE

In a novel model of embedded primary care child psychiatry serving an urban Latino population, we examined determinants of successful referral and relationship between clinical need and service intensity.

METHODS

We conducted a chart review of referred patients from July 2013-March 2015. We used multiple logistic regressions controlling for confounders to identify determinants of successful referral. We examined the relationship between service intensity and clinical need using Poisson regression, adjusting for exposure time, age, sex, ethnicity, and language.

RESULTS

Seventy-four percent of patients completed an evaluation. Younger children (p=.0397) and those with a history of therapy (p=.0077) were more likely to make initial contact. The markers of clinical need included PSC-35 Global Scores (p=.0027) and number of psychiatric diagnoses (p=.0178) predicted number of visits.

CONCLUSIONS

Our findings support early referral to improve engagement, and provide initial evidence that embedded child psychiatry consultation is feasible and may increase access to care.

Having a Regular Primary Care Provider Is Associated With Improved Markers of Well-Being Among Children With Attention-Deficit Hyperactivity Disorder

We examined the association between having a regular primary care physician (PCP) and measures of flourishing and academic success in children with attention-deficit hyperactivity disorder (ADHD). We performed a cross-sectional study using data from the 2011-2012 National Survey of Children's Health. Children aged 6 to 17 years with a diagnosis of ADHD were included in the study (n = 8173). The exposure was whether the guardian identified a regular PCP for their child. The outcomes were parental-reported measures of child well-being and academic performance. Among the study population, 8.9% reported no regular PCP. These children were found to be significantly less likely to finish assigned tasks (adjusted odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.35-0.79), care about school (adjusted OR = 0.62, 95% CI = 0.38-0.92), and finish homework (adjusted OR = 0.58, 95% CI = 0.36-0.88). There were no differences in other examined outcomes. Enhancing longitudinal care for this population may optimize their academic performance.

Integration of Pediatric Behavioral Health Services in Primary Care: Improving Access and Outcomes with Collaborative Care

OBJECTIVE

To examine collaborative care interventions to integrate pediatric mental health services into primary care as a means of addressing barriers to mental health service delivery, improving access to care, and improving health outcomes.

METHOD

Selective review of published literature addressing structural and attitudinal barriers to behavioural health service delivery and the integration of behavioural health services for pediatric mental problems and disorders into primary care settings, with a special focus on Canadian and U.S.

RESULTS

Integration of pediatric behavioural health services in primary care has potential to address structural and attitudinal barriers to care delivery, including shortages and the geographical misdistribution of behavioural health specialists. Integration challenges stigma by communicating that health cannot be compartmentalized into physical and mental components. Stepped collaborative care interventions have been demonstrated to be feasible and effective in improving access to behavioural health services, outcomes, and patient and family satisfaction relative to existing care models.

CONCLUSION

Collaborative integration of behavioural health services into primary care is a promising means of improving access to care and outcomes for children and adolescents struggling with mental problems and disorders. Dissemination to real-world practice settings will likely require changes to existing models of reimbursement and the culture of health service delivery.

Comparing Two Models of Integrated Behavioral Health Programs in Pediatric Primary Care

This study examined how to design, staff, and evaluate the feasibility of 2 different models of integrated behavioral health programs in pediatric primary care across primary care sites in the Bronx, NY. Results suggest that the Behavioral Health Integration Program model of pediatric integrated care is feasible and that hiring behavioral health staff with specific training in pediatric, evidence-informed behavioral health treatments may be a critical variable in increasing outcomes such as referral rates, self-reported competency, and satisfaction.

Quality improvement, implementation, and dissemination strategies to improve mental health care for children and adolescents: a systematic review

BACKGROUND

Some outcomes for children with mental health problems remain suboptimal because of poor access to care and the failure of systems and providers to adopt established quality improvement strategies and interventions with proven effectiveness. This review had three goals: (1) assess the effectiveness of quality improvement, implementation, and dissemination strategies intended to improve the mental health care of children and adolescents; (2) examine harms associated with these strategies; and (3) determine whether effectiveness or harms differ for subgroups based on system, organizational, practitioner, or patient characteristics.

METHODS

Sources included MEDLINE®, the Cochrane Library, PsycINFO, and CINAHL, from database inception through February 17, 2017. Additional sources included gray literature, additional studies from reference lists, and technical experts. Two reviewers selected relevant randomized controlled trials (RCTs) and observational studies, extracted data, and assessed risk of bias. Dual analysis, synthesis, and grading of the strength of evidence for each outcome followed for studies meeting inclusion criteria. We also used qualitative comparative analysis to examine relationships between combinations of strategy components and improvements in outcomes.

RESULTS

We identified 18 strategies described in 19 studies. Eleven strategies significantly improved at least one measure of intermediate outcomes, final health outcomes, or resource use. Moderate strength of evidence (from one RCT) supported using provider financial incentives such as pay for performance to improve the competence with which practitioners can implement evidence-based practices (EBPs). We found inconsistent evidence involving strategies with educational meetings, materials, and outreach; programs appeared to be successful in combination with reminders or providing practitioners with newly collected clinical information. We also found low strength of evidence for no benefit for initiatives that included only educational materials or meetings (or both), or only educational materials and outreach components. Evidence was insufficient to draw conclusions on harms and moderators of interventions.

CONCLUSIONS

Several strategies can improve both intermediate and final health outcomes and resource use. This complex and heterogeneous body of evidence does not permit us to have a high degree of confidence about the efficacy of any one strategy because we generally found only a single study testing each strategy.

TRIAL REGISTRATION

PROSPERO, CRD42015024759 .

Specific Components of Pediatricians' Medication-Related Care Predict Attention-Deficit/Hyperactivity Disorder Symptom Improvement

OBJECTIVE

The development of attention-deficit/hyperactivity disorder (ADHD) care quality measurements is a prerequisite to improving the quality of community-based pediatric care of children with ADHD. Unfortunately, the evidence base for existing ADHD care quality metrics is poor. The objective of this study was to identify which components of ADHD care best predict patient outcomes.

METHOD

Parents of 372 medication-naïve children in grades 1 to 5 presenting to their community-based pediatrician (N = 195) for an ADHD-related concern and who were subsequently prescribed ADHD medication were identified. Parents completed the Vanderbilt ADHD Parent Rating Scale (VAPRS) at the time ADHD was raised as a concern and then approximately 12 months after starting ADHD medication. Each patient's chart was reviewed to measure 12 different components of ADHD care.

RESULTS

Across all children, the mean decrease in VAPRS total symptom score during the first year of treatment was 11.6 (standard deviation 10.1). Of the 12 components of ADHD care, shorter times to first contact and more teacher ratings collected in the first year of treatment significantly predicted greater decreases in patient total symptom scores. Notably, it was timeliness of contacts, defined as office visits, phone calls, or email communication, that predicted more ADHD symptom decreases. Office visits alone, in terms of number or timeliness, did not predict patient outcomes.

CONCLUSION

The magnitude of ADHD symptom decrease that can be achieved with the use of ADHD medications was associated with specific components of ADHD care. Future development and modifications of ADHD quality care metrics should include these ADHD care components.

Accuracy of Electronic Health Record-Derived Data for the Identification of Incident ADHD

OBJECTIVE

To assess the accuracy of electronic health record (EHR)-derived diagnoses in identifying children with incident (i.e., newly diagnosed) ADHD.

METHOD

In 10 large health care organizations, electronic diagnoses data were used to identify all potential cases of incident ADHD among 3- through 9-year-old children. A random sample of records was manually reviewed to determine whether a diagnosis of ADHD was documented in clinician notes.

RESULTS

From electronic diagnoses data, a total of 7,362 children with incident ADHD were identified. Upon manual review of 500 records, the diagnosis of incident ADHD was confirmed in clinician notes for 71.5% (95% confidence interval [CI] = [56.5, 86.4]) of records for 3- through 5-year-old children and 73.6% (95% CI = [65.6, 81.6]) of records for 6- through 9-year-old children.

CONCLUSION

Studies predicated on the identification of incident ADHD cases will need to carefully consider study designs that minimize the likelihood of case misclassification.

Impact of Mental Health Comorbidities on the Community-Based Pediatric Treatment and Outcomes of Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

Children with attention deficit hyperactivity disorder (ADHD) often exhibit psychiatric comorbidities, which may impact illness presentation, diagnosis, and treatment outcomes. Guidelines exist for dealing with these complex cases but little is known about how comorbidities are being handled in community pediatric settings. The purpose of this study was to evaluate how mental health comorbidities affect community physicians' ADHD care practices and patients' symptom trajectories.

METHOD

Medical charts of 319 children presenting at primary care clinics for ADHD-related concerns were reviewed. Physician assessment and treatment behaviors were extracted and parents rated ADHD symptoms at the time of diagnosis and at 3, 6, and 12 months. Baseline ratings were used to group children, as no comorbid mental health condition, internalizing, or externalizing comorbid condition. Multilevel analyses compared community physician care behaviors and ADHD symptom trajectories across groups.

RESULTS

Approximately, 50 percent of the sample met screening criteria for a comorbid mental health condition. For children diagnosed with ADHD and treated with medication, community physician care largely did not differ across groups, but children with internalizing comorbidities made significantly smaller improvements in inattentive and hyperactive/impulsive symptoms compared with children with no comorbidities.

CONCLUSION

Children with ADHD and mental health comorbidities, particularly internalizing disorders, exhibit less robust response to ADHD medication and may require additional testing before starting medication and/or alternative treatment approaches. Potential barriers to conducting comprehensive assessments and to providing multi-modal treatment are discussed.

Impact of a Web-Portal Intervention on Community ADHD Care and Outcomes

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.

Systematic Review of Knowledge Translation Strategies to Promote Research Uptake in Child Health Settings

Strategies to assist evidence-based decision-making for healthcare professionals are crucial to ensure high quality patient care and outcomes. The goal of this systematic review was to identify and synthesize the evidence on knowledge translation interventions aimed at putting explicit research evidence into child health practice.

METHODS

A comprehensive search of thirteen electronic databases was conducted, restricted by date (1985-2011) and language (English). Articles were included if: 1) studies were randomized controlled trials (RCT), controlled clinical trials (CCT), or controlled before-and-after (CBA) studies; 2) target population was child health professionals; 3) interventions implemented research in child health practice; and 4) outcomes were measured at the professional/process, patient, or economic level. Two reviewers independently extracted data and assessed methodological quality. Study data were aggregated and analyzed using evidence tables.

RESULTS

Twenty-one studies (13 RCT, 2 CCT, 6 CBA) were included. The studies employed single (n=9) and multiple interventions (n=12). The methodological quality of the included studies was largely moderate (n=8) or weak (n=11). Of the studies with moderate to strong methodological quality ratings, three demonstrated consistent, positive effect(s) on the primary outcome(s); effective knowledge translation interventions were two single, non-educational interventions and one multiple, educational intervention.

CONCLUSIONS

This multidisciplinary systematic review in child health setting identified effective knowledge translation strategies assessed by the most rigorous research designs. Given the overall poor quality of the research literature, specific recommendations were made to improve knowledge translation efforts in child health.

Collaborative care for children with ADHD symptoms: a randomized comparative effectiveness trial

OBJECTIVES

Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity.

METHODS

We conducted a randomized comparative effectiveness trial of 2 care management systems for 6- to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child's treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year.

RESULTS

Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were -0.14 (95% confidence interval -0.34 to 0.07) for inattention; -0.13 (-0.31 to 0.05) for hyperactivity/impulsivity; -0.09 (-0.28 to 0.11) for oppositionality; and 3.30 (-1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of -0.36 (-0.69 to -0.03), oppositionality -0.40 (-0.75 to -0.05), and social skills 9.57 (1.85 to 17.28).

CONCLUSIONS

Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care.

Variability in ADHD care in community-based pediatrics

BACKGROUND

Although many efforts have been made to improve the quality of care delivered to children with attention-deficit/hyperactivity disorder (ADHD) in community-based pediatric settings, little is known about typical ADHD care in these settings other than rates garnered through pediatrician self-report.

METHODS

Rates of evidence-based ADHD care and sources of variability (practice-level, pediatrician-level, patient-level) were determined by chart reviews of a random sample of 1594 patient charts across 188 pediatricians at 50 different practices. In addition, the associations of Medicaid-status and practice setting (ie, urban, suburban, and rural) with the quality of ADHD care were examined.

RESULTS

Parent- and teacher-rating scales were used during ADHD assessment with approximately half of patients. The use of Diagnostic and Statistical Manual of Mental Disorders criteria was documented in 70.4% of patients. The vast majority (93.4%) of patients with ADHD were receiving medication and only 13.0% were receiving psychosocial treatment. Parent- and teacher-ratings were rarely collected to monitor treatment response or side effects. Further, fewer than half (47.4%) of children prescribed medication had contact with their pediatrician within the first month of prescribing. Most variability in pediatrician-delivered ADHD care was accounted for at the patient level; however, pediatricians and practices also accounted for significant variability on specific ADHD care behaviors.

CONCLUSIONS

There is great need to improve the quality of ADHD care received by children in community-based pediatric settings. Improvements will likely require systematic interventions at the practice and policy levels to promote change.

Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains

OBJECTIVE

Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.

METHOD

A systematic search in PubMed, Ovid, Web of Knowledge, ERIC, and CINAHAL databases (up to February 5, 2013) identified published randomized controlled trials measuring a range of patient and parent outcomes for children and adolescents diagnosed with ADHD (or who met validated cutoffs on rating scales).

RESULTS

Thirty-two of 2,057 nonduplicate screened records were analyzed. For assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardized mean difference [SMD] for positive parenting 0.68; SMD for negative parenting 0.57), parenting self-concept (SMD 0.37), and child ADHD (SMD 0.35), conduct problems (SMD 0.26), social skills (SMD 0.47), and academic performance (SMD 0.28). With probably blinded assessments, significant effects persisted for parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31).

CONCLUSION

In contrast to the lack of blinded evidence of ADHD symptom decrease, behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems. These effects also may feed through into a more positive parenting self-concept but not improved parent mental well-being.

Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial

OBJECTIVE

To assess the efficacy of collaborative care for behavior problems, attention-deficit/hyperactivity disorder (ADHD), and anxiety in pediatric primary care (Doctor Office Collaborative Care; DOCC).

METHODS

Children and their caregivers participated from 8 pediatric practices that were cluster randomized to DOCC (n = 160) or enhanced usual care (EUC; n = 161). In DOCC, a care manager delivered a personalized, evidence-based intervention. EUC patients received psychoeducation and a facilitated specialty care referral. Care processes measures were collected after the 6-month intervention period. Family outcome measures included the Vanderbilt ADHD Diagnostic Parent Rating Scale, Parenting Stress Index-Short Form, Individualized Goal Attainment Ratings, and Clinical Global Impression-Improvement Scale. Most measures were collected at baseline, and 6-, 12-, and 18-month assessments. Provider outcome measures examined perceived treatment change, efficacy, and obstacles, and practice climate.

RESULTS

DOCC (versus EUC) was associated with higher rates of treatment initiation (99.4% vs 54.2%; P < .001) and completion (76.6% vs 11.6%, P < .001), improvement in behavior problems, hyperactivity, and internalizing problems (P < .05 to .01), and parental stress (P < .05-.001), remission in behavior and internalizing problems (P < .01, .05), goal improvement (P < .05 to .001), treatment response (P < .05), and consumer satisfaction (P < .05). DOCC pediatricians reported greater perceived practice change, efficacy, and skill use to treat ADHD (P < .05 to .01).

CONCLUSIONS

Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services.

The integration of behavioral health interventions in children's health care: services, science, and suggestions

Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.

The integration of behavioral health interventions in children's health care: services, science, and suggestions

Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.

Improving care for depression and suicide risk in adolescents: innovative strategies for bringing treatments to community settings

This article reviews the literature on interventions and services for depression and suicide prevention among adolescents, with the goals of placing this science within the context of currently changing health care environments and highlighting innovative models for improving health and mental health. We examine the challenges and opportunities offered by new initiatives and legislation designed to transform the US health and mental health care systems; summarize knowledge regarding the treatment of depression and suicidality/self-harm in adolescents; and describe innovative models for partnering with health systems and communities. This review demonstrates that treatment models and service delivery strategies are currently available for increasing evidence-based care, particularly for depression, and concludes with recommendations for future research and quality improvement initiatives aimed at inspiring additional efforts to put science to work, bridge science and community practice, and develop strategies for partnering with communities to improve care, mental health, and well-being among adolescents.

Dissemination and implementation of evidence-based practices for child and adolescent mental health: a systematic review

OBJECTIVE

Although there has been a dramatic increase in the number of evidence-based practices (EBPs) to improve child and adolescent mental health, the poor uptake of these EBPs has led to investigations of factors related to their successful dissemination and implementation. The purpose of this systematic review was to identify key findings from empirical studies examining the dissemination and implementation of EBPs for child and adolescent mental health.

METHOD

Of 14,247 citations initially identified, 73 articles drawn from 44 studies met inclusion criteria. The articles were classified by implementation phase (exploration, preparation, implementation, and sustainment) and specific implementation factors examined. These factors were divided into outer (i.e., system level) and inner (i.e., organizational level) contexts.

RESULTS

Few studies used true experimental designs; most were observational. Of the many inner context factors that were examined in these studies (e.g., provider characteristics, organizational resources, leadership), fidelity monitoring and supervision had the strongest empirical evidence. Albeit the focus of fewer studies, implementation interventions focused on improving organizational climate and culture were associated with better intervention sustainment as well as child and adolescent outcomes. Outer contextual factors such as training and use of specific technologies to support intervention use were also important in facilitating the implementation process.

CONCLUSIONS

The further development and testing of dissemination and implementation strategies is needed to more efficiently move EBPs into usual care.

Methodology for conducting the children's attention-deficit hyperactivity disorder telemental health treatment study in multiple underserved communities

BACKGROUND

Children living in nonmetropolitan communities are underserved by evidence-based mental health care and are underrepresented in clinical trials.

PURPOSE

In this article, we describe lessons learned in conducting the Children's Attention-Deficit Hyperactivity Disorder (ADHD) Telemental Health (TMH) Treatment Study (CATTS), a randomized controlled trial testing the effectiveness of TMH in improving outcomes of children with ADHD living in underserved communities.

METHODS

Children were referred by primary care providers (PCPs). The test intervention group received six telepsychiatry sessions with each session followed by an caregiver behavior training session delivered in-person by a local therapist. A secure website was used to support decision making by the telepsychiatrists and to facilitate real-time collaboration between the telepsychiatrists and community therapists. The control group received a single telepsychiatry consultation. Questionnaires tapping ADHD symptoms and other outcomes were administered to parents and teachers online through a secure portal from personal computers.

RESULTS

total of 88 PCPs in seven communities referred the 223 children who participated in the trial. Attrition in treatment sessions and research assessments was very low. Lessons learned TMH proved to be a viable means of providing evidence-based pharmacological services to children and training to local therapists. Recruitment was enhanced by offering the control group a telepsychiatry consultation. Site-specific strategies were needed to meet recruitment targets.

CONCLUSIONS

The CATTS trial used methods designed to optimize inclusion of children living in multiple dispersed and underserved areas. The study will serve as a model for other research projects aiming at reducing geographic disparities in access to quality mental health care.

The myADHDportal.com Improvement Program: An innovative quality improvement intervention for improving the quality of ADHD care among community-based pediatricians

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.

Promoting productive interactions between parents and physicians in the treatment of children with attention-deficit/hyperactivity disorder

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.

Use of an Internet portal to improve community-based pediatric ADHD care: a cluster randomized trial

OBJECTIVE

To determine the effectiveness of a quality improvement program to improve pediatricians' adherence to existing, evidence-based, attention-deficit/hyperactivity disorder (ADHD) practice guidelines.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Computer-assisted management of attention-deficit/hyperactivity disorder

OBJECTIVES

Medication management of attention-deficit/hyperactivity disorder (ADHD) is often suboptimal. We examined whether (1) brief physician training plus computer-assisted medication management led to greater reduction in ADHD symptoms and (2) adherence to the recommended titration protocol produced greater symptomatic improvement.

METHODS

A randomized medication trial was conducted that included 24 pediatric practices. Children who met criteria for ADHD were randomly assigned by practice to treatment-as-usual or a specialized care group in which physicians received 2 hours of didactic training on medication management of ADHD plus training on a software program to assist in monitoring improvement. Parent and teacher reports were obtained before treatment and 4, 9, and 12 months after starting medication.

RESULTS

Children in both specialized care and treatment-as-usual groups improved on the ADHD Rating Scales and SNAP-IV, but there were no group differences in improvement rates. Brief physician training alone did not produce improvements. When recommended titration procedures were followed, however, outcomes were better for total and inattentive ADHD symptoms on both the ADHD Rating Scales and SNAP-IV parent and teacher scales. Results were not attributable to discontinuation because of adverse effects or failure to find an effective medication dose.

CONCLUSIONS

Brief physician training alone did not lead to reductions in ADHD symptoms, but adherence to a protocol that involved titration until the child's symptoms were in the average range and had shown a reliable change led to better symptom reduction. Computer-assisted medication management can contribute to better treatment outcomes in primary care medication treatment of ADHD.

Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common condition that often results in child and family functional impairments. Although there are evidence-based treatment modalities available, implementation of and persistence with treatment plans vary with patients. Family preferences also vary and may contribute to variability in treatment utilization.

OBJECTIVE

The objective of this study is to describe the evidence-based treatments available for ADHD, identify patterns of use for each modality, and examine patient and parent treatment preferences.

METHOD

Literature review.

RESULTS

Treatment options differ on benefits and risks/costs. Therefore, treatment decisions are preference sensitive and depend on how an informed patient/parent values the tradeoffs between options. Literature on patient and parent ADHD treatment preferences is based on quantitative research assessing the construct of treatment acceptability and qualitative and quantitative research that assesses preferences from a broader perspective. After a child is diagnosed with ADHD, a variety of factors influence the initial selection of treatment modalities that are utilized. Initial parent and child preferences are shaped by their beliefs about the nature of the child's problems and by information (and misinformation) received from a variety of sources, including social networks, the media, and health care providers. Subsequently, preferences become further informed by personal experience with various treatment modalities. Over time, treatment plans are revisited and revised as families work with their health care team to establish a treatment plan that helps their child achieve goals while minimizing harms and costs.

CONCLUSIONS

Studies have not been able to determine the extent to which utilization rates are consistent with the underlying distribution of informed patient/parent treatment preferences. There are challenges to ensure that patient/parent preferences are consistently well informed, elicited, and discussed in the treatment planning process. Interventions are needed to promote such interactions.

Attention-deficit/hyperactivity disorder and telemental health

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders diagnosed in children and adolescents (youth). ADHD is equally distributed geographically, but services are not. Access to expert evaluation and treatment remains limited for youth with ADHD living in rural areas, as well as for ethnic and racial minority youth. Telepsychiatry is a service delivery model with the potential to reach these youth and to develop collaborative models of care among local primary care physicians, remote telepsychiatrists, and local families. Care delivered through telepsychiatry can readily adhere to the practice parameters of the American Academy of Child and Adolescent Psychiatry. Work to date indicates that ADHD is the most common disorder treated through telepsychiatry. This article reviews the status of child and adolescent telepsychiatry, with particular focus on its potential to improve the care and outcomes of underserved populations of youth diagnosed with ADHD.

Packages of care for attention-deficit hyperactivity disorder in low- and middle-income countries

In the sixth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Alan Flisher and colleagues discuss the treatment of attention-deficit hyperactivity disorder.

Comparing medical homes for children with ADHD and asthma

OBJECTIVE

The aims of our study were, among children with attention-deficit/hyperactivity disorder (ADHD) compared with children with asthma: 1) to assess characteristics associated with parent report of having a medical home for children with either of these 2 conditions; 2) to determine whether, controlling for these characteristics, the likelihood of having a medical home differs between children with ADHD and asthma; and 3) to identify the specific components of a medical home that are lacking for children with these 2 conditions.

METHODS

Cross-sectional analysis of the National Survey of Children with Special Health Care Needs, 2005-2006 (NS-CSHCN) was used. The outcome variable was parent report of their child's practice having specific attributes of the medical home. We used multivariate logistic regression to test whether the likelihood of having a medical home and its components differed for children with ADHD in comparison to children with asthma.

RESULTS

The NS-CSHCN interviewed parents of 11 674 children with ADHD and 13 517 children with asthma aged between 4 to 17 years. Significantly fewer children with ADHD compared with children with asthma have a medical home (OR [odds ratio] 0.68; P < .001). Specifically, parents reported differences in receiving family-centered (OR 0.79; P < .001) and coordinated care (OR 0.59; P < .001).

CONCLUSION

Parents of children with ADHD report worse performance across key dimensions of primary care compared with parents of children with asthma. For primary care to be optimally effective in addressing the needs of children with ADHD, efforts to significantly strengthen these key dimensions are needed.

Health literacy and quality: focus on chronic illness care and patient safety

Despite a heightened focus on improving quality, recent studies have suggested that children only receive half of the indicated preventive, acute, or chronic care. Two major areas in need of improvement are chronic illness care and prevention of medical errors. Recently, health literacy has been identified as an important and potentially ameliorable factor for improving quality of care. Studies of adults have documented that lower health literacy is independently associated with poorer understanding of prescriptions and other medical information and worse chronic disease knowledge, self-management behaviors, and clinical outcomes. There is also growing evidence to suggest that health literacy is important in pediatric safety and chronic illness care. Adult studies have suggested that addressing literacy can lead to improved patient knowledge, behaviors, and outcomes. Early studies in the field of pediatrics have shown similar promise. There are significant opportunities to evaluate and demonstrate the importance of health literacy in improving pediatric quality of care. Efforts to address health literacy should be made to apply the 6 Institute of Medicine aims for quality-care that is safe, effective, patient centered, timely, efficient, and equitable. Efforts should also be made to consider the distinct nature of pediatric care and address the "4 D's" unique to child health: the developmental change of children over time; dependency on parents or adults; differential epidemiology of child health; and the different demographic patterns of children and their families.

Parental angst making and revisiting decisions about treatment of attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral conditions of childhood and adolescence. Despite availability of effective treatment options, initiation of treatment is variable and persistence with therapeutic regimens is poor.

OBJECTIVE

We sought to better understand how parents make decisions about treatment for their child or adolescent with ADHD.

METHODS

We conducted a qualitative study among parents of children and adolescents; 52 parents participated in 1 of 12 focus groups. Parents answered questions about decision-making, information sharing, and sources of conflict and uncertainty. Sessions were audiotaped and transcribed verbatim. Themes were coded independently by 4 of the investigators, who then agreed on common themes.

RESULTS

Parents in our study made decisions about treatment for their child with ADHD in the midst of experiencing a variety of emotions as they witnessed child functional impairments at home and at school. In addition, parents felt stress as a result of their daily efforts to manage their child's struggles. Multiple factors influenced the decision to initiate medication. Subsequently, revisiting the decision to give their child medicine for ADHD was common. Many parents contrasted time on and off medicine to help inform management decisions. Trials stopping medication were almost always parent- or child-initiated.

CONCLUSIONS

Decisions about medication use for children and adolescents with ADHD are made and frequently revisited by their parents. Choices are often made under stressful conditions and influenced by a variety of factors. Striking a balance between benefits and concerns is an ongoing process that is often informed by contrasting time on and off medication. Development of strategies to support families across the continuum of decisions faced while managing ADHD is warranted.

Interventions to promote the evidence-based care of children with ADHD in primary-care settings

Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been published by the American Academy of Pediatrics that provides best-practice diagnostic procedures for primary-care physicians. These recommendations emphasize the importance of using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as the basis for making an ADHD diagnosis and conducting systematic follow-up, including the collection of parent and teacher ratings scales to quantitatively assess response to treatment. Although these recommendations have been widely disseminated and their adoption actively promoted, guideline adherence, in general, is known to be poor. Two types of intervention models, ancillary service and office systems modification, have been proposed to promote adoption of evidence-based ADHD practice in primary-care settings. The present article reviews the efficacy of these intervention models, and discusses the cost and sustainability of each model as related to feasibility of intervention dissemination.

Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians

OBJECTIVES

The goals were to implement and to test a quality-improvement intervention aimed at improving community-based primary care providers' adherence to the American Academy of Pediatrics, evidence-based diagnostic and treatment guidelines for attention-deficit/hyperactivity disorder.

METHODS

Nineteen practices (with 84 primary care providers) from a large urban community were trained by using quality-improvement methods with some academic detailing. Pretraining and posttraining adherence to evidence-based practices was assessed through review of patient charts.

RESULTS

Preintervention rates of guideline usage were uniformly low. After the intervention, primary care providers showed substantial improvement in their use of the guidelines for the assessment and treatment of elementary school-aged patients with newly diagnosed attention-deficit/hyperactivity disorder. Use of parent and teacher assessment rating scales increased from levels of 52% to 55% to levels of nearly 100%. Systematic monitoring of responses to medication improved from a baseline level of 9% to 40%.

CONCLUSIONS

Quality-improvement interventions such as the one used in this study seem quite effective in improving primary care providers' practices at offices that express interest in improving the quality of care for attention-deficit/hyperactivity disorder. The design of the intervention, problems associated with improving and sustaining treatment monitoring, and issues related to generalizability of the intervention model are discussed.