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

Leveraging a Large Language Model to Assess Quality-of-Care: Monitoring ADHD Medication Side Effects

Objective

To assess the accuracy of a large language model (LLM) in measuring clinician adherence to practice guidelines for monitoring side effects after prescribing medications for children with attention-deficit/hyperactivity disorder (ADHD).

Methods

Retrospective population-based cohort study of electronic health records. Cohort included children aged 6-11 years with ADHD diagnosis and ≥2 ADHD medication encounters (stimulants or non-stimulants prescribed) between 2015-2022 in a community-based primary healthcare network (n=1247). To identify documentation of side effects inquiry, we trained, tested, and deployed an open-source LLM (LLaMA) on all clinical notes from ADHD-related encounters (ADHD diagnosis or ADHD medication prescription), including in-clinic/telehealth and telephone encounters (n=15,593 notes). Model performance was assessed using holdout and deployment test sets, compared to manual chart review.

Results

The LLaMA model achieved excellent performance in classifying notes that contain side effects inquiry (sensitivity= 87.2%, specificity=86.3/90.3%, area under curve (AUC)=0.93/0.92 on holdout/deployment test sets). Analyses revealed no model bias in relation to patient age, sex, or insurance. Mean age (SD) at first prescription was 8.8 (1.6) years; patient characteristics were similar across patients with and without documented side effects inquiry. Rates of documented side effects inquiry were lower in telephone encounters than in-clinic/telehealth encounters (51.9% vs. 73.0%, p<0.01). Side effects inquiry was documented in 61% of encounters following stimulant prescriptions and 48% of encounters following non-stimulant prescriptions (p<0.01).

Conclusions

Deploying an LLM on a variable set of clinical notes, including telephone notes, offered scalable measurement of quality-of-care and uncovered opportunities to improve psychopharmacological medication management in primary care.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Effect of a parent agreement on return rates of Vanderbilt assessments and treatment adherence in pediatric attention-deficit/hyperactivity disorder patients

Objective

We implemented a parent–teacher Vanderbilt agreement program to increase return rates of Vanderbilt assessment scales for children in our primary care practice, and compared the assessment return rate before and after agreement signature.

Methods

We retrospectively reviewed children diagnosed with attention-deficit/hyperactivity disorder (ADHD) who had a signed Vanderbilt agreement and were under continuous care at our clinic. Return rates were compared 1 year before and 1 year after the agreement date.

Results

Among 195 children, prior to the agreement, 71% returned teacher assessments, and 59% returned parent forms; after the intervention, assessment rates were not significantly different (76%, p = .255; and 65%, p = .185, respectively). The median number of returned assessments increased after the agreement.

Conclusions

Lack of documented parent and teacher Vanderbilt assessments remain a barrier to appropriate management of ADHD. Improving the rate of assessments returned is an important outcome for treating ADHD in the primary care setting.

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.

Primary Care Management of Children with Attention-Deficit/Hyperactivity Disorder Appears More Assertive Following Brief Psychiatric Intervention Compared with Single Session Consultation

Objectives: We examined primary care providers' (PCPs') management of attention-deficit/hyperactivity disorder (ADHD) during and following families' participation in two arms of the Children's ADHD Telemental Health Treatment Study. We hypothesized that more intensive treatment during the trial would show an "after-effect" with more assertive PCPs' management during short term follow-up. Methods: We conducted a pragmatic follow-up of PCPs' management of children with ADHD who had been randomized to two service delivery models. In the Direct Service Model, psychiatrists provided six sessions over 22 weeks of pharmacotherapy followed by behavior training. In the Consultation Model, psychiatrists provided a single-session consultation and made treatment recommendations to PCPs who implemented these recommendations at their discretion for 22 weeks. At the end of the trial, referring PCPs for both service delivery models resumed ADHD treatment for 10 weeks. We performed intent-to-treat analysis using all 223 original participants. We applied linear regression models on continuous outcomes, Poisson regression models on count outcomes, and logistic regression models to binary outcomes. Missing data were addressed through imputations. Results: Participants in the Direct Service Model had more ADHD visits than those in the Consultation Model across the full 32 weeks (mean = 7.05 visits vs. 3.36 visits; adjusted rate ratio = 2.1 [1.85-2.38]; p < 0.0001). During follow-up, participants in the DSM were more likely to be taking ADHD-related medications (82% vs. 61%; adjusted odds ratio = 2.44 [1.24-4.81], p = 0.01). At 32 weeks, participants in the Direct Service Model had higher stimulant dosages (adjusted difference = 5.64 [0.12-11.15] mg; p = 0.046). Conclusion: These results from a pragmatic follow-up of a randomized trial suggest an "after-effect" for brief intensive treatment in the Direct Service Model on the short term follow-up management of ADHD in primary care.

The Role of Parental Knowledge and Attitudes about ADHD and Perceptions of Treatment Response in the Treatment Utilization of Families of Children with ADHD

The present study examined the impact of parental knowledge and attitudes about attention-deficit/hyperactivity disorder (ADHD), and parental perceptions of treatment response on the utilization of behavioral and pharmacological ADHD treatments, using data from a longitudinal treatment study designed to assess physical growth in children with ADHD. It also explored if these relations were moderated by race/ethnicity. Participants include 230 (74% Hispanic) families of treatment naïve children with ADHD (M age = 7.56, SD = 1.94; 73% male). Families were randomly assigned to receive behavior therapy (BT) or stimulant medication (MED; which also included low dose BT). After 6 months, families whose children still showed at least moderate impairment had access to either treatment for a total of 30 months. Utilization was measured using the number of BT sessions attended and total mg of MED taken over the study period. Families who reported more willingness to use medication for their child's ADHD at baseline were more likely to use MED and less likely to use BT, regardless of race/ethnicity. Parental knowledge about ADHD was only important in predicting BT utilization for White non-Hispanic families. Greater reduction in ADHD symptoms and impairment significantly predicted more MED utilization for Hispanic families. Results highlight the need to explore multiple parent (e.g., medication willingness) and child (e.g., symptom severity) factors when considering treatment utilization. Results also highlight ethnic differences in which factors affect treatment utilization.

Comparison of Attention-Deficit/Hyperactivity Disorder Care Between School-Based Health Centers and a Continuity Clinic

BACKGROUND

School-based health centers (SBHC) are in a unique position to provide guideline-driven attention-deficit/hyperactivity disorder (ADHD) care. In this study, we compared adherence to 2 components of ADHD guidelines in SBHC versus a continuity clinic.

METHODS

We compared proportions of ADHD visits that had a structured symptom report available and timely follow-up in SBHC to a continuity clinic using chart review. We used multiple logistic regression to estimate the association between guideline adherence and clinic type.

RESULTS

Participants who had a medication dose change were 3.9 times more likely (relative risk [RR] = 3.9, 95% confidence interval [CI] 3.0-5.1) to have a structured report present and 1.7 times more likely (RR = 1.7, 95% CI 1.2-2.2) to have follow-up within 30 days if they were seen in SBHC versus continuity clinic. Participants who were stable on their medication dose were 18 times more likely (RR = 18.0, 95% CI 11.3-29.0) to have a structured report present and 1.4 times more likely (RR = 1.4, 95% CI 1.3-1.6) to have follow-up within 100 days if they were seen in SBHC versus continuity clinic.

CONCLUSIONS

Care provided in SBHC was associated with improved adherence to guidelines and has the potential to the improve pediatric ADHD outcomes.

Office Visits to Monitor Stimulant Medication Safety and Efficacy: Recommended Care

The clinical guidance based on the research article, "Specific Components of Pediatricians' Medication-Related Care Predict Attention-Deficit/Hyperactivity Disorder Improvement," published in the June 2017 issue,¹ might be premature. The authors, Epstein et al., suggest that "Physicians do not need to necessarily rely on office visits to monitor medication response and side effects in the week(s) after initially prescribing medication, but instead could use phone calls or email correspondence to check in with the family" (p. 489). However, this advice has the potential to be misinterpreted that phone or email contact is acceptable clinical practice to monitor stimulant medication safety and efficacy, especially during the maintenance phase. It also could be erroneously interpreted that phone or email contact is sufficient for follow-up care for children receiving medication treatment for attention-deficit/hyperactivity disorder (ADHD) for national quality measures.

Predictors of Medication Continuity in Children With ADHD

OBJECTIVES

To identify predictors of attention-deficit/hyperactivity disorder (ADHD) medication continuity, hypothesizing greater continuity among children with (1) greater child acceptance of treatment, (2) parent belief in longer time course for ADHD, (3) positive differential between parent-perceived need for and concerns about medication, and (4) greater parent-perceived alliance with their child's doctor.

METHODS

We conducted a prospective longitudinal cohort of 89 children aged 6 to 10 years old newly treated for ADHD by 1 of 44 pediatricians in 11 practices. Parents completed validated surveys on their beliefs about ADHD and medicine. We audited charts and obtained pharmacy dispensing records. In our analyses, we examined the relationship between predictor variables (eg, sociodemographic and clinical characteristics, quality of care, and belief measures) and short-term (first 90 days after starting medication) and long-term (91-450 days) medication continuity as defined by the number of days covered with medication.

RESULTS

Children had a median of 81% of days covered over 0 to 90 days and 54% of days covered over 91 to 450 days after starting medicine. In the first 90 days, medication coverage related to child age, satisfaction with information about medicine, medication titration, symptom reduction, parent beliefs about control over symptoms, uncertainty about treating with medicine, and working alliance. Long-term medication continuity related to child acceptance of treatment and differential between parent-perceived need for and concerns about medication at 3 months, not baseline factors.

CONCLUSIONS

Adherence is a process that can change over time in response to experiences with treatment. Interventions are needed to promote productive interactions between pediatricians and families in support of continuity.