Intervening to improve communication between parents, teachers, and primary care providers of children with ADHD or at high risk for ADHD

Non-pharmacological treatment of Attention Deficit Disorder with or without Hyperactivity (ADHD). Overview and report of the first international symposium on the non-pharmacological management of ADHD

Attention Deficit Disorder with or without Hyperactivity (ADHD is a neurodevelopmental disorder which affects the day-to-day functioning of children and adults with this condition. Pharmacological treatment can reduce the symptoms associated with ADHD, but it has some limitations. The objective of this symposium is to determine the effects of non-pharmacological approaches on ADHD symptoms. Results indicate that the following intervention are promising approaches: cognitive behavioral therapy (CBT), mindfulness-based interventions (MBI), yoga, cognitive and metacognitive intervention, neurofeedback and parental training programs. Current research advocates multimodal approaches in conjunction with school or work accommodations integrating innovative technologies.

Understanding Barriers and Facilitators of Attention-Deficit/Hyperactivity Disorder Treatment Initiation and Adherence in Black and Latinx Children

OBJECTIVE

Despite evidence that consistent treatment is important for Attention-Deficit/Hyperactivity Disorder (ADHD) management, ADHD treatment initiation and adherence remains suboptimal in minoritized children. The goal of this study was to explore barriers and facilitators to ADHD treatment initiation/adherence for minoritized children to further inform development of our family navigation intervention.

METHODS

Using a virtual platform, we completed 7 focus group sessions (total n.ß=.ß26) and 6 individual interviews with representatives from 4 stakeholder groups: experienced caregivers of children with ADHD, caregivers of children newly diagnosed with ADHD, family navigators, and clinicians who care for children with ADHD. All caregivers identified as Black and/or Latinx. Separate sessions were conducted for each stakeholder group and caregivers had the option to attend an English or Spanish session. Using a thematic analysis strategy, barriers and facilitators to ADHD treatment initiation and/or adherence were coded in focus group/interview data and themes were identified across groups.

RESULTS

The primary barriers to ADHD treatment initiation and/or adherence identified for minoritized children were lack of support from school/healthcare/family members, cultural barriers, limited resources, limited access, and treatmentconcerns, with variability in endorsement across participants. Reported facilitators included caretakers having experience with ADHD, strong support, access to resources, andwitnessing their child...s functional improvement with treatment.

CONCLUSIONS

Caregiver experience with and knowledge about ADHD, support, and access to resources facilitate ADHD treatment in minoritized children. The results from this study have the potential to improve ADHD treatment initiation/adherence and outcomes for minoritized children through the development of culturally tailored, multipronged interventions.

Implementing School-Based Mental Health Services: A Scoping Review of the Literature Summarizing the Factors That Affect Implementation

Background: Mental illness in children and youths has become an increasing problem. School-based mental health services (SBMHS) are an attempt to increase accessibility to mental health services. The effects of these services seem positive, with some mixed results. To date, little is known about the implementation process of SBMHS. Therefore, this scoping review synthesizes the literature on factors that affect the implementation of SBMHS. Methods: A scoping review based on four stages: (a) identifying relevant studies; (b) study selection; (c) charting the data; and (d) collating, summarizing, and reporting the results was performed. From the searches (4414 citations), 360 were include in the full-text screen and 38 in the review. Results: Implementation-related factors were found in all five domains of the Consolidated Framework for Implementation Research. However, certain subfactors were mentioned more often (e.g., the adaptability of the programs, communication, or engagement of key stakeholders). Conclusions: Even though SBMHS differed in their goals and way they were conducted, certain common implementation factors were highlighted more frequently. To minimize the challenges associated with these types of interventions, learning about the implementation of SBMHS and using this knowledge in practice when introducing SBMHS is essential to achieving the best possible effects with SMBHSs.

Impact of attention deficit hyperactivity disorder and gender differences on academic and social difficulties among adolescents in Qatari Schools

Background: To evaluate the social and academic impact of adolescents with Attention Deficit Hyperactivity Disorder (ADHD) and gender differences compared with their non-ADHD peers.

Methods: A cross-sectional descriptive study using a standardized rating scale of teacher observations was conducted in the schools of Qatar from 7^th to 12^th grades. Teachers completed Swanson, Nolan, and Pelham (SNAP-IV) rating scale questionnaires for the ADHD core symptoms together with nine questions to evaluate the academic and social difficulties in all participants.

Results: A total of 1775 students (mean age: 15 ± 1.5 years; boys/girls: 717/1058) were included in this study. Based on the SNAP-IV rating scale, 150 students were showing core symptoms of ADHD and classified as having ADHD (8.5%; boys/girls; 93/57) and 1625 students as non-ADHD peers (91.5%; boys/girls; 624/1001). Prevalence of ADHD among adolescent students is 8.5%, and it varied significantly between genders with 13% of boys and 5.4% of girls affected by this disorder. Adolescents with ADHD had more academic and social difficulties than their non-ADHD peers, the boys more so than the girls. Boys with inattentive subtype of ADHD had more academic difficulties than girls, while girls had more social difficulties than boys.

Conclusion: The results of this study revealed that ADHD among adolescents is substantially associated with academic and social difficulties in the school environment. Gender differences among students with ADHD should be considered in the school and clinical environment.

Partners in School: Optimizing Communication between Parents and Teachers of Children with Autism Spectrum Disorder

Partners in School is a consultation model with the goal of enhancing communication between two of the most important stakeholders in children's lives - parents and teachers. Using a single-group pre-post design, this preliminary study examined the effect of Partners in School on parent-teacher communication outcomes and the factors associated with these outcomes. Participants were 26 teachers and 49 parents of children with autism spectrum disorder (ASD). Parents and teachers completed surveys before and after participating in Partners in School. Teachers reported an increase in their communication to parents. However, parents did not report an increase in their communication to teachers. Teachers' self-efficacy, expectations, and intervention fidelity were associated with increased communication to parents. Parental self-efficacy and teacher experience were associated with parents' reports of communication to teachers. Our findings suggest that family-school consultation services may be used to enhance teachers' communication with parents.

Exploring Factors Influencing Medication Adherence From Initiation to Discontinuation in Parents and Adolescents With Attention Deficit Hyperactivity Disorder

This study explored factors influencing parents' and adolescents' decisions to initiate, continue, and discontinue medication for attention deficit hyperactivity disorder (ADHD). Three focus groups were conducted with parents (n = 23) of children with ADHD, and 2 with adolescents diagnosed with ADHD (n = 11). Parents and adolescents independently discussed the complexities surrounding their decisions to adhere to ADHD medication. Parents' negative beliefs about medication (fear of side effects) discouraged them from initiating therapy. Once initiated, parents struggled in balancing the need to medicate (improvements in learning and behavior) and concerns (weight loss, perceived delayed development) about the medication. Parents who had more concerns about the medication were more in favor of discontinuation. For adolescents, the desire for self-expression without being medicated was the primary factor determining nonadherence and/or discontinuation of the medication. Adolescents' medication-related concerns were relatively different from the parents. Phase- and group-specific interventions are required to improve medication adherence in people with ADHD.

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

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.

School-based Screening to Identify Children At Risk for Attention-Deficit/Hyperactivity Disorder: Barriers and Implications

This report describes a school-based screening project to improve early identification of children at risk for attention-deficit/hyperactivity disorder (ADHD) and communicate these concerns to parents, recommending that they contact their child's primary care provider (PCP). Of 17,440 eligible children in first through fifth grades in five school districts, 47.0% of parents provided required written consent, and teachers completed 70.4% of the online screeners (using the Vanderbilt AD/HD Diagnostic Teacher Rating Scale). Of 5,772 screeners completed, 18.1% of children (n = 1,044) were identified as at risk. Parents of at-risk children were contacted to explain risk status and recommended to visit their child's PCP for further evaluation. It was not possible to contact 39.1% of parents of at-risk children. Of the 636 parents of at-risk children who could be contacted, 53.1% (n = 338) verbally accepted the recommendation to follow-up with their PCP, which was not related to ADHD symptom severity. Parents of children with IEPs or related services were more likely to accept the recommendation to visit the PCP. Our exploration of the potential for school-based screening for ADHD identified a number of barriers to successful execution, but the data also indicated that this is an important problem to address.

Collaboration Between PNPs and School Nurses: Meeting the Complex Medical and Academic Needs of the Child With ADHD

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.

Practitioner Review: Pathways to care for ADHD - a systematic review of barriers and facilitators

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder starting in childhood that may persist into adulthood. It can be managed through carefully monitored medication and nonpharmacological interventions. Access to care for children at risk of ADHD varies both within and between countries. A systematic literature review was conducted to investigate the research evidence related to factors which influence children accessing services for ADHD.

METHOD

Studies investigating access to care for children at risk of ADHD were identified through electronic searches of the international peer-reviewed and grey literature. Databases were searched from inception till 30th April 2012. This identified 23,156 articles which were subjected to three levels of screening (title, abstract and full text) by a minimum of two independent reviewers. Due to the heterogeneity in the study designs, a narrative approach was used to present the findings.

RESULTS

Twenty-seven papers met the inclusion criteria; these were grouped into four main themes, with some papers being included in more than one. These were wider determinants (10 papers); identification of need (9 papers); entry and continuity of care (13 papers) and interventions to improve access (4 papers). Barriers and facilitators to access were found to operate at the individual, organisational and societal level. Limited evidence of effective interventions to improve access was identified.

CONCLUSION

This review explored the multilayered obstacles in the pathway to care for children at risk of ADHD and the lack of evidence-based interventions designed to address these issues, thereby indicating areas for service development and further evaluative research.

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.

Parent training interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years

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.

Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007

OBJECTIVE

To determine patterns of comorbidity, functioning, and service use for US children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Bivariate and multivariable cross-sectional analyses were conducted on data from the 2007 National Survey of Children's Health on 61 779 children ages 6 to 17 years, including 5028 with ADHD.

RESULTS

Parent-reported diagnosed prevalence of ADHD was 8.2%. Children with ADHD were more likely to have other mental health and neurodevelopmental conditions. Parents reported that 46% of children with ADHD had a learning disability versus 5% without ADHD, 27% vs 2% had a conduct disorder, 18% vs 2% anxiety, 14% vs 1% depression, and 12% vs 3% speech problems (all P < .05). Most children with ADHD had at least 1 comorbid disorder: 33% had 1, 16% had 2, and 18% had 3 or more. The risk for having 3 or more comorbidities was 3.8 times higher for poor versus affluent children (30% vs 8%). Children with ADHD had higher odds of activity restriction (odds ratio: 4.14 [95% confidence interval: 3.34-5.15]), school problems (odds ratio: 5.18 [95% confidence interval: 4.47-6.01]), grade repetition, and poor parent-child communication, whereas social competence scores were lower and parent aggravation higher. Functioning declined in a stepwise fashion with increasing numbers of comorbidities, and use of health and educational services and need for care coordination increased.

CONCLUSIONS

Clinical management of ADHD must address multiple comorbid conditions and manage a range of adverse functional outcomes. Therapeutic approaches should be responsive to each child's neurodevelopmental profile, tailored to their unique social and family circumstances, and integrated with educational, mental health and social support services.

Evidence for family-centered care for children with special health care needs: a systematic review

OBJECTIVE

Family-centered care (FCC) has received widespread endorsement for use in care in the United States. In this study, we conducted a systematic review of evidence for FCC focusing specifically on family-provider partnership as the activity that constitutes FCC.

METHODS

We found and reviewed articles from the medical, nursing, psychology, and sociology literature spanning 1986 to 2010. We also reviewed articles obtained through related references and through recommendations from key informants. Four sets of terms were used to search, including FCC, child/adolescent, children with special health care needs (CSHCN, defined broadly or by condition), and a relevant outcome.

RESULTS

Twenty-four studies met the review criteria. Eight were cross-sectional studies from the National Survey of Children With Special Health Care Needs, and 7 were reports of randomized, controlled trials. Of the 24 articles reviewed, 13 examined populations of CSHCN or similar populations, 6 examined children with asthma, and the remaining studied children with other specific conditions. We found positive associations of FCC with improvements in efficient use of services, health status, satisfaction, access to care, communication, systems of care, family functioning, and family impact/cost. There was little available evidence, however, for some outcomes, including cost and transition.

CONCLUSIONS

The available evidence suggests that FCC is associated with improved outcomes for CSHCN. With positive findings for most of the studies reviewed here and the compelling arguments for FCC, we recommend the use of this approach by individuals and organizations.

Moderators and predictors of clinical outcome in a randomized trial for behavior problems in pediatric primary care

OBJECTIVES

To evaluate putative moderator, predictor, and treatment parameter variables in relation to three outcomes in a clinical trial that compared a modular protocol for on-site, nurse-administered intervention (PONI) and enhanced usual care (EUC) for pediatric behavioral problems in primary care.

METHODS

Patients were 163 clinically referred children for behavior problems in six primary care offices. PONI consisted of seven treatment modules adapted from prior treatment trials with this population, whereas EUC involved a facilitated referral to a community provider. Outcome measures were based on standardized scales reflecting one parent-rated aggregate (child dysfunction) and one child-rated aggregate (child health), and diagnostic interviews with both informants (remission in oppositional defiant disorder).

RESULTS

Moderator analyses revealed that PONI was more effective than EUC in reducing child dysfunction by 12-month follow-up among Caucasian children, whereas EUC was more effective than PONI among non-Caucasian children. In the full sample, child health improvement was predicted by the severity of the child's depression and anxiety, and level of family conflict. Duration of child exposure to cognitive-behavioral treatment in PONI was related to greater improvement in overall child health, but other treatment parameters were unrelated to outcome.

CONCLUSIONS

These few significant relationships notwithstanding the findings indicate that the two treatments had robust effects on several outcomes and across selected child, parent, family, and treatment variables. The findings extend efforts to incorporate mental health services in pediatric practice.

Pediatricians' attitudes and practices on ADHD before and after the development of ADHD pediatric practice guidelines

PURPOSE

The study aims to assess the changes in attitudes and practices about ADHD reported by AAP fellows between 1999 and 2005 during which AAP ADHD guidelines, training, and quality improvement initiatives occurred.

METHOD

The study assesses AAP-initiated surveys that were conducted between 1999 and 2005 and involving a random sample of 1,000 and 1,603 pediatricians, respectively.

RESULTS

The findings reveal that significant, although modest, increases occurred in pediatric practitioners' self-reported adherence to the guidelines. About 81% of respondents reported routine use of formal diagnostic criteria (up from 67%), and 67% of the respondents routinely use ADHD teacher rating scales (compared to 49% in the 1999 survey). Findings further reveal that treatment with stimulant medications was used extensively by pediatricians from both surveys; more pediatricians in the 2005 survey reported use of a second stimulant if the first did not work, and still more reported almost always providing parent training, although the estimated number remained only about a quarter of the total; and greater familiarity with the initiatives predicted better reported adherence to the guidelines.

CONCLUSION

The reported behaviors of practitioners have moved in the direction of greater adherence with the recommended AAP ADHD guidelines, and there was a positive response to, and a greater use of, the materials developed to enhance practice. The authors infer that practice changes may be due to many factors, including AAP guidelines and associated implementation efforts. Changing physician practices needs to be sustained through a continuing process that requires multiple, varying, sustained efforts directed at physicians, other providers, and families.

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.

ADHD service use patterns in youth

OBJECTIVE

To review what is currently known about service use by youth with attention-deficit/hyperactivity disorder (ADHD) and discuss research and policy implications.

METHODS

Literature review.

RESULTS

The primary care, mental health, and educational service system sectors all play an essential role in caring for youth with ADHD. Recent studies also suggest increasing use of stimulants and other psychoactive medication for youth with ADHD, decreasing mental health visits for ADHD unassociated with medication use, increased use of other psychotropic medications, and a number of barriers to care coordination across primary care, mental health, and schools.

CONCLUSIONS

Four important services, research, and policy areas that need to be addressed over the next decade include: 1) delving deeper into current service use, 2) paying attention to the context in which service use occurs, 3) operationalizing evidence-based care for real-world settings, and 4) learning what changes clinician and educator behavior.