Assessment and Management of Attention-Deficit/Hyperactivity Disorder: Pediatric Resident Perspectives on Training and Practice

Attention-deficit/hyperactivity disorder (ADHD) is a common presenting concern in primary care. This study examined the relationship between pediatric residency training program characteristics and residents' ADHD knowledge, attitudes, and comfort in providing ADHD services. Given the familiarity that pediatric chief residents have with the training and experiences within their residency programs, a 30-item survey was mailed to pediatric chief residents. A total of 100 residents returned their surveys (response rate 49.5%) and were included in the descriptive quantitative and thematic qualitative analyses. The majority of participants rated their ADHD knowledge as at least average. However, approximately half of the participants were comfortable with screening, and less than half were comfortable with managing stimulant medication or behavioral treatments. Participants emphasized the importance of interprofessional collaboration, clinical experiences, and integrated ADHD education throughout training. These results emphasize the importance of improved training in screening, diagnosing, and managing ADHD to increase resident comfort regarding these practices.

Primary care providers' practices regarding patient sleep: Impact of integrated behavioral health

INTRODUCTION

Adequate sleep is crucial for effective functioning. Although many children and adolescents have sleep issues, research indicates pediatric providers rarely address them. No research has examined whether primary care providers (PCPs) who practice within an Integrated Primary Care (IPC) model are more likely to assess sleep concerns than PCPs without IPC. The current study aimed to examine providers' current practices and knowledge regarding common sleep topics from clinics with and without IPC.

METHOD

PCPs across a large health system were surveyed. Participants were 101 providers across 38 clinics, some within IPC clinics (n = 67), and others not (n = 34). Participants responded to questions regarding current sleep assessment and intervention practices, general sleep, and medications knowledge.

RESULTS

Providers reported moderate comfort with behavioral interventions and low comfort with medical interventions. IPC providers were more likely to screen for snoring. Regardless of integration status, PCPs had low medication knowledge scores.

DISCUSSION

IPC may enhance some areas of PCPs' knowledge and comfort with behavioral interventions. PCPs need further training in understanding and implementing interventions for sleep concerns. IPC behavioral health providers may facilitate such trainings and work collaboratively with PCPs to improve patient access to sleep interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Characterizing U.S. mothers with high human papillomavirus vaccine intent yet unvaccinated adolescents

HPV vaccination rates remain suboptimal in the United States. While the current literature focuses on expressly hesitant parents, few studies have examined parents with "high intent", or those indicating they definitely will vaccinate and have had the opportunity but not yet vaccinated their adolescents. Our objective was to differentiate characteristics of mothers with high intent from those who already vaccinated their adolescents using various socioeconomic, previous vaccine decision-making, and healthcare provider relationship-related variables. English-speaking mothers or female guardians of adolescents ages 11-14 years living in low HPV vaccine uptake states within the U.S. in September 2018 were recruited from a national survey panel as part of a larger study. We assessed HPV vaccine status of their adolescents and categorized respondents into two categories: Already Vaccinated and High Intent. We assessed differences using a multivariable logistic regression model. Among 2406 mothers, 18% reported high intent vs. 82% already having vaccinated. Mothers with high intent were more likely to identify as non-Hispanic White (p = 0.01), to have a younger adolescent (p < 0.001), and to report not receiving a provider HPV vaccination recommendation (p < 0.001). Mothers who estimated that half/more (vs. less) of their child's friends have received/will receive the vaccine had higher odds of already vaccinating (p < 0.001). Our findings suggest that clinicians may be able to improve HPV vaccination uptake within their practices by giving repeated, high-quality recommendations to parents of children who are not yet vaccinated. Additionally, these findings indicate perceived social norms may play a large role in on-time vaccine uptake. Reassuring hesitant parents that most parents accept the vaccine may also improve uptake in clinical practice.

Perspectives of Rural Primary Care Clinicians on Pediatric Attention-Deficit/Hyperactivity Disorder Care

OBJECTIVE

Despite efficacious treatments, evidence-based guidelines, and increased availability of integrated behavioral health care, youth coping with attention-deficit/hyperactivity disorder (ADHD) receive suboptimal care. More research is needed to understand and address care gaps, particularly within rural health systems that face unique challenges. We conducted a qualitative study within a predominantly rural health system with a pediatric-integrated behavioral health care program to address research gaps and prepare for quality improvement initiatives, including primary care clinician (PCC) trainings and clinical decision support tools in the electronic health record (EHR).

METHOD

Semistructured interviews were conducted with 26 PCCs representing clinics within the health system. Interview guides were based on the Practical Robust Implementation and Sustainability Model to elicit PCC views regarding determinants of current practices and suggestions to guide quality improvement efforts. We used thematic analysis to identify patterns of responding that were common across participants.

RESULTS

PCCs identified several internal and external contextual factors as determinants of current practices. Of note, PCCs recommended increased access to continuing education trainings held in clinic over lunch and delivered in less than 30 minutes. Suggested improvements to the EHR included incorporating parent and teacher versions of the Vanderbilt Rating Scale into the EHR, documentation templates aligned with evidence-based guidelines, and alerts and suggestions to aid medication management during appointments.

CONCLUSION

Future research to identify implementation strategies to help rural PCCs adopt innovations are needed given the increased responsibility for managing ADHD care and intractable gaps in access to behavioral health care in rural regions.

Engaging Parents and Health Care Stakeholders to Inform Development of a Behavioral Intervention Technology to Promote Pediatric Behavioral Health: Mixed Methods Study

BACKGROUND

Despite effective psychosocial interventions, gaps in access to care persist for youth and families in need. Behavioral intervention technologies (BITs) that apply psychosocial intervention strategies using technological features represent a modality for targeted prevention that is promising for the transformation of primary care behavioral health by empowering parents to take charge of the behavioral health care of their children. To realize the potential of BITs for parents, research is needed to understand the status quo of parental self-help and parent-provider collaboration to address behavioral health challenges and unmet parental needs that could be addressed by BITs.

OBJECTIVE

The aim of this study is to conduct foundational research with parents and health care stakeholders (HCS) to discover current practices and unmet needs related to common behavioral health challenges to inform the design, build, and testing of BITs to address these care gaps within a predominantly rural health system.

METHODS

We conducted a convergent mixed-parallel study within a large, predominantly rural health system in which the BITs will be developed and implemented. We analyzed data from parent surveys (N=385) on current practices and preferences related to behavioral health topics to be addressed in BITs along with focus group data of 48 HCS in 9 clinics regarding internal and external contextual factors contributing to unmet parental needs and current practices. By comparing and relating the findings, we formed interpretations that will inform subsequent BIT development activities.

RESULTS

Parents frequently endorsed several behavioral health topics, and several topics were relatively more or less frequently endorsed based on the child's age. The HCS suggested that BITs may connect families with evidence-based guidance sooner and indicated that a web-based platform aligns with how parents already seek behavioral health guidance. Areas of divergence between parents and HCS were related to internalizing problems and cross-cutting issues such as parenting stress, which may be more difficult for health care HCS to detect or address because of the time constraints of routine medical visits.

CONCLUSIONS

These findings provide a rich understanding of the complexity involved in meeting parents' needs for behavioral health guidance in a primary care setting using BITs. User testing studies for BIT prototypes are needed to successfully design, build, and test effective BITs to empower parents to take charge of promoting the behavioral health of their children.

Integrated care is associated with increased behavioral health access and utilization for youth in crisis

INTRODUCTION

Pediatric integrated care is well-positioned to play a substantial role in crisis intervention; however, few studies have investigated the impact of these services.

METHOD

We investigated differences in service utilization for youth experiencing a crisis in a large, predominantly rural health system by comparing outcomes for 171 youth who received a crisis evaluation in a primary care behavioral health (PCBH) setting to 171 youth presenting to the emergency department at the main hospital campus using a retrospective cohort study design.

RESULTS

PCBH patients were less likely to be male, more likely to be diagnosed with an Adjustment Disorder and less likely to be diagnosed with Autism Spectrum Disorder. Youth evaluated in PCBH were more likely to receive a psychiatric admission, had a shorter latency to the next BH appointment, and had higher rates of completing at least 1 visit in the year following the evaluation. A statistically nonsignificant reduction in frequency of psychiatric admission was observed in the year after the index date, with 3 integrated care patients (vs. 18 on index date) and 5 ED patients (vs. 6 on index date) admitted.

DISCUSSION

Opportunities for future research on cost-effectiveness of care and continuous improvement aligned with quadruple aim outcomes are discussed. Overall, this study is among few others investigating the potential for pediatric integrated care models to contribute to youth suicide prevention and the study demonstrated promising increases in access and engagement with timely behavioral health care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Efficacy of tailored messages to improve behavioral intent to accept HPV vaccination among mothers may be moderated by sociodemographics

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The efficacy of a tailored video intervention differed by sociodemographics.

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Further research should evaluate interventions tailored by sociodemographics.

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Tailoring interventions by child age and other factors may improve efficacy.

We assessed differences in response to a tailored recommendation intervention for HPV vaccine by participants’ sociodemographic characteristics in this exploratory sub-analysis of a larger web-based, randomized-controlled trial on tailored messaging among mothers with low intent to vaccinate their 11–14-year-old child against HPV. The intervention consisted of pre-recorded video messages tailored to 1–5 common concerns about HPV vaccine. In these exploratory analyses, we used generalized linear models to assess differences in post-intervention intent across intervention arms, stratified by sociodemographic characteristics among 496 trial participants. We found significantly higher post-intervention intent in the intervention participants versus the control group among mothers: 1) with younger children; 2) with white vs. black children; 3) with Non-Hispanic children; 4) who were younger; 5) with some college or vocational training; with household incomes of ≥$100,000; and 7) with 1–2 children. Our findings of effect modification by certain sociodemographic factors such as age, race/ethnicity, and household income should be considered when designing similar tailored messaging interventions.

The relationship between integrated pediatric psychology and primary care visit length, revenue, content over 24 months

Introduction: Integrating behavioral health providers into pediatric primary care to provide behavioral health (BH) services is both effective and efficient; however, the impact of pediatric integrated services on the operational and financial outcomes of primary care provider (PCP) visits has not been thoroughly investigated. The present study examined whether length of practice integration predicts the relationship between BH content addressed in a PCP visit, visit length, and revenue generation. Method: A total of 1,209 pediatric encounters with 25 PCPs across 7 primary care offices in a predominantly rural health system were abstracted for the presence or absence of BH content, visit length, duration of integration, and revenue. χ2 analyses and the generalized linear model framework were used to address the study objectives. Results: Integration was associated with more PCP visits with a BH topic discussed at 6-11 months of integration but not at 14-24 months. Visits with a BH topic were longer than medical-only visits and shorter when a practice was integrated for 6-11 months but not at 14-24 months of integration. Public insurance and integration were associated with lower revenue generation per minute. Visit content was not associated with PCP revenue. Discussion: Results suggest a relationship between integration and the operational and financial outcomes of PCP visits. This study shows that initial efficiencies or improvements (e.g., time, cost, content) associated with integrating BH may be lost over time. Future studies should evaluate sustainability in relation to program impact. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Pediatric reporting of genomic results study (PROGRESS): a mixed-methods, longitudinal, observational cohort study protocol to explore disclosure of actionable adult- and pediatric-onset genomic variants to minors and their parents

BACKGROUND

Exome and genome sequencing are routinely used in clinical care and research. These technologies allow for the detection of pathogenic/likely pathogenic variants in clinically actionable genes. However, fueled in part by a lack of empirical evidence, controversy surrounds the provision of genetic results for adult-onset conditions to minors and their parents. We have designed a mixed-methods, longitudinal cohort study to collect empirical evidence to advance this debate.

METHODS

Pediatric participants in the Geisinger MyCode® Community Health Initiative with available exome sequence data will have their variant files assessed for pathogenic/likely pathogenic variants in 60 genes designated as actionable by MyCode. Eight of these genes are associated with adult-onset conditions (Hereditary Breast and Ovarian Cancer Syndrome (HBOC), Lynch syndrome, MUTYH-associated polyposis, HFE-Associated Hereditary Hemochromatosis), while the remaining genes have pediatric onset. Prior to clinical confirmation of results, pediatric MyCode participants and their parents/legal guardians will be categorized into three study groups: 1) those with an apparent pathogenic/likely pathogenic variant in a gene associated with adult-onset disease, 2) those with an apparent pathogenic/likely pathogenic variant in a gene associated with pediatric-onset disease or with risk reduction interventions that begin in childhood, and 3) those with no apparent genomic result who are sex- and age-matched to Groups 1 and 2. Validated and published quantitative measures, semi-structured interviews, and a review of electronic health record data conducted over a 12-month period following disclosure of results will allow for comparison of psychosocial and behavioral outcomes among parents of minors (ages 0-17) and adolescents (ages 11-17) in each group.

DISCUSSION

These data will provide guidance about the risks and benefits of informing minors and their family members about clinically actionable, adult-onset genetic conditions and, in turn, help to ensure these patients receive care that promotes physical and psychosocial health.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03832985. Registered 6 February 2019.

Double-blind, placebo-controlled, crossover study of the efficacy and safety of lisdexamfetamine dimesylate in college students with ADHD

OBJECTIVE

To evaluate stimulant medication on symptoms and functioning for college students with ADHD using double-blind, placebo-controlled, crossover design.

METHOD

Participants included 24 college students with ADHD and 26 college students without psychopathology. Lisdexamfetamine dimesylate (LDX) was examined for ADHD participants over five weekly phases (no-drug baseline, placebo, 30-, 50-, and 70-mg LDX per day). Self-report rating scales of functioning and direct assessment of ADHD symptoms, verbal learning/memory, and adverse side effects were collected (baseline only for control students).

RESULTS

LDX was associated with large reductions in ADHD symptoms and improvement in executive functioning along with smaller effects for psychosocial functioning. Reduction in ADHD symptoms was found for 86.4% of participants; however, large differences in symptoms and executive functioning remained relative to controls.

CONCLUSION

LDX is a safe, efficacious treatment for symptom relief in college students with ADHD. Research documenting medication effects on academic functioning and evaluating psychosocial/educational interventions is needed.

College students with ADHD: current status and future directions

Approximately 2 to 8% of the college population reports clinically significant levels of ADHD symptomatology and at least 25% of college students with disabilities are diagnosed with ADHD. A comprehensive review of the literature was conducted with findings consistently indicating academic deficits associated with ADHD in college students. It is less clear whether this disorder significantly impacts social, psychological, and neuropsychological functioning. Although several self- and parent-report measures have been developed for this population, very few studies of assessment methods have been conducted. Similarly, no controlled studies of psychopharmacological, psychosocial, or educational interventions have been completed in samples of college students with ADHD. Non-prescribed use (i.e., diversion) of stimulant medication is a growing problem with approximately 7% of college students reporting this behavior. Studies, to date, are limited by lack of controlled investigations, use of small samples, and lack of confirmation of diagnostic status. Comprehensive and methodologically sound investigations are needed, especially regarding treatment, to promote the success of students with ADHD in higher education settings.

Characteristics of patients and patterns of psychiatric service use in ethnic minorities

BACKGROUND

The differential uptake of psychiatric services by ethnic minorities has been widely reported. Less attention has been given to comparisons of these patients and variations in the types of interventions they receive.

AIMS

To assess whether for people accessing psychiatric services in the UK, differences exist across ethnic groups both in their sociodemographic characteristics and patterns of mental health care utilisation.

METHODS

All adults resident in an inner city health district and using psychiatric services during a six-month period were identified. Demographic, clinical and service use data were collected from staff and records. These were compared across black Caribbean, Indian, Pakistani, Irish and white ethnic groups for two broad diagnostic categories: psychotic/bipolar and depressive/neurotic disorders.

RESULTS

There were significant differences between ethnic groups on most demographic variables in each of the diagnostic categories. There were variations in the level of contact with different mental health professionals. The only significant difference in the use of specific services was for those with psychotic/bipolar disorders, black Caribbean patients being more likely to be detained in hospital compulsorily.

CONCLUSIONS

Ethnic diversity both in the characteristics of patients and their patterns of psychiatric care should be addressed when planning and developing services.