Toolkit for PCBH in Pediatric Primary Care

Lesley Manson, Psy.D., Assistant Chair of Integrated Initiatives, Clinical Assistant Professor, Arizona State University, Phoenix, AZ

Tawnya Meadows, Ph.D., BCBA-D, Co-Chief of Behavioral Health in Primary Care-Pediatrics, Geisinger, Danville, PA

Matthew Tolliver, PhD, Assistant Professor/Psychologist, Eastern Tennesee State University Pediatrics, Johnson City, TN

Allison Allmon Dixson, Ph.D., Pediatric Psychologist, Gundersen Health System, La Crosse, WI

Cody Hostutler, Ph.D., Psychologist, Nationwide Children's Hospital, OH

Sarah Trane, PhD, Assistant Professor, Division of Integrated Behavioral Health (Pediatrics), Mayo Clinic Health System, La Crosse, WI

Brian DeSantis, Psy.D., ABPP, VP, Behavioral Health, Peak Vista Community Health Centers, Colorado Springs, CO

Session # PC 3

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

ADHD Assessment and Treatment in Primary Care• Matthew Tolliver, Ph.D., Assistant Professor, ETSU Pediatrics

• Brian DeSantis, Psy.D., ABPP, VP, Behavioral Health, Peak Vista Community Health Centers

• Hayley Quinn, Psy.D., Psychologist, Ambulatory Behavioral Health, West Seattle Pediatrics

Session # track letter and number

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

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Faculty Disclosure

The presenters of this session have NOT had any

relevant financial relationships during the past 12

months.

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Conference Resources

Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018

Slides and handouts are also available on the mobile app.

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Learning Objectives

At the conclusion of this session, the participant will be able to:

1. Describe approaches to assessing and treating ADHD in pediatric primary care

2. Describe how behavioral health and medical providers can collaborate on ADHD management

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1. American Academy of Pediatrics. (2011). ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and Adolescents. Pediatrics, 128(5), 1007-1022. doi:10.1542/peds.2011.2654

2. Chankalal, R. & Daily, R. (2014). Evaluating and treating ADHD in primary care settings with updated AAP guidelines. Kansas Journal of Medicine, 7(3), p. 118.

3. Evans, S. W., Owens, J. S., Wymbs, B. T., & Ray, A. R. (2018). Evidence-Based Psychosocial Treatments for Children and Adolescents With Attention Deficit/Hyperactivity Disorder. Journal of Clinical Child and Adolescent Psychology, 47(2), 157-198. doi:10.1080/15374416.2017.1390757

4. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

5. Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics, 127(3), 462-470. doi:10.1542/peds.2010-0165

Bibliography / Reference

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Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted

at the end of this presentation.

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ADHD

•Prevalence: Affects approximately 5-10% of U.S. population (CDC 2016)

•Etiology: Role of genetics/environment

•Prognosis: Chronic disorder of inhibition, inattention, self-regulation

•3 types: inattentive, hyperactive-impulsive, combined type

8M

9M

10B

Assessment in Primary Care

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AAP Rec’s for Assessment

1. Youth who present with inattention/hyperactivity should be evaluated

2. Youth should meet DSM-5 criteria before making a dx

3. Assessment requires direct evidence from parents and teachers regarding core symptoms, duration, and degree of impairment.

4. Assess for comorbid conditions.

5. Other diagnostic tests not indicated to establish diagnosis (evidence: strong, recommendation: strong).

(American Academy of Pediatrics, 2011)12M

AAP: Youth should meet DSM-5 criteria before making a dx

•A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

•Not just oppositional behavior, defiance, hostility, or failure to understand tasks or instructions.

• Sx prior to age 12 years and occur in 2+ settings

• Interfere with social, academic, or occupational functioning

13M

AAP: Assessment requires direct evidence from

parents and teachers regarding core

symptoms, duration, and degree of impairment.

14 M

Assesses Impairment:

•Relationships with peers, siblings, caregivers, teachers

•Academic progress

•Self esteem

•Family functioning

15M

Review school Records

16B

AAP: Assess for comorbid conditions

(Chankalal & Daily, 2014) 17B

(Larson, Russ, Kahn, & Halfon, 2011)18B

https://www.medscape.com/viewarticle/573817_319B

Psychological or Neuropsychological Testing?

•Not included in diagnostic guidelines (AACAP, APA, AAP, etc.) for routine ADHD evals

•Limited utility given the aim of testing, barriers to access, & cost to patient

•Recommended when LD, developmental delay, or cognitive impairment is suspected

• Purely learning/disordered children often present as inattentive

20M

ADHD Evaluation Summary• Preschool, child, or adolescent evals should consist of clinical interviews with

the parent and patient, obtaining standardized behavioral rating scales from

home and preschool or school settings, assessing family functioning, and

review of patient’s medical, developmental, social, and family histories.

• If patient’s medical history is unremarkable, laboratory, electrophysiological

studies, neuroimaging, or neurological testing is not indicated.

• Psychological and neuropsychological tests are not mandatory for diagnosing

• BH providers must evaluate for the presence of comorbid psychiatric

disorders and R/O other psychosocial explanations for presenting symptoms

21M

Special Diagnostic Considerations•Choice broadband vs. narrowband behavioral rating scales

•Differing teacher-parent ratings…what to do?

•Special populations•Preschoolers

•Adolescents

• young Hispanic kids (kinder, first grade) who are not yet bilingual and receiving ESL services

• low IQ/cognitive confounds

22B

Treatment in Primary Care

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Well established treatment▪RCT

▪Independent variable defined, treatment manuals

▪Population clarified

▪Reliable and valid outcome assessment measures

▪Appropriate data analyses and sample size

▪2+ independent research settings and by 2+ independent investigatory teams showing the treatment to be either:

▪Better than placebo OR equivalent to another well established tx

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Well Established

Combined training treatments with relevant skills and extensive practice and feedback Probably

Efficacious

Possibly Efficacious

Experimental

Questionable Efficacy

Preschool Elementary Adolescent

Behavioral Parent TrainingBx Classroom ManagementCombined Bx Mgt Intervent.

Behavioral Parent TrainingBx Classroom ManagementBx Peer InterventionOrganization TrainingCombined Bx Mgt Intervent.

Organization Training

Behavioral Parent TrainingNeurofeedback Training

Cognitive Training

Social Skills TrainingPhysical Activity

Omega 3/6 supplements

Combined training treatments: skills relevant to daily functioning but with limited practice/feedback. CBT techniques & brief behavioral parent training

(Evans, Owens, Wymbs, & Ray, 2018)25M

AAP Guidelines on Treatment4-5 y/o

◦ Behavior therapy is first line (quality of evidence A – strong recommendation)

◦ methylphenidate only if bx therapy not effective and moderate-severe impairment (quality of evidence B – recommendation)

6-11 y/o

◦ FDA approved ADHD med AND/OR

◦ Behavioral parent training AND/OR Teacher administered behavior therapy

◦ Preferably both (quality of evidence B – recommendation)

12-18 y/o

◦ FDA approved ADHD med (quality of evidence A – strong recommendation)

◦ May prescribe behavior therapy (quality of evidence C – recommendation)

(American Academy of Pediatrics, 2011)26M

NIMH Multimodal Treatment Study of Children with ADHD (MTA)• Large 14 mo. comparison of 144 kids ages 7-9 per group (MTA Comparative Group, 1999)

• Manage Meds (MM) vs. Behavioral Therapy (BT) vs. Combined vs. TAU (medicated community group)

• 19 outcome measures; all 4 groups improved • Concluded MM superior to BT; combined brought no advantages

• However, on closer inspection…..• Only 3 of 19 outcome measures, all unblinded, found differences

favoring Ritalin• Neither blinded classroom observers, the children themselves or

their peers found meds superior to behavioral treatment • BT group ended treatment 4-6 months

27B

MTA Follow Up Studies • 24 mo. f/u resulted in smaller group differences (MTA Cooperative Group, 2004)

• MM and combined groups lost much of their effect (up to 50%)

• BT and Community Groups retained theirs

• At 36 mos. did not differ significantly on any measure ( Jensen et al., 2007)

• Medicated children averaged 2.0 centimeters and 2.7 kilograms less growth than non-medicated children, without evidence of growth rebound at 3 yrs. (Swanson et al., 2007)

• MTA f/u study into young adulthood demonstrated symptom persistence (Swanson et al., 2017)

• Extended use of medication was associated with suppression of adult height, but not with reduction of symptom severity

28B

Treatments with little to no supportTraditional 1:1 counseling or play therapy

Cognitive therapy

Elimination diets

Biofeedback

Allergy treatments

Chiropractic

Sensory Integration Training

Dietary supplements

29B

Treatment of ADHD in Primary Care:

Help with school support/coordination of care

Provide psychoeducation about ADHD

Parenting skills & behavior management

Address self-esteem issues, psychosocial problems

Make a treatment plan for comorbid conditions

With PCP, monitor growth, assess for adverse side effects of meds

30B

“Active Ingredients” in Behavioral Interventions

Predictability/

consistency

Differential reinforcement

Practice/

repetition

Proximity of consequences to

bx

31M

Point/token systems

Establish house rules/structure

Visual supports

•timers/clocks, posted rules/routines

Reinforcement of + behavior

Effective commands

Planned ignoring

When…then contingencies

Time out/loss of privileges

Organizational skills, HW plan

Behavioral Interventions to Address Home Behaviors

32M

Framework for Brief Bx Parent Training•Psychoed about ADHD

•Message: Child behaviors are not caregivers fault, but they can play a special role to help the child by learning advanced ADHD parenting skills

• Caregiver presented with list of skills• The ability to clearly establish and communicate expectations

• The ability to clearly discuss consequences ahead of time and to follow through with them consistently

• The ability to ignore behaviors which do not threaten the basic quality of life, limb, and property

•Caregiver identifies their parenting strengths and 1-2 areas they would like to practice more

33M

Daily Report Card(home-school

note)

Advocacy for IEP/504 planRequest FBA

Class-wide interventions

(Good Bx Game)

Encourage parent-teacher communication

Organizational skills

Interventions to Address School Problems

34M

Teams and Teamwork

Roles and Responsibilities

Interprofessional Communication

Values and Ethics

Assessment & Treatment in the Context of Interprofessional Core Competencies

(Interprofessional Education Collaborative Expert Panel, 2011) 35M

Summary of ADHD Treatment Recommendations• A comprehensive Tx plan should be collaboratively developed with family

• BT may be recommended as an initial treatment for preschoolers, for kids with mild symptoms and minimal impairment, or parental preference

• Initial psychopharmacological Tx should be with a FDA approved medication

• For medication Tx, BH providers could help with monitoring effectiveness and adverse side effects

• Comorbid conditions (i.e. ODD, LD, anxiety) will have to be treated with the appropriate school based and psychosocial treatments

• Patients treated with medication should have height and weight monitored during treatment

36B

Take Home Points◦ Importance of clinical pathway that defines roles/responsibilities for each

member of the team

◦ AAP guidelines helpful for assessment/treatment framework

◦ Assessment should be multi-setting and consider a wide range of comorbidities, especially LDs

◦ Behavioral parent training/classroom management well established tx for preschool and elementary aged

◦ Need to find ways to continue to adapt larger evidence based tx’s for primary care and study them

◦ Don’t forget role of interprofessional competencies

37M

Questions

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Session Evaluation

Use the CFHA mobile app to complete the

evaluation for this session.

Thank you!

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