From Data to Practice Change: Bringing Youth ADHD Evidence ......# of GA children (2-18 years)...

W O R K S H O P

L I N D A M C C A L L , L . C . S . W .D E P A R T M E N T O F C O M M U N I T Y H E A L T H

A N G E L A S N Y D E R , P H . D .G E O R G I A S T A T E U N I V E R S I T Y

C E N T E R O F E X C E L L E N C E F O R C H I L D R E N ’ S B E H A V I O R A L H E A L T H

W E N D Y W H I T E T I E G R E E N , M . S . W .D E P A R T M E N T O F B E H A V I O R A L H E A L T H & D E V E L O P M E N T A L D I S A B I L I T I E S

O C T O B E R 2 0 1 6

From Data to Practice Change: Bringing Youth ADHD Evidence-Based

Practice to Scale

2Georgia Department of Behavioral Health and Developmental Disabilities

Georgia Interagency Directors Team (IDT)


Georgia Interagency Directors Team (IDT):Reflecting a System of Care


Prevalence of ADHD among School-Aged Youth

National Population Estimates 6.4 million youth 4-17 years diagnosed as of 2011-20122 million more than in 2003

5.1 million with a current ADHD diagnosis

National Prevalence Rate (%) 11% of youth 4-17 years of age ever diagnosedUp from 7.8% in 2003-2004; a 42% increase

8.8% with a current diagosis

Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M., . . . Blumberg, S. J. (2014).Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003–2011. Journal of the American Academy of Child and Adolescent Psychiatry, 53(1), 34-46.e32.


0

2

4

6

8

10

12

1998 2000 2002 2004 2006 2008 2010 2012 2014

Pre

vale

nce

est

imat

e (%

)

Year

Diagnosed ADHD Prevalence Estimates: National Survey Data

National Survey of Children's Health

National HealthInterview Survey

0% 5% 10% 15% 20% 25%

4567891011121314151617

Girls

Current ADHDdiagnosis andtaking medication

Current ADHDdiagnosis but nottaking medication

Ever had ADHDdiagnosis but notcurrent ADHD

0%5%10%15%20%25%

Boys

2011-2012

Age in years

Weighted Prevalence Estimates (%) of Attention-Deficit/Hyperactivity Disorder (ADHD) Diagnosis by a Health Care Provider among U.S. Children, by Age and Medication Status

Parent-Reported Data from the National Survey of Children’s Health

Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M., . . . Blumberg, S. J. (2014). Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003–2011. Journal of the American Academy of Child and Adolescent Psychiatry, 53(1), 34-46.e32.


WHAT DO WE KNOW ABOUT ADHD

DIAGNOSIS AND TREATMENT IN

GEORGIA?


Current ADHD Diagnosis: United States, 2011-12

National Average: 8.8%

9.3%


Current ADHD Medication Treatment: United States, 2011-12

National Average: 69%

65%

Diagnosed and Medicated ADHD in GA

7.8%

9.5%

11.0%9.4%

9.2%

12.1%

0%2%4%6%8%

10%12%14%16%18%20%

2003 2007 2011

% R

epor

ting

ADH

D

Ever Diagnosed: GA

US Georgia

In 2011, 8.8% of US children and 9.3% of children in GA had current ADHD, by parent report.

9.3%

Among all US states, GA ranked 25th highest.

In 2011, 6.1% of US children and 6.1% of children in GA were taking medication for ADHD.

6.1%

Among all US states, GA ranked 30th highest.


IDT COLLABORATION

GA MEDICAID DATA ANALYSES


Medicaid Claims Data System

Medically managed ADHD (2012-2014) # of GA children (2-18 years) enrolled in

Medicaid with >= 1 ADHD Dx codes by year % of children in Medicaid who had medically managed ADHD by year

Medicated ADHD (2012-2014) # of GA children (2-18 years) enrolled in Medicaid with >= 1 ADHD Dx code

and >= 1 ADHD medication claim, using National Drug Codes for medications FDA-approved for pediatric ADHD treatment*

% of children in Medicaid with ADHD who received medication by year

Behavioral Treatment (2012-2014) # of GA children (2-18 years) enrolled in Medicaid who have received

behavioral treatment or psychological services by year % of children in Medicaid with ADHD receiving behavioral therapy by year

* AAP Subcommittee on Attention-Deficit/Hyperactivity Disorder Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, et al. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011; 128(5):1007-1022.


List of FDA-approved ADHD medications used in the abstraction of medication claims for

ADHD among children in MedicaidMedication Drug Class

Adderall Central nervous system stimulant (CNS Stimulant)Atomoxetine Selective norepinephrine reuptake inhibitor (SNRI)Concerta CNS StimulantDaytrana Patch CNS StimulantDexedrine CNS StimulantDextrostat CNS StimulantDextro-Amphetamine CNS StimulantDexmethylphenidate CNS StimulantFocalin CNS StimulantGuanfacine Centrally acting alpha-adrenergic receptor agonistIntuniv Centrally acting alpha-adrenergic receptor agonistKapvay Central alpha-2 agonistMetadate CNS StimulantMethylin CNS StimulantMethylphidate CNS StimulantRitalin CNS StimulantStrattera SNRITenex Centrally acting alpha-adrenergic receptor agonistVyvanse CNS Stimulant

% of GA Children in Medicaid with 1+ ADHD Diagnosis Codes, by age: 2012 - 2014

GA Medicaid FilesADHD ICD Codes: 314.XX

1.0% 1.0% 0.9%

5.7% 5.8% 5.8%

11.3% 11.7% 11.8%

6.9% 7.4% 7.5%7.8% 8.1% 8.3%

0%

2%

4%

6%

8%

10%

12%

14%

2012 2013 2014

2 -3 4-5 6-12 13-18 All ages

ADHD Treatment Rates among GA Children in Medicaid with

1+ ADHD Diagnosis Codes and 1+ Treatment Claim

48 44 4049

4352

7687

81 84

0102030405060708090

100

2-3 4-5 6-12 13-18 All

Per

cen

t

Psychological ServicesADHD Medication

48 4439

45 41

49

72

8680 83

0102030405060708090

100

2-3 4-5 6-12 13-18 All

Per

cen

t

Psychological ServicesADHD Medication

Unpublished data; released in collaboration with Georgia Inter-Agency Directors Team

2012 2014

Data Source: GA Medicaid Files


ADHD Treatment among GA Toddlers

T H E R E A R E N O C U R R E N T G U I D E L I N E S T H A T G U I D E T H E D I A G N O S I S A N D T R E A T M E N T O F A D H D A M O N G C H I L D R E N U N D E R 4 Y E A R S O F A G E

• In GA, about 1% of 2-3 year olds in Medicaid had an ADHD diagnosis code

• 48% had a behavioral therapy claim, while 52% had a medication claim in 2012

• Only amphetamine and d-amphetamine is FDA-approved for ADHD treatment for children as young as 3 years of age

• Valid diagnosis of ADHD in a toddler is not supported by evidence.T H E S E M E D I C A T I O N T R E A T M E N T P A T T E R N S A R E N O T U N I Q U E T O G E O R G I A


National MarketScan Database: PathwaysUS: ADHD Diagnosis and Medication Treatment

among 2-3 Year Olds (Private Claims)

* Among a MarketScan sample of 10,000,000 individuals

38.8%34.4% 37.9%

31.2%37.7%

0.29%0.25%

0.27% 0.27%0.24%

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008 2009 2010 2011 2012

Per

cen

t of

2-3

Yea

r O

lds

wit

h A

DH

D

Dx

Per

cen

tage

of

AD

HD

Med

icat

ed

ADHD Meds among Dx (%) ADHD Dx (%)

Implications

In 2012, approximately 1,660 toddlers in GA were being medically managed for ADHD in GA and about 760 of these had a claim for ADHD medication (class II controlled substances)

Only about 43% of all children 2-18 with an ADHD Dx code had a behavioral therapy/psych claim in 2012

Data suggest areas for quality improvement in GA and beyond, particularly among toddlers and preschoolers

Additional research and investigation is needed Education about AAP best practices Investigation of coding practices Investigation of the infrastructure for the provision of behavioral

therapy


M U C H L I K E T H E I D T C O N S I D E R E D …

Participant Interaction 1

…seeing this data, what are challenges?


SHARE


28Georgia Department of Behavioral Health and Developmental DisabilitiesAHRQ, 2011


Refer parents of young children with ADHD for training in behavior therapy

before prescribing medicine (CDC-Vital Signs and AAP)

Steps for healthcare providers

1. Assess a young child with ADHD symptoms using clinical practice guidelines (CDC) Evaluate anyone with academic or behavioral problems and symptoms

of inattention, hyperactivity, or impulsivity [AAP] Determine whether DSM criteria have been met (Ruling out other

causes, based on reports from parents and other supportive sources, etc.) [AAP]

Assess comorbidities [AAP] Recognize ADHD as a chronic condition [AAP]



before prescribing medicine (CDC, Vital Signs)


2. Talk with parents about ADHD treatment and explain the benefits of behavior therapy as the first line of treatment [CDC, AAP]

a. Improved behavior, self-control, and self-esteem for children. b. Better relationships and reduced stress for families.c. Benefits are lifelong for children and families.


CDC





3. Refer parents to a therapist before prescribing medicine. Find a therapist who:

a. Teaches parents to better manage their child’s behavior and strengthen parent-child relationship.

b. Encourages parents to practice between sessions, regularly monitors progress, and adjusts strategies as needed.





4. Follow up with the family during and after treatment to confirm progress.


MODELS


MODELS

Incredible Years Parenting Program

Parent Child Interaction

TherapyNew Forest Parenting

Programme

Triple P: Positive

Parenting Program


• T r a i n s p a r e n t s v a r i o u s s t r a t e g i e s t o h e l p c h i l d r e n r e g u l a t e t h e i r e m o t i o n s , i m p r o v e t h e i r s o c i a l s k i l l s , a n d d o b e t t e r a c a d e m i c a l l y .

• P a r e n t s a r e g i v e n o p p o r t u n i t i e s t o c o l l e c t i v e l y a n d i n d i v i d u a l l y d e v e l o p n e w s t r a t e g i e s f o r m a n a g i n g t h e i r c h i l d r e n a n d w o r k i n g t o g e t h e r i n c o l l a b o r a t i v e p a r t n e r s h i p s .

• C h i l d r e n r e c e i v e t r a i n i n g i n h o w t o f o l l o w r u l e s a n d c o o p e r a t e , e x p r e s s e m o t i o n s , p r o b l e m - s o l v e , m a n a g e a n g e r , a n d m a k e g o o d f r i e n d s .

• G r o u p a n d I n d i v i d u a l m o d e s o f d e l i v e r y



E m p h a s i z e s p a r e n t i n g s k i l l s k n o w n t o p r o m o t e c h i l d r e n ' s s o c i a l c o m p e t e n c e a n d r e d u c e b e h a v i o r p r o b l e m s s u c h a s :

• how to play with children, • social, emotional , academic and persistence skills coaching, • effective praise and use of incentives, • establishing predictable routines and rules and promoting responsibility, • effective limit-setting, • strategies to manage behavior,• teaching children to problem solve. • effective communication skills, • anger and depression management, • problem-solving between adults, • ways to give and get support • approaches designed to promote children’s academic skills.



Parent

Child

Family



COMMUNITY SUPPORTS: Skills Development; Skills Acquisition for Managing Behavior; Skills/Strategies for personal development, school performance, work performance, and functioning; Enhancing social and coping skills; etc.

FAMILY TRAINING: development of methods of intervention, interaction and mutual support the family can use to assist their family member; symptom management; behavioral management; Adaptive behaviors and skills; Interpersonal skills, etc.

GROUP TRAINING: development of methods of intervention, interaction and mutual support the family can use to assist their family member; symptom management; behavioral management; Adaptive skills; Interpersonal skills, etc.


• An evidence-based treatment for young chi ldren with emotional and behavioral disorders

• Places emphasis on improving the qual i ty of the parent-chi ld relat ionship and changing parent-chi ld interact ion patterns.

Parent Child Interaction Therapy


A P P R O A C H :

• C h i l d r e n a n d t h e i r c a r e g i v e r s a r e s e e n t o g e t h e r i n P C I T . • M o s t o f t h e s e s s i o n t i m e i s s p e n t c o a c h i n g c a r e g i v e r s i n

t h e a p p l i c a t i o n o f s p e c i f i c t h e r a p e u t i c s k i l l s . • T h e r a p i s t s t y p i c a l l y c o a c h f r o m a n o b s e r v a t i o n r o o m w i t h

a o n e - w a y m i r r o r i n t o t h e p l a y r o o m , u s i n g a “ b u g - i n - t h e -e a r ” s y s t e m f o r c o m m u n i c a t i n g t o t h e p a r e n t s a s t h e y p l a y w i t h t h e i r c h i l d .

• C o n c l u d i n g e a c h s e s s i o n , t h e r a p i s t a n d c a r e g i v e r t o g e t h e r d e c i d e w h i c h s k i l l t o f o c u s o n m o s t d u r i n g d a i l y 5 - m i n u t e h o m e p r a c t i c e s e s s i o n s t h e f o l l o w i n g w e e k .



Family



FAMILY THERAPY: systematic interactions between the identified individual, staff and the individual's identified family members, restoration, development, enhancement or maintenance of functioning of the identified individual/family unit, includes: Cognitive processing skills; Healthy coping mechanisms; Adaptive behaviors and skills; Interpersonal skills; Family roles and relationships; family’s methods of intervention, interaction and mutual support the family can use to assist their family member therapeutic goals.


Parent Child Interaction

Therapy


• T a r g e t s y o u t h a g e s 3 - 1 1 w i t h m o d e r a t e t o s e v e r e s y m p t o m s o f A D H D

• T a k e s p l a c e i n t h e f a m i l y ’ s h o m e t h r o u g h e i g h t w e e k l y v i s i t s .

• Each session lasts two hours and is either for the parent only (four sessions) or the parent and child together.

• Single Practitioner Intervention• During these visits, parents learn strategies for managing their

children’s behavior and difficulties with attention.

New Forest Parenting Programme (NFPP)


W H A T H A P P E N S D U R I N G T H E I N T E R V E N T I O N ?

• P a r e n t s l e a r n a b o u t t h e n a t u r e o f A D H D a n d h o w t o m a n a g e t h e i r c h i l d ’ s b e h a v i o r t h r o u g h g a m e s t h a t e n g a g e c h i l d r e n ’ s a t t e n t i o n , e n c o u r a g e t h e i r p a t i e n c e a n d i n c r e a s e t h e i r c o n c e n t r a t i o n .

• T h e p r a c t i t i o n e r o b s e r v e s t h e p a r e n t a n d c h i l d p l a y i n g t h e g a m e t o g e t h e r a n d p r o v i d e s f e e d b a c k o n t h e q u a l i t y o f t h e i r i n t e r a c t i o n .

New Forest Parenting Programme (NFPP)


New Forest Parenting

Programme


Parent

Family


Programme



FAMILY THERAPY: systematic interactions between the identified individual, staff and the individual's identified family members, restoration, development, enhancement or maintenance of functioning of the identified individual/family unit, includes: Cognitive processing skills; Healthy coping mechanisms; Adaptive behaviors and skills; Interpersonal skills; Family roles and relationships; family’s methods of intervention, interaction and mutual support the family can use to assist their family member therapeutic goals.



Programme


Triple P: Positive Parenting Program

Levels Modality1 Public Health Approach2 Direct Family Intervention3 Direct Family Intervention4 Direct Family Intervention5 Direct Family Intervention



Levels Modality

1 Public Health Approach

2 Direct Family Intervention




“Stay Positive”



Levels Modality






• "light touch" intervention• provides one-time assistance to parents who are

generally coping well but have 1-2 concerns with their child's behavior or development

• Seminar or brief consultation


Triple P: Positive Parenting ProgramLevels Modality






• Targeted counseling for parents of a child with mild to moderate behavioral difficulties

• Deal with a specific problem behavior or issue• One-on-One Modality: Brief face-to-face or telephone

intervention • Group Modality: Two-hour small group sessions, targeting a

specific problem behavior or issue.








• Promotes core positive parenting skills that can be adapted to a wide range of parenting situations.

• Variety of service delivery modalities:• Group– Groups of no more than 12 parents attend five sessions and supported

with three phone counseling/catch-up sessions at home. • Individual counseling- Delivered over ten (1 hour) sessions. • Online – Eight-session web-based program that guides parents through Triple

P's 17 core parenting skills• Self-directed– A ten week workbook self-help program, Parents who need

additional support can receive weekly 15–30 minute telephone consultations.

• For parents of children with more behavioral difficulties








• Intensive support for families with complex concerns• Modalities: Group/Individual• Targets:

• For parents whose family situation is complicated by problems such as partner conflict, stress or mental health issues; OR

• For parents at risk of child maltreatment. Covers anger management and other behavioral strategies to improve a parent's ability to cope with raising children.


Parent

Family

Level 2-4?


COMMON ELEMENTS?

Trends



BASED ON THIS INFORMATION, WHAT ARE 3

CHANGES THAT YOU PROPOSE TO MAKE IN YOUR

UNIQUE SETTING?


SHARE




WHAT ARE TWO WAYS TO GET BUY-IN FROM YOUR

AGENCY LEADERSHIP ON ACCOMPLISHING YOUR

NAMED GOALS?


SHARE



Next Steps

• Consideration Of Alternative ADHD Strategies (UR Analysis, PBM Controls, Etc.)

• Statewide Practitioner Survey• CEU Webinars• Provider/Practitioner Registry


Resources and References

ADHD in Young Children, http://www.cdc.gov/vitalsigns/pdf/2016-05-vitalsigns.pdf, Publication date: 05/03/2016, accessed August 30, 2016.

American Academy of Pediatrics' Subcommittee on Attention-Deficit/Hyperactivity Disorder Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, et al. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. November 1, 2011 2011;128(5):1007-1022.

Attention-Deficit/Hyperactivity Disorder (ADHD): Behavior therapy for young children with ADHD, Centers for Disease Control and Prevention, http://www.cdc.gov/ncbddd/adhd/behavior-therapy.html, accessed June 20, 2016.

Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment, Agency for Healthcare Research and Quality, Comparative Effectiveness Review Number 44, Pun No. 12-EHC003-1, October 2011.

Georgia State University, Center of Excellence in Child & Adolescent Behavioral Health, Interagency Directors’ Team, http://gacoeonline.gsu.edu/idt/, Accessed September 19, 2016.

The Incredible Years, http://incredibleyears.com/, Accessed August 30, 2016.

http://www.cdc.gov/vitalsigns/pdf/2016-05-vitalsigns.pdf

http://www.cdc.gov/ncbddd/adhd/behavior-therapy.html

http://gacoeonline.gsu.edu/idt/

http://incredibleyears.com/


Resources and References Visser, et.al. The State of ADHD Care in Georgia: From Data to Action, Georgia Mental

Health Forum, The Carter Center, May 16, 2014 Visser, et.al. Attention-Deficit/Hyperactivity Disorder among Preschoolers and Toddlers,

http://gacoeonline.gsu.edu/files/2014/05/SOC-Presentation_06-25-14_final2.pdf, June 2014.

Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, et.al. (2014). Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003–2011. Journal of the American Academy of Child and Adolescent Psychiatry, 53(1), 34-46.e32.

Parent-Child Interaction Therapy (PCIT), International, http://www.pcit.org/, Accessed September 30, 2016.

Stroul, B. A., Blau, G., & Friedman, R. (2010). Updating the System of Care concept and philosophy. Washington, D.C., Georgetown University Center for Child and Human Development National Technical Assistance Center for Children’s Mental Health.

The New Forest Parenting Programme, http://guidebook.eif.org.uk/programmes-library/new-forest-parenting-programme-nfpp, Accessed September 21, 2016.

Triple P, http://www.triplep-parenting.com/us-en/triple-p/, Accessed September 30, 2016.

http://gacoeonline.gsu.edu/files/2014/05/SOC-Presentation_06-25-14_final2.pdf

http://www.pcit.org/

http://guidebook.eif.org.uk/programmes-library/new-forest-parenting-programme-nfpp

http://www.triplep-parenting.com/us-en/triple-p/

From Data to Practice Change: Bringing Youth ADHD Evidence ......# of GA children (2-18 years)...

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