Toolkit for PCBH in Pediatric Primary Care · Preferably both (quality of evidence B –...
Transcript of Toolkit for PCBH in Pediatric Primary Care · Preferably both (quality of evidence B –...
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
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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
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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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