Intervention Aims to Promote Effective Practice for ADHD

Approximately 7,800 children with attention-deficit/hyperactivity disorder (ADHD) visit primary care practices across The Children’s Hospital of Philadelphia Care Network. Treating such a large patient population that is coping with a multifaceted, chronic condition can be demanding for busy primary care physicians (PCPs). That is why a study team at CHOP is launching an outcomes improvement project in the fall to promote PCPs’ use of clinical practice guidelines for managing ADHD consistently and efficiently.

ADHD is the most common neurobehavioral disorder among children, occurring in about 8 percent of youth. Yet each child experiences symptoms of inattention, impulsivity, and hyperactivity differently, so delivering treatment that is responsive to individuals’ specific needs, goals, and family preferences can be time-consuming and complex.

The major features of treatment for children with ADHD include parental support and education in behavioral training, appropriate school placement, and medication. Subsequently, the ADHD care team goes beyond the pediatrician office’s walls and extends to families, teachers, guidance counselors, coaches, social workers, and other healthcare providers including psychologists, psychiatrists, and neurologists.

“ADHD is somewhat more difficult to manage than some other conditions in the sense that many of the problems show up at school and home, so it takes care coordination across different settings,” said Alexander G. Fiks, MD, MSCE, associate medical director of the Pediatric Research Consortium (PeRC), and associate director for Outpatient Research Activities, Center for Pediatric Clinical Effectiveness (CPCE) at CHOP. “It is hard to keep engaged with multiple healthcare providers, schools, and families and easily exchange information.”

For children who are prescribed medications for ADHD, Dr. Fiks added, it may take a few months to achieve optimal success, and the guidelines recommend that medication efficacy should be systematically monitored at regular intervals. It can be cumbersome to schedule and accomplish those follow-ups from an organizational standpoint.

Even with these challenges, keeping ADHD management on track is crucial, Dr. Fiks said, because early detection and intervention can reduce the severity of symptoms, decrease the interference with school functioning, enhance the child’ self-esteem and social relationships, and improve the quality of life experienced by children or adolescents with ADHD and their families.

The study team’s project aims to give PCPs the tools they need to initiate and sustain appropriate treatments and achieve successful long-term outcomes. In preparation for the project, a set of practice supports will be built into a web-based portal linked to CHOP’s electronic health record to promote shared decision-making. Practitioners also will be offered the option of obtaining American Board of Pediatrics Maintence of Certification Part IV credit through their participation.

Overall, the intervention will include an integrated approach featuring:

  • education about ADHD management
  • communication training
  • collaborative consultation
  • performance feedback.

The investigators will conduct a randomized controlled clinical trial to evaluate the effectiveness of the intervention over eight months to increase the use of evidence-based practices among PCPs for children with ADHD. They will contact providers in CHOP’s 31 primary care practices to inform them of the study, which focuses on patients in the age range from 5 to 12 years.

Providers in the control group will be given brief education about how to use the portal, while the experimental group will receive detailed guidance about the portal along with the multiple components of the integrated approach. The study team already has formed an advisory board that consists of parents, clinicians, and teachers from throughout the communities that CHOP’s Care Network serves.

“We predict that if clinicians have more knowledge and backup support, then they will feel more confident in the recommendations that they have for families,” Dr. Fiks said. “Introducing the EHR technology as a way to facilitate information exchange also will make ongoing communication easier. And by giving feedback, clinicians will see their strengths and weaknesses, in order to help improve the care that they deliver.”

The project is a collaborative effort that taps the talents of several CHOP experts including co-principal investigator Thomas J. Power, PhD, director of the Center for Management of ADHD; co-investigator Nathan J. Blum, MD, acting associate chief of the Division of Child Development, Rehabilitation Medicine and Metabolic Disease; co-investigator James Guevara, MD, MPH, attending physician; collaborator Robert Grundmeier, MD, attending physician; and other team members from the Center for Biomedical Informatics, PolicyLab, CPCE, and PERC. It is funded by an unrestricted, independent research grant from Pfizer.

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