Collaborative care may improve outcomes in childhood ADHD

1. Enhanced care using motivational interviewing and positive parenting techniques improved symptoms in children with attention-deficit hyperactivity disorder (ADHD).

2. Specifically, enhanced care improved scores in inattention, hyperactivity/impulsivity, oppositionality, and social skills in children with ADHD-consistent symptoms.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Collaborative care has been shown to be an effective method of improving guideline adherence for the treatment and management of ADHD, but there have been no studies examining patient-level outcomes. This randomized trial compared basic collaborative care and enhanced collaborative care, examining individual-level outcomes in inattention, hyperactivity, oppositionality, and social skills. Evidence-based basic care consisted of primary care-led teams and care managers while enhanced care included additional training in family and social support for care managers. Overall, there was no significant difference in mean changes in scores for inattention, hyperactivity/impulsivity, oppositionality, or social skills between the 2 groups. However, when comparing the subgroup of individuals with ADHD-consistent symptoms at presentation, there was significantly greater improvement in hyperactivity/impulsivity, oppositionality, and social skills among the enhanced care group.

This study provides evidence that social support in the form of motivational interviewing and parenting guidance from care managers may improve outcomes in ADHD in urban populations. However, it is unclear how generalizable these results are to larger, non-urban populations. In addition, the effect requires accurate diagnosis of ADHD as there did not appear to be any improvement in outcomes when comparing all individuals suspected of ADHD by primary care providers.

Click to read the study, published today in Pediatrics

Relevant Reading: Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians.

In-Depth [randomized trial]: This study prospectively examined 156 children in urban Boston between the ages of 6 and 12 who were referred from either a university or community primary care practice for ADHD evaluation. Subjects were then randomized to basic collaborative care and enhanced collaborative care. Basic care consisted of primary care-physician led teams with assistance from lay care managers and diagnostic support from experts. Subjects in the enhanced care group received additional in-person meetings from care managers with training in motivational interviewing techniques and Triple P (a parenting and family support system). Following expert decision support, 40% of all participants were found to have symptoms consistent with ADHD. Subjects were then assessed at 6 and 12 months, with 91% completing follow up at 12 months. Participants were scored for inattention, hyperactivity/impulsivity, and oppositionality using the SNAP-IV scoring system, as well as for social skills with the Social Skills Rating System. Results indicated no significant difference in the mean changes in any area between basic and enhanced collaborative care. However, when comparing the subgroup of individuals with presentations consistent with ADHD, the enhanced care group showed a significant difference at 12 months in the mean change in hyperactivity/impulsivity (–0.36; 95% CI –0.69 to –0.03), oppositionality (–0.40; 95% CI –0.75 to –0.05), and social skills (9.57; 95% CI 1.85 to 17.28) when compared to those in the basic group. Of note, there was a non-significant increase in medication use by the enhanced care group.

Image: PD

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