Feasibility and effectiveness of implementing an integrated care model for attention deficit hyperactivity disorder in primary care pediatrics

Abstract

Introduction: Attention Deficit Hyperactivity Disorder (ADHD) is a common behavioral health disorder with annual costs approaching $80 billion dollars in the United States alone. It is well-established that ADHD is best treated using a chronic care model but integrating such models into primary care is challenging. We report on the feasibility and effect of an integrated behavioral health approach to ADHD in pediatric primary care. Theory/Methods: We collected feedback from families and primary care providers to create an assessment profile following the principles of family-centric ADHD care. Validated scales measured parental stress, self-efficacy of parenting skills, treatment preferences, barriers and goals, child impairment, and externalizing and internalizing symptoms. Families completing the profile were invited to a 30-minute engagement session in the pediatric office by clinic staff (RN or LCSW) to identify treatment goals and services to help reach these goals. Adolescents had separate parent and teen sessions followed by a family session. This was implemented at a large academic primary care pediatric clinic. Results: Of 7150 patients aged 4-17 we identified 411 (5.7%) diagnosed with ADHD. 121 (29%) of these completed the initial profile and all were referred to the engagement session. Of invited families, 98 (81%) scheduled a session, and 82 (68%) completed one. Factors significantly associated with session attendance were elevated levels of child impairment and caregiver strain, a parent whose treatment goals focused on academics, lower self-efficacy of parenting skills, lower levels of medication stigma and fewer reported medication side effects. Current medication use was not predictive. Over 90% of attending families identified a new ADHD treatment for their child with high desirability and readiness to initiate this treatment (mean score=8.9 on a 1-10 Likert). Participants completing an engagement session had more medical office visits for ADHD (excluding the engagement session) over the next 6 months than those who did not (p<.05). Families completing sessions were 2.6 times (p<.01) more likely to meet with the clinic’s care coordinator to find new services, although actual rates of treatment seeking remained low in both groups (17% versus 7%). Families completing sessions received more prescriptions for ADHD medication over the 6 months post session versus the prior 6 months (p<.01). Larger increases in engagement and service utilization were seen in adolescents versus children. Discussion: Results demonstrate the intervention’s feasibility in primary care and its capacity to impact motivation for care and treatment seeking behaviors. Families currently experiencing the greatest challenges with their child, who prioritized academics and were open to ADHD medication were most likely to participate. Conclusions/Lessons Learned: A brief pre-visit survey assessing current functioning and treatment goals combined with an in-office engagement session run by non-physician staff was feasible and effective for increasing treatment seeking behaviors, especially in families of adolescents where the parent and patient often have opposing views of treatment. Limitations: This is a single site intervention that reachedonly a subset of families. Suggestions for Future Research: Further research should be aimed at learning how to better engage families with less immediate ADHD concerns.

Keywords

• integrated care
• adhd
• pediatrics
• mental health