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ADHD & Mental Health Training
in Ambulatory Pediatrics
Zhouying Yu, MSIII
Yingshan Shi, MD, FAAP
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Literature Search
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Key
words
ADHD
Management
ADHD
medical education
ADHD and
medical student curriculum
ADHD and
medical student curriculum and internet
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Reviews
379
50
2
1
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Articles
1469
236
22
2
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1.
Policy
statement--The future of pediatrics: mental health competencies for pediatric
primary care. 2009
2.
Interventions to
promote the evidence-based care of children with ADHD in primary-care
settings.2009
3.
Medical
student participation in an adult ADHD outpatient clinic: an ideal setting for
education in outpatient psychiatry. 2009
4.
Using children as simulated patients in communication
training for residents and medical students: a pilot program. 2005
5.
Primary care
treatment of attention-deficit/hyperactivity disorder. 2006
6.
Implementing the American Academy of Pediatrics
attention-deficit/hyperactivity disorder diagnostic guidelines in primary care
settings. 2004
Pediatrics. 2009 Jul;124(1):410-21.
Policy statement--The future of
pediatrics: mental health competencies for pediatric primary care.
Committee on Psychosocial Aspects of
Child and Family Health and Task Force on Mental Health.
Collaborators (34)
Coleman WL, Dobbins MI, Garner AS, Siegel BS, Wood DL, Earls MF, Brown RT, Kupst MJ, Martini DR, Sheppard M, Cohen GJ, Smith KS, Foy JM, Duncan P, Frankowski B, Kelleher K, Knapp PK, Laraque D, Peck G, Regalado M, Swanson J, Wolraich M, Dolan M, Joffe A, O'Malley P, Perrin J, McInerny TK, Wegner L, Carmichael T, Gruttadaro D, Sigman G, Sullivan M, Sulik LR, Paul L.
Pediatric primary care clinicians have unique
opportunities and a growing sense of responsibility to prevent and address
mental health and substance abuse problems in the medical home. In this report,
the American Academy of Pediatrics proposes competencies requisite for
providing mental health and substance abuse services in pediatric primary care
settings and recommends steps toward achieving them. Achievement of the
competencies proposed in this statement is a goal, not a current expectation.
It will require innovations in residency training and continuing medical
education, as well as a commitment by the individual clinician to pursue, over
time, educational strategies suited to his or her learning style and skill
level. System enhancements, such as collaborative relationships with mental
health specialists and changes in the financing of mental health care, must
precede enhancements in clinical practice. For this reason, the proposed
competencies begin with knowledge and skills for systems-based practice. The
proposed competencies overlap those of mental health specialists in some areas;
for example, they include the knowledge and skills to care for children with
attention-deficit/hyperactivity disorder, anxiety, depression, and substance
abuse and to recognize psychiatric and social emergencies. In other areas, the
competencies reflect the uniqueness of the primary care clinician's role:
building resilience in all children; promoting healthy lifestyles; preventing
or mitigating mental health and substance abuse problems; identifying risk
factors and emerging mental health problems in children and their families; and
partnering with families, schools, agencies, and mental health specialists to
plan assessment and care. Proposed interpersonal and communication skills
reflect the primary care clinician's critical role in overcoming barriers
(perceived and/or experienced by children and families) to seeking help for
mental health and substance abuse concerns.
Langberg JM, et al.
Interventions to promote the evidence-based care of
children with ADHD in primary-care settings.
Expert
Rev Neurother.
2009 Apr;9(4):477-87.
Cincinnati
Children's Hospital Medical Center, Division of Behavioral Medicine and
Clinical Psychology, Center for ADHD, 3333 Burnet Ave, MLC 10006, Cincinnati
OH, 45229-3039, USA. joshua.langberg@cchmc.org
http://www.ncbi.nlm.nih.gov/pubmed/19344300?dopt=Citation
Attention-deficit/hyperactivity
disorder (ADHD) is a commonly occurring behavioral disorder among children.
Community-based physicians are often the primary providers of services for
children with ADHD. A set of consensus guidelines has been published by the American Academy of Pediatrics that provides best-practice diagnostic
procedures for primary-care physicians. These recommendations emphasize the
importance of using the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition criteria as the basis for making an ADHD diagnosis and
conducting systematic follow-up, including the collection of parent and teacher
ratings scales to quantitatively assess response to treatment. Although these
recommendations have been widely disseminated and their adoption actively
promoted, guideline adherence, in general, is known to be poor. Two types of
intervention models, ancillary service and office systems modification, have
been proposed to promote adoption of evidence-based ADHD practice in
primary-care settings. The present article reviews the efficacy of these
intervention models, and discusses the cost and sustainability of each model as
related to feasibility of intervention dissemination.
Acad Psychiatry.
2009 Jan-Feb;33(1):80-1.
Medical student participation in an
adult ADHD outpatient clinic: an ideal setting for education in outpatient
psychiatry.
Wetzel MW.
Acad Med. 2005
Dec;80(12):1114-20.
Using children as
simulated patients in communication training for residents and medical
students: a pilot program.
Brown R, Doonan S, Shellenberger S.
Department
of Psychiatry and Behavioral Science, Mercer School of Medicine, 655 First
Street, Macon, GA 31201, USA. brown_rm@mercer.edu
Medical schools are charged with the challenge of
teaching effective communication skills, a core competency for residents and
medical students. Especially challenging is the task of developing effective
methods for training residents and students to communicate with children with
mental health issues. The authors describe a pilot program at Mercer University
School of Medicine that used pediatric standardized patients (SPs), ages 9-19, to aid in training residents and medical
students in complex interviewing skills addressing mental health issues. New
curriculum components for four pediatric problems, anorexia nervosa,
depression, separation anxiety, and attention deficit hyperactivity disorder (ADHD),
were designed and implemented by the authors in 2002-04. The training sessions
were evaluated by the participating SPs as well as
the residents and medical students in training. The components of the training
were a lecture and subsequent practice using pediatric SPs
and adults acting as their mothers. Evaluation included the qualitative
analysis of SPs' reactions to participation in the
training as described during a posttraining-session
focus-group, as well as questionnaire responses by residents and medical
students. The children role-playing the scenario of a difficult-to-manage
situation and their adult "parent" actors voiced strongly positive
reactions to participating in training residents and medical students. The
reactions of physicians in training were also positive. The authors thus
conclude that child and adolescent actors can be effectively used as SPs to train residents and students in complex interviewing
skills, even in cases involving children with challenging mental health issues.
Culpepper L.
Primary care treatment of
attention-deficit/hyperactivity disorder (review).
J
Clin Psychiatry. 2006;67 Suppl 8:51-8. http://www.ncbi.nlm.nih.gov/pubmed/16961431?dopt=Citation
Department of Family Medicine, Boston University, Boston, Mass. 02118, USA. larry.culpepper@bmc.org
Primary care
physicians should consider the role of families of patients with
attention-deficit/ hyperactivity disorder (ADHD) not just in terms of their
genetic relationship but also in terms of the role family can play in assisting
in the treatment and management of the disorder. When first encountering a new
case of ADHD, primary care physicians should confirm the diagnosis, identify comorbidities and other primary disorders, and develop a
comprehensive assessment of the patient with ADHD that includes consideration
of family-related influences. Management of multiple medical, mental health, and psychosocial problems over time will often be
ineffective if ADHD is not adequately managed. The most effective management
should be multimodal, with patients benefiting from caring professionals with
special expertise in the treatment of ADHD as well as the primary care
physician. Successful management of ADHD begins with establishing a therapeutic
alliance with the patient and affected family that includes patient and family
education and agreement on patient-specific goals, treatment, follow-up, and
monitoring. As pharmacotherapy controls the core symptoms of ADHD, the primary
care physician and treatment team should discuss with the patient other
supportive interventions.
Leslie LK, et
al.
Implementing the American Academy of Pediatrics attention-deficit/
hyperactivity disorder diagnostic guidelines in primary care
settings.
Pediatrics. 2004 Jul;114(1):129-40.
Child and Adolescent Services Research Center, Children's Hospital, San Diego, California 92123-0282, USA. leslie@casrc.org
http://www.ncbi.nlm.nih.gov/pubmed/15231919?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
OBJECTIVES: To
evaluate the feasibility of the San Diego Attention-Deficit/Hyperactivity
Disorder Project (SANDAP) protocol, a pediatric community-initiated quality
improvement effort to foster implementation of the American Academy of
Pediatrics (AAP) attention-deficit/hyperactivity disorder (ADHD) diagnostic
guidelines, and to identify any additional barriers to providing evidence-based
ADHD evaluative care. METHODS: Seven research-naïve primary care offices in the
San Diego area were recruited to participate. Offices were
trained in the SANDAP protocol, which included 1) physician education, 2) a
standardized assessment packet for parents and teachers, 3) an ADHD coordinator
to assist in collection and collation of the assessment packet components, 4) educational
materials for clinicians, parents, and teachers, in the form of handouts and a
website, and 5) flowcharts delineating local paths for referral to medical subspecialists, mental health practitioners, and
school-based professionals. The assessment packet included the parent and
teacher versions of the Vanderbilt ADHD Diagnostic Rating Scales. In this
study, we chose a conservative interpretation of the AAP ADHD guidelines for
diagnosing ADHD, requiring that a child met criteria for ADHD on both the parent
and teacher rating scales. A mixed-method analytic strategy was used to address
feasibility and barriers, including quantitative surveys with parents and
teachers and qualitative debriefing sessions conducted an average of 3 times
per year with pediatricians and office staff members. RESULTS: Between December
2000 and April 2003, 159 children were consecutively enrolled for evaluation of
school and/or behavioral problems. Clinically, only 44% of the children met
criteria for ADHD on both the parent and teacher scales, and 73.5% of those
children were categorized as having the combined subtype. More than 40% of the
subjects demonstrated discrepant results on the Vanderbilt scales, with only
the parent or teacher endorsing sufficient symptoms to meet the criteria of the
Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
Other mental health and learning problems were common in the sample; 58.5% of
subjects met screening criteria for oppositional defiant disorder/conduct
disorder, 32.7% met screening criteria for anxiety/depression, and
approximately one-third had an active individualized education program in place
or had received an individualized education program in the past. On evaluation,
the SANDAP protocol was acceptable and feasible for all stakeholders. However,
additional barriers to implementing the AAP ADHD guidelines were identified,
including 1) limited information in the guidelines regarding the use of
specific ADHD rating scales, the evaluation and treatment of children with discrepant
and/or negative results, and the indications for psychologic evaluation of
learning problems, 2) families' need for education regarding ADHD and support,
3) characteristics of physical health and mental health plans that limited care
for children with ADHD, and 4) limited knowledge and use of potential community
resources. CONCLUSIONS: Our results indicate that children presenting for
evaluation of possible ADHD in primary care offices have complex clinical
characteristics. Providers need mechanisms for implementing the ADHD diagnostic
guidelines that address the physician education and delivery system design
aspects of care that were developed in the SANDAP protocol. Additional barriers
were also identified. Careful attention to these factors will be necessary to
ensure the sustained provision of quality care for children with ADHD in
primary care settings.
[No
authors listed]
Clinical
Practice Guideline: Treatment of the School-Aged Child With
Attention-Deficit/Hyperactivity Disorder.
American Academy of Pediatrics. Pediatrics. 2001 Oct.;108(4):1033-44.
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/4/1033
[No
authors listed]
Clinical practice guideline: diagnosis and evaluation
of the child with attention-deficit/hyperactivity disorder.
American Academy of Pediatrics. Pediatrics. 2000 May;105(5):1158-70.
Comment in: Pediatrics. 2001 May;107(5):1239. http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;105/5/1158
http://www.ncbi.nlm.nih.gov/pubmed/10836893?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed
This clinical
practice guideline provides recommendations for the assessment and diagnosis of
school-aged children with attention-deficit/hyperactivity disorder (ADHD). This
guideline, the first of 2 sets of guidelines to provide recommendations on this
condition, is intended for use by primary care clinicians working in primary
care settings. The second set of guidelines will address the issue of treatment
of children with ADHD. The Committee on Quality Improvement of the American Academy of Pediatrics selected a committee composed of
pediatricians and other experts in the fields of neurology, psychology, child
psychiatry, development, and education, as well as experts from epidemiology
and pediatric practice. In addition, this panel consists of experts in
education and family practice. The panel worked with Technical Resources
International, Washington, DC, under the auspices of the Agency for Healthcare
Research and Quality, to develop the evidence base of literature on this topic.
The resulting evidence report was used to formulate recommendations for
evaluation of the child with ADHD. Major issues contained within the guideline
address child and family assessment; school assessment, including the use of
various rating scales; and conditions seen frequently among children with ADHD.
Information is also included on the use of current diagnostic coding
strategies. The deliberations of the committee were informed by a systematic
review of evidence about prevalence, coexisting conditions, and diagnostic
tests. Committee decisions were made by consensus where definitive evidence was
not available. The committee report underwent review by sections of the American Academy of Pediatrics and external organizations before
approval by the Board of Directors. The guideline contains the following
recommendations for diagnosis of ADHD: 1) in a child 6 to 12 years old who
presents with inattention, hyperactivity, impulsivity, academic
underachievement, or behavior problems, primary care clinicians should initiate
an evaluation for ADHD; 2) the diagnosis of ADHD requires that a child meet
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria;
3) the assessment of ADHD requires evidence directly obtained from parents or
caregivers regarding the core symptoms of ADHD in various settings, the age of
onset, duration of symptoms, and degree of functional impairment; 4) the
assessment of ADHD requires evidence directly obtained from the classroom
teacher (or other school professional) regarding the core symptoms of ADHD,
duration of symptoms, degree of functional impairment, and associated
conditions; 5) evaluation of the child with ADHD should include assessment for
associated (coexisting) conditions; and 6) other diagnostic tests are not
routinely indicated to establish the diagnosis of ADHD but may be used for the
assessment of other coexisting conditions (eg, learning disabilities and mental
retardation). This clinical practice guideline is not intended as a sole source
of guidance in the evaluation of children with ADHD. Rather, it is designed to
assist primary care clinicians by providing a framework for diagnostic decisionmaking. It is not intended to replace clinical
judgment or to establish a protocol for all children with this condition and
may not provide the only appropriate approach to this problem.