By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
Source: Silverstein M, et al. Collaborative care for children with ADHD symptoms: A randomized comparative effectiveness trial. Pediatrics 2015;135:e858-67. doi: 10.1542/peds.2014-3221.
Summary Point
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Strengthening collaborative care improves reduction of ADHD symptoms in a population of inner-city, low-income children.
Evidence-based treatment of attention deficit hyperactivity disorder (ADHD) involves medication and behavioral management, but increasingly health care providers are turning to team-based treatment that may incorporate integrative modalities. The authors of this study, which included approximately 150 children ages 6-12 years, hypothesized that training care managers in motivational interviewing, medical history taking, and Triple P (Positive Parenting Program — a multimodality program targeting preventive interventions taught to parents of high-risk pre-adolescents) could enhance collaborative care of ADHD and improve symptom reduction. Recognizing the difficulty and expense involved in recruiting care managers with mental health backgrounds, college graduates without such backgrounds were hired as lay care managers and trained in these specific areas.
The study followed two subsets or arms of the original group of recruited pediatric patients. The first arm had conventional or baseline care management (in-person meeting until diagnosis, then telephone follow-up.) The enhanced arm utilized multiple in-person meetings with the patient and family. A primary objective for motivational interviewing was to resolve ambivalence regarding medication use, increase medication compliance, and help identify and refer parents for any relevant mental health problems of their own.
The subjects included inner city, low-income children referred to primary care for an ADHD work-up. Diagnostic criteria were employed during the study; about 40% of these children were diagnosed with ADHD. Symptom improvement in the enhanced arm was statistically significant only in the children diagnosed with ADHD. In this group, significant differences in reduction of primary measures of ADHD symptoms, as well as the secondary measures of oppositional behaviors and improvement in social skills, were seen at 6 months and more dramatically at 12 months (see Table).
Table: Differences in Reduction of Primary and Secondary Measures of ADHD Symptoms |
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6 Months |
12 Months |
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Primary Measures |
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Inattention |
0.05 (mean decrease) |
0.08 effect size |
0.16 (mean decrease) |
0.24 effect size |
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Hyperactivity/Impulsivity |
0.22 (mean decrease) |
0.49 effect size |
0.36 mean decrease) |
0.57 effect size |
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Secondary Measures |
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Oppositional |
0.10 (mean decrease) |
0.18 effect size |
0.40 (mean decrease) |
0.55 effect size |
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Social Skills |
1.68 (mean increase) |
0.13 effect size |
9.57 (mean increase) |
0.69 effect size |
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Adapted from: Silverstein M, et al. Collaborative care for children with ADHD symptoms: A randomized comparative effectiveness trial. Pediatrics 2015;135:e858-67. doi: 10.1542/peds.2014-3221. |
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The takeaway message is that optimization of ADHD treatment in this challenging population does not necessarily mean increasing doses of medication. Physicians should look toward interventions, in this case, motivational interviewing, targeted to increase medication compliance and parenting effectiveness.
Strengthening collaborative care improves reduction of ADHD symptoms in a population of inner-city, low-income children.
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