Pediatric Annals

CME Article 

Approaching ADHD as a Chronic Condition: Implications for Long-term Adherence.

Jeanne Van Cleave, MD; Laurel K. Leslie, MD, MPH

Abstract

Stacy, a 7-year-old girl, recently came to her primary care provider with her parents to be seen for “attention problems.” Fortunately, Stacy’s primary care practice, a group of seven forward-thinking clinicians, had just “renovated” how children and adolescents with attention problems are evaluated and treated for attention-deficit/hyperactivity disorder (ADHD). Shortly after Stacy’s mother made the appointment for her attention problems, a staff member of the practice, who acts as a contact person for ADHD management, called Stacy’s mother for initial information and mailed evaluation scales provided by the American Academy of Pediatrics (AAP)/National Initiative for Children’s Health Care Quality (NICHQ) ADHD Toolkit for her parents and teacher to complete. When Stacy and her mother arrived for the visit, the office staff scanned the completed forms into Stacy’s electronic medical record (EMR), so that the clinician could view them prior to the visit. During the visit, Stacy’s clinician documented the encounter using a template that prompts the clinician to ask questions necessary to establish the diagnosis of ADHD and to screen for co-existing conditions. With the help of clinical decision support tools built into the ADHD template, the clinician scored the evaluation forms, diagnosed Stacy with ADHD, and prescribed a long-acting stimulant medication. Through the EMR system, the clinician quickly e-mailed a standardized letter to Stacy’s teacher. After the clinician was finished, the designated ADHD staff member visited with Stacy and her mother to provide education about behavior strategies and to share additional materials about ADHD, medications, and side effects. The staff member then referred Stacy’s mother to a local support group of parents with children with ADHD and to a group parent training program. Stacy was then added to the practice’s registry of children and adolescents with ADHD. A 1-week follow-up phone call to review Stacy’s response to the medication and to consider a dose change, as well as a 1-month follow up appointment, were scheduled.

ABOUT THE AUTHORS

Jeanne Van Cleave, MD, is with the Center for Child and Adolescent Health Policy, Massachusetts General Hospital for Children, and is Instructor, Harvard Medical School. Laurel K. Leslie, MD, MPH, is Associate Director of the Center on Child and Family Outcomes in the Institute for Clinical Research and Health Policy Studies, and is Associate Professor of Medicine and Pediatrics at Tufts University School of Medicine.

Address correspondence to: Laurel K. Leslie, MD, MPH, 750 Washington Street, #345, Boston, MA 02111; fax 617-636-6280; e-mail lleslie@tufts-nemc.org.

Dr. Van Cleave and Dr. Leslie have disclosed no relevant financial relationships.

EDUCATIONAL OBJECTIVES

  1. Discuss the management of attention-deficit/hyperactivity disorder (ADHD) in the context of a chronic condition.
  2. Apply the Chronic Care Model for Child Health to the care of children and adolescents with ADHD.
  3. Assess the barriers to adherence to long-term treatment of ADHD and strategies that may be employed to overcome these barriers.

Abstract

Stacy, a 7-year-old girl, recently came to her primary care provider with her parents to be seen for “attention problems.” Fortunately, Stacy’s primary care practice, a group of seven forward-thinking clinicians, had just “renovated” how children and adolescents with attention problems are evaluated and treated for attention-deficit/hyperactivity disorder (ADHD). Shortly after Stacy’s mother made the appointment for her attention problems, a staff member of the practice, who acts as a contact person for ADHD management, called Stacy’s mother for initial information and mailed evaluation scales provided by the American Academy of Pediatrics (AAP)/National Initiative for Children’s Health Care Quality (NICHQ) ADHD Toolkit for her parents and teacher to complete. When Stacy and her mother arrived for the visit, the office staff scanned the completed forms into Stacy’s electronic medical record (EMR), so that the clinician could view them prior to the visit. During the visit, Stacy’s clinician documented the encounter using a template that prompts the clinician to ask questions necessary to establish the diagnosis of ADHD and to screen for co-existing conditions. With the help of clinical decision support tools built into the ADHD template, the clinician scored the evaluation forms, diagnosed Stacy with ADHD, and prescribed a long-acting stimulant medication. Through the EMR system, the clinician quickly e-mailed a standardized letter to Stacy’s teacher. After the clinician was finished, the designated ADHD staff member visited with Stacy and her mother to provide education about behavior strategies and to share additional materials about ADHD, medications, and side effects. The staff member then referred Stacy’s mother to a local support group of parents with children with ADHD and to a group parent training program. Stacy was then added to the practice’s registry of children and adolescents with ADHD. A 1-week follow-up phone call to review Stacy’s response to the medication and to consider a dose change, as well as a 1-month follow up appointment, were scheduled.

ABOUT THE AUTHORS

Jeanne Van Cleave, MD, is with the Center for Child and Adolescent Health Policy, Massachusetts General Hospital for Children, and is Instructor, Harvard Medical School. Laurel K. Leslie, MD, MPH, is Associate Director of the Center on Child and Family Outcomes in the Institute for Clinical Research and Health Policy Studies, and is Associate Professor of Medicine and Pediatrics at Tufts University School of Medicine.

Address correspondence to: Laurel K. Leslie, MD, MPH, 750 Washington Street, #345, Boston, MA 02111; fax 617-636-6280; e-mail lleslie@tufts-nemc.org.

Dr. Van Cleave and Dr. Leslie have disclosed no relevant financial relationships.

EDUCATIONAL OBJECTIVES

  1. Discuss the management of attention-deficit/hyperactivity disorder (ADHD) in the context of a chronic condition.
  2. Apply the Chronic Care Model for Child Health to the care of children and adolescents with ADHD.
  3. Assess the barriers to adherence to long-term treatment of ADHD and strategies that may be employed to overcome these barriers.

Stacy, a 7-year-old girl, recently came to her primary care provider with her parents to be seen for “attention problems.” Fortunately, Stacy’s primary care practice, a group of seven forward-thinking clinicians, had just “renovated” how children and adolescents with attention problems are evaluated and treated for attention-deficit/hyperactivity disorder (ADHD). Shortly after Stacy’s mother made the appointment for her attention problems, a staff member of the practice, who acts as a contact person for ADHD management, called Stacy’s mother for initial information and mailed evaluation scales provided by the American Academy of Pediatrics (AAP)/National Initiative for Children’s Health Care Quality (NICHQ) ADHD Toolkit for her parents and teacher to complete. When Stacy and her mother arrived for the visit, the office staff scanned the completed forms into Stacy’s electronic medical record (EMR), so that the clinician could view them prior to the visit. During the visit, Stacy’s clinician documented the encounter using a template that prompts the clinician to ask questions necessary to establish the diagnosis of ADHD and to screen for co-existing conditions. With the help of clinical decision support tools built into the ADHD template, the clinician scored the evaluation forms, diagnosed Stacy with ADHD, and prescribed a long-acting stimulant medication. Through the EMR system, the clinician quickly e-mailed a standardized letter to Stacy’s teacher. After the clinician was finished, the designated ADHD staff member visited with Stacy and her mother to provide education about behavior strategies and to share additional materials about ADHD, medications, and side effects. The staff member then referred Stacy’s mother to a local support group of parents with children with ADHD and to a group parent training program. Stacy was then added to the practice’s registry of children and adolescents with ADHD. A 1-week follow-up phone call to review Stacy’s response to the medication and to consider a dose change, as well as a 1-month follow up appointment, were scheduled.

ABOUT THE AUTHORS

Jeanne Van Cleave, MD, is with the Center for Child and Adolescent Health Policy, Massachusetts General Hospital for Children, and is Instructor, Harvard Medical School. Laurel K. Leslie, MD, MPH, is Associate Director of the Center on Child and Family Outcomes in the Institute for Clinical Research and Health Policy Studies, and is Associate Professor of Medicine and Pediatrics at Tufts University School of Medicine.

Address correspondence to: Laurel K. Leslie, MD, MPH, 750 Washington Street, #345, Boston, MA 02111; fax 617-636-6280; e-mail lleslie@tufts-nemc.org.

Dr. Van Cleave and Dr. Leslie have disclosed no relevant financial relationships.

EDUCATIONAL OBJECTIVES

  1. Discuss the management of attention-deficit/hyperactivity disorder (ADHD) in the context of a chronic condition.
  2. Apply the Chronic Care Model for Child Health to the care of children and adolescents with ADHD.
  3. Assess the barriers to adherence to long-term treatment of ADHD and strategies that may be employed to overcome these barriers.

10.3928/00904481-20080101-07

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