Primary Care Management of Children with Attention-Deficit/
Hyperactivity Disorder Appears More Assertive Following Brief Psychiatric Intervention Compared with Single Session Consultation
Rockhill CM, Carlisle LL, Qu P, Vander Stoep A, French W, Zhou C, Myers K.
J Child Adolesc Psychopharmacol. 2020
Commentary* by Dr. Margaret Weiss: Shared care in Canada is based both on consultation and specialist assessment, stabilization and access to specialized psychosocial treatment. This article suggests that the initial costs of more intensive specialist intervention at the front end may lead to significant greater gains in the longer-term PCP management.
Objectives: We examined primary care providers’ (PCPs’) management of attention-deficit/hyperactivity disorder (ADHD) during and following families’ participation in two arms of the Children’s ADHD Telemental Health Treatment Study. We hypothesized that more intensive treatment during the trial would show an “after-effect” with more assertive PCPs’ management during short term follow-up.
Methods: We conducted a pragmatic follow-up of PCPs’ management of children with ADHD who had been randomized to two service delivery models. In the Direct Service Model, psychiatrists provided six sessions over 22 weeks of pharmacotherapy followed by behavior training. In the Consultation Model, psychiatrists provided a single-session consultation and made treatment recommendations to PCPs who implemented these recommendations at their discretion for 22 weeks. At the end of the trial, referring PCPs for both service delivery models resumed ADHD treatment for 10 weeks. We performed intent-to-treat analysis using all 223 original participants. We applied linear regression models on continuous outcomes, Poisson regression models on count outcomes, and logistic regression models to binary outcomes. Missing data were addressed through imputations.
Results: Participants in the Direct Service Model had more ADHD visits than those in the Consultation Model across the full 32 weeks (mean = 7.05 visits vs. 3.36 visits; adjusted rate ratio = 2.1 [1.85-2.38]; p < 0.0001). During follow-up, participants in the DSM were more likely to be taking ADHD-related medications (82% vs. 61%; adjusted odds ratio = 2.44 [1.24-4.81], p = 0.01). At 32 weeks, participants in the Direct Service Model had higher stimulant dosages (adjusted difference = 5.64 [0.12-11.15] mg; p = 0.046).
Conclusion: These results from a pragmatic follow-up of a randomized trial suggest an “after-effect” for brief intensive treatment in the Direct Service Model on the short-term follow-up management of ADHD in primary care.
* Abstracts are selected for their clinical relevance by Dr. Margaret Weiss, Director of Clinical Research, Child Psychiatry, Cambridge Health Alliance, Harvard University. Her commentary reflects her own opinion. It is not approved or necessarily representative of the CADDRA board.