Improving Engagement in ADHD Care.

Abstract

Optimal treatment of a child or adolescent with attention-deficit/hyperactivity disorder (ADHD) begins by establishing a collaborative care team consisting of the family, school personnel, primary care clinician (PCC), mental health and subspecialty clinicians, and other adults, such as tutors and coaches.1 To facilitate communication among care team members, a standardized, reliable system should be established to securely collect and share information about the child’s ADHD symptoms and functioning, medication side effects, receipt of ADHD treatments, family treatment preferences and goals, and educational resources.1Unfortunately, the fragmentation of ADHD care across health care, mental health, and education sectors is a substantial barrier to communication and collaboration among care team members.1,2 Each sector has its own rules and policies regarding confidentiality and privacy, and individual daily schedules are typically incompatible, making a meaningful, timely, and efficient exchange of information, whether synchronous (eg, phone call) or asynchronous (eg, e-mail), extremely challenging.In many quality improvement efforts to implement the ADHD guidelines, team communication and collaboration have been addressed, most commonly by focusing on improving the receipt of parent- and teacher-completed ADHD rating scales to inform clinician medical decision-making. These efforts have included developing extensive tool kits and online educational resources for PCCs3,4; redesigning office workflows (eg, designating a staff member to manage rating scale collection)5,6; using care managers to serve as the conduit of information across PCCs, parents, teachers, and other clinicians7,8; and developing or adopting ADHD-specific electronic systems or portals that may stand alone and/or be integrated with the electronic health record to varying degrees.9 Over time, these ADHD portals have become increasingly robust in their functionality and usability and have been shown to improve clinician adherence to ADHD guidelines as well as reduce ADHD symptoms in children.10 In some practices, ADHD portals have become the standard of care for children with ADHD.In this issue of Pediatrics, Guevara et al11 compare the effectiveness of a patient portal combined with care management with that of a patient portal alone on ADHD symptoms, treatment goal attainment, and other patient-reported outcome measures. Embedded in the electronic health record, the ADHD patient portal was designed to facilitate the collection and communication of ADHD symptoms and impairment, family treatment preferences and goals, and medication side effects among parents, teachers, and PCCs. ADHD-care managers contacted families and teachers by phone, text message, or e-mail at least once every 3 months to provide education on ADHD treatment, monitor the attainment of treatment goals, and address the patient’s and/or family’s emerging concerns. The authors found that, although both groups had reductions in ADHD symptoms over time, there was no difference between the 2 groups in ADHD symptom improvement, goal attainment, or other outcomes at any time point. This suggested that care management did not lead to improved ADHD symptoms beyond the effect of the patient portal alone.These results are somewhat surprising in light of other work revealing the benefits of care management for families of children with ADHD7,8 as well as for adults with depression and other chronic conditions.12 Indeed, in sensitivity analyses, Guevara et al11 did find that, although parent and teacher engagement with care managers was modest overall, children in families who received ≥2 care management sessions experienced greater ADHD symptom reduction than those with 1 or 0 sessions. The authors speculated that the virtual nature of their care management intervention (ie, e-mail, phone, or text message) may not have engaged parents as much as would otherwise be expected, compared with studies involving face-to-face care management.What should not be overlooked in this study, however, is that 68% of all study participants used the ADHD portal to complete rating scales at least once, and 30% had a teacher complete rating scales. Considering the impersonal nature of an electronic system, this is an impressive level of parent and teacher engagement, which is essential to the success of care for children and adolescents with ADHD. Engaged parents are more likely to participate in the collaboration activities that inform shared decision-making, such as completing ADHD rating scales regularly, scheduling and keeping ADHD follow-up appointments, and discussing treatment options, preferences, and goals with other care team members. Similarly, engaged teachers are more likely to complete rating scales and implement appropriate classroom-based interventions.Ultimately, the specific method by which to engage parents and teachers in ADHD collaborative care and treatment adherence matters less than the fact that there are a variety of effective methods that can be tailored for best fit with different families. Some will require the “high touch” of a human being; some will do well with a patient portal; others may need both. The overall goal remains the same: to reduce functional impairment and maximize the well-being of children with ADHD.