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Study: An innovative telehealth service to provide high quality ADHD treatment

telehealth_adhd.

An unfor­tu­nate real­i­ty is that many chil­dren with ADHD do not have access to high qual­i­ty, evi­dence-based treat­ment for ADHD. This is espe­cial­ly true in rur­al com­mu­ni­ties where chil­dren are gen­er­al­ly treat­ed by pri­ma­ry care providers who may have less ADHD-spe­cif­ic train­ing than child psy­chi­a­trists and where high qual­i­ty behav­ioral treat­ment may also be less read­i­ly avail­able. Increas­ing access to excel­lent ADHD treat­ment is thus an impor­tant pri­or­i­ty, even as efforts to devel­op new and poten­tial­ly more effec­tive ADHD treat­ments are ongo­ing.

The new study

A study pub­lished recent­ly in the Jour­nal of the Amer­i­can Acad­e­my of Child and Ado­les­cent Psy­chi­a­try, Effec­tive­ness of a tele­health ser­vice deliv­ery mod­el for treat­ing Atten­tion-Deficit/Hyper­ac­tiv­i­ty Dis­or­der: A com­mu­ni­ty-based ran­dom­ized con­trolled tri­al, describes an inno­v­a­tive method for increas­ing access to high qual­i­ty ADHD treat­ment for chil­dren and fam­i­lies using video con­fer­enc­ing meth­ods and web-based train­ing for pro­fes­sion­als in rur­al com­mu­ni­ties.

Par­tic­i­pants were 223 chil­dren ages 5.5 to 12 (near­ly 70% boys)referred by 88 pri­ma­ry care providers across 7 rur­al com­mu­ni­ties in Wash­ing­ton and Ore­gon — all were diag­nosed with the com­bined type of ADHD, i.e., they had both inat­ten­tive and hyper­ac­tive-impul­sive symp­toms. Chil­dren were ran­dom­ly assigned to one of two treat­ment con­di­tions — a tele­health deliv­ery mod­el or to aug­ment­ed pri­ma­ry care. These treat­ment modal­i­ties are described below.

Tele­health deliv­ery mod­el — This treat­ment arm com­bined med­ica­tion treat­ment with behav­ior train­ing for par­ents. Both ser­vices were pro­vid­ed at com­mu­ni­ty clin­ics.

Child psy­chi­a­trists were trained to deliv­er evi­dence-based med­ica­tion treat­ment for ADHD through video con­fer­enc­ing. This enabled youth to receive high qual­i­ty med­ica­tion treat­ment for ADHD deliv­ered by expe­ri­enced child psy­chi­a­trists. Six tele­con­fer­ence ses­sions were con­duct­ed at com­mu­ni­ty clin­ics with ade­quate video con­fer­enc­ing capa­bil­i­ties; dur­ing these ses­sions, par­ents were edu­cat­ed about the poten­tial role and val­ue of med­ica­tion in treat­ing their child. Med­ica­tion treat­ment for each child was pre­scribed by the ‘telepsy­chi­a­trists’ using evi­dence-based algo­rithms devel­oped in the Texas Children’s Med­ica­tion Algo­rithm for Project.

Fol­low­ing the med­ica­tion treat­ment con­fer­ences, fam­i­lies met with a master’s lev­el com­mu­ni­ty ther­a­pist who pro­vid­ed care­giv­er behav­ior train­ing. Com­mu­ni­ty clin­i­cians were trained to pro­vide the behav­ior man­age­ment pro­gram via an online cur­ricu­lum devel­oped by the study research psy­chol­o­gist and through dis­cussing train­ing cas­es with the psy­chol­o­gist. This enabled rur­al clin­i­cians to pro­vide evi­dence-based behav­ioral par­ent train­ing for ADHD to par­ents in their com­mu­ni­ty.

The 6-ses­sion cur­ricu­lum focused on key ele­ments of evi­dence-based par­ent train­ing pro­grams for ele­men­tary school chil­dren with ADHD. Par­ents acquired an under­stand­ing of ADHD based on cur­rent sci­en­tif­ic knowl­edge, learned to pro­vide clear instruc­tions and to use time-out and oth­er con­se­quences effec­tive­ly, devel­oped prais­ing and ignor­ing skills, learned to use time-out and oth­er con­se­quences effec­tive­ly, and learned how to advo­cate for their child at school.

Telepsy­chi­a­try ses­sions and the behav­ior man­age­ment pro­gram were spread over 22 weeks, with 3–4 weeks between ses­sions.

Aug­ment­ed pri­ma­ry care — Chil­dren in the con­trol con­di­tion were treat­ed by their pri­ma­ry care provider. This was con­sid­ered aug­ment­ed pri­ma­ry care because unlike in typ­i­cal prac­tice, each pri­ma­ry care physi­cian received an exten­sive video con­sul­ta­tion with a child psy­chi­a­trist. The ‘telepsy­chi­a­trists’ were instruct­ed to pro­vide a com­pre­hen­sive con­sul­ta­tion that includ­ed med­ica­tion rec­om­men­da­tions and rec­om­men­da­tions for men­tal health ser­vices and school pro­grams when con­sid­ered appro­pri­ate. Once the con­sul­ta­tion was pro­vid­ed, pri­ma­ry care physi­cians con­duct­ed treat­ment as they saw fit. Infor­ma­tion on the num­ber of chil­dren in this group who received any treat­ments oth­er than med­ica­tion was not pro­vid­ed.

Out­comes mea­sures — Care­givers and teach­ers com­plet­ed the Van­der­bilt ADHD Rat­ing Scale at base­line and 4 sub­se­quent times; the final time point occurred 3 weeks after the last ses­sion for the tele­health deliv­ery group. All behav­ior rat­ings were pro­vid­ed via the inter­net. The Van­der­bilt includes items that assess the DSM-V symp­toms of ADHD, oppo­si­tion­al-defi­ant behav­ior, and children’s aca­d­e­m­ic, behav­ioral, and social func­tion­ing.

The results

Although chil­dren in both study arms improved over time, chil­dren in the tele­health deliv­ery arm showed sig­nif­i­cant­ly greater ben­e­fits accord­ing to par­ents. This was evi­dent in the fol­low­ing key find­ings:

- At base­line, approx­i­mate­ly 83% of chil­dren in both groups were rat­ed as show­ing at least 6 inat­ten­tive symp­toms by their par­ents. At week 25, this was report­ed by only 23% of tele­health par­ents and 48% of con­trol par­ents. Six or more hyper­ac­tive-impul­sive symp­toms were report­ed by rough­ly 60% of par­ents in each group; at week 25 this had dropped to 16% for tele­health par­ents and 31% for con­trol par­ents. Greater improve­ments for the tele­health group were evi­dent by week 10 for hyper­ac­tiv­i­ty and by week 19 for inat­ten­tion.

- Par­ents’ rat­ings also indi­cat­ed that sig­nif­i­cant­ly greater reduc­tions in oppo­si­tion­al-defi­ant behav­ior and sig­nif­i­cant­ly greater improve­ment in aca­d­e­m­ic, behav­ioral, and social func­tion­ing. The mag­ni­tude of the dif­fer­ences between the treat­ment groups would be con­sid­ered to fall in the small to mod­er­ate range.

Dif­fer­ences between the 2 treat­ment approach­es were less evi­dent in the teacher rat­ings, but in the direc­tion of favor­ing the tele­health mod­el.

Summary and Implications

Results from this study demon­strate the effec­tive­ness of a tele­health ser­vice deliv­ery mod­el for treat­ing ADHD in com­mu­ni­ties with lim­it­ed access to spe­cial­ty men­tal health ser­vices. Par­ents of chil­dren assigned to the tele­health group report­ed sig­nif­i­cant­ly greater improve­ment in their child’s ADHD symp­toms and func­tion­ing com­pared to par­ents of chil­dren who received aug­ment­ed pri­ma­ry care. Results based on teacher report — although not gen­er­al­ly sta­tis­ti­cal­ly sig­nif­i­cant — were in the same direc­tion. Thus, this deliv­ery mod­el may be a cost-effec­tive and viable way to increase the num­ber of chil­dren with ADHD who have access to high qual­i­ty, evi­dence-based care.

There are lim­i­ta­tions to this study that are impor­tant to note. First, it is dis­ap­point­ing that results were not more robust for teach­ers, giv­en the impor­tance of improv­ing school func­tion­ing in chil­dren with ADHD. This may reflect the fact that the con­trol con­di­tion in this study, i.e., aug­ment­ed pri­ma­ry care, includ­ed expert psy­chi­atric con­sul­ta­tion that is rarely obtained in rou­tine pri­ma­ry care. Thus, the out­comes for chil­dren in the aug­ment­ed pri­ma­ry care group may have already been bet­ter than what is typ­i­cal for chil­dren treat­ed by pri­ma­ry care providers alone.

It is also the case that behav­ioral train­ing was pro­vid­ed only to par­ents, and the tele­health mod­el did not include any direct training/consultation with teach­ers. Behav­ioral treat­ments gen­er­al­ly yield the largest effects in the set­ting in which they are imple­ment­ed. Thus, although the care­giv­er train­ing may have had a sub­stan­tial impact on children’s behav­ior at home, the impact on their school behav­ior would not be as pro­nounced. Thus, this inter­ven­tion may have ben­e­fit­ed by the addi­tion of a school com­po­nent in which teach­ers received con­sul­ta­tion regard­ing class­room behav­ior man­age­ment via tele­con­fer­enc­ing.

Final­ly, the last out­come assess­ment occurred only 3 weeks after the tele­health inter­ven­tion end­ed. Thus, although it would be impor­tant to know whether the more exten­sive treat­ment received by tele­health chil­dren and fam­i­lies result­ed in sus­tained ben­e­fits, the cur­rent study does not allow for this. Address­ing this ques­tion require more exten­sive fol­low up data than was report­ed, e.g., 3 months, 6 months, 1 year. Per­haps such data will be forth­com­ing short­ly.

These lim­i­ta­tions aside, this study pro­vides an excel­lent mod­el for how high qual­i­ty, evi­dence-based treat­ment for ADHD can be pro­vid­ed to a greater num­ber of chil­dren and fam­i­lies. Whether this ser­vice deliv­ery mod­el gains trac­tion in the years ahead remains to be seen.

Rabiner_David– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes the Atten­tion Research Update and is teach­ing the upcom­ing online course  How to Nav­i­gate Con­ven­tional and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment (May 2015; reg­is­tra­tion open).

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