Monday, July 7, 2008

Improved care for children with ADHD

An innovative program is helping busy primary care physicians improve the care they provide for school-aged children with Attention-Deficit/Hyperactivity Disorder (ADHD), according to a study led by researchers at Cincinnati Children's Hospital Medical Center and published in the July edition of Pediatrics.

The study is the first to intervene with an entire community of primary care physicians and help them more accurately diagnose and effectively monitor treatment response of their patients with ADHD, said Jeff Epstein, Ph.D., director of the Center for ADHD at Cincinnati Children's and lead author of the study. Although community practitioners are the first point of contact for children with ADHD, the use of standardized evidence-based diagnosis and treatment guidelines established by the American Academy of Pediatrics (AAP) was infrequent at most of the participating pediatric practices before the study began.

The intervention consisted of an innovative training program developed by Cincinnati Children's on how to implement AAP diagnosis and treatment guidelines. The training focused on modifying office systems to accommodate the AAP guidelines, said Dr. Epstein. This included building in the use of parent and teacher ADHD rating scales into the evaluation and treatment monitoring process.

After 84 Cincinnati-area community physicians finished training and implemented AAP guidelines at their practices, the use of ADHD child assessment rating scales by parents and teachers soared from 55 percent and 52 respectively to nearly 100 percent, the research team reported. This led to more accurate diagnosis of prospective patients and fewer children being started on medication inappropriately. Systematic monitoring of patient medication response improved from a baseline of 9 percent to over 40 percent. For patients who were being monitored systematically, most had documentation of significant symptom reduction during their first several months of treatment

"An additional benefit of the intervention is it appears that as a result of participating in the intervention, physicians in the community are now better equipped to recommend alternatives to medication – such as behavioral therapy – engage families in setting treatment goals, and more effectively coordinate care with the child's school.," said Dr. Epstein.

ADHD is the most commonly diagnosed behavioral disorder in childhood, with prevalence rates among grade-schoolers children estimated at 3 to 8 percent. ADHD is characterized by developmentally inappropriate symptoms of inattention, hyperactivity and impulsivity. These symptoms produce significant impairment in school performance, social interactions with peers and family, daily self-management activities and self-esteem.

Although ADHD is classified as a mental disorder, the majority of children with ADHD are evaluated and treated by primary care physicians rather than by mental health specialists. The AAP has encouraged its members to become more knowledgeable about best-practice standards for ADHD diagnosis and management and in 2001 published an evidence-based guideline for pediatricians to follow.

"A significant problem, both locally and nationally, is that guidelines, once published, rarely find their way quickly into clinical usage," Dr. Epstein said. "A large part of the problem is that no means exists for systematically exposing physicians to the guidelines and teaching them how to adapt them for use in their busy practices. This was the case in the Cincinnati-area practices with the ADHD guidelines."

Taper Meds in Kids With Stable Asthma

Note to Pediatricians: Taper Meds in Kids With Stable Asthma; Hopkins Children's Study Shows Many Doctors Wouldn't

BAA study of how pediatricians prescribe asthma medications suggests that while most would readily increase a child's medication if needed, many are reluctant to taper off drug use when less might be best. A report on the study, led by Johns Hopkins Children's Center researchers, appears in the July issue of Pediatrics.

"Asthma medications can have serious, albeit infrequent, side effects, and while under-treatment is undeniably a big problem, not stepping down treatment when a child is doing well may be too," says lead investigator Sande Okelo, M.D., an asthma specialist at Hopkins Children's.

In the research, conducted among 310 pediatricians nationwide, 40 percent said they would not step down high-dose treatment even if a child's symptoms were well controlled and infrequent.

"If a child is doing well and her symptoms are well under control, why not take that chance and see if a smaller dose would do the trick?," says senior investigator Gregory Diette, M.D., M.H.S., a lung specialist at Hopkins.

Beyond side effects, Okelo says, a failure by pediatricians to taper off drugs may also lead parents to do so on their own by skipping doses or decreasing them.

"Past research shows that when parents are concerned about side effects and their child is doing well, they may take action without a doctor's approval," Okelo says.

For the study, the pediatricians were asked to devise treatment plans using different patient scenarios, describing various elements, including whether a child had been hospitalized recently, how bothersome and frequent a child's symptoms were, whether symptoms had recently intensified or lessened and whether the child had wheezing on a physical exam. Most doctors reported they would step up treatment in patients with: 1) recent hospitalizations 2) frequent symptoms 3) parents who said they were bothered by their child's symptoms 4) those who had wheezing on exam.

While current treatment guidelines focus on symptom frequency, nearly all pediatricians reported using multiple factors in their decision-making, including quality of life and how bothered parents were by their child's symptoms.

Okelo says pediatricians might greatly benefit from a step-by-step, "frontlines" tool that tells them how to specifically apply treatment guidelines and how to use different dimensions of the disease in their day-to-day practice.

Because asthma is an unstable disease and can change often and unpredictably, it is essential that children with asthma get regular follow-up exams every three to six months even in the absence of symptoms, researchers recommend.

Asthma is the most common pediatric chronic illness, affecting 6.5 million children in the United States, according to the Centers for Disease Control and Prevention.