ADHD children may gain more from family-centered care

(HealthDay)—For children with attention-deficit/hyperactivity disorder (ADHD), receiving more family-centered, compassionate care may be more effective than standard care, a new study found.

Researchers compared two types of "collaborative care," in which special care managers act as intermediaries between a family and their child's doctors.

One approach was standard collaborative care while the other was "enhanced," which meant the care managers had received several days of training to teach parents healthy parenting skills and interact with families in an open-minded, non-judgmental, empathetic way.

"I think it's a very powerful tool in medicine and it's being used more and more, but it's still not widespread in terms of how doctors interact with patients and their families," said study author Dr. Michael Silverstein, an associate professor of pediatrics at Boston University School of Medicine.

Silverstein added that the care managers who were trained did not have advanced degrees or formal mental health education and licensing. "This could be potentially significant for how to provide care in settings or among populations who might not be able to afford or have access to Ph.D.-level psychologists," he said.

One expert further explained the importance of collaborative care.

"Collaborative care attempts to improve adherence by checking in with families regularly to see how they are doing, helping to ensure they understand and agree with the treatment recommendations, and identifying and alleviating any obstacles to effective treatment that may arise as promptly as possible," explained Dr. Glen Elliott, chief psychiatrist and medical director of Children's Health Council in Palo Alto, Calif.

The findings were published online March 23 and will appear in the April print issue of the journal Pediatrics.

The researchers followed 156 children in an urban setting for one year after they were referred for testing for ADHD. The children were randomly assigned to receive standard collaborative care or enhanced collaborative care.

Care managers delivering enhanced care received training in the Positive Parenting Program (Triple P) and a technique called motivational interviewing. Motivational interviewing uses empathy to build a relationship between a care manager and a family, which helps the family identify what it wants and develops the motivation to reach those goals, said Mayra Mendez, a program coordinator for intellectual and developmental disabilities and mental health services at Providence Saint John's Child and Family Development Center in Santa Monica, Calif.

"Based on a non-confrontational approach, motivated interviewing is conducted in an atmosphere of acceptance, compassion and equality," Mendez noted.

The children in this study, ranging from age 6 to 12, had not been diagnosed with ADHD at the start of the study but were recommended for testing by their primary care doctors. Ultimately, 40 percent of them were found to have ADHD symptoms that would qualify for a diagnosis.

After one year, the children as a whole showed improvements in hyperactivity, impulsivity, inattention and social skills, which is not surprising, Elliott said.

"Even without intervention, children with ADHD generally get less symptomatic over time," Elliott explained. "Absent a 'control' group [children who did not receive any care], it is hard to know how big an impact either of these interventions had on that general trend."

However, the researchers reported that significantly greater improvements in all these areas occurred among the children who had symptoms that would qualify for an ADHD diagnosis and received enhanced collaborative care—but not among those who received collaborative care but did not end up having symptoms that would qualify for an ADHD diagnosis.

"ADHD has treatments known to work, but only if they are applied consistently," Elliott said.

Study author Silverstein explained that three factors can interfere with a child's ability to receive successful treatment. These include: difficulty adhering to the therapy (for economic, family or other reasons); a mother's mental health problems; and other conditions the child has, such as oppositional defiance disorder, depression, anxiety, learning disabilities or even post-traumatic stress disorder.

The enhanced collaborative care approach tried to help with those factors, Silverstein said.

One goal is to reduce "coercive parenting," a style that uses "authoritarian, threatening, punishing, shouting and non-reflective methods of disciplining children," Mendez said.

"It's negative feedback for things done wrong, rather than positive feedback when kids succeed," Mendez added. "Lots of evidence shows that it is effective in the short run but counterproductive in the long run."

Silverstein suspects that the children with ADHD symptoms who received enhanced collaborative care experienced more improvement because the family could better stick to the therapies that treated the child's condition.

"Motivational interviewing is an inherently patient or family-centric way of communicating," Silverstein said. "If done right, it allows patients or their parents to reflect on their own health behaviors from an empowered, non-judged position and builds trust between the family and the care team," he added.

"In this case, this type of communication style may have started a cascade of events that opened the door to increased receptivity to ADHD medication or to engagement with parenting advice offered through Triple P," Silverstein suggested.

"I would hope that if the benefits that we demonstrated bear out in future research, that insurance companies will see fit to pay for this because we know that kids that have ADHD symptoms that are not under control tend to have more injuries, have more interaction with the health care system and tend to get into trouble in school," Silverstein said.

Further, most components for enhanced collaborative care already exist in many communities, he said: "I see the challenge ahead being bundling these components into a coordinated care system."

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