Say you’re a pediatrician whose 8-year-old patient is showing symptoms of Attention Deficit Hyperactivity Disorder. That’s not unusual, up to 12 percent of American kids are diagnosed with it.
But you know that in general, ADHD treatment tends not to work as well in poor kids, like your patient, as it does in their better-off peers. And you also happen to know that the symptoms began two months after the patient’s father was incarcerated. It might be ADHD, or it might just be horrible stress. What do you do?
This is the kind of challenge that routinely faces pediatricians at Boston Medical Center, where most of their patients comes from the inner city, says Dr. Michael Silverstein, chief of the hospital’s division of General Academic Pediatrics.
In a study of 156 young patients just out in the journal Pediatrics, Silverstein and colleagues report some success with an experimental intervention they designed to address such challenging cases.
They found that with a relatively modest investment — about a week of training for a care manager that the patients’ families interact with anyway — they could “move the needle” on ADHD symptoms and social skills, he says.
I asked him to elaborate. First, the background:
General pediatricians tend to be fully equipped to treat straightforward cases of ADHD, Dr. Silverstein says, but for tougher cases like the one described above, and many among BMC’s population of vulnerable kids, they need specialists to address the more vexing issues. One proven model of providing that expertise is called “collaborative care.”
Providing care for low-income kids through mechanisms that address the health of both generations, parents and children.
The pediatrician is “driving the boat,” he says, but the specialists “essentially provide what we call ‘decision support.’ They say, ‘For someone like who you’re describing to me, I would try something like this.’ They give the rules of the road to the primary care doc, but the primary care doc drives.
And because it’s so hard to get busy people into the same room at the same time, the communication between the primary care doctor and the specialist is mediated through a ‘care manager’ intermediary.” (Ideally, a child psychiatrist would be right down the hallway, but that’s “pie in the sky” for under-resourced hospitals like the BMC, he notes.)
Research has shown that collaborative care works well, “but at BMC and places like it, this way of delivering care is probably necessary but not sufficient.” The reason? “A lot of kids with symptoms of ADHD don’t get better even when treated optimally. Why is that? You give them access to proper medication, the diagnosis is made properly, yet they don’t get better. And we homed in on three reasons that kids with ADHD symptoms may not get better that really were relevant to our population:
• The first is that we know that parents of children with ADHD have a disproportionate burden of mental illness themselves. You could imagine a child’s improvement trajectory might not be as good if his mother is depressed.
• Also, in general we see a guardedness about going to the doctor for behavioral problems — that’s not in everyone’s cultural frame of reference. So the idea of medication for inattention might not be where everyone is at. These are potentially stigmatizing conditions, so lots of times people recommend a course of action — medication or something else — but the families aren’t quite there.
• And the third reason is that we know that for certain children with ADHD, behavioral therapies work really well in addition to medication, but our families tend not to have access to those.
So we developed an intervention that was hung on the structure of collaborative care, where the care managers who serve as intermediaries between specialists and generalists are trained to address those three things.
The care manager typically would be bilingual, usually a woman in her mid-twenties. We would train this person in an interactional technique called motivational interviewing. It’s a very non-judgmental, client-centered way of interacting with a patient or patient’s family that lets them – the patient’s mother or father — explore why or why not they might be ambivalent to engage with care on behalf of their child or their own mental health.
So the care managers that were providing an enhanced level of care had week-long training in motivational interviewing and also had training in the fundamentals of how to help parents manage what we sometimes call oppositional behaviors in their children in a much more positive way, reframing certain behaviors.
It included some really concrete parenting techniques that might be applicable to kids with ADHD or oppositionality. In essence, that’s what the enhanced care arm of this study got — a little more than a week of training for these young women.
In terms of outcomes, the study looked at a couple of things: We looked at the traditional symptoms of ADHD, which would be inattention and hyperactivity/impulsivity. We looked at oppositionality and we looked at social skills, which some people think is more important. Looking at kids a full year down the line, we were able to move the needle in these categories.”
So now what?
“The researcher in me wants to replicate this and be sort of guarded in interpreting the results,” Silverstein says. “Provided these results hold up, I think it’s an issue of implementation, and when people talk about the Patient-Centered Medical Home, we really have to think about what this has to look like for specific populations that have specific challenges.
I’ve been making the case that a thoughtful, coordinated way of providing care for low-income kids is through mechanisms that address the health of both generations, parents and children, and pay attention deliberately to issues of trust of the health care system and cultural brokerage.
That’s our hypothesis. One of the things about a study like this — a randomized trial is widely seen to be the gold standard in proving what happens when you do something — but when that something is complicated or has multiple facets to it, you’re often left saying, ‘Why, why did this particular project generate these results?’ And that’s a viable next step – to figure that out.
My gut sense is that the active ingredient of our care model was that this motivational interviewing component started a cascade of events that led to more discussion between family and pediatrician around prescribing patterns of ADHD medication and other culturally acceptable ways of addressing the symptoms.
At the end of the day we can’t say, ‘We know exactly what the active ingredient of this was.’ But it had to do with meeting the families where they are and having them accept certain elements of the care.”
Readers, reactions? Thoughts about using a model like this even in better-off families?