Problem Addressed

• Common disorder, with detrimental effects: Conservatively, an estimated 3 to 5 percent of U.S. children (approximately 2 million children) have ADHD.¹ Symptoms include hyperactivity, distractibility, poor concentration, and impulsivity, which can affect school performance, social relationships, and in-home behavior.¹
• Poor PCP adherence to guidelines: At least half of patients with ADHD initially receive treatment from PCPs.² However, PCPs often fail to use established criteria (known as DSM-IV, which stands for Diagnostic and Statistic Manual of Mental Disorders, 4th edition) for diagnosing patients, which can lead to either over- or underdiagnosis.² When a diagnosis is made, PCPs often do not adhere to evidence-based guidelines promulgated by the American Academy of Pediatrics and other organizations. ³ For example, one study found that only about half of participating PCPs collected parent or teacher rating scale results during assessment; only 38 percent verified the child's diagnosis using DSM-IV criteria; only 1 percent gave patients and families written care management plans; and only 9 percent obtained follow up rating scale results from parents and teachers.⁴ Community physicians may receive training on guideline-based ADHD management, but may still not know how to titrate medications appropriately when faced with individual patient cases.³

Description of the Innovative Activity

• Software and accompanying manual: Pediatricians receive a software program and accompanying manual that support them in diagnosing, treating, and managing ADHD. The software assists with determining the severity of symptoms (and hence the need for medication) and in monitoring the patient's response to treatment. The printed manual helps clinicians use the software and offers detailed information about ADHD symptoms, evaluation, diagnosis, and medications. Content for the manual and software comes from established clinical practice guidelines promulgated by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry. The manual includes copies of the relevant guidelines. (The Tools and Other Resources section provides more information on these guidelines.)
• Evaluation of symptoms in suspected cases: Whenever ADHD is suspected, the pediatrician asks the parents to complete the 18-item ADHD Rating Scales-IV parent survey (more commonly referred to ADHDRS), and asks the parents to distribute the survey to their child's teacher(s). These widely-accepted surveys evaluate ADHD symptoms at home and in school.⁵ Once parents return their survey and the teacher's survey to the practice, a practice staff member within the pediatric practice enters them into the software, which converts the raw data into a standardized score and percentile based on the child's age and gender. Higher percentiles indicate more severe ADHD symptoms. 
• Additional evaluation, education for those with severe symptoms: If the child scores above the 75th percentile on both ADHDRS surveys, the child and family are invited to the practice for a further evaluation to confirm the diagnosis. (Note: Children suspected of meeting diagnostic criteria for ADHD need to be evaluated carefully by a competent clinician.) The doctor assesses whether or not ADHD symptoms are present and meet DSM-IV criteria. The physician also assesses the presence of other common problems for the 6- to 11-year-old age group; this assessment includes, but is not limited to, determining whether the child is depressed, anxious, oppositional, or conduct-disordered. 
• Treatment initiation: After obtaining the pretreatment ADHDRS, the physician prescribes the initial dose of medication for the child. As appropriate based on established guidelines, the pediatrician initiates treatment with a recommended medication, such as a short- or long-acting stimulant. The pediatrician consults the care manual for guidance on appropriate drug selection and dose, usually starting the patient on a low dose.
• As-needed adjustments based on software-generated feedback: After the child has been on the medication for a week, the practice asks parents (who also ask the teacher) to again complete the ADHDRS; parents submit the completed forms to the practice. A staff member enters the follow up results into the software, which recalculates the severity of symptoms and updates the percentile. The program then provides a report indicating the percentile of the rating on the ADHDRS obtained by that child. It also will indicate whether the change from the pretreatment level is statistically reliable (i.e., exceeds the level of change that might be related to routine measurement error). If the child's percentile ranking is not in the average range and a reliable change has not been achieved, the physician will increase the medication dose and obtain another ADHDRS rating 1 week after doing so. This process continues until the child's percentile scores indicate he or she is now in the average range for frequency of ADHD symptoms and a reliable change has been achieved. Adjustments will generally be necessary until the child falls below the 68th percentile, representing the upper end of the average range.

References/Related Articles

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Results

• Greater improvement in symptoms: A randomized trial conducted in 24 community pediatric practices (with randomization by practice) found that children treated by physicians who used the computer software and accompanying manual showed greater improvements in ADHD symptoms (as measured by ADHDRS and the Swanson, Nolan, and Pelham IV or SNAP-IV rating scale⁶) than did children whose physicians did not use them.³
• No impact from training alone: The study found that a 2-hour ADHD training program provided to pediatricians without using the computer software and manual did not lead to an improvement in patient outcomes.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Determining content for software and manual: Children's Memorial Hospital child psychiatrists and psychologists developed the content for the software and manual by blending recommendations from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry.  
• Choosing rating scale: The development team selected a rating scale to form the basis of the computer software. They chose ADHDRS over other evaluation tools because of its documented test and retest reliability, which allows for determination as to whether symptom changes over time are statistically meaningful.
• Developing software: Children's Memorial Hospital contracted with a vendor to write the software, based on content provided by the development team.
• Identifying physicians for test: Children's Memorial Hospital worked with the Pediatric Practice Research Group (a consortium of Chicago pediatricians with an interest in collaborating on research projects) to identify physicians willing to test the software and manual.

Resources Used and Skills Needed

• Staffing: The initiative required no new staff, as existing staff incorporated related activities into their daily routines.
• Costs: Upfront development included software development costs (which ran between $10,000 and $15,000), the time spent by those creating the accompanying manual, and the expenses associated with designing and executing the randomized trial.

Funding Sources

Tools and Other Resources

• Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158-70. Available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/5/1158
• Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108(4):1033-44. Available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/4/1033

ADHD clinical practice guidelines from The American Academy of Child and Adolescent Psychiatry are available at:

• Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):894-921. Available at: [PubMed]
• Greenhill LL, Pliszka S, Dulcan MK, et al. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002 Feb;41(2 Suppl):26S-49S. Review. [PubMed]

ADHD clinical practice guidelines from the Texas Children’s Medication Algorithm Project are available at:

• Pliszka SR, Greenhill LL, Crismon ML, et al. The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part I. Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. 2000 Jul;39(7):908-19. Review. [PubMed]
• Pliszka SR, Greenhill LL, Crismon ML, et al. The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part II: Tactics. Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. 2000 Jul;39(7):920-7. Review. [PubMed]

Getting Started with This Innovation

• Assign software use to one person: Assigning one individual at each practice site to enter all ADHDRS data into the software helps that person become proficient and efficient at the task. 
• Enlist parents' help in getting teacher feedback: Because it can be difficult to obtain information from the schools, parents should be encouraged to actively request that teachers fill out the ADHDRS. For example, physicians can remind parents that changes to medications cannot be made (and hence further improvements will likely not occur) until the teacher returns the form, and parents can then relay this message to the teachers.

Sustaining This Innovation

• Incorporate process into workflow: The process can be easily sustained once pediatricians become accustomed to asking parents and teachers for ADHDRS surveys, and data entry becomes part of the assigned staff member's regular workflow.

Use By Other Organizations

• Approximately 24 Chicago-area pediatric practices with roughly 70 physicians use the software program and manual; an undetermined number of practices elsewhere in the country have downloaded program-related materials.