ADHD and the Underserved: Clinical Pearls for the Real World

Educational Objectives

The goal of this lecture is to improve the management of attention-deficit/hyperactivity disorder (ADHD) in children from medically underserved populations. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the underdiagnosis and undertreatment of ADHD in medically underserved populations.

2. Target elements of the evaluation for ADHD to issues specific to medically underserved children.

3. Employ effective behavioral management, medication, and other treatment options for ADHD for all children, including the underserved.

Summary

Medically underserved population: those who — lack access to primary and specialty (eg, mental health) care; are socioeconomically disadvantaged; have cultural and language barriers that impede access to care

Attention-deficit/hyperactivity disorder: affects 4% to 12% of school-aged children; Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis with strict criteria (eg, symptoms exhibited in 2 settings, functional impairment); standard of care involves multimodal treatment; considered primary care diagnosis by AAP; ≤14 million children require primary mental health care, and many lack access; further disparities exist among underserved populations

Evidence on treatment: Multimodal Treatment Study of Children with ADHD (MTA) — among ≈600 children treated for ADHD over 14 mo, combination of medication and behavioral management more effective than either modality alone or generic community care of ADHD; effect more pronounced in children of lower socioeconomic status; data collected at 3 yr and 8 yr showed most children in all groups improved; no significant differences persisted among treatment groups; greatest impact of treatment occurred in initial period; Preschool ADHD Treatment Study (PATS) — showed reduction of symptoms in preschool-aged children receiving short-acting methylphenidate 3 times/day

Issues specific to underserved populations: represent minority of study participants; in MTA study, 20% had low socioeconomic status (ie, at risk for being underserved); in general, nonwhite racial and ethnic groups represent minority of study participants; large studies presumably conducted in English; underdiagnosis and undertreatment common among black and Hispanic populations; parental perceptions — differing perceptions about treatment found in small studies; eg, Hispanic mothers less likely to prefer medication to counseling and had negative perceptions of pharmacologic treatment; other studies show less frequent use of counseling in low socioeconomic groups; adherence may vary among ethnic groups

Bailey (2005): identified barriers to access to care among black populations; eg, inadequate information and knowledge, fear of consequences of treatment or misdiagnosis; acquisition of data on baseline behavior from teachers possibly biased

Rothe (2005): disparities in treatment of ADHD among Hispanic children may result from language barriers, diversity of beliefs among Spanish-speaking populations, degree of acculturation, and lack of cultural competency among providers and systems

Other disparities: evaluation tools in Spanish and English, but not other languages; low socioeconomic status linked to altered function of prefrontal cortex; families with unmet basic needs less likely to comply with complicated care; parental involvement in coordination of care complicated by economic demands

AAP practice guidelines: updated in October 2011; ADHD evaluation appropriate for any child 4 to 18 yr of age with academic or behavioral problems that impair function; increase in age of onset to ≤12 yr of age anticipated in DSM-5; rule out differential diagnosis and comorbidities; manage as children and youth with special health care needs; use age-specific treatment; titrate medication doses effectively

Age-specific treatment: preschool — behavioral management first-line treatment; prescribe methylphenidate if significant impairment persists (eg, safety concerns); school-aged — medication approved by Food and Drug Administration (FDA) plus behavioral treatment; adolescents — medical treatment with the assent of adolescent

Assessment tools: ADHD toolkit; Vanderbilt rating scales; Spanish version of most forms available; parent education materials available in Spanish, but not other languages; consider customizing electronic medical record for ease of entering often-asked questions; new AAP guidelines recognize importance of cultural differences in diagnosis and treatment of ADHD, but do not address them

Evaluation

History: speak with child first; identify strengths; ask about school, activities after school, and friends; ask parents about aggression, unsafe behaviors, and impulsive threats; past history — lead exposure; cardiac disease and seizures (to identify contraindications to stimulant medications); birth history — in utero exposure to alcohol, drugs, or tobacco; developmental history — early intervention; previous treatment of ADHD; family history — ADHD; maternal depression; sudden cardiac death; social history — witness to domestic violence; absent father figure; other family stressors (eg, illness, death, substance abuse); chronic homelessness; cultural beliefs about disorder

Physical examination: baseline height, weight, blood pressure, hearing, and vision; rule out structural heart defect if murmur detected; signs of trauma; dysmorphisms; full neurologic examination; examine use of writing instrument for writing and drawing shapes

Examination room: provide comfortable and family-friendly environment with place for siblings to play

Treatment

Behavioral: Russell Barkley approach — reward good behavior; externalize consequences; Ross Green approach — externalize choices; another approach — patterns of behavior within family that reinforce desired behaviors over time; evidence-based AAP guidelines — train parents and teachers; train children in social skills; in-home therapy — for families with barriers to leaving house; parent support groups — helpful if transportation and child care available; educate parents about — availability of after-school programs offering help with homework; new tools for communicating with their children; finding community resources that allow children to get exercise after school; therapeutic mentoring (eg, Big Brother and Big Sister programs); encourage advocacy in school system (eg, for 504 plans [plans for including children with disabilities in schooling and programs, as required by law], written request for special education evaluation); provide sample letter from ADHD toolkit

Collaboration of clinicians with schools: speaker communicates with schools through Vanderbilt rating scales; call teachers or other school staff if possible; attend school meetings if possible; collaborate with school nurses if medication dosing necessary in school; school-based health centers — collaborative on-site care; coordination of care

Family systems approach: parental depression — assist both parents; single-parent households — assess family infrastructure; domestic violence — affects mother-child dynamic; boys who witness domestic violence exhibit marked tendency for aggression toward mother; assess current safety; refer for witness-to-violence therapy; other issues — chronic homelessness (determine whether family has support system); coordination of care important

Medications: classes approved by FDA — stimulants (eg, methylphenidate [eg, Concerta, Metadate, Ritalin]); norepinephrine reuptake inhibitors (eg, atomoxetine); α-blockers; speaker starts with long-acting methylphenidate (once-daily dosing; less prone to drug diversion); titrate weekly to monthly; track side effects; use Vanderbilt rating scales; most treatment accomplished with stimulants; delivery systems — sprinkle capsules; liquid; patch; long-acting osmotic pump; options and choices — amphetamines more potent than methylphenidate; options available with less appetite suppression; guanfacine effective adjunct for extreme impulsivity; address sleep problems by titrating stimulant medications in daytime and/or giving melatonin in small doses (appears safe and effective; off-label use); clonidine used for controlling impulsivity in preschool-aged children (off-label use)

Comorbidities: heart murmur — refer to pediatric cardiologist for electrocardiography; address cardiac risk factors — obesity; high blood pressure; high cholesterol; elevated glucose; depression — refer for consultation with child psychiatrist

Parental noncompliance: involve school nurse; confirm that parents understand policy on prescriptions

Referrals: safety concerns — emergency mental health; mobile crisis team; Child Protective Services; physical abnormalities — neurologist; genetic testing; working with schools — evaluate and treat ADHD first; if other learning problems present and attempts to reduce symptoms not adequate, consider evaluation for special education

Goal: speaker tries not to promote idea that children with ADHD disabled and advocates working redemptively with children and families; help child to reach full potential; instill hope and self-worth

 

Readings

A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. 1999;56(12):1073-86; School-based health centers and pediatric practice. Pediatrics. 2012;129(2):387-93; Arcia E et al: Latina mothers' stances on stimulant medication: complexity, conflict, and compromise. J Dev Behav Pediatr. 2004;25(5):311-7; Arnold LE et al: Effects of ethnicity on treatment attendance, stimulant response/dose, and 14-month outcome in ADHD. J Consult Clin Psychol. 2003;71(4):713-27; Bailey RK: Diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in African-American and Hispanic patients. J Natl Med Assoc. 2005;97(10 Suppl):3S-4S; Bailey RK, Owens DL: Overcoming challenges in the diagnosis and treatment of attention-deficit/hyperactivity disorder in African Americans. J Natl Med Assoc. 2005;97(10 Suppl):5S-10S; Bauermeister JJ et al: Stimulant and psychosocial treatment of ADHD in Latino/Hispanic children. J Am Acad Child Adolesc Psychiatry. 2003;42(7):851-5; Begeer S et al: Underdiagnosis and referral bias of autism in ethnic minorities. J Autism Dev Disord. 2009;39(1):142-8; Bussing R et al: Knowledge and information about ADHD: evidence of cultural differences among African-American and white parents. Soc Sci Med. 1998;46(7):919-28; Dyches TT et al: Multicultural issues in autism. J Autism Dev Disord. 2004;34(2):211-22; Foy JM, Earls MF: A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder. Pediatrics. 2005;115(1):e97-104; Greenhill L et al: Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284-93; an JE, Freeman RD: Melatonin therapy for circadian rhythm sleep disorders in children with multiple disabilities: what have we learned in the last decade? Dev Med Child Neurol. 2004;46(11):776-82; Jensen PS et al: 3-year follow-up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry. 2007;46(8):989-1002; Jensen PS et al: Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr. 2001;22(1):60-73; Kishiyama MM et al: Socioeconomic disparities affect prefrontal function in children. J Cogn Neurosci. 2009;21(6):1106-15; Liptak GS et al: Disparities in diagnosis and access to health services for children with autism: data from the National Survey of Children's Health. J Dev Behav Pediatr. 2008;29(3):152-60; Mandell DS et al: Racial/ethnic disparities in the identification of children with autism spectrum disorders. Am J Public Health. 2009;99(3):493-8; Manning SE et al: Early diagnoses of autism spectrum disorders in Massachusetts birth cohorts, 2001-2005. Pediatrics. 2011;127(6):1043-51; Molina BS et al: Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. J Am Acad Child Adolesc Psychiatry. 2007;46(8):1028-40; Molina BS et al: The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5):484-500; Perrin JM et al: Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics. 2008;122(2):451-3; Rothe EM: Considering cultural diversity in the management of ADHD in Hispanic patients. J Natl Med Assoc. 2005;97(10 Suppl):17S-23S; Shonkoff JP, Garner AS: The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-46; Stevens J et al: Ethnic and regional differences in primary care visits for attention-deficit hyperactivity disorder. J Dev Behav Pediatr. 2004;25(5):318-25; Wolraich M et al: ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-22.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose. In this lecture, Dr. Pietry presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Pietry was recorded at Steven J. Parker Memorial Developmental Behavioral Pediatric Conference, held March 23-24, 2012, in Cambridge, MA, and presented by the Boston University School of Medicine. To learn more about CME activities presented by the Boston University School of Medicine, please visit www.bunc.bu.edu/cme. The Audio-Digest Foundation thanks the speaker and the Boston University School of Medicine for their cooperation in the production of this program.

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