BHIPP Bulletin
Volume 7, Issue 4
October 2021
Special Announcement

On Tuesday, October 19th 2021, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declared a National State of Emergency in Children’s Mental Health. The rates of mental health concerns among children and families have dramatically increased due to the COVID-19 pandemic and racial justice issues. This state of emergency advocates for innovative strategies to address children’s mental health – including integrated mental health in primary care, suicide prevention in primary care, and continued availability of telemental health services. Maryland BHIPP fully supports this National State of Emergency and implores you to engage with our consultation and training services in an effort to integrate mental health in pediatric primary care. We also offer telemental health services and care coordination for select locations. Call 855-MD-BHIPP for more information. To read the full declaration of the National State of Emergency click here.

ADHD: Back to the Basics
This months' BHIPP Bulletin is a contribution from Carisa Parrish, PhD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine, Director of Pediatric Health Psychology, Johns Hopkins Children's Center and BHIPP Consultant. Additionally, this month's BHIPP Resilience Break focused on "Helping Families Manage ADHD in Primary Care" and was presented by Mark Riddle, MD, Child and Adolescent Psychiatrist and BHIPP Consultant. To view the full session recording, slides, and related resources: click here!

Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common disorders to emerge in childhood. Parent concerns about a child’s ADHD commonly present in primary care settings, and concerns regarding children’s inattention and/or hyperactivity/impulsivity are a frequent source of questions to the BHIPP consultation line. As October is ADHD Awareness Month, we will examine strategies for in-office behavioral and psychosocial interventions for ADHD in the primary care setting.
 
Background: ADHD symptoms are grouped into two major clusters of inattention and hyperactivity/impulsivity which must be present in two or more settings for 6 months or more and demonstrate an early onset in childhood. Estimated prevalence is 3-7% among youth worldwide, with a male to female ratio of 3:1. Family studies indicate that ADHD is very heritable, with estimates as high as 80%. Other biological factors increase risk for ADHD as well (e.g., prenatal exposure to substances, prematurity, exposure to excessive lead levels, injury). ADHD is currently considered a chronic condition that persists into adulthood. Individuals with ADHD often develop comorbid psychological conditions along the way, including disruptive behavior problems, learning disorders and poor school achievement, depression and low self-esteem, and risk for substance use/misuse. Despite the long history of academic research validating the existence of ADHD, skepticism persists regarding the biological, genetic, and neurodevelopmental origins of this condition. Thus, enumerating the wide-ranging and profound negative consequences of (un)treated ADHD may be important for some caregivers and/or educators to appreciate the need for personalized and cross-setting interventions.
 
Assessment: The Vanderbilt screening tool uses parent and teacher ratings to assess ADHD symptoms, in addition to other emotional and behavioral concerns. The AAP provides an extensive toolkit for assessing, treating, and supporting youth with ADHD. The toolkit provides many helpful documents that may ease the burden for busy clinicians in primary care (e.g., sample letter for requesting teacher ratings; clinician action checklist; ideas for comorbidity screenings; guidance for differential diagnosis). 

Evidence base for ADHD treatment: The Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study was a seminal study designed to evaluate the leading treatments for ADHD, including behavior therapy, medications, and their combination, in comparison to the “treatment as usual” control group (nearly 70% of whom were on ADHD medication during the study). Many papers have been published from the MTA Study since the preliminary paper in 1999. The major results indicated that combination treatment (medication + behavior therapy) and medication management alone were both significantly superior to intensive behavioral treatment alone and to routine community care in reducing ADHD symptoms. Combined treatment was particularly beneficial to address anxiety symptoms, academic performance, parent-child relationships, and social skills. Children randomized to the combined treatment group ended up taking lower doses of medication than children in the medication-only group. For youth receiving medication in the MTA study, there was a difference in the quality and intensity of medication management in the active treatment group compared to the “treatment as usual” control group, including more frequent initial visits to titrate medication, reviewing teacher information on a regular basis, and increasing medication as needed to optimize medication efficacy. For more information about the MTA Study results, visit NIMH.gov.

Treatment: The pediatric primary care provider can help set the child and family up for success by educating families about ADHD and how to tailor interventions for the individual needs of their child. Providers can assist families to a) develop a behavior plan that meets the child’s individual needs, b) develop mechanisms for effective communication with school, c) set up strategies to address organizational and homework difficulties, and d) establish consistent rituals and routines, and ways to respond to oppositional behavior. The CDC infographic fact sheets may serve as a useful discussion aid for pediatric clinicians in primary care to assist families with creating a treatment plan. 
Evidence-based practice considers 3 important elements: research evidence, clinical expertise (including clinical experience and judgment), and patient/family preference. Keeping patient/family preference in mind may help providers create roadmaps for when an initially declined treatment could be re-considered later on, based on functional improvement or lack thereof.

Positive Parenting Strategies (aka Behavioral Parent Training): Positive behavior management strategies are the key psychosocial treatment for children with ADHD. While it is unlikely that any outpatient provider (pediatrician, psychologist, or other!) will be able to recreate the intensive behavioral approach that was tested in the MTA study (see Figure 1 above), it may be helpful to be familiar with positive behavioral strategies. Moreover, it may be helpful to know the key principles of behavioral parent training, so that you can determine when your patients and their parents/caregivers are receiving it (or not). For providers working with young children, reviewing the Preschoolers with ADHD Study (PATS) may be a helpful reminder that a time-limited trial of behavioral parent training was required before preschoolers (ages 3-5.5 years old) were entered into the medication phase of that study. The American Psychological Association (APA) Division 53, the Society of Clinical Child & Adolescent Psychology, maintains a website dedicated to evidence-based psychotherapy, which provides an excellent introduction to behavior therapy, including parent management training: https://effectivechildtherapy.org/therapies/what-is-behavior-therapy/.

Finally, the American Academy of Child and Adolescent Psychiatry (AACAP) has published two practice parameters that highlight the importance of parent training and are summarized further below. Several books have been written by leading child psychologists for parents managing disruptive behavior in children and are listed at the end of this newsletter. 

For a list of parenting tip sheets created by UNICEF for the COVID-19 pandemic, please visit covid19parenting.com and look for the Public Service Announcements section for links to 1-page parent tip sheets on a range of positive parenting topics, based on decades of research related to behavioral parent training.
 
The sample provided here describes One-on-One Time, with examples of how to implement across different development stages. Other titles include:
  • Keeping it Positive
  • Structure Up
  • When Children Misbehave
  • Family Harmony at Home
  • Keep Calm and Manage Stress
 
Bonus: tips are provided in 100+ languages!
The 2007 AACAP practice parameter on ADHD (Pliszka et al., 2007; see page 903) identified the following components of evidence-based parent training, delivered across 10 to 20 sessions of 1 to 2 hours in which parents:
  1. are given information about the nature of ADHD,
  2. learn to attend more carefully to their child’s misbehavior and to when their child complies,
  3. establish a home token economy,
  4. use time out effectively,
  5. manage noncompliant behaviors in public settings,
  6. use a daily school report card, and
  7. anticipate future misconduct.
 
In the AACAP practice parameter for youth with oppositional defiant disorder, Steiner and Remsing (2007) further distilled the core components shared by empirically-supported parent training programs as:
  1. Reducing positive reinforcement of disruptive behavior.
  2. Increasing reinforcement of prosocial and compliant behavior. Positive reinforcement varies widely, but parental attention is predominant (e.g., one-on-one time, labeled praise). Punishment usually consists of a form of time out, loss of tokens, and/or loss of privileges.
  3. Applying consequences and/or punishment for disruptive behavior.
  4. Making parental response predictable, contingent, and immediate.

Communication between home and school: Due to the frequency of school-related functional impairments, parents/caregivers often receive negative feedback about their child’s behavior at school. Unfortunately, that communication may not be specific, consistent, or actionable for parents. Without a 504 plan or IEP in place, teachers may be placing undue burden on parents to discipline their child at home to improve maladaptive behaviors at school. While a home-based behavior modification system can certainly tackle negative behaviors at school, its success will be dependent on consistent, specific, and frequent information from teachers. The sample home-school report form below was designed by child psychologist Russell Barkley PhD to facilitate consistent and frequent communication between teachers and parents/caregivers.
In summary, ADHD is a common condition that will likely require a multi-pronged approach that involves clinic, home, and school-based supports to optimize parent and teacher management of child behavior. Prominent organizations including the AAP, APA Division 53, AACAP, CDC, and UNICEF all recognize the importance of positive parenting approaches for managing childhood behavioral challenges. When such behavioral problems are manifestations of ADHD, consideration of medication for school-age youth is also indicated. Finally, ongoing coordination with the school, including obtaining teacher ratings on a regular basis to optimize medication dose and inform IEPs/504 plans are critical for positive adjustment. Your BHIPP colleagues are eager to assist you with learning more about all of these intervention approaches, so please send your questions our way!
Resources

Websites
Russell Barkley, PhD, Child Psychologist:
CDC:


Books and Peer-Reviewed Publications
Taking Charge of ADHD, Fourth Edition: The Complete, Authoritative Guide for Parents, Fourth Edition
by Russell A. Barkley PhD (Author)
 
Parenting the Strong-Willed Child: The Clinically Proven Five-Week Program for Parents of Two- to Six-Year-Olds, Third Edition Paperback – July 13, 2010 by Rex Forehand PhD (Author), Nicholas Long PhD (Author)
 
Your Defiant Child, Second Edition: Eight Steps to Better Behavior, Second Edition, by Russell A. Barkley PhD (Author), Christine M. Benton (Author)
 
Kollins, S., Greenhill, L., Swanson, J., Wigal, S., Abikoff, H., McCracken, J., Riddle, M., McGough, J., Vitiello, B., Wigal, T., Skrobala, A., Posner, K., Ghuman, J., Davies, M., Cunningham, C., & Bauzo, A. (2006). Rationale, design, and methods of the Preschool ADHD Treatment Study (PATS). Journal of the American Academy of Child and Adolescent Psychiatry, 45(11), 1275–1283. https://doi.org/10.1097/01.chi.0000235074.86919.dc
 
Pliszka, S., & AACAP Work Group on Quality Issues (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 894–921. https://doi.org/10.1097/chi.0b013e318054e724
 
Steiner, H., Remsing, L., & Work Group on Quality Issues (2007). Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(1), 126–141. https://doi.org/10.1097/01.chi.0000246060.62706.af
 
Steven W. Evans, Julie Sarno Owens, & Nora Bunford (2013). Evidence-Based Psychosocial Treatments for Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Journal of Clinical Child & Adolescent Psychology Vol. 43 Issue 4, 527-551. 


As always, if you have questions about behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.
BHIPP Announcements
BHIPP in Your Neighborhood
  • November 2, 2021 12:30-1:30pm
  • BHIPP Resilience Break Disruptive Behaviors and DMDD presented by Robert Paine, DO
  • Register here!

  • Interested in organizing a (virtual) training event? Need more information? Message our team!
BHIPP Holiday Closures Calendar
Please note that the telephone consultation line will be closed on the following upcoming holiday(s):

  • Thursday, November 11
  • Thursday, November 25
  • Friday, November 26
  • Friday, December 24
  • Friday, December 31
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BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.

BHIPP and this newsletter are also supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $433,296 with approximately 20% financed by non-governmental sources. The contents of this newsletter are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, visit www.hrsa.gov.

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