Eugenia Chan

Complementary and alternative therapies in childhood attention and hyperactivity problems.

ABSTRACT. To determine the prevalence and factors associated with complementary and alternative medicine (CAM) use for childhood attention and hyperactivity problems, we surveyed parents of children referred for evaluation of attention-deficit hyperactivity disorder (ADHD). Parents indicated whether they had used CAM therapies (e.g., acupuncture, nutritional supplements) in the past year and rated how important different reasons were in making their therapy decisions. Overall, 62 of 114 (54%) parents reported using CAM, most commonly expressive therapies, vitamins, and dietary manipulation, to treat their child’s attention problems. Parents who used CAM rated a “natural therapy” and “having more control over treatments” significantly more important in their choice of therapy than parents who did not use CAM. Only 11% of parents discussed using CAM with their child’s physician. Because parents often use CAM to treat their child’s attention and hyperactivity problems without their pediatrician’s knowledge, pediatricians need to initiate discussions of CAM use with patients and families.

The Brookline Early Education Project: A 25-Year Follow-up Study of a Family-Centered Early Health and Development Intervention

Background. Clinicians, scientists, and policy makers are increasingly taking interest in the long-term outcomes of early intervention programs undertaken during the 1960s and 1970s, which were intended to improve young childrens health and educational prospects. The Brookline Early Education Project (BEEP) was an innovative, community-based program that provided health and developmental services for children and their families from 3 months before birth until entry into kindergarten. It was open to all families in the town of Brookline and to families from neighboring Boston, to include a mixture of families from suburban and urban communities. The goal of the project, which was administered by the Brookline Public Schools, was to ensure that children would enter kindergarten healthy and ready to learn. Objective. Outcome studies of BEEP and comparison children during kindergarten and second grade demonstrated the programs effectiveness during the early school years. The goal of this follow-up study was to test the hypotheses that BEEP participants, in comparison with their peers, would have higher levels of educational attainment, higher incomes, and more positive health behaviors, mental health, and health efficacy during the young adult period. Methods. Participants were young adults who were enrolled in the BEEP project from 1973 to 1978. Comparison subjects were young adults in Boston and Brookline who did not participate in BEEP but were matched to the BEEP group with respect to age, ethnicity, mothers educational level, and neighborhood (during youth). A total of 169 children were enrolled originally in BEEP and monitored through second grade. The follow-up sample included a total of 120 young adults who had participated in BEEP as children. The sample differed from the original BEEP sample in having a slightly larger proportion of college-educated mothers and a slightly smaller proportion of urban families but otherwise resembled the original BEEP sample. The demographic features of the BEEP and comparison samples were similar. The young adults were asked to complete a survey that focused on the major domains of educational/functional outcomes and health/well-being. The study used a quasi-experimental causal-comparative design involving quantitative analyses of differences between the BEEP program and comparison groups, stratified according to community. Hypotheses were tested with analysis of variance and multivariate analysis of variance techniques. Analyses of the hypotheses included the main effects of group (BEEP versus comparison sample) and community (suburban versus urban location), as well as their interaction. Results. Young adults from the suburban community had higher levels of educational attainment than did those in the urban group, with little difference between the suburban BEEP and comparison groups. In the urban group, participation in the BEEP program was associated with completing >1 additional year of schooling. Fewer BEEP young adults reported having a low income (less than

Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review

20000); the income differences were accounted for largely by the urban participants. The percentage of subjects with private health insurance was significantly lower in the urban group overall, but the BEEP urban group had higher rates of private insurance than did the comparison group. More than 80% of both suburban samples reported being in very good or excellent health; the 2 urban groups had significantly lower ratings, with 64% of the BEEP group and only 41.67% of the comparison group reaching this standard. Overall, suburban participants reported more positive health behaviors, more perceived competence, and less depression. Among the urban samples, however, participation in BEEP was associated with higher levels of health efficacy, more positive health behaviors, and less depression than their peers. Conclusions. No previous study has focused as extensively on health-related outcomes of early education programs. BEEP participants living in urban communities had advantages over their peers in educational attainment, income, health, and well-being. The educational advantages found for BEEP participants in the early years of schooling included executive skills such as planning, organizing, and completing school-related tasks. It is likely that these early advantages in executive function extended beyond education-related tasks to other activities as participants became responsible for their own lives. The long-term benefits revealed in this study are consistent with the findings of previous long-term studies that indicated that participants in high-quality intervention programs are less likely to cost taxpayers money for health, educational, and public assistance services. The BEEP program appears to have somewhat blunted differences between the urban and suburban groups. The results of this study add to the growing body of findings that indicate that long-term benefits occur as the result of well-designed, intensive, comprehensive early education. The health benefits add a unique and important extension to the findings of other studies.

The role of complementary and alternative medicine in attention-deficit hyperactivity disorder

IMPORTANCE Although attention-deficit/hyperactivity disorder (ADHD) is highly prevalent in adolescents and often persists into adulthood, most studies about treatment were performed in children. Less is known about ADHD treatment in adolescents. OBJECTIVE To review the evidence for pharmacological and psychosocial treatment of ADHD in adolescents. EVIDENCE REVIEW The databases of CINAHL Plus, MEDLINE, PsycINFO, ERIC, and the Cochrane Database of Systematic Reviews were searched for articles published between January 1, 1999, and January 31, 2016, on ADHD treatment in adolescents. Additional studies were identified by hand-searching reference lists of retrieved articles. Study quality was rated using McMaster University Effective Public Health Practice Project criteria. The evidence level for treatment recommendations was based on Oxford Centre for Evidence-Based Medicine criteria. FINDINGS Sixteen randomized clinical trials and 1 meta-analysis, involving 2668 participants, of pharmacological and psychosocial treatments for ADHD in adolescents aged 12 years to 18 years were included. Evidence of efficacy was stronger for the extended-release methylphenidate and amphetamine class stimulant medications (level 1B based on Oxford Centre for Evidence-Based Medicine criteria) and atomoxetine than for the extended-release α2-adrenergic agonists guanfacine or clonidine (no studies). For the primary efficacy measure of total symptom score on the ADHD Rating Scale (score range, 0 [least symptomatic] to 54 [most symptomatic]), both stimulant and nonstimulant medications led to clinically significant reductions of 14.93 to 24.60 absolute points. The psychosocial treatments combining behavioral, cognitive behavioral, and skills training techniques demonstrated small- to medium-sized improvements (range for mean SD difference in Cohen d, 0.30-0.69) for parent-rated ADHD symptoms, co-occurring emotional or behavioral symptoms, and interpersonal functioning. Psychosocial treatments were associated with more robust (Cohen d range, 0.51-5.15) improvements in academic and organizational skills, such as homework completion and planner use. CONCLUSIONS AND RELEVANCE Evidence supports the use of extended-release methylphenidate and amphetamine formulations, atomoxetine, and extended-release guanfacine to improve symptoms of ADHD in adolescents. Psychosocial treatments incorporating behavior contingency management, motivational enhancement, and academic, organizational, and social skills training techniques were associated with inconsistent effects on ADHD symptoms and greater benefit for academic and organizational skills. Additional treatment studies in adolescents, including combined pharmacological and psychosocial treatments, are needed.

Quality of Efficacy Research in Complementary and Alternative Medicine

ABSTRACT. The use of complementary and alternative medicine (CAM) in pediatrics has become widespread. Parents of young children with developmental and behavioral problems such as attention-deficit hyperactivity disorder (ADHD) are particularly drawn to CAM interventions to avoid or decrease use of psychotropic medications. This paper reviews the epidemiology of CAM use for ADHD, describes a conceptual model of CAM, discusses a variety of commonly used therapies for ADHD, and introduces a systematic, pragmatic approach to discussing CAM therapy use with parents.

The Patient-Centered Medical Home, Practice Patterns, and Functional Outcomes for Children with Attention Deficit/Hyperactivity Disorder

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) has received increased attention in mainstream medicine since a 1993 study demonstrated that onethird of US adults used some form of “unconventionalmedicine.” By2002, theprevalenceofCAMusebyadults had increased to 62% to 68%, and it has become clear that users of CAM are not primarily dissatisfied with conventional care, but have a more holistic approach to health or simply appreciate multiple treatment options. What was once identified as “alternative medicine” has become “complementary,” “holistic,” and “integrative”; indeed, CAM therapies, such as probiotics, melatonin, massage, yoga, and acupuncture, have become part of the conventional medicine armamentarium, and the demarcation between CAM and mainstream medicine continues to shift. Physicians have been scrambling to catch up with the exponential increase in CAM use among their patients. Most discussions of CAM are initiated by patients and families, rather than by physicians, and patients may not disclose CAM use to their physicians. Recent surveys show that most physicians are aware of their patients’ interest in using CAM, believe that CAM may have beneficial effects, and are eager to seek reliable, evidence-based information about CAM for both personal and professional practice. Limiting the indiscriminate use of costly or dangerous ineffective therapies—whether based in conventional or unconventional medicine—should be a high priority for all clinicians. This is especially true for children, whose unique physiology, developmental and cognitive trajectories, and position in society render them particularly vulnerable. Although often touted as “natural” and “safe,” some CAM therapies have the potential for adverse effects (eg, lead poisoning from some ayurvedic remedies), may cause interactions with mainstream medical therapies (eg, oral contraceptives and St John’s wort), and involve significant time, effort, and cost burdens for families (eg, biofeedback). In this issue of JAMA, Weber and colleagues report the results of an 8-week randomized, placebo-controlled, doubleblind trial of Hypericum perforatum (St John’s wort) in 54 children aged 6 through 17 years who met criteria for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and who were not receiving any other ADHD-related treatments, including pharmaceuticals, during the study. Changes in ADHD symptoms as measured by the ADHD Rating ScaleIV, changes in global functioning as rated on the Clinical Global Impression Improvement Scale, and safety as rated by theMonitoring of Side Effects Scale were the primary outcomes. Additional assessments included the parent-report Child Behavior Checklist (CBCL) and Conners’ Parent Rating Scale, CBCL-Youth Self Report Form for children aged 11 years or older, and the parentand child-report forms of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales. In both intent-to-treat and per-protocol analyses, the researchers found no significant group differences on any of the efficacy measures or in frequency of adverse effects. Medication adherence was 82%, and parents, children, and the principal investigator were not able to correctly and consistently identify the child’s treatment status, indicating adequate blinding. NotonlyisthisthefirstreportedstudyofHypericumforADHD inchildrenandadolescents,but it isalsoanoteworthyexample of a high-quality randomized controlled trial (RCT) evaluating a specific CAM therapy in children. Among the strengths of the trial are a stringent research diagnosis of ADHD using a structured psychiatric diagnostic interview, rather than relyingonADHD-specificratingscalesalone;apharmaceuticalwashout period; a placebo run-in phase to assess likely adherence and placebo responders; blinding of both participants and investigators;acentralized,concealedallocationsequenceforrandomizationcoordinatedbyan independentdatamanager; randomization occurring after eligibility exclusions were made; explicitassessmentofmedicationadherence;checksontheadequacyofblinding;objectivelydefinedandmeasuredoutcome variables; intent-to-treat analysis; and full disclosure and descriptionofexclusionspriortorandomization,erroneouslyrandomizedparticipants,andpostrandomizationwithdrawals.The primary study limitations are its small sample size and enrollment of only 57% of eligible participants. The number of RCTs of CAM indexed in MEDLINE increased from fewer than 200 in 1982 to 1200 in 2002. In 2008, more than 7500 CAM trials were indexed in MEDLINE, with more than 1600 involving children aged 18 years or

ADHD, Stimulant Treatment, and Growth: A Longitudinal Study

OBJECTIVE To determine whether children with attention deficit/hyperactivity disorder (ADHD) receive care in a patient-centered medical home (PCMH) and how that relates to their ADHD treatment and functional outcomes. METHODS Cross-sectional analysis of the 2007 National Survey for Childrens Health, a nationally representative survey of 91,642 parents. This analysis covers 5169 children with parent-reported ADHD ages 6-17. The independent variable is receiving care in a PCMH. Main outcome measures are receiving ADHD medication, mental health specialist involvement, and functional outcomes (difficulties with participation in activities, attending school, making friends; having problem behaviors; missed school days; and number of times parents contacted by school). RESULTS Only 44% of children with ADHD received care in a PCMH. Children with ADHD receiving care in a PCMH compared with those who did not were more likely to receive medication for ADHD (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.9); less likely to have mental health specialist involvement (OR, 0.6; 95% CI, 0.4-0.7); less likely to have difficulties participating in activities (OR, 0.6; 95% CI 0.4-0.8), making friends (OR, 0.6; 95% CI, 0.5-0.9), and attending school (OR, 0.4; 95% CI, 0.3-06); less likely to have problem behaviors (OR 0.6; 95% CI 0.5-0.9); had fewer missed school days (β = -1.5, 95% CI -2.4 to -0.5); and parents were contacted by school less frequently (β = -0.2, 95% CI -0.3 to -0.1). CONCLUSIONS For children with ADHD, receiving care in a PCMH is associated with practice pattern change and better outcomes. The PCMH may represent a promising opportunity to improve quality of care and outcomes for children with ADHD.

Pediatrician-Psychiatrist Collaboration to Care for Children With Attention Deficit Hyperactivity Disorder, Depression, and Anxiety

BACKGROUND AND OBJECTIVE: There is ongoing concern that stimulant medications may adversely affect growth. In a sample of attention-deficit/hyperactivity disorder (ADHD) cases and controls from a population-based birth cohort, we assessed growth and the association between stimulant treatment and growth. METHODS: Subjects included childhood ADHD cases (N = 340) and controls (N = 680) from a 1976 to 1982 birth cohort (N = 5718). Height and stimulant treatment information were abstracted from medical records and obtained during a prospective, adult follow-up study. For each subject, a parametric penalized spline smoothing method modeled height over time, and the corresponding height velocity was calculated as the first derivative. Peak height velocity (PHV) age and magnitude were estimated from the velocity curves. Among stimulant-treated ADHD cases, we analyzed height Z scores at the beginning, at the end, and 24 months after the end of treatment. RESULTS: Neither ADHD itself nor treatment with stimulants was associated with differences in magnitude of PHV or final adult height. Among boys treated with stimulants, there was a positive correlation between duration of stimulant usage before PHV and age at PHV (r = 0.21, P = .01). There was no significant correlation between duration of treatment and change in height Z scores (r = −0.08 for beginning vs end change, r = 0.01 for end vs 24 months later change). Among the 59 ADHD cases treated for ≥3 years, there was a clinically insignificant decrease in mean Z score from beginning (0.48) to end (0.33) of treatment (P = .06). CONCLUSIONS: Our findings suggest that ADHD treatment with stimulant medication is not associated with differences in adult height or significant changes in growth.

Introduction to quality improvement part one: defining the problem, making a plan.

Objective: To describe pediatrician experiences collaborating with psychiatrists when caring for children with attention deficit hyperactivity disorder (ADHD), depression, and anxiety. Method: A random sample of Massachusetts primary care pediatricians completed a mailed self-report survey. Results: Response rate was 50% (100/198). Most pediatricians preferred psychiatrists to initiate medications for anxiety (87%) or depression (85%), but not ADHD (22%). Only 14% of respondents usually received information about a psychiatry consultation. For most (88%), the family was the primary conduit of information from psychiatrists, although few (14%) believed the family to be a dependable informant. Despite this lack of direct communication, most pediatricians reported refilling psychiatry-initiated prescriptions for ADHD (88%), depression (76%), and anxiety (72%). Conclusions: Pediatricians preferred closer collaboration with psychiatrists for managing children with anxiety and depression, but not ADHD. The communication gap between psychiatrists and pediatricians raises concerns about quality of care for children with psychiatric conditions.

Complex attention-deficit hyperactivity disorder, more norm than exception? Diagnoses and comorbidities in a developmental clinic.

Peter J. Chung, MD,* Rebecca A. Baum, MD,† Neelkamal S. Soares, MD,‡ Eugenia Chan, MD, MPH§ Although the term “quality” has different meanings for different stakeholders (providers, patients, payers, employers), all can agree on the goal of delivering the highest quality care possible to patients and families. How to achieve this goal, however, is often a daunting task, especially for clinicians who face many competing challenges in today’s health care environment. Quality improvement (QI) is a systematic, iterative process that calls for introducing a change in practice, measuring its effects, learning from the data, and continuing to make adjustments until results reach a target goal. Although every QI project is different, the process of creating effective and sustainable change follows the same general principles and presents similar themes and challenges. This 2-part series, while not intended to be a comprehensive overview, will introduce the reader to the field of QI, using a case scenario to illustrate how the methods and tools of QI can be used in developmentalbehavioral pediatrics. Part 1 will focus on defining the problem and developing a plan for change, and Part 2 will focus on the change process itself. More information regarding the tools used in the case can be found in the resources listed in Table 1.