Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings
Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings
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DOI：
10.1542/peds.114.1.129
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发表时间：
2004-07-01
期刊：
影响因子：
8
通讯作者：
Eastman, S
中科院分区：
文献类型：
--
作者：
Leslie, LK;Weckerly, J;Eastman, S
目标.评估圣地亚哥注意力缺陷/多动障碍项目（SANDAP）方案的可行性，该方案是一项儿科社区发起的质量改进工作，旨在促进美国儿科学会（AAP）注意力缺陷/多动障碍（ADHD）诊断指南的实施，并确定提供循证ADHD评估护理的任何其他障碍。七个研究天真的初级保健办事处在圣地亚哥地区被招募参加。办公室接受了SANDAP协议的培训，其中包括1）医生教育，2）家长和教师的标准化评估包，3）ADHD协调员，以协助收集和整理评估包组件，4）以讲义和网站形式提供给临床医生，家长和教师的教育材料，以及5）描绘转诊给医疗亚专家的当地路径的流程图，心理健康从业人员和学校专业人员。评估包包括家长和教师版本的范德比尔特多动症诊断评定量表。在这项研究中，我们选择了一个保守的解释AAP ADHD诊断ADHD的指南，要求一个孩子符合标准的ADHD的父母和教师的评级量表。采用混合方法分析策略解决可行性和障碍，包括与家长和教师的定量调查，以及与儿科医生和办公室工作人员平均每年3次的定性汇报会。在2000年12月至2003年4月期间，连续登记了159名儿童接受学校和/或行为问题评估。在临床上，只有44%的儿童符合父母和教师量表上的ADHD标准，其中73.5%的儿童被归类为合并亚型。超过40%的受试者在范德比尔特量表上表现出不一致的结果，只有父母或老师认可足够的症状符合《精神障碍诊断和统计手册》第4版的标准。58.5%的受试者符合对立违抗性障碍/品行障碍的筛选标准，32.7%符合焦虑/抑郁的筛选标准，大约三分之一的人有一个积极的个性化教育计划，或者在过去接受过个性化教育计划。经评估，SANDAP协议对所有利益攸关方来说都是可以接受和可行的。然而，还发现了实施AAP ADHD指南的其他障碍，包括：1）指南中关于使用特定ADHD评定量表、评估和治疗结果不一致和/或阴性儿童以及学习问题心理评估指征的信息有限，2）家庭对ADHD教育和支持的需求，3）限制ADHD儿童护理的身体健康和心理健康计划的特点; 4）有限的知识和潜在社区资源的使用。我们的研究结果表明，在初级保健办公室评估可能的ADHD的儿童具有复杂的临床特征。提供者需要实施ADHD诊断指南的机制，这些指南解决了SANDAP协议中开发的医生教育和医疗服务系统设计方面的问题。还查明了其他障碍。仔细注意这些因素将是必要的，以确保在初级保健环境中为ADHD儿童提供持续的优质护理。
Objectives. To evaluate the feasibility of the San Diego Attention-Deficit/Hyperactivity Disorder Project (SANDAP) protocol, a pediatric community-initiated quality improvement effort to foster implementation of the American Academy of Pediatrics (AAP) attention-deficit/hyperactivity disorder (ADHD) diagnostic guidelines, and to identify any additional barriers to providing evidence-based ADHD evaluative care.Methods. Seven research-naive primary care offices in the San Diego area were recruited to participate. Offices were trained in the SANDAP protocol, which included 1) physician education, 2) a standardized assessment packet for parents and teachers, 3) an ADHD coordinator to assist in collection and collation of the assessment packet components, 4) educational materials for clinicians, parents, and teachers, in the form of handouts and a website, and 5) flowcharts delineating local paths for referral to medical subspecialists, mental health practitioners, and school-based professionals. The assessment packet included the parent and teacher versions of the Vanderbilt ADHD Diagnostic Rating Scales. In this study, we chose a conservative interpretation of the AAP ADHD guidelines for diagnosing ADHD, requiring that a child met criteria for ADHD on both the parent and teacher rating scales. A mixed-method analytic strategy was used to address feasibility and barriers, including quantitative surveys with parents and teachers and qualitative debriefing sessions conducted an average of 3 times per year with pediatricians and office staff members.Results. Between December 2000 and April 2003, 159 children were consecutively enrolled for evaluation of school and/or behavioral problems. Clinically, only 44% of the children met criteria for ADHD on both the parent and teacher scales, and 73.5% of those children were categorized as having the combined subtype. More than 40% of the subjects demonstrated discrepant results on the Vanderbilt scales, with only the parent or teacher endorsing sufficient symptoms to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Other mental health and learning problems were common in the sample; 58.5% of subjects met screening criteria for oppositional defiant disorder/conduct disorder, 32.7% met screening criteria for anxiety/depression, and approximately one-third had an active individualized education program in place or had received an individualized education program in the past. On evaluation, the SANDAP protocol was acceptable and feasible for all stakeholders. However, additional barriers to implementing the AAP ADHD guidelines were identified, including 1) limited information in the guidelines regarding the use of specific ADHD rating scales, the evaluation and treatment of children with discrepant and/or negative results, and the indications for psychologic evaluation of learning problems, 2) families' need for education regarding ADHD and support, 3) characteristics of physical health and mental health plans that limited care for children with ADHD, and 4) limited knowledge and use of potential community resources.Conclusions. Our results indicate that children presenting for evaluation of possible ADHD in primary care offices have complex clinical characteristics. Providers need mechanisms for implementing the ADHD diagnostic guidelines that address the physician education and delivery system design aspects of care that were developed in the SANDAP protocol. Additional barriers were also identified. Careful attention to these factors will be necessary to ensure the sustained provision of quality care for children with ADHD in primary care settings.