As many families of kids with ADHD know, effective care is hard to come by—especially if the child also has coexisting conditions. Many parents find their pediatrician is inadequately trained in behavioral and mental health and/or thinks that ADHD is outside the scope of primary care. Moreover, parents’ efforts to get timely treatment are hampered by shortages of child and adolescent psychiatric and mental health providers. Even when families are able to access treatment, they may be stymied by the cost, much of which may not covered by insurance. Finally, in some cultures and communities, ADHD still carries a stigma due to misinformation and lack of understanding even among some medical professionals.
To address these barriers, some health-care providers are leading the charge to develop new care models. A particularly promising approach is the integrative care model developed at the University of Washington. In this model, behavioral care managers, often trained as social workers, counselors, psychologists, nurses, behavioral health professionals, or pediatric therapists, play a key role within a clinical setting.
Working in teams of primary-care providers and psychiatric professionals, the collaboration makes sure that children and adolescents with ADHD and related conditions receive the patient-centered, cost-effective care necessary to ensure early and accurate diagnoses, effective medication management, successful behavioral therapies and interventions, and other necessary support, including educational advocacy.
Case Example: Sarah’s Story
Pediatrician Sheryl Morelli, MD, clinician Leslie F. Graham, MSW, and child and adolescent psychiatrist Douglas Russell, MD, all affiliated with the University of Washington, use 8-year-old Sarah, a hypothetical patient, to explain how a collaborative-care team can provide an accurate diagnosis, effective treatment, and family support.
As part of the routine well-child checkup with the Primary Care Provider (PCP), a behavioral health screening takes place, during which Sarah’s mom indicates Sarah is doing poorly in school and struggles with friendships.
Alerted to a potential problem, PCP introduces integrated care model: explains process; obtains informed consent/information releases to communicate with school personnel; begins diagnostic assessment; initiates a warm connection to the Behavioral Health Care Manager (BHCM).
BHCM, a pivotal connection between patient, family, primary-care facility, and school personnel, creates alliance of trust with parents, outlines goals, and develops plan:
- Listens to Sarah’s family’s concerns and further explains collaborative process.
- Reviews referral, past medical records/treatments, school records; gathers additional medical/school history (academic/behavioral challenges, family circumstances, prior treatments, school supports); obtains all necessary permissions.
- Determines what other screenings are needed and implements them.
- Identifies and networks with school personnel, other doctors and mental- health professionals to build partnerships and provide evidence-based treatments.
Through working with family and school, BHCM learns Sarah may be showing signs of anxiety. BHCM updates file, introduces role of psychiatry to family and reaches out to collaborative care team’s Psychiatric Consultant (PC).
Before meeting Sarah, PC reviews shared file for information collected by PCP and BHCM, including ADHD screening tools and teacher notes.
From history and evaluation, PC learns:
- Sarah meets criteria for inattentive ADHD. Data in shared file indicates symptoms of inattention since kindergarten.
- Sarah’s anxiety and impairments are based on math concepts and merit a psychoeducational evaluation.
- School problems have created tensions at home. File indicates father has ADHD, multi-generational trauma and dysfunction meriting referral for behavioral therapy to benefit entire family.
PC recommends trial of stimulant medication; reviews medication process in detail with Sarah and family.
Family meets again with PCP, who now has wealth of additional information gathered by BHCM and PC. With family’s agreement, PC will write prescription for stimulant, observe Sarah over time, and update diagnosis/treatment as needed.
Going forward, BHCM will work with family and collaborate with team:
- Outline goals; develop long-term treatment plan, adjusting as needed.
- Connect family with behavioral parent training provider.
- Reach out to school to share results of psychoeducational testing with Sarah’s school team.
- Inform parents of legal rights and advocate for Sarah with school personnel and at IEP/Section 504 meetings.
- Monitor Sarah’s progress in school, with math, anxiety, and friendships.
PC will provide ongoing guidance, manage medication, monitor improvement, and change course as necessary.
BHCM, PCP and PC will continue to meet monthly to review screenings and fine-tune treatment.
While the integrated care model is still in its infancy and not available to all, it represents an exciting direction in health care that will have a positive impact on children and adolescents with ADHD, their families, and their schools.
This article is based on an ADDitude webinar, Integrated Care for Children with ADHD: How to Form a Cross-Functional Care Team, by Pediatrician Sheryl Morelli, MD, clinician Leslie F. Graham, MSW, and child and adolescent psychiatrist Douglas Russell, MD, all affiliated with the University of Washington. Eve Kessler, Esq., a former criminal appellate attorney, is Executive Director of SPED*NET, www.spednet, and a Contributing Editor of Smart Kids.