Optimal treatment of a child or adolescent with attention-deficit/hyperactivity disorder (ADHD) begins by establishing a collaborative care team consisting of the family, school personnel, primary care clinician (PCC), mental health and subspecialty clinicians, and other adults, such as tutors and coaches.1  To facilitate communication among care team members, a standardized, reliable system should be established to securely collect and share information about the child’s ADHD symptoms and functioning, medication side effects, receipt of ADHD treatments, family treatment preferences and goals, and educational resources.1 

Unfortunately, the fragmentation of ADHD care across health care, mental health, and education sectors is a substantial barrier to communication and collaboration among care team members.1,2  Each sector has its own rules and policies regarding confidentiality and privacy, and individual daily schedules are typically incompatible, making a meaningful, timely, and efficient exchange of information, whether synchronous (eg, phone call) or asynchronous (eg, e-mail), extremely challenging.

In many quality improvement efforts to implement the ADHD guidelines, team communication and collaboration have been addressed, most commonly by focusing on improving the receipt of parent- and teacher-completed ADHD rating scales to inform clinician medical decision-making. These efforts have included developing extensive tool kits and online educational resources for PCCs3,4 ; redesigning office workflows (eg, designating a staff member to manage rating scale collection)5,6 ; using care managers to serve as the conduit of information across PCCs, parents, teachers, and other clinicians7,8 ; and developing or adopting ADHD-specific electronic systems or portals that may stand alone and/or be integrated with the electronic health record to varying degrees.9  Over time, these ADHD portals have become increasingly robust in their functionality and usability and have been shown to improve clinician adherence to ADHD guidelines as well as reduce ADHD symptoms in children.10  In some practices, ADHD portals have become the standard of care for children with ADHD.

In this issue of Pediatrics, Guevara et al11  compare the effectiveness of a patient portal combined with care management with that of a patient portal alone on ADHD symptoms, treatment goal attainment, and other patient-reported outcome measures. Embedded in the electronic health record, the ADHD patient portal was designed to facilitate the collection and communication of ADHD symptoms and impairment, family treatment preferences and goals, and medication side effects among parents, teachers, and PCCs. ADHD-care managers contacted families and teachers by phone, text message, or e-mail at least once every 3 months to provide education on ADHD treatment, monitor the attainment of treatment goals, and address the patient’s and/or family’s emerging concerns. The authors found that, although both groups had reductions in ADHD symptoms over time, there was no difference between the 2 groups in ADHD symptom improvement, goal attainment, or other outcomes at any time point. This suggested that care management did not lead to improved ADHD symptoms beyond the effect of the patient portal alone.

These results are somewhat surprising in light of other work revealing the benefits of care management for families of children with ADHD7,8  as well as for adults with depression and other chronic conditions.12  Indeed, in sensitivity analyses, Guevara et al11  did find that, although parent and teacher engagement with care managers was modest overall, children in families who received ≥2 care management sessions experienced greater ADHD symptom reduction than those with 1 or 0 sessions. The authors speculated that the virtual nature of their care management intervention (ie, e-mail, phone, or text message) may not have engaged parents as much as would otherwise be expected, compared with studies involving face-to-face care management.

What should not be overlooked in this study, however, is that 68% of all study participants used the ADHD portal to complete rating scales at least once, and 30% had a teacher complete rating scales. Considering the impersonal nature of an electronic system, this is an impressive level of parent and teacher engagement, which is essential to the success of care for children and adolescents with ADHD. Engaged parents are more likely to participate in the collaboration activities that inform shared decision-making, such as completing ADHD rating scales regularly, scheduling and keeping ADHD follow-up appointments, and discussing treatment options, preferences, and goals with other care team members. Similarly, engaged teachers are more likely to complete rating scales and implement appropriate classroom-based interventions.

Ultimately, the specific method by which to engage parents and teachers in ADHD collaborative care and treatment adherence matters less than the fact that there are a variety of effective methods that can be tailored for best fit with different families. Some will require the “high touch” of a human being; some will do well with a patient portal; others may need both. The overall goal remains the same: to reduce functional impairment and maximize the well-being of children with ADHD.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-031518.

     
  • ADHD

    attention-deficit/hyperactivity disorder

  •  
  • PCC

    primary care clinician

1
Wolraich
ML
,
Hagan
JF
 Jr
,
Allan
C
, et al;
Subcommittee on Children and Adolescents With Attention-Deficit/Hyperactive Disorder
.
Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents [published correction appears in Pediatrics. 2020;145(3):e20193997]
.
Pediatrics
.
2019
;
144
(
4
):
e20192528
2
Guevara
JP
,
Feudtner
C
,
Romer
D
, et al
.
Fragmented care for inner-city minority children with attention-deficit/hyperactivity disorder
.
Pediatrics
.
2005
;
116
(
4
):
e512
e517
3
American Academy of Pediatrics
.
EQIPP: ADHD - Diagnose, Treat, Monitor
.
Itasca, IL
:
American Academy of Pediatrics
;
2019
4
American Academy of Pediatrics
.
Caring for Children with ADHD: A Practical Resource Toolkit for Clinicians
. 3rd ed.
Elk Grove Village, IL
:
American Academy of Pediatrics
;
2019
5
Leslie
LK
,
Weckerly
J
,
Plemmons
D
,
Landsverk
J
,
Eastman
S
.
Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings
.
Pediatrics
.
2004
;
114
(
1
):
129
140
6
Epstein
JN
,
Langberg
JM
,
Lichtenstein
PK
,
Mainwaring
BA
,
Luzader
CP
,
Stark
LJ
.
Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians
.
Pediatrics
.
2008
;
122
(
1
):
19
27
7
Silverstein
M
,
Hironaka
LK
,
Walter
HJ
, et al
.
Collaborative care for children with ADHD symptoms: a randomized comparative effectiveness trial
.
Pediatrics
.
2015
;
135
(
4
):
e858
e867
8
Kolko
DJ
,
Hart
JA
,
Campo
J
, et al
.
Effects of collaborative care for comorbid attention deficit hyperactivity disorder among children with behavior problems in pediatric primary care
.
Clin Pediatr (Phila)
.
2020
;
59
(
8
):
787
800
9
Wolraich
ML
,
Chan
E
,
Froehlich
T
, et al
.
ADHD diagnosis and treatment guidelines: a historical perspective
.
Pediatrics
.
2019
;
144
(
4
):
e20191682
10
Epstein
JN
,
Langberg
JM
,
Lichtenstein
PK
,
Kolb
R
,
Altaye
M
,
Simon
JO
.
Use of an Internet portal to improve community-based pediatric ADHD care: a cluster randomized trial
.
Pediatrics
.
2011
;
128
(
5
):
e1201
e1208
11
Guevara
JP
,
Power
TJ
,
Beans
K
, et al
.
Improving communication in attention-deficit/hyperactivity disorder: a randomized controlled trial
.
Pediatrics
.
2020
;
148
(
2
):
e2020031518
12
Gilbody
S
,
Bower
P
,
Fletcher
J
,
Richards
D
,
Sutton
AJ
.
Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes
.
Arch Intern Med
.
2006
;
166
(
21
):
2314
2321

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated that no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.