ABSTRACT FROM: Myers K, Vander Stoep A, Zhou C, et al. Effectiveness of a telehealth service delivery model for treating attention-deficit/hyperactivity disorder: a community-based randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2015;54:263–74.
What is already known on this topic
Disparity in availability of mental healthcare based on geography is so prevalent that federal mandates, such as the American Recovery and Reinvestment Act (http://www.recovery.gov/arra/About/Pages/The_Act.asp) have been developed to encourage the use of technology to rectify reduced mental healthcare access in rural areas. Even with such encouragement, however, the use of ‘virtual visits’ through video teleconferencing (VTC) remains relatively underutilised by providers and third-party payers.1 This study evaluated the impact of improving access to expert care for youth with ADHD in rural areas by utilising a ‘hub and spoke’ model to deliver mental healthcare from a central, urban academic ‘hub’ to distal ‘spokes’ through VTC technologies.
Methods of the study
This study is the first ever community-based effectiveness study for telemental health.
Randomising to a model of care rather than different components of treatment is unique. The study randomised 223 children to either the combined six-session treatment completed over 25 weeks, or a single consultation with a child and adolescent psychiatrist who provided recommendations to the primary care provider. This approach is supported by meta-analysis of ADHD treatment studies concluding that combined treatment leads to better functional outcomes.2 The combined intervention included: (1) a psychotherapy arm of caregiver behaviour training delivered locally and supervised remotely at the ‘hub’ using VTC. This psychotherapy treatment was adapted from evidence-based treatment and trained caregivers on behavioural interventions such as time out and point system, and school advocacy. (2) A psychopharmacology arm which used expert consensus-driven medication algorithms for the management of ADHD with and without comorbidities. Caregivers and teachers rated the participating child's symptoms of inattention, hyperactivity–impulsivity and oppositionality at 4, 10, 19 and 25 weeks after randomisation, and the comparison of effectiveness of the two groups was based on improvement in ADHD symptoms.
What does this paper add?
This study provides an excellent example of how, regardless of whether care is delivered in person or via VTC, mental health outcomes can be improved when evidence-based psychotherapy and psychopharmacology are delivered together.
Although ADHD symptoms improved for both groups, the combined intervention showed greater improvement in caregiver reported ADHD symptoms (OR=0.14 for inattention, 0.14 for hyperactivity, 0.13 for ADHD-combined, and 0.15 for oppositional-defiant disorder (ODD) symptoms at 25 weeks; p<0.01 for each).
Teacher findings of greater improvement among children who received the combined intervention on inattention (OR=0.25, p<0.01), hyperactivity (OR=0.17, p<0.01), ADHD (OR=0.15, p<0.01) and ODD (OR=0.33, p<0.05) symptoms at 25 weeks adds strength to the recommendation for combined treatment.
Limitations
This study provided intervention to preadolescents; generalisation to adolescents should not be presumed. However, neuropsychological differences associated with ADHD have been shown to be stable during this developmental time period.3
Children with autism and bipolar disorder were excluded; these results may not generalise to those populations. This exclusion is appropriate given MRI studies have found distinct anatomical differences in the brains of youth with ADHD compared with youth with bipolar disorder4 and autism.5
What next in research
This study did not evaluate the impact of treatment of ADHD symptoms on grades, which should be examined in future research.
ADHD symptoms tend to persist into adulthood, conferring greater risk for academic underachievement and psychosocial problems.6 Future longitudinal research should examine whether effective treatment is associated with improved adult outcomes.
Do these results change your practices and why?
Yes, these results support change in current treatment of youth with ADHD, especially the use of combined psychotherapy and pharmacotherapy to treat youth with ADHD and the use of algorithm-based ADHD medication treatment. This study also creates an imperative to increase the availability of quality, evidence-based care to rural communities, including training local therapists in rural communities on how to implement evidence-based interventions and working towards overcoming barriers such as lack of insurance reimbursement that serve as a disincentive to the use of telemedicine.
Footnotes
Competing interests: None declared.
References
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