Education Columns

by Gabriela Gibson-Lopez, PsyD; University of Texas Health San Antonio, San Antonio, TX

Background

Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral condition common in children and adolescents that can persist into adulthood. Among adults who meet criteria for ADHD, few receive treatment for their symptoms. Given how many children are initially diagnosed with ADHD by their primary care provider (PCP), it is reasonable to assume that many adults will also present to their PCP for evaluation of ADHD. Unfortunately, many PCPs struggle with diagnosing and treating adult ADHD for various reasons including diagnostic complexity, lack of time, lack of experience, or lack of confidence in determining optimal treatment regimens.^{3, 6} The Accreditation Council for Graduate Medical Education (ACGME) requires that family physicians demonstrate competence in diagnosing, managing, and integrating care for common mental health issues in patients of all ages.² Therefore, addressing this gap in knowledge and skills related to adult ADHD is imperative.

Intervention

The family medicine residency at University of Texas Health San Antonio has three full-time behavioral science faculty and uses the Primary Care Behavioral Health model of integration, which is a team-based primary care approach to managing behavioral health problems and biopsychosocial-influenced health conditions.⁵ Within this model are clinical pathways that are a multidisciplinary management tool developed to improve outcomes for a target group of patients, using evidence-based practice and resources available. The clinical pathway allows for assessing and treating adult ADHD by the behavioral health faculty with the aim of helping resident physicians feel more confident in assessing and treating adult ADHD. We turned to the existing but limited research for guidance on developing such a pathway in primary care.^4,7 Patients were identified by resident physicians and referred to a behavioral health consultant for a two-visit screening process that included a contextual interview, review of medical records, narrow and broadband self-report measures, and an assessment of ADHD symptoms and functioning. The results of the screening process were shared with the referring resident physician with recommendations for treatment.

Results

After 1 ½ years of implementing the clinical pathway, a six-item survey was created and sent to the family medicine residents to assess their use of the pathway, satisfaction with the pathway, likeliness to continue to use the pathway, and the impact of the pathway on their confidence in assessing and treating adult ADHD in primary care. The survey had a 78% response rate among our 42 resident physicians. Only 40% of the respondents indicated having used the pathway. Satisfaction, usefulness, and likeliness were assessed using a 5-point Likert scale where higher scores indicated higher satisfaction, usefulness, and likeliness. Overall, residents were satisfied with the pathway, reported the pathway as useful, and indicated that they would likely continue to use the pathway (Table 1). Seventy-six percent reported that the pathway increased their confidence in assessing and treating adult ADHD. Residents were given the opportunity to provide a qualitative answer expanding how the pathway increased their confidence. One resident shared, “I previously felt uneasy with prescription of medications without being able to spend the time to confirm diagnosis or history from the patient and need for medication.” Another shared, “Reading the notes from BHC has helped me to understand better how I would structure and focus an interview/history for ADHD screening in the future.”

Table 1: Adult ADHD Clinical Pathway-Physician Satisfaction Survey

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; BHC, behavioral health consultant.

Conclusion

Our results suggest that an interdisciplinary approach and clinical pathways can support family medicine resident education in the assessment of adult ADHD in primary care. Such an approach can also help increase confidence in treating adult ADHD. The two most-reported barriers to utilizing the pathway were identified as a lack of time to introduce the pathway and a lack of knowledge of the existence of the pathway. We have been addressing the latter through continuous reminders about the pathway during team meetings and encouraging residents to utilize the pathway before initiating medications when the diagnostic picture is unclear. With growing demand for integrated and interprofessional training experiences in family medicine, we also hope to continue developing interdisciplinary approaches to target other behavioral health issues commonly seen in primary care and assess their impact on resident education.¹

References

1. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Family Medicine. Common Program Requirements. Accessed March 3, 2022. https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/120_FamilyMedicine_2020.pdf
2. American Academy of Family Physicians. Recommended Curriculum Guidelines for Family Medicine Residents- Human Behavior and Mental Health Reprint No. 270. Family Medicine Residency Curriculum Guidelines. Accessed March 3, 2022. from https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint270_Mental.pdf
3. Adler L, Shaw D, Sitt D, Maya E, Morrill M. Issues in the Diagnosis and Treatment of Adult ADHD by Primary Care Physicians. Prim Psychiatry. 2009:16.
4. Loskutova NY, Lutgen CB, Callen EF, Filippi MK, Robertson EA. Evaluating a Web-Based Adult ADHD Toolkit for Primary Care Clinicians. J Am Board Fam Med. 2021;34(4):741-752. doi:10.3122/jabfm.2021.04.200606
5. Robinson PJ, Reiter JT. Behavioral Consultation and Primary Care: A Guide to Integrating Services Second Edition. Springer International Publishing; 2019.
6. Searight HR, Burke JM, Rottnek F. Adult ADHD: evaluation and treatment in family medicine. Am Fam Physician. 2000;62(9):2077-2086, 2091-2092.
7. University of Wisconsin Hospital and Clinics. (2014). Screening, Referral and Treatment for Attention Deficit and Hyperactivity Disorder (ADHD) – Adult – Ambulatory Clinical Practice Guideline. 2014. https://ghcscw.com/SiteCollectionDocuments/Clinical_Practice_Guidelines/18_CPG_ADHD_Adult.pdf