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Service Delivery Innovation Profile

Implementation of Attention Deficit Hyperactivity Disorder Guidelines With Community-Based Physicians Results in Fewer Hospital Referrals and Improved Outcomes


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Snapshot

Summary

Cincinnati Children's Hospital Medical Center created an initiative called the Attention Deficit Hyperactivity Disorder Collaborative to work with local primary care physicians to standardize their management of attention deficit/hyperactivity disorder. The collaborative aims to improve patient care and reduce unnecessary hospital referrals by providing physicians with strategies to implement evidence-based guidelines. The collaborative sponsors a Web portal that prompts ongoing parent and teacher assessment and documentation of attention deficit/hyperactivity disorder symptoms, generates algorithm-driven reports for physicians that that summarize and interpret data and provide treatment guidance, and provides feedback to physicians regarding their performance; the collaborative also facilitates expert consultation. Participating physicians are more likely to adhere to key elements of the evidence-based guidelines, including increased use of rating scales and care management plans and more followup contact during treatment; participating physicians are also less likely to refer uncomplicated cases to the hospital.

Evidence Rating (What is this?)

Strong: The evidence consists of a cluster randomized trial and other post-implementation assessments of outcomes measures including adherence to various aspects of evidence-based guidelines, including use of rating scales and diagnostic criteria, and the percentage of PCPs diagnosing and treating patients with potential ADHD. Findings of sustained symptom improvement are also provided.
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Developing Organizations

Cincinnati Children's Hospital Medical Center
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Date First Implemented

2004
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Patient Population

Vulnerable Populations > Children; Mentally illend pp

Problem Addressed

Attention deficit/hyperactivity disorder (ADHD) is a common childhood condition that is characterized by poor concentration and inattentiveness. Although primary care physicians (PCPs) are often the first point of contact and provide the majority of care to patients with ADHD, of those surveyed by the innovator at Cincinnati Children's Hospital Medical Center, many did not follow the evidence-based diagnosis and treatment guidelines.
  • Common disorder with detrimental effects: An estimated 3 to 5 percent of U.S. children (approximately 2 million children) have ADHD. Symptoms include hyperactivity, distractibility, poor concentration, and impulsivity, which can affect school performance, social relationships, and in-home behavior.1
  • PCP-based care for initial diagnosis and treatment: Owing to shortages of pediatric mental health providers, at least one-half of patients with ADHD initially receive treatment from PCPs. However, studies show that PCPs are often unfamiliar with the diagnosis and treatment of ADHD and often do not use the DSM-IV (Diagnostic and Statistic Manual of Mental Disorders, 4th edition) diagnostic criteria, which can lead to either over- or underdiagnosis of patients.2 PCPs who are not trained to manage the condition often refer uncomplicated ADHD cases to hospital-based mental health providers, who are often overburdened. This practice sometimes results in long patient waiting times, even for patients with complex problems.3 For example, patients who were referred for an appointment to Cincinnati Children's commonly waited 3 to 4 months.
  • Poor PCP adherence to guidelines: Although guidelines developed by Cincinnati Children's Hospital Medical Center based on American Academy of Pediatrics (AAP) evidence-based guidelines for the diagnosis and treatment of ADHD were available, many PCPs did not use them. An assessment of PCPs' adherence to these guidelines before participating in the collaborative's intervention showed that only about one-half of participating PCPs collected parent or teacher rating scale results during assessment; 38 percent verified the child's diagnosis using DSM-IV criteria; 1 percent gave patients and families written care management plans; and 9 percent obtained followup rating scale results from parents and teachers.4

What They Did

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Description of the Innovative Activity

Through the ADHD Collaborative, Cincinnati Children's Hospital Medical Center works with local PCPs to standardize ADHD management. The collaborative sponsors a Web portal that prompts ongoing online parent and teacher assessment and documentation of ADHD symptoms, incorporates computerized algorithms that automatically score and interpret rating scale results for physicians, and provides feedback to physicians about their performance regarding ADHD care. The collaborative also offers evidence-based diagnostic and treatment guidelines and facilitates expert consultation. Key elements of the program are described below:
  • Web portal: Information provided in February 2012 indicates that an ADHD Web portal (myADHDportal.com) allows parents, teachers and pediatricians to input information about the child, after which information is scored, interpreted and formatted in a report style that is helpful to the pediatrician in his/her assessment and treatment of ADHD. Depending on the module the pediatrician selects (i.e., assessment or medication monitoring), the parent and teacher (s) will be asked to complete the appropriate questionnaires and rating scales about the child's behavior.
    • Parent/teacher completion of rating scales: After a physician registers a child on the Web portal in the assessment module. Subsequently, the parent and teacher receive e-mail messages with links to the Web portal requesting that they complete an online version of the Vanderbilt Parent and Teacher Rating Scale. Office staff may input information for families who cannot log on to the Web portal to complete the rating scales.
    • Report sent to physician with results and guidance: Once these initial rating scales are completed, computer algorithms score and interpret the results. Physicians then receive a concise report with pertinent information, including number of ADHD symptoms, total symptom score, comorbidity screening criteria, and areas of impairment. Algorithm-generated textual passages provide guidance to the physician regarding diagnostic presentation and recommendations for further assessment and/or treatment. Reports may be printed or saved electronically as an attachment to the electronic medical record.
    • Treatment schedule: Using the medication monitoring module, physicians select a medication and a monitoring schedule for a specific patient. For example, the pediatrician may specify that the patient is to take 18 mg of Concerta® and that rating scales are to be completed each month (or other designated time interval).
    • Automated prompts for ongoing questionnaire completion: Thereafter, parents and teachers receive e-mails at the designated time interval prompting them to complete the Vanderbilt Parent and Teacher Rating Scale and a side-effect questionnaire (the Pittsburgh Side Effects Rating Scale); the e-mail provides a link to the Web portal to facilitate access to these tools. Whenever information is input by parents and/or teachers, computerized algorithms score and interpret this information and a report is produced and sent to the physician.
    • Immediate notification of physician about side effects, symptom deterioration: Pediatricians are alerted via e-mail immediately if any exacerbation of side effects or deterioration in ADHD symptoms occurs. Otherwise, the updated report resides in the system and may be accessed by the pediatrician at the patient's next scheduled visit.
    • Optional messaging service to facilitate physician/parent/teacher communication: The Web portal also offers parents, teachers, and physicians an optional messaging service that allows them to address ADHD management issues via e-mail; parents may also agree to allow direct communication between teachers and the child's primary care physician.
  • Incorporating guidelines into everyday office flow: With support from the ADHD Collaborative, PCPs provide evidence-based care for ADHD patients by incorporating guidelines developed by Cincinnati Children's Hospital Medical Center (based on the American Academy of Pediatrics [AAP] guidelines; for more information, see the Planning and Development section) into their office workflow; examples include the following:
    • Coordination with school: After a patient is diagnosed with ADHD, the PCP is encouraged to communicate with the patient's teachers regarding the diagnosis and treatment and relay their expectation that teachers will assist with the patient's management by periodically completing the Vanderbilt Rating Scales.
    • Patient followup: Information provided in February 2012 indicates that, using the ADHD Web portal, patients are asked to complete rating scales 7 to 14 days after medication initiation to assess medication adherence, side effects, and symptoms, and discuss followup visits. Symptoms and medication side effects are also documented by the physician during an office visit scheduled within 6 weeks of starting medication. Behavior rating scales are subsequently completed monthly by parents and teachers until the patient is appropriately titrated on their medication and quarterly thereafter.
    • Parent education: Information provided in February 2012 indicates that practices provide parents with detailed information about the diagnosis and treatment process. For example, after the initial visit, parents receive a welcome letter containing instructions for activating their Web portal account, completing rating scales, inviting a teacher to complete rating scales, and scheduling a followup appointment. In addition, the Web portal offers an information tab that provides parents with information about ADHD, common problems associated with ADHD, and how ADHD may affect their child.
  • Physician consultation service: Information provided in February 2012 indicates that, although most ADHD cases can be managed by PCPs, the collaborative provides practices with access to Cincinnati Children's behavioral health specialists who can consult on complicated cases. PCPs involved in the collaborative have access to this service via e-mail and telephone.
  • Continuous performance feedback: Information provided in February 2012 indicates that the Web portal’s report card feature annotates patient data for individual physicians so that they can monitor performance relative to the AAP ADHD guideline standards. Physicians are encouraged to review their performance report card on a regular basis to identify areas where they may be underperforming. Physicians are required to meet on a quarterly basis to develop and document "tests of change" or "Plan-Do-Study-Act (PDSA) cycles" as a means to improve and maintain AAP guideline compliance. The Web portal has an integrated wizard that prompts physicians to use PDSAs that have proven to be successful at other practices.

Context of the Innovation

Cincinnati Children's Hospital Medical Center, a 475-bed, not-for-profit teaching hospital affiliated with the University of Cincinnati, is the only primary pediatric medical center in the region. The impetus for the program's development arose from a hospital-wide effort to examine prolonged waiting times throughout the medical center. As part of this analysis, a task force found that many community PCPs referred children whose parents thought they may have ADHD to the hospital rather than diagnosing and treating these children on their own. This referral practice contributed to long waits (often up to 4 months) for children to see a hospital psychologist or psychiatrist, even for patients with complex mental health problems. After initially considering the development of an ADHD clinic at the hospital, senior hospital officials decided that a more effective approach was to establish a program to help community PCPs diagnose and treat ADHD. After an evaluation showed that many PCPs were unfamiliar with existing evidence-based guidelines on ADHD, the hospital focused the program on educating PCPs to improve their use of evidence-based diagnosis and treatment guidelines.

Did It Work?

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Results

The 2008 assessment of 19 participating practices with 84 PCPs conducted 9 months after program completion found that participants were more likely to adhere to key elements of evidence-based guidelines and less likely to refer uncomplicated ADHD patients to the hospital. In 2010, the ADHD Collaborative demonstrated significantly improved symptom scores for patients treated by protocol-trained physicians. Information provided in February 2012 indicates that in 2011, results from the cluster randomized clinical trial demonstrated that the modified intervention with Web portal integration significantly improved the quality of ADHD care in a community-based pediatric setting.

Results from the 2008 open trial of the intervention:
  • Increased use of rating scales and DSM-IV criteria: Collection of Vanderbilt Rating Scales from parents during assessment increased from 55 to 100 percent, while collection of assessment data from teachers rose from 52 to 96 percent. Collection of followup rating scales increased from 9 to 40 percent among parents and from 9 to 43 percent among teachers. The percentage of diagnosed patients who had chart documentation (e.g., a psychologist report or ADHD rating scale results) verifying that the diagnosis satisfied DSM-IV criteria increased from 38 to 83 percent.
  • Increased use of care management plans: The percentage of PCPs who gave patients and families written care management plans increased from 1 to 73 percent.
  • More followup contact during treatment: The percentage of patients who were contacted by the physician's office within 14 days of initiating medication increased from 27 to 74 percent, and the percentage of patients who had followup office visits within 6 weeks of medication initiation increased from 52 to 75 percent.
  • More PCPs diagnosing and treating ADHD: The percentage of PCPs who diagnose and treat patients with potential ADHD (versus referring them to the hospital) increased from approximately 80 to 99 percent during the program.
  • Evidence of improved outcomes: Information provided in January 2010 about a study of treatment efficacy sustainability performed among 158 protocol-trained physicians (from 47 practices) showed that parent and teacher symptom scores within 3 months of initiating medication for 785 newly diagnosed elementary school-aged children were significantly decreased (indicating improvement in symptoms). Symptomatic improvement for these patients was sustained for up to 12 months according to periodic data collection of rating scales to monitor response to medication.
Results from the 2011 cluster-randomized trial (added February 2012):
  • Increased use of rating scales and DSM-IV criteria: Pediatricians at practices assigned to the intervention group demonstrated significant increases for many ADHD care behaviors post-intervention. Included were the use of parent and teacher rating scales and DSM-IV ADHD criteria during an ADHD evaluation. In addition, the use of parent and teacher rating scales to monitor response to treatment were higher among intervention physicians. At the 15-month followup, pediatricians in the intervention group demonstrated continued improvement in their provision of ADHD care with respect to assessment behaviors.
  • More followup contact during treatment: The use of teacher rating scales to monitor response to treatment was higher amongst physicians assigned to the intervention group compared with pediatricians in the control group.
  • More PCPs diagnosing ADHD: Pediatricians in the intervention group demonstrated decreased reliance on mental health referrals for diagnosis of ADHD among their patients, compared with pediatricians in the control group.
  • High PCP satisfaction: Consumer satisfaction ratings completed by pediatricians in the intervention group indicated high level of satisfaction with the intervention. Eighty-six percent of intervention pediatricians responded that the quality of ADHD care they provide had increased as a result of ADHD Collaborative participation.

Evidence Rating (What is this?)

Strong: The evidence consists of a cluster randomized trial and other post-implementation assessments of outcomes measures including adherence to various aspects of evidence-based guidelines, including use of rating scales and diagnostic criteria, and the percentage of PCPs diagnosing and treating patients with potential ADHD. Findings of sustained symptom improvement are also provided.

How They Did It

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Planning and Development Process

Key steps in the planning and development process are described below:
  • Developing the curriculum: In 2003 and early 2004, the hospital formed an ADHD team including a pediatrician, two psychologists, and several hospital staff members with expertise in quality improvement (e.g., the pediatrician had participated in a year-long National Initiative for Children's Healthcare Quality–sponsored ADHD collaborative with 35 practices in the United States that involved extensive quality improvement training and community outreach). The hospital team was charged with developing and delivering a training program for area PCPs. Meeting weekly, the team reviewed ADHD literature, researched other ADHD training programs, and sought ideas from community PCPs about curriculum content and the best methods to deliver the content.
  • Developing evidence-based diagnosis and treatment guidelines: Cincinnati Children's Hospital Medical Center based their diagnosis and treatment of ADHD guidelines (see Tools and Other Resources section) on the existing AAP guidelines and incorporated the findings from the National Institute of Mental Health's Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (also known as the MTA study). Based on the findings of the MTA study, the Cincinnati Children's Hospital Medical Center guidelines included additional features beyond what was included in the AAP guidelines such as the recommendation for phone followup within 2 weeks of initiating medication.
  • Creating incentives for participation: The team developed the following incentives to encourage PCPs participation in the collaborative: access to the fast-track referral service for complex cases, continuing education unit credits for completing the course, and applying the PCP's participation in the collaborative (which included guideline use) toward the maintenance of certification quality improvement project requirement for relicensure from the American Board of Pediatrics.
  • Pilot testing: In May 2004, the team recruited five PCPs to complete the training program (see below for more details on the training) and to test the initiative for 6 months. Feedback from the pilot helped the team to improve program content and delivery.
  • Initial recruiting of participants and program rollout: In early 2005, the team mailed a brochure and letter that described the program and participation requirements to 209 practices representing 569 physicians. Two weeks later, a team member called each practice to discuss the PCP's interest in participation. If requested, the team's pediatrician visited the practice to answer questions about the program. Fifty-five practices employing 202 PCPs agreed to participate.
  • Local training sessions: Beginning in June 2005, the team delivered the training course to groups of 5 to 10 participating practices at a time. Training consisted of a series of four training sessions delivered over a 3-month period, including two 90-minute classroom-type sessions at the hospital and two 60-minute, practice-based training sessions held at the physician's offices. Along with the PCPs, key office staff, such as nurse practitioners, nurses, medical assistants, and office personnel, were also encouraged to attend. Sessions focused on the following:
    • Learning key skills related to ADHD guidelines and care: During the sessions, office staff were trained to score and interpret the Vanderbilt ADHD Rating Scales, use the monitoring grid, capitalize on technology to improve efficiency in patient diagnosis and treatment (e.g., an automated e-mail system that reminds parents and teachers to submit Vanderbilt scales each week), and bill appropriately for ADHD treatment services.
    • Improving office flow: Participants were taught quality improvement techniques, such as the Deming PDSA cycle, to redesign office policies and procedures to improve adherence to evidence-based guidelines. During the training sessions, PCPs created an office flow chart that depicts how ADHD patients were currently treated. This current-practice flow chart was compared with an idealized flow diagram that included office processes to help comply with the guidelines. The idealized diagram served as a general guide to PCPs on use of the guidelines for assessment, treatment, and, if necessary, referral.
    • Refining and improving the program: In 2006, two team members completed a 100-hour training course at the hospital based on a quality improvement model developed by Dr. Brent James. The course, which is now offered every 6 months, helped the team further refine and adjust the training program and improve teaching methods/expertise.
  • Distance training sessions: Information provided in February 2012 indicates that since 2008, the revised training model delivers the four-part course to one participating practice at a time. With the use of conferencing software, live 60-minute sessions are delivered over a 2- to 4-week period. Training includes two didactic sessions that focus on the evidence base for AAP assessment and treatment recommendations. Didactic sessions are attended by all pediatricians in the practice and a practice-identified ADHD champion. Each didactic session is followed by a workshop led by a quality improvement consultant that focuses on three main goals: (1) modifying office flow, (2) learning to perform tests of change, and (3) training on the ADHD Web portal. Workshops are attended by all physicians and staff members who interact with ADHD patients.
  • Online training: Information provided in February 2012 indicates that in 2010, the "myADHDportal Improvement Program" was launched to help primary care physicians incorporate AAP evidence-based guidelines for ADHD care into their process for assessing and managing patients with ADHD from any location with Internet access. The comprehensive training program consists of four sessions: (1) AAP ADHD guideline training focusing on evidence-based processes for diagnosing and treating ADHD; (2) Web portal training modules; (3) office flow training to incorporate AAP guidelines into routine practice; and (4) maintenance of performance training featuring quality improvement tools to enhance office procedures and reimbursement. If within a minimum of 3 months participating physicians return their self-guided baseline score card, complete all four-part self-paced Web based trainings, provide direct or consultative care to a minimum of 10 ADHD patients, and implement changes designed to improve care with at least three PDSA cycles, they are awarded full participation credit.

Resources Used and Skills Needed

  • Staffing: Information provided in February 2012 indicates that the ADHD Collaborative team includes one pediatrician, one psychologist, and four other hospital staff members, including a quality improvement consultant, a Web portal support manager, and two research assistants. Costs: Information provided in February 2012 indicates that the program's annual operating costs are approximately $500,000.
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Funding Sources

National Institutes of Health; Patient Innovation Fund (within Cincinnati Children's Hospital Medical Center)
Information provided in February 2012 indicates that funding sources include a 5-year, $1.8 million Cincinnati Children’s Hospital Medical Center Patient Innovation Grant; a 3-year, $371,250 National Institutes of Health R21 Grant; and a 5-year $2.5 million National Institutes of Health R01 Grant.end fs

Tools and Other Resources

The Cincinnati Children's Hospital Medical Center's clinical practice guidelines on diagnosis, evaluation, and treatment of children with ADHD is available at: http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2807/2829/2835/2837/2839
/f80b122e-d00e-4d28-a468-80e5ff3b34ff.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

More information on the National Institute of Mental Health's Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (also known as the MTA study) is available at: http://www.help4adhd.org/en/treatment/guides/mta.

Additional information on the ADHD Collaborative is available on the Cincinnati Children's Hospital Medical Center Web site at: http://www.cincinnatichildrens.org/service/c/adhd/hcp/collaborative/.

Tools for practices to implement and sustain the implementation of evidence-based guidelines are available at: http://www.cincinnatichildrens.org/service/c/adhd/hcp/portal-improvement/.

The tools used by practices in the ADHD collaborative are available at: http://www.cincinnatichildrens.org/service/c/adhd/services/default.

Adoption Considerations

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Getting Started with This Innovation

  • Include and highlight incentives for participation: During the promotional mailings and followup phone calls to PCPs, highlight the benefits/value of PCP's participation, such as rapid access to hospital services, continuing education unit credits, and assistance with relicensure.
  • Include an established practitioner and well-known expert on the training team: Including a team member who has a strong reputation within the community helps give credibility to the program. In addition, involving a leader who is a nationally recognized expert on ADHD helps to build enthusiasm for the program.

Sustaining This Innovation

  • Stay on top of technological developments: Information provided in February 2012 indicates that program adopters should monitor technological advances to improve the program. For example, in 2008, the ADHD Collaborative introduced an ADHD Web portal that enables parents and teachers to complete the assessment and treatment Vanderbilt Rating Scales online.
  • Seek participants' feedback: Include a mechanism for soliciting participants' feedback, such as course evaluation forms. Participating physicians were formally surveyed at two key junctures for the purpose of obtaining information about the effectiveness of the teaching intervention. In both cases, feedback resulted in significant refinement in course focus and content. Also, focus groups involving parents, teachers, and physicians were used to modify and improve the usability of the interactive ADHD Web portal.

Spreading This Innovation

In 2008, the ADHD Collaborative, with National Institutes of Health grant support, began training three pediatric practices in Dayton, OH, using a modified format that uses teleconference-based training and Web portal–based patient management. As of 2009, this training has spread to Louisville, Frankfort, and Lexington, KY. The collaborative is also actively working with physician groups around the country to establish opportunities for training and participation.

More Information

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Contact the Innovator

Jeffery Epstein, PhD
Director, Center for ADHD
Cincinnati Children's Hospital Medical Center
3333 Burnet Ave., ML-10006
Cincinnati, OH 45229-3039

Philip K. Lichtenstein, MD
Medical Director, ADHD Collaborative
Cincinnati Children's Hospital Medical Center
3333 Burnet Ave., ML-10006
Cincinnati, OH 45229-3039
(513) 636-7755
E-mail: phil.lichenstein@cchmc.org

Rebecca Kolb
Project Coordinator, ADHD Collaborative
Cincinnati Children's Hospital Medical Center
3333 Burnet Ave., ML-10006
Cincinnati, OH 45229-3039
(513) 636-8764
E-mail: adhdcollaborative@cchmc.org

Innovator Disclosures

Dr. Epstein, Dr. Lichtenstein, and Ms. Kolb have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Epstein JN, Langberg JM, Lichtenstein PK, et al. Sustained improvement in pediatricians' ADHD practice behaviors in the context of a community-based quality improvement initiative. Children's Health Care. 2010;39:295-311.

Epstein JN, Langberg JM, Lichtenstein PK, et al. Use of a web portal to improve community-based pediatric ADHD care; a cluster randomized trial. Pediatrics. 2011;e1210-e1217.

Epstein JN, Langberg JM, Lichtenstein PK, et al. Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians. Pediatrics. 2008;122(1):19-27. [PubMed]

Epstein JN, Langberg JM, Lichtenstein PK, et al. Attention deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings. Arch Pediatr Adolesc Med. 2010;164(2):160-5. [PubMed]

Cincinnati Children's ADHD Collaborative [Web site]. Available at: http://www.cincinnatichildrens.org/service/c/adhd/hcp/collaborative/.

Program Web Site: http://www.myADHDportal.com.

Footnotes

1 National Institute of Mental Health. Attention Deficit Hyperactivity Disorder. Bethesda (MD): National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services; 2006 revision. Available at: http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml.
2 Leslie LK, Weckerly J, Plemmons D, et al. Implementing the American Academy of Pediatrics attention deficit/hyperactivity disorder diagnostic guidelines in primary care settings. Pediatrics. 2004;114(1):129-40. [PubMed]
3 Cincinnati Children's Hospital Medical Center. ADHD Collaborative [Web site]. Available at: http://www.cincinnatichildrens.org/service/c/adhd/hcp/collaborative/.
4 Epstein JN, Langberg JM, Lichtenstein PK, et al. Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians. Pediatrics. 2008;122(1):19-27. [PubMed]
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Original publication: May 25, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 22, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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