Stephen V. Faraone, PhDA systematic review found five studies that evaluated shared care models involving children and adolescents, in which primary care providers (PCPs) collaborated with mental health care providers in treating ADHD. The 655 participants ranged in age from 5 to 17.

Two of the studies were randomized. In one, the largest, with 321 participants, care managers acted as liaisons between PCPs and psychiatrists, and provided psychoeducation and skills training for families. Effect sizes on the Vanderbilt ADHD Diagnostic Teacher Rating Scale were very small, ranging from a standardized mean differences (SMDs) of 0.07 to 0.12. Improvement on the Clinical Global Impression scale was also small (SMD = 0.3) and was not significant (p = 0.4).

In the other randomized study, with 63 participants, care managers also acted as liaisons between PCPs and a psychiatric decision support panel to provide Positive Parenting Training. The SNAP-IV hyperactivity/impulsivity score showed a medium effect size (SMD = 0.7), with a medium-to-large effect size (0.7) for improvement in social skills. The score difference for SNAP-IV inattention was not statistically significant.

The other three studies followed groups of individuals over time. In one cohort with 129 participants, PSPs consulted with psychiatrists by telephone; an evaluation, where necessary, performed within 4 weeks. As assessed by the Clinical Global Impression–Severity scale, symptoms declined from moderately severe to mild or borderline. On the Children’s Global Assessment Scale, there was improvement from problems in more than one area of functioning to just one area.

In another cohort with 116 participants, care managers acted as liaisons between pediatricians and a psychiatrist, and provided education to parents. Just over a quarter of participants showed improvement of greater than one standard deviation on the Vanderbilt ADHD Diagnostic Parent Rating Scale, and just under one in seven on the Vanderbilt ADHD Diagnostic Teacher Rating Scale.

The remaining cohort had only 26 participants. It offered PCPs access to outpatient psychiatric consultations within three weeks. PCPs reported a high level of satisfaction with their improved skills in mental health care. There was no evaluation of effect on symptoms.

With varied study designs, methodologies, and outcomes, the authors of the review could only conclude “that PCP collaboration with psychiatrists may be associated with increased comfort level. However, the association with symptom outcome and increased capacity was variable.” Given that randomized studies report only small effects, these shared care models cannot be routinely recommended.

REFERENCES
Meshal A. Sultan, Carlos S. Pastrana, and Kathleen A. Pajer, “Shared Care Models in the Treatment of Pediatric Attention-Deficit/Hyperactivity Disorder (ADHD): Are They Effective?” Health Services Research and Managerial Epidemiology, vol. 5, 1-7 (2018).

Stephen V. Faraone, PhD

About Stephen V. Faraone, PhD

Dr. Faraone is the Principal ADHD Expert for ADHD in Adults. He is Distinguished Professor of Psychiatry, SUNY Upstate Medical University, and is a member of the Board of APSARD, the American Professional Society of ADHD and Related Disorders. He is the Principal Investigator for ADHD in Adults.com and serves on the Advisory Board.