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An action guide for adhd: next steps for patients, clinicians, and insurers <> treatment options for attention deficit hyperactivity disorder

Treatment Options for Attention Deficit Hyperactivity Disorder
The New England Comparative Effectiveness Public Advisory Council
An Action Guide for ADHD: Next Steps for
Patients, Clinicians, and Insurers
August 2012
Completed by:
The Institute for Clinical and Economic Review
About this guide
Evidence from clinical effectiveness reviews is critical to judgments that patients, clinicians, and health insurers must make about treatment choices and coverage policies. Yet that evidence is often not translated in a way that is helpful to inform healthcare decisions. This document is a companion policy guide designed to help patients, clinicians, and insurers make use of the results of two reports: 1) the evidence review on treatment options for Attention Deficit Hyperactivity Disorder (ADHD) produced by the Agency for Healthcare Research and Quality (AHRQ)1; and a supplementary report with additional data and analyses on ADHD treatment options developed by the Institute for Clinical and Economic Review (ICER). These two reports were used to support the deliberations of the New England Comparative Effectiveness Public Advisory Council (CEPAC) – an independent body that provides objective guidance on how information from federally produced evidence reviews can best be used by regional decision-makers to improve the quality and value of healthcare services.2 CEPAC held its meeting on ADHD treatment options on June 1, 2012. A full report summarizing the discussion and votes taken is available at We have developed this action guide in order to provide a user-friendly overview of the CEPAC findings and an associated list of specific evidence-based action steps that patients, clinicians, and insurers can take to improve patient outcomes and the overall value of ADHD services. This information is being provided for informational purposes only. A note on CEPAC evidence voting
Each public meeting of CEPAC involves deliberation and voting on key questions on the comparative clinical effectiveness of various treatment options discussed. When a majority of CEPAC votes that the evidence is adequate to demonstrate that an intervention produces patient outcomes equivalent or superior to a reference option, council members are also asked to vote on whether the intervention represent a "high", "reasonable", or "low" economic value. The value perspective that members of CEPAC are asked to assume is that of a state Medicaid making resource decisions within a fixed budget for care. 1 The full AHRQ report can be accessed here: Charach A, et al. October 2011. Attention deficit hyperactivity disorder: effectiveness of treatment in at-risk pres-schoolers; long-term effectiveness in all ages; and variability in prevalence, diagnosis, and treatment; comparative effectiveness review No. 44. Rockville, MD: Agency for Healthcare Research and Quality; October 2011; Accessed July 19, 2012 2 For more information on CEPAC, vis Treatment Options for Children with ADHD
Background
The number of individuals diagnosed with ADHD has risen in recent years, and it is now regarded to be a common condition among children in the United States. While reported prevalence ranges widely between 6-16% depending on location and measurement technique (Pastor, 2008; Elder, 2010; Froehlich, 2007), it has been estimated that ADHD affects at least 5 million children aged 4-17 years in the U.S. (CDC, 2010). Over 2.5 times as many boys have a diagnosis of ADHD as girls (Froehlich, 2007; Pastor, 2008), and children from lower income families are at nearly double the risk of ADHD relative to those from higher income strata (Froehlich, 2007). Presentation of ADHD symptoms is heterogeneous, and includes various subtypes as well as co-morbid psychiatric conditions. Subtypes are primarily defined as inattentive, hyperactive-impulsive, and a combination of the two (Elia, 2009). Other common and highly correlated disorders include oppositional defiant disorder (ODD), which involves disobedient, hostile, and defiant behavior toward authority figures (A.D.A.M. Medical Encyclopedia, 2012); and conduct disorders , which are often more serious and involve aggression toward people or animals, destruction of property, dishonesty, and other delinquent and/or criminal behavior (Lahey, 2000). These disorders are often grouped together as disruptive behavior disorders (DBD). In addition, children with ADHD often have substantial psychiatric comorbidity, including separation or other anxiety disorders, obsessive-compulsive disorder, and major depression (Ghanizadeh, 2009). In the long term, a diagnosis of ADHD in children has been associated with poorer outcomes in social functioning (Hodgkins, 2012), academic performance (Galéra, 2009; Hodgkins, 2012), adolescent substance abuse (Hodgkins, 2012; Molina, 2007), and delinquent behavior (Hodgkins, 2012; Molina, 2007). The economic burden of ADHD has been estimated at over $30 billion annually in the US, over 10% of which can be attributed to work loss of parents caring for affected children (Birnbaum, 2005). Management options for children with ADHD
Parent Behavior Training Parent behavior training involves individual or group training sessions which typically track progress through a training manual. Sessions generally last 1-2 hours per week over a treatment course of 8-20 weeks. Overarching objectives include management of problem behaviors and fostering of positive and caring parent-child relationships. While available programs differ somewhat in their approach, all utilize rewards and other non-punitive tools to modify child behavior. Manual-based programs known by their brand names include the Triple P – Positive Parenting Program®, The Incredible Years® parenting program, and Parent-Child Interaction Therapy (see Action Steps for Patients for further details). Other programs exist, and may be delivered through interactive materials, individual or group-based sessions in a clinic setting, or telephone-based therapy discussions. CEPAC Votes and Deliberation on Parent Behavior Training:
Preschoolers CEPAC unanimously voted that the evidence is adequate to demonstrate that parent behavior training is superior to usual care in improving the outcomes of preschoolers with ADHD. The majority of CEPAC also voted that parent behavior training for the parents of preschoolers with ADHD had high or reasonable value compared to usual care (5 high, 7 reasonable). Given the strength of evidence for parent behavior training, the uncertainty regarding appropriate diagnosis of ADHD in younger children, and potential long-term effects of medication, CEPAC indicated that parent behavior training is an appropriate first-line treatment for most preschoolers (medication may still be more appropriate as a first-line therapy for preschoolers with severe symptoms or certain psychiatric comorbidities). Chil dren Six and Older For children with ADHD over age six, a majority of CEPAC (9 to 4) voted that the evidence on the long- term risks and benefits was inadequate to demonstrate that parent behavior training was as good as or better than usual care. Medication Several stimulants are used in children of all ages for the treatment of ADHD symptoms. FDA-approved therapies evaluated in the AHRQ review include methylphenidate (e.g., Ritalin®), dextroamphetamine (e.g., Dexedrine®) and mixed amphetamine salts (Adderall®). Methylphenidate is the oldest available medication, gaining FDA approval in 1955, followed by mixed amphetamine salts in 1960 and dextroamphetamine in the 1970s. Stimulants work to improve symptoms such as inattention, impulsivity, and hyperactivity by increasing and balancing levels of neurotransmitters in the brain (Mayo Clinic, 2011). Other medications with FDA approval for use in ADHD include atomoxetine (Strattera®), a selective norepinephrine-reuptake inhibitor, and extended-release formulations of two alpha2-agonists originally used as antihypertensive medications: guanfacine (Intuniv®) and clonidine (Kapvay™). Atomoxetine is widely considered to be a second-line agent following a trial of stimulant medication, but may be selected by parents choosing to avoid stimulant therapy or in patients with current substance abuse problems as well as those at risk for future abuse (Pliszka, 2007). It has been suggested that patients with comorbidities like ODD or anxiety may also experience better efficacy with atomoxetine (Dell'Agnello, 2009; Geller, 2007). CEPAC Votes and Deliberation on Medication:
Pr eschoolers A majority of CEPAC (10 to 3) voted that the evidence is adequate to demonstrate that methylphenidate is as good as or better than usual care (i.e. no specific ADHD management) for most preschoolers with ADHD or DBD. Other medications may be more appropriate in the presence of certain clinical indications, like tics, anxiety disorder, or potential diversion. The majority of CEPAC also voted that methylphenidate has high or reasonable value compared to usual care (6 High, 3 Reasonable, and 1 Abstain). Children Six and Older CEPAC stipulated that the evidence is adequate to demonstrate that medication is better than usual care (i.e. no specific ADHD management) for treating ADHD in children over six. For this age group, a slight majority of CEPAC (7 to 6) voted that the evidence is adequate to demonstrate that other medications may be as effective as methylphenidate in treating ADHD, with CEPAC emphasizing the superiority of specific medications in treating certain subpopulations (like patients with tics). However, when addressing comparative value, a majority (5 to 2) of CEPAC voted that other medications had low long-term comparative value. ined therapy Some clinical guidelines recommend combining behavioral therapies with medication in children with ADHD or DBD, particularly for children with psychiatric comorbidities or without supportive home environments. Behavioral therapies can include parent behavior training, school-based interventions, or other forms of therapy, which can combine behavioral and psychosocial approaches. Behavioral therapy is comprised of techniques designed to change the physical and social environment of a child with ADHD through utilization of reward systems for positive behaviors and consequences for undesirable behaviors (Subcommittee-AAP, 2011; Rader, 2009). Psychosocial therapy addresses the emotions and thought processes involved in destructive behaviors (Subcommittee-AAP, 2001), and may consist of individual psychotherapy, play therapy, or cognitive behavioral therapy (Pelham, 1998). These therapeutic approaches may be utilized alone or as a part of a multimodal program that may also include parent training, social skills training, traditional psychotherapy, and school-based interventions (see following page). CEPAC Votes and Deliberation on Combined Behavioral and Medication
Therapy:
School-based interventions Preschoolers For children under six, a majority of CEPAC (10 to 3) voted that evidence on long-term benefits and harms is inadequate to demonstrate that medication combined with behavioral/psychosocial interventions (including parent behavior training) is as good as or better than medication alone in treating ADHD or DBD. Children Six and Older For children over six, a majority of CEPAC (10 to 2) voted that the evidence is adequate to demonstrate that medication combined with psychosocial interventions (including parent behavior training) is better than medication alone. CEPAC members were split evenly on deciding whether combination therapy had low, reasonable or high value. School-based in terventions Multiple school-based interventions exist for ADHD, including classroom-based special education services, individualized student training, and specialized teacher training to develop strategies of behavior modification (Ansthel, 2011). Specialized classroom environments utilize teachers and aides specifically trained and supervised by child psychologists, employing behavioral methods and unique treatment curriculums (Barkley, 2000). Use of communication tools such as daily school behavior report cards facilitates communications with parents regarding behavioral trends in children (Antshel, 2011). Positive reinforcement, peer-tutoring, and organizational skills training are other school-based approaches for children with ADHD (Antshel, 2011). CEPAC Deliberation
on School-based Interventions
Though CEPAC did not formally vote on long-term effectiveness of school-based interventions, the council acknowledged that school-based interventions are an especially important component of ADHD treatment, as they may provide the only access to behavioral/psychosocial interventions for low-income and/or rural patients. Action Steps for Patients and Caregivers
If your child has been diagnosed with ADHD, the following steps are designed to help you make choices about the various ADHD treatment options for your child, based on the best available evidence. 1. Become an expert: learn as much as you can about the various treatment options for ADHD.
This guide outlines the major approaches to ADHD treatment: parent-behavior training, medication, and combined therapies (e.g. medication plus behavioral therapies, such as parent behavior training, school-based interventions, or other behavioral interventions). 2. Discuss these treatment options with your doctor, identifying the pros and cons of each
treatment option, and the most important risks and benefits for your child.
The AHRQ consumer summary provides an overview of the different types of ADHD treatment
and their associated costs, with information on how to discuss with your child's doctor the
various treatment options for ADHD.
This summary can be accessed online at
or you can order free print copies by calling 800-358-9295.
3. Talk to your child's teacher about your child's diagnosis and treatment plan, and discuss any
school-based interventions that are available in your community.
School-based interventions can be effective in helping some children with ADHD decrease
disruptive behavior and improve work productivity, especially in communities where other
behavioral interventions are not available.
4. If considering medication, ask your doctor about any generic options that are available, and
call your health insurance plan about the different out-of-pocket costs associated with each.
Many medicines for ADHD work equally well, but differ in value. Talk to your doctor about
which medication options have the highest value for your child, given your child's individual
needs.
5. If considering parent-behavior training, seek out therapists who use a certified approach.
A major obstacle in accessing appropriate ADHD treatment is the limited availability of qualified therapists that provide behavioral/psychosocial services, such as parent behavior training, in many geographical areas. The list on page 10 of certified parent behavior training providers is designed to help parents and caregivers with young children locate providers for parent behavior training in their area. All programs are designed to help parents manage behavior through rewards and non-punitive strategies and by fostering a positive and caring parent-child relationship. Note: these are the "branded" parent behavior training programs; many mental health providers are trained to offer parent behavior training but do not get certified or accredited by these groups. 6. Keep a journal that tracks your child's progress with treatment. Bring this journal with you to
your child's appointments and discuss with your doctor any changes over time.

Parent Behavior Training Resource List
Description
Insurance Coverage
Triple P – Positive Parenting Parents meet individually with a
For the ADHD and DBD practitioner for 1-1.5 hrs for 10-12 weeks available from Triple P program, most providers are able to bill Program focuses on teaching parents 17 Website claims 20,000 private insurance and core child management strategies to get reimbursed as if it promote child development and help Options include: was a "typical" mental manage misbehavior 146 providers in New
for those Triple P Parents also do self-directed study with
England, but no
providers that do not "homework" from workbooks that help -Costs built into specific information
accept insurance, costs them set and monitor their own goals provided by program: are out-of-pocket for
Several of the sessions take place in the provided free to (mostly in the Lower Naugatuck Valley) Accreditation offered to professional (practitioners are practitioners with post-secondary spread across the qualifications in health, education, or social services with knowledge of child/ Massachusetts: 51 adolescent development and experience (mostly in Springfield working with families; not all providers are licensed mental health practitioners New Hampshire: 17 (mostly in Groveton and Gorham) Rhode Island: 0 Vermont: 1 The Incredible Years® parenting Group sessions for parents run by two
Certification available specially trained leaders for 12, 2-2.5 hour parenting from Incredible Years insurance coverage weekly sessions for 10-14 participants – found – some private components of the Basic parent program insurers may cover the for a full session o Program 1 - Strengthening required for purchase Children's Social Skills, Emotional Regulation and School Readiness Requested but did not o Program 2 - Using Praise and Incentives to Encourage information regarding Cooperative Behavior providers in New o Program 3 - Positive Discipline - Rules, Routines and Effective Limit o Program 4 - Positive Discipline - Handling Misbehavior Emphasizes parenting skills to promote children's social competence and to reduce behavior problems, and it teaches parents how to play with children, help children to learn, give effective praise and incentives, use limit-setting, and handle misbehavior. Leaders are from many disciplines, including counseling, social work, psychology, psychiatry, nursing, and education and have training in child development, behavior management and group process. Leaders are trained and accredited from the Incredible Years organization Parent-Child Interaction Therapy Based on a clinician's guide developed in Official therapist Some practitioners aid 1995 by Hembree-Kigin and McNeil certification is under parents in filing development, but to Parents and child meet individually with a
date there is no practitioner (often behind a one-way official certification some claim that PCIT is mirror giving tips via wireless microphone session for a total process. The often covered under to the parent) for "special playtime" following providers insurance plans as where parents are taught skills to modify are confirmed to have family therapy or as unwanted behavior to be deployed during received training in individual child playtime – known as Relationship psychotherapy if the practitioner is covered by the insurance Parents also learn "discipline skills" where parents are taught behavior management many practitioners offer strategies – known as Child Management Donna Pincus, PhD sliding scale fees Sessions continue until the parent has mastered the skills and the child is in the Melanie Fernandez, normal range on a behavior-rating scale; typically 12-20 weekly sessions (1-2 hr Steven Kurtz, PhD, Phyllis Ohr, PhD Practitioners must have at least a Masters Katherine Gibson, PhD degree in a mental health field Hayley Cooper, PhD Helping the Non-Compliant Child For parents of 3 to 8 year old children Typically covered by who have difficulty following directions, The Behavior Therapy private insurance are aggressive, and display other and Psychotherapy disruptive behaviors Center, University of Vermont, 2 Colchester Program focuses on changing the parent- Avenue, Burlington, child interaction by teaching parents more Vermont 05405-0134, effective ways to interact with their children, including providing attention to appropriate behavior, issuing effective The following clinics instructions, and using disciplinary strategies that work providers available trained in the program: MA: Greater Boston Family Services, 31 Heath Street, Jamaica, Plain, MA 02130, (617) 523-6400 NH: Sarah D. Stearns, Ph.D., Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Psychiatric Associates, One Medical Center Drive, Lebanon, NH 03756-0001, (800) 556-6249 Community Partners, Dover, NH, (603) 749-4015 Manchester Mental Health Center, Manchester, NH, (603) 668-4111 Seacoast Mental Health Center, Portsmouth, NH, (603) 431-6703 West Central Behavioral Health, Lebanon, NH, (603) 448-0126 Genesis Behavioral Health, Laconia, NH, (603) 524-1100 Monadnock Family Services, Keene, NH, (603) 357-4400 Greater Nashua Mental Health Center, Nashua, NH, (603) 889-6147 Northern Human Services, Conway, NH, (603) 447-3347 Center for Life Management, Derry, NH, (603) 434-1577 Riverbend Community Mental Health, Concord, NH, (603) 228-1551 VT: Northwestern Counseling and Support Services, Inc, St. Albans, VT, (802) 524-6554 Action Steps for Clinicians
If you are a clinician treating a patient with ADHD, the following steps are designed to help you develop a treatment plan that incorporates the best available evidence. 1. Use an evidence-based approach to diagnosis, using appropriate diagnostic criteria including
the ruling out of comorbid conditions such as obstructive sleep apnea.
Clinical guidelines are available from the following medical societies, which outline evidence-
based approaches to diagnosis and treatment for children with ADHD:
American Academy of Child and Adolescent Psychiatry (2007): American Academy of Pediatrics (2011): Institute for Clinical Systems Improvement (2012) National Institute for Health and Clinical Excellence (2009): Preschool Psychopharmacology Working Group (2007): 2. Discuss all relevant risks and benefits of treatment options with parents.
The AHRQ Clinician Research Summary on ADHD summarizes the evidence on the comparative clinical effectiveness of the various treatment options for ADHD, and gives information on what to communication to patients and their caregivers when discussing various treatment options. This research summary for clinicians is available at 3. Seek opportunities for collaborative co-management of patients between primary care and
specialty care, particularly for complex patients or those who do not respond adequately to
initial treatment.

4. Use consistent outcomes measures throughout the course of treatment in order to evaluate
your patient's response to treatment.

5. For patients under the age of 6, consider parent behavior training as a first-line therapy unless
the patient's symptoms are so severe to necessitate medication, or the caregiver is unable or
unwilling to participate in behavioral therapy.

6. When a patient under 6 requires medication, consider prescribing methylphenidate as a first-
line treatment except in the presence of certain clinical indications, like tics, anxiety disorder,
and potential for diversion. Avoid the use of antipsychotics, and consider seeking
consultation with a specialist before starting a second medication in a patient "not
responding" to an initial drug choice.

7. For all patients who begin medication, ensure that doses are appropriately titrated on a
regular basis to achieve optimum benefits. Evidence suggests that many patients are
underdosed or overdosed.

8. When referring patients and their families for parent behavior training, select therapists
offering an evidence-based approach and use available CPT codes for billing.
A list of parent behavior training providers throughout New England is available on page 9.
Anecdotal evidence suggests that providers are often required to give parents a diagnosis in
order to receive reimbursement for parent behavior training. Two CPT codes that may be
helpful to providers billing for parent behavior training programs for when the patient is or is
not present are:
90846: Family psychotherapy, without the patient present
90847: Family psychotherapy (conjoint psychotherapy), with patient present
Most insurers allow for both codes to be billed on the same date of service for traditional/commercial business, but individual plans may vary. It is important to note that these codes may only be used for individual parent behavior training sessions, and not for families participating in parent behavior training as a group. Action Steps for Payers
The following steps are designed to help payers develop policies that incentivize the use of evidence-based treatment options for ADHD: 1. Create and support payment structures that encourage innovative collaboration between
primary care and specialty care, such as co-management of patients via telepsychiatry.

2. Heighten efforts to reduce administrative burden for clinicians seeking exceptions from
clinical policies for clinically appropriate reasons.
3. Maintain or strengthen medical policies that discourage the use of antipsychotics and other
agents that lack evidence to support their effectiveness in children with ADHD.
4. Maintain or strengthen medical policies that incentivize the use of methylphenidate as a
first-line treatment for patients with ADHD or DBD requiring medication.
Based on the findings of the Agency for Healthcare Research and Quality (AHRQ) review and
CEPAC votes on the comparative clinical effectiveness and value of other medications
compared to methylphenidate, payers may consider designing medical policies that incentivize
the use of methylphenidate as a first-line treatment for patients with ADHD or DBD requiring
medication.
ICER did not find an example of any medical policy or formulary for ADHD medications from the major national or regional payers that required patients to fail methylphenidate first before receiving reimbursement for other ADHD medications. The following medical policies are provided as a reference, as they currently reimburse methylphenidate without restriction and could be adapted to encourage first-line use of methylphenidate over other ADHD medications. Blue Cross Blue Shield of Rhode Island

dexmethylphenidate, dextroamphetamine, methylphenidate/ER mixed amphetamine salts/ER, Focalin XR, Concerta, Straterra Adderall XR, Concerta, Daytrana, Metadate CD, Vyvanse Tufts Health Plan

Step-1 therapies: covered without prior mixed amphetamine salts, Adderall, dexmethylphenidate, dextroamphetamine, Metadate ER, methylphenidate/ER, methamphetamine, Methylin/ER Step- 2 therapies: coverage requires Adderall XR, Concerta, Daytrana, Focalin XR, documentation of 30-day trial with one of the Metadate CD, Procentra, Ritalin, Ritalin DR, Step-1 or Step-2 medications within the previous Vyvanse, Ritalin LA MassHealth (Massachusetts Medicaid)

All ADHD medications require prior authorization above established quantity limits (>60 units/month for
long-acting agents, >90 units/month for shot- to intermediate acting agents).
The following medications have additional prior authorization requirements:
Adderall XR (amphetamine salts ER)
Documentation of inadequate response (≥ 7 days
of therapy) or an adverse response to a generic
equivalents; and one of the following:
Inadequate response to a long-acting Adverse reaction to a long or short-acting Requested quantity must be ≤60 tablets/30 days. Concerta ER (methylphenidate ER) Documentation of inadequate response or an
adverse response to a generic equivalents; and
one of the following:
Inadequate response to a long-acting Adverse reaction to a long or short-acting Requested quantity must be ≤60 tablets/30 days. Daytrana (methylphenidate transdermal) Documentation of medical rational for use in a member that is < 6 years or ≥ 18 years old Desoxyn (methamphetamine) Documentation of diagnosis of ADHD and an adverse reaction or inadequate response to all other stimulant or non-stimulant medications Intuniv (guanfacine extended-release) Documentation of the following: Diagnosis of ADHD; and
Inadequate response or adverse reaction
to immediate-release guanfacine; and
Inadequate response, adverse reactions, or contraindication to atomoxetine (Strattera); And one of the following:
Inadequate response to a long-acting amphetamine; or
Adverse reaction to a long or short-acting Member must be ≥6 years old and requested quantity must be ≤30 tablets/30 days Kapvay (clonidine ER) Documentation of the following: Diagnosis of ADHD; and
Inadequate response or adverse reaction
to immediate-release clonidine; and
Inadequate response, adverse reactions, or contraindication to atomoxetine (Strattera); And one of the following:
Inadequate response to a long-acting methylphenidate; or
Adverse reaction or contraindication to a long- or short-acting methylphenidate And one of the following:
Inadequate response to a long-acting amphetamine; or
Adverse reaction to a long or short-acting Member must be ≥6 years old. Strattera (atomoxetine) Documentation of the following is required: An adverse reaction or contraindication to
a methylphenidate and/or amphetamine
product; or
An inadequate response to a
methylphenidate and an amphetamine
product; or
The member (≤ 18 years of age) or
immediate family member in household
has a history of substance abuse; or
For adults (≥ 19 years of age) with a history of substance abuse, documentation must be provided regarding an inadequate response (defined as ≥ 14 days of therapy) or an adverse reaction to a non-stimulant medication such as a tricyclic antidepressant or bupropion Harvard Pilgrim Health Care

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