clinicaltrials.gov Identifier: NCT01021384.

FN may be a promising intervention to address barriers that impede timely ASD diagnosis.

OBJECTIVES: Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity. METHODS:We conducted a randomized comparative effectiveness trial of 2 care management systems for 6-to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child's treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year.RESULTS: Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were -0.14 (95% confidence interval -0.34 to 0.07) for inattention; -0.13 (-0.31 to 0.05) for hyperactivity/impulsivity; -0.09 (-0.28 to 0.11) for oppositionality; and 3.30 (-1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of -0.36 (-0.69 to -0.03), oppositionality -0.40 (-0.75 to -0.05), and social skills 9.57 (1.85 to 17.28).CONCLUSIONS: Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care. WHAT'S KNOWN ON THIS SUBJECT:Collaborative care is known to be an effective system to manage child behavioral health conditions in the primary care setting. WHAT THIS STUDY ADDS:Among urban children with attention-deficit/hyperactivity disorder, using lay care managers to address barriers to engagement with care and challenging child behaviors has the potential to improve the effectiveness of conventional collaborative care. Dr Silverstein conceptualized and designed the study, oversaw its implementation, and drafted the initial manuscript; Drs Hironaka and Walter conceptualized and designed the study, oversaw its clinical implementation, reviewed and revised the entire manuscript, and assisted in the interpretation of analyses; Dr Feinberg assisted in conceptualizing and designing the study, oversaw its clinical implementation at one site, assisted in the interpretation of analyses, and reviewed and revised the manuscript; Ms Sandler managed the data for the project, assisted in preparing the analyses, and reviewed and revised the manuscript; Ms Pellicer supervised the care managers for the project, and reviewed and...

Background Violent trauma is common in urban communities. We explored the hypothesis that past trauma could moderate the effect of a cognitive behavioral intervention designed to prevent depression among urban, low-income mothers. Methods Synthesis of two pilot randomized trials of problem solving education (PSE), among 93 mothers of children hospitalized in the neonatal intensive care unit or enrolled in community-based Early Intervention programs. Outcomes included depressive symptoms, perceived stress, social functioning. Results were adjusted for baseline depressive symptoms, then stratified according to subjects’ trauma history. Results Fifteen of 44 PSE subjects (34%) experienced a moderately severe depressive symptom episode during the four-month follow-up period, as opposed to 21 of 45 control subjects (47%) – for a nearly significant adjusted odds ratio (aOR) of 0.36 (95% CI 0.13, 1.02). Among mothers without trauma histories, far fewer PSE mothers (5 of 24; 21%) experienced an episode of moderately severe depressive symptoms than control mothers (12 of 26; 46%), for a significant aOR of 0.15 (95% CI 0.03, 0.79). Conversely, among mothers with trauma histories, a similar proportion of PSE mothers (10 of 19; 53%) experienced an episode of moderately severe depressive symptoms as control mothers (9 of 19; 47%). Similar trends held for perceived stress and social functioning. Conclusions PSE may be more effective at preventing depression among mothers without trauma histories. Our results are consistent with the depression treatment literature, but are novel because they support the principle of intervention moderation in a risk-prevention – as opposed to treatment – paradigm.