Short research communication
Ammar Albanna,1 Karina Soubra,1 Deena Alhashmi,2 Zainab Alloub,1 Fatma AlOlama,3 Paul Hammerness,4 Jeyaseelan Lakshmanan,2 Lily Hechtman5 and Hesham M. Hamoda4
1 Al Jalila Children’s Specialty Hospital, Dubai, United Arab Emirates. 2 Mohamed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates. 3 Dubai Health Authority, Dubai, United Arab Emirates. 4 Department of Psychiatry, Boston Children’s Hospital and Harvard Medical School, Boston, United States of America. 5 McGill University, Montreal, Canada. (Correspondence to Ammar Albanna:
Abstract
Background: Attention deficit hyperactivity disorder is a common neurodevelopmental disorder. Accessing services for this disorder is a worldwide challenge and requires innovative interventions.
Aims: The Effectiveness of Collaborative Tele-Mental Health Services for ADHD in Primary Care trial is a registered randomized controlled trial that aims to investigate the effectiveness of tele-collaborative care for attention deficit hyperactivity disorder in primary health care centres in Dubai.
Methods: Six trained physicians started collaborative care clinics across Dubai. Eligible children with attention deficit hyperactivity disorder were randomized to receive tele-health collaborative care, or standard treatment. Waiting times and clinical and functional outcomes were measured in both groups and compared.
Results: Among the referred children (n = 112), 11 boys and 6 girls met the eligibility criteria (mean age 7.8 years). The drop-out rate at 6 months in the control group was 80% compared with 50% in the intervention group. The mean waiting time was significantly shorter in the intervention group (1.3 weeks) than the control group (7.1 weeks); P = 0.026. The mean difference in the Childhood Behavior Checklist total score over time was significantly higher in the intervention arm (P = 0.042), but the mean difference in the Vanderbilt scale was not significant.
Conclusion: Tele-collaborative care for children with attention deficit hyperactivity disorder within primary health care is feasible.
Keywords: attention deficit hyperactivity disorder, child psychiatry, mental health, primary care, Dubai.
Citation: Albanna A; Soubra K; Alhashmi D; Alloub Z; AlOlama F; Hammerness P, et al. Effectiveness of collaborative tele-mental health care for children with attention deficit hyperactivity disorder in primary care centres: randomized controlled trial in Dubai. East Mediterr Health J. https://doi.org/10.26719/emhj.23.076 Received 06/05/2022 ; accepted: 05/01/2023
Copyright © World Health Organization (WHO) 2023. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license https://creativecommons.org/licenses/by-nc-sa/3.0/igo
Introduction
Attention deficit hyperactivity disorder (ADHD) is a pervasive neurodevelopmental disorder characterized by developmentally inappropriate levels of inattention and/or hyperactivity/impulsivity (1,2). ADHD is associated with long-term adverse outcomes and is a public health burden (3–5). Despite the availability of safe and effective treatments for ADHD (6), a large proportion of children with ADHD are unable to access services (7). This is because of limited availability of qualified professionals (8) and a lack of awareness of the condition among the public (9), among other reasons.
Dubai is the financial hub of the United Arab Emirates with a population of about 3.2 million (10). The prevalence of ADHD in school-aged students in the United Arab Emirates is about 4% (11). Specialized ADHD services are limited in Dubai, despite 2000 paediatric psychiatry assessments a year (12). Furthermore, the United Arab Emirates and the Eastern Mediterranean region in general have a considerable shortage of mental health resources for young people (13). Thus, new approaches are needed to improve health care access for children with ADHD.
Several methods have been implemented worldwide to improve access to paediatric mental health services in general (14) and for ADHD specifically, including tele-health services (15) and collaborative care models (16,17). This paper presents the results of a randomized controlled trial that examined the effectiveness of collaborative tele-mental health for children with ADHD in primary health care in Dubai: Effectiveness of Collaborative Tele-Mental Health Services for ADHD in Primary Care (ECTSAP) (ClinicalTrials.gov Identifier: NCT03559712) (18). The outcomes of the first phase of the ECTSAP trial are reported, which involved the development, implementation and evaluation of an intensive ADHD training programme tailored to the needs of primary health care physicians for the purpose of implementing a collaborative care model. The outcomes in a sample of children with ADHD randomized to receive care from the trained primary health care physicians (experimental arm) or standard care are examined.
Methods
Training of primary care physicians
A 35-hour ADHD course was designed and delivered. Pre- and post-course assessments were done, including multiple-choice questions and structured clinical stations to assess the participant’s knowledge and clinical interviewing skills. A confidence survey consisting of six items, five close-ended questions (Likert scale) and one open-ended question, was administered at baseline and at the end of the training programme.
Patients and eligibility
Children aged 6–12 years attending primary health care centres who met the DSM-5 criteria for ADHD (1), as determined by both clinical assessment and meeting the threshold on the Vanderbilt ADHD rating scale (19) in two or more settings, were enrolled in the study. Children with cardiac disorders, seizures, autism spectrum disorder, intellectual disability, and active primary psychiatric illness other than ADHD were not eligible for this study. Verbal consent was obtained from patients and signed consent was obtained from the parents. Randomization was done using a computer-generated randomization code at the primary health care centres at the time of the initial consultation to determine eligibility for the study. Individual allocation was sealed in sequentially numbered opaque envelopes which were opened after consent was obtained. The randomization sequence was created using Stata 14.2 software with a 1:1 allocation using random block sizes of two and four. The blocks of two were done for 60% of the participants and blocks of four for 40% of the participants. This mixing of block sizes was done to avoid the research team guessing the allocation.
Baseline assessments included: the Vanderbilt Behavioral Assessment Scale (19); the Columbia Impairment Scale (20); the Childhood Behavior Checklist (21); and the Strength and Difficulties Questionnaire (22). Parents also completed a questionnaire on sociodemographic, clinical and medical characteristics of their child. The as-usual treatment primarily consisted of referral to specialized mental health services. The participants in this control arm also completed the same baseline, 3- and 6-month assessments and scales. Research appointments to complete outcome scales were scheduled at 3 and 6 months after recruitment into the study and included administering the Vanderbilt Behavioral Assessment Scale and the Columbia Impairment Scale for both groups.
Statistical analysis
Continuous variables are presented as means and standard deviations (SD). Categorical variables such as sex are presented as numbers and percentages. Continuous outcome variables were compared using the Student t-test. As the outcome variables such as the Vanderbilt Behavioral Assessment Scale and Columbia Impairment Scale were measured at various times (baseline, 3 months and 6 months) repeated measures analyses for longitudinal data were done with an exchangeable correlation structure. Exact P values are presented.
Ethical approval
The project was approved by the Dubai Scientific Research Ethics Committee, under the Dubai Health Authority, and exempted by Harvard University given that the study was conducted in the United Arab Emirates and Harvard University had not clinical involvement. Administrative approval was obtained from Al Jalila Children’s Specialty Hospital management and primary health care centres in the Dubai Health Authority. The study is registered under ClinicalTrials.gov, identifier: NCT03559712 (18) and was funded by the Dubai-Harvard Center for Global Health Delivery in Dubai.
Results
Stage 1: training of primary health care physicians
All physicians working in childcare clinics in primary health care centres under the Dubai Health Authority were invited to be included in the study (n = 12). Six attended the 35-hour ADHD course, three declined due to time constraints and three did not respond. Physicians who participated in the training were similar to all the physicians in terms of sex distribution: 50% of physicians enrolled were males and 58% of the total physicians were males. After the training, participants reported improved confidence in the following areas: recognizing symptoms of ADHD (mean (SD): 1.66 (0.51), P = 0.001); using clinical tools (mean (SD): 1.83 (1.16), P = 0.012); developing a treatment plan (mean (SD): 2.83 (0.98), P = 0.001); prescribing and monitoring medications (mean (SD): 2.33 (1.36), P = 0.009); and answering parents questions about ADHD (mean (SD): 1.83 (1.16), P = 0.012). In terms of knowledge, the mean percentage pre-course score in the multiple-choice questions was 42%, while the mean percentage post-course score was 78% (P = 0.001). All candidates successfully passed the structured clinical stations.
Stage 2: Randomization phase, and ongoing training
In stage 2 of the training programme, primary care physicians attended monthly live ADHD online seminars and had weekly supervision meetings via videoconferencing with a senior child psychiatrist to discuss clinical cases. The six primary care physicians who we trained started ADHD collaborative care clinics that were distributed across different areas of Dubai. All primary care physicians under the Dubai Health Authority were informed about these research clinics. Once the referral by the primary health care doctor was made to an ADHD clinic, the child was screened by the research psychologist for eligibility criteria, consent was obtained, and the child was randomly assigned to one of the two study arms, either assessment and treatment by a trained primary care physician (intervention arm), or referral to mental health services (control arm).
Sample characteristics and findings
A total of 112 patients were referred to the collaborative care ADHD clinics, and 18% of the referred sample (n = 20) were eligible for inclusion in the study. The most common reason for non-eligibility was age younger than 6 years (44%), not meeting ADHD criteria (29%) and presence of autism comorbidity (12%). Of the 20 children enrolled, 10 were allocated to the intervention arm and 10 to the control arm. Figure 1 is a flowchart of the recruitment of patients into the study and Table 1 summarizes the baseline clinical characteristics of the sample and the Childhood Behavior Checklist scores.
The drop-out rate at 6 months in the control group was 80% compared with 50% in the intervention group.
The mean difference for the outcome in the Childhood Behavior Checklist internalizing scores was 12.3 (95% CI: –1.6 to 26.3) suggesting that the intervention arm had higher scores than the control arm (P = 0.078). Similarly, the difference in the Childhood Behavior Checklist externalizing score was 11.9 (95% CI: 0.9 to 22.9) which was significantly higher in the intervention arm (P = 0.036). The mean difference in the Childhood Behavior Checklist total score was 12.4 (95% CI: 0.5 to 24.4), again significantly higher in the intervention arm (P = 0.042).
The efficacy analyses, that is, the mean difference and 95% confidence intervals (CI) of the outcome variables (Vanderbilt scores and performance scores) between the two arms are presented in Table 2. The table also presents the findings of the repeated measures regression analyses for Vanderbilt outcomes as measured at baseline, 3 month and 6 months. In the outcome Vanderbilt scale, although the score in the intervention arm increased over time – mean difference 2.0 (95% CI: –6.5 to 10.5) – the difference was not statistically significant. Similarly, the outcome performance declined in the control arm at 6 months completely, as compared with the intervention arm. However, the mean difference over time was not statistically significant: –0.719 (95% CI: –2.2 to 0.81). The mean (SD) of waiting time was 1.3 (4.0) weeks in the experimental group which was significantly shorter compared with 7.1 (6.3) weeks in the control arm (P = 0.026).
Discussion
This paper describes ECTSAP, a clinical trial in Dubai to enhance access to mental health care in primary health care centres for children with ADHD using a collaborative tele-mental health approach. Primary health care physicians were successfully recruited and trained for this study, despite many obstacles, including busy schedules. As a result, ECTSAP trained physicians were able to assess and follow up children with ADHD through the collaborative care model. However, this result should be viewed with caution given the limited sample size and slow recruitment. The higher drop-out rate in the control arm may suggest that parents are either going elsewhere or giving up on having their children assessed and treated because of the very long wait times; this observation warrants further exploration. Despite the small size of the patient sample so far, its demographic and clinical characteristics (predominantly male, high oppositional defiant disorder and anxiety comorbidity) are similar to larger samples from other countries (23).
Our study has a number of limitations. First, the sample size of six trainees was small which raises questions about the generalizability of the findings. However, it is important to note that this number was 50% of the eligible physicians for our study and therefore represents good engagement and commitment. Furthermore, the patient sample was recruited through primary health care centres and recruiting from the community would improve the representativeness of the sample. One of the most surprising findings was the slow recruitment rate of patients so far. This may reflect existing barriers that require further investigation, such as public awareness and stigma.
An important finding is that the wait-time for assessment and treatment was significantly shorter in the intervention arm. This finding, together with the higher drop-out rate in the control arm, indicates that such innovative approaches can solve some challenges in the health care system, including long wait times for clinical services. Furthermore, the comparable outcomes in the two groups indicate that primary care physicians who are trained on ADHD and work collaboratively with experienced clinicians may be able to effectively diagnose and treat ADHD. However, the small sample size and limitations of our study must be borne in mind in relation to this finding.
Acknowledgement
We thank Dr Manal Taryam, CEO of Primary Healthcare in the Dubai Health Authority, and the management of Al Jalila Children’s Specialty Hospital for facilitating this clinical trial. We also thank Dr Haitham Mahmoud, Dr Idris Alhmid and Dr Aditya Garg from the Dubai Health Authority. Furthermore, we thank the Harvard Center for Global Health Delivery in Dubai for providing research and statistical support for this study, especially Dr Subhash Chandir for statistical support, Dr Jerome Galea for research methodology input, and Dr Nasreen Adamjee and Ms Rachele Cox for administrative support. Finally we thank primary health care Nurse Elize George from the Dubai Health Authority for coordination support.
Funding: This study was funded by a research grant from the Harvard Center for Global Health Delivery in Dubai (No. 027562-746845-0105).
Competing interests: None declared.
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Figure 1. Flowchart of recruitment into the clinical trial: Effectiveness of Collaborative Tele-Mental Health Services for ADHD in Primary Care
ADHD: attention-deficit hyperactivity disorder.
Table 1. Baseline characteristics of the sample
Table 2. Outcomes of Effectiveness of Collaborative Tele-Mental Health Services for ADHD in Primary Care trial
