Attention-deficit/hyperactivity disorder, sometimes called ADHD, is a chronic condition and the most commonly diagnosed behavioral disorder among children and adolescents. It affects between 3 and 5 percent of school-aged children in a 6-month period (U.S. Department of Health and Human Services, 1999).
Children and adolescents with attention-deficit/hyperactivity disorder have difficulty controlling their behavior in school and social settings. They also tend to be accident-prone. Although some of these young people may not earn high grades in school, most have normal or above-normal intelligence.
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What are the signs of attention-deficit/hyperactivity disorder?
There are three different types of attention-deficit/hyperactivity disorder, and each has different symptoms. The types are inattentive, hyperactive-impulsive, and combined attention-deficit/hyperactivity disorder.
Children with the inattentive type may:
Have short attention spans.
Be distracted easily.
Not pay attention to details.
Make many mistakes.
Fail to finish things.
Have trouble remembering things.
Not seem to listen.
Not be able to stay organized.
Children with the hyperactive-impulsive type may:
Fidget and squirm.
Be unable to stay seated or play quietly.
Run or climb too much or when they should not.
Talk too much or when they should not.
Blurt out answers before questions are completed.
Have trouble taking turns.
Interrupt others.
The most common type is combined attention-deficit/hyperactivity disorder, which, as the name implies, is a combination of the inattentive and the hyperactive-impulsive types.
A diagnosis of one of the attention-deficit/hyperactivity disorders is usually made when children have several of the above symptoms that begin before age 7 and last at least 6 months. Generally, symptoms have to be observed in at least two different settings, such as home and school, before a diagnosis is made.
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How common is attention-deficit/hyperactivity disorder?
Attention-deficit/hyperactivity disorder is found in as many as one in every 20 children (U.S. Department of Health and Human Services, 1999). Boys are four 4 times more likely than girls to have the disorder (U.S. Department of Health and Human Services, 1999).
Children and adolescents with attention-deficit/hyperactivity disorder are at risk for many other mental disorders. About half of those with attention-deficit/hyperactivity disorder also have oppositional or conduct disorder, and about a fourth have an anxiety disorder. As many as one-third have depression, and about one-fifth have a learning disability. Sometimes children or adolescents will have two or more of these disorders in addition to attention-deficit/hyperactivity disorder. Children with attention-deficit/hyperactivity disorder are also at risk for developing personality and substance abuse disorders when they are adolescents or adults.
Attention-deficit/hyperactivity disorder is a major reason that children are referred for mental health services. Boys are more likely to be referred for treatment than girls, in part, because many boys with attention-deficit/hyperactivity disorder also have conduct disorder. Although mental health and special education services for children and adolescents with attention-deficit/hyperactivity disorder cost millions of dollars each year, in the long run, underachievement and lost productivity can be more costly for them and their families.
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What causes attention-deficit/hyperactivity disorder?
Many causes of attention-deficit/hyperactivity disorder have been studied, but no one cause seems to apply to all young people with the disorder. Viruses, harmful chemicals in the environment, genetics, problems during pregnancy or delivery, or anything that impairs brain development can play a role in causing the disorder.
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What help is available for families?
Many treatments, some with scientific basis and some without, have been recommended for children and adolescents with attention-deficit/hyperactivity disorder. Traditional approaches to treatment involve medications and/or behavior therapy.
Many types of medications have been used to treat attention deficit/hyperactivity disorder. The most widely used drugs are stimulants. Stimulants increase activity in parts of the brain that appear to be underactive in children and adolescents with attention-deficit/hyperactivity disorder. Experts believe that this is why stimulants improve attention and reduce impulsive, hyperactive, or aggressive behavior. For some children and adolescents, certain antidepressants may also help alleviate symptoms of the disorder. Tranquilizers also have been effective for some individuals. Care must be taken when prescribing and monitoring all medications, and it is important to note that these are not the only medications that may be prescribed for this disorder.
Like most medications, those used to treat attention-deficit/hyperactivity disorder have side effects. These medications may cause some children to lose weight, have reduced appetites, and temporarily grow more slowly. Others may have trouble falling asleep. However, many doctors believe the benefits of these medications outweigh the possible side effects. Often, health care providers can alleviate side effects by adjusting the dosage.
Another treatment approach, called behavior therapy, involves using techniques and strategies to modify the behavior of children with the disorder. Behavior therapy may include:
Instruction for parents and teachers on how to manage and modify children's or adolescents' behavior, such as rewarding good behaviors.
Daily report cards to link efforts between home and school, where parents reward children or adolescents for good school performance and behavior.
Summer and Saturday programs.
Special classrooms that use intensive behavior modification.
Specially trained classroom aides.
While a combination of stimulants and behavior therapy is believed to be helpful, it is not clear how long the benefits from this approach last. The Federal government's National Institute of Mental Health is supporting research on the long-term benefits of various treatments, as well as research to determine if medication and behavior treatment are more effective when combined. Ongoing research efforts also are aimed at identifying new medicines and treatments.
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Can attention-deficit/hyperactivity disorder be prevented?
Given that there are many suspected causes of attention-deficit/hyperactivity disorder, prevention may be difficult. However, as a precaution, it is always wise for expectant mothers to receive prenatal care and stay away from alcohol, tobacco, and other harmful chemicals during pregnancy. It also makes good sense for mothers to obtain good health care for their children. These recommendations may be particularly important when attention-deficit/hyperactivity disorder is suspected in other family members.
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What else can parents do?
When it comes to attention-deficit/hyperactivity disorder, parents and other caregivers should be careful not to jump to conclusions. A high energy level alone in a child or adolescent does not mean that he or she has attention-deficit/hyperactivity disorder. The diagnosis depends on whether the child or adolescent can focus well enough to complete tasks that suit his or her age and intelligence. This ability is most likely to be noticed by a teacher. Since some children with attention-deficit/hyperactive disorder have many different types of needs and often require special accommodations to help them function, input from teachers should be taken seriously.
If parents or caregivers suspect attention-deficit/hyperactivity disorder, they should:
Make an appointment with a psychiatrist, psychologist, child neurologist, or behavioral pediatrician for an evaluation. (Ask the child's doctor for a referral.)
Be patient if the young person is diagnosed with attention-deficit/hyperactivity disorder, and recognize that progress takes time.
Instill a sense of competence in the child or adolescent. Promote his or her strengths, talents, and feelings of self-worth.
Remember that, in many instances, failure, frustration, discouragement, low self-esteem, and depression cause more problems than the disorder itself.
Get accurate information from libraries, hotlines, or other sources.
Ask questions about treatments and services.
Talk with other families in their communities.
Find family network organizations.
People who are not satisfied with the mental health care they are receiving should discuss their concerns with the provider, ask for information, and/or seek help from other sources. It may take time for families and providers to find the right "mix" of services and supports that work best for a child. While treatment may not fully eliminate unwanted symptoms, most children with attention deficit/hyperactivity disorder do respond to medication and behavioral therapy.
Children with attention-deficit/hyperactivity disorder may qualify for free services within public schools. Most children with attention-deficit/hyperactivity disorder or other disabilities are eligible to receive special education services under the Individuals with Disabilities Education Act (IDEA). This act guarantees appropriate services and a public education to children ages 3 to 21 with disabilities.
This is one of many fact sheets in a series on children's mental health disorders. All the fact sheets listed below are written in an easy-to-read style. Families, caretakers, and media professionals may find them helpful when researching particular mental health disorders. To obtain free copies, call 1-800-789-2647 or visit http://mentalhealth.samhsa.gov/child.
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Other Fact Sheets in this Series are:
Order Number Title
CA-0000 Caring for Every Child's Mental Health Campaign Products Catalog
CA-0004 Child and Adolescent Mental Health
CA-0005 Child and Adolescent Mental Health: Glossary of Terms
CA-0006 Children and Adolescents With Mental, Emotional, and Behavioral Disorders
CA-0007 Children and Adolescents With Anxiety Disorders
CA-0009 Children and Adolescents With Autism
CA-0010 Children and Adolescents With Conduct Disorder
CA-0011 Children and Adolescents With Severe Depression
CA-0014 Facts About Systems of Care for Children's Mental Health
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Important Messages About Children's and Adolescents' Mental Health:
Every child's mental health is important.
Many children have mental health problems.
These problems are real and painful and can be severe.
Mental health problems can be recognized and treated.
Caring families and communities working together can help.
February 23, 2010
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Online Continuing Education for LMFT, MFTI, LCSW, ASW
Satisfy your CE requirements conveniently anywhere you have online access.
Take your test and even print your completion certificate at any time.
Take as much time as needed to complete the exam.
Take the exam as many times necessary to receive a 70% passing score.
Pay only after you have passed your exam.
Earn hours for passing exams based on books you may have already read.
Listen to selected audio courses directly from your computer or MP3 player.
Take some time to browse our courses, and become a part of the Aspira family.
Course Listing:
Domestic Violence/Spousal and Partner Abuse
Substance Abuse and Dependence
Law and Ethics (Califonia only)
HIV and Aids
Aging and Long Term Care
Child Abuse
Crisis Counseling
Cross Cultural Counseling
Managed Care
PTSD
Anxiety Disorders
Depressive Disorder
Medical Necessity
Cognitive Behavioral Therapy
Pychopharmacology
BipolarDisorder
Conflict Resolution
Anger Management
Assessment and Diagnosis
Elder Abuse
Family Therapy
Group Therapy
Human Sexuality
MFT CEUS and MFT Resources
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Online Continuing Education for LMFT, MFTI, LCSW, ASW
Satisfy your CE requirements conveniently anywhere you have online access.
Take your test and even print your completion certificate at any time.
Take as much time as needed to complete the exam.
Take the exam as many times necessary to receive a 70% passing score.
Pay only after you have passed your exam.
Earn hours for passing exams based on books you may have already read.
Listen to selected audio courses directly from your computer or MP3 player.
Take some time to browse our courses, and become a part of the Aspira family.
Course Listing:
Domestic Violence/Spousal and Partner Abuse
Substance Abuse and Dependence
Law and Ethics (Califonia only)
HIV and Aids
Aging and Long Term Care
Child Abuse
Crisis Counseling
Cross Cultural Counseling
Managed Care
PTSD
Anxiety Disorders
Depressive Disorder
Medical Necessity
Cognitive Behavioral Therapy
Pychopharmacology
BipolarDisorder
Conflict Resolution
Anger Management
Assessment and Diagnosis
Elder Abuse
Family Therapy
Group Therapy
Human Sexuality
Online Continuing Education for LMFT, MFTI, LCSW, ASW
Satisfy your CE requirements conveniently anywhere you have online access.
Take your test and even print your completion certificate at any time.
Take as much time as needed to complete the exam.
Take the exam as many times necessary to receive a 70% passing score.
Pay only after you have passed your exam.
Earn hours for passing exams based on books you may have already read.
Listen to selected audio courses directly from your computer or MP3 player.
Take some time to browse our courses, and become a part of the Aspira family.
Course Listing:
Domestic Violence/Spousal and Partner Abuse
Substance Abuse and Dependence
Law and Ethics (Califonia only)
HIV and Aids
Aging and Long Term Care
Child Abuse
Crisis Counseling
Cross Cultural Counseling
Managed Care
PTSD
Anxiety Disorders
Depressive Disorder
Medical Necessity
Cognitive Behavioral Therapy
Pychopharmacology
BipolarDisorder
Conflict Resolution
Anger Management
Assessment and Diagnosis
Elder Abuse
Family Therapy
Group Therapy
Human Sexuality
Substance Abuse and Chemical Dependency Continuing Education CEU
B. Models of Preventive Services
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
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The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.
for more information on this topic click link below
substance abuse ceus continuing education
The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.
The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.
The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.
Figure 1. Continuum of Health Care
Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.
Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.
Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.
Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).
Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.
The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.
Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:
Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.
C. Clinical vs. Community Preventive Services
Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.
This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.
Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).
It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.
D. Health Care Delivery System Provision of Preventive Behavioral Services
The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).
Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).
The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:
Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.
SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:
Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.
During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.
In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.
NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.
Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.
DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.
In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).
Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:
Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.
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