Effects of Training on Use of Stimulant Diversion Prevention Strategies by Pediatric Primary Care Providers: Results from a Cluster-Randomized Trial.

Pediatric primary care is a promising setting for reducing diversion of stimulant medications for ADHD. We tested if training pediatric primary care providers (PCPs) increased use of diversion prevention strategies with adolescents with ADHD. The study was a cluster-randomized trial in 7 pediatric primary care practices. Participants were pediatric PCPs (N = 76) at participating practices. Practices were randomized to a 1-h training in stimulant diversion prevention or treatment-as-usual. At baseline, 6 months, 12 months, and 18 months, PCPs rated how often they used four categories of strategies: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes, implementation climate, knowledge/skill, and resource constraints. Generalized Estimating Equations estimated differences in outcomes by condition. Mediation analyses tested if changes in knowledge/skill mediated training effects on strategy use. PCPs in the intervention condition reported significantly greater use of patient/family education strategies at all follow-up time points. There were no differences between conditions in medication management, assessment of mental health symptoms/functioning, or assessment of risky behaviors. At 6 months, PCPs in the intervention condition reported more positive attitudes toward diversion prevention, stronger implementation climate, greater knowledge/skill, and less resource constraints. Differences in knowledge/skill persisted at 12 months and 18 months. Brief training in stimulant diversion had substantial and enduring effects on PCPs' self-reported knowledge/skill and use of patient/family education strategies to prevent diversion. Training had modest effects on attitudes, implementation climate, and resource constraints and did not change use of strategies related to medication management and assessment of mental health symptoms/functioning and risky behaviors. Changes in knowledge/skill accounted for 49% of the total effect of training on use of patient/family education strategies. Trial registration This trial is registered on ClinicalTrials.gov (NCT03080259). Posted March 15, 2017.

Highly Involved Parenting of Adolescents With ADHD: Examination of the Psychometric Properties of a Measure of "Helicopter Parenting".

OBJECTIVE: The concept of the "helicopter parent" was popularized in the 2000s and 2010s by Western culture, and it has recently begun to be examined by researchers to describe parental over-involvement and intrusive behavior that impedes transition into adulthood. Research has yet to investigate the viability of this construct for adolescents when parenting is needed to facilitate the development of autonomy. The present study examined the psychometric structure of a modified "helicopter parenting" measure adapted for use in a sample with increased likelihood of highly involved parenting: adolescents with ADHD. METHODS: Adolescents (n = 333; age 13-18 years; 25% female) and their parents (n = 341, 91% female) completed a survey for a study on provider training in stimulant diversion prevention in 2016 and 2017. We modified a previously validated measure of "helicopter parenting" for young adults. Other previously established parenting measures were included. We conducted principal component analysis for both informants' reports of the modified measure. We examined associations between the components and informants' demographic characteristics and parenting measures to begin to examine convergent and discriminant validity. RESULTS: Two components were identified for adolescent and parent reports and labeled parental Intervention and Day-to-day Monitoring and Planning. These components were differentially associated with demographic characteristics and other measures of parenting. For example, across reporters, parents exhibited less Day-to-Day Monitoring and Planning for older adolescents. Racially/ethnically minoritized parents and male adolescents reported more Intervention parenting. Modest-sized statistically significant associations were found between these indicators of highly involved parenting and the other measures of parenting. CONCLUSION: Findings provide initial evidence of construct validity. Future work with more heterogeneous samples should examine if this measure captures adaptive parenting, or behaviors that interfere with developing independence, for adolescents with ADHD and neurotypically developing adolescents.

Adolescents Treated for Attention-Deficit/Hyperactivity Disorder in Pediatric Primary Care: Characterizing Risk for Stimulant Diversion.

OBJECTIVE: To describe the clinical and psychosocial characteristics, and their hypothesized interrelations, as it pertains to risk for stimulant diversion (sharing, selling, or trading) for adolescents in pediatric primary care treatment for attention-deficit/hyperactivity disorder. METHODS: Baseline data for 341 adolescents in a cluster-randomized controlled trial of stimulant diversion prevention in pediatric primary care (NCT_03080259) were used to (1) characterize diversion and newly measured risk factors, (2) examine their associations with age and sex, and (3) test whether associations among risk factors were consistent with model-implied predictions. Data were collected through multi-informant electronic surveys from adolescents and parents. RESULTS: Diversion was rare (1%) in this sample (Mage = 15, SD = 1.5, 74% male participants). Older age was associated with being approached to divert (r = 0.25, p < 0.001) and higher risk on variables pertinent to stimulant treatment, such as treatment disclosure (r = 0.12, p < 0.05), tolerance for stimulant misuse and diversion (r = 0.17, p < 0.05), and peer norms favorable to stimulant misuse and diversion (r values = 0.15-0.34, p < 0.001). Sex differences were minimal. Variables from our conceptual model and specific to stimulants (e.g., perceived likelihood of negative consequences from diversion and schoolmate stimulant misuse/diversion) were related in multivariable regressions to hypothesized immediate precursors of diversion (e.g., diversion intentions). CONCLUSION: Although diversion was rare for these primary care-treated adolescents, risk levels appear to be higher for older adolescents. Prevention may be most effective by capitalizing on current psychosocial strengths and discussing stimulant-specific attitudes, behaviors, and social norms before vulnerability to diversion increases in the final years of high school and into college.

Use of Stimulant Diversion Prevention Strategies in Pediatric Primary Care and Associations With Provider Characteristics.

PURPOSE: Diversion of stimulant medications for ADHD is a prevalent problem. Pediatric primary care providers (PCPs) are well-positioned to reduce diversion risk among adolescents prescribed stimulants, but little is known about their use of prevention strategies. The objectives of this study were to describe the frequency with which pediatric PCPs use diversion prevention strategies and examine potential determinants (facilitators and barriers) of strategy use. METHODS: Participants were pediatric PCPs (N = 76) participating in a randomized controlled trial of stimulant diversion prevention strategies. At baseline, before randomization, PCPs rated the frequency with which they used specific strategies in each of four categories: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes toward diversion prevention, subjective norms (i.e., implementation climate), and perceived behavioral control (i.e., knowledge/skill, resource constraints). Associations between determinants and strategy use were tested with correlational and regression analyses. RESULTS: PCPs used strategies for assessing mental health symptoms/functioning most frequently and patient/family education strategies least frequently. Attitudes about the effectiveness of diversion prevention, implementation climate, knowledge/skill, and resource constraints were positively correlated with the use of at least one category of strategies. In regression analysis, PCP knowledge/skill was positively associated with patient/family education, medication management, and risk assessment strategies. CONCLUSIONS: Findings suggest that improving knowledge and skill may increase the use of diversion prevention strategies by PCPs. Identifying provider-level determinants of strategy use informs implementation efforts in pediatric primary care and can facilitate efforts to prevent stimulant diversion among adolescents.

Stimulant Diversion Risk Among College Students Treated for ADHD: Primary Care Provider Prevention Training.

OBJECTIVE: To address increasing rates of stimulant misuse in college students, this study developed an evidence-based, brief clinical practice intervention for primary care providers (PCPs) to reduce stimulant medication diversion among young adults with attention-deficit/hyperactivity disorder (ADHD). METHODS: College students (N-114; 18-25 years; 68% attending universities; 24% attending community college) treated for ADHD with a stimulant and their PCPs across six practices participated in this initial, uncontrolled study of pre- to post-intervention change. An educational workshop providing strategies aimed at reducing stimulant diversion was developed and delivered to providers and staff across all practices (50% pediatric; 50% family medicine). Patients and providers completed baseline and post intervention surveys. RESULTS: Diversion was relatively infrequent, 16.7% at baseline and 14.9% post-intervention, respectively. Statistically significant decreases from baseline to post-intervention were found for three diversion risk factors: (1) number of times approached to divert, (2) intent to share, sell, or trade stimulants, and (3) disclosure of stimulant use. Providers and staff reported mostly high satisfaction with the training. CONCLUSIONS: This study provides initial evidence for a PCP-delivered intervention to reduce stimulant diversion. Research is needed on the efficacy of targeting college students directly, working with pharmacies and student health centers, and preventing misuse among teenagers.