Published on in CHOP News
December 20, 2010 — For doctors and parents to jointly decide how to attack pediatric conditions, such as attention-deficit/hyperactivity disorder (ADHD), practical barriers to recommended health treatments need to be overcome, according to a study by The Children’s Hospital of Philadelphia. In considering their options, parents preferred their physicians to offer an unbiased presentation of all available treatments.
The study, published online today in the journal Pediatrics, compares the contrasting perspectives of parents and pediatricians when planning how to treat a child diagnosed with ADHD. Researchers selected ADHD because it is common in all communities, there are several treatment options available to families, and success often depends on how well a family adheres to a treatment plan.
We studied this process in ADHD and found that parents very much want to hear an even-handed presentation of all treatment options,” said Alexander G. Fiks, MD, MSCE, lead author and pediatrician at Children’s Hospital. “However, pediatricians, aware of the practical difficulties in obtaining behavioral health services, often limit their discussion of this option, and direct families toward medication, which is perceived as more readily available.”
Effectiveness of shared decision making in developing treatment plans
The study set out to examine how effective “shared decision-making” is in determining a treatment plan for children. Shared decision-making (SDM) is a technique in which families and clinicians jointly participate in decisions, exchange information and preferences, and decide on a treatment plan. This process is particularly helpful when clinical situations have multiple evidence-based options and when variation exists in how families weigh their risks and benefits.
To gather information, study researchers conducted in-depth interviews from March 2008 to March 2009 with 60 parents of children with ADHD, ages 6 through 12, and 30 pediatricians.
Parent and physician views of shared decision making differ
Parents conceptualized SDM as an equal partnership, with parents and clinicians contributing distinct but valuable perspectives. They emphasized the importance of doctors providing information regarding all treatment options and reacted negatively to doctors who “pushed” medication without offering a balanced presentation of alternatives.
Parents consistently emphasized perceived barriers to their treatment of choice and focused on practical barriers they had already faced in accessing healthcare for their children. Barriers included limited insurance coverage and consequent out-of pocket costs, and the time required to schedule and attend doctor’s appointments. About one-third of parents described making treatment choices based on insurance coverage rather than effectiveness. Even with coverage, co-pays represented a burden for many families.
Although clinicians, like parents, were receptive to SDM, almost three-fourths described it as a process of engaging parents to convince them to accept a preferred option. Rather than first exchanging information and then sharing treatment preferences, as is typical in SDM, clinicians often reversed the order of these steps, the researchers said.
Doctors were aware of the barriers families faced, which informed how they presented treatment options. In particular, they focused on the limited availability of affordable behavior therapy.
Study notes improvements needed
Results suggest that, to realize the promise of SDM in pediatrics, modifications are needed at the practice and policy levels. The researchers suggested additional doctor training, adding decision aids and improved strategies to facilitate communication, and improved efforts to ensure that evidence-based treatment is accessible.
About the authors
Co-authors include Cayce C. Hughes, MPH; Angela Gafen, and James P. Guevara, MD, MPH, at Children’s Hospital, and Frances K. Barg, PhD, MEd at The School of Medicine at The University of Pennsylvania.
The full study, Contrasting Parents’ and Pediatricians’ Perspectives on Shared Decision Making: The Example of ADHD, is published online today in the journal Pediatrics.