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ADHD: Framework for Treatment Planning

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Title: ADHD: Framework for Treatment Planning


1
ADHD Framework for Treatment Planning
  • James H. Johnson, Ph.D., ABPP
  • University of Florida

2
Focusing on Treatment Planning
  • The topic for the day has to do with ADHD
    treatment planning.
  • important in managed care systems,
  • Important in guiding therapy, and
  • role in treatment evaluation.
  • The focus will be on developing comprehensive
    treatment plans that will meet the accountability
    requirements of modern day clinical practice.

3
Assessment as the Foundation for Treatment
Planning
  • Proper assessment of the child is essential for
    ADHD treatment planning.
  • Indeed, adequate assessment information is the
    foundation on which the treatment plan is built.
  • For a treatment plan to be useful the assessment
    must be well conceived and comprehensive in
    nature.

4
ADHD Assessment Overview
  • While issues related to the assessment of ADHD
    have been touched on in discussing practice
    parameters, it should again be noted that
    assessment involves several basic elements.
  • Assessing the presence/severity of core symptoms
    across situations.
  • Assessing age of onset and duration of symptoms
  • Assessing the nature and severity of existing
    impairment
  • Assessing factors that can mimic symptoms of
    ADHD.
  • Assessing conditions that may co-occur with ADHD.
  • Assessing the impact of ADHD on family
    functioning.

5
Assessing Core Symptoms
  • Focused Interviewing Behavioral observations
    School Clinic
  • Parent and teacher questionnaires assessing core
    symptoms (e.g., Conners).
  • Comprehensive measures of Inattention (TeaCh)
  • Continuous Performance Test (CPT)
  • Parent and Teacher ratings of impairment
    Assessment of Impairment Should Include Social,
    Academic, Family, Adaptive Functioning

6
Assessment of Factors that Might Mimic Symptoms
of ADHD.
  • Will most likely get this type of information
    from parent and child interviews, medical
    records, and/or formal psychological testing
    (e.g. BASC, CBCL).
  • Seizure disorders
  • Medication effects
  • Anxiety disorders
  • Depressive disorders
  • Bipolar disorder
  • PTSD

7
Assessment of Comorbid Conditions
  • Considered here are comorbid disorders that can
    be seen in children with ADHD.
  • Learning Disabilities
  • ODD/CD
  • Anxiety Disorders
  • Depressive Disorder
  • Bipolar Disorder
  • Tic Disorders
  • Others

8
Approaches to the Assessment of Comorbidity
  • Informal or structured interviews with parent
    and/or child.
  • Parent questionnaires that can be used to assess
    for comorbid conditions (e.g., PIC, CBCL, BASC)
  • Child questionnaires to assess for convergence
    with parent report data (e.g., CDI, R-CMAS).
  • Child questionnaires to tap other specific
    possibilities (e.g., Child Trauma Symptom
    Checklist)
  • Direct testing of the child (IQ, Achievement,
    personality assessment measures e.g., MMPI A).

9
Assessing The Impact of ADHD on The Family
  • It is clear that it is important to assess the
    impact of ADHD related stress on the family.
  • High levels of stress may impact on the ability
    to carry out complex treatment programs.
  • It can impact on parent mental health.
  • High levels of parent stress can also impact
    negatively on parent child interactions.
  • It may also increased probability of
    unintentional injuries in the home.

10
Assessing The Impact of ADHD on The Family
  • Assessing family stress resulting from ADHD and
    its effects can be accomplished through the use
    of parental interviews and various questionnaire
    measures
  • Parenting Stress Index
  • Disruptive Behavior Stress Inventory
  • Etc.

11
Role of the Clinician in the Assessment Process
  • While information can be obtained through the use
    of measures like those described here, assessment
    involves more than simply obtaining scores from
    test measures.
  • Central to the assessment process is the ability
    of the clinician to integrate data from
    assessment methods in such a way as to obtain an
    accurate picture of the child and his/her
    difficulties that has implications for treatment
    planning.
  • Especially relevant to treatment planning is
    information regarding important areas of
    impairment.

12
From Assessment to Intervention
  • ADHD assessment should have direct implications
    for treatment planning.
  • The focus of treatment should be on the full
    range of difficulties displayed by the child, as
    these problems are displayed in various settings
    (with consideration being given to assumed causal
    factors).
  • The extensiveness of the treatment approach is
    likely to vary with the complexity of the case.

13
Issues in ADHD Treatment
  • While pure cases of ADHD may involve only one
    approach to treatment ,via a single modality,
    many children with ADHD will require treatments
    that are multi-modal in nature (as these may
    relate to different problems).
  • Here, specific consideration should be given to
    matching effective treatments to the specific
    needs of the child.

14
Issues in ADHD Treatment Planning
  • Commonly used treatment approaches may involve
  • Various forms of pharmacological treatment
  • Behavioral approaches to intervention in the
    home, the school, and/or the clinic.
  • Various types of classroom accommodations
  • Special educational assistance in the case of
    learning disabilities
  • As well as other approaches

15
ADHD Treatment Planning
  • Given the uniqueness of each child, a wide range
    of treatment activities may go into treatment
    planning.
  • In the sections to follow, we will highlight
    possible interventions strategies that may be
    useful for children with ADHD.
  • Not all of the examples presented here would
    necessarily be useful for all children with ADHD.
  • Likewise, interventions other than the ones
    considered here may be required for some children
    with ADHD especially those with comorbid
    disorders.

16
The Importance of Treatment Plans
  • It is desirable that a formal plan be developed
    to guide the treatment of children with ADHD.
  • Again, most managed care providers require it!
  • Treatment plans are also important in guiding the
    direction of therapy.
  • As treatment plans require well defined
    (measurable) objectives, they make it easier for
    the effects of treatment to be evaluated in an
    objective manner.
  • Finally, objective treatment plans fit nicely
    within a scientist-practitioner approach to
    clinical work, where accountability is considered
    important.

17
Developing Treatment Plans Essential Elements
  • Treatment plans are based on data derived from a
    comprehensive assessment which serves as a
    foundation for the plan.
  • Essential elements of a formal treatment plan
    include the following
  • Problem Selection
  • Problem Definition
  • Goal Development
  • Developing Treatment Objectives
  • Selecting Interventions
  • The following draws heavily on Jongsma, et al
    (2003). The Child Psychotherapy Treatment
    Planner, New York John Wiley and Sons.

18
Sample Treatment Plan Basic Structure
  • Problem
  • Behavioral Definition (Operationally Define
    Problem
  • Goals
  • Treatment Objectives/Interventions
  • Objective 1 Intervention One
  • - Intervention Two
  • Objective 2 Intervention One
  • - Intervention Two
  • Objective 3 Intervention One
  • - Intervention Two
  • Diagnosis

19
Problem Selection
  • What is the nature of the childs presenting
    problem(s)?
  • Determine the Primary Problem, those problems
    that are Secondary, as well as those that are
    less urgent (which could be deferred until later
    in treatment).
  • Solicit parent/child input to insure that
    problems are appropriately prioritized and relate
    to issues seen as being most relevant to the
    reasons for seeking help.

20
Problem Definition
  • Problem behaviors are expressed in different ways
    by different children.
  • For this reason it is important that each problem
    selected for treatment be behaviorally defined in
    terms of how it is reflected in the behavior of
    the specific child being treated.
  • The selection of problem behaviors should be
    associated with the DSM IV diagnosis.
  • Problem definition must be sufficiently objective
    that it is possible to determine changes in
    these problems behaviors resulting from treatment
    (the issue of accountability).

21
Goal Development
  • Step three of the treatment plan involves
    developing broad goals for the resolution of
    problem behaviors.
  • These treatment goals do not have to be stated in
    measurable terms.
  • Rather, they can take the form of more global
    long-term goals that are relevant to a desired
    positive treatment outcome.

22
Developing Treatment Objectives
  • Treatment objectives must be stated in
    behaviorally measurable language.
  • It must be clear when the patient has achieved
    the established objectives.
  • Vague subjective statements of objectives are not
    acceptable.
  • Here it can be noted that HMOs and other managed
    care organizations require that psychosocial
    treatment outcomes be measurable.

23
Developing Treatment Objectives (cont.)
  • Each objective should be presented as a step
    toward attaining a broad treatment goal.
  • Here, objectives can be thought of as a series of
    steps that will result in achieving longer term
    therapeutic goals.
  • There should be at least two objectives for each
    presenting problem on the problem list (and at
    least one problem), but the clinician may
    construct as many as is necessary for goal
    achievement.

24
Developing Treatment Objectives (cont.)
  • New objectives may be added to the plan if
    additional problems are delineated as treatment
    progresses.
  • When all the objectives have been achieved the
    target problems should have been resolved
    successfully.
  • If this is not the case, then new objectives may
    be added to address these unresolved issues.

25
Selecting Interventions
  • Interventions are those things the therapist does
    that are designed to meet therapy objectives.
  • If the patient does not accomplish the objectives
    after initial interventions, then new
    interventions should be added to the treatment
    plan.
  • Intervention should be selected based on the
    specific needs of the patient and the
    therapists full therapeutic repertoire.

26
Selecting Interventions (cont.)
  • Ideally, interventions should be Evidence-Based.
  • In the absence of these, interventions should
    represent those consistent with accepted clinical
    practice.
  • Intervention may be provided by a single provider
    or by multiple professionals with skills in
    specific areas, working in different settings.
  • There should be as many interventions as
    necessary to meet the specific treatment
    objective.

27
Relationship of Treatment Planning to Diagnosis
  • While the development of a treatment plan usually
    focuses more on specific problems, rather than
    specifically on the childs diagnosis, a
    diagnosis is required for third-party
    reimbursement.
  • The problems, goals, objectives, and
    interventions defined in the final treatment plan
    should bear a significant relationship to
    problems associated with the childs diagnosis.

28
Evaluating Success
  • As treatment objectives, linked to presenting
    problems, treatment goals, and interventions are
    objectively defined (and measurable) it should be
    possible to determine the degree to which
    treatment has been effective.
  • Such outcome data can be extremely useful in
    assessing improvement
  • When possible termination is being considered
  • When requesting additional therapy sessions from
    a managed care program, and
  • When the treatment summary is being prepared.

29
Sample Treatment Plan Problems and Definition
  • Problem ADHD
  • Definitions
  • Displays short attention span Consistently
    shows difficulty sustaining attention.
  • Distracted by environmental stimuli and internal
    thoughts - shows high levels of off-task
    behavior.
  • Repeatedly fails to follow instructions and
    complete in-class assignments on time.
  • Fails to complete homework and perform household
    chores.

30
Sample Treatment Plan Goals
  • Sustain attention and concentration for
    consistently longer periods of time and reduce
    impulsive behavior.
  • Take stimulant medication as prescribed to
    decrease inattention and impulsivity.
  • Teacher implement classroom accommodations to
    reduce distractions and increase on-task
    behavior.
  • Parents and/or teachers successfully use behavior
    management strategies to increase desirable
    behaviors and reduce undesirable behaviors.

31
Sample Treatment Plan Objectives and
Interventions
  • Objective 1 Take medication as prescribed by
    pediatrician.
  • Arrange for medication evaluation by primary care
    physician.
  • Monitor patient for medication usage Assess
    compliance, effectiveness, side effects.
  • Consult with prescribing physician regularly.

32
Sample Treatment Plan Objectives and
Interventions
  • Objective 2 Delay instant gratification in favor
    of achieving meaningful long-term goals.
  • Teach the child mediational and self control
    strategies (e.g., Stop, Look, Listen, and
    Think) to inhibit impulsive behavior and achieve
    long term goals.
  • Assist parents in increasing structure in the
    home to help patient learn to delay gratification
    (e.g., completing chores before playing).

33
Sample Treatment Plan Objectives and
Interventions
  • Objective 3 Parent and teachers identify and use
    a variety of effective reinforcers to increase
    positive and reduce negative behaviors.
  • Identify a variety of positive reinforcers or
    rewards to maintain the patients interest and
    motivation in achieving desired goals/changes in
    behavior.
  • Teach parents and teachers basic behavior
    management principles to insure correct use of
    behavioral principles.

34
Sample Treatment Plan Objectives and
Interventions
  • Objective 4 Patient and parents comply with the
    implementation of behavior management strategies
    to reduce the frequency of inattentive,
    impulsive, and non-compliant behaviors.
  • Design a reward and/or contingency contract
    system to reinforce the patients desired
    behavior and reduce inappropriate behaviors.

35
Sample Treatment Plan Objectives and
Interventions
  • Objective 5 Teachers implement classroom
    accommodations to reduce distractions and
    increase attention.
  • Provide seating arrangement to minimize
    distractions close to teacher away from door,
    windows, and distracting classmates.
  • Provide advance cues when patient is about to
    transition from one task to another.
  • Provide reinforcement for complying with seat
    work and other academic activities requiring
    on-task behavior.

36
Sample Treatment Plan Objectives and
Interventions
  • Objective 7 Parent and teacher implement system
    to enhance homework completion.
  • Design a Day Planner system to insure that
    parents are aware of all assignments and teacher
    is aware that homework has been completed.
  • Parent works with child to break homework
    assignments into smaller units with breaks
    between units.
  • Parents use rewards to increase homework
    completion at appropriate level of accuracy.

37
Quantifying the Treatment Plan
  • In addition to including the type of information
    just presented, clinicians should attempt to
    introduce measurable/quantifiable aspects of the
    child, parent and teacher behavior into the
    treatment plan.
  • Competes homework 90 of the time.
  • Does chores 90 of the time.
  • Takes medication 100 of the time.
  • By 03/15/2009 scores on Conners ADHD Index
    within the normal range.

38
Other Examples of Objectives Interventions for
ADHD Children
  • Items in the previous treatment plan illustrate
    Definitions, Goals, Objectives Interventions
    for a relatively straight forward case of ADHD.
  • Other children with ADHD may require very
    different types of interventions, depending on
    the nature of their specific problems.
  • In the slides to follow we will look at some
    frequently used Behavioral Definitions, Common
    Long-Term Goals, and a range of (Objectives and
    Interventions) that might be possible additions
    to ADHD treatment plans.
  • The following draws heavily on Jongsma, et al
    (2003). The Child Psychotherapy Treatment
    Planner, New York John Wiley and Sons.

39
Commonly Used Behavioral Definitions
  • Short attention span difficult sustaining
    attention on a consistent basis.
  • Susceptibility to distraction by extraneous
    stimuli and internal thoughts.
  • Gives impression that he/she is not listening.
  • Repeated failure to follow through on
    instructions or complete school assignments or
    chores in a timely manner.
  • Poor organizational skills as demonstrated by
    forgetfulness, inattention to details, and losing
    things necessary for tasks.

40
Commonly Used Behavioral Definitions
  • Hyperactivity as evidenced by a high energy
    level, restlessness, difficulty setting still, or
    loud excessive talking.
  • Impulsivity as evidenced by difficulty awaiting
    turn in group situations, blurting out answers to
    questions before the questions have been
    completed, and frequent intrusions into others
    personal business.

41
Commonly Used Behavioral Definitions
  • Frequent disruptive, aggressive, or negative
    attention-seeking behaviors.
  • Tendency to engage in careless or potentially
    dangerous activities.
  • Difficulty accepting responsibility for actions,
    projecting blame for problems onto others, and
    failing to learn from experience.
  • Low self-esteem and poor social skills.

42
Common Long-Term Goals
  • Sustain attention and concentration for
    consistently longer periods of time.
  • Increase the frequency of on-task behaviors.
  • Demonstrate marked improvement in impulse
    control.
  • Regularly take medication as prescribed to
    decrease impulsivity, hyperactivity, and
    distractibility

43
Common Long-Term Goals
  • Parents and/or teachers successfully use a reward
    system, contingency contract, or token economy to
    reinforce positive behaviors and deter negative
    behaviors.
  • Parents set firm, consistent limits and maintain
    appropriate parent-child boundaries.
  • Improve self-esteem.
  • Develop positive social skills to help maintain
    lasting peer friendships.

44
ADHD Objectives/Interventions A Treatment Sampler
  • Complete psychological assessment to confirm the
    diagnosis of ADHD and/or rule out other factors.
  • Arrange for psychological testing to confirm the
    diagnosis of ADHD and/or rule out emotional
    factors that may be contributing to the childs
    inattentiveness, impulsivity and hyperactivity.
  • Give feedback to the client and his/her parents

45
ADHD Objectives/Interventions A Treatment Sampler
  • Take prescribed medication as directed by the
    physician.
  • Arrange for a medication evaluation for the
    child.
  • Monitor patient for medication prescription
    compliance, side effects and effectiveness.
  • Consult with prescribing physician at regular
    intervals.

46
ADHD Objectives/Interventions A Treatment Sampler
  • Delay instant gratification in favor of achieving
    meaningful long-term goals.
  • Teach the child mediational and self control
    strategies (e.g., Stop, Look, Listen, and
    Think) to inhibit impulsive behavior and achieve
    long term goals.
  • Assist parents in increasing structure to help
    patient learn to delay gratification (e.g.,
    completing chores before playing).

47
ADHD Objectives/Interventions A Treatment Sampler
  • Parents and child increase knowledge about ADHD.
  • Educate parents and siblings about symptoms of
    ADHD and how to manage them.
  • Assign the parents readings to increase their
    knowledge about ADHD
  • Assign the child reading to increase his/her
    knowledge about ADHD and ways to manage symptoms

48
ADHD Objectives/Interventions A Treatment Sampler
  • Parents develop and use an organized system to
    keep track of childs school assignments, courses
    and household responsibilities.
  • Assist the parents in developing and implementing
    a system to increase the childs on-task
    behaviors and completion of school assignments,
    chores and household responsibilities (using
    calendars, charts, notebooks, day planners, and
    class syllabi.)
  • Assist the parents in developing a routine
    schedule to increase the childs compliance with
    school, chores, or household responsibilities.

49
ADHD Objectives/Interventions A Treatment Sampler
  • The parents maintain regular communication with
    the school to monitor the childs academic,
    behavioral, emotional, and social progress.
  • Encourage parents and teachers to maintain
    regular communication about the childs academic,
    behavioral, emotional, and social progress.

50
ADHD Objectives/Interventions A Treatment Sampler
  • Use effective study skills on a regular basis to
    improve academic performance.
  • Teach the child more effective skills (e.g.,
    reducing distractions, studying in quiet places,
    scheduling breaks in studying)
  • Assign parents to read The ADD Hyperactivity
    Handbook for Schools (Parker) to improve the
    childs school performance and behavior process
    the reading with the therapist.
  • Assign the child 13 Steps to Better Grades
    (Silverman) to improve organizational and study
    skills.

51
ADHD Objectives/Interventions A Treatment Sampler
  • Increase the frequency of completion of school
    assignments, chores and household
    responsibilities.
  • Assist parents in developing a routine schedule
    to increase compliance with school, chores, or
    household responsibilities (charts other
    prompts).
  • Consult with the childs teachers to implement
    strategies to improve school performance (e.g.
    setting in front row of class, using prearranged
    signals to redirect child back to a task,
    providing frequent feedback, calling on the child
    often, arranging for a listening buddy).
  • Encourage parents/teachers to use a school
    contract and reward system to reward completion
    of work.

52
ADHD Objectives/Interventions A Treatment Sampler
  • Implement effective test-taking strategies on a
    consistent basis to improve academic performance.
  • Teach the child more efficient test-taking
    strategies (e.g., reviewing material regularly,
    reading directions twice, rechecking work)

53
ADHD Objectives/Interventions A Treatment Sampler
  • Parents reduce extraneous stimuli as much as
    possible when giving directions to the child.
  • Instruct the parent on how to give the child
    proper directions (e.g., get the childs
    attention make one request at a time clear away
    distractions repeat instructions obtain
    frequent feedback from child to insure
    understanding.

54
ADHD Objectives/Interventions A Treatment Sampler
  • Parents set firm limits and use natural logical
    consequences to deter the childs impulsive
    behaviors.
  • Establish clear rules for the child at home and
    at school ask him/her to repeat the rules to
    demonstrate an understanding of the expectations
  • Encourage parents to use natural, logical
    consequences for the childs disruptive and
    negative attention seeking behavior.

55
ADHD Objectives/Interventions A Treatment Sampler
  • Express feelings through controlled, respectful
    verbalizations and healthy physical outlets.
  • Teach child effective communication and
    assertiveness skills to express feelings in a
    controlled fashion and meet his/her needs through
    more constructive actions.
  • Use the therapeutic game Stop, Relax, Think
    (Bridges) to assist the child in developing self
    control.

56
ADHD Objectives/Interventions A Treatment Sampler
  • Identify and implement effective problem-solving
    strategies.
  • Teach the child effective problem solving skills
    (e.g., identifying problems, brainstorming
    alternative solutions, selecting an option,
    implementing a course of action and evaluating)
  • Use Lets Work it Out A conflict Resolution Tool
    Kit (Shapiro) in sessions to teach the child
    effective problem-solving skills.

57
ADHD Objectives/Interventions A Treatment Sampler
  • Identify stressors or emotions that trigger and
    increase in hyperactivity and impulsivity
  • Explore and identify stressful events or
    emotional factors that contribute to an increase
    in impulsivity, hyperactivity and
    distractibility. Help the child and parent
    develop positive coping strategies (e.g., Stop,
    look, listen and Think relaxation techniques
    positive self-talk) to manage stress more
    effectively.

58
ADHD Objectives/Interventions A Treatment Sampler
  • Increase verbalizations of acceptance of
    responsibility for misbehavior.
  • Firmly confront the childs impulsive behaviors,
    pointing out consequences for himself/herself or
    others.
  • Confront statements where the child blames others
    for his/her annoying or impulsive behavior and
    fails to accept responsibility for his/her
    actions.

59
ADHD Objectives/Interventions A Treatment Sampler
  • Increase the frequency of positive interactions
    with parents.
  • Assess periods of time when child demonstrates
    good impulse control and engages in fewer
    disruptive behaviors process his/her responses
    and reinforce positive coping approaches that
    were used to deter impulsive or disruptive
    behavior.
  • Encourage parent to record three to five positive
    child behaviors displayed between sessions
    reward these behaviors.
  • Encourage parents to spend 15 20 minutes daily
    of one-on-one time with child to create a closer
    parent-child bond. Allow child to take lead in
    selecting activity or task.

60
ADHD Objectives/Interventions A Treatment Sampler
  • Increase the frequency of socially appropriate
    behavior with siblings/peers.
  • Identify and reinforce positive social behaviors
    to help child establish and maintaining
    friendships.
  • Use the therapeutic game, the Helping, Sharing
    and Caring Game (Gardner), to help child develop
    positive social skills.
  • Assign the child the task of showing empathy,
    kindness, or sensitivity to others (e.g.,
    allowing sibling or peer to take first turn in a
    video game, helping with a school fund raiser).
  • Have child identify 5 10 strengths or
    interests review the list encourage him/her to
    use strengths or interests to establish
    friendships.

61
ADHD Objectives/Interventions A Treatment Sampler
  • Identify and list constructive ways to use
    energy.
  • Instruct the child to create drawings reflecting
    the positive and negative aspects of his/her high
    energy level process the content of these
    drawings with the therapist.
  • Use puppets, dolls, or stuffed animals to create
    a story that models positive ways to use energy
    and gain attention from peers then ask the child
    to create a story with similar characters and
    themes.

62
ADHD Objectives/Interventions A Treatment Sampler
  • Implement a process of monitoring and assessing
    own behavior.
  • Encourage the child to use self-monitoring
    checklists to improve his/her attention and
    social skills.
  • Assign the Social Skills Exercise in the Brief
    Child Therapy Homework Planner (Jongsma, Peterson
    and McInnis)

63
ADHD Objectives/Interventions A Treatment Sampler
  • Parents and the child regularly attend and
    actively participate in group therapy.
  • Arrange for the child to attend group therapy to
    build social skills.
  • Encourage the childs parents to participate in
    an ADHD support group.

64
ADHD Objectives/Interventions A Treatment Sampler
  • The Child and parents comply with the
    implementation of behavior management strategies
    to reduce the frequency of impulsive, disruptive,
    and negative attention-seeking behaviors.
  • Identify a variety of positive reinforcers to
    maintain the childs interest and motivation in
    achieving desired goals or changes in behavior.
  • Design a reward and/or contingency contract
    system to reinforce the childs positive behavior
    and deter impulsive behaviors.
  • Design and implement a token economy to improve
    the childs academic performance, social skills,
    and impulse control.

65
Final Comments
  • It is important to note that, while the
    objectives and examples of interventions listed
    here may be applicable to developing treatment
    plans for many children with ADHD, they my not be
    sufficient for many cases.
  • Here it can be noted that a range of other
    interventions may be required in cases where
    children display comorbid conditions.
  • Interventions that relate specifically to
    problems resulting from comorbid conditions may
    need to be included in these treatment plans.

66
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