CLMD - ADHD; Integrated Behavioral Medicine

Question 1

Pediatric prevalence of ADHD

Answer 1

8.7% of children aged 8-15 years (approx. 2.4 million children)

Question 2

Which gender is less likely to have their ADHD recognized, as well as present more commonly with inattentive subtype?

Answer 2

Females

Question 3

Estimated prevalence of clinician-assessed adult ADHD and the percent that received treatment

Answer 3

Estimated prevalence of clinical-assessed adult ADHD = 4.4%

Only 10.9% of respondents with adult ADHD received treatment (12.1% of females vs. 10.1% of males)

Question 4

Most common comorbidities with ADHD in adults

Answer 4

Mood disorders
Anxiety disorders
Substance disorders
Intermittent explosive disorder

Question 5

Most common pediatric comorbidities with ADHD

Answer 5

Tourette’s syndrome (tics, ADHD, and OCD manifestations)

Chronic tic disorder

Suicide

Question 6

What is the Tourette’s syndrome triad?

Answer 6

Tics
OCD
ADHD

Question 7

What are some components of executive functioning?

Answer 7

Ability to assess a situation

Prioritizing what is relevant vs. irrelevant

Filtering out extraneous information

Make a plan how to act

Execute the plan

Assess effect of action in a fluid manner

Question 8

ADHD relates to executive functioning in that there is an information processing dysfunction within the _____ ______, primarily due to a deficiency of _______ and _______

Answer 8

Prefrontal cortex; dopamine; NE

Question 9

What SPECIFIC part of the brain is dysfunctional in ADHD?

Answer 9

Dorsal anterior midcingulate cortex

Question 10

In order to make the diagnosis of ADHD based on the DSM-V criteria — children should have ______ symptoms of the disorder, and pts age 17+ should have at least _______ symptoms

Answer 10

6+; 5

Question 11

Diagnostic criteria for ADHD-inattentive type

Answer 11

Fails to give close attention to details or makes careless mistakes

Has difficulty sustaining attention

Does not appear to listen

Struggles to follow through on instructions

Has difficulty with organization

Avoids or dislikes tasks requiring a lot of thinking

Loses things

Is easily distracted

Is forgetful in daily activities

Question 12

Diagnostic criteria for ADHD—hyperactive type

Answer 12

Fidgets with hands or feet or squirms in chair

Has difficulty remaining seated

Runs about or climbs excessively in children; extreme restlessness in adults

Difficulty engaging in activities quietly

Acts as if driven by a motor; adults will often feel inside like they were driven by a motor

Talks excessively

Blurts out answers before questions have been completed

Difficulty waiting or taking turns

Question 13

Relevant components of problem-focused history while evaluating a pt for ADHD

Answer 13

How is it affecting pts life, have they ever been tested for learning d/o in the past, have they ever received tx for ADHD or learning d/o

Mom difficulties in pregnancy? Developmental milestones? Childhood illnesses?

Hx of accidents, LOC, head trauma, seizures, cardiac abnormalities

FH of ADHD or psychiatric illness, cardiac abnormalities, substance abuse

Screen for comorbidities

Question 14

Evaluation methods for ADHD

Answer 14

TOVA = Test of Variables of Attention

Conners Continuus Performance Test

Conner’s Adult ADHD Rating Scales (CAARS)

Question 15

Evaluation method for ADHD that measures reaction times, sufficiently long to measure vigilance, and is a shorter test for young children

Answer 15

TOVA

Question 16

Evaluation method for ADHD that is a task-oriented computerized assessment of attention-related problems in pts aged 8+; indexes pts performance in areas of inattentiveness, impulsivity, sustained attention, and vigilance

Answer 16

Conners continuous performance test

Question 17

Evaluation method for ADHD that is based on normative data with high reliability and validity

Answer 17

Conners adult ADHD rating scales

Question 18

APA treatment guidelines for treating ADHD in preschool age children (age 4-5 years)

Answer 18

Prescribe evidence-based parent-and/or teacher-administered behavior therapy as first line tx

Prescribe methylphenidate if behavior therapy does not provide significant improvement and child continues to have moderate to severe symptoms

Question 19

APA treatment guidelines for treating ADHD in elementary age children (age 6-11)

Answer 19

Prescribe FDA approved meds for ADHD (stimulants are probably best) and/or evidence-based parent and/or teacher-administered behavior therapy

preferably both meds and behavior therapy should be used together

Question 20

APA treatment guidelines for treating ADHD in preschool age children (age 12-18)

Answer 20

Prescribe FDA approved meds for ADHD with assent of adolescent

Prescribe behavior therapy as treatment for ADHD, although preferably both meds and behavior therapy should be used together

Question 21

Medication options for ADHD

Answer 21

Stimulants — methylphenidate, amphetamine

Alpha-2 adrenergic agonists — guanfacine, clonidine

Buproprion (may increase risk of seizure)

Atomoxetine (can produce QTc prolongation)

Modafinil (adults only!)

Question 22

Identify and articulate factors driving the integrated healthcare movement

Answer 22

Extremely high prevalence of behavioral health conditions in primary care

Most behavioral health conditions remain undetected and untreated

Cost of untreated behavioral health conditions (especially with comorbid health conditions) is exorbitant

Poor follow-through on referrals to outside specialty care

Poor healthcare outcome when compared to other wealthy countries

Excessive healthcare expenditures

Policy changes — parity, ACA, etc

Severe healthcare disparities (URM, mentally ill, SES)

Provider burnout

Question 23

Discuss benefits of integrated healthcare

Answer 23

Improved pt experience

Improved pt outcomes

Decreased healthcare expenditures

Improved access to care

Improved provider satisfaction and less burnout

Cultural competence (pt values)

Question 24

The Institute for Healthcare Improvement devised a framework called the “Triple Aim” as an approach to optimizing health system performance. What are the 3 components of the triple aim?

Answer 24

Improving the patient experience of care (including quality and satisfaction)

Improving the health of populations

Reducing the per capita cost of health care

[quadruple aim includes satisfaction of providers]

Question 25

Describe what an effective fully integrated care team looks like in terms of location, systems/pathways, type of collaboration, team types, treatment plans, etc

Answer 25

Location: SHARED treatment space

Systems/pathways: SHARED care provision, medical records

Type of collaboration: FULL and reciprocal

Teams: composition (ENTIRE clinic staff), approach/function (team HUDDLES before clinic — potential “case-finding”; review daily schedules for “targets of opportunity”)

Treatment plans: SHARED and mutually supported

Scope of problems targeted (targeted vs. non-targeted)

Allows for immediate “warm handoffs”; BHCs can see double the volume of pts vs. specialty MH; easier and better communication

Facilitates universal screening because you have someone who can help immediately if you identify someone with acute needs

Potential for co-scheduled visits/shared medical visits/medical group visits

Meeting NCQA PCMH

Question 26

Who among the integrated care team retains full responsibility for the patient and possesses the final decision making authority for patients?

Answer 26

The PCP!

Question 27

Who are some of the members of an effective integrated care team?

Answer 27

PCP
Dietician
Hospital staff
Specialty physician
Counselor
Lab/radiology/pharmacy
Nurse care manager

Question 28

What are some of the functions that a behavioral health consultant (BHC) can provide to assist a physician in their day-to-day practice?

Answer 28

Assessment
Education
Brief intervention
Referral
Warm hand-offs
Chronic illness
Mental health disorders
Prevention
Quality improvement+assurance
Early intervention
Treatment plan adherence
Stress-mediated diseases/sxs
Chronic pain management
Program development
Chronic care registries
Substance misuse
Improved provider/pt communication