CLMD - ADHD; Integrated Behavioral Medicine Flashcards
Pediatric prevalence of ADHD
8.7% of children aged 8-15 years (approx. 2.4 million children)
Which gender is less likely to have their ADHD recognized, as well as present more commonly with inattentive subtype?
Females
Estimated prevalence of clinician-assessed adult ADHD and the percent that received treatment
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)
Most common comorbidities with ADHD in adults
Mood disorders
Anxiety disorders
Substance disorders
Intermittent explosive disorder
Most common pediatric comorbidities with ADHD
Tourette’s syndrome (tics, ADHD, and OCD manifestations)
Chronic tic disorder
Suicide
What is the Tourette’s syndrome triad?
Tics
OCD
ADHD
What are some components of executive functioning?
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
ADHD relates to executive functioning in that there is an information processing dysfunction within the _____ ______, primarily due to a deficiency of _______ and _______
Prefrontal cortex; dopamine; NE
What SPECIFIC part of the brain is dysfunctional in ADHD?
Dorsal anterior midcingulate cortex
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
6+; 5
Diagnostic criteria for ADHD-inattentive type
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
Diagnostic criteria for ADHD—hyperactive type
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
Relevant components of problem-focused history while evaluating a pt for ADHD
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
Evaluation methods for ADHD
TOVA = Test of Variables of Attention
Conners Continuus Performance Test
Conner’s Adult ADHD Rating Scales (CAARS)
Evaluation method for ADHD that measures reaction times, sufficiently long to measure vigilance, and is a shorter test for young children
TOVA
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
Conners continuous performance test
Evaluation method for ADHD that is based on normative data with high reliability and validity
Conners adult ADHD rating scales
APA treatment guidelines for treating ADHD in preschool age children (age 4-5 years)
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
APA treatment guidelines for treating ADHD in elementary age children (age 6-11)
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
APA treatment guidelines for treating ADHD in preschool age children (age 12-18)
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
Medication options for ADHD
Stimulants — methylphenidate, amphetamine
Alpha-2 adrenergic agonists — guanfacine, clonidine
Buproprion (may increase risk of seizure)
Atomoxetine (can produce QTc prolongation)
Modafinil (adults only!)
Identify and articulate factors driving the integrated healthcare movement
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
Discuss benefits of integrated healthcare
Improved pt experience
Improved pt outcomes
Decreased healthcare expenditures
Improved access to care
Improved provider satisfaction and less burnout
Cultural competence (pt values)
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?
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]
Describe what an effective fully integrated care team looks like in terms of location, systems/pathways, type of collaboration, team types, treatment plans, etc
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
Who among the integrated care team retains full responsibility for the patient and possesses the final decision making authority for patients?
The PCP!
Who are some of the members of an effective integrated care team?
PCP Dietician Hospital staff Specialty physician Counselor Lab/radiology/pharmacy Nurse care manager
What are some of the functions that a behavioral health consultant (BHC) can provide to assist a physician in their day-to-day practice?
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
