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Contents
WhyCNSVitalSigns?..
WhyCNSVitalSignsinAD/HD?..
AD/HDGuidelinesandCNSVitalSigns..
AboutCNSVitalSignsAssessmentPlatforms..
CNSVitalSignsADD AD/HDCaseStudies.....
OptimizedforAD/HDGuidelines..
AboutCNSVitalSignsClinicalDomainsinAD/HD
CNSVitalSignsAssessmentPlatformImplementation
AD/HDReimbursementInformation.
NextSteps..
3
4
7
10
14
18
28
31
35
36
Thefollowingpageshavebeenassembledfromvarioussourcesandpublicationsandismeanttobea
referenceorroadmapguidetoassistandinformhowCNSVitalSignscanbeusedtoimproveclinical
insightandcaremanagement,enablecurrentguidelines,beintegratedintoaclinicorpractice,and
helpimprovedpracticerevenuesandperformance.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Accuratelymeasuringandcharacterizinga
patientsneurocognitivefunctionbasedon
hisorherstatusoreffort
Facilitatingthethinkingaboutthepatients
condition(50+wellknownmedicaland
healthratingscales)andhelpingtoexplain
thepatientscurrentdifficulties
Optimizingserialadministrationwhichhelps
tomonitorandguideeffectiveintervention
andenablesevidencebasedmedicineand
outcomes
CNSVitalSignsoffersmultipleassessment
platformoptionsthatcanbeeasilyconfigured
anddeployeddependingoneachpracticesgoals
andneeds.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Enhanced
Patient Insight
and Care
Management
OBJECTIVE,PRECISE,andSTANDARDIZED
AssessmentsthatSupportsmany
NeuroPsych ClinicalGuidelines
$
Extend Practice
Efficiency
ObjectiveandEvidenceBased
AssessmentDataCollected,Auto
ScoredandSystematically
Documented.
Develop
Enhanced
Revenue Streams
WellEstablishedBilling
CodestoImprovePractice
Performance
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
FREE Screening
Clinical Pathology
Comorbid Status
PracticeEfficiency
MeasureandMonitor
MeasureandMonitor
CNSVitalSignsFREEcomputerized
screeningtoolsallowscliniciansto
SCREENforpossibleNeuroPsych,
Mental,andBehavioralHealth
Issuesthatcaneffecteducational
orvocationalproductivityand
performance.
CNSVitalSignscomputerized
neurocognitivetestingallowsclinicians
toassessabnormalcognitive
impairmentbycomparingpatientsto
ourPEERREVIEWEDnormativedata
setfromages8to90 acrossthe
lifespan e.g.levelofdisability.
ThreeVersionsofthePediatric
SymptomChecklist,manyother
ratingscales.
CertainDOMAINScorescanbe
informativeinconfirmingapossible
clinicalconditione.g.,frontallobe
tests.
CNSVitalSignsenablestherecently
updatedAAPandpastAACPAD/HD
guidelines.
Evidencebasedratingscalesand
neurocognitivetestingcanhelp
clinicianssortoutsymptom,
behavioral,andcomorbidissuesand
helpbetterunderstandpossiblebrain
andbehaviorrelationships.
50+freeratingscales:Vanderbilt
AD/HD(Parent&Teacher),NeuroPsych
Questionnaires207&45,SCARED,Etc.
Diseasesofthebraincommonlyproducechangesinbehavior,includingimpairmentofcognitiveabilitiesandproduction
ofneuropsychiatricsymptoms.Knowledgeofthepresenceandcharacteristicsofthesechangescanaidintheevaluation,
management,andlongitudinalcareofpatientswithneurologicandpsychiatricdiseases.Adaptedfrom:Neurology1996;47:592599.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
MANAGEMENTTEAM
TheCNSVitalSignstestscancomplimentotherExecutiveFunction
assessmentse.g.,BrownAD/HD,BRIEF, CONNERS,Barkley,etc.tohelp
identifyandeffectivelyaddressneurocognitivechallengesthatcanhave
dramaticimpactonacademicandvocationalperformance.
Neurocognitive
Function
InformationProcessingSpeed
ComplexAttention
VisualPerceptualSpeed
InformationProcessingSpeed
ExecutiveFunction
SimpleandComplexReactionTime
SpeedAccuracyTradeOff
InformationProcessingSpeed
Inhibition/Disinhibition
Approx.2.5Minutes
ExecutiveFunction:ShiftingSets
ReactionTime
InformationProcessingSpeed
SpeedAccuracyTradeoff
Continuous
Performance
(CPT)
SustainedAttention
ChoiceReactionTime
Impulsivity
SustainedAttention
WorkingMemory
Clinical
Domains
Processing
Speed
Measure: Howwellasubjectrecognizesandprocessesinformationi.e.,perceiving,
attending/respondingtoincominginformation,motorspeed,finemotor
coordination,andvisualperceptualability.Relevance: Abilitytorecognizeand
respond/reacti.e.,fitnesstodrive,occupationissues,possibledanger/risksignsor
issueswithaccuracyanddetail.
Executive
Function
Measure: Howwellasubjectrecognizesrules,categories,andmanagesornavigates
rapiddecisionmaking.Relevance: Abilitytosequencetasksandmanagemultiple
taskssimultaneouslyaswellastrackingandrespondingtoasetofinstructions.
Complex
Attention
Measure: Abilitytotrackandrespondtoinformationoverlengthyperiodsoftime
and/orperformmentaltasksrequiringvigilancequicklyandaccurately.Relevance:
Selfregulationandbehavioralcontrol.
Cognitive
Flexibility
Measure: Howwellsubjectisabletoadapttorapidlychangingandincreasingly
complexsetofdirectionsand/ortomanipulatetheinformation.Relevance:
Reasoning,switchingtasks,decisionmaking,impulsecontrol,strategyformation,
attendingtoconversation.
Stroop
Test
(ST)
Approx.4 5Minutes
Shifting
Attention
(SAT)
Approx.5Minutes
4PartContinuous
Performance
(FPCPT)
Approx.7Minutes
Autoscored
Approx.4Minutes
Working
Memory
Sustained
Attention
Measure: Howwellasubjectcanperceiveandattendtosymbolsusingshortterm
memoryprocesses(4PCPT).Relevance: Abilitytocarryoutshorttermmemorytasks
thatsupportdecisionmaking,problemsolving,planning,andexecution.Enables
rightnowresponses.
Measure: Howwellasubjectcandirectandfocuscognitiveactivityonspecific
stimuli.Relevance: Howwellasubjectcanfocusandcompletetaskoractivity,
sequenceaction,andfocusduringcomplexthought.
CNSVitalSignsisusedthroughouttheworldasaclinicaltooltoevaluateandmanageADHD.ExecutiveFunctioning,sometimescalledexecutivecontrol
system,isgenerallyconsideredafrontallobe(seeorangesectionofthebrain)neurocognitivesystemthatcontrolsandmanagesothercognitive
processes.Itisconsideredahigherorderbrainfunction,whichincludeattention,behavioralplanningandresponseinhibition, andthemanipulationof
informationinproblemsolvingtasks.Sometimesreferredtoasthe"commandandcontrol"orthe"conductor"ofmanycognitiveskills.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Attentiondeficit/hyperactivitydisorder(ADHD)is
themostcommonneurobehavioraldisorderof
childhoodandcanprofoundlyaffecttheacademic
achievement,wellbeing,andsocialinteractionsof
children;theAmericanAcademyofPediatricsfirst
publishedclinicalrecommendationsforthe
diagnosisandevaluationofADHDinchildrenin
2000;recommendationsfortreatmentfollowedin
2001.Pediatrics2011;128:000
1.TheprimarycareclinicianshouldinitiateanevaluationforADHDforany
child4through18yearsofagewhopresentswithacademicorbehavioral
problemsandsymptomsofinattention,hyperactivity,orimpulsivity(qualityof
evidenceB/strongrecommendation).
2.TomakeadiagnosisofADHD,theprimarycareclinicianshoulddeterminethat
DiagnosticandStatisticalManualofMentalDisorders,FourthEditioncriteria
havebeenmet(includingdocumentationofimpairmentinmorethan1major
setting);informationshouldbeobtainedprimarilyfromreportsfromparentsor
guardians,teachers,andotherschoolandmentalhealthcliniciansinvolvedin
thechildscare.Theprimarycareclinicianshouldalsoruleoutanyalternative
cause(qualityofevidenceB/strongrecommendation).
3.IntheevaluationofachildforADHD,theprimarycareclinicianshould
includeassessmentforotherconditionsthatmightcoexistwithADHD,
includingemotionalorbehavioral(e.g.,anxiety,depressive,oppositionaldefiant,
andconductdisorders),developmental(e.g.,learningandlanguagedisordersor
otherneurodevelopmentaldisorders),andphysical(e.g.,tics,sleepapnea)
conditions(qualityofevidenceB/strongrecommendation).
4.TheprimarycareclinicianshouldrecognizeADHDasachronicconditionand,
therefore,considerchildrenandadolescentswithADHDaschildrenandyouth
withspecialhealthcareneeds.Managementofchildrenandyouthwithspecial
healthcareneedsshouldfollowtheprinciplesofthechroniccaremodelandthe
medicalhome(qualityofevidenceB/strongrecommendation).
5.RecommendationsfortreatmentofchildrenandyouthwithADHDvary
dependingonthepatientsage
6.TheprimarycareclinicianshouldtitratedosesofmedicationforADHDto
achievemaximumbenefitwithminimumadverseeffects(qualityofevidence
B/strongrecommendation).
=HowCNSVitalSignsCanHELP
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Guidlines.gov
Pliszka S,AACAPWorkGrouponQualityIssues.Practiceparameterfortheassessmentandtreatmentofchildrenand
adolescentswithattentiondeficit/hyperactivitydisorder.JAmAcad ChildAdolesc Psychiatry 2007Jul;46(7):894921.
Diagnosis / Evaluation /
Screening
Screeningpatientsforattention
deficit/hyperactivitydisorder(ADHD)aspart
ofmentalhealthassessment
Patientevaluationincludinginterviewswith
parentandpatient,obtaininginformation
aboutpatient'sschoolordaycare
functioning,reviewofthepatient'smedical,
social,andfamilyhistories
Psychologicalandneuropsychologicaltestsif
thepatient'shistorysuggestslowcognitive
abilityorlowacademicachievements
Evaluationforcomorbidpsychiatric
disorders
=HowCNSVitalSignsCanHELP
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Management / Treatment
Developmentofcomprehensivetreatment
plan
Parentandchildpsychoeducation about
ADHDanditsvarioustreatmentoptions
Psychopharmacologicalintervention
includingstimulants,atomoxetine,
bupropion,tricyclicantidepressants,and
alphaagonists
Monitoringfortreatmentsideeffects
Psychosocialintervention(including
behaviortherapy)ifindicated,in
conjunctionwithmedicationtreatment
Followupincludingassessmentofthe
continuedneedfortreatmentand
monitoringpatient'sheightandweight
Guidlines.gov
Pliszka S,AACAPWorkGrouponQualityIssues.Practiceparameterfortheassessmentandtreatmentofchildrenand
adolescentswithattentiondeficit/hyperactivitydisorder.JAmAcad ChildAdolesc Psychiatry 2007Jul;46(7):894921.
Major Outcomes
Considered
Incidenceofcomorbiddisorders
Effectivenessoftreatment
Adverseeffectsofmedication
Major Recommendations
Recommendation1.ScreeningforAttentionDeficit/Hyperactivity
Disorder(ADHD)ShouldBePartofEveryPatient'sMentalHealth
Assessment.
Recommendation2.EvaluationofthePreschooler,Child,or
AdolescentforADHDShouldConsistofClinicalInterviewswiththe
ParentandPatient,ObtainingInformationaboutthePatient'sSchool
orDayCareFunctioning,EvaluationforComorbidPsychiatric
Disorders,andReviewofthePatient'sMedical,Social,andFamily
Histories.
Recommendation3.IfthePatient'sMedicalHistoryIsUnremarkable,
LaboratoryorNeurological
Recommendation4.PsychologicalandNeuropsychologicalTests
AreNotMandatoryfortheDiagnosisforADHD,butShouldBe
PerformedifthePatient'sHistorySuggestsLowGeneralCognitive
AbilityorLowAchievementinLanguageorMathematicsRelativeto
thePatient'sIntellectualAbilityTestingIsNotIndicated
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Recommendation5.TheClinicianMustEvaluatethePatientwith
ADHDforthePresenceofComorbidPsychiatricDisorders
Recommendation6.AWellThoughtOutandComprehensive
TreatmentPlanShouldBeDevelopedforthePatientwithADHD
Recommendation7.TheInitialPsychopharmacologicalTreatment
ofADHDShouldBeaTrialwithanAgentApprovedbytheFoodand
DrugAdministration(FDA)fortheTreatmentofADHD
Recommendation8.IfNoneoftheAboveAgentsResultin
SatisfactoryTreatmentofthePatientwithADHD,theClinicianShould
UndertakeaCarefulReviewoftheDiagnosisandThenConsider
BehaviorTherapyand/ortheUseofMedicationsNotApprovedby
theFDAfortheTreatmentofADHD
Recommendation9.DuringaPsychopharmacologicalIntervention
forADHD,thePatientShouldBeMonitoredforTreatmentEmergent
SideEffects
Recommendation10.IfaPatientWithADHDHasaRobustResponse
toPsychopharmacologicalTreatmentandSubsequentlyShows
NormativeFunctioninginAcademic,Family,andSocialFunctioning,
ThenPsychopharmacologicalTreatmentoftheADHDAloneIs
Satisfactory
Recommendation11.IfaPatientwithADHDHasaLessThanOptimal
ResponsetoMedication,HasaComorbidDisorder,orExperiences
StressorsinFamilyLife,ThenPsychosocialTreatmentinConjunction
withMedicationTreatmentIsOftenBeneficial
Recommendation12.PatientsShouldBeAssessedPeriodicallyto
DetermineWhetherThereIsContinuedNeedforTreatmentorIf
SymptomsHaveRemitted.TreatmentofADHDShouldContinueas
LongasSymptomsRemainPresentandCauseImpairment
Recommendation13.PatientsTreatedWithMedicationforADHD
ShouldHaveTheirHeightandWeightMonitoredThroughout
Treatment
Patient
Health
Outcomes
Caregiver &
Informants
Evaluation and
Management
Brain Behavior
Objective
Neurocognitive
Assessment
Care Team
TheCNSVitalSignsAD/HDToolboxhelpsclinicianssystematicallycollectAD/HDbrainfunction,symptoms,and
comorbiditiesdata,automaticallyscoringandsystematicallydocumentingtheresultingclinicalendpoints.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
10
AD/HDRatingScales
CNSVitalSignsisacomputerizedneurocognitive
healthassessmentplatformthatenablesthe
OBJECTIVEEVALUATIONofCOGNITION
PatientInTake/
EarlyDetection
Screening
Identify
PossibleBehavioralor
ComorbidIssues
CognitiveStatus Baseline
NeuroPsych,Mental,and
BehavioralHealthIssues
(symptomsthatcaneffect
educationalorvocational
productivityand
performance)
WEB&
COMPUTER
BasedTesting
identifyingsymptoms,possiblecomorbidities,
behavioralissues,andotherimportantclinical
information.
MultiModalProfessional
Assessment
EvidenceBased
RatingScales
Behavioral
NeuropsychiatricSymptoms
&Comorbidities
Attentional Issues
Internalizing(anxiety
depression PTSD)Issues
Externalizing(behavioral
conduct)issues
andmanymore.
Neurocognitive
Testing
Brain
Memory
Attentional
ExecutiveControl
ProcessingSpeed
CognitiveFlexibility
SocialAcuity
Reasoning
WorkingMemory
andmanymore
MeasureProgress
andPerformance
Followupand
Outcomes
Monitor
AssessMedicationEffect
MeasureProgressor
Changes
DocumentforOutcomes
and/orResearch
ConductWebBasedMental
andBehavioralHealth
Surveillance
ImproveCompliance
11
Clinician Expertise
BrainFunction:Attentional,
ExecutiveFunctions,and
WorkingMemory
Computerized
Neurocognitive Testing
NineNeurocognitiveDomains
Measured
ThreeExecutiveControlTests
TwoAttentional Tests
WorkingMemory Nback Test
ImmediateAuto ScoredReports
RapidAssessment 30MinuteInitial
Assessment/Baseline,15Minute
FollowupforTreatmentEffect
EasytoInterpret
Systematic&Standardized
DocumentationforPatient
Registry/Research
HIPAACompliant
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Behaviors,
Symptoms,and
Comorbidities
12
Medication Management
Overthepastcentury,thesyndromecurrently
referredtoasattentiondeficit/hyperactivity
disorder(ADHD)hasbeenconceptualizedin
relationtovaryingcognitiveproblemsincluding
attention,rewardresponse,executive
functioning,andothercognitiveprocesses.More
recently,ithasbecomeclearthatwhereasADHD
isassociatedatthegrouplevelwitharangeof
cognitiveimpairments,nosinglecognitive
dysfunctioncharacterizesallchildrenwith
ADHD.Inotherwords,ADHDisnotaonesize
fitsallphenomenon.Patientswiththis
syndromedonotfitintoanyonecategoryand
presentwithwidelydifferingcooccurring
disordersincludingvaryingcognitiveprofiles.
Source:CognitiveImpairmentsWithADHD,byJoelT.
Nigg,PhD;PsychiatricTimes.Vol.26No.3,2009
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
carefulfinetuningisrequiredfor
stimulantmedicationsforADHD;these
agentstendnottofollowmg/kg
guidelinesformanypatients.Effective
dosingofstimulantsisnotrelated
consistentlytoage,weight,orsymptom
severity;thecriticalvariableissensitivity
oftheindividualpatientsbodychemistry
totheparticularmedicationused.
SOURCE:ThomasE.Brown,PhD
http://www.drthomasebrown.com/pdfs/cmgarticle.pdf
13
Pre Dose
Post Dose
Domainsmostsensitivetoattentiondeficitconditions.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
14
=LowFrontalLobeDomainScores
Patient History:
JamesK.a21yearoldcollegestudentonaPresidentialscholarshipforhispianoplayingability.Jamesisgiftedmusically,hasplayedwith
symphonyorchestras,andcanwatchsomeoneplayamusicalpiecethenrepeatfrommemorythepiece.Jameshighschoolacademic
performancewasaverageandhe wasapopularstudent.AtcollegeJameshasstruggled,hereportshehasa problemconcentratinginthe
librarycomparedtohispeers.Hehas struggledwithanumberofcoursesandhasdroppedatleastonecoursepersemester.Apeerinhis
dormtoldJamesheshouldgetsomeAdderall.Jameswasreferredforclinicalevaluation.
Clinical Findings:
AspartofthepatientintakehewasadministeredtheAdultADHDSelfReportScaleinwhichhescoreda40overallanda25inthe
inattentivecategory(24orgreater=HighlylikelytohaveADHD).JameswasalsoadministeredtheCNSVitalSignsneurocognitive 1
assessmentandwasidentifiedashavingpossiblefrontallobedeficits.BasedonthisinformationJameswasgiventheBrown ADDScales
whichconfirmedpossibleexecutiveandattentional dysfunction.ReviewingJamesinitialDomainDashboardconfirmsJameshasabove
averageskillsinMemory,ProcessingSpeed,andPsychomotorSpeedwhichwouldbeexpectedgivenhisconsiderablepianoplayingskills.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
15
Howoftendoyouhavetroublewrappingupthefinaldetailsofaproject,oncethechallengingpartshavebeendone?
3 Often
Howoftendoyouhavedifficultygettingthingsinorderwhenyouhavetodoataskthatrequiresorganization?
3 Often
Howoftendoyouhaveproblemsrememberingappointmentsorobligations?
2 Sometimes
Whenyouhaveataskthatrequiresalotofthought,howoftendoyouavoidordelaygettingstarted?
4 VeryOften
Howoftendoyoufidgetorsquirmwithyourhandsorfeetwhenyouhavetositdownforalongtime?
1 Rarely
Howoftendoyoufeeloverlyactiveandcompelledtodothings,likeyouweredrivenbyamotor?
2 Sometimes
Howoftendoyoumakecarelessmistakeswhenyouhavetoworkonaboringordifficultproject?
4 VeryOften
Howoftendoyouhavedifficultykeepingyourattentionwhenyouaredoingboringorrepetitivework?
4 VeryOften
Howoftendoyouhavedifficultyconcentratingonwhatpeoplesaytoyou,evenwhentheyarespeakingtoyoudirectly?
2 Sometimes
Part A (Inattentive)
25
10
Howoftendoyoumisplaceorhavedifficultyfindingthingsathomeorwork?
11
Howoftenareyoudistractedbyactivityornoisearoundyou?
3 Often
12
Howoftendoyouleaveyourseatinmeetingsorothersituationsinwhichyouareexpectedtoremainseated?
1 Rarely
13
Howoftendoyoufeelrestlessorfidgety?
0 Never
14
Howoftendoyouhavedifficultyunwindingandrelaxingwhenyouhavetimetoyourself?
2 Sometimes
15
Howoftendoyoufindyourselftalkingtoomuchwhenyouareinsocialsituations?
2 Sometimes
16
Whenyou'reinaconversation,howoftendoyoufindyourselffinishingthesentencesofthepeopleyouaretalkingto,
beforetheycanfinishthemthemselves?
2 Sometimes
17
Howoftendoyouhavedifficultywaitingyourturninsituationswhenturntakingisrequired?
0 Never
18
Howoftendoyouinterruptotherswhentheyarebusy?
1 Rarely
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
4 VeryOften
Part B (Hyperactive/Impulsive)
15
40
16
The Results:
Jameswasprescribed20mgofVyvanseandreturnedforafollowuptomeasuretheimpactofVyvanseonneurocognitivefunction.The
DomainDashboardtestscores, 2 POSTMEDICATION,revealsabeneficialorpositiveshiftinhisneurocognitivefunction.Nosideeffects
wereexperiencedorobservedbythestudent.ThecollegehealthcenterprovidedJameswithcopiesofhistestswhichhewasable toshare
withhisfamily.ThefamilywasimpressedthattheCNSVitalSignstestwasabletoquantifyandilluminatethevariousneurocognitive
functionsandhelpthembetterunderstandtheirsonsstatusandseetheimpactmedicationhadontheirsonscognition.Vyvanseisaproductof
ShirePharmaceuticals.
CNSVitalSignsneurocognitivetestsarepsychometricallysoundandincludemeasuresofthemostcommoncomplaintsofAD/HD:inattention (Complex
AttentionDomain),impulsiveresponding(ComplexAttentionandExecutiveFunctionDomain),executivecontrol(ExecutiveFunction,Cognitive
Function),andspeedofprocessing (ProcessingSpeedDomain),andworkingmemory(fourpartCPT).Clinicianscannoweasilyandobjectivelymeasure
executivecontrol,attention,andotherimportantdomainsaspartoftheirevaluationandmanagementactivities.CNSVitalSigns helpscontributetoan
efficient,systematiccontinuitybetweenevaluationandtreatment(medicationmanagement).
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
17
Legend
=CNSVitalSignsCan
HelpEnableGuidelines
=CNSVitalSigns
cansupportteam
=Start
=Action/Process
=Decision
=ContinuedCare
PerformDiagnosticEvaluation
forADHDandEvaluateorScreen
forOther/CoexistingConditions
Family (parents,guardian,other
frequentcaregivers):
Chiefconcerns
Historyofsymptoms(e.g.,ageof
onsetandcourseovertime)
Family,PastMedical,&
PsychosocialHistory
Reviewofsystems
ValidatedADHDinstrument
Evaluationofcoexisting
conditions
Reportoffunction,bothstrengths
andweaknesses
School (andimportantcommunity
informants):
Concerns
ValidatedADHDinstrument
Evaluationofcoexisting
conditions
Reportonhowwellpatients
functioninacademic,work,and
socialinteractions
Academicrecords(e.g.,report
cards,standardizedtesting,
psychoeducational evaluations)
Administrativereports(e.g.,
disciplinaryactions)
Child/Adolescent
(asappropriateforchildsageand
developmentalstatus):
Interview,includingconcerns
regardingbehavior,family
relationships,peers,school
Foradolescents:validatedself
reportinstrumentofADHDand
coexisting conditions
Reportofchildsselfidentified
impressionoffunction,both
strengthsandweaknesses
Cliniciansobservationsofchilds
behavior
Physicalandneurologic
examination
TFOMHindicatesTaskForceonMentalHealth;CYSHCN,child/youthwithspecialhealthcareneeds
DSMIV
diagnosis
ofADHD?
Coexisting
conditions?
YES
NO
Assessimpacton
treatmentplan
Furtherevaluation
/referralas
needed
YES
NO
YES
Other
condition?
Exitthisguideline.
Evaluateorrefer,as
appropriate.Identify
thechildasCYSHCN
ifappropriate.
Provideeducationtofamily
andchildre:concerns(e.g.,
triggersforinattentionor
hyperactivity)andbehavior
managementstrategiesor
schoolbasedstrategies
Inattentionand/or
hyperactivity/impulsivity
problemsnotrisingtoDSMIV
diagnosis
ESTABLISHMANAGEMENTTEAM
NO
Coexisting
disorders
preclude
primarycare
management?
NO
Apparently
typicalor
developmental
variation?
NO
YES
Provide
education
addressingconcern
(e.g., expectations
forattention asa
functionofage)
Enhanced
Surveillance
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Provideeducationoffamilyandchild
re:concerns(e.g.,triggersfor
inattention orhyperactivity)and
behaviormanagementstrategiesor
schoolbasedstrategies.
Identifychild
asCYSHCN
Enhanced
Surveillance
Collaboratewith
family,school,
andchildto
identifytarget
goals.
Establishteam
including
coordination
plan.
YES
Followupand
establishco
management
PlanSeeTFOMH
Algorithms
BEGINTREATMENT
Option:Medication
(ADHDonlyandpastmedicalor
familyhistoryofcardiovascular
diseaseconsidered)
Initiatetreatment
Titratetomaximumbenefit,
minimumadverseeffects
Monitortargetoutcomes
Followupforchronic
caremanagementat
least2x/yearfor
ADHDissues.
YES
Option:BehaviorManagement
(developmentalvariation,
problemorADHD)
Identifyserviceorapproach
Monitortargetoutcomes
Do
symptoms
improve?
NO
Option:Collaboratewith
SchooltoEnhanceSupports
andServices
(developmentalvariation,
problem,orADHD)
Identifychanges
Monitortargetoutcomes
Reevaluate:
toconfirmdiagnosisand/orprovide
educationtoimproveadherence.
Reconsider:
treatmentplanincludingchangingofthe
medicationordose,addingamedication
approvedforadjuvanttherapy,and/or
changingbehavioraltherapy.
AdaptedFrom:ADHD:ClinicalPracticeGuidelinefortheDiagnosis,Evaluation,andTreatmentof
AttentionDeficit/HyperactivityDisorderinChildrenandAdolescentsSUBCOMMITTEEON
ATTENTIONDEFICIT/HYPERACTIVITYDISORDER,STEERINGCOMMITTEEONQUALITY
IMPROVEMENTANDMANAGEMENT;Pediatrics2011;peds.20112654
18
AAPCommitteeonChildrenwithDisabilities
recommendsroutinestandardized
developmentalandbehavioralscreening
reaffirmthemandateforchildhealthprofessionals to
provideearlyidentificationof,andinterventionfor,
children withdevelopmentaldisabilitiesthrough
communitybasedcollaborative systems.
SOURCE:CouncilonChildrenWithDisabilities,
etal.Pediatrics 2006;118:405420
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
19
Dashboard
Inattentive
Questions
Action statement 2:
TomakeadiagnosisofADHD,theprimarycareclinicianshould
determinethatDiagnosticandStatisticalManualofMental
Disorders,FourthEdition(DSMIVTR)criteriahavebeenmet
(includingdocumentationofimpairmentinmorethan1major
setting),andinformationshouldbeobtainedprimarilyfrom
reportsfromparentsorguardians,teachers,andotherschooland
mentalhealthcliniciansinvolvedinthechildscare.Theprimary
careclinicianshouldalsoruleoutanyalternativecause(qualityof
evidenceB/strongrecommendation).
Hyperactive/Impulsive
Questions
Oppositional
DefiantQuestions
Conduct
Questions
Anxiety/Depression
Questions
SchoolPerformance
Questions
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
20
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
ChildObsessiveCompulsiveDisorder
Inventory(OCDC)SF20
SocialAnxietyScaleforChildrenand
Adolescents(SASCA)SF20
EpworthSleepinessScale(ESS)SF8
PittsburghSleepQualityIndex(PSQI)SF10;
Zung DepressionandAnxietyScales
+ManyMore
21
Autoscores
Twenty
NeuroPsych
Symptomsand
EightPossible
Comorbidities
Age: 23
Domain
Attention
Impulsive
Learning
Memory
Anxiety
Panic
Agoraphobia
Score
238
270
209
171
89
33
80
Severity
Severe
Severe
Moderate
Moderate
Not a Problem
Mild
Mild
60
Mild
Social Anxiety
Depression
Mood Stability
Mania
Aggression
Psychotic
Somatic
Fatigue
Sleep
Suicide
Pain
Substance Abuse
125
160
192
70
150
70
78
150
225
70
100
140
Mild
Moderate
Moderate
Not a Problem
Moderate
Not a Problem
Mild
Moderate
Severe
Not a Problem
Mild
Mild
142
Mild
PTSD
Bipolar
Autism
Aspergers
ADHD
MCI
Concussion
222
155
158
153
253
108
172
Moderate
Mild
Mild
Mild
Severe
Mild
Moderate
Anxiety/Depression
150
Moderate
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
Description
The Neuropsych Questionnaire asks patients
(or an appropriate observer) a series of
questions about their clinical state. The
questions are about the symptoms of various
neuropsychiatric disorders. The terminology is
similar to that used in the diagnostic manuals,
and in many familiar clinical questionnaires and
rating scales; but it has been simplified, and all
symptoms are scored on the same metric.
Scores are reported on a scale of 0 (not a
problem) to 300 (severe). As a rule,
scores above 225 indicate a severe
problem; scores from 150-224 indicate a
moderate problem; and scores from 75149, a mild problem. A high score on the
Neuropsych Questionnaire means that the
patient is reporting more symptoms of
greater intensity.
It doesn't necessarily mean that the patient
has a particular condition; just that he or she
(or their spouse, parent or caregiver) are
saying that they have a lot of intense
symptoms. Conversely, a low score simply
means that the patient (or caregiver) is not
reporting
symptoms
associated
with
a
particular condition, at least during the period
of time specified. It does not mean that the
patient does not have the condition. Just as
some people over-state their problems, others
tend to under-state their problems. The
Neuropsych Questionnaire is not a diagnostic
instrument. The results it generates are only
meant to be interpreted by an experienced
clinician in the course of a clinical examination.
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SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
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HealthyControl
MoodDisorder,NormalCognition
MoodDisorder,CognitiveImpairment
45
40
35
30
25
20
15
10
5
0
40-49
50-59
60-69
70-79
Fig.3.DistributionsofCNSVitalSignscognitiveflexibilityindexscoreinpatientswithorwithout
impairedcognition.Figurenote:Healthycontrol,N=660.Mooddisorder,normalcognition,n=128.
Mooddisorder,cognitiveimpairment,n=58.*Normativescoresweretruncatedat40.Eachvalue
representsthepercentageofsubjectsinthatscorerange.
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ManagingNeurocognitiveandBehavioralHealth
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ManagingNeurocognitiveandBehavioralHealth
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Longitudinal Tracking
110
90
80
70
0
11/26/2009
10/16/10 12/15/10
PsychomotorSpeed
StandardScore
110
90
80
70
0
11/26/2009
10/16/10 12/15/10
ComplexAttention*
StandardScore
110
90
80
70
0
11/26/2009
10/16/10 12/15/10
VisualMemory
StandardScore
110
90
80
70
0
11/26/2009
90
80
70
0
11/26/2009
10/16/10 12/15/10
ExecutiveFunction
StandardScore
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
110
StandardScore
shouldrecognizeADHDasachronicconditionand,
therefore,considerchildrenandadolescentswithADHDas
childrenandyouthwithspecialhealthcareneeds.
Managementofchildrenandyouthwithspecialhealthcare
needsshouldfollowtheprinciplesofthechroniccare
modelandthemedicalhome(qualityofevidenceB/strong
recommendation).
10/16/10 12/15/10
ProcessingSpeed
110
90
80
70
0
11/26/2009
10/16/10 12/15/10
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70%ofchildrenandyouthwithADHDrespondtoone
ofthestimulantmedicationsatanoptimaldosewhena
systematictrialisused.Childrenwithlessfrequent
monitoringandhadlessoptimalresults.Because
stimulantsmightproducepositivebutsuboptimaleffects
atalowdoseinsomechildrenandyouth,titrationto
maximumdosesthatcontrolsymptomswithoutadverse
effectsisrecommendedinsteadoftitrationstrictlyona
milligramperkilogrambasis.
thattheprocessmightrequireafewmonthstoachieve
optimalsuccess,andthatmedicationefficacyshouldbe
systematicallymonitoredatregularintervals.
Evenwithoptimaltreatment,basedonparentsand
teachersopinions,subtleandnotsosubtleneurocognitive
impairmentspersistedintheADHDpatients.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
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ManagingNeurocognitiveandBehavioralHealth
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TheCNSVitalSignsADHDneurocognitivetestingproceduretakes15to45minutesdependingonthenumberofneurocognitiveteststhatare
selected.Theassessmentplatformcollectsobjectivedataonthepatientsneurocognitiveperformancee.g.,executivefunction,complex
attention,cognitiveflexibility,etc.Thetestingresultsareimmediatelyautoscoredandpresentedineasytoreadandinterpretreports.
Key Advantage
AkeyadvantagetotheVSXassessmentplatformistheautoscoringofembeddedindicatorsofpatienttestingeffort.Aswithallpsychological
andneuropsychologicaltestingneuropsychiatricpatientscanfeign theirresponsesduetoincentivessuchasacademicaccommodations.
Whenanalyzingtestdata,eitherinresearch,orinclinicalpractice,itisimportanttoknowwhetheratestresultisvalidornot. Cliniciansneed
toknowiftestingsubjectsaregeneratingdubiousresultsoranoncredibleresponsepattern.CNSVitalSignshasdeveloped validity
indicatorsforitstestsanddomainsthatindicatewhetherthepatientgavepooreffortorgeneratedinvalidresults.TheValidityIndicatoralerts
thecliniciantothepossibilityofaninvalidtestallowingtheclinician,examinerortestingtechniciantoquestionthetestingsubject:Dothe
testingresultsreflectanunderstandingofthetestandtheinstructions?Didthetestingsubjectputforththeirbesteffort? Didtheygetagood
nightssleep?Doesthesubjecthavepoorvisionandneedtheirglasses?
Shouldasubjecttestabnormallylowtriggeringaninvalidtest(NOasdisplayedintheValidityIndicatorsectionofthereport)thenthatwould
beareasonforretestingtheindividual,unlessyourclinicaljudgmentmakesyoubelievethatisthebestscorethepatientcan achieve.Likeany
suspiciouslab,thetestshouldbereadministered,anditcanbedonewithCNSVitalSignsthroughtheRETESTfunction.Before Retesting,the
testexaminerortechnicianshouldreinforcetheneedforthesubjecttogiveagoodtestingeffortandusetheValidityIndicatorasatoolto
helpwiththereinforcement.ToRETESTasubjectgotoMENU>RETESTSUBJECT>andselecttheappropriatesubjectandretestthe subject.
Uponretest,shouldasubjecttestabnormallylowagaintriggeringyetanotherinvalidtest(NOasdisplayedintheValidityIndicatorsectionof
thereport)andtheclinicianbelievesitwasthepatientsbesteffortfurtherevaluationorreferralsshouldbeconsidered.
ThecliniciangenerallyintegratestheVSX ADHDTestreportwithinformationfromotherscreening assessmenttoolsandtheclinical
evaluationtohelpguidethediscussiononthelevelofimpairmentandthepossibletreatmentstrategiesandplan.Longitudinalassessments
canhelptailor/optimizemedicationsandtrackthepatientsconditionandoutcomesaccordingtothechroniccaremodel.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
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ManagingNeurocognitiveandBehavioralHealth
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SolutionsforMeasuring,Monitoring,and
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Implementation Example
IntegratingDevelopmental,Behavioral,andMentalHealthScreening,andAssessmentintoaPractice
PediatricSymptomChecklistExample
Annual Well Child Visit (5-19 years of Age)
ChooseStandardScreeningTool:setselection
policye.g. 514yearsofagehaveObserver
(parent,othercaregiver)completeeitherthe
PediatricSymptomChecklist(PSC35)orthe
PediatricSymptomChecklist(PSC17)older
than14havethechildtakethePediatric
SymptomChecklistYouthReport(YPSC).
(ValidatedandwidelyusedMurphyetal.,1992,1996;Galletal.,2000;Pagano etal.,2000)
FRONTOFFICESTAFF:Sendoutreminderemail
ormakeremindercall12daysbeforevisitfor
parentswhohaveyettocompletetheir
assessments.
Ifpatientrefusesscreeningintakemakenotein
chart.
DuringOfficeVisit:
PriortoOfficeVisit:
FRONTOFFICESTAFF:Mailoremailthe
scheduledpatienttherequisiteCNSVSOnLine
Loginandtestinginformation,(seeCNSVS
templates)aspartofpracticeintakeprocedure.
Ifpatientdoesnothaveemailoraccesstothe
internetschedulethepatientandcaregiverfor
inclinicassessment15minpriortonormalvisit
forassessmentontheCNSVSlocalversion.
FRONTOFFICESTAFF:Logintodetermine
whetherCNSVSOnLineassessmentshavebeen
completed.
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SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
AdministerandconductscreeningonlocalCNS
VSassessmentplatform.Havepatientswithout
Internetcompleterequiredratingscales.(5to15
minutes)
Positive Screen
Protocol
Refer patient to mental
health provider or
conduct extended
testing (CPT 96111)
using the CNS VS
neurocognitive
assessment platform.
PostScreeningInterview:
Looktoseeifanswersclusterbyinternal(anxiety/depression);attention(ADHD);and/orexternal
(conduct/oppositionaldefiantdisorder)
Exploresymptomsthatwereendorsedonthescreeningtool
Inquireaboutsuicidalthoughtsandbehaviors
Assessthelevelofimpairmentcausedbythesymptomsatschool,athomeandwithpeers
Determineiffurtherevaluationortreatmentwouldbebeneficial
ForpatientswhoscorenegativeonthePSC,itisrecommendedthatyoubrieflyreviewthe
symptomsendorsedassometimesandoftenwiththepatient.
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NOTE:SeethereimbursementWebpageatCNSVS.comforadditionalreimbursementinformation
Neurocognitiveassessmentsmaybedeemedmedicallyunnecessaryforuncomplicated(primarycare,schoolpsychologist)casesofattention
deficitdisorderwith/withouthyperactivity(ADHD).Ifapatientisclearlyseekingthetestingforeducationalreasonse.g., special
accommodationssuchasextendedtimeontestingorotherspecialservicesinschool,theseservicesgenerally,areprovidedbyschoolsystems
underapplicablestateandfederalrulesandgenerallyarenotreimbursedbyinsurancecarriers.Mostbenefitplansexcludecoverageof
educationaltesting.Checkthepatientsbenefitplanaspaymentmayneedtobepaiddirectlytothepracticebythepatientfortheservices.
However,manyemployerbasedbenefitshavespecialsetasidehealthaccountsthatcanbeusedforpaymentofnoncoveredbenefitssuch
asneurocognitiveassessmentsforAD/HD.Healthplansmayreimburseandconsidertheproceduremedicallynecessaryfortheevaluation
andmanagementofcomplicatedcasese.g.executivedysfunction,examiningexpandeddevelopmentalconcerns,neurologically
complicatedcasesofADHD,e.g.,postheadtrauma,seizures,orcomprehensivebiopsychosocialtreatmentforthesedisordersin
collaborationwithprimarycarephysiciansandotherspecialists.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
CPTCodesforScreeningandAssessment
96110 DevelopmentalTesting,limited,withinterpretationand
report(e.g.CNSVitalSignsmedical,behavioral,andheathrating
scaletools)
96111 Developmentaltesting;extended(includesassessmentof
motor,language,social,adaptiveand/orcognitivefunctioningby
standardizeddevelopmentalinstrumentse.g.CNSVitalSigns
neurocognitiveassessmenttools)withinterpretationandreport.
96116 Neurobehavioralstatusexamwithinterpretationand
report,perhour
99420 Administrationandinterpretationofahealthrisk
assessmentforchildren(e.g.,mentalhealthscreening)
Adaptedfrom:AAPDevelopmentalScreening/TestingCodingFactSheetforPrimaryCarePediatricians
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Contactmetoreceivereportexamples,case
studies,administrationguidesetc.
Website: www.CNSVS.com
Phone: 888.750.6941
Email: support@cnsvs.com
Address:
598 Airport Blvd.
Suite 1400
Morrisville, NC 27560
ThewebinartrainingwasterrificitcoveredtheValidity&Reliabilityoftheplatform,the
interpretationofresults,billingandcoding,testingprotocol,andtheintegrationoftheCNS
VitalSignsplatformintoourpractice. PracticeAdministrator
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth
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