Monitoring the Individualized Management Plan

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Regularly assessing patient symptoms is a critical part of the multimodal management plan, and patients, parents, other caregivers, and health care professionals all play a role in this.1 The health care professional should obtain baseline information on the patient's impairment at school, work, or home before carrying out the management plan. As the plan is carried out and adjustments are made as needed, changes in academic and work performance should be monitored.1,2

Periodic use of behavior rating scales may be helpful for monitoring patient response.2 For example, the ADHD-RS-IV for children and teenagers and the ADHD-RS-IV with Adult Prompts are useful due to their quick completion, easy scoring, and sensitivity to treatment.3 Whichever tool is used, assessments need to be socially valid, tied to important functional outcomes, and conducted on an ongoing basis.

Common Behavior Rating Scales Used to Assess ADHD and Monitor Treatment

ADHD Rating Scale-IV (ADHD-RS-IV)

  • An 18-item scale corresponding to the 18 items in the DSM criteria that is divided into 2 subscales: hyperactivity/impulsivity and inattentiveness4
  • Items scored on a 4-point frequency scale ranging from 0 = never/rarely to 3 = very often4
  • Available in a form for parents/caregivers and for teachers4

ADHD Rating Scale IV (ADHD-RS-IV) with Adult Prompts

  • An 18-item scale corresponding to the 18 items in the DSM criteria, providing physicians with a method to rate adults by the frequency and severity of symptoms5-6
  • Contains 9 items assessing inattentive symptoms and 9 items assessing hyperactive/impulsive symptoms4
  • Scoring is based on a 4-point Likert-type severity scale ranging from 0 = never to 3 = very often4
  • Extensive prompts can be used to elicit a numbered response for the item6
  • The clinician should score the highest score generated from the prompts for each item6

Conners' Rating Scales

  • Scales consisting of the Conners' Parent Rating Scale-Revised and the Conners' Teacher Rating Scale-Revised, filled out by parents/caregivers and teachers, respectively7
  • Short versions of the scales consist of 27 or 28 questions divided into 4 subscales of oppositional problems, cognitive problems, hyperactivity, and an ADHD index7
  • Questions scored on a 4-point scale (0-3), where a higher score indicates more severe symptom presentation7-8

Involvement of Parents/Caregivers in Monitoring

Parent, caregiver, and teacher participation in a child's ADHD management plan is valuable and necessary. Monitoring behavioral changes is essential to arriving at the optimal management plan. A practical reporting schedule includes regular feedback from teachers, parents, and caregivers.1-2

Spouse and caregiver participation in an adult's ADHD management plan is valuable but not required. Spouses and caregivers can provide helpful feedback on symptom improvement or exacerbation following changes in therapy. As such, a health care professional may consider asking for feedback on patient progress from spouses and caregivers. Spouses and caregivers can also offer the patient support in adhering to his or her management plan.6,9

References

  1. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011:128(5):1007-1022, SI1-SI21.
  2. Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.
  3. Collett BR, Ohan JL, Myers KM. Ten-year review of rating scales, V: scales assessing attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2003;42(9):1015-1037.
  4. DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD Rating Scale-IV: Checklists, Norms, and Clinical Interpretation. New York, NY: The Guilford Press. 1998.
  5. Adler L, Cohen J. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004;27(2):187-201.
  6. Murphy K, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiatry. 2004;65(suppl 3):12-17.
  7. Conners CK. Development of the CRS-R. In: Conners CK, ed. Conners’ Rating Scales-Revised. North Tonawanda, NY: Multi-Health Systems. 2001:83-98.
  8. Conners CK, Sitarenios G, Parker JD, Epstein JN. The revised Conners’ Parent Rating Scale (CPRS-R): factor structure, reliability, and criterion validity. J Abnorm Child Psychol. 1998;26(4):257-268.
  9. Murphy K. Psychosocial treatments for ADHD in teens and adults: a practice-friendly review. J Clin Psychol. 2005;61(5):607-619.