2020 MBHR Measure: Symptom Improvement in adults with ADHD

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Justification

Impact. As with ADHD in children and adolescents there is a robust and extensive literature on the prevalence and impact of ADHD in adults. ADHD is conceptualized as a neurodevelopment disorder in the DSM 5 (APA, 2013) with prevalence estimated to be between 5 and 10% (e.g. Rowland, Skipper, & Umbach, 2015; Thomas, Sanders, Doust, Beller, & Glousiou, 2015). Current estimates are that between 4 and 5% of adults have ADHD (Kessler, et. al 2006) in the United States. ADHD in adults is also related to difficulties in school, occupational functioning, relationships, health, and various adaptive and psychological problems (see Barkley, 2015 as an example). Once thought to be a disorder of childhood, ADHD is now understood to be a disorder that continues well into adulthood including older adulthood.

Assessment and Treatment. Given the now well understood importance of ADHD in adults there are has been significant advancement in identifying how to assess and treat ADHD. The literature is voluminous. As with impact there are now a significant number of reviews of how to screen and diagnosis ADHD in adulthood (see Goodman, 2009; Ramsay, 2017; Ramsay & Rostain, 2016 in addition to the general reviews cited above as well as the CADDRA and NICE Guidelines). Given that attentional issues saturate multiple clinical presentations it is important that clinicians complete a thorough assessment using multiple methods to arrive at a proper diagnosis of ADHD. There are effective medications for ADHD as well as effective psychosocial treatments for this disorder. The issues in the current literature focus on relative efficacy and effectiveness of individual and combined treatments (see Ramsay & Rostain, 2016 as an example).

Underlying Mechanisms and Measuring Outcomes. Even though the word attention is prominent in the very diagnostic label (ADHD), the problems reflected in this diagnosis actually reflect deficits in more central cognitive processes, especially executive functioning (EF or on the deficit side, ED referring to executive dysfunction). Effective EF is needed for success in most tasks of adulthood in this society – planning, organization, execution, prioritizing, social skill, delay of gratification, and impulse control. Individuals with ADHD as defined in the DSM have difficulty with these tasks, and the issue in much of the literature has focused on whether ED is a correlate of ADHD or a criterial feature of ADHD much like the other symptoms in the DSM. There is uniform agreement that individuals with ADHD have difficulty with EF when it is assessed in addition to assessing the diagnostic symptoms of ADHD. Executive Dysfunction (ED) is the mechanism that translates the diagnosis of ADHD in the life difficulties experienced by adults who have this disorder. Therefore, any assessment or formal tracking of treatment outcomes must also address ED.

Specific Rationale for the Proposed Measurement Process. For the purpose of the proposed measure in this document the work of Adler and his colleagues provides the rationale and justification for the selection of the ASRS as the outcome assessment tool. The ASRS developed by the WHO Workgroup on Adult ADHD, is a patient report rating scale based on DSM ADHD symptoms that has been extensively used in clinical work and in research. (Adler, Kessler & Spencer, 2003; Kessler, et. al., 2005). The ASRS is publicly available and is easy to use in clinical settings. Given that ED central to addressing the impact of treatment it needs to be part of the assessment of outcome. In a series of important papers on this topic Adler and his associates have investigated the relation between ADHD/ED relationship and have demonstrated that independent measures of ED are highly correlated with ADHD symptoms in multiple samples (Adler, Faraone, Spencer, Berglund, Alperine, & Kessler, 2017; Silverstein, Faraone, Alperin, Biederman, Spencer, & Adler, 2018; Silverstein, Faraone, Leon, Biederman, Spencer, & Adler, 2018). In Adler et al. (2017), the intercorrelations between symptoms and ED are so substantial that the argument is made that ED is a core feature of ADHD and not simply a correlate of it. For the purpose of the measure proposed in the current document this work means that using the ASRS serves not only as a symptom measure but also serves as a proxy for the measurement of ED. Therefore, there is substantial empirical support for using only a symptom measure to track outcomes of care because this assessment also measures the mechanism that underlies the surface symptoms that are both reported by patients and observed by researchers.

The use of the ASRS in the current project is iterative step in developing a robust set of metrics and measures for assessing and monitoring the process and outcomes of care for adult ADHD. Also related to ADHD in adults are other emotional issues and quality of life difficulties (Agarwal, Goldenberg, Perry, & Ishak, 2012; Barkley, 2015).While these topics are important, and can be addressed either in metric refinement or new measures, they are excluded from this initial measure in this important area. The identification and development of this measure is consistent with the measure development model developed by the American Psychological Association (APA, see Wright, Goodheart, Bard, Bobbitt, Butt, Lysell, McKay, & Stephens, 2019 for overview of the APA project). Also excluded from this metric is proscription about the type of treatment that patients receive. It is expected that clinicians from different professional backgrounds will draw upon the above referenced Guidelines and also on the extant published literature on clinical best practices.