Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting an estimated 5–11% of children and adolescents (American Psychiatric Association [APA], 2013; Centers for Disease Control and Prevention [CDC], 2014). Attention-deficit/hyperactivity disorder is increasingly diagnosed and treated in primary care and is one of the most frequently managed conditions in pediatric settings (Daley et al., 2014).
The physical and psychological morbidities of poor school performance, social isolation, depression, and potential related long-term effects of underemployment may result in increased societal and health care costs (Shaw et al., 2012). Children with ADHD often have associated learning disabilities, making reading or attending to written tasks difficult. This may further an academic achievement gap, thereby calling for lengthy and arduous assessments (DuPaul, Gormley, & Laracy, 2012).
The American Academy of Pediatrics (AAP, 2011) recommends the use of standardized instruments in the diagnosis and ongoing treatment of ADHD. However, some studies demonstrate that only 55–85% of initial diagnoses are made using a standardized tool (Epstein et al., 2014). In follow-up assessments, less than 10% of primary care providers (PCPs) use validated instruments (Epstein et al., 2014; Jain, 2016).
Considering the potential long-term health care and societal costs, the number of clients theoretically affected, and the current recommendations, the question arises, are there rapid assessment tools that PCPs can use? This article explores the development of a visual analog scale (VAS) and preliminary understandings about the use of the scale in practice.
Attention-deficit/hyperactivity disorder is characterized by inattention, forgetfulness, impulsivity, disorganization, distractibility, and hyperactivity. These symptoms occur frequently and their severity is inconsistent with age or developmental level (APA, Diagnostic and Statistical Manual-V [DSM-V], 2013). Attention-deficit/hyperactivity disorder impairments often shape social, academic, and occupational functioning (Uchida, Spencer, Faraone, & Biederman, 2015). To meet the diagnostic threshold, symptoms must occur in multiple settings (e.g., home, school).
Eleven percent of the pediatric population may have ADHD (APA, 2013). This estimate does not reflect children (a) obtaining care from nontraditional providers (e.g., naturopaths), (b) unable to access the health care system due to immigration or economic status, or (c) with parents who have a philosophical or political belief, which inhibits them from accessing allopathic care. These exclusions may mean that more than 11% of children have ADHD symptoms.
The long-term consequences of untreated or undertreated ADHD are many (Uchida et al., 2015). Adults diagnosed with ADHD in childhood, but not treated, have been reported to have poor outcomes in many areas of life, including social function, education, criminality, substance use, and occupational achievements (Shaw et al., 2012). Additionally, reduced earnings and social well-being (e.g., fewer friends and increased risk of divorce) may be the result of undertreated or nontreated ADHD. Families of children with ADHD have high levels of stress which may lead to increased family conflict, undermining of positive parenting resources, escalation of childhood dysfunctional behaviors, and negative influence on the family process (Algorta et al., 2014). All these contribute to morbidity and require early attention (Uchida et al., 2015).
Current practice guidelines
Current guidelines for the diagnosis and treatment of ADHD in children and adolescents (4–18 years) have been published by the AAP (2011) and are currently considered the best practice for US health care providers (CDC, 2017). The recommendations vary by age and include the use of standardized scales at diagnosis and follow-up, with the recommendation that medication treatment be augmented by behavioral support. The diagnosis is based on input from the family, caregivers, and school. It is important that the symptoms must occur in multiple venues.
Follow-up assessment should occur at regular intervals (e.g., monthly) until there is an optimal and consistent medication response and then at every 3 months (due to federally mandated prescribing requirements) to best achieve client outcomes (Gabay, 2013). As mentioned, the use of standardized instruments in follow-up visits may be less than 10% in PCP's practice (Epstein et al., 2014).
Barriers to assessment instrument use
One third to one half of children with ADHD have associated learning disorders (DuPaul et al., 2012), which may render lengthy assessment tools difficult for this population (Reif, 2005) and undermine their utility. Also, children younger than 8–9 years may not be developmentally able to assess their symptoms.
Attention-deficit/hyperactivity disorder is increasingly managed by PCPs who have limited time to conduct comprehensive client interviews (Stein et al., 2008; 2009). It is difficult for these providers to collect, collate, and score information from multiple sources, and many believe that they lack the training to manage mental health concerns (Stein et al., 2008). The development of shorter versions of rating scales has not dramatically increased the use of standardized tools in follow-up appointments (Epstein et al., 2014; Jain, 2016).
These constraints may undercut current instruments for collecting, monitoring, or optimizing the impairments prioritized by the client. The design of currently available ADHD rating scales for children and adolescents may not be ideal for capturing and quantifying client perception. Consequently, this article focuses on an alternative tool design to improve clinician effectiveness and efficiency in quantifying the perceptions and experiences of pediatric patients with ADHD.
The question arises: in follow-up appointments, would an alternative instrument improve provider efficacy and productivity in quantifying the perceptions and experiences of pediatric clients with ADHD? A VAS may assist in the assessment of client symptoms, especially with the pediatric population and their families. This question is explored more fully later.
Initial assessment of the Devney visual analog scale (DVAS) was done using three methods, including a brief literature review, an interview with the instrument developer, and a limited chart review. The purpose of the developer interview and chart review is discussed next under each section.
A PubMed, Articles+, ERIC, CINAHL, and Google Scholar search was conducted. The search identified articles, studies, and reviews on the use of instruments supporting clinician management of ADHD and determining whether any VASs for ADHD currently exist in the literature. MeSH and/or search terms included “ADHD,” “scale,” “instrument,” “visual analog,” “measure,” and “outcome.” Searches were limited to sources published within the last 25 years and were selected for the initial review based on the title and/or abstract relevance. References within selected publications were reviewed to identify additional sources not found in the initial search parameters. Sources older than 25 years were occasionally included to provide appropriate historical context. Of 47 articles reviewed, 37 were included. Articles were excluded based on topic and scope relevance, following abstract review. Only articles in English were included.
The results of the literature review suggest that no VASs have been proposed or published for use in pediatric patients with ADHD, even though VASs are easy to use and have been demonstrated as beneficial for use in other psychiatric conditions (Williams, Morlock, & Feltner, 2010). Current ADHD assessment tools require time and resources, entail additional training, and involve coordination of assessments from multiple sources (Epstein et al., 2014; Stein et al., 2008).
Currently available, standardized assessment tools
It is currently unknown which standardized test is used most frequently for ADHD diagnosis in primary care. An all-inclusive list of instruments is beyond the scope of this literature review; however, those commonly used include (a) Child Behavior Checklist (CBCL/6–19) (also known as the Achenbach CBCL [Achenbach & Ruffle, 2000]), (b) Conners' Scale-Revised Parents/Caregivers and Scale-Revised Teacher (Conners, 2018) and the Conners-Wells' Adolescent Self-Report Scale for Teenagers, (c) Vanderbilt ADHD Parent Rating Scale (2002) and the Vanderbilt Teacher Rating Scale (National Institute for Children's Health Quality, 2003), and finally for children is the (d) ADHD Rating Scale-IV (DuPaul, Power, Anastopoulos, & Reid, 2016). Each of these tests has been standardized and is readily available but not without constraints or potential limitations. Table 1 provides a summary of the required time, the potential number of forms, and information for these tests.
Organizing input from multiple sources, tallying, and interpretation are required. Most of these tests require a small amount of additional training to understand their strengths, limitations, and ranking processes. These elements contribute to the underuse of standardized tests in follow-up appointments (Epstein et al., 2014).
Nonetheless, the consistent use of standardized rating scales during client visits yields numerous benefits, such as (a) improved client outcomes, (b) consistent assessment of the same symptoms, (c) facilitating client–provider communication about symptoms perceived to be most challenging for the client, (d) educating the client about the expected outcomes, (e) assessing symptoms in different venues, and (f) reduction in the incidence of potentially catastrophic results, like suicide or hospitalization (Baer & Blais, 2009).
Provider time constraints and limitations of available tools may mean a more accessible measurement instrument is warranted. Considering these factors, the authors demonstrate initial benefits of an as yet unvalidated VAS based on an interview with the developer and a limited chart review.
Visual analog scales
Visual analog scales have been used since the early 1900s in psychological assessments; they offer minimal provider and respondent burden and are effective in assessing mood, pain, quality of life, and anxiety (Williams et al., 2010). They are well established as a valid and reliable instrument for measuring subjective experience (McCormack, Horne, & Sheather, 1988) and are efficient to administer. Their established effectiveness in other psychiatric disorders served as a foundation for the development of the DVAS. Given the clinical and operational considerations of providers and requirements of clients with ADHD, a VAS may fill an unmet need in follow-up appointments for a viable alternative to current rating scales. To date, no VAS appears to have been described or published for clinical use in pediatric clients with ADHD.
Current practice context
Because current ADHD tools require staff, provider, and patient time, and despite the development of shorter versions of rating scales, the use of standardized tools in follow-up appointments has not dramatically increased (Epstein et al., 2014). Understanding the benefits and challenges (Baer & Blais, 2009) of standardized tests and that they are underused may facilitate the adoption of a VAS in the practice environment of today.
Interview with “D” visual analog scale developer
After completion of the literature review, a structured interview was conducted between Dr. D., community child psychiatrist, the developer and initial tester of the DVAS, and J.S. This took place on October 13, 2016, in the practitioner's office. The structured interview described the development and clinical application of the DVAS and collected the developer's initial data on the effectiveness and utility of the DVAS. The assumptions on which the instrument was built are outlined in the Discussion section.
The DVAS for ADHD was developed to quantify, monitor, and optimize the medication management of patients with ADHD. The DVAS was established to support efficiency and quality of follow-up clinical assessments in ADHD medication response, especially within clinical settings under increased time constraints. The DVAS provides clinicians with an easy-to-use and consistent instrument during clinical interviews. It allows for quantitative monitoring and documentation, thereby supporting the optimization of medication management over time.
The DVAS provides a graphical representation of a client's perception of their current ADHD symptom control compared with their peers without ADHD. Scoring ranges from zero (ADHD symptom impairment without medication) to more than 125. One hundred represents the average ability of peers without ADHD. The partial distribution curve within the DVAS represents a cross-section of peers without ADHD for the symptoms of inattention, forgetfulness, distractibility, disorganization, hyperactivity, and impulsivity (R. Devney, MD, personal communication, October 13, 2016) (Appendix, Supplemental Digital Content 1, http://links.lww.com/JAANP/A20).
According to D. (personal communication, October 13, 2016), the DVAS is intended for use in follow-up appointments after establishing a formal diagnosis of ADHD using DSM-V (2013) criteria, preferably with the support of a validated ADHD Rating Scale, such as the Conners ADHD Rating Scale. The developer states that it is crucial that provider, patient, and caregiver(s) share a common baseline understanding of the patient's particular ADHD impairments, relative to peers without ADHD, before the DVAS is incorporated into follow-up appointments. Although complete elimination of ADHD impairments may be unattainable, the DVAS targets symptom control between 80 and 100 (Appendix, Supplemental Digital Content 1, http://links.lww.com/JAANP/A20). This represents patient function comparable with a peer without ADHD (instructions for DVAS given in the Appendix, Supplemental Digital Content 1, http://links.lww.com/JAANP/A20).
The DVAS has been successfully incorporated into the developer's practice for a decade and used in more than 1,000 patients. D. states (personal communication October 13, 2016) that the DVAS has been well received by pediatric clients and their caregivers. The use of the DVAS during follow-up ADHD appointments improved the understanding of client perceptions and treatment goals (personal communication). The DVAS provided the ability to quantitatively assess medication effectiveness at specific points in time and illustrated trends over time, thereby improving provider–client efficiency and alignment of treatment expectations and decisions. The psychometric properties of the DVAS still need to be assessed within a broader cross-section of providers. Nevertheless, this instrument may improve the efficiency of provider–client dialogue, treatment follow-up, and alignment of goals during the clinical interview process.
In July 2018, a chart review was conducted. The purpose of the chart review was to determine whether the DVAS was used during the clinical interview. If so, did it (a) alter the practice, (d) change the assessment, and (c) change the patient's prescription? The review was completed in a community psychiatrist's office. Two providers were psychiatric mental health nurse practitioners and one was a psychiatrist.
Attention-deficit/hyperactivity disorder diagnosis code (combined and inattentive predominant), treatment within the past year, and age (5–22 years) were the inclusion criteria. The exclusion criteria were age above 22 years, no ADHD diagnosis code, and no treatment within the past year.
The office manager selected the first 27 charts meeting inclusion criteria. Ten charts per provider was deemed a representative sample because each provider thought this equaled about 5% of their patients with ADHD. One provider was new and only had seven relevant charts. Most patients had comorbidities; these are listed in Table 2. The impact of the comorbidities and medications may have an effect on patient symptoms and perception of ADHD symptoms. This warrants further study.
One of the providers demonstrated the routine use of the DVAS in follow-up visits and the other two did not. The DVAS user did not use it at every follow-up visit but did when the patient or the family noted that there was behavior change indicated in the chart note. The provider using the DVAS was the instrument developer. A notable difference between the DVAS user and nonusers is detailed next.
Chart review findings
The significant finding from the chart review was that the use of the DVAS highlighted each symptom of ADHD, that is, inattentive, impulsive, and the symptom assessment was more comprehensive. Nonusers asked only about focus. The effect of medication was viewed more broadly with DVAS use. Patients were asked about the full range of symptoms, not focus alone. The use of the DVAS may assist in aligning client and provider goals by decreasing ADHD symptoms and thereby supporting provider efficacy. These findings may support DVAS use, but more study is required.
To maximize treatment outcomes, the diagnosis should be made efficiently and follow-up completed in a systematic manner (AAP, 2011). Considerations must be given to (a) increasing ADHD treatment and diagnosis in primary care, (b) greater pressure on PCPs to efficiently manage patients with ADHD, (c) current tools requiring intensive provider and staff time, (d) patient difficulty using longer and more comprehensive evaluations, (e) high number of children with ADHD, (f) the resultant negative sequelae and potential poor outcomes of under or nontreated ADHD, and (g) the impact on families.
Despite these concerns, many providers continue to express objections to the regular inclusion of standardized instruments within clinical practice. These reservations include (a) the length of time to administer and score, (b) fears of practice mechanization, (c) undermining client–provider dialogue, (d) beliefs that quantification is not necessary to treat subjective conditions effectively (Goodman, 2009), and (e) administrative burden of collecting and collating materials. Increasing administrative load and burnout among US health care providers, especially those in primary care, indicate that they may benefit from more efficient patient evaluation tools (Shanafelt et al., 2015). A VAS for use in ADHD follow-up appointments may improve care without increasing provider workload (Shanafelt et al., 2015).
The DVAS may be a VAS that facilitates follow-up; however, there are many underlying assumptions with this instrument. One of these is that patients and families have a good sense of how peers without ADHD operate in the world. Additionally, they assume that those they are observing do not have ADHD. Also, different families, cultures, socioeconomic classes, races, and religious denominations have different expectations about children's behavior. It is unknown how these elements may affect the patient and family scoring on the DVAS. Self-scoring, by definition, can be highly subjective; however, because the client/family is assessing their own symptoms, it may not be a significant consideration.
The DVAS was initially used in a community psychiatric practice. As a result, many of the patients had co-occurring diagnoses. This population may be different from that seen in the primary care arena, which may affect the utility of the instrument in this environment.
A beneficial finding from the small chart review was that the provider using a rapid assessment tool (DVAS) asked about the range of symptoms of ADHD (inattentive, impulsive, forgetful, distractible, disorganized, and hyperactive), whereas those not using the DVAS simply inquired about the focus. The tool may support a more comprehensive understanding of the effect of treatment on all ADHD symptoms.
Advantages of the DVAS may be (a) the ease of use for patient and provider, (b) more expeditious and comprehensive follow-up assessment of ADHD symptoms, and (c) a regularized approach to ADHD assessment within a group of providers. Currently, there are no easy to use ADHD patient assessment tools. The authors offer several conclusions based on the investigation.
To the best of the authors' knowledge, the DVAS is the first VAS developed specifically for use in clients with ADHD. Additional research is needed to establish the validity and reliability and is recommended as the next step. Future research on the DVAS will include gathering, assessing, and integrating provider feedback from a broad cross-section of clinicians, identifying opportunities to improve both patient usability and provider utility. After completion of this process, multisite and multiuser investigations are planned to further assess the psychometric properties, clinical settings, and client populations that may benefit from this tool. Consideration will be given to developing electronic or app-based versions.
Considering the changing landscape of health care, patient requirements, and PCP needs, an easily accessible instrument for ADHD assessment is needed. Initial exploration of the DVAS via chart review and developer data highlights the importance of using an instrument to assess all ADHD symptoms and response to treatment in follow-up visits. Standardization of the DVAS may provide a quick, efficient tool for the assessment of ADHD symptoms during evaluation of medication management after ADHD diagnosis.
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