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CNS Vital Signs Advancing

Attention Deficit Care


AddingValuetoYourPracticebyProvidingSolutionsforMeasuring,
MonitoringandManagingNeurocognitiveandBehavioralHealth

www.CNSVS.com

Contents

WhyCNSVitalSigns?..
WhyCNSVitalSignsinAD/HD?..
AD/HDGuidelinesandCNSVitalSigns..
AboutCNSVitalSignsAssessmentPlatforms..
CNSVitalSignsADD AD/HDCaseStudies.....
OptimizedforAD/HDGuidelines..
AboutCNSVitalSignsClinicalDomainsinAD/HD
CNSVitalSignsAssessmentPlatformImplementation
AD/HDReimbursementInformation.
NextSteps..

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36

Thefollowingpageshavebeenassembledfromvarioussourcesandpublicationsandismeanttobea
referenceorroadmapguidetoassistandinformhowCNSVitalSignscanbeusedtoimproveclinical
insightandcaremanagement,enablecurrentguidelines,beintegratedintoaclinicorpractice,and
helpimprovedpracticerevenuesandperformance.

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

Why CNS Vital Signs?


CNSVitalSignsstrivestoprovidecliniciansavalid,
reliable,andaffordable,researchquality
assessmentplatform.TheCNSVitalSigns
assessmentplatformshelpsto supportapractices
comprehensive,stateoftheartclinical
assessment,andevidencebasedtreatment
servicesforchildren,adolescents,andadults
acrossthelifespanby:

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

Introduction: CNS Vital Signs in AD/HD


CNSVitalSignsprovidescliniciansandresearcherswithleadingedgeneurocognitiveandbehavioralhealthassessmenttechnologiesthat
efficientlycollectsvalidandreliablebrain&behavioralclinicalendpointsforamoreobjectiveviewofapatientsfunctionalstatus,disease
progression,andoutcomes. Attentiondeficit/hyperactivitydisorder(ADHD)isacommonneurobehavioralconditionthatimpairsfunctioning
throughoutchildhood,adolescence,andadulthood.EvidencebasedguidelinesforthetreatmentofADHDrecommendrecognizingADHD asa
chronicconditionacrossthelifespan.TheCNSVitalSignsAssessmentplatformsupportsalifespanchroniccaremodelandhelpsenable
productiveinteractionsbetweenthefamily,teachers,andaspecialistpracticeteam.Keyparentandyouthscreeningtools,parentteacher
physicianassessment(ratingscales),andneurocognitivetestingassessmentscanbeusedtoefficientlyevaluateandmanageAD/HD,
medicationtitrationandongoingmonitoring.BarriersinprimarycaresettingscanimpedethedeliveryofhighqualityAD/HDcareanda
collaborative(specialist),systemsbasedapproachcanhelpsupportthecurrentguidelines andadvanceAD/HDcare.
CNSVitalSignscomputerizedneuropsychologicaltests canenhanceefficiencyandinsightinassessingcognitivestatusandthedifference
betweennormalperformanceandapatientscurrentstatusand providestheclinicianwithanormativecomparisonthatcanbepairedwith
aninterview,exam,andothervalidtest(s)e.g.BRIEF,Conners,Brown,Barkley,etc.tohelpaddvaliditytotheevaluationandmanagementof
attentional andexecutivedeficitsordysfunction.ReevaluationorserialtestingwithCNSVitalSignssupportstheeffectivemanagementand
tailoringofmedicationsandassessmentofoutcomes.Averydetailedassessmentofabilitiesisautoscored,andthepatternofstrengthsand
weaknessescanbeusedintreatmentplanningandmeasuringprogress.
CNSVitalSignsVSXBRIEFCOREassessmentplatformcontainsseventestsofneurocognitivefunctionwhichareautoscoredintonineclinical
domains,theVSNPbatteryaddsthreeadditionalnormedtests.TheCNSVitalSignsAD/HDtoolboxalsocontainsFREEevidencebasedrating
scalessuchastheVanderbiltADHDDiagnosticParent&TeacherRatingScales,VanderbiltAssessmentFollowupParent&TeacherRating
Scales,AdultADHDSelfReportScale,PediatricSymptomChecklistPSC35YouthSelfReportYPSC35 &PSC17,NeuroPsych Questionnaire
NPQ207&NPQ45bothAdolescent&Adult,SCAREDChildAnxietyRatingScale,ChildOCDInventory,andtheEpworthandPittsburghSleep
Scales.TheCNSVitalSignsADD AD/HDToolboxautomaticallyscoresandsystematicallydocumentstheresultingclinicalendpoints.The
resultingreportscanhelpinform(ruleinorruleout),confirmstatus(levelofimpairment)andlongitudinallytrackacondition(outcomes).
Ifyouhavequestionorwouldliketoregisterforafreeinservicewebinargotowww.CNSVS.com oremailsupport@cnsvs.com orcall
1.888.750.6941.

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

Why Use CNS Vital Signs to Assess AD/HD?


TheCNSVitalSignsVSXAssessmentPlatformrepresentsalegacyofinnovationandacommitmenttoadvancing
neurocognitiveandbehavioralclinicalassessmenttoolsthathelpsupportaTEAMMANAGEMENTconceptbetween
primarycareandspecialists.

FREE Screening

Clinical Pathology

Comorbid Status

PracticeEfficiency

MeasureandMonitor

MeasureandMonitor

Assess and Determine


Possibility of IMPAIRMENT

Assess BRAIN FUNCTION, to


help Rule-In or Rule-Out

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

Why Use CNS Vital Signs to Assess AD/HD?


Frontal Lobe
ObjectiveMeasureofClinicalPathology
Frontal Lobe
Tests
Symbol
Digit
Coding
(SDC)

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

Optimized to Support NEW AAP Guidelines


Summary of key action statements:

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

Optimized to Support AACAP Guidelines


AmericanAcademyofChildandAdolescentPsychiatry(AACAP)

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

Optimized to Support AACAP Guidelines


AmericanAcademyofChildandAdolescentPsychiatry(AACAP)

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

Optimized for ADD AD/HD Assessments

Patient

Health
Outcomes

Caregiver &
Informants

Evaluation and
Management

Brain Behavior
Objective
Neurocognitive
Assessment

e.g. Parent, Teacher,


Spouse, etc.

Evidence Based Health


Rating Scales

Care Management Reports


BrainFunction Symptoms Comorbidities

Standardized and Secure Data


EasyExporttoEMRandSpreadsheetforAnalysis
1600+NormsfromAges8to90 SystematicDocumentation

Care Team

CNS Vital Signs Neurocognitive


Battery in AD/HD
Theneuropsychologicalproblemsassociated
withADHDhavebeenwelldocumented,and
typicallyarecharacterizedascoredeficitsin
attentionandexecutivefunctioning.
Computerizedneuropsychologicalbatteries,
likeCNSVitalSigns,arebecomingmore
popularinADHDclinicalresearchand
practice.Themethodforsimultaneously
interpretingthedomainscoresfromthis
batteryconstitutesauniqueapproachthat
appearstoidentifythesubsetofpatients
withADHDwhopresentwithneurocognitive
deficitspriortoreceivingtreatment.
Adaptedfrom:ClinicalUsefulnessofCNSVitalSignsfor
AssessingNeurocognitioninADHD;APA2007

TheCNSVitalSignsAD/HDToolboxhelpsclinicianssystematicallycollectAD/HDbrainfunction,symptoms,and
comorbiditiesdata,automaticallyscoringandsystematicallydocumentingtheresultingclinicalendpoints.

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

10

A Systems Based Approach


AD/HDNeurocognitiveTests

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

SOPHISTICATEDyet SIMPLE SystemsBased


approachtoScreening,Assessment,&Surveillance
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

11

Advancing Attention Deficit Care


CNSVitalSignsADDAD/HDNeurobehavioralToolbox

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

Computerized Medical and


Health Rating Scales*
VanderbiltADHDDiagnosticParent&Teacher
RatingScales
VanderbiltAssessmentFollowupParent&
TeacherRatingScales
AdultADHDSelfReportScale
PediatricSymptomChecklistPSC35Youth
SelfReportYPSC35 &PSC17
NeuroPsychQuestionnaireNPQ207&NPQ
45bothAdolescent&Adult
SCAREDChildAnxietyRatingScale
ChildOCDInventory
EpworthandPittsburghSleepScales
* UsedwithpermissionFreeuseofratingscales

12

How can CNS Vital Signs HELP?


Unique Cognitive Profile

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.

Clinical Tailoring of Medications


for Impairments of Executive
Function in ADHD

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

Every patient with ATTENTION DEFICIT


has a Unique PROFILE.
Johnny,atwelveyearoldboy
strugglinginschoolwasgiven
CNSVitalSignsVSXBRIEF
COREClinicalBatteryhe
scoredbelowaveragein5of9
cognitivedomains(predose).
AfterexaminingtheH&P,the
testresults,andthePCS
pediatricsymptomchecklist&
VanderbiltAD/HDrating
scales;Johnnywasgivena
prescriptionmedication.Four
weekslaterhewas
administeredthetestagain
(postdose).
TheCNSVitalSignsreportis
availablesecondsafterthe
testingsessionendsandisa
usefultoolforassessing
academicandvocational
accommodationsaswellas
measuringmedicationeffect
andhelpingclinicianstailor
medicationstogetthe
minimumdosevs.maximum
neurocognitiveeffect.

Pre Dose

Post Dose

Domainsmostsensitivetoattentiondeficitconditions.

For the first time I am able to show my son that his


mind functions better when he is on his medication
than when he is not Johnny's Mother

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

Our relatives are always giving us a hard time about


giving our boys AD/HD medicine. For the first time I
have proof that they need their medicine.
Johnny's Father

14

College Student Attention Deficit Case Study


1 PRE: Part of AD/HD Assessment Protocol

=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

College Student Attention Deficit Case Study


1 PRE: Part of AD/HD Assessment Protocol
James K. 21 Year Old College Student: Adult ADHD Self-Report Scale (ASRS-v1.1)
1

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

ASRS Total Score

40

16

College Student Attention Deficit Case Study


2 POST: Part of AD/HD Assessment Follow-up

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

NEW AAP AD/HD Process-of-Care Algorithm


HOW CNS Vital Signs CAN HELP!
4to18yearold
patientidentified
withsignsor
symptoms
suggesting
ADHD.Symptoms
cancomefrom
parentsdirect
concernsorthe
mentalhealth
screen
recommendedby
theTFOMH

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

Optimized to Enable Guidelines


FREE Screening
Action Statement 1:
Theprimarycareclinicianshould
initiateanevaluationforADHDforany
child4through18yearsofagewho
presentswithacademicorbehavioral
problemsandsymptomsof
inattention,hyperactivity,or
impulsivity(qualityofevidence
B/strong recommendation).

Pediatric Symptom Checklist


Validatedandwidelyusedscreeninginstrument:Murphy
etal.,1992,1996;Galletal.,2000;Paganoetal.,2000
http://www2.massgeneral.org/allpsych/psc/psc_home.htm

AAPCommitteeonChildrenwithDisabilities
recommendsroutinestandardized
developmentalandbehavioralscreening

reaffirmthemandateforchildhealthprofessionals to
provideearlyidentificationof,andinterventionfor,
children withdevelopmentaldisabilitiesthrough
communitybasedcollaborative systems.
SOURCE:CouncilonChildrenWithDisabilities,
etal.Pediatrics 2006;118:405420

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

19

Optimized to Enable Guidelines


FREE AD/HD Scales

Validated and widely used AD/HD


Assessment Instruments:
VanderbiltADHDDiagnosticParent&Teacher
RatingScales
VanderbiltAssessmentFollowupParent&
TeacherRatingScales
AdultADHDSelfReportScale
VanderbiltADHD
DiagnosticParent
Example

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

Optimized to Enable Guidelines


Comorbid Assessment

50+ Well Known Symptom,


Behavioral, and Comorbid
Assessment Instruments
NeuroPsych QuestionnaireNPQ207Intake
Adolescent&Adult
NeuroPsych QuestionnaireNPQ45Followup
Adolescent&Adult
ScreenforChildAnxietyRelatedDisorders
(SCARED)ChildVersionLF41
ScreenforChildAnxietyRelatedDisorders
(SCARED)ParentVersionLF41
Usedwithpermission:BorisBirmaher,M.D.,Suneeta Khetarpal,M.D.,Marlane Cully,
M.Ed.,DavidBrentM.D.,andSandra,McKenzie,Ph.D.,WesternPsychiatricInstitute
andClinic,UniversityofPgh.

Action statement 3: Intheevaluationofachildfor


ADHD,theprimarycareclinicianshouldinclude
assessmentforotherconditionsthatmightcoexistwith
ADHD,includingemotionalorbehavioral(eg,anxiety,
depressive,oppositionaldefiant,andconductdisorders),
developmental (eg,learningandlanguagedisordersor
otherneurodevelopmentaldisorders),andphysical(eg,
tics,sleepapnea)conditions(qualityofevidenceB/strong
recommendation).

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

ChildObsessiveCompulsiveDisorder
Inventory(OCDC)SF20
SocialAnxietyScaleforChildrenand
Adolescents(SASCA)SF20
EpworthSleepinessScale(ESS)SF8
PittsburghSleepQualityIndex(PSQI)SF10;
Zung DepressionandAnxietyScales
+ManyMore

21

Tools to Help Assess AD/HD and Comorbidities


NPQ 207
RapidIntaketo
AssesstheNeuro
PsychStatusofa
Patient
Reported Symptoms
Possible
Comorbidities

Autoscores
Twenty
NeuroPsych
Symptomsand
EightPossible
Comorbidities

NeuroPsych Questionnaire (NPQ) LF-207 (Page 1 of 9)


Subject Reference/ID: John Doe

Test Date: February 11 2009 11:24:43

Age: 23

Administrator: Med Tech

Total Test Time: 10:31 (min:secs)

Language: English (United States)

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

Average Symptom Score

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

Obsessions & Compulsions

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.

22

Helping Assess Comorbidities


Cognition and Depression
Indeed,thereissomesuggestionthatcognitiveor
executivefunctioningdeficitsmaybeatraitriskfactor
fordepression(DouglasandPorter,2009;Fraschetal.,
2009;Miccoetal.,2009;Reppermundetal.,2009).
Furthermore,worseneuropsychologicaltest
performanceatbaselineisassociatedwithpoorer
responsetotreatment(Dunkinetal.,2000;Kampf
Sherfetal.,2004;MohlmanandGorman,2005),and
cognitivedeficitsaremorepronouncedinpatients
whoareunemployed(Baune etal.,2010).Itispossible
thattreatmentrefractorydepressionisasubtype
characterizedinpartbycognitiveimpairment.
Theaccurateidentificationandquantificationofneurocognitiveimpairmentareimportantforresearchrelatingto
neurobiologicalunderpinnings,treatment,andfunctionaloutcomeinpatientswithmooddisorders.Itisessential,
methodologically,thatwehaveaccuratemethodsforidentifyingthosepatientswhoareobjectivelycognitivelyimpairedand
separatethemfrompatientswhohavethesubjectiveexperienceofpoorthinkingskillsorthinkingthatiseasilyperturbedby
negativeaffect,butperformnormallyoncognitivetestingincontrolledconditions.Thetreatmentsandoutcomesforthesetwo
groupsmaydiffermarkedly,aswellastheprognosis.
Source:Identifyingacognitiveimpairmentsubgroupin
adultswithmooddisorders.JAffectDisord.2011
Aug;132(3):3607.Epub 2011Mar25.
http://www.ncbi.nlm.nih.gov/pubmed/21439647

23

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

23

Cognition and Depression


Cognitive Flexibility

HealthyControl
MoodDisorder,NormalCognition
MoodDisorder,CognitiveImpairment

Domain scored from two venerable AD/HD tests

45
40
35
30
25
20
15
10
5
0
40-49

50-59

60-69

70-79

80-89 90-99 100-109 110-119 120-129 130-139

Fig.3.DistributionsofCNSVitalSignscognitiveflexibilityindexscoreinpatientswithorwithout
impairedcognition.Figurenote:Healthycontrol,N=660.Mooddisorder,normalcognition,n=128.
Mooddisorder,cognitiveimpairment,n=58.*Normativescoresweretruncatedat40.Eachvalue
representsthepercentageofsubjectsinthatscorerange.

24

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

24

The Comorbidity of Depression and Attention /


Cognitive Deficits are well Known
ToolstoAssessComorbidityandDifferentialDiagnosis
Theclinicianneedstoolsthatassistwithscreeningandrecordinginformationonsymptomsofpossiblecomorbid conditions
andthatprovidetheinformationneededtorecognizewhenfurtherexpertiseorevaluationisneededtomakeadifferential
diagnosis.Thesetoolsmustbeuserfriendlyandfreeofcharge,andneedtoincludebothdevelopmentalandadultonset...
FrequentClinicalDilemmasandDecisionPoints
MoodSymptoms
Approximately50%ofadultswithADHDhavemoodsymptoms.Acommon
questioniswhichtotreatfirst:theADHDorthemoodsymptoms.Atreatment
strategyshouldbedevelopedinanticipationofsuboptimal responsetothefirst
agent.ADHDspecialiststypicallyseepatientswhohavepreviouslybeen
diagnosedortreatedformilddepressionordysthymia.Forpatientswho
presentwithaclearhistoryof ADHD,itisoftenbesttotreattheADHDfirst,
whilemonitoringthemoodsymptomsinresponsetothetreatment.
Inaprimarycaresettingoronewherethepractitionerhasnothadexperience
withADHD,thechallengeistoidentify someonewithpreviouslyundiagnosed
ADHD.Often,ADHDdiagnosesaremissedbecausethecomorbid disorderis
moreprominentorisonethatthepractitionerismoreaccustomedtoscreening
forbasedupontheirowntraining(depression).
SomeofthegreatestclinicalsuccessesarepatientswhohaveADHDandmildmoodsymptomsordemoralization,wherethe
ADHDhasnotbeenpreviouslytreated.WhentheADHDistreatedoptimally,themoodsymptomsoftenrespond.5 Overall,it
maybe besttoselectonetreatmentandthenmonitorbothoutcomesratherthancombineseveralmedicationsatonceso
thattreatmentresponseisnotobscuredbymultipleagents(Slide4).
CNSSpectr.2007;12(8Suppl 12):116

25

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

25

Optimized to Enable Guidelines


NeurocognitionIndex(NCI)
StandardScore

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

Action statement 4: Theprimarycareclinician

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

26

Optimized to Enable Guidelines


Medication Management
Action Statement 6:
Primarycarecliniciansshould
titratedosesofmedicationfor
ADHDtoachievemaximum
benefitwithminimumadverse
effects(qualityofevidence
B/strongrecommendation).

70%ofchildrenandyouthwithADHDrespondtoone
ofthestimulantmedicationsatanoptimaldosewhena
systematictrialisused.Childrenwithlessfrequent
monitoringandhadlessoptimalresults.Because
stimulantsmightproducepositivebutsuboptimaleffects
atalowdoseinsomechildrenandyouth,titrationto
maximumdosesthatcontrolsymptomswithoutadverse
effectsisrecommendedinsteadoftitrationstrictlyona
milligramperkilogrambasis.
thattheprocessmightrequireafewmonthstoachieve
optimalsuccess,andthatmedicationefficacyshouldbe
systematicallymonitoredatregularintervals.

Evenwithoptimaltreatment,basedonparentsand
teachersopinions,subtleandnotsosubtleneurocognitive
impairmentspersistedintheADHDpatients.

2008 MHS Keith Conners Award


for Scholarly Contribution
JADispleasedtoannouncethe2008winneroftheMHSKeith
Conners Awardforscholarlycontributiontothefieldof
attentiondeficithyperactivitydisorder(ADHD).The winning
articletitled,MedicationsDoNotNecessarilyNormalize
CognitioninADHDPatients,appearedinVolume11,pages
459469.Theauthors,C.ThomasGualitieri andLyndaG.
Johnson,areassociatedwiththeNorthCarolina
NeuropsychiatryClinics.Theirarticleevaluatedperformance
onacomputerized,neurocognitivebatteryforpatientstaking
threedifferentADHDmedicationscomparedtopatientswith
ADHD,absentmedicationandnormalcontrols.Significant
differencesweredetectedbetweennormalpersonsand
untreatedpatientswithADHD.TreatedpatientswithADHD
performedbetterthanuntreatedpatientsbutremained
significantlyimpairedcomparedtonormalpersons.
AdaptedFrom:2008JADAwards;JAtten Disord 2009;13;203

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

27

About CNS Vital Signs AD/HD Domains


The Executive Function Domain
ExecutiveFunctioningreferredtoasthe"commandandcontrol"function(frontallobe);theexecutivefunctioncanbeviewedasthe
"conductor"ofmanycognitiveskills.TheShiftingAttention(rules,categories,rapiddecisionmaking)testresultsareusedto calculatethis
frontallobedomain.OfallthetestsinCNSVitalSigns,itisprobablythemostsensitive.ADHDpatientsmakefewercorrectresponsesthan
normals,andmoreerrors.ADHDpatients,asagroup,havelongerreactiontimesontheSAT.Asagroup,ADHDpatientsareslowerandless
accuratethannormals.However,someADHDpatientsaremuchfasterthannormals onthistest,butmuchlessaccurate. CNSVitalSignsis
usedtocomplimentotherassessmentsofexecutivefunctionsuchastheBRIEF(Gioia),BrownAD/HD,BarkleyScales,Etc.
The Complex Attention Domain
TheStroopTest,theContinuousPerformanceTest,andtheShiftingAttentionTestcontributetotheComplexAttentiondomain. Allthreeare
testsofattention.ThecomplexattentiondomainisthetotalnumberoferrorsmadeontheStroopTest,totalnumberoferrorsontheShifting
AttentionTestandtotalnumberoferrorsontheCPT.Thecomplexattentiondomainisvery,veryclosetothecognitiveflexibilitydomainso
thetwoareusuallycorrelated.TheyarenotperfectlycorrelatedbuttheyusuallymovetogetherandtheyarestronglyindicativeofAD/HD.If
somebodyisveryloworlowonthesetests,itcanindicateorhelpruleinAD/HD.Attentionisahighercognitivefunctionthatislargely
mediatedbythefrontallobesbutotherpartsofthebrainincludingthebasalgangliaandthecerebellum.Ascliniciansknowtherearemany,
manydifferentkindsofattention.IntheShiftingAttentionTestyouhavetoshiftyourattentionfromonethingtoanother, in theStroopTest
youhavetoinhibitoneformofconceptualizationandactivateanother,andtheContinuousPerformanceTestisavenerabletest, ifyouare
doingpoorlyonthistestyoumaywellhaveAD/HD.Butallofthesethreetestsparticipateinthebroadcognitivedomainknownasattention
andforthatreasontheyallcontributetothedomainonthedashboardthatisknownasComplexAttention.
The Cognitive Flexibility Domain
TheStroopTest(ST)andtheShiftingAttentionTest(SAT)contributetotheCognitiveFlexibilityDomain.TheShiftingAttentionTestandthe
StroopTestisameasureofthepatientsabilitytoinhibitandtodisinhibitorperformexecutivecontrol,cognitiveflexibilitytaskssuchas:
decisionmaking,multitasking,goingquicklyandaccurately,orchoosinganeffectivestrategyandsoon.Theseareveryimportanttestsof
executivecontrol.ADHDpatientsalsohaveslowerreactiontimescoresontheStrooptest forsimpleRT,complexRTandtheStroopRT.This
indicatestheirrelativeinefficiencyinthiscomplextask.AD/HDPatientsalsomakemoremistakesonPart3oftheST.So:not onlydotheytake
longer,buttheymakemoremistakes.AsADHDpatientsgrowolder,theylearntomakefewermistakesontasksliketheST,buttheirRTs
remaincomparativelyslower.TheSATisalsowhatiscalledaspeedaccuracytradeofftest.Thatmeansthesubjectcanchoose togofaster
onthetest,withmorecorrectresponsesandashorterreactiontime.Thatstrategy,though,willgeneratemoreerrors.An alternativestrategy
istominimizeerrorsbygoingmoreslowly;inthiscase,thesubjectwillgetfewercorrectresponsesandwillhavealonger reactiontime.
SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

28

About CNS Vital Signs AD/HD Domains


The Sustained Attention Domain
Oneformofattentionissustainedattentionorvigilance.ThesustainedAttentiondomainisscoredfromtheinitialCPTportion ofthe4Part
ContinuousPerformancetest.Sustainedattentionorvigilantattentionisthepatientsabilitytostayalertthroughadull,boringtask.Vigilant
attentionissustainedattention.Youhavetosustainyourattentionduringaboringtask.SustainedAttentionisaspecialskillthatismeasured
bycontinuousperformancetesting.ThecontinuousperformancetypeoftestshavebeentraditionallyusedfortheassessmentofADHD.
ADHDpatientsmakefewercorrectresponsesandmoreerrorsontheCPT,andtheirCPTreactiontimeisusuallylongerthannormals.Normal
peopleovertheageof10seldommakemorethan2errorsontheCPTandrarely,ifever,makemore4errors.Itmaybesurprisingtolearnthat
ADHDpatientshavereactiontimesontheCPTthatareslower thannormals.Itis,however,inkeepingwithmoderntheoriesofADHDthat
refertoaprimarydeficitinexecutivecontrolsystems,andarelativeinefficiencyinprocessinginformationineffortfultasks.
Working Memory Domain
TheNBacksectionsofthe4PartContinuousPerformancetestisusedtoscoretheWorkingMemorydomain.Workingmemory istheability
toactivelyholdinformationinthemindneededtodocomplextaskssuchasreasoning,comprehensionandlearning.Workingmemorytasks
arethosethatrequirethegoalorientedactivemonitoringormanipulationofinformationorbehaviorsinthefaceofinterferingprocessesand
distractions.Thecognitiveprocessesinvolvedincludethe executive and attention controlofshorttermmemory whichprovidefortheinterim
integration,processing,disposal,andretrievalofinformation.TheNBacktestsarevenerableassessmentsofworkingmemory. TheNback
appraisestheupdatingfunctionofthecentralexecutiveassubjectsneedtoremembertheshape1back,2backand3backrespectively.
The Processing Speed Domain
TheSymbolDigitCodingtestisusedtocalculatetheProcessingSpeeddomain.Processingspeedreferstotherateatwhichwedealwith
instructionsandinformation.ImpairedorslowprocessingspeedcanbeanissuewithmanyADDorADHDpatients.Patientswith slower
processingspeedmayhaveproblemsacademicallyorvocationally:theymaynotcatchalltheinstructionsforcompletingatask, theymaybe
sloweratcopyingdowninformation,andtheymaybeslowertoretrieveinformationthattheyneed.Patientswithsymptomsofinattention
sometimeshaveslowand/orvariableprocessingspeeds.Processingspeedcanbecriticalforwritingessaysandworkingmathproblemsand
patientscanhavedifficultyholdingideasinmind,actinguponandorganizingideas,organizingthematerialinalogicalsequence,etc.Thisis
notamatterofintelligencebutslowedprocessingspeedcanmakeithardtodemonstrateknowledge.

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

29

About CNS Vital Signs AD/HD Domains


The Memory Domains
ThefirsttwotestsareVerbalandVisualMemoryTests;thesearebasicwaysoftestingmemory.Verbalandvisualmemoryevaluationisa
traditionalmeasureinpsychology;donemainlyinaverbal(words)andaVisual(figures)format.Verbalmemoryaccessesthelanguagebased
semanticchannel,lefthemisphere,andvisualmemoryiskindofagestaltchannelorarighthemispherechannel.CNSVitalSignsmeasures
howmanycorrectresponsesyoumakeonthistest.TheMemorytestsarepresentedatthebeginningandthenrepeatedattheendofthe
battery.Thispresentationisdonesoclinicianscanmeasurebothimmediatememoryanddelayedmemory.Thetwomemorytestsare highly
correlatedwiththetraditionallyadministeredneuropsychologicalexams.WhilememorytestarenotatraditionaltestforAD/HD;ifclinicians
seeclientswithanisolatedlowscoreinmemory,itmaybethattheyhavealearningdisabilityandthatthelearningdisabilitywasnever
diagnosed.Patientslearnhowtoaccommodateandtheylearnhowtocompensate.Inanyevent,anisolatedlowscoreinmemoryis
somethingyouwillwanttoinvestigateandpossiblyinquireaboutlearningdisabilities.
The Psychomotor Speed Domain
FingerTappingTestandtheSymbolDigitCodingSDCtestsgeneratethePsychomotorSpeeddomain.TheFingerTappingTestisoneofthe
mostreliableandvalidtestinallofNeuropsychology.Anothertestthatcontributestothepsychomotorspeeddomainisthe SymbolDigit
Codingtestwhereyouhavetolookatthesymbol,andconnectthesymboltoanumberandrecordacorrectnumberresponse.AD/HD
patientstendtoperformnormalontestsofpsychomotorspeed.However,patientssufferingwithaconcussionorbraininjurieshaveshown
abnormalitiesinpsychomotorspeed.ManysportsrelatedconcussionsarefrontallobeinnatureandthePSdomainmighthelpclinicians
determinewhetheralowscoreinthefrontallobedomainsarerelatedtobraininjuryorattentiondeficit.Patienthistoryandphysical,
however,isgenerallythebestindicatorofbraininjuriesbuttheFTTcanaddtotheevaluationprocess.
The Reaction Time Domain
TheStroopTestandtheShiftingAttentionTestcontributetotheReactionTimedomain. Reactiontimescoresareveryinterestingbecausein
AD/HDthosescorescanbelow.CliniciansmightthinkthatAD/HDkidshaveafastreactiontimebuttheyusuallydont.WhenAD/HDpatients
trytoperformaccuratelyitisamuchmorelaborioustaskforthem,theyhavetogomuchmoreslowly,theyhavetotaketheirtime.They
performmuchlessefficientlyonthesecomplexinhibitions disinhibition testsliketheStroopTest.

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

30

CNS Vital Signs: Complex Assessment Made Easier


ADHDScreening,NeurocognitiveTestProcedure,EvidenceBasedRatingScales

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

31

CNS Vital Signs: Complex Assessment Made Easier


ADHDScreening,NeurocognitiveTestProcedure,EvidenceBasedRatingScales
Screening
TheVSXADHDToolboxcontainsthreeversionsofthePediatricSymptomChecklist(childrenandadolescents)andtheAdultADHDSelfReport
Scale(ASRSv1.1)whicharevalidandreliablescreeningtoolstorapidlyassessATRISKindividuals.Theseinstrumentscaneitherbedone
remotelyviaCNSVSOnlinewebbasedassessmentplatformorintheclinicusingahandhelde.g.,iPad,Androidorlaptopcomputer.
NOTE: Brain and Behavioral Specialists CNSVitalSignssupportsthespecialistTeamManagementorCenterof
Excellencepracticestrategy.Thisisawayforspecialisttoprovidesupportservicestoprimarycarepractices.TheCNSVital Signsplatform
helpsenableaseamlesscontinuumofcare.FromPrimaryCaretoSpecialistbacktoPrimaryCare.Contactusformoreinformation.
Neurocognitive Testing & Vanderbilt AD/HD Assessments
TheVSXADHDToolbox/Testmaybeadministeredattheinitialvisittohelpquantifytheseverityofdeficitsrelatedtoneurocognition.Objective
neurocognitivetestingdatafromtheVSX reportsupplementsinformationgatheredthroughtheCNSVitalSignsratingscalesfromparents,
teachersandselfreports.ThebaselineVSXADHDTestprovidesafoundationofobjectiveinformationaboutthepatientsneurocognitivestatus
andhelpstoguidetheconversationaboutanindividualizedtreatmentplan,ifADHDisthediagnosis.
Follow-up Testing
ClinicianscanusetheCNSVSOnlinewebbasedassessmentplatformtocollectfollowupratingscalese.g.,Vanderbilt,NPQ45to track
symptoms andbehaviors.ClinicianscanalsorunaseriesofCNSVitalSignsneurocognitiveassessmentstohelptailor(maximizeneurocognition
whileminimizingdosage)orinformmedicationmanagementtoachievegreaterclinicalefficacy.TheCNSVitalSignsassessmentplatformis
usedtoevaluateprogresstowardgoalsandtohelpguidetreatmentplanning.Asstatedearliertheprofessionalguidelinesrecommends
systematicmonitoringofdosageandsideeffects.AndtheAmericanAcademyofChildandAdolescentPsychiatrists(AACAP)recommendsan
officevisitinthefirst30daystomonitormedicationtolerance,sideeffectsandprogressandofficevisitsatleastmonthlyuntilsymptomshave
beenstabilized.AACAPguidelinesstate, ThepatientwithADHDshouldhaveregularfollowupformedicationadjustmentstoensurethatthe
medicationisstilleffective,thedoseisoptimalandthesideeffectsareclinicallyinsignificant.
Clientshaveexpressedthatparentsfindthemedicationoptimizationandmanagementtobeavaluableclinicalservice.

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

32

Brain and Behavioral Team Management


MultiplePracticeswithMultiplePractitionersusingaSingleSystem

SolutionsforMeasuring,Monitoring,and
ManagingNeurocognitiveandBehavioralHealth

Brain and Behavioral specialist or specialty clinic sets-up a


WEB Master Account at CNS Vital Signs.

Brain and Behavioral specialist or specialty clinic provides


each primary care practice a customized LOGIN

Brain and Behavioral specialist and primary care


practitioner customizes (configures) patient notification
process and assessment strategy e.g. referrals

Primary care clinic provides patients LOGIN information to


complete screening and/or testing

Assessment results from screening or testing can be


AUTO Emailed or Faxed to each Primary Care Practice or
to each Practitioner

Brain and Behavioral specialist referral is generated

Brain and Behavioral specialist can oversee assessment


database and easily export to a spreadsheet or database
for outcomes and quality care research.

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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.

34

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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AD/HD Reimbursement Information

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.

Screening, Surveillance, & Assessment


Surveillance,Screening,orAssessment
Surveillance:recognizingchildrenwhomaybeatriskof
developmentaldelays
Screening:isusingabriefstandardizedtoolthataids
theidentificationofchildrenatrisk
ofadevelopmentaldisorder
Assessment:toidentifythechildsstrengthsand
weaknesses,presentlevelofperformance,and
indicatedintervention
doesnot resultineitheradiagnosisortreatmentplan
butassiststhecliniciansE&Mprocesses.
Adaptedfrom:Pediatrics,July2006

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

35

NEXT STEPS:

Contact Us

Getting Started

Learn More

Step One: Registeratwww.CNSVS.com


AfterregisteringdownloadtheVSXBriefCore
AssessmentSoftware with5FREETestSessions
Takeitforatestdrive.

Contactmetoreceivereportexamples,case
studies,administrationguidesetc.

Step Two: ScheduleaFREEOneonOneIn


ServiceWebinar ContactCNSVitalSigns
Supportsupport@cnsvs.com withdatesand
timesthatyouwillbeavailable.
AfterthewebinarthetotalCNSVitalSigns
Assessmentplatform(Web&Local)canbe
configuredtomeetyourpracticeneeds.

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

36