2021 MBHR Measure: Outcome monitoring of ADHD functional impairment in children and youth 

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Title Outcome monitoring of ADHD functional impairment in children and youth
NQS Domain Effective Clinical Care
Measure ID MBHR9
Measure Type Patient Reported Outcome (PRO)
High Priority? Yes
Description Percentage of children aged 4 through 18 years, with a diagnosis of attention deficit/hyperactivity disorder (ADHD), who demonstrate a change score of 0.25 or greater on the Weiss Functional Impairment Rating Scale – Parent Report (WFIRS-P) within 2 to 6 months after an initial positive finding of functional impairment. To see additional details, please view the workflow diagram for this measure: View diagram
Denominator Denominator (Submission Criteria 1):All patients aged 4 to 18 years of age receiving a psychiatric or behavioral intake visit during the measurement period.   Denominator (Submission Criteria 2):All patients aged 4 to 18 years of age receiving a psychiatric or behavioral intake visit with a WFIRS-P total mean score of 0.65 or greater during the measurement period.
Denominator Exclusion Death
Denominator Exception Patient refuses to participate or is unable to complete the questionnaire.
Numerator Numerator (Submission Criteria 1)Patients who were administered a validated ADHD functional impairment assessmentNumerator (Submission Criteria 2)Patients who demonstrated a positive improvement of 0.25 or more points on the total mean score of the WFIRS-P assessment taken 2 to 6 months later.
Data Source Claims, EHR, Paper Medical Record, Registry
Meaningful Measure Area Functional Outcomes
Meaningful Measure Rationale Assessing and monitoring functioning for ADHD in children and adolescents will promote interventions and best practices that are effective at reducing symptoms and improve functional status and quality of life by identifying and addressing appropriate treatment needs. This provides a standardized way to communicate status which will improve both quality of treatment and efficient use of resources
Inverse Measure? No
Proportional Measure? Yes
Continuous Variable Measure? No
Ratio Measure No
Number of Performance Rates 2
Risk Adjusted Yes
Preferred Specialty mental and behavioral health
Applicable Specialties Family Practice, Internal Medicine, Geriatric Medicine, Psychiatry, Behavioral Health


Measure Justification

Attention deficit/hyperactivity disorder (ADHD) is among the most common neurodevelopmental disorders in children and adolescents with typical prevalence estimates ranging between 5 and 10%.5-9 The disorder is also associated with significant functional impairments as evidenced by the high comorbidity with disruptive behavioral disorders (oppositional defiant and conduct disorder)10,11 and findings of increased rates of learning difficulties, risk-taking behaviors, criminality, substance use, injury, suicide, and other psychiatric illnesses.12-18 Researchers estimate that U.S. educational and judicial system responses to functional problems cost society an additional $15.5 to $25.5 billion annually (in 2010 dollars).19 Longitudinal cohort data can now begin framing the public health implications for these problems in terms of early mortality risks with new findings citing an absolute 4.4% increase in mid-life fatalities20 and an 8.4 year reduction in estimated life expectancy21 among adults characterized with select ADHD profiles in childhood. Annual excess healthcare costs for children and adults with ADHD exceed $35 and $100 billion, respectively,19 and when differentiated, a significant portion of these expenses are dedicated to non-treatment related care (e.g., inpatient, emergency department, etc.).22 Several evidence-based behavioral and pharmacological treatment options are available,1,23,24 but low accession and lack of sustained utilization currently limit the public health impact of interventions.20,21 Higher quality care, marked by routine outcome monitoring and adaptive treatment response,1,25 is a best practice model proposed by many to combat these costly trends.21,22,26,27Presence of functional impairment is most often the cause for seeking initial medical attention; yet, historically, care providers tend to focus on symptom reduction as the primary emphasis of treatment.28 The distinction between symptoms and function can be murky.29 Symptoms tend to be more general, less context dependent and are traditionally viewed as proxies for more specific functional outcomes that reflect “real-world consequences of the disorder.”28 While symptom reduction is a worthy goal of treatment, when unaccompanied by significant functional improvement, lower symptom scores are unlikely to be perceived as successful treatment outcomes in the eyes of a patient or patient’s family. The need to align improvements in functional problems and symptoms has begun to receive recognition among diagnostic classification systems30-32 and treatment guideline developers.1,33 The measure proposed herein takes this a step further, with an exclusive focus on function for ADHD treatment monitoring. In line with goals of the Mental and Behavioral Health Registry of the American Psychological Association, this function measure intends to capture a treatment outcome that is most meaningful to both practitioners and patients. A single instrument for measuring ADHD function is selected for this purpose, the Weiss Functional Impairment Rating Scale (WFIRS). The WFIRS is chosen because it includes wide coverage of functioning, is freely reproducible, and demonstrates psychometric support for validity and reliability.34,35 A minimal important difference (MID) is also established for the parent report version (WFIRS-P) and can be used as a change sensitivity indicator for treatment monitoring.36 Interestingly, this MID is virtually identical to the calculated reliable change index from the same study.

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  36. Hodgkins P, Lloyd A, Erder MH, et al. Estimating minimal important differences for several scales assessing function and quality of life in patients with attention-deficit/hyperactivity disorder. CNS spectrums. 2017;22(1):31-40.


MBHR-2021, Mental/Behavioral Health-2021, Psychology-2021