Attention Deficit Hyperactivity Disorder
Evaluation and Treatment
What is ADHD?
Developmentally underdeveloped self-regulation of:
 Attention
 Activity level
 Impulse control
 Motivation
 Other Executive Functions
 Onset in childhood
 Relatively persistent & pervasive (25% "grow out" of symptoms as adults)
 Creates significant impairment in major life activities
 Not due to PDD, severe MR, psychosis, etc.
 Continuum of impairment (studies show about a two year lag in brain
development compared to non-ADHD controls)
Three types of ADHD
1.
Hyperactive/Impulsive
2.
Inattentive
3.
Combined
Attention Deficit Disorder
Problems with Executive Abilities
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Inhibition (the mind’s brakes)
Visual imagery (the mind’s eye)
Internal speech (the mind’s voice)
Emotional control (the mind’s heart)
Planning and problem-solving (the mind’s playground)
Taken from Barkley, 2011
Deficits From Poor Executive
Abilities
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Limited hindsight, foresight, and anticipation of
the future
Impaired sense of time and time management
Difficulties following rules and instructions and
comprehending what you hear and read
Poor emotional control and low self-motivation
Impaired problem-solving and “simulating” the
possible future and what your options are for
dealing with it
What Are The Developmental Risks?
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Academic Under-performance (90%+)
Retention in Grade (25-50%)
Require Special Education (35-60%)
Failure to Graduate High School (30-40%)
Less Likely to Attend College (20%)
Less Likely to Graduate College (5%)
Taken from Barkley, Murphy, & Fischer 2008
More Developmental Risks
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Peer Relationship Problems (50%+) (Bagwell, et al., 2001)
Delinquency (25-35%)
Substance Dependence/Abuse (10-20%) (Bieerman et al., 1997)
Driving Problems (Speeding, Accidents)
Earlier Sexual Activity and More Partners (Barkley et al., 2006)
Teen Pregnancy (38%+); Riskier sex activities (Barkley et al., 2006)
Increased Risk for STDs (16%) (Barkley et al., 2006)
33% of those with ADHD make suicide attempts
Sleep Problems (Cortese et al., 2006)
Greater Health Risks
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54-84% Oppositional
Defiant Disorder (Pliszka et al.,
1999)
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30-50% Learning
Disabilities (Pliszka et al., 1999)
25% Childhood Conduct
Disorder
45% Adolescent Conduct
Disorder
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25% Adults Antisocial
Pers. Dis.
Up to 33% Childhood
Depression (Pliszka et al., 1999)
16% Mania (Biederman et al.,
1992)
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25% Childhood Anxiety
(Tannock, 2000)
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7% Tics or Tourette’s
Up to 87% have at least one other disorder; up to
67% have at least two other disorders
(Kadesjo & Gillberg, 2001)
Rates of Comorbid Disorders
What Are The Probable Causes?
Heredity: Risk to
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Siblings: 25-35%
Twin: 70-97%
Mother: 15-20%
Father: 20-30%
Offspring of an adult with ADHD: 43-57%
(Barkley et al., 2006)
Genetic Contribution (at least 78% or more)
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No contribution of the rearing environment
Genes found to date:
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DRD4-7 repeat gene (Novelty-seeking)
DAT1 gene (dopamine transporter)
DBH, DRD5, SNAP25, ADRD2A
What Doesn’t Cause ADHD?
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Food Additives, Allergies, Sugar, Milk in Diet
Excessive Caffeine in Diet
Environmental Allergens
Poor Child Management by Parents
Family Stress; Chaotic Home Life
Excessive Use of TV, Video-games
Increased Cultural Tempo
PTSD, Depression, Anxiety, Learning Disability
Two ADHD Testing Tracks
1.
ADHD Screen (PCPs, psychiatrists,
psychologists, examiners & trained counselors)
2.
Psychological /
Psychoeducation Testing
(Psychologists and Psychological Examiners)
(e.g. Child can sit still with meds, but still cant read, or cant
focus due to traumatic stress symptoms, like flashbacks)
ADHD Screen
Evidence-based minimum
standard
Appropriate for about 50% of
patients
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Determine presence of ADHD symptoms and differential diagnosis
from other disorders…Dx vs No Dx
Establish the presence or not of comorbid disorders
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Up to 87% have one other disorder, LDs,
internalizing/externalizing
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Up to 65% have two other disorders
Screen for disorders in parents or familial factors that impact child
Establish the domains of impairment and the priority for treatment
Assess need for appropriate referrals for psychological / medical
testing or treatment
ADHD Screen
Time required
15-60 min
Clinical Interview
Unstructured parent interview
• History - Onset, course, etc
• Environmental Factors Family Environment Parental ADHD, Parenting, Stress, and Competence
Semi-structured ADHD specific interview
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15-25 min
Differential Diagnosis / Comorbidity
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Broad band rating scales
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Child Behavior Checklist (Achenbach -ASEBA)
Behavioral Assessment System for Children
(Pearsonassessments.com)
Structured interview of diagnostic criteria for DSM
disorders (CHIPS or KSADS)
Time required
5-15 min
Narrow band (ADHD Specific Symptoms)
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5-10 min
Conners, Brown, SNAP-IV, Vanderbilt, etc
Parent and Teacher / Other report
Functional Impairment
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WEIS or Barkley Scales
Total time required of patients: 40 - 150 minutes
Total time required of clinician: 15 - 60 minutes
Scoring time depends on the tests used
ADHD Screen
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Poor Grades (Potential evidence of learning problems)
Extremes of behavior (ex. High risk behavior, rage
episodes, Self-injury, etc)
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Complex Psychosocial or Medical History (ex.
Abuse, multiple home placements, TBI’s, complicated divorces,
etc)
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Intense Family Conflict / Parenting Stress
Family Mental Health History (ex. Bipolar,
Schizophrenia, LD’s, Autism, etc)
Criteria Requiring Referral for
Comprehensive Testing,
Track Two
Psychological / Psychoeducational
Assessment (Track Two)
Patient-Centered, individualized assessment
Profiles child strengths and weaknesses in cognitive
abilities, attention, and academic ability
Identify differential diagnosis and comorbid disorders in
more complex cases.
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R/O anxiety, depression, bipolar, behavior probs etc
*Establish range, severity, and source of symptoms compared to
peers, rather than the Dx vs No Dx approach of the ADHD
Screen
Identify environmental changes likely to improve
functioning
Delineate types of treatments likely to be most effective
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Behavioral, Family, Meds Alone, CBT for Dep or Anx, Tutoring,
School Accommodations
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Explore the resources available to the family in their
region
Examples of Track Two cases
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Ex. Children with abuse history and ADHD symptoms
Ex. ADHD symptoms and episodes of rage
Ex. High levels family conflict and parenting stress
Ex. Symptoms of both ADHD and Aspergers
Psychological / Psychoeducational
Assessment (Track Two)
Psychological / Psychoeducational Testing
- Track Two
Time required
30-60 min
15-25 min
5-15 min
5-10 min
30-90 min
Interview - Individual, family, parent functioning,
developmental history
Broadband - parent
Narrow Band - teacher / other
Functional Impairment
Cognitive Functioning
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30-90 min
Learning ability, specific deficits, processing, overall level of functioning academic accommodations that often influence a child’s behavior and
performance at home and school.
IQ Screen or full IQ test. (WISC-IV, SB5, RIAS, KBIT, WASI,
Academic achievement screening
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Learning Disabilities (WRAT, WIAT, Woodcock-Johnson)
Attention Capacity. (optional)
15-45 min (Optional)
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CPT, TEA-Ch, IVA, TOVA
Psychological / Psychoeducational Testing
- Track Two
Total time required of patients: 115-335 minutes
(1h 55m – 5h 30m) Average: 1hr interview, 3hrs testing,
1hr feedback
Time required of clinician:
Scoring 30-60 min
Report Writing 30-150 min
Total Clinician Time (3 - 8hrs)
Average Clinician time (4 - 6hrs)
Non-RSPMI Rates
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Interview $57.84 /hr
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Testing hours 1-2 = $84.00/hr (same day)
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Testing hour 3 = 51.84/hr
RSPMI Rates
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Interview 115.20
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Testing = $115.20 /hr
An RSPMI provider does not have to be a licensed
psychologist with a Ph.D.
Current Reimbursement
Rates
Feedback Conference
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Patient-centered explanation of test results and tx options
Walk parents through the testing results and information
revealed
Provide patient-education
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ADHD and comorbid disorders identified during evaluation
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Nature, causes, course, risks for future impairments
Explain treatment options and explore their availability
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Medication
Behavioral Parent Training
Family Accommodations
Academic Accommodations (IEP’s and 504 plans)
Review other issues identified during the evaluation
Assist family in connecting with other professionals and
resources/referrals as needed
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Specialists: Psychiatric, therapy, sleep studies, OT, Speech, etc
1.
Canadian ADHD Practice Guidelines CADDRA
website http://www.caddra.ca/cms4/index.php?option=com_content&view=article&id=26&Item
id=70&lang=en
Full Guidelines http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf
2.
National institute of Clinical Excellence
(NICE)Guidelines http://guidance.nice.org.uk/CG72
Full guidelines http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf
Quick reference guide http://www.nice.org.uk/nicemedia/live/12061/42107/42107.pdf
3.
Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk/guidelines/fulltext/112/index.html
Full guidelines http://www.sign.ac.uk/pdf/sign112.pdf
Quick reference http://www.sign.ac.uk/pdf/qrg112.pdf
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American Academy of Pediatrics guidelines
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;128/5/1007
ADHD Guidelines
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Interview
Parent Report
Other/Teacher Report
Appropriate Referrals for Medical /
Psychological Testing or Treatment When
Needed
All Four Guidelines Recommend
“ADHD SCREEN” as Standard
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ADHD Assessment Form
Weis Symptom Checklist
ADHD Checklist
SNAP-IV-26
Weis Functional Impairment Rating Scale
Teacher Assessment Form
CADDRA Guidelines Page 85
Website
http://www.caddra.ca/cms4/index.php?option=com_content&view=article&i
d=26&Itemid=70&lang=en
Guidelines
http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf
CADDRA Recommended
“Assessment Toolkit”
Broadband (Overall Mental Health Screener)
• Strengths & Difficulties Questionnaire ww.sdqinfo.org
• Weis Symptom Checklist
Narrowband (ADHD Specific)
• Vanderbilt ADHD Rating Scale
http://www.dss.mo.gov/mhd/cs/psych/pdf/adhd_rating
_teacher.pdf
• SNAP-IV-26
Valid/Reliable – Brief & Free
Assessment Tools
What Are The 4 Stages of Treatment?
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Evaluation
Education
Medication
Accommodation
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Parenting / Restructuring the home
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Changes in school
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Assistance in the community
Empirically Proven Treatments
Parent Education About ADHD
Psychopharmacology
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Stimulants (e.g., Ritalin, Adderall, etc.)
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Noradrenergic Medications (e.g., Strattera)
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Tricyclic Anti-depressants (e.g., desipramine)
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Anti-hypertensives (e.g., Catapres, Intuniv)
Parent Training in Child Management
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Children (<11 yrs., 65-75% respond)
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Adolescents (25-30% show reliable change)
Empirically Proven Treatment (2)
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Teacher Education About ADHD
Teacher Training in Classroom Behavior Management
Special Education Services (IDEA, 504)
Residential Treatment
Parent/Family Services
Parent/Client Support Groups (CHADD, ADDA,
Independents)
Unproved/Disproved Therapies
in ADHD Treatment
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Elimination Diets – removal of sugar, additives, etc. (Weak
evidence)
Megavitamins, Anti-oxidants, Minerals
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(No compelling proof or disproved)
Sensory Integration Training (disproved)
Chiropractic Skull Manipulation (no proof)
Play Therapy (disproved)
Biofeedback (EMG or EEG) (experimental)
• 2 randomized trials found no convincing effects
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BASC – Behavior Assessment System for •
Children, Second Edition
CBCL – Child Behavior Checklist
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WISC – Wechsler Intelligence Scale for
Children, Fourth Edition
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WAIS – Wechsler Adult Intelligence
Scale
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WASI – Wechsler Abreviated Scale of
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Intelligence
WIAT – Wechsler Individual
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Achievement Test
WJ-III – Woodcock-Johnson Test of
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Acheivement
SB5 – Stanford-Binet Intelligence Test
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CPT – Conners Continuous Performance •
Test
IVA – Integrated Visual and Auditory
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Performance Test
TOVA – Test of Variable Attention
SNAP-IV - Swanson, Nolan, & Pelham
TEA-Ch – Test of Everyday Attention in
Children
SDQ – Strengths and Difficulties
Questionnaire
Vanderbilt – Vanderbilt ADHD
Teacher/Parent Rating Scales
Brown – Brown ADD Scales
Conners – Conners Parent Rating ScalesRevised
CHIPS – Children’s Interview for
Psychiatric Syndromes
KSADS – Kiddie Schedule of Affective
Disorders and Schizophrenia
KBIT – Kauffman Brief Intelligence Test
RIAS – Reynolds Intellectual
Assessment Scales
BFIS – Barkley Functional Impairment
Scales
Psychological Measures
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ADHD Evaluation and Treatment