Putting Solutions into Action
ADHD and Learning Disorders
in High School
Robert Milin, MD
Director, Adolescent Day Treatment Unit
Youth Psychiatry Program
Royal Ottawa Mental Health Centre
Clinical Scientist
Institute of Mental Health Research
Associate Professor
Department of Psychiatry
University of Ottawa
Date: February 15, 2013
Disclosures of Potential Conflicts
Source
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Squibb
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Institute of
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for Mental
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Learning Disorders (LD)
 DSM-IV definition:
 Individual’s achievement as measured by standardized
tests (academic achievement) in reading, math, or written
expression is substantially lower than expected for age,
schooling and intellectual level
 Significant impairment in academic achievement or
activities of daily living that requires the specific learning
skill/ability
Learning Disorders
 Prevalence rates range from 2-10%
 5% of US public school students identified with a learning
disorder
 Reading Disorder is believed to be the most prevalent LD
at ~4%
 It is important to differentiate and take into
consideration such factors as lack of opportunity,
poor teaching or culture
Learning Disorders
 About 1.5 times greater school drop out rate
 Common co-occurrence (10-25%) with Disruptive
Behavioural Disorders
 Conduct Disorder
 Oppositional Defiant Disorder
 ADHD
Communication Disorders
 Types include:
 Expressive Language Disorder
 Mixed Receptive-Expressive Language Disorder
 Phonological Disorder (formerly Developmental
Articulation Disorder)
Intellectual Functioning
 General intellectual functioning is defined by the
intelligence quotient (IQ or IQ-equivalent) on
individual assessment with a standardized
intelligence test
 Important that IQ testing procedures adequately
reflect the individual’s ethnic, cultural or linguistic
background
IQ
Range
Score
Percentile Rank
Average
80-120
9-91%
True Average
90-110
25-75%
Low Average
80-90
9-25%
High Average
110-120
75-91%
IQ Indices
 Verbal Comprehension
 Perceptual Reasoning
 Working Memory (WM)
 Processing Speed (PS)
 WM & PS are referred to as the cognitive proficiency
indices
Borderline Intellectual Functioning
 DSM-IV definition:
 When overall cognitive abilities fall within the IQ range of
71-84
 An IQ score of 85 is equivalent to the 16% rank
ADHD DSM-IV CRITERIA
A.
Either (1) or (2):
1.
Six or more of the following symptoms of inattention have persisted for at least 6 months
to a degree that’s maladaptive and inconsistent with developmental level
INATTENTION
a)
b)
c)
d)
e)
f)
g)
h)
i)
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or
other activities
Often has difficulty sustaining attention in tasks or play activities
Does not seem to listen when spoken to directly
Often does not follow through on instructions, fails to finish schoolwork, chores or duties in the
workplace
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
ADHD DSM-IV CRITERIA
A. Either (1) or (2):
2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted
for at least 6 months to a degree that’s maladaptive and inconsistent with
developmental level
HYPERACTIVITY
a) Often fidgets with hands or feet or squirms in seat
b) Often leaves seat in the classroom or in other situations in which remaining seated is
expected
c) Often runs about or climbs excessively in situations in which it is inappropriate
d) Often has difficulty playing or engaging in leisure activities quietly
e) Is often “on the go” or often acts as if “driven by a motor”
f) Often talks excessively
IMPULSIVITY
g) Often blurts out answers before questions have been completed
h) Often interrupts or intrudes on others
ADHD DSM-IV CRITERIA
B.
Some hyperactive-impulsive or inattentive symptoms that
caused impairment were present before age 7 years
C.
Some impairment from the symptoms is present in two or
more settings
D.
There must be clear evidence of clinically significant
impairment in social, academic, or occupational functioning
E.
The symptoms do not occur exclusively during the course of
PDD, schizophrenia or other psychotic disorder and are not
better accounted for by another mental disorder
Characterization of DSM-IV ADHD subtypes:
ADHD/AD - academic problems, fewer behavioural
problems and higher proportion of girls (20-30%),
prevalence increases with age
ADHD/HI - behavioural problems, few academic
problems and low rate of anxiety or depressive
symptoms (<10-15%)
ADHD/CT - both behavioural and academic
problems, most prevalent subtype and likely most
impaired subtype with the worst prognosis (5075%)
DSM-V Changes in ADHD
 Maximum age of onset of 12 years; up from 7
years
Elimination of DSM-IV subtypes; include
specifiers of current manifestation at the time
of assessment
Broaden age-related symptoms to include
examples relevant to adults
DSM-V Changes in ADHD
Broaden comorbidities to include Autism
Spectrum Disorders (previously excluded)
ADHD clustered under Neurodevelopmental
Disorders rather than Disruptive Behavioural
Disorders
Epidemiology
Estimate of 3-7% of school-aged children in
the U.S.
Ontario Child Health Study-6.3%. Most
common diagnosis, ADHD ages 4-11 and
Conduct Disorder, ages 12-16.
Adults ~ 4% in the US.
Gender ratio 3 Boys: l Girl, approaches 1:1 in
adulthood.
30% - 50% of all child psychiatric outpatients
demonstrate symptoms of ADHD.
Cross culture differences in prevalence rates
related to differences in nomenclature, diagnostic
decision processes and cultural variations in
perceptions of disruptive childhood behaviours.
ADHD: Worldwide Prevalence (%)
Spain
New Zealand
Canada
Ireland
United Kingdom
Israel
Switzerland
Netherlands/Belgium
Germany
Ukraine
Brazil
Japan
New Zealand
Netherlands
China
India
NY, MI, WI
N. Carolina
Virginia
Missouri
Oregon
Minnesota
Tennessee
Iowa
Pittsburgh
New York City
Puerto Rico
0
5
10
15 20
Faraone SV et al. World Psychiatry 2003;2:104-113.
0
5
10
15
20
ADHD Types: Childhood vs. Adulthood
Inattentive
Type
22%
56%
Inattentive
Type
44%
Combined
Type
Combined
Type
78%
Spencer, 2005, Harvard Update;
McGough, Smalley, McCracken et
al.
American Journal of Psychiatry,
September 2005, Vol. 162, Page
1621
In Childhood
In Adulthood
3:1
Male to Female
1:1
Male to Female
Assessment of ADHD in Youth
Modified from Weiss & Murray,
CMAJ, March 2003
 Assess current ADHD symptoms using interview and
rating scales with youth norms
 Establish childhood history of ADHD– retrospective parent
or self-report - collateral history including elementary
school report cards and previous psychological assessment
 Assess functional impairment in multiple domains
Assessment of ADHD in Youth
 Developmental history—especially behavioural and school
history including indication of a learning disorder/disability
 Psychiatric history
—rule out or establish comorbid disorder
—particular attention to substance use history
 Family psychiatric history
 Rule out medical causes
ADHD remains a clinical diagnosis with
clinician-administered interview as the
cornerstone of diagnostic evaluation