Attention Deficit /
Hyperactivity Disorder
(ADHD)
Common Symptoms, Differential
Diagnoses, and Treatment Options
Dr. Rachel Andaloro
Metrowest Neuropsychology
ASHPAC meeting 3/17
ADHD
One of the most common childhood
disorders
 ADHD affects about 9% of American children
from 13-18 and about 4.1% of adults
 Average age of onset is 7 years of age
 Boys are four times more likely to be
diagnosed than girls
 The number of kids being diagnosed with
ADHD is increasing

DSM-V ADHD Criteria

Persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with
functioning or development
◦ Inattention: (≥6 of following symptoms have persisted
for at least 6 months; for >17 years ≥ 5 are required)
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Fails to give close attention to details
Difficulty sustaining attention in tasks or play activities
Does not seem to listen when spoken to directly
Often does not follow through
DSM-V Criteria cont.
(Inattention)
 Difficulty organizing tasks and activities
 Often avoids/dislikes/reluctant to engage in
tasks that require sustained mental effort
 Often loses things necessary for tasks and
activities
 Often distracted by extraneous stimuli
 Often forgetful in daily activities
DSM ADHD Criteria cont.
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2) Hyperactivity/Impulsivity: (≥ 6, for >17 at least
5)
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Often fidgets, squirms in seat
Often leaves seat
Often runs about or climbs
Often unable to engage in leisure activities quietly
Often on the go
Often talks excessively
Often blurts out an answer
Often has difficulty waiting his or her turn
Often interrupts or intrudes on others
ADHD Criteria cont.
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Several symptoms were present < age of 12
Symptoms are present in two or more settings
Symptoms interfere with social, academic, or
occupational functioning
Symptoms are not better explained by another
mental disorder (*mood disorder, anxiety,
personality disorder, psychotic disorder, substance
intoxication or withdrawal)
Can be combined presentation if both domains are
met or predominantly inattentive presentation if
criterion 2 are not met or vice versa
Neuropsychological Assessment

ADHD is diagnosed based on these criteria

But, it can be difficult to tease out other
possible etiologies without a thorough
evaluation.

Neuropsychological evaluation provides a
thorough assessment of history as well as a
broad measurement of overall cognitive
functioning
ADHD and cognition

ADHD is associated with deficits in executive
functioning

Executive functions affect many aspects of
behavior

Determine our development of strategies to
approach, plan, or carry out cognitive tasks,
monitor or regulate behavior

Measure a broad range of cognitive functions,
with emphasis on measures of executive skills
Other Possible Etiologies…
NP eval is important in ruling in or out other
disorders
 Depression and anxiety - associated with
deficits in executive functioning, and can
present with similar symptoms
 Underlying mood disorder?
 Other health issues?

◦ Lyme Disease

Obtaining a thorough history is key in teasing
these apart.
Comorbidities

ADHD is often comorbid with other
mental health disorders:
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Oppositional Defiant Disorder
Conduct Disorder
Autism Spectrum Disorders
Learning Disabilities
If co-morbid with LD, ADHD symptoms
may be masking the LD (or LD may cause
inattention)
Treatment

Options for treatment:
◦ Behavioral interventions first
◦ Medication as a last resort
Medications
70% improve with use
 Amphetamines (Adderall, Dexedrin)
 Methylphenidate (Concerta, Metadate,
Ritalin)
 Strattera (non-stimulant option)
 Clonidine and guanfacine (Intuniv):
nonstimulant medicines approved to treat
aggression and impulsivity not controlled by
other ADHD medicines.
 Antidepressants (Vyvanse, Wellbutrin)
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Medications cont.

Stimulants may be related to slower growth
in children. Most children seem to catch up
in height and weight by the time they are
adults. (medication holidays)

Stimulants can be abused

Can cause sleep disturbance

Research has shown that these medicines,
when taken correctly, don't cause
dependence.
Behavior Modification for ADHD
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Preferential seating, additional time, separate room for
quizzes and tests
Be on time, sit in the front row (limits distractions)
Work with ADHD coach, mentor / advisor to help
establish a plan and organizational strategy
Frequent, brief contact with mentor
Audio record lectures- can be replayed in order to
review missed information
Continuous note-taking to increase attention to
lectures
Work closely with more organized students
Attend after-class help sessions whenever possible
Behavior Modification cont.
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Provide simple instructions and repeat if necessary.

Have child repeat information/ instructions back in their own
words, to ensure understanding

Gentle and repeated prompting/reminders to engage in
tasks/remain on-task

Coached to quietly talk himself though tasks, step-by-step, as
a means to maintain focus and sequence tasks appropriately.

Regular refresher breaks to help refresh and refocus (e.g.,
movement or water breaks), given before student becomes
overwhelmed and starts to lose focus.
Behavior Modification cont.

Consistent praise for periods of (for
example) ten minutes or more, when child
remains on-task.
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Consider other rewards at school and home
for substantial periods of controlled and
attentive behavior (including assignments
successfully completed).
Organization
◦ Clean workspace
◦ Maintain planner and review notes with teachers to
ensure that student has recorded each item and
understands the purpose of each assignment.
◦ Checklist for materials
◦ Organized binder with sections devoted to each
subject where hand-outs, notes, and assignments can
be placed.
◦ Structure!
Oppositionality

Time-out (approximately 5 – 10 minutes) in a quiet,
supervised area (should not be able to use behavior as
manipulation to avoid work)

Student should be given one calm, but firm warning when
becoming disorderly.
◦ If student does not heed warnings, there should be a
consistent system in place for applying sanctions. The use of
time-outs and/or taking privileges away for unruly behavior
may be beneficial.

Oppositional students tend to respond best to both high
structure and high warmth.

Consistent disciplinary procedures be followed at both
school and home.
Positive Behavior Support
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Proactive rather than reactive approach

Set basic and clear expectations for behavior
◦ Be safe
◦ Be respectful of others
◦ Be responsible for students own well-being

Clear examples of what it means to meet these
expectations in various contexts should be
given.
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PBIS.org
PBS cont.

Student should receive the most attention
(and also praise) when meeting expectations.

Respond to any negative behaviors with brief
redirection in a calm but firm manner, by
stating and optimally demonstrating the type
of behavior you want to see instead.
PBS cont.
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Error corrections should be provided.
◦ Set expectations and pre-correct as much as
possible. Monitor his response to the precorrections and provide reinforcement accordingly.
◦ Reward positive behaviors rather than punish
negative ones (5:1 ratio)
◦ Praise and error corrections should follow a
NORMS format (Neutral, Observation-based,
Reliable, Measurable, and Supportive).
PBS cont.
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PBS approach should be extended into
the home
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If significant externalizing behaviors
persist despite consistent behavioral
intervention, a therapeutic school setting
may be of benefit.
◦ Provide emotional and behavioral support
◦ Individualized attention, smaller class sizes
Thanks!
Contact info:
r.andaloro@metrowestneuropsych.com
Metrowest Neuropsychology
1900 West Park Drive, Suite 280
Westborough, MA 01581
www.metrowestneuropsych.com