Innovations in the Assessment of AD/HD:

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Innovations in the Assessment of AD/HD Assessing
Executive Operations in the Diagnosis of
AD/HD   Presented at the CHADD 15th Annual
International Conference AD/HD Through the Years
From Science to Practice OCTOBER 31,
2003     Thomas K. Pedigo Ed. D. Pediatric
Adolescent Psychology P.C. 37 West Fairmont Ave.,
Suite 211 Savannah, GA 31406
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Introduction          Current/Common Assessment
Practices in the evaluation of AD/HD         
Comorbidity Issues in ADHD Diagnosis         
Executive Functions and how they relate to AD/HD
Diagnosis          Why this is important in
Primary Care and Private Sector
Settings          Review of the Pediatric
Attention Disorders Diagnostic System
(PADDS)          Current Supportive Research
for PADDS
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Common Assessment Practices in the Evaluation of
AD/HD   Concerns typically originate from
observations of behavior and/or performance at
school, home and other extra curricular
activities which are eventually reported to a
physician or other health care professional.
Attempts to validate these concerns will
usually consist of
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Behavior Rating Scales While these are often
normed and efficient, they can be redundant and
prone to bias. Comorbid conditions are often not
assessed. A review of behavior ratings should be
considered as one line of evidence when
evaluating AD/HD.
Class Room Observations This approach can obtain
real time data but is time consuming. Multiple
observations are usually impractical. These
observations are non-standardized and may
influence class room behavior on the part of both
teachers and students.
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In Office Observations Physician may witness
problem behavior. However, office settings may
not create demands sufficient to observe
problems, may lack a standardized approach and
may not address comorbid conditions.
Psychological Evaluation This process can be
comprehensive and often will address comorbid
conditions. Psychological evaluations can be
expensive, time consuming and variable in
procedures. In addition these measures may not
adequately represent a child's true potential and
are often not normed for AD/HD diagnosis.
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Diagnostic Challenges/Comorbidity with ADHD  
Other Comorbid conditions often occur with ADHD.
These conditions may include but are not limited
to Mood Disorders, Anxiety Disorders, Disruptive
Behavior Disorders and Learning Disorders.
Bipolar Disorder is becoming increasingly
recognized by some professionals within
adolescent populations. The importance of
considering other conditions that may mimic or
exacerbate the presence of ADHD is essential to
successful intervention.
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The following listing of ranges for ADHD and
Comorbid conditions was adapted from the
following source Pliszka, S. R., Carlson, C.
L., Swanson, J. M., (1999). ADHD with Comorbid
Disorders Clinical assessment and Management.
New York, N.Y. The Guilford Press.    Primary
Diagnosis / Secondary Diagnosis Range of
Prevalence Page Number ADHD/ODD-CD 15
to 61 90 ODD-CD/ADHD 35 to 87 90  
ADHD/Depression 0 to 38 127
Depression/ADHD 0 to 57 127  
ADHD/Anxiety 23 to 30 151 Anxiety/ADHD
9 to 35 151
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Primary Diagnosis / Secondary Diagnosis Range of
Prevalence Page Number ADHD/LD 7 to
60 192 (Across- Reading, Spelling,
Math)   ADHD/OCD 6 to 33 214   Other
related conditions needing assessment/
consideration include   Neurological Impairment
  Developmental disabilities   PDD/Autistic
spectrum disorders
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Executive Functions and Diagnosis of ADHD
Recent developments within the field of ADHD
have increasingly pointed to the need to evaluate
the various executive operations and working
memory of children suspected of Attention
Disorders. (Brown, T.E., 2002, 2000,1999
Barkley, R.A. 1997,1998 Denckla M, 1996.)
Generally, executive functions are defined as
controls that allow one to perform complex
behaviors that require among other things
planning, attending, organizing input, storing
and retrieving information, modulating emotions
and sustaining effort.
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The development of executive functions begins
in early childhood occurs across time through
early adulthood. As these processes emerge there
is an expected increase in expectations for
independent and functional behavior Brown,
T.E. (2002). Children also learn from
experience and observation in concert with the
development of Executive Functions. Thus,
children with chronic medical conditions, social,
emotional or language based impairments often do
not have the experience base attained by their
typically developing counterparts.
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While the identification of significantly
hyperactive children can be simple, the
evaluation of children who only display
difficulty in learning or in completing more
complex activities is where the greatest need for
improvement lies. Difficulties in these
executive processes exemplify the complaints of
teachers and parents. Situations that require
an orchestration of these abilities are often
most problematic for AD/HD students. Parents will
often report confusion at their child's ability
to play video games, watch television or engage
in favorite activities. However, on closer
inspection, these activities often do not produce
the same demands as found within the classroom.
These favorite activities are often
overlearned, fast pace, and allow the child to
move freely in and out of the activity. Changing
the structure of these activities can quickly
produce frustration in AD/HD children.
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Basic Demands of the Classroom   Attending to
instruction Assimilating information Accommodating
information Organizing, sequencing, manipulating
information Monitoring emotional
activity Formulating a plan of action Implementing
the plan   Other Factors   Working under time
pressure Avoiding distraction Being adequately
prepared
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  How EF applies in the classroom   Examples
of Executive Function Indicators relevant to
AD/HD Diagnosis   1. Tommy needs frequent
re-instruction, without this he drifts and often
does not complete his work. His teacher is
concerned that skills he learns one day do not
transfer to the next day. Tommy has made comments
that " his brain just won't work right". He seems
capable but only produces satisfactory work when
given one to one attention.   2. Tommy often
cannot find his home work and has difficulty
getting organized when completing class work. He
will often forget instructions when preparing to
work. Tommy often will confuse instructions and
will repeatedly ask for assistance. He often
stays in for recess and takes class work home to
complete. Tommy often becomes frustrated and
discouraged.   3. Tommy chronically complains
that "I can't do it!", even though he appears
capable. His parents help him study and he seems
to have a grasp of the information. However,
Tommy consistently does poorly on tests and often
makes mistakes with his class work. He
occasionally will become emotional and tear up
his papers.
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Relevance/Application to the Primary Care
Setting   According to the American Academy of
Pediatrics, ADHD is the most commonly diagnosed
childhood psychiatric disorder affecting school
age children. Epidemiological studies have shown
a prevalence rate ranging from 3 percent to 6
percent of school age children. Concern has been
expressed for the these large numbers coupled
with reportedly wide variations in clinical
practice and research approaches all point to
the need to develop pragmatic assessment tools
and approaches for use in the major systems of
service entry. Specifically of importance are
assessment approaches that can be used within
primary care settings, schools and clinics as
well as within the private sector.   Reference
Chan, E., Hopkins, M., Perrin, J. M., Herrerias,
C., Homer, C. J., (2002) VARIATIONS IN
DIAGNOSTIC PRACTICES FOR ATTENTION DEFICIT
HYPERACTIVITY DISORDER A NATIONAL SURVEY OF
PRIMARY CARE PHYSICIANS Homer Division of General
Pediatrics, Children's Hospital, Boston, MA
American Academy of Pediatrics, Elk Grove
Village, IL Center for Child and Adolescent
Health Policy, MassGeneral Hospital for Children,
Boston, MA National Initiative for Children's
Healthcare Quality, Institute for Healthcare
Improvement, Boston, MA. (2002) Pediatric
Academic Societies Abstract.
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During the 1998 NIH Consensus Development
Conference it was determined that Development and
Validation of Diagnostic Tools Grounded in the
Basic Sciences was warranted.   Key areas of
interest to the NIH   The Development and
Validation of Diagnostic Tools Grounded in the
Basic Sciences   Consequently, there is a
continued need to develop more objective
assessment tools, rating scales and/or diagnostic
interviews that map onto basic underlying
processes as well as a need to supplement
behavioral assessment tools with improved
cognitive and/or neuropsychological measures.
The Development of Strategies for Assessing,
Monitoring and Administering Treatment in
Primary Care Settings   Many of the currently
utilized assessment measures and treatments for
ADHD are incompatible with the primary care
setting. There is also a dearth of practical
decision-making tools for medication monitoring,
differential diagnosis, and the distinction of
referral service needs based upon impairment
severity. Consequently, there is a great need
for the development of practical, reliable and
valid procedures to be used in primary care
settings to identify and manage ADHD symptoms, as
well as to distinguish appropriate referral
needs.
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PADDS
The Clinicians ADHD Toolbox

• Computer based system to collect and compare
  multiple lines of evidence for ADHD diagnosis
• Patient Information Database and Reporting
• Comprehensive Parent and Teacher Interviews in a
  self-running or Clinician input format
• A battery of newly developed cognitive tests
  presented in a challenging, enjoyable format
• Automatic Report Generator with domain specific
  alerts and recommendations, and follow up
  comparisons of Treatments and Progress

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Medical History/Systems Review Developmental
History Social/Emotional Functioning Depression/An
xiety Attention/Hyperactivity Behavioral/School
History
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Cognitive Tests Executive Functioning
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Target Recognition presents five large colored
squares with smaller squares inside them. Through
153 presentations some number of the large
squares will have smaller squares of the same
color and some number will be different colors.
The child is taught a strategy to read from left
to right and count only the number of squares
with matching colors. This task requires
suppression of information, attention to detail,
formulation of a response to changes in stimuli,
modulation of emotions and persistence.
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Target Sequencing presents five large colored
circles. In each of 39 trials a small colored
square appears and then disappears in each
circle, in varied sequences. The child is taught
to only attend to circles with a matching colored
square. At the end of the trial the child is
required to click on each matching circle in the
order observed ( first match first,
second match second and last match last). Target
Sequencing requires the ability to avoid
distraction, attention to detail, organization
and sequencing during input of information,
planning and organization of a response,
modulation of emotion and sustained effort.
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Target Tracking presents four colored shapes at
the top and bottom of the computer screen. The
computer moves two or three shapes from the top
to the bottom shapes. The child is required to
remember the order of these moves and to recreate
them once all shapes have returned to the top of
the screen. Target Tracking requires the ability
to organize two and three step instructions, and
to recreate these instructions in the order
presented while modulating emotions and
sustaining effort across 20 trials.
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Cognitive Tests Executive Functioning
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Generate Reports Cognitive Tests Report
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PADDS SUPPORTIVE RESEARCH FOR TARGET SUBTESTS
ADHD N 65 Correctly ID 63 Missed 2 Total
Discrimination 96
TYPICAL N 60 Correctly ID 51 Missed 9 Total
Discrimination 86
TOTAL DISCRIMINATION 91 of 125 test subjects
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PADDS SUPPORTIVE RESEARCH FOR CROSS VALIDATION
SAMPLE
ADHD N 63 Correctly ID 59.22 Missed
3.7 Total Discrimination 94
TYPICAL N 62 Correctly ID 52.7 Missed
9.3 Total Discrimination 89.5
TOTAL DISCRIMINANT ABILITY 89.5
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PADDS SUPPORTIVE RESEARCH TOTAL DISCRIMINANT
ABILITY ACROSS BOTH STUDIES
ADHD N 125 Trial 1 96 Cross Validation
94 Total Discrimination 95
TYPICAL N 125 Trial 1 86 Cross Validation
85 Total Discrimination 85.5
TOTAL DISCRIMINATION 90.25 of 250 test
subjects
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PADDS SUPPORTIVE RESEARCH TEST / RETEST 43
SUBJECTS DRAWN FROM BOTH STUDIES
43 ADHD SUBJECTS N 43 Trial 1 40 Miss 3 R
.93
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Innovations in the Assessment of AD/HD Assessing
Executive Operations in the Diagnosis of
AD/HD   Presented at the CHADD 15th Annual
International Conference AD/HD Through the Years
From Science to Practice OCTOBER 31,
2003     Thomas K. Pedigo Ed. D. Pediatric
Adolescent Psychology P.C. 37 West Fairmont Ave.,
Suite 211 Savannah, GA 31406