Evaluation and Treatment

1
Attention Deficit Hyperactivity Disorder

• Evaluation and Treatment

2
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)

3
Attention Deficit Disorder

• Three types of ADHD
• Hyperactive/Impulsive
• Inattentive
• Combined

4
Problems with Executive Abilities

• Inhibition (the minds brakes)
• Visual imagery (the minds eye)
• Internal speech (the minds voice)
• Emotional control (the minds heart)
• Planning and problem-solving (the minds
  playground)
• Taken from Barkley, 2011

5
Deficits From Poor Executive Abilities

• 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

6
What Are The Developmental Risks?

• 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

7
More Developmental Risks

• 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

8
Rates of Comorbid Disorders

• 54-84 Oppositional Defiant Disorder (Pliszka et
  al., 1999)
• 30-50 Learning Disabilities (Pliszka et al.,
  1999)
• 25 Childhood Conduct Disorder
• 45 Adolescent Conduct Disorder
• 25 Adults Antisocial Pers. Dis.
• Up to 33 Childhood Depression (Pliszka et al.,
  1999)
• 16 Mania (Biederman et al., 1992)
• 25 Childhood Anxiety (Tannock, 2000)
• 7 Tics or Tourettes

Up to 87 have at least one other disorder up
to 67 have at least two other disorders
(Kadesjo Gillberg, 2001)
9
What Are The Probable Causes?

• Heredity Risk to
• 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)
• No contribution of the rearing environment
• Genes found to date
• DRD4-7 repeat gene (Novelty-seeking)
• DAT1 gene (dopamine transporter)
• DBH, DRD5, SNAP25, ADRD2A

10
What Doesnt Cause ADHD?

• 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

11
Two ADHD Testing Tracks

• ADHD Screen (PCPs, psychiatrists, psychologists,
  examiners trained counselors)
• 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)

12
ADHD Screen
Evidence-based minimum standard Appropriate for
about 50 of patients

• Determine presence of ADHD symptoms and
  differential diagnosis from other disordersDx vs
  No Dx
• Establish the presence or not of comorbid
  disorders
• Up to 87 have one other disorder, LDs,
  internalizing/externalizing
• 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

13
ADHD Screen
Time required 15-60 min 15-25 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
• Differential Diagnosis / Comorbidity
• Broad band rating scales
• Child Behavior Checklist (Achenbach -ASEBA)
• Behavioral Assessment System for Children
  (Pearsonassessments.com)
• Structured interview of diagnostic criteria for
  DSM disorders (CHIPS or KSADS)

14
ADHD Screen
Time required 5-15 min 5-10 min

• Narrow band (ADHD Specific Symptoms)
• Conners, Brown, SNAP-IV, Vanderbilt, etc
• Parent and Teacher / Other report
• Functional Impairment
• 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

15
Criteria Requiring Referral for Comprehensive
Testing, Track Two

• Poor Grades (Potential evidence of learning
  problems)
• Extremes of behavior (ex. High risk behavior,
  rage episodes, Self-injury, etc)
• Complex Psychosocial or Medical History (ex.
  Abuse, multiple home placements, TBIs,
  complicated divorces, etc)
• Intense Family Conflict / Parenting Stress
• Family Mental Health History (ex. Bipolar,
  Schizophrenia, LDs, Autism, etc)

16
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.
• 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

17
Psychological / Psychoeducational Assessment
(Track Two)

• Identify environmental changes likely to improve
  functioning
• Delineate types of treatments likely to be most
  effective
• Behavioral, Family, Meds Alone, CBT for Dep or
  Anx, Tutoring, School Accommodations
• Explore the resources available to the family in
  their region
• Examples of Track Two cases
• 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

18
Psychological / Psychoeducational Testing -
Track Two

• Interview - Individual, family, parent
  functioning,
• developmental history
• Broadband - parent
• Narrow Band - teacher / other
• Functional Impairment
• Cognitive Functioning
• Learning ability, specific deficits, processing,
  overall level of functioning - academic
  accommodations that often influence a childs
  behavior and performance at home and school.
• IQ Screen or full IQ test. (WISC-IV, SB5, RIAS,
  KBIT, WASI,
• Academic achievement screening
• Learning Disabilities (WRAT, WIAT,
  Woodcock-Johnson)
• Attention Capacity. (optional)
• CPT, TEA-Ch, IVA, TOVA

Time required 30-60 min 15-25 min 5-15
min 5-10 min 30-90 min 30-90 min 15-45
min (Optional)
19
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)
20
Current Reimbursement Rates

• Non-RSPMI Rates
• Interview 57.84 /hr
• Testing hours 1-2 84.00/hr (same day)
• Testing hour 3 51.84/hr
• RSPMI Rates
• Interview 115.20
• Testing 115.20 /hr
• An RSPMI provider does not have to be a licensed
  psychologist with a Ph.D.   

21
Feedback Conference

• Patient-centered explanation of test results and
  tx options
• Walk parents through the testing results and
  information revealed
• Provide patient-education
• ADHD and comorbid disorders identified during
  evaluation
• Nature, causes, course, risks for future
  impairments
• Explain treatment options and explore their
  availability
• Medication
• Behavioral Parent Training
• Family Accommodations
• Academic Accommodations (IEPs and 504 plans)
• Review other issues identified during the
  evaluation
• Assist family in connecting with other
  professionals and resources/referrals as needed
• Specialists Psychiatric, therapy, sleep
  studies, OT, Speech, etc

22
ADHD Guidelines

• Canadian ADHD Practice Guidelines CADDRA
  website http//www.caddra.ca/cms4/index.php?option
  com_contentviewarticleid26Itemid70langen
        Full Guidelines http//www.caddra.ca/cms4/pd
  fs/caddraGuidelines2011.pdf
• National institute of Clinical Excellence
  (NICE)Guidelines http//guidance.nice.org.uk/CG72
          Full guidelines http//www.nice.org.uk/nic
  emedia/live/12061/42060/42060.pdf
•  Quick reference guide http//www.nice.org.uk/nice
  media/live/12061/42107/42107.pdf
• Scottish Intercollegiate Guidelines Network
   (SIGN)           http//www.sign.ac.uk/guideline
  s/fulltext/112/index.html     
  Full guidelines http//www.sign.ac.uk/pdf/sign112.
  pdf      Quick reference http//www.sign.ac.uk/pd
  f/qrg112.pdf
• American Academy of Pediatrics guidelines     
   http//aappolicy.aappublications.org/cgi/content/
  full/pediatrics128/5/1007

23
All Four Guidelines Recommend ADHD SCREEN as
Standard

• Interview
• Parent Report
• Other/Teacher Report
• Appropriate Referrals for Medical / Psychological
  Testing or Treatment When Needed

24
CADDRA Recommended Assessment Toolkit

• 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_contentviewarticleid26Itemid70langen
• Guidelines
• http//www.caddra.ca/cms4/pdfs/caddraGuidelines201
  1.pdf

25
Valid/Reliable Brief Free Assessment Tools

• 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

26
What Are The 4 Stages of Treatment?

• Evaluation
• Education
• Medication
• Accommodation
• Parenting / Restructuring the home
• Changes in school
• Assistance in the community

27
Empirically Proven Treatments

• Parent Education About ADHD
• Psychopharmacology
• Stimulants (e.g., Ritalin, Adderall, etc.)
• Noradrenergic Medications (e.g., Strattera)
• Tricyclic Anti-depressants (e.g., desipramine)
• Anti-hypertensives (e.g., Catapres, Intuniv)
• Parent Training in Child Management
• Children (lt11 yrs., 65-75 respond)
• Adolescents (25-30 show reliable change)

28
Empirically Proven Treatment (2)

• 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)

29
Unproved/Disproved Therapies in ADHD Treatment

• Elimination Diets removal of sugar, additives,
  etc. (Weak evidence)
• Megavitamins, Anti-oxidants, Minerals
• (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

30
Psychological Measures

• BASC Behavior Assessment System for Children,
  Second Edition
• CBCL Child Behavior Checklist
• WISC Wechsler Intelligence Scale for Children,
  Fourth Edition
• WAIS Wechsler Adult Intelligence Scale
• WASI Wechsler Abreviated Scale of Intelligence
• WIAT Wechsler Individual Achievement Test
• WJ-III Woodcock-Johnson Test of Acheivement
• SB5 Stanford-Binet Intelligence Test
• CPT Conners Continuous Performance Test
• IVA Integrated Visual and Auditory 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 Scales- Revised
• CHIPS Childrens Interview for Psychiatric
  Syndromes