Evaluation and TreatmentEvaluation and Treatment

Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder

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)

What is ADHD?What is ADHD?

Three types of ADHD1. Hyperactive/Impulsive2. Inattentive3. Combined

Attention Deficit Attention Deficit DisorderDisorder

• 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

Problems with Executive AbilitiesProblems with 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

Deficits From Poor Executive Deficits From Poor Executive AbilitiesAbilities

• 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

What Are The Developmental Risks?What Are The 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

More Developmental RisksMore Developmental Risks

Rates of Comorbid Disorders

Up to 87% have at least one other disorder; up to67% have at least two other disorders

(Kadesjo & Gillberg, 2001)

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

What Are The Probable Causes?What Are The Probable Causes?

• 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

What Doesn’t Cause ADHD?What Doesn’t Cause ADHD?

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)

Two ADHD Testing Tracks Two ADHD Testing Tracks

• Determine presence of ADHD symptoms and differential diagnosis from other disorders…Dx 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

ADHD Screen ADHD Screen Evidence-based minimum

standard

Appropriate for about 50% of patients

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)

ADHD ScreenADHD Screen

Time required15-60 min

15-25 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

ADHD ScreenADHD Screen

Time required5-15 min

5-10 min

• Poor Grades Poor Grades (Potential evidence of learning (Potential evidence of learning problems)problems)

• Extremes of behavior Extremes of behavior (ex. High risk behavior, (ex. High risk behavior, rage episodes, Self-injury, etc)rage episodes, Self-injury, etc)

• Complex Psychosocial or Medical History Complex Psychosocial or Medical History (ex. Abuse, multiple home placements, TBI’s, (ex. Abuse, multiple home placements, TBI’s, complicated divorces, etc)complicated divorces, etc)

• Intense Family Conflict / Parenting Intense Family Conflict / Parenting StressStress

• Family Mental Health History Family Mental Health History (ex. Bipolar, (ex. Bipolar, Schizophrenia, LD’s, Autism, etc)Schizophrenia, LD’s, Autism, etc)

Criteria Requiring Referral for Criteria Requiring Referral for Comprehensive Testing, Comprehensive Testing,

Track TwoTrack 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

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

Psychological / Psychoeducational Psychological / Psychoeducational Assessment Assessment (Track Two) (Track Two)

Interview - Individual, family, parent functioning, developmental historyBroadband - parentNarrow Band - teacher / other Functional Impairment

Cognitive Functioning •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 •Learning Disabilities (WRAT, WIAT, Woodcock-Johnson)

Attention Capacity. (optional)• CPT, TEA-Ch, IVA, TOVA

Psychological / Psychoeducational Testing Psychological / Psychoeducational Testing

- Track Two- Track TwoTime required30-60 min

15-25 min5-15 min5-10 min

30-90 min

30-90 min

15-45 min (Optional)

Psychological / Psychoeducational Testing Psychological / Psychoeducational Testing - Track Two- 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 minReport Writing 30-150 minTotal Clinician Time (3 - 8hrs)Average Clinician time (4 - 6hrs)

Current Current Reimbursement RatesReimbursement 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.   

• 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 (IEP’s 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

Feedback ConferenceFeedback Conference

1. Canadian ADHD Practice Guidelines CADDRA website http://www.caddra.ca/cms4/index.php?option=com_content&view=article&id=26&Itemid=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

2. 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

American Academy of Pediatrics guidelines       http://aappolicy.aappublications.org/cgi/content/full/pediatrics;128/5/1007

ADHD GuidelinesADHD Guidelines

• InterviewInterview• Parent Report Parent Report • Other/Teacher ReportOther/Teacher Report• Appropriate Referrals for Medical / Appropriate Referrals for Medical /

Psychological Testing or Treatment Psychological Testing or Treatment When NeededWhen Needed

All Four Guidelines All Four Guidelines Recommend “ADHD Recommend “ADHD SCREEN” as StandardSCREEN” as Standard

• ADHD Assessment FormADHD Assessment Form• Weis Symptom ChecklistWeis Symptom Checklist• ADHD ChecklistADHD Checklist• SNAP-IV-26SNAP-IV-26• Weis Functional Impairment Rating ScaleWeis Functional Impairment Rating Scale• Teacher Assessment FormTeacher Assessment Form

CADDRA Guidelines Page 85CADDRA Guidelines Page 85Website http://www.caddra.ca/cms4/index.php?Website http://www.caddra.ca/cms4/index.php?

option=com_content&view=article&id=26&Itemid=70&loption=com_content&view=article&id=26&Itemid=70&lang=enang=en

GuidelinesGuidelineshttp://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdfhttp://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf

CADDRA Recommended CADDRA Recommended “Assessment Toolkit”“Assessment Toolkit”

Broadband (Overall Mental Health Screener)Broadband (Overall Mental Health Screener)•Strengths & Difficulties Questionnaire Strengths & Difficulties Questionnaire ww.sdqinfo.org ww.sdqinfo.org •Weis Symptom ChecklistWeis Symptom Checklist

Narrowband (ADHD Specific)Narrowband (ADHD Specific)•Vanderbilt ADHD Rating Scale Vanderbilt ADHD Rating Scale http://www.dss.mo.gov/mhd/cs/psych/pdf/adhd_rahttp://www.dss.mo.gov/mhd/cs/psych/pdf/adhd_rating_teacher.pdf ting_teacher.pdf •SNAP-IV-26 SNAP-IV-26

Valid/Reliable – Brief & Free Valid/Reliable – Brief & Free Assessment ToolsAssessment Tools

• Evaluation• Education• Medication• Accommodation

• Parenting / Restructuring the home• Changes in school• Assistance in the community

What Are The 4 Stages of Treatment?What Are The 4 Stages of Treatment?

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 (<11 yrs., 65-75% respond)• Adolescents (25-30% show reliable change)

Empirically Proven TreatmentsEmpirically Proven Treatments

• 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)

Empirically Proven Treatment Empirically Proven Treatment (2)(2)

• 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

Unproved/Disproved Therapies Unproved/Disproved Therapies in ADHD Treatmentin ADHD Treatment

Psychological Psychological MeasuresMeasures