Attention deficit hyperactivity disorder
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Evaluation and Treatment. Attention 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)

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Attention Deficit Hyperactivity Disorder

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Attention deficit hyperactivity disorder

Evaluation and Treatment

Attention Deficit Hyperactivity Disorder


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)

  • What is ADHD?


    Attention deficit disorder

    Three types of ADHD

    • Hyperactive/Impulsive

    • Inattentive

    • Combined

    Attention Deficit Disorder


    Problems with executive abilities

    • 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 Abilities


    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

    Deficits From Poor Executive Abilities


    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

    What Are The Developmental Risks?


    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

    More Developmental Risks


    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 Tourette’s

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

    67% have at least two other disorders

    (Kadesjo & Gillberg, 2001)

    Rates of Comorbid Disorders


    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

    What Are The Probable Causes?


    What doesn t 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

    What Doesn’t Cause ADHD?


    Attention deficit hyperactivity disorder

    Two ADHD Testing Tracks

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

    • Psychological / PsychoeducationTesting (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)


    Adhd screen

    Evidence-based minimum standard

    Appropriate for about 50% of patients

    • Determine presence of ADHD symptoms and differential diagnosis from other disorders…Dxvs 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 screen1

    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)

    Time required

    15-60 min

    15-25 min

    ADHD Screen


    Adhd screen2

    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

    ADHD Screen


    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, TBI’s, complicated divorces, etc)

    • Intense Family Conflict / Parenting Stress

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

    Criteria Requiring Referral for Comprehensive Testing, Track Two


    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 probsetc

    • *Establish range, severity, and source of symptoms compared to peers, rather than the Dxvs No Dx approach of the ADHD Screen

    Psychological / Psychoeducational Assessment (Track Two)


    Psychological psychoeducational assessment track two1

    • 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 / PsychoeducationalAssessment (Track Two)


    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 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

    Time required

    30-60 min

    15-25 min

    5-15 min

    5-10 min

    30-90 min

    30-90 min

    15-45 min (Optional)

    Psychological / Psychoeducational Testing - Track Two


    Attention deficit hyperactivity disorder

    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)


    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.   

    Current Reimbursement Rates


    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 (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 Conference


    Adhd guidelines

    • 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

    • National institute of Clinical Excellence (NICE)Guidelines http://guidance.nice.org.uk/CG72Full 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

    • 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 guidelineshttp://aappolicy.aappublications.org/cgi/content/full/pediatrics;128/5/1007

    ADHD Guidelines


    All four guidelines recommend adhd screen as standard

    • Interview

    • Parent Report

    • Other/Teacher Report

    • Appropriate Referrals for Medical / Psychological Testing or Treatment When Needed

    All Four Guidelines Recommend “ADHD SCREEN” as Standard


    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_content&view=article&id=26&Itemid=70&lang=en

      Guidelines

      http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf

    CADDRA Recommended “Assessment Toolkit”


    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

    Valid/Reliable – Brief & Free Assessment Tools


    What are the 4 stages of treatment

    • Evaluation

    • Education

    • Medication

    • Accommodation

      • Parenting / Restructuring the home

      • Changes in school

      • Assistance in the community

    What Are The 4 Stages of Treatment?


    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 (<11 yrs., 65-75% respond)

    • Adolescents (25-30% show reliable change)

    Empirically Proven Treatments


    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)

    Empirically Proven Treatment (2)


    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

  • Unproved/Disproved Therapies in ADHD Treatment


    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 – Children’s Interview for Psychiatric Syndromes

    • KSADS – Kiddie Schedule of Affective Disorders and Schizophrenia

    • KBIT – Kauffman Brief Intelligence Test

    • RIAS – Reynolds Intellectual Assessment Scales

    • BFIS – Barkley Functional Impairment Scales

    Psychological Measures


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