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SCREENING AND DIAGNOSING ADHD IN PEDIATRICS Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT Attention Deficit Hyperactivity Disorder is a diagnosis that tends to cause a lot of fear and confusion in parents and caregivers, but receiving the proper information in a timely manner from health clinicians can help alleviate many of those feelings. It includes a combination of symptoms, including hyperactivity, impulsivity, and difficulty sustaining attention. Millions of children struggle with these symptoms, which frequently ease as the patient reaches adulthood. It is important for clinicians to carefully screen patients according to current medical standards before making a diagnosis of attention deficit hyperactivity disorder. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Depending on their role and training, clinicians may or may not have primary responsibility to diagnose ADHD; however, often nurses and therapists contribute to the formulation of a diagnosis and plan of care through observation and interaction with children, parents and teachers and rely upon expert knowledge to use the right screening tool and methods to identify behaviors and social challenges associated with ADHD. Course Purpose To prepare clinicians to have knowledge of pediatric ADHD, methods of diagnosing associated disorders and behavioral outcomes, and to participate in interprofessional collaborative treatment that involves the patient and their family. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 3 1. _________________ are the primary neurotransmitters that mediate frontal-lobe function. a. b. c. d. Amino acids Catecholamines Gaba peptides Acetlycholine derivites 2. The predominantly hyperactive/impulsive type of ADHD is usually characterized by high energy and constant movement. The classic manifestation(s) of this type of ADHD is/are _____________. a. b. c. d. Inattentiveness or lack of attention Disorganization Forgetfulness All of the above 3. Children with predominantly ___________ type of ADHD face barriers when trying to form social relationships with other children due to their tendency to be easily angered and provoked. a. b. c. d. Inattentive Impulsivity Autistic Hyperactivity 4. A comprehensive neurologic examination needs to be performed in children with ADHD to rule out the possibility of neurodegenerative disorders such as _______________. a. b. c. d. Alzheimer’s Disease Parksinson’s Disease Adrenal leukodystrophy Mad Cow disease 5. The formal diagnosis of ADHD in children, adolescents, and adults usually occur in __________________. a. b. c. d. School Primary care settings Secondary care settings Home Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 4 Introduction According to the National Institute of Mental Health, attention deficit hyperactive disorder or ADHD is a relatively common brain disorder that is often diagnosed at childhood and continues to adolescence and adulthood.1 Children with ADHD sometimes exhibit uncontrollable behavioral symptoms that are frequent and severe which interferes with their ability to cope at school and live normal lives outside of it. Pediatric ADHD causes hyperactivity and impulsivity and/or inattention in affected children. Many children experience these behavioral issues at some time during their childhood. However, in children with ADHD, these behavioral problems persist over a long period of time. This course discusses the management and diagnostic approaches that every health professional in contact with an ADHD patient should be familiar with and understand. ADHD: An Overview To be diagnosed with ADHD, behaviors of hyperactivity, impulsivity and inattentiveness must continue for at least six months and be present in two environments such as home and school. Clinicians should be able to diagnose this disorder early on to evaluate the patient and provide for all the necessary pharmacotherapeutic and behavioral interventions that will minimize symptoms and restore social and academic functions. An effective management of ADHD requires a multidisciplinary team approach that includes the patient, the family, the school, and the clinician. History The modern concept of attention deficit hyperactivity disorder (ADHD) as defined by the Diagnostic and Statistical Manual IV (DSM-IV) is fairly new. However, its hallmark symptoms of over activity, inattentiveness, and Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 5 impulsiveness in children have been observed and recorded by physicians as early as the 19th century. A notable example is Sir Alexander Crichton (1978) who wrote a book entitled “On Attention and its Diseases”. In this book, he defined ADHD as; “when any object of external sense, or of thought, occupies the mind in such a degree that a person does not receive a clear perception from any other one, he is said to attend to it”. Crichton further records his observations of the progression of the disorder, and wrote that ”when born with a person it becomes evident at a very early period of life, and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education. But it seldom is in so great a degree as totally to impede all instruction; and what is very fortunate, it is generally diminished with age”.2 The idea brought forth another idea, which was that ADHD is a pediatric disorder which patients outgrow as they age. This idea of growing out of ADHD was prevalent up until the late 1990s. It was only fairly recently that scientific studies have shown otherwise; in fact, affected children diagnosed with ADHD continue to exhibit the symptoms well into their adulthood.3 Another physician, Heinrich Hoffman, published a series of illustrated children’s books depicting characters with symptoms of ADHD. One of the most notable ones was Johnny Look-in-the-air, who was depicted as a boy who exhibited telltale symptoms of inattention. In the book, Johnny was always “looking at the sky and the clouds that floated by”, a symptom that the American Psychiatric Association (APA) attributes to frequent distraction by an extraneous stimuli.4 The scientific concept of ADHD started with the publication of Goulstonian Lectures by the British pediatrician, Sir Frederic Still. In these lectures, he described symptoms of abnormal defect of moral control in children with Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 6 mental retardation, which are commonly seen today in patients diagnosed with ADHD. Some of these symptoms are passionateness, spitefulness, jealousy, lawlessness, dishonesty, and destructiveness. The common thread that ties these symptoms together is immediate self-gratification with disregard for the good of others or one’s self.5 Self-gratification is a major problem in patients with ADHD. It is closely tied to impulsivity, one of the identifying symptoms of ADHD. It wasn’t until 1932 that Franz Kramer and Hans Pollow reported hyperkinetic disorder as a single disorder, instead of part of residual effects of encephalitis. The two German physicians described motor symptoms that coincide with modern day’s diagnostic criteria for ADHD. Essentially, their report established a concept of hyperkinetic disorder that closely resembles the modern concept of ADHD. The earliest stimulant used to treat hyperactivity symptoms in children was benzedrine. The drug resulted in significant behavior improvement and school performance in some of the children it was tested on.6,7 Epidemiology The 2007 National Survey of Children's Health (NSCH) published a report on the epidemiology of ADHD. The report showed an almost 22% increase in the number of children between 4-17 years of age who were reported by their parents to exhibit symptoms of attention-deficit/hyperactivity disorder. This result reinforced to the medical community what it knows already, that parents and guardians play a vital role in early detection and subsequent treatment.8 As of 2007, there are approximately 5.4 million American children with ADHD. Children with ADHD exhibit symptoms of either inattention and hyperactivity or impulsivity, or both. These symptoms interfere with not just the children’s social and academic functions at home, Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 7 at school, or with friends but also strain the family ties with those who have to bear this burden. Pediatric ADHD is a public health concern. It affects all aspects of family life, which include expectations of what a typical day is going to be like through to expectations of school achievements, and relationships with family and friends. Indeed, there are very difficult challenges for families to face day to day, and with every passing year.8 The results of the NSCH survey were not surprising; more pediatric health professionals have to deal with ADHD patients. By 2007, 2.7 million children diagnosed with ADHD were reported to be taking medication.8 The results of the NSCH also highlighted some significant demographic prevalence previously reported by population-based studies. Specifically, the study revealed a 2:1 or even a 3:1 ratio of boys to girls in terms of diagnostic prevalence. These rates were also found to increase with age, which was an expected finding since many parents were told of their children’s ADHD diagnosis.8 The report also found a significantly greater increase of prevalence among 15-17 year old adolescents as compared with younger children. This suggested that clinicians may be encountering late diagnosis, and subsequently delayed treatment interventions and management of ADHD than in past years.8 This finding may also be attributed to a decrease in stigma related to ADHD in the recent years and greater acceptance of available treatment strategies. The NSCH report also brought to light the prevalence of pediatric ADHD among ethnic groups. In the past, the rates of ADHD in the United States have been lower among the Latino groups compared with non-Latino groups.8 Another significant finding in the report pointed to greater rates of Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 8 diagnosis brought on by parent reporting among multiracial children. There are, however, no clear indications of the driving factors behind this.8 Also, it is worth noting that genes play a role in the development of ADHD. In any population there will be a core group of children who, by virtue of their genetic make up, are more prone to develop ADHD regardless of the environmental factors surrounding them.8 There is also a dramatic difference among U.S. state regions in the prevalence of pediatric ADHD reported by parents. It has been reported that the state with the largest prevalence of parent-reported ADHD was North Carolina at 15.6%, representing nearly a 63% increase in ADHD prevalence from 2003 to 2007.8 These differences are not clearly understood but some researchers attribute them to demographic factors. The risk for ADHD increases as income decreases, this is usually brought on by lesserresourced educational services, fewer support systems for parents and guardians, and greater behavioral problems combined with lesser accessibility of adequate resources and services.8 This wide disparity may also be due to some U.S. states having greater and more aggressive health screening and diagnostic practices and protocols in place. States with improved health prevention and screening practices have been reported to have higher reports of prevalence rates. The more rigorous the screening process, the greater the likelihood of finding more symptoms related to a diagnosis of ADHD.8 Greater awareness and better screening efforts may be the two greatest determining factors to diagnose ADHD. There has been quite a lot of education in most recent years. The American Academy of Pediatrics, for example, has really focused on quality improvement for pediatric practices, Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 9 and the efforts around autism and ADHD have been focused on trying to standardize the approach to screen and diagnose behavioral issues.8 Pathophysiology Of ADHD Various neuropsychological studies propose a causal link between the frontal cortex and the networks connecting them to the basal ganglia in the pathophysiology of pediatric ADHD. These links are very important for many decision-making functions and, therefore, also for attention and inhibition. The frontal lobe is responsible for the majority of decision-making functions. Magnetic Resonance Imaging (MRI) results of the right medial prefrontal cortex in ADHD patients show clearly its diminished activation during activities needing both inhibition of a planned motor response and timing it to a sensory stimulation. The same images also exhibit weak right inferior prefrontal cortical and left caudal stimulation during activities involving timing of a motor response to a sensory stimulus.10 A study by Spinelli et al. explored the neural correlates that regulate response inhibition deficits in pediatric ADHD. It studied closely the many functional MRI brain activation activities of children between the ages of 8 and 13 years who were both diagnosed and not diagnosed with ADHD on a go/no-go task. It found lapses in attention that preceded the response inhibition errors in the children with no ADHD. It also found involvement of brain circuitry in the response selection and control activation occurring before these errors in children diagnosed with ADHD.3 Catecholamines are the primary neurotransmitters that mediate frontal-lobe function. Neurotransmission mediated by the dopaminergic and noradrenergic receptors seem to be the primary medication targets when Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 10 treating ADHD. A decade-long study by the National Institute of Mental Health (NIMH) found that the brains of children and teens with ADHD are 34% smaller in size compared to children without the disorder. The finding also pointed out that pharmacologic treatment played no role in this case. The greater the symptom severity of pediatric ADHD were, as rated by parents and clinicians, the smaller were their frontal lobes, temporal gray matter, caudate nucleus, and cerebellum. The results from 357 healthy subjects, acquired from the NIH MRI Study of Normal Brain Development, also found that a thinner cortex due to slow cortical thinning process was linked to greater attention problem scores. These results suggested an association between attention and cortical maturation. Aside from the significant role of neurotransmission, pathways, and frontal lobe involvement, certain imaging studies have started exploring the involvement of 5-hydroxytryptamine or serotonin in the pathology of ADHD.10-11 Even though the brain’s motor areas are innervated by serotonin projections, there has been no link between this neurotransmitter and ADHD motor pathology to date. However, there have been associations made to attention-related activation. A change in 5-HT activity seems to be partly to blame for the difficulties with perceptual sensitivity and appropriate recognition of the relative significance of stimulation. Additionally, prior twin studies has suggested that traits of hyperactivity and inattentiveness were strongly inheritable.12 Types Of ADHD There are three different types of pediatric attention deficit hyperactivity disorders. The disorder is also sometimes called hyperkinetic disorder in other literature, most notably the World Health Organization (WHO) Integrated Classification of Diseases (ICD). The classification is based on Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 11 varying degrees of maladaptive patterns of impulsivity, inattention and hyperactivity. The names and other descriptors applied to the disorder are based on how children afflicted by it behave under the observation of specialists. Impulsivity refers to the child’s tendency to carry on actions that are thoughtless and premature, usually without forethought. Hyperactivity denotes the excessive movement that is usually restless and shifting in nature. Inattention is described as being disorganized in thought that prevents efforts to sustain attention or focus in a given thought or concept.13 It is more commonly diagnosed in children and adolescents, with boys accounting for a larger percentage of the affected population. The epidemiology of pediatric ADHD in the U.S. has previously been discussed. However, it is worth noting that its prevalence worldwide is much more varied because of the different diagnostic and classification criteria that differ between countries. Unfortunately, there are some countries wherein diagnosis is not even made because of the lack of proper guidelines and protocols for it. In the United Kingdom, for example, because of the lack of proper guidelines, only 0.9-3.6% (depending on age) of the population was reportedly diagnosed with pediatric ADHD, including any ADHD types.14 On the other hand, in the U.S., because of the advent of more generalized and broader clinical guidelines in place, a greater number of the pediatric population is screened, showing 10% of the pediatric population being affected. To date, there are approximately 7.5% of children worldwide diagnosed with ADHD, with male children accounting for a greater share of this percentage. Specifically, the male children outnumber the female children.15 However, the worldwide data on ADHD tends to be controversial because of the possibility of males being overly diagnosed with the problem than females due to their behaviors during play and other forms of social interactions. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 12 Attention deficit hyperactivity disorder is referred to as a form of hyperkinetic disorder in the WHO’s International Statistical Classification of Diseases and Related Health Problems, Revision 10 (ICD-10),13 and in the American Psychological Association (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) scheme of diagnoses. The diagnostic criteria set forth by these organizations do not focus on the theories surrounding the etiology of the problem, but rather on the behavioral symptoms that children exhibit at school, at home, and at other social settings. Because of the wide differences in the symptoms seen in patients with the disorder, ADHD is subdivided into three types. These types are based on the most predominant symptom and behavioral pattern seen in the patient: 1) predominantly inattentive, 2) predominantly hyperactive and impulsive, and 3) combination of both. Each of these types is discussed in detail in the following sections. A great number of parents are more likely to report having observed the signs and symptoms of ADHD in their children when they are very young. Most ADHD cases tend to be diagnosed during the preschool years. However, this is not always the case. Some cases of ADHD are diagnosed only during their school years when the children begin interactions with other children, and their behaviors and attitudes can then be compared to them. During infancy years, children with ADHD are usually characterized as being fussy and temperamental. They are also more likely to have sleep problems. Toddlers usually exhibit an observable on the go attitude, ready to bolt or run anytime. They also are more likely to attempt multitasking, putting their hands into doing several things at the same time. One of the most common problems seen in this age is when they show a tendency for breaking toys and setting out to dismantle other things around the house. Parents usually Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 13 report exhaustion because of having to stop them from running around the house during the day or trying to stop them from jumping on beds and couches. Parental desperation also sets in when they do not listen to commands or pay attention when the parent talks to them.16 Once these children enter school, ADHD can cause a lot of problems for them, as well as for their parents and teachers. Teachers often find it difficult to instruct children with ADHD symptoms of impulsivity and inattentiveness, which often interfere with their learning progress and academic performance. The habit of fidgeting or moving from one seat to another causes disruption in classroom activity as well as frequent tapping on tables or making unnecessary sounds using pencils. Because these children are easily distracted, environmental noises like rustling of leaves or flapping of birds’ wings steals away their focus from lessons at hand, and subsequently causes poor academic performance. This manifests in mistakes committed because of haste, forgetfulness when it comes to home works and assigned tasks, and an inability to follow directions.16,18 Outside academic settings, children with ADHD also face difficulties in forming social relationships and networks. They are often labeled as being bossy or too aggressive, or simply being too difficult to be with by teachers and fellow peers. As a result, they are avoided by classmates and not invited or deliberately not included in games and other social activities outside the classroom. This reaction is understandable since children with ADHD have a hard time cooperating with other children during play, and are more often unwilling to wait for their turn to play. Additionally, they also tend to be accused of having the habit of constantly interrupting people. Rejection often occurs, which creates an environment wherein they feel unwelcomed, uninvited, and isolated. Such an environment promotes the undesired Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 14 symptoms of impulsivity and destructive behaviors, which is very dangerous as adolescence approaches if left undiagnosed. During adolescence, the accumulated feelings of isolation and deprived friendships foster other negative outcomes such as refusal to go to school or cutting classes. Adolescents with ADHD are given harsher punishments compared to normal children. The mode of disciplinary actions taken against them often includes detention, suspension of varying lengths of time and, in worse cases, expulsion from school.16-21 A study by Wender (2000) found pediatric patients with ADHD manifested symptoms well into their adult years, as opposed to the common belief that children with the problem “outgrow” their behavior.22 It has also been found that an approximately 30-50% of children who were diagnosed with ADHD continued to manifest symptoms into adulthood despite being treated during their childhood years. Adults with ADHD are also more likely to manifest behaviors such as restlessness, impaired social interactions, nervousness, episodes of depression, and very low threshold for stress and frustration. In addition to these symptoms, they are also found to have higher risks of developing psychiatric and other personality disorders, resort to drug and alcohol use, face numerous battles with the law, and are generally more impulsive than their peers.3,22 Predominantly Inattentive Type of ADHD Predominantly inattentive type of ADHD is most commonly referred to as Attention Deficit Hyperactivity Disorder-Predominantly Inattentive (ADHD-PI). This type was first introduced in the mid-1990s with the introduction of the DSM-IV Category of Mental Illnesses.4 Among the three types, this is the Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 15 more uncommon type and also harder to diagnose. ADHD-PI is usually characterized by plain fatigue, which may be a sign of laziness or both. The classic manifestations of this type of ADHD are inattentiveness or lack of attention, disorganized tasks and thoughts, forgetfulness, and obvious attitude to procrastinate regardless of the importance of their accomplishment. Although these symptoms are also found in the other two types, it should be noted that in children with predominantly inattentive ADHD, these symptoms are usually accompanied with episodes of lethargy or excessive fatigue, and decreased or almost no symptom of the usual hyperactivity or impulsivity seen in other types.17 The two main characteristics of this subtype are 1) deficient or diminished concentration when faced with tasks and chores, and 2) presence of severe fatigue when asked to focus attention on activities related to learning. These two characteristics are especially evident in children who suddenly express fear or revulsion when activities requiring greater focus and attention are given to them, or when they are asked to be part of a group performing such tasks.17 These children tend to show abhorrence and avoidance of any planned work, especially when it is structured and requires long hours of focus and attention to detail. Such responses occur even when a concept that is related to the task is not new to them, or could be something that they even excel at. On the other hand, when these children are assigned a task or an activity they find to be interesting, they are noted to spend more time than they used to in other tasks; although there is no study yet that proves these children have higher success rates of finishing such tasks even in the presence of increased interest. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 16 Children who suffer from inattentive type of ADHD usually face various academic difficulties such as failure in several subjects, being labeled as simply lazy or disinterested in learning, branded as a problematic student, or given other negative feedbacks such as being incompetent and irresponsible. The worst possible scenario that can happen is when these children completely withdraw from school either by their own volition or through administrative expulsion. The withdrawal from school and all its social and academic opportunities only serve to delay such children’s social, intellectual, and emotional development even more. As children with ADHD-PI grow older, they may become aware of the apparent differences between their own behavior and attitudes compared to other children their age. They are most likely to notice that they behave differently than their peers and that their actions and behaviors are not generally acceptable most of the time to the people they interact with. Because of this, they are also more likely to accept negative reactions and perceptions of themselves by other people. When this happens, they tend to create within themselves a negative sense of self and project it outside to their environment and the people surrounding them. Because this behavior sometimes gives them an illusion of protecting themselves from societal stigma, they have the tendency to reinforce this behavior well into their adolescence and adulthood if left untreated. The false sense of protection children with ADHD tend to develop from projecting negative perceptions of themselves onto others tends to fuel their destructive behavior. Children who exhibit this type of behavior usually experience problems in initiating and maintaining interpersonal relationships, which can affect not only how they relate to people at school but also to the whole society in general. This becomes an unending vicious cycle where the Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 17 problems confound themselves and lead to subsequent ineffective coping mechanisms. Results of various ineffective coping mechanisms may be evident later on in life in terms of substance use (alcohol, narcotics or both), development of self-destructive behaviors such as sexual promiscuities, and other mental health disorders.17,18 If treatment of the inattentive type of ADHD is performed as soon as diagnosis is made, children affected by ADHD-PI would be able to adapt behaviors to enable them to adjust cognitively and to develop coping mechanisms necessary to decrease the effects of inattentiveness while in and out of school. Despite this, it is worth noting that the main problems related to the disorder do not disappear entirely. They are simply controlled and managed at a level where children with ADHD-PI are able to carry out normal activities without or with minimal disruptive symptoms. Also, when compared to the combined type of ADHD, children diagnosed with the inattentive type have been found to perform with less favorable outcomes. A prior meta-analysis of 37 studies conducted by Lane (2004)19 to assess and compare the cognitive functions of different types of ADHD found that children with the inattentive type have slower intellectual processes, shorter attention spans, lower intelligence quotient, poorer memory, and exhibit lesser fluency compared to those with the combined type of ADHD. Predominantly Hyperactive/Impulsive Type of ADHD The second type of ADHD is the predominantly hyperactive-impulsive type. It is also the second most common type. The predominantly hyperactiveimpulsive type of ADHD has become one of the most well known manifestations of ADHD in children, and even in some adults. This type is usually diagnosed in childhood before the age of seven. Because the Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 18 symptoms of the disorder are very similar to the other usual childhood behaviors, many parents fail to recognize them and therefore delay their children’s diagnosis. Some children were found to have already manifested the disorder some 6 months or more before the diagnosis was made.17,18 One thing that most parents fail to recognize is that while some of the symptoms of ADHD hyperactive-impulsive type are much more similar and typical with other childhood behaviors, children with this type of ADHD manifest them in a relatively extreme degree and oftentimes experience great difficulty to control behavior. Children with this type of ADHD often experience problems in social settings. Like other types of ADHD, they will have great difficulty interacting with other people and creating meaningful and lasting relationships with them. Friendship becomes a difficult goal for them to attain due to the extreme behaviors they manifest, causing peers to keep them out of their social circle or rejecting them outright. Difficulty interacting with peers and peer rejection leads to the development of depression during early childhood years, and the possibility of turning the frustration and disappointment outward to other people in the form of delinquency, substance use (alcohol and narcotics) and even self-destructive behaviors. Self-destructive behaviors in early childhood years can be manifested through refusal to eat even when hungry, engaging in selfmutilating behaviors, and performing actions they know would result in punishment and other disciplinary actions. One of the barriers these children face when trying to form social relationships with other children is their tendency to be easily angered and provoked.20-23 They easily show displays of ill temper. Apart from these most common problems, children with predominantly hyperactive-impulsive ADHD Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 19 also present with penmanship that is described as either poor or barely legible, delays in speech and language development, and also delays in motor skills development. Poor handwriting can be attributed to developmental problems of their motor skills, which manifest usually as hyperactivity. Language and speech problems can include episodes of stuttering, stammering or both. Often, motor skill problem can be seen when children with predominantly hyperactive type of ADHD usually bump into things, or suffer from accidents due to poorly coordinated movements. Symptoms presented by children with ADHD can be grouped as either predominantly hyperactive or impulsive in nature. Those who manifest hyperactive behaviors are usually seen exhibiting a sense of restlessness, being fidgety or unable to stay still, and frequently fiddle with things when not on the move. When these children are asked to take a seat, they usually start squirming within the first 10 minutes and progress for the worst the longer they remain seated. This is, in fact, one of the most commonly reported troubles these children have at school. Additionally, these children can also endlessly move about unless exhaustion causes them to stop or slow down. They are generally unhappy with quiet and calm activities such as doing schoolwork and watching television. Because of the risk of exhaustion, children with predominantly impulsive type of ADHD are not usually encouraged to participate in active sports since the activities involved only seem to heighten their symptoms of hyperactivity and restlessness. Impulsive behaviors manifested by children with predominantly hyperactiveimpulsive type of ADHD are the reason behind failed attempts at building and maintaining social relationships. The impulsiveness exhibited by these children can be described as either minor or major. Minor symptoms include Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 20 interrupting others during conversations and intrusive behaviors that may be labeled by other people as being nosy. Intrusive behaviors are also seen when children with this type of ADHD suddenly insert themselves uninvited into activities of other children and later on take over the entire game. Major symptoms of impulsiveness can be manifested through unstable relationships or frequent fights with friends. Waiting and being under pressure are other situations wherein these children may find it hard to control themselves. Mood swings are also common among them, as well as reckless thoughts and actions. These children also tend to have shorter tempers, which can be highlighted by explosive emotional outbursts or tantrums. These outbursts often happen at inopportune times and places, putting the parents and other caregivers in embarrassing positions especially when in the company of other people or in a public place. Clinicians, parents, caregivers, and teachers are prudent to remember that the symptoms presented by children with hyperactive-impulsive type of ADHD vary in severity and are prone to change over time. However, despite the challenging symptoms that are associated with this particular type of ADHD, these children also show longer attention spans, especially when they are given tasks that they find particularly interesting.17,18 Combined Type of ADHD The most common of the three types of pediatric ADHD is the combined type, i.e., the combination of inattentive and impulsive symptoms. It is usually diagnosed when children manifest both inattentiveness and hyperactivityimpulsiveness. Apart from being one of the most common, this particular type of ADHD is also considered to be one of the worst types because of the Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 21 greater behavioral symptoms children exhibit. For diagnosis of the combined type of ADHD to be made, children would need to positively exhibit at least 6 symptoms of both types of ADHD (discussed later in this course). Due to the number and mix of symptoms manifested, children with the combined type usually suffer far more problems and associated symptoms than those who only suffer from either one. Children with this diagnosis often have poor prognosis and require long-term therapies.17 Since this type of ADHD is a combination of inattentiveness and hyperactivity-impulsivity, children can develop severe restlessness that carries on well into their adulthood, lack of focus and spur of the moment tendencies, which impair important decision-making skills. Problems with schoolwork and academic performance as well as interpersonal relationships are also frequently seen with these children.17 The inattention or loss of focus is usually seen intermittently during schoolwork, especially when tasks requiring focus is handed to these children. They are also more likely to be inattentive even when they are part of group-related activities. The impulsiveness that these children exhibit reflects in the manner they choose things and tasks, which often lead to frustration when they do not get their way. Academic performance suffers because of their inability to finish tasks and pay attention to classroom activity. It is not uncommon for these children to fail their subjects and be recommended to repeat them the following school term. Symptoms related to inattentiveness manifest in individuals diagnosed with the combined type as easy distractibility, inattention to details, forgetfulness, and habits of starting on projects without actually finishing them. Moreover, children with this type of ADHD are also more likely to express boredom when it comes to doing schoolwork and other tasks, find it difficult to Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 22 organize thoughts and activities, and follow and obey instructions given to them. Wandering around the classroom or in hallways is a common complaint from teachers handling these children, especially when their diagnosis is not disclosed. Hyperactivity symptoms that are evident in the combined type includes excessive talkativeness, squirming in seats and being fidgety, constantly moving around and having extreme trouble and discomfort at sitting still. With the symptom of talkativeness, the child usually rambles on a lot of things, which often do not make complete sense and in worst cases, say inappropriate words and thoughts for their age. Also, impulsivity may be highlighted in these children when they lose patience when waiting for their turn or on other things, they exhibit the habit of randomly saying anything without regard for others’ feelings, act out their frustrations and feelings, and constantly interrupt people during speech or activity. Anger management is also an issue with these children, causing them to lose favor with both friends and their teachers.17 Due to the great difficulty of these children in handling interpersonal relationships and their inept social skills, they have a very difficult time forming and maintaining relationships among their peers. Often, they are socially isolated because of the rejection they face from their peers and other people around them. The continued isolation and lack of social support leads to the development of depression, a marked reduction in their selfesteem, failure in school work and academics, and resorting to violent and destructive behaviors.17 Apart from the aforementioned symptoms and problems encountered by children with the combined type ADHD, they are also more likely to face Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 23 higher risk of emotional and mental disorders in later life. One of the most common related disorders that these children may face is the development of conduct and oppositional defiant disorders.12,17 Conduct disorders first become apparent when children with combined type ADHD do things without any regard for others and their well being, and habitually violate rules and the rights of other children. These children are frequently involved in mindlessly taking other children’s belongings and acting out on their frustrations. These children are also more likely to pick on smaller or younger kids and bully them. These disruptive disorders are often met with disciplinary actions and parents being called to the school to discuss their children’s behavior. If the disorder remains untreated, it can very well become the precursor of an anti-social personality disorder later on in life.26,28 Oppositional defiant disorder, on the other hand, is seen when children engage themselves in ongoing destructive patterns that is defined by persistence of disobedience and triggered by anger and hostility. Also, these children exude defiance against authoritative figures that are not typical of children their age. It may be accompanied by extreme anger and stubbornness that is also not exhibited by most children of the same age. Aside from the risk of the developing conduct and oppositional defiant disorders, children with the combined type of ADHD have higher risk of developing bipolar disorder and other psychiatric problems. These other psychiatric problems are often the result of their social isolation, neglect, and stigma they’ve experienced early in life. Presentation Of ADHD As mentioned previously, Sir Alexander Crichton described attention deficit hyperactivity disorder in the literature as early as 1798. In this work, he Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 24 accepted the condition only as manifesting hyperactivity and therefore a part of the normal human condition.2 However, it was George Still who, in 1902, clearly described ADHD. The description he made then has since evolved into what we know today as ADHD.5 In the prior section, it was mentioned that ADHD has presenting symptoms that vary based on the specific type affecting the individual. A child may manifest predominantly inattentive, predominantly hyperactive/impulsive subtype, or the combined type of ADHD. In the following sections, the patient history and physical presentation of ADHD as well as how to best ascertain the ADHD category a child falls into will be discussed. Patient History Conducting a thorough patient interview and gathering clinical data on a child’s functional abilities is part of the initial intake and patient history. The DSM-5 criteria are also used by many child psychologists in assessing the presenting symptoms and play a significant role in the eventual diagnosis.30 It is also during this data gathering that significant information about comorbid or preceding conditions are to be included. When taking the patient history, clinicians need to pay attention to detail and exercise good observation skills. History of Present Illness When recording the history of present illness, the clinician should use the set of criteria outline by the American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition. In general, a confirmed diagnosis of ADHD is made when the diagnostic criteria are met, which are reviewed below.12,30 To be diagnosed with predominantly inattentive type of ADHD, the patient must present with six or more symptoms of inattention for children up to Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 25 age 16, or five or more for adolescents 17 and older and adults. Symptoms of inattention must have been present for at least 6 months, and they are inappropriate for the patient’s developmental level, such as: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (i.e., loses focus, sidetracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (i.e., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted Is often forgetful in daily activities. To be diagnosed with the impulsivity-hyperactivity type of ADHD, the patient must present at least six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults. Symptoms of hyperactivity-impulsivity must have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 26 Often unable to play or take part in leisure activities quietly. Is often on the go acting as if driven by a motor. Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (i.e., butts into conversations or games). Additionally, the following criteria must also be met: Many of the major inattentive or hyperactive-impulsive symptoms are already present before the child reached the age of seven. The symptoms are also present in more than one setting such as both the home and school. In adults, the symptoms can be seen at work. There is also the presence of distress or impairment in a social or academic context. The present behavior is not suggestive of other mental health disorders such as mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). Past Medical History The past medical history is important in providing clues as to the possible triggers that precipitated the behavioral symptoms, other than ADHD itself. The presence of other conditions that might have triggered the condition is explored as well as the use of medications and other substances that can cause side effects or interacted with ADHD medications.9,10 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 27 Conditions that may exist prior to or after the diagnosis of ADHD in patients include psychiatric problems, which affect approximately 30-50% of all patients with ADHD. These problems are normally: • Disorders that are primarily considered as rooted in anxiety such as OCD (obsessive compulsive disorder), panic disorder, GAD (generalized anxiety disorder) and social phobia • Mood swings which are characteristic of bipolar disorder • Receptive or expressive communication disorders which can sometimes occur simultaneously • Oppositional defiant disorders, or conduct disorders, specifically in children with combined type of ADHD • Existence of depression in varying degrees • In rare cases, dissociative disorders • Eating disorders such as anorexia • Bed-wetting • Presence of learning difficulties other than lack of focus or attention • Sleep disturbances • Disorders that are psychotic in nature • Tic disorders such as Tourette syndrome Coexistence of physiologic problems is not usually associated with the presence of ADHD, but when these are present, they are usually an effect of hyperactivity of these children. However, the coexistence of some diseases is vigilantly assessed since some of the medications prescribed for these Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 28 conditions might interact significantly with ADHD medications. These are identified as:9,10 • Stimulant drugs used for patients with coronary artery diseases may interact with other stimulants given for inattention to increase attention span. • Medications used for pediatric (and adult) patients with narrow-angle glaucoma such as imipramine and desipramine may interact with ADHD medications. • Medications used to treat patients with heart diseases may cause significant drug-drug interactions when given concomitantly with ADHD medications. • Cardiac glycosides such as digoxin causes negative chronotropic effect, which has been shown to cause unwanted effects in patients on ADHD medication therapy. Pregnancy is also assessed in a child’s mother since most anti-ADHD medications may exert fatal effects on the fetus, and should be included in the child’s medical history. Interactions with other medications and food supplements are also assessed, which include: • Anticonvulsant drugs such as phenytoin • Medications used to treat pediatric hypertension • Drugs with caffeine content • Ephedra and pseudo-ephedrine-containing medications Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 29 • Drugs used to treat depression such as monoamine oxidase inhibitors (MAOIs) Family History The family history of the child should also be assessed. Specifically, the general health and wellbeing of the child and the parents need to be carefully assessed, most especially of the mother. The following areas need to be assessed to determine any influence family history may have on the development of ADHD:3 Age during or prior to pregnancy General physical condition of the mother during pregnancy Dietary intake Intake of medications and other supplements Use of alcohol and cigarette Substance use problems, if any Developmental History Children of all ages are affected by ADHD, which can go on until adulthood. ADHD affects children during the stages of growth and development in a variety of ways, therefore it is considered to be a chronic lifetime disorder.3 However, it has also been a common consideration in research studies conducted to treat the preschool years as a particular point of concern since it is during this time that ADHD is usually diagnosed. Also, when children with ADHD are diagnosed as early as this stage, there is a higher rate of success to prevent the onset of any psychopathological conditions that can follow.3 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 30 There are a variety of templates that can be for the developmental history. To better understand the developmental history of a child with ADHD, it is best to study it according to the respective stages of growth and development. ADHD During the Preschool Age The assessment and diagnosis of children with ADHD in the preschool stage is usually achieved by means of rating scales and observations of the behavioral pattern.3,9 A rating scale is to be used during the assessment of these children and should include, but not be limited to the following symptoms.31 • Difficulty to maintain prolonged attention • An increased level of distractibility • The state of being on the go most of the time • Running around the house and climbing onto furniture excessively • Difficulty to follow instructions • Observed difficulty and discomfort in having to remain still It is also during this developmental age that a higher rate of coexisting conditions and complications can start to appear, with approximately a majority of children developing disorders such as oppositional defiant disorder, communication disorders and anxiety-related disorders. Because of this outcome, it is important that ADHD cases diagnosed in the preschool age be treated as soon as possible, otherwise these symptoms may negatively impact the child’s development.25,31-33 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 31 ADHD Among Children in the School-Age and Adolescence In the school-age group ADHD cases are reported to be increasing, with boys making up the greater part of the prevalence rate than girls. Apart from the use of rating scales, which are more applicable during the preschool age, the diagnosis of ADHD in this group also includes interviews with people who are usually with the child (parents, teachers, other relatives, etc.), as well as asking children above the age of 11 to self-report symptoms. Apart from this, computerized diagnostic testing is carried out to determine the child’s attention span and regulation. This includes inhibition of stimuli, division of attention and flexibility of reaction. The child’s ability to maintain attention is also assessed, with parameters such as vigilance in focusing, endurance of attention over time and activity, and ability to stay alert as the focus of the assessment.12,35,36 Since this stage is crucial to the child’s future development, there is high risk for negative impact to the child if left untreated. There is the possibility of functional impairment during adolescence. The data indicates that children during school age and adolescence exhibit oppositional behaviors and some cases with coexisting anxiety disorders. Since development is usually impaired or delayed, children with ADHD at this stage might experience learning problems and difficulty in keeping up with peers and academic demands at school.17 Aggressive behavior is also very common in this stage, leaving children with ADHD having to face difficulties in interpersonal relationships. It is also at this stage that affected children experience decreased motivation to do or achieve something. As the child grows older, so does the extent of emotional problems that are oftentimes the consequences of being rejected by peers, Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 32 the rejection and harsh treatment from teachers, and the nagging feeling of being different from anyone else.17 ADHD in Adulthood One of the primary things about ADHD that clinicians and parents need to recognize is that often as children grow into adulthood their symptoms and other associated problems not only persist, but are also magnified with more than of half of the adult population with ADHD showing unremitting behavioral problems. These problems occur regardless of the gender of the individual. Moreover, the most common problems coexisting with ADHD as the child grows to adulthood appears to include a substance use problem, antisocial behaviors, borderline personality disorder, and the presence of disorders involving mood. These have been found to exist due to a strong relationship with the neurobiological processing mechanisms involved in ADHD and these disorders.17,27 There is also evidence that suggests that an individual with ADHD can experience problems with general emotional health and social wellbeing due to the negative influence brought about by the aforementioned comorbidities and other impairments that go along with them. Adults who have ADHD also exhibit difficulty in carrying out their daily duties, which can very well lead to the development of problems at home, at work and in social situations where socially acceptable behaviors are expected. Emotional problems throughout a person’s lifespan with ADHD tend to be common because there is poor regulation of emotions, and this problem can result in poor interactions with other people. The presence of negative social interactions can also heighten the psychological impact of the problem in the Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 33 individual, thereby increasing the risk of developing other comorbid conditions that are psychiatric in nature. This risk and its associated severity, however, are parallel with the characteristics of the patient and the availability of necessary support and resources. Physical Assessment Physical assessment of the patient with ADHD can be performed in various ways. It can be performed through thorough examination of the physical attributes or with the help of diagnostic and other imaging studies. Since the condition primarily affects the structure and function of the brain, one of the most common diagnostic tests conducted is the use of imaging technology to assess for structural and functional changes. Studies on Brain Function As mentioned in the previous sections, imaging studies have revealed that children diagnosed with ADHD show a substantial reduction of the brain volume, most specifically in the left side, with the prefrontal cortex being the part that is most severely affected.11 There is also involvement of the pathways that serve as connection between the striatum and the prefrontal cortex. These images support the theory that a frontal lobe dysfunction is a major pathologic cause in ADHD, being responsible for many of its associated symptoms of inattention, impulsivity, and hyperactivity. On the other hand, the cerebellar region and other regions of the brain may also be involved since it has been found that there are indeed significant differences in the functioning of brain systems in people with and without ADHD.10,11 Apart from imaging studies, tests involving neurotransmitters and their normal functioning in patients with ADHD are also helpful. In the past, one Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 34 of the emerging ideas concerning the role of neurotransmitters in the brain function of patients with ADHD is the observed increased amount of dopamine transporters. This is significant since this is the mechanism by which hyperactivity is attributed in ADHD patients. However, it has been proven by a research study that the elevation of dopamine transporter numbers in the brain is an adaptive process that is a response to the administration of stimulant medications.10-12 Studies also suggest that individuals who are diagnosed with ADHD may have a lower threshold of arousal, which is attributed to the brain’s effort to compensate for the greater stimulation it is subjected to, causing a disruption in the attention span and the acting out of behaviors that are hyperactive in nature. Generally speaking, the root cause of all these abnormal processes is attributed to the apparent abnormalities in which the dopamine system generates a response when stimulated. Apart from abnormalities within the dopamine system, children with any type of ADHD have also been found to exhibit abnormal levels of other neurotransmitters such as serotonin, cholinesterase, adrenalin, and GABA. These neurotransmitters and their pathways, as a result of ADHD, have been found by researchers to be altered.34,35,37 Executive function is also affected in individuals diagnosed with ADHD, and causes significant difficulty. The executive functions include mental processes that are necessary to carry out and regulate daily tasks and to control and perform the management of daily tasks. Impaired executive function leads to problems with keeping track of time, organizing things, the habit of procrastinating things excessively, problems with achieving and maintaining concentration, speed in processing impulses and information, regulation of emotions, the use of working memory and problems with an Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 35 individual’s short term memory. This is the exact opposite in people who do not have ADHD, where the short-term memory functions well enough. The problem with executive functioning occurs in approximately half of ADHD children, and increases as the brain undergoes a phase of maturation and the demands placed upon it becomes more complex with increasing age. This is one of the primary reasons why patients with ADHD do not often manifest the full extent of problems in executive functioning until later on in life. Neuropsychological Assessment Findings and Executive Functioning Neuropsychological tests and its value in the diagnosis of ADHD have been gaining popularity in the last 30 years. A substantial amount of research studies have also been undertaken in an effort to clarify the pathologic profile of children diagnosed with ADHD. In addition, these tests are also performed to determine the presence of executive function deficits in children with ADHD.41 As mentioned previously, executive functions are mental processes that allow children to carry out, control and manage daily tasks. These processes are neurocognitive in nature and help children achieve and maintain skills to solve problems and to achieve future goals. Executive functions regulate the following: Execution and inhibition of a response Ability to carry on information self-updates Working memory necessary to process such information Task capacity and switching when necessary Interferences in thought processes Organization and planning of things Perseverance to finish started tasks Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 36 Orientation of the visual-spatial dimension Working memory for both spatial and verbal context There are several theories linked to the relationship of executive functions and the neuropsychological findings in children with ADHD. The Inhibitory Control Deficit Theory presents the idea of neurological impairment patterns characterized by general abnormalities in the development of inhibitory control. The resulting deficits are usually related to memory problems (specifically verbal in nature), attention and focus dysfunctions, incapacity to sustain attention, and problems involving the working memory as it relates to abstract thinking and problem-solving. This section highlights past and present theories related to ADHD and neuropsychological development.40-43 The Delay Aversion Theory proposes a biological-based impairment in children with ADHD, which causes them to exhibit intolerance to delays that in turn affects their cognitive functioning and behavior in general. The ability to tolerate delays is measured by a tool known as the Choice Delay Task. Another theory involves the Cognitive-Energetic Model that proposes neurocognitive problems are caused by the presence of abnormalities in the information processing at the state and computational levels of the brain.42 State level functioning is responsible for controlling efforts essential to complete tasks, as well as the capacity to be aroused or excited, and the activation of the mind to perform such tasks. On the other hand, computational functioning is responsible for the organization of motor movements, the capacity to search and encode information in the mind, and decision-making. This theory also suggests that an imbalance and overlap in functioning causes the problems associated with ADHD to arise and persist. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 37 The Theory of Sluggish Cognitive Tempo is rooted in the premise that there is a difference in the manifestation of inattention in patients, depending on the specific type of ADHD. The most common differences between the different types are the time for information retrieval and processing, levels of alertness, and the level of difficulty in making sense of orientation and memory. Another paradigm called the Multiple Pathway Model emphasizes and examines parallels that occur between the neuropsychological deficits present as core symptoms of ADHD and the domains of regular temperament based on the propositions made by other neuropsychological models. Other Physical Assessment Findings Apart from the changes that children with ADHD exhibit in imaging studies done on the brain as well as the tests on neurotransmitter levels and their pathways, there are also other physical assessment findings that are commonly seen among these patients. Other physical findings in ADHD children are discussed here.12,50-52,54 Among these findings is the presence of sensory deficits. Sensory deficits in these children may appear either as auditory problems or visual impairment and are often the reason why children are often disorganized in their thoughts and lack attention or focus on objects. The sensory deficits hinder the ability to interpret stimuli correctly and use it to carry out meaningful tasks and behavior. These deficits however should be assessed thoroughly as they may be interpreted as core symptoms and not associated physical disorders related to ADHD. A comprehensive neurologic examination needs to be performed in children with ADHD to rule out the possibility of neurodegenerative disorders such as Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 38 neuronal ceroid lipofuscinosis and adrenal leukodystrophy. Also, symptoms that may be related to these neurodegenerative disorders such as regression or a plateau that occurs during development, hyperactivity, easy distractibility and behaviors that are off-kilter should be observed and noted. General physical examination must also be performed along with vital neurologic examination. The physical examination procedures should include assessment of the abdomen of the child to check for the presence of organ enlargement (organomegaly). The clinician must also consider performing a funduscopic assessment especially if a neurodegenerative disorder is strongly suspected. Lead toxicity and its resulting morbidities such as mental retardation and hypothyroidism (most specifically cretinism) should also be ruled out. Motor movements and their associated strength and reflexes of the tendons and joints must also be thoroughly assessed since these are usually misleading in the diagnosis of ADHD, especially in children who present with school problems. Also, gait and balance should be assessed since both are usually affected in children with ADHD. Abnormalities, although they appear subtly, such as poor coordination of rapid and sequential movements are present in most children. The most common manifestation of the problem with coordination and rapid-sequential movements is seen when they are asked to perform tasks such as tapping the fingers and toes and patting the hands. These are to be done successively, one after the other to see their capacity to carry them out successfully. If they are unable to do all these in an assessment, it may be an indication of poor inhibitory control of motor movements; a very strong reason why these children experience great difficulty in staying still and finishing tasks. These difficulties in gait, balance and coordination are especially very apparent in school-age children. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 39 Other findings may reveal that children with ADHD are also dyslexic and present with tongue wiggling movements, and these children tend to perform poorly and awkwardly when asked to do diagnostic procedures, such as the finger-to-thumb-touch exercise. The clinician must also pay close attention and focus on certain dysmorphic features that may be present in children with ADHD. These might indicate a deeper problem, which may be genetic in nature. Examples of these genetic problems may include, but are not limited to: Fragile X Syndrome (higher rates are prevalent in female patients than in males) Klinefelter Turner’s syndrome During physical evaluation the skin should be inspected properly to assess for the presence of lesions, which is indicative of neurocutaneous disorders (i.e., neurofibromatosis type I and tuberous sclerosis). These are mostly present in children who exhibit learning difficulties associated with ADHD. The most important thing to remember when performing an assessment of the child’s history and physical evaluation is to remain objective about the symptoms and their severity levels. Knowledge of neurocognitive behaviors and how it affects the manner in which children with ADHD behave are also vital to determine their severity and how their interplay results in the behavior, cognitive capacity, impulse control, and the overall appearance and demeanor of the affected children. Diagnosis Of ADHD The diagnostic criteria set forth by the American Psychiatric Association’s Diagnostic and Statistical Manual-Fourth Edition had been briefly outlined in Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 40 the prior section. The National Institute of Health and Care Excellence (NICE) guidelines for diagnosing ADHD in children will be now be discussed. Both guidelines are similar and are used as a standard by many mental health clinicians. The diagnosis of ADHD is made by breaking down the symptoms in two classes based on presenting symptoms: inattentive and hyperactiveimpulsive. According to the National Institute of Health and Care Excellence (NICE) guidelines, a diagnosis of ADHD is made when at least 6 out of 9 symptoms outlined below are present. This is also referred to as a combined type of diagnosis. Symptoms are chronic in nature, i.e., present for at least 6 months. Maladaptive symptoms cause functional impairment functionally in more than one area of life. Symptoms are inconsistent with the level of development and not attributed to other forms of mental disorders. The diagnostic criteria for diagnosing ADHD has become so comprehensive that an increasing number of children especially females and adolescents are being diagnosed with the disorder and treated with stimulant medication for longer periods of time. Getting the diagnosis correct through various tests will also highlight the short-term symptomatic and academic improvement of the affected children.9,12,16 Key Assessment Criteria While diagnosis is primarily focused on the assessment of the symptoms of ADHD manifested in the patient, health clinicians must take care not to overlook the inputs of parents, caregivers, and teachers. Additionally, they Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 41 must also consider the role and effects of stress on the patient. Essentially, the key assessment criteria are listed below as: Detection of core problem areas such as inattention, hyperactivity and impulsivity Comparison between these characteristics in the suspected patient and other normal children of same age group The onset and duration of symptoms Difficulties and challenges at home, school and other social settings Negative effects of these characteristics on the general development and psychosocial adjustment Presence of certain learning disabilities and other cognitive and mental health disorders Presence of other cognitive behavioral problems or mental disorders coexisting with the symptoms of ADHD The most common and persistent symptoms forming the basis of diagnostic criteria for ADHD are listed below.12,17 Inattention, which has been present for a period of at least 6 months or over and is damaging for the normal development of the child. Hyperactivity and impulsive behavior in children up to age of 16 years, which has been present for a period of 6 months and is disruptive and inappropriate for the normal development of the child. Diagnostic Approaches There are various approaches used by health clinicians when forming a diagnosis of ADHD in children. It involves a complete assessment process, which examines the characteristic features and the fulfillment of diagnostic criteria mentioned previously. They include the severity of the problems, Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 42 extent to which the problems are affecting the child’s life, characteristic symptoms, probable cause or origin of the problem, and the presence of other clinical problems including those that are physical, cognitive or mental. The different diagnostic modules include a stepwise process, which includes a clinical interview and an establishment of the rating scale for parents and teachers. Other assessment criteria includes direct observation in educational settings such as schools, play schools, and cognitive and neuropsychological assessment of developmental and literacy skills. These are secondary and may or may not be included in the diagnostic process. It is also imperative to mention here that diagnosis, care and management in the primary care setting are more important when compared with psychiatric clinics. Pediatricians are in agreement that children with ADHD known to have received their diagnosis and management from a primary care facility face lesser comorbid psychiatric disorders and milder symptoms associated with other mental disorders as compared with their counterparts who received theirs at psychiatric clinics. It has also been studied that children with ADHD are more likely to exhibit the prototypical symptoms of the disorder; they have higher levels of comorbidities related to mood, anxiety, and disruptive behavior and impairments in their cognitive, interpersonal and academic functions.17,50,60 Generally speaking, those children diagnosed in pediatric practices have fewer comorbid conditions and dysfunctions when compared with their counterparts diagnosed in child psychiatry clinics. In the U.S., mental health professionals use the DSM-5 to help them in their diagnosis of children with ADHD symptoms. Many European and other countries rely on the International Classification of Diseases (ICD) to make their diagnosis. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 43 Pre-diagnostic Intervention and Referral Prior to a formal diagnosis of ADHD, the school or primary care clinician may refer children and adolescents with behavior problems suggestive of ADHD for participation in parent-training and education programs. The diagnosis of ADHD in children, adolescents, and adults usually occur in secondary care settings. According to the NICE guidelines, there are several points to remember when identifying and referring suspected ADHD patients:17,112 • Universal screening for ADHD should not be undertaken in nursery, primary and secondary schools. • When a child or young person with disordered conduct and suspected ADHD is referred to a school's special educational needs coordinator (SENCO), the SENCO, in addition to helping the child with their behavior, should inform the parents about local parent-training and education programs. • Referral from the community to secondary care may involve health, education and social care professionals (for example, primary care clinicians, pediatricians, educational psychologists, SENCOs, social workers) and care pathways can vary locally. The person making the referral to secondary care should inform the child or young person's primary care clinician. • When a child or young person presents in primary care with behavioral and/or attention problems suggestive of ADHD, primary care clinicians should determine the severity of the problems, how these affect the child or young person and the parents or caregivers and the extent to which they pervade different domains and settings. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 44 • If the child or young person's behavioral and/or attention problems suggestive of ADHD are having an adverse impact on their development or family life, health clinicians should consider: a period of watchful waiting of up to 10 weeks offering parents or caregivers a referral to a parent-training and education program (this should not wait for a formal diagnosis of ADHD) • If the behavioral and/or attention problems persist with at least moderate impairment, the child or young person should be referred to secondary care, such as a child psychiatrist, pediatrician, ADHD specialist or CAMHS (Child and Adolescent Mental Health Services) for assessment. • If the child or young person's behavioral and/or attention problems are associated with severe impairment, referral should be made directly to secondary care, such as a child psychiatrist, pediatrician, ADHD specialist or CAMHS for assessment. • Group-based parent-training and education programs are recommended in the management of children with conduct disorders. • Primary care clinicians should not make the initial diagnosis or start drug treatment in children or young people with suspected ADHD. • A child or young person who is currently treated in primary care with methylphenidate, atomoxetine, dexamfetamine, or any other psychotropic drug for a presumptive diagnosis of ADHD, but has not yet been assessed by a specialist in ADHD in secondary care, should be referred for assessment to a child psychiatrist, pediatrician, ADHD specialist or CAMHS as a matter of clinical priority. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 45 Identification and Referral in Adults with ADHD Adults presenting with symptoms of ADHD in primary care or general adult psychiatric services, who do not have a childhood diagnosis of ADHD, should be referred for assessment by a mental health clinician trained in the diagnosis and treatment of ADHD, where there is evidence of typical manifestations of ADHD (hyperactivity/impulsivity and/or inattention) that: Began during childhood and have persisted throughout life. Are not explained by other psychiatric diagnoses (although there may be other coexisting psychiatric conditions). Have resulted in or are associated with moderate or severe psychological, social and/or educational or occupational impairment. Adults who have previously been treated for ADHD as children or young people and present with symptoms suggestive of continuing ADHD should be referred to adult psychiatric services for assessment. The symptoms should be associated with at least moderate or severe psychological and/or social or educational or occupational impairment.3 Diagnosis of Children with ADHD A correct diagnosis of ADHD in children involves conducting multiple assessment methods, such as: Diagnostic interview with the child’s parents and/or teachers Behavior rating scales completed by parents and teachers Direct observations of classroom and playground behavior Assessment of academic functioning Academic skills are tested through examination of completed written work and administration of curriculum-based measurement probes. Formal tests Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 46 utilizing assessment instruments such as IQ tests, standardized achievement tests, or other neuropsychological tests are performed as means of identifying students with ADHD. Psychoeducation and medical tests have proven to be beneficial in ruling out other comorbid conditions or complications such as learning disabilities, mental retardation, and allergies that may mimic the symptoms of ADHD behaviors.43 A comprehensive neuropsychological testing is performed to assist in confirming the diagnosis of ADHD. Children with ADHD may perform poorly is several areas of evaluation including tests involving learning skills, language skills, visual-motor skills or auditory processing mechanisms. To measure verbal and nonverbal performance skills, intelligence measure scales such as Wechsler Intelligence scale for children or Differential Abilities Scale are employed to help identify the language and visual-spatial processing impairments present. Similarly, the Wechsler Individual Achievement Test is used to assess academic skills and achievements while the Wide Range Achievement test is used to identify potential learning disabilities. Psychometric testing is also conducted to identify specific problem areas for children with ADHD that may include abstract reasoning, mental flexibility, planning and working memory, and executive functions, which is a mixture of various skills. Neuropsychological assessment of these skills is performed to directly measure and assess the attention and behavioral disinhibition, which is significant in facilitating diagnosis and planning pharmacological, environmental and behavioral interventions as well as assessment of the treatment progress.43 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 47 Interviewing The Patient With ADHD A pediatrician, psychiatrist, child psychologist or a specialist nurse usually serve as interviewer and carries out the clinical interview of the patient, parent or even teachers to investigate the key characteristic features presented by the patient suspected of having ADHD. A structured format is used for the interview to allow for a systematic analysis. Information gathering before the interview involves several stages. A support staff member instead of the clinician usually carries out the first stage of the diagnostic interview. It is at this stage that the examiner can collect information using a variety of ways, without actually meeting face to face. Information is collected through phone interviews and a packet of questionnaires or behavior rating forms, and various methods are highlighted in this section.17,43,56-66,71,88,98 The phone interview gives crucial information conducted by a well-trained staff member; otherwise, it is a lost opportunity. Once a parent calls to request an evaluation, the interviewer must collect the following information: 1. Ask the reason for the evaluation request. The interviewer must take note of how the parent poses their questions, for example, was it open-ended such as, What’s wrong with my child? Or was it a specific one, such as Does my child have ADHD? 2. Who referred the parent or family? The interviewer must find out if it was a self-referral or did members read or view a TV program about ADHD? Did the child’s teacher or school psychologist or pediatrician refer them to the facility? Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 48 3. Have the parents and child already seen another professional who suspected ADHD but needed a second opinion or diagnostic confirmation? The interviewer needs to confirm if the child has been previously evaluated or tested by someone else or if the family needs a reevaluation of ADHD that was diagnosed when the child was younger. 4. Does the child have any other diagnosed conditions, especially mental or developmental disorders? The interviewer must take note of coexisting mood disorders, substance abuse, and developmental and cognitive delays. 5. Has the child already undergone treatment with medications? The interviewer must ask the parent if the evaluation is specifically for the child’s response to the medication instead of an initial diagnostic assessment. If the child is on stimulant medication, the interviewer must ask the parent if he/she can consent to withholding the medication on the day or the day before the evaluation to allow observations of the unmedicated behaviors during the evaluation. Ultimately, the phone interview should clarify and leave no room for doubt as to the reason for the evaluation request. The quality of the content of the diagnostic interview depends on the questions mentioned above, which in turn will give the clinician a basic foundation upon which to conduct the interview. Additionally, the information gathered from the telephone interview also permits the clinician to start some of the initial procedures. Specifically, it is important at this point to do the following: Get appropriate releases of information to allow reports of previous professional evaluations that may be required later. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 49 Get in touch with the child’s current physician for further information on health status and medication treatment, if any. Get the results of the latest evaluation from the child’s school. Send the packet of questionnaires for parents and teachers to fill up. These questionnaires are usually posed in behavior rating format that must be completed and returned prior to the setting of the initial appointment with the clinician. Along with these questionnaires, the parent must not forget to include the written release of information permission form. Get any useful information from social services that may be part of providing services to the child. As mentioned previously, packets of questionnaires need to be sent out to parents and teachers at school in advance, after the telephone interview but ahead of the initial evaluation appointment with the clinician. In fact, many referred children and parents are often not given an appointment date until such packets of information are filled up and returned to the clinic. This ensures that the packets are completed without delay, allowing the clinicians to review them prior to the scheduled meeting with the parents and the child. The system of information collection mentioned above makes the evaluation process very efficient in its collection of important information. Due to the growing cost-consciousness mindsets towards mental health evaluations, especially in managed care settings, efficient evaluation processes are very important to implement and maintain. On top of the initial indirect evaluation costs, the time spent interacting directly with the parents and the child are usually limited and at a premium. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 50 Along with the set of questionnaires and request of consent of release of information forms, the packet also usually contains the following: A cover letter from the professional asking the parents to complete the packet of information A general instruction guide A child and family information form A developmental and medical history form Some clinicians may also include any other behavior rating scales into this packet that may or may not specifically assess ADHD symptoms such as: 1. Child Behavior Checklist 2. Behavior Assessment System for Children 3. Rating scale form from the Barkley and Murphy clinical manual The rating scale from the Barkley and Murphy clinical manual allows the clinician to get information ahead of the first patient encounter regarding the presence of symptoms of behavioral disorders common to children such as oppositional defiant disorder (ODD) and conduct disorder (CD), as well as ADHD symptoms and their severity. Both ODD and CD are frequent occurrences among children referred for ADHD, and knowing about their presence ahead of the appointment is useful to the clinician in formulating the right questions to ask. Should the clinician require a more comprehensive rating scale of executive function deficits that are almost always tied with ADHD, the Barkley Deficits in Executive Functioning Scale – Children and Adolescents or the Behavior Rating Inventory of Executive Functioning may be used. In addition to that, clinicians who require assessment of adaptive behavior may find the results of the Normative Adaptive Behavior Checklist administered on the scheduled evaluation day useful. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 51 Dysfunctional life activities are an important criterion requirement for all psychiatric disorders outlined in the DSM-5. Some information on impairment can be gleaned from the face pages of the CBCL (Child Behavior Checklist) or BASC-2 (Behavior Assessment System for Children). The use of a rating scale of impairment has been introduced in the recent years and may be inserted with this packet of other forms for gathering information on the fifteen various aspects of life activities in children. Lastly, the Home Situations Questionnaire (HSQ) may also be sent out along with the other contents of the packet or administered on the day of the scheduled patient evaluation to allow the clinician a quick understanding of the frequency and severity of the child’s disruptive behavior in several home settings.185 The information obtained from the HSQ will also allow clinicians to open up dialogue on situations pertaining to these during the evaluation and later on, such as during the parent-training program. On top of the questionnaires, telephone interview, and rating scales, clinicians may also need to obtain and review previous records prior to the scheduled evaluation interview. These records may include: Academic report cards Standardized testing results Medical records such as neurological, audio test, optometric, speech, and occupational therapy results Individual educational plans Psychoeducational testing results Psychological testing results Psychotherapy results Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 52 A comparable packet of information may also need to be mailed to the teachers of the child, along with parental written permission obtained beforehand. The contents of the packet do not usually include the medical and developmental history form or any adaptive behavior survey that may have been present in the packet for parents. However, the packet for teachers could contain the teacher version of the CBCL or BASC, the School Situations Questionnaire (SSQ), and the same rating scale for assessing ADHD symptoms from the Barkley & Murphy clinical manual. The Social Skills Rating System can also be inserted into the packet for inclusion should the clinician require more comprehensive information on the child’s social problems at school and academic incompetencies. Information gathering through surveys, questionnaires and rating scales utilized by teachers allows the clinician to see the teacher’s assessment of the child’s academic performance at grade level in several subjects, and in group-administered achievement or aptitude tests. It also allows the clinician a subjective impression of the child’s overall mood and behavioral functioning. Some clinicians may also contact the teacher for a brief telephone interview before the scheduled evaluation appointment with the parents and the child. Otherwise, a teacher-clinician meeting may also be appropriate after the evaluation appointment with the parents and the child. After receiving the completed parent and teacher packets, an appointment date for the evaluation may be set for the family. It is not unusual for clinics and facilities to send out a confirmation of the appointment, along with a short guide on preparation tips for the evaluation. The guide provides parents information on what to expect on the day of the evaluation and what information to gather before the appointment. It usually answers some of the questions they may have about the appointment and helps to put them Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 53 at ease. The scheduled evaluation usually consists of three important elements: 1) Parental and child interview, 2) Completion of self-report rating scales by the parents, and 3) Psychological testing, if needed. Interview of the Child The main objective behind interviewing the child is to gather information about the complete set of problems, patient history, along with information on family, health, social life, education, and demography. An interview of the patient and the family provides significant information on the various coping mechanisms they have tried in order to deal with the problem. It also gives the interviewer a picture of the impact of these problems on the child and the family. Any other information that may be necessary to assess the condition of the patient and helpful in the correct diagnosis and intervention planning is also gathered through the clinical interview. Interview of the child involves the following: A duration of approximately 2 to 3 hours arranged over two sessions A session with parents and teachers to facilitate the gathering of relevant information A session with the patient alone Interview of the Parent The input of the parent is crucial to the thorough assessment of the patient. Health professionals usually need the parent’s input on the child’s behaviors in conjunction with the observed behavior. Questionnaires are given to parents to help health professionals quantify their responses. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 54 The diagnostic interviews of parents as well as the completed behavior rating scales of their child are helpful in determining the severity of the ADHD symptoms based on the guidelines provided by either NICE or American Psychiatric Association’s DSM-5 diagnostic criteria. They also provide the clinician with relevant information related to the developmental, medical, and family history of the patient. The interview of the parent offers several advantages to the ultimate diagnosis of the child. • It creates a necessary bridge between the parents, the child, and the interviewer that is very important in encouraging parental cooperation during the later stages of assessment and treatment. • It is an apparent source of very detailed information about the child and family, often giving the interviewer specific parental views of the child’s behavioral problems. It can single out specific details that may prove to be crucial during the later stages of the assessment. • It can very easily show the severity of stress that parents are going through as a result of the child’s problems. It can help the interviewer assess the general psychological wellbeing of the parent. Sometimes, an interview can even reveal a genetic component to the behavioral symptoms, i.e., parental personality or psychiatric problems such as depression and hostility. There are two things to remember at this juncture. Firstly, interviewers must be wary of over-interpreting any informal observations made by parents during this clinic visit. They must not also jump into conclusions when observing the child during such visits. This is Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 55 because the office behavior of ADHD children is more likely to be “good” than that observed at home. Such observations can only raise assumptions about possible parent-child interaction issues, which can be examined in greater depth with parents during the end of the interview as well as during later direct behavioral observations of parent and child when playing and performing tasks together. At the end of this part, the interviewer must inquire how the immediate behavior of the child compares to that observed at home in the presence of other adults. Secondly, it may not be wise to engage the parent in this type of interview in the presence of the child. This is because the presence of the child may make parents less than forthcoming about their answers especially when sensitive issues are asked and brought to light. They may not wish to further sensitize or inflame the child unnecessarily or create another issue for hostility and difficulties at home. Other interviewers may choose to have the child present during the interview and are heedless of the potential problems it poses to the already delicate parent-child relationship. Still, some parents may use the interview as an opportunity to embarrass the child by mentioning the behavioral deficiencies in public. Nevertheless, the interviewer must always discuss and reconsider the issues and review with each parent the pros and cons of having the child present before the start of each interview. The first parent interview can help steer the focus to parental perceptions of the child’s problems on significant and more particular controlling events in the family. Parents have the tendency to emphasize past or developmental causes generally when discussing their child’s problems, such as the behavior or actions that lead to failure at certain academic subjects or parental decisions that led to the problem such as placement of the child in Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 56 daycare, and an early divorce. This type of interactional dialogue can help transfer parental focus to more current antecedents and consequences surrounding child behaviors, thus, preparing them for the first stages of parent training in child management skills. The interview is designed to formulate a diagnosis as well as develop management and therapy recommendations. Although diagnosis is not always a prerequisite for treatment planning (an account of the developmental and behavioral dysfunctions are often sufficient), the diagnosis of ADHD, however, is very useful especially when it comes to predicting the developmental course and prognosis for the child, determining eligibility for certain unique educational settings, and predicting possible patient response to a trial on stimulant medication. Several pediatric behavioral problems are believed to develop over a short span of time, in as many as 75% of the cases. However, ADHD is considered a lifelong condition, which requires greater caution when giving future prognosis and careful preparation of the family for coping with problems that may be encountered in later life. The interview may serve as a stress reliever for the parent, particularly if the initial interview is also the first time that professional involvement is encountered or sought. The interviewer should take care not to hurry along the interview, and give sufficient time to allow parents to ventilate their distress, hostility, or frustrations. It may also be the time for parents to point out their distress, confusion, or unsuccessful and hostile past encounters with professionals and educators, as well as well-intentioned but often misinformed relatives who have tried to help. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 57 Similar to other distressing disorders, interviewers may need to show compassion and empathy for parents of children with ADHD; a professional approach that can provide an open environment conducive for an honest and forthcoming interview. It can help establish rapport and encourage parental participation in subsequent treatment recommendations. When done correctly, parents will respond positively and feel that they have finally found someone who really understands their child’s behavior problems and the distress they have experienced in trying to remedy them. These recommended approaches are not part of rigid guidelines. Rather, they may be followed when interviewing parents of ADHD children. Each interview is different and the approach must be tailored specifically to each individual child’s case and parental circumstances. Generally speaking, relevant information to be obtained from the interview process with the parent must include, but not limited to: Demographic information Child-related information School-related information Details about the parents, and other family members Information on availability of community resources Interview of the Teacher The teachers are also another valuable source of information whose input into the complete assessment of suspected ADHD children is crucial. They are the primary persons who can provide the health professional with the patient’s developmental progress as it relates to academic and non-academic performances. Their input is important criterion in the assessment of the patient. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 58 Teachers may also be required to provide specific information about the social and academic functioning of the student. They are provided with a structured questionnaire and interviewed independently by the health clinician. The interview with teachers constitutes the first line of the stepwise diagnostic process in identifying students with ADHD. It provides clinicians important clues on the severity and frequency of symptoms, since almost all school-age children spend the majority of their time at school, not at home. While interviewing teachers and rating their observations, it is important for the clinician to assess and reconcile the present behavior in both the classroom and clinic settings. Observations need to be conducted on more than one occasion; the frequency of both the on- and off- task behaviors including both motor and vocal actions. Teachers should also provide data regarding the productivity, accuracy, and progress of the child. Psychometric Testing Psychological and psychometric assessments are important tools in the diagnosis of ADHD in children. Its significance is especially apparent in cases where the clinical picture obtained from parents or teachers are ambiguous; for example, their objectivity during the whole process may be less than expected. A clinical child psychologist uses skill and training to provide a proper and accurate cognitive assessment of the patient’s abilities and achievement. Research has established that children with ADHD symptoms form a heterogeneous group and exhibit a wide range of cognitive problems. These children show many apparent differences from normal children in various performance tests such as mental control and cognitive effort. This is why a Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 59 neuropsychological assessment measure to assess children is very important in order to classify the case as either ADHD alone or with other mental disabilities. This neuropsychological assessment measure is useful in diagnosing and planning the interventions. It may also be used in the differential diagnosis of ADHD. The clinical psychologist also takes assessment tests to determine whether there are any learning difficulties such as poor literacy skills, dyslexia, or other problems including dyscalculia (math difficulties) or non-verbal learning difficulties. This assessment helps in the detection of the problems related to attention, which is an integral part of the treatment and management plan. Other problems that need to be assessed before making a diagnosis are global learning disabilities especially in ADHD cases of predominantly hyperkinetic disorder. The therapy must be based on the patient’s intellectual level, which is assessed using psychometric assessment. The damage to memory, attention or other cognitive factors also needs to be investigated with the help of clinical psychologists. Various tests are performed for the psychological assessment, which include: Test of everyday attention for children Visual and auditory attentional subtests in neuropsychological batteries for children Auditory continuous performance test for children These neuropsychological tests are extremely helpful in guiding the health professional when making psychological decisions and interventions. Conventional psychological tests can detect the presence of inattention and impulsiveness. They are also very useful in identifying any cognitive Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 60 disabilities, which may worsen the problems of ADHD and present complications for its management. The presence of a borderline IQ score, memory problem, or a specific learning disability underlines the need for a comprehensive treatment program. ADHD sufferers may score poorly in conventional IQ tests such as Weschler Intelligence Scale for Children (WISC) or Weschler Adult Intelligence Scale (WAIS). These scales measure their relative strengths and weakness in different given tasks. Additionally, they also perform poorly in auditory immediate memory, working memory, and processing speed tasks. Since the conventional tests are inadequate in detecting attention deficits, locomotor hyperactivity, and cognitive impulsivity, many psychologists complement their neuropsychological tests with computerized tests of attention. Educational Testing For The ADHD Patient It is a well-known fact that various psychological and developmental disorders co-exist in children diagnosed with or being evaluated for ADHD. Poor school performance may sometimes indicate a learning disability. Hence, a need for educational testing arises in order to determine whether there is a variation between the learning potential and the actual academic progress, which may later on indicate the presence of a learning disability. Educational and psychoeducational tests are performed to create an overall assessment of the child being evaluated for ADHD. Different educational tests such as Woodcock-Johnson Tests of Achievements are utilized to assess the learning ability of the child. This particular test is intended to assess what the child has learnt from the school or daily life. Educational tests assess what the child has learned in school. They are needed to assess the child’s information processing dysfunction, which is generally found Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 61 concomitantly with ADHD. This is significant since its presence will put a severe blow to the child’s academic achievements. NICE clinical guidelines have suggested that educational testing is able to demonstrate global learning disabilities and intellectual status. Continuous performance tests need to be taken to assess the cognitive impairments involving the memory and attention. Educational and psychoeducational tests are also used to determine the processing mechanisms of the brain, test of intelligence such as the WAISIII, and the way information is processed. The various brain process mechanisms give a clear picture on the learning ability of the child with or suspected to have ADHD. An assessment of educational achievement is also used to clearly demonstrate the impact on the child’s learning ability at school. Educators and psychologists also make use of standard cores to determine the learning disability profile of the child based on their cognitive potential and academic achievement. A low average range and poor result on the performance intelligence quotient are some indicators of poor cognitive skills. Educational and psychological tests both are required to diagnose a possible learning disability in children with ADHD; the main reason for the relative weakness and academic impairment at school. Educational tests clearly demonstrate that a poor achievement is not a measure of learning disability. Psychological tests such as the WAIS III breakdown the cognitive abilities into various phases and use them to measure the child’s ability to process various types of information. The various educational tests, which are used in the diagnosis of ADHD in children are highlighted below. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 62 Woodcock Johnsons test of achievement Wechsler individual achievement tests Wide range achievement test Other achievement measure Psychoeducational assessments measure the functional and performance areas of difficulty in children suffering from ADHD. Specifically, they measure: The rate of completion of a given work Attention to detail Concentration in studying for exams Attention in classroom lectures Organizational skills Management of time Self-monitoring Evidence suggests that there is a strong correlation between the presence of learning disorders and ADHD. There is a high number of children with ADHD who also have a specific academic skill deficit and/or learning disorder manifested in areas such as reading, written language, or mathematics. Educational tests that provide IQ scores are helpful in identifying the various learning disabilities including reading disorder, mathematics disorder, disorder of written expression, and developmental coordination disorder. The presence of inattentiveness is also an indication of subnormal intelligence, which can be detected through psychoeducational tests. Educational assessment will also determine whether the academic difficulties experienced by the student are due to ADHD, learning disabilities or both. It will also be able to assess with certainty whether the symptoms are due to Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 63 the presence of a primary stage of ADHD or a learning disability since the two often not only coexist but also overlap in occurrence. There is evidence that academic performance problems may be present even in children who have adequate cognitive abilities as seen in standard educational and psychological tests. It has also been found that persistent and increasing behavioral symptoms of ADHD may very well disrupt the academic skill acquisition and performance of the child. Conners’ Parent and Teacher Rating Scales Various tests are performed for the purpose of diagnosing ADHD. The Conners’ parent and teacher rating scales have been found to be useful in the assessment of both children diagnosed with ADHD and those suspected of it and pending diagnosis. In fact, clinical studies have recommended the use of Conners’ teachers and parent rating scales in the assessment of ADHD. These scales have been reported to accurately classify the problems and symptoms, which were designed to assess ADHD. It has also been reported by the same clinical study that teachers, when compared to parents, rated students diagnosed with ADHD to exhibit greater levels of behavioral difficulties and provided more sensitive, specific, and overall accurate assessment. This is why teachers have been given free access and administration of the rating scales to students. The results obtained from such tests are not only very accurate but also predictive. The Conners’ rating scale was developed by Dr. C. Keith Conners to assist in the assessment and evaluation of children with or suspected of ADHD. It is a screening questionnaire that has to be answered by both parents and teachers. As part of the comprehensive assessment and diagnosis tests, it is Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 64 designed in such a way that it can be easily administered and scored. It is also often referred to as Conners’ test. The two versions of the Conners’ scale are long and short and can be successfully administered to children between the ages of 3 to 17 years. The longer version contains about 80 questions for parents and 59 questions for teachers. The shorter version on the other hand contains about 27 questions for parents and 28 for teachers. The cores are evaluated and interpreted by a clinician in combination with other diagnostic tools to make a final and accurate assessment. The parent and teachers tests are applicable to children between 6 to 18 years. A self-administered test is appropriate for children aged between 8 to 18 years. It uses both observer ratings and self-report ratings to help assess and evaluate ADHD symptoms of attention deficit or hyperactivity. It also evaluates behavior problems in children and adolescents. It is also used in the differential diagnosis of oppositional defiant disorder and conduct disorder. The Conners’ test helps the clinician or child psychologist in assessing the behavior of the child as observed by the parent or the teacher. As mentioned previously, the test is intended for parents, teachers and children/adolescents (who rate their own behaviors) themselves to answer. It can be completed within a time period of 5 to 30 minutes depending on the version of the test used, i.e., short or the long version. The Conners’ test is also employed during routine assessment of children’s mental status in schools, mental health clinics, residential treatment centers, pediatric offices and other community health settings. The test is available in three different Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 65 scoring options inclusive of paper and pencil, software and Conners 3 interpretive update. The clinicians obtain a clear picture of a child’s everyday behavior through people who interact with the child daily - the parents and teachers. Hence, the Conners’ test has been cited as an invaluable diagnostic tool in measuring hyperactivity in children and adolescents. It is also taken during follow up examination for future assessment of the child. The Conners’ test has been found to be helpful in evaluating and assessing the following: Hyperactivity in children and adolescents Behavior of children through the eyes of those who interact with the child regularly such as teachers and parents Information regarding the mental acumen so that further treatment and management can be applied effectively Important and integral information regarding the child to facilitate the conclusions, diagnosis, and treatment and condition management decisions Conners’ rating scale is associated with several advantages: It provides a large prescriptive data base It offers a multidimensional approach It is applicable to managed care situations The different psychological characteristics measured by the Conners’ test are general psychopathology, inattention, hyperactive or impulsive behavior, learning disorder, executive functioning, aggression, relationship with peers, relationship with family, inattention due to ADHD, and oppositional defiant disorder or conduct disorder. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 66 Brown Attention Deficit Scales (BADDS) Brown Attention Deficit Disorder Scales are used to clinically evaluate the deficiency in executive function and emotional difficulties. These scales are composed of five subscales, which are used to measure difficulties in work organization and activation, sustaining attention and concentration, sustaining energy and efforts, management of affective interference and the utilization of working memory and accessing recall. The deterioration in executive function which occurs in ADHD is cited as one of the most compelling reasons for the manifestation of behavioral symptoms such as poor concentration, impaired working memory, problems related to shifting among tasks, and prioritizing and planning complex sets of tasks or completing long term projects at work or school. Problems with self-regulation and control of emotional behaviors are also observed in children suffering from ADHD, which may also be evaluated using BADDS. Various research studies have reported that self-reporting scales such as Brown Attention Deficit Disorder Scales are useful in the assessment and diagnosis of ADHD clinical symptoms in children and adults. They have also been cited as the best rating scale along with ADHD rating scale when it comes to making the most accurate clinical diagnosis of attention deficit hyperactivity disorder in children. Devised by Dr. Thomas Brown, the Brown Attention Deficit Disorder Scales provide a consistent measure of ADHD in children and adolescents. Considered to exhibit a cutting edge technique, the scales assess, evaluate and diagnose the executive cognitive function of children and adolescents affected with ADHD. These scales are largely used by psychologists, physicians, psychiatrists, school psychologists and other educational, medical or mental health professionals involved in child disorders and Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 67 trained to diagnose ADHD. They are appropriate for a wide range of age groups of children and adolescents: Children 3 to 7 years of age Children 8 to 12 years of age Adolescents 12 to 18 years of age Adults 18 years and above The Brown Attention Deficit Disorder Scale is considered to be particularly useful in the following situations. Assessing children and adolescents who may benefit from an accurate diagnosis of ADD or ADHD The comprehensive assessment of those who are suspected to have ADD or ADHD Supervision of the effectiveness of the treatment, management, and follow up visits The BADDS is available in several formats: • Paper and pencil • Clinical interview • Software BADDS is also used in many clinical trials and research studies involving ADHD. Continuous Performance Test Another widely used diagnostic tool in the assessment of ADHD is the Continuous Performance Test (CPT). It provides a measure of sustained Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 68 attention and relies on the inhibition of cognition. The test has been found to be essentially useful in the diagnosis of sustained attention deficit such as ADHD in children as well as those at greater risk of developing pediatric schizophrenia between the ages of 6 and 15 years. The continuous performance test is a standardized test, which is administered using a computer. The test format consists of single letters presented on a computer screen at varying rates: once per second, once every 2 seconds, and once every 4 seconds. Many versions of the continuous performance test are available, with versions differing in their stimuli, event, rate, and signal probability. These are used to assess and evaluate the three major symptoms of ADHD, of inattention, hyperactivity and impulsivity. The Continuous Performance Test is an impressive test of vigilance or sustained attention. It has been successfully employed in the assessment of patients who sustained a traumatic brain injury (TBI) as well as those who are epileptics. It has also been successful in the assessment of long-standing ADHD children. The CPT is also available in its visual and auditory versions for children suspected of psychiatric disorders and auditory attention difficulties. Both versions are important adjuncts in the clinical diagnosis of ADHD but cannot be used solely for the purpose of assessment and evaluation. The Conners’ Continuous Performance Test can yield the following important information in children with ADHD: Response time Alterations in the reaction time, the rate of alteration in the reaction time and consistency of the result Confidence index Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 69 Commission errors Omission errors Studies have reported that children with ADHD and low sleep efficiency can actually improve their performance when given pharmacotherapy, resulting in moderate levels of arousal, which are presumed to assist in vigilance performance. It has also been found by various studies that sleep efficiency in children with ADHD show moderate performance in the continuous performance test when given either a placebo or methylphenidate. The concept of the Continuous Performance Test was originally developed by Mackworth and later on developed further and used by other clinicians to assess the neuropsychological performance deficits of children with ADHD. Multiple researchers have shown that children with ADHD consistently show performance deficits and perform poorly on the continuous performance test. Similar to the other diagnostic tests mentioned previously, it is a common clinical tool used by many clinicians, and forms an integral part of the ADHDfocused neuropsychological batteries. Continuous performance testing has also been found to be useful in differentiating the developmental deficit symptoms between children with ADHD and those of normal children although there is insufficient evidence to point out exactly which behavioral symptoms may be. Specifically, the test is useful in predicting the presence of many ADHD symptoms and provides a reliable confirmation of the relationship between neuropsychological tasks and ADHD. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 70 Integrated Visual and Auditory Continuous Performance Test The Integrated Visual and Auditory Continuous Performance Test (IVA-CPT) is another diagnostic tool used by clinicians in the diagnosis of ADHD. Study data have reported it to be particularly effective in diagnosing ADHD in younger children. The sensitivity and specificity of IVA-CPT has been reported to be higher for children in the age group of 6 to 9 years. The IVA-CPT test is a combined auditory and visual continuous performance test, which is utilized by the clinicians in making an accurate diagnosis of ADHD in children, adolescents and adults. The results of the test provide clinicians’ data related to the child’s ability to concentrate and impulsivity. It also helps in the differential diagnosis of the three different types of ADHD discussed in the previous section. The test is predominantly used to diagnose and differentiate the three types of attention deficit/hyperactivity disorders, which are ADHD-predominantly inattentive type, ADHDpredominantly hyperactive-impulsive type, and ADHD-combined type. The IVA-CPT is a diagnostic tool that assesses auditory and visual attention on the same task. Research studies have clearly demonstrated how low performance on an IVA-CPT task results in poor educational and work performances, which are in children suffering from ADHD. One major drawback of the IVA-CPT test is that it cannot differentiate clearly between patients with ADHD and those exhibiting ADHD-like symptoms due to a traumatic brain injury. It forms one of the important components of a multimodal diagnostic assessment of individuals with psychological disorders. Together with the clinical interview and various rating scales, many clinicians especially use the IVA-CPT in order to diagnose children that have psychological disorders. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 71 Various behavioral scales and IVA-CPT are used together to detect differences in the behaviors, which may have clinical relevance and are considered necessary in the diagnostic test battery. The IVA-CPT is the only test that can verify the significant abnormal brain patterns related to poor attention functioning. The test lasts for almost 13 minutes and presents 500 trials of visual and auditory 1’s and 2’s in a pseudo-random manner, which is based on predetermined shifting between the visual and auditory modalities. The test taker is required to click only when “1” is seen or heard, and inhibit clicking when “2” is seen or heard. During certain parts of the test, the “1” appear more often than the “2”, creating a response set that invites errors due to commission, or impulsiveness. During alternating parts of the test, the “1” can occur less often which in turn invites more errors due to omission, or inattention, since the subject must remain watchful while waiting to hear or see “1”. The IVA-CPT test comprises four categories: Attention Response control Attribute Validity Scores from each category are presented either as raw or quotient scores. The basis for statistical analysis is similar to those used in many IQ tests; all quotient scores have a mean of 100 and a standard deviation of 15. These familiar guidelines make it easy to interpret the IVA-CPT results. The score interpretation provides adequate information about the learning abilities such as balance and readiness, and the rate of information processing. The two main diagnostic scales of the IVA-CPT are the Full Scale Response Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 72 Control Quotient and the Full Scale Attention Quotient scores. The Response Control Quotient scores are obtained from three visual and auditory elements, as highlighted below. Prudence: Prudence measures impulsivity and response inhibition, which are made apparent by three different types of errors of commission. Consistency: Consistency measures the general reliability and variability of response times. It is also helpful in measuring the ability to stay on task. Stamina: Stamina provides a comparative look at the average reaction times of right responses during the first 200 trials to the last 200 trials. The score obtained here is helpful in identifying problems related to sustaining attention and effort over time. The Full Scale Attention Quotient is obtained from different auditory and visual attention quotients. The Attention Quotient scores depend on equal measures of three visual and auditory elements of vigilance, focus and speed. • Vigilance: Vigilance measures inattention, which is made apparent by two different types of mistakes of omission. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 73 • Focus: Focus measures the total variability of mental processing speed for all right responses. • Speed: Speed measures the average reaction time for all right responses during the test. It is very helpful in identifying attention-processing problems associated with slow discriminatory mental processing. Additionally, the IVA-CPT attribute scales provide a wealth of information about the learning styles of test takers. These are identified as: • Balance: Balance specifies the test taker’s preferred information processing modality, i.e., whether visual or audio stimulation derives faster response times. • Readiness: Readiness specifies the test taker’s response time to processing information either when demand is quicker or slower. It also provides a small clue to inattention when the test taker exhibits inability to keep up with the demand. IVA-CPT validity scales consist of auditory and visual elements of comprehension, persistence and sensory/motor scales. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 74 Comprehension: Comprehension singles out random responding, preventing the faulty interpretation of other IVA scale scores. Studies have pointed this to be a very sensitive subscale in discriminating ADHD. Persistence: Persistence is a motivation measure based on the test taker’s response when asked to perform another task. This measure is also indicative of motor or mental fatigue. Sensory/Motor Scales: These are used in the differential diagnosis of sensory and motor symptoms of ADHD from other neuropsychological disorders exhibiting similar deficits. Basically, it rules out possible neurological, psychological or learning problems through slow simple response time. The IVA-CPT has also been proven clinically significant in providing detailed information about behavior and abilities with respect to sustaining attention, inhibiting impulsive behavior, flexibility of thought and reasoning, and ability to shift attention and continuously perform tasks. It has several advantages when it comes to making a differential diagnosis of various psychological disorders, including ADHD, which include: Easy administration Easy interpretation Accuracy Easy communication between the patients, parent, teacher and clinician Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 75 Helpful in the objective assessment of the clinical results Nadeau/Quinn/Littman ADHD Self-rating Scale for Girls The Nadeau/Quinn/Littman ADHD self-rating scale is part of the psychometric and educational testing in ADHD diagnosis of young girls. The need for a specific test for girls arose because it was found in certain studies that they make up almost 20% of the total hyperactive/impulsive group, 27% of the inattentive group, and 12% of the combined-type group. It has also been seen that by following the currently available tests, many girls are overlooked and, hence, creating the need for current diagnostic criteria that is gender specific. Girls are known to be biologically and neurologically different; they have different attitudes towards socializing and verbalizing their emotions, and, as such, they also face a different set of social norms. Based on these, it is befitting to assume that girls face specific problems and exhibit different behaviors compared to boys who are also living with ADHD. The Nadeau/Quinn/Littman ADHD self-rating scale is a self-rating scale, which specifically helps identify girls with ADHD. It constitutes a unique checklist and comprises issues that are internal and cannot be observed by others. This is not a definitive diagnostic tool, but provides a strong indication of the possible problems specifically faced by girls. The girl, under the supervision of a parent, teacher, or a clinical professional, should complete the checklist provided in the test. Specifically, the test gives a clear picture of the following points. Problems with productivity or efficiency or initiation Inattention or concentration deficit or distractibility Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 76 Social skills deficit Hyperactivity Self-control or impulsive behavior Self-esteem related problems Disorganization Poor management of time Anxiety or depression Anxiety related to school Emotional over reactivity Sleep or arousal problem Feeling of being misunderstood or criticized Apart from this checklist, parents are also required to fill in or provide information about any additional behavioral problems they may have observed in the test taker. IQ Testing An IQ test is very helpful in diagnosing children with ADHD. Its diagnostic usefulness is based on the very well known fact that children with ADHD do not necessarily have lower intelligence when compared to asymptomatic children, but may exhibit cognitive deficits, which are strong indications of executive dysfunction. Such patients also exhibit symptoms of hyperactivity and attention disorders. Intelligence plays a significant role in executive function seen in ADHD. An IQ test demonstrates the current negative effects of ADHD symptoms on learning abilities. IQ tests are meant to assess the child for the ability to respond to the environment and the ability to learn from past experiences. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 77 IQ tests administered to young people are intended to observe patterns of behavior, which may be consistent with the symptoms of ADHD. It has been reported by different studies that people with ADHD perform poorly on intelligence tests compared to those considered without ADHD. Additionally, it has also been seen that ADHD occurs as a valid diagnosis in children with remarkably high IQ test scores. The characteristics of ADHD in children with high IQ are similar to those with low IQ. Psychiatric comorbidities and functional impairments are also found to be comparable in both groups of children. Children with both high IQ and ADHD experience more pronounced functional impact of ADHD and are at greater risk of underachieving due to frustrations brought on by misinterpretations of learning abilities and talents. Such children are also more likely to experience negative psychosocial outcomes. Because of these, there is greater awareness and need for correct diagnosis and treatment of ADHD in children with varying degrees of cognitive function. The drawback of intelligence tests is that these tests have limited rates of success. The various intelligence tests used in children and adolescents as ADHD diagnostic tools are listed below: Weschler Intelligence Scale for Children (WISC) Stanford Binet test Achievement tests Woodcock Johnson III Wide Range Achievement Test Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 78 Weschler Intelligence Scale for Children (WISC) The Weschler Intelligence Scale for Children (WISC), briefly referred to earlier in the study, was developed in 1949 and is currently the most commonly used intelligence quotient test. The test is used to evaluate and determine the verbal and performance skills of children. The scores are obtained to arrive at a combined score, which is called the IQ score. The derived IQ score is then used to compare individuals. The basic aptitudes that can be measured with the application of this test are factual knowledge, spatial skills, logical thinking and mathematical abilities. It can be used in children between the ages of 6 years to 16 years. The Wechsler intelligence scale for children has many subtests which are used to measure perceptual organization, planning problem solving, nonverbal reasoning, direction of attention, visual sequences, analysis and synthesis, visual-motor coordination, mental processing speed, spatial relationships, and working memory. The subtests are useful in identifying children suspected with ADHD. Stanford Binet Test The Stanford Binet Intelligence Scales test is applied to determine knowledge of vocabulary, comprehension skills and recognition of visual patterns. The use of this test can determine the typical age at which an individual can answer specific questions. It tests the abilities for matrices, vocabulary, and visual-spatial processing. It also tests the IQ, verbal IQ, non-verbal IQ, quantitative reasoning, picture absurdities, and memory. Additionally, the Stanford Binet Test shows variable differences of these abilities between normal children and those with ADHD. It can also be used Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 79 for differential diagnosis of other conditions such as learning disability, and children with motor and speech problems. Achievement Tests Achievement tests are administered to determine the degree of academic function with respect to specific school subjects such as oral language, reading, writing, and math. They are tests based on an indirect measure of intelligence. It is not uncommon for children with ADHD who are very bright to still score poorly in intelligence tests. They may not perform well in academic tests due to a low IQ level. In these cases, achievement tests can provide a true and exact indication of current academic functional abilities. Achievement tests reveal that children with ADHD show a typical pattern of performance, which is extremely helpful in making a correct diagnosis of ADHD. These tests are also used in the differential diagnosis of concentration problems from a simple lack of ability to concentrate. Woodcock Johnson III The Woodcock Johnson III is a standardized assessment tool that provides an index of general intellectual acumen and ability, as well as specific cognitive abilities. It is used to measure abilities inclusive of executive process, cognitive fluency, broad attention, and working memory cluster. Based on these measures, it is useful in differentiating children with ADHD from those without it. This test tool includes factors representing the specific cognitive abilities and their uses as separate constructs. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 80 The Woodcock Johnson III test was developed to determine general intellectual ability, specific cognitive abilities, scholastic aptitude, oral language skills and academic achievement. It is applicable to individuals between the ages of 2 to 90 years old. One of its advantages is its easy application in children who are slow, have reading disabilities, or who have concentration problems for long periods of time. It is also useful in stating a student’s areas of strength and academic characteristics of concern, their learning style, and aptitude in any area, as well as any problems related to perception. It is comprised of clusters and many subtests, which include: Working memory cluster Broad attention cluster Cognitive fluency cluster Executive processes cluster The working memory clusters is made up of two subtests: Numbers reversed Auditory working memory These subtests assess the ability to hold and manipulate information that is of immediate memory. The broad attention cluster includes four subtests: Attention capacity Sustained attention Selective attention Auditory working memory These subtests measure the ability to concentrate on attention resources and manipulating information. The cognitive fluency cluster is made up of three subtests: Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 81 Retrieval fluency Decision speed Rapid picture naming These subtests measure fluency and speed in performing simple and complicated cognitive tasks. The executive processes cluster includes three subtests: Concept formation Planning Pair cancellation These tests measure abilities to develop and enact strategic planning, proactive interference control and shift of mental set repeatedly. Wechsler Individual Achievement Test The Wechsler Individual Achievement Test (WIAT) is an achievement test used in the determination of academic problem areas and other learning disabilities. The test scores are also helpful in comparing the actual versus expected performance and intelligence levels in growing children. There are many subtests in this test, which can be administered to students without any time limit, except for the written expression subtest, which has a time limit for completion. The test is formatted to assess the child in various academic areas such as reading, mathematics, written language and oral language. It evaluates abilities associated with word reading, reading comprehension, phonetic, numerical operations, math reasoning, spelling, written expression, listening comprehension, and oral expression. The U.S. edition of the test, WIAT-III test comprises 16 subtests. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 82 The other version, the WIAT-II test, has certain limitations. For example, the test fails to assess and measure all parts of academic achievements. The test only measures aspects of learning processes that occur in the traditional academic settings such as reading, writing, mathematics and oral language. It is not designed to accurately measure the academic giftedness of children with high IQ or older adolescents. Wide Range Achievement Test The Wide Range Achievement Test (WRAT) is used to determine reading recognition, spelling, and math computation in children with ADHD. This test has two versions; the first version is used in children who are in the age range of 5 to 11 years, and the second version is used in older children, usually 12 years old and above. Using age as a reference point, it is also beneficial in comparing one person with another to measure any alterations in the learning ability and disability. Brain Wave Testing The U.S. Food and Drug Administration (FDA) has recently approved the first medical scanning test to help in the diagnosis of ADHD in children by measuring brain waves. The test makes use of the device, Neuropsychiatric EEG-Based Assessment Aid (NEBA) system, to record the various types of electrical waves produced by neurons in the brain and the frequency, which these impulses are given off per second. The NEBA system, approved for use by medical and mental health clinicians, is used to test children between the ages of 6 years to 17 years to confirm the diagnosis of ADHD, or to determine if further tests are required for an assessment. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 83 The NEBA device is an EEG-based assessment aid and used as part of a complete medical or psychological examination to confirm the diagnosis of ADHD or evaluate the need for further diagnostic tests. The device works by measuring the ratio of two standard brain waves, the theta and beta waves. Research studies have reported that children with ADHD have a higher ratio of theta to beta waves when compared with other asymptomatic children or those who do not have ADHD. The test is non-invasive and lasts between 15 to 20 minutes. Its diagnostic usefulness depends on its results to paint a more accurate picture of the behavioral symptoms to the clinician. It is considered to be generally safe without any adverse effects. A research trial conducted on approximately 275 children and adolescents between the ages of 6 years to 17 years have shown that the use of NEBA system helped the clinicians in making a more accurate and correct diagnosis of ADHD when employed together with a clinical assessment for ADHD, compared with clinical assessment alone. Laboratory Testing The validity of ADHD as a disorder is often called in question because of the lack of a measurable biomarker. But like many mental disorders, the absence of biomarkers has not deterred psychologists and medical experts on finding ways to treat and manage it. As discussed extensively in the previous sections, the diagnosis of ADHD is based on a combination of history, presenting complaints and symptoms (for example, behavioral problems), consistency of symptoms, and ruled out possible explanations of the symptoms. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 84 Summary Pediatric ADHD is a common developmental disorder that is characterized by symptoms of hyperactivity, inattention and impulsivity of varying degrees. It is often diagnosed in school age children, although children as young as 6 years old or below are also increasingly diagnosed. There are three major steps in the diagnostic process of ADHD, which include a clinical interview, medical examination, and establishment of the rating scale for parents and teachers. Other assessment criteria includes direct observation in educational settings such as schools, play schools, and cognitive and neuropsychological assessment of developmental and literacy skills. These are secondary and may or may not be included in the diagnostic process. Children diagnosed with ADHD may also experience a variety of related disorders or comorbidities. These comorbidities vary according to the prevailing type of ADHD, their severity, as well as the developmental stage of the child when they were first seen. These comorbidities are divided into two broad categories of learning disorders and psychiatric disorders. Because of the complexity of ADHD, its therapy requires a multimodal approach. Psychotherapy, which includes behavioral interventions, and, pharmacotherapy, are worthy topics related to the ongoing treatment of ADHD that clinicians focused on pediatric treatment are encouraged to pursue. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 85 Definition of Terms: 1. Hyperactivity: Refers to constant activity, being easily distracted, impulsiveness, inability to concentrate, aggressiveness, and similar behaviors. 2. Impulsivity: Refers to actions that are poorly conceived, prematurely expressed, and unduly risky, or inappropriate to the situation. 3. Inattention: Refers to inability to focus Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 86 1. _______________________ are the primary neurotransmitters that mediate frontal lobe function. a. b. c. d. 2. The predominantly hyperactive/impulsive type of ADHD is usually characterized by high energy and constant movement. The classic manifestation(s) of this type of ADHD is/are: a. b. c. d. 3. Alzheimer’s Disease Parksinson’s Disease Adrenal leukodystrophy Mad Cow disease What is a comorbidity of ADHD when children engage themselves in ongoing destructive patterns that is defined by persistence of disobedience and triggered by anger and hostility. a. b. c. d. 5. Inattentiveness or lack of attention Disorganization Forgetfulness All of the above A comprehensive neurologic examination needs to be performed in children with ADHD to rule out the possibility of neurodegenerative disorders such as _______________. a. b. c. d. 4. Amino acids Catecholamines Gaba peptides Acetlycholine derivites Autism Antisocial Disorder Oppositional defiant disorder Asperger’s Syndrome True or False. ADHD is considered a condition of childhood, which requires less caution when giving future prognosis. a. True b. False Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 87 6. Children with attention deficit hyperactivity disorder are _______ likely to have ________ levels of comorbidities related to mood, anxiety, and disruptive behavior disorders and impairments in the cognitive, interpersonal and academic functions. a. b. c. d. 7. In obtaining the __________ history of the child suspected of ADHD, the general health and well-being of both the child and the parents need to be carefully assessed. a. b. c. d. 8. More; higher Less; lower More; lower Less; higher Social Family Psychiatric Medical Information about the presence of other conditions that might have triggered ADHD, and the use of medications and other substances that can cause side effects or interact with ADHD medications are obtained in the ______________. a. b. c. d. 9. Medications list Social history Family history Past medical history The interview with teachers constitutes the _________ line of the stepwise diagnostic process in identifying students with ADHD. a. b. c. d. First Second Third Last Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 88 10. The two versions of the Conners’ scale are long and short and can be successfully administered to children between the ages of ___________years. a. b. c. d. 2 5 3 7 to to to to 10 15 17 18 11. True or False. Apart from abnormalities within the dopamine system, children with any type of ADHD have also been found to exhibit abnormal levels of other neurotransmitters such as serotonin, cholinesterase, adrenalin, and GABA. a. True b. False 12. The Continuous Performance Test (CPT) is an impressive test of vigilance or sustained attention. It has been successfully employed in the assessment of patients who sustained a. b. c. d. traumatic brain injuries. epileptics. long-standing ADHD children. All of the above. 13. Among other things, deterioration in executive function leads to problems with a. b. c. d. poor concentration impaired working memory prioritizing and planning complex sets of tasks All of the above 14. The Woodcock Johnson III test was developed to determine general intellectual ability, specific cognitive abilities, scholastic aptitude, oral language skills and academic achievement. It is applicable to individuals between the ages of ___________ years old. a. b. c. d. 2 to 90 18 to 60 2 to 18 30 to 40 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 89 15. Children with predominantly ___________________ type of ADHD face barriers when trying to form social relationships with other children due to their tendency to be easily angered and provoked. a. b. c. d. Inattentive Impulsivity Autistic Hyperactivity 16. True or False. It is not uncommon for children with ADHD who are very bright to still score poorly in intelligence tests. a. True b. False 17. The ____________ lobe is responsible for the majority of decision-making functions. a. b. c. d. Cerebellar temporal frontal parietal 18. Imaging studies have revealed that children diagnosed with ADHD show a substantial ______________ of the brain volume. a. b. c. d. enlargement reduction less gray matter more gray matter 19. The diagnosis of ADHD in children, adolescents, and adults usually occur in _______________ care settings. a. b. c. d. secondary tertiary school psychiatry Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 90 20. True or False. States with improved health prevention and screening practices have been reported to have lower reports of prevalence rates. a. True b. False 21. Because of the complexity of ADHD, its therapy requires a ______________ approach. a. b. c. d. Psychiatric Therapeutic Multimodal None of the above. 22. The clinician must also pay close attention and focus on certain dysmorphic features that may be present in children with ADHD, EXCEPT for: a. b. c. d. Fragile X Syndrome Hydrocephalus Klinefelter Turner’s syndrome 23. The Delay Aversion Theory proposes a ________________ impairment in children with ADHD, which causes them to exhibit intolerance to delays that in turn affects their cognitive functioning and behavior in general. a. b. c. d. Hearing and visual Morally-learned Biological-based Family-learned Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 91 24. The ______________________ test is a standardized test, which consists of single letters presented on a computer screen at varying rates: once per second, once every 2 seconds, and once every 4 seconds. These are used to assess and evaluate the three major symptoms of ADHD, of inattention, hyperactivity and impulsivity. a. b. c. d. continuous performance mental status exam memory/cognition neurofeedback. 25. Interview of the child involves a: a. duration of approximately 2 to 3 hours arranged over two sessions. b. session with parents and teachers to facilitate the gathering of relevant information c. session with the patient alone d. All of the above. 26. True or False. IQ tests administered to young people are intended to observe patterns of behavior, which may be consistent with the symptoms of ADHD. a. True b. False 27. The NEBA device is an ________________ aid and used as part of a complete medical or psychological examination to confirm the diagnosis of ADHD or evaluate the need for further diagnostic tests. a. b. c. d. Neurofeedback EEG-based assessment XRAY Both a and b above. 28. Impaired executive function can lead to problems with a. b. c. d. organization achieving and maintaining concentration regulation of emotions All of the above. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 92 29. The Home Situations Questionnaire (HSQ) may allow the clinician a quick understanding of a. the frequency and severity of the child’s disruptive behavior in several home settings. b. marital discord in the home c. incidence of child abuse in the home d. Both a and c above. 30. The IVA-CPT test comprises four categories, EXCEPT a. b. c. d. Attention Response control Expansive mood Validity Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 93 Correct Answers: 1) _____________________ are the primary neurotransmitters that mediate frontal-lobe function. b. Catecholamines “Catecholamines are the primary neurotransmitters that mediate frontal-lobe function”. 2) The predominantly hyperactive/impulsive type of ADHD is usually characterized by high energy and constant movement. The classic manifestation(s) of this type of ADHD is/are __________________. a. b. c. d. restlessness exhaustion failed attempts at building social relationships All of the above [Correct Answer] “Those who manifest hyperactive behaviors are usually seen exhibiting a sense of restlessness, being fidgety or unable to stay still, and frequently fiddle with things when not on the move… these children can also endlessly move about unless exhaustion causes them to stop or slow down… Impulsive behaviors manifested by children with predominantly hyperactive-impulsive type of ADHD are the reason behind failed attempts at building and maintaining social relationships”. 3) A comprehensive neurologic examination needs to be performed in children with ADHD to rule out the possibility of neurodegenerative disorders such as _______________. c. Adrenal leukodystrophy “A comprehensive neurologic examination needs to be performed in children with ADHD to rule out the possibility of neurodegenerative disorders such as neuronal ceroid lipofuscinosis and adrenal leukodystrophy.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 94 4) What is a comorbidity of ADHD when children engage themselves in ongoing destructive patterns that is defined by persistence of disobedience and triggered by anger and hostility. c. Oppositional defiant disorder “Oppositional defiant disorder, on the other hand, is seen when children engage themselves in ongoing destructive patterns that is defined by persistence of disobedience and triggered by anger and hostility. Also, these children exude defiance against authoritative figures that are not typical of children their age. It may be accompanied by extreme anger and stubbornness that is also not exhibited by most children of the same age.” 5) True or False. ADHD is considered a condition of childhood, which requires less caution when giving future prognosis. b. False “ADHD is considered a lifelong condition, which requires greater caution when giving future prognosis and careful preparation of the family for coping with problems that may be encountered in later life.” 6) Children with attention deficit hyperactivity disorder are _______ likely to have ________ levels of comorbidities related to mood, anxiety, and disruptive behavior disorders and impairments in the cognitive, interpersonal and academic functions. a. More; higher “It has also been studied that children with ADHD are more likely to exhibit the prototypical symptoms of the disorder; they have higher levels of comorbidities related to mood, anxiety, and disruptive behavior and impairments in their cognitive, interpersonal and academic functions.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 95 7) In obtaining the __________ history of the child suspected of ADHD, the general health and well-being of both the child and the parents need to be carefully assessed. b. Family “The family history of the child should also be assessed. Specifically, the general health and wellbeing of the child and the parents need to be carefully assessed,…” 8) Information about the presence of other conditions that might have triggered ADHD, and the use of medications and other substances that can cause side effects or interact with ADHD medications are obtained in the ______________. d. Past medical history “The past medical history is important in providing clues as to the possible triggers that precipitated the behavioral symptoms, other than ADHD itself. The presence of other conditions that might have triggered the condition is explored as well as the use of medications and other substances that can cause side effects or interacted with ADHD medications.” 9) The interview with teachers constitutes the _________ line of the stepwise diagnostic process in identifying students with ADHD. a. First “The interview with teachers constitutes the first line of the stepwise diagnostic process in identifying students with ADHD.” 10) The two versions of the Conners’ scale are long and short and can be successfully administered to children between the ages of ___________years. c. 3 to 17 “The two versions of the Conners’ scale are long and short and can be successfully administered to children between the ages of 3 to 17 years.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 96 11) True or False. Apart from abnormalities within the dopamine system, children with any type of ADHD have also been found to exhibit abnormal levels of other neurotransmitters such as serotonin, cholinesterase, adrenalin, and GABA. a. True “Apart from abnormalities within the dopamine system, children with any type of ADHD have also been found to exhibit abnormal levels of other neurotransmitters such as serotonin, cholinesterase, adrenalin, and GABA. These neurotransmitters and their pathways, as a result of ADHD, have been found by researchers to be altered.” 12) The Continuous Performance Test (CPT) is an impressive test of vigilance or sustained attention. It has been successfully employed in the assessment of patients who sustained a. b. c. d. traumatic brain injuries. epileptics. long-standing ADHD children. All of the above. [Correct Answer] “Another widely used diagnostic tool in the assessment of ADHD is the Continuous Performance Test (CPT)… The Continuous Performance Test is an impressive test of vigilance or sustained attention. It has been successfully employed in the assessment of patients who sustained a traumatic brain injury (TBI) as well as those who are epileptics. It has also been successful in the assessment of long-standing ADHD children.” 13) Among other things, deterioration in executive function leads to problems with a. b. c. d. poor concentration impaired working memory prioritizing and planning complex sets of tasks All of the above [Correct Answer] “The deterioration in executive function which occurs in ADHD is cited as one of the most compelling reasons for the manifestation of behavioral symptoms such as poor concentration, impaired working memory, problems related to shifting among tasks, and prioritizing and planning complex sets of tasks or completing long term projects at work or school.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 97 14) The Woodcock Johnson III test was developed to determine general intellectual ability, specific cognitive abilities, scholastic aptitude, oral language skills and academic achievement. It is applicable to individuals between the ages of ___________ years old. a. 2 to 90 “The Woodcock Johnson III test was developed to determine general intellectual ability, specific cognitive abilities, scholastic aptitude, oral language skills and academic achievement. It is applicable to individuals between the ages of 2 to 90 years old.” 15) Children with predominantly ___________________ type of ADHD face barriers when trying to form social relationships with other children due to their tendency to be easily angered and provoked. b. Impulsivity “Impulsive behaviors manifested by children with predominantly hyperactive-impulsive type of ADHD are the reason behind failed attempts at building and maintaining social relationships.” 16) True or False. It is not uncommon for children with ADHD who are very bright to still score poorly in intelligence tests. a. True “It is not uncommon for children with ADHD who are very bright to still score poorly in intelligence tests.” 17) The ____________ lobe is responsible for the majority of decision-making functions. c. frontal “The ____________ lobe is responsible for the majority of decisionmaking functions.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 98 18) Imaging studies have revealed that children diagnosed with ADHD show a substantial ______________ of the brain volume. b. reduction “… imaging studies have revealed that children diagnosed with ADHD show a substantial reduction of the brain volume,…” 19) The diagnosis of ADHD in children, adolescents, and adults usually occur in _______________ care settings. a. secondary “The diagnosis of ADHD in children, adolescents, and adults usually occur in secondary care settings.” 20) True or False. States with improved health prevention and screening practices have been reported to have lower reports of prevalence rates. b. False “States with improved health prevention and screening practices have been reported to have higher reports of prevalence rates. The more rigorous the screening process, the greater the likelihood of finding more symptoms related to a diagnosis of ADHD.” 21) Because of the complexity of ADHD, its therapy requires a ______________ approach. c. Multimodal “Because of the complexity of ADHD, its therapy requires a multimodal approach.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 99 22) The clinician must also pay close attention and focus on certain dysmorphic features that may be present in children with ADHD, EXCEPT for: b. Hydrocephalus “The clinician must also pay close attention and focus on certain dysmorphic features that may be present in children with ADHD. These might indicate a deeper problem, which may be genetic in nature. Examples of these genetic problems may include, but are not limited to: • Fragile X Syndrome (higher rates are prevalent in female patients than in males) • Klinefelter • Turner’s syndrome” 23) The Delay Aversion Theory proposes a ________________ impairment in children with ADHD, which causes them to exhibit intolerance to delays that in turn affects their cognitive functioning and behavior in general. c. Biological-based “The Delay Aversion Theory proposes a biological-based impairment in children with ADHD, which causes them to exhibit intolerance to delays that in turn affects their cognitive functioning and behavior in general.” 24) The ______________________ test is a standardized test, which consists of single letters presented on a computer screen at varying rates: once per second, once every 2 seconds, and once every 4 seconds. These are used to assess and evaluate the three major symptoms of ADHD, of inattention, hyperactivity and impulsivity. a. continuous performance “The continuous performance test is a standardized test, which …. consists of single letters presented on a computer screen at varying rates: once per second, once every 2 seconds, and once every 4 seconds … used to assess and evaluate the three major symptoms of ADHD, of inattention, hyperactivity and impulsivity.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 100 25) Interview of the child involves a: a. duration of approximately 2 to 3 hours arranged over two sessions. b. session with parents and teachers to facilitate the gathering of relevant information c. session with the patient alone d. All of the above. [Correct Answer] “Interview of the child involves the following: • A duration of approximately 2 to 3 hours arranged over two sessions • A session with parents and teachers to facilitate the gathering of relevant information • A session with the patient alone” 26) True or False. IQ tests administered to young people are intended to observe patterns of behavior, which may be consistent with the symptoms of ADHD. a. True “IQ tests administered to young people are intended to observe patterns of behavior, which may be consistent with the symptoms of ADHD.” 27) The NEBA device is an ________________ aid and used as part of a complete medical or psychological examination to confirm the diagnosis of ADHD or evaluate the need for further diagnostic tests. b. EEG-based assessment “The NEBA device is an EEG-based assessment aid and used as part of a complete medical or psychological examination to confirm the diagnosis of ADHD or evaluate the need for further diagnostic tests.” Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 101 28) Impaired executive function can lead to problems with a. b. c. d. organization achieving and maintaining concentration regulation of emotions All of the above. [Correct Answer] “The executive functions include mental processes that are necessary to carry out and regulate daily tasks and to control and perform the management of daily tasks. Impaired executive function leads to problems with keeping track of time, organizing things, the habit of procrastinating things excessively, problems with achieving and maintaining concentration, speed in processing impulses and information, regulation of emotions, the use of working memory and problems with an individual’s short term memory.” 29) The Home Situations Questionnaire (HSQ) may allow the clinician a quick understanding of a. the frequency and severity of the child’s disruptive behavior in several home settings. “… the Home Situations Questionnaire (HSQ) may also be sent out along with the other contents of the packet or administered on the day of the scheduled patient evaluation to allow the clinician a quick understanding of the frequency and severity of the child’s disruptive behavior in several home settings.” 30) The IVA-CPT test comprises four categories, EXCEPT c. Expansive mood “The IVA-CPT test comprises of four categories: • Attention • Response control • Attribute • Validity” References Section Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 102 The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. [This is Part 1 of a 2 Part series on Pediatric ADHD]. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. National Institute of Mental Health. Attention Deficit Hyperactivity Disorder. Retrieved from http://www.nimh.nih.gov/health/publications/attention-deficithyperactivity-disorder/index.shtml Crichton, A. (1798). An inquiry into the nature and origin of mental derangement: comprehending a concise system of the physiology and pathology of the human mind and a history of the passions and their effects. Cadell, T. Jr, Davies, W., London [Reprint: Crichton, A. (2008). An inquiry into the nature and origin of mental derangement. On attention and its diseases. Journal of Attention Disorder 12:200–204. Bukstein, O. (2016). Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis. Up To Date. Retrieved online at https://www.uptodate.com/contents/attention-deficit-hyperactivitydisorder-in-adults-epidemiology-pathogenesis-clinical-features-courseassessment-anddiagnosis?source=search_result&search=adhd&selectedTitle=2~150 Diagnostic and statistical manual of mental disorders (DSM-II), 4th edn Text revision. Washington DC: American Psychiatric Association; 2000. Still, G.F. (1902). Some abnormal psychical conditions in children: the Goulstonian lectures. Lancet, 1:1008–1012. Brown, W.A., Bradley, Charles, M.D. (1998). American Journal of Psychiatry, 155:968. Gross, M.D. (1995). Origin of stimulant use for treatment of attention deficit disorder. American Journal of Psychiatry, 152:298–299. Centers for Disease Control and Prevention. (2010). Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children --- United States, 2003 and 2007. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm Krull, K.R. (2016). Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents. Up To Date. Retrieved online at https://www.uptodate.com/contents/pharmacology-of-drugs-used-totreat-attention-deficit-hyperactivity-disorder-in-children-andadolescents?source=search_result&search=adhd%20and%20catechola mines&selectedTitle=4~150 Spinelli, S., Joel, S., Nelson, T.E., Vasa, R.A., Pekar, J.J., Mostofsky, S.H. (2011). Different neural patterns are associated with trials Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 103 11. 12. 13. 14. 15. 16. 17. 18. 19. preceding inhibitory errors in children with and without attentiondeficit/hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 50(7):705-715.e3. Ducharme, S., Hudziak, J.J., Botteron, K.N., Albaugh, M.D., Nguyen, T.V., Karama, S. (2012). Decreased regional cortical thickness and thinning rate are associated with inattention symptoms in healthy children. Journal of American Academy of Child and Adolescent Psychiatry, 51(1):18-27.e2. Krull, K. (2016). Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Up To Date. Retrieved online at https://www.uptodate.com/contents/attention-deficithyperactivity-disorder-in-children-and-adolescents-epidemiology-andpathogenesis?source=search_result&search=adhd%20and%20twins&s electedTitle=2~150. International Classification of Diseases (ICD). World Health Organization. Retrieved 23 November 2010. Holden, S., et al. (2013). The prevalence and incidence, resource use and financial costs of treating people with attention deficit/hyperactivity disorder (ADHD) in the United Kingdom (1998 to 2010). Child Adolesc Psychiatry Ment Health. 2013; 7: 34. Published online 2013 Oct 11. doi:10.1186/1753-2000-7-34. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3856565/. National Resource Center on ADHD (2016). General Prevalence. Retrieved online at http://www.chadd.org/understanding-adhd/aboutadhd/data-and-statistics/general-prevalence.aspx. Bruchmuller, Katrin; Margraf, Schneider (2012). "Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis". Journal of Consulting and Clinical Psychology 80: 128–138. doi:10.1037/a0026582. Krull, K. (2016). Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. Up To Date. Retrieved online at https://www.uptodate.com/contents/attentiondeficit-hyperactivity-disorder-in-children-and-adolescents-overview-oftreatment-andprognosis?source=search_result&search=ADHD%20and%20inattentiv e&selectedTitle=1~150. Mendiola, Lee MD (2013). Predominantly Hyperactive Impulsive Type. http://leemendiolamd.com/predominantly_hyperactive_impulsivetype. html Lane, K. (2007). Academic Performance of Students with Emotional and Behavioral Disorders Served in a Self-Contained Setting. Journal of Behavioral Education 17:1 (March 2008), pp. 43–62; doi: 10.1007/s10864-007-9050-1 Copyright © 2007 Springer Science+Business Media, Inc. Retrieved online at Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 104 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1044&cont ext=specedfacpub. Mikami AY (June 2010). "The importance of friendship for youth with attention-deficit/hyperactivity disorder". Clin Child Fam Psychol Rev 13 (2): 181–98. doi:10.1007/s10567-010-0067-y. PMC 2921569. PMID 20490677 Racine, MB.; Majnemer, A.; Shevell, M.; Snider, L. (Apr 2008). "Handwriting performance in children with attention deficit hyperactivity disorder (ADHD)". J Child Neurol 23 (4): 399–406. doi:10.1177/0883073807309244. PMID 18401033 Bellani, M.; Moretti, A.; Perlini, C.; Brambilla, P. (Dec 2011). "Language disturbances in ADHD". Epidemiol Psychiatr Sci 20 (4): 311–5. doi:10.1017/S2045796011000527. PMID 22201208. Walitza S, Drechsler R, Ball J (August 2012). "[The school child with ADHD]". Ther Umsch (in German) 69 (8): 467–73. doi:10.1024/00405930/a000316. PMID 22851461. Wender, P. H. (2000). Adult manifestations of attention deficit/hyperactivity disorder. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (7th ed., pp. 2688–2692). Philadelphia: Lippincott Williams & Wilkins. Dobie, C (2012). Diagnosis and management of attention deficit hyperactivity disorder in primary care for school-age children and adolescents. Institute for Clinical Systems Improvement. p. 79. National Institute of Mental Health (2008). "Attention Deficit Hyperactivity Disorder (ADHD)". United States: National Institutes of Health. Black, D (2016). Treatment of antisocial personality disorder. Up To Date. Retrieved online at https://www.uptodate.com/contents/treatment-of-antisocialpersonalitydisorder?source=search_result&search=conduct%20disorders&selecte dTitle=4~59. Pardini, D.A., Frick, P.J., & Moffitt, T.E. (2010) Building an Evidence base for DSM-5 Conceptualizations of Oppositional Defiant Disorder and Conduct Disorder: Introduction to the Special Section. Journal of Abnormal Psychology. 119(4) 683-688 Millichap, J.G. (2010). "Definition and History of ADHD". Attention Deficit Hyperactivity Disorder Handbook. Springer Verlag Gmbh. pp. 2–3. ISBN 978-1-4419-1409-5. American Psychiatric Association (2013). Attention Deficit/Hyperactivity Disorder. Retrieved online at www.dsm5.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5-ADHD.pdf. Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 105 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 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