Download Assessment and Treatment of ADHD An Update

Stephan M. Silverman, Ph.D.
Certified School Psychologist
Licensed Psychologist
DIRECTOR OF PSYCHOLOGICAL
AND BEHAVIORAL SERVICES
THE WEINFELD EDUCATION GROUP
January 14, 2011
Definition of ADHD by CHADD
 ADHD is a neurobiological disability that affects
three-to-five percent of school-age children.
 ADHD is characterized by developmentally
inappropriate impulsivity, inattention, and in
some cases, hyperactivity.
Surprising Increase in Prevalence of ADHD
 According to a report released on November 10, 2010
by the Centers for Disease Control and Prevention
(CDC), rates of parent-reported ADHD diagnosis are
increasing, and new patterns of ADHD diagnosis are
emerging in the United States. From 2003 to 2007,
there was a 22 percent increase in the percentage of
children aged four to seventeen years diagnosed with
ADHD . The data indicate that by 2007, nearly one in
ten school-aged children had been diagnosed with
ADHD.
CORE SYMPTOMS OF ADHD
 DISTRACTIBILITY
 IMPULSIVITY
 MOTOR RESTLESSNESS
CO-EXISTING CONDITIONS
 ANXIETY
 DEPRESSION
 DISORGANIZATION
 FORGETFULNESS
 IMPATIENCE
 OPPOSITION
 LEARNING DISABILITIES
 CONDUCT DISORDER
 BIPOLAR DEPRESSION
 OCD
 SLEEP DISORDERS
 TOURETTE’S SYNDROME
FOUR SUBTYPES OF ADHD IN DSM-IV
 Predominantly Hyperactive/Impulsive
 Predominantly Inattentive Type (Different
mechanism and brain function.
 Combined Type
 and Not Otherwise Specified
Considerations Under Discussion for DSM-V
 Diagnostic Criteria for Attention
Deficit/Hyperactivity Disorder
(SMS:CONCEPT OF DEMAND)
 The disorder consists of a characteristic pattern of
behavior and cognitive functioning that is present
in different settings where it gives rise to social and
educational or work performance difficulties. The
manifestations of the disorder and the difficulties
that they cause are subject to gradual change being
typically more marked during times when the
person is studying or working and lessening during
vacation
Diagnosis by Consensus
 In children and young adolescents, the diagnosis
should be based on information obtained from parents
and teachers. When direct teacher reports cannot be
obtained, weight should be given to information
provided to parents by teachers that describe the
child’s behavior and performance at school.
Examination of the patient in the clinician’s office may
or may not be informative. For older adolescents and
adults, confirmatory observations by third parties
should be obtained whenever possible.
POSSIBLE CHANGES BEING DISCUSSED
FOR DSM-V FOR 2013
POSSIBLE SEPARATE DISORDERS:
 ADHD HYPERACTIVE/IMPULSIVE TYPE
 ADHD PREDOMINANTLY INATTENTIVE
TYPE
 ADHD RESTRICTIVE INATTENTIVE TYPE
(FEWER CRITERIA MET FOR
HYPERACTIVE/IMPULSIVE TYPE
 Combined Presentation: If both Criterion A1
(Inattention) and Criterion A2 (HyperactivityImpulsivity) are met for the past 6 months.
MORE ON ADHD IN DSM-V
 EMPHASIS ON IMPULSIVITY AS PIVOTAL
ASPECT OF ADULT ADHD
 CHANGING AGE OF ONSET FROM ON OR
BEFORE AGE 7 TO AGE 12
 CONSIDERATION OF INCLUDING AND NOT
EXCLUDING ADHD WITH AN AUTISTIC
SPECTRUM DISORDER
ADDA Recommendations to Proposed Changes
in DSM-V. 8/2010
 A distinct list of symptoms developmentally
appropriate for use with adult patients
 A separate diagnostic category “Adult
Attention Deficit Disorder,” comprised of
empirically-derived items from research
 A higher age threshold of 15 or 16 years-old
(and many Professional Advisory Board
members suggested an age threshold of 18
years-old)
 Mild, Moderate, Severe degrees of impairment
EXECUTIVE FUNCTIONS
 Focusing and Sustaining Attention
 Sustaining Alertness, Effort, and
Processing Speed
 Managing Frustration and Modulating
Affect
 Utilizing Working Memory and
Accessing Recall
 Inhibiting and Regulating Verbal and
Motoric Action
 Organizing, Prioritizing and Activating
Tasks
ADHD LOOK-ALIKES
• THYROID PROBLEMS
• SEVERE NUTRITIONAL DEFICIENCIES
• ENVIRONMENTAL OVERSTIMULATION
• SITUATIONAL DEPRESSION
• POST-TRAUMATIC STRESS DISORDER
• BIPOLAR DISORDER
• DISSOCIATION
• ALLERGIC REACTIONS
Types of Attention
1. Focused attention describes the ability to respond
specifically to visual, auditory, or tactile input.
2. Sustained attention refers to the ability to maintain
a response to input continuously. This may include
vigilance, working memory, and mental control.
3. Selective attention is the ability to maintain a
behavioral or cognitive “set” when faced with
distraction. This requires freedom from distractibility,
a much used and abused term in cognitive psychology.
Types of Attention Continued
4. Alternating attention is the ability to shift focus
from one thing to another. This involves the ability to
shift response requirements between different inputs.
5. Divided attention is the ability to respond at the
same time to multiple task demands.
Genetics
Is ADHD simply a case of
Inherited Impatient Temperament?
Inattention In a Variety of Conditions
 Bipolar Disorders – Inattention may not manifest
only as typical ADHD symptoms but may be
exhibited in pressured flight of ideas.
 Accompanying a Learning Disability – Often
with a reading disability or non-verbal learning
disorder
 Schizotypal - Inattention may be revealed
through associative, tangential thinking. Is it
ADHD?
 Autism Spectrum Disorders – Inattention is
through self-absorption and perseverative focus.
Psychometrics of ADHD with Gifted Kids
The hyperfocus of the highly intelligent child will
confound measures of attention when attempted
through testing. They “beat” many psychometric
tests . The American Association of Pediatrics
does not recognize the value of psychometric
tests in diagnosing ADHD. The cues are often in
test-taking behaviors more than scores, such as
losing the instructional set through lapses in
working memory.
The Concept of the Variable,
Vulnerable Nervous System
“Soft Signs” of Neurological
Vulnerability
May Include:
 irritability
 motor automatisms like tics and tremors, including Tourette’s syndrome
 low frustration tolerance
 fatigue
 lack of perseverance
 lack of resilience
 rigidity and difficulties with transitions and change
 stubbornness
 oppositionality
 perseveration—repeating actions, thoughts, verbalizations
 emotional immaturity
 emotional vulnerability
 emotional lability (unpredictable propensity to change)
 impulsivity
 explosiveness
 auditory or visual perceptual discrimination errors
“Soft Signs” Continued
lack of thorough perceptual scanning
speech/language symptoms, especially articulation and slow
and uneven pacing of words, and retrieval, hesitation, or
immaturity in formulation
 somatic complaints including headaches;
 gross and fine-motor awkwardness, poor coordination, or
balance
 sequential, short-term, and working memory problems
 impaired social perception
 impaired comprehension
 limitations in judgment; and
 general problems in executive functioning
PSYCHOLOGICAL ASSESSMENT GUIDELINES:
OTHER HEALTH IMPAIRMENT (OHI)
DCPS
 Definition:
Having limited strength, vitality, or alertness, including
a heightened alertness to environmental stimuli,
resulting in limited alertness with respect to the
educational environment, and adversely affecting a
child’s education performance, due to chronic or acute
health problems.
DCPS ASSESSMENT GUIDELINES CONTINUED
ASSESSMENT GUIDELINES CONTINUED
Elements of a Good Assessment
 THE PURPOSE AND DIAGNOSTIC
QUESTIONS ARE CLEAR
 THE GOALS FOR USING DATA ARE
COLLABORATIVE
 STRENGTHS AND NEEDS ARE IDENTIFIED
WITH AN EMPHASIS ON A STRENGTHS
APPROACH
 CO-MORBIDITIES ARE IDENTIFIED AS WELL
AS THE IDENTIFICATION OF CORE
SYMPTOMS
COMPLEXITIES IN DIAGNOSIS OF ADHD
 Children differ in the severity and number of symptoms of
ADHD
 Unlike a number of health conditions, there is no one, single test
for ADHD (and that would be assuming that ADHD is a single
unitary entity).
 Some symptoms are more predominant in one individual
compared to another.
 Within-subject variability
No Single Instrument Yet Identifies ADHD
Schaefer, and DeLong (2003) conducted a national
survey of training and assessment practices in
the schools.
In the assessment of ADHD, the results indicated
that school psychologists are using multiple
informants, methods, and settings, with rating
scales, observations, and interviews the most
common methods identified.
Discussion
What Constitutes a
“Comprehensive” Assessment
Battery for ADHD?
A trained professional assembles a
comprehensive test battery on only what is
needed.
The Following Components Can Form Your Test Battery Menu:
1. A thorough medical and developmental history
taken from parent when possible.
2. #1 should include a very thorough interview with
stakeholders, including parents, teachers, tutors,
counselors, coaches, and therapist
3. One or more observations in a natural
environment such as home or school,
4. An interview with the child.
5. Rating scales of core symptoms from multiple
environments and observers, including selfratings as needed.
(The ADHD-IV by DuPaul et al is free and keyed to the DSM)
Test Battery Choices Continued
6. Rating scales of personality and
psychopathology to confirm co-morbidities:
such as BASC-II, Achenbach, etc.
7. Measures of Executive Function such as BRIEF
and/or DKEFS
8. Psychometric instruments of cognitive
ability, achievement, and memory as needed
to reflect current strengths and needs for
educational purposes.
9.Continuous Performance Tests (CPT) such as
TOVA, IVA, Conners
10. Self-ratings of self-esteem.
Is an IQ Test Always Needed in ADHD Assessment?
It is inappropriate to test children with too
many or unnecessary instruments.
 An IQ test is often unnecessary. May be
necessary for initial assessment.
 On the other hand, when important
information is sought about a number of
areas of functioning, an IQ test may be very
valuable in helping to identify areas of
strength and weaknesses for educational
planning and areas affected by ADHD or comorbid conditions.
 What about testing for transition?
Important Tips
Be sure to employ a ready signal to insure that the
directions will be registered or you are failing to
deliver the directions for the purpose of the item
being administered.
Pay special attention to working memory in the
subject’s failure to grasp instruction.
If needed, consider a separate measure of working
memory such as memory for sentences.
CAVEATS ABOUT CPTS
ADMINISTERED ALONE
Turkelson et al (2000) could not predict real-world
ADHD symptoms from CPTs and were unable to find
literature that supported or did not support CPTs for
monitoring medication effects.
Published reports of national professional medical
associations, national medical policy organization
positions, or reports of national expert opinion
organizations did not demonstrate a consensus in the
medical community that CPTs were safe and
efficacious for the purpose of making the ADHD
diagnosis. All guidelines advised against the use of
CPTs alone.
NEWER MEASURES OF ADHD
• The Test of Everyday Attention: For Adults. Some
subtests more reliable than others.
• Conners’ CPT – II: Reliable but subject to concerns of
all CPT-s.
• Conners’ Rating Scales- 3 – Very well reviewed in
Buros Mental Measurements Yearbook
• Conners’ Kiddie CPT: the K-CPT scores do not have
adequate reliability and validity evidence for
diagnostic purposes. The K-CPT scores alone should
not be used to make diagnostic decisions in the
absence of additional valid evidence.
NEWER MEASURES OF ADHD
 QEEG Brainmapping: Positive preliminary results,
not available everywhere, not standardized.
 Genetic markers.
 The Quotient™ ADHD System evaluates the levels
and patterns of a subject’s motor activity, attention and
impulsivity during a 15 or 20-minute, office visit. The
subject sits in front of the Quotient™ ADHD System
kiosk and responds to a series of demanding yet
monotonous tasks. Provides a quick readout
comparison to non ADHD populations by age and
gender.
Tips on Achievement Testing
 Look for the effects of inattention on listening
and reading comprehension. Comprehension
measures reveal whether or not new
information has been absorbed or registered.
 Consider adding a reading measure that
includes rate and recall (such as the GORT)
Components of Written Language
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2.
3.
4.
5.
6.
7.
Motor execution as measured by speed, coordinated
size of letters, variation in spacing and slant. Look
for developmental immaturity in writing and the
effects of medication.
Look at timed versus untimed measures of writing.
Consider spelling, capitalization, spelling, grammar,
and punctuation as separate skill sets. These are
called “rule governed skills”
Look for phonological areas of spelling to detect comorbid reading disability.
Read for sophistication of content in giftedness.
Look for formulation of expression for
consideration of co-morbid language problems.
Look for abstraction level of language compared to
cognitive level in giftedness.
Tips in Assessment of Math
Math skills are not unitary. They include: Logic,
Calculation, Memory, Geometry, and Word
Problems
Math calculation problems are very common in children
with ADHD because long-term memories for math
facts have not “registered”.
Look for :
 spatial alignment problems on the page
 carrying errors
 spatial reasoning and memory
 using the wrong sign
Utilize Assessment in a Comprehensive
Wraparound Plan
An example of a multi-modal treatment and
education approach to ADHD can be found in
“School Success for Kids with ADHD” by
Silverman, Iseman, and Jeweler (Prufrock Press,
2009) and “101 School Success Tools for Students
with ADHD” (Prufrock Press, 2010) by Iseman,
Silverman, and Jeweler (Prufrock Press)
Bibliographic References Available Upon Request
Noteworthy
 ADHD should be treated before learning disorders,
 Dr Alka Subramanyam, psychiatrist from Nair
hospital, Mumbai, India
 Seems logical.
FINALLY A CONNECTION BETWEEN TREATMENT
AND ACHIEVEMENT
Richard Scheffler, Ph.D. et al, of U.C. Berkeley analyzed
a sample of 594 children diagnosed with ADHD , part
of the national Early Childhood Longitudinal Study—
Kindergarten Class of 1998-1999, a U.S.D.E. survey.
Children from grades K to 5.The study found that
students with ADHD who took medication had math
scores that were on average 2.9 points higher and
reading scores on average 5.4 points higher than their
unmedicated peers with ADHD.
Updates on the MTA Studies
 The MTA was the first major multi-site trial comparing
different treatments for ADHD in childhood. The
initial results of the 14-month study, in which 579
children were involved in 1999.
 The researchers found that the intensive medication
management alone or in combination with the
behavioral therapy produced better symptomatic relief
for children with ADHD than just behavioral therapy
or usual community care.
 Children who received the combination treatment
fared best in other areas of functioning such as social
skills and parent-child relations.
More Updates on MTA Study
 About half of the initial benefits of the intensive
medication management and combination treatments
dissipated by the first follow-up, which was two years
after the trial began.
 A follow up study in 2007 found that, although most
children had maintained improvement three years
after the trial began, the initial advantages of intensive
medication management alone or in combination with
behavioral treatment had waned.
 Most recent analysis by Brooke Molina Ph.D., of the
University of Pittsburgh, and colleagues aimed to
characterize the long-term functioning of the children
eight years after they were enrolled in the trial.
More Updates on MTA ADHD Study
 Parent, teacher and self-reports from the subjects, now
in high school, found functioning improved overall
compared to the beginning of the study, suggesting
that available treatments can still be effective.
 However, the 8-year follow-up revealed no differences
in symptoms or functioning among the youths
assigned to the different treatment groups as children.
The type or intensity of a one-year treatment for
ADHD in childhood does not predict future
functioning.
Updates on MTA ADHD Study Continued
 Youths with ADHD still had significantly more
academic and social problems compared with peers
who did not have ADHD with more conduct problems
including run-ins with police, depression, and
psychiatric hospitalizations.
 But, youths who had responded well to treatment and
maintained their gains for two more years after the end
of the trial tended to be functioning the best at eight
years after.
Updates on MTA ADHD Study Continued
 61.5 % of the subjects who were medicated at the end
of the 14-month trial had stopped taking medication
by the eight-year follow-up, suggesting that
medication treatment may lose appeal with families
over time.
 Children who were no longer taking medication at the
eight-year follow-up were generally functioning as well
as children who were still medicated, raising questions
about whether medication treatment beyond two
years continues to be beneficial or needed by all.
The Growing Brain
 Philip Shaw, M.D of NIMH (2007) found, through
imaging studies, that the brain matures in a normal
pattern but is delayed three years in some regions, on
average, compared to youth without the disorder.
 The delay in ADHD was most prominent in regions at
the front of the brain’s outer cortex, important for the
ability to control thinking, attention and planning.
 Both groups showed a similar back-to-front wave of
brain maturation with different areas peaking in
thickness at different times.
 The imaging techniques were improved over prior
studies. Techniques are not yet complete, but reveal
growth and possible symptom reduction with age.
Comprehensive Team Approach from School Success for
Kids With ADHD
Determine the accurate diagnosis.
Identify and nurture student’s strengths.
Parent education.
Parent consultation.
Evaluate and manage family stress.
Carefully monitor student’s medications.
Emphasize exercise & good nutrition.
Assign a case manager.
Provide support at school to teachers.
Negotiate a contract with the school and student.
Build student’s self-esteem through counseling if
needed.
12. Manage student’s stress through calming techniques.
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Web Resources:
 Children and Adults With Attention
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Deficit/Hyperactivity Disorder (CHADD),
www.chadd.org
Attention Deficit Disorder Association (ADDA),
www.add.org
National Resource Center on AD/HD,
www.help4adhd.org
Council for Exceptional Children, www.cec.sped.org
National Dissemination Center for Children With
Disabilities, www.nichcy.org
The National Institute of Mental Health,
www.nimh.nih.gov
Information on Attention Deficit Disorder and ADHD,
www.helpforadd.com/info
ADDitude Magazine, www.additudemag.com/adhdguide/adhd-at-school.html
THANK YOU!!!!
Contact Information:
Stephan M. Silverman, Ph.D.
Email: [email protected]
Website: stephansilverman.com
Weinfeld Education Group, LLC
www.richweinfeld.com