Innovations in the Assessment of AD/HD: Assessing Executive Operations in the Diagnosis of AD/HD Presented at the CHADD

1. Innovations in the Assessment of AD/HD: Assessing Executive Operations in the Diagnosis of AD/HD Presented at the CHADD 15th Annual International Conference AD/HD Through the Years: From Science to Practice OCTOBER 31, 2003 Thomas K. Pedigo Ed. D. Pediatric & Adolescent Psychology P.C. 37 West Fairmont Ave., Suite 211 Savannah, GA 31406

2. Introduction ·        Current/Common Assessment Practices in the evaluation of AD/HD ·        Comorbidity Issues in ADHD Diagnosis ·        Executive Functions and how they relate to AD/HD Diagnosis ·        Why this is important in Primary Care and Private Sector Settings ·        Review of the Pediatric Attention Disorders Diagnostic System (PADDS) ·        Current Supportive Research for PADDS

3. Common Assessment Practices in the Evaluation of AD/HD: Concerns typically originate from observations of behavior and/or performance at school, home and other extra curricular activities which are eventually reported to a physician or other health care professional. Attempts to validate these concerns will usually consist of:

4. Behavior Rating Scales :While these are often normed and efficient, they can be redundant and prone to bias. Comorbid conditions are often not assessed. A review of behavior ratings should be considered as one line of evidence when evaluating AD/HD. Class Room Observations: This approach can obtain real time data but is time consuming. Multiple observations are usually impractical. These observations are non-standardized and may influence class room behavior on the part of both teachers and students.

5. In Office Observations: Physician may witness problem behavior. However, office settings may not create demands sufficient to observe problems, may lack a standardized approach and may not address comorbid conditions. Psychological Evaluation: This process can be comprehensive and often will address comorbid conditions. Psychological evaluations can be expensive, time consuming and variable in procedures. In addition these measures may not adequately represent a child's true potential and are often not normed for AD/HD diagnosis.

6. Diagnostic Challenges/Comorbidity with ADHD Other Comorbid conditions often occur with ADHD. These conditions may include but are not limited to Mood Disorders, Anxiety Disorders, Disruptive Behavior Disorders and Learning Disorders. Bipolar Disorder is becoming increasingly recognized by some professionals within adolescent populations. The importance of considering other conditions that may mimic or exacerbate the presence of ADHD is essential to successful intervention.

7. The following listing of ranges for ADHD and Comorbid conditions was adapted from the following source: Pliszka, S. R., Carlson, C. L., & Swanson, J. M., (1999). ADHD with Comorbid Disorders: Clinical assessment and Management. New York, N.Y. The Guilford Press. Primary Diagnosis / Secondary DiagnosisRange of PrevalencePage Number ADHD/ODD-CD 15% to 61% 90 ODD-CD/ADHD 35% to 87% 90 ADHD/Depression 0% to 38% 127 Depression/ADHD 0% to 57% 127 ADHD/Anxiety 23% to 30% 151 Anxiety/ADHD 9% to 35% 151

8. Primary Diagnosis / Secondary DiagnosisRange of PrevalencePage Number ADHD/LD 7% to 60% 192 (Across- Reading, Spelling, & Math) ADHD/OCD 6% to 33% 214 Other related conditions needing assessment/ consideration include: Neurological Impairment Developmental disabilities PDD/Autistic spectrum disorders

9. Executive Functions and Diagnosis of ADHD Recent developments within the field of ADHD have increasingly pointed to the need to evaluate the various executive operations and working memory of children suspected of Attention Disorders. (Brown, T.E., 2002, 2000,1999; Barkley, R.A. 1997,1998; Denckla M, 1996.) Generally, executive functions are defined as controls that allow one to perform complex behaviors that require among other things: planning, attending, organizing input, storing and retrieving information, modulating emotions and sustaining effort.

10. The development of executive functions begins in early childhood occurs across time through early adulthood. As these processes emerge there is an expected increase in expectations for independent and functional behavior Brown, T.E. (2002). Children also learn from experience and observation in concert with the development of Executive Functions. Thus, children with chronic medical conditions, social, emotional or language based impairments often do not have the experience base attained by their typically developing counterparts.

11. While the identification of significantly hyperactive children can be simple, the evaluation of children who only display difficulty in learning or in completing more complex activities is where the greatest need for improvement lies. Difficulties in these executive processes exemplify the complaints of teachers and parents. Situations that require an orchestration of these abilities are often most problematic for AD/HD students. Parents will often report confusion at their child's ability to play video games, watch television or engage in favorite activities. However, on closer inspection, these activities often do not produce the same demands as found within the classroom. These favorite activities are often overlearned, fast pace, and allow the child to move freely in and out of the activity. Changing the structure of these activities can quickly produce frustration in AD/HD children.

12. Basic Demands of the Classroom: Attending to instruction Assimilating information Accommodating information Organizing, sequencing, manipulating information Monitoring emotional activity Formulating a plan of action Implementing the plan Other Factors: Working under time pressure Avoiding distraction Being adequately prepared

13. How EF applies in the classroom: • Examples of Executive Function Indicators relevant to AD/HD Diagnosis 1. Tommy needs frequent re-instruction, without this he drifts and often does not complete his work. His teacher is concerned that skills he learns one day do not transfer to the next day. Tommy has made comments that " his brain just won't work right". He seems capable but only produces satisfactory work when given one to one attention. 2. Tommy often cannot find his home work and has difficulty getting organized when completing class work. He will often forget instructions when preparing to work. Tommy often will confuse instructions and will repeatedly ask for assistance. He often stays in for recess and takes class work home to complete. Tommy often becomes frustrated and discouraged. 3. Tommy chronically complains that "I can't do it!", even though he appears capable. His parents help him study and he seems to have a grasp of the information. However, Tommy consistently does poorly on tests and often makes mistakes with his class work. He occasionally will become emotional and tear up his papers.

14. Relevance/Application to the Primary Care Setting According to the American Academy of Pediatrics, ADHD is the most commonly diagnosed childhood psychiatric disorder affecting school age children. Epidemiological studies have shown a prevalence rate ranging from 3 percent to 6 percent of school age children. Concern has been expressed for the these large numbers coupled with reportedly wide variations in clinical practice and research approaches; all point to the need to develop pragmatic assessment tools and approaches for use in the major systems of service entry. Specifically of importance are assessment approaches that can be used within primary care settings, schools and clinics as well as within the private sector. Reference: Chan, E., Hopkins, M., Perrin, J. M., Herrerias, C., & Homer, C. J., (2002) VARIATIONS IN DIAGNOSTIC PRACTICES FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER: A NATIONAL SURVEY OF PRIMARY CARE PHYSICIANS Homer Division of General Pediatrics, Children's Hospital, Boston, MA; American Academy of Pediatrics, Elk Grove Village, IL; Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston, MA; National Initiative for Children's Healthcare Quality, Institute for Healthcare Improvement, Boston, MA. (2002) Pediatric Academic Societies Abstract.

15. During the 1998 NIH Consensus Development Conference it was determined that Development and Validation of Diagnostic Tools Grounded in the Basic Sciences was warranted. Key areas of interest to the NIH The Development and Validation of Diagnostic Tools Grounded in the Basic Sciences Consequently, there is a continued need to develop more objective assessment tools, rating scales and/or diagnostic interviews that map onto basic underlying processes as well as a need to supplement behavioral assessment tools with improved cognitive and/or neuropsychological measures. The Development of Strategies for Assessing, Monitoring and Administering Treatment in Primary Care Settings Many of the currently utilized assessment measures and treatments for ADHD are incompatible with the primary care setting. There is also a dearth of practical decision-making tools for medication monitoring, differential diagnosis, and the distinction of referral service needs based upon impairment severity. Consequently, there is a great need for the development of practical, reliable and valid procedures to be used in primary care settings to identify and manage ADHD symptoms, as well as to distinguish appropriate referral needs.

17. PADDS The Clinician’s ADHD Toolbox • Computer based system to collect and compare multiple lines of evidence for ADHD diagnosis • Patient Information Database and Reporting • Comprehensive Parent and Teacher Interviews in a self-running or Clinician input format • A battery of newly developed cognitive tests presented in a challenging, enjoyable format • Automatic Report Generator with domain specific alerts and recommendations, and follow up comparisons of Treatments and Progress

18. Medical History/Systems Review Developmental History Social/Emotional Functioning Depression/Anxiety Attention/Hyperactivity Behavioral/School History

19. Cognitive Tests Executive Functioning

20. Target Recognition presents five large colored squares with smaller squares inside them. Through 153 presentations some number of the large squares will have smaller squares of the same color and some number will be different colors. The child is taught a strategy to read from left to right and count only the number of squares with matching colors. This task requires suppression of information, attention to detail, formulation of a response to changes in stimuli, modulation of emotions and persistence.

21. Target Sequencing presents five large colored circles. In each of 39 trials a small colored square appears and then disappears in each circle, in varied sequences. The child is taught to only attend to circles with a matching colored square. At the end of the trial the child is required to click on each matching circle in the order observed ( first match first, second match second and last match last). Target Sequencing requires the ability to avoid distraction, attention to detail, organization and sequencing during input of information, planning and organization of a response, modulation of emotion and sustained effort.

22. Target Tracking presents four colored shapes at the top and bottom of the computer screen. The computer moves two or three shapes from the top to the bottom shapes. The child is required to remember the order of these moves and to recreate them once all shapes have returned to the top of the screen. Target Tracking requires the ability to organize two and three step instructions, and to recreate these instructions in the order presented while modulating emotions and sustaining effort across 20 trials.

23. Cognitive Tests Executive Functioning

24. Generate Reports Cognitive Tests Report

25. PADDS SUPPORTIVE RESEARCH FOR TARGET SUBTESTS ADHD N = 65 Correctly ID = 63 Missed = 2 Total Discrimination = 96% TYPICAL N = 60 Correctly ID = 51 Missed = 9 Total Discrimination = 86% TOTAL DISCRIMINATION = 91% of 125 test subjects

26. PADDS SUPPORTIVE RESEARCH FOR CROSS VALIDATION SAMPLE ADHD N = 63 Correctly ID = 59.22 Missed = 3.7 Total Discrimination = 94% TYPICAL N = 62 Correctly ID = 52.7 Missed = 9.3 Total Discrimination = 89.5% TOTAL DISCRIMINANT ABILITY = 89.5%

27. PADDS SUPPORTIVE RESEARCH TOTAL DISCRIMINANT ABILITY ACROSS BOTH STUDIES ADHD N = 125 Trial 1 = 96% Cross Validation = 94% Total Discrimination = 95% TYPICAL N = 125 Trial 1 = 86% Cross Validation = 85% Total Discrimination = 85.5% TOTAL DISCRIMINATION = 90.25% of 250 test subjects

28. PADDS SUPPORTIVE RESEARCH TEST / RETEST: 43 SUBJECTS DRAWN FROM BOTH STUDIES 43 ADHD SUBJECTS N = 43 Trial 1 = 40 Miss = 3 R = .93

29. Innovations in the Assessment of AD/HD: Assessing Executive Operations in the Diagnosis of AD/HD Presented at the CHADD 15th Annual International Conference AD/HD Through the Years: From Science to Practice OCTOBER 31, 2003 Thomas K. Pedigo Ed. D. Pediatric & Adolescent Psychology P.C. 37 West Fairmont Ave., Suite 211 Savannah, GA 31406