Attention Deficit Hyperactivity Disorder

1. Evaluation and Treatment Attention Deficit Hyperactivity Disorder

2. Developmentally underdeveloped self-regulation of: • Attention • Activity level • Impulse control • Motivation • Other Executive Functions • Onset in childhood • Relatively persistent & pervasive (25% "grow out" of symptoms as adults) • Creates significant impairment in major life activities • Not due to PDD, severe MR, psychosis, etc. • Continuum of impairment (studies show about a two year lag in brain development compared to non-ADHD controls) What is ADHD?

3. Three types of ADHD • Hyperactive/Impulsive • Inattentive • Combined Attention Deficit Disorder

4. Inhibition (the mind’s brakes) • Visual imagery (the mind’s eye) • Internal speech (the mind’s voice) • Emotional control (the mind’s heart) • Planning and problem-solving (the mind’s playground) Taken from Barkley, 2011 Problems with Executive Abilities

5. Limited hindsight, foresight, and anticipation of the future • Impaired sense of time and time management • Difficulties following rules and instructions and comprehending what you hear and read • Poor emotional control and low self-motivation • Impaired problem-solving and “simulating” the possible future and what your options are for dealing with it Deficits From Poor Executive Abilities

6. Academic Under-performance (90%+) • Retention in Grade (25-50%) • Require Special Education (35-60%) • Failure to Graduate High School (30-40%) • Less Likely to Attend College (20%) • Less Likely to Graduate College (5%) Taken from Barkley, Murphy, & Fischer 2008 What Are The Developmental Risks?

7. Peer Relationship Problems (50%+) (Bagwell, et al., 2001) • Delinquency (25-35%) • Substance Dependence/Abuse (10-20%) (Bieerman et al., 1997) • Driving Problems (Speeding, Accidents) • Earlier Sexual Activity and More Partners (Barkley et al., 2006) • Teen Pregnancy (38%+); Riskier sex activities (Barkley et al., 2006) • Increased Risk for STDs (16%) (Barkley et al., 2006) • 33% of those with ADHD make suicide attempts • Sleep Problems (Cortese et al., 2006) • Greater Health Risks More Developmental Risks

8. 54-84% Oppositional Defiant Disorder (Pliszka et al., 1999) • 30-50% Learning Disabilities (Pliszka et al., 1999) • 25% Childhood Conduct Disorder • 45% Adolescent Conduct Disorder • 25% Adults Antisocial Pers. Dis. • Up to 33% Childhood Depression (Pliszka et al., 1999) • 16% Mania (Biederman et al., 1992) • 25% Childhood Anxiety (Tannock, 2000) • 7% Tics or Tourette’s Up to 87% have at least one other disorder; up to 67% have at least two other disorders (Kadesjo & Gillberg, 2001) Rates of Comorbid Disorders

9. Heredity: Risk to • Siblings: 25-35% Twin: 70-97% • Mother: 15-20% Father: 20-30% • Offspring of an adult with ADHD: 43-57% (Barkley et al., 2006) Genetic Contribution (at least 78% or more) • No contribution of the rearing environment Genes found to date: • DRD4-7 repeat gene (Novelty-seeking) • DAT1 gene (dopamine transporter) • DBH, DRD5, SNAP25, ADRD2A What Are The Probable Causes?

10. Food Additives, Allergies, Sugar, Milk in Diet • Excessive Caffeine in Diet • Environmental Allergens • Poor Child Management by Parents • Family Stress; Chaotic Home Life • Excessive Use of TV, Video-games • Increased Cultural Tempo • PTSD, Depression, Anxiety, Learning Disability What Doesn’t Cause ADHD?

11. Two ADHD Testing Tracks • ADHD Screen (PCPs, psychiatrists, psychologists, examiners & trained counselors) • Psychological / PsychoeducationTesting (Psychologists and Psychological Examiners) (e.g. Child can sit still with meds, but still cant read, or cant focus due to traumatic stress symptoms, like flashbacks)

12. Evidence-based minimum standard Appropriate for about 50% of patients • Determine presence of ADHD symptoms and differential diagnosis from other disorders…Dxvs No Dx • Establish the presence or not of comorbid disorders • Up to 87% have one other disorder, LDs, internalizing/externalizing • Up to 65% have two other disorders • Screen for disorders in parents or familial factors that impact child • Establish the domains of impairment and the priority for treatment • Assess need for appropriate referrals for psychological / medical testing or treatment ADHD Screen

13. Clinical Interview • Unstructured parent interview • History - Onset, course, etc • Environmental Factors Family Environment -Parental ADHD, Parenting, Stress, and Competence • Semi-structured ADHD specific interview Differential Diagnosis / Comorbidity • Broad band rating scales • Child Behavior Checklist (Achenbach -ASEBA) • Behavioral Assessment System for Children (Pearsonassessments.com) • Structured interview of diagnostic criteria for DSM disorders (CHIPS or KSADS) Time required 15-60 min 15-25 min ADHD Screen

14. Time required 5-15 min 5-10 min • Narrow band (ADHD Specific Symptoms) • Conners, Brown, SNAP-IV, Vanderbilt, etc • Parent and Teacher / Other report • Functional Impairment • WEIS or Barkley Scales Total time required of patients: 40 - 150 minutes Total time required of clinician: 15 - 60 minutes Scoring time depends on the tests used ADHD Screen

15. Poor Grades (Potential evidence of learning problems) • Extremes of behavior (ex. High risk behavior, rage episodes, Self-injury, etc) • Complex Psychosocial or Medical History (ex. Abuse, multiple home placements, TBI’s, complicated divorces, etc) • Intense Family Conflict / Parenting Stress • Family Mental Health History (ex. Bipolar, Schizophrenia, LD’s, Autism, etc) Criteria Requiring Referral for Comprehensive Testing, Track Two

16. Patient-Centered, individualized assessment • Profiles child strengths and weaknesses in cognitive abilities, attention, and academic ability • Identify differential diagnosis and comorbid disorders in more complex cases. • R/O anxiety, depression, bipolar, behavior probsetc • *Establish range, severity, and source of symptoms compared to peers, rather than the Dxvs No Dx approach of the ADHD Screen Psychological / Psychoeducational Assessment (Track Two)

17. Identify environmental changes likely to improve functioning • Delineate types of treatments likely to be most effective • Behavioral, Family, Meds Alone, CBT for Dep or Anx, Tutoring, School Accommodations • Explore the resources available to the family in their region • Examples of Track Two cases • Ex. Children with abuse history and ADHD symptoms • Ex. ADHD symptoms and episodes of rage • Ex. High levels family conflict and parenting stress • Ex. Symptoms of both ADHD and Aspergers Psychological / PsychoeducationalAssessment (Track Two)

18. Interview - Individual, family, parent functioning, developmental history Broadband - parent Narrow Band - teacher / other Functional Impairment Cognitive Functioning • Learning ability, specific deficits, processing, overall level of functioning - academic accommodations that often influence a child’s behavior and performance at home and school. • IQ Screen or full IQ test. (WISC-IV, SB5, RIAS, KBIT, WASI, Academic achievement screening • Learning Disabilities (WRAT, WIAT, Woodcock-Johnson) Attention Capacity. (optional) • CPT, TEA-Ch, IVA, TOVA Time required 30-60 min 15-25 min 5-15 min 5-10 min 30-90 min 30-90 min 15-45 min (Optional) Psychological / Psychoeducational Testing - Track Two

19. Psychological / Psychoeducational Testing - Track Two Total time required of patients: 115-335 minutes (1h 55m – 5h 30m) Average: 1hr interview, 3hrs testing, 1hr feedback Time required of clinician: Scoring 30-60 min Report Writing 30-150 min Total Clinician Time (3 - 8hrs) Average Clinician time (4 - 6hrs)

20. Non-RSPMI Rates • Interview $57.84 /hr • Testing hours 1-2 = $84.00/hr (same day) • Testing hour 3 = 51.84/hr RSPMI Rates • Interview 115.20 • Testing = $115.20 /hr An RSPMI provider does not have to be a licensed psychologist with a Ph.D.    Current Reimbursement Rates

21. Patient-centered explanation of test results and tx options • Walk parents through the testing results and information revealed • Provide patient-education • ADHD and comorbid disorders identified during evaluation • Nature, causes, course, risks for future impairments • Explain treatment options and explore their availability • Medication • Behavioral Parent Training • Family Accommodations • Academic Accommodations (IEP’s and 504 plans) • Review other issues identified during the evaluation • Assist family in connecting with other professionals and resources/referrals as needed • Specialists: Psychiatric, therapy, sleep studies, OT, Speech, etc Feedback Conference

22. Canadian ADHD Practice Guidelines CADDRA website http://www.caddra.ca/cms4/index.php?option=com_content&view=article&id=26&Itemid=70&lang=en      Full Guidelines http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf • National institute of Clinical Excellence (NICE)Guidelines http://guidance.nice.org.uk/CG72Full guidelines http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf  Quick reference guide http://www.nice.org.uk/nicemedia/live/12061/42107/42107.pdf • Scottish Intercollegiate Guidelines Network  (SIGN)http://www.sign.ac.uk/guidelines/fulltext/112/index.html      Full guidelines http://www.sign.ac.uk/pdf/sign112.pdf      Quick reference http://www.sign.ac.uk/pdf/qrg112.pdf • American Academy of Pediatrics guidelineshttp://aappolicy.aappublications.org/cgi/content/full/pediatrics;128/5/1007 ADHD Guidelines

23. Interview • Parent Report • Other/Teacher Report • Appropriate Referrals for Medical / Psychological Testing or Treatment When Needed All Four Guidelines Recommend “ADHD SCREEN” as Standard

24. ADHD Assessment Form • Weis Symptom Checklist • ADHD Checklist • SNAP-IV-26 • Weis Functional Impairment Rating Scale • Teacher Assessment Form CADDRA Guidelines Page 85 Website http://www.caddra.ca/cms4/index.php?option=com_content&view=article&id=26&Itemid=70&lang=en Guidelines http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf CADDRA Recommended “Assessment Toolkit”

25. Broadband (Overall Mental Health Screener) • Strengths & Difficulties Questionnaire ww.sdqinfo.org • Weis Symptom Checklist Narrowband (ADHD Specific) • Vanderbilt ADHD Rating Scale http://www.dss.mo.gov/mhd/cs/psych/pdf/adhd_rating_teacher.pdf • SNAP-IV-26 Valid/Reliable – Brief & Free Assessment Tools

26. Evaluation • Education • Medication • Accommodation • Parenting / Restructuring the home • Changes in school • Assistance in the community What Are The 4 Stages of Treatment?

27. Parent Education About ADHD Psychopharmacology • Stimulants (e.g., Ritalin, Adderall, etc.) • Noradrenergic Medications (e.g., Strattera) • Tricyclic Anti-depressants (e.g., desipramine) • Anti-hypertensives (e.g., Catapres, Intuniv) Parent Training in Child Management • Children (<11 yrs., 65-75% respond) • Adolescents (25-30% show reliable change) Empirically Proven Treatments

28. Teacher Education About ADHD • Teacher Training in Classroom Behavior Management • Special Education Services (IDEA, 504) • Residential Treatment • Parent/Family Services • Parent/Client Support Groups (CHADD, ADDA, Independents) Empirically Proven Treatment (2)

29. Elimination Diets – removal of sugar, additives, etc. (Weak evidence) • Megavitamins, Anti-oxidants, Minerals • (No compelling proof or disproved) • Sensory Integration Training (disproved) • Chiropractic Skull Manipulation (no proof) • Play Therapy (disproved) • Biofeedback (EMG or EEG) (experimental) • 2 randomized trials found no convincing effects Unproved/Disproved Therapies in ADHD Treatment

30. BASC – Behavior Assessment System for Children, Second Edition • CBCL – Child Behavior Checklist • WISC – Wechsler Intelligence Scale for Children, Fourth Edition • WAIS – Wechsler Adult Intelligence Scale • WASI – Wechsler Abreviated Scale of Intelligence • WIAT – Wechsler Individual Achievement Test • WJ-III – Woodcock-Johnson Test of Acheivement • SB5 – Stanford-Binet Intelligence Test • CPT – Conners Continuous Performance Test • IVA – Integrated Visual and Auditory Performance Test • TOVA – Test of Variable Attention • SNAP-IV - Swanson, Nolan, & Pelham • TEA-Ch – Test of Everyday Attention in Children • SDQ – Strengths and Difficulties Questionnaire • Vanderbilt – Vanderbilt ADHD Teacher/Parent Rating Scales • Brown – Brown ADD Scales • Conners – Conners Parent Rating Scales- Revised • CHIPS – Children’s Interview for Psychiatric Syndromes • KSADS – Kiddie Schedule of Affective Disorders and Schizophrenia • KBIT – Kauffman Brief Intelligence Test • RIAS – Reynolds Intellectual Assessment Scales • BFIS – Barkley Functional Impairment Scales Psychological Measures