Multidimensional, and Multipurpose Assessment of ADHD

1. Multidimensional, and Multipurpose Assessment of ADHD R. W. Kamphaus, Ph.D. The University of Georgia

2. Acknowledgements Cecil R. Reynolds, co-author Mark Daniel and Rob Altmann of AGS Co-researchers Andy Horne, Carl Huberty, and Michele Lease of UGA, Jean Baker of Michigan State, Christine DiStefano of Louisiana State University, Linda Mayes of Yale Child Study Center, David Pineda of Universidad de Antioquia Student research team members Anne Winsor, Ellen Rowe, Jennifer Thorpe, Cheryl Hendry, Amanda Dix, Erin Dowdy, Anna Kroncke, Sangwon Kim, Tracey Troutman, and Mauricio Garcia. Alumni research team members Drs. Nancy Lett, Shayne Abelkop, Martha Petoskey and Ann Heather Cody Some cited research was supported in part by grant number R306F60158 from the At-Risk Institute of the Office of Educational Research and Improvement of the United States Department of Education, to R. W. Kamphaus, J. A. Baker, & A. M. Horne.

3. Psychiatric Assessment Presence of marker symptoms or deviant signs defines the syndrome (e.g. cell characteristic of cancer) as espoused originally by Kreapelin Syndromes are mutually exclusive (e.g. mental retardation, autism, versus pervasive developmental disorder) but potentially comorbid (e.g. diabetes and heart disease) Syndromes have differing etiologies, outcomes (morbidities), and prognoses (e.g. schizophrenia versus reading disability (i.e. dyslexia) Diagnosis is dichotomous; that is one either has the disorder or not (e.g. ADHD, irritable bowel syndrome, clinical depression). Severity of symptoms is not measured. In other words criteria do not exist to define �severe� ADHD. Subtyping is common. For example, there are numerous types of cancer, three types of ADHD, etc. Differential diagnosis is emphasized thus there is an emphasis on �rule outs,� or determining whether or not there are alternative causes for the disorder (e.g. inattention or hyperactivity caused by clinical depression). Conventional clinical wisdom involves diagnosis of high frequency disorders before those with a low rate of occurrence. Reliability and validity of diagnoses tend to be lower than is characteristic of psychological tests Differential diagnosis of ADHD, CD, and ODD remains controversial

4. DSM IV Criteria Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder A. Either (1) or (2): (1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful of daily activities

5. DSM IV Criteria (continued) (2)�� six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a)often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c)often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e)is often �on the go� or often acts as if �driven by a motor� (f)� often talks excessively Impulsivity (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i)� often interrupts or intrudes on others (e.g., butts into conversation or games)

6. DSM IV Criteria (continued) Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. C.���� Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and home). D.���� There must be clear evidence of clinically significant impairment in social academic, or occupational functioning. E.���� The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Code based on type: 314.01� Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months 314.00� Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months 314.01� Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, �In Partial Remission� should be specified.

7. DSM IV Research Findings Combined, hyperactive-impulsive, and inattentive subtypes Differences in functional impairment Differences in comorbidity

8. Psychological Assessment Measures �latent traits� or �latent constructs� made up of multiple indicators (i.e. items) or behaviors (Kamphaus, 2001; Kamphaus & Frick, 2002) Traits are distributed dimensionally in the population thus making it possible to assess �severity� or amount of the latent trait possessed Norm referencing to a population is used to define deviance Positive or adaptive traits are of relatively greater interest Much of the statistical methods used requires large samples making this method less helpful for the identification of relatively rare disorders (e.g. schizophrenia, Autism) �Subsyndromal� as well as �hypersyndromal� cases can be identified for both clinical and research purposes (Scahill et al., 1999) Evidence of reliability and validity is more common for trait measures Measures are well suited for assessing response to treatment or intervention (e.g. effectiveness of medications)

9. Assessment forDiagnosis and Classification Assess core symptoms (DSM IV) and severity (rating scales) Assess age of onset (history), developmental course (history), and multiple contexts (history and rating scales) Rule out alternative causes (history and rating scales) Rule in comorbidities (history, DSM IV, IDEA, and rating scales)

10. History Taking Identify age of symptom onset prior to age 7 Developmental course or chronicity of symptoms Assessment of etiology (e.g. Thyroid condition) Treatment or intervention design � using solution focus interviewing Assessment of risk and resilience factors (e.g. family resemblance, peers, recreation) Documentation of educational or other impairment (e.g. grades, productivity, test scores, relations with peers or parents, school attendance)

11. TRS Reliability and Validity Traits that are considered stable are rated consistently by teachers over a 2 to 8 week interval (Reynolds & Kamphaus, 1992). A study of three clinical samples produced median test-retest values of .89, .91, and .82 for preschool, child, and adolescent levels. Different teachers rate the same child similarly (Reynolds & Kamphaus, 1992). A sample of 30 children was rated by two teachers each within a few days of one another. Interrater coefficients were variable ranging from a low of .53 for social skills to .94 for learning problems. Most clinical scales had adequate reliabilities such as aggression .71, anxiety .82, attention problems .68, and learning problems. 94. Teacher internal consistency coefficients are higher than those for either parents or adolescent self-reports (Reynolds & Kamphaus, 1992).

12. TRS Reliability and Validity Teacher ratings are better able to diagnose the subtypes of ADHD than classroom observations by independent observers (Lett & Kamphaus, 1997). The TRS was significantly better than the SOS at differentiating non-disabled, ADHD combined type, and ADHD combined type plus conduct problem groups with about a 70% accuracy rate. Teacher ratings are significantly associated with adjustment to school (Baker, Kamphaus, & Horne, Project ACT Early) Teacher ratings are predictive of adjustment six years later (Verhulst et al., 1994)

13. George � Referral Information George was referred by his parents because of school difficulties. His mother said, "We want him in a learning disabilities class." He has difficulty writing to the point that his parents admit to doing some of his homework for him. Some curricular adaptations have been made according to his parents, including reducing the size of his spelling word list. According to his mother, he "hates school." She also notes that he has difficulty sitting still and attending in school. George currently resides with his birth parents and 18-year-old sister, Kim. She is a high school senior, who is apparently doing well in school. George's mother noted that Kim was "hyper" in elementary school as well, but she was less active in middle school and obtained good grades in high school. George's mother works as a housewife and his father as a carpenter. Both parents completed eleven years of schooling.

14. George � Teacher Rating Scales