ADHD Assessment

1. ADHD Assessment Megan Arsenault Merril Dean Cara Freeman

2. Overview of ADHD • A neurobiological disorder • Inattention • Hyperactivity • Impulsivity • At least some symptoms evident before age 7, in at least 2 different environments • Causes clinically significant impairment in social, academic, or occupational functioning. • Prevalence: • 3%-7% in school-age children

5. Cognitive Deficits

6. Social/ Adaptive Functioning

7. Motivational & Emotional

8. Motor, Physical, Health

9. Assessment Considerations • The following must be considered in the assessment process: • Presence of symptoms • Number, type, severity, duration • Verbal, nonverbal, memory, cognitive abilities • Co-occurring disorders • Social competence and adaptive behaviour • Educational and instructional needs

11. Considerations for Assessment Gender Difference • Gender ratio of diagnosed ADHD is approximately 3:1 (Barkley, 2012) • Inattentive Type has a less pronounced gender ratio • Symptoms more severe in girls; more co-morbid conditions in adolescence in girls (Monuteaux, Mick, Faraone, Biederman, 2009)

12. Considerations When Assessing Risk Factors • Genetic • Heritability • Environmental • Prenatal exposure to nicotine, alcohol and drugs • Maternal psychosocial stress • Prenatal/postnatal to toxic substances (lead, mercury and pesticides may contribute • Structured environments at home and school may mitigate symptoms • Unstructured or chaotic home/school environments

13. Considerations When Assessing Resiliency Factors • Structured home/school environment • Reinforcement of self-esteem • Teaching of skills to develop planning, organization • Teaching of problem solving skills: identify problem areas, develop possible solutions, implement and assess • Promote use of ‘islands of competence’ as a way to see they can make contributions • Provide positive feedback and encouragement • (Goldstein, 2012)

14. Interviews Parent • Interview both if possible • Pre and post natal development • Medical, social and academic history • Medications • Parent perception of frequency, duration, range • Parenting styles including discipline

15. Interviews Teacher • Frequency, duration, range • Specific examples of when and what • Factors that exacerbate problem behaviors • Academic strengths and weaknesses • Peer relationships • Strategies that have been attempted to increase time on task or decrease behaviors • Information from more than 1 teacher, or different subject teachers

16. Interviews Child • May be valuable but child may minimize behavior • Often children affected by ADHD are unaware of the significance of their behavior

17. Observations & Monitoring Classroom • ABC • Intensity, duration and rate • Factors contributing too or sustaining behaviors • 2 or more classrooms/situations, different times of day • Playground/Sports, preferred activities During Testing • Focus/attention • Distractibility • Able to sit still

18. Types of Observation • Momentary Time Sampling • Record target behavior at 1 set point during time interval • Less likely to over-estimate but may miss large numbers of behaviors out the moment • Best used if no clear onset or end such as paying attention to lesson • Partial Interval • Record behavior if it occurs at any point of the interval you are watching. • May overestimate frequency of behavior • Use for serious negative behaviors such as physical aggression

19. Types of Observation (cont’d) • Event or Frequency Recording • Behaviors that start and end at readily recognizable times • Record separate incidents in the time interval • Use for single callouts, touching another student, out of seat • Whole Interval • Mark if behavior occurs and takes place through the entire interval • Underestimates as behavior may not persist through whole interval • Useful for tracking academic appropriate behaviors

20. Types of Observation • Running Record • Record what the child is doing by notes every 15 seconds • Difficult to do but supplies great deal of ‘unnoticed’ behaviors

22. General classroom observations • Does teacher: • check if students are paying attention; does she cue the class for transitions, important information etc. • Monitor if students understood • Handle disruptions immediately • Have clearly stated expectations for behavior • Ensure consistency of expectations • Ensure there is an appropriate general noise level and behavior conducive to the activity occurring in the classroom

23. Observations • Always ensure you are comparing to peers • Time frames for intervals should be between 15-30 seconds • Record time, date, subject • Make general classroom observations as well (see next slide) • three most common ‘diagnostic’ indicators in direct observations are: verbalizations/callouts; excessive motor activities and amount of off-task behavior (Goldstien, 2006) • 2-3 different days; minimum 20 minutes per observation; 2-3 different subjects

24. Rating Scales • Broadband vs. Narrowband • Normative base • Psychometric properties • Parents and teachers are the most reliable informants (Fitzgerald, Bellgrove, Gill, 2007)

25. Broadband • BASC TRS predictive ability for children who do not meet ADHD criteria (Vaughn, Riccio, Hynd, & Hall, 2010). • TRS, PRS specific subtypes of ADHD (Vaughn, Riccio, Hynd, & Hall, 2010). • Coverage of major dimensions of child psychopathology

26. Broadband • Child Behavior Checklist (CBCL); Teacher Rating Form (TRF); Youth Self Report (YSR) • Coverage of major dimensions of child psychopathology • 85 languages, multicultural scoring • DSM oriented scales: • Affective Problems; Anxiety Problems; Somatic Problems; Attention Deficit/Hyperactivity Problems; Oppositional Defiant Problems; Conduct Problem

27. Broadband • Designed to provide a complete overview of child and adolescent concerns and disorders • Extensive evidence base with normative and clinical populations (Fitzgerald, Bellgrove & Gill, 2007) • Recommended for assessment that covers externalizing, internalizing, and academic issues • Useful for initial screening • Limited breadth of coverage across dimensions

28. Personality Inventory for Children (PIC-2) • Broadband • Cognitive, social, emotional, behavioural concerns • Parent form (no comparison with teacher, child reports) • Narrowing down differential diagnoses • Identification of co-morbidities • Full form (40 min) • Behavioural Summary (15 min) • Can be used for screening or monitoring • Limited criterion related validity (Frick, Barry, & Kamphaus, 2010)

29. CRS-R • Narrowband • “The Conners 3 is a well-designed instrument with excellent technical properties that promises to be instrumental in the evaluation, diagnosis, and treatment response of children with ADHD and co-morbid disorders.” (Arffa, in press).

30. Brown ADD Scales (BADDS) • Narrowband • Measures underlying deficits in executive functioning in ADHD • Differentiating subtypes (McCandless, McClellan, & O’Laughlin, 2007)

31. BRIEF • Narrowband • Degree of impairment in executive function abilities • Strong relationship with interviews and other parent rating measures of behaviors seen in ADHD • More diagnostic utility in predicting ADHD than performance based measures of ADHD (Toplak, Bucciarelli, Jain, Tannock, 2008).

32. IQ Tests • “Not sufficiently sensitive to be used exclusively in making a diagnosis of ADHD or in discrimination among various subtypes of ADHD" (Mayes, Calhoun & Crowell, 1998, p. 380). • IQs in the Average range • 7-14 points lower than those of their peers • Difficulty on WMI and PSI • Digit Span, Arithmetic, Coding, and Symbol Search (Mayes, Calhoun, & Crowell, 1998).

33. Academic Tests • Significant direct effect of inattention on early academic skills. (Thorell, L.B., 2007). • Brief items and short subtests may allow a child with a short attention span to show their strongest abilities • Multiple choice tests may penalize impulsive children but may be more favorable for children who struggle to sustain attention on paper and pencil tasks. • EF deficits of inattention often impact mathematics and language skills • Lower word recognition (Clark, C., Prior, M., & Kinsella, G., 2002).

34. Continuous Performance Tests • Response patterns on the CPT II provide information that enables the practitioner to better understand the type of deficits that might be present. • For example, some response patterns suggest inattentiveness or impulsivity, while other response patterns may indicate activation/arousal problems or difficulties maintaining vigilance. • Useful for: • Differentiating subtypes of ADHD • Determining strengths and weaknesses • Developing intervention strategies tailored to indivdual • Determining if there has been improvement or deterioration with medication.

35. Neuropsychological Tests • Basic Attention • Digit Span, Word Span, Number Letter recall, simple cancellation tasks • Complex Attention • Auditory Consonant Trigrams, Digit Span Reversed, Number Letter Sequencing, Paced Serial Addition Test (PASAT) • Inhibition • Stroop Color Word Test, • Attention, Inhibition, Response Set of the NEPSY • Stroop tasks on the DKEFS, • Executive Functions • Task planning: Tower Test of the DKEFS; Route Finding on the NEPSY • Abstract thinking, logical reasoning: 20 Questions, Similarities, Word Reasoning • Hyperactivity • Statue test on the NEPSY

36. Differential Diagnosis • Mental Retardation • Individuals with High Intelligence • Oppositional Defiance • Individuals with difficulty with goal-directed behaviour • Children from chaotic, disorganized environments or inadequate environments • Stereotypic Movement Disorder

37. Differential Diagnosis • Other Mental Disorders – Mood Disorders (Bipolar Disorder), Anxiety Disorder, Dissociative Disorders, Personality Disorder, Personality Change due to General Medical Conditions or a Substance Related Disorder

38. Co-morbidities • Learning Disorders: 25-50% • Oppositional Defiant Disorder: 25-33% • Conduct Disorder: 26% • Depressive Disorder: 18% • Anxiety Disorder: 26% • Also: mood disorders, communication disorders, Tourette’s disorder • May also display: aggressive behaviour, low self-esteem, low tolerance to frustration, lability of moods, temper outbursts (Sattler & Hoge, 2006)

39. Important Consideration . The symptoms can 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 Disorders, or a Personality Disorder.

40. A Final Checklist

41. A Final Checklist

42. References • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Arlington, VA: Author. • Arffa, S. (in press). Test review of the Conners 3rd Edition™ (Conners 3™). From K. F. Geisinger, R. A. Spies, & J. F. Carlson (Eds.), The eighteenth mental measurements yearbook [Electronic version]. • Barkley, R.A. (2012). Frequently Asked Questions about ADHD. Retrieved from http://russellbarkley.org • Barkley, R.A. & Murphy, K.R. (2006). Attention deficit hyperactivity disorder: A clinical workbook. (3rd ed.). New York: Guilford Publications. • Clark, C., Prior, M., & Kinsella, G. (2002). The relationship between executive function abilities, adaptive behaviour, and academic achievement in children with externalizing behaviour problems. Journal of Child Psychology and Psychiatry, 43 (6): 785–796. • Fitzgerald, M., Bellgrove, M., & Gill, M. (2007). Handbook of Attention Deficit Hyperactivity Disorder. West Sussex, England: John Wiley & Sons. • Frick, P.J., Barry, C.T., & Kamphaus, R.W. (2010). Clinical Assessment of Child and Adolescent Personal and Behavior. New York: Springer.

43. References • Goldstein, S. & Brooks, R. (2012). Risk, resilience and ADHD: Changing lives of challenged children. Retrieved from http://www.addvisor.com/goldstein_risk_resilience_adhd.htm • Mash, E.J. & Barkley, R.A.(Eds.) (2003). Child psychopathology (2nd ed.). New York, NY: Guilford Press. • McCandless, S., McClellan, J.L., & O'Laughlin, L. (2007). The clinical utility of the Behavior Rating Inventory of Executive Function (BRIEF) in the diagnosis of ADHD. Journal of Attention Disorders, 10 (4): 381-389. • Monuteaux, M., Mick E., Faraone, S. & Biederman, J. (2009). The influence of sex on the course and psychiatric correlates of ADHD from childhood to adolescence: A longitudinal study. Journal of Child Psychology and Psychiatry. 51(3). 233-241.DOI:10.1111/j.1469-7610.2009.02152.x

44. References • Sattler, J.M. & Hoge, R.D. (2006). Assessment of children: Behavioural, social, and clinical foundations (5th edition). La Mesa, CA: Jerome M. Sattler, Publisher. • Thorell, L.B. (2007). Do delay aversion and executive function deficits make distinct contributions to the functional impact of ADHD symptoms? A study of early academic skill deficits Journal of Child Psychology and Psychiatry, 48 (11): 1061–1070. • Toplak, M. E., Bucciarelli, S.M., Jain, U., & Tannock, R., 2008). Executive functions: Performance-based measures and the Behavior Rating Inventory of Executive Function (BRIEF) in Adolescents with Attention Deficit/ Hyperactivity Disorder. Child Neuropsychology, 15(1): 53-72. • Vaugh, M.L., Riccio, C.A., Hynd, G.W., & Hall, J. (2010). Diagnosing ADHD (predominately inattentive and combined type subtypes): Discriminant validity of the behavior assessment system for children and the Achenbach parent and teacher rating scales. Journal of Clinical Child Psychology, 26(4): 349-357. • Wright, J. (2002). Attention-Deficit Hyperactivity Disorder: A school-based evaluation manual. New York, NY: Syracuse City School District.