Attention Deficit Hyperactivity Disorder

ADHDIlona T. Tsvetkova

Phil, stop acting like a worm; The table is no place to squirm; Thus speaks the father to his son; Severely says it, not in fun; Mother frowns and looks around; Although she doesn’t make a sound; But Phillip will not advise; He’ll have his way at any price; He turns; And churns; He wiggles; And jiggles; Here and there on the chair; Phil, these

twists I cannot bear.

Nursery rhyme by Henrich Hoffman, a German psychiatrist, (mid 1800s).

IntroductionNature of the problem:

ADHD is a neurobehavioral developmental disorder of childhood that is characterized by developmentally inappropriate levels of

Hyperactivity Impulsivity Inattention

Subtypes of ADHD: Attention Deficit Hyperactivity Disorder –

Predominantly Inattentive Type Attention Deficit Hyperactivity Disorder –

Predominantly Hyperactive-Impulsive Type Attention Deficit Hyperactivity Disorder – Combined New subtype: Sluggish Cognitive Tempo

Epidemiology:

ADHD is considered to be the most common and diagnosed psychiatric disorder in children, with prevalence ratings ranging from 3% to 7% of the school aged children

ADHD occurs more often in males than females, estimates of rations vary significantly

Ranges from 2:1 to 9:1 have been reported with the gender differences less pronounced for the inattentive type of ADHD

Accounts for a large number of referrals to pediatricians, family physicians and child mental health professionals – estimated around 40%

It is considered to be a chronic disorder, with 30% to 50% of individuals diagnosed with ADHD in childhood continue to have symptoms into adulthood.

Have high comorbidity with other psychiatric disorders   (Diagnostic and Statistic Manual of Mental Disorders [4th ed.]

Controversies and Unresolved Issues: What is normal versus clinical? The issue involving the diagnosis of ADHD,

inattentive type. ADHD diagnosis and age.

Case study: Richie is a 7 year old right-handed male who was brought to my

office by his mother to evaluate for possible ADHD symptoms. Richie attends his first grade in a public elementary school. His mother is employed as a math teacher in a community based college and his father is an automobile mechanic.While pregnant with Richie, mother described her attitude as depressed and moody. In addition the mother reported to have smoked 1.5 packages of cigarettes within the first 1 months of pregnancy and approximately half pack a day for the next 2 months before quitting . She have also reported to have moderately consumed alcohol while at the first month of her pregnancy. There was no diagnostic history of severe mental illness within Riches family.

I. Initial Interview I have decided to interview Richie and his mother in the same

day, separately ( the waiting time between two separate interviews was 45 minutes).

Interviewing parent: I will use semistructured interviewRationale for using semistructured interview:

› The interview will focus on the specific complaints about the child’s psychological adjustment and any functional parameters.

› However, the interview will also provides the phenomenological data that rating scales cannot capture Although storable data will be obtained, the small details and nuances of

parental observation will interact with my acquired knowledge (from, research, readings, workshops etc.) – this will support my final diagnostic conclusions.

( Barkley, 2006)

Important areas of evaluation would include:

Demographic information (age of the family members; child’s date of birth; parents names and address; and occupations; the child’s school, teacher and physician) – obtained at the outset of the appointment.

Child related information› Major referral concerns: Specific questions about:

-child behavior and history of the problem -history of other medical conditions

Important areas of evaluation continue:

School related information Details about the parents, other family members and

community resources that might be available to the family

Parental history of psychopathology Psychosocial status Parental stress, marital discord,

Note: The choice of the assessment tools I will employ in the latter session will be contingent upon the information collected in the interview phase.

(Sample illustrating some of the questions I would ask Richie’s mother):

1. When the problems were first noticed or reported?

2. What parenting strategies do parents employ when Richie misbehave?

3. Are they any current family circumstances that are related to the Richie’s problems severity? (such as intramerital conflict, divorce or family illness)

4. What are Richie’s relationships with his peers?

Child Interview: Why it is important? Help the clinician to correct any misinterpretations that the

child might have about why she or he is seeing the mental health professional (e.g., “I’m crazy” etc.)

Provide valuable information about child’s internalistic problems (such as mood states and feelings)

Indicative of child’s motivation to participate in the therapy process

Help establish therapeutic alliance

(Barkley, 2006)

Sample of the questions I would ask Richie:

Do you ever find that you have been sitting in class, and suddenly you realize that your teacher has been talking and you have no idea what the teacher is talking about?

Does it ever seem to you to you longer to complete your school work than compared to other kids?

Is there anything that worries you a lot?

Is there anything that makes you angry?

What did interview data revealed: Richie’s Behavior HistoryRichie’s teacher indicated that he exhibits difficulties focusing, sustaining attention and

has encountering ongoing classroom problems. His teacher reported that Riche is always fidgeting in his seat, throws items at other students and frequently leave his seat during classroom instruction. He was placed on discipline plan and his behavior was reportedly improved. Richie school grades are “hardly satisfactory” and his daily performance is inconsistent. Mother stated, “one day he comes home with excellent on his worksheet, 4 day latter he doesn’t even try to complete the work sheet, and that’s the way it goes.”

Richie’s behavior problems were initially reported in kinder garden and have continued troughs his first grade. Richie has been found climbing the roofs of the houses, running into the street without looking. When Riche misbehaved, his parents usually employed physical and verbal punishment to enforce discipline. Rewards for good behavior included play time and money. In describing his peer relationships, mother indicated that Richie had always good friends in the neighborhood but they quickly become irritated with his aggressive behavior. The mother as well reported aggressive outbursts’; however she also stated that her son is “generally a good child.”

Richie has been seeing by an outpatient counselor to address his behavior problems at home and school. He was recently evaluated by an occupational therapist who reported difficulties in the fine motor skills.

During the initial interview, there were no indicative signs of motor retardation, agitation or gait difficulties. Speech was within a normal limit, there was no indication of difficulties with world fluency, neologisms, or auditory comprehension. Riches affect was appropriate; his thoughts flowed logically with no evidence of hallucinations or delusions. However, Richie showed signs of responding to extraneous stimuli and had to be redirected numerous times. When he didn’t found a particular task appealing, he lost interest quickly.

II. Assessment StageAccording to Fishmen (2005) the assessment is problem

oriented (not undertaking as a mere exercise in applying assessment techniques), - designed to answer questions not only about the diagnosis (ADHD) but about the factors underlying the development and the maintenance of the presented problem (in Whitefield and Edwards, 2009).

Combinations of tools should be used.

Behavior checklist and Rating Scales for ADHD:Generally used for initial screening purposes Advantages:

› Cost and time effective (most could be completed in less than 15 minutes)

› because they are completed retrospectively reactivity is not a concern

Disadvantages:› might be affected by the accuracy of the observer› subjective (rating scales discourage complete confidence

in their reliability).Rating scale should be selected based on multiple aspects, including their psychometric properties, ability to screen for comorbid conditions, completion time, cost, accessibility and the need of self report (Madaan, 2008)

Connors Rating Scales (CRS):

the only scale that provides normative data for preschool children (to age 3 years)

can be re-administered, which could help monitor treatment response

additional utility in initial assessments, particularly when comorbidities are suspected (Vanderbilt scale serves this function as well).

Assessment tools administered to Richie:

ADHD Parent Rating Scale Wechsler Intelligence Scale for Children Fourth Edition Continuous Performance Test (CPT)

CPT requires the patient to sit at a computer terminal and press keys on the keyboard in response to visual images or stimuli that appear on the screen.

Scorers calculate the rate of missed cues and erroneous responses. Individuals with ADHD tend to make more errors on the test than people who do not have the condition.

Additional Information: CPT & ADHD | eHow.com http://www.ehow.com/about_6556867_cpt-adhd.html#ixzz14Hke3JwQ

Wide Range Assessment of Memory and Learning (WRAML-2; Sheslow & Adams. 2003) – objective assessment of memory functions

Cognitive Functioning Tasks Tactual Performance Test

Madaan V., DaughtonJ., Lubberstedt B., Mattai A., Vaughan B., Kratochvil J (2008).

Assessing for the efficacy of treatments for ADHD. CNS Drugs 22, 4

Advantages of CPTs: Increased objectivity Time efficient (can be taking within 15 minutes) Have increased sensitivity for detecting inattention in

the absence of explicit hyperactivity and /or impulsivity

can help monitor the treatment Observing a child taking CPT can also provide

information about the motor activity and response to commands

Neuropsychological Test Findings:

Results from research involving neuropsychological testing has often suggested that children with ADHD have problems;› in inhibiting behavioral responses,› with working memory,› with planning and organization, › with verbal fluency,› with perseveration,› In motor sequencing,› with other frontal lobe functions.

Laboratory Tests used to assess ADHD conditions:

Blood work Urinalysis Chromosome studies EEG’s MRIs Computerized tomography (CT) scans.Some of these studies have demonstrated such differences

in ADHD patients such as altered Encephalographic (EEG) activity (greater slow wave, reduced fast wave), reduced cerebral blood flow to the striatum, or diminished orienting galvanic skin responses.

However, it has been suggested that none of this laboratory measures are of significant value in the diagnostic process of ADHD as yet

Such laboratory studies should not be used routinely in the evaluation of children with ADHD and when used to be interpreted within the contest of the overall assessment.

Only when the medical and developmental history of physical exams suggest that a treatable medical problem such as (e.g., seizure disorder) exists, or that a genetic syndrome is a possibility, should this laboratory procedures be recommended (Barkley, 2008).

What the test scores revealed for Richie:  The ADHD Parent’s Rating Scale: This scale was employed by Richie’s Mother to determine his

problematic behavior at home. Richie scored on this scale was 21 which placed him in the 99th percentile, with his mother specifically accentuating problems with restlessness, disturbing other children and failing to finish things. Fidgeting and distractibility have been also noted.

General Intellectual Information:The Wechsler Intelligence Scale for Children (WISC-IV) was administered to Richie to assess general intellectual abilities. Richie performed very well on the subsets of Verbal Comprehension and Perceptual Reasoning. Although his IQ was 109 (in the high average range), in subtests looking at the Processing Speed and Working Memory, he consistently scored in the low average range of intellectual functioning. He appeared to have difficulties in the areas requiring non-distractible attention span for good performance.

Continuous Performance Test and Wide Range Assessment of Memory and Learning 2:On CPT’s (visual/nonverbal part) Richie showed difficulties with inattention marked by the large number of commission errors and difficulties of identifying targets and non-targets. On CPT’s Auditory-Verbal part. Richie performed in the high average on both of the Controlled Oral Fluency Tests.The WRAML 2 memory test indicated that Richie’s overall immediate verbal auditory memory was average, however his immediate visual memory was in the low average range.

Sensory/Tactile:In the Tactual performance Test (Reitan, 1979), Richie showed average performance when using his dominant right hand and was in high average range using his non dominant hand. Both hands and the total time were also in the average range. On the Line Bisecton Task There was no indication for hemi-inattentions or hem-neglect.

Case Conceptualization and Diagnosis ADHD:

Results of neuropsychological testing indicated that Richie's general intellectual functioning is in the Average, high average range . He showed particular strengths in the areas of verbal related knowledge, fluency and reasoning, in addition to nonverbal fluid reasoning and good motor integration skills. This optimistic findings could help explain why Richie's teachers often remarked how successful he can be once he “settles down and focuses on his work”. In fact, it is quite possible that Richie's overall intellectuals functioning's are underestimated because of the weaknesses in mental and motor speed, and working memory. It has been suggested that weaknesses in this areas are often secondary to difficulties with inattention and concentration.

Richie's Neuropsychological Tests revealed that he has indicate many strengths. It is important to continuously communicate this strengths to the parents to engage them in establishing appropriate treatment plan and encourage their child to continue master his areas of weakness.

III. Treatment Plan Guiding concepts and relevant research:

› Methods of treatment for ADHD often involve some combination of behavior and cognitive modification, lifestyle changes counseling and medication

› Combination of Medical Treatment and Behavior Management is suggested to be some of the most effective ADHD management strategies, followed by medication alone. Research also cautious that while medication has been shown to

improve behavior when taking over short period of time, they have not been shown to alter long term outcomes of ADHD.

Jensen P., Garcia J., Glied S. (2004). Cost effectiveness of ADHD treatments: findings from the multimodal treatment study of children with ADHD. The American Journal of Psychiatry 162, 9.

Options for interventions in the treatment of ADHD:

Treatment Continues:In Richie's case I have decided upon implementing multiple treatment strategies. It has been suggested that combination of treatment strategies contributes to favourable long term

outcomes in ADHD (Madaan V, 2008)The treatment will consist of biological, psychosocial, and cognitive rehabilitation interventions

› Cognitive - behaviour management› Medication – Methylphenidate (Ritalin) , stimulant drug

• Typically the goal to reduce impulsivity and hyperactivity and improve attention abilities

› Psychosocial treatment focuses on broader issues (improving academic performance, decreasing disruptive behavior, and improving social skills) Structure play, home and school environment Parental management (PMT) training

› Cognitive Rehabilitation therapy (involves structured activities designed to improve cerebral functioning and teach compensation techniques).

› Mindfulness training for children (optional alternative)

(American Academy of Pediatrics, 2000; Sohlberg, 1989).

Effectiveness of the intervention: Because both parents and teachers had implemented the

program with care and understanding, no further intervention was offered

However, this is NOT always the case (E.g., in Richie’s case if his mother was unable to follow the behavior management procedures or was unwilling to attend the therapy session the outcomes would substantially differ)

Note: That is why it is always important to assess the family functioning and to note potential family disruptions that would need attention to help parents more effectively manage their child diagnosed with ADHD