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ADHDEvaluation

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"Think of an absentminded professor "Think of an absentminded professor who can find a cure for cancer but not who can find a cure for cancer but not his glasses in the mess on his desk. his glasses in the mess on his desk. These are the inventors, creators, poets These are the inventors, creators, poets -- the people who think creative -- the people who think creative thoughts because they don't think like thoughts because they don't think like everyone else." everyone else."

- Martha Denckla, M.D., Director of the - Martha Denckla, M.D., Director of the Department of Developmental Department of Developmental Cognitive Neurology at the Kennedy-Cognitive Neurology at the Kennedy-Drieger Institute at John Hopkins Drieger Institute at John Hopkins speaking on ADHDspeaking on ADHD

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ObjectivesObjectives

Know the symptoms typical of ADHDKnow the symptoms typical of ADHD

Be familiar with the common co-Be familiar with the common co-morbidities of ADHDmorbidities of ADHD

Recognize that the diagnosis of Recognize that the diagnosis of ADHD cannot be made by use of a ADHD cannot be made by use of a specific testspecific test

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Practice GuidelinesPractice Guidelines

Primary care cliniciansPrimary care clinicians

Children 6-12 years oldChildren 6-12 years old

Framework for diagnostic decision Framework for diagnostic decision makingmaking

Evidence based reviewEvidence based review

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ADHD patients?

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Review and Review and RecommendationsRecommendations

Strong recommendationStrong recommendation: high-: high-quality scientific evidence or strong quality scientific evidence or strong expert consensusexpert consensus

Fair/weakFair/weak: lesser quality, limited : lesser quality, limited data, or expert consensusdata, or expert consensus

Clinical OptionsClinical Options: reasonable : reasonable provider provider

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Recommendation Recommendation #1#1

If inattention, hyperactivity, impulsivity, If inattention, hyperactivity, impulsivity, academic underachievement, behavior academic underachievement, behavior problemsproblems

THEN primary care clinician needs to THEN primary care clinician needs to initiateinitiate the evaluation the evaluation

GoodGood evidence evidence StrongStrong recommendationrecommendation

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Screening QuestionsScreening Questions

How is __ doing in school?How is __ doing in school? Are there any problems with Are there any problems with

learning that you/teacher see?learning that you/teacher see? Is your child happy in school?Is your child happy in school? Are you concerned…behaviors at Are you concerned…behaviors at

home/school/play with friends?home/school/play with friends? Is your child having problems Is your child having problems

completing classwork or homework?completing classwork or homework?

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Recommendation #2Recommendation #2

ADHD diagnosis must meet ADHD diagnosis must meet DSM-IVDSM-IV criteriacriteria

Symptoms Symptoms andand functional impairment functional impairment Criteria remain Criteria remain subjectivesubjective and no and no

reliable measures in primary carereliable measures in primary care

GoodGood evidence evidence StrongStrong recommendationrecommendation

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DSM-IV CriteriaDSM-IV Criteria

6 of 9 symptoms in 2 core areas6 of 9 symptoms in 2 core areas InattentiveInattentive Hyperactive/ImpulsiveHyperactive/Impulsive Combined (both)Combined (both)

causes distress or causes distress or impairmentimpairment

inconsistent with developmental levelinconsistent with developmental level

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DSM-IV CriteriaDSM-IV Criteria

starts before 7 years oldstarts before 7 years old lasts over 6 monthslasts over 6 months two or more situations (environments)two or more situations (environments) not due to:not due to:

Autism, Pervasive Dev DisorderAutism, Pervasive Dev Disorder Mood or Anxiety DisorderMood or Anxiety Disorder Psychotic DisorderPsychotic Disorder Dissociative or Personality Disorder Dissociative or Personality Disorder

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DSM-IV CriteriaDSM-IV CriteriaInattentionInattention

1.1. fails to give close attention to fails to give close attention to details, makes careless mistakes in details, makes careless mistakes in schoolwork or other activitiesschoolwork or other activities

2.2. has difficulty sustaining attention has difficulty sustaining attention to task or play activitiesto task or play activities

3.3. does not seem to listen what is said does not seem to listen what is said to him/herto him/her

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DSM-IV CriteriaDSM-IV CriteriaInattentionInattention

4.4. Does not follow through on Does not follow through on instructions; fails to finish instructions; fails to finish schoolwork, chores, duties in schoolwork, chores, duties in workplace (not due to oppositional workplace (not due to oppositional behavior or failure to understand)behavior or failure to understand)

5.5. difficulty organizing tasks/activitiesdifficulty organizing tasks/activities

6.6. avoids/dislikes tasks that require avoids/dislikes tasks that require sustained mental effortsustained mental effort

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DSM-IV CriteriaDSM-IV CriteriaInattentionInattention

7.7. loses things necessary for tasks or loses things necessary for tasks or activities (school assignments, activities (school assignments, pencils, books, tools, toys)pencils, books, tools, toys)

8.8. easily distracted by extraneous easily distracted by extraneous stimulistimuli

9.9. forgetful in daily activitiesforgetful in daily activities

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DSM-IV CriteriaDSM-IV CriteriaHyperactivity/ImpulsivityHyperactivity/Impulsivity

1.1. often fidgets with hands/feet or often fidgets with hands/feet or squirms in seatsquirms in seat

2.2. leaves seat in classroom or in other leaves seat in classroom or in other situations in which remaining situations in which remaining seated is expectedseated is expected

3.3. runs about or climbs excessively runs about or climbs excessively where inappropriate (teens or where inappropriate (teens or adults may be limited to subjective adults may be limited to subjective feelings of restlessnessfeelings of restlessness

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DSM-IV CriteriaDSM-IV CriteriaHyperactivity/ImpulsivityHyperactivity/Impulsivity

4.4. difficulty playing or engaging in difficulty playing or engaging in leisure activities quietlyleisure activities quietly

5.5. talks excessivelytalks excessively

6.6. acts as if “driven by a motor” and acts as if “driven by a motor” and cannot remain stillcannot remain still

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DSM-IV CriteriaDSM-IV Criteria

Hyperactivity/ImpulsivityHyperactivity/Impulsivity

7.7. blurts out answers before questions blurts out answers before questions completedcompleted

8.8. difficulty waiting in lines or for turn in difficulty waiting in lines or for turn in games or group situationsgames or group situations

9.9. interrupts or intrudes on othersinterrupts or intrudes on others

• Hyperactive Type ADHD much more Hyperactive Type ADHD much more common in boyscommon in boys

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Recommendation #3Recommendation #3

Evidence of Evidence of core symptomscore symptoms from from parents and caregiversparents and caregivers

various various settingssettings age age onsetonset; ; duration duration of symptomsof symptoms degreedegree of functional impairment of functional impairment GoodGood evidence evidence StrongStrong

recommendationrecommendation

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Recommendation #3ARecommendation #3A

Rating scales are an Rating scales are an optionoption Questions subjective and subject to Questions subjective and subject to

biasbias ? If additional benefit? If additional benefit

StrongStrong evidence; evidence; strongstrong recommendationrecommendation

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Recommendation #3BRecommendation #3B

Broad-band Broad-band scales/questionnaires scales/questionnaires notnot recommendedrecommended

May be useful for other purposesMay be useful for other purposes

Strong Strong evidence evidence StrongStrong recommendationrecommendation

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Recommendation #4Recommendation #4

School evidenceSchool evidence required required

Core symptoms, durationCore symptoms, duration Functional impairmentFunctional impairment Coexisting conditionsCoexisting conditions

Good Good evidence evidence StrongStrong recommendationrecommendation

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Recommendation #4ARecommendation #4A

Rating scales a Rating scales a clinical optionclinical option

sensitivity/specificity >94%sensitivity/specificity >94%

? If any ? If any addedadded benefit benefit

StrongStrong evidence evidence StrongStrong recommendationrecommendation

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Recommendation #4BRecommendation #4B

Global scalesGlobal scales not not recommendedrecommended

May be useful for other purposesMay be useful for other purposes Frequent discrepancies Frequent discrepancies Can use other informantsCan use other informants

StrongStrong evidence evidence StrongStrong recommendationrecommendation

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Recommendation #5Recommendation #5

Assess for Assess for coexisting coexisting conditionsconditions ODD 35 %ODD 35 % Conduct Disorder 26%Conduct Disorder 26% Anxiety Disorder 26 %Anxiety Disorder 26 % Depressive Disorder 18%Depressive Disorder 18%

StrongStrong evidence evidence StrongStrong recommendationrecommendation

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Recommendation #6Recommendation #6

Other diagnostic tests Other diagnostic tests not not routinely indicatedroutinely indicated Pb; resistance to thyroid hormonePb; resistance to thyroid hormone Brain imaging; EEGBrain imaging; EEG Continuous performance testingContinuous performance testing

sensitivity/specificity <70%sensitivity/specificity <70%

StrongStrong evidence evidence StrongStrong recommendationrecommendation

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Diagnosis Guidelines Diagnosis Guidelines ConclusionsConclusions

Use explicit Use explicit DSM-IVDSM-IV criteriacriteria

Symptoms in >1 Symptoms in >1 settingsetting

Search for Search for coexisting coexisting conditionsconditions