KEY ISSUES IN THE ASSESSMENT AND

MANANGEMENT OF ADHDDr. Jonine Biesman

Clinical Psychologist and Neuropsychologist

drbiesman@yahoo.com

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IMPORTANT ADHD FACTS

• AN EXECUTION/PERFORMANCE DISORDER. NOT A PROBLEM OF SKILL OR KNOWING. A PROBLEM WITH DOING WHAT YOU KNOW (YOU REALIZE YOU SHOULD HAVE USED WHAT YOU KNOW BUT DID NOT). THUS, TROUBLE WITH THE WHEN AND WHERE, NOT THE HOW AND WHAT.

• ADHD CREATES TIME PROBLEMS. CAN’T SEE INTO THE FUTURE OR MANANGE TIME BECAUSE ARE PRONE TO LIVING IN THE MOMENT.

• OFTEN EXISTS WITH OTHER DISORDERS (LD, ODD, CD, MOOD, ANXIETY, SLEEP, EATING, TICS, OCD)

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ADHD FACTS (cont.)• LARGELY A DEVELOPMENTAL DISORDER, FEWER CASES ACQUIRED

(AGE OF ONSET OF 7 NOT SO VALID).

• HUGE IMPORTANCE OF APPRECIATING SUBTYPES AND INDIVIDUAL DIFFERENCES (DIFFERENCES IN MOTOR PLANNING ABILITIES OR WAYS OF PROCESSING AUDITORY OR VISUAL INFORMATION)

• NEW CHANGES IN THE CONCEPTUALIZATION AND DIAGNOSTIC CRITERIA FOR ADHD TO INCLUDE WORKING MEMORY AND EXECUTIVE FUNCTIONING DEFICITS

• WITHIN MULITPLE SYSTEMS OF ATTENTION, IT IS ESSENTIAL TO KNOW WHAT IS IMPAIRED AND WHAT IS SPARED.

• FOR A DIAGNOSIS, THERE MUST BE SIGNIFICANT IMPAIRMENT IN DAILY FUNCTIONING.

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IMPORTANT ASPECTS OF ATTENTION AND HYPERACTIVITY/IMPULSIVITY

• AROUSAL/ALERTNESS• SELECTIVE ATTENTION• DIVIDED ATTENTION• SPAN• PERSISTENCE/VIGILANCE/SUSTAINED ATTENTION• SHIFTING OF ATTENTION (ABILITY TO RE-ENGAGE WHEN

DISTRACTED)• INHIBITION (ABILITY TO SUPPRESS DISTRACTIONS AND

IMPULSIVE DECISION-MAKING)• WORKING MEMORY– ONLINE MEMORY, REMEMBERING TO

DO THINGS• OTHER EXECUTIVE FUNCTIONS (SELF-REGULATION,

PLANNING, PROBLEM-SOLVING)

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LIKELY CHANGES TO DIAGNOSIS (DSM-V)

• COMBINED TYPE ONLY BUT WITH INDICATION OF SEVERITY

• ADHD WITH OR WITHOUT CONDUCT DISORDER

• SLUGGISH COGNITIVE TEMPO (INATTENTION) MORE PROBLEMS WITH ACCURACY VS. PRODUCTIVITY (DISTINCT FROM

ADHD?) DAYDREAMING, SPACEY, STARE, HYPOACTIVE, SLOW MOVING, LETHARGIC,

MORTORICALLY AND COGNITIVELY SLUGGISH, EASILY CONFUSED, MENTALLY FOGGY, SLOW RESPONSE SPEED AND REACTIONS, ERROR PRONE, DECREASED FOCUS OR SELECTIVE ATTENTION, POSSIBLE PROBLEMS WITH RETRIEVING INFORMATION, MAY BE SOCIALLY WITHDRAWN, NO IMPULSIVITY OR DISINHIBITION, NOT MUCH EVIDENCE OF EXECUTIVE DYSFUNCTION, MAY BE LESS REPSONSIVE TO MEDS, MORE RESPONSIVE TO SOCIAL SKILLS

Russell Barkley, 1998

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DEVELOPMENTAL ISSUES• MAJORITY OF CASES GENETIC/BIOLOGICAL

• BECAUSE IS A DEVELOPMENTAL CONDITION, NEED TO COMPARE FUNCTIONING TO A NORMATIVE SAMPLE (WHAT SHOULD WE EXPECT AT THIS POINT IN DEVELOPMENT?)

• PRESCHOOL DURATION MAY NEED TO BE LONGER THAN 6 MONTHS TO ASSIGN A DIAGNOSIS (GIVE PRESCHOOLERS AT LEAST A YEAR TO GROW OUT OF WHAT MAY SIMPLY BE NORMAL AGE-RELATED BEHAVIORS)

• HYPERACTIVITY DECREASES WITH AGE AS MOTOR RESTLESSNESS BECOMES INTERNALIZED (MAY SEEM MORE LIKE THE NEED TO BE BUSY ALL THE TIME)

• AS CHILDREN PROGRESS THROUGH THE GRADES, INATTENTION AND EXECUTIVE FUNCTION SYMPTOMS HAVE THE GREATER IMPACT ON ACADEMIC PERFORMANCE

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DEVELOPMENTAL ISSUES (cont.)

• THE TRANSITION TO MIDDLE SCHOOL IS OFTEN MET WITH TEMPORARY DECLINE, SO IS A VERY IMPORTANT TIME PERIOD TO MAKE SURE SUPPORTS AND INTERVENTIONS ARE IN PLACE.

• IN ADOLESCENCE, ACADEMIC IMPAIRMENTS INCREASE. REDUCED PRODUCITIVTY IS A SIGNIFICANT PROBLEM. INCREASED HOMEWORK DEMANDS TAX ATTENTION AND EXECUTIVE FUNCTIONS.

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DEVELOPMENTAL ISSUES (cont.)

EXECUTIVE FUNCTION DEFICITS AND THEIR IMPACT EMERGE AS MOST SIGNIFICANT AS CHILDREN AGE.

Less follow-through on promises and commitment Impaired planning and anticipation; not ready for the future as it arrives Reduced valuing of future rewards so less persistence toward future goals Poor emotional regulation (anger management and frustration tolerance issues) Decreased fluency or rapid construction of ideas By adolescence, less productivity and accuracy, less accountability, poorer ability to handle

demands for self-regulation and time management In adolescence and adulthood, symptoms may also manifest as inattention in traffic, higher rates

of accidents, use of nicotine, caffeine and other drugs, compromised work performance, inattention to others’ comments and needs in social activities. BUT THERE ARE MODERATORS AND CASES WHERE SYMPTOMS REMIT (1/6th to 1/3rd of cases).

Russell Barkley, 1998

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DEVELOPMENTAL ISSUES (cont.)

• IN SUM, ADHD IS A DEVELOPMENTAL DISORDER IMPACTING OPTIMAL FUNCTIONING ACROSS SEVERAL AREAS – EDUCATIONAL, OCCUPATIONAL, SOCIAL, MEDICAL, DRIVING, SEXUAL, ETC.

• THUS, START INTERVENTIONS EARLY, SUSTAIN THEM LONGER ACROSS THE DAY AND ACROSS DEVELOPMENT, AND TARGET MULTIPLE DOMAINS, NOT JUST EDUCATIONAL.

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BEST PRACTICES IN THE ASSESSMENT OF ADHD

• COMPREHENSIVE, STRENGTH-BASED APPROACH. HONOR THE INDIVIDUAL, CAPTURE THEIR ESSENCE.

• ANSWER THE QUESTIONS CLEARLY AND WITHOUT JARGON.

• OBSERVE BEHAVIOR ACROSS SETTINGS (ESPECIALLY SCHOOL). TALK TO TEACHERS, FIND OUT WHAT WORKS, WHAT DOESN’T. DON’T REINVENT THE WHEEL OR MAKE SUGGESTIONS THAT ARE GENERIC. ASK TEACHERS WHAT THEY NEED FROM THE EVALUATION AND WHAT QUESTIONS THEY HAVE. WHERE ARE THEY GETTING STUCK?

• MANY EVALUATIONS FOR ADHD ARE CONDUCTED TO DETERMINE IF A DIAGNOSIS EXISTS. THESE EVALUATIONS MAY BE INTERVIEW BASED, MAY USE RATING SCALES, OR MAY BE PSYCHOEDUCATIONAL. ONLY A NEUROPSYCHOLOGIST CAN PROVIDE THE COMPLETE PICTURE. PSYCHOEDUCATIONAL TESTING THROUGH THE SCHOOL OR CONDUCTED PRIVATELY IS OFTEN INSUFFICIENT. TOO MANY QUESTIONS GO UNANSWERED AND IMPORTANT INFORMATION IS LEFT UNCOVERED.

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ASSESSMENT (cont.)• SPEAK WITH ANY AND ALL COLLATERAL CONTACTS. REVIEW SCHOOL

RECORDS.

• CONDUCT A THOROUGH INTERVIEW WITH PARENTS INCLUDING DEVELOPMENTAL, EDUCATIONAL, FAMILY, SOCIAL, MEDICAL HISTORIES. SCREEN FOR ANY ISSUES THAT MAY INTERFERE WITH TREATMENT. UNDERSTAND THE CHILD AS A WHOLE. DO NOT JUST LOOK AT NUMBERS AND TEST RESULTS IN ISOLATION.

• DO NOT LEAVE OUT SLEEP, NUTRITION, MOTIVATION, INTERESTS, STRENGTHS, AND INDIVIDUAL SENSORY PROFILES.

• DO NOT PUSH CHILDREN TO SIT THROUGH 3-4 HOUR TEST SESSIONS. BREAK THEM UP AS NEEDED. ALLOW FOOD AND DRINK, FREQUENT BREAKS, AND PLAY. BE AS PATIENT AS NEEDED AND OPTIMIZE PERFORMANCE. WE WANT TO KNOW THE UPPER LIMITS OF CAPACITIES.

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ASSESSMENT (cont.)• MAKE SURE TO TEST LIMITS. FIND OUT WHAT IS NEEDED TO HELP A

STUDENT SUCCEED AND WHAT IS INTERFERING. BREAKS TASKS DOWN INTO THEIR COMPONENT PARTS TO MAKE THIS DETERMINATION.

• EVALUATE THE INDIVIDUAL’S PROCESS. THIS IS ACUTELY IMPORTANT. KEENLY OBSERVE APPROACH TO TASKS, ERROR TYPES, PERSISTANCE, RESPONSES TO CHALLENGES, ETC.

• MUST ASSESS DIFFERENT COMPONENTS OF ATTENTION, MEMORY, AND LEARNING, WORKING MEMORY AND EXECUTIVE FUNCTIONS AND ANY OTHER DOMAINS THAT ARE SUSPICIOUS INCLUDING VISUAL-MOTOR, SENSORIMOTOR, AND AUDITORY PROCESSING.

• DIAGNOSE ADHD ONLY WHEN ALL OTHER CONDITIONS HAVE BEEN CONSIDERED (EMOTIONAL, ENVIRONMENTAL). DETERMINE IF THERE IS VALID “CO-MORBIDITY” OR MULTIPLE DIAGNOSES. ALWAYS DETERMINE WHAT IS DRIVING THE ENGINE, OR MAIN CONTIBUTOR TO PRESENTING PROBLEMS.

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ASSESSMENT (cont.)• RECOMMENDATIONS SHOULD BE UNIQUE AND THOROUGH. THERE SHOULD

BE A CLEAR PATH FOR INTERVENTION.

• ACCESS TO THE NEUROPSYCHOLOGIST SHOULD BE ONGOING TO ANSWER ANY QUESTIONS RELATED TO TEST RESULTS, TO ATTEND MEETINGS, OR TO SPEAK WITH OTHER PROFESSIONALS.

• TEST RESULTS SHOULD BE DELIVERED IN A TIMELY MANNER.

• FEEDBACK SHOULD ALSO BE OFFERED TO THE STUDENT IN CHILD-FRIENDLY TERMS EMPHASIZING STRENGTHS.

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EXAMPLES OF ACADEMIC ACCOMMODATIONS

• QUIET EXAM AREAS• USE OF HEADPHONES• FREQUENT BREAKS• REDUCED HOMEWORK LOADS• PROVISION OF CLASS NOTES• ADDITIONAL TIME IF NEEDED (ON ALL STANDARDIZED EXAMS AS WELL)• VARIED TEACHING STYLES AND TEACHING WITH EXCITEMENT• ALTERNATING FUN AND BORING MATERIAL• OPPORTUNITIES FOR MULTISENSORY, EXPERIENTIAL LEARNING• ALLOW MOVEMENT AROUND THE CLASSROOM.• SUGGEST SWINGING OR CLIMBING AT RECESS• KEYBOARDING• ALLOWANCE FOR TAPING• ORGANIZATIONAL AIDS• AREA IN THE CLASSROOM TO RECONSTITUTE

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EXAMPLES OF ACADEMIC ACCOMMODATIONS (cont.)

• DIFFICULT MATERIAL IN THE MORNING• PREFERENTIAL SEATING• PAIRING WITH ORGANIZED STUDENTS• OPPORTUNITIES TO ELEVATE GRADES• CHUNKING OF MATERIAL• REPEAT INSTRUCTIONS AS NEEDED• WEEKLY HOME-SCHOOL COMMUNICATION• REINFORCEMENT FOR ON-TASK BEHAVIORS, SELF-MONITORING AND SELF-

REGULATION• OPPORTUNITY FOR MASTERY EXPERIENCES WITHIN THE CLASSROOM• REFRAIN FROM SENDING HOME INCOMPLETE CLASSROOM ASSIGNMENTS• EXTERNAL TIME SIGNALS• ENCOURAGE CONTINUOUS NOTE-TAKING• ALLOW WATER, GUM, OR SUCKERS• OFFER AFTER-SCHOOL HELP

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EXAMPLES OF ACADEMIC ACCOMMODATIONS (cont.)

• REGULAR PARENT-TEACHER MEETINGS• TARGET PRODUCTIVITY FIRST, ACCURACY LATER• PROVIDE HOMEWORK ASSIGNMENTS AND PROJECTS IN ADVANCE• ALLOW FOR SPECIAL CUSHION ON CHAIR THAT MOVES• ALLOW STUDENT TO CREATE SOME ASSIGNMENTS TO ENHANCE

MOTIVATION• EXTRA SET OF TEXT BOOKS AT SCHOOL• BOOKS ON TAPE• ABILITY TO TAKE EXAMS OVER 2 DAYS

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CURRENT TREATMENTS(COMBINED MAY BE MOST EFFECTIVE)

• PSYCHOPHARMACOLOGICAL

• PARENT TRAINING AND EDUCATION

• FAMILY THERAPY (PROBLEM-SOLVING, COMMUNICATION)

• SUPPORT GROUPS

• SOCIAL SKILLS (BETTER WITH INATTENTION ISSUES)

• EXERCISE

• TEACHER EDUCATION AND CLASSROOM BEHAVIOR MANAGEMENT

• SELF-INSTRUCTIONAL TRAINING

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METHODS REQUIRING FURTHER STUDY

• NEUROFEEDBACK (THE JURY IS STILL OUT. NIMH TO CONDUCT A STUDY. NEED FOR CONTROLLED STUDIES AND META-ANALYSES)

• COGNITIVE TRAINING OF WORKING MEMORY (E.G., ROBO MEMO AT COGMED.COM)

• DIET AND VITAMINS (ALTHOUGH GOING ORGANIC AND TAKING OMEGAS CAN’T HURT)

• FLOORTIME (SEE ICDL.COM AND STANLEY GREENSPAN) – A DEFINITE FAVORITE!

• MINDFUL AWARENESS

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RESOURCES

• Websites:• www.icdl.com (official website of the Interdisciplinary Council on Developmental and Learning Disorders)• www.chadd.org (official website of Children and Adults with Attention Deficit/Hyperactivity Disorder)• http://marc.ucla.edu (Mindful Awareness Research Center at UCLA)• www.abpdn.org (American Board of Pediatric Neuropsychology) • www.russellbarkley.org (Resources for Attention Deficit/Hyperactivity Disorder)• www.eeginfo.com/research (Neurofeedback resources and information)

• Print:• Parent Coaching Cards, Richfield, S.• Building Healthy Minds, Stanley Greenspan, M.D.• The Challenging Child, Stanley Greenspan, M.D. • Parenting from the Inside Out, Daniel J. Siegel, M.D; Mary Hartzell, M.Ed. • The Developing Mind, Daniel J. Siegel• The Out of Sync Child, Carol Stock Kranowitz, M.A.• Touchpoints, T. Berry Brazelton M.D; Joshua Sparrow, M.D.• The Mislabeled Child, Brock Eide, M.D., M.A; Fernette Eide, M.D.• The ADHD Report, Russell Barkley, Guilford Publications• Driven to Distraction, Edward Hallowell, M.D., John J. Ratey• Change Your Brain, Change Your Life, Daniel Amen, M.D.• Brain Lock: Free Yourself from Obsessive Compulsive Behavior, Jeffrey M. Schwartz, M.D.