Stephan M. Silverman, Ph.D.Certified School Psychologist

Licensed Psychologist DIRECTOR OF

PSYCHOLOGICAL AND BEHAVIORAL SERVICES

THE WEINFELD EDUCATION GROUP

January 14, 2011

Definition of ADHD by CHADD

ADHD is a neurobiological disability that affects three-to-five percent of school-age children.

ADHD is characterized by developmentally inappropriate impulsivity, inattention, and in some cases, hyperactivity.

Surprising Increase in Prevalence of ADHD

According to a report released on November 10, 2010 by the Centers for Disease Control and Prevention (CDC), rates of parent-reported ADHD diagnosis are increasing, and new patterns of ADHD diagnosis are emerging in the United States. From 2003 to 2007, there was a 22 percent increase in the percentage of children aged four to seventeen years diagnosed with ADHD . The data indicate that by 2007, nearly one in ten school-aged children had been diagnosed with ADHD.

CORE SYMPTOMS OF ADHD

DISTRACTIBILITYIMPULSIVITYMOTOR RESTLESSNESS

CO-EXISTING CONDITIONSANXIETYDEPRESSIONDISORGANIZATIONFORGETFULNESSIMPATIENCEOPPOSITIONLEARNING DISABILITIES CONDUCT DISORDERBIPOLAR DEPRESSIONOCDSLEEP DISORDERSTOURETTE’S SYNDROME

FOUR SUBTYPES OF ADHD IN DSM-IV

Predominantly Hyperactive/Impulsive

Predominantly Inattentive Type (Different mechanism and brain function.

Combined Type and Not Otherwise Specified

Considerations Under Discussion for DSM-V

Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder (SMS:CONCEPT OF DEMAND)

The disorder consists of a characteristic pattern of behavior and cognitive functioning that is present in different settings where it gives rise to social and educational or work performance difficulties. The manifestations of the disorder and the difficulties that they cause are subject to gradual change being typically more marked during times when the person is studying or working and lessening during vacation

Diagnosis by Consensus

In children and young adolescents, the diagnosis should be based on information obtained from parents and teachers. When direct teacher reports cannot be obtained, weight should be given to information provided to parents by teachers that describe the child’s behavior and performance at school. Examination of the patient in the clinician’s office may or may not be informative. For older adolescents and adults, confirmatory observations by third parties should be obtained whenever possible.

POSSIBLE CHANGES BEING DISCUSSED FOR DSM-V FOR 2013

POSSIBLE SEPARATE DISORDERS:ADHD HYPERACTIVE/IMPULSIVE TYPEADHD PREDOMINANTLY INATTENTIVE

TYPE ADHD RESTRICTIVE INATTENTIVE TYPE

(FEWER CRITERIA MET FOR HYPERACTIVE/IMPULSIVE TYPE

Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past 6 months.

MORE ON ADHD IN DSM-V

EMPHASIS ON IMPULSIVITY AS PIVOTAL ASPECT OF ADULT ADHD

 CHANGING AGE OF ONSET FROM ON

OR BEFORE AGE 7 TO AGE 12

CONSIDERATION OF INCLUDING AND NOT EXCLUDING ADHD WITH AN AUTISTIC SPECTRUM DISORDER

ADDA Recommendations to Proposed Changes in DSM-V. 8/2010

A distinct list of symptoms developmentally appropriate for use with adult patients

A separate diagnostic category “Adult Attention Deficit Disorder,” comprised of empirically-derived items from research

A higher age threshold of 15 or 16 years-old (and many Professional Advisory Board members suggested an age threshold of 18 years-old)

Mild, Moderate, Severe degrees of impairment

EXECUTIVE FUNCTIONSFocusing and Sustaining

AttentionSustaining Alertness, Effort, and

Processing SpeedManaging Frustration and

Modulating AffectUtilizing Working Memory and

Accessing RecallInhibiting and Regulating Verbal

and Motoric ActionOrganizing, Prioritizing and

Activating Tasks

ADHD LOOK-ALIKES• THYROID PROBLEMS

• SEVERE NUTRITIONAL DEFICIENCIES

• ENVIRONMENTAL OVERSTIMULATION

• SITUATIONAL DEPRESSION

• POST-TRAUMATIC STRESS DISORDER

• BIPOLAR DISORDER

• DISSOCIATION

• ALLERGIC REACTIONS

Types of Attention1. Focused attention describes the ability to

respond specifically to visual, auditory, or tactile input.

2. Sustained attention refers to the ability to maintain a response to input continuously. This may include vigilance, working memory, and mental control.

3. Selective attention is the ability to maintain a behavioral or cognitive “set” when faced with distraction. This requires freedom from distractibility, a much used and abused term in cognitive psychology.

Types of Attention Continued4. Alternating attention is the ability to shift

focus from one thing to another. This involves the ability to shift response requirements between different inputs.

5. Divided attention is the ability to respond at the same time to multiple task demands.

Genetics

Is ADHD simply a case of Inherited Impatient Temperament?

Inattention In a Variety of ConditionsBipolar Disorders – Inattention may not

manifest only as typical ADHD symptoms but may be exhibited in pressured flight of ideas.

Accompanying a Learning Disability – Often with a reading disability or non-verbal learning disorder

Schizotypal - Inattention may be revealed through associative, tangential thinking. Is it ADHD?

Autism Spectrum Disorders – Inattention is through self-absorption and perseverative focus.

Psychometrics of ADHD with Gifted Kids

The hyperfocus of the highly intelligent child will confound measures of attention when attempted through testing. They “beat” many psychometric tests . The American Association of Pediatrics does not recognize the value of psychometric tests in diagnosing ADHD. The cues are often in test-taking behaviors more than scores, such as losing the instructional set through lapses in working memory.

The Concept of the Variable, Vulnerable Nervous System

“Soft Signs” of Neurological Vulnerability

May Include: irritability motor automatisms like tics and tremors, including Tourette’s syndrome low frustration tolerance fatigue lack of perseverance lack of resilience rigidity and difficulties with transitions and change stubbornness oppositionality perseveration—repeating actions, thoughts, verbalizations emotional immaturity emotional vulnerability emotional lability (unpredictable propensity to change) impulsivity explosiveness auditory or visual perceptual discrimination errors

“Soft Signs” Continuedlack of thorough perceptual scanning

speech/language symptoms, especially articulation and slow and uneven pacing of words, and retrieval, hesitation, or immaturity in formulation

somatic complaints including headaches;

gross and fine-motor awkwardness, poor coordination, or balance

sequential, short-term, and working memory problems

impaired social perception

impaired comprehension

limitations in judgment; and

general problems in executive functioning

 PSYCHOLOGICAL ASSESSMENT GUIDELINES: OTHER HEALTH

IMPAIRMENT (OHI)DCPS

Definition: Having limited strength, vitality, or alertness,

including a heightened alertness to environmental stimuli, resulting in limited alertness with respect to the educational environment, and adversely affecting a child’s education performance, due to chronic or acute health problems.

Elements of a Good Assessment

THE PURPOSE AND DIAGNOSTIC QUESTIONS ARE CLEAR

THE GOALS FOR USING DATA ARE COLLABORATIVE

STRENGTHS AND NEEDS ARE IDENTIFIED WITH AN EMPHASIS ON A STRENGTHS APPROACH

CO-MORBIDITIES ARE IDENTIFIED AS WELL AS THE IDENTIFICATION OF CORE SYMPTOMS

COMPLEXITIES IN DIAGNOSIS OF ADHD

Children differ in the severity and number of symptoms of ADHD

Unlike a number of health conditions, there is no one, single test for ADHD (and that would be assuming that ADHD is a single unitary entity).

Some symptoms are more predominant in one individual compared to another.

Within-subject variability

No Single Instrument Yet Identifies ADHD

Schaefer, and DeLong (2003) conducted a national survey of training and assessment practices in the schools.

In the assessment of ADHD, the results

indicated that school psychologists are using multiple informants, methods, and settings, with rating scales, observations, and interviews the most common methods identified.

Discussion

What Constitutes a “Comprehensive”

Assessment Battery for ADHD?

A trained professional assembles a comprehensive test battery on only

what is needed.

The Following Components Can Form Your Test Battery Menu:

1. A thorough medical and developmental history taken from parent when possible.

2. #1 should include a very thorough interview with stakeholders, including parents, teachers, tutors, counselors, coaches, and therapist

3. One or more observations in a natural environment such as home or school,

4. An interview with the child. 5. Rating scales of core symptoms from

multiple environments and observers, including self-ratings as needed.

(The ADHD-IV by DuPaul et al is free and keyed to the DSM)

Test Battery Choices Continued

6. Rating scales of personality and psychopathology to confirm co-morbidities: such as BASC-II, Achenbach, etc.

7. Measures of Executive Function such as BRIEF and/or DKEFS

8. Psychometric instruments of cognitive ability, achievement, and memory as needed to reflect current strengths and needs for educational purposes.

9.Continuous Performance Tests (CPT) such as TOVA, IVA, Conners

10. Self-ratings of self-esteem.

Is an IQ Test Always Needed in ADHD Assessment?

It is inappropriate to test children with too many or unnecessary instruments.

An IQ test is often unnecessary. May be necessary for initial assessment.

On the other hand, when important information is sought about a number of areas of functioning, an IQ test may be very valuable in helping to identify areas of strength and weaknesses for educational planning and areas affected by ADHD or co-morbid conditions.

What about testing for transition?

Important TipsBe sure to employ a ready signal to insure

that the directions will be registered or you are failing to deliver the directions for the purpose of the item being administered.

Pay special attention to working memory in the subject’s failure to grasp instruction.

If needed, consider a separate measure of working memory such as memory for sentences.

CAVEATS ABOUT CPTS ADMINISTERED ALONE

Turkelson et al (2000) could not predict real-world ADHD symptoms from CPTs and were unable to find literature that supported or did not support CPTs for monitoring medication effects.

Published reports of national professional medical associations, national medical policy organization positions, or reports of national expert opinion organizations did not demonstrate a consensus in the medical community that CPTs were safe and efficacious for the purpose of making the ADHD diagnosis. All guidelines advised against the use of CPTs alone.

NEWER MEASURES OF ADHD

• The Test of Everyday Attention: For Adults. Some subtests more reliable than others.

• Conners’ CPT – II: Reliable but subject to concerns of all CPT-s.

• Conners’ Rating Scales- 3 – Very well reviewed in Buros Mental Measurements Yearbook

• Conners’ Kiddie CPT: the K-CPT scores do not have adequate reliability and validity evidence for diagnostic purposes. The K-CPT scores alone should not be used to make diagnostic decisions in the absence of additional valid evidence.

NEWER MEASURES OF ADHDQEEG Brainmapping: Positive preliminary

results, not available everywhere, not standardized.

Genetic markers.The Quotient™ ADHD System evaluates the

levels and patterns of a subject’s motor activity, attention and impulsivity during a 15 or 20-minute, office visit. The subject sits in front of the Quotient™ ADHD System kiosk and responds to a series of demanding yet monotonous tasks. Provides a quick readout comparison to non ADHD populations by age and gender.

Tips on Achievement Testing

Look for the effects of inattention on listening and reading comprehension. Comprehension measures reveal whether or not new information has been absorbed or registered.

Consider adding a reading measure that includes rate and recall (such as the GORT)

Components of Written Language

1. Motor execution as measured by speed, coordinated size of letters, variation in spacing and slant. Look for developmental immaturity in writing and the effects of medication.

2. Look at timed versus untimed measures of writing.

3. Consider spelling, capitalization, spelling, grammar, and punctuation as separate skill sets. These are called “rule governed skills”

4. Look for phonological areas of spelling to detect co-morbid reading disability.

5. Read for sophistication of content in giftedness.

6. Look for formulation of expression for consideration of co-morbid language problems.

7. Look for abstraction level of language compared to cognitive level in giftedness.

Tips in Assessment of Math

Math skills are not unitary. They include: Logic, Calculation, Memory, Geometry, and Word Problems

Math calculation problems are very common

in children with ADHD because long-term memories for math facts have not “registered”.

Look for : spatial alignment problems on the page carrying errors spatial reasoning and memory using the wrong sign

Utilize Assessment in a Comprehensive Wraparound Plan

An example of a multi-modal treatment and education approach to ADHD can be found in “School Success for Kids with ADHD” by Silverman, Iseman, and Jeweler (Prufrock Press, 2009) and “101 School Success Tools for Students with ADHD” (Prufrock Press, 2010) by Iseman, Silverman, and Jeweler (Prufrock Press)

Bibliographic References Available Upon Request

NoteworthyADHD should be treated before learning

disorders,

Dr Alka Subramanyam, psychiatrist from Nair hospital, Mumbai, India

Seems logical.

FINALLY A CONNECTION BETWEEN TREATMENT AND ACHIEVEMENT

Richard Scheffler, Ph.D. et al, of U.C. Berkeley analyzed a sample of 594 children diagnosed with ADHD , part of the national Early Childhood Longitudinal Study—Kindergarten Class of 1998-1999, a U.S.D.E. survey.

Children from grades K to 5.The study found that students with ADHD who took medication had math scores that were on average 2.9 points higher and reading scores on average 5.4 points higher than their unmedicated peers with ADHD.

Updates on the MTA StudiesThe MTA was the first major multi-site trial

comparing different treatments for ADHD in childhood. The initial results of the 14-month study, in which 579 children were involved in 1999.

The researchers found that the intensive medication management alone or in combination with the behavioral therapy produced better symptomatic relief for children with ADHD than just behavioral therapy or usual community care. 

Children who received the combination treatment fared best in other areas of functioning such as social skills and parent-child relations. 

More Updates on MTA StudyAbout half of the initial benefits of the intensive

medication management and combination treatments dissipated by the first follow-up, which was two years after the trial began.

A follow up study in 2007 found that, although most children had maintained improvement three years after the trial began, the initial advantages of intensive medication management alone or in combination with behavioral treatment had waned.

Most recent analysis by Brooke Molina Ph.D., of the University of Pittsburgh, and colleagues aimed to characterize the long-term functioning of the children eight years after they were enrolled in the trial.

 

More Updates on MTA ADHD Study

Parent, teacher and self-reports from the subjects, now in high school, found functioning improved overall compared to the beginning of the study, suggesting that available treatments can still be effective.

However, the 8-year follow-up revealed no differences in symptoms or functioning among the youths assigned to the different treatment groups as children. The type or intensity of a one-year treatment for ADHD in childhood does not predict future functioning.

Updates on MTA ADHD Study ContinuedYouths with ADHD still had significantly more

academic and social problems compared with peers who did not have ADHD with more conduct problems including run-ins with police, depression, and psychiatric hospitalizations.

But, youths who had responded well to treatment and maintained their gains for two more years after the end of the trial tended to be functioning the best at eight years after.

Updates on MTA ADHD Study Continued61.5 % of the subjects who were medicated at

the end of the 14-month trial had stopped taking medication by the eight-year follow-up, suggesting that medication treatment may lose appeal with families over time. 

Children who were no longer taking medication at the eight-year follow-up were generally functioning as well as children who were still medicated, raising questions about whether medication treatment beyond two years continues to be beneficial or needed by all.

The Growing BrainPhilip Shaw, M.D of NIMH (2007) found, through

imaging studies, that the brain matures in a normal pattern but is delayed three years in some regions, on average, compared to youth without the disorder.

The delay in ADHD was most prominent in regions at the front of the brain’s outer cortex, important for the ability to control thinking, attention and planning. 

Both groups showed a similar back-to-front wave of brain maturation with different areas peaking in thickness at different times.

The imaging techniques were improved over prior studies. Techniques are not yet complete, but reveal growth and possible symptom reduction with age.

Comprehensive Team Approach from School Success for Kids With ADHD

1. Determine the accurate diagnosis.2. Identify and nurture student’s strengths.3. Parent education.4. Parent consultation.5. Evaluate and manage family stress.6. Carefully monitor student’s medications.7. Emphasize exercise & good nutrition.8. Assign a case manager.9. Provide support at school to teachers.10. Negotiate a contract with the school and

student.11. Build student’s self-esteem through counseling

if needed.12. Manage student’s stress through calming

techniques.

Web Resources:Children and Adults With

Attention-Deficit/Hyperactivity Disorder (CHADD), www.chadd.org

Attention Deficit Disorder Association (ADDA), www.add.org

National Resource Center on AD/HD, www.help4adhd.org  

Council for Exceptional Children, www.cec.sped.org

National Dissemination Center for Children With Disabilities, www.nichcy.org

The National Institute of Mental Health, www.nimh.nih.gov

Information on Attention Deficit Disorder and ADHD, www.helpforadd.com/info

ADDitude Magazine, www.additudemag.com/adhd-guide/adhd-at-school.html

THANK YOU!!!!

Contact Information:

Stephan M. Silverman, Ph.D.Email: Doc@stephansilverman.comWebsite: stephansilverman.com

Weinfeld Education Group, LLCwww.richweinfeld.com