adhd: the finer points of assessment. copyright © the reach institute. all rights reserved....

ADHD: The Finer Points of Assessment

http://www.thereachinstitute.org/

Copyright © The REACH Institute. All rights reserved.

Learning ObjectivesLearning Objectives

• Present evidence-based information about ADHD to patients and their families (Section 1)

• Assess special populations for ADHD: preschoolers, adolescents, parents, complicated children (Section 2)

• Discuss the effective use of ADHD rating scales (Section 3)


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ADHD DSM-5 Criteria


1. Combined: Diagnosed if criteria for both inattention and hyperactivity-impulsivity are met for the past 6 months.

2. Predominantly Inattentive: Diagnosed if only inattention criteria are met, past 6 months.

3. Predominantly Hyperactive-Impulsive: Diagnosed if only criteria for hyperactivity-impulsivity are met for the past 6 months.

Note: Not Otherwise Specified: Diagnosed if there are prominent symptoms of inattention or hyperactivity-impulsivity that do not meet full criteria for ADHD.

DSM-5: ADHD has 3 Presentations

DSM-5. 2013. American Psychiatric Association.


ADHD DSM-5 Criteria:Inattentive Presentation

• Carelessness• Difficulty sustaining

attention during activity• Trouble following

through• Avoids tasks requiring

sustained mental effort

• Difficulty organizing• Loses important items • Easily distracted • Forgetful in daily activities• Does not appear to be

listening when spoken to directly

Manifestation of the following symptoms occurs OFTEN:

Must have 6 or more symptoms for a period of 6 months to a degree that is maladaptive and inconsistent with developmental level.


ADHD DSM-5 Criteria:Hyperactive/Impulsivity Presentation

Hyperactivity: • Squirms and fidgets • Cannot stay seated • Runs/climbs excessively• On the go/driven by a motor• Talks excessively• Cannot perform leisure activities

quietly

Impulsivity: • Blurts out answer • Cannot wait turn • Intrusive/interrupts

others

Must have 6 of 9 symptoms or more for a period of 6 months to a degree that is MALADAPTIVE AND INCONSISTENT WITH DEVELOPMENTAL LEVEL.

Manifestation of the following symptoms occurs OFTEN:


DSM-V. 2013. American Psychiatric Association.

A. Symptoms must be present, past 6 months

B. Some symptoms must be present < 12 y.o.

C. Some impairment from symptoms must be

present in 2 or more settings

D. Significant impairment: social, academic, oroccupational

E. Excluded other mental disorders

There Is More to DiagnosisThan Symptoms


The 8 Most Important Questions You Need To

Be Able To Answer About ADHD

The 8 Most Important Questions You Need To

Be Able To Answer About ADHD

Section 1


Table Activity: Practice Answering the Tough Questions

• Look in the middle of your table for your group’s “tough questions” (J 1.1) about ADHD.

• As a group, discuss and practice how to most effectively answer these questions. 5 minutes!

• Choose a rep for your table.

• Your table’s rep will answer the “tough question” with a tough parent!


ADHD is not real, it is an attempt to “take the boyhood out of the boy”!

ADHD is not real, it is an attempt to “take the boyhood out of the boy”!

#1


Why We Know ADHD is Real!

ADHD’s Diagnostic Validity

Genetic Studies

Consistent Impairments

(Concurrent Validity)

It Is Not A Phase!(Predictive Validity)

Imaging Studies

ADHD Is Everywhere!(Cross-Cultural Validity)


Johnny can play Gameboy all day, but when it comes to math homework, he is just lazy!

Johnny can play Gameboy all day, but when it comes to math homework, he is just lazy!

#2


What is theCurrent Concept about ADHD?

What is theCurrent Concept about ADHD?

• Brain disorder of response inhibition in executive functioning (prefrontal)

• Attention is different for different tasks (exciting stimuli may draw attention)


What or who causedmy child to have ADHD?

What or who causedmy child to have ADHD?

#3


What Causes ADHD?

CNS InjuryGenetics

Environment

ADHD

Biederman J, Faraone SV. Lancet. 2005;366:237-248


Twin Studies Show ADHD is a Highly Genetic DisorderTwin Studies Show ADHD

is a Highly Genetic Disorder

Faraone. J Am Acad Child Adolesc Psychiatry. 2000;39:1455-1457. Hemminki. Mutat Res. 2001;25:11-21.


Will my child evergrow out of their ADHD?

Will my child evergrow out of their ADHD?

#4


Hyperactivity

—Advancing Age—

Impulsivity

Inattention

The Natural Course of ADHD The Natural Course of ADHD —

Sym

pto

m S

ever

ity—

Wasserstien, JCLP, 2005


Isn’t ADHD only aschool-based problem?

Isn’t ADHD only aschool-based problem?

Bonus Question for All!


Adults

Potential Areas of Impairment With ADHD

Potential Areas of Impairment With ADHD

Academiclimitations

Poor Peer Relationships

Increased Injuries

AdolescentsLow self-esteem

Risk-taking activities

Smoking, substance abuse, sexual activity

Motor vehicleaccidents

Legaldifficulties

Occupational/vocational

Swensen A, et al. J Adolesc Health. 2004;35:346.e1-346.e8.

Children


ADHD Assessment inSpecial Populations:

Preschoolers, Adolescents, Parents, and Neurobehavioral

Disorders

ADHD Assessment inSpecial Populations:

Preschoolers, Adolescents, Parents, and Neurobehavioral

Disorders

Section 2


The Case of 4 Year Old JimmyThe Case of 4 Year Old Jimmy

• Busy in the womb

• Multiple trips to the ER for impulsive injuries

• You treat Jimmy’s two older brothers for ADHD

• Jimmy has been asked to leave 3 daycare settings for impulsive behaviors


The Case of Emily, a 16 y/o FemaleThe Case of Emily, a 16 y/o Female

• Bright young woman with no learning disabilities

• Emily did well academically until the 6th grade when she began a steady academic decline

• She appears demoralized about her poor grades but not clinically depressed

• No substance use

• Review of school records indicate mild chronic organizational problems but until the 6th grade no significant impairment


The Case of Mrs. Smith, 37 y/o Mom of Your Patient James

The Case of Mrs. Smith, 37 y/o Mom of Your Patient James

• Mrs. Smith is the mother of a child you treat for ADHD

• Mrs. Smith often misses appointments or shows up the day after her scheduled appointment

• She struggles following through on your directions with the school, meds, or behavioral plans

• Identifies with her child’s ADHD symptoms


The Case of Jessica, a 6 y/o girl with Fetal Alcohol Exposure

• Jessie was exposed to a significant amount of alcohol during fetal period

• IQ 70 with clumsiness, a speech disorder and fine motor impairment

• Dx: alcohol-related neurodevelopmental disorder (absence of FAS facial features, microcephaly, and short stature)

• Hyperactivity, impulsivity and inattention occur in the classroom and when interacting with peers/parents


Table ActivityTable Activity

1. Identify the specific challenges and obstacles to assessing ADHD in this population (5 minutes), and then….

2. Identify strategies how you can overcome these problems! (5 minutes)

3. Debrief…(5 minutes)


What do you find difficult

about assessing

preschoolers

for ADHD?

What do you find difficult

about assessing

preschoolers

for ADHD?


Assessment Challenges for Preschool Children


• ADHD-like behaviors may be developmentally normal in this group when they are mild to moderate and without impairment

• ADHD versus environmental versus developmental disorder versus ODD/BPD

• Early intervention change trajectory?


Pre-School ADHD PresentationPre-School ADHD Presentation

• Very hyperactive: always, always on the go

• Dangerously daring

• Multiple accidental injuries

• Very destructive play

• Difficulty with the initiation of sleep is common

• Lower levels of adherence

• Difficulty sustaining baby sitters or day care

Greenhill LL. J Clin Psychiatry.1998;59:31-41




• Examples of scales to use:

– Assessment scales: Connors Scales

– Treatment monitoring: SNAP IV

– Vanderbilt

• Careful assessment of parenting first and referral to parent training when indicated


What are some of the challenges in assessing adolescents with ADHD?

What are some of the challenges in assessing adolescents with ADHD?


Factors Which Will Delay a Diagnosis of ADHD

Factors Which Will Delay a Diagnosis of ADHD

• Primary Inattentive Presentation

• Female Sex

• Highly Supportive Family

• High IQ

• Well Developed Social Skills


Factors Complicating the Assessment of ADHD in Adolescents

Factors Complicating the Assessment of ADHD in Adolescents

• Multiple teachers for shorter periods of observation

• Less observation time with the parents

• Different clinical presentation of ADHD in adolescents

• How do we assess clinical information and rating scales from the teen, parents and teachers?

• Increased rate of co-morbid conditions in adolescents compared to elementary school-age children


What We Know About ADHD Assessment in AdolescentsWhat We Know About ADHD Assessment in Adolescents

• Teacher scales may be less valuable

• Self reports help with rapport and gives an opening to teach the adolescent but may not be diagnostically helpful

• Review school records for some evidence of chronicity of symptoms

• Look for the higher rates of co-morbid conditions


What do you do if you have a parent you thinkmay haveADHD?

What do you do if you have a parent you thinkmay haveADHD?


What About Children with a Neurodevelopmental Disorder?

• Children with neurodevelopmental disorders are often hyperactive, impulsive and inattentive

• ADHD can be diagnosed using standard behavioral criteria

• Neurodevelopmental disorders associated with ADHD:– Fetal alcohol syndrome – Alcohol related neurodevelopmental disorder– Down syndrome– Prader-Willi syndrome– Williams syndrome – Tourette syndrome– Turner syndrome

• Studies with small samples show benefit from stimulant medication


Pre-schooler Adolescents Parents NeuroDevelEvaluate parenting carefully

Often strong family history of ADHD

Often extreme hyperactivity

Consider PDD

Use Vanderbilt, Conners, or SNAP IV Scales

Evaluate carefully for Co-morbid conditions

Parent or Youth Rating scales may be the most helpful

Forming a rapport is essential

If family states the child had ADHD and grew out of it, reevaluate

Untreated ADHD in parents has a major impact on the child

Adult Rating Scales Adult Self Report Scale (ASRS v1:1) J 1.8 – 2.0

Barkley and Brown Scales ($)

Getting someone to evaluate a parent for ADHD

-Child & Adolescent Psychiatrists-Adult Psychiatrists-Family Physicians

Untreated ADHD can have a major impact on these children

Use Standard rating scales

Treat with caution


ADHD Rating ScaleBoot Camp

ADHD Rating ScaleBoot Camp

Section 3


Table Activity: ADHD Rating Scale

Boot Camp

Table Activity: ADHD Rating Scale

Boot Camp


Your Mission ObjectivesYour Mission Objectives

• Learn how to score a Vanderbilt rating scale

• Learn how to clinically and meaningfully use rating scales when trying to establish a diagnosis.


Table ActivityTable Activity

1. Silently read the Vanderbilt scoring instructions in Workbook, p. J1.3

2. As a group, score Jimmy’s Teacher Vanderbilt, p. J1.4-1.5

3. SCRIBES: On the flipchart, write all the scores for the “Office Use Only” box, p. J1.5 (except last line, “Average Performance Score”)


Summary of the Finer Points of ADHD Assessment

• Practice answering tough questions using evidence based information

• Remember how to adjust the ADHD assessment process for different age groups

• Use standardized ADHD rating scale to assist in the assessment of ADHD and other co-morbid psychiatric conditions

• Implement practical interventions in you office to save time and get paid (more to come)


Additional Points for ADHD Assessment & Treatment Planning

•

• Refer to childhood mental health specialist for additional evaluations and behavioral therapy (parent training), esp. children < 6

• Your initial evaluation sets the stage and prepares parents for helpful interventions, such as teacher education, parent management, relaxation, problem-solving and social/communication skills.


REMINDER: Please fill out Unit J

evaluation


Getting it Paid For: Self-Study

Do you know how to code these cases so you will get paid?

Do you know when to use these coding variations?

Getting it Paid For: Self-Study

Do you know how to code these cases so you will get paid?

Do you know when to use these coding variations?


Jimmy’s Diagnosis Jimmy’s Diagnosis

314.01 Attention deficit disorder, with mention of hyperactivity, combined inattentive subtype

314.9 Unspecified hyperkinetic syndrome, Attention deficit hyperactivity disorder, NOS


Jimmy’s Visit: 99214Jimmy’s Visit: 99214

With the exception of Jimmy’s father’s observations of his son’s behavior and the comments regarding his own behaviors, over 50% of this encounter was spent in counseling the father and trying to come to some common understanding

Reasonable length of the visit: 25 min.


Jimmy’s Visit: ProceduresJimmy’s Visit: Procedures

Vanderbilt ADHD Scale: Father

Mother’s Vanderbilt Scale and Pediatric Symptom Checklist-17 had presumably been administered, scored and interpreted at previous visit


Jimmy’s VisitJimmy’s Visit

99214-25 96127

99214 96127-59

99214-25 96127-76

adhd: the finer points of assessment. copyright © the reach institute. all rights reserved....

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