Evidence-based Assessment

of ADHD

Sarah Karalunas, PhD

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Disclosures

• No commercial interests, conflicts of

interests, or other disclosures to report

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Some ADHD History

See the naughty restless child

Growing still more rude and wild,

Till his chair falls over quite.

Philip screams with all his might.

Catches at the cloth, but then

That makes matters worse again.

Down upon the ground they fall.

Glasses plates, knives, forks at all.

How Mamma did fret and frown,

When she saw them tumbling down!

And Papa made such a face!

Philip is in sad disgrace.

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Some ADHD History

1902 1930 1952 1968 1980 1987 1994 2013

ADHD-like

syndrome

described

Minimal Brain

Damage

Minimal Brain

Dysfunction

(DSM-I)

Hyperkinetic

reaction of

childhood

(DSM-II)

Attention-

deficit disorder

(DSM-III)

Attention-deficit

Hyperactivity

disorder (DSM-III-R)

ADHD

-Hyperactive

-Inattentive

-Combined

DSM-5

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• ADHD is a common, chronic, impairing condition affecting

2-7% of children

• Cost $36-52 billion annually

• ADHD diagnosis remains controversial

• Diagnosis is complicated by heterogeneous symptom

presentations

ADHD Today

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What is ADHD?

• Makes careless mistakes

• Difficulty sustaining attention

• Does not listen

• Fails to follow through

• Disorganized

• Avoids sustained mental

effort

• Loses things

• Easily distracted

• Forgetful

• Fidgets

• Difficulty remaining seated

• Runs or climbs excessively

• Loud

• “On the go” or “driven by a motor”

• Talks excessively

• Blurts out

• Interrupts

• Difficulty waiting turn

Inattention Hyperactivity/ImpulsivityOHSU

What is ADHD?

• Makes careless mistakes

• Difficulty sustaining attention

• Does not listen

• Fails to follow through

• Disorganized

• Avoids sustained mental

effort

• Loses things

• Easily distracted

• Forgetful

• Fidgets

• Difficulty remaining seated

• Runs or climbs excessively

• Loud

• “On the go” or “driven by a motor”

• Talks excessively

• Blurts out

• Interrupts

• Difficulty waiting turn

Inattention Hyperactivity/ImpulsivityOHSU

What is ADHD?

• Makes careless mistakes

• Difficulty sustaining attention

• Does not listen

• Fails to follow through

• Disorganized

• Avoids sustained mental

effort

• Loses things

• Easily distracted

• Forgetful

• Fidgets

• Difficulty remaining seated

• Runs or climbs excessively

• Loud

• “On the go” or “driven by a motor”

• Talks excessively

• Blurts out

• Interrupts

• Difficulty waiting turn

Inattention Hyperactivity/ImpulsivityOHSU

What is ADHD?

• Makes careless mistakes

• Difficulty sustaining attention

• Does not listen

• Fails to follow through

• Disorganized

• Avoids sustained mental

effort

• Loses things

• Easily distracted

• Forgetful

• Fidgets

• Difficulty remaining seated

• Runs or climbs excessively

• Loud

• “On the go” or “driven by a motor”

• Talks excessively

• Blurts out

• Interrupts

• Difficulty waiting turn

Inattention Hyperactivity/ImpulsivityOHSU

Is ADHD “Real”?

• There are no objective tests (e.g. bloodwork, brain scan, or cognitive tests) that can diagnose ADHD

• Everyone has some level of these behaviors

• ADHD is “real” in that the behaviors are extreme and impairing for the child, but it also reflects a misfit between the child and environment

Upper Extreme,

93rd-98th

percentile

ADHD SymptomsOHSU

Is ADHD “Real”?

• There are no objective tests (e.g. bloodwork, brain scan, or cognitive tests) that can diagnose ADHD

• Everyone has some level of these behaviors

• ADHD is “real” in that the behaviors are extreme and impairing for the child, but it also reflects a misfit between the child and environment

Average

Upper Extreme,

93rd-98th

percentile

ADHD SymptomsOHSU

Is ADHD over diagnosed?

• DSM-5 estimates the prevalence of ADHD between 2-5%

of school-age children

• Cuffe et al., 2012 looked at records of >10,000 children

age 4-17 in the National Health Interview Survey (NHIS)

– Parent-reported history of diagnosis

– Elevated score on standardized behavior ratings (SDQ)

• Of those with

elevated behavioral

Ratings, only 60% have

a prior diagnosis

ADHD

diagnosis…

By history By behavior

rating scale

Boys 6.8% 4.2%

Girls 2.5% 1.8%

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Evidence-Based Assessment

• Why use formalized assessments?

– Because clinical judgment is subject to many

types of biases

• Ignoring base rates

• Availability error

• Premature closure

• Anchoring errors

• Confirmation bias

– Actuarial judgment generally outperforms clinical

judgment (Dawes et al., 1989; Grove et al., 2000)

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ADHD Assessment

1

• Symptom Assessment with Rating Scales• Parent

• Teacher

2• Diagnostic Interview

3• Cognitive/Neuropsychological Assessment

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Rating Scales

1

• Symptom Assessment with Rating Scales

• Parent

• TeacherOHSU

Prevalence of Concerns

• Psychological disorders are the most common

chronic conditions in pediatric populations

(Kelleher & Stevens, 2009)

• Physical and mental health concerns often co-

occur

• Primary care settings remain the most common

point of access for identification and treatment

(Stancin & Perrin, 2014)

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Choosing a Rating Scale

• What’s the purpose of the assessment?

• Initial information gathering Broadband scales

• Assessment of specific symptoms Narrow band

scales

• Treatment monitoring Scales with sensitivity to

change

• How much time do I have?

– Longer rating scales do not necessarily improve

over shorter ones

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Choosing a rating scale

• Broadband scales

• Strengths & Difficulties Questionnaire*

• Pediatric Symptom Checklist*

• Behavioral Assessment System for Children, 2nd ed

(BASC-2)

• Child Behavior Checklist (CBCL)

• Targeted symptom assessment

• ADHD Rating Scale, 5th ed. (ADHD-RS V)

• Conners’, 3rd ed. (Full length, short-forms, 10-item)

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Why use rating scales?

• Rating scales help to:– Ensure systematic coverage of behavior

– Quantify presence, frequency, and severity of behaviors

– Help youths disclose symptoms

– Reveal difficult to observe behavior

– Assess change over time

• Standardized tools increase rates of identification• But can also result in over- and under-identification (Wissow

et al., 2013)

• Patients prefer universal screening and presenting screening as routine increases completion rates from 45% to 95%.

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Who should fill out ratings?

• Behavior differs by settings, so parent and teacher reports

may both be informative

• Children (<10yo) tend to be poor reporters

• In adolescence, parents are better reporters of externalizing

behavior, children are better reporters of internalizing

behaviorYeah, but what are you actually

feeling?

https://whatsyourgrief.com/

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Scoring rating scales

• Good norms are essential for interpreting

responses on rating forms

• Scoring measures increases likelihood that

providers will discuss concerns (Wissow et al.,

2013)

• For ADHD, there are well-validated approaches for

combining information across reporters

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Scoring rating scales

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Scoring rating scales

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Scoring rating scales

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Scoring rating scales

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Scoring rating scales

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1

• Symptom Assessment with Rating Scales

• Parent

• Teacher

2• Diagnostic InterviewOHSU

Diagnostic Interviews

• Considered the “gold standard”

• Can take a long time (especially with multiple informants)

• Optimal for assessing timeline

– Symptoms across development

– Antecedents, Behaviors, Consequences (ABCs) related to

symptomsOHSU

Differential Diagnosis

• A few other “red flags” for ADHD that often

come up when talking with parents

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But he can pay attention when

he wants to…

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In the real world…

Controlled, Cognitive, “Cool”

Reactive, Emotional, “Hot”

Action and DecisionsOHSU

In the real world…

Controlled, Cognitive, “Cool”

Reactive, Emotional, “Hot”

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But he can pay attention when

he wants to…

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It’s not all about attention…

• Emotion dysregulation

• Academic underachievement

• Social/Peer relationship problems

• Disruptive behaviors

• Anxiety/Depression

• Fine motor/gross motor problems

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ADHD Assessment

1

• Symptom Assessment with Rating Scales• Parent

• Teacher

2• Diagnostic Interview

3• Cognitive/Neuropsychological Assessment

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ADHD on the Brain

Shaw et al., 2007

Delays in peak

cortical

thickness in

prefrontal areasOHSU

Neuropsychological Testing

• Executive Function / Top-down control

• Working Memory

• Planning

• Organization

• Impulse Control

• Response to rewards

• Motor control and timing

• Attention and arousal

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• Focus on the behavioral expression of

brain dysfunction

• Emphasis on functional impairment

Neuropsychological Testing

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Referrals

• Identifying who might benefit

• Valid performance depends upon obtaining the patient’s best performance– Uncooperative

– Fatigued

– Actively psychotic/agitated

– Severely depressed and/or anxious

• Preparing the patient

• Formulating the referral question that best defines the needed information– Reason why evaluation is being requested– Description of the problem to be assessed– Pertinent history– History of testing/upcoming other testing

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Summary

• ADHD diagnosis captures a broad variety of symptom

presentations and associated features

• Structured or formalized assessment improves

diagnostic accuracy

• Reliable and valid diagnosis can be made using rating

scales, but parent and teacher report should be

considered

• Cognitive assessment can be useful for clarifying

diagnostic picture or identifying needed supports

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Some Useful Rating Scales

Broadband Strengths & Difficulties Questionnaire (SDQ)*

Pediatric Symptom Checklist*

Behavioral Assessment System for Children, 2nd ed (BASC-2)

Child Behavior Checklist (CBCL)

Domain Specific ADHD and DBD: ADHD Rating Scale, 5th ed. (ADHD-RS V)

Conners’, 3rd ed. (Full length, short-forms, 10-item)

Depression: Center for Epidemiological Studies Depression Scale for Children*

Child Depression Inventory (CDI-II) / Beck Depression Inventory (BDI-II)

Patient Health Questionnaire-9 (PHQ-9)

Anxiety: Screen for Childhood Anxiety Related Disorders (SCARED)*

Multiaxial Anxiety Scale for Children, 2nd Ed. (MASC-2)

Trauma Adverse Childhood Experiences scale (ACE)*

Developmental Ages & Stages Questionnaire, 3rd ed. (ASQ-3)

Social Responsiveness Scale, 2nd ed. (SRS-2)

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