The Role of Neuropsychological Assessment in a Comprehensive

ADHD Evaluation

Dustin B. Hammers, Ph.D., ABPP(CN)Board Certified in Clinical NeuropsychologyDepartment of NeurologyCenter for Alzheimer's Care, Imaging & ResearchUniversity of Utah09/26/2014

Center for Alzheimer’s Care,Imaging and Research (CACIR)

Objectives

• Discuss new DSM-5 criteria for ADHD

• Explain what neuropsychological or cognitive evaluations are and how they can be used to aid ADHD diagnosis and treatment

• Consider common obstacles to ADHD diagnosis and treatment

• Review case examples of cognitive profiles and personalized ADHD treatment

Recent Trends

Rates rising

Mental health referrals and physician office visits

Boys vs. girls

DSM-IV-TR ADHD Criteria• 6 of 9 characteristics in either or both major categories below.

• Symptoms present for at least six months, beginning before the age of 7. Behaviors must create significant difficulty in at least two areas of life.

• Situation not explained by other medical or psychiatric condition

• ADHD - Predominantly Inattentive Type • Fails to give close attention to details or makes careless mistakes, Has difficulty sustaining

attention, Does not appear to listen, Struggles to follow through on instructions, Has difficulty with organization, Avoids or dislikes tasks of sustained mental effort, Loses things, Is easily distracted, Forgetful in daily activities.

• ADHD - Predominantly Hyperactive/Impulsive Type• Fidgets with hands or feet or squirms in chair, Has difficulty remaining seated, Runs about

or climbs excessively, Difficulty engaging in activities quietly, Acts as if driven by a motor, Talks excessively, Blurts out answers before questions completed, Difficulty waiting/taking turns, Interrupts or intrudes upon others.

• ADHD - Combined Type• Individual meets both sets of inattention and hyperactive/impulsive criteria.

DSM-5 Criteria Differences

• Increasing age

• Rule – outs

• Number of symptoms required

• Symptoms added for adults

• Given these diagnostic criteria, where does cognitive performance fit in?

Neuropsychology

Assessment or evaluation of cognitive functioning

Identification of individual strengths and weaknesses

Report includes results, and implications/recommendations

Evaluation Components• Clinical Interview• Mental Status Examination• Family Interview• Behavioral Observation• Standardized Psychometric Testing• Interpretive Report• Integrated Feedback Session

Neuropsychological Domains

• Given these diagnostic criteria, where does cognitive performance fit in?

• Technically, it doesn’t, ADHD is a behavioral diagnosis

• However…

Neuropsychological Evaluation

• Has the capacity to…

• Assess ADHD patient’s unique collection of skills

• Identify comorbid conditions associated with development or mood/conduct

• Allow for the consideration of personalized treatment plans

Overcoming Diagnosis and Treatment Issues

• Accuracy of Reporting and Categorization

• Transition from childhood to adulthood

Slow, inefficient, disorganized

Paralyzing procrastination

Poor time management

Doesn’t listen

No follow through

Loses important items

Lifetime Course of ADHD Symptoms: Inattention Domain

Childhood Adult

APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000.Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.

APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000.Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.

Inefficiencies at work

Drives too fast

Can’t tolerate frustration

Makes inappropriate comments

Squirming, fidgeting

Runs/climbs excessively

On the go/driven by motor

Blurts out answers

Childhood Adult

Lifetime Course of ADHD Symptoms: Hyperactivity/Impulsivity Domain

Overcoming Diagnosis and Treatment Issues

• Accuracy of Reporting and Categorization

• Transition from childhood to adulthood

• Comorbidities

• Alternative Explanations

Medical Differentials Thyroid disease Head trauma OSA Seizures Vitamin B12 deficiency Drug interactions Heavy metal poisoning Hearing deficits Liver disease Lead toxicity

Psychiatric Differentials Major depression Bipolar disorders GAD Substance abuse Personality disorders

Alternative Explanations

•Why can’t I just get an MRI?”

MRIs and PET scans of ADHD patients show changes in:

Anterior frontal lobe, along with temporal and parietal lobe

Splenium of corpus callosum and anterior cingulate

Smaller basal ganglia

• Similar networks for major depression, bipolar disorder, and substance abuse

Neuroimaging and ADHD

•“Do all people with ADHD have the same problems that I do?”

Treatment for ADHD Not Uniform

• ADHD is a behaviorally defined disorder

• Creation of specific treatment plan vs. application of label

• As many treatment recommendations as cognitive weaknesses

Specific Cognitive Profiles

• Attention difficulty observed

“Silent deficits” often not asked about◦ Executive functioning

◦ Memory

◦ Processing speed

◦ Motor Dexterity

◦ Emotional

Example 1

• 21-year old woman with Associates Degree and enrolled in Cosmetology Program. Works as hostess part-time.

• Adderall given at age 18 by PCP but never received ADHD diagnosis

• Without medication• Easily overwhelmed by information, forgetful, and she has consistently had

instructors point out her attention difficulties in class

• Struggles with procrastination and task transition for “to do” lists

Example 1• Cognitive Profile:

Example 2

• 31-year old man with a Doctorate in Pharmacy and in his 2nd year of Residency

• Diagnosed with ADHD at 7 years old, highly enriched environment

• On Ritalin in youth, strong college and grad school GPA

• Without medication: • Fidgeting and pacing when at home, multiple tasks at once, struggles to attend

to and retain conversations, sensation seeking behaviors

• Oversights on the job have been documented and excessive hours

Example 2

• Cognitive Profile:

Profiles

• Patient 1: Inattention and slowed processing predominant• Diagnosis: ADHD Inattentive Type• Sluggish Cognitive Tempo

• Patient 2: Hyperactivity and impulsivity predominant• Diagnosis: ADHD Hyperactive/Impulsive Type• Behavioral Dysinhibition Hypothesis

How this Specific Information Can

Help• Comorbidities and Alternative Explanations

• Targeting treatments • Medication vs. Behavioral

• Legal services

• Daily recommendations

Medication Treatment for ADHD

• Standard medication treatment with stimulants

• Methylphenidate: Ritalin, Methlyn, Concerta, Focalin• Amphetamine: Adderall, Dexadrine, Vyvanse

• Anti-depressants to treat adults with ADHD • Strattera• Tricyclics• Effexor• Wellbutrin

www.nimh.nih.gov

Behavioral Therapy for ADHD• Best for social skills and reduced parent/peer relationships,

also to focus on core symptoms and self-regulation

• Behavioral Parent Training plus medication

• Behavioral Classroom Interventions

• Social Skills Interventions

• Academic Interventions

• Cognitive Behavioral Therapy

ADA Accommodations

• Academic accommodations available

• 504/IEP Behavioral Plans established through school systems• University Office for Student Disability Services

• Specific cognitive profiles allow tailoring of accommodations

• Extended time on exams• Note-taking supports • Distraction free or isolated exam-taking

Personalized Recommendations• Example for reaction time weakness:

• Incorporate periods of ‘disconnected time’ where not likely to become distracted, particularly at the beginning of the day

• Examples for organizational/executive weakness: • Create checklists and protocols for procedures during work; such structure will

be of benefit since motivation is often increased when clear plans are able to be followed

• Breaking day into 1 hour blocks, or even 15 minute increments, may be more beneficial to increase novelty and reduce distraction

ADHD Recommended Readings

Books•Childhood ADHD

• Driven to Distraction by Edward Hallowell, 1995 • Parenting Children with ADHD by Vincent Monastra, 2005• Taking Charge of ADHD by Russell Barkley, 2013

•Adult ADHD• Succeeding with Adult ADHD by Abigail Levrini and Frances Prevatt, 2012 • More Attention, Less Deficit by Ari Tuckman, 2009 • Taking Charge of Adult ADHD by Russell Barkley, 2010

Organizations and Helpful Websites•Children and Adults With Attention-Deficit-Hyperactivity Disorder (www.chadd.org )•National Resource Center for ADHD www.help4adhd.org•www.ADDWarehouse.com

Thank you!

Questions?

dustin.hammers@hsc.utah.edu

www.utahmemory.org