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Evidence-based Assessment
of ADHD
Sarah Karalunas, PhD
OHSU
Disclosures
• No commercial interests, conflicts of
interests, or other disclosures to report
OHSU
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.
OHSU
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
OHSU
• 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
OHSU
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%
OHSU
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)
OHSU
ADHD Assessment
1
• Symptom Assessment with Rating Scales• Parent
• Teacher
2• Diagnostic Interview
3• Cognitive/Neuropsychological Assessment
OHSU
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)
OHSU
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
OHSU
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)
OHSU
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%.
OHSU
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/
OHSU
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
OHSU
Scoring rating scales
OHSU
Scoring rating scales
OHSU
Scoring rating scales
OHSU
Scoring rating scales
OHSU
Scoring rating scales
OHSU
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
OHSU
But he can pay attention when
he wants to…
OHSU
In the real world…
Controlled, Cognitive, “Cool”
Reactive, Emotional, “Hot”
Action and DecisionsOHSU
In the real world…
Controlled, Cognitive, “Cool”
Reactive, Emotional, “Hot”
OHSU
But he can pay attention when
he wants to…
OHSU
It’s not all about attention…
• Emotion dysregulation
• Academic underachievement
• Social/Peer relationship problems
• Disruptive behaviors
• Anxiety/Depression
• Fine motor/gross motor problems
OHSU
ADHD Assessment
1
• Symptom Assessment with Rating Scales• Parent
• Teacher
2• Diagnostic Interview
3• Cognitive/Neuropsychological Assessment
OHSU
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
OHSU
• Focus on the behavioral expression of
brain dysfunction
• Emphasis on functional impairment
Neuropsychological Testing
OHSU
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
OHSU
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
OHSU
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)
OHSU