UNDERSTANDING

COMPREHENSIVE

ASSESSMENT COMPONENTS

FOR ADHD

Maricela Dominguez Gulbronson, MD, FAAP

Medical Director, Developmental Pediatric Medicine

Clinical Assistant Professor TAMU Department Of Pediatrics

Children’s Physician Services Of South Texas

SPEAKER’S

DISCLOSURE

The speaker of this CME

activity has no relevant

financial relationships

with commercial

interests to disclose.

CASE VIGNETTE:

Male youngster

presents with

maternal

complaints for

behavioral

challenges

associated with

increased

hyperactivity and

impulsiveness and

out of control

temper outbursts

WHERE TO BEGIN

The primary care clinician may

initiate an evaluation for ADHD for

any child 4 through 18 years of

age who presents with academic

or behavioral problems and

symptoms of inattention,

hyperactivity, or impulsivity

WHO’S DIAGNOSING

Pediatricians diagnosed 39% of all children with ADHD, while 23% of children under age 6 were diagnosed by psychiatrist.www.aapnews.org

2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome

COMPREHENSIVE

ASSESSMENT

• Although ADHD may be present,

there are many other conditions

that can look like ADHD: anxiety,

learning disorders, conduct

problems, depression, and even

PTSD.

• Conduct a comprehensive

assessment to ensure that all

possible causes are considered.

GOALS

• Know the prevalence rates of ADHD

• Learn key diagnostic DSM-V criteria for ADHD

• Promote use of DSM-oriented parent and teacher rating scales

• Know how to assess functional impairment secondary to ADHD

• Know how to screen for additional co-occurring conditions

PREVALENCE

• Approximately 2% to 6% of

preschoolers

• About 9% of school-age

children

• 2-6% in adolescent samples

• 2% of adults

WHERE TO BEGIN?

• The Diagnostic and Statistical Manual

for Mental Disorder, Fifth Edition (DSM-

V)

• AAP 2011 ADHD clinical guidelines

• JAACAP 2007 ADHD practice

parameters

• AAP Guidelines and ADHD Tool Kit

place ADHD diagnosis and treatment

clearly within the scope of PCP

DSM-V CRITERIA

• DSM-V classifies core symptoms

into categories.

DSM-V CRITERIA

• For the use of DSM based criteria,

child generally should be age 6 or

older and typically less than 12 years.

• New AAP 2011 guidelines includes 4-

5 year olds. Minimal developmental

age of 4 year old.

DSM-V CRITERIA FOR ADHD

A. Inattentive symptoms

1. Makes careless mistakes

2. Trouble paying attention to task

3. Not listening

4. Not following instructions

5. Trouble organizing

6. Avoiding or disliking sustained effort

7. Losing things

8. Easily distracted

9. Forgetful

DSM-V CRITERIA FOR ADHD

B. Hyperactive/Impulsive Symptoms

1. Fidgety and squirmy

2. Running or climbing excessively

3. Trouble playing quietly

4. “On the go” or “driven by a motor”

5. Talks Excessively

6. Blurting our answers

7. Trouble taking turns

8. Interrupting or intruding

9. Not remaining seated when expected

DSM-V KEY DIAGNOSTIC

FEATURES FOR ADHD

• Persistent pattern of inattention and/or hyperactivity-

impulsivity that interferes with functioning or

development

• Threshold number of symptoms: ≥6/9 symptoms for

inattention & hyp/imp

• In addition, the following conditions must be met:

• Several core symptoms before age 12 years.

• Several symptoms are present in 2 or more settings

• Functional impairment in at least 1 area

DOCUMENT ADHD-

TYPE BEHAVIORS

• While use of ADHD-behavior rating

scales helps gather important

clinical data efficiently for a busy

pediatric practice, behavior

symptoms may also be obtained by

other methods:

• Open-ended questions

• Semi-structured interviews

• Questionnaires

BE EFFICIENT AND USE DSM-ORIENTED

SCALES FOR PARENT AND TEACHER:

Vanderbilt Rating Scales (VARS)

Conner’s Rating Scales

Brown ADHD Rating Scales

Attention Deficit Disorder Evaluation Scale 4th ed. -(ADDES-4)

ACTeRS

The SNAP-IV

THE VANDERBILT ADHD

RATING SCALES (VARS)

• Based on DSM-oriented criteria for ADHD

diagnosis

• AAP’s ADHD toolkit include versions specific for

parents and teachers.

• Psychometrically sound measures are easily

accessible and simple to interpret.

• ADHD symptom-specific rating scales

effectively discriminate between children with

and without ADHD, and accurately predict

presentation specifiers (subtypes).

BROADER BEHAVIOR

RATING SCALES

For Primary Care Provider:

Pediatric Symptom Checklist

For mental health providers:

Behavior Assessment System for

Children,3rd ed. (BASC-3)

Child Behavior Checklist (CBCL)

OBTAIN ROUTINE

HISTORYDSM-oriented clinical

interview and history or

use Vanderbilt behavior

rating scales to help

document:

• Symptoms of

inattention,

hyperactivity,

impulsivity

• Degree of functional

impairment.

OBTAIN ROUTINE

HISTORYPRENATAL RISK FACTORS FOR ADHD

Prenatal exposures to cocaine, nicotine, alcohol,

amphetamines, marijuana, and VPA

Very-low birthweight

Severe intrauterine growth restriction

Perinatal HIE

Environmental toxins (i.e. Lead)

Infections (i.e. meningitis, HIV)

Brain injury (i.e. IVH, PVL)

OBTAIN ROUTINE

HISTORY

Explore developmental milestones (DD?)

At primary care level, review Ages and

Stages® Questionnaire results from most

recent well child exam.

Minimal developmental age of 4 year old to

formally consider ADHD

Challenges with attention regulation and

impulse control are also cognitively

mediated

OBTAIN ROUTINE

HISTORY

Ask about school functioning (risk for ID/LD?)

• Longstanding GDD

• Prematurity < 27 weeks increased risk for ID

• Prematurity >27 weeks LD more common

• Family history of LD

Language-based learning difficulties are the most

commonly encountered in children with ADHD.

NOT ROUTINELY RECOMMENDED

FOR ADHD EVALUATION

• Psychoeducational testing

• Continuous performance

test

• Lead level

• EEG

• TSH

LD PREVALENCE IN

ADHD 15-25%

Testing for a learning

disability should occur

in children with ADHD

with persistently poor

academic performance.

Specific LD at school is

usually not established

until 3rd grade.

CONTINUOUS

PERFORMANCE TEST (CPT)

A continuous performance

task, continuous performance

test, or CPT, is any of several

kinds of neuropsychological

test that measures a person's

sustained and selective

attention.

Sustained attention is the

ability to maintain one’s

focus.

Selective attention the ability

to focus attention to a

particular stimulus and to

discriminate relevant from

irrelevant information.

CONTINUOUS

PERFORMANCE TEST (CPT)

• Conners’ CPT has questionable value as a diagnostic

instrument.

• CPT can be one component of a diagnostic evaluation, but most

ADHD experts underscore the need to avoid using CPT results

as a primary basis for deciding whether or not a child has

ADHD. In many cases, doing so is likely to result in diagnostic

errors that result in the selection of ill-advised treatments.

• Parents and clinicians are advised to be cautious in attributing

too much significance to how a child performs on a CPT.

• For the time being, the use of careful clinical interviews that

incorporate information from multiple sources will remain the

cornerstone of a comprehensive ADHD evaluation.

CONTINUOUS

PERFORMANCE TEST (CPT)

The American Academy of

Pediatrics (2011) and the American

Academy of Child and Adolescent

Psychiatry (2007) have published

guidelines for the evaluation of

ADHD and neither advocates that

any such tests be routinely

incorporated into ADHD

evaluations.

REVIEW OF SYSTEMS

Ask about signs and symptoms that are

associated with ADHD imposters on ROS

• Pica resulting in elevated Lead

• Absence Seizures

• Hypothyroidism

• Allergic Rhinitis

• Chronic insomnia

CONDUCT PHYSICAL

EXAM

Is hearing normal?

Is vision normal?

Neurologic Exam: Are there any focal

neurologic signs? Are there any soft

neurological signs indicating immaturity?

Have you ruled out evidence of other

medical conditions that may cause ADHD-

like symptoms?

ADHD MANAGEMENT

Most cases of ADHD are

managed by PCP when

no significant learning or

psychiatric problems are

suspected or present

OPTIMIZING ADHD

MANAGEMENT

OPTIMIZING ADHD MANAGEMENT

COMPLEX ADHD

When ADHD behaviors seem

refractory to the usual medication,

more attention needs to be paid to

potential comorbidities or to an

alternative diagnosis.

The AAP guidelines also note the

importance of screening for comorbid

conditions.

COMPLEX ADHD

Minimal guidance

is provided

regarding how

physicians might

use parent and

teacher VARS data

to screen for the

other comorbidities

and when they

should make

referrals

COMPLEX ADHD (NELSON TEXTBOOK OF PEDIATRICS 17 ED.)

Co-existing Condition Prevalence in Children with ADHD (%)

Oppositional Defiant Disorder (ODD) 32

Conduct Disorder (CD) 25

Anxiety 21

Depression 18

Learning disability (LD) 12

School Underachievement 60

Language Disorder 4

COMPLEX ADHD

• The VARS effectively discriminate

between children with and without

ADHD, and accurately predict

presentation specifiers (subtypes).

• The VARS comorbidity screening

scales may be helpful in

determining which children likely

DO NOT meet diagnostic criteria for

ODD, CD, anxiety, or depression.

COMPLEX ADHD

Further assessment is needed

in ruling in a comorbid

diagnosis related to anxiety or

depression (i.e. use of

SCARED, SPENCE, PHQ-9)

TOOLS FOR ASSESSMENT

OF ANXIETY

Parent and child versions

Completed in 5 to 10 minutes

Scored under 5 minutes

The Screen for Child Anxiety Related Emotional

Disorders (SCARED); children 8 to 18 years,

www.pediatricbipolar.pitt.edu/resorces/instruments

The Spence Children’s Anxiety Scale for children 6-

18 years, www.scawebsite.com. There is also a

preschool scale for children ages 3-6 years.

IDENTIFYING

DEPRESSION

The US Preventive Services Task Force (USPSTF)

found adequate evidence that screening

instruments for depression can accurately identify

MDD in adolescents aged 12 to 18 years in primary

care settings.

However, the USPSTF found no studies of

screening instruments for depression in children

aged ≤11 years in primary care (or comparable)

settings and concludes that the evidence is

inadequate.

PHQ-9- CAN BE USED IN ADOLESCENTS

AS YOUNG AS 12 YEARS OF AGE

PHQ-9 is the 9-item depression module from the full

Patient Health Questionnaire (PHQ).

Very useful clinical tool. PHQ-9 scores ≥10 had a

sensitivity of 88% and a specificity of 88% for Major

Depressive Disorder (MDD)

MDD diagnosed if 5 or more of the 9 depressive

symptom criteria present at least “more than half

the days” in the past 2 weeks, and includes

anhedonia.

PHQ-9 score cut-offs Depression symptom severity

5 Mild

10 Moderate

15 Moderately severe

20 Severe

BEHAVIOR THERAPY FOR BEHAVIOR

OR CONDUCT PROBLEMS

Children with

Disruptive Behavior

Disorder, Oppositional

Defiant Disorder, and

Conduct Disorder,

account for >50% of

those referred for

mental health services.

EXAMPLES OF DISRUPTIVE

BEHAVIOR:

Refusal to comply with teacher or parent directives

Challenges to authority

Loud, distracting or erratic behavior inappropriate to the setting

Overt hostility, defiance, insults

Verbal or physical threats to self or other

Verbal assault or abuse (cursing or foul language)

Sexually explicit language or behavior

Physical Intimidation

MANAGING DISRUPTIVE

BEHAVIORS

The Journal of Clinical Child and Adolescent Psychology has

published a study reviewing the research on treatments for

disruptive behavior problems in children aged 12 years and under.

In this study, CDC researchers looked at different approaches to

treatment and found Parent behavior therapy has the strongest

evidence as an effective treatment for disruptive behavior

problems in children.

• Group parent behavior therapy

• Individual parent behavior therapy with child participation

https://doi.org/10.1080/15374416.2017.1310044

Psychologists, social workers (LCSW’s), and licensed counselors

(LPC’s) can provide this kind of training to parents.

WHEN TO REFER TO

PSYCHOLOGIST

The following kinds of concerns may be addressed

by psychologist depending on scope of training and

expertise:

• Learning disabilities

• Autism spectrum disorders (ADOS-2)

• ADHD and disruptive behaviors

• Developmental delay

• Anxiety and depression

• Psychological evaluation with IQ, cognitive, academic and

language testing, adaptive skills

WHEN TO REFER TO

PSYCHIATRY

Psychiatrist or Mental Health Center for

significant psychiatric illness suspected:

• Conduct Disorder

• Bipolar

• Severe Depression

• Severe Anxiety

• Psychotic features

• Substance abuse

DEVELOPMENTAL-

BEHAVIORAL PEDIATRICIANS

As a Developmental-Behavioral Pediatricians, provide

consultations for diagnostic clarification and commonly

address behavioral and medication management needs

related to:

• Developmental delay, with or without behavioral

symptoms

• ADHD plus mild co-morbidities such as anxiety and

dysthymia (mild depression)

• Autism spectrum disorders and related behavioral

challenges

• Genetic syndromes with behavioral symptoms

DEVELOPMENTAL-

BEHAVIORAL PEDIATRICIANS

• DBP’s perform medical and developmental

evaluations, interpret results of psychological

testing and initiate or adjust medication

management for optimal care.

• In most cases, when treatment goals have been

attained, at DCH children are able to transition

back to their medical home for continued

coordination of care and medication

management through their primary care

provider.

RESOURCES

www.chadd.org

www.addwarehouse.com

www.add.org

www.nichy.org

www.nimh.nih.gov

www. Childmind.org