pediatric neuropsychology case studies || the energizer bunny meets shirley temple: attention...

Chapter 15

The Energizer Bunny Meets Shirley Temple:

Attention Deficit Hyperactivity Disorder,

Combined Type

Michael J. Zaccariello

‘‘She will not sit still and be quiet! She just goes and goes nonstop.’’ Jenna’s

exasperated mother moaned during the initial clinical interview. Her voice was

tinged with both frustration and guilt over her reactions to her daughter’s behavior

that occasionally resulted in abrupt, sharp rebukes. In addition, Jenna herself had

begun to realize that something was ‘‘wrong.’’ This previously effervescent and

optimistic child began to remark that she was stupid and dumb and was being

ridiculed by peers at school.

Historically, Jenna was a highly energetic toddler who talked excessively.

Although never significantly or consistently oppositional or argumentative, her

behavior became increasingly more difficult to control as she grew older. Jenna’s

mother noted that she literally played all day long and seemingly never tired. In

addition, it was impossible for her to sit down appropriately for longer than a few

minutes at a time. She constantly fidgeted, kicked her legs, or touched objects.

Cognitively, she had extreme difficulty staying focused and on-task, and needed

frequent redirection or a quiet, nonstimulating environment to complete work. She

had a tendency to be impulsive, rushing through her school assignments, which

resulted in careless mistakes. She had organizational problems in her day-to day-

activities (e.g., frequently losing objects or articles of clothing). Academically, she

had always been an average to above average student, but starting in the second

grade she began to demonstrate some struggles in mathematics, spelling, and

handwriting. Her mother’s perception was that Jenna’s difficulties in these academ-

ic areas were not reflective of a skill deficit but, rather, extreme problems with

sustained focus and impulsivity.

Medically, Jenna was in perfect health, and both language and motor develop-

mental milestones were reached within normal limits. She had no significant

problems with vision, hearing, eating, or sleeping. She was prescribed no medica-

tion at the time of the evaluation.

Socially, Jenna was described as an outgoing and engaging child who enjoyed

horseback riding and any outdoor activities. She lived with her parents and an older

J.N. Apps et al. (eds.), Pediatric Neuropsychology Case Studies: 141

From the Exceptional to the Commonplace.# Springer Science þ Business Media, LLC 2010

brother who had been diagnosed with Attention Deficit Hyperactivity Disorder-

Primarily Inattentive Type (ADHD-I) by a pediatric neuropsychologist. The home

environment was described as positive and loving.

Jenna’s parents requested a neuropsychological evaluation to identify her pattern

of cognitive strengths and weaknesses. However, their prime concern was her

increasing restlessness and difficulties with attention. They were also concerned

with the emotional toll of social ridicule because of her high energy behavior. Her

parents questioned if she met formal criteria for Attention Deficit Hyperactivity

Disorder (ADHD) and wished for professional corroboration of their suspicion.

Jenna had never undergone a neuropsychological evaluation, and her mother

was curious about her overall cognitive skill set. Consequently, a broad approach

was taken, with a focus on attention and mental executive function measures.

Measures of attention are thought to assess one’s ability to direct and maintain

focus on a task. Executive functions are considered a related construct and involve

higher-ordered, goal-directed abilities that are organizational or supervisory in

nature. This cluster of abilities allows one to engage in abstract reasoning, prob-

lem-solving, judgment, cognitive flexibility, planning, and organization. Utilizing

feedback to correct responses, inhibit inappropriate behavior, and sustain one’s

attention is also considered in this area. Specific domains that were assessed

included intellectual ability, fine motor functions, attention, executive functions,

language fluency, visual-spatial abilities, and comprehensive academic skills de-

velopment. Behavioral ratings scales completed by both Jenna’s teacher and par-

ents were included as a critical foundation of the assessment.

Conceptual Diagnostic Background

With the introduction of the Diagnostic and Statistical Manual of Mental Disorders,

Third Edition, in 1980, delineation was made between the presence and absence of

hyperactive symptoms in children with attentional difficulties. Current diagnostics

further clarified this distinction into three types: primarily inattentive (ADHD-I),

primarily hyperactive-impulsive (ADHD-H), and combined (ADHD-C). However,

some recent studies have questioned the diagnostic accuracy of the current categor-

ical subtypes of ADHD and propose more of a dimensional model (Frazier, Young-

strom, & Naugle, 2007). Prevalence studies indicate that ADHD (devoid of a

specific subtype) is diagnosed three times as often in boys than girls in community

samples. This discrepancy rises to five to nine times more often in clinic-referred

groups. It is thought that ADHD-C occurs more often in boys and that ADHD-I

tends to be diagnosed more in girls. As children age, hyperactive symptoms

typically dissipate, but inattention symptoms can remain prominent. In a sense,

one does not typically outgrow ADHD.

There has been much debate in the literature concerning the usefulness

and relevance of neuropsychological tests in the diagnosis of ADHD. Although

a comprehensive review of this issue is beyond the scope of this brief case,

142 M.J. Zaccariello

indications suggest that the most scientific and powerful diagnostic indicator of

ADHD is a significant level of inattention or hyperactive symptoms as reported on

behavioral rating scales.

So, this begs the question, what is the point of a comprehensive neuropsycho-

logical evaluation of a child with ADHD features? Although not necessarily

diagnostic, a neuropsychological evaluation can provide a snapshot of how signifi-

cantly inattention or hyperactivity interacts with performance in other cognitive and

academic domains. Once such areas have been identified, specific recommenda-

tions beyond those typically given for ADHD can be outlined in the report to

maximize a child’s learning potential (Tables 15.1–15.3).

Test Results

On formal testing, Jenna presented as an absolutely delightful and pleasant young

girl. She readily engaged in conversation and expressed an appropriate range of

emotion throughout the evaluation. Her social interactions were appropriate, and

she spontaneously demonstrated a very kind and helpful attitude (e.g., picking up

dropped items).

In terms of her approach to testing, there was significant evidence of motor

restlessness throughout the evaluation, coupled with moderate levels of distracti-

bility, inattentiveness, and impulsivity. She had extreme difficulty sitting upright

and still in her seat. She frequently fidgeted, got out of her chair, rubbed the walls,

and looked at herself in an one-way mirror. Rather frequently, she reached for test

stimuli before being told to do so and/or blurted out answers before receiving

Table 15.1 Intellectual

Wechsler Intelligence Scale for Children – Fourth Edition Scorea Percentile

Full Scale IQ 113 81st

General Ability Index 111 77th

Verbal Comprehension Index 99 47th

Similarities (10)

Vocabulary (8)

Comprehension (12)

Perceptual Reasoning Index 121 92nd

Block Design (12)

Picture Concepts (14)

Matrix Reasoning (14)

Working Memory Index 110 75th

Digit Span (11)

Letter-Number Sequencing (13)

Processing Speed Index 109 73rd

Coding (12)

Symbol Search (11)a Standard score, (scaled score), [T-score], {z-score}.

15 The Energizer Bunny Meets Shirley Temple 143

Table 15.2 Academic achievement

Woodcock Johnson Tests of Achievement – Third Edition Score Percentile

Broad reading 108 71st

Letter-word identification 110 75th

Passage comprehension 100 51st

Reading fluency 108 70th

Basic reading skills 109 73rd

Letter-word identification 110 75th

Word attack 106 66th

Broad math 120 91st

Calculation 113 80th

Applied problems 126 96th

Math fluency 103 59th

Broad written language 104 60th

Spelling 103 58th

Writing samples 104 60th

Writing fluency 102 55th

Academic skills 110 75th

Academic applications 112 78th

Academic fluency 106 65th

Table 15.3 Other cognitive functions

Tests Scorea Percentile

Attention-Deficit Hyperactivity Disorder RatingScale – Fourth Edition

Home Version

Total >99th

Hyperactivity-impulsivity 97th–98th

Inattention 98th–99th

School Version

Total 95th–96th

Hyperactivity-impulsivity 94th–95th

Inattention 94th–95th

Achenbach Child Behavior Checklist

Parent Form

Anxious/depressed [63] 90th

Withdrawn/depressed [50] 50th

Somatic complaints [53] 62nd

Social problems [50] 50th

Thought problems [58] 79th

Attention problems [80] >97th

Rule-breaking behavior [55] 69th

Aggressive behavior [60] 84th

Teacher’s Report Form

Anxious/depressed [50] 50th

Withdrawn/depressed [50] 50th

Somatic complaints [50] 50th

(continued)


instructions. Despite these behaviors, she was relatively easy to redirect but did

require constant prompting throughout the test session.

Consistent with Jenna’s test session behavior, both her parents and teacher were

observing a significant level of inattentive and hyperactive symptoms. Her mother

also noted marked problems with impulse control, general organizational skills, and

the ability to self-monitor behavior. Her cognitive and behavioral difficulties were

leading to mild to moderate compliance issues at home and school.

Table 15.3 (continued)

Tests Scorea Percentile

Social problems [54] 65th

Thought problems [50] 50th

Attention problems [71] >97th

Rule-breaking behavior [59] 81st

Aggressive behavior [60] 84th

Gordon Diagnostic System

Vigilance task (9 minutes)

Correct 100 50th

Commission errors <1 <1st

NEPSY

Auditory Attention and Response Set (10) 50th

Attention Task (12) 75th

Response set task (10) 50th

Wisconsin Card Sorting Test

Categories >16th

Total errors 96 39th

Perseverative responses 98 45th

Perseverative errors 98 45th

Nonperseverative errors 92 30th

Conceptual level responses 100 50th

Failure to maintain set 2nd–5th

Learning to learn 2nd–5th

The Tower of London 72 3rd

Behavior Rating Inventory of Executive Function

Parent Form

Behavioral regulation index [61] 86th

Inhibit scale [80] 96th

Shift scale [45] 38th

Emotional control scale [48] 50th

Metacognition index [74] 97th

Initiate scale [67] 95th

Working memory scale [70] 94th

Plan/organize scale [69] 94th

Organization of materials scale [59] 83rd

Monitor scale [87] 99th

Global executive composite [70] 96th


A quick glance at Jenna’s neuropsychological profile revealed that most of her

scores were average to above average. Overall intellectual ability was high average

with a significant strength in nonverbal intellectual ability relative to her solidly

average verbal intellectual ability. She had little difficulty on specific tests of

language, visual-spatial processing, or fine motor dexterity. Her academic skills

development was progressing at the expected rate with no evidence of deficit in any

academic domain.

A different picture emerged on tests of attention and mental executive function.

Her test scores ranged from average to impaired. Jenna had difficulty on most tasks

where she had to rely on self-regulation strategies to successfully negotiate the

measure and did not have the examiner encouraging her to remain attentive. She

was impulsive, which resulted in a high number of mistakes. In addition, she

displayed a weakness in being able to change problem solving strategies efficiently.

Formulation and Recommendations

On the basis of the responses to behavioral questionnaires and test session behavior,

Jenna had significant inattention, distractibility, impulsivity, and motor restless-

ness, which were consistent with individuals diagnosed with ADHD-C. She could

not sit appropriately for longer than 10–15 min at a time and frequently reached for

test stimuli or blurted out answers.

Jenna was subsequently diagnosed with ADHD-C, which includes a mixture of

problems with behavioral inhibition, sustained attention, organization, consistency

of performance, and/or goal-directed behavior. ADHD-C is the most common form

of ADHD that arises in childhood in 3–7% of the population (American Psychiatric

Association, 2000). The symptoms of ADHD do not spontaneously disappear in the

majority of cases but can be treated to some extent with behavior management and/

or medication. Jenna’s combination of ADHD-C features included average intel-

lectual ability and average to above average underlying academic skills. Therefore

it would be realistic for her to attain average to above average performance in

school most of the time.

Although not directly assessed, another important finding concerned is the

Jenna’s emotional functioning. During the assessment, she acknowledged strug-

gles in school and admitted self-esteem issues related to her attentional prob-

lems. Studies have shown that 40% of children with ADHD show signs of either

depression and/or anxiety (Spencer, Biederman, & Wilens, 1999). It is vitally

important to address the behavioral and cognitive difficulties that children with

ADHD typically experience. However, professionals, caretakers, and school per-

sonnel should also be acutely aware of the impact and range that ADHD can have

on a child’s emotional and social well-being. Her parents were provided with

psychotherapy referrals, which they could use if her distress continued or worsened.

At least 75% of children with ADHD benefit from stimulant medication. Jenna’s

behavioral and cognitive presentation of ADHD symptoms make an evaluation for

stimulant medication routinely recommended. If she continues using the medica-


tion over a long period of time, observation trials off medication for a week at a time

approximately twice during each school year would be useful to monitor her

ongoing benefit or need for the medication.

Standard suggestions for managing attention and organization problems in the

classroom included obtaining eye contact with Jenna prior to delivering directions.

It may be helpful to place a hand on her shoulder or arm and to be sure that

directions are clear, simply stated, and given one at a time. Delivering more com-

plex directions in brief, simple, numbered steps (e.g., ‘‘First, read pages 1–10;

second, answer questions 1–5; and third, check answers in the back of the book’’)

would also be helpful. If Jenna continues to have difficulty, writing down key

instructions and taping them to her desk may help cue her.

Presenting material in small, successive units that can be mastered hierarchically

would allow Jenna to maximize her attentional capacity, assist in organizing the

material to be learned, reduce the feeling of being overwhelmed by the material,

and develop greater self-confidence as she progresses through the material.

Jenna would need distractions minimized to the greatest extent possible in the

classroom (e.g., seating her at the front of the class and increased one-to-one contact

with the teacher), as well as regular feedback provided with concrete suggestions for

appropriate behaviors. It would also be helpful to provide consistency and structure

through daily schedules; standard seating arrangements; clearly defined class-

room expectations, rules and consequences; and clear places for necessary materi-

als, such as color-coded subject folders, and reinforcement for using organizers.

Jenna needs guided practice in planning how to complete assigned tasks (what

is needed, how to break tasks into manageable parts, estimating time needed for

each part) and to be assigned tasks or classroom duties that she can successfully

complete.

It would be helpful to provide other organizational checklists, such as steps to

get ready to go home after school, and to remind Jenna at the end of the day about

what she needs for home and the next day. Also, Jenna would benefit from pacing

her work and changing the pace or task frequently and from opportunities for

controlled movement.

Given Jenna’s inattentive and hyperactive tendencies, she would not always beexpected to perform at top efficiency level on timed tasks. Extra time can be given

strategically when needed, and curriculum requirements such as timed math tests

might be loosened or modified for her, but not omitted.

At home, Jenna needs more frequent attentional cueing. Adults should help her

break complex tasks into smaller steps. Commands should be given one or two at a

time, and longer sets of commands should be repeated, rehearsed, or written down.

More frequent attentional cueing (e.g., ‘‘look at this now’’; ‘‘this is important to pay

attention to’’) in everyday life will be needed in the long run, and adults should try

to avoid becoming frustrated with this need. She should be given extra instruction in

organizational skills such as outlining, diagramming, planning a sequence of steps

in complex tasks, and taking strategic breaks during extended study time.

Jenna and her family would benefit from ongoing consultation with a psycholo-

gist who is knowledgeable about behavior management approaches for children


with ADHD symptoms. Family psychotherapy could also provide an opportunity to

work on family interaction issues, emotional issues, and/or peer interaction issues

that often accompany ADHD.

Jenna’s difficulties with abstract reasoning and logical problem-solving tasks

suggest that she may have difficulty with some complex, novel tasks. Specifically,

she may find it difficult to analyze the requirements of a task and apply effective

strategies toward a solution. As a result, she may get frustrated with the acquisition

of novel cognitive skills such as higher level academics.

Although not indicated at this time given her average to above average academic

skills development, with a diagnosis of ADHD, Jenna may be eligible to have an

Accommodation Plan prepared for her as mandated under Section 504 of the

Rehabilitation Act of 1973. This could be particularly important if her academic

performance begins to suffer due to her ADHD presentation as she progresses to

higher grades with greater requirements for attention and self-control. Many of the

specific attention and organization suggestions outlined could be incorporated into

an Accommodation Plan.

Additional Resources

Key Concepts and Terms

Attention The cognitive process of selectively concentrating on one aspect of the

environment while ignoring other things.

Executive functions Processes that are most involved in giving organization and

order to actions and behavior. Executive functions involve (1) strategic thinking

and future planning, (2) the ability to inhibit or delay responding, (3) initiating

behavior, and (4) shifting between activities flexibly.

References

Resources for Clinicians

American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders(4th ed., Text revision). Washington, DC: American Psychiatric Association.

Barkley, R. A. (2006). Attention-deficit hyperactivity disorder. (3rd ed.). New York: Guilford

Press.

Cutting, L. E., & Denckla, M. B. (2003). Attention: Relationships between attention-deficit

hyperactivity disorder and learning disabilities. In H. L. Swanson, K. R. Harris, & S. Graham

(2003), Handbook of learning disabilities (pp. 125–139). New York: Guilford Press.

Ellison, P. (2005). School neuropsychology of attention-deficit/hyperactivity disorder. In R. C.

D’Amato, E. Fletcher-Janzen, & C. R. Reynolds (Eds.), Handbook of school neuropsychology(pp. 460–486). New Jersey: Wiley


Frazier, T. W., Youngstrom, E. A., & Naugle, R. I. (2007). The latent structure of attention-deficit/

hyperactivity disorder in a clinic-referred sample. Neuropsychology, 21, 45–64.Spencer, T., Biederman, J., & Wilens, T. (1999). Attention-deficit/hyperactivity disorder and

comorbidity. Pediatric Clinics of North America, 46, 915–927.U.S. Department of Education, Office of Special Education Programs’ (OSEP), Individuals with

Disabilities Education Act (IDEA) web site: http://www.idea.ed.gov/explore/home

Resources for Families

A.D.D. Warehouse, www.addwarehouse.com/shopsite_sc/store/html/index.html. Provides general

information on Attention Deficit Hyperactivity Disorder and a comprehensive catalog of

books, tapes, and training materials.

Barkley, R. A. (2000). Taking charge of ADHD: The complete, authoritative guide for parents.

(2nd ed.) New York: Guilford Press.

Children with Attention Deficit Disorders (CHADD), http://www.chadd.org. Lecture programs,

parent support groups, and valuable information for parents and teachers.

Dawson, P., & Guare R. (2003). Executive skills in children and adolescents: A practical guide to

assessment and intervention. New York: Guilford Press.

Flick, G. L. (1996). Power parenting for children with ADD/ADHD: A practical parent’s guide for

managing difficult behaviors. Hoboken, New Jersey: Jossey-Bass.

Learning Disabilities Association of America, http://www.ldanatl.org

National Center for Learning Disabilities, http://www.ncld.org, www.schwablearning.org and

http://www.ldonline.org/.


http://www.idea.ed.gov/explore/home

http://www.chadd.org

http://www.ldanatl.org

http://www.ncld.org

http://www.ldonline.org/

www.addwarehouse.com/shopsite_sc/store/html/index.html

www.schwablearning.org

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