ADHD times 2

Question 1

DSM-5 Criteria for ADHD

Answer 1

(A) Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by Inattention and/ or Hyperactivity / Impulsivity

(B) Symptoms present prior to age 12

(C) Occur across 2 or more settings (cross informant agreement is not critical for diagnosis)

(D) Result in significant impairment in major life activities (no impairment = no disorder even if you have all of the symptoms).

(E)Symptoms does not occur exclusively during the course of schizophrenia or another psychotic disorder and are not explained by another mental disorder

Question 2

ADHD Diagnostic Criteria (A)

Answer 2

(A) Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/ or (2)

    (1) Inattention
    (2) Hyperactivity - Impulsivity

Question 3

Inattention

Answer 3

Six or more of the following symptoms that have persisted for at least 6 months that is inconsistent with developmental level and that negatively impacts directly on social and academic/ occupational activities

Inattention symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions.

Older adolescents/adults at least 5 symptoms are required

Question 4

Hyperactivity and Impulsivity

Answer 4

Six or more of the following symptoms that have persisted for at least 6 months that is inconsistent with developmental level and that negatively impacts directly on social and academic/ occupational activities
Hyperactive / Impulsive symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions.
Older adolescents/adults at least 5 symptoms are required

Question 5

Understanding ADHD

Answer 5

ADHD is the only disorder that deals with inhibition that dates back to childhood. So inhibition is a good differential diagnosis marker

If an adult comes in with sudden onset of inattention or impulsivity, you should look at other disorders (e.g. Depression) or label as acquired ADHD secondary to other pathology

The majority of children are identifiable as deviating from normal by caregivers between 3 and 4 years of age

You can reliably diagnose ADHD in preschoolers (e.g. 3.7 years old), but the precisions and reliability of diagnosis subtypes do not stabilize until about 7 or 8 years old

Question 6

Childhood Academic Impairments

Answer 6

Poor School Performance: 90 % +
Reduced productivity is the greatest problem

Accuracy is only mildly below normal (85 %)

Children with ADHD are unavailable for learning. By the end of 6th grade, many are at least 1 standard deviation below the mean.

Learning Disabilities (24 – 70 %)
LD is independent of ADHD.  They share some underlying genes (in reading especially) but it is not a causative relationship

Reading: 8 – 39 %; Math (12 – 27 %), Spelling (12 – 30 %), Handwriting (60 %+).

Reading and listening deficits through the impact of ADHD on working memory.

Question 7

Educational Outcomes

Answer 7

More often retained (25 – 45 %)
More often in special education (25 – 50%)
More often suspended (40 – 60 %)
Greater expulsion rates (10 – 18 %)
Higher drop out rate (30 – 40 %)
Lower class raking
Lower GPA
Fewer enter college
Lower college graduation rate

Question 8

Social- Emotional Impairments & ADHD

Answer 8

Peer Relationship Problems (50 – 70 %)
Less sharing, cooperation, turn taking
Intrusive, angry, reduced empathy and guilt
Most serious in ODD/ CD subgroup
70 % of children with ADHD are rejected by peers by 3rd grade
Social skills training is not very effective for kids with ADHD, any improvement seen are when parents are involved.

Poor emotional self regulation

Question 9

Cultural Considerations

Answer 9

Meta-analysis by Miller, Nigg and Miller (2009) found that African American youth had more ADHD symptoms but were diagnosed two-thirds as often as Caucasian youth.
May be influenced by parent beliefs about ADHD, more risk factors, and lack of treatment access

Ramierez & Shapiro (2005): Hispanic teachers rated the behavior of Hispanic students more severely, suggesting stricter standards of behavior within their own culture.

Hosterman et al (2008): Teacher’s ratings of ADHD symptoms in ethnic minority students (Hispanic / African American) were found to be more accurate reflections of true behavioral levels (observational data) than ratings of Caucasian students.

Question 10

Goals of Assessment

Answer 10

Confirm the presence or absence of ADHD & differential diagnosis
Dimensional in nature
Inform Intervention selection
Identify comorbid conditions & how it affects prognosis or decisions about treatment
Identify patterns of psychological strengths & weaknesses
Caregiver knowledge & motivation to change

Question 11

Stages of Assessment

Answer 11

Stage 1: Screening/ Teacher rating of ADHD symptoms
Stage 2: Multi-method assessment
Stage 3: Interpretation of Results
Stage 4: Developmental of Treatment Plan

Question 12

Assessment: ADHD

Answer 12

Multi-modal Behavioral Assessment
Varied measurement approaches
Rating Scales
Direct observations
Varied sources
Parent
Teacher
Self
Varied Settings
School
Home

Question 13

Assessment Methods: Interview

Answer 13

What info can interviews obtain
Developmental milestones and family history
Information about core symptoms
Health & educational history
Examples of behavioral functioning
Environmental variables

Examples
DISC: Diagnostic Interview Schedule for Children
DICA: Diagnostic Interview for Children & Adolescents
Does not allow for acute normative comparisons

Question 14

Assessment Methods: Observations

Answer 14

What info can observations obtain?
Direct observations of many types of behavior
Duration, partial/whole interval, momentary time sampling

Direct Observational Procedures:
BASC SOS – Behavior Assessment System for Children, Student Observation System
BOSS – Behavioral Observation of Students in Schools
AET-SSBD = Academic Engaged Time -Systematic Screen for Behavior Disorder
ADHD SOC – ADHD School Observation Code
DOF – Direct Observation Form

Question 15

BASC (SOS) Structured Observation System

Answer 15

Purpose: The BASC–2 Student Observation System lets you code and record direct observations of a child’s behavior. Using momentary time sampling–during 3-second intervals spaced 30 seconds apart for 15 minutes–you can objectively rate a wide range of behaviors.

It provides numerical recording of the behaviors occurring in the natural setting
Confirm or disconfirm teacher impressions
Determine the severity of the problem
Provide a baseline / benchmark for which to assess effectiveness of intervention
Provide feedback for parents

Question 16

Key Points for Effective Interventions

Answer 16

Timing is everything!
ADHD children have problems with impulse control, so reinforcers should be given immediately after goal behavior
Try to limit the delay between behavior and reward
Individualize it!
All students are different – make sure you know what is rewarding for the student you are working with
Stay positive!
Target behaviors should always be stated in positive terms – what do you want to see?
Be consistent, and eventually you will see change
Sometimes it gets worse before it gets better – don’t give up!

Question 17

Antecedent-Based Strategies

Answer 17

Antecedent interventions are things done before the target behavior occurs, preventing problems before they occur

These strategies also involve designing the environment to be suitable for a child with ADHD:
fewer visual and auditory distractions, removing play materials from workspace, modifying the length of tasks, working in closed spaces, and checking in with students during independent seat work

Question 18

Environmental Modifications

Answer 18

Preferential Seating
Refocusing of attention before asking a question and frequent checks for understanding
Work modifications (e.g., reducing the amount of work on a page, color coding and highlighting)
Remind and communicate to students about rules / expected behaviors
Circulate in classroom to monitor/provide feedback
Use nonverbal cues to redirect
Maintain brisk pace of instruction but ensure understanding of activities
Manage transitions in well-organized manner

Question 19

Consequence-Based Strategies

Answer 19

Manipulation of events after a target behavior to:
Increase probability of adaptive responding
Decrease probability of problematic behavior

Token reinforcement programs
Contingency contracting
Daily Report Card
Response cost
Time-out from positive reinforcement

Question 20

Daily Report Card

Answer 20

Child /parent receives daily feedback about performance in several areas of classroom functioning on a daily basis

Can be used by teacher to provide student with reward at the end of the day and can be sent home with child and the rewards are given at home, based on feedback on performance

Several behavioral goals are selected depending on presenting problems in child (no more than 5 behaviors)
Ratings from 1-5 are entered by teacher at different points throughout the day for each goal
Can be used by multiple teachers and can include comments

For home-based contingency:
Can be signed and brought home each day & returned the next
Child can earn rewards at home based on number of points accumulated
Requires advance communication with families involved and their cooperation
See attached sample

Question 21

Behavioral Peer Interventions

Answer 21

Social Skills training conducted weekly in clinical/school settings not evidenced-based
Some conducted with Behavioral Parent Training
Summer Treatment Programs are well-established
Day long programs over multiple weeks (5-8)
200-400 hour long treatment
SST followed by coached group play in recreational activities
Children will listen more often to other children than adults

Question 22

General Classroom Suggestions

Answer 22

Intersperse low appeal with high appeal activities
Be more animated, theatrical, dramatic
Schedule most difficult subjects in the morning
Use direct instruction or highly structured teaching materials
Have child state pre-work goals (How many do you think you will complete?)
Require continuous note taking during lectures and while reading
Increase praise, approval, appreciation (1 minute manager)
Try team based reward approach
Allow access to rewards often (daily or more)
Home-school connection