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Diagnosing ADHD: Conducting Valid, Comprehensive, and Collaborative Assessments Caroline Buzanko Assistant Professor Athabasca University carolinebuzanko@athabascau.ca
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Overview Brief overview of the nature of ADHD Assessment of ADHD Purpose Methods & measures Working collaboratively Integrating results Linking results to intervention
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ADHD Affects 5-8% of the population 70% increase in children 100% increase in adults Male:female ratio: 6:1 (clinical) 3:1 (community)
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ADHD Cluster of behavioral deficits Impairments to meet societal expectations
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ADHD Use a practical definition of ADHD to guide assessment Greater understanding of the child Translates data into functional behavior
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Practical Definition
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ADHD: A disorder of inhibition (vs. attention)
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ADHD: A problem of performance and of inconsistency (vs. skill deficit or inability)
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ADHD: A Disorder of EF
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“By the time I think about what I’m going to do I’ve already done it”
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EF: Developmental Considerations
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ADHD Secondary impacts Family functioning Adults vulnerable to multitude of difficulties: Psychiatric Emotional Cognitive Academic Vocational Substance Antisocial
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What is the Purpose of Assessment?
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Purpose of Assessment? Determine presence/absence of ADHD Second opinion Social/Emotional/Behavioral/Academic functioning Outline appropriate interventions to address the impairments revealed Funding purposes Determine comorbid conditions Affect prognosis? Identify child’s strengths and weaknesses and treatment planning Parents: Understanding of ADHD & intervention strategies Motivation for change
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Evidence Based Assessments Using research and theory to inform the assessment process Reliability and validity Context of instruments Incremental validity and clinical utility
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“Textbook approach” Comprehensive Thorough emotional, behavioural, and developmental assessment Multiple sources across settings (home, school and social settings) Multiple measures Decisions based on accepted standard
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Assessing ADHD
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Assessing ADHD
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Assessing ADHD *****Planning for intervention*****
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Assessing ADHD: Beyond Symptoms
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Assessing Comorbidities
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Assessing Comorbidities Is a diagnosis be the main focus? What is the nature of the impairment? What are the behaviours that need to be targeted? Measures of impairment vs. symptoms Rating scales & FBA Developmental deviance?
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Assessment considerations Working understanding of diagnostic criteria Practical understanding of symptoms’ affect individual’s functioning Diagnostic strategy Multidimensional Frequency/severity fluctuate across settings and people Ultimate goal: promoting success
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Objectives Reliability and validity of approaches to assessing symptoms and impairments of ADHD Effective integration of information Balance between treatment utility and cost effectiveness
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Methods Social, Emotional, Behavioral, and Academic Functioning (across contexts) History and Clinical interviews Empirically supported behaviour rating scales Review of files Behavioural observations Anecdotal comments Measures of Psychological Processes Cognitive ability Academic achievement Neuropsychological tests
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Parents experiences
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Phase 1: Intake Clinical interviews Engaging parents
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Intake: Textbook recommendations Initial questions: Referral question & purpose of the assessment Previous assessments? Other diagnoses? Medications? If so, possible to withhold for testing? Initial paperwork (1st or 2nd phase): Information forms/demographic information Developmental/medical forms Behavior rating scale Rating scale for ADHD symptoms EF rating scale Adaptive functioning checklist Home/school situations questionnaire Previous reports/records
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Intake: Clinical interviews With parents Clarify reason for assessment Child’s development and behavior General descriptions and presenting problems Get specifics Range of behaviours and settings EF and manifestations at home and school Rule out alternative explanations
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Intake: Clinical interviews Functioning in developmental domains Academic, intellectual, language, motor, emotional Consideration of differential diagnosis Social Trouble making/keeping friends? Interactions/behaviors with peers? Relationships with classmates? Recreational activities School History (preschool to present) Relationships with teachers/classmates, academic functioning, accommodations/strategies, comments from teachers about performance/behaviors
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Intake: Clinical interviews Extended family history Sibling development, parent development, psychiatric difficulties in the child/family, medical history, developmental disorders or tic disorders Family relations & other parental factors Employment problems Family functioning (e.g., stress, parent-child interactions, child compliance, marital difficulties, parent and child’s social network) Parent psychopathology, knowledge and skills Previous treatment Parent understanding of ADHD
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Intake: Clinical interviews Medical history Significant events Obtain impressions on child and parent functioning Parent-child interactions
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Intake: Clinical interviews With teachers Symptoms and associated impairments Productivity Behaviours and environmental influences Relationships (teacher/peers) Academic skills and challenges Learning to learn skills/EF skills Strategies
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Sample questions: Range of behaviors: When does student pay attention? When does student have trouble paying attention? Why do you think there is a difference between these situations? What typical activities do you share/direct with this student? e.g., Classroom lectures vs. interactive hands-on activities; chores and homework vs. leisure activities Obtain benchmark samples of behaviors Probe: degree of problems/success with task, influences on behavior in the task, developmental appropriateness of the behavior
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Intake: Clinical Interviews Unstructured Allows for flexibility Can be useful for treatment planning BUT Questionable reliability and validity Influence of personal biases Structured Reliability/validity Map onto DSM criteria BUT Limited utility for treatment planning Time-consuming, rigid
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Intake: Engage parents through preparation
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Phase 2: Formal assessment Rating scales Clinical measures Collaboration Assessment intervention
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Engage Parents: communicate throughout
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Rating Scales At least two adults who interact with the child regularly (e.g., teacher and parent) Assessment tools: Broadband assessments Not sufficient for diagnosis but useful for: screening for ADHD, identifying comorbidities, developmental appropriateness of behaviour Narrowband Non-DSM based ADHD rating scales
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Rating Scales Symptom count and pervasiveness of difficulties at home and school Measuring impairment Teacher and parent report Can provide information on key impaired functional domains (for further assessment/treatment) Parent functioning
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Rating Scales Consider: Purpose of instrument Choice of respondents Length of time known child Familiarity with behaviours in specific setting Interrater reliability Reliability/validity of instruments Incremental validity Clinical utility
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Rating Scales: Engage parents Explanations of purpose Amount expected to complete Extended Inquiry!!!
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Functional impairment Clinically meaningful symptoms AND clinically meaningful impairment Determine if symptoms cause impairment Measuring impairment Can provide information on impaired functional domains Across contexts Teacher and parent report situational and contextual factors explored
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Functional Impairment
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Functional Impairment
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Functional Impairment
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Behavioural Observations Within clinic (analog) Two children may obtain similar scores, but one may respond impulsively without checking his answer, whereas the other one takes her time and second guesses herself Within classroom (natural) Independent observer Supplemented by teacher or parent implemented frequency counts
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Additional Information Anecdotal information School records Report cards Group achievement testing Individualized education program Assessment data
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Functional Behaviour Analysis
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Functional Behaviour Analysis
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Clinical Measures MUST have a specific goal for using a measure before you begin Explore extraneous factors or coexisting conditions Potential causes of attention problems Clarify nature and extend of child’s difficulties
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Psychological Processes Cognitive capacity Executive functions
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Psychological Processes
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Psychological Processes
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Clinical Measures Considerations: Determine the processing demands of the tasks Psychometric properties Context being used Incremental validity Clinical utility Child’s age Area of difficulty What has already been given
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Clinical Measures Consider level of performance, pattern between measures, and manifestation in real world E.g., functional working memory Careful with interpretation! Medications Provision of prompts and reinforcement
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Incremental Validity How to conduct the most efficient and effective assessment? Child’s age Useful informants Relevant constructs
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Incremental Validity Uses of information Clinical utility? Does more testing give us new , useful information? Interviews and/or rating scales? Are the outcomes/purpose of the assessment met? Subset of items on a measure vs. full measure? Will observations/other methods provide information beyond rating forms? Verbally intrusive behaviors , seatwork completion/accuracy & required supplies in desk FBAs that focus on functioning vs. DSM symptoms
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Potential Problems
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Integrating data Need to have enough: Information for diagnostic accuracy Information for diagnostic certainty Move beyond symptom count What are kids referred for? Focus assessment on specific areas of impairment Highlight strengths and challenges
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Linking to intervention
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Linking to intervention Using data to inform interventions Understanding impairment & real world outcomes Linking results to specific difficulties the child has, family needs, and referral question
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Linking to intervention
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Symptom vs. impairment “often does not seem to listen when spoken to directly”
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Assessment intervention Purpose: Engage in meaningful discussions about client concerns Test items can be used to invoke the issues found relevant through prior discussion/testing Test hypotheses Practice potential intervention strategies Collaborative problem-solving
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Third phase: Communicating the Diagnosis Influential in how parents perceive entire process Majority of parents who have expressed dissatisfaction were most dissatisfied with how the diagnosis was communicated Three major reasons: Professional manner of clinicians Context in which the diagnosis was communicated How information imparted
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Professional Manner
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Professional Manner Be careful with words used Avoid negative comments Maintain a hopeful and strengths-based approach (Congratulations!) Be direct and transparent Open and honest about child’s difficulties and needs
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Privacy In-person Both parents together Context
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Communicating the results Acknowledge anxiety/worries, questions/concerns Collaborative summary discussion Describe the measure overall No need for detailed review of test scores
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Communicating the results Offer a “day in the life” of the child Extent and severity of problems experienced in different areas of functioning Relationship of one problem to another Hypothesized reasons for problems How these problems affect the child
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Communicating the results Clear information about diagnosis How diagnosis was made (explain process etc.) Common sense definitions (i.e., what parents already likely know) Immediate and long-term implications of diagnosis Relationships between diagnoses
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Communicating the results Specific information as it relates to their child Relevant information about how child’s presenting difficulties relates to diagnosis What are the child’s needs/target problems Describe child vs. label Information as it relates to their family Issue concerning the affect on families (e.g., stress, marital conflict, parent psychopathology) Help them understand they may operate differently Highlight child’s strengths and abilities
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Communicating the results Specific information how to best support the child Appropriate, individualized, specific treatment recommendations Specific behaviour management strategies etc. How recommendations to be implemented What can be done to further insulate the child from additional problems Help them to understand the forces that affect their child
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Parents need to leave with a layman’s understanding of their child’s problems, their strengths, their diagnosis and recommendations
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Communicating collaboratively Parents reflect on how the results fit their own experience and understanding Give real-life examples to help refine the meanings of the assessment findings Through collaborative dialogue, the meaning of test results is reached By the end of the meeting, there are joint answers to the assessment questions
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Communicating collaboratively Parents to take an active role, primary role for creating change Parent assessment about ADHD Identify specific and useful information how to best support the child Empower parents to accept their responsibility for supporting/managing child’s problems Highlight family variables that can promote child development, such as lifestyle, emotional support etc. Brainstorm Interventions
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considerations
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References American Academy of Pediatrics Committee on Quality Improvement and Management, Subcommittee on Attention-Deficit/Hyperactivity Disorder. (2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/ hyperactivity disorder in children and adolescents. Pediatrics, 128(5), 1007-1022. doi: 10.1542/peds.2011-2654 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Anastopoulos, A. D., & Shelton, T. L. (2001). Assessing attention-deficit/hyperactivity disorder. New York: Kluwer Academic/Plenum. Angold, A., Costelio, E. J., Farmer, E. M., Burns, B. J., & Erkanli, A. (1999). Impaired but undiagnosed. Journal of American Academy of Child and Adolescent Psychiatry, 38(2), 129-137. doi: 10.1097/00004583-199902000-00011 Aschieri, F. (2012). Epistemological and ethical challenges in standardized testing and collaborative assessment. Journal of Humanistic Psychology, 52(3), 350–368. doi:10.1177/0022167811422946. Aschieri, F., Fantini, F., & Bertrando, P. (2013). Therapeutic assessment with children (TA-C): Psychological assessment as a family systems intervention. Australian and New Zealand Journal of Family Therapy, 33(4), 285–298. doi:10.1017/aft.2012.37 Barkley, R. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York, NY: Guilford Press. Barkley, R. & Mash, E. J. (2007). Assessment of childhood disorders. New York: Guilford Press. Biederman, J. (2005). Attention-deficit/hyperactivity disorder: A selective overview. Biological Psychiatry, 57(11), 1215-1220. doi: 10.1016/j.biopsych.2004.10.020 Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA; 2011). Canadian ADHD practice guidelines (3rd. ed.). Toronto ON: CADDRA. Retrieved from http://www.howardschneider.ca/resources/caddraGuidelines2011.pdf Goldstein, S. (2010). Attention-Deficit/Hyperactivity Disorder. In S. Goldstein & C. R. Reynolds Handbook of neurodevelopmental and genetic disorders in children, Second edition (pp. 131-144). New York: Guilford Press.
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References Goldstein, S. & Naglieri, J. A. (2008). The school neuropsychology of ADHD: Theory, assessment, and intervention. Psychology in Schools, 45, 859-874. doi: 10.1002/pits.20331 Goldstein, S., & Naglieri, J. A. (2006). The role of intellectual processes in the DSM-V diagnosis of ADHD. Journal of Attention Disorders, 10, 3–8. doi: 10.1177/1087054705286059 Hale, J. B., Reddy, l. A., Wilcox, G., McLaughlin, A., Hain, L., Stern, A.,Henzel, J., & Eusebio, E. (2010). Assessment and intervention practices for children with ADHD. In D. C. Miller (Ed.) Best practices in school neuropsychology (pp. 225-279). New Jersey: John Wiley & Sons. Hale, J. B., Yim, M., Schneider, A. N., Wilcox, G., Henzel, J., & Dixon, S. Cognitive and neuropsychological assessment of Attention-Deficit/Hyperactivity Disorder. In Contemportary intellectual assessment: Theories, tests and issues, Third edition (pp. 687-707). New York: Guilford Press. Heffer, R. W., Barry, T. D., & Garland, B. (2009). History, overview and trends in child and adolescent psychological assessment. In Matson et al. (eds) Assessing Childhood Psychopathology and Developmental Disabilities. doi: 10.1007/978-0-387-09528-8 Hunsley, J., & Mash, E. J. (2007). Evidence-based assessment. Annual Review of Clinical Psychology, 3, 29-51. doi: 10.1146/annurev.clinpsy.3.022806.091419 Johnston, C., & Mash, E. J. (2001). Families of children with attention-deficit/hyperactivity disorder: Review and recommendations for future research. Clinical Child and Family Psychology Review, 4(3), 183–206. doi: 10.1023/A:1017592030434 Koonce, D. (2007). Attention Deficit Hyperactivity Disorder assessment practices by practicing school psychologists. Journal of Psychoeducational Assessment, 25, 319-333. doi: 10.1177/0734282906298264 National Association of School Psychologists (2011). Position statement: Students with attention deficit hyperactivity disorder. Retrieved from http://www.nasponline.org/about_nasp/positionpapers/Students_With_ADHD.pdf National Institute for Clinical Excellence (NICE; 2013). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. (London, NICE). Retrieved from http://www.nice.org.uk/nicemedia/live/12061/42059/42059.pdfPelham, W. E., Fabiano, G. A., & Massetti, G. M. (2005). Evidence-based assessment of Attention Deficit Hyperactivity Disorder in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 449-476. doi: 10.1207/s15374424jccp3403_5
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References Pelham, W. E., Fabiano, G. A., & Massetti, G. M. (2005). Evidence-based assessment of Attention Deficit Hyperactivity Disorder in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 449-476. doi: 10.1207/s15374424jccp3403_5 Sayal, K., Letch, N., & El Abd, S. (2008). Evaluation of screening in children referred for an ADHD assessment. Child and Adolescent Mental Health, 13, 41–46. doi: 10.1111/j.1475-3588.2007.00463.x Sowerby, P., & Tripp, G. (2009). Evidence-based assessment of attention-deficit/hyperactivity disorder (ADHD). In J. L. Matson et al. (Eds). Assessing childhood psychopathology and developmental disabilities (pp. 209-239). doi: 10.1007/978-0-387-09528-8 Wolraich, M. L., Lambert, E. W., Bickman, L., Simmons, T., Doffind, M. A., & Worley, K. A. (2004). Assessing the impact of parent and teacher agreement on diagnosing Attention-Deficit Hyperactivity Disorder. Developmental and Behavioral Pediatrics, 25, 41- 47. doi: 0196-206X/00/2501-0041 Wright, K. D., Waschbusch, D. A., Frankland, B. W. (2007). Combining data from parent ratings and parent interview when assessing ADHD. Journal of Psychopathology and Behavior Assessment, 29, 141–148. doi: 10.1007/s10862-006-9039-4