Developmental Psychopathology at School Series Editors: Stephen E. Brock, California State University, Sacramento, CA, USA Shane R. Jimerson, University of California, Santa Barbara, CA, USA
For further volumes: http://www.springer.com/series/7495
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Stephen E. Brock · Shane R. Jimerson Robin L. Hansen
Identifying, Assessing, and Treating ADHD at School
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Stephen E. Brock Department of Special Education Rehabilitation School Psychology and Deaf Studies California State University Sacramento 6000 J Street Sacramento, CA, 95819-6079 USA
[email protected]
Shane R. Jimerson Gevirtz Graduate School of Education University of California Santa Barbara 2208 Phelps Hall Santa Barbara, CA, 93106-9490 USA
[email protected]
Robin L. Hansen University of California at Davis M.I.N.D. Institute 2825 50th Street Sacramento, CA, 95817 USA
[email protected]
ISBN 978-1-4419-0500-0 e-ISBN 978-1-4419-0501-7 DOI 10.1007/978-1-4419-0501-7 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2009931799 © Springer Science+Business Media, LLC 2009 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)
Christine Jane Brock Suzanne W. Hansen
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Acknowledgments
As with any project of this magnitude we feel it important to acknowledge the contributions of the individuals who contributed to our efforts. First, Dr. Brock would like to thank Dr. Aimee Clinton for her assistance reviewing the literature on the diagnosis of ADHD. He would also like to thank California State University, Sacramento, school psychology students Bethany Grove, Melanie Serals, Maria Puopolo, Christa Cummings, and Darren Husted for their assistance reviewing the ADHD treatment literature. Dr. Jimerson would like to acknowledge the contributions of Ms. Kaitlyn Stewart, a doctoral student at the University of California, Santa Barbara for her reviews and assistance with the preparation of the tables and figures. He would also like to acknowledge the inspiring scholarship of Dr. George DuPaul, who continues to advance both the science and scholarship related to understanding and assisting students with ADHD. Finally, Dr. Hansen would like to acknowledge each of her fellows, Jean, Steve, Nicole, Kathy, Scott, and Lulu, for inspiring her to keep learning.
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Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . Why School Professionals Should Read This Book . . . . . . Conceptualizations of Attention-Deficit/Hyperactivity Disorder ADHD and Educational Placement and Services . . . . . . . . Purpose and Plan of This Book . . . . . . . . . . . . . . . . .
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1 1 3 4 8
2 Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family Studies . . . . . . . . . . . . . . . . . . . . . . . . . . Twin Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . Adoption Studies . . . . . . . . . . . . . . . . . . . . . . . . . Genome Search Studies . . . . . . . . . . . . . . . . . . . . . Candidate Gene Searches . . . . . . . . . . . . . . . . . . . . . Concluding Comments Regarding the Role of Genetics . . . . . Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological Factors . . . . . . . . . . . . . . . . . . . . . . . . Psychosocial Factors . . . . . . . . . . . . . . . . . . . . . . . Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Television Viewing . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments Regarding the Role of the Environment . Neurobiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neuropsychology . . . . . . . . . . . . . . . . . . . . . . . . . Neurophysiology . . . . . . . . . . . . . . . . . . . . . . . . . Neurochemistry . . . . . . . . . . . . . . . . . . . . . . . . . . Concluding Comments Regarding the Role of Neurobiology . . Concluding Comments . . . . . . . . . . . . . . . . . . . . . . .
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3 Prevalence and Associated Conditions . . . . . . . . . . ADHD Rates in the General Population . . . . . . . . . . Students with ADHD in Special Education . . . . . . . . . ADHD’s Correlates and Association with Other Conditions Concluding Comments . . . . . . . . . . . . . . . . . . .
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4 Case Finding and Screening . Case Finding . . . . . . . . . Looking . . . . . . . . . . . Listening . . . . . . . . . . Questioning . . . . . . . . . Screening . . . . . . . . . . . Concluding Comments . . . .
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Diagnostic Assessment . . . . . . . . . . . . . . . . . . . . . . Diagnostic Criteria . . . . . . . . . . . . . . . . . . . . . . . . Birth, Developmental, Health, Family, and Behavioral Histories . Commonly Recommended Diagnostic Procedures . . . . . . . . Other Less Frequently Recommended Diagnostic Procedures . . The Identification of Preschoolers . . . . . . . . . . . . . . . . The Identification of Minority Youth . . . . . . . . . . . . . . . Concluding Comments . . . . . . . . . . . . . . . . . . . . . .
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49 50 55 62 73 76 77 78
6 Psycho-educational Assessment . . . . . . . . . . . . . . . . . . Testing Accommodations and Modifications . . . . . . . . . . . . Allow for Frequent Test Session Breaks . . . . . . . . . . . . . Allow for Physical Movement . . . . . . . . . . . . . . . . . . Minimize Distractions . . . . . . . . . . . . . . . . . . . . . . Make Use of Powerful External Rewards . . . . . . . . . . . . Provide Clear Test-Taking Rules . . . . . . . . . . . . . . . . . Carefully Pre-select Task Difficulty . . . . . . . . . . . . . . . Allow the Student to Pace Him- or Herself . . . . . . . . . . . Schedule the Testing Session Early in the Day . . . . . . . . . . Provide Structure and Organization . . . . . . . . . . . . . . . Modify Test Administration and Allow Nonstandard Responses Specific Psycho-educational Assessment Practices . . . . . . . . . Behavioral Observations and Functional Assessment . . . . . . Psycho-educational Testing . . . . . . . . . . . . . . . . . . . Concluding Comments . . . . . . . . . . . . . . . . . . . . . . .
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7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusting the Classroom Environment: Setting the Student Up for Success . . . . . . . . . . . . . . . . . . . . . . . . . Psychosocial Interventions: Encouraging Appropriate Behavior Psychoeducational . . . . . . . . . . . . . . . . . . . . . . . . Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . Alternative Therapies . . . . . . . . . . . . . . . . . . . . . . Concluding Comments . . . . . . . . . . . . . . . . . . . . .
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Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Appendix C
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Appendix D: ADHD Resources Online . . . . . . . . . . . . . . . . . . .
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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Chapter 1
Introduction
Attention-Deficit/Hyperactivity Disorder (ADHD) is the diagnostic category currently used to describe individuals with clinically significant problems with inattention and/or hyperactivity and impulsivity (American Psychiatric Association [APA], 2000). From data provided by the 2003 National Survey of Children’s Health (Visser & Lesense, 2005) it has been estimated that 7.8% of children age 4–17 years (or about two students in every kindergarten through 12th grade classroom) have at some point in their lives been diagnosed with ADHD. When this high prevalence is combined with the fact that ADHD is typically associated with school adjustment difficulties, it is not surprising to find that school psychologists annually receive an average of 17 referrals for ADHD assessment (Demaray, Schaefer, & Delong, 2003) and that 27% of children receiving special education assistance are reported by their parents to have this disorder (U.S. Department of Education, 2003; Wagner & Blackorby, 2004). Consequently, it is clear that school professionals need to be prepared to identify and serve students with ADHD. Facilitating attainment of the knowledge and readiness needed to serve these students is the primary goal of this book. In this introductory chapter we begin by providing a further rationale for why this book is needed, an overview of ADHD (including its history and current conceptualization), and an examination of ADHD in relation to educational services and placement.
Why School Professionals Should Read This Book Along with the high prevalence of ADHD, there are several other reasons why school professionals should increase their knowledge of this disorder. In this section, we review some of the issues that have generated an imperative for school psychologists and other educators to be prepared to address the needs of students with ADHD. ADHD is one of the most common childhood psychiatric disorders. Given its high prevalence in the general population, it is not surprising that ADHD is one of the most frequent reasons for referrals to school psychologists (Barkley, 2006). Simply put, all educators can expect to be required to address many students with ADHD S.E. Brock et al., Identifying, Assessing, and Treating ADHD at School, Developmental Psychopathology at School, DOI 10.1007/978-1-4419-0501-7_1, C Springer Science+Business Media, LLC 2009
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during their careers. In fact, it will be the exception that a given classroom will not have at least one student with this disorder. ADHD may be under-identified. Contrary to media reports and popular beliefs, it has been suggested that there is currently not enough evidence to support the conclusion that ADHD is systematically over-diagnosed (Sciutto & Eisenberg, 2008). In fact, there is some evidence to suggest that the opposite is the case. Reich, Huang, and Todd (2006), in a population based study of 1610 Missouri twins, report that only about half of the participants who could be diagnosed as having ADHD were receiving any medication treatment. Reich and colleagues state “. . . that many problems remain with implementation of diagnostic screening and appropriate treatment among practitioners” (p. 807). ADHD is associated with significant school adjustment difficulties. The importance of identifying, assessing, and treating the student with ADHD is emphasized by the fact that this disorder is typically associated with behaviors that interfere with school success. For example, both academic performance and skill deficits are common among these children. Over a quarter of these students will experience grade retention, be placed in a special education program, and/or fail to graduate from high school. In addition, almost half will be suspended at some point and 10–20% will be expelled from school (Barkley, 2006; DuPaul & Power, 2008). School professionals play a key role in the identification of ADHD. While there is no one protocol that has been agreed upon for the identification of ADHD, it is generally accepted that caregiver reports and direct behavioral observation are a part of the comprehensive diagnostic assessment. Given that ADHD symptoms are especially prevalent in the school environment, teacher reports and classroom observations should be considered an important part of any ADHD assessment (Brock, 1999; Brock & Clinton, 2007; Koonce, 2007). Accurate identification is important. Accompanying the reality that school professionals play an important role in the identification of ADHD, is the fact that there are important reasons for ensuring an accurate diagnosis. Specifically, this diagnosis is not without negative consequences. While the diagnosis can open doors to special support services and accommodations, its diagnosis and medical treatment can also close doors. For example, it can provide grounds for disqualified from military services (especially if the individual has taken medication for ADHD within one year of planned enlistment; Lansford, 2002). In addition, the medical treatments for ADHD, while relatively safe, are not without their undesired effects and other psychopathologies with similar behavior features (e.g., bipolar disorder) can be made worse by the inappropriate prescription of stimulant medication (Hart, Brock, & Tang, in press). School-based interventions are an important element of ADHD treatment. While the use of medications in the treatment of ADHD has been found to be highly effective, psychosocial interventions, such as those typically offered as part of a school-based treatment plan, are generally considered to be an important part of a comprehensive intervention program. In other words, school professionals should not simply rely on physicians and their use of medications to treat ADHD. Rather,
Conceptualizations of Attention-Deficit/Hyperactivity Disorder
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they must be a collaborative partner in any ADHD treatment plan (Chronis, Jones, & Raggi, 2006; Jensen et al., 2002). Inclusion of children with ADHD in general education classrooms. It is important to acknowledge that research and practice has been moving toward the integration of special and general education for some time (Sailor, Gerry, & Wilson, 1991). Consequently, students with disabilities are increasingly placed in general education settings. Regarding students with ADHD, a survey of 34 mid-western elementary and middle school students suggests that the vast majority spend most of their school days in a general education classroom (Reid, Magg, Vasa, & Wright, 1994). Consequently, all educators, both special and general educators alike, need to have up-to-date information on ADHD. Mandates generated by federal statutes. Finally, it should be recognized that Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 (ADA), and Part B of the Individuals with Disabilities Act of 2004 (IDEA) place significant responsibilities on schools when it comes to serving students with ADHD. Among these responsibilities, as identified by Soleil (2000), schools must identify and assess these students and provide them with an appropriate education at public expense. As indicated, these educational services must be individualized and should involve the student’s families. Furthermore, the educators who provide these services must be appropriately trained and provided the support (including staff development) needed to meet the needs of the student with ADHD. Finally, to the extent that the student with ADHD has associated behavioral challenges resulting in school disciplinary procedures, school districts must ensure that such procedures do not interfere with the provision of a free and appropriate public education.
Conceptualizations of Attention-Deficit/Hyperactivity Disorder As currently conceptualized, ADHD includes at least three different sub-types (Inattentive, Hyperactive/Impulsive, and Combined Types; APA, 2000). This section reviews how our understanding of this disorder has changed over time and how we currently conceptualize ADHD. The evolution of ADHD. It is generally acknowledged that George Still (1902) provided the first clinical description of what is now referred to as ADHD. In a series of papers published in the Lancet, Still referred to children in his clinical practice, who had problems with sustained attention and overactivity, as having a “defect in moral control.” Later, following an encephalitis epidemic in 1917 and 1918, it was observed that a number of children who survived this infection developed ADHD-like behavioral and cognitive challenges (Barkley, 2006). Given this association, it is not surprising that the disorder was initially thought to be due to minimal brain damage or dysfunction (MBD). By the 1960s, in North America, terms like MBD were fading from use as a clinical label for children with ADHD. Instead attention was directed to what was
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considered to be the primary behavioral manifestation of the disorder, hyperactivity (Barkley, 2006). Subsequently, in the late 1960s, the disorder “Hyperkinetic Reaction of Childhood” appeared in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM II; APA, 1968). In DSM II the disorder was described as being “. . . characterized by overactivity, restlessness, distractibility, and short attention span, especially in young children; the behavior diminishes by adolescence” (p. 50). By the 1970s, in North America, researchers began to question whether hyperactivity was the primary symptom of the disorder. Instead, stimulated in large part by the work of Virginia Douglas (1972) and her colleagues, they began to focus on inattention as the primary symptom. Subsequently, in 1980 the term “Attention Deficit Disorder” (or ADD) appeared in the third edition of DSM (APA, 1980). In DSM III the disorder included sub-types and using this system an individual could be diagnosed as having ADD with or without hyperactivity. At the time, this subtyping was controversial and its validity questioned. While research would soon validate that there were clinically significant differences between these sub-types, when DSM III was revised (APA, 1987) the label for the disorder was changed to “Attention-Deficit Hyperactivity Disorder” and sub-typing was for a relatively short period of time discontinued. The current conceptualization of ADHD. The current criteria for ADHD are found in the fourth edition of the DSM (APA, 1994) and its text revision (APA, 2000). According to DSM IV-TR, the primary symptoms of ADHD are developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity. From research suggesting that sub-types of ADHD have valid clinical distinctions (e.g., August & Garfinkel, 1989; Lahey et al., 1994), the current criteria allow a child to be diagnosed as either Predominantly Inattentive, Predominantly HyperactiveImpulsive, or Combined types. Diagnostic criteria for ADHD Predominantly Inattentive Type require that six or more of the nine symptoms of inattention be present. Criteria for ADHD Predominantly Hyperactive-Impulsive Type require that four or more of the six symptoms of hyperactivity and impulsivity be present. Criteria for ADHD Combined Type require that both Inattentive and Hyperactive-Impulsive criteria be met. In addition to displaying symptoms, these criteria require that they have persisted for at least 6 months, be inconsistent with developmental level, have their onset before the age of 7 years, be displayed in two or more different settings (e.g., school and home), and be considered clinically significant (APA, 2000). Further discussion of the diagnostic criteria for ADHD is provided in Chapter 5.
ADHD and Educational Placement and Services A DSM diagnosis of ADHD does not automatically qualify a student for any special education placement and/or related services (U.S. Department of Education, 2006). In fact, as has already been mentioned, a large majority of these students spend most of their school days in general education classrooms (Reid et al., 1994). However,
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it is clear that depending upon the severity of a student’s ADHD, he or she may be considered eligible for services under Part B of the Individuals with Disabilities Act (IDEA), and/or related aids and services under Section 504 of the Rehabilitation Act of 1973. This section will discuss the series of changes in educational regulations that now govern the provision of special services to ensure that the student with ADHD receives a free and appropriate public education (FAPE). IDEA 1990. Although initially viewed as a medical/psychiatric condition, ADHD has increasingly come to be recognized as a major educational issue (Reid & Katsiyannis, 1995). By the early 1990s, national advocacy organizations (e.g., Children and Adults with Attention Deficit Disorders [CHADD]) had begun to work toward improving educational services for students with ADHD (Aleman, 1991). Among these efforts was an attempt to make what was then referred to as ADD a disability category under the Individuals with Disabilities Education Act (IDEA) of 1990. The U.S. Department of Education opposed this change as it judged that students with ADD who required special education would already meet existing eligibility criteria. Subsequently, the U.S. Congress made no change to the definitions of “children with disabilities” with respect to ADHD (although it did add categories for Traumatic Brain Injury and Autism). At the same time, however, Congress did direct the Secretary of Education to issue a Notice of Inquiry (NOI) asking for public comment on special education for students with ADHD (Davila, Williams, & MacDonald, 1991). September 16, 1991, Policy Memorandum. From the Department’s review of over 2000 comments generated by the NOI, it was concluded that there was confusion regarding the extent to which students with ADHD may be eligible for special education services and general education accommodations. As a result, the Department issued a policy memorandum titled “Clarification of Policy to Address the Needs of Children with Attention-Deficit Disorders within General and/or Special Education” (Davila et al., 1991; copy provided in Appendix A). Signed jointly by the Assistant Secretaries of the Office of Civil Rights (OCR), Office of Elementary and Secondary Education (OESE), and Office of Special Education and Rehabilitative Services (OSERS), this document indicated that students with ADD who require special education are eligible under the IDEA disability categories of “other health impairment,” “specific learning disability,” or “serious emotional disturbance.” Further, it specified that students with ADHD who do not require special education may nevertheless be eligible for specialized services, under Section 504 of the Rehabilitation Act of 1973 (which prohibits agencies that receive federal funds from discriminating against persons with disabilities on the basis of their disability). Eligibility for 504 services would be based upon the finding that the student with ADHD was judged to be a “handicapped person” (i.e., the student’s ADHD substantially limits the major life activity of learning; Davila et al., 1991). Under Section 504 the student with ADHD and judged to be a “handicapped person,” is entitled to FAPE. According to the Davila and colleagues (1991) policy memorandum, this may include either “regular or special education and related aids and services. . ..” Although not required, an individualized education program (IEP) was identified as one way to provide FAPE. However, assuming that special
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education services are not appropriate for the student with ADHD (and the student is judged to be a “handicapped person”). Davila and colleagues specify that the student’s education “must be provided in the regular education classroom.” Further, general education classroom teachers were explicitly identified as being “important” in the identification of required instructional adaptations and interventions. Specific examples of general education adaptations for the student with ADHD mentioned in the Davila and colleagues policy memorandum included (a) providing a structured learning environment; (b) repeating and simplifying instructions about in-class and homework assignments; (c) supplementing verbal instructions with visual instructions; (d) using behavioral management techniques; (e) adjusting class schedules; (f) modifying test delivery; (g) using tape recorders, computer-aided instruction, and other audiovisual equipment; (h) selecting modified textbooks or workbooks; (i) tailoring homework assignments; (j) reduced class size; (k) use of one-on-one tutorials; (l) classroom aides and note takers; (m) involvement of a “services coordinator” to oversee implementation of special programs and services; and (n) possible modification of nonacademic times such as lunchroom, recess, and physical education. Although not specifically mentioned in the September 1991 Policy Memorandum, it is significant to note that the Americans with Disabilities Act of 1990 (ADA), also applies to students with ADHD. ADA prohibits discrimination against persons with disabilities at work, at school and in public accommodations, and applies to institutions that do not receive federal funds. Because ADA has been interpreted as incorporating many of the Section 504 requirements, it has been suggested that by meeting 504 requirements, school districts meet their ADA obligations (Soleil, 2000). April 29, 1993, Clarification Memorandum. Following the 1991 Policy Memorandum, Acting Assistant Secretary for Civil Rights, Jeanette J. Lim, authored a second memorandum titled “Clarification of School Districts’ Responsibilities to Evaluate Children with Attention Deficit Disorders (ADD)” (Lim, 1993; copy provided in Appendix B). Offered as a response to what was viewed as a misinterpretation of earlier communications (including the Davila et al. 1991 Memorandum), this memorandum addressed the responsibility of school districts to evaluate students “suspected” of having ADHD. The Lim (1993) memorandum reiterated that the Davila and colleagues (1991) Memorandum was intended to ensure that students suspected of having ADHD and believed by the school district to need special education or related services are evaluated for such (and that these statements were necessary since many districts prior to the 1991 memorandum felt that they did not need to conduct such evaluation given that ADHD was not an IDEA disability category). However, the Lim memorandum also clarified that it was not the intent of prior communications to require school districts to evaluate every student suspected of having ADHD, “based solely on parental suspicion and demand.” It concluded that if a school district did not judge that a student required special education or related services, then it may refuse to evaluate the child (and notify the parents of their due process rights). The Lim memorandum also included an updated version
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of a technical assistance presentation titled “OCR Facts: Section 504 Coverage of Children With ADD” (copy provided in Appendix B). October 22, 1997, Notice of Proposed Rule Making (NPRM). Published in the Federal Register (U.S. Department of Education, 1997) this NPRM was designed to elicit public comment on the 1997 reauthorization of IDEA. The elements that related to ADHD offered clarification of the conditions under which a student with ADHD would be eligible for IDEA services. “Note 5” indicated that some students with ADHD will meet the criteria for other health impairments (OHI) if (a) the ADHD is “determined to be a chronic health problem that results in limited alertness that adversely affects educational performance” and (b) “special education and related services are needed.” In addition, the note clarifies that the term “limited alertness,” a key element of OHI criteria, “includes a child’s heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment” (p. 55070). The NPRM’s Note 5 further clarifies that some students with “ADHD may be eligible for services under other disability categories in §300.7(b) if they meet the applicable criteria for those disabilities” and “if those children are not eligible under this part, the requirements of section 504 of the Rehabilitation Act of 1973 and its implementing regulations may still be applicable” (U.S. Department of Education, 1997, p. 55031). March 12, 1999, Final Regulations for IDEA 1997. The analysis of comments and changes to IDEA generated by the October 1997 NPRM, and relevant to ADHD, are provided in Table 1.1 (U.S. Department of Education, 1997). As originally proposed, the final regulations added ADHD to the list of conditions that may result in special education eligibility [Part B, Definition of “Child with a Disability” − 20 U.S.C. 1401(3)(A); 300.7(c)(9)(I) ADD and ADHD − 300.7(c)(9)(i)]. These regulations also clarified that the phrase “limited strength or vitality or alertness” that defines OHI includes “a child’s heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment,” which is characteristic of many students with ADHD (U.S. Department of Education, 1997, p. 55031). The Topic Brief, published by the U.S. Department of Education (1999), designed to clarify these changes, is provided in Appendix C. August 14, 2006, Final Regulations for IDEA 2004. Regulations for the most recent reauthorization of IDEA were published in the Federal Register (U.S. Department of Education, 2006). With this reauthorization no substantive changes were made and the student with ADHD as their primary disability continues to potentially qualify for special education under one of three different eligibility categories: (a) specific learning disability, (b) emotionally disturbed, and (c) other health impaired. However, the only specific mention of ADHD is found in the OHI criteria [§300.8(c)(9)(i)] which states, “Other health impairment means having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that” − “Is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell
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Table 1.1 The analysis of comments and changes to IDEA generated by the October, 1997 NPRM Proposed Section 300.7 would make the following changes to the current regulatory definition of “children with disabilities”. . . Note 1 following Section 300.7 of the current regulations . . . would be added without change to proposed Section 300.7, and four new notes would be added to that section, as follows: . . . Note 5 would address the conditions under which a child with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) is eligible under Part B of the Act. The note clarifies that some children with ADD or ADHD who are eligible under this part meet the criteria for “other health impairments” if (1) the ADD or ADHD is determined to be a chronic health problem that results in limited alertness that adversely affects educational performance, and (2) special education and related services are needed because of the ADD or ADHD. (The note clarifies that the term “limited alertness” includes a child’s heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment.) The note further clarifies that (1) some children with ADD or ADHD may be eligible for services under other disability categories in Section 300.7(b) if they meet the applicable criteria for those disabilities, and (2) if those children are not eligible under this part, the requirements of Section 504 of the Rehabilitation Act of 1973 and its implementing regulations may still be applicable. Note: From U.S. Department of Education (1997, p. 55031)
anemia, and Tourette syndrome; and” . . . “adversely affects a child’s educational performance” (emphasis added, p. 46757).
Purpose and Plan of This Book In the pages that follow school professionals are provided with information needed to be better prepared to identify and address ADHD. Chapter 2 offers an exploration of the etiology of ADHD. In Chapter 3, epidemiological issues and associated conditions are reviewed. Included here will be a discussion of the rate of ADHD in both special education and in the general population. Chapters 4, 5, and 6 review information essential to identification and assessment, and finally Chapter 7 presents a summary of research examining the effectiveness of interventions for children with ADHD. In addition, this book also offers a list of Internet resources that provides additional ADHD resources in Appendix D.
Chapter 2
Causes
To date no single factor has been identified as the cause of ADHD. Rather, as is the case for other psychopathologies (e.g., schizophrenia, autism, PTSD, bipolar disorder), ADHD is thought to be the result of complex interactions between genetic, environmental, and neurobiological factors (Kieling, Goncalves, Tannock, & Castellanos, 2008; Mick & Faraon, 2008; Shastry, 2004; Spencer, Biederman, Wilens, & Farone, 2002). Specifically, it appears that the genetic and environmental etiologies of ADHD lead to the neurobiological differences, which in turn manifest as ADHD symptoms (Biederman & Faraone, 2002). These hypothetical relationships are illustrated in Fig. 2.1, which suggests that genetic and neurobiological variables appear to be the greatest contributors to ADHD symptoms (Barkley, 2006). Further, it is clear that environmental variables play a less significant role in the development of most cases of ADHD and it is not known if environmental insults are required for ADHD to emerge (Das Banerjee, Middleton, & Faraone, 2007). To the extent they are involved it seems likely that they contribute to ADHD symptoms by interacting with genetic predispositions. However, in a few cases (i.e., significant neurological injury) ADHD can arise without genetic predisposition (Max et al., 2005a, 2005b). While psychosocial factors do not appear to cause ADHD per se, they clearly have the potential to effect symptom expression (Barkley, 2006).
Genetics There is strong evidence that genetics plays a powerful etiological role in ADHD (Biederman, 2005; Daley, 2006; Mick & Farone, 2008; National Institute of Mental Health [NIMH], 2006). Evidence in support of this conclusion comes from a variety of sources including family, twin, adoption, genome, and candidate gene search studies.
S.E. Brock et al., Identifying, Assessing, and Treating ADHD at School, Developmental Psychopathology at School, DOI 10.1007/978-1-4419-0501-7_2, C Springer Science+Business Media, LLC 2009
9
10
2
Genetic Causes
Gene X Environment Interactions
Environmental Causes
Causes
Pre- & Postnatal Environments
Significant Neurological Injury
Neurobiological Differences Appears to effect the Prefrontal – striatal – cerebellar network
Psychosocial Factors
ADHD Sx Fig. 2.1 This figure illustrates the hypothetical relationships between genetics, the environment, and the neurobiological differences associated with ADHD. Each of these factors likely has a role in the development and/or manifestation of ADHD and its symptoms
Family Studies Because children share 50% of their genes with each parent, for genes to be important in the development of ADHD it must run in families (Acton, 1998). Despite changes in diagnostic criteria (as described in Chapter 1), Biederman’s (2005) overview of the literature found consistent agreement that the parents and siblings of children with ADHD have a two- to eight-fold increased risk for the disorder. For example, the incidence of ADHD among the parents and siblings of children diagnosed with ADHD is reported to be 25–26% respectively (Biederman, Faraone, Keenan, Knee, & Tsuang, 1990; Welner, Welner, Steward, Palkes, & Wish, 1977). Even more impressive is the report that the incidence of ADHD among children of parents with ADHD is 55% (Biederman et al., 1995). Thus, a family history of ADHD is an important variable to consider when diagnosing this disorder.
Twin Studies These studies compare identical (monozygotic) twins to fraternal (dizygotic) twins. While identical twins share 100% of their genes, fraternal twins (as is the case with other siblings) share only 50% of their genes. The extent to which identical twin pairs are more likely to have ADHD than fraternal twin pairs is used to estimate “heritability” or the proportion of individual differences in ADHD within a population that can be attributed to genetic differences.
Genetics
11
Tharpar, Harrington, Ross, and McGuffin’s (2000) literature review suggested the heritability of ADHD to range from 64 to 91%, while Faraone and colleagues’ (2005) review of 20 twin studies found a mean heritability estimate of 76%. More recently, Barkley’s (2006) review of 18 twin studies suggested the average heritability of ADHD to be “at least” 80–90% (p. 227). From these data it can be concluded that a substantial proportion of the individual differences in ADHD may be attributed in some way to individual genetic differences. It is interesting to note that among fraternal twins (who have developed from two separate ova), the risk of both twins having ADHD is reported by Gilger, Pennington, and DeFries (1992) to be no greater than that found among non-twin siblings (i.e., 29%), despite sharing the same maternal environment during pregnancy.
Adoption Studies Because family members share, if not the same, very similar environments it is possible that ADHD is transmitted by the common environment and not by common genes. To test this hypothesis adoption studies have been conducted. If genetics (and not shared environment) is the primary factor in the development of ADHD, then siblings with ADHD reared apart should be more similar than adopted siblings reared in the same family (Acton, 1998). Early adoption studies focused on hyperactivity and confirmed that the biological relatives of children who were hyperactive were more likely to have hyperactivity than the adopted relatives of these children (Cantwell, 1975; Morrison & Stewart, 1971). A more recent study employing DSM III-R ADHD diagnostic criteria also found that the biological relatives of children with ADHD are more likely to have ADHD than their adopted relatives (Sprich, Biederman, Crawford, Mundy, & Faraone, 2000). In sum, family, twin, and adoption studies indicate a strong genetic influence in the development of ADHD. In fact, according to Spencer and colleagues (2002), it “is more attributable to genetic factors than are depression, generalized anxiety disorder, breast cancer, and asthma” (p. 6). However, these studies do not identify the specific chromosome regions, or more precisely the specific genes, that are associated with this disorder. To do so genome and candidate gene search studies have been conducted.
Genome Search Studies The human genome is comprised of 23 pairs of chromosomes (numbered 1–22, with X and Y designating the sex chromosomes). Combinations of 30,000–40,000 different genes form each chromosome. Composed of deoxyribonucleic acid (DNA), genes function as blueprints for growth and development. If a particular gene is changed in some way, its ability to direct normal development is affected. Similarly,
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Causes
if a chromosome is damaged in some way, it can affect normal development by altering the numerous genes located in that part of the chromosome (Brock, Jimerson, & Hansen, 2006). Genome search studies examine all chromosomal locations of families that include individuals with ADHD without any prior assumptions being made about what specific genes underlie ADHD (Biederman & Faraone, 2002). Within these families, DNA sequences (or markers) along different chromosomes are examined by researchers for slight differences (or polymorphisms). Researchers then try to find differences that are consistently found among family members who have ADHD, but not among those without this disorder. By determining how close these polymorphisms unique to the ADHD family members are to a specific gene (done via statistical methods), it can be “linked” to that gene. When such linkages are made the hunt for specific ADHD genes within that chromosome region (or candidate gene searches) can be conducted (Brock et al., 2006). Waldman and Gizer’s (2006) review of the genetics of ADHD report the results of four genome scans for ADHD from three different samples. While there were many discrepant findings, it was reported that three chromosomal regions in two of three samples showed common linkages (i.e., 5p13, 11q22–25, and 17p11).
Candidate Gene Searches This research begins with the assumption that certain specific genes are likely to be associated with ADHD. These prior assumptions are based upon clinical and empirical evidence (including whole genome searches) that a specific gene is associated with the development of specific ADHD symptoms. Some of the more common candidates to be studied are those genes known to regulate the brain chemicals (e.g., dopamine) and regions (e.g., frontal-subcortical networks) thought to be associated with ADHD. Mick and Faraone’s (2008) review of the literature candidate gene studies of ADHD identifies five different genes for which there appears to be substantial evidence implicating them in the etiology of this disorder. These genes are:
1. Dopamine D4 Receptor (DRD4, prevalent in frontal-subcortical networks and associated with the personality trait of novelty seeking), 2. Dopamine D5 Receptor (DRD5, abnormalities in this brain chemical are thought to underlie ADHD), 3. Dopamine SLC6A3 Transporter (regulates dopamine and is affected by stimulant medication), 4. Synaptosomal-Associated Protein of 25kD (SNAP-25, which effects dopamine and serotonin levels and might cause hyperactivity), 5. Serotonin HTR1B Receptor (thought to underlie the impulsive symptoms of ADHD).
Environment
13
However, it is important to note that Mick and Faraone caution that the associations with these genes and ADHD are small “and consistent with the idea that genetic vulnerability to ADHD is medicated by many genes of small effects” (pp. 275–276).
Concluding Comments Regarding the Role of Genetics While family, twin, and adoption studies offer persuasive evidence that ADHD is highly heritable, genome and candidate gene searches suggest that the genetics of ADHD is complex. At this point in time it is safe to say that this disorder is likely mediated by many different genes (Faraone et al., 2005; Mick & Faraone, 2008). Further, one recent study of note suggested the possibility that the genetics of ADHD is a dynamic process wherein different genes are being turned on across development (Kuntsi, Rijsdijk, Ronald, Asherson, & Plomin, 2005). Finally, as illustrated in Fig. 2.1, it would appear that ADHD is not entirely heritable and that there may be some role for environmental factors and/or gene by environment interactions as a cause of ADHD (Das Banerjee et al., 2007; Larsson, Larsson, & Lichtenstein, 2004).
Environment Among family members the manifestations of ADHD can vary substantially. This fact argues that simple models of inheritance do not account for all of the individual differences in ADHD symptoms (Barkley, 2006), and has supported the hypothesis that environmental variables may be playing a role in the development of ADHD (Das Banerjee et al., 2007). Further supporting a causal role for the environment is prior research documenting that environmental factors (e.g., alcohol) can cause developmental disabilities (e.g., fetal alcohol syndrome). Environmental variables thought to be playing a role in ADHD symptom expression include both biological and psychosocial factors (Biederman & Faraone, 2002; Das Banerjee et al., 2007). However, according to Barkley (2006), “We are very near to reaching the time when we can conclude unequivocally that ADHD cannot and does not arise from purely social factors. . .” (p. 220). Two other environmental variables that have not received support as being a cause of ADHD include diet and television viewing.
Biological Factors A variety of biological factors have been associated with an increased risk for ADHD. These include pre-, peri-, and post-natal complications; toxins; and brain injury.
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Causes
Pre-, peri- and post-natal complications. A variety of pregnancy, birth, and neonatal complications have been associated with a predisposition to ADHD. These include duration of labor, fetal distress, fetal post-maturity, forceps delivery, toxemia or eclampsia, poor maternal health, younger maternal age, and low birth weight (Barkley, 2006; Biederman & Faraone, 2002). Each of these complications can be associated with hypoxic insults, which in turn are hypothesized to affect the brain structures implicated in ADHD (Das Banerjee et al., 2007). For example, Ben Amor and colleagues (2005), report that the mean number of neonatal complications is significantly greater among children with ADHD as compared to their unaffected siblings (3.9 vs. 2.5, p =.006). In particular, numerous studies have suggested that low birth weight is a risk factor for ADHD (Biederman & Faraone, 2005). For example, from a case-controlled family study Mick, Biederman, Prince, Fischer, and Faraone (2002) estimated that 13.8% of ADHD cases in the U.S. population could be attributed to low (<2500 g/5.5 lbs) birth weight. More recently, Shum, Neulinger, O’Callaghan, and Mohay (2008) reported children born very early (≤27 weeks) or with an extremely low birth weight (≤1000 g or 2.2 pounds) had more problems with attention (as measured by psychological tests and parent/teacher rating scales) than a control group at 7–9 years of age. It is important to acknowledge, however, that by themselves low birth weight and the other pre-, peri-, and post-natal complications, lead to a relatively small proportion of children with ADHD (APA, 2000). Toxins. According to Das Banerjee and colleagues’ (2007) review of the literature, exposure to several different toxins have been associated with an increased risk for ADHD, including lead, mercury, manganese, and polychlorinated biphenyls (PCBs). However, it is important to acknowledge that most children with ADHD do not have such exposures. Further, many individuals with high lead levels for example, do not demonstrate ADHD symptoms (Biederman & Faraone, 2005). Barkley’s (2006) review of the literature suggests that no more than 4% of the variance in ADHD symptom expression can be explained by elevated lead levels. Prenatal exposures to tobacco smoke and alcohol have also been suggested to be risk factors for ADHD (Das Banerjee et al., 2007). For example, Linnet and colleagues’ (2003) review of 24 studies offers strong evidence in support of the hypothesis that prenatal tobacco smoke exposure is associated with ADHD. Further, several prospective studies of infants demonstrate that fetal exposure to maternal alcohol use leads to behavior problems consistent with ADHD symptoms (Biederman & Faraone, 2005). Finally, among children with ADHD, there is an increased likelihood of having been exposed to alcohol as a fetus (Mick, Biederman, Faraone, Sayer, & Kleinman, 2002). Brain injury. As was mentioned in Chapter 1, following an encephalitis epidemic in 1917 and 1918, it was observed that a number of children who survived this infection developed ADHD-like behaviors. Consequently early theories of the cause of ADHD focused on brain injury. However, it is now clear that such trauma accounts for only a small percentage (fewer than 5%) of individuals with ADHD (Barkley, 1990). Nevertheless, this disorder has been documented to occur secondary to brain injury (e.g., head trauma, stroke) in childhood, with the occurrence of ADHD being
Environment
15
positively correlated with increased injury severity (Max et al., 1997, 1998, 2002). In two recent studies of children (ages 5–14 years) with brain injury, 15–21% were found to demonstrate “secondary ADHD” (Max et al., 2005a, 2005b). It is important to acknowledge, however, that ADHD itself may be a risk factor for TBI, so genetic and brain injury causes may not be entirely independent.
Psychosocial Factors Some studies have suggested that the severity of ADHD is associated with family stressors and other psychosocial variables. For example, making use of Rutter’s (Rutter, Cox, Tupling, Berger, & Yule, 1975) “adversity indicators” (i.e., severe marital discord, low social class, large family size, paternal criminality, and maternal mental disorder), Biederman, Faraone, and Monuteaux (2002) found that the risk of ADHD increased as the number of adversity factors increased, and Pressman and colleagues (2006), in a study of families with two children diagnosed with ADHD conclude, “There are strong links between impairment in children with ADHD and family environment” (p. 346). In interpreting these results, it is important to keep in mind that it is possible that the same genetic influences that cause ADHD may also be associated with these psychosocial factors. In the words of Biederman et al. (2002), Although our results show that psychosocial adversity is associated with ADHD risk, it is not possible to separate the effects of genetic and environmental influences on our measures of adversity. That is, the pathogenic genes that make a child susceptible to ADHD can lead to psychopathology in the parents and adversity in the family environment. (p. 1561)
Given these observations and the powerful data regarding the heritability of ADHD, it is generally concluded that psychosocial factors do not cause ADHD per se (Barkley, 2006). However, it is safe to say that the severity of symptoms is related to the stress and social adversity experienced among the families of children with ADHD (Jensen, 2000; Remschmidt & the Global ADHD Working Group, 2005). In other words, while they would not appear to cause ADHD, psychosocial factors clearly effect the expression of this disorder.
Diet It has been suggested that for the vast majority of children, ADHD is neither caused nor exacerbated by refined sugar or food additives (Das Banerjee et al., 2007). In 1982, the National Institutes of Health held a consensus conference and concluded that diet restrictions help only about 5% of children with ADHD, and that such children are mostly those with food allergies. Other more recent studies have supported this conclusion (NIMH, 2006).
16
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Causes
Television Viewing An association between early television viewing (at ages 1 and 3 years) and later attention problems (at age 7 years) has been reported by Christakis, Zimmerman, DiGiuseppe, & McCarty (2004). However, this study did not measure ADHD symptoms per se. Further, additional research has not been able to document a relationship between ADHD and television viewing, which has lead to the conclusion that it is not a risk factor for ADHD (Das Banerjee et al., 2007).
Concluding Comments Regarding the Role of the Environment Currently, there is very little evidence supporting any one environmental factor as playing a significant etiological role in ADHD. As illustrated in Fig. 2.2, genetics (i.e., having a family history of ADHD) is a much more powerful risk factor than any of the environmental variables. With the exception of significant neurological injuries, such as head trauma and stroke, to the extent environmental factors have a causal role, it seems likely that they do so by interacting with genetic factors (Das Benerjee et al., 2007). Psychosocial factors seem more likely to effect the symptom expression of ADHD, than to be a cause of the disorder per se. Diet and television viewing do not appear to play a role in the etiology of ADHD.
Risk Factor
Parent Behav. a b Tobacco Alcoholb Low Birthweight
a
High Blood Lead
c
Parental ADHD
0
1
a
2
3
4
5
6
7
8
Odds Ratio Genetic Risk Factor
Biological Risk Factor
Psychosocial Risk Factor
Parent Behav. = Antisocial behavior or conduct disorder in parent; Tobacco = Prenatal tobacco exposure; Alcohol = Prenatal alcohol exposure; Low Birthweight = < 2500grams; High Blood Lead = 1st vs. 5th quintile; Parental ADHD = ADHD in either parent
Fig. 2.2 Selected odds ratios, determined by logistic regression analysis, obtained by three studies (a Mick, Biederman, Prince, et al., 2002; b Mick, Biederman, Faraon et al., 2002; c Braun, Kahn, Forehlic, Auinger, & Lanphear, 2006) for genetic, psychosocial, and biological ADHD risk factors. Odds ratios greater than one imply that the factor is more likely to be present among children with ADHD than among those without this disorder
Neurobiology
17
Neurobiology Researchers generally agree that ADHD’s behavioral abnormalities are the result of developmental brain pathologies (presumably caused by the genetic differences and/or environmental insults previously discussed). In particular, it has been suggested that ADHD is linked to dysfunction of the frontal – striatal – cerebellar circuits (Kieling et al., 2008; Krain & Castellanos, 2006) and associated deficits in specific neurotransmitters (e.g., dopamine and norepinephrine; Barkley, 2006). Neuropsychological, neurophysiological, and neurochemical research methods have all been used to understand the neurobiology of ADHD.
Neuropsychology Neuropsychological research suggests that the inattention, hyperactivity, and impulsivity that characterize ADHD are the result of underlying deficits in behavioral inhibition, resistance to distraction, and executive functioning. These psychological functions have been linked to the prefrontal cortex, and its networks within the striatum and cerebellum (Barkley, 2006; Krain & Castellanos, 2006). This research has provided specific direction to neurophysiological research.
Neurophysiology Making use of advances in functional imaging technology, such as functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and single photon emission computer tomography (SPECT), much has been learned in recent years about the neurophysiology of ADHD (NIMH, 2006). In fact, there is now convincing evidence that ADHD is associated with significant differences in brain development. These include overall brain size; and specific prefrontal, striatal, and cerebellar differences. These specific brain regions are illustrated in Fig. 2.3. Decreased overall brain size. When compared to age- and sex-matched peers without ADHD, individuals with ADHD have about a 3–8% smaller brain volume (Kieling et al., 2008). By in large these differences are consistent throughout childhood and adolescence, and do not appear to be related to medication status (i.e., whether or not the individual had taken medication to manage ADHD symptoms; Castellanos et al., 2002). As measured by behavior rating scales and neuropsychological tests, more severe ADHD symptoms are associated with smaller brain volumes (Bush, Valera, & Seidman, 2005). Future research will be necessary to determine if these brain size differences are stable into adulthood. Prefrontal cortex. Consistent with neuropsychological research findings, neurophysiological research has tended to focus on the frontal lobes of the brain and those associated networks responsible for attention, behavioral inhibition, resistance to distraction, and executive functioning. The prefrontal cortex has been found to be
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Causes
Prefrontal Cortex Dorsolateral prefrontal cortex Basal Ganglia Striatum Caudate nucleus Putamen Pallidum
Cerebellum
Fig. 2.3 Major brain structures implicated in ADHD
significantly smaller among children with ADHD as compared to controls. This brain structure is near the front of the frontal lobes and is thought to be responsible for executive functions. In Seidman, Valera, and Makris’ (2005) review of the literature, all studies that have measured at least one part of the prefrontal cortex found this structure to be smaller among children with ADHD. More specifically, brain size reductions in particular regions of the prefrontal cortex, such as the dorsolateral prefrontal cortex, have been implicated in the pathophysiology of ADHD (Bush et al., 2005; Kieling et al., 2008; Krain & Castellanos, 2006; Seidman et al., 2005). Basal ganglia (striatum). The caudate nucleus, putamen, and the pallidum, which serve as the entry point to the basal ganglia, have also been implicated in ADHD (Krain & Castellanos, 2006). This brain structure is located deep within the cerebral hemispheres and serves as a connection between the cerebrum and cerebellum (NIMH, 2004). Damage to this structure is associated with secondary ADHD and in animal studies has been found to produce hyperactivity. In Seidman and colleagues’ (2005) review, 9 out of 13 studies found individuals with ADHD to have smaller caudate volumes, and all 4 studies of the pallidum found children with ADHD to have smaller volumes. Interestingly, the one brain structure that appears to normalize in size by mid-adolescence is the caudate nucleus, which has lead to speculation that this may be the neurophysiological basis for why symptoms of hyperactivity diminish with increasing age (Castellanos et al., 2002). Cerebellum. In addition to its role in the coordination of motor movements, this brain structure is also involved in timing and attention shifting via its connections with frontal regions (Krain & Castellanos, 2006). This structure is located at the
Concluding Comments
19
lower back part of the brain, and in Seidman and colleagues’ (2005) review, all five research groups studying the cerebellum noted structural abnormalities including reduced volume.
Neurochemistry Based primarily on the responses of children with ADHD to medications that increase the availability of dopamine and norepinephrine, neurochemical explanations for ADHD have also been proposed (Biederman & Farone, 2005). These medications include methylphenidate (Ritalin), pemoline (Cylert), and dextroamR ), which increase the release and inhibit the reuptake of phetamine (Dexedrine dopamine (thereby increasing the availability of this brain chemical). They also R ), which is a norepinephrine reuptake inhibitor (i.e., include atomoxetine (Strattera it elevates this neurotransmitter by inhibiting its reuptake from the synaptic cleft thereby increasing its availability). Further evidence supporting the neurochemical basis of ADHD include (a) studies suggesting decreased brain dopamine in the cerebral spinal fluid of children with ADHD (as compared to children without this disorder), (b) animal studies (which, for example, have shown that methyphenidate increases norepinephrine and dopamine out flow within the prefrontal cortex), and (c) the fact that the genes implicated in ADHD are known to regulate brain chemicals (Barkley, 2006; Berridge et al., 2006; Biederman & Faraone, 2005; Remschmidt et al., 2005).
Concluding Comments Regarding the Role of Neurobiology In addition to being highly heritable, there is strong evidence in support of a neurobiologic basis for ADHD. Recent imaging research has documented that differences in overall brain size and specific brain regions appear to distinguish children with ADHD from those without this disorder. These studies have suggested that the behavioral manifestations of ADHD are the result of dysfunction in the frontal – striatal – cerebellar circuits. Also implicated in the pathophysiology of ADHD are deficits in specific neurotransmitters (e.g., dopamine and norepinephrine). The fact that the medications used to treat ADHD increase the availability of these brain chemicals offers further evidence in support of a neurobiological basis for this disorder.
Concluding Comments The etiology of ADHD is complex and a precise understanding of what causes this disorder, particularly in individual cases, has not yet been obtained. However, at this point in time it is safe to say that ADHD is a highly heritable neurobiological disorder. To the extent that biological factors in the environment plays a role
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Causes
in the etiology of ADHD, in all but a few cases (i.e., traumatic brain injury) they likely do so by interacting with specific genetic factors. In concluding this chapter it is also important to acknowledge that much has been learned about what does not cause ADHD. Specifically, diet, poor parenting or dysfunctional family environments, and excessive television viewing do not appear to cause ADHD per se. Clearly such factors can make ADHD symptoms better or worse, but they do not cause the neurobiological differences associated with this disorder.
Chapter 3
Prevalence and Associated Conditions
This chapter provides a review of research examining the incidence of ADHD (both in the general population and in special education). In addition, ADHD’s association with other conditions is examined.
ADHD Rates in the General Population According to the DSM IV-TR (APA, 2000), the incidence of ADHD in the general population ranges from 3 to 7%. More recently, however, from the 2003 National Survey of Children’s Health (a parent survey completed on behalf of 102,353 children, with a 68.8% return rate), the Centers for Disease Control (Visser & Lesesne, 2005) have estimated that there are approximately 4.4 million U.S. children aged 4−17 years with a history of ADHD (i.e., had a parent who responded in the affirmative to the question “Has a doctor or health professional ever told you that [child] has attention-deficit/hyperactivity disorder, that is ADD or ADHD?”). This number suggests that 7.8% of school-aged youth have at some point in their lives been diagnosed with ADHD. In other words, in the typical 25 student classroom just short of 2 (1.95) students will be individuals who have been diagnosed with ADHD. Table 3.1 summarizes the national prevalence of parent reported ADHD among 4–17-year-olds, their current medication status, and also compares selected sociodemographic characteristics. Figure 3.1 reports the prevalence of ADHD estimates by State. As suggested by Table 3.1, regardless of the sociodemographic characteristic, ADHD is much more common among males than females (national prevalence estimate of 11.0 vs. 4.4), and least likely to have been diagnosed among youth under 9 years of age. Having a primary language other than English, Hispanic ethnicity, and a lack of health-care coverage are also associated with lower rates of a child (having been reported by their parents as) ever having been diagnosed with ADHD. As illustrated by Fig. 3.1, within the United States there are significant state by state differences in the rates of a child ever having been diagnosed with ADHD. Specifically, children residing in the western states of Colorado, California, Utah, and Arizona report the lowest incidence (all below 6%). Children residing in the S.E. Brock et al., Identifying, Assessing, and Treating ADHD at School, Developmental Psychopathology at School, DOI 10.1007/978-1-4419-0501-7_3, C Springer Science+Business Media, LLC 2009
21
Table 3.1. CDC prevalence estimates of youth with ADHD and medication status, by gender and sociodemographic characteristics
Male Characteristic
Currently Taking Medication for ADHD
Female
Total
Male
Female
Total
%
95% CIa
%
95% CI
%
95% CI
%
95% CI
%
95% CI
%
95% CI
11.0
10.4–11.5
4.4
4.1–4.8
7.8
7.4–8.1
6.2
5.8–6.6
2.4
2.2–2.7
4.3
4.1–4.6
6.0 13.5 13.8
5.3–6.7 12.5–14.5 12.9–14.8
2.1 5.9 5.4
1.7–2.5 5.1–6.7 4.9–6.0
4.1 9.7 9.7
3.7–4.5 9.1–10.4 9.2–10.3
3.6 8.8 6.7
3.1–4.2 8.0–9.6 6.1–7.4
1.5 3.6 2.4
1.2–1.8 3.0–4.3 2.0–2.8
2.6 6.2 4.6
2.3–2.9 5.7–6.7 4.2–5.0
9.5 12.9 10.4
7.5–11.8 11.8–14.1 9.8–11.0
3.3 4.2 4.6
2.3–4.8 3.6–5.0 4.2–5.1
6.5 8.6 7.6
5.3–7.9 7.9–9.3 7.2–8.0
4.6 6.8 6.1
3.3–6.4 6.1–7.7 5.7–6.6
2.0 2.3 2.5
1.2–3.4 1.9–2.9 2.2–2.8
3.4 4.6 4.4
2.6–4.4 4.1–5.1 4.1–4.6
12.0 12.0 13.5 6.6
11.4–12.6 10.4–13.8 10.1–17.9 4.6–9.2
5.0 3.6 5.8 2.3
4.6–5.4 2.7–4.6 4.1–8.2 1.0–5.0
8.6 7.7 9.7 4.5
8.2–9.0 6.8–8.7 7.7–12.2 3.3–6.2
7.1 6.0 6.5 3.0
6.6–7.6 4.9–7.4 4.8–8.7 1.9–4.7
2.8 1.5 3.0 1.3
2.5–3.2 1.1–2.1 1.7–5.3 0.4–4.6
5.0 3.7 4.8 2.2
4.7–5.3 3.1–4.5 3.6–6.2 1.4–3.6
4.8 12.2
3.9–5.9 11.6–12.8
2.5 4.8
1.8–3.4 4.4–5.2
3.7 8.6
3.1–4.4 8.2–8.9
2.1 7.0
1.6–2.7 6.6–7.5
1.0 2.7
0.6–1.7 2.4–3.0
1.6 4.9
1.3–2.0 4.6–5.2
12.3 1.6
11.7–12.8 1.1–2.2
4.9 0.9
4.5–5.3 0.5–1.8
8.6 1.3
8.3–9.0 0.9–1.7
7.0 0.5
6.6–7.4 0.3–0.8
2.7 –b
2.4–3.0 –
4.9 0.3
4.6–5.2 0.2–0.5
14.8 11.2 10.2
13.1–16.8 10.0–12.5 9.7–10.8
4.2 4.7 4.5
3.4–5.1 4.0–5.6 4.0–5.0
9.6 8.0 7.4
8.6–10.7 7.3–8.8 7.1–7.8
7.4 6.6 6.1
6.2–8.8 5.6–7.6 5.7–6.6
2.1 2.8 2.5
1.6–2.8 2.2–3.5 2.1–2.9
4.8 4.7 4.3
4.1–5.6 4.1–5.3 4.1–4.6
11.4 6.5
10.9–12.0 5.1–8.2
4.5 3.2
4.2–4.9 2.3–4.4
8.1 4.9
7.7–8.4 4.0–5.9
6.7 1.7
6.3–7.1 1.3–2.4
2.5 1.3
2.3–2.8 0.7–2.1
4.6 1.5
4.4–4.9 1.1–2.0
Note: From Visser and Lesene (2005). a Confidence interval within which there is a 95% certainty that the true population prevalence falls. b Not included as the relative standard error was greater than 30%.
3 Prevalence and Associated Conditions
National Prevalence Age group (yrs) 4–8 9–12 13–17 Highest education in family Less than high school High school graduate More than high school Race White Black Multiracial Other Ethnicity Hispanic Non-Hispanic Primary language in home English Other Federal Poverty Level <100% 100–199% ≥200% Any health-care coverage Yes No
22
Reported ADHD Diagnosis
ADHD Rates in the General Population
0
1
US Population Prevalence, 7.8%
US, 7.8 CO, 4.95 CA, 5.34 UT, 5.49 AZ, 5.89 NM, 6.1 HI, 6.14 NY, 6.27 IL, 6.32 ID, 6.38 NE, 6.39 SD, 6.49 VT, 6.9 VT, 6.9 AK, 7.07 MT, 7.09 WY, 7.13 OR, 7.15 WA, 7.18 NJ, 7.22 NV, 7.22 CT, 7.38 MN, 7.53 MO, 7.67 TX, 7.69 ME, 7.92 IN, 7.93 WI, 8.06 OK, 8.11 KS, 8.14 PA, 8.17 IA, 8.35 MA, 8.51 OH, 8.88 MD, 9.11 NH, 9.14 MI, 9.21 FL, 9.21 VA, 9.28 ND, 9.39 GA, 9.37 NC, 9.54 MS, 9.59 DE, 9.74 RI, 9.81 TN, 9.87 AR, 9.88 SC, 9.98 WV, 10.08 KY, 10.12 LA, 10.31 AL, 11.09
23
2
3
4
5 6 7 8 Percent of the Population
9
10
11
12
Fig. 3.1 Percent of Youth 4–17 ever diagnosed with ADHD by state according to the National Survey of Children’s Health, 2003. Source: National Center on Birth Defects and Developmental Disabilities (2005), http://www.cdc.gov/ncbddd/adhd/adhdprevalence.htm
southern/eastern states of Alabama, Louisiana, Kentucky, and West Virginia report the highest incidence (all above 10%). Internationally it would appear that ADHD is no more common in the United States than in other countries. In a review of the literature Faraone, Sergeant,
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3 Prevalence and Associated Conditions
Gillberg, and Biederman (2003) report the results of 13 prevalence studies of ADHD (among children with an approximate range for mean age being 7.5–11 years) using DSM IV criteria. The countries from which data were available included Australia, Brazil, Colombia, Germany, Iceland, Sweden, and the Ukraine. Five of these studies yielded prevalence estimates ranging from 16 to 19.8% and four of these studies yielded estimates ranging from 2.4 to 7.5%. In concluding their literature review Faraone and colleagues state, “. . .the data from studies using DSM criteria to assess the prevalence of ADHD in representative child and adolescent populations suggest that there is no convincing difference between the prevalence of this disorder in the USA and most other countries or cultures” (p. 111).
Students with ADHD in Special Education It has been suggested that most students with ADHD can be found within general education classroom settings and, while they may need some accommodations, do not require special education services (Barkley, 2006). Of those who are judged to require special education, most are served under the Emotionally Disturbed (ED) or Other Health Impaired (OHI) categories (Schnoes, Reid, Wagner, & Marder, 2006). While it may be only a minority of students with ADHD who require special education services, children with this disability nevertheless comprise a substantial percentage of the special education population. For example, from the first wave of the Special Education Elementary Longitudinal Study (SEELS) it was reported that 27% of children receiving special education assistance were indicated by their parents to have ADHD (Wagner & Blackorby, 2004). More recent SEELS data, collected during the 2004/2005 school year, suggests that 23.8% of youth within the special education population are students with ADHD. Further, as illustrated in Fig. 3.2 and consistent with other reports (e.g., Schnoes et al., 2006) the percentage of students with ADHD is particularly high among students whose special education eligibility is based upon the OHI (66.8%) and ED criteria (60.4%; SRI International, 2006). There is reason to believe that the incidence of students with ADHD in the OHI category has increased substantially since 1990. Among the reasons for this belief is the fact that it was not until 1991 that the U.S. Department of Education “clarified” that ADHD was a condition that could result in eligibility for special education services using OHI eligibility criteria (in addition to LD and ED; Davila et al., 1991). Consistent with the argument that such clarification increased the number of ADHD students in the OHI category is the data provided in Fig. 3.3. As illustrated by this figure, relative to the number of students in the ED and Specific Learning Disability categories (categories within which students with ADHD have historically been found eligible for services), the number of students in the OHI category has increased dramatically (U.S. Department of Education, 2005). While the number of students in the ED and SLD categories has increased by 18 and 22% respectively, the number of students in the OHI category has increased by 860%. Furthermore,
Students with ADHD in Special Education
25
% with ADHD
VI S/LI HI LD AD OI MD MR TBI ED OHI
0
10
20
30
40
VI = Visual Impairment S/LI = Speech/Language Impairment HI = Hearing Impairment LD = Learning Disability AD = Autism OI = Orthopedic Impairment
50 Percent
60
70
80
90
100
MD = Multiple Disabilities MR = Mental Retardation TBI = Traumatic Brain Injury ED = Emotional Disturbance OHI = Other Health Impairment
Fig. 3.2 The percentage of students with ADHD in the special education eligibility categories Notes: From SEELS Wave 3 Data Tables (SRI International, retrieved January 9, 2006, from http://www.seels.net/search/tables/17/si361afrm.html). There were fewer than 10 students with ADHD in the Deaf/Blindness category.
in the 6–11-year-old age group since 1990 there has been an increase of 7.59 per every 1000 students in the OHI category. The only other category to show such a significant increase is Autism, which increased 3.91 per every 1000 students in the same time frame1 (Brock, 2006). Consistent with SEELS findings (Wagner & Blackorby, 2004), it would appear that ADHD is becoming more prominent among older special education students. As illustrated in Fig. 3.4 OHI eligibility has in recent years become more prevalent among 12–17-year-old versus 6–11-year-old special education students (U.S. Department of Education, 2005). Given that a majority of students in the OHI category are students with ADHD, it can be assumed that among older special education students there are increased numbers with ADHD. Finally, internationally one study of special education students outside of the U.S. generated data regarding the prevalence of ADHD. Déry, Toupin, Pauzé, and Verlaan (2004) examined the prevalence of mental health disorders among students receiving special education services, for behavioral difficulties, in public schools located in Quebec, Canada. Results suggested that almost three quarters (74.3%) of the sample of students in grades 1 through 6 met DSM IV criteria for ADHD.
1 It
was in 1991 that autism was added as a special education eligibility category.
26
3 Prevalence and Associated Conditions 3,000,000
Number of Eligible Students
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year OHI
SLD
ED
Fig. 3.3 Number of students found eligible for special education in the ED, SLD, and OHI special education eligibility categories since 1991 Note: From U.S. Department of Education (2005)
ADHD’s Correlates and Association with Other Conditions This section explores specific features and conditions associated with ADHD. Specifically, it examines comorbid psychiatric conditions; school performance; cognitive development; learning disabilities; language development; and social, emotional, and behavioral problems. Comorbid psychiatric conditions. ADHD is frequently comorbid with other disorders (Pliszka et al., 1999). For instance, research reveals that 54–84% of children and adolescents with ADHD may meet criteria for oppositional defiant disorder (ODD); and is recognized as a salient risk factor for the development of conduct disorder (CD; Barkley, 2005; Côté, Tremblay, Nagin, Zoccolillo, & Vitaro, 2002; Faraone, Biederman, Jetton, & Tsuang, 1997; Mannuzza, Klein, Abikoff, Moulton, 2004; van Lier, van der Ende, Koot, & Verhulst, 2007). ADHD is often diagnosed prior to the onset of CD (Tillman et al., 2003). Research regarding the link between smoking, substance abuse, and ADHD reveals that 15–19% of
ADHD’s Correlates and Association with Other Conditions
27
Number of Students in the OHI Category
300,000
250,000
200,000
150,000
100,000
50,000
0 1990
1992
1994
1996
1998
2000
2002
2004
Year 6–11 years
12–17 years
Fig. 3.4 Older students are becoming more prominent in the OHI special education eligibility category (the majority of which are students with ADHD) Note: From U.S. Department of Education (2005)
youth with ADHD will start to smoke or develop other substance abuse disorders (Biederman et al., 1997; Milberger et al., 1997; Szobot et al., 2007). Anxiety disorders have been documented in up to 33% of youth with ADHD (Biederman, Newcorn, & Sprich, 1991; MTA Cooperative Group, 1999; Pliszka, Carlson, & Swanson, 1999; Tannock, 2000). Comorbidity of ADHD and tic-disorders are also common, with about 20% of youth with ADHD also displaying tic-disorders, and about 50% of youth with tic-disorders also displaying ADHD (Banaschewski, Neale, Rothenberger, & Roessner, 2007). Research also reveals that girls with ADHD have been found 3.6 times more likely to meet criteria for an eating disorder, either anorexia or bulimia (Biederman et al., 2007). There is controversy regarding the prevalence of mood disorders among youth with ADHD, with studies showing 0–33% of patients with ADHD meeting criteria for a depressive disorder (Pliszka et al., 1999). The prevalence of mania among patients with ADHD remains a contentious issue (Biederman, 1998). For instance,
28
3 Prevalence and Associated Conditions
Biederman, Faraone, and Lapey (1992) found that 16% of a sample of ADHD patients met criteria for mania, however, the National Institute of Mental Health (NIMH) Multimodal Treatment of ADHD (MTA) study (Jensen et al., 2001) did not find it necessary to exclude any child with ADHD because of a diagnosis of bipolar disorder. Comorbidity patterns among adults with ADHD have been similar to patterns among children; however, anti-social personality often replaces ODD or CD as the main behavioral psychopathology and mood disorders increase in prevalence (Biederman, 2004). The comorbidity of ADHD, CD, and ODD may make it difficult for professionals to distinguish these disorders from one another (Rowland, Lesesne, & Abramowitz, 2002). For example, disruptive behaviors of more than 2000 10–12-year-olds in the general Dutch population were assessed using the Achenbach Child Behavior Checklist (CBCL) and Youth Self-Report (YSR). Results of analyses revealed three groups: (a) those characterized by high scores on ADHD, CD, and ODD items, (b) a group typified by ADHD and ODD symptoms, and (c) a group which scored low on all items (Sondeijker et al., 2005). Thus, it is important to consider the specific constellation of behaviors of a particular student. School performance. Poor academic performance is among the most prominent features associated with ADHD. Students with ADHD are at greater risk of grade retention (Fergusson & Horwood, 1995), increased risk of learning disability (Seidman, Biederman, Monuteaux, Doyle, & Faraone, 2001), and lower scores on standardized achievement tests (e.g., Marshall, Hynd, Handwerk, & Hall, 1997). Research reveals that students with ADHD do not achieve academically at the level predicted by their age or IQ (Frick & Lahey, 1991; Kamphaus & Frick, 1996). Children who exhibit the Predominantly Inattentive Type are more likely to be placed in special education classes for students with learning disabilities, whereas children who exhibit the Combined and Hyperactive-Impulsive Types are more likely to be placed in special education classrooms for children with emotional and behavioral disorders (Warner-Rogers, Taylor, Taylor, & Sandberg, 2000). The comorbidity with school performance further highlights the importance of schoolbased professionals being prepared to provide support services for students with ADHD. Cognitive development. The current literature indicates there is little doubt that as a consequence of this disorder; students with ADHD score an average of nine points lower than their age peers on tests of intelligence (Barkley, 2006; Frazier, Demaree, & Youngstrom, 2004). Some scholars have suggested that deficits in problem-solving and other cognitive processes are likely linked with the poor academic performance associated with ADHD. For example, in addition to slower computational performance in mathematics, which may be behavioral (i.e., slow output of work), children with ADHD also have been shown to score lower on measures of their problem-solving ability in conceptual math (Zentall, Smith, Lee, & Wieczorek, 1994). Executive Functions (EF) are also implicated as underlying influences on the academic performance of students with ADHD. EF has been defined as the “cognitive abilities necessary for complex goal-directed behavior and adaptation to a range of environmental changes and demands” (Loring, 1999, p. 64). The
ADHD’s Correlates and Association with Other Conditions
29
complex mental abilities considered to be part of the EF constellation generally include planning and organizing; maintaining an appropriate problem solving set to achieve a future goal; inhibiting an inappropriate response or deferring a response to a more appropriate time; representing a task mentally (i.e., in working memory); cognitive flexibility; and deduction based on limited information (e.g., Banich, 1997; Denckla, 1994; Loring, 1999; Pennington & Ozonoff, 1996). Considering the role of attention processes in EF, it has been suggested that children with ADHD experience deficits in some of the abilities constituting this construct. Willcutt, Doyle, Nigg, Faraone, and Pennington (2005) conducted a meta-analysis of 83 studies that administered EF measures to children with ADHD (total n = 3734) and without ADHD (n = 2969). Results revealed that groups with ADHD exhibited significant impairment on all EF tasks. Effect sizes for all measures fell in the medium range (0.46–0.69), however, the strongest and most consistent effects were obtained on measures of response inhibition, vigilance, working memory, and planning. Learning disabilities. Mayes, Calhoun, and Crowell (2000) examined the overlap between ADHD and learning disabilities in a clinical sample of 8–16-year-old youth, and found that a Learning Disability (LD) was present in 70% of the children with ADHD. A LD in written expression was twice as common as a LD in reading, math or spelling. Furthermore, children with both a LD and ADHD had more severe learning problems than children who had a LD but not ADHD as well as had more severe attention problems than children with ADHD but not a LD. Mayes and colleagues concluded that learning and attention problems are best conceptualized as existing on a continuum where they usually are interrelated and coexist. Language development. Depending on the precise psychometric definition, 25–35% of children with ADHD will have a coexisting learning or language problem (Pliszka et al., 1999), and roughly 10% have been reported to have reading disabilities (Shaywitz & Shaywitz, 1991). Given that language skills are fundamental in providing a foundation for subsequent learning, it is important that support services aim to promote language and reading skills early. Social, emotional, and behavioral features. The attention and impulsivity problems that are hallmarks of ADHD symptoms result in numerous challenges. Common social maladjustment includes behaviors such as aggressiveness, defiance, stubbornness, and verbal hostility towards others. Common emotional maladjustment includes low frustration tolerance, mood swings, temper tantrums, and anger management challenges. Barkley (1997b) has characterized these challenges as stemming from lack of behavioral inhibition and self-regulation of emotions and behaviors. As mentioned earlier in this chapter, the number of boys diagnosed with ADHD outnumbers girls. This higher ratio of males in clinic samples may be due to selective referral, rather than actual incidence. Females are more likely to exhibit internalizing symptoms, such as inattention, that involve mood, affect and emotion, whereas males typically display more externalizing symptoms, such as hyperactivity and impulsivity, that involve aggressive and anti-social behaviors.
30
3 Prevalence and Associated Conditions
Concluding Comments Epidemiological studies are useful in establishing a baseline regarding the prevalence of ADHD and have served to refine the criteria for diagnosing this disorder, and differentiating it from other disorders with similar symptomatology. The heterogeneity of the population of children with ADHD revealed in epidemiological data suggests that there are a host of risk factors implicated in the development of ADHD. Future epidemiological research will continue to advance our understanding of the prevalence of ADHD and the contribution of potential risk factors. Given the overlap of ADHD with oppositional defiant disorder, conduct disorder, and learning disabilities, school psychologists need to consider related domains of functioning when addressing a referral question regarding ADHD.
Chapter 4
Case Finding and Screening
From the findings mentioned in Chapters 1 and 3, it is imperative that school professionals be vigilant for the symptoms of ADHD among the students they serve. In particular, all school professionals need to be informed about the risk factors and warning signs of ADHD, developmental considerations, as well as how to engage in screening procedures and make appropriate referrals for diagnostic and/or psychoeducational evaluations. This chapter examines ADHD risk factors and discusses how the age and development of the child can affect the presentation of ADHD warning signs. In addition, how to gather and understand relevant information is reviewed, along with a review of specific screening strategies. While it is anticipated that not all school psychologists will be required and/or able to diagnose ADHD, it is expected that all will know how to assist in the processes of cases finding and screening, which are prerequisite to diagnosing this disorder. In addition, all school psychologists should be able to conduct psychoeducational assessments of students with ADHD to determine learning strengths and challenges, as well as to help determine special education eligibility, and develop IEP goals and objectives. Relationships among these identification steps are summarized in Fig. 4.1, which presents Brock and colleague’s (2006) adaptation of Filipek and colleague’s (1999) algorithm for the process of diagnosis.
Case Finding Case finding refers to routine surveillance of all students in the general population to identify atypical developmental patterns. Case finding does not diagnose ADHD or other developmental disorders; rather it is designed to identify the risk factors and recognize the presence of warning signs that would signal the need for further screening and evaluation. As mandated by Child Find regulations in the Individuals with Disabilities Education Improvement Act – 2004 (IDEIA; see www.childfindidea.org/overview.htm for more information about these regulations) all school personnel should play an important role in case finding. Child Find requires all school districts to identify, locate, and evaluate students with disabilities, regardless of the severity of their S.E. Brock et al., Identifying, Assessing, and Treating ADHD at School, Developmental Psychopathology at School, DOI 10.1007/978-1-4419-0501-7_4, C Springer Science+Business Media, LLC 2009
31
32
4 Case Finding and Screening
Case Finding
YES
Screening Indicated
NO
Continue to monitor development
ADHD Screening
YES
ADHD Inicated
NO
Refer for assessment as indicated
Diagnostic Assessment
Psycho-educational Assessment Fig. 4.1 Brock et al.’s (2006) adaptation of Filipek et al.’s (1999) algorithm for the process of diagnosis. Note: Adapted with permission of Springer Science and Business Media. (Copyright 1999) Plenum Publishing Corporation
disabilities. Furthermore, it is important to understand there is an obligation to identify all students who may need special education services, even if the school is not currently providing special education services to the child. IDEIA 2004’s greater emphasis on early identification and screening would appear to strengthen and further enable Child Find mandates (Klotz & Nealis, 2005). For school psychologists and special education personnel, this would include training general educators to identify the risk factors for, and warning signs of, ADHD. Case finding involves looking, listening, and questioning. First, school professionals need to look for and be able to recognize ADHD risk factors and warning signs. In addition, to the direct evaluation of individual students, such “looking” may include school-wide developmental screening and staff development. Second, school professionals (especially school psychologists) need to be good listeners and able to recognize caregiver concerns that signal the possible presence of ADHD symptoms. Finally, they need to know how to question caregivers so as to further identify ADHD symptoms. It is particularly important that school psychologists listen to teachers, as they are often the first to observe behavioral warning signs and become aware of risk factors associated with ADHD. Along with parents, teachers have the opportunity to observe patterns in a child’s behavior. Teachers can also provide the context for discrete behaviors observed by others. For example, while observing that a child is inattentive and/or hyperactive is important; knowing the history associated with these behaviors (i.e., risk factors) may affect the interpretation of behavior. Thus, teacher input is critical for understanding behavioral events.
Case Finding
33
Looking Given its relatively high prevalence, school staff in general, and school-based mental health professionals in particular, need to be vigilant for the risk factors and warning signs of ADHD. This section discusses those factors that educators should be especially attentive for and presents strategies for “looking” for ADHD. Risk factors. These factors are those variables, which when present, increase the odds of a student having ADHD. As discussed in Chapter 2 there are a variety of factors associated with an increased risk of ADHD. Among these risk factors is a history of parental anti-social behavior or conduct disorder, prenatal tobacco and/or alcohol exposure, and low birth weight. However, the most powerful risk factor is a family history of ADHD (Braun, Kahn, Forehlic, Auinger, & Lanphear, 2006; Mick, Biederman, Faraon et al., 2002; Mick, Biederman, Prince et al., 2002). Thus, whenever school personnel become aware of a family history of ADHD, they should be especially attentive for the behavioral warning signs of this disorder. Warning signs. While the presence of risk factors signals the need to be vigilant for symptoms of ADHD, observation of warning signs provides concrete evidence suggestive of this disorder. For ADHD, the primary red flags or warning signs are excessive motor activity, impulsivity, and/or inattention. Checklists of warning signs, which might prove useful in case finding, are provided in Figs. 4.2 and 4.3. It is very important to consider the developmental level of the student when evaluating these warning signs. ADHD can be difficult to identify among preschool-age children as their age appropriate behaviors can be similar to the symptoms of this disorder. Among preschool-age children, high levels of hyperactive or impulsive behaviors do not necessarily indicate a “disorder” if the behavior does not impair functioning. Typical activities such as jumping, running, and yelling are not atypical, rather when there is excessive motor activity, impulsive behaviors, or inattention relative to age peers, concern is warranted. For instance, for preschool-age children
ADHD Warning Signs: A Checklist for Parents and Professionals The child… is constantly moving something — fingers, hands, arms, feet, or legs. walks, runs, or climbs around when others are seated. has trouble waiting in line or taking turns. gets bored after just a short while. daydreams or seems to be in another world. talks when other people are talking. gets frustrated with schoolwork or homework. acts quickly without thinking first. is sidetracked by what is going on around him or her.
Fig. 4.2 A warning signs checklist for parents and professionals. Note: Adapted from NIMH (2004). If multiple warning signs are present, further assessment and behavioral observation is warranted to understand whether these behaviors impair the child’s functioning
34
4 Case Finding and Screening ADHD Warning Signs: A Checklist for Educators
Developmentally Inappropriate Hyperactivity Often fidgeting with hands or feet, or squirming while Persistent Restlessness seated. Running in the halls, climbing on desks, or leaving a seat Motor Activity in situations where sitting or quiet behavior is expected. Developmentally Inappropriate Impulsivity Blurting out answers before hearing the whole question. Impulsivity Impatience
Having difficulty waiting in line or taking turns.
Developmentally Inappropriate Inattention Easily distracted by irrelevant classroom activities, sights, Distractibility and sounds. On assignments and when given instructions, may not pay Short Attention Span attention to details and makes careless mistakes. May display persistent difficulty following instructions Not Following Instructions carefully. May misplace, lose, or forget pencils, books, and tools Losing/Misplacing Materials needed for a task. May skip from one uncompleted activity to another. This Lack of Focus may result in problems with completing homework.
Fig. 4.3 A warning signs checklist for educators that documents school-related ADHD behaviors. Note: Adapted from NIMH (2006). If multiple warning signs are present, further assessment and behavioral observation is warranted to understand whether these behaviors impair the child’s functioning
changing activities every few minutes without being able to focus on a given task for 10 min or longer would be of concern. Among school-age youth warning signs include symptoms of inattention that often interfere with the completion of class work and academic functioning. Impulsive behavior that often results in the breaking of social, familial, and school rules would also be an ADHD warning sign among school-age youth. During adolescence, with the increased demands of school, warning signs that warrant careful consideration include developmentally inappropriate inattention, poor organizational habits, poor task completion, and very negative attitudes toward school. Of course, providing interventions to target these behaviors is optimal regardless of whether the scope of behaviors meets the diagnostic ADHD criteria. When warning signs are noted by school personnel (especially in the presence of ADHD risk factors), the next step is to conduct a screening for ADHD. However, there are several issues related to child cognitive and social development that are critical to consider for accurate interpretation of screening results. As discussed previously, the age of the child is an important consideration in understanding the implications of specific behaviors. In addition, how behavior problems develop over the lifespan needs to be examined. Ultimately, developmental levels can inform placement and treatment. School-wide developmental screening. In addition to being able to recognize and respond to the warning signs described above among individual students, case finding may also include more proactive strategies such as school-wide developmental
Case Finding
35
screenings. These activities would help to not only identify developmental variations that are consistent with ADHD, but will also help to identify other developmental disorders. As such, these screenings would be consistent with the federal “child find” regulations discussed above. A developmental screening technique that might be helpful is the Systematic Screening for Behavior Disorders (SSBD; Walker & Severson, 1992). This measure provides a multi-gating, mass screening process to identify students who may develop behavior disorders by giving regular classroom teachers uniform behavioral standards. A brief summary of the SSBD is provided in Table 4.1. Another measure that is potentially useful as a mass screener is the Preschool and Kindergarten Behavior Scales-Second Edition (PKBS-2; Merrell, 2003). The PKBS-2 includes 76 items that may be completed by teachers or parents, to measure social skills, problem behaviors, aggression, hyperactivity, anti-social behaviors of children ages 3–6. The PKBS-2 can be used as a screening tool for identifying atrisk children and can be used to inform appropriate interventions (Fairbank, 2006; Jentzsch & Merrell, 1996; Madle, 2006; Merrell, 1996a, 1996b, 2008). A recently developed measure that was specifically designed as a school-wide screener is the Early Childhood Behavior Problem Screening Scale (ECBPSS; Epstein & Nelson, 2006). The ECBPSS includes a teacher and parent form, each with 12 items that use a 4-point Likert-type scale that ranges from 0 (not at all like my child) to 3 (very much like my child). Initial investigations of reliability and convergent validity are promising (Griffith, Nelson, Epstein, & Pederson, 2008; Nelson, Epstein, Griffith, & Harper, 2007). Staff development. Efforts to educate teachers about the risk factors and warning signs of ADHD would also be consistent with child find regulations, and the recent IDEIA reauthorization appears to increase the availability of federal funding for such training (Klotz & Nealis, 2005). Giving general and special education teachers the information they need to look for ADHD (such as is presented in this section’s discussion of risk factors and warning signs) will facilitate case finding efforts.
Listening When parents have concerns about their child’s development they are usually correct (Filipek et al., 1999; Glascoe, 1997). It is also important to note that teachers may
Table 4.1 Three phases of the Systematic Screening for Behavior Disorders (SSBD) 1) Teacher nominations of children whose characteristic behavior patterns most closely resemble profiles of behavior disorders occurring in the school setting and ranking of those students. 2) Screening of teacher-nominated students, using a series of rating items to identify behavioral severity and define the specific content of their behavior problems. 3) Systematic observation of students using a classroom code and a playground code. Note: Reprinted with permission from Sopris West Educational Services. Systematic Screeming for Behavior Disorders (SSBD), by Hill Walker and Herbert Severson (Copyright 1192).
36
4 Case Finding and Screening
be an especially valuable resource given their knowledge of developmentally appropriate behavior, and their daily observations of learning and social behavior in the classroom and on the playground (Molina, Smith, & Pelma, 2001; Wender, 1988). Listening to parents and teachers concern is paramount in the process of identifying students who are troubled or troubling. Table 4.2 provides a list of parental concerns that might be considered “Red Flags” for ADHD. The greater the number of these concerns the greater the need for an ADHD screening. While isolated concerns may be indicative of normal developmental variations, a more significant number of concerns (especially when combined with ADHD risk factors) are important red flags of ADHD.
Questioning While parental concerns about atypical development are powerful indicators of the need for screenings, the absence of such does not necessarily eliminate the possibility of ADHD. Thus, it is critical that for school professionals to be able to ask questions that will facilitate the identification of behaviors consistent with ADHD. Figures 4.2 and 4.3 can be used to prompt such questioning.
Screening As indicated by the degree of functional impairment, students considered to be at-risk for ADHD (as identified by case finding efforts) should be screened for this disorder. Such screening is designed to help determine the need for additional Table 4.2 Parental concerns considered ADHD red flags Attention Concerns
Activity Level Concerns
Impulsivity Concerns
• Fails to finish most tasks. • Skips from one uncompleted activity to the next. • Easily bored. • Frequently daydreams. • Appears “spacey.” • Easily frustrated and readily gives up. • Easily distracted. • Doesn’t pay attention. • Directions frequently need to be repeated and/or are not followed. • Makes careless errors. • Frequently loses materials.
• Always moving (as if driven by a motor). • Unable to remain seated. • Difficulty sitting still (fidgets with hands/feet, and/or constantly squirming). • Constantly running and climbing.
• Has trouble waiting his or her turn. • Has trouble waiting in line. • Talks when others are talking. • Very quick to respond (without thinking things through). • Answers questions too quickly.
Note: Adapted from NIMH (2004, 2006).
Screening
37
diagnostic and/or psycho-educational assessments. Because these screenings are relatively affordable, quick, and easy it has been suggested that screening referral decisions should be rather liberal. It is important to acknowledge that the purpose of screening is not to diagnose ADHD, but rather to determine if additional diagnostic and/or psycho-educational assessments are warranted. All school psychologists should be able to distinguish between screening and diagnosis. Given their training in behavioral observation and knowledge of the appropriate use of behavior rating scales, school psychologists are exceptionally well qualified to conduct the behavioral screening of students suspected to have ADHD. While there are a variety of screening tools that can be used to facilitate identification and are important to the diagnosis of ADHD, the ones selected for review in this chapter are (a) brief, (b) readily accessible via the Internet, and (c) have documented psychometric properties. Additional published diagnostic measures are reviewed in Chapter 5’s discussion of behavior rating scales. Swanson, Nolan and Pelham (SNAP-IV) rating scale. The SNAP-IV items designed to screen for ADHD are provided in Fig. 4.4 and available via the Internet at www.adhd.net/SNAP_SWAN.pdf. A 26-item SNAP-IV version, also referred to as the MTA version (Multimodal Treatment Study of ADHD), assesses ADHD core symptoms of hyperactivity/impulsivity and inattention, along with symptoms of ODD. Additional scoring instructions can be found at www.adhd.net/snap-ivinstructions.pdf. A 4-point response is used, with each item being scored 0–3 (Not at All = 0, Just A Little = 1, Quite A Bit = 2, and Very Much = 3). Scores on the SNAP-IV are calculated by summing the scores on the items in the specific subset (i.e., Inattention and Hyperactive/Impulsive) and dividing by the number of items in the subset (i.e., 9). The score for any subset is expressed as the Average Rating-Per-Item. Different cutoff scores considered to be suggestive of ADHD are offered for both parents and teachers. For teacher the Inattentive Type cutoff score is 2.56, the Hyperactive/Impulsive Type cutoff score is 1.78, and the Combined Type cutoff score is 2.0. For parents the Inattentive Type cutoff score is 1.78; the Hyperactive/Impulsive Type cutoff score is 1.44, and the Combined Type cutoff score is 1.67 (Swanson et al., 2005). Recent research suggests promising psychometric properties and also provides valuable normative ratings (Bussing et al., 2008). The SNAP-IV is a promising screening measure for behavioral concerns, performing adequately, with modest parent or teacher SNAP-IV subscale score elevations predicting useful increases in the likelihood of concern. Bussing and colleagues conclude that “clinicians in moderate-to-high prevalence settings can be fairly certain that parent SNAP-IV scores above 1.2 and teacher scores above 1.8 signal behavioral concerns that the child merits a diagnostic assessment for ADHD” (p. 326). Strengths and Weakness of ADHD-symptoms and Normal-behavior (SWAN) scale. The SWAN is provided in Fig. 4.5 and available via the Internet at www.adhd.net/SNAP_SWAN.pdf. Its development was based on the observation that the SNAP-IV tended to over-identify extreme cases. Assuming ADHD is found among 5% of the population, the SNAP IV identified 1.7 times more than the expected number of cases (8.4%). The SWAN re-worded items to make them
38
4 Case Finding and Screening Swanson, Nolan and Pelham (SNAP-IV) Rating Scale
Name:
Gender:
Ethnicity: African-American
Asian
Caucasian
For teacher: Completed by:
Class size:
Recommended times for follow-up call: # Parents Living in Home:
For parent: Completed by: Period of Time Covered by Rating: Past Week
Past Month
Past Year
For each item, check the column that best describes this child: 1.
Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks
2.
Often has difficulty sustaining attention in tasks or play activities
3.
Often does not seem to listen when spoken to directly
4.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties
5.
Often has difficulty organizing tasks and activities
6.
Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort
7.
Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books)
8.
Often is distracted by extraneous stimuli
9.
Often is forgetful in daily activities
10.
Often fidgets with hands or feet or squirms in seat
11.
Often leaves seat in classroom or in other situations in which remaining seated is expected
12.
Often runs about or climbs excessively in situations in which it is inappropriate
13.
Often has difficulty playing or engaging in leisure activities quietly
14.
Often is "on the go" or often acts as if "driven by a motor"
15.
Often talks excessively
16.
Often blurts out answers before questions have been completed
17.
Often has difficulty awaiting turn
18.
Often interrupts or intrudes on others (e.g., butts into conversations/games)
Total Average
Grade:
Other
Type of Class:
Telephone # at school:
ADHD-In
Age:
Hispanic
Not At All
Lifetime Just A Little
Family Size: Other Quite A Bit
Very Much
ADHD-H/IM
#1
#10
#2
#11
#3
#12
#4
#13
#5
#14
#6
#15
#7
#16
#8
#17
#9
#18
= =
= =
The 4-point response is scored 0–3 (Not at All = 0, Just A Little = 1, Quite A Bit = 2, and Very Much = 3). Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the specific subset (eg., Inattention) and dividing by the number of items in the subset (e.g., 9). The score for any subset is expressed as the Average Rating-Per-Item.
Fig. 4.4 The Swanson, Nolan and Pelham (SNAP-IV) rating scale. Note: Reprinted from Schoolbased Assessments and Interventions for ADD students (Swanson, 1992, pp. 48–49) with permission from Dr. James Swanson. Copyright 1992
dimensional (vs. statistical cutoffs that defined abnormal behavior) and in doing so captured variations related to strengths and weaknesses. It also employed a 7-point response scored +3 to –3 (Far Below Avg. = 3, Below Avg. = 2, Slightly Below Avg. = 1, Average = 0, Slightly Above Avg. = –1, Above Average = –2, and Far Above Average = –3). Subscale scores on the SWAN are calculated by
Screening
39
Strengths and Weakness of ADHD-symptoms and Normal-behavior (SWAN) scale Gender:
Age:
Grade:
Name: Completed by:
Class size:
Ethnicity (circle one which best applies):
African-American
Asian
Type of Classroom: Caucasian
Hispanic
Other
Children differ in their abilities to focus attention, control activity, and inhibit impulses. For each item listed below, how does this child compare to other children of the same age? Please select the best rating based on your observations over the past month. Compared to other children, how does this child do the following:
1.
Give close attention to detail and avoid careless mistakes
2.
Sustain attention on tasks or play activities
3.
Listen when spoken to directly
4.
Follow through on instructions and finish school work or chores
5.
Organize tasks and activities
6.
Engage in tasks that require sustained mental effort
7.
Keep track of things necessary for activities
8.
Ignore extraneous stimuli
9.
Remember daily activities
10.
Sit still (control movement of hands or feet or control squirming)
11.
Stay seated (when required by class rules or social conventions)
12.
Modulate motor activity (inhibit inappropriate running or climbing)
13.
Play quietly (keep noise level reasonable)
14.
Settle down and rest (control constant activity)
15.
Modulate verbal activity (control excess talking)
16.
Reflect on questions (control blurting out answers)
17.
Await turn (stand in line and take turns)
18.
Enter into conversations & games without interrupting or intruding
ADHD-In
ADHD-H/IM
#1
#10
#2
#11
#3
#12
#4
#13
#5
#14
#6
#15
#7
#16
#8
#17
#9
#18
far below avg.
below
slightly below avg.
avg.
slightly above avg.
above
Far above avg.
Total = = Average = = The 7-point response is scored +3 to – 3 (Far Below Avg. = 3, Below Avg. = 2, Slightly Below Avg. = 1, Average = 0, Slightly Above Avg. = –1, Above Average = –2, and Far Above Average = –3). Subscale scores on the SWAN are calculated by summing the scores on the items in the specific subset (e.g., Inattention) and dividing by the number of items (e.g., 9) to express the summary score as the Average Rating-Per-Item.
Fig. 4.5 Strengths and Weakness of ADHD-symptoms and Normal-behavior (SWAN) scale. Note: Reprinted from Categorical and Dimensional Definitions and Evaluations of Symptoms of ADHD: The SNAP and the SWAN Ratings Scales (Swanson, 2005, p. 16) with permission from Dr. James Swanson
summing the scores on the items in the specific subset (i.e., Inattention and Hyperactive/Impulsive) and dividing by the number of items in the subset (i.e., 9). The score for any subset is expressed as the Average Rating-Per-Item. Cutoff scores considered to be suggestive of ADHD are offered for teacher ratings and are as follows: 2.11 for Combined Type, 2.48 for Inattentive Type, and 2.00 for Hyperactive/Impulsive Type (Swanson et al., 2005).
40
4 Case Finding and Screening
Parent/Teacher Disruptive Behavior Disorder Rating Scale (DBD). The DBD is provided in Fig. 4.6 and available via the Internet at http://ccf.buffalo.edu/ pdf/DBD_rating_scale.pdf. This measure can be used to screen not only for ADHD, but also for Oppositional Defiant and Conduct Disorders. As indicated on the
Parent/Teacher DBD Rating Scale Child's Name: Grade:
Date of Birth:
Form Completed by: Sex: Date Completed:
Check the column that best describes your/this child. Please write DK next to any items for which you don't know the answer. Not at All often interrupts or intrudes on others (e.g., butts into conversations or games) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) 3. often argues with adults 4. often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others) 5. often initiates physical fights with other members of his or her household 6. has been physically cruel to people 7. often talks excessively 8. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) 9. is often easily distracted by extraneous stimuli 10. often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking 11. often truant from school, beginning before age 13 years 12. often fidgets with hands or feet or squirms in seat 13. is often spiteful or vindictive 14. often swears or uses obscene language 15. often blames others for his or her mistakes or misbehavior 16. has deliberately destroyed others' property (other than by fire setting) 17. often actively defies or refuses to comply with adults' requests or rules 18. often does not seem to listen when spoken to directly 19. often blurts out answers before questions have been completed 20. often initiates physical fights with others who do not live in his or her household (e.g., peers at school or in the neighborhood) 21. often shifts from one uncompleted activity to another 22. often has difficulty playing or engaging in leisure activities quietly 23. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities 24. is often angry and resentful 25. often leaves seat in classroom or in other situations in which remaining seated is expected 26. is often touchy or easily annoyed by others 27. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) 28. often loses temper 29. often has difficulty sustaining attention in tasks or play activities 30. often has difficulty awaiting turn 31. has forced someone into sexual activity 32. often bullies, threatens, or intimidates others 33. is often "on the go" or often acts as if "driven by a motor" 34. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) 35. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) 36. has been physically cruel to animals 37. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) 38. often stays out at night despite parental prohibitions, beginning before age 13 years 39. often deliberately annoys people 40. has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) 41. has deliberately engaged in fire setting with the intention of causing serious damage 42. often has difficulty organizing tasks and activities 43. has broken into someone else's house, building, or car 44. is often forgetful in daily activities 45. has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife,gun) parent/teacher dbd.v1
Just a Little
Pretty Much
Very Much
1. 2.
© CTADD
Fig. 4.6 Disruptive Behavior Disorder Rating Scale. Note: From Pelham, Gnagy, et al. (1992)
Screening
41
screening form, there are two ways to screen for the presence of these disorders. The first method involves counting the number of symptoms for each disorder. If either the parent or teacher rate six or more of the scale’s inattentive items (numbers 9, 18, 23, 27, 29, 34, 37, 42, 44) as “pretty much” or “very much” then the result is positive for ADHD Predominantly Inattentive Type. If either the parent or teacher rate six or more of the scale’s hyperactive/impulsive items (numbers 1, 7, 12, 19, 22, 25, 30, 33, 35) as “pretty much” or “very much” then the result is positive for ADHD Predominantly Hyperactive/Impulsive Type. For both of these scales, the six items may be rated “pretty much” or “very much” on teacher or parent ratings, or a combination of both parent and teacher ratings (e.g., 4 symptoms endorsed on the parent DBD and 2 separate symptoms endorsed on the teacher DBD). However, the same symptom should not be counted twice if it appears on both parent and teacher rating scales. When scored in this fashion, if six or more items are endorsed on both inattentive and hyperactive/impulsive scales then the result is positive for ADHD Combined Type. If 4 or more of the Oppositional Defiant Disorder items (numbers 3, 13, 15, 17, 24, 26, 28, 39) are rated as “pretty much” or “very much” on either the parent or teacher forms then the result is positive for this disorder. If three or more of the Conduct Disorder items within four categories (or combination of categories) are rated as “pretty much” or “very much” on either parent or teacher forms then the result is positive for this disorder. Conduct Disorder categories are (a) aggression to people and animals (numbers 6, 20, 31, 32, 36, 40, 45), (b) destruction of property (numbers 16, 41), (c) deceitfulness or theft (numbers 4, 8, 43), and (d) serious violation of rules (numbers 2, 11, 38). Research reveals adequate technical properties (Erford, 1998; Pelham, Evans, Gnagy, & Greenslade, 1992). An additional method of scoring the DBD involves comparing the student’s rating scale score to established norms (see Pelham Gnagy, Greenslade, & Milich, 1992, for further discussion). With this method, scores are determined by obtaining the average rating for each of three factors (i.e., Oppositional/Defiant, Inattention, and Impulsivity/Overactivity) using the following scoring: “Not at all” = 0, “Just a little” = 1, and “Very much” = 3. Item numbers associated with each factor are as follows: Oppositional/Defiant, numbers 3, 13, 15, 17, 24, 26, 28, 39; Inattention, numbers 9, 18, 23, 27, 29, 34, 37, 42, 44; and Impulsivity/Overactivity, numbers 1, 7, 12, 19, 22, 25, 30, 33, 35. ADHD Rating Scale. The ADHD Rating Scale (The Foundation for Medical Practice Education, (2008) www.fmpe.org) is available via the Internet at http://www.fmpe.org/en/documents/appendix/Appendix%201%20-%20ADHD%20Rating%20Scale.pdf and http://www.psy-world.com/adhd_print.htm. The ADHD Rating Scale includes the 18 criteria for ADHD, for use with children 6–12 years old. Parents, teachers, clinicians or youth may rate the frequency (during past 6 months) of each symptom as never, sometimes, often, or very often. This brief scale takes 10–15 minutes to complete. To meet the criteria for ADHD inattentive subtype, there must be six or more symptoms in the Inattention section rated as “Always or very often” or “Often.” To be consistent with the criteria for ADHD hyperactive sub-type, six or more of the hyperactive symptoms must be rated in as “Always
42
4 Case Finding and Screening VANDERBILT ADHD DIAGNOSTIC PARENT RATING SCALE
Child’s Name:
Today’s Date:
Date of Birth:
Age:
Grade:
Each rating should be considered in the context of what is appropriate for the age of your child. 0 = Never
Frequency Code:
1 = Occasionally
2 = Often
3 = Very Often
1.
Does not pay attention to details or makes careless mistakes, for example homework
2.
Has difficulty sustaining attention to tasks or activities
3.
Does not seem to listen when spoken to directly
4.
Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)
5.
0
1
2
0
0
1
1 2
2
0
3
0
1
2
3
6.
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities (school assignments, pencils or books)
8.
Is easily distracted by extraneous stimuli
9.
Is forgetful in daily activities
0
1
0 2
1
2
0
11. Leaves seat when remaining seated is expected
1
2
0
1
14. Is “on the go” or often acts as if “drive by a motor”
2
0
2
0
1
2
3
3
1
2
1
2
3
3
0
1
2
0
1
3
18. Interrupts or intrudes on others (e.g., butts into conversations or games)
1
0
2
2 3
17. Has difficulty waiting his/her turn
0
3 3
3
1
16. Blurts out answers before questions have been completed
20. Loses temper
2 2
3
13. Has difficulty playing or engaging in leisure/play activities quietly
0
1 1
3
12. Runs about or climbs excessively in situations when remaining seated is expected
1
0 0
3
10. Fidgets with hands or feet or squirms in seat
19. Argues with adults
3
3
7.
0
2
3
Has difficulty organizing tasks and activities
15. Talks too much
1
1 2
2
3
3
21. Actively defies or refuses to comply with adults’ requests or rules 22. Deliberately annoys people
0
3
0
1
2
23. Blames others for his or her mistakes or misbehaviors 24. Is touchy or easily annoyed by others
0
1
2
3
3
0
1
2
0
1
2
3
3
Fig. 4.7 Vanderbilt ADHD diagnostic parent rating scale. Note: Reprinted from https://kr.ihc.com/ ext/Dcmnt?ncid=51069669 with permission from Dr. Mark Wolraich, from the Monroe Carell Jr. Children’s Hospital at Vanderbilt
Screening
43 25. Is angry or resentful
0
1
26. Is spiteful and vindictive
2
0
3
1
2
3
27. Bullies, threatens, or intimidates others 28. Initiates physical fights
0
1
2
0
1
2
3
3
29. Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others)
0
1
2
0
1
2
3
45. Feels lonely, unwanted, or unloved: complains that “no one loves him/her”
0
1
2
30. Is truant from school (skips school) without permission 31. Is physically cruel to people
0
1
2
32. Has stolen items of nontrivial value
1
2
1 0
2 1
3 2
3
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 35. Is physically cruel to animals
0
1
2
3
36. Has deliberately set fires to cause damage
0
2
3
37. Has broken into someone else’s home, business, or car
0
38. Has stayed out at night without permission 39. Has run away from home overnight
0
0
1
1
0 1
40. Has forced someone into sexual activity 41. Is fearful, anxious, or worried
0 2
1
2
2
3
1
2
0
1
2
44. Blames self for problems, feels guilty
46. Is sad, unhappy, or depressed
0
1
47. Is self-conscious or easily embarrassed
1
2
3
1
2
3
3
3
3
42. Is afraid to try new things for fear of making mistakes 43. Feels worthless or inferior
3
3
3
0
33. Deliberately destroys others’ property
0
0
3 0
1
2 0
2
3 3
3 1
2
3
Fig. 4.7 (Continued)
or very often” or “Often.” If the criteria for both inattention and hyperactivity are met (i.e., six or more in both), then symptoms meet criteria of the ADHD combined sub-type. The Foundation for Medical Practice Education website also includes a brief guide to interpretation of the ADHD Rating Scale. As it uses the DSM-IVTR ADHD diagnostic symptoms, this scale may be useful for screening ADHD, however, no psychometric data or publications were located. Vanderbilt ADHD Diagnostic Parent Rating Scale (ADPRS). The ADPRS is provided in Fig. 4.7 and available via the Internet at https://kr.ihc.com/ext/Dcmnt?ncid=51069669 The ADPRS can be used to screen not only for ADHD, but also for Oppositional-Defiant and Conduct Disorders, and anxiety or depression symptoms. A 4-point response is used, with each item being scored 0–3 (Never = 0, Occasionally = 1, Often = 2, and Very Often = 3). As indicated on the form, scores on this measure are counted if they are scores a 2 (Often) or a 3 (Very Often). Assuming a score of 1 or 2 on any of the items in the performance section, the result is positive for Inattentive Type if six or more items are counted from questions 1 to
44
4 Case Finding and Screening PERFORMANCE 1. Overall Academic Performance a. Reading b. Mathematics c. Written Expression
Problematic 1 2 1 2 1 2 1 2
Average 3 3 3 3
Above Average 4 5 4 5 4 5 4 5
2. Overall Classroom Behavior a. Relationship with peers b. Following Directions/Rules c. Disrupting Class d. Assignment Completion e. Organizational Skills
Problematic 1 2 1 2 1 2 1 2 1 2 1 2
Average 3 3 3 3 3 3
Above Average 4 5 4 5 4 5 4 5 4 5 4 5
Scoring Instructions for the ADPRS *Predominately inattentive subtype requires 6 of 9 behaviors, (scores of 2 or 3 are positive) on items 1 through 9, and a performance problem (scores of 1 or 2) in any of the items on the performance section. *Predominately hyperactive/Impulsive subtype requires 6 of 9 behaviors (scores of 2 or 3 are positive) on items 10 through 18 and a problem (scores of 1 or 2) in any of the items on the performance section. *The Combined Subtype requires the above criteria on both inattention and hyperactivity/impulsivity. *Oppositional-defiant disorder is screened by 4 of 8 behaviors, (scores of 2 or 3 are positive) (19 through 26). *Conduct disorder is screened by 3 of 15 behaviors, (scores of 2 or 3 are positive) (27 through 40). *Anxiety or depression are screened by behaviors 41 through 47, scores of 3 of 7 are required, (scores of 2 or 3 are positive).
Fig. 4.7 (Continued)
9, Hyperactive/Impulsive Type if six or more items are counted from questions 10 to 18, for Combined Type if both Inattentive and Hyperactive/Impulsive criteria are met. The result would be considered positive for Oppositional-Defiant Disorder if 8 or more items are counted from questions 19 to 26, for Conduct Disorder if three or more items are counted from questions 27 to 40, and for anxiety or depression symptoms if three or more items are counted from questions 41 to 47. Wolraich, Lambert, Doffing and colleagues (2003) report acceptable psychometric properties of the ADPRS. Vanderbilt ADHD Diagnostic Teacher Rating Scale (ADTRS). The ADTRS is provided in Fig. 4.8 and available via the Internet at www.brightfutures.org/mentalhealth/pdf/professionals/bridges/adhd.pdf. Like the parent version, the ADTRS can be used to screen not only for ADHD, but also for Oppositional Defiant and Conduct Disorders, and anxiety or depression symptoms. A 4-point response is used, with each item being scored 0–3 (Never = 0, Occasionally = 1, Often = 2, and Very Often = 3). As indicated on the form, scores on this measure are counted if they are scores a 2 (Often) or a 3 (Very Often). The result is positive for Inattentive Type if six or more items are counted from questions 1 to 9, Hyperactive/Impulsive Type if six or more items are counted from questions 10 to 18, for Combined Type if both Inattentive and Hyperactive/Impulsive criteria are met, for Oppositional and Conduct Disorders if three or more times are counted from questions 19 to 28, and for anxiety or depression symptoms if three or more items are counted from questions 29 to 35. The performance section is scored as indicating some impairment in
Screening
45 Vanderbilt ADHD Diagnostic Teacher Rating Scale
Name: Date of Birth:
Grade: Teacher:
School:
Each rating should be considered in the context of what is appropriate for the age of the children you are rating. Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 1.
Fails to give attention to details or makes careless mistakes in schoolwork
0
1
2
3
2.
Has difficulty sustaining attention to tasks or activities
0
1
2
3
3.
Does not seem to listen when spoken to directly
0
1
2
3
4.
Does not follow through on instruction and fails to finish schoolwork
0
1
2
3
(not due to oppositional behavior or failure to understand) 5.
Has difficulty organizing tasks and activities
0
1
2
3
6.
Avoids, dislikes, or is reluctant to engage in tasks that require sustaining
0
1
2
3
0
1
2
3
3
mental effort 7.
Loses things necessary for tasks or activities (school assignments, pencils, or books)
8.
Is easily distracted by extraneous stimuli
0
1
2
9.
Is forgetful in daily activities
0
1
2
3
10. Fidgets with hands or feet or squirms in seat
0
1
2
3
11. Leaves seat in classroom or in other situations in which remaining seated
0
1
2
3
0
1
2
3
is expected 12. Runs about or climbs excessively in situations in which remaining seated is expected 13. Has difficulty playing or engaging in leisure activities quietly
0
1
2
3
14. Is “on the go” or often acts as if “driven by a motor”
0
1
2
3
15. Talks excessively
0
1
2
3
16. Blurts out answers before questions have been completed
0
1
2
3
17. Has difficulty waiting in line
0
1
2
3
18. Interrupts or intrudes on others (e.g., butts into conversations or games)
0
1
2
3
19. Loses temper
0
1
2
3
Fig. 4.8 Vanderbilt ADHD diagnostic teacher rating scale. Note: Reprinted from the Journal of Abnormal Child Psychology (Wolraich et al., 1998, pp. 151–152) with permission from Springer Publishing. Copyright © Springer Science + Business Media, 1998.
functioning if the student is scored at a 1 or 2 on at least one item. Wolraich, Feurer, Hannah, Baumgaertel and Pinnock (1998) and Wolraich, Lambert, Baumgaertel et al. (2003) report adequate psychometric properties for the ADTRS. Each of the assessments described above would be appropriate for screening. If the findings from the screening reveal that further assessment was warranted, it would be important to consider administration of diagnostic assessments of ADHD, such as Attention Deficit Disorders Evaluation Scale-Third Edition (ADDES-3; McCarney, 2004), the ADHD Rating Scale-IV (ADHD-IV; DuPaul, Power, Anastopoulos, & Reid, 1998), and the Conners’ Rating Scales-Revised (CRS-R; Conners, 1997). Discussion of these and other more involved diagnostic
46
4 Case Finding and Screening Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
20. Actively defies or refuses to comply with adults’ requests or rules
0
1
2
3
21. Is angry or resentful
0
1
2
3
22. Is spiteful and vindictive
0
1
2
3
23. Bullies, threatens, or intimidates others
0
1
2
3
24. Initiates physical fights
0
1
2
3
25. Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others)
0
1
2
3
26. Is physically cruel to people
0
1
2
3
27. Has stolen items of nontrivial value
0
1
2
3
28. Deliberately destroys others’ property
0
1
2
3
29. Is fearful, anxious, or worried
0
1
2
3
30. Is self-conscious or easily embarrassed
0
1
2
3
31. Is afraid to try new things for fear of making mistakes
0
1
2
3
32. Feels worthless or inferior
0
1
2
3
33. Blames self for problems, feels guilty
0
1
2
3
34. Feels lonely, unwanted, or unloved; complains that “no one loves
0
1
2
3
0
1
2
3
him/her” 35. Is sad, unhappy, or depressed
PERFORMANCE Problematic
Average
Above Average
Academic Performance a. Reading
1
2
3
4
5
b. Mathematics
1
2
3
4
5
c. Written Expression
1
2
3
4
5
Classroom Behavioral Performance a. Relationship with peers
1
2
3
4
5
b. Following Directions/Rules
1
2
3
4
5
c. Disrupting Class
1
2
3
4
5
d. Assignment Completion
1
2
3
4
5
e. Organizational Skills
1
2
3
4
5
Fig. 4.8 (Continued)
procedures are discussed in detail in Chapter 5. Psycho-educational assessment is discussed thoroughly in Chapter 6 (also see Pelham, Fabiano, & Massetti, 2005, for a review of ADHD rating scales).
Concluding Comments It is an important role of the school psychologist to alert school personnel to risk factors and warning signs of ADHD. Further, school psychologists should be instrumental in leading screening activities for children in schools so that specific behaviors can be evaluated in terms of their deviation from the expected developmental path. If the data from screening procedures, which typically include teacher
Concluding Comments
47
and parent input, and observations lead to the question of whether a disorder is present, then professionals should refer for a formal evaluation. As discussed further in Chapter 5, school psychologists are adequately trained to identify a variety of DSM disruptive behavior disorders, including ADHD. In addition, school psychologists can translate such diagnoses for multidisciplinary teams to determine special education eligibility decisions and also identify school-based intervention strategies and support services to facilitate student learning and development. This later issue will be discussed in Chapter 6.
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Chapter 5
Diagnostic Assessment
As discussed in Chapter 4, screening test results can be used to determine if an ADHD diagnostic assessment is required. When such diagnostic assessments are indicated, it is important to keep in mind that no single test will reliably identify this disorder. Thus, diagnostic assessments require multiple methods, employed across multiple settings, by a multidisciplinary team of specialists (Brock, 1999). When a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision [DSM IV-TR]; American Psychiatric Association [APA], 2000) diagnosis is being sought, whether or not a school psychologist completes this task is often determined by local precedent and practice. Consequently, it has been observed that some districts prohibit school psychologists from making ADHD diagnoses. These prohibitions can be problematic given that (a) federal regulations clearly specify that students with ADHD may be eligible for special education services or Section 504 protections (Davila et al., 1991) and (b) school districts must conduct assessments in all areas of suspected disability and are required to identify such special needs (34 C.F.R. §§ 104.32, 104.35, 300.304). While this is an area of some disagreement (Kidder, 2002), it is the opinion of the authors that appropriately trained school psychologists are well qualified to make this diagnosis. At the very least it is suggested that these school-based mental health professionals have access to data sources (e.g., classroom behavior, school records, parent and teacher reports) important to making an ADHD diagnosis (LaFleur & Northup, 1997). Regardless of whether a school psychologist actually makes a DSM IV-TR diagnosis, it will be important for him or her to know the elements of an ADHD diagnosis so as to be better able to support this process. In addition, while it is the Individuals with Disabilities Education Act (IDEA) and not DSM IV-TR that drives special education eligibility decisions, these diagnoses are often offered as evidence that a student is in need of special educational programming. Thus, knowledge of how to make a DSM IV-TR ADHD diagnosis is important, and providing such information is the goal of this chapter. To obtain this goal, discussion will first provide a review of diagnostic criteria. Then, the developmental, health, and family history elements of diagnosis are reviewed; and the specific diagnostic procedures most frequently recommended by the literature are discussed. Finally, special issues associated with the evaluation of preschool and minority youth are discussed.
S.E. Brock et al., Identifying, Assessing, and Treating ADHD at School, Developmental Psychopathology at School, DOI 10.1007/978-1-4419-0501-7_5, C Springer Science+Business Media, LLC 2009
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5 Diagnostic Assessment
Diagnostic Criteria As was mentioned in Chapter 1, ADHD includes three different subtypes, with the specific diagnostic criteria provided in the DSM IV-TR (APA, 2000). In DSM IVTR ADHD is placed within the subclass of “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (pp. 39–134) that is referred to as “AttentionDeficit and Disruptive Behavior Disorders” (pp. 85–103). In addition to ADHD, this subclass includes Conduct Disorder (pp. 93–99) and Oppositional Defiant Disorder (pp. 100–103). According to DSM IV-TR, ADHD’s primary symptoms are developmentally inappropriate inattention and/or impulsivity and hyperactivity. Using DSM IV-TR criteria a child can be diagnosed as either Predominantly Inattentive, Predominantly Hyperactive-Impulsive, or Combined types. Criteria for the Inattentive Type require that six or more of nine symptoms be present. Criteria for the HyperactiveImpulsive Type require that four or more of six symptoms be present. Criteria for the Combined Type require that both Inattentive and Hyperactive-Impulsive criteria are met (APA, 2000). Table 5.1 provides the specific diagnostic criteria. Although the specific behavioral symptoms presented by DSM IV-TR are relatively straightforward, other diagnostic requirements deserve further elaboration and will now be discussed. Symptom onset. According to DSM IV-TR, “Most parents first observe excessive motor activity when the children are toddlers, frequently coinciding with the development of independent locomotion” (APA, 2000, p. 90). While the diagnosis of ADHD can be made in adulthood, diagnostic criteria require that symptoms have been present and have caused clinically significant functional impairment, before the child’s seventh birthday. Further, while it is possible for a neurologically compromising event, such as head trauma or hypoxic injury, to cause ADHD after the child’s seventh birthday (Max et al., 1997, 1998, 2002), if symptom onset occurs well beyond this age, it is usually caused by something other than ADHD (e.g., substance abuse, learning disabilities, physical illness; Burke, Loeber, & Lahey, 2001; Pennington, 1991; Root & Resnick, 2003). However, among children with the Predominantly Inattentive Type of ADHD, some have argued that later symptom onset criteria (e.g., 9 years of age) might be appropriate (Barkley, 1998), and DSM IV-TR acknowledges that symptoms “may not come to clinical attention until late childhood” (p. 90). Developmental level. DSM IV-TR (APA, 2000) specifies that a diagnostic criterion is met only if the behavior is “. . .inconsistent with developmental level” (p. 92). It is important to acknowledge that symptoms of inattention are frequently displayed by children with mental retardation, especially when a classroom’s curriculum is developmentally inappropriate. Consequently, DSM IV-TR states that among children with mental retardation “. . . an additional diagnosis of Attentiondeficit/Hyperactivity Disorder should be made only if the symptoms of inattention or hyperactivity are excessive for the child’s mental age” (APA, 2000, p. 91). This means, for example, that if a 10-year-old with a mental age of 5 years displays a criterion behavior in a manner typical of a 5-year-old, it would not meet DSM IV-TR
Diagnostic Criteria
51
Table 5.1 DSM-IV-TR criteria for attention-deficit/hyperactivity disorder A. Either (1) or (2): (1) Six (or more) of the following symptoms of inattention have been present for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities. (2) six (or more) of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often “on the go” or often acts as if “driven by a motor” (f) often talks excessively Impulsivity (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Note: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition. (Copyright 2000). American Psychiatric Association (APA, 2000, pp. 92–93).
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5 Diagnostic Assessment
criteria for ADHD. However, if the same child displays criterion behaviors in a manner that is typical of a 3-year-old, it would meet DSM IV-TR criteria. Similarly, gifted children may display inattentiveness when they are placed in under-stimulating classrooms. Symptom duration. First, ADHD criterion behaviors must “have persisted for at least 6 months . . .” (APA, 2000, p. 92). Adherence to this requirement is especially critical among preschoolers as a significant percentage of these youth are rated as inattentive and hyperactive by their parents (Barkley, 1990; Gimpel & Kuhn, 1998; Loughran, 2003; Smith & Corkum, 2007). Clearly, however, not all of these children have ADHD and in the majority of cases concerns remit within 12 months (Campbell, 1990). Consequently, it is important to recognize that inattention and hyperactivity in the 3–4-year-old is not necessarily an indication of ADHD (Barkley, 1998). Symptom duration is also critical when differentiating ADHD from common behaviors typically associated with school adjustment or transient environmental stressors (Brock & Clinton, 2007). Multiple settings. For the ADHD diagnosis to be made, symptoms must be displayed in two or more settings. According to DSM IV-TR (APA, 2000), “Attentional and behavioral manifestations usually appear in multiple contexts, including home, school, work, and social situations” (p. 86). Consequently, when making the ADHD diagnosis it is critical that data be obtained from two or more different sources and/or settings (e.g., parents and teachers and/or home and school). If symptoms are present in only one setting then alternative explanations for the ADHD-like behaviors must be considered. For example, the presence of a reading disability may result in ADHD-like behaviors at school, but not in home or community settings. Clinical significance. DSM IV-TR (APA, 2000) specifies that for the diagnosis of ADHD to be made, “There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning” (p. 93). Thus, the diagnostic assessment must include data indicating that ADHD symptoms have an adverse effect. This means, for example, that if an inattentive and hyperactive student is obtaining passing grades, following school rules, and has adequate peer relationships, there would be reason to question if an ADHD diagnosis is appropriate. Associated features. Academic deficits and school-related problems are most often seen among individuals who demonstrate the inattentive symptoms of ADHD, whereas peer rejection is more likely among those who demonstrate hyperactiveimpulsive symptoms. Oppositional defiant and conduct disorders are frequently comorbid conditions, especially among children with hyperactive/impulsive symptoms (APA, 2000). Age-specific features and prognosis. As was mentioned above, ADHD can be difficult to diagnose among preschool children as their typical behavior can be similar to the symptoms of this disorder. In this age group, high levels of hyperactive/impulsive behavior do not indicate a problem or disorder if the behavior does not impair functioning (American Academy of Pediatrics [AAP], 2000). Symptoms of ADHD are typically most prominent during the elementary school years (Barkley, 2006). During this time activity may be high during play and impulsive behaviors may occur, especially in peer pressure situations (AAP, 2000).
Diagnostic Criteria
53
Among school-age youth symptoms of inattention often interfere with class work and academic functioning, while symptoms of impulsivity often result in the breaking of social, familial, and school rules (APA, 2000). Independent seat work tasks can be especially challenging, and as a result, on-task behavior and task completion are poor. School-aged children with ADHD typically do not have good organizational habits, as can be readily observed by inspecting their binders or looking in their desks. By late childhood and early adolescence the more overt manifestations of ADHD become less conspicuous. Specifically, symptoms of excessive hyperactivity become less common and may be replaced by an internal sense of restlessness (APA, 2000). As was mentioned in Chapter 2, there is speculation that this lessening of hyperactive symptoms may be due to specific neurophysiological changes that take place by mid-adolescence (Castellanos et al., 2002). However, the increased work demands of these later school years, combined with the typically poor organizational habits of these children, result in excessively poor task completion and very negative attitudes toward school. Further, it has been suggested that the increasing demands presented by the transition from elementary to middle school interrupt the general trend of a decline in symptoms as children get older (Langberg et al., 2008). About a third of children diagnosed with ADHD will continue to meet diagnostic criteria into adulthood, with about the same number demonstrating sub-threshold symptoms (Kessler et al., 2005). In adulthood, the restlessness associated with ADHD may result in avoidance of activities that offer limited opportunities for spontaneous movement, such as desk jobs. Social dysfunction may also be noted (APA, 2000). Differential diagnosis. Finally, ADHD diagnostic requirements require that other conditions with similar symptoms be ruled out before an ADHD diagnosis is made (APA, 2000). Table 5.2 provides some guidance regarding how ADHD is different from other common psychiatric disorders. In addition, the differential diagnosis of this disorder requires that age-appropriate behaviors among younger children (e.g., jumping, running, and yelling among preschoolers), mental retardation, under-stimulating environments, oppositional behavior, and other mental disorders (e.g., Pervasive Developmental Disorders, Psychotic Disorder, Bipolar Disorder, and Other Substance-Related Disorder Not Otherwise Specified) be considered and ruled out as primary causes of the observed behaviors before the diagnosis of ADHD is made. This requirement highlights the fact that a variety of conditions may generate ADHD-like behaviors and that the diagnostic evaluation must include evaluation tools designed to consider these alternative explanations for ADHD behaviors (Brock, 1998, Spring, 1999). Summary. From this discussion of DSM IV-TR criteria, the need for different diagnostic procedures should have become apparent. In particular, given the differential diagnosis requirements, knowledge of a range of diagnostic procedures is necessary. For example, to determine whether or not behavior is developmentally inappropriate it will be necessary to estimate the child’s developmental functioning level, and this may require intelligence testing. Additionally, to document the
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5 Diagnostic Assessment Table 5.2 Differential diagnosis of ADHD
Disorder
Differentiating Features from ADHD
Oppositional Defiant and Conduct Disorders
• Defies initial adult direction, but once engaged in a task is able to persist (sustain attention). • Lacks hyperactive/impulsive behaviors. • Behavioral problems most acute in the home (defiance often directed primarily toward parents). • Symptoms are specific to academic setting and/or subjects (e.g., reading groups). • Lacks early history of hyperactivity and problems associated with impulsivity (e.g., no aggression and/or disruption). • Problems with focused (not sustained) attention. • Family history of these disorders (vs. a history of ADHD). • Overinhibited (not impulsive). • Symptom on-set after 7 years of age (lacks preschool history of hyperactivity). • School adjustment typically does not include disruptive behavior or teacher concerns regarding hyperactivity, impulsivity, or inattention. • Symptom on-set after 7 years of age. • Early school adjustment typically does not include disruptive behavior or teacher concerns regarding hyperactivity, impulsivity, or inattention. • Poor reality contact. • Symptom on-set after 7 years of age. • Family history of this disorder (vs. a history of ADHD). • Severe and persistent irritability and/or elated mood. • Temper outbursts (that can become severe (e.g., destructive or violent). • Grandiosity. • Decreased need for sleep. • Hypersexuality. • Distractible inattention related to internal (not external) stimuli. • Deterioration in attention and vigilance over time not as pronounced. • Relative to developmental level, attention span not severely impaired. • Relative to developmental level, activity level considered appropriate. • Acute symptom on-set after 7 years of age • Symptoms related to the use of medication (e.g., bronchodilators, isoniazid, akathisa from neuroleptics).
Learning Disorders
Anxiety and Mood Disorders
Thought Disorders
Bipolar Disorder
Pervasive Developmental Disorder (autism)
Mental Retardation
Substance-Related Disorder Other Substance-Related Disorder (NOS)
Note: Sources APA, 2000; Barkley, 2006; Geller, Williams et al., 1998
symptom onset, clinical significance, and symptom duration requirements, school record review and/or parent and teacher interviews may be important. In addition, to ensure that behaviors are displayed in multiple settings, direct observation and/or behavior rating scales may be necessary (Brock, 1999; Brock & Clinton, 2007).
Birth, Developmental, Health, Family, and Behavioral Histories
55
Birth, Developmental, Health, Family, and Behavioral Histories Often the first step of the diagnostic assessment process is to review with parents their child’s history. The following discussion highlights factors that would support an ADHD diagnosis. Given that an interview of this type is typically a part of any psycho-educational evaluation, it is important for all school psychologists to be aware of these factors. Figure 5.1 provides an interview form that could be used when collecting this information. Prenatal risk factors. A variety of pre-, peri-, and postnatal risk factors are associated with an increased risk for ADHD (Barkley, 2006). However, the relative influence of these factors is still controversial (Zappitelli, Pinto, & Grizenko, 2001). Prenatally there is a relationship between maternal lifestyle factors and ADHD among their offspring (Linnet et al., 2003). One of the more powerful correlates with ADHD is maternal smoking (Huizink & Mulder, 2006; Rodriguez & Bohlin, 2005). In a review of the literature by Linnet and colleagues (2003), maternal smoking during pregnancy was significantly associated with ADHD symptoms in a majority of the studies considered. The odds of having a child with the predominately inattentive type of ADHD has been suggested to be 3.44 times higher among children whose mothers smoked 10 or more cigarettes per day during pregnancy (when compared to children whose mothers did not smoke; Schmitz et al., 2006). The pathophysiological explanation for how nicotine exposure is connected to ADHD includes the facts that (a) maternal smoking leads to fetal hypoxia (Longo, 1977) and (b) that nicotine causes disturbances to the dopamine systems in the prefrontal cortex (Fung & Lau, 1989). Although not as consistently associated with ADHD as nicotine exposure, maternal alcohol use has also been suggested to be related to symptoms of ADHD (Huizink & Mulder, 2006). In a review of the literature by Linnet and colleagues (2003), maternal alcohol consumption during pregnancy was significantly associated with ADHD symptoms in four of nine studies considered. For example, among children who did not have fetal alcohol syndrome (FAS), children diagnosed with ADHD were 2.5 times more likely than children without ADHD to have been exposed to alcohol in utero (Mick, Biederman, Prince et al., 2002). Also associated with ADHD is heavy maternal cannabis use (Huizink & Mulder, 2006) and cocaine exposure (Linares et al., 2006). In addition, the offspring of mothers who abused multiple drugs (including tobacco) have been found to be significantly more likely than non-drug exposed peers to display elevated levels of impulsivity and attention problems at 2–41/2 years, even when they are placed in quality foster care (Slinning, 2004). Other prenatal maternal characteristics found to be related to the development of ADHD among their offspring include poor maternal health, eclampsia, maternal bleeding, complications from maternal accidents (Zappitelli et al., 2001), younger maternal age, and lower levels of maternal education (Claycomb, Ryan, Miller, & Schnakenberg-Ott, 2004). Prenatal maternal PKU and resulting exposure to phenylalanine has also been associated with ADHD and appears to effect offspring in a dose-dependent manner, with higher levels of phenylalaine exposure being
56
5 Diagnostic Assessment COLLEGE OF EDUCATION DEPARTMENT OF SPECIAL EDUCATION, REHABILITATION SCHOOL PSYCHOLOGY AND DEAF STUDIES School Psychology Diagnostic Clinic
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
6000 J Street Sacramento, California 95819-6079
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER DIAGNOSTIC EVALUATION: HEALTH, FAMILY, DEVELOPMENTAL, & BEHAVIORAL HISTORY INTERVIEW FORM Child’s Name: School: Parent(s): Home phone: Languages spoken in the home: Siblings (ages): Other adults living in the home:
Birth date: Grade: E-mail: Alt. Phone:
Referring concern:
At what age did the referring concerns first emerge?
Health History (Perinatal Factors) 1. General obstetric status (circle one):
Optimal
Adequate
Poor
2. Prenatal care (describe):
3. Maternal stressor (list and describe):
4. Complications during pregnancy (circle all that apply):
Placenta previa Abnormal fetal position
Multiple pregnancies Other (list):
5. Maternal illnesses during the pregnancy (circle all that apply and list when illness occurred):
Eclampsia Diabetes mellitus
Maternal PKU Other (list):
6. Maternal accidents during the pregnancy (list when accident occurred):
Fig. 5.1 This form could be used when collecting health, family, developmental and behavioral history regarding a child suspected to have ADHD
Birth, Developmental, Health, Family, and Behavioral Histories
57
7. Mother’s age at time of the pregnancy (list): 8. Nicotine exposure during pregnancy (circle):YES a. How often did mother smoke? Every day b. How much did mother smoke? < 10 cigarettes c. When during pregnancy did the mother smoke? 1st trimester
NO If YES answer the following: Once a week Rarely ≥10 cigarettes 2nd Trimester
3rd trimester
9. Alcohol exposure during pregnancy (circle): YES a. How often did mother drink? Every day b. How much did mother drink? Just a little c. When during pregnancy did the mother drink? 1st trimester
NO Once a week One drink
Rarely Several drinks
2nd Trimester
3rd trimester
YES
NO
If YES answer the following:
1st trimester
2nd Trimester
3rd trimester
10. Medication/Drug exposure during pregnancy (circle): What drugs were taken? (list):
a.
When during pregnancy were medications/drugs taken?
11. Birth weight (list):
lbs.
If YES answer the following:
oz.
(if exact weight not known check one of the following)
less than 2.2 lbs. less than 3.3 lbs.
12. Length (list):
less than 5.5 lbs. more than 5.5 lbs.
inches
13. Length of pregnancy (circle/list):
Full term
Premature @
14. Was an incubator required (circle):
YES
NO
If YES report how long:
15. Was oxygen therapy required (circle):
YES
NO
If YES report how long:
16. Complications during labor/delivery (circle)? a. What complications?
b. c.
C-section Apgar (list):
weeks
If YES answer the following: YES NO Respiratory distress Meconium aspiration Prolonged labor Prolapsed umbilical cord Fetal postmaturity Forceps delivery Cardiopulmonary abnormalities Other (list):
YES 1-min.
NO Planned Emergency 5-min. 10-min.
Fig. 5.1 (Continued)
associated with more severe symptoms of both hyperactivity/impulsivity and inattention (Antshel & Waisbren, 2003). Finally, prenatal maternal stress has also been associated with the development of ADHD among their offspring (Linnet et al., 2003; Rodriguez & Bohlin, 2005). Perinatal risk factors. Events occurring around the time of delivery have also been suggested to increase the chances of a child developing ADHD (Claycomb et al., 2004). Given the results of animal studies suggesting that intra-uterine anoxia
58 17. Neonatal surgery (circle): a. Reason for surgery? b. Outcome of surgery? c. Complications?
5 Diagnostic Assessment YES
NO
If YES answer the following:
Developmental History 18. Age major milestones were obtained (list)? First word Sentences
First steps Walks alone Stands alone
Health History (Infancy and childhood) 19. Childhood infections (circle)?
Meningitis Other (list):
Encephalitis
20. Childhood viruses (circle all that apply/list when illness occurred)?
Mumps Chicken pox Unexplained fever
Ear infections Other (list):
21. Medical Diagnoses/Issues (circle):
Fetal alcohol syndrome Lead poisoning Chronic ear infections Immune dysfunction Arthritis
Epilepsy Pica Tube placement Thyroid problems Rashes
Allergy history symptoms
Gastrointestinal
Asthma
PKU
Other (list):
22. Head injury with loss of consciousness
YES NO If YES describe. Include how long consciousness was lost:
23. Psychiatric Diagnoses/Issues (circle):
Conduct disorder Depression Anxiety disorder
Oppositional defiant disorder Learning disorder Bipolar disorder
Fig. 5.1 (Continued)
damages the dopaminergic system and is associated with hyperactivity (Zappitelli et al., 2001), any factor that reduces oxygen to the neonate can be considered a risk factor for ADHD. An early study often sited as being supportive of this hypothesis was conducted by Hartsough and Lambert (1985) who found that fetal distress during the delivery was significantly more common among children with ADHD as compared to those without this disorder (17% vs. 8%). A variety of factors may
Birth, Developmental, Health, Family, and Behavioral Histories
59
Other (list):
24. Medications currently prescribed (list):
25. Vision Screening (list):
Date:
26. Suspected hearing loss
YES concern:
27. Hearing Screening (list):
Date:
Near 20/ NO
Far 20/
If YES describe reasons for
Result:
Family History 28. Siblings with ADHD (circle)? a. Is sibling an identical twin?
YES YES
NO NO
29. Siblings with ADHD-like behavior (circle)? YES a. Is sibling an identical twin? YES
NO NO
30. Parent with ADHD (circle)? a. Relationship to child (circle):
YES NO biological father biological mother step-parent
31. Parent with ADHD-like behavior (circle): a. Relationship to child (circle):
YES NO biological father biological mother step-parent
32. Parent with anti-social behavior history or conduct disorder (circle)? a. Relationship to child (circle):
YES NO biological father biological mother step-parent
33. Other family members with ADHD (circle)?YES a. Relationship to child (list): 34. Other family members with ADHDlike behavior (circle)? a. Relationship to child (list):
NO
YES
NO
35. Other family members with an anti-social behavior history/conduct disorder (circle)? YES a. Relationship to child (list):
NO
36. Family history of alcoholism (circle)?
NO
YES
Fig. 5.1 (Continued)
lead to hypoxia. These include prenatal eclampsia and diabetes mellitus, obstetrical difficulties such as prolapsed umbilical cord, unusually long labor, placenta previa, or multiple pregnancies; abnormal fetal position, prolonged labor, prematurity, respiratory distress, and cardiopulmonary abnormalities (Claycomb et al., 2004; Zappitellie et al., 2001).
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5 Diagnostic Assessment
37. Highest parental educational attainment (list)
Mother
grade Father
grade
Behavioral History 38. Abnormal eating or sleeping habits (list):
39. Is/Was the child hyperactive and/or impulsive? a.
Early childhood:
YES
NO
If YES answer the following:
Does/Did s/he run in circles, not stopping to rest? Does/Did s/he bang into objects or people? Does/Did s/he constantly ask questions?
Y/N Y/N Y/N
NOTES:
DIAGNOSTIC NOTE: During infancy and the preschool years the child may be very active and impulsive, and may need constant supervision to avoid injury. This constant activity may be stressful to adults who do not have the energy or patience to tolerate such behavior.
b.
Middle childhood:
Does/Did s/he play active games for long periods? Does/Did s/he occasionally do things impulsively?
Y/N Y/N
NOTES:
DIAGNOSTIC NOTE: During school years and adolescence, activity may be high in play situations and impulsive behaviors may occur, especially in peer pressure situations.
c.
Adolescence:
Does s/he engage in active social activities (e.g., dancing) for long periods? Y/N Does s/he engage in risky behaviors with peers? Y/N
NOTES:
DIAGNOSTIC NOTE: High levels of hyperactive/impulsive behavior do not indicate a problem or disorder if the behavior does not impair function.
40. Is/Was the child inattentive? a.
Early childhood:
YES
NO
If YES answer the following:
Does/Did s/he have difficulty attending, except briefly, to a storybook or a quiet task such as coloring or drawing. Y/N
NOTES:
DIAGNOSTIC NOTE: A young child will have a short attention span that will increase as the child matures. The inattention may be appropriate for the child’s level of development and not cause any impairment.
b.
Middle childhood:
Does/Did s/he fail to persist very long with a task the child does not want to do such as read an assigned book, homework, or a task that requires concentration such as cleaning something? Y/N
NOTES:
c.
Adolescence
Is s/he is easily distracted from tasks he or she does not desire to perform? Y/N
NOTES:
1
Adapted from American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with Attention-Deficit/Hyperactivity Disorder. Pediatrics, 105, 1158-1170.
Fig. 5.1 (Continued)
Birth, Developmental, Health, Family, and Behavioral Histories
61
Prematurity and low birth weight are also perinatal risk factors for ADHD (Botting, Powls, Cooke, & Marlow, 1997; Farel, Hooper, Teplin, Henry, & Kraybill, 1998). Cherkes-Julkowski (1998), for example, reports that even mild prematurity has negative consequences that include an increased risk for ADHD. They report that among a group of children born on average 49 days early, with an average birth weight of 4.14 lbs, by fifth grade 75% had at least one learning problem including ADHD. More recently, Mick, Biederman, Prince and colleagues (2002), in a study comparing 252 ADHD cases to 231 non-ADHD controls, found that children with ADHD were 3.1 times more likely to have been born with a low birth weight (<2,500 g or 5.5 lbs). However, it is important to acknowledge that most children with ADHD do not have a low birth weight (APA, 2000). Postnatal risk factors. Postnatal hypoxic events have also been associated with the development of ADHD (Zappitelli et al., 2001). For example, Chandola, Robling, Peters, Melville-Thomas, and McGuffin (1992) found referral for hyperactivity at 3–6 years of age to be associated with low Apgar scores. In addition, among very low birth weight infants, chronic lung disease (defined as having required oxygen therapy for 30 days or more after birth) was found to confer additional risk (beyond that conveyed by being of low birth weight) for inattention and hyperactivity (Farel et al., 1998). The autosomal recessive disorder known as PKU (phenylketonuria) and resulting exposure to phenylalanine appears to be associated with ADHD symptoms in a dose-dependent manner. However, when compared to prenatal exposure (via maternal PKU), postnatal exposure has been suggested to be more strongly associated with inattentive symptoms (than with hyperactive/impulsive symptoms; Antshel & Waisbren, 2003). Lead exposure during the first 2–3 years of life has been suggested to increase the risk for developing ADHD. However, it is important to acknowledge that most children with this disorder do not show lead contamination and that many with high lead levels do not demonstrate ADHD symptoms (Biederman & Faraone, 2005). Barkley’s (2006) review of the literature suggests that no more than 4% of the variance in ADHD symptom expression can be explained by elevated lead levels. Finally, traumatic brain injury (TBI) is a risk factor for ADHD, although it is clear that such trauma accounts for fewer than 5% of individuals with ADHD (Barkley, 1990). Nevertheless, ADHD has been documented to occur secondary to brain injury (e.g., head trauma, stroke) in childhood, with the occurrence of this disorder being correlated with the severity of injury (Max et al., 1997, 1998, 2002). However, it is important to acknowledge that ADHD itself may be a risk factor for TBI, so genetic and brain injury causes may not be entirely independent. Developmental history. The diagnostic evaluation should also collect information regarding early development. In particular, questions should be asked regarding attainment of major language and social developmental milestones. As was mentioned earlier in this chapter, establishing the child’s developmental level is critical given that diagnostic criteria require that ADHD behaviors be considered diagnostic only if they are “. . . inconsistent with developmental level” (p. 92).
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5 Diagnostic Assessment
Diagnostic history. A diagnostic history should be gathered as ADHD often cooccurs with other psychiatric disturbances. According to the APA (2000) approximately half of clinic-referred children with ADHD also have Conduct Disorder or Oppositional Defiant Disorder. Other associated conditions may include Anxiety, Mood, and Learning Disorders. ADHD is also common among children with Tourette’s disorder (although most children with ADHD do not have this tic disorder). Family history. There is strong evidence that genetics plays a powerful etiological role in ADHD (Biederman, 2005; Daley, 2006; National Institute of Mental Health [NIMH], 2006). Thus, it is critical for the diagnostic evaluation to inquire about the presence of a family history of ADHD or ADHD-like behaviors. Behavioral history. As was mentioned earlier in this chapter, ADHD symptoms change with development. Thus, it is important for the diagnostic evaluation to inquire about how symptoms have manifested themselves during the different stages of development. Figure 5.1 includes questions adapted from the AAP’s (2000) Clinical Practice Guidelines, which can assist in identifying ADHD symptoms at different stages of development.
Commonly Recommended Diagnostic Procedures The diagnosis of ADHD requires use of both indirect and direct assessment techniques. Indirect assessment techniques involve obtaining data from caregivers about the student being assessed (e.g., by asking parents and teachers to complete behavior rating scales and conducting interviews). They have the advantage of tapping into the significant amount of experiences working with, and observing, the student typically possessed by these caregivers. However, it is important to acknowledge the subjective nature of indirect assessment. On some occasions parents and teachers have biased and/or inaccurate views of a student’s behavior (Brock et al., 2006). Thus, direct assessment is also an important element of any diagnostic assessment. Direct assessment involves obtaining data by directly observing the student suspected to have ADHD (e.g., via psychological testing and behavioral observation). It has the advantage of being relatively objective and is less influenced by biased and/or inaccurate caregiver perceptions of the child’s behavior. However, it is important to acknowledge that the behavior of children with ADHD can be quite variable (from one situation to the next), thus the generalizability of this type of assessment data must always be questioned. Consequently, indirect assessments are important elements of any diagnostic assessment. By questioning parents and teachers about the behaviors observed during a direct assessment, individuals making an ADHD diagnosis will be able to determine if the obtained observational data are typical. In a recent review of the literature published within the last 15 years (and making use of the PsycINFO database), Brock and Clinton (2007) concluded that the four most frequently recommended diagnostic procedures include the indirect assessment techniques of behavior rating scales and interview and the direct assessment techniques of laboratory/psychological testing and behavioral observations. The results of their literature review are summarized in Table 5.3.
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63
Table 5.3 AD/HD diagnostic procedures recommended in recent publicationsa Diagnostic procedureb Source 1. American Academy of Pediatrics (2000) 2. Anastopoulos & Shelton (2001) 3. Atkins & Pelham (1991) 4. Barkley (1990) 5. Barkley (1991) 6. Barkley (1997a) 7. Barkley (1998) 8. Barkley (2006) 9. Brown (2000) 10. Burcham & DeMers (1995) 11. Casat, Pearons, & Casat (2001) 12. Cipkala-Gaffin (1998) 13. Detweiler, Hicks, & Hicks (1999) 14. DuPaul, Guevremont, & Barkley (1991) 15. DuPaul & Stoner (1994) 16. Guevremont & Barkley (1992) 17. Guevremont et al. (1990) 18. Hardy, Warmbrodt, & DeBasio (2004) 19. Hechtman (2000) 20. Hinshaw (1994) 21. Leach & Brewer (2005) 22. Learner, Lowenthal, & Learner (1995) 23. Martin (2003) 24. Meyer (1999) 25. Nahlik (2004) 26. Oesterheld, Shader, & Wender (2003) 27. Pelham et al. (2005) 28. Quinlan (2000) 29. Quinn (1997) 30. Rapport (1993) 31. Robin (1998) 32. Root & Resnick (2003) 33. Schaughency & Rothlind (1991) 34. Searight, Nahlik, & Campbell (1995) 35. Shelton & Barkley (1994) 36. Shelton & Barkley (1995) 37. Silver (1999) 38. Silver (2004) 39. Slomka (1998) 40. Swanson & Smith (1996) 41. Wolraich et al. (2005) Totals
RS
INT
L/T
√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
√ √
√ √
√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
√ √ √ √ √ √ √ √ √ √ √
100%
98%
90%
√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
DO √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ 68%
Notes: a Adapted from Brock & Clinton (2007). b RS = Rating scales; INT = Parent, teacher, and child interviews; DO = Direct observation; L/T = Laboratory, psychological, and psychoeducational testing; ME = Medical evaluation; SR= School record review; PA = Peer Ratings and Nominations.
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Rating scales. All of the literature reviewed by Brock and Clinton (2007) suggested behavior rating scales to be an important part of the ADHD diagnostic process. However, it is important to add that use of these tools, by themselves, is insufficient when it comes to making an ADHD diagnosis (Tripp, Schaughency, & Clarke, 2006). When assessing ADHD, rating scales should include both broad- and narrowband measures (Gordon, Barkley, & Lovett, 2006). Table 5.4 offers a listing of these tools. The broad-band measures typically used include the Behavior Assessment System for Children-Second Edition (BASC-2; Reynolds & Kamphaus, 2004) and the Achenbach System of Empirically Based Assessment (more popularly known as the “Child Behavior Checklist” or “CBCL”; Achenbach & Rescorla, 2000, 2001). These measures have the advantage of helping to document not only the presence of ADHD behaviors, but also other behavioral and emotional disorders. The importance of being able to do so is emphasized by the facts that (a) ADHD frequently Table 5.4 Behavior rating scales helpful in the diagnosis of ADHD
Broad-Band Scales BASC-2 (Reynolds & Kamphaus, 2004) CBCL (Achenbach & Rescorla, 2000, 2001)
Age range
Respondent(s)
Publisher
2–22 years
Teacher, parent, and self-report Teacher, parent, and self-report
American Guidance Services ASEBA
MetriTech
5–18 years
Teacher, parent, and self-report Teacher and parent
Guilford Press
4–18 years
Teacher and parent
Hawthorne Press
6–18 years
Narrow-Band Scales ACTeRS (Ullman, Sleator, & Sprague, 2000) ADHD-IV (DuPaul, Ervin, Hook, & McGoey, 1998) ADDES-3 (McCarney, 2004) ADHD-SRS (Holland, Gimpel, & Merrell, 2001) ADHDT (Gilliam, 1995)
5–18 years
Teacher and parent
PAR
3–23 years
Pro-ed
BADDS (Brown, 2001)
3–18 years
CRS-R (Conners, 1997)
3–17 years
SNAP-IV (Swanson, 1992) VARS (Wolraich, 2002)
5–11 years K-5 grades
Teacher and caregiver Teacher, parent, and self-report Teacher, parent, and self-report Teacher and parent Teacher and parent
K-8 grades
PsychCorp Multi-health Systems www.ADHD.net www.nichq.org
Notes: CBCL, Child Behavior Checklist; BASC-2, Behavior Assessment System for ChildrenSecond Edition; ACTeRS, ADD-H: Comprehensive Teacher’s Rating Scale; ADHD-IV; ADHD Rating Scale-IV; ADDES-2, Attention Deficit Disorders Evaluation Scale-Second Edition; ADHD-SRS, ADHD Symptoms Rating Scale; ADHDT, Attention Deficit/Hyperactivity Disorder Test; BADDS, Brown Attention-Deficit Disorder Scales for Children and Adolescents; CRSR, Conners’ Rating Scales-Revised; SNAP-IV, Swanson, Nolan, and Pelham-IV Questionnaire; VARS, Vanderbilt ADHD Rating Scales
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co-exists with other disorders and (b) there are a variety of other conditions that have symptoms similar to ADHD (Brock, 1998, Spring; Jensen et al., 2001). Thus, there is a need to identify other disorders that may be either exacerbating the challenges associated with ADHD or that may offer an alternative explanation for symptoms (other than ADHD). The BASC-2 (Reynolds & Kamphaus, 2004) is a psychometrically solid and wellstandardized (Stein, 2007; Watson, & Wickstrom, 2007) comprehensive set of rating scales and forms including the Teacher Rating Scales (TRS, includes 100–139 items), Parent Rating Scales (PRS, includes 134–150 items), Self-Report of Personality (SRP, includes 64–185 items), Student Observation System (SOS), and Structured Developmental History (SDH). The materials can be used with children 2 years through 21 years (TRS and PRS); and 6 years through college age (SRP). The BASC-2 was designed to facilitate the differential diagnosis and educational classification of a variety of emotional and behavioral disorders of children and to aid in the design of treatment plans. There are five composite scale scores: Adaptive Skills, Behavioral Symptoms Index, Externalizing Problems, Internalizing Problems, and School Problems. For the student forms, there are also five composite scale scores: Emotional Symptoms Index, Inattention/Hyperactivity, Internalizing Problems, Personal Adjustment, and School Problems. A number of studies have validated the BASC for use in identifying ADHD (e.g., Jarratt, Riccio, & Siekierski, 2005; Manning & Miller, 2001; Ostrander, Weinfurt, Yarnold, & August, 1998), with the Attention Problems scale being a powerful predictor of an ADHD diagnosis (Ostrander et al., 1998). Further, according to a study by Manning and Miller (2001), mean Externalizing Behavior (i.e., Hyperactivity, Aggression, Conduct Problems scales) ratings in the at-risk/clinically significant range on the PRS differentiated youth with the Hyperactive/Impulsive type (M = 67.71) from the Inattentive type (M = 56.25). Similarly, mean Atypicality (i.e., “odd” or immature behavior) ratings in the clinically significant range on the TRS differentiated youth with the Inattentive type (M = 71.92) from the Hyperactive/Impulsive type (M = 58.93). The CBCL (Achenbach & Rescorla, 2000, 2001) is a well-standardized and psychometrically sound (Flanagan, 2005; Watson, 2005) measure designed for parents, teachers, and students to report about a variety of problem behaviors. Parents complete the CBCL/11/2−5 (for preschoolers) or the CBCL/6–18 for school-aged youth. Teachers complete the Teacher Report Form (TRF/6–18) or the Caregiver-Teacher Report (C-TRF), and students themselves complete the Youth Self-Report (YSR) form. The CBCLs for preschool and school-aged youth include a DSM-oriented Attention Deficit/Hyperactivity Problems scale, and the TRF includes an Attention Problems scale (which includes items that could be categorized as both inattentive and hyperactive/impulsive; Flanagan, 2005). A number of studies have validated the CBCL for use in identifying ADHD (e.g., Biederman et al., 1993; Chen, Faraone, Biederman, & Tsuang, 1994; Ostrander et al., 1998; Vaughn, Riccio, Hynd, & Hall, 1997), with the TRF’s Attention Problems scale being a predictor of an ADHD diagnosis. Further, high scores on the DSM-oriented Attention Deficit/Hyperactivity Problems scale have been suggested
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to be helpful (though not sufficient) in making an ADHD diagnosis (Watson, 2005). In addition, according to research by Biederman et al. (1995) and Geller, Warner, Williams, and Zimerman (1998), the CBCL has the ability to discriminate youth with ADHD from mood disorders (including bipolar disorder). However, the ability of the YSR to assist in the diagnosis of ADHD has been questioned (Vreugdenhil, van den Brink, Ferdinand, Wouters, & Doreleijers, 2006). While broad-band measures are essential when considering the possibility of disorders other than ADHD, when it comes to making a specific ADHD diagnosis, narrow-band measures are recommended (AAP, 2000). These tools (see Table 5.4) have the advantage of providing more exact information regarding the clinical significance of ADHD symptoms. They can also be effective in the monitoring of treatment effectiveness (Gordon et al., 2006). Of the available narrow-band measures, Demaray, Elting, and Schaefer (2003) have suggested that the Attention Deficit Disorders Evaluation Scale-Second Edition (ADDES-2; McCarney, 1995), the ADHD Rating Scale-IV (ADHD-IV; DuPaul et al., 1998), and the Conners’ Rating Scales-Revised(CRS-R; Conners, 1997) have “the strongest standardization samples and evidence for reliability and validity” (p. 360). Further, the CRS-R has been suggested to be best equipped to evaluate both the broader context and DSM-IV symptoms of ADHD, and the ADHD-IV has been suggested to be best for monitoring treatment effects (Collett, Ohan, & Meyers, 2003). It is recommended that these scales be completed by both parents and teachers. While parent ratings have been suggested to demonstrate high sensitivity (and thus be appropriate as an initial screening strategy), teacher reports have been found to outperform parent reports when it comes to sensitivity, specificity, and overall classification accuracy (Tripp et al., 2006).1 Interviews. Virtually all (98%) of the literature reviewed by Brock and Clinton (2007) suggested interviews of the parent, teacher, and/or student to be an important part of the ADHD diagnostic process. This diagnostic strategy has been suggested by some to be the single most important part of the diagnostic evaluation (Root & Resnick, 2003) and is an important complement to behavior rating scales (Molina et al., 2001). According to Hinshaw (1994), Nahlik (2004), Parker (1992), and Pennington (1991) interviews address a number of diagnostic questions including the following: 1) Are ADHD symptoms present and under what conditions are they seen? 2) When was the onset of ADHD symptoms and how long have symptoms been present? 3) Is the environment playing a role in ADHD symptomology? 4) Is there a family history of ADHD?
1 Sensitivity indicates the probability that a child with ADHD will test positive for this disorder (be suggested to have ADHD), and specificity indicates the probability that a child without ADHD will test negative for this disorder (be suggested to not have ADHD).
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5) Is the developmental history suggestive of ADHD? 6) Are there school adjustment and/or learning difficulties? 7) Are there interpersonal and/or emotional difficulties? Interviews can be either structured (heavily scripted), semi-structured (scripted, but with the option for open-ended questioning), or unstructured. The advantage of structured formats is that they allow for normative comparisons and are better at detecting ADHD (Anastopoulos & Barkley, 1992; McGrath, Handwerk, Armstrong, Lucas, & Freman, 2004; Schaughency & Rothlind, 1991). At the same time, however, highly structured interviews tend to be more cumbersome and are of limited value when it comes to the development of psycho-educational interventions (Anastopoulos & Barkley, 1992; Anastopoulos & Shelton, 2001; Landau & Burcham, 1995). Unstructured interview formats, on the other hand, are more flexible and as a result allow for a greater focus on the interviewee’s specific concerns. The weakness of the unstructured interview is that it is relatively unreliable when it comes to making an ADHD diagnosis (Anastopoulos & Barkley, 1992; Hinshaw, 1994; Schaughency & Rothlind, 1991). Parent interviews are typically a critical part of the ADHD diagnostic assessment (Barkley, 1990; Landau & Burcham, 1995; Nahlik, 2004; Parker, 1992), as no adult is likely to have more information regarding a child’s functioning (especially in regards to developmental and school histories) than parents. However, at the same time it is acknowledged that the parent interview can be unreliable (Barkley, 1990, 1991, 1998; Guevremont, DuPaul, & Barkley, 1990; Hinshaw, 1994). To be positive for ADHD, it has been suggested that these interviews should document symptoms of ADHD from an early age and the presence of a family history of ADHD (DuPaul, 1992; Guevremont et al., 1990; Pennington, 1991). Of almost equal importance is the teacher interview. In fact, Swanson (1992) recommends that in the case of conflicting opinions about an ADHD diagnosis, special consideration be given to the teacher’s reports. Teachers are suggested to be an especially valuable resource given their knowledge of developmentally appropriate behavior and their observations of learning and social behavior (Molina et al., 2001; Wender, 1988). Besides documenting ADHD symptoms, the teacher interview is also helpful in assessing the nature of problem behaviors (DuPaul, 1992) and in providing information regarding the child’s present levels of academic functioning (Barkley, 1991; Guevremont et al., 1990). As such, this interview is especially important to intervention planning. While it has been recommended that in the school setting the ADHD diagnosis not be made without these reports, they are reported to not be a well-utilized resource (Parker, 1992). However, it has been suggested that the diagnosis of ADHD in a clinic setting can be made without these reports. This suggestion comes from the observation that if a parent report is positive for ADHD, there is a 90% probability that the teacher report will also be positive (Biederman, Keenan, & Faraone, 1990). Finally, a child interview has also been suggested to be useful in diagnosing ADHD. However, it is important to acknowledge that self reports may not be valid in documenting ADHD symptoms, especially among younger (elementary grade)
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students (DuPaul & Stoner, 1994; Hinshaw, 1994; Landau & Burcham, 1995). This is not surprising given that it has been documented that children commonly report fewer externalizing symptoms than those indicated by adults (Hart, Lahey, Loeber, & Hanson, 1994; Volpe, DuPaul, Loney, & Salisbury, 1999). Thus, when it comes to the diagnosis of this externalizing behavior disorder, parent and teacher interview data are more valid than is the child interview (Gordon et al., 2006). On the other hand, the child interview may be especially important in determining the presence of other psychopathologies, especially internalizing behavior disorders (e.g., depression and anxiety), as some have suggested children’s self-reports of these conditions to be more reliable (Hinshaw, 1994). In addition, behavior observed during the interview may in some instances be diagnostically significant. However, because the interview setting is likely to be novel, the absence of ADHD symptoms during the interview should not by itself be used to rule out ADHD (Guevremont et al., 1990). Finally, it has been suggested that in the case of adolescents, interviews may be important in obtaining their acceptance of the ADHD diagnosis, as well as in ensuring treatment compliance (Nahlik, 2004). Psychological testing. The vast majority (90%) of the literature reviewed by Brock and Clinton (2007) suggested psychological testing in one form or another to be another recommended element of the ADHD diagnostic process. While there is no single test or test battery that reliably diagnoses this disorder, these data are nevertheless important in (a) establishing the child’s developmental level, (b) evaluating other disorders that might better explain ADHD symptoms and/or co-exist with this disorder, and (c) offering data in support of the ADHD diagnosis. Given the requirement that ADHD symptoms must be inconsistent with the child’s developmental level (APA, 2000), data regarding general intellectual functioning are important to the diagnostic process. According to Gordon and colleagues (2006), while an IQ test need not be a part of all ADHD diagnostic evaluations, without some estimate of the child’s intelligence it will not be possible to rule out cognitive delays as being a possible explanation for ADHD symptoms (i.e., that the general education curriculum is moving too quickly for the student). Similarly, estimates of IQ can also be used to consider the hypothesis that the student is intellectually precocious and that such might be the explanation for his or her inattention (i.e., that the general education curriculum is moving too slowly). Barkley (2006) further recommends that if an estimate of general intellectual functioning is not available, then a brief IQ screening test be administered, with a more comprehensive measure given only if the results yield scores falling significantly outside of normal limits. In the authors’ opinion, one of the more important purposes of psychological testing is to assist in the identification of disorders that might in and of themselves better account for ADHD symptoms or that may represent comorbid conditions. It is a well-established fact that there are a number of variables that can lead to clinically significant inattention and/or hyperactivity and impulsivity. These variables include learning disabilities, family stressors, other environmental stressors, achievement motivation, and other psychiatric disturbances (Brock, 1998, Spring). The comprehensive psycho-educational evaluation (which will be discussed further
Commonly Recommended Diagnostic Procedures
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in Chapter 6) is an effective strategy for considering and ruling out or ruling in these factors as explanations for ADHD symptoms or identifying comorbid psychiatric challenges. While many specific tests and test batteries have been purported to be valuable in the diagnosis of ADHD per se, very few have consistent empirical support and at present there does not exist any “gold standard” psychological test or test battery for the diagnosis of ADHD (Gordon et al., 2006; Rapport, Chung, Shore, Denney, & Isaacs, 2000). Of the available psychological tests, the one that appears to have the most empirical support for use in ADHD diagnosis is continuous-performance tests (CPTs; Nichols & Wasenbusch, 2004). First developed by Rosvold, Mirsky, Sarason, Bransome, and Beck (1956), CPTs typically require a child to listen to or look at a specific target stimuli for an extended period of time and to respond in some way (e.g., pressing a button) whenever a certain stimuli or pairs of stimuli are presented. Scores are typically based on the number of correct responses, errors of omission, and errors of commission. Examples of commercially available CPTs include the Conners CPT II (Conners, 2000), the Gordon Diagnostic System (GDS; Gordon, 1983), the Test of Variables of Attention (TOVA; Greenberg & Kindschi, 1996), and the Auditory CPT (Keith, 1994). While these measures are suggested to have “reasonable sensitivity and specificity, as well as promising positive predictive power” (Gordon et al., 2006, p. 384), they have a relatively high rate of false-negatives (e.g., 15–52% on the GDS; Gordon et al., 2006). Thus, obtaining scores in the average range on a CPT does not reliably indicate the absence of ADHD. On the other hand, while failing a CPT might be considered to provide data in support of an ADHD diagnosis, false-positives are also observed (e.g., 30% on the TOVA, Schatz, Ballantyne, & Trauner, 2001). It is also important to acknowledge that while CPTs may be effective when it comes to differentiating ADHD from normal control groups, they may not be able to make this distinction between ADHD and reading-disable groups. Specifically, McGee, Clark, and Symons (2000) found that Conners’ CPT scores were higher among children with reading disabilities than among those with ADHD (who did not have a reading disability). This is probably due to the fact that the Conner’s CPT involves the rapid identification of letters and that rapid automatic naming has been found to be a common deficit among both reading-disabled and ADHD children (Brock & Christo, 2003). In conclusion, as with all other diagnostic strategies, psychological testing of any sort (including CPTs) is by itself judged to be insufficient when diagnosing ADHD (Gordon et al., 2006; Schatz et al., 2001; Swanson, 1992). For a further discussion of psychological testing the reader is referred to Chapter 6 and its exploration of the psycho-educational evaluation. Finally, it is important to acknowledge that in addition to test scores, observation of test-taking behavior may also be helpful in the diagnostic process (Goldstein & Goldstein, 1990b). Research has shown that observations of children while being administered a CPT may be as sensitive to discriminating ADHD children from other diagnostic groups as are the CPT scores themselves (Barkley, 1990s). During testing ADHD children typically make more impulsive and care-
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less errors (Goldstein & Goldstein, 1990a; Sattler, 1988). Furthermore, they may have difficulty sitting still, display sustained attention concentration difficulties, and may be easily distracted. Test performance is also often characterized by oversights, such as insertions or omissions, or misinterpretation of easy items when well motivated (not just when completing tasks that hold little intrinsic value; Sattler, 1988). Behavioral observations. The majority (60%) of the literature reviewed by Brock and Clinton (2007) suggested direct behavioral observations to be an element of the ADHD diagnostic process. Acknowledged to be one of the most costly diagnostic practices (Atkins & Pelham, 1991; Guevremont et al., 1990; Schaughency & Rothlind, 1991), some have argued that for clinical use the collection of these data is not practical (e.g., Gordon et al., 2006; Pelham, Fabiano, & Massetti, 2005). However, for the school psychologist these data are readily accessible and thus should be considered a standard part of the school-based diagnostic assessment. This is especially important given the observation that “. . . such procedures are often more reliable and valid than clinic-based laboratory assessment devices” (Anastopoulos & Barkley, 1992, p. 422). In addition, these data are essential if a functional behavioral assessment is to be conducted. Behavioral observations are designed to verify interview and rating scale data regarding the presence or absence of ADHD symptoms (Parker, 1992). Their use is supported by the finding that students with ADHD have been consistently found to demonstrate, relative to their typically developing peers, deficient and more variable on-task behaviors (Kofler, Rapport, & Alderson, 2008). They are especially important when there is substantial disagreement regarding symptom severity among interviewees/raters. Relative to rating scales, behavioral observations are typically not as influenced by bias (Atkins & Pelham, 1991; Schaughency & Rothlind, 1991). These data are also helpful in assessing interpersonal and social skills (Hinshaw, 1994). Along with the cost and practicality concerns raised by those in clinical practice, other weaknesses of observations include an absence of normative data, the possibility that low-frequency behaviors may be missed by certain observational techniques, and that they require extensive training (Guevremont et al., 1990; Schaughency & Rothlind, 1991). Given that ADHD symptoms often vary considerably across time and setting (Landau & Burcham, 1995), whenever possible, several observations in different settings/situations should be obtained. However, as a rule it is recommended that the child be observed in the setting(s) where the symptoms are most prominent and problematic. This guideline is especially important given that ADHD symptoms are often not seen in what is for most the relatively novel office setting (Copeland & Wolraich, 1987; Pennington, 1991; Silver & Brunsletter, 1986; Sleator & Ullmann, 1981). Given that primary complication of ADHD is school failure (APA, 2000), classroom observations are especially important, and it has been suggested that “Such observations are likely to prove as useful as (or more useful than) any other sources of information in the evaluation, because they directly assess
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the actual ADHD symptoms of concern to the child’s teacher” (Barkley, 1990, p. 339). In-class observations correlate highly with teacher ADHD symptom ratings and with measures of academic accuracy and productivity (DuPaul, 1992). Observational strategies include both anecdotal (Parker, 1992) and systematic (Barkley, 1990) approaches. Sattler and Hoge (2006) offer two examples of systematic strategies (i.e., Classroom Observation Code, Structured Observation of Academic and Play Settings; pp. 685–696). As no single observational system is appropriate for all situations, the method chosen should be dependent upon the child’s specific behaviors. Options for systematic observations include frequency, duration, and time sampling data. Frequency data documents the number of discrete behaviors. It is the strategy of choice if the ADHD-associated behavior has a clear beginning and end and is measured over a specified time period. Examples of such behaviors include hitting, running from the room, shouting out a response, hand raises, problems or worksheets completed, and questions answered correctly. Among the advantages of this type of data is the fact that it is easy to record (Sulzer-Araroff & Mayer, 1991). Figure 5.2 offers a form appropriate for use when collecting frequency data. Duration data documents the length of time, from beginning to end, of a behavior. It is the strategy of choice if the ADHD-associated behavior lasts several minutes and/or does not occur very frequently. Examples of such behaviors include temper tantrums, being on-task, being out of one’s seat, and the time it takes to follow teacher directions. Among the advantages of this type of data is the fact that it is more sensitive to changes in the severity of a behavior. On the other hand, disadvantages include that it requires the use of a clock or a stopwatch (Sulzer-Araroff & Mayer, 1991). Figure 5.3 offers a form appropriate for use when collecting duration data. Interval data documents the number of time intervals within which the behavior occurs. Using this strategy, the total observation time is divided into equal intervals and the behavior’s presence or absence within that interval is recorded. It is the strategy of choice if the ADHD-associated behavior occurs frequently (at least once every 15 min). Examples of such behaviors include being on- or off-task. Among the advantages of this type of data is the fact that it can be used to record behaviors that are not clearly discrete (do not have clear beginnings and endings). Interval time sampling can be whole-, partial-, or momentary-interval time sampling. Figure 5.4 offers a from appropriate for use when collecting interval data. Whole-interval time sampling records the behavior when it is displayed throughout the entire interval. It can be used to measure on-task behavior. However, it tends to underestimate occurrences of behavior. This strategy is most useful when it is important to know that the behavior has not been interrupted. Partial-interval time sampling records the behavior when a single instance is displayed at any time during the interval. It can be used to measure swearing or bizarre gestures. However, it tends to overestimate occurrences of behavior. This strategy is most useful when recording behaviors that are fleeting. Momentary-interval time sampling records the response if it is displayed at the end (or beginning) of a specific interval. It can
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5 Diagnostic Assessment COLLEGE OF EDUCATION DEPARTMENT OF SPECIAL EDUCATION, REHABILITATION SCHOOL PSYCHOLOGY AND DEAF STUDIES School Psychology Diagnostic Clinic
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
6000 J Street Sacramento, California 95819-6079
Behavior Frequency Data Collection Form Behavioral event to be counted
Date
Frequency
Antecedents
Consequences
Fig. 5.2 This form would be appropriate for use when collecting frequency data
be used to measure in-seat behavior. This strategy is most useful when evaluating behaviors that are apt to persist for a while (Sulzer-Araroff & Mayer, 1991). For a further discussion of observation techniques the reader is encouraged to refer to Barkley (1990), Parker (1992), and Sattler and Hoge (2006).
Other Less Frequently Recommended Diagnostic Procedures
73 COLLEGE OF EDUCATION
DEPARTMENT OF SPECIAL EDUCATION, REHABILITATION SCHOOL PSYCHOLOGY AND DEAF STUDIES School Psychology Diagnostic Clinic
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
6000 J Street Sacramento, California 95819-6079
Duration Data Collection Form Behavioral event to be counted and timed
DATE: Start: Stop: Duration: Start: Stop: Duration: Start: Stop: Duration: Start: Stop: Duration: Start: Stop: Duration:
DATE: Start: Stop: Duration: Start: Stop: Duration: Start: Stop: Duration: Start: Stop: Duration: Start: Stop: Duration:
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Fig. 5.3 This form would be appropriate for use when collecting duration data
Other Less Frequently Recommended Diagnostic Procedures In addition to the commonly recommended diagnostic procedures discussed above, Brock and Clinton (2007) identified several other diagnostic strategies that were
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5 Diagnostic Assessment
Whole
Interval Data Collection Form Partial
Momentary
Interval Duration = Behavioral event to be counted
Interval:
DATE:
DATE:
DATE:
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Fig. 5.4 This form would be appropriate for use when collecting interval data
less frequently recommended. Specifically, 34% of the sources they reviewed recommended that a medical evaluation be conducted, 24% recommended that school records should be examined, and 7% recommended peer nominations and ratings be employed as a part of the diagnostic process. Medical examinations. While some have argued that the “best person to make a diagnosis is a specialist pediatrician with an interest and expertise” in the area (Selikowitz, 2004, p. 123), others have indicated that a medical evaluation is by itself inadequate to diagnose ADHD (Barkley, 1990) and that “Routine physical examinations of children with ADHD frequently indicate no physical problems and are of little help in diagnosing the condition or suggesting its management”
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(Barkley, 2006, p. 360). Brock and Clinton (2007) suggest that, most importantly, the findings of a medical evaluation support the diagnostic process, by providing information important to differential diagnosis. It can do so by ruling out those relatively rare medical conditions that may be the cause of the ADHD-like symptoms such as pinworms, Tourette’s disorder, and absence seizures. It has been suggested that the medical examination is especially important for children with a seizure disorder, as about 30% of these youth have ADHD or have its symptoms worsened with anticonvulsants, such as Dilantin or Phenobarbital (Wolf & Forsythe, 1978). The presence of an asthma diagnosis is another important reason for having a medical examination as a part of the diagnostic evaluation, as asthma medications (such as Albuterol) may affect attention span and/or exacerbate ADHD (Barkley, 1990; Parker, 1992; Robinson & Geddes, 1996). While a medical examination per se is not a frequently recommended element of the diagnostic process, some have argued that especially as it relates to the Other Health Impaired (OHI) special education eligibility category, a medical diagnosis of ADHD is necessary as in this category ADHD is considered to be a chronic health problem (e.g., Montana education code requires such [ARM 10.16.3018 criteria] for identification of a student as having other health impairment). Regarding this issue it is important to note that while a school district may choose to require such a diagnosis to establish IDEA eligibility, it is not required (Grice, 2002; OSEP Letter to Michel Williams, 1994). According to the U.S. Department of Education (2006), “Part B of IDEA does not necessarily require a school district to conduct a medical evaluation for the purpose of determining whether a child has ADHD” (p. 9). This determination can also be made by psychologists or other qualified professionals. Similarly, section “504 does not require that a school district conduct a medical assessment of a student who has or is suspected of having ADHD unless the district determines it is necessary in order to determine if the student has a disability” (Williamson County [TN] School District, 32 IDELR 261 [OCR 2000]). However, it is important to note that if a school district requires a medical diagnosis to help determine either special education or Section 504 eligibility, then the medical examination must be provided by the district at no cost to the parents (Grice, 2002). Review of school records. Examination of school records was recommended as part of the ADHD diagnostic process by a minority of the sources reviewed by Brock and Clinton (2007). This low rate may be due to the fact that many of the sources considered within their literature review were addressing ADHD diagnosis from a clinical, not a school-based, perspective. Thus, the fact that relatively few resources recommend reviewing school records might simply reflect limited access to what the authors of this book view to be an incredibly powerful data source. As suggested by Brock and Clinton (2007) a review of these records (which include report cards and disciplinary histories) has the potential to yield information regarding when symptoms were first observed and their severity across time. Additionally, they can provide information related to a child’s work habits, task completion, and academic functioning.
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Peer assessments. Finally, only a small minority of the sources reviewed by Brock and Clinton (2007) recommended peer nominations and/or ratings be used as a part of the ADHD diagnostic process. It was suggested that the rationale for use of these procedures can be found in the well-documented social difficulties experienced by children with ADHD (Whalen & Henker, 1985) and that the severity of such challenges can be an indicator of later adjustment (Hinshaw, 1994). Use of peer nominations typically requires children to nominate classmates whom they like the most, and those whom they like the least. Peer ratings, on the other hand, obtain from classmates information regarding specific behaviors that lead to rejection, neglect, and popularity.
The Identification of Preschoolers As was mentioned earlier in this chapter the identification of ADHD among preschool youth can be especially challenging as their typical behavior can be similar to the symptoms of this disorder. However, the earlier ADHD can be identified the sooner interventions aimed at addressing its negative consequences can be implemented. Thus, there is a need to give special attention to the assessment of this population. Those preschoolers who are appropriately given a DSM IV-TR ADHD diagnosis will be extremely active and impulsive, will need constant supervision to avoid injury, and will be difficult to contain (AAP, 2000; APA, 2000). This constant activity can be very stressful to adults who may not have the energy or patience to tolerate such behavior (AAP, 2000). It has been suggested that task persistence is a feature of preschool ADHD. Specifically, while the preschooler without ADHD can stick with a task for at least 10 min, the preschooler with ADHD is ready to change activities every few minutes. In addition, the preschooler with ADHD is in constant motion: running and climbing, and unable to sit still (Chandler, 2002). Consistent with the recommended assessment practices discussed above (Brock, 1999; Brock & Clinton, 2007), Smith and Corkum’s (2007) review of the literature (from 1985 to 2005) judged to be relevant to assessing ADHD among preschoolers suggested four core areas of assessment: (a) behavior rating scales, (b) interviews, (c) direct observations of behavior, and (d) direct measures of attention and hyperactivity/impulsivity. In addition, to identifying these general areas of assessment, Smith and Corkum critically evaluated specific measures cited in the literature reviewed according to three “quality indicator domains”: (a) symptom description, (b) psychometrics, and (c) logistics. From their evaluation of these measures Smith and Corkum concluded that there are several rating scales appropriate for use in assessing the behaviors of preschool children. They include the Conners’ Parent and Teacher Rating Scales (Conners, 1997), the Child Behavior Checklist (Achenbach & Rescorla, 2001), and the Preschool Behavior Questionnaire (Behar, 1977). The literature reviewed also suggested infor-
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mal behavioral observations (in both low- and high-structured settings), informal background information interviews, and the Conners’ Continuous Performance Test (Conners, 2000) to be most frequently used. However, from their evaluation of quality indicator domains they concluded that there was a critical need to develop measures appropriate for preschoolers, particularly in the areas of diagnostic interviews and those that directly assess the core symptoms of ADHD.
The Identification of Minority Youth As indicated in Table 3.1 there are some significant demographic differences associated with having been diagnosed with ADHD and/or currently being treated for this disorder. Specifically, it would appear that youth with Hispanic ethnicity, those who do not speak English, and those who do not have any health-care coverage are significantly less likely to be diagnosed or treated; and Black youth are significantly less likely to currently be taking medication (Visser & Lesene, 2005). Black youth (as compared to White youth) with ADHD are also less likely to receive special education services (Mandell, Davis, Bevans, & Guevara, 2008). Further, despite findings that teacher screenings suggest twice the number of AfricanAmerican (as compared to Caucasian) students to have ADHD (Reid et al., 1998), the percentage of Black youth reported to have an ADHD diagnosis is lower than that seen among White youth (7.7 vs. 8.6%; Visser & Lesene, 2005). Explanations for these differences offered by Hervey-Jumper, Douyon, Falcone, and Franco’s (2008) review of the literature include the observations that minority parents may (a) have less knowledge of ADHD, (b) be more likely to be influenced by the stigma of “diagnosis,” (c) have a higher threshold for seeking services, and (d) have unique cultural perspectives on interventions and illness. Hervey-Jumper and colleagues also suggest that health-care providers and clinicians may have difficulty making this diagnosis in minority youth. To address these challenges Hervey-Jumper and colleagues (2008) have made several recommendations for clinicians working with minority youth. Specifically, their recommendations include that (a) the ADHD evaluation be conducted by individuals of the same racial/ethnic background as the youth being evaluated or that evaluators have completed training in cultural competence; (b) cultural considerations factor into the selection and interpretation of assessments; and (c) parents be provided thorough, clear, and understandable explanations of assessment findings so as to facilitate a therapeutic alliance. They conclude: “Training clinicians in cultural competence, organizing community educational events, and increasing collaboration among school personnel, families, and clinicians are urgently needed” (p. 526). For more information on this topic the reader is also referred to Tannebaum, Counts-Allan, Jakobsons, and Repper (2007).
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Concluding Comments As discussed at the beginning of this chapter there are important legal reasons for the school psychologist being involved with the ADHD diagnosis (i.e., the combination of child find regulations, and requirements that children be assessed in all areas of suspected disability). However, it should be clear that in addition to these legal motivations, there are also practical reasons for the school psychologist being an important part of the ADHD diagnostic process. Specifically, there is no other mental health professional that has greater access to the multiple information sources and diagnostic procedures considered essential to making an ADHD diagnosis (i.e., rating scales; parent, teacher, and student interviews; psychological testing; and behavioral observations) than the school psychologist. For example, the classroom observational data that some working in clinical practice (e.g., Gordon et al., 2006) have come to argue are too costly to include in the standard diagnostic process, are readily accessible and relatively affordable to the school psychologist. While the diagnosis of ADHD is complicated and perfect diagnostic reliability has yet to be obtained, it is suggested that there is significant consensus among authorities in the field regarding what the comprehensive evaluation of the child suspected to have ADHD should involve. Specifically, it would appear that rating scales, interviews, psychological testing, and behavioral observation are the commonly recommended diagnostic techniques. Awareness of this consensus can help to guide practice. It can also be used to support the argument that school psychologists should be able to make an ADHD diagnosis. Specifically, it is clear that not only do school psychologists have ready access to the most commonly recommended diagnostic techniques, but they also have, as a part of their standard pre-service preparation, training in the use of these tools (i.e., how to use rating scales, conduct interviews, administer and interpret psychological tests, and conduct behavioral observations). Thus, assuming the appropriate supervised practice, it is argued that school psychologists are well positioned to conduct (or at the very least assist in) the ADHD diagnosis. In addition, it is important to acknowledge that awareness of the consensus that exists regarding elements of the ADHD diagnosis will be indispensable when evaluating the adequacy of the many students who present to their school psychologists with ADHD diagnoses made by other (typically non-school based) health and mental health professionals. It is anticipated that knowledge of what constitutes a complete ADHD diagnosis will assist these school psychologists in critically evaluating these independent ADHD diagnostic assessments.
Chapter 6
Psycho-educational Assessment
While it may be controversial whether or not the school psychologist should make a DSM IV-TR ADHD diagnosis, there should be no disagreement regarding the fact that all school psychologists must be able to conduct the psycho-educational evaluation of students with ADHD. While the diagnostic assessment is designed to address the question of whether or not a student meets ADHD criteria, the psycho-educational assessment is designed to assess student strengths and challenges (including the effect of ADHD symptoms on school functioning) and to obtain important program planning data (including the development of specific learning goals and objectives and the documentation of possible special education or Section 504 eligibility). As was mentioned in Chapter 1, students with ADHD who require special education services may be eligible under the IDEA disability categories of “other health impairment,” “specific learning disability,” or “emotional disturbance.” Further, students with ADHD who do not require special education may nevertheless be eligible for specialized services, under Section 504 of the Rehabilitation Act of 1973. Eligibility for Section 504 services would be based upon the finding that the student with ADHD was judged to be a “handicapped person” (Davila et al., 1991). However, as was also mentioned in Chapter 1, DSM IV-TR (American Psychiatric Association [APA], 2000) diagnostic criteria are not synonymous with eligibility for either special education or Section 504 services. While suggestive of the need for such, an ADHD diagnosis is not sufficient when determining either special education or Section 504 eligibility. Thus, school psychologists will need to conduct psychoeducational assessments to assist IEP/assessment teams in determining if a student with ADHD requires special services, accommodations, and/or modifications. When assessing the present levels of functioning of students with ADHD, it is essential to keep in mind that the core deficits of this disorder can significantly impact test performance (Goldstein & Goldstein, 1990b). For example, hyperactivity may make it difficult to sit still and complete performance oriented/timed tasks, impulsivity may adversely affect tasks that require the consideration of several different response items, and inattention may interfere with the ability to remain focused on a test for an extended period of time. In addition, there are many psycho-educational variables associated with ADHD. Thus, the ability to conduct
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psycho-educational assessments will require knowledge of (a) the accommodations necessary to obtain valid test results for students with ADHD and (b) specific assessments appropriate for use with this population. To address these psycho-educational assessment issues, this chapter begins with an examination of ADHD testing accommodations and modifications and then discusses specific psycho-educational assessment practices for use with students who have ADHD.
Testing Accommodations and Modifications While the identification and direct assessment of ADHD behaviors per se is the essential task of the diagnostic assessment, the psycho-educational assessment will do much more. It will also assess psycho-educational variables such as intelligence, academic achievement, and other psychological processes that are important to educational performance. To obtain valid estimates of these variables, school psychologists must be able to constantly assess the degree to which tests being used reflect symptoms of ADHD or the specific targeted abilities. For example, in the case of an IQ test examiners must constantly question whether obtained scores reflect cognitive potential or the inattention and impulsivity associated with ADHD. To address the challenges to obtaining valid psycho-educational test scores, examiners will often need to make testing accommodations (Brock, 1998, February). Before offering specific suggestions that might be appropriate for these students, it is important to acknowledge that the ADHD population is very heterogeneous. Thus, there is no single set of testing accommodations that will work for every student. Rather, it is important to consider each student as an individual and to select specific testing accommodations to meet specific needs. With this preface in mind the following accommodations are offered.
Allow for Frequent Test Session Breaks To accommodate for the inattention and difficulty remaining on-task often associated with ADHD, testing sessions should be brief and feedback regarding test-taking efforts should be immediate (Pfiffner & Barkley, 1990). Longer tests should be broken up into manageable parts (Sandoval, 1982), and it may be appropriate to offer more frequent test session breaks than is typically the case. These breaks should be relatively brief (e.g., 5 minute), allow for some sort of productive physical movement (e.g., a walk to the drinking fountain), and can be enforced with timers. It is important to note that these breaks should be offered before test-taking effort significantly decays. Otherwise, this accommodation may actually reinforce a decreased test-taking effort, as the student may come to believe that his or her inattention to test directions and/or off-task behavior results in a negatively reinforcing consequence (i.e., avoidance of the “aversive” test-taking situation). Given this possibility, it is recommended that before beginning a psycho-educational evaluation, the examiner consult with the student’s parents and/or teacher regarding how long a
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sustain test-taking effort might be expected, and schedule breaks in advance of what is predicted to be the limit of the student’s attention span. Further, before each and every break it will be important to reinforce the students test-taking effort and allow the student to believe that it is such effort that is obtaining the potentially reinforcing consequence (i.e., avoidance of the test-taking situation).
Allow for Physical Movement To accommodate for the hyperactivity that is often associated with ADHD, it may be appropriate to allow for physical movement during the testing session (Sandoval, 1982; Shuck, Liddell, & Bigelow, 1987). Such an accommodation is especially important for the student who is clearly having difficulty sitting still. An example of this accommodation might include an examiner allowing a student to stand and stretch (or even walk around the testing room) during the administration of tests that involve auditory stimuli and a verbal response. While allowing for physical movement may not be possible during all psycho-educational tests (e.g., a student must be seated for tests that involve visual stimuli and a fine motor response), the first author’s (Brock) experiences have found that among hyperactive students allowing such movement improves test-taking effort.
Minimize Distractions Given that many students with ADHD are extremely inattentive it would be important to minimize competing stimuli that might be viewed as attractive alternatives to the test-taking session. For example, if the examiner’s office is physically proximal to the playground it would not be a good idea to assess a student with ADHD during a recess period (Brock, 1998, February).
Make Use of Powerful External Rewards Given the challenges associated with ADHD (e.g., difficulty sustaining attention and sitting still) it would not be surprising to find students with this disorder to be unmotivated to perform in testing sessions. In fact, they may find it aversive. Thus, not surprisingly, even when they understand what a good test-taking effort involves, students with ADHD are often not convinced that such behavior is worth the effort (O’Neill & Douglas, 1991). From this result it is suggested that the student with ADHD needs external criteria for test completion and needs a pay off for increased test-taking effort. In other words, relying on intangible rewards is often not enough. Thus, it will be important to consider how to reward test performance and increase test-taking motivation. Specific strategies include the use of frequent reinforcement breaks and behavioral shaping. For example, at the conclusion of a testing session the student with ADHD may be given the reward of engaging in a highly preferred activity. Of course, as is the case with all efforts to use external rewards to influence
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behavior, it will be essential to ensure that the individual student finds the selected reinforcer reinforcing. Further, it is important to acknowledge that the consequences offered to the student with ADHD will likely need to be more powerful and of a higher magnitude than is required for students without this disorder (Pfiffner & Barkley, 1990). Finally, parents and/or teachers should always be consulted about the appropriateness of the selected reinforcers.
Provide Clear Test-Taking Rules Special attention should be given to the rules that govern the test-taking situation (Pfiffner & Barkley, 1990). The rules given to the student with ADHD must be well defined, specific, and frequently reinforced. Well-defined rules with clear consequences are essential (Sandoval, 1982; Shuck et al., 1987). Pfiffner and Barkley (1990) point out that relying on the student’s memory of rules is not sufficient. Thus, it is suggested that visual rule reminders or cues be placed within the test-taking environment. It may also be helpful if these rules are reviewed at the start of each testing session (Rosenberg, 1986).
Carefully Pre-select Task Difficulty Another strategy to maintain the student’s motivation is to alternate difficult tasks (typically language items) with easy tasks (e.g., tasks that are brief). Data obtained from classroom observations and parent and teacher interviews should inform the examiner regarding what kinds of tasks will be difficult for the student with ADHD and what tasks will be relatively easy. With this knowledge, difficult tasks can be followed by what is expected to be an easy task, which in turn can help to maintain the student’s test-taking motivation.
Allow the Student to Pace Him- or Herself When possible (e.g., during the administration of power tests), it is helpful to allow the student with ADHD to set his or her own pace for test completion. Support for this accommodation comes from Whalen and Henker (1985) who found the intensity of problematic ADHD behaviors to lessen when students’ work was self paced, as compared to situations wherein the work pace was set by others.
Schedule the Testing Session Early in the Day From reports that the on-task behavior of the student with ADHD progressively worsens over the course of the day (Zagar & Bowers, 1983), it has been suggested
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that academic tasks (which may include psycho-educational testing) be provided in the morning (Pfiffner & Barkley, 1990). During the afternoon, when problemsolving skills are especially poor, psycho-educational testing should be avoided.
Provide Structure and Organization The first author’s (Brock) practical experiences suggest it to be critical to clearly define for the student with ADHD what is expected during the testing session. For example, before beginning a testing session the examiner should clearly define the requirements of a completed test session (e.g., "You will be finished with today’s testing session when all of the materials in this test kit have been used;” Brock, 1998, February).
Modify Test Administration and Allow Nonstandard Responses Many of the just mentioned accommodations might be implemented without having to break standardized test administration and scoring procedures. Obviously, to the extent it is possible, standardized administrations are preferred. However, if it becomes necessary, changing test directions (e.g., shortening and/or repeating them), allowing the student to respond to the task in alternative ways (e.g., allowing a student to dictate, instead of writing, their responses to stimulus items), and/or allowing additional time to respond to test items may be appropriate. While such modifications will affect the examiner’s ability to compare the student’s test performance to those of students in the given standardization sample, such non-standard administrations can be helpful in understanding the student’s relative pattern of strengths and weaknesses. In addition, re-administration of tests that were suspected to have been adversely affected by ADHD behaviors may provide data regarding the effects of the students ADHD-associated learning challenges on their school performance.
Specific Psycho-educational Assessment Practices In addition to knowledge of appropriate testing accommodations and modifications, it is essential that the school psychologist be knowledgeable of the specific assessment practices and tools often useful when assessing the student with ADHD. Thus, this section provides a review of behavioral observation and functional assessment and specific psycho-educational tests (i.e., tests of cognitive functioning, adaptive behavior, language functioning, perceptual processing, academic functioning, and emotional functioning). Developmental, health, and family history should also be a part of the comprehensive psycho-educational evaluation and for information about the important elements of this assessment practice the reader is referred to Chapter 5 and Fig. 5.1.
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Behavioral Observations and Functional Assessment As is the case with all psycho-educational assessments, behavioral observations are essential. Students with ADHD are a very heterogeneous group, and in addition to the core features of ADHD, it is not unusual for them to display a wide range of other behaviors and symptoms that may significantly affect educational functioning. Obviously, identification of these unique behavioral challenges will be important for educational program planning. Observation of the student with ADHD in typical environments, such as the classroom, will also facilitate the evaluation of test-taking behavior. From such observations judgments regarding how typical the student’s test-taking behaviors can be made and the validity of the obtained test results assessed. In addition, observation of the student’s test-taking behavior may also help to document the core features of ADHD. For example, observation of difficulties remaining seated, an impulsive response style, and/or inattention would be consistent with the ADHD diagnosis. A specific tool for evaluating the test session behavior, suggested to be valid and reliable (Corkill, 1998; Sanford, 1998), is the Guide to the Assessment of Test Session Behavior (Glutting & Oakland, 1993). Parent and teacher interviews will also be important to understanding the student’s behavior and are key elements of a functional behavioral assessment. O’Neill and colleagues (1997) provide recommendations for conducting such interviews. From the work of O’Neill and his colleagues Fig. 6.1 provides the author’s functional assessment interview form (Brock et al., 2006).
Psycho-educational Testing When administered with the previously mentioned accommodations and modifications in mind, a variety of traditional psycho-educational measures are appropriate when assessing the student with ADHD’s present levels of functioning. As required by IDEA regulations (U.S. Department of Education, 2006, August), the student with ADHD should be evaluated in all areas of suspected disability. This means that the evaluation should include measures designed to help determine eligibility for special education services under the learning disabled, other health impaired, and emotionally disturbed criteria. Thus, the evaluation will typically include measures of cognitive functioning, adaptive behavior, basic psychological processes, academic achievement, emotional functioning, and language functioning. From the authors’ applied experiences, and a review of the literature, the following discussion examines some of the issues associated with selecting, administering, and interpreting psycho-educational tests among students with ADHD. Cognitive functioning. Obtaining a global estimate of intelligence is often necessary to establish the student’s developmental level. As was mentioned in Chapter 5, given the requirement that ADHD symptoms must be inconsistent with developmental level (APA, 2000), data regarding overall cognitive functioning is important.
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Functional Assessment of Behavior Student: Date of interview:
Age
Gender:
Interviewer:
Target Behavior(s):
Behavior History: How long have the target behavior(s) been a problem?
What has previously been tried to address the target behavior(s)?
What has been the effect of the previous behavior intervention(s)?
Consequences of the Target Behavior(s): What happens immediately after the behavior(s) that might be reinforcing?
What does the student get?
What does the student avoid?
Are there specific/unique situations that typically generate specific consequences? If so what are these situations.
Fig. 6.1 This figure provides an interview form appropriate for use when collecting behavioral data regarding students with ADHD
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Replacement Behavior(s): What other behavior(s), which are incompatible with the target behavior(s) and ideally obtain the same goals addressing the target behavior(s), can be encouraged? Define the replacement behavior(s) in terms that are measurable and readily observable
Does the student currently display this behavior(s), or does it need to be taught to the student?
Consequences of the Replacement Behavior(s) [SRF]: What happens immediately after the behavior(s) that might be reinforcing?
What does the student get?
What does the student avoid?
Are there specific/unique situations that typically generate specific consequences? If so what are these situations.
Establishing Operations What events, when present, make it more or less likely that the target or replacement behavior(s) will be viewed as reinforcing and are thus be more likely to occur? a)
What medications is the student taking?
Fig. 6.1 (Continued)
Specific Psycho-educational Assessment Practices What affect do they have on the target behavior(s)?
What affect to they have on the replacement behavior(s)?
b)
Does the student have any medical or physical conditions (e.g., asthma, allergies, rashes, dental problems, sinus infections, seizures, etc.)? What affect do they have on the target behavior(s)?
What affect to they have on the replacement behavior(s)?
c)
What affect do they have on the target behavior(s)?
What affect to they have on the replacement behavior(s)?
d)
What are the studentís eating patterns or diet? What affect do they have on the target behavior(s)?
What affect to they have on the replacement behavior(s)?
e)
How predictable is the student’s daily routine? What affect does the routine have on the target behavior(s)?
What affect does the routine have on the replacement behavior(s)?
f)
What are some of the choices the student makes during the course of a school day?
Fig. 6.1 (Continued)
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6 Psycho-educational Assessment What affect does the ability to make choices have on the target behavior(s)?
What affect does the ability to make choices have on the replacement behavior(s)?
g)
Are there some situations, settings, or days that present the student with an unusually crowded and/or noisy environment? What affect does a crowded or noisy environment have on the target behavior(s)?
What affect does a crowded or noisy environment have on the replacement behavior(s)?
h)
What is the pattern of staffing support present in the student’s environment (e.g., 1:1 or 2:1)?
Is there a particular staffing level that has an affect on the target and/or replacement behavior(s)? Are their types of staff interactions that appear to have an affect on the target and/or replacement behavior(s)? Does the type of staff training have and affect on the target and/or replacement behavior(s)?
i)
Are there any other events, occurring either the night before, or the morning that, the behavior(s) was(are) displayed, that are suspected to play a role in the target and/or replacement behavior(s)?
Immediate Antecedents [SD]: What are the specific events that immediately precede and predict occurrence of the target and replacement behavior(s)? These events are the cues, signals, or signposts that tell the student that a given behavior will yield a reinforcing outcome. a)
Time of day. When is the target behavior(s) most likely to occur? When is the replacement behavior(s) most likely to occur? When is the target behavior(s) least likely to occur? When is the replacement behavior(s) least likely to occur?
b)
Setting. Where is the target behavior(s) most likely to occur?
Fig. 6.1 (Continued)
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Where is the replacement behavior(s) most likely to occur? Where is the target behavior(s) least likely to occur? Where is the replacement behavior(s) least likely to occur? c)
People. With whom is the target behavior(s) most likely to occur? With whom is the replacement behavior(s) most likely to occur? With whom is the target behavior(s) least likely to occur? With whom is the replacement behavior(s) least likely to occur?
d)
Activity. During what activities is the target behavior(s) most likely to occur? During what activities is the replacement behavior(s) most likely to occur? During what activities is the target behavior(s) least likely to occur? During what activities is the replacement behavior(s) least likely to occur?
e)
Other antecedents. Are there any other antecedents that appear to cue or trigger the target behavior (e.g., specific task demands, noises, lights, clothes, smells, etc.)?
f)
If you wanted to guarantee that the target behavior would occur, what would you do?
Fig. 6.1 (Continued)
According to Gordon and colleagues (2006) without some estimate of the child’s intelligence it will not be possible to rule out cognitive delays as an explanation for ADHD symptoms. When considering intelligence test results, it is important to keep in mind that the current literature indicates that as a consequence of this disorder; students with ADHD score an average of nine points lower than their age peers (Barkley, 2006; Frazier et al., 2004). Further, while of limited diagnostic value, it is commonly agreed that when compared to their non-disabled peers, students with ADHD often score lower on intelligence test tasks that assess executive functions such as working memory (in particular verbal working memory) and processing speed (Barkley, 2006). Specific intelligence test profiles commonly associated with ADHD are summarized in Table 6.1. Adaptive behavior. Relative to students without disabilities several studies have found that students with ADHD score lower on measures of adaptive behavior (with scores on average falling in the low-average to borderline ranges; Barkley, 2006). Further, relative to other clinical groups, the discrepancy between IQ test and adaptive behavior scale scores is often larger among students with ADHD (with IQ standard scores being higher than adaptive behavior scores; Stein, Szumowski, Blondis, & Roizen, 1995). Given these observations, measures such as the Vineland Adaptive
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Summary Statements: EO[(SD)R>SRE)] Target Behavior
Consequences
EO
Antecedents SD
R
SRF
Distant Setting Event
Immediate Antecedent (Trigger)
Response
Rewarding Stimulus
Target Behavior
Consequences
Antecedents EO
SD
R
SRF
Distant Setting Event
Immediate Antecedent (Trigger)
Response
Rewarding Stimulus
Target Behavior
Consequences
Antecedents EO
SD
R
SRF
Distant Setting Event
Immediate Antecedent (Trigger)
Response
Rewarding Stimulus
Fig. 6.1 (Continued)
Behavior Scales (Sparrow, Cicchetti, & Balla, 2006, 2005) should be administered and may serve as a measure of the functional impairments associated with ADHD and can also be used to establish a baseline for, and evaluate attainment of, IEP objectives. Psychological processes. Given the frequent comorbidity of ADHD with reading disabilities, it is recommended that assessment of phonological processing always be considered for inclusion in the psycho-educational evaluation of any student with ADHD. Among the measures appropriate for such assessment is the Comprehensive Test of Phonological Processing (CTOPP; Wagner, Torgesen, & Rashotte, 1999).
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Table 6.1 IQ test profiles frequently associated with ADHD Intelligence Test (Test Author)
ADHD Profile (Study Notes/Authors)
Differential Ability Scales (DAS; Elliott, 1990)
Relative to normal controls, low scores on the Sequential and Quantitative Reasoning, and Recall of Digits subtests (Note: subjects, 63% combined type; Gibney, McIntosh, Dean, & Dunham, 2002). Relative to general education students, significantly lower Planning Scale scores (Note: subjects, students referred for ADHD evaluation; Naglieri, Salter, & Edwards, 2004). Relative weakness on the Hand Movements subtest (Note: test used, KABC; Barkley, 2006).
Cognitive Assessment System (CAS; Naglieri & Das, 1997)
Kaufman Assessment Battery for Children (KABC-II; Kaufman & Kaufman, 2004) Stanford-Binet Intelligence Scale-Fifth Edition (SB-V; Roid, 2003) Universal Nonverbal Intelligence Test (UNIT; Bracken & McCallum, 1998) Wechsler Intelligence Scale for Children (WISC-IV; Wechsler, 2003)
Relative to normal controls, significantly lower Working Memory factor scores (Note: subjects, combined type; Blashko, 2006). Memory Quotient score on average 10 points lower than Reasoning Quotient score (Pendley, Myers, & Brown, 2004). Relative to Full Scale IQ, 84% have significant Processing Speed + Freedom from Distractibility weaknesses (Notes: subjects, inattentive subtype; test used, WISC III; Calhoun & Mayes, 2005). Woodcock-Johnson Test of Relative to children without ADHD, significantly lower Cognitive Abilities (WJ-III Cog; Processing Speed scores (Note: subjects, all but one Woodcock, McGrew, & Mather, combined type; Penny, Waschbusch, Carrey, & Drabman, 2001b) 2005).
However, when interpreting the results of the CTOPP or other measures of phonological processing, it is important to acknowledge that even in the absence of a reading disability, students with ADHD may demonstrate significant deficits with rapid automatic naming (Brock & Christo, 2003). Given the association between ADHD and executive functioning, measures designed specifically to address these abilities may also be included in the psychoeducational evaluation. For example, the NEPSY: A Developmental Neuropsychological Assessment (NEPSY; Korkman, Kirk, & Kemp, 1998), while not appropriate for ADHD diagnosis (Atkinson, 2004), has been suggested to differentiate individuals with the inattentive type of ADHD from those with the combined type (Pottinger, 2002). This measure has also been suggested to be based on sound theory and research (Haynes, 2001) and to have good psychometric properties (Miller, 2001). Another measure of executive functioning is the Behavior Rating Inventory of Executive Functioning (BRIEF; Giola, Isquith, Guy, & Kenworthy, 2000). These parent and teacher rating scales have been suggested to have some promise in identifying intervention targets (Jarratt et al., 2005) and to account for a significant amount of academic achievement and adaptive behavior variance among students with ADHD (Di Pinto, 2006). This measure has also been suggested to be well-designed
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and useful (Fitzpatrick, 2003) and a quick and efficient measure of executive functioning (Schraw, 2003). Finally, given the observation that students with ADHD often have associated motor coordination problems and poor graphomotor ability (Barkley, 2006), measures designed to assess visual-motor skill may be included in the assessment battery. Among the measures that could be used to assess this ability is the Developmental Test of Visual-Motor Integration (VMI-5; Beery, Buktenica, & Beery, 2004). Academic achievement. Given its association with learning disabilities (Seidman, 2006), it is not surprising to find that ADHD is typically associated with significant deficits in academic achievement (Barry, Lyman, & Klinger, 2002; Frazier et al., 2004; Marshall et al., 1997). Given this observation, measures such as the Woodcock-Johnson III: Tests of Achievement (WJ-III ACH; Woodcock, McGrew, & Mather, 2001a) and the Wechsler Individual Achievement Test (WIAT-2; Wechsler, 2003) should be administered. These may serve as a measure of the academic achievement deficits associated with ADHD and can be used to establish a baseline for, and evaluate attainment of, IEP objectives. There is some evidence to suggest that even in the absence of comorbid learning disabilities, students with ADHD may have relative academic achievement deficits. For example, Brock and Knapp (1996) reported that relative to carefully matched non-disabled peers, ADHD students without learning disabilities still had lower reading comprehension test scores. However, it is important to note that the reading comprehension deficits reported by Brock and Knapp were documented via measures that required the reading of extended passages. Thus, to evaluate the effect of ADHD on reading comprehension it is recommended that tests be used that require the reading of longer passages. For example, the examiner might make use of the Gray Oral Reading Test’s (Wiederholt & Bryant, 2001) Comprehension score instead of the Woodcock-Johnson Tests of Achievement’s (Woodcock et al., 2001a) Passage Comprehension subtest. While the former measure requires reading of relatively extended passages before answering comprehension questions, the stimulus items found on the Passage Comprehension subtest are relatively brief. Emotional functioning. According to Barkley’s (2006) review, 75% or more of students with ADHD will at some point develop a comorbid psychiatric disorder, with girls being at a lower risk for developing a comorbid disruptive behavior disorder than boys (Biederman, Mick et al., 2002). The percentages of clinic referred children with ADHD who have a comorbid psychiatric disorder is offered in Table 6.2. Given these possibilities, it will also be important for the school psychol-
Table 6.2 Percentage of clinic referred ADHD children who also have a comorbid psychiatric disorder
Psychiatric Disorder
Percentage
Oppositional Defiant Disorder Major Depressive Disorder Conduct Disorder Anxiety Disorders Bipolar Disorder (Type I)
Up to 84 15–75 15–56 10–50 6–27
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ogist to evaluate the student’s emotional/behavioral status. Traditional measures such as the Behavioral Assessment System for Children (BASC-2; Reynolds, & Kamphaus, 2004) would be appropriate as a general purpose screening tool, while more specific measures such as The Children’s Depression Inventory (CDI; Kovacs, 1992) and the Revised Children’s Manifest Anxiety Scale: Second Edition (RCMA2; Reynolds & Richmond, 2008) would be appropriate for assessing more specific presenting concerns. Language functioning. In a recent parent survey, language was rated as one of the least problematic areas for the student with ADHD. Nevertheless, 67% of respondents were reported to have language problems, with language comprehension and communication being rated problematic three times as high as problems with expressive language (Bruce, Thernlund, & Nettelbladt, 2006). Consistent with this report, Barkley’s (2006) review suggests that children with ADHD do not appear to have higher rates of serious or generalized language delays. However, they may be more likely to have specific speech development challenges. Given these observations, referral to a speech and language pathologist may be a common supplement to the psycho-educational evaluation.
Concluding Comments While not all school psychologists will be expected to diagnose ADHD, all should be capable of conducting the psycho-educational evaluation of these students. Consequently, it is essential that school psychologists be informed of the techniques and strategies helpful in obtaining valid assessment data. In addition, it is important to understand some of the unique test profiles and assessment findings that are associated with an ADHD diagnosis. With this information a student’s specific learning strengths and challenges can be identified, instructional goals and objectives developed, and special education and/or Section 504 eligibility determined.
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Chapter 7
Treatment
Few clinical issues have been more hotly contested than the treatment of ADHD, particularly the relative value of medication versus behavioral/psychosocial treatments (DuPaul & Power, 2008; Toplak, Connors, Shuster, Knezevic, & Parks, 2008; Wauschbusch & Hill, 2003). Treatment decisions are often complicated by biases reflecting media coverage of diagnostic and treatment controversies, cultural background, previous experiences or anecdotal stories from family and friends as well as school personnel. Fortunately, there is a body of well-designed, longitudinal data on which to base treatment decisions and discussions with families (American Adademy of Child and Adolescent Psychiatry [AACAP] Practice Review, 2007; Toplak et al., 2008). The empirical evidence base for effective treatment of ADHD is one of the strongest for any chronic or mental health disorder. Effective treatment is most often multi-modal, including medical, behavioral, and educational strategies. The most important aspect of successful treatment for children with ADHD is comprehensive evaluation and accurate diagnosis for ADHD as well as other comorbidities described in previous chapters that frequently occur in children with ADHD. This evaluation needs to include education of the child with ADHD and his or her family about the diagnosis itself, its neurobiogical basis and chronicity, as well as development of a collaborative team approach to ongoing treatment. A family-centered approach is important, in which decision making is shared between the child and family, clinician, and school personnel (e.g., school psychologist, teacher, and nurse). The choice of treatments, whether pharmacological, psychosocial and/or psychoeducational, is influenced by the nature of the patient’s comorbid disorder(s), level of impairment, and family issues or concerns. Once the diagnosis is agreed upon and understood, the team needs to identify treatment targets, outcomes, and goals that are objective and measurable. When considering such targets it is important to acknowledge that while students with ADHD do have a core set of common difficulties, this group is very heterogeneous. Consequently, instead of targeting ADHD symptoms, intervention should begin by identifying specific challenging behaviors. Next, alternative desired behaviors, incompatible with the challenging behaviors, should be identified. It is important to keep both sets of behaviors in mind since educators, and others involved in the treatment
S.E. Brock et al., Identifying, Assessing, and Treating ADHD at School, Developmental Psychopathology at School, DOI 10.1007/978-1-4419-0501-7_7, C Springer Science+Business Media, LLC 2009
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of students with ADHD, need to not only make clear to students what behavior is unacceptable, but they also need to make clear what behavior is acceptable. Whenever considering behavioral treatments, it is also important to ensure that the intervention is based on a functional assessment of behavior. Antecedents and consequences of both problem and desirable behaviors need to be identified. Antecedents suggest environmental adjustments that can set the student up for success, while the consequences suggest those environmental conditions that reinforce behavior. The function of the problem behavior should guide interventions. For example, if the behavior is maintained by positive reinforcement (e.g., obtaining attention) the intervention should ensure that this goal is not obtained by the challenging behavior. At the same time, the intervention should teach the student that the desirable behavior is a more effective and efficient way of obtaining the desired behavioral goal (e.g., attention; Brock, Puopolo, Cummings, & Husted, 2004). Regardless of the nature of the treatment or treatments, target outcomes should be based on improving functioning in different contexts, primarily at school and home, and addressing self-esteem concerns. Treatment targets should be prioritized to first address those areas that most impair functioning. Establishing targets that initially address challenging behaviors, followed by academic performance and social interaction goals is generally most successful. Targeted outcomes should be specific, quantifiable behaviors. Agreement on prioritizing treatment targets, measurement strategies, and methods to ensure ongoing communication regarding follow-up amongst the team members is important, and the participation of school personnel is of utmost importance to the success of any treatment strategy. Parental ADHD and other family dysfunction that will undermine successful treatment need to be addressed as part of any treatment plan. Establishing an ongoing collaborative relationship with families is critical to treatment success (DuPaul & Power, 2008).
Adjusting the Classroom Environment: Setting the Student Up for Success The physical as well as “cultural” environment of the classroom is important to all children, but is especially critical for students with ADHD. Teachers must have training and support from other school personnel to successfully manage students with ADHD in the general education classroom. The traditional classroom setup, with desks facing forward toward the teacher, is usually better than open-plan designs for students with ADHD, and having the youth close to the teacher in the front of the room rather than in the back is also helpful in terms of reinforcing positive behaviors and preventing or intervening quickly in off-task or disruptive behaviors. Establishing predictable routines, clear rules, and limits with immediate and appropriate enforcement is important. Teachers should use multiple approaches to teaching material. Ideally, placing children with ADHD in smaller classes with lower student–teacher ratios should be a priority when possible.
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Utilizing instructional strategies within the classroom that promote success for the student with ADHD is an important aspect of treatment. These strategies also support learning for all students in the general education classroom. As detailed in the review offered by Brock, Grove, and Searls (in press), the following classroom environmental changes are offered as options for addressing problematic behaviors and learning difficulties in the classroom setting.1 These interventions might be thought of as setting the student with ADHD up for success. Task duration. To accommodate to a student’s short attention span, academic assignments should be brief, and immediate feedback regarding accuracy provided (Pfiffner & Barkley, 1998). For example, long projects can be broken up into smaller parts (Sandoval, 1982). In addition, allowing students to take breaks during long periods of class work is another possible accommodation (Zentall, 2005). Task difficulty. Adjusting task difficulty (e.g., matching difficulty to the student’s instructional level) is a way to engage students with ADHD and to help them avoid frustration. Students with ADHD are more likely to give up and become frustrated when given an academic task that exceeds their instructional level. They also tend to become bored and inattentive with simple tasks as compared to students who do not have ADHD. Some students with ADHD may also benefit from starting with easier tasks and slowly progressing to more difficult tasks as their confidence and self efficacy builds (Zentall, 2005). Direct instruction. Attention and on-task behavior can be improved when the student with ADHD is engaged in teacher directed (vs. independent seat-work) activities. Teaching note-taking strategies further increases the benefits of direct instruction, and has also been shown to significantly improve on-task behavior, scores on assignments, and comprehension (Raggi & Chronis, 2006). Students with ADHD may also benefit from explicit direct instruction on attention (i.e., attention training sessions). Skills practiced in these sessions can include avoiding irrelevant cues and selectively attending to important material (Zentall, 2005). Peer tutoring. Peer tutoring has been shown to be effective in facilitating academic and behavioral gains among students with ADHD. It is recommended that peer tutors be of the same gender, and have higher academic and better behavioral skills, than the student with ADHD. Further, the highest academic gains are made when students are presented with challenging material and when teacher feedback is frequent. As little as 20 min per-day of peer tutoring has been found to result in significant increases in on-task behavior (DuPaul et al., 1998). Class-wide peer tutoring. Students with ADHD who have participated in classwide peer tutoring have been reported to demonstrate increased on-task behavior and improved accuracy on academic tasks (Raggi & Chronis, 2006). This intervention involves first providing students with instruction on how to be an effective tutor and then being given scripts of academic materials. Immediate feedback is given
1 Copyright 2004 by National Association of School Psychologists. Bethesda, MD. Adapted with permission of the publisher www.nasponline.org.
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and points are awarded for correct responses. Each student plays the role of a tutor and a tutee and teachers are required to carefully monitor the process. Scheduling. Given that the on-task behavior of students with ADHD typically worsens as the academic day progresses, it is recommended that instruction be provided in the morning. During the afternoon, when problem-solving skills tend to be especially poor, more active, non-academic activities can be scheduled (Barkley, 1998). Further, preferred activities can be scheduled after non-preferred activities to provide an incentive to complete challenging tasks (Reid, 1999). Novelty. Increasing the novelty and interest level of tasks through enhanced stimulation (e.g., color, shape, and texture) reduces activity level, increases attention, and improves the overall performance of students with attention problems (Zentall & Meyer, 1987). Teachers can use novelty in the classroom by bolding important elements of written directions, using brightly colored paper, animation, or even different intonations when giving instructions or teaching a lesson. Students with ADHD respond positively to the novelty provided by films, models, and skits (Zentall, 2005). Conversely, it is also important to minimize assigning repetitive tasks for students with ADHD, as they increase off-task behaviors. Provide structure and organization. Students with ADHD respond positively to structure and predictability (Raggi & Chronis, 2006). These students can benefit from the use of a daily schedule and maintaining a consistent day-to-day routine. It may also be helpful to give students with ADHD advanced notice of changes in the class routine. Lessons themselves can be carefully structured and important points clearly identified. For example, providing a lecture outline is a helpful aid that increases memory of main ideas. Students with ADHD perform better on memory tasks when material is meaningfully structured for them (O’Neill & Douglas, 1991). Rule reminders and visual cues. The rules given to students with ADHD should be well defined, specific, frequently reinforced, and associated with clear consequences. Relying on the student’s memory of rules is insufficient. Thus, visual rule reminders should be placed throughout the classroom. It is also helpful if rules are reviewed before activity transitions and following school breaks (Barkley, 1998). Teaching students self-monitoring skills by using visual cues has been shown to improve selective and sustained attention, and language, while at the same time reducing impulsivity. Such instruction can be facilitated by providing students with a list of questions to run through when starting a new assignment such as “What is the problem?” “What is my plan?” “Am I following my plan?” “How did I do?” (Zentall, 2005). Pacing of work. When possible, it is helpful to allow students with ADHD to set their own pace. The intensity of problematic ADHD behaviors is lessened when work is self-paced, as compared to situations where others set the pace for the student (Whalen & Henker, 1985). Instructions. Students with ADHD often have difficulty following multi-step directions. Thus, it is important for directions to be short, specific, and direct (Goldstein & Goldstein, 1990b). By using fewer more direct words to explain assignments, teachers can increase the understanding and engagement of students with ADHD (Zentall, 2005). To ensure understanding, it is helpful if students with
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ADHD are asked to rephrase directions in their own words. Additionally, teachers should be prepared to repeat directions frequently, and recognize that these students may often miss what was said due to the inattention associated with their ADHD (Pfiffner & Barkley, 1998; Zentall, 2005). Choice.Allowing students a choice of activities can help to reduce disruptive behaviors, and increase on-task behavior and task completion (Dunlap, Kern-Dunlap, Clarke, & Robbins, 1991; Raggi & Chronis, 2006). This accommodation might involve giving a student a list of possible tasks to complete and to permit a choice regarding what to work on first. For example, choices might include working on either a math or a language arts assignment for 15 minute before being required to switch to the other subject. This technique is reported to be most effective when it is used in combination with other behavioral techniques (Dunlap et al., 1991). Productive physical movement. Students with hyperactive symptoms may have difficulty sitting still for prolonged periods of time. Thus, productive physical movement should be planned. Such increased physical movement has been shown to improve the on-task behavior of students with ADHD. It may be helpful to develop a repertoire of physical activities for the entire class such as stretch breaks. Other examples might include a trip to the office, a chance to sharpen a pencil, taking a note to another teacher, watering the plants, feeding classroom pets, or simply standing at a desk while completing class-work. Even the movement required by calculator use has been shown to increase on-task behavior (Zentall, 2005). Alternating seat-work activities with other activities that allow for movement is essential. It is also important to keep in mind that on some days it will be more difficult for the student to sit still than on others. Thus, teachers need to be flexible and modify instructional demands accordingly (Pfiffner & Barkley, 1998). Active vs. passive involvement. Tasks that require active (as opposed to passive) responses can help hyperactive students channel their disruptive behaviors into constructive responses (Zentall & Meyer, 1987). While it can be challenging for these children to sit and listen to a long lecture, teachers will find that students with ADHD can be successful participants in the same lecture when asked to assist in some way (e.g., help with audio-visual aids, write important points on the chalk board). Feedback. Students with ADHD have been found to respond better to crossmodal feedback. For example, students respond better to verbal feedback when completing visual tasks. Students also tend to do better when response options are available in a format different from the question. For example, when presented with a question orally, students do better when their response options are listed visually. Cross-modal feedback allows students with ADHD to differentiate the information they are receiving about their performance from their task and differentiate the information they are taking in from the information they are generating (Bennett, Zentall, French, & Giorgetti-Borucki, 2006). Distractions. Placing the student in close proximity to the teacher and away from high traffic areas can reduce distractions and increase attention (e.g., seating the student away from activity centers, mobiles, doorways, and windows; Barkley, 1998). Eliminating irrelevant and highly desirable distractions such as toys or cartoons from the work area is also an effective modification. Auditory distractions (e.g., side
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conversations) during complex and cognitively effortful tasks tend to be the most problematic for students with ADHD and thus are especially important to minimize or eliminate (Zentall, 2005). Anticipation. Knowledge of ADHD and its primary symptoms is helpful in anticipating difficult situations. It is important to keep in mind that some situations will be more difficult for some students than others. For example, effortful problem solving tasks may be especially troublesome due to the low frustration threshold of many students with ADHD (Wigal et al., 1998). These situations should be anticipated and appropriate accommodations made. For example, when presenting a task that the teacher suspects might exceed the student’s attentional capacity, it is appropriate to reduce assignment length and emphasize quality as opposed to quantity.
Psychosocial Interventions: Encouraging Appropriate Behavior Although classroom environmental changes and accommodations can be helpful in reducing problematic behaviors and learning difficulties, by themselves they are often not sufficient and other psychosocial interventions are often indicated. Chronis, Jones, and Raggi (2006) reviewed the evidence base for effective psychosocial interventions in children with ADHD. Behavioral parent training and behavioral school interventions have both been established as the only non-medical empirically validated treatment strategies with adequate scientific evidence base. Behavioral interventions alone, while generally not shown to be as effective as medication alone or in combination with medication, can be recommended as initial treatment if the impairments are mild, the parents are very resistant to medication trials or there is diagnostic uncertainty/disagreement. Fabiano and colleagues (2007) recently reported lower doses of medication were effective in achieving the same outcomes when combined with behavior modification as a higher dosage of medication alone, which supports the need for school psychologists, teachers, physicians, and parents to work together on effective collaborative interventions. Behavioral treatment helps address problems beyond the core symptoms of ADHD, which often include academic performance, noncompliance, and relationships with peers, siblings, and parents. Three important components of behavioral interventions for ADHD, which should be integrated, include parent training, school-based interventions and child-focused treatments. Chronis and colleagues (2006) report average effect sizes of 0.87 for parent training programs and 1.44 for school-based behavioral programs. School psychologists need to have training and expertise in behavioral interventions so that they can provide explicit teaching and support for teachers and parents in developing and monitoring the effectiveness of behavioral interventions, identify what is working or what is not in order to modify goals and strategies over time, and facilitate communication between teacher, child, and family. The Center for Children and Families at the University of Buffalo has an excellent summary of psychosocial behavioral intervention strategies and evidence based resources
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available on their website at http://ccf.buffalo.edu. DuPaul (2007) recently reviewed school-based interventions, emphasizing token reinforcement and response cost, the two consequence-based interventions with the strongest empirical support. Token reinforcement programs (providing immediate reinforcers or tokens contingent on appropriate behavior) have been used effectively to reduce off-task, disruptive behaviors, and to enhance task engagement. Similarly, response cost (the removal of token reinforcers contingent on inappropriate behavior) has been found to increase on-task behavior and work productivity. Fabiano and colleagues (2007) found that key components of effective school behavior modification programs included (a) posting and daily review of classroom rules; (b) liberal use of praise and social reinforcement for appropriate behavior; (c) use of some kind of time-out procedure for aggressive, destructive, or defiant behavior; and (d) daily report card linked to rewards provided by parents on at least a weekly basis. Behavioral interventions should be designed using functional assessment data, with selection of limited number of clearly defined behavioral targets likely to have an affect on academic functioning, and contingencies maintaining the target behaviors identified. Usually the intervention should include frequent and immediate positive reinforcement and/or response cost and the specific consequences should be matched to the purported function of the challenging behavior. Ongoing systematic direct observations along with teacher ratings should be used to monitor effectiveness of the interventions. Taken directly from the review offered by Brock, Grove, and Searls (in press), the following contingencies that reinforce appropriate or desired behaviors, and discourage inappropriate or undesired behaviors, should be available. Powerful external reinforcement. Students with ADHD typically need an external measure of success and a pay-off for increased performance. Relying on intangible rewards is often not enough for these students. Further, it is important to keep in mind that the contingencies or consequences used must be delivered more immediately and frequently than is typically the case. Students with ADHD tend to be more influenced by current rewards then by prior reinforcement (Zentall, 2005). Additionally, behavioral consequences will need to be more powerful and of a higher magnitude than is required for other students (Wigal et al., 1998). Use of both negative and positive consequences is essential (Rosén, O’leary, Joyce, Conway, & Pfiffner, 1984). However, before negative consequences are implemented, appropriate and rich incentives should first be developed to reinforce desired behavior. It is important to give much encouragement, praise, and affection, as students with ADHD are easily discouraged (Zentall, 2005). When negative consequences are administered they should be delivered in a fashion that does not embarrass the student. In addition, it is important to acknowledge that the rewards used with these students may lose their reinforcing power quickly and thus should be frequently changed or rotated (Pfiffner & Barkley, 1998). Self-monitoring. Many students with ADHD have the skill to perform desired behaviors; however they are not able to perform consistently over time due to challenges with self-regulation (Ardoin & Martens, 2004; Reid, Trout, & Schartz,
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2005). Thus, self-monitoring can be another intervention helpful to the student with ADHD, and has been found to increase on-task behavior. It is a strategy that can, for example, involve the use of a tape with tones played at random intervals to remind a student to monitor his or her behavior. The student and the teacher listen for the tones and record whether or not the student is on-task. At predetermined times during the day the teacher and student records are compared and the student is reinforced for agreement with teacher responses. Once the student becomes accurate in assessing his or her behavior, he or she will then be reinforced for improvements in on-task behavior. Once students have been taught to monitor and reinforce their behaviors, fading can be used to decrease any external monitoring and reinforcement (DuPaul & Weyandt, 2006). Additionally, self-monitoring has been shown to be especially effective when the targeted behaviors or the desired outcomes are valuable to the students (Harris, Friedlander, Saddler, Frizzelle, & Graham, 2005). Regardless of whether or not a child with ADHD responds to medication, self-monitoring strategies have been found to result in gains in on-task behavior, improvements in selective and sustained attention, as well as reducing impulsivity (Zentall, 2005). These results suggest that self-monitoring may be a particularly promising technique for children whose challenging behaviors are effected by medication (Mathes & Bender, 1997). Token economy systems. These systems are an example of a behavioral strategy proven to be helpful in improving both the academic and behavioral functioning of students with ADHD. These typically involved giving students tokens (e.g., poker chips) when they display appropriate behavior. These tokens are in turn exchanged for tangible rewards or privileges at specified times (McGoey & DuPaul, 2000). The use of a token economy is an effective way to deliver an immediate contingency frequently to students in a busy environment (DuPaul & Weyandt, 2006). Response-cost programs. While verbal reprimands are sufficient for some students, more powerful negative consequences, such as response-cost programs, are needed for others (Pfiffner & Barkley, 1998). The use of a response-cost system has been demonstrated to increase the levels of on-task behavior, seatwork productivity, and academic accuracy of students with ADHD (DuPaul & Weyandt, 2006). A specific response-cost program found to be effective with ADHD students involves giving a specific number of points at the start of each day. When a rule is broken (i.e., a problem behavior is displayed) points are taken away. Thus, to maintain their points and receive reinforcement, students must avoid displaying inappropriate behaviors. Since students with ADHD are easily frustrated it may be helpful to allow them the opportunity to earn points back by displaying appropriate behavior. At the end of the period or day students are allowed to exchange the points they have earned for a tangible reward or privilege (Barkley, 1998). When there are high student-teacher ratios in a classroom, response-cost programs have been found to be more practical to implement than other behavioral interventions since it is difficult to continuously monitor every student’s behavior (McGoey & DuPaul, 2000). Time-out. Time-out typically involves removing the student from classroom activities. Before time-out is implemented it should be clear that it is not reinforc-
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ing for the child (i.e., giving the student what he or she wants). For example, if a student is displaying aggressive or disruptive behaviors to receive attention from peers, removing the student from his or her peers (i.e., time-out) would be effective. However, if a student is trying to avoid schoolwork, time-out can be reinforcing if it allows the student to avoid his or her schoolwork. The time-out area should be a pleasant environment and the student should be placed in it for only a short time. At its conclusion a discussion of what went wrong and how to prevent the problem in the future takes place (Pfiffner & Barkley, 1998). While these procedures are effective with ADHD students, it is recommended that they be used only with the most disruptive classroom behaviors and only when there is a highly trained staff member available (Abramowitz & O’Leary, 1991). Close consultation and support between school psychologists and teachers is critical to implementing effective school based interventions for children with ADHD. Jitendra and colleagues (2007) examined models of consultation and found the following components essential: (a) education of teachers about the nature of ADHD and effective classroom interventions; (b) a collaborative process in which teacher and consultant together design academic interventions that teachers identify as appropriate for their classrooms; (c) detailed plans that outline the specific instructional steps teachers need to use, along with all the necessary support materials for implementation; (d) a range of interventions to choose from, including teachermediated, peer-mediated, computer-assisted and self-mediated strategies; and (e) weekly contact between consultant and teacher to provide updates and address concerns or questions. Individual psychotherapy and psychodynamic family therapy have not been shown to be effective in treating ADHD symptoms, although may be indicated as adjunctive therapies in treating comorbidities within the child and family that are affecting the success of pharmacologic and/or behavioral interventions. The evidence base for cognitive-behavioral therapy for ADHD is reviewed below.
Psychoeducational Students with ADHD often have difficulties with academic achievement, related both to their underlying ADHD as well as comorbid disorders of learning. Toplak and colleagues (2008) reviewed the existing empirical evidence base for cognitivebehavioral, cognitive and neural based interventions for ADHD. Although they found promising aspects to all three approaches, they conclude there is not a sufficiently consistent or methodologically rigorous research base to currently recommend these interventions as efficacious. They encourage ongoing research, particularly in further evaluating these interventions as adjunctive therapies combined with established behavioral and medical interventions. Additional review of existing EEG biofeedback research is included below, since this intervention has become commercially available in many communities.
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Medications Both the short and long-term efficacy of medication management for children with ADHD has been well established, and reviewed in several recent professional publications (AACAP Practice Parameter, 2007; MTA Cooperative Group, 2004a, 2004b). FDA approved for the treatment of ADHD, stimulant medication is the first-line treatment and has been repeatedly found to be effective in up to 85% of children with ADHD (AACAP Practice Parameter, 2007). In double-blinded, placebo controlled treatment studies, the effect size of stimulant treatment relative to placebo averages about 1.0, one of the largest effects for any psychotropic medication (AACAP Practice Parameter, 2007). The types of stimulants, methylphenidate R R ) and amphetamine (Adderall ), have been shown to be equally effica(Ritalin cious in treating ADHD. Many different formulations have been studied over the last several years, showing both efficacy and safety as well as increased convenience due to the effectiveness of extended release formulations. These extended release formulations, which are effective for 8–12 hours, also eliminate the need for children to take medication at school under the supervision of school personnel, increase confidentiality and decrease misuse. Table 7.1 includes a brief summary of medications often used to help children with ADHD. Monitoring treatment effectiveness. School personnel should play a central role in monitoring the effectiveness, as well as the side effects, of stimulant medications. While clinical guidelines regarding dosing parameters have been developed (AACAP Practice Parameter, 2007), each patient has a unique dose-response curve. In other words, the dose that works for one student of a given age and weight, will not necessarily be equally effective for another similar peer. It is also not evident how to predict which child will respond better to either methylphenidate or amphetamine formulations. Arnold (2000) reviewed responses of subjects undergoing trials of both methylphenidate and amphetamine, and found that 41% with ADHD responded equally to both, while 44% responded preferentially to one or the other. The MTA study, in which children were carefully titrated to a maximally effective dose without significant side effects, established the importance of increasing doses initially every one to three weeks until the maximum recommended dose was reached, symptoms of ADHD remitted or side effects prevented further titration, which ever occurred first (Jensen et al., 2001). This is in contrast to using the lowest dose that improves ADHD symptoms, which is now felt to be under-treating the disorder. Narrow-band behavior rating scales are useful both for initial diagnostic evaluation as well as for monitoring response to treatment. Several of these are listed in Table 5.4. The use of a school-home daily report card (sample illustrated in Fig. 7.1) is also helpful in monitoring response to treatment and attainment of target goals. The use of a daily report card also increases ongoing communication between the teacher and parent, provides data on objective behaviors that have been targeted by the team that are particularly important over time for decision making regarding treatment efficacy. Guidelines for families and teachers to establish and maintain a school-home daily report card for a child with ADHD are available
Medications
Table 7.1 Medications often used to help children with ADHD Generic Class/ Brand name
Dose/form
Typical starting dose
FDA∗ max/day
Methylphenidate preparations Short acting:
Comments Often used for initial treatment, small children; need dose 2–3 times/day
Ritalin Methylin Focalin Intermediate:
5, 10, 20 mg tab 5,10, 20 mg tab 2.5, 5, 10 mg cap
5 mg twice/day 5 mg twice/day 2.5 mg twice/day
60 mg 60 mg 20 mg
Ritalin SR Ritalin LA Metadate ER Metadate CD Methylin ER Long acting: Concerta
20 mg tab 10, 20, 30, 40 mg cap 10, 20 mg cap 10, 20, 30, 40, 50, 60 mg cap 10, 20 mg
10 mg morning 20 mg morning 10 mg morning 20 mg morning 10 mg morning
60 mg 60 mg 60 mg 60 mg 60 mg
18, 27, 36, 54 mg cap
18 mg morning
72 mg
Daytrana patch
10, 15, 20, 30 mg patches
Focalin XR
5, 10, 15, 20 mg cap
10 mg patch each day, 30 mg titrate up 5 mg morning 30 mg
Greater convenience, compliance but may increase effects on evening appetite and sleep capsule can be opened and sprinkled on food capsule can be opened and sprinkled on food
Non-absorbable capsule shell may be seen in stool Skin irritation under patch may occur
(Continued)
105
106
Table 7.1 (Continued) Generic Class/ Brand name
Dose/form
Typical starting dose
FDA∗ max/day
Amphetamine preparations
BLACK BOX warning: Misuse of amphetamines may cause sudden death/serious cardiovascular events Often used for initial treatment, small children; need dose 2–3 times/day
Short acting: Adderall
5, 7.5, 10, 12.5, 15, 20, 30 mg
Dexedrine DextroStat Long acting: Adderall XR
5 mg cap 5, 10 mg cap
3–5 yr: 2.5 mg 40 mg 6 & older: 5 mg once to twice /day Same as Adderall 40 mg Same as Adderall 40 mg
5,10, 15, 20, 25, 30 mg cap
6 yr & older: 10 mg morning 30 mg
Dexedrine Spansule
5,10, 15 mg cap
Lisdexamfetamine Vyvanse Selective norepinephrine reuptake inhibitor Atomoxetine Strattera
30, 50, 70 mg cap
6 yr & older: 5–10 mg 40 mg once-twice/day 6 yr & older: 30 mg morning 70 mg
10, 18, 25, 40, 60, 80, 100 mg cap
<70 kg:0.5 mg/kg/ day for 4 Lesser of Not a schedule II medication; BLACK days; then 1.4 mg/kg/day or BOX warning: monitor closely for 1 mg/kg/day for 4 days; then 100 mg suicidal thinking and behavior, clinical 1.2 mg/ kg/day, divided once worsening, unusual changes in or twice/day behavior.
Treatment
U.S. Food and Drug Administration
Capsule can be opened and sprinkled on food
7
∗ FDA=
Comments
Medications
107
School-Home Daily Report Card Child's Name: Date: Teacher: Classroom Periods/Subject Areas Target Behaviors
Language Arts
Math
Reading
Science
Follows class rules. (no more than 2 rule violations per period)
Yes / No
Yes / No
Yes / No
Yes / No
Complies with teacher requests. (no more than 1 instance of noncompliance per period)
Yes / No
Yes / No
Yes / No
Yes / No
Completes assignments within the designated time.
Yes / No
Yes / No
Yes / No
Yes / No
Completes assignments with at least 75% accuracy.
Yes / No
Yes / No
Yes / No
Yes / No
Follows lunch rules. (no more than 3 violations)
Yes / No
Follows recess rules. (no more than 3 violations)
Yes / No
Summary: Total Number of Yes =
Total Number of No =
Percentage Yes =
Comments:
Fig. 7.1 This figure provides an example of a school-home daily report card for a child with ADHD (Additional examples and detailed information to develop school-home daily report cards available online at http://ccf.buffalo.edu through the Center for Children and Families at the University of Buffalo)
online at http://ccf.buffalo.edu, through the Center for Children and Families at the University of Buffalo. Undesired effects. For stimulant medications, the most common side effects are appetite suppression, weight loss, stomachache, sleep disturbance, or headache. Many of these will decrease with ongoing use of medication, but will need to be monitored by the prescribing physician. Less common is the onset of tics and emotional lability or irritability. It is unclear how often stimulant medication induce tics
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in children with ADHD, and two recent studies of both immediate-release and long acting stimulants did not find an increase in tics over placebo (Biederman, Lopez, Boeller, & Chandler, 2002; Wolraich et al, 2001). Gadow, Sverd, Sprafkin, Nolan, and Grossman (1999) showed that children with ADHD and a comorbid tic disorder, on average, had a decrease in tics after treatment with stimulants, even after a year of treatment. Children with treatment emergent tics that impact social function or self-esteem should be tried on another stimulant or a non-stimulant medication. Children whose ADHD symptoms are responsive only to a stimulant medication that induces tics may need to be on combined regimen of a stimulant and an alpha-agonist such as clonidine or guanfacine (Tourette’s Syndrome Study Group, 2002). Recently, concerns regarding increased suicidal ideation and toxic psychotic symptoms involving visual and tactile hallucinations, were investigated by the Pediatric Advisory Committee for the FDA. No changes in the labeling for stimulant medications were made in this regard, although a boxed warning was added to the non-stimulant atomoxetine, also approved by the FDA for ADHD treatment, regarding a small increased risk regarding onset of suicidal ideation that needs to be monitored with treatment. Cardiovascular events related to sudden death did not show increased rates above the baseline rate that could be related to stimulant medication, although package inserts recommend these medications not be used in children and adolescents with preexisting heart disease or symptoms suggesting significant cardiovascular disease such as severe palpitations, fainting, exercise intolerance or a strong family history of sudden death (Winterstein et al., 2007). R ) is the only other medication Second line treatments. Atomoxetine (Strattera approved for ADHD treatment by the FDA currently, although other second line medications are used off-label when stimulants are either not effective or contraindicated. Atomoxetine is a noradrenergic reuptake inhibitor that has been shown to be more effective than placebo in treating children and adolescents with ADHD, although with effect sizes lower than the stimulants, particularly in ADHD with no comorbidity. It’s onset of action is longer than the stimulants, so dosage trials may need to be prolonged over several weeks. A recent study (Geller et al., 2006) found that atomoxetine was successful in treating both the ADHD and anxiety symptoms in children with comorbid ADHD and anxiety disorder. It may also be considered as a first medication for ADHD in individuals with substance abuse problems or tics. Atomoxetine should be considered the preferred treatment if a child has severe side effects to stimulants such as mood lability or tics, and is dosed one or two times a day. It carries a box warning, mentioned above, regarding a small increased risk for suicidal thinking. Re-evaluation of the diagnosis of ADHD should be considered if the child does not respond to medication trials with stimulants and/or atomoxetine, particularly for undetected comorbidities such as mood disorders, anxiety disorders, and other developmental disorders which may be primary to the ADHD symptoms. Bipolar disorder, in particular, has many overlapping symptoms with ADHD as well as frequent comorbidity. However, in differentiating bipolar disorder from ADHD, the response, or lack thereof, to stimulants is not usually diagnostically helpful
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(Lansford, 2005). Key symptoms that help in distinguishing childhood bipolar and ADHD include elated mood, grandiosity, racing thoughts, decreased need for sleep and hypersexuality in the absence of sexual abuse or overstimulation (Geller, Warner et al., 1998; Geller et al., 2002). Hyperactivity may be more episodic in children with bipolar disorder, but general hyperactivity, irritability, accelerated speech, and distractibility are so common in both disorders that they are usually less helpful in the differential diagnosis (Geller et al., 2002). The highest rate of onset of bipolar disorder has been reported to be between 15 and 19 years of age (Burke, Burke, Regier, & Rae,1990) but often begins between 11 and 12 years (Sachs, Baldassano, Truman, & Guil, 2000). A longitudinal study has shown that 98% of manic youth also had ADHD (Wozniak, Biederman, & Richards, 2001). ADHD, in fact, may be the initial manifestation of mania. If the diagnosis is not correct, stimulant medications may exacerbate or further complicate deleterious behaviors, for instance, professionals are encouraged to first rule out bipolar disorder, as stimulants may increase mood swings. Further medication trials with medications that have shown efficacy for treating ADHD symptoms, even though they are not approved for this purpose by the FDA, should be considered based on re-evaluation of diagnosis. These R ), imipramine medications include the antidepressants, bupropion (Wellbutrin R R (Tofanil ) and nortriptyline (Pamelor ), and the alpha-adrenergic agonists, cloniR R ), and guanfacine (Tenex ). dine (Catapres Long-term management. Determining the length and type of treatments is another issue for which school personnel play a key role. While long-term studies have confirmed the lack of major medical adverse events with stimulants and atomoxetine, concerns regarding stimulant induced growth delays have continued to be debated. Several studies, reviewed in AACAP Practice Parameter (2007) have shown an association with a reduction in expected height gain, at least in the first 1–3 years of treatment, although in an analysis of cross-sectional data, Spencer and colleagues (1996) found no height deficits in childhood, a small but statistically significant reduction at puberty. However, no differences in height were reported in adulthood. It is not clear whether the use of drug holidays is useful in reducing effects of stimulant medication on growth. The MTA follow-up studies suggest that there is a group of children who initially respond to medication and then deteriorate in spite of medication (these are more likely to have comorbidity at baseline diagnosis) and another group which responds to medication with remission of symptoms and continues to do well despite discontinuing medication (MTA, 2004a, 2004b). Helping families make decisions regarding symptom remission or persistence in the school setting and participating in monitoring response to trials off medication for those children whose ADHD symptoms have been in remission are key roles for school personnel. These generally should not be at the beginning of a school year, but after the school routine has been established. Adolescence presents new challenges for treatment. During early adolescence the transition to seeing the child as the patient is important for buy-in to assume as much responsibility as possible for care, and to assure understanding of ADHD
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as a chronic disorder. Teenagers who “own” their own problems, successes, and treatment plan will do much better. Hyperactivity symptoms tend to improve during adolescence (see discussion of the caudate nucleus in Chapter 2 as a possible explanation for why this occurs), but demands for organization/attention increase and difficulties with attention/distractability remain. As many as 65% of children diagnosed with ADHD will continue to meet diagnostic criteria in adolescence (Wolraich et al., 2005) yet adolescents dramatically underreport impairment and symptoms. Peer relationships also become more important and more difficult to negotiate and cognitive demands increase during middle and high school. Teens may begin to dislike the feelings that a particular medication creates, and many want to discontinue their medication due to age appropriate desires for independence, resistance to adult direction and conformity with peers, so reconsideration of dose or specific medication may be important. Using extended release formulations of stimulants or atomoxetine may help increase compliance, reduce street value and potential for abuse. Overall, substance abuse disorders are two times greater over the lifespan in individuals with ADHD than those without. Concerns regarding the risk of substance abuse in adolescents taking medication for ADHD symptoms have been evaluated, and a meta-analysis of open-label long-term studies of stimulant treatment concluded that stimulant treatment does not increase the risk but may even have a protective effect (Wilens, Faraone, Biederman, & Gunawardene, 2003). It is important to have ongoing communication between treating physicians and school psychologists/teachers regarding adolescents’ readiness to change and to take responsibility for medication maintenance or discontinuation and overall treatment management. This communication is particularly important in assessing comorbidities that may emerge in later school age and adolescence in almost a half of adolescents with ADHD, such as anxiety, depression, bipolar disorder, oppositional defiant disorder, and conduct disorders (Wolraich et al., 2005). The potential for abuse/diversion of medications is higher in individuals with ADHD and CD, especially with use of short or intermediate action medications with higher abuse and diversion potential. Misuse. Wilens and colleagues (2008) recently reviewed the literature on stimulant misuse and diversion among ADHD and non-ADHD individuals and reports overall rates of past-year non-prescribed stimulant use ranged from 5 to 9% in grade and high school-age children and 5 to 35% in college-age individuals. Lifetime rates of diversion ranged from 16 to 29% of students with stimulant prescriptions, who gave, sold, or traded their medications. Individuals at highest risk for misuse and diversion included whites, members of fraternities and sororities, lower GPAs, use of immediate rather than extended release preparations and current reported symptoms of ADHD. Preschool children. Diagnosing and medicating preschool age children with ADHD warrants special consideration. The Preschool ADHD Treatment Study (PATS, Greenhill et al., 2006) included a six center randomized controlled trial to determine the efficacy and safety of immediate release methyphenidate, given TID to children 3–5. This study consisted of an eight phase 70 week protocol with 10 weeks of parent training and a 5 week trial of increasing doses for effectiveness of
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symptom response, two double-blind controlled phases, a crossover-titration trial followed by a placebo controlled parallel trial. Families were randomly assigned to behavioral treatments. The behavioral parent training combined with encouragement of more constructive interactions between parents and children with ADHD had better outcomes and was as effective as methylphenidate but only when conducted by specialists. MPH was more effective than placebo but had less effect size than for school age children, and at lower doses than those most effective for older children. Almost one third dropped out because of worsening behavior (45% placebo, 15% drug). Side effects overlapped with those most commonly seen in school age children (decreased appetite, delayed sleep, headaches and stomachaches) although occurred at a higher rate and had a higher incidence of emotional outbursts, irritability, repetitive behaviors and thoughts reported, particularly during initial titration. Eleven percentage stopped due to side effects. Methylphenidate had no more effect on heart rate or blood pressure than placebo (Wigal et al., 2006). Long term effects on annual growth rates for children remaining on medications were 20.3% less than expected for height and 55.2% for weight. However, the preschoolers with ADHD started out taller and heavier than average (Swanson et al., 2006).
Alternative Therapies Many unproven treatments may promise “cures” or “natural treatments” and are much more accessible and widely disseminated to parents because of the Internet. School personnel can play an important role in helping parents to understand how to evaluate the validity of claims for unproven treatments. For example, helping them understand how a proposed treatment is scientifically evaluated for efficacy and safety is an important role for school personnel as well as the treating clinician. Although there are many interventions currently considered alternative because of the lack of well-designed efficacy studies, ongoing research is producing more evidence on which to further evaluate efficacy and safety, such as EEG biofeedback and dietary interventions. The National Center for Complementary and Alternative Medicine at the NIH (www.nccam.nih.gov) and the National Resource Center on AD/HD (www.help4adhd.org) are both excellent resources for professionals and families regarding evaluation of complementary/alternative treatments, as is the American Academy of Pediatrics ADHD guide (Reiff & Tippins, 2004). Dietary interventions have been one of the most longstanding, and well studied, alternative therapies for ADHD, most well known due to the Feingold diet popularized by Dr. Feingold (1975; Reiff & Tippins, 2004). Many parents believe that a dietary trial is safe to try, although maintaining a highly restrictive diet in children who are consuming much of their daily diet out of the home is very difficult. The evidence supporting and refuting the effectiveness of dietary interventions as a treatment for the core symptoms of ADHD is difficult to evaluate, but most welldesigned studies and meta analysis reviews provide no convincing evidence suggesting that dietary insufficiencies or supplements cause or treat ADHD in the majority of children or adults.
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Children with inhaled and food allergies, family history of migraines and food reactivity are more likely to respond to elimination diets, particularly younger children. In most children, the link between sensitizing foods and behavioral characteristics of ADHD is accompanied by a variety of coexisting health and behavioral difficulties, particularly sleep-related and neurological problems (Reiff & Tippins, 2004). Elimination of milk, nuts, wheat, fish and soy, in addition to food additives, may be tried if baseline behaviors are established and monitored. If improvement is found, adding back one category at a time with ongoing monitoring may establish foods that exacerbate symptoms. Ten percent of children with ADHD demonstrated allergies to food dyes and 2% put on the Feingold Diet showed consistent behavioral improvement when food dyes were removed (Reiff & Tippins, 2004). In general, for most children with ADHD who do not have food sensitivities, as well as for some who do, elimination diets are not effective treatments for ADHD itself, are hard to maintain and monitor, and may waste important time without more effective treatments. Dietary supplementation with omega 3 fatty acids, which have membrane enhancing capabilities in brain cells and may enhance neuronal growth, is supported by observational studies that found lower levels of O3FA in ADHD children than controls (Stevens et al., 1995). However, randomized controlled trials have been done with small numbers and have had negative (Hirayama, Hamazaki, & Terasawa, 2004; Voight et al., 2001) or ambiguous results (Richardson & Puri, 2002). Theoretical risks of O3FA include immune suppression, reduction of glycemic control among patients with diabetes and hyperlipidemia have been raised but not well documented. At present, there is insufficient evidence to substantiate efficacy and safety of supplementation as an effective treatment strategy for ADHD, but further investigations are underway. Other dietary supplementations for ADHD symptoms are reviewed in Reiff and Tippins (2004). To date, there is insubstantial evidence to support the use of glyconutritional supplements, megavitamin dosages, amino acid supplements or other herbal supplements such as hypericum, Ginko biloba or pycnogenol, and some of these supplements may incur risks to health such as possible liver toxicity, immunological and neurological problems. Review of the evidence also showed no evidence to support homeopathic treatments for ADHD (Coulter & Dean, 2007). Electroencephalographic (EEG) biofeedback is based on a body of research documenting differences in electrical brainwave activity, measured on the scalp, between children with and without ADHD that correspond to many of the differences in thalamocortical activity measured by functional neuroimaging studies (Monastru, 2005). The rationale for EEG biofeedback is derived from neuroimaging studies indicating involvement of frontal lobes, basal ganglia, corpus collosum and cerebellum and neurophysiologic research clarifying the relationship between surface EEG recordings and underlying thalmocortical mechanisms responsible for its rhythms and frequency modulations. Changes in predominant rhythms and frequency modulations on quantitative EEG recordings have been characterized depending on an individual’s state of alertness and activity, and in individuals with ADHD there have been different patterns over brain regions implicated in ADHD.
Alternative Therapies
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EEG biofeedback interventions are designed to train individuals to learn how to alter their predominant brain waves measured at particular areas so that they either suppress slow wave (theta) activity and increase fast wave (beta and SMR) activity. Toplak and colleagues (2008) reviewed the existing literature on neural feedback research; while many studies have promising results the research is currently confounded by methodological concerns regarding lack of adequate controls, confounding related to multiple interventions, and inconsistent use of clinically relevant dependent outcome measures. Continuous performance test measures are most consistently used to measure treatment response, with variability in effect size calculations reported between 0.02 and 0.87. Behavior ratings by both teachers and parents have shown large effect size on ratings of attention (1.02–5.35) with relatively smaller effect size on ratings of hyperactivity and impulsivity (0.82–1.07) and measures of intellectual ability (0.09–0.26). At this point, clinical implications for EEG biofeedback may include failure to respond to a series of at least two stimulant medications and a trial on a nonstimulant such as atomoxetine or severe adverse effects/contraindications and/or parent concern about mediation use. However, the availability of treatment facilities with rigorously trained practitioners is currently very limited in most parts of the United States, and the costs, lack of insurance reimbursement, transportation and scheduling problems remain further limitations in the wider use of EEG biofeedback. If efficacy is established in further studies and issues related to the fidelity of personnel training and protocol delivery, accessibility, and reimbursement can be addressed, this intervention may become integrated into clinical parameters and recommendation protocols. Sensory integration based interventions derive from theories that relate difficulties/dysfunction in sensory processing, such as vision/hearing/ balance/sensory integration, to core symptoms of ADHD. Most of these theories are unsubstantiated and intervention studies are largely uncontrolled and anecdotal (Reiff & Tippins, 2004). While sensory processing problems may be associated with ADHD in some children, there are no well-controlled studies that indicate these are causal in ADHD and treatment studies are not sufficient to recommend sensory integration therapy as an intervention for ADHD symptoms specifically. Behavioral optometry, or eye training exercises, has been proposed as a treatment for learning problems that frequently accompany ADHD. The American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology issued a joint policy statement in 1984 affirming that there is no scientific evidence to support this treatment, and there has not been additional research since that time to alter the policy (Reiff & Tippins, 2004). Treatments for motion sickness, such as meclizine and cyclizine, have been suggested as a treatment based on an unsubstantiated theory that ADHD symptoms are related to inner ear problems (Levison, 1990), however the only controlled trial of this treatment was negative (Fagan, Kaplan, Raymond, & Edginton, 1988). Auditory stimulation training has been proposed as an intervention for ADHD based on a theory that difficulty organizing and attending to sound is
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causal to the symptoms of ADHD. The Tomatis method is one such approach (www.tomatis.com), in which children are treated through special headphones to a variety of different sounds of differing frequencies. No scientifically controlled studies have supported either the theory or the effectiveness of this method for treating ADHD (Reiff & Tippins, 2004).
Concluding Comments The empirical evidence base for effective treatment of ADHD is one of the strongest for any chronic or mental health disorder, although it remains a challenge to integrate comprehensive treatment strategies that address not only the primary symptoms of ADHD but the frequently comorbid disorders associated with it. Effective treatment is most often multi-modal, including medical, behavioral, and educational strategies, must be long term, appropriate across developmental stages and must involve a collaborative team of school professionals, health care professionals and families. In their recent editorial, Improving School Outcomes for Children with ADHD, DuPaul and Power (2008) state that “the key to school success for students with ADHD is the implementation of the right strategies in the context of the right relationships” (p. 519). Collaborative relationships that respect personal, cultural, and socioeconomic differences that affect families’ abilities to adhere to treatment regimens are crucial. In addition, a tremendous amount of research is underway to establish the efficacy of many of the treatments described above that do not yet meet rigorous scientific standards but are promising. Keeping up to date on new advances and sharing new knowledge with families is critical for school psychologists and teachers to maintain the “right relationships” that promote the best outcomes for children and adolescents with ADHD.
Appendix A
September 16, 1991, Davila, Williams and MacDonald Policy Memorandum UNITED STATES DEPARTMENT OF EDUCATION OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES THE ASSISTANT SECRETARY
MEMORANDUM DATE TO FROM
SUBJECT:
SEP 16, 1991 Chief State School Officers Robert R. Davila, Assistant Secretary Office of Special Education and Rehabilitative Services Michael L. Williams, Assistant Secretary Office for Civil Rights John T. MacDonald, Assistant Secretary, Office of Elementary and Secondary Education Clarification of Policy to Address the Needs of Children with Attention-Deficit Disorders within General and/or Special Education
I. Introduction There is a growing awareness in the education community that attention deficit disorder (ADD) and attention deficit hyperactive disorder (ADHD) can result in significant learning problems for children with those conditions.1 While estimates of the prevalence of ADD vary widely, we believe that three to five percent of school-aged children may have significant educational problems related to this disorder. Because ADD has broad implications for education as a whole, the Department believes it should clarify State and local responsibility under Federal law for addressing the needs of children with ADD in the schools. Ensuring that these students are able to reach their fullest potential is an inherent part of the National education goals and AMERICA 2000. The National goals, and the strategy for achieving them, are based on the assumptions that: (1) all S.E. Brock et al., Identifying, Assessing, and Treating ADHD at School, Developmental Psychopathology at School, DOI 10.1007/978-1-4419-0501-7_BM2, C Springer Science+Business Media, LLC 2009
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children can learn and benefit from their education; and (2) the educational community must work to improve the learning opportunities for all children. This memorandum clarifies the circumstances under which children with ADD are eligible for special education services under Part B of the Individuals with Disabilities Education Act (Part B), as well as the Part B requirements for evaluation of such children’s unique educational needs. This memorandum will also clarify the responsibility of State and local educational agencies (SEAs and LEAs) to provide special education and related services to eligible children with ADD under Part B. Finally, this memorandum clarifies the responsibilities of LEAs to provide regular or special education and related aids and services to those children with ADD who are not eligible under Part B, but who fall within the definition of “handicapped person” under Section 504 of the Rehabilitation Act of 1973. Because of the overall educational responsibility to provide services for these children, it is important that general and special education coordinate their efforts. II. Eligibility for Special Education and Related Services under Part B Last year during the reauthorization of the Education of the Handicapped Act [now the Individuals with Disabilities Education Act], Congress gave serious consideration to including ADD in the definition of “children with disabilities” in the statute. The Department took the position that ADD does not need to be added as a separate disability category in the statutory definition since children with ADD who require special education and related services can meet the eligibility criteria for services under Part B. This continues to be the Department’s position. No change with respect to ADD was made by Congress in the statutory definition of “children with disabilities”; however, language was included in Section 102(a) of the Education of the Handicapped Act Amendments of 1990 that required the Secretary to issue a Notice of Inquiry (NOI) soliciting public comment on special education for children with ADD under Part B. In response to the NOI (published November 29, 1990 in the Federa1 Register), the Department received over 2000 written comments, which have been transmitted to the Congress. Our review of these written comments indicates that there is confusion in the field regarding the extent to which children with ADD may be served in special education programs conducted under Part B. A. Description of Part B Part B requires SEAs and LEAs to make a free appropriate public education (FAPE) available to all eligible children with disabilities and to ensure that the rights and protections of Part B are extended to those children and their parents. 20 U.S.C. 1412(2); 34 CFR §§ 300.121 and 300.2. Under Part B, FAPE, among other elements, includes the provision of special education
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and related services, at no cost to parents, in conformity with an individualized education program (IEP). 34 CFR § 300.4. In order to be eligible under Part B, a child must be evaluated in accordance with 34 CFR §§ 300.530−300.534 as having one or more specified physical or mental impairments, and must be found to require special education and related services by reason of one or more of these impairments.2 20 U.S.C. 1401(a)(1); 34 CFR § 300.5. SEAs and LEAs must ensure that children with ADD who are determined eligible for services under Part B receive special education and related services designed to meet their unique needs, including special education and related services needs arising from the ADD. A full continuum of placement alternatives, including the regular classroom, must be available for providing special education and related services required in the IEP. B. Eligibility for Part B services under the “Other Health Impaired” Category The list of chronic or acute health problems included within the definition of “other health impaired” in the Part B regulations is not exhaustive. The term “other health impaired” includes chronic or acute impairments that result in limited alertness, which adversely affects educational performance. Thus, children with ADD should be classified as eligible for services under the “other health impaired” category in instances where the ADD is a chronic or acute health problem that results in limited alertness, which adversely affects educational performance. In other words, children with ADD, where the ADD is a chronic or acute health problem resulting in limited alertness, may be considered disabled under Part B solely on the basis of this disorder within the “other health impaired” category in situations where special education and related services are needed because of the ADD. C. Eligibility for Part B services under other Disability Categories Children with ADD are also eligible for services under Part B if the children satisfy the criteria applicable to other disability categories. For example, children with ADD are also eligible for services under the “specific learning disability” category of Part B if they meet the criteria stated in §§ 300.5(b)(9) and 300.541 or under the “seriously emotionally disturbed” category of Part B if they meet the criteria stated in § 300.5(b)(8). III. Evaluations under Part B A. Requirements SEAs and LEAs have an affirmative obligation to evaluate a child who is suspected of having a disability to determine the child’s need for special education and related services. Under Part B, SEAs and LEAs are required
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to have procedures for locating, identifying and evaluating all children who have a disability or are suspected of having a disability and are in need of special education and related services. 34 CFR §§ 300.128 and 300.220. This responsibility, known as “child find,” is applicable to all children from birth through 21, regardless of the severity of their disability. Consistent with this responsibility and the obligation to make FAPE available to all eligible children with disabilities, SEAs and LEAs must ensure that evaluations of children who are suspected of needing special education and related services are conducted without undue delay. 20 U.S.C. 1412 (2). Because of its responsibility resulting from the FAPE and child find requirements of Part B, an LEA may not refuse to evaluate the possible need for special education and related services of a child with a prior medical diagnosis of ADD solely by reason of that medical diagnosis. However, a medical diagnosis of ADD alone is not sufficient to render a child eligible for services under Part B. Under Part B, before any action is taken with respect to the initial placement of a child with a disability in a program providing special education and related services, “a full and individual evaluation of the child’s educational needs must be conducted in accordance with requirements of § 300.532.” 34 CFR § 300.531. Section 300.532 (a) requires that a child’s evaluation must be conducted by a multidisciplinary team, including at least one teacher or other specialist with knowledge in the area of suspected disability. B. Disagreements over Evaluations Any proposal or refusal of an agency to initiate or change the identification, evaluation, or educational placement of the child, or the provision of FAPE to the child is subject to the written prior notice requirements of 34 CFR §§ 300.504-300.505.3 If a parent disagrees with the LEA’s refusal to evaluate a child or the LEA’s evaluation and determination that a child does not have a disability for which the child is eligible for services under Part B, the parent may request a due process hearing pursuant to 34 CFR §§ 300.506300.513 of the Part B regulations.
IV. Obligations Under Section 504 of SEAs and LEAs to Children with ADD Found Not To Require Special Education and Related Services under Part B Even if a child with ADD is found not to be eligible for services under Part B, the requirements of Section 504 of the Rehabilitation Act of 1973 (Section 504) and its implementing regulation at 34 CFR Part 104 may be applicable. Section 504 prohibits discrimination on the basis of handicap by recipients of
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Federal funds. Since Section 504 is a civil rights law, rather than a funding law, its requirements are framed in different terms than those of Part B. While the Section 504 regulation was written with an eye to consistency with Part B, it is more general, and there are some differences arising from the differing natures of the two laws. For instance, the protections of Section 504 extend to some children who do not fall within the disability categories specified in Part B.
A. Definition Section 504 requires every recipient that operates a public elementary or secondary education program to address the needs of children who are considered “handicapped persons” under Section 504 as adequately as the needs of nonhandicapped persons are met. “Handicapped person” is defined in the Section 504 regulation as any person who has a physical or mental impairment which substantially limits a major life activity (e.g., learning). 34 CFR § 104.3(j). Thus, depending on the severity of their condition, children with ADD may fit within that definition. B. Programs and Services Under Section 504 Under Section 504, an LEA must provide a free appropriate public education to each qualified handicapped child. A free appropriate public education, under Section 504, consists of regular or special education and related aids and services that are designed to meet the individual student’s needs and based on adherence to the regulatory requirements on educational setting, evaluation, placement, and procedural safeguards. 34 CFR §§ 104.33, 104.34, 104.35, and 104.36. A student may be handicapped within the meaning of Section 504, and therefore entitled to regular or special education and related aids and services under the Section 504 regulation, even though the student may not be eligible for special education and related services under Part B. Under Section 504, if parents believe that their child is handicapped by ADD, the LEA must evaluate the child to determine whether he or she is handicapped as defined by Section 504. If an LEA determines that a child is not handicapped under Section 504, the parent has the right to contest that determination. If the child is determined to be handicapped under Section 504, the LEA must make an individualized determination of the child’s educational needs for regular or special education or related aids and services. 34 CFR § 104.35. For children determined to be handicapped under Section 504, implementation of an individualized education program developed in accordance with Part B, although not required, is one means of meeting the free appropriate public education requirements of Section 504.4 The child’s education must be provided in the regular education classroom unless it is demonstrated that education in the regular
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environment with the use of supplementary aids and services cannot be achieved satisfactorily. 34 CFR § 104.34. Should it be determined that the child with ADD is handicapped for purposes of Section 504 and needs only adjustments in the regular classroom, rather than special education, those adjustments are required by Section 504. A range of strategies is available to meet the educational needs of children with ADD. Regular classroom teachers are important in identifying the appropriate educational adaptations and interventions for many children with ADD. SEAs and LEAs should take the necessary steps to promote coordination between special and regular education programs. Steps also should be taken to train regular education teachers and other personnel to develop their awareness about ADD and its manifestations and the adaptations that can be implemented in regular education programs to address the instructional needs of these children. Examples of adaptations in regular education programs could include the following: providing a structured learning environment; repeating and simplifying instructions about in-class and homework assignments; supplementing verbal instructions with visual instructions; using behavioral management techniques; adjusting class schedules; modifying test delivery; using tape recorders, computer-aided instruction, and other audiovisual equipment; selecting modified textbooks or workbooks; and tailoring homework assignments. Other provisions range from consultation to special resources and may include reducing class size; use of one-on-one tutorials; classroom aides and note takers; involvement of a “services coordinator” to oversee implementation of special programs and services, and possible modification of nonacademic times such as lunchroom, recess, and physical education. Through the use of appropriate adaptations and interventions in regular classes, many of which may be required by Section 504, the Department believes that LEAs will be able to effectively address the instructional needs of many children with ADD. C. Procedural Safeguards Under Section 504 Procedural safeguards under the Section 504 regulation are stated more generally than in Part B. The Section 504 regulation requires the LEA to make available a system of procedural safeguards that permits parents to challenge actions regarding the identification, evaluation, or educational placement of their handicapped child whom they believe needs special education or related services. 34 CFR § 104.36. The Section 504 regulation
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requires that the system of procedural safeguards include notice, an opportunity for the parents or guardian to examine relevant records, an impartial hearing with opportunity for participation by the parents or guardian and representation by counsel, and a review procedure. Compliance with procedural safeguards of Part B is one means of fulfilling the Section 504 requirement.5 However, in an impartial due process hearing raising issues under the Section 504 regulation, the impartial hearing officer must make a determination based upon that regulation. V. Conclusion Congress and the Department have recognized the need to provide information and assistance to teachers, administrators, parents and other interested persons regarding the identification, evaluation, and instructional needs of children with ADD. The Department has formed a work group to explore strategies across principal offices to address this issue. The work group also plans to identify some ways that the Department can work with the education associations to cooperatively consider the programs and services needed by children with ADD across special and regular education. In fiscal year 1991, the Congress appropriated funds for the Department to synthesize and disseminate current knowledge related to ADD. Four centers will be established in Fall, 1991 to analyze and synthesize the current research literature on ADD relating to identification, assessment, and interventions. Research syntheses will be prepared in formats suitable for educators, parents and researchers. Existing clearinghouses and networks, as well as Federal, State and local organizations will be utilized to disseminate these research syntheses to parents, educators and administrators, and other interested persons. In addition, the Federal Resource Center will work with SEAs and the six regional resource centers authorized under the Individuals with Disabilities Education Act to identify effective identification and assessment procedures, as well as intervention strategies being implemented across the country for children with ADD. A document describing current practice will be developed and disseminated to parents, educators and administrators, and other interested persons through the regional resource centers network, as well as by parent training centers, other parent and consumer organizations, and professional organizations. Also, the Office for Civil Rights’ ten regional offices stand ready to provide technical assistance to parents and educators. It is our hope that the above information will be of assistance to your State as you plan for the needs of children with ADD who require special education and related services under Part B, as well as for the needs of the broader group of children with ADD who do not qualify for special education and related services under Part B, but for whom special education or adaptations in regular education programs are needed. If you [have] any questions, please contact Jean
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Peelen, Office for Civil Rights; (Phone: 202/732-1635), Judy Schrag, Office of Special Education Programs (Phone: 202/732-1007); or Dan Bonner, Office of Elementary and Secondary Education (Phone: 202/401-0984).
1 While
we recognize that the disorders ADD and ADHD vary, the term ADD is being used to encompass children with both disorders. 2 The Part B regulations define 11 specified disabilities. 34 CFR § 300.5(b)(1)–(11). The Education of the Handicapped Act Amendments of 1990 amended the Individuals with Disabilities Education Act [formerly the Education of the Handicapped Act] to specify that autism and traumatic brain injury are separate disability categories. See Section 602(a)(1) of the Act, to be codified at 20 U.S.C. 1401(a) (1). 3 Section 300.505 of the Part B regulations sets out the elements that must be contained in the prior written notice to parents: 1. A full explanation of all of the procedural safeguards available to the parents under Subpart E; 2. A description of the action proposed or refused by the agency, an explanation of why the agency proposes or refuses to take the action, and a description of any options the agency considered and the reasons why those options were rejected; 3. A description of each evaluation procedure, test, record, or report the agency uses as a basis for the proposal or refusal; and 4. A description of any other factors which are relevant to the agency’s proposal or refusal. 34 CFR § 300.505(a)(l)–(4). 4 Many LEAs use the same process for determining the needs of students under Section 504 that they use for implementing Part B. 5 Again, many LEAs and some SEAs are conserving time and resources by using the same due process procedures for resolving disputes under both laws.
Appendix B
April 29, 1993, Lim Clarification Memorandum [April 29, 1993] UNITED STATES DEPARTMENT OF EDUCATION Washington, DC 20202 MEMORANDUM TO : Regional Civil Rights Directors, Regions I-X FROM : Jeanette J. Lim, Acting Assistant Secretary for Civil Rights SUBJECT : Clarification of School Districts’ Responsibilities to Evaluate Children with Attention Deficit Disorders (ADD) It recently has come to our attention that many school districts and parents appear to be misinterpreting a statement contained in the September 16, 1991, memorandum concerning “Clarification of Policy to Address the Needs of Children with Attention Deficit Disorders within General and/or Special Education.” This statement, on page 6 of the memorandum, concerns the responsibility of local education agencies (LEAs) to evaluate children suspected of having ADD. The statement reads as follows: “Under Section 504, if parents believe that their child is disabled by ADD, the LEA must evaluate the child to determine whether he or she has a disability as defined by Section 504.” A similar version of this statement is contained in the Questions and Answers Handout (Handout) on ADD, entitled “OCR Facts: Section 504 Coverage of Children with ADD.” The Handout was attached to a model technical assistance (TA) presentation on ADD, disseminated to Regions on October 31, 1991, and is used as a TA resource. The intent of this statement was to reaffirm that children suspected of having ADD and believed (by the LEA) to need special education or related services would have
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to be evaluated by the LEA pursuant to Section 504. These children are afforded protection and rights as any other children with disabilities under Section 504. This statement was necessary since many school districts, prior to issuance of the September 21, 1991, memorandum, held the position that they were not obliged to evaluate any child suspected of having ADD since it was not a disability specifically listed in the Individuals with Disabilities Education Act. To our dismay, this statement has been interpreted to mean that school districts are required to evaluate every child suspected of having ADD, based solely on parental suspicion and demand. This was not the intent of the statement. Rather, under Section 504, if parents believe their child has a disability, whether by ADD or any other impairment, and the LEA has reason to believe the child needs special education or related services, the LEA must evaluate the child to determine whether he or she is disabled as defined by Section 504. If the LEA does not believe that the child needs special education or related services, and thus refuses to evaluate the child, the LEA must notify the parents of their due process rights. This memorandum is intended to clarify the responsibility of LEAs to evaluate children suspected of having ADD, based on parental request. We have also taken the opportunity to revise the Handout, as appropriate. (See answer to the question “Must children thought to have ADD be evaluated by school districts?” on the first page of the Handout.) In addition, the Handout has been revised to reflect the term “disability” instead of “handicap,” consistent with the 1992 Amendments to the Rehabilitation Act of 1973 (October 29, 1992). Please have your staff discard the October 1991 version of the Handout and replace it with the attached. If you have any questions regarding this memorandum, please contact Jean Peelen, Director, Elementary and Secondary Education Policy Division, at (202) 205-8637. Attachment As stated
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OCR FACTS: SECTION 504 COVERAGE OF CHILDREN WITH ADD QUESTION:What is ADD? ANSWER: Attention Deficit Disorder (ADD) is a term used to describe a chronic behavioral disorder in children who are inattentive, easily distracted, and impulsive. This kind of behavior is usually matched with certain other criteria, such as hyperactivity, before a child is diagnosed as having ADD. Symptoms of ADD may be manifested differently depending on the particular subtype of the disorder and its severity. For example, with Attention Deficit Hyperactive Disorder (ADHD), hyperactivity is the primary characteristic. In this fact sheet, the term ADD is being used to refer to any form of the disorder. QUESTION: Are all children with ADD automatically protected under Section 504? ANSWER: NO. Some children with ADD may have a disability within the meaning of Section 504; others may not. Children must meet the Section 504 definition of disability to be protected under the regulation. Under Section 504, a “person with disabilities” is defined as any person who has a physical or mental impairment which substantially limits a major life activity (e.g., learning). Thus, depending on the severity of their condition, children with ADD may or may not fit within that definition. QUESTION: Must children thought to have ADD be evaluated by school districts? ANSWER: YES. If parents believe that their child has a disability, whether by ADD or any other impairment, and the school district has reason to believe that the child may need special education or related services, the school district must evaluate the child. If the school district does not believe the child needs special education or related services, and thus does not evaluate the child, the school district must notify the parents of their due process rights. QUESTION: Must school districts have a different evaluation process for Section 504 and the IDEA? ANSWER: NO. School districts may use the same process for evaluating the needs of students under Section 504 that they use for implementing IDEA. QUESTION:Can school districts have a different evaluation process for Section 504? ANSWER: YES. School districts may have a separate process for evaluating the needs of students under Section 504. However, they must follow the requirements for evaluation specified in the Section 504 regulation. QUESTION: Is a child with ADD, who has a disability within the meaning of Section 504 but not under the IDEA, entitled to receive special education services?
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ANSWER: YES. If a child with ADD is found to have a disability within the meaning of Section 504, he or she is entitled to receive any special education services the placement team decides are necessary. QUESTION: Can a school district refuse to provide special education services to a child with ADD because he or she does not meet the eligibility criteria under the IDEA? ANSWER: NO. QUESTION: Can a child with ADD, who is protected under Section 504, receive related aids and services in the regular educational setting? ANSWER: YES. Should it be determined that a child with ADD has a disability within the meaning of Section 504 and needs only adjustments in the regular classroom, rather than special education, those adjustments are required by Section 504. QUESTION: Can parents request a due process hearing if a school district refuses to evaluate their child for ADD? ANSWER: YES. In fact, parents may request a due process hearing to challenge any actions regarding the identification, evaluation, or educational placement of their child with a disability, whom they believe needs special education or related services. QUESTION: Must a school district have a separate hearing procedure for Section 504 and the IDEA? ANSWER: NO. School districts may use the same procedures for resolving disputes under both Section 504 and the IDEA. In fact, many local school districts and some state education agencies are conserving time and resources by using the same due process procedures. However, education agencies should ensure that hearing officers are knowledgeable about the requirements of Section 504. QUESTION: Can school districts use separate due process procedures for Section 504? ANSWER: YES. School districts may have a separate system of procedural safeguards in place to resolve Section 504 disputes. However, these procedures must follow the requirements of the Section 504 regulation. QUESTION: What should parents do if the state hearing process does not include Section 504? ANSWER: Under Section 504, school districts are required to provide procedural safeguards and inform parents of these procedures. Thus, school districts are responsible for providing a Section 504 hearing even if the State process does not include it.
Appendix C
The 1999 “Topic Brief” published by the U.S. Department of Education to clarify IDEA changes as they relate to ADHD. This document is available at http://www.ed.gov/policy/speced/leg/idea/brief6.html
Children with ADD/ADHD – Topic Brief March 1999 Adding “ADD/ADHD” to the list of eligible conditions under “OHI.” The definition of “child with a disability” in the Part B regulations has been amended to add “attention deficit disorder” (“ADD”) and “attention deficit hyperactivity disorder” (“ADHD”) to the list of conditions that could render a child eligible for Part B services under the “other health impairment” (“OHI”) category. Many children with ADD/ADHD have been eligible under Part B − consistent with the Department’s long-standing policy related to serving these children. In 1991, the Department issued a memorandum entitled “Clarification of Policy to Address the Needs of Children with [ADD] within General and/or Special Education,” which was jointly signed by the Assistant Secretaries of OCR, OESE, and OSERS. The substance of the 1991 policy clarification was included in the NPRM, and, specifically in Note 5 following §300.7 (definition of “child with a disability”) – to ensure that school administrators, teachers, parents, and other members of the general public would be fully aware that some children with ADD/ADHD are eligible under Part B. (Adding that interpretation to the NPRM was consistent with the Department’s plan to include all major long-term policy interpretations related to Part B in a single regulatory document, along with the new provisions added by the IDEA Amendments of 1997.)
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The 1991 policy interpretation clarified that -• ALL CHILDREN WITH ADD/ADHD CLEARLY ARE NOT ELIGIBLE under Part B to receive special education and related services – just as all children who have one or more of the other conditions listed under the “other health impairment” category are not necessarily eligible (e.g., children with a heart condition, asthma, diabetes, and rheumatic fever).” • TO BE ELIGIBLE UNDER PART B, A CHILD WITH ADD/ADHD (as with all other children covered under this part) must meet a two-pronged test of eligibility (i.e., 1. have a condition that meets one of the disability categories listed under §300.7, and 2. need special education and related services because of that disability). • CHILDREN WITH ADD/ADHD ARE A DIVERSE GROUP. Some children with ADD/ADHD may be eligible under other disability categories if they meet the criteria for those disabilities, while other children may not be eligible under Part B, but might qualify under section 504 of the Rehabilitation Act.
Department’s 1991 policy memorandum not fully implemented. From the public comments received on the NPRM related to ADD/ADHD (and the Department’s experience in administering Part B), it is clear that the 1991 policy is not being fully and effectively implemented. Ensuring that eligible children with ADD/ADHD receive Part B services. To ensure that each child with ADD/ADHD who meets the eligibility criteria under Part B receives special education and related services in the same timely manner as other children with disabilities, it is important to 1. add “ADD/ADHD” to the list of conditions that could render a child eligible under this part, and 2. appropriately address (in Attachment 1 to the final regulations) the large number of comments received on this topic. Clarifying “limited strength, vitality, or alertness” under “OHI.” The final regulations also clarify that the term “limited strength, vitality, or alertness” in the definition of “OHI” (when applied to children with ADD/ADHD) includes “a child’s heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment.” (This clarification was
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included in note 5 following §300.7 of the NPRM, based on the Department’s previous interpretation of the term as it applies to children with ADD/ADHD). Including “ADD/ADHD” not a new requirement Including “ADD” and “ADHD” as potentially eligible conditions under the Part B regulations does not add a new requirement. It simply codifies the Department’s long-standing policy related to serving these children.
∗ On October 22, 1997, a Notice of Proposed Rulemaking (NPRM) was published in the Federal Register to amend the regulations under Part B of the Individuals with Disabilities Education Act (IDEA). The purposes of the NPRM were to implement changes made by the IDEA Amendments of 1997, and make other changes that facilitate the implementation of Part B. The changes made since the NPRM are based mainly on public comments received.
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Appendix D: ADHD Resources Online
Valuable Information on the Internet The Internet can be a valuable source of information for parents, teachers, and practitioners seeking information on Attention-deficit/Hyperactivity Disorder and related topics. However, the abundance of information that is typically retrieved in any given search can also make it a time-consuming and unwieldy resource. To facilitate access to online resources, some useful websites are listed below. The following list includes websites regarding epidemiology and general information, assessment, treatment, and advocacy. The list is not comprehensive, however it includes links to some of the valuable materials that are currently available online.
Epidemiology and General Information Medline Plus − National Library of Medicine and National Institute of Health http://www.nlm.nih.gov/medlineplus/attentiondeficithyperactivitydisorder.html MedlinePlus brings together authoritative information from the U.S. National Library of Medicine (NLM), the U.S. National Institutes of Health (NIH), and other U.S. government agencies and health-related organizations. MedlinePlus provides easy access to medical journal articles. MedlinePlus also has extensive information about drugs, an illustrated medical encyclopedia, interactive patient tutorials, and latest health news. This website not only gives the latest news on ADHD, with links to the most current articles and also has links to major government and national agencies, non-profit foundations, national libraries, professional organizations, and other sites that cover multiple areas of ADHD. This website provides links on issues like law and policy, special aspects of ADHD, and has information for children, teenagers, and women. It also provides coping advice for parents of children with ADHD, and has links in Spanish as well. 131
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Department of Health and Human Services − Centers for Disease Control and Prevention http://www.cdc.gov/ncbddd/adhd http://www.cdc.gov/ncbddd/adhd/adpub.htm The Department of Health and Human Services − Centers for Disease Control and Prevention (CDC) provides annual data regarding the prevalence of ADHD in the United States. Available publications and reports include the; The Epidemiology of Attention-deficit/Hyperactivity Disorder (ADHD): A Public Health View, and Prevalence of Diagnosed and Medicated Attention-deficit/Hyperactivity Disorder. The website also includes a link to the National Action Agenda for Children’s Mental Health, which outlines goals and strategies to improve the services for children and adolescents with mental health problems and their families. According to the report, the nation is facing a public crisis in mental health for children and adolescents.
US Department of Education − Office of Special Education Programs http://www.ed.gov http://www.ed.gov/rschstat/research/pubs/adhd/adhd-identifying.html http://www.ed.gov/rschstat/research/pubs/adhd/adhd-teaching.html The U.S. Department of Education has developed a report and resources titled; Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home. This report from 2006 includes research addressing educational evaluations and treatment considerations. There is also another document specifically focusing on Teaching Children With Attention Deficit Hyperactivity Disorder: Instructional Strategies and Practices. These resources and others provided by the US Department of Education offer valuable information for parents and professionals.
Medscape Today from WebMD http://www.medscape.com Medscape is purported to be one of the largest collections of professional medical information available on the Internet. Medscape provides a search function that helps you find information regarding your practice and research questions and provides valuable information on the latest developments in your medical area of interest. Medscape provides links to the latest medical research on the etiology and treatment of ADHD as well as other topics related to ADHD. Searches can be limited to specific periods of time, for instance, including only the past 12 months. The
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database includes articles, conference summaries, treatment updates, clinical management modules, practice guidelines, and textbooks. Searches can also be made on other databases such as MEDLINE, News, Drugs by Name, and Drugs by Disease. Use of the Medscape database is free.
National Resource Center for AD/HD http://www.help4adhd.org/index.cfm The National Resource Center (NRC) on AD/HD is a national clearinghouse for science-based information about all aspects of ADHD. The NRC on AD/HD is funded through a cooperative agreement with the Centers for Disease Control and Prevention, the NRC on AD/HD was created to meet the information needs of professionals and the general public. This website provides a wealth of information, including a general overview, information regarding diagnosis and treatment, dealing with systems, living with ADHD, and educational issues. The educational issues section provides valuable information regarding educational rights of children with AD/HD, 504 services, Individual with Disabilities Education Act, and State Department of Education contact information. The NRC on AD/ADHD has partnered with the National Alliance for Hispanic Health to produce an introduction to ADHD in children that is available in both English and Spanish.
Assessment American Academy of Pediatrics http://www.aap.org/healthtopics/adhd.cfm The American Academy of Pediatrics provides valuable information and guidelines regarding the assessment and diagnosis of children with ADHD. The AAP guidelines are designed for use by primary care practitioners and are the result of an extensive AAP Committee literature review of the topic. Among the valuable resources on the AAP website, particularly noteworthy items include a parent page, family and community resources, and an ADHD toolkit. The toolkit provides practical tools to help incorporate the new AAP guidelines into office practice, including; symptom checklists for use by parents and teachers, guidance on selecting appropriate therapy, forms to acquire teacher reports, examples of written management plans to help strengthen family skills, and strategies to assist the clinician in monitoring the child. Many of the materials, including the AAP ADHD toolkit are available in English and Spanish.
Quality Tools − The Agency for Healthcare Research and Quality http://www.qualitytools.ahrq.gov / The Quality Tools website is a clearinghouse for practical, ready-to-use tools for measuring and improving the quality of health care. Quality Tools is sponsored
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by the Agency for Healthcare Research and Quality (AHRQ). This website provides a link to the National Initiative for Children’s Healthcare Quality (NICHQ) ADHD Practitioners’ Toolkit. This is a free, online version of the Vanderbilt Parent and Teacher Initial and Follow-up rating scales for ADHD diagnosis (described in Chapter 4). The Vanderbilt scale is designed for use by clinicians in the diagnosis and evaluation of children with ADHD. The assessment system includes a parent and teacher assessment checklist for ADHD symptom evaluation, information for parents and teachers about ADHD, review of DSM-IV guidelines, and ADHD resources for parents, clinicians, and teachers. Several of the materials are also available in Spanish. Copies of the assessment forms and scoring information are available to download.
Screening Tools − School Psychiatry Program at Massachusetts General Hospital http://www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp This website hosted by the School Psychiatry Program at Massachusetts General Hospital provides links and information to various rating and screening tools for a variety of child mental health problems. The rating scales described in the ADHD section include the ADDES-3, the ADHD Rating Scale-IV, the Vanderbilt Scales, the SNAP-IV-R, and the ACTeRS(described in Chapters 4 and 5). The table includes information on who completes the checklist, administration time, the age ranges that the scales can assess for, and links to websites to view or purchase the scales. Of the rating scales described, the Vanderbilt ADHD Rating Scale the ADHD Rating Scale are available free online and linked to this website (in addition the SNAP-IV-Ris available free online at www.adhd.net/SNAP_SWAN.pdf ).
Treatment National Institute of Mental Health http://www.nimh.nih.gov/health/publications/adhd/complete-publication.shtml The National Institute of Mental Health (NIMH) is the largest scientific organization in the world dedicated to research focused on the understanding, treatment, and prevention of mental disorders and the promotion of mental health. The NIMH website provides access to a booklet about ADHD. This booklet includes information regarding ADHD symptoms, diagnosis, treatment, family factors, behavioral interventions, and developmental considerations. The information provided by NIMH is a valuable resource to provide to parents, teachers, and other mental health professionals. The NIMH website also provides links to many other publications including scientific reports addressing topics such as interventions, genetics research, and medications.
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WebMD − ADHD Treatment and Care http://www.webmd.com/add-adhd/guide/adhd-treatment-care This web site provides a treatment overview and describes the American Academy of Pediatrics recommendations for treatments of ADHD, which include medication and/or behavior therapy. Additional links provide more information on stimulant medication, behavioral therapy and a list of key points to help parents make the decision about putting their child on stimulants. This website provides valuable information for patients, parents, and professionals who are seeking details about the various treatments. The content includes an overview of common shortterm and long-term side effects and their management, slow release versus immediate release, costs, required monitoring for the individual, pros and cons for each drug, safety and warnings, and important questions to consider regarding pharmacological treatments. This site also provides a description of behavioral therapy. Information is provided regarding what interventions may entail at different developmental stages, specifically for preschool-aged, school-aged and teenaged children.
American Academy of Child and Adolescent Psychiatry http://www.aacap.org The American Academy of Child and Adolescent Psychiatry (AACAP) website is designed to give members, parents, and families information about the treatment and diagnosis of developmental, behavioral, and mental disorders that affect children and adolescents. The website includes information about ADHD symptoms, current research, best practices, and treatment options. The website also includes a search engine called “Facts For Families” that provides fact sheets in both Spanish and English about ADHD and other childhood behavioral disorders. In 2007, the AACAP published a Practice Parameters for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder, and also the ADHD Parents Medication Guide, which are both available online.
American Psychological Association http://www.apa.org/topics/topicadhd.html The American Psychological Association provides contemporary information regarding ADHD and other mental health disorders. The website provides numerous links to recent publications and resources. The links highlighting psychology news are updated frequently.
The Center for Children and Families http://ccf.buffalo.edu The website of The Center for Children and Families at the University of Buffalo offers a summary of psychosocial behavioral intervention strategies and evidence-
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based resources. A description of research projects is provided, as well as, publications and training and continuing education information. The website is well organized and provided valuable information for parents, educators, and other professionals.
Advocacy National Attention Deficit Disorder Association http://www.add.org The National Attention Deficit Disorder Association (ADDA) is a nonprofit organization, built around the needs of adults and young adults with ADHD. The mission of ADDA is to provide information, resources, and networking to adults with ADHD and to the professionals who work with them. Information on research, treatment, books on ADHD, family issues, legal issues, support groups and personal interviews, and weblinks are available. There are areas devoted to specific groups (e.g., children, women, and teens) as well as various contexts (e.g., school, work and career).
Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) http://www.chadd.org CHADD is a non-profit organization the supports leadership, education, advocacy, and research for children and adults with ADHD. This website includes useful information for parents, educators, professionals, and the general public. The CHADD website is a clearinghouse of information, including current information on the new FDA warning labels for ADHD medication, information about summer programs for children with ADHD, parent trainings, and recent news articles about ADHD. CHADD also publishes the journal ATTENTION! and members can access this journal from the website. This site also includes sections written in Spanish.
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Index
Note: The letters ‘f’ and ‘t’ following locators refer to figures and tables respectively. The locators in bold represent appendix.
A AACAP, see American Adademy of Child and Adolescent Psychiatry (AACAP) AACAP Practice Parameter, 104, 109 Abikoff, H., 26 Abramowitz, A. J., 28, 103 Achenbach System of Empirically Based Assessment, 64 See also Child Behavior Checklist (CBCL) Achenbach, T. M., 65, 74, 76 Acton, G. S., 10, 11 ADA, see Americans with Disabilities Act (ADA) ADD, see Attention Deficit Disorder (ADD) ADDES, see Attention Deficit Disorders Evaluation Scale (ADDES) ADHD red flags, parental concerns activity level concerns, 36t attention concerns, 36t impulsivity concerns, 36t ADHD resources online, 131–136 ADHD warning signs during adolescence, 34 checklist for educators, 34f for parents and professionals, 33f preschool-age children, impulsive behaviors/inattention in/motor activity, 33–34 ADHD warning signs checklist, 33f, 34f Adolescence ADHD warning signs, 34 hyperactivity symptoms during, 110 Adoption studies, 11 Adversity indicators, 15 Alderson, R. M., 70 Aleman, S. R., 5 Alpha-adrenergic agonists, 109 American Academy of Ophthalmology, 113
American Academy of Pediatrics, 52, 63, 111, 113, 133, 135 American Academy of Child and Adolescent Psychiatry (AACAP), 95, 135 American Association for Pediatric Ophthalmology and Strabismus, 113 Americans with Disabilities Act (ADA), 3, 6 R Amphetamine (Adderall ), 104, 106t Anastopoulos, A., 63, 67 Anastopoulos, A. D., 45, 67, 70 Anorexia/bulimia, 27 Antidepressants, 109 Anxiety and mood disorders, 54t Ardoin, S. P., 101 Armstrong, K., 67 Arnold, L. E., 104 Asherson, P., 13 Atkins, M. S., 63, 70 Atkinson, G. S., 91 R Atomoxetine (Strattera ), 19, 106, 108, 109, 110, 113 Attention deficit disorder (ADD), 4, 5, 6, 7, 115, 123, 125, 127 Attention Deficit Disorders Evaluation Scale (ADDES), 45, 50, 64, 66, 134 Attention-deficit/hyperactivity disorder (ADHD) conceptualization of combined types, 3 “defect in moral control,” 3 hyperactive/impulsive type, 3 hyperkinetic reaction of childhood disorder, 4 inattentive type, 3 definition, 1 diagnosis, importance, 2
157
158 Attention-deficit/hyperactivity disorder (ADHD) (cont.) educational placement and services, 4–8 clarification memorandum (April 29, 1993), 6–7 Davila and colleagues policy memorandum, adaptations of, 6 FAPE, 5 NPRM, 7 policy memorandum (September 16, 1991), 5–6 regulations for IDEA 1997/2004, 7–8, 8t Section 504 services (handicapped person), 5–6 identifying/assessing/treating, importance of, 2 1610 Missouri twins, study of, 2 school professionals, key role in identification of, 2 Auditory stimulation training, 113–114 August, G. J., 4, 65 Auinger, P., 16, 33 Autism, 5, 9, 25f, 54t Average rating-per-item, 37, 39 B Baldassano, C. F., 109 Balla, D. A., 90 Ballantyne, A. O., 69 Banaschewski, T., 27 Banich, M. T., 29 Barkley, R. A., 1, 2, 3, 4, 9, 13, 14, 15, 17, 19, 24, 26, 28, 29, 50, 52, 54, 55, 61, 63, 64, 67, 68, 69, 70, 71, 72, 74, 75, 80, 82, 83, 89, 91, 92, 97, 98, 99, 101, 102, 103 Barry, T. D., 92 Basal ganglia (striatum), 18, 18f, 112 Baumgaertel, A., 45 Beck, L. H., 69 Beery, K. E., 92 Beery, N. A., 92 Behar, L. B., 76 Behavioral optometry/eye training exercises, 113 Behavior Assessment System for Children-Second Edition (BASC-2), 64 Behavior Rating Inventory of Executive Functioning (BRIEF), 91 Ben Amor, L., 14 Bender, W. N., 102
Index Bennett, D. E., 99 Berger, M., 15 Berridge, C. W., 19 Bevans, K., 77 Biederman, J., 9, 10, 11, 12, 13, 14, 15, 16, 19, 24, 26, 27, 28, 33, 55 , 61, 62, 65, 66, 67, 92, 108, 109, 110 Bigelow, S., 81 Biological causes brain injury, 14–15 pre-, peri- and post-natal complications, 14 toxins maternal alcohol use, risk associated, 14 Bipolar disorder, 2, 28, 53, 54t, 66, 92t, 108–109, 110 Birth, developmental, health, family, and behavioral histories, 55–62 behavioral history, 62 developmental history, 61 diagnostic history, 62 family history, 62 interview form, 56–60f perinatal risk factors, 57–61 dopaminergic system, intra-uterine anoxia effects on, 57–58 prematurity and low birth weight, 61 postnatal risk factors, 61 chronic lung disease, 61 lead exposure, 61 PKU (phenylketonuria), 61 traumatic brain injury (TBI), 61 prenatal risk factors, 55–57 Blackorby, J., 1, 24, 25 Blashko, P. C., 91 Blondis, T. A., 89 Boeller, S. W., 108 Bohlin, G., 55, 57 Botting, N., 61 Bowers, N. D., 82 Bracken, B. A., 91 Brain chemicals, 12, 19 injury, 14–15 structures implicated in ADHD, 18f Bransome, E. D., 69 Braun, J., 33 Brewer, D. F., 63 Brock, S. E., 1, 2, 9, 12, 25, 31, 32, 49, 52, 53, 54, 62, 64, 65, 66, 68, 69, 70, 73, 75, 76, 80, 81, 83, 84, 91, 92, 96, 97, 101 Brown, M. B., 63
Index Brown, R. D., 91 Brown, T. E., 64 Bruce, B., 93 Brunsletter, R. W., 70 Bryant, B. R., 92 Buktenica, N., 92 R Bupropion (Wellbutrin ), 109 Burcham, B., 63 Burcham, B. G., 63, 67, 68, 70 Burke, J. D., 50, 109 Burke, K. C., 109 Bush, G., 17, 18 Bussing, R., 37 C Calhoun, S. L., 29, 91 Campbell, D. C., 63 Campbell, S. B., 52 Candidate gene searches, 12–13 Cantwell, D. P., 11 Caregiver-Teacher Report (C-TRF), 65 Carlson, C. L., 27 Carrey, N., 91 Casat, C. D., 63 Casat, J. P., 63 Case finding Child Find, 31–32 definition, 31 listening, 35–36 parental concerns, 36t looking, 33–35 risk factors, 33 school-wide developmental screening, 34–35 staff development, 35 warning signs, 33–34 process of diagnosis, algorithm for, 32 questioning, 36 Castellanos, F. X., 9, 17, 18, 53 Causes environment biological factors, 13–15 diet, 15 psychosocial factors, 15 role of, 16 television viewing, 16 See also Biological causes genetic, psychosocial, and biological risk factors, odds ratios for, 16f genetics adoption studies, 11 candidate gene searches, 12–13 family studies, 10
159 genome search studies, 11–12 role of, 13 twin studies, 10–11 genetics/environment/neurobiological differences, hypothetical relationships between, 10f neurobiology brain structures implicated in ADHD, 18f neurochemistry, 19 neurophysiology, 17–19 neuropsychology, 17 role of, 19 CBCL, see Child Behavior Checklist (CBCL) CDC, see Centers for Disease Control (CDC) Center for Children and Families, University of Buffalo, 100–101 Centers for Disease Control (CDC), 21, 132, 133 Cerebellum, 18–19 CHADD, see Children and Adults with Attention Deficit Disorders (CHADD) Chandler, J., 76 Chandler, M. C., 108 Chandola, C. A., 61 Chen, L., 65 Chen, W., 65 Cherkes-Julkowski, M., 61 Child behavior checklist (CBCL), 28, 64, 65–66 Children and Adults with Attention Deficit Disorders (CHADD), 5, 136 Christakis, D. A., 16 Christo, C., 69, 91 Chronic lung disease, 61 Chronis, A. M., 3, 97, 98, 99, 100 Chung, K. M., 69 Cicchetti, D. V., 90 Cipkala-Gaffin, J. A., 63 Clarke, B., 64 Clarke, S., 99 Clark, S. E., 69 Claycomb, C. D., 55, 57, 59 Clinton, A., 2, 52, 54, 62, 64, 66, 68, 70, 73, 75, 76 R Clonidine (Catapres ), 108, 109 Collett, B. R., 66 Combined/Hyperactive-Impulsive Type, 28 Comprehensive Test of Phonological Processing (CTOPP), 90 Conduct Disorder, 50 categories, 41
160
Index
for Combined Type, 50 differential diagnosis, 53, 54t DSM-IV-TR criteria, 51t for Hyperactive-Impulsive Type, 50 for Inattentive Type, 50 multiple settings, 52 reading disability, example, 52 symptom duration, 52 symptom onset, 50 Diagnostic procedures, 62–76 commonly recommended, 62–73, 63t behavioral observations, 70–72 behavior frequency data collection form, 72f behavior rating scales, 64t duration data collection form, 73f indirect/direct assessment D techniques, 62 Daley, D., 9, 62 interviews, structured (semi/un), Das Banerjee, T. D., 9, 13, 14, 15, 16 66–68 Das, J. P., 91 psychological testing, 68–70 Davila and colleagues policy memorandum, 6 rating scales, 64–66 Davila, R. R., 5, 6, 24, 49, 79 less frequently recommended Davis, J. K., 77 medical examinations, 74–75 Dean, M. E., 112 peer assessments, 76 Dean, R. S., 91 school records, review, 75 DeBasio, N. O., 63 Differential diagnosis of ADHD, 54t DeFries, J. C., 11 DiGiuseppe, D. L., 16 Delong, L., 1 Di Pinto, M., 91 Demaray, M., 1 Direct assessment techniques, 62 Demaray, M. K., 66 advantage of, 62 Demaree, H. A., 28 example, 62 DeMers, S. T., 63 Direct vs. indirect assessment techniques, 62 Denckla, M. B., 29 Disruptive behavior disorder rating scale, 40f Denney, C. B., 69 DNA, see Deoxyribonucleic acid (DNA) Deoxyribonucleic acid (DNA), 11, 12 Doffing, M. A., 44 D´ery, M., 25 Dopamine, 12, 17, 19, 55 Detweiler, R., 63 R Dopamine D4 receptor (DRD4), 12 Dextroamphetamine (Dexedrine ), 19 Dopamine D5 receptor (DRD5), 12 Diagnostic and Statistical Manual of Mental Dopaminergic system, 58 Disorders (DSM II), 4 Dopamine SLC6A3 transporter, 12 Diagnostic assessment birth/developmental/health/family/behavioral Doreleijers, T., 66 Douglas, V. I., 4, 81, 98 histories, 55–62 Douyon, K., 77 criteria, 50–54 Doyle, A., 28 minority youth, identification of, 77 Doyle, A. E., 29 preschoolers, identification of, 76–77 Drabman, R. S., 91 procedures DSM-IV-TR, criteria for ADHD, 51t commonly recommended, 62–73, 63t DSM IV-TR, primary symptoms of ADHD, 4 less frequently recommended, 73–76 Diagnostic criteria, 50–54 Dunham, M., 91 age-specific features and prognosis, Dunlap, G., 99 52–53 DuPaul, G. J., 2, 45, 63, 64, 66, 67, 68, 71, 95, clinical significance, 52 96, 97, 101, 102, 114 Conners, C. K., 45, 64, 66, 69, 76, 77 Connors, L., 95 Continuous-performance tests (CPT), 69 Conway, G., 101 Cooke, R. W. I., 61 Copeland, L., 70 Corkill, A. J., 84 Corkum, P., 52, 76 Cˆot´e, S., 26 Coulter, M. K., 112 Counts-Allan, C., 77 Cox, A., 15 Crawford, M. H., 11 Crowell, E. W., 29 Cummings, C., 96
Index E Early Childhood Behavior Problem Screening Scale (ECBPSS), 35 Edginton, E. S., 113 Edwards, G. H., 91 EEG biofeedback, 103, 111, 112, 113 clinical implications, 113 Eisenberg, M., 2 Electroencephalographic (EEG), 112 Elliott, C. D., 91 Elting, J., 66 Emotionally Disturbed (ED), 24 Emotional maladjustment behaviors, 29 Epstein, J. N., 35 Epstein, M. H., 35 Erford, B. T., 41 Ervin, R. A., 64 Evans, S. W., 41 Executive Functions (EF), definition, 28 F Fabiano, G. A., 46, 70, 100, 101 Fagan, J. E., 113 Fairbank, D. W., 35 Falcone, T., 77 Family studies, 10 FAPE, see Free and appropriate public education (FAPE) Faraone, J., 9, 11, 12, 13, 14, 15, 19, 23, 24, 26, 28, 29, 61, 65, 67, 110 Faraone, S., 65 Faraone, S. V., 9, 10, 11, 12, 13, 14, 15, 19, 23, 24, 26, 28, 29, 61, 65, 67, 110 Farel, A. M., 61 Feingold, B. F., 111, 112 Feingold diet, 112 Ferdinand, R., 66 Fergusson, D. M., 28 Fetal alcohol syndrome (FAS), 13, 55 Fetus distress, 14, 58 hypoxia, 55 post-maturity, 14 Feurer, I. D., 45 Filipek, P. A., 31, 32, 35 Fischer, M. J., 14 Fitzpatrick, C., 92 Flanagan, R., 65 fMRI, see Functional magnetic resonance imaging (fMRI) Food additives, 15, 112 allergies, 15, 112
161 dyes, 112 Forehlic, T., 16, 33 Forsythe, A., 75 Franco, K. N., 77 Fraternal (dizygotic) twins, 10 Frazier, T. W., 28, 89, 92 Free and appropriate public education (FAPE), 3, 5, 116, 118 Freman, C., 67 French, B. F., 99 Frick, P. J., 28 Friedlander, B. D., 102 Frizzelle, R., 102 Frontal-striatal-cerebellar circuits, 10f, 17, 19 Frontal-subcortical networks, 12 Functional magnetic resonance imaging (fMRI), 17 Fung, Y. K., 55 G Gadow, K. E., 108 Garfinkel, B. D., 4 Geddes, D. M., 75 Geller, B., 66, 108, 109 Genome search studies, 11–12 chromosomal regions, linkages in, 12 Gerry, M., 3 Gibney, L. A., 91 Gilger, J. W., 11 Gillberg, C., 24 Gilliam, J. E., 64 Gimpel, G. A., 52, 64 Giola, G. A., 91 Giorgetti-Borucki, K., 99 Gizer, I. R., 12 Glascoe, F. P., 35 Glutting, J. J., 84 Gnagy, E. M., 40, 41 Goldstein, M., 69, 70, 79, 98 Goldstein, S., 69, 70, 79, 98 Goncalves, R. R. F., 9 Gordon, M., 64, 66, 68, 69, 70, 78, 89 Graham, S., 102 Greenberg, L. M., 69 Greenhill, L., 110 Greenslade, K. E., 41 Grice, K., 75 Griffith, A. K., 35 Grizenko, N., 55 Grossman, S., 108 Grove, B., 97, 101 Guanfacine/clonidine (alpha-agonist), 108 R Guanfacine (Tenex ), 108, 109
162 Guevara, J. P., 77 Guevremont, D. C., 63, 67, 68, 70 Guil, C., 109 Gunawardene, S., 110 Guy, S. C., 91 H Hall, J., 28, 65 Hamazaki, T., 112 Handwerk, M., 67 Handwerk, M. J., 28 Hannah, J. N., 45 Hansen, R. L., 12 Hanson, K. S., 68 Hardy, E., 63 Harrington, R., 11 Harris, K. R., 102 Hart, E. L., 68 Hart, S., 2 Hartsough, C. S., 58 Haynes, S. D., 91 Hechtman, L., 63 Henker, B., 76, 82, 98 Henry, M. M., 61 “Heritability,” 10 Hervey-Jumper, H., 77 Hicks, A., 63 Hicks, M., 63 Hill, G. P., 95 Hinshaw, S. P., 63, 66, 67, 68, 70, 76 Hirayama, S., 112 Hoge, R. D., 71, 72 Holland, M. L., 64 Hook, C. L., 64 Hooper, S. R., 61 Horwood, L. J., 28 Huang, H., 2 Huizink, A. C., 55 Human genome, 11 Husted, D., 96 Hynd, G. W., 28, 65 I IDEA, see Individuals with Disabilities Education Act (IDEA) Identical (monozygotic) twins, 10 IEP, see Individualized education program (IEP) Imaging technologies fMRI, 17 PET, 17 SPECT, 17 R ), 109 Imipramine (Tofanil Impulsive behavior, results, 34
Index Indirect assessment techniques, 62 advantage of, 62 example, 62 Individualized education program (IEP), 5, 117, 119 Individuals with Disabilities Act of 2004, 3 Individuals with Disabilities Education Act (IDEA), 5, 49, 116, 121, 124 Individuals with Disabilities Education Improvement Act – 2004 (IDEIA), 31 Isaacs, P., 69 Isquith, P. K., 91 J Jakobsons, L. J., 77 Jarratt, K. P., 65, 91 Jensen, C. L., 28, 65, 104 Jensen, P., 15 Jensen, P. S., 3, 28, 65, 104 Jentzsch, C. E., 35 Jetton, J. G., 26 Jimerson, S. R., 12 Jitendra, A. K., 103 Jones, H. A., 3, 100 Joyce, S. A., 101 K Kahn, R. S., 16, 33 Kamphaus, R. W., 28, 64, 65, 93 Kaplan, B. J., 113 Kaufman, A. S., 91 Kaufman, N. L., 91 Keenan, K., 10, 67 Keith, R., 69 Kemp, S., 91 Kenworthy, L., 91 Kern-Dunlap, L., 99 Kessler, R. C., 53 Kidder, K. R., 49 Kieling, C., 9, 17, 18 Kindschi, C. L., 69 Kirk, U., 91 Kleinman, S., 14 Klein, R. G., 26 Klinger, L. G., 92 Klotz, M. B., 32, 35 Knapp, P. K., 92 Knezevic, B., 95 Kofler, M. J., 70 Koonce, D. A., 2 Koot, H. M., 26 Korkman, M., 91 Kovacs, M., 93
Index Krain, A. L., 17, 18 Kraybill, E. N., 61 Kuhn, B. R., 52 Kuntsi, J., 13 L LaFleur, L. H., 49 Lahey, B. B., 4, 28, 50, 68 Lambert, E. W., 45 Lambert, N. M., 58 Lambert, W., 44 Landau, S., 67, 68, 70 Langberg, J. M., 53 Lanphear, B. P., 16, 33 Lansford, A., 2 Lansford, A. H., 108–109 Lapey, K., 28 Larsson, H., 13 Larsson, J. -O., 13 Lau, Y. S., 55 Leach, D. J., 63 Learner, J. W., 63 Learner, S. R., 63 Learning disability (LD), 29 Learning disorders, 54t, 62 Lee, Y. B., 28 Lesesne, C. A., 28 Levison, H., 113 Lichtenstein, P., 13 Liddell, M., 13 Lim, J. J., 6 Lim memorandum, 6 Linares, T. J., 55 Linnet, K. M., 14, 55, 57 Loeber, R., 50, 68 Logistic regression analysis, 16f Loney, J., 68 Longo, L., 55 Lopez, F. A., 108 Loring, D. W., 28, 29 Loughran, S. B., 52 Lovett, B. J., 64 Low birth weight, risk factor for ADHD, 14 Lowenthal, B., 63 Lucas, P., 67 Lyman, R. D., 92 M McCallum, R. S., 91 McCarney, S. B., 45, 64, 66 McCarty, C. A., 16 MacDonald, J. T., 5 McGee, R. A., 69 McGoey, K. A., 64
163 McGoey, K. E., 102 McGrath, A., 67 McGrew, K. S., 91, 92 McGuffin, P., 61 McIntosh, D. E., 91 Madle, R. A., 35 Magg, J. W., 3 Makris, N., 18 Mandell, D. S., 77 Manning, S. C., 65 Mannuzza, S., 26 Marder, C., 24 Marlow, N., 61 Marshall, R. M., 28, 92 Martens, B. K., 101 Martin, G. L., 63 Massetti, G. M., 46, 70 Mass screening process, 35 Maternal alcohol use, risk associated, 14 Mather, N., 91, 92 Mathes, M. Y., 102 Max, J. E., 9, 15, 50, 61, 105, 106 Mayer, G. R., 71, 72 Mayes, S. D., 29, 91 MBD, see Minimal brain damage or dysfunction (MBD) Meclizine and cyclizine, 113 Melville-Thomas, G., 61 Mental retardation, 53, 54t Merrell, K. W., 35, 64 R ), 19, 104, 111 Methylphenidate (Ritalin Meyer, A., 63 Meyer, M. J., 98 Mick, E., 9, 12, 13, 33, 55, 61 Middleton, F., 9 Milberger, S., 27 Milich, R., 41 Miller, D., 91 Miller, D. C., 65 Miller, L. J., 55 Minimal brain damage or dysfunction (MBD), 3 Minority youth, identification of, 77 Mirsky, A. F., 69 Models of consultation, 103 Mohay, H., 14 Molina, B. S., 36, 66, 67 Monastru, V., 112 Monuteaux, M. C., 15, 28 Mood disorders, 27, 28, 54t, 66, 108 Morrison, J. R., 11 Motion sickness, treatments for, 113 Motor activity, excessive, 33, 50
164 Moulton, J. L., III., 26 MTA version (multimodal treatment study of ADHD), 37 See also Swanson, Nolan and Pelham (SNAP-IV) rating scale Mulder, E. J. H., 55 Multimodal treatment of ADHD (MTA), 27, 28, 37, 104, 109 Mundy, E., 11 Myers, C. L., 91 N Nagin, D. S., 26 Naglieri, J. A., 91 Nahlik, J., 63, 66, 67, 68 Nahlik, J. E., 63 National Institute of Mental Health (NIMH), 9, 28, 62, 134 National Survey of Children’s Health (2003), 1, 21, 23f Neale, B. M., 27 Nealis, L., 32, 35 Nelson, J. R., 35 NEPSY: A Developmental Neuropsychological Assessment (NEPSY), 91 Nettelbladt, U., 93 Neulinger, K., 14 Neurophysiology basal ganglia (striatum), 18 cerebellum, 18–19 decreased overall brain size, 17 prefrontal cortex, 17–18 Neurotransmitters, 17, 19 Newcorn, J., 27 Nichols, S. L., 69 Nicotine exposure, 55 Nigg, J. T., 29 Nolan, E. E., 37, 38, 108 Non-medical treatment strategies, 100 Norepinephrine, 17, 19, 106t Northup, J., 49 R ), 109 Nortriptyline (Pamelor Notice of Proposed Rule Making (NPRM), 7 NPRM, see Notice of Proposed Rule Making (NPRM) O Oakland, T., 84 O’Callaghan, M., 14 OCR, see Office of Civil Rights (OCR) Odds ratios, 16f OESE, see Office of Elementary and Secondary Education (OESE) Oesterheld, J. R., 63
Index Office of Civil Rights (OCR), 5 Office of Elementary and Secondary Education (OESE), 5 Office of Special Education and Rehabilitative Services (OSERS), 5 Ohan, J. L., 66 O’Leary, S. G., 101, 103 Omega 3 fatty acids (O3FA), 112 O’Neill, M. E., 81, 98 O’Neill, R. E., 84 Oppositional defiant and conduct disorders, 40, 43, 44, 52, 54 Oppositional defiant disorder (ODD), 26, 41, 44, 50, 62, 92t, 110 OSERS, see Office of Special Education and Rehabilitative Services (OSERS) Ostrander, R., 65 Other Health Impaired (OHI), 7, 24, 75, 117 Ozonoff, S., 29 P Palkes, H., 10 Parental anti-social behavior, 33 Parent rating scales (PRS), 65 Parent/teacher disruptive behavior disorder rating scale (DBD), 40–41, 40f conduct disorder categories, 41 Parker, H. C., 66, 67, 70, 72, 75 Parks, S., 95 Pauz´e, R., 25 Pearons, D. A., 63 Pederson, B., 35 Pelham, W. E., 37, 38, 40, 41, 46, 63, 70 Pemoline (Cylert), 19 Pendley, J. D., 91 Pennington, B. F., 11, 29, 50, 66, 67, 70 Penny, A. M., 91 Pervasive developmental disorder (autism), 53, 54t Peters, T. J., 61 Pfiffner, L. J., 80, 82, 83, 97, 99, 101, 102, 103 Pinnock, T. Y., 45 Pinto, T., 55 PKU (phenylketonuria), 55, 56, 58, 61 Pliszka, S. R., 26, 27 Plomin, R., 13 Polychlorinated biphenyls (PCB), 14 Polymorphism, 12 Poor maternal health, 14, 55 Positron emission tomography (PET), 17 Pottinger, L. S., 91 Power, T. J., 2, 45, 81, 96, 101
Index Powls, A., 61 Predominantly inattentive Type, 4, 28, 41, 50 Prefrontal cortex, 17–18, 19, 55 Pre-, peri- and post-natal complications duration of labor, 14 fetal distress, 14 fetal post-maturity, 14 low birth weight, 14 poor maternal health, 14 toxemia/eclampsia, 14 younger maternal age, 14 Preschool and Kindergarten Behavior Scales-Second Edition (PKBS-2) application, 35 Preschoolers, identification of, 76–77 Pressman, L. J., 15 Prevalence/associated conditions ADHD rates among general population, 21–24 gender and sociodemographic characteristics, CDC estimates by, 22t 4.4 million U.S. children with ADHD, survey results, 21 western vs. eastern states, incidence of, 21–23 % of youth age 4–17 diagnosed state-wise, 23f ADHD’s correlates and association with other conditions, 26–29 cognitive development, 28–29 comorbid psychiatric conditions, 26–28 language development, 29 learning disability, 29 school performance, 28 social, emotional, and behavioral features, 29 special education for students, 25f ED/OHI categories, 24 ED/SLD/OHI, eligibility categories for(since 1991), 26f OHI eligibility category in older students, 27f SEELS reports, 24 12–17-year-old vs. 6–11-year-old, OHI eligibility, 25 Prince, J., 14, 16, 33, 55, 61 Psycho-educational assessment practices behavior, functional assessment of, 85f–89f, 84 psycho-educational testing, 84–93 testing accommodations and modifications
165 clear test-taking rules, 82 distractions, minimize, 81 frequent test session breaks, 80–81 physical movement, 81 powerful external rewards, making use of, 81–82 structure and organization, 83 student to pace him/herself, 82 task difficulty, pre-selection, 82 test administration and nonstandard responses, modification, 83 testing session, schedule, 82–83 Psycho-educational testing, 84–93 academic achievement, 92 Wechsler Individual Achievement Test (WIAT-2), 92 Woodcock-Johnson III, Tests of Achievement, 92 adaptive behavior, 89 cognitive functioning, 84 emotional functioning, 92–93 children with ADHD & psychiatric disorder, 92t IQ test profiles, 91t language functioning, 93 psychological processes, 90–92 visual-motor integration (VMI-5), developmental test of, 92 PsycINFO database, 62 Puopolo, M., 96 Puri, B. K., 112 Q Quinlan, D. M., 63 Quinn, P. O., 63 R Rae, D. S., 109 Raggi, V. L., 3, 97, 98, 99, 100 Rapport, M. D., 63, 69, 70 Rashotte, C. A., 90 Raymond, J. E., 113 “Red Flags” for ADHD, 36 Regier, D. A., 109 Rehabilitation Act of 1973, 3, 5, 7, 8, 79, 116, 118, 124 Reich, W., 2 Reid, R., 3, 4, 5, 24, 45, 77, 98, 101 Reiff, M. I., 111, 112, 113, 114 Remschmidt, H., 15, 19 Repper, K. K., 77 Rescorla, L. A., 64, 65, 76 Resnick, R., 50, 63, 66 Reynolds, C. R., 64, 65, 93
166 Riccio, C. A., 65 Richards, J., 109, 112 Richardson, A. J., 112 Richmond, B. O., 93 Rijsdijk, F., 13 Robbins, F. R., 99 Robin, A. L., 63 Robinson, D. S., 75 Robling, M. R., 61 Rodriguez, A., 55, 57 Roessner, V., 27 Roid, G. H., 91 Roizen, N. J., 89 Ronald, A., 13 Root, R., 50, 63, 66 Rosenberg, M. S., 82 Ros´en, L. A., 101 Ross, K., 11 Rosvold, H. E., 69 Rothenberger, A., 27 Rothlind, J., 63, 67, 70 Rowland, A. S., 28 Rutter, M., 15 Ryan, J. J., 55 S Sachs, C. S., 109 Saddler, B., 102 Sailor, W., 3 Salisbury, H., 68 Salter, C. J., 91 Sandberg, S., 28 Sandoval, J., 80, 81, 82, 97 Sanford, E. E., 84 Sarason, I., 69 Sattler, J. M., 69–70, 71, 72 Sayer, J., 14 Schaefer, K., 1, 66 Schartz, M., 101–102 Schatz, A. M., 69 Schaughency, E. A., 63, 64, 67, 70 Schmitz, M., 55 Schnakenberg-Ott, S. D., 55 Schnoes, C., 24 School-based interventions response cost, 101 token reinforcement, 101 School-wide developmental screening, 32, 34–35 three phases of SSBD, 35t Schraw, G., 92 Sciutto, M. J., 2 Screening
Index ADHD rating scale, 41–43 ADPRS, 42–44f, 43–44 ADTRS, 44–46, 45–46f parent/teacher DBD rating scale, 40–41, 40f purpose of, 37 scoring instructions for ADPRS, 44f SNAP-IV, 37, 38f SWAN, 37–39, 39f Searight, H. R., 63 Searls, M., 97, 101 Secondary ADHD, 15, 18 SEELS, see Special Education Elementary Longitudinal Study (SEELS) Seidman, L. J., 17, 18, 19, 28, 92 Self-monitoring strategies, 101–102 Selikowitz, M., 74 Sergeant, J., 23–24 Serotonin HTR1B receptor, 12 Severson, H., 35 Shader, R. I., 63 Shastry, B. S., 9 Shaywitz, B. A., 29 Shaywitz, S. E., 29 Shelton, T., 63, 67 Shelton, T. L., 63 Shore, G., 69 Shuck, A., 81, 82 Shum, D., 14 Shuster, J., 95 Siekierski, B. M., 65 Silver, L. B., 63, 70 Single photon emission computer tomography (SPECT), 17 Sleator, E. K., 64, 70 Slinning, K., 55 Slomka, G., 63 Smith, B. H., 36 Smith, K. G., 52, 76 Smith, T. E., 63 Smith, Y. N., 28 Social maladjustment behaviors, 29 Soleil, G., 3, 6 Sondeijker, F. E., 28 Sparrow, S. S., 90 Special Education Elementary Longitudinal Study (SEELS), 24, 25f SPECT, see Single photon emission computer tomography (SPECT) Spencer, T., 9, 11 Spencer, T. J., 109 Sprafkin, J., 108 Sprague, R. L., 64
Index Sprich, S., 11, 27 Stein, M. A., 89 Stein, S., 65 Stevens, L. J., 112 Steward, M., 10 Stewart, M. A., 11 Still, G. R., 3 Stimulant medication, side effects, 107 Stoner, G., 63, 67–68 Strengths and Weakness of ADHD-symptoms and Normal-behavior (SWAN) scale, 37–39, 39f Student observation system (SOS), 65 Substance-related disorder, 53, 54t Sulzer-Araroff, B., 71, 72 Sverd, J., 108 Swanson, J., 111 Swanson, J. M., 27, 37, 38, 39, 64, 67, 69 Swanson, M. E., 63 Swanson, Nolan and Pelham (SNAP-IV) rating scale, 37, 38f scores, calculation of, 37 Symons, D. K., 69 Synaptosomal-associated protein of 25kD (SNPA-25), 12 Systematic Screening for Behavior Disorders (SSBD), 35, 35f Szobot, C. M., 27 Szumowski, E., 89 T Tang, I., 2 Tannebaum, K. R., 77 Tannock, R., 9, 27 Taylor, A., 28 Taylor, E., 28 Teacher rating scales (TRS), 65 Teplin, S. W., 61 Terasawa, K., 112 Tharpar, A., 11 Thernlund, G., 93 Thought disorders, 54t Tillman, R., 26 Tippins, S., 111, 112, 113, 114 Todd, R. D., 2 Token economy systems, 102 Token reinforcement programs, 101 Toplak, M. E., 95, 103, 113 Torgesen, J. K., 90 Toupin, J., 25 Tourette’s disorder, 62, 75 Toxemia/eclampsia, 14 Traumatic brain injury (TBI), 5, 20, 25f, 61
167 Trauner, D. A., 69 Treatment alternative therapies, 111–114 auditory stimulation training, 113–114 behavioral optometry/eye training exercises, 113 dietary interventions with O3FA, risk of, 111–112 EEG biofeedback, 112 motion sickness, treatments for, 113 sensory integration based interventions, 113 behavioral treatments, 96, 100 antecedents and consequences, 96 classroom environment, adjusting of, 96–100 active vs. passive involvement, 99 anticipation, 100 choice, 99 class-wide peer tutoring, 97–98 direct instruction, 97 distractions, 99–100 feedback, 99 instructions, 98–99 novelty, 98 pacing of work, 98 peer tutoring, 97 productive physical movement, 99 rule reminders and visual cues, 98 scheduling, 98 setting student up for success, 97 structure and organization, 98 task difficulty, 97 task duration, 97 medications, 104–111, 105t–106t double-blinded, placebo controlled treatment study, 104 long-term management, 109–110 misuse, 110 monitoring treatment effectiveness, 104–107 in preschool children, 110–111 school-home daily report card, 107f second line treatments, 108–109 undesired effects, 107–108 psychoeducational, 103 psychosocial interventions, encouraging appropriate behavior, 100–103 behavior modification programs, key components, 101 powerful external reinforcement, 101 response-cost programs, 102 self-monitoring strategy, 101–102
168 Treatment (cont.) time-out, example, 103 token economy systems, 102 treatment targets, 96 Tremblay, R. E., 26 Tripp, G., 64, 66 Trout, A. L., 101–102 Truman, C. J., 109 Tsuang, M., 65 Tsuang, M. T., 10, 26 Tupling, C., 15 Twin studies, 10–11 “heritability” of ADHD, estimation, 10–11 identical vs. fraternal twins, 10 U Ullmann, R. K., 70 V Valera, E. M., 17, 18 Van den Brink, W., 66 Vanderbilt ADHD Diagnostic Parent Rating Scale (ADPRS), 42f–44f, 43–44 Vanderbilt ADHD Diagnostic Teacher Rating Scale (ADTRS), 44–46, 45f–46f Van der Ende, J., 26 Van Lier, P. A. C., 26 Vasa, S. F., 3 Vaughn, M. L., 65 Verhulst, F. C., 26 Verlaan, P., 25 Vineland Adaptive Behavior Scales, 89–90 Visser, S. N., 1, 21, 77 Vitaro, F., 26 Voight, R. G., 112 Volpe, R. J., 68 Vreugdenhil, C., 66 W Wagner, M., 1, 24, 25 Wagner, R. K., 90 Waldman, I. D., 12 Walker, H., 35 Warmbrodt, L., 63
Index Warner, K. L., 66, 109 Warner-Rogers, J., 28 Waschbusch, D. A., 91 Watson, T. S., 65–66 Wauschbusch, E. A., 95 Wechsler, D., 91, 92 Welner, A., 10 Welner, Z., 10 Wender, P. H., 36, 63, 67 Weyandt, L. L., 102 Whalen, C. K., 76, 82, 98 Wickstrom, K., 65 Wieczorek, C., 28 Wiederholt, J. L., 92 Wigal, S. B., 100, 101 Wigal, T., 100, 101, 111 Wilens, T. E., 9, 110 Willcutt, E. G., 29 Williams, M., 54, 66, 75 Williams, M. L., 5 Wilson, W. C., 3 Winterstein, A. G., 108 Wish, E., 10 Wolf, S. M., 75 Wolraich, M., 70 Wolraich, M. L., 42, 44, 45, 63, 64, 108, 110 Woodcock, R. W., 91, 92 Wouters, L., 66 Wozniak, G., 109 Wright, G., 3 Y Yarnold, P. R., 65 Youngstrom, E. A., 28 Youth Self-Report (YSR), 28, 65 Yule, W., 15 Z Zagar, R., 82–83 Zentall, S. S., 28, 97, 98–99, 100, 101, 102 Zimerman, B., 66 Zimmerman, F. J., 16 Zoccolillo, M., 26