The Role of Neuropsychological Assessment in a Comprehensive ADHD Evaluation

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The Role of Neuropsychological Assessment in a
Comprehensive ADHD Evaluation

• Dustin B. Hammers, Ph.D., ABPP(CN)
• Board Certified in Clinical NeuropsychologyDepart
  ment of NeurologyCenter for Alzheimer's Care,
  Imaging ResearchUniversity of Utah09/26/2014

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Objectives

• Discuss new DSM-5 criteria for ADHD
• Explain what neuropsychological or cognitive
  evaluations are and how they can be used to aid
  ADHD diagnosis and treatment
• Consider common obstacles to ADHD diagnosis and
  treatment
• Review case examples of cognitive profiles and
  personalized ADHD treatment

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Recent Trends

• Rates rising
• Mental health referrals and physician office
  visits
• Boys vs. girls

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DSM-IV-TR ADHD Criteria

• 6 of 9 characteristics in either or both major
  categories below.
• Symptoms present for at least six months,
  beginning before the age of 7. Behaviors must
  create significant difficulty in at least two
  areas of life.
• Situation not explained by other medical or
  psychiatric condition
• ADHD - Predominantly Inattentive Type
• Fails to give close attention to details or makes
  careless mistakes, Has difficulty sustaining
  attention, Does not appear to listen, Struggles
  to follow through on instructions, Has difficulty
  with organization, Avoids or dislikes tasks of
  sustained mental effort, Loses things, Is easily
  distracted, Forgetful in daily activities.
• ADHD - Predominantly Hyperactive/Impulsive Type
• Fidgets with hands or feet or squirms in chair,
  Has difficulty remaining seated, Runs about or
  climbs excessively, Difficulty engaging in
  activities quietly, Acts as if driven by a motor,
  Talks excessively, Blurts out answers before
  questions completed, Difficulty waiting/taking
  turns, Interrupts or intrudes upon others.
• ADHD - Combined Type
• Individual meets both sets of inattention and
  hyperactive/impulsive criteria.

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DSM-5 Criteria Differences

• Increasing age
• Rule outs
• Number of symptoms required
• Symptoms added for adults

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• Given these diagnostic criteria, where does
  cognitive performance fit in?

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Neuropsychology

• Assessment or evaluation of cognitive
• functioning
• Identification of individual strengths and
  weaknesses
• Report includes results, and implications/recommen
  dations

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Evaluation Components

• Clinical Interview
• Mental Status Examination
• Family Interview
• Behavioral Observation
• Standardized Psychometric Testing
• Interpretive Report
• Integrated Feedback Session

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Neuropsychological Domains
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• Given these diagnostic criteria, where does
  cognitive performance fit in?
• Technically, it doesnt, ADHD is a behavioral
  diagnosis
• However

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Neuropsychological Evaluation

• Has the capacity to
• Assess ADHD patients unique collection of skills
• Identify comorbid conditions associated with
  development or mood/conduct
• Allow for the consideration of personalized
  treatment plans

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Overcoming Diagnosis and Treatment Issues

• Accuracy of Reporting and Categorization
• Transition from childhood to adulthood

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Lifetime Course of ADHD Symptoms Inattention
Domain
Childhood
Adult
Slow, inefficient, disorganized Paralyzing
procrastination Poor time management
Doesnt listen No follow through Loses
important items
APA. Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV-TR).
2000. Weiss MD, Weiss JR. J Clin Psych.
200465(suppl 3)27-37.
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Lifetime Course of ADHD Symptoms
Hyperactivity/Impulsivity Domain
Childhood
Adult
Inefficiencies at work Drives too fast Cant
tolerate frustration Makes inappropriate
comments
Squirming, fidgeting Runs/climbs
excessively On the go/driven by motor Blurts
out answers
APA. Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV-TR).
2000. Weiss MD, Weiss JR. J Clin Psych.
200465(suppl 3)27-37.
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Overcoming Diagnosis and Treatment Issues

• Accuracy of Reporting and Categorization
• Transition from childhood to adulthood
• Comorbidities
• Alternative Explanations

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Alternative Explanations

• Medical Differentials
• Thyroid disease
• Head trauma
• OSA
• Seizures
• Vitamin B12 deficiency
• Drug interactions
• Heavy metal poisoning
• Hearing deficits
• Liver disease
• Lead toxicity

• Psychiatric Differentials
• Major depression
• Bipolar disorders
• GAD
• Substance abuse
• Personality disorders

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• Why cant I just get an MRI?

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Neuroimaging and ADHD

• MRIs and PET scans of ADHD patients show changes
  in
• Anterior frontal lobe, along with temporal and
  parietal lobe
• Splenium of corpus callosum and anterior
  cingulate
• Smaller basal ganglia
• Similar networks for major depression,
  bipolar disorder, and substance abuse

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• Do all people with ADHD have the same problems
  that I do?

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Treatment for ADHD Not Uniform

• ADHD is a behaviorally defined disorder
• Creation of specific treatment plan vs.
  application of label
• As many treatment recommendations as cognitive
  weaknesses

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Specific Cognitive Profiles

• Attention difficulty observed
• Silent deficits often not asked about
• Executive functioning
• Memory
• Processing speed
• Motor Dexterity
• Emotional

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Example 1

• 21-year old woman with Associates Degree and
  enrolled in Cosmetology Program. Works as hostess
  part-time.
• Adderall given at age 18 by PCP but never
  received ADHD diagnosis
• Without medication
• Easily overwhelmed by information, forgetful, and
  she has consistently had instructors point out
  her attention difficulties in class
• Struggles with procrastination and task
  transition for to do lists

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Example 1

• Cognitive Profile

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Example 2

• 31-year old man with a Doctorate in Pharmacy and
  in his 2nd year of Residency
• Diagnosed with ADHD at 7 years old, highly
  enriched environment
• On Ritalin in youth, strong college and grad
  school GPA
• Without medication
• Fidgeting and pacing when at home, multiple tasks
  at once, struggles to attend to and retain
  conversations, sensation seeking behaviors
• Oversights on the job have been documented and
  excessive hours

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Example 2

• Cognitive Profile

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Profiles

• Patient 1 Inattention and slowed processing
  predominant
• Diagnosis ADHD Inattentive Type
• Sluggish Cognitive Tempo
• Patient 2 Hyperactivity and impulsivity
  predominant
• Diagnosis ADHD Hyperactive/Impulsive Type
• Behavioral Dysinhibition Hypothesis

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How this Specific Information Can Help

• Comorbidities and Alternative Explanations
• Targeting treatments
• Medication vs. Behavioral
• Legal services
• Daily recommendations

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Medication Treatment for ADHD

• Standard medication treatment with stimulants
• Methylphenidate Ritalin, Methlyn, Concerta,
  Focalin
• Amphetamine Adderall, Dexadrine, Vyvanse
• Anti-depressants to treat adults with ADHD
• Strattera
• Tricyclics
• Effexor
• Wellbutrin

www.nimh.nih.gov
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Behavioral Therapy for ADHD

• Best for social skills and reduced parent/peer
  relationships, also to focus on core symptoms and
  self-regulation
• Behavioral Parent Training plus medication
• Behavioral Classroom Interventions
• Social Skills Interventions
• Academic Interventions
• Cognitive Behavioral Therapy

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ADA Accommodations

• Academic accommodations available
• 504/IEP Behavioral Plans established through
  school systems
• University Office for Student Disability Services
• Specific cognitive profiles allow tailoring of
  accommodations
• Extended time on exams
• Note-taking supports
• Distraction free or isolated exam-taking

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Personalized Recommendations

• Example for reaction time weakness
• Incorporate periods of disconnected time where
  not likely to become distracted, particularly at
  the beginning of the day
• Examples for organizational/executive weakness
• Create checklists and protocols for procedures
  during work such structure will be of benefit
  since motivation is often increased when clear
  plans are able to be followed
• Breaking day into 1 hour blocks, or even 15
  minute increments, may be more beneficial to
  increase novelty and reduce distraction

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ADHD Recommended Readings

• Books
• Childhood ADHD
• Driven to Distraction by Edward Hallowell, 1995
• Parenting Children with ADHD by Vincent Monastra,
  2005
• Taking Charge of ADHD by Russell Barkley, 2013
• Adult ADHD
• Succeeding with Adult ADHD by Abigail Levrini and
  Frances Prevatt, 2012  
• More Attention, Less Deficit by Ari Tuckman, 2009
  
• Taking Charge of Adult ADHD by Russell Barkley,
  2010
• Organizations and Helpful Websites
• Children and Adults With Attention-Deficit-Hyperac
  tivity Disorder (www.chadd.org )
• National Resource Center for ADHD
  www.help4adhd.org
• www.ADDWarehouse.com

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Thank you!Questions?

• dustin.hammers_at_hsc.utah.edu
• www.utahmemory.org