1. The Role of Neuropsychological Assessment in a Comprehensive ADHD Evaluation
Dustin B. Hammers, Ph.D., ABPP(CN)
Board Certified in Clinical Neuropsychology Department of Neurology Center for Alzheimer's Care, Imaging & Research University of Utah 09/26/2014
Center for Alzheimer’s Care,
Imaging and Research (CACIR)

2. 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

3. Recent Trends Rates rising
Mental health referrals and physician office visits
Boys vs. girls
From 7% in 2000 to 9% in 2009
30–50% of child mental health referrals
9.7 million physician-office visits yearly
Diagnosed in boys 3-4 often than in girls

4. 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.
Such as home, social settings, school, or work

5. DSM-5 Criteria Differences
Increasing age
Rule – outs
Number of symptoms required
Symptoms added for adults
Increasing age of onset from 7 to 12
Presence of Autism Spectrum no longer exclusionary
17+ year old patients now only need 5 of 9 symptoms instead of 6 of 9
Examples added to each symptom item to improve clarity and relevance across the lifespan

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

7. Neuropsychology Assessment or evaluation of cognitive functioning
Identification of individual strengths and weaknesses
Report includes results, and implications/recommendations
“Scientific study of relationship between brain and behavior”
Assessment or evaluation of cognitive functioning, by comparing administering cognitive tasks and examining objective performance to peers
Typically associated with a variety of diseases (e.g., dementia, TBI)
Identification of individual strengths and weaknesses
Report generated usually 2-4 pages in length, and include results, and implications/ recommendations (medication and behavioral)

8. Evaluation Components
Clinical Interview
Mental Status Examination
Family Interview
Behavioral Observation
Standardized Psychometric Testing
Interpretive Report
Integrated Feedback Session
Interview of Psychosocial and Developmental History

9. Neuropsychological Domains
Clinical interview
Attention
Perception & Construction
Language
Learning & Memory
Executive Functioning
Processing Speed
Intellectual/Achievmnt
Motor
Affective or Psychiatric Symptoms

10. Given these diagnostic criteria, where does cognitive performance fit in?
Technically, it doesn’t, ADHD is a behavioral diagnosis
However…

11. Neuropsychological Evaluation
Has the capacity to…
Assess ADHD patient’s unique collection of skills
Identify comorbid conditions associated with development or mood/conduct
Allow for the consideration of personalized treatment plans

12. Overcoming Diagnosis and Treatment Issues
Accuracy of Reporting and Categorization
Transition from childhood to adulthood
1. Adults generally describe their childhood behaviors as ADHD-like
Over 80% recall experiencing >5 DSM symptoms occasionally, 25% recall having them very often
Weak relationship between number of symptoms reported and actual impairment in daily life
2. Persistence into adulthood in as many as 30% to 50%
Upwards of 50% of adult clientele accurately diagnosed with ADHD as children may have “grown out of their symptoms” and a diagnosis is not relevant anymore

13. Lifetime Course of ADHD Symptoms: Inattention Domain
Childhood
Adult
Doesn’t listen
No follow through
Loses important items
Slow, inefficient, disorganized
Paralyzing procrastination
Poor time management
APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR)
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.

14. Lifetime Course of ADHD Symptoms: Hyperactivity/Impulsivity Domain
Childhood
Adult
Squirming, fidgeting
Runs/climbs excessively
On the go/driven by motor
Blurts out answers
Inefficiencies at work
Drives too fast
Can’t tolerate frustration
Makes inappropriate comments
APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR)
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.

15. Overcoming Diagnosis and Treatment Issues
Accuracy of Reporting and Categorization
Transition from childhood to adulthood
Comorbidities
Alternative Explanations
3. ADHD without a comorbidity is the exception rather than the rule
ADHD co-occurs with Learning Disability in 25-40% of the cases
Factors hard to untangle between Learning Disability and ADHD
Hard for patients to differentiate poor attending to incoming information vs. poor decoding of letters to sounds
4. Symptoms of ADHD are a collection of behaviors that commonly occur in daily life
On their own, not unique to ADHD
Result is that numerous other conditions can mimic symptoms of ADHD

16. 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
Similar to Learning Disorder, issues with depression and anxiety commonly co-occur
25% of adults with ADHD have depression
50% of adults with ADHD have anxiety (Wilens et al., 2004)
Which came first??
Many factors to consider during an introductory interview for differential diagnosis

17. Why can’t I just get an MRI?”

18. 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
FRONTO- STRIATAL-THALAMIC –CEREBELLAR
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
decreased communication and processing of information between hemispheres
Smaller basal ganglia
Unfortunately, complex networks involved and same findings observed for major depression, bipolar disorder, and substance abuse

19. “Do all people with ADHD have the same problems that I do?”

20. 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
ADHD is a behaviorally defined disorder, tending to result in wide variety of strengths and weaknesses
Creation of a specific treatment plan vs. application of a label
Many possible cognitive weaknesses in ADHD, subsequently many different treatment recommendations

21. Specific Cognitive Profiles
Attention difficulty observed
“Silent deficits” often not asked about
Executive functioning
Memory
Processing speed
Motor Dexterity
Emotional
Attention difficulty observed (pretty-much by definition)
Sustained attention, selective attention, vigilance, consistency
“Silent deficits” often not asked about
Executive functioning: problem solving, behavioral interference, manipulation, organization, time management/ carelessness
Memory: learning/encoding difficulty for list learning, organization difficulty for story-learning
Processing speed: ↓ reaction time
Language: word generation issues if timed
Sensorimotor: ↓ motor dexterity, praxis, precision
Emotional: Altered arousal, activation, novelty, reward motivation

22. 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
Multiple Eustachian tube drainage affected speech and balance in youth.
B student in remedial courses in HS, twin sister Honors valedictorian.
Makes a number of “to do” lists at home, though she struggles with procrastination and task transition in order to complete any of the items on her lists.

23. Example 1
Cognitive Profile:

24. 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
At the age of 7 diagnosed with ADHD at his school and got him involved in “Gifted Program”. Highly enriched environment allowed him to proceed through information quickly.
Without medication: less relaxed, fidgeting and pacing when at home. Excessive energy reduces focus, needs to keep himself busy with multiple tasks at once, and he struggles to attend to and retain conversations.
has eliminated his free time and family time.

25. Example 2
Cognitive Profile:

26. 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
Patient 1: inattention and slowed processing predominant
Sluggish Cognitive Tempo
↓ sustained attention, daydreaming, lethargy, physical underactivity, slowed movement and responsiveness
“Spaced out”, slowed info processing, confused erratic memory retrieval, socially reticent or under-involved
Patient 2: hyperactivity and impulsivity predominant
Behavioral Dysinhibition Hypothesis
ADHD is lack of ability to adjust activity level to fit setting
↓Self-regulation, heightened arousal needs, excess energy reduces attending and distract, interrupts others
Different reasons for Processing Speed weakness

27. How this Specific Information Can Help
Comorbidities and Alternative Explanations
Targeting treatments
Medication vs. Behavioral
Legal services
Daily recommendations

28. 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
Standard medication treatment with stimulants or noradrenergic agents (Strattera), although not all of these medications are approved for all ages
Methylphenidate: Ritalin, Methlyn, Concerta, Focalin
Amphetamine: Adderall, Dexadrine, Vyvanse
Stimulants block norepinephrine (NE) and dopamine (DA) reuptake in neuron, amphetamines also directly release NE and DA
Anti-depressants sometimes used to treat adults with ADHD
Tricyclics affect NE and DA
Venlafaxine (Effexor) affects NE
Bupropion (Wellbutrin) affects DA and showed benefits for adults with ADHD in 2005 drug trial
Prescriptions for stimulants and other medications require special considerations. For example, other medications for physical problems may interact badly with stimulants

29. 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
Best for social skills and reduced parent/peer relationships, also to focus on core symptoms and self-regulation
Behavioral Parent Training plus medication
Train caregivers in contingency management strategies (rewards, etc.)
Behavioral Classroom Interventions
Token Economy or Point System as reward
Peer-related interventions
Social Skills Groups
Academic Interventions
Modifying delivery of instructions, shorten tasks, oral vs. written responding, hands-on approach to increase engagement
Cognitive Behavioral Therapy
Structured treatment for adults to work on behavioral goals related to ADHD symptoms, improve mood and relationships

30. 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
Children/ young adults with ADHD are eligible to apply for academic accommodations throughout elementary/HS or college
504/IEP Behavioral Plans established through school systems
Academic accommodations granted through University Office for Student Disability Services
Specific cognitive profiles allow tailoring of accommodations
Extended time on exams helpful because of ↓ processing speed or comorbid LD, also allows “walking breaks” for hyperactivity
Note-taking supports beneficial because of inability to attend during lectures
Recording lectures, handout of notes before lecture, scribes
Distraction free or isolated exam-taking

31. 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
Based on individual’s unique profile of cognitive strengths and weaknesses
Examples for reaction time weakness:
Reduce multi-tasking
Incorporate periods of ‘disconnected time’ (from or telephone) where not likely to become distracted, particularly at the beginning of the day.
Even beginning day with 30 minutes of distraction-free work will allow patient to feel more productive and less stressed throughout and at the end of the day.
Examples for organizational/ executive weakness:
Increased structure and prioritizing will be vital given responsibilities and demands
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.
Researching time management resources would highly benefit the patient, as procrastination is a common problem for adults with attentional difficulties.

32. 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-Hyperactivity Disorder ( )
National Resource Center for ADHD

33. dustin.hammers@hsc.utah.edu www.utahmemory.org
Thank you! Questions?