All That Wiggles Is Not ADHD History, Assessment, and Diagnosis of ADHD Jodi A. Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute, UNMC Director, Hastings Behavioral Health Clinic

Attention-Deficit Hyperactivity Disorder History: Where did ADHD come from?

“Defects in Moral Control” George Still, M.D. (1902) A “cluster” of behaviors which: 4were more common in males 4seemed to run in families 4were associated with certain congenital anomalies 4were not accounted for by any known neurological deficit

Other Names/Classifications 4 Post-encephalic Brain Disorder 4 Brain Injured Child Syndrome 4 Minimal Brain Dysfunction 4 Hyperkinetic Reaction of Childhood (DSM-II) 4 Attention-Deficit Disorder (DSM-III, 1980)

Current Conceptualization Attention-Deficit Hyperactivity Disorder (ADHD) DSM-IV, 1994 Three subtypes: 4Predominantly Inattentive 4Predominantly Hyperactive/Impulsive 4Combined

Adolescent and Adult Outcomes 4 Some symptoms into adolescence: 70% 4 Some symptoms into adulthood: 50% 4 At increased risk for: VSubstance abuse VTraffic citations VAutomobile accidents

Cause of ADHD No one cause identified. Not caused by 4Diet (i.e. food additives, sugar) 4Poor parenting

Other Myths/Misconceptions 4 ADHD is outgrown in adolescence.

Other Myths/Misconceptions 4 ADHD is outgrown in adolescence. 4 Girls are not hyperactive.

Other Myths/Misconceptions 4 ADHD is outgrown in adolescence. 4 Girls are not hyperactive. 4 There is a single test for ADHD.

Other Myths/Misconceptions 4 ADHD is outgrown in adolescence. 4 Girls are not hyperactive. 4 There is a single test for ADHD. 4 Stimulant medication can “diagnose” ADHD.

Other Myths/Misconceptions 4 ADHD is outgrown in adolescence. 4 Girls are not hyperactive. 4 There is a single test for ADHD. 4 Stimulant medication can “diagnose” ADHD. 4 There is a “cure” for ADHD.

Prevalence of ADHD Best current estimate: 3%-5% school age population are affected.

Attention-Deficit Hyperactivity Disorder Diagnosis: Who has ADHD?

Formal Diagnostic Criteria DSM-IV, 1994 Criterion A: Six or more symptoms from one or both of these lists: 4 Inattentive Type 4 Hyperactive/Impulsive Type …have been present for at least 6 months.

Symptom Lists Inattentive Type 3 fails to attend to details, makes careless mistakes 3 difficulty sustaining attention in play or work 3 does not listen when spoken to 3 does not follow through 3 difficulty organizing tasks 3 avoids task requiring sustained mental effort 3 loses things needed 3 distracted by extraneous stimuli 3 often forgetful Hyper/Impulsive Type 3 often fidgets hands/feet or squirms 3 often leaves seat when sitting is expected 3 runs about or climbs excessively 3 difficulty playing or engaging in leisure activities quietly 3 often “on the go”/ “driven by motor” 3 talks excessively 3 blurts out answers before questions completed 3 difficulty awaiting turn 3 interrupts or intrudes on others

Formal Diagnostic Criteria DSM-IV, 1994 Criterion B: Some of the symptoms were present before the age of seven years.

Formal Diagnostic Criteria DSM-IV, 1994 Criterion C: Some impairment from the symptoms is present in two or more settings (e.g., home, and school or work).

Formal Diagnostic Criteria DSM-IV, 1994 Criterion D: There is evidence of clinically significant impairment in social, academic, or occupational functioning.

Formal Diagnostic Criteria DSM-IV, 1994 Criterion E: The identified symptoms are not better accounted for by another mental disorder.

Attention-Deficit Hyperactivity Disorder Assessment: All that wiggles is not ADHD

Comprehensive Diagnosis for ADHD There is no single test or laboratory measure which can reliably detect ADHD.

Comprehensive Diagnosis for ADHD Information gained by qualified clinician: 4From family V standardized, norm-referenced ratings V detailed history

Comprehensive Diagnosis for ADHD Information gained by qualified clinician: 4From family V standardized, norm-referenced ratings V detailed history 4From school V standardized, norm-refernced ratings V academic history V in-class observations

Comprehensive Diagnosis for ADHD Information gained by qualified clinician: 4From family V standardized, norm-referenced ratings V detailed history 4From school V standardized, norm-referenced ratings V academic history V in-class observations 4From clinician V observations

Other Common Causes of Concentration Problems 4 Depression/anxiety

Other Common Causes of Concentration Problems 4 Depression/anxiety 4 Drug/alcohol use

Other Common Causes of Concentration Problems 4 Depression/anxiety 4 Drug/alcohol use 4 Poor fit between academic demands and individual’s capabilities

Other Common Causes of Concentration Problems 4 Depression/anxiety 4 Drug/alcohol use 4 Poor fit between academic demands and individual’s capabilities 4 Physical illness

Other Common Causes of Concentration Problems 4 Depression/anxiety 4 Drug/alcohol use 4 Poor fit between academic demands and individual’s capabilities 4 Physical illness 4 Adjustment

Associated Problems 4 Learning Disability: %

Associated Problems 4 Learning Disability: % 4 Oppositional Defiant Disorder: %

Oppositional Defiant Disorder Pattern of negative, hostile, and defiant behavior: 3 Often loses temper 3 Often argues with adults 3 Often actively defies or refuses to comply with adults’ requests or rules 3 Often deliberately annoys people 3 Often blames others for his/her mistakes or behavior 3 Often touchy or easily annoyed by others 3 Often angry or resentful 3 Often spiteful or vindictive

Associated Problems 4 Learning Disability: % 4 Oppositional Defiant Disorder: % 4 Variable academic quality

Associated Problems 4 Learning Disability: % 4 Oppositional Defiant Disorder: % 4 Variable academic quality 4 Poor social skills, peer relationships

Who Has ADHD? Percent Attentiveness 3-5%

Who Has ADHD? Percent Attentiveness 3-5% 3-15%?

ADHD as Heterogeneous Disorder Inattentive Type fails to attend to details, careless mistakes difficulty sustaining attention in play or work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental effort loses things needed distracted by extraneous stimuli often forgetful Hyper/Impulsive Type often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others Associated Problems Learning Disability Oppositional Defiant Disorder Variable academic quality Poor social skills, peer relationships

ADHD as Heterogeneous Disorder Inattentive Type fails to attend to details, careless mistakes difficulty sustaining attention in play or work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental effort loses things needed distracted by extraneous stimuli often forgetful Hyper/Impulsive Type often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others Associated Problems Learning Disability Oppositional Defiant Disorder Variable academic quality Poor social skills, peer relationships

ADHD as Heterogeneous Disorder Inattentive Type fails to attend to details, careless mistakes difficulty sustaining attention in play or work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental effort loses things needed distracted by extraneous stimuli often forgetful Hyper/Impulsive Type often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others Associated Problems Learning Disability Oppositional Defiant Disorder Variable academic quality Poor social skills, peer relationships Child with ADHD

Importance of Diagnosis l Can help schools document need for additional services. l Research purposes. l Professional communication. l But it doesn’t help individualize a treatment strategy!

Importance of Diagnosis More important than a diagnosis: is a comprehensive, functional assessment of the child’s impairment in daily life with peers. with teachers. with siblings. with parents.

New Conceptualization of ADHD Dr. Russell Barkley: “ADHD is a delay in the development of behavioral inhibition.”