User:Ongmianli/Portfolios/Attention deficit hyperactivity disorder

Section 2.1: DSM 5 Diagnostic Criteria for ADHD
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
 * 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
 * Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
 * a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
 * b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
 * c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
 * d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
 * e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
 * f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
 * g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
 * h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
 * i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).


 * 2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
 * Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
 * a. Often fidgets with or taps hands or feet or squirms in seat.
 * b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
 * c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
 * d. Often unable to play or engage in leisure activities quietly.
 * e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
 * f. Often talks excessively.
 * g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
 * h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
 * i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

Additional Criteria
 * 1. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
 * 2. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
 * 3. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
 * 4. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
 * 5. Specify whether:
 * a. 314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.
 * b. 314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.
 * c. 314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.
 * 6. Specify if:
 * a. In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning.
 * 7. Specify current severity:
 * a. Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
 * b. Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
 * c. Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

Areas Under the Curve (AUCs) and Likelihood Ratios for potential diagnostic and screening measures for child ADHD
TABLE/DATA FOR THE SAME INFO ON ADULT ADHD?? MISSING CLINICAL GENERALIZEABILITY LEVEL FOR MINI-KID

Note: All studies with one exception used structured or semi-structured clinical interviews to establish diagnosis of ADHD. The exception, the Sprafkin & Gadow study (2007), used a combination of CBCL rating scales, clinician review, and clinician consensus to confirm ADHD diagnosis. “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000).

Executive Summary

 * If, based on the evidence I collected, I had to choose one parent report, one teacher report, and one diagnostic interview upon which to base a diagnosis of child or adolescent ADHD, I would choose the following:
 * Parent Report Form: CBCL, specifically the CBCL Attention Problems Scale
 * Teacher Report Form: Conners Teacher Rating Scale Revised-Long Form (CTRSR-L), though it should be noted that there is not a lot of evidence that any teacher rating scale is really very effective in informing one's diagnosis of ADHD, and teacher report adds questionable incremental validity in terms of ADHD diagnosis over and above parent-report (Pelham, Fabiano, & Massetti, 2005; Shemmassian & Lee, 2011)
 * Diagnostic Interview: MINI-KID, though others are also acceptable.

Recommended Diagnostic Interviews:

 * MINI-KID : MINI-KID has good to excellent AUC values for most individual disorders, and good AUC values for ADHD diagnosis. MINI-KID also provides both positive and negative likelihood ratios that are helpful in determining changes in probability that clients has the disorder. Finally, the MINI-KID takes 68% less time (33 minutes versus 103 minutes) than the K-SADS-PL (Sheehan et. al, 2009).

Other recommended structured diagnostic interviews:

 * Diagnostic Interview Schedule for Children Version IV (DISC-IV; Jensen et al., 1996): Moderate to high test-retest reliability for the parent version (.79), adequate interrater reliability (0.70), demonstrated that children classified using the DISC had higher risk on indexes of child impairment, sensitive to behavioral and pharmacological treatment effects (Pelham et. al, 2005).
 * Diagnostic Interview for Children and Adolescents-Revised (DICA-R; Boyle et. al, 1993): High reliability scores for the parent version, parent assessment of ADHD tended to be more reliable for older children, stability of diagnosis demonstrated over 1 to 3 years. Good sensitivity and specificity of assessment and diagnosis reported (Pelham et al., 2005).

Other recommended semi-structured diagnostic interviews:

 * Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Biederman et al., 1993): Interrater reliability of К = .56, but demonstrated excellent convergence with CBCL Attention Problems Scale, used as the "gold-standard" against which numerous ADHD screening instruments and diagnostic interviews are compared (Pelham et al., 2005).

Recommended Screening Measures:

 * Parent Report:
 * CBCL Attention Problems Scale: The CBCL Attention Problems Subscale was the parent-reported subscale that had been analyzed using ROC methodology in multiple studies, resulting in AUC values ranging from 0.84-0.90. Those AUC values were the highest observed in my search of the literature. Additionally, in different studies the CBCL Attention Problems Scale produced LR+ values that ranged 6.92 to 47, which means they ranged from helpful to clinically decisive, though LR- ratios produced by the scale were less helpful (the lowest negative likelihood ratio value found was 0.19 and LR- values ranged from 0.19 to 0.66).
 * Other Recommended Measures:
 * Disruptive Behavior Disorder Rating Scale-Parent Report : Very similar results to CBCL. Slightly smaller AUC, (AUC = .78), and LR+ value (5.06), but more useful LR- value (0.20).
 * Teacher Report:
 * Conners Teacher Rating Scale Revised-Long Form (CTRS-R-L): There were no AUC values reported for the CTRS-R-L but the CTRS-R-L was the only scale to demonstrate a LR+ value (8.66) and a LR- value (0.24) that were both in the range of values that were clinically helpful.
 * Other (very tenatively) Recommended Measures:
 * TRF Attention Problems Subscale: No AUC value reported, somewhat clinically helpful LR+ value (LR+ = 3.66), not a clinically helpful LR- value (=0.73).

Section 3.1: Treatment for child/adolescent ADHD Executive Summary and Useful References
Executive Summary:

1. If intervening with children ages 4-5, behavior therapy should be the first line of treatment.

2. If intervening with children ages 6-11, behavior therapy should be the first line of treatment, in conjunction with medication.

3. If intervening with children ages 12-18, medication should probably be the first line of treatment, though behavior therapy could be used in combination.

4. Three types of therapeutic interventions have well established evidence-bases:
 * a. Behavioral Parent Training Interventions
 * b. Behavioral Classroom Management Interventions
 * c. Behavioral Peer interventions involving recreational peer groups (e.g. summer camps)

5. If considering a classroom management intervention:
 * a. Academic and Cognitive-Behavioral Interventions are most effective in changing academic outcomes
 * b. Cognitive Behavioral and Contingency Management Interventions are most effective in changing behavioral outcomes

American Academy of Pediatrics Clinical Practice Guidelines for ADHD by Age (Subcommittee on AD/HD Disorder, 2011)

1. For preschool-aged children (ages 4-5), primary care clinicans should prescribe evidence-based parent and/or teacher-administered behavior therapy as the first line of treatment, and may prescribe methylphenidate if behavioral interventions are not effective

2. For elementary-aged children (ages 6-11), primary care clinicians should prescribe FDA-approved medications for ADHD and/or evidence based parent and teacher administered behavior therapy. Preferably, both medication and behavior therapy will be prescribed.

3. For adolescents (ages 12-18), primary care clinicians should prescribe FDA approved medications for ADHD with the assent of the adolescent and may prescribe behavior therapy as a treatment for ADHD, preferably both.

Different Types of Behavioral Therapies which meet American Academy of Pediatrics and American Psychological Association Task Force criteria for well-established Evidence-Based Treatments

* Descriptions and Effect sizes taken from (Subcommitte on AD/HD Disorder, 2011; Pelham & Fabiano, 2008)

Behavioral Parent Training: Behavior modification principles provided to parents for implementation in home settings. Typical outcomes include improved compliance with parental commands, improved parental understanding of behavioral principles, high levels of parental satisfaction with treatment.

Median effect size: 0.55

Behavioral Classroom Management: Behavior-modification principles provided to teachers for implementation in classroom settings. Typical outcomes include improved attention to instruction, improved compliance with classroom rules, decreased disruptive behavior, improved work productivity, and improved academic achievement.

Median effect size: 0.61

Behavioral Peer Interventions: Interventions focused on peer interactions/relationships. These could include group-based interventions provided weekly and include clinic-based social skills training used either alone or concurrently with behavioral parent training and/or medication. Typical outcomes are more mixed with these interventions. Some clinical-office based interventions have produced minimal effects, while some studies of behavioral peer intervention coupled with behavioral parent training found positive effects on parental ratings of ADHD symptoms. No studies of this type of intervention reveal differences on social functioning or parental ratings of social behavior. Behavioral Peer Interventions implemented in peer group/recreational settings (e.g. summer camps) have the most evidence of being effective.

Median effect size: None reported, effect sizes found are considered moderate.

Findings from DuPaul and colleagues review of school based interventions (DuPaul, Eckert, & Vilardo, 2012)

-Academic intervention (Interventions that focus primarily on manipulating antecedent conditions via things like peer tutoring, computer- aided instruction, and organizational skills interventions) and combined academic and contingency management interventions were associated with greater effects on academic outcomes.

Table 3.11: Single Subject Design Effect Sizes for Academic Outcomes

-Contingency management (Interventions that use reinforcement and punishment) and cognitive behavioral interventions (Interventions focused on development of self-control skills and reflective problem-solving strategies) were associated with greater effects for behavior outcomes.

Table 3.12: Single Subject Design Effect Sizes for Behavioral Outcomes

Section 4.1: Sources Consulted
ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. (2011). Pediatrics, 128 (5),
 * 1007-1022.

Pelham, W. R., & Fabiano, G. A. (2008). Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. ''Journal of
 * Clinical Child and Adolescent Psychology, 37 (1), 184-214.

DuPaul, G. J., Eckert, T. L., & Vilardo, B. (2012). The effects of school-based interventions for attention deficit hyperactivity disorder: A meta-analysis 1996-2010. ''School
 * Psychology Review, 41(4), 387-412.

Other Treatment Resources to Check Out:
Christophersen, E. R., & VanScoyoc, S. (2013). ''Treatments that work with children: Empirically supported strategies for managing childhood problems (2nd ed.)''. Washington, DC
 * ''US: American Psychological Association.

'' Eiraldi, R. B., Mautone, J. A., & Power, T. J. (2012). Strategies for implementing evidence-based psychosocial interventions for children with attention-deficit/hyperactivity disorder.
 * Child and Adolescent Psychiatric Clinics Of North America, 21(1), 145-159.

Hodgkins, P., Dittmann, R. W., Sorooshian, S., & Banaschewski, T. (2013). Individual treatment response in attention-deficit/hyperactivity disorder: Broadening perspectives and
 * improving assessments. Expert Review of Neurotherapeutics, 13(4), 425-433.

Neef, N. A., Perrin, C. J., & Madden, G. J. (2013). Understanding and treating attention- deficit/hyperactivity disorder. In G. J. Madden, W.V. Dube, T. D. Hackenberg, G. P. Hanley,
 * K. A. Lattal (Eds.), APA handbook of behavior analysis, Vol. 2: Translating principles into practice (pp. 387-404). Washington, DC US: American Psychological Association

Schultz, B. K., Storer, J., Watabe, Y., Sadler, J., & Evans, S. W. (2011). School-based treatment of attention-deficit/hyperactivity disorder. Psychology In The Schools,48(3),
 * 254-262.

Table 4.1. Clinically Significant Change Benchmarks with Common Instruments and ADHD Rating Scales
* “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean. Sources Consulted:
 * Sullivan, J. R., & Riccio, C. A. (2007). Diagnostic group differences in parent and teacher ratings on the BRIEF and Conners' scales. Journal of Attention Disorders, 11(3), 398-
 * 406.
 * Shemmassian, S. K., & Lee, S. S. (2012). Comparing four methods of integrating parent and teacher symptom ratings of attention-deficit/hyperactivity disorder (ADHD).''Journal
 * of Psychopathology and Behavioral Assessment'', 34(1), 1-10.

Search terms: [ADHD or CONNERS or DBD] AND [clinical significance OR group means] in PsycINFO

Section 4.2: Process Measures
1. CBCL Attention Problems Subscale: Could be used on a weekly basis to track changes in ADHD symptomotology. T-scores from this measure could also be recorded on a weekly basis to determine if reliable and clinically significant changes in ADHD symptoms are occuring. The CBCL Attention Problems Subscale has repeatedly demonstrated good-to-excellent convergence with diagnostic interviews for diagnosing ADHD (Pelham et al., 2005; Lampert, Polanczyk, Tramontina, Mardini, & Rohde, 2004; Hudziak et al, 2004; Chen et al., 1994). The CBCL Attention Problems Subscale is a scale on the CBCL, which is readily available at the Finley Clinic.

2. Daily Report Card: Several scholars have pointed out that it is equally important to track changes in the functional behaviors that a child with ADHD engages in, in addition to their ADHD symptoms, to capture the full range of adaptive changes that are made by children with ADHD throughout the course of treatment (Pelham et. al, 2005; Sowerby & Tripp, 2009). The daily report card is a mechanism by which such adaptive behavioral changes can be tracked. When implementing the daily report card, problematic child behaviors at home and at school are targeted for change. Rewards are offered to the child for reaching daily and weekly goals for reducing maladaptive behaviors and increasing adaptive behaviors. Parents and Teachers track child behaviors on a daily basis and provide feedback to one another and the child with behavior frequency counts and/or daily "grades" on how well the child behaved. Daily report cards are a mainstay of cognitive-behavioral and behavioral modification evidence-based intervention strategies for ADHD (DuPaul et al., 2012; Eiraldi et al., 2012) and are highly recommended for tracking child treatment outcomes. Instructions for creating a daily report card are attached in Appendix 1.

Section 5.1: Sources Consulted that have not yet been cited:
Lampert, T. L., Polanczyk, G. G., Tramontina, S. S., Mardini, V. V., & Rohde, L. A. (2004). Diagnostic performance of the CBCL-
 * Attention Problem Scale as a screening measure in a sample of Brazilian children with ADHD. Journal of Attention Disorders, 8(2),
 * 63-71.

Sowerby, P., & Tripp, G. (2009). Evidence-based assessment of attention-deficit hyperactivity disorder (ADHD). In J. L. Matson, F.
 * Andrasik, M. L. Matson (Eds.), Assessing childhood psychopathology and developmental disabilities (pp. 209-239). New York, NY
 * US: Springer Science + Business Media.