Transcript Case Study of LH

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)
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
Recent Trends
 Rates rising
 Mental health referrals and physician office visits
 Boys vs. girls
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.
DSM-5 Criteria Differences
• Increasing age
• Rule – outs
• Number of symptoms required
• Symptoms added for adults
• Given these diagnostic criteria, where
does cognitive performance fit in?
Neuropsychology
 Assessment or evaluation of cognitive
functioning
 Identification of individual strengths and weaknesses
 Report includes results, and implications/recommendations
Evaluation Components
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Clinical Interview
Mental Status Examination
Family Interview
Behavioral Observation
Standardized Psychometric Testing
Interpretive Report
Integrated Feedback Session
Neuropsychological Domains
Attention
Affective
or
Psychiatric
Symptoms
Perception &
Construction
Motor
Language
Clinical
interview
Learning &
Memory
Intellectual/
Achievmnt
Processing
Speed
Executive
Functioning
• Given these diagnostic criteria, where
does cognitive performance fit in?
• Technically, it doesn’t, ADHD is a behavioral
diagnosis
• However…
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
Overcoming Diagnosis and Treatment Issues
• Accuracy of Reporting and Categorization
• Transition from childhood to adulthood
Lifetime Course of ADHD Symptoms:
Inattention Domain
Childhood
Doesn’t listen
No follow through
Loses important items
Adult
Slow, inefficient, disorganized
Paralyzing procrastination
Poor time management
APA. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR). 2000.
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.
Lifetime Course of ADHD Symptoms:
Hyperactivity/Impulsivity Domain
Childhood
Squirming, fidgeting
Runs/climbs excessively
On the go/driven by motor
Blurts out answers
Adult
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). 2000.
Weiss MD, Weiss JR. J Clin Psych. 2004;65(suppl 3):27-37.
Overcoming Diagnosis and Treatment Issues
• Accuracy of Reporting and Categorization
• Transition from childhood to adulthood
• Comorbidities
• Alternative Explanations
Alternative Explanations
 Medical Differentials
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Thyroid disease
Head trauma
OSA
Seizures
Vitamin B12 deficiency
Drug interactions
Heavy metal poisoning
Hearing deficits
Liver disease
Lead toxicity
 Psychiatric Differentials
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Major depression
Bipolar disorders
GAD
Substance abuse
Personality disorders
•Why can’t I just get an MRI?”
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
•“Do all people with ADHD have
the same problems that I do?”
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
Specific Cognitive Profiles
• Attention difficulty observed
 “Silent deficits” often not asked about
◦ Executive functioning
◦ Memory
◦ Processing speed
◦ Motor Dexterity
◦ Emotional
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
Example 1
• Cognitive Profile:
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
Example 2
• Cognitive Profile:
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
How this Specific Information Can Help
• Comorbidities and Alternative Explanations
• Targeting treatments
• Medication vs. Behavioral
• Legal services
• Daily recommendations
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
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Strattera
Tricyclics
Effexor
Wellbutrin
www.nimh.nih.gov
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
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
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
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
(www.chadd.org )
• National Resource Center for ADHD www.help4adhd.org
• www.ADDWarehouse.com
Thank you!
Questions?
[email protected]
www.utahmemory.org