Transcript DIAGNOSIS DU JOUR? RESEARCH AND PERSPECTIVES ON …

ASSESSMENT OF LEARNING DISABILITIES
AND ATTENTION-DEFICIT
HYPERACTIVITY/DISORDER IN ADULTS
Robert L. Mapou, Ph.D., A.B.P.P. (CN)
William R. Stixrud, Ph.D. and Associates, LLC
Silver Spring, MD
Departments of Psychiatry and Neurology
Uniformed Services University of the Health Sciences, Bethesda, MD
Department of Neurology (Psychology)
Georgetown University School of Medicine, Washington, DC
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R. L. Mapou, Ph.D., ABPP-CN
CONTACT INFORMATION
Robert L. Mapou, Ph.D., ABPP-CN
William Stixrud, Ph.D. and Associates, LLC
8720 Georgia Avenue
Suite 300
Silver Spring MD 20910
(301) 565-0534 x264
(301) 565-2217 FAX
E-mail: [email protected]
Web: www.stixrud.com
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R. L. Mapou, Ph.D., ABPP-CN
WHAT IS A
DISABILITY?
WHAT IS A LEARNING
DISABILITY?
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ISSUES TO CONSIDER
 Learning
disabilities was a conceptual rather than
a legal term.
 Educational law did not specify degree of
disability.
 Focus
on identification, often by discrepancy only
 Focus on service delivery
 Educational
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law did not apply to adults.
R. L. Mapou, Ph.D., ABPP-CN
DEFINITION OF A DISABILITY UNDER
THE 1990 AMERICANS WITH
DISABILITIES ACT
 A disability
is:
 “a
physical or mental impairment that substantially
limits one or more of the major life activities of [an]
individual.”
 A person
is considered disabled if:
 “the
individual's important life activities are restricted
as to the conditions, manner, or duration under which
they can be performed in comparison to most people.”
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R. L. Mapou, Ph.D., ABPP-CN
THEREFORE . . .
NOT ALL DISORDERS WITH
IMPAIRMENT ARE
DISABILITIES!
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R. L. Mapou, Ph.D., ABPP-CN
LEARNING DISABILITIES:
DEFINITIONS
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CURRENT DEFINITIONS
Individuals with Disabilities Education
Improvement Act of 2002
(IDEA 2004)
National Joint Committee on Learning
Disabilities (1981, 1987, 1990)
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PROBLEMS WITH CURRENT
DEFINITIONS
Limit areas of impairment to language and academics
 Does not consider the brain (IDEA 2004)
 Does not recognize that problems occur across the
lifespan (IDEA 2004)
 Includes acquired disorders, some of which would not be
considered LDs in adults (IDEA 2004)
 Excludes difficulties related to nonverbal LDs, attention,
and executive functioning (NJCLD)

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A NEUROPSYCHOLOGICAL
DEFINITION?
Rehabilitation Services Administration
(1985)
A specific learning disability is a disorder in one or more of the
central nervous system processes involved in perceiving,
understanding, and/or using concepts through verbal (spoken or
written) language or nonverbal means. This disorder manifests
itself with a deficit in one or more of the following areas: attention,
reasoning, processing, memory, communication, reading, writing,
spelling, calculation, coordination, social competence, and
emotional maturity.
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A PROPOSED NEUROPSYCHOLOGICAL
DEFINITION
Mapou (In preparation)
A learning disability is a neurodevelopmental
disorder affecting a specific academic and/or
cognitive skill that occurs in the presence of intact
skills in most other realms. The specific
impairments are presumed to be due to
dysfunction of the brain and to have been present
since birth, although their impact may not become
fully obvious until later in life.
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R. L. Mapou, Ph.D., ABPP-CN
A PROPOSED NEUROPSYCHOLOGICAL
DEFINITION
Mapou (In preparation)
Although most learning disabilities affect
academic skills (reading, writing, mathematics)
and the associated underlying neuropsychological
functions needed for these skills, a learning
disability can also affect specific areas of
neuropsychological functioning, including
attention, executive functions and problemsolving abilities, spoken language, visuospatial
skills, or learning and memory.
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R. L. Mapou, Ph.D., ABPP-CN
A PROPOSED NEUROPSYCHOLOGICAL
DEFINITION
Mapou (In preparation)
A learning disability substantially limits
functioning in one or more aspects of a person’s
life (e.g., school, work, home, social). It is not
better explained by an acquired neurological
disorder that occurs either in childhood or later in
life, mental retardation, or a pervasive
developmental disorder, It is also not due
primarily to cultural factors, psychosocial factors,
psychiatric disorder, or lack of education, although
it may co-exist with these factors.
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TYPES OF LEARNING DISABILITIES
Fletcher, et. al (2007); Tsatsanis & Rourke (2008); Wasserstein et
al., (2008); Cutting & Denckla (2003); Wasserstein & Denckla
(in press)

Reading disability
Word recognition (dyslexia)
 Fluency
 Comprehension

Mathematics disability (computations and/or problemsolving)
 Written language disability (handwriting, spelling, and/or
composition)
 Nonverbal learning disability
 Attention and executive functioning disorder

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RESEARCH:
LEARNING DISABILITIES IN
ADULTS
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RESEARCH ON ADULT LD
Problems with earlier (and some current) research
include small samples, limited test batteries, lack of
controls, inappropriate statistical methods, and
conclusions based on limited data.
 There is no “gold standard” or biological marker for LD
diagnosis, and studies define LD differently.
 Most neuropsychological research has focused on
dyslexia, perhaps because of its high prevalence and
being more easily defined.
 Most research has used college students or young adults.

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PREVALENCE OF LEARNING
DISABILITIES
General
Katz et al. (2001); Henderson (1999); Horn et al. (1999);
Sack et al. (2008)
3 to 20% in the general population
 20 to 89% of adults enrolled in ABE or GED programs
 2 to 4% of college students, based on surveys in 1996
and 1998
 2.3% of U.S. medical students were reported to have
requested accommodations, of which over 90% were for
LDs or ADHD

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PREVALENCE OF LEARNING
DISABILITIES
Specific
Katz et al. (2001)
 80%
of all LDs are estimated to affect reading.
 1 to 6% of LDs are estimated to affect
mathematics.
 1 to 10% of LDs are estimated to be nonverbal
LDs.
 10% of children in school may have LDs affecting
writing.
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NEUROPSYCHOLOGICAL FINDINGS
READING DISABILITIES-CORE DEFICITS
Birch & Chase (2004); de Gelder & Vrooman (1996); Elbro,
(1998); Hugdahl et al. (1995); Lovrich et al. (1997); Katz et al.
(2001); Paulesu et al. (2001); Shaywitz & Shaywitz (2005);
Shaywitz et al. (2006)
 The
core dyslexia deficit is in phonemic
processing and phonological awareness,
demonstrated through neuropsychological and
ERP studies. This is found cross-culturally.
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NEUROPSYCHOLOGICAL FINDINGS
READING DISABILITIES-CORE DEFICITS
Birch & Chase (2004); Cirino et al. (2005); Vukovic, et. al (2004)

Support for the double-deficit hypothesis of dyslexia
(impairment in phonological awareness/rapid visual
naming) has also been demonstrated for adults. However
support is weaker, and factors including general
processing speed, vocabulary, single-word reading, and
reading rate may better account for speeded naming
deficits.
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NEUROPSYCHOLOGICAL FINDINGS
READING DISABILITIESASSOCIATED DEFICITS
Katz et al. (2001); Isaki & Plante (1997); Ransby & Swanson
(2003)
 Associated deficits have been found in language skills
and auditory verbal-attention.
 More recent studies have found that naming speed, verbal
working memory, vocabulary, listening comprehension,
and lexical knowledge contribute independently to
reading comprehension, beyond the impact of
phonological processing.

Phonological processing may be more important for reading
acquisition, rather than for reading comprehension in adults.
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NEUROPSYCHOLOGICAL FINDINGS
READING DISABILITIES-VISUAL DEFICITS
Ben-Yehudah et al. (2001); Eden & Zeffiro (1998); Graves et al.
(1999); Hari et al. (2001); Iles et al. (2000); Vellutino et al. (2004)
 Vellutino
et al. (2004) have noted that the visual
theory of dyslexia has been largely discounted.
 However, some individuals with dyslexia show
visual psychophysical abnormalities.
 Magnocellular
pathway deficits
 More problems with visual target localization
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NEUROPSYCHOLOGICAL FINDINGS
READING DISABILITIESQUALITY OF READING
Birch & Chase (2004); Cirino et al. (2005); Shaywitz &
Shaywitz (2005); Vukovic et al. (2004)
 Dyslexic
adults are typically slow, inefficient
readers, despite having average decoding and
single-word reading skills.
 Lack
of fluency with words and/or text can affect
comprehension.
 Timed measures appear most sensitive to reading
difficulties in adults.
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NEUROPSYCHOLOGICAL FINDINGS
READING DISABILITIESQUALITY OF READING
Wilson & Leseaux (2001); Simmons & Singleton (2000)
Wilson and Leseaux found that dyslexic college students,
although average on reading and spelling measures,
scored less well than normal students and showed
weaknesses in accuracy and speed of phonological
processing.
 Simmons and Singleton reported that dyslexic college
students have more problems with inferential than with
literal reading comprehension.

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NEUROPSYCHOLOGICAL FINDINGS
MATHEMATICS DISABILITIES
Katz et al. (2001)
 Deficits
can be found in visuospatial and motor
skills, similar to what is found in children.
 Although attentional problems can contribute to
mathematics disabilities, there is no research on
this.
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NEUROPSYCHOLOGICAL FINDINGS
MATHEMATICS DISABILITIES
Greiffenstein & Baker (2002); Cirino et al. (2002)
 The
first study found that adults with mathematics
LDs had deficits in nonverbal reasoning and
constructional skills.
 In contrast, the second study of college students
referred for LD assessment found that
mathematics skills were related to semantic
knowledge retrieval and executive functioning,
but not to visuospatial skills.
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NEUROPSYCHOLOGICAL FINDINGS
MATHEMATICS DISABILITIES
Osmon et al. (2006b)
 Evidence
was found for a double deficit in college
students with mathematics disorders.
 One
group showed spatial impairment.
 A second group showed executive functioning
impairment.
 A group with impairments in both areas had the most
impaired math skills.
 Right hemisphere impairment was hypothesized.
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NEUROPSYCHOLOGICAL FINDINGS
WRITTEN LANGUAGE DISABILITIES
Connelly et al. (2006)
 College students with dyslexia wrote essays of poorer
quality due to writing more slowly, making more spelling
errors, and using fewer words than normal students.
 They made more spelling errors in their essays than
expected based on a separate spelling test.
 They also had poorer decoding and shorter listening span
 The best predictors of essay quality were handwriting
speed and spelling accuracy.
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NEUROPSYCHOLOGICAL FINDINGS
WRITTEN LANGUAGE DISABILITIES
Gregg et al. (2007)
 The
best predictors of the quality of essay writing
in college students with dyslexia were vocabulary
complexity, verbosity (length of writing), spelling,
and handwriting.
 These
factors were more important for those with
dyslexia than for normal students.
 The
authors concluded that an inability to write
fluently placed students with dyslexia at a
disadvantage on timed writing tasks.
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NEUROPSYCHOLOGICAL FINDINGS
NONVERBAL LEARNING DISABILITIES
Rourke et al (1986); Tsatsanis & Rourke (2008); Wasserstein et
al. (2008)
 There
is limited work on adults with nonverbal
LDs.
 Early work showed neuropsychological deficits
similar to those in children, along with social
deficits.
 Subsequent studies have shown deficits in
visuospatial skills, motor skills, complex problem
solving, and arithmetic.
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R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
NONVERBAL LEARNING DISABILITIES
Katz et al. (2001); Ahmad et al. (2002); Tsatsanis & Rourke
(2008)
 Cognitive
and social deficits are worse in adults
than in children, with the largest differences seen
in problem-solving, concept formation, and
hypothesis testing.
 This contrasts with similar deficits in adults and
children with language-based LDs.
 Most studies have been cross sectional.
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R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
NONVERBAL LEARNING DISABILITIES
Wasserstein et al. (2008)
 Conclusions:
 Some
adults with nonverbal LDs show the
traditional deficits, but not all do.
 Nonverbal LD may not be a unitary entity.
 Poor outcome is not universal.
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R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
GIFTED ADULTS WITH LEARNING
DISABILITIES
 There
Ferri et al. (1997); Gregg et al. (1996)
is no neuropsychological research on this
issue.
 Variability in intellectual and academic profiles
have been reported, with differences between
gifted and non-gifted adults with LDs.
 Caveats:
 Variability
in test results is the rule rather than the
exception (Schretlen et al. 2003).
 Everyone has strengths and weaknesses.
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OUTCOME AND EARLY INTERVENTION
INTERACTION BETWEEN GENES AND
ENVIRONMENT
Shaywitz et al. (2006)
 Recent longitudinal follow-up studies of adults with
dyslexia diagnosed as children found different brain
connectivity patterns on fMRI for those who developed
good reading skills and those who did not.
 The authors concluded that despite a genetic
underpinning for dyslexia, having better cognitive skills
to start and access to intervention will greatly influence
outcome.
 This reinforces the need for early intervention.
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R. L. Mapou, Ph.D., ABPP-CN
CO-OCCURRING DISORDERS AND
COMPLICATING FACTORS
PSYCHIATRIC DISORDERS
Cleaver & Whitman (1998); Gregg, et al (1992); Hooper &
Olley (1996); Hoy & Manglitz (1996); Katz et al. (2001); Vogel
& Forness (1992)
 Adults
with LDs remain at increased risk for
psychosocial and psychiatric difficulties.
 This is true for nonverbal LDs, which affect
emotional processing, as well as for languagebased LDs.
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R. L. Mapou, Ph.D., ABPP-CN
CO-OCCURRING DISORDERS AND
COMPLICATING FACTORS
PSYCHIATRIC DISORDERS
Tsatsanis & Rourke (2008); Mesulam & Weintraub (1983);
Greiffenstein & Baker (2002)
 Adults
with nonverbal LDs are especially
vulnerable to internalizing disorders because of
the impact on interpersonal skills and everyday
functioning.
 However, studies differ in the degree of
psychosocial impairment, and some individuals
have no psychosocial problems.
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DIAGNOSIS
DISCREPANCY VS. CLINICAL
APPROACHES
Seigel (1993)
Discrepancy approaches are still mandated by many
states.
 Yet, it is clear that such an approach is not useful and is
outdated, given research on learning disabilities and,
especially, dyslexia.
 Assumptions about the usefulness of discrepancy
approaches are often based on clinical lore rather than
research.

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DIAGNOSIS
DISCREPANCY VS. CLINICAL
APPROACHES
Fletcher et al. (2007)

Multiple factors contribute to underachievement:
Emotional and behavioral difficulties
 Socioeconomic factors
 Inadequate instruction


Response to instruction should be used to assess the
possibility of an LD, provided that instruction is shown
to be adequate.
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R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS
DISCREPANCY VS. CLINICAL
APPROACHES
Mapou (in preparation: Brackett & McPherson (1996); Hoy et al.
(1996)
 Fletcher
et al.’s approach has not been used with
adults.
 There is no research on response to intervention
with adults.
 Earlier, but limited research indicated that a
comprehensive, clinical approach is more
effective with adults than a discrepancy approach.
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R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS
DISCREPANCY VS. CLINICAL
APPROACHES
Mapou (In preparation); Wolf et al. (2008)

Conclusions:
 Discrepancy approaches should not be used as the basis for
learning disability diagnosis.
 Although selective assessment and/or response-to-intervention
have empirical support with children, there is no research basis
for these approaches in adults.
 Comprehensive assessment, including a consideration of
demographic, historical, emotional/behavioral, and
neuropsychological factors, currently has the most support for
assessment of learning disabilities in adults.
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R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF MOTIVATION AND
EFFORT
Osmon et al. (2006a)

In an analog study, a new computerized forced-choice
measure of reading/word matching, the Word Reading
Test, has shown promise for identifying individuals
feigning deficits of reading skill or speed.
A double dissociation was found between those asked to feign a
reading deficit vs. a speed deficit.
 The Word Memory Test also was sensitive, but less so.


Clinical studies remain to be completed.
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ASSESSMENT OF MOTIVATION AND
EFFORT
Dombroski et al. (2006); Lu et al. (2004)

In the context of personal injury litigation, Lu et al.
reported that showing a normal interference effect on the
Stroop Test identified individuals faking illiteracy.


This could potentially be used to identify feigned reading
disorders.
In contrast, Dombroski et al. found that the Rarely
Missed Index did not show sensitivity to simulated LD,
despite sensitivity to effort in those with TBI.
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ASSESSMENT OF MOTIVATION AND
EFFORT
Alfano & Boone (2007)
 Preliminary
data found that individuals diagnosed
with LDs did not fail symptom validity measures,
based on the presence of LDs alone.
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ASSESSMENT OF MOTIVATION AND
EFFORT
Sullivan et al. (2007)

A study of consecutive referrals for LD/ADHD
evaluation in a college assessment center found that
15.4% of those seeking LD evaluation and 9.4% of those
seeking LD/ADHD evaluation failed the Word Memory
Test, based on Green’s (2003) cutoffs.
This was much lower than the failure rate for those seeking
ADHD evaluation.
 It was concluded that either secondary gain was less of an issue
for LD diagnosis or else the WMT was not sensitive to this.

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R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
SPECIFIC INTERVENTIONS
Shaywitz (2003); Shaywitz & Shaywitz, (2005); Shaywitz
et al. (2006)
 Shaywitz
and colleagues have described
evidence-based programs for improving reading
skills in children and adults with dyslexia.
 Nonetheless, studies with adults are still in their
infancy.
 It is clear that intervention should occur as early
as possible.
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R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
SPECIFIC INTERVENTIONS
Eden et al. (2004); Katz et al. (2001)
 Eden et al. showed that improvement resulting from a
phonologically-targeted training program for adults with
dyslexia, which led to improvement in everyday reading
skills, was associated with changes on fMRI in brain
regions important for reading.
 No research has shown efficacy of programs to remediate
specific deficits in other LDs, and Katz et al. reported
that little work has examined the efficacy of
compensatory strategies outside the educational setting.
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R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
ACCOMMODATIONS-EXTENDED TIME
Shaywitz & Shaywitz (2005); Ofiesh & Hughes (2002)
Extended time on classroom tests is the most common
academic accommodation requested for post-secondary
education students.
 Shaywitz & Shaywitz consider it “essential.”
 A review of seven studies by Ofiesh and Hughes showed
that additional time used ranged from 50% to double
time. Factors that affected the decision about how much
time to use included educational setting, the student’s
limitations, and the test characteristics.

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R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
ACCOMMODATIONS-EXTENDED TIME
Alster (1997); Leadbetter et al. (2001); Runyan (1991); Ofiesh
et al. (2005)
Several studies have shown that extended time helps
those with LDs in reading or math, but does not help
normal learners.
 Ofiesh et al. found that the best predictors of the need for
extended time in college students were simple timed
academic tasks (i.e., WJ3ACH Academic Fluency) rather
than timed neuropsychological tasks (i.e., WAIS-III
Processing Speed).

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ADULT INTERVENTION
ACCOMMODATIONS-COURSE
SUBSTITUTION
Downey et al. (2000)


College students with dyslexia performed less well than normal
students on measures of foreign language aptitude, single-word
reading, spelling, and phonological analysis, but did not differ on
timed reading comprehension or single-word repetition.
However, they did not differ from normal students in final grades
or final scores on a translation proficiency test in a modified
foreign language class.





Courses taught by “master instructors”
Slower pace of instruction
Highly structured and predictable course content
Required daily amount of study time
Use of tutors as needed.
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ADULT INTERVENTION
ACCOMMODATIONS-COURSE
SUBSTITUTION
Sparks et al. (2003)

In contrast, these authors found that college students with LDs
seeking foreign language exemption did not differ in language
skills, academic skills, or GPA from those who did not seek
exemption.




A mediating factor appeared to be overall aptitude, as measured by ACT
scores.
Those seeking exemption had done less well in foreign language classes and
often sought first time LD evaluation because of this.
LD documentation was often inadequate.
The authors concluded that requests for foreign language
substitution should be carefully reviewed, especially if based on a
new LD diagnosis.
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R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
ACCOMMODATIONS-COURSE
SUBSTITUTION
Sparks (2006)
 There is no research support for a foreign
language LD.
 Students
with LDs do not always have trouble learning
a foreign language.
 Students who have difficulty learning a foreign
language do not differ in cognitive or academic
profiles based on the presence of a learning disability.
 IQ-achievement discrepancies have no relationship to
cognitive or academic skills in these students.
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R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
ACCOMMODATIONS-COURSE
SUBSTITUTION
Sparks (2006)

Conclusions
The ability to learn a foreign language is on a continuum.
 Variables other than a learning disability play a role.
 Native language ability, including phonological and
orthographic skills, is a strong predictor of foreign language
learning.
 More effective interventions to assist students with learning a
foreign language, similar to interventions for dyslexia, should
be developed.

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R. L. Mapou, Ph.D., ABPP-CN
RESEARCH:
ADHD IN ADULTS
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R. L. Mapou, Ph.D., ABPP-CN
RESEARCH ON ADULT ADHD
Research on ADHD has seemed more advanced and well
developed than research on LDs, perhaps because of a
“gold standard.”
 Similarly it appeared that more studies had been
published on etiology, neuropsychology, and outcome,
and that they were more rigorous than those on LDs.
 However, research on LDs has “caught up.”
 As with LDs, we are still early in the research process.

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R. L. Mapou, Ph.D., ABPP-CN
PREVALENCE OF ADHD
Murphy & Barkley (2006); Prince et al. (2006); Wender et
al. (2001); Kessler et al. (2006); Barkley et al (2008)






3 to 10 percent of school age children have been estimated to have
ADHD.
50 to 80 percent of children continue to have symptoms as adults.
Therefore, we can estimate that between 1 and 8 percent of adults
have been estimated as meeting criteria for diagnosis of ADHD.
However, Murphy and Barkley gave a lower estimate of 4 to 5
percent.
A recent population study reported a prevalence of 4.4%, but the
authors cautioned that this was conservative, due to using standard
DSM-IV criteria
Barkley et al. (2008) estimated that ADHD affects at least 5% of
adults.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
CORE DEFICITS
Barkley (2006a); Epstein et al. (1997, 1998); Jenkins et al.
(1998); Johnson et al., (2001); Seidman et al. (1997, 1998);
Schreiber et al. (1999)
 Findings
are similar to those in children.
 Individual studies have reported impairment on
measures of attention, information processing
speed, executive functioning, learning, and
memory.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
CORE DEFICITS
Hervey et al. (2004); Schoechlin & Engel (2005); Woods et al.
(2002a)
 Three reviews, including two meta-analyses have
reported that:
Impairments are evident in divided and sustained attention,
timed word generation, auditory-verbal list learning, planning,
organization, impulsivity/response inhibition, cognitive
flexibility, problem solving with working memory, and
information processing speed.
 Impairments are selective rather than global, showing the need
for multiple measures of attention and executive functioning.
 Deficits are more likely on complex measures than on simpler
measures.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
CORE DEFICITS
Boonstra, Oosterlaan et al. (2005)
 A fourth
meta analysis focusing on executive
functioning, found impairment in executive
functioning on measures of verbal fluency,
response inhibition, and set shifting, but also
found impairment in other non-executive
domains.
 However, the non-executive domains mainly
reflected attention and processing speed.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
ATTENTIONAL IMPAIRMENT
Barkley et al. (2008)
 Reaction
time variability and errors of
commission were best for discriminating between
adults with ADHD and clinical or community
controls.
 A high level of response variability may be
specific to ADHD.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
BARKLEY’S THEORY
Barkley et al. (2001); Epstein et al. (2001); Murphy et al.
(2001); Rapport et al., (2001); Wodushek & Neumann (2003);
Young et al. (2007)
 Studies
have supported Barkley’s (2006c) model,
showing deficits in response inhibition, time
estimation, interference control, and nonverbal
working memory and the impact of response
inhibition on emotion processing.
 All deficits hypothesized to be linked to frontal
lobe system dysfunction.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
NEUROPSYCHOLOGICAL FINDINGS
BARKLEY’S THEORY
Carr et al. (2006); Wiersema et al. (2006)
 More
recent studies on response inhibition are
mixed.
 Carr
et al. found a deficit in motoric inhibition, but not
attentional inhibition.
 Wiersema et al. failed to find any deficit in response
inhibition.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
PSYCHOSOCIAL FUNCTIONING
EMOTIONAL
PROCESSING/INTERPERSONAL SKILLS
Friedman et al. (2003); Rapport et al. (2002)
 Heightened
emotional responsiveness has been
linked to deficits in affect perception in adults
with ADHD providing additional support for
Barkley’s (2006c) theory.
 Adults with ADHD have also been found to have
lower social-emotional competence. Although
aware of their deficits, impulsivity prevented
them from using their knowledge effectively.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
PSYCHOSOCIAL FUNCTIONING
IMPACT ON DRIVING
Fischer et al. (2007)
 In a longitudinal study, young adults with ADHD had
higher rate of traffic citations, license suspensions, and
crashes, based on both self-report and parent report, as
well as driving records, in comparison with community
controls.
 However, the rate of adverse events was lower than in the
clinic-referred group.
 Driving simulator performance showed a range of
deficits, reflecting inattention and impulsivity.
 Ratings by driving instructors showed more impulsive
errors in an on-the-road test.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
PSYCHOSOCIAL FUNCTIONING
IMPACT ON DRIVING
Barkley et al. (2008)
 Treatment
with psychostimulant medication or
atomoxetine (Strattera) can improve driving
performance.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
CHANGES IN SYMPTOM PRESENTATION
Barkley (2006a, c); Barkley et al. (2008); Murphy & Barkley
(2006); Prince et al. (2006)
 Symptoms
of motor hyperactivity tend to
diminish with age, while problems with
inattention and impulsivity continue and affect
self-regulation, planning, organization, and time
management in everyday life.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
CHANGES IN SYMPTOM PRESENTATION
Barkley et al. (2002a); Barkley et al. (2008)

However, prevalence can be a function of the respondent
and age at the time of assessment.
Prevalence of ADHD at age 21 using DSM criteria was 12%
based on reports of the young adults, but 66% based on reports
of their parents.
 In contrast, prevalence of ADHD at age 27 was no longer found
to differ as a function of the respondent.

Roughly 50% of young adults and observers both reported persisting
symptoms that met ADHD DSM diagnostic criteria.
 An additional 20% had residual symptoms.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
PREDICTORS OF OUTCOME
Barkley (2006a);Barkley et al. (2008)
No single variable from childhood has been found to
predict adult outcome in longitudinal studies, although
several have shown relationships.
 However, co-occurrence of conduct disorder has been
found to predict anti-social behavior, drug use, school
dropout, and teen pregnancy and leads to more negative
outcomes.
 Predicting outcome is complex, as different variables
predict different aspects of outcome.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
IMPACT ON ADULT LIFE
Barkley (2006a); Barkley, Fischer, et al (2002); Biederman
et al., (1993); Fischer et al. (1990); Manuzza et al. (1993);
Seidman et al. (1998)
 Longitudinal
studies have shown lower academic
achievement, more cognitive impairment, lower
occupational attainment, and poorer social
functioning in those diagnosed with ADHD as
children.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
IMPACT ON ADULT LIFE
Barkley et al. (2008); Murphy & Barkley (2006)
 Those
followed longitudinally from childhood
tend to be more impaired than adults seeking
evaluation in a clinic.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
PSYCHIATRIC AND OTHER DISORDERS
Kessler et al (2006); Barkley et al (2008); Katz et al. (2001)
Over 80% of adults with ADHD in a population-based
study had at least one co-occurring psychiatric disorder.
 “Pure” ADHD is rare in adults.
 Multiple medications may be more necessary in
treatment of adults with ADHD than in children.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
NEUROPSYCHOLOGICAL FUNCTIONING
Fischer et al. (2005)

Longitudinal follow-up of an adult cohort diagnosed with
ADHD in childhood showed that those who still met
diagnostic criteria had more evidence of impairment in
attention, disinhibition, slowed processing speed, and
observed ADHD behavior during testing.
Co-existing anxiety added to problems, while co-existing
depression did not.
 Those with a history of conduct disorder also showed evidence
of response perseveration.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
LACK OF GENDER EFFECTS
Barkley (2006a); Barkley et al (2008); Biederman et al. (2004)
There is a higher proportion of women in clinic samples,
perhaps because they are diagnosed later than men.
 Women show cognitive impairment and psychosocial
difficulties that are similar to those of men.
 Gender differences, when present, are similar to gender
differences in normal adults.
 Women with ADHD do not appear to have problems that
are different from those of men.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
OUTCOME AND CO-OCCURRING
DISORDERS
ADHD AS A DISABLING CONDTION
Barkley et al (2008)
 The
effects of ADHD are not benign, but, rather,
lead to substantial impairment in functioning.
 ADHD does not confer any special gifts, such as
creativity.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS
DIAGNOSTIC CRITERIA
Barkley (2006a); Barkley et al. (2008)
 The
DSM-IV diagnostic criteria are too
conservative and can miss adults who have the
disorder.
 Diagnostic criteria should be adjusted for age.
 For adults, four symptoms rather than six appear
to be developmentally abnormal.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS
DIAGNOSTIC CRITERIA
Barkley & Murphy (2006); Barkley et al. (2008); Conners
et al. (1998); Riccio et al., (2005); Wender (1995)
 Diagnostic
criteria also need to be altered to
reflect the behavioral manifestations of ADHD in
adults, which differ from those of children.
 Barkley and colleagues have recently proposed a
new set of diagnostic criteria, based on initial
research.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS
NEUROPSYCHOLOGICAL TESTING
Lovejoy et al. (1999); Woods, Lovejoy, & Ball (2002);
Woods, Lovejoy, Stutts et al. (2002)
 Neuropsychological tests are modestly reliable in
detecting ADHD in adults.
Although an abnormal finding can correctly predict ADHD, a
normal finding does not indicate its absence.
 Therefore, definitive diagnosis still requires the presence of
specified symptoms and a history of the same.


Tests most sensitive to ADHD include measures of
response inhibition, timed word generation, auditoryverbal list learning, and sustained attention (continuous
performance tests; CPTs).
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS
NEUROPSYCHOLOGICAL TESTING
Katz et al. (1998); Walker et al. (2000); Woods, Lovejoy &
Ball (2002)
Neuropsychological measures are sensitive, but not
specific.
 Individuals with psychiatric disorders can show similar
neuropsychological deficits to those with ADHD, with
poor predictive power when discriminating between
psychiatric disorders and ADHD.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS
SELF-REPORT MEASURES
Hill et al. (2006); McCann et al. (2000); Murphy & Barkley
(2006); Murphy & Schachar, (2002); Zucker et al. (2002);
Barkley et al (2008)
Similarly, rating scales may be sensitive to problems due
to other psychiatric disorders or to demographic factors.
 Caution must be taken with retrospective rating scales of
ADHD symptoms, although modest relationships
between ratings from adults with ADHD and their
parents have been reported.
 A multi-dimensional assessment is essential.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF MOTIVATION AND
EFFORT
Alfano & Boone (2007); Harrison et al. (2007); Sullivan et
al. (2007); Harrison (2006)
 Faking ADHD
may be done to provide access to
psychostimulant medication and
accommodations.
 Harrison (2006) found that 20% of students
seeking evaluation for ADHD showed evidence of
poor effort based on typical criteria established
for other disorders.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF MOTIVATION AND
EFFORT
Leark et al. (2002); Henry (2005); Quinn (2003)

CPTs can be useful to detect faking of ADHD,
particularly when results on symptom rating scales are
positive for ADHD.
Instructions to “fake bad” on the Test of Variables of Attention
led to much poorer performances than did standard instructions.
 Probable malingers in a group of mild TBI patients performed
less well on the Test of Variables of Attention.
 A study of college students by Quinn using the Integrated
Visual and Auditory CPT found that those instructed to fake
ADHD showed poorer performance than did those who were
actually diagnosed with ADHD.


Both groups endorsed a similar number of ADHD symptoms, however.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF MOTIVATION AND
EFFORT
Harrison et al. (2007)
 Simple
timed academic and processing speed
measures (WJ3) may also be sensitive, as shown
by slower speed and more errors in students
instructed to fake ADHD, in comparison with
normal controls and those with ADHD.
 These same students also reported more ADHD
symptoms on the Conners Adult ADHD Rating
Scale than those with ADHD.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF MOTIVATION AND
EFFORT
Sullivan et al. (2007); Fisher and Watkins (2008)

Using Green’s (2003) cutoffs, Sullivan et al. found a
failure rate of 47.6% on the WMT among those seeking
evaluation for ADHD.


Poorer performance on the WMT also correlated with lower
Performance IQ, poorer memory skills, and endorsement of
more symptoms on the CAARS.
Fisher et al. found that five minutes of studying
information on ADHD enabled 77% to 93% of students
to produce a credible ADHD symptom profile.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
PSYCHOPHARMACOLOGICAL
TREATMENT
Horrigan & Barnhill (2000); Maidment (2003); Prince et al.
(2006); Saffren, Otto et al. (2005); Spencer, Biederman,
Wilens et al. (2001)

Psychostimulants are the most effective treatment, with a response
rate 25% to 78%.






Studies have examined Ritalin, Dexedrine, Adderall, Focalin, and the
extended release versions in adults.
Response rates are lower than in children.
Differences across studies reflect study differences in diagnostic criteria,
stimulant dosage levels, high levels of co-occurring disorders, and different
methods of measure response.
Up to 50% of adults may not respond or have side-effects that prevent use of
psychostimulants.
Medications do not treat co-occurring psychiatric disorders.
More data are needed to confirm long-term efficacy.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
PSYCHOPHARMACOLOGICAL
TREATMENT
Spencer et al. (1998); Michelson et al. (2003); Prince et al.
(2006); Barkley et al. (2008)
Strattera (atomoxetine), a noradrenergic agonist, has been
added to the list of effective treatments, although
anecdotal reports suggest that it is more effective for
depression than for ADHD.
 It may be a better choice than psychostimulants for adults
with co-occurring mood, anxiety, tic, or substance abuse
disorders.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
PSYCHOPHARMACOLOGICAL
TREATMENT
NEUROPSYCHOLOGICAL EFFECTS
Boonstra, Kooij et al. (2005); Wilson et al. (2006)
 Two
studies have shown improvement in
neuropsychological functioning with stimulant
treatment (Ritalin, Concerta, Adderall XR) in late
adolescents and adults.
 The effects of Adderall were seen as long as 15
hours after administration.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
PSYCHOPHARMACOLOGICAL
TREATMENT
SUBSTANCE ABUSE
Wilens (2004); Barkley et al. (2008); Wilens et al. (2003);
Levin et al. (1998)





Substance abuse frequently co-occurs with ADHD.
Psychostimulant treatment in childhood may be protective against
substance abuse.
Psychostimulants may be effective when treating adults with
substance abuse.
However, it may be better to begin with non-psychostimulant
medication, such as Wellbutrin or Strattera.
Treatment of ADHD is crucial when treating substance abusers,
because of the impact ADHD on self-regulation.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
Nadeau (1995); Saffren, Perlman et al. (2005); Wender et
al. (2001); Wasserstein & Lynn (2001)
Medication does not address educational issues,
problematic social interactions, nor ways to compensate
for difficulties.
 Also, many adults do not respond well to medication.
 Unfortunately, there is little research showing efficacy
for methods to treat these problems in adults with
ADHD, despite a large popular literature and several
scholarly works.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
COGNITIVE BEHAVIORAL THERAPY
Rostain & Ramsay (2006); Ramsay & Rostain (2008)
Saffren, Otto et al. (2005); Saffren, Perlman et al. (2005)
Stevenson et al. (2002)





Group-based and individually based CBT has been used effectively
in these studies to treat problems associated with ADHD.
Programs included psychoeducation and modules to address
problems with organization and planning, distractibility,
motivation, concentration, listening, impulsivity, stress
management, anger control, and communication.
Participants remained on medication.
A reduction in ADHD symptoms, anxiety, depression, and other
problems were reported by participants and independent raters.
Books to guide treatment have been published.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
NEUROFEEDBACK
Riccio & French (2004)
 In
a review of empirical support for treatment of
attention deficits, Riccio and French concluded
that there was tentative support for EEG
biofeedback treatment of adults with ADHD.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
ASSISTIVE TECHNOLOGY
Hecker et al. (2002)
 Use
of the Kurzweil 3000 assistive reading
software program helped college students with
ADHD better attend to reading more effectively
for longer periods and helped reduce stress and
fatigue from reading, but did not improve
comprehension.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
ACCOMMODATIONSEXTENDED TIME
Leadbetter et al. (2001)
 Extended
time on reading comprehension tests
improved scores of college students with
ADHD/depression or with a reading disability, but
resulted in far less improvement for those with
ADHD alone.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADULT INTERVENTION
ACCOMMODATIONSCOURSE SUBSTITUTION
Sparks et al. (2004)
 College
students with ADHD had little difficulty
passing both lower and upper level foreign
language courses.
 ADHD alone should not be grounds for foreign
language substitution.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF
LEARNING DISABILTITES
AND
ADHD
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT COMPONENTS
Mapou (2004, 2008)
 History
interview
 Record review
 Interview focused on ADHD symptoms
 Behavioral rating scales (self and other report)
 Intellectual/academic/cognitive evaluation,
including behavioral observations
 Personality/emotional assessment
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
HISTORY
Early Development
III.
A.
B.
C.
D.
E.
F.
G.
Pregnancy, labor, and delivery
Problems immediately following birth
Developmental milestones
Serious illnesses or injuries
Frequent ear infections and drainage tube placement
Febrile or other types of seizures
Primary language
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
HISTORY
Education
IV.
A.
B.
C.
D.
E.
F.
Early subject-specific difficulties
Attentional problems and hyperactivity
Diagnosed LD or ADHD
Special education, accommodations, tutoring, and other
assistance in primary and secondary education (e.g.
Individualized Education Program or 504 Plan)
Repeated grades and reasons
Results of standardized testing (e.g., psychoeducational,
yearly, entrance examinations)
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
HISTORY
Education
IV.
Total number of years in school
Grades in high school, college, and beyond
Specific problems in high school and college
G.
H.
I.
1.
2.
3.
4.
AACN June 2008
Paying attention and taking notes in class
Paying attention when studying
Retaining studied material
Completing tests in the allotted time
R. L. Mapou, Ph.D., ABPP-CN
HISTORY
Education (Continued)
IV.
Specific problems in high school and college
I.
Retrieving studied information when tested
Problems with specific test formats
Time management and procrastination
Not turning in work
Failed or incomplete courses
Selecting college classes to maximize grades
5.
6.
7.
8.
9.
10.
J.
K.
Accommodations and support in post-secondary education
Degrees received
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
RECORD REVIEW









Report cards with teacher comments
Standardized academic testing (e.g. CTBS, CTP III, CAT, OtisLennon, Iowa, Stanford)
Secondary School Admission Test
College entrance examinations (e.g., SAT, ACT)
Graduate/professional school entrance examinations (e.g., GRE,
GMAT, LSAT, MCAT)
Transcripts from college and postgraduate study
Letters documenting accommodations from testing agencies and
university disability support services
Reports from previous evaluations
Medical records
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
TAKE HOME POINT:
A DETAILED HISTORY IS
KEY
TO UNDERSTANDING A CLIENT
AND ESSENTIAL
FOR GETTING
ACCOMMODATIONS
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
BEHAVIORAL RATING SCALES
Wender Utah Rating Scale and Parents’ Rating Scale
(WURS and PRS; Ward et al., 1993)
 Childhood and Current ADHD Symptoms Scales
(DuPaul et al., 1998; Murphy & Barkley, 1996)
 Brown Attention Deficit Disorder Scales (BADDS;
Brown, 1996)
 Conners’ Adult ADHD Rating Scales (CAARS; Conners
et al., 1998)
 Behavior Rating Inventory of Executive FunctioningAdult Version (BRIEF-A; Roth et al., 2005)

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERVIEW FOCUSED ON ADHD
SYMPTOMS
Wender (1995); Mapou (2006, in preparation)
 Physical
or cognitive restlessness
 Problems with attention and concentration when
listening to others
 Difficulty remembering things told to you
 Problems with attention and concentration when
reading or studying
 Difficulty comprehending and remembering
written material
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERVIEW FOCUSED ON ADHD
SYMPTOMS
 Forgetfulness
 Organizational
difficulties (School, work, home)
 Time management difficulties and procrastination
 Problems with initiation and follow-through
 Impulsivity in speaking or acting
 Risk-taking
 Emotional lability, temper, stress management
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERVIEW FOCUSED ON ADHD
SYMPTOMS
Barkley et al. (2008); Barkley (2007)
 New
criteria proposed for adults with ADHD,
which have empirical support, can be used to
guide an interview.
 Barkley’s Quick Check for Adult ADHD
Diagnosis can be used to guide an interview for
past and current symptoms
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
FRAMEWORK FOR COGNITIVE ASSESSMENT
Mapou (1995, 2004, 2008)
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Mapou (2004, 2008)
 Items
with an asterisk make up my core battery.
 Additional measures from the group are selected,
based on the referral question.
 This not a definitive nor comprehensive test list.
 There
are other measures that can be chosen
 These can be used as part of a psychoeducational or
neuropsychological assessment.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
(Mapou, 2008)
Global Functioning
Measures Used
Intellectual Functioning
WAIS-III*
Academic Skills
Reading
Decoding
Recognition
Automaticity
AACN June 2008
WJ3ACH Word Attack*
WIAT-II Pseudoword Decoding
WJ3ACH Letter-Word Identification*
WIAT-II Word Reading
Test of Word Reading Efficiency
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Global Functioning
Academic Skills
Reading
Comprehension
AACN June 2008
Measures Used
WJ3ACH Reading Fluency*
Nelson-Denny Reading Test*
SATA Reading Comprehension
Gates-MacGinitie Reading Test – Level AR
WIAT-II Reading Comprehension
WJ3ACH Passage Comprehension
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Global Functioning
Measures Used
Academic Skills
Writing
Encoding
WJ3ACH Spelling of Sounds
Spelling/Writing Mech. WJ3ACH Spelling*
SATA Writing Mechanics
WIAT-II Spelling
Expressive
WJ3ACH Writing Fluency*
WIAT-II Written Expression*
SATA Writing Composition
WJ3ACH Writing Samples
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Global Functioning
Academic Skills
Arithmetic
Calculational Skills
Measures Used
Problem-Solving
Knowledge/Concepts
AACN June 2008
WJ3ACH Math Fluency*
WJ3ACH Calculation*
WRAT-4 Arithmetic
SATA Math Calculation
WIAT-II Numerical Operations
WJ3ACH Applied Problems
SATA Math Application
WIAT-II Math Reasoning
WJ3ACH Quantitative Concepts
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Foundation Skills
Attention
Deployment
Alertness
Focused attention
Sustained attention
AACN June 2008
Measures Used
Observation
WAIS-II Digit Symbol*
WAIS-III Symbol Search*
WAIS-III Processing Speed Index*
WJ3COG Visual Matching, Decision
Speed, and Processing Speed score
or Trail Making Test and Digit
Vigilance Test*
IVA Continuous Performance Test or
Test of Variables of Attention*
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Foundation Skills
Attention
Encoding
Span of attention
AACN June 2008
Measures Used
WAIS-III or WMS-III Digit Span
Forwards*
California Verbal Learning Test-II,
Trial 1*
WJ3COG Memory for Sentences*
WMS-III Logical Memory I, 1st
Recall Total*
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Foundation Skills
Attention
Encoding
Resistance to
interference
Mental manipulation/
divided attention
AACN June 2008
Measures Used
Consonant Trigrams
WAIS-III or WMS-III Digit Span
Backwards*
WAIS-III Arithmetic*
WAIS-III Letter-Number Sequencing*
WAIS-III Working Memory Index*
Paced Auditory Serial Addition Test
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Foundation Skills
Motor Skills
Strength
Speed
Dexterity
Measures Used
Grip Strength
Finger Tapping
Grooved Pegboard
Executive Functions, Problem-Solving Skills, & Reasoning Abilities
Planning and ProblemTower of LondonDX-2nd Edition*
Solving
D-KEFS 20 Questions*
D-KEFS Tower Test
Porteus Maze Test
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Foundation Skills
Measures Used
Executive Functions, Problem-Solving Skills, & Reasoning Abilities
Flexibility of Thinking
Wisconsin Card Sorting Test
Organization
AACN June 2008
California Verbal Learning Test-II,
Semantic vs. Serial Clustering*
Rey-Osterrieth Complex Figure Test,
Copy*
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Foundation Skills
Measures Used
Executive Functions, Problem-Solving Skills, & Reasoning
Abilities
Reasoning
WAIS-III Similarities,
Comprehension,
Picture Completion, Picture
Arrangement, and Matrix
Reasoning*
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Modality-Specific Skills
Language Skills
Phonological Awareness
AACN June 2008
Measures Used
Comprehensive Test of Phonological
Processing
WJ3COG Sound Blending,
Incomplete Words, and Phonemic
Awareness Cluster score
WJ3ACH Sound Awareness (with
above, gives Phonemic Awareness
3 Cluster score)
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Modality-Specific Skills
Language Skills
Comprehension
Single Word
Complex
AACN June 2008
Measures Used
WAIS-III Vocabulary*
Peabody Picture Vocabulary Test-III
WJ3ACH Understanding Directions*
OWLS Listening Comprehension or
WJ3ACH Oral Comprehension and
Listening Comprehension Cluster*
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Modality-Specific Skills
Language Skills
Production
Naming
Measures Used
Boston Naming Test or WJ3ACH
Picture Vocabulary*
Speeded Naming
WJ3COG Rapid Picture Naming
Single Word
Controlled Oral Word Association Test
(Letters F,A,S and animals) or
D-KEFS Verbal Fluency
Sentence and Discourse Observation*
TLC-E Level 2 Oral Expression
OWLS Oral Expression
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Modality-Specific Skills
Language Skills
Foreign Language
Aptitude
AACN June 2008
Measures Used
Modern Language Aptitude Test
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Modality-Specific Skills
Visuospatial Skills
Perception
Construction
AACN June 2008
Measures Used
Boston Naming Test-visual errors*
Rey-Osterrieth Complex Figure
Test*
WJ3COG Spatial Relations and
Visual Closure
WAIS-III Block Design*
Rey-Osterrieth Complex Figure Test,
Copy*
WAIS-III Object Assembly
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Integrated Skills
Learning and Memory
Verbal
Visual
AACN June 2008
Measures Used
California Verbal Learning Test-II*
WMS-III Logical Memory*
Rey-Osterrieth Complex Figure Test,
Immediate and Delayed Recall*
WMS-III Family Pictures or Faces*
WAIS-III Digit Symbol-Incidental
Learning*
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT PROCEDURES
Personality and Emotional Assessment
MMPI-2
Symptom Checklists (For those with reading difficulties)
Beck Depression Inventory
Beck Hopelessness Scale
Beck Anxiety Inventory
SCL-90-R
Projective testing not routinely used (see Smith et al., 2007
for cautions against using the Rorschach
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF MOTIVATION AND
EFFORT: SHOULD WE USE SYMPTOM
VALIDITY MEASURES?
 ADHD
and LD are developmental disorders.
 There
must be some evidence of problems dating to
childhood.
 These disorders do not suddenly appear in college or
beyond.
 There
are established cognitive profiles for LDs.
 Data
should be consistent with expectations.
 Results
AACN June 2008
should be consistent with prior testing.
R. L. Mapou, Ph.D., ABPP-CN
ASSESSMENT OF MOTIVATION AND
EFFORT: SHOULD WE USE SYMPTOM
VALIDITY MEASURES?
 Test
data should be consistent with everyday
difficulties.
 Exceptionally
poor performances are suspicious.
 Use
embedded neuropsychological measures.
 The WMT may be sensitive to feigned ADHD.
 There
are no studies of other measures.
 The
Stroop test may be sensitive to feigned
reading disability.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ABBREVIATED BATTERIES
Linked to documentation requirements
 WAIS-III
 WJ3ACH Word Attack, Letter-Word Identification,
Reading Fluency, Spelling, Writing Fluency (Math
Fluency and Calculation if math is an issue)
 Nelson-Denny Reading Test, Comprehension section,
with standard and extended time
 WIAT-II Written Expression (if writing or speed when
writing is an issue)
 Sampling of core neuropsychological measures that are
marked with an asterisk, based on the referral question

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSTIC ISSUES
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS OF LEARNING
DISABILITIES
 No
one accepted method
 Aptitude-achievement discrepancy models
 Regression models
 Simple cutoff score
 Research-based clinical model (Matarazzo, 1990),
which is supported by legal precedent.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIAGNOSIS OF LEARNING
DISABILITIES
 Clear
weakness in a specific academic skill or
cognitive realm
 Neuropsychological profile is consistent with
research findings about the disorder
 Difficulties are consistent with the person’s
everyday functioning
 The problem is disabling
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
READING DISABILITIES
 Phonological
awareness
 Spoken language comprehension
 Single
word (vocabulary)
 Sentence and discourse level
 General
knowledge
 Span for auditory-verbal information
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
READING DISABILITIES

Word retrieval
Confrontation naming
 Rapid visual naming
 Timed word generation (verbal fluency)


Phonological and orthographic skills
Decoding when reading
 Single-word reading
 Encoding when spelling
 Spelling

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
READING DISABILITIES
 Automaticity
when reading single words
 Fluency when reading text
 Timed vs. extended time reading comprehension
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
MATHEMATICS DISABILITIES
Attention
 Planning, organization, and problem-solving
 Visuospatial skills
 Semantic knowledge
 Fluency when completing simple math facts
 Written calculation
 Word problem solving (written and mental)
 Mathematical knowledge and concepts

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
WRITTEN LANGUAGE DISABILITIES
 Fine
motor speed and dexterity
 Handwriting quality
 Fluency when writing words and sentences
 Phonological and orthographic skills
 Encoding
when spelling
 Spelling
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
WRITTEN LANGUAGE DISABILITIES
 Oral
sentence formulation
 Verbal organization
 Essay writing
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
NONVERBAL LEARNING
DISABILITIES
 Interpersonal
skills
 Visuospatial skills
 Attention
 Fine motor skills
 Executive functioning, problem-solving, and
reasoning abilities
 Mathematics
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
American Psychiatric Association (2000)
 DSM-IV
Criteria
 6/9
inattention symptoms
 6/9 hyperactive/impulsive symptoms
 Childhood onset
 Impairment in two or more settings, noted in social,
academic, or occupational functioning
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
Wender (1995)

Utah Criteria (Use Wender-Reimherr Attention Deficit
Disorder Scale to assess)
Specifically designed for adults
 Childhood onset, meeting DSM criteria
 Attentional difficulties and motor hyperactivity, together with
two of the following five symptoms: affective lability;
disorganization, inability to complete tasks; hot temper,
explosive short-lived outbursts; impulsivity; emotional overreactivity
 Exclusion of other disorders that better account for symptoms

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
Barkley et al. (2008)
Has six (or more) of the following symptoms
that have persisted for at least 6 months to a
degree that is maladaptive and
developmentally inappropriate:
A.
1.
2.
3.
Often is easily distracted by extraneous stimuli
Often makes decisions impulsively
Often has difficulty stopping activities or behavior
when he or she should do so
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
Barkley et al. (2008)
Criteria continued
A.
4.
5.
6.
Often starts a project or task without reading or
listening to directions carefully
Often shows poor follow-through on promises or
commitments he or she may make to others
Often has trouble doing things in their proper order
or sequence
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
Barkley et al. (2008)
Criteria continued
A.
7.
8.
9.
Often more likely to drive a motor vehicle much
faster than others (excessive speeding) [Alternate
symptom for those adults with no driving
experience: Often has difficulty engaging in leisure
activities or doing fun things quietly]
Often has difficulty sustaining attention in tasks or
leisure activities
Often has difficulty organizing tasks and activities
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
Barkley et al. (2008)
B.
C.
Some symptoms that caused impairment were
present in childhood to adolescence (before age
16 years).
Some impairment from the symptoms is
present in two or more settings (e.g., work,
educational activities, home life, community
functioning, social relationships).
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
Barkley et al. (2008)
D.
E.
There must be clear evidence of clinically significant
impairment in social, educational, domestic (dating,
marriage or cohabiting, financial, driving, childrearing, etc.), occupational, or community
functioning.
The symptoms do not occur exclusively during the
course of a Pervasive Developmental Disorder,
Schizophrenia, or other Psychotic Disorder and are
not better accounted for by another mental disorder
(e.g., Mood Disorder, Anxiety Disorder, Dissociative
Disorder or a Personality Disorder).
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD DIAGNOSTIC CRITERIA
Barkley (2007)
 For
adults reporting six of the adult symptoms
and four of the DSM-IV childhood symptoms
 87%
likelihood of having ADHD
 13% likelihood of having another psychiatric disorder
 0% likelihood of being normal
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
VALUE AND IMPORTANCE OF
NEUROPSYCHOLOGICAL
ASSESSMENT
Establish the presence of a co-occurring learning
disability
 Determine whether a learning disability or other
neuropsychological disorder better explains symptoms
 Provide information for developing interventions and
compensatory strategies
 Special educators and college counselors note that an
ADHD diagnosis alone is insufficient for designing an
intervention program for students

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ADHD AND SIMILAR DISORDERS
 WAIS-III
IQ and Indices profile
 Attention
 Executive
functions, problem-solving skills, and
reasoning abilities
 Learning and memory
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIFFERENTIAL DIAGNOSIS
A history dating to childhood must be established.
 Diagnosis cannot be based solely on test results.
 Co-occurring disorders are common.

Psychiatric disorders
 Those with LD or ADHD may be at higher risk for traumatic
brain injury, alcoholism, or substance abuse because of
impulsivity, risk-taking, and low self-esteem.


Differential diagnosis requires a careful history and
review of cognitive test results, all considered in the
context of the whole person.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
DIFFERENTIAL DIAGNOSIS

Must rule these out as the primary cause
Neurological disorders
 Psychiatric disorders, including alcohol/substance abuse
 Medical disorders

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CLIENT FEEDBACK
AND
DOCUMENTATION
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
THE INTERPRETIVE CONFERENCE
Mapou (2004, 2008)

Feedback is a key component of the evaluation
 Provide test scores, interpreted within a cognitive framework
 Explain the meaning and limitation of each
 Discuss how weaknesses can affect everyday functioning, with
examples
 Discuss how to use strengths
 Provide recommendations
 Answer questions
 Provide a brief written summary, if the report will be delayed.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
GUIDELINES FOR DOCUMENTATION
Association on Higher Education and Disability (1997, July).
Guidelines for documentation of a learning disability in
adolescents and adults.
Educational Testing Service (2007). Policy statement for
documentation of a learning disability in adolescents and
adults (2nd. Edition).
Educational Testing Service (1999, June). Policy statement
for documentation of attention-deficit/hyperactivity disorder in
adolescents and adults (Revised; Second revision in process).
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
GUIDELINES FOR DOCUMENTATION
These guidelines have been adapted by other
organizations responsible for “high stakes” entrance
examinations (e.g., GRE, GMAT, LSAT, MCAT) and
professional examinations (e.g. USMLE, medical boards,
bar examinations).
 Guidelines can vary slightly among organizations, and
changes occur periodically. Guidelines, along with
necessary forms for the examiner to complete, can be
found on the organizations’ websites.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
GUIDELINES FOR DOCUMENTATION
ETS (1999, 2007)
 On
letterhead, with evaluator signature and
credentials
 Be current (within 3 years for ADHD and 5 years
for LD).
 ETS
has new guidelines for waiving comprehensive
evaluation, if certain criteria are met.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
GUIDELINES FOR DOCUMENTATION
 Comprehensive
evaluation including
 A complete
history relevant to the disability, showing
that the disability has been present since childhood,
even if undiagnosed.
 For LD, include a full assessment of cognitive and
academic skills, including a list of all measures and
standard scores.
 Qualitative
information can supplement, but cannot replace
this.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
GUIDELINES FOR DOCUMENTATION

Comprehensive evaluation including
For ADHD, show that the diagnostic criteria have been met
through diagnostic interview, history, and a review of current
symptoms, beyond the test results.
 An interpretation of the results
 A clearly stated diagnosis
 A description of the functional limitations
 Recommendations, including a rationale for accommodations


Supplementary information can be included (IEP or 504
Plan, transcripts, letter from disability support service,
etc.).
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERPRETATION OF THE ADA




Many testing agencies have equated the “average” person standard
with average test scores (e.g, Gordon and Keyser, 1998).
However, average test scores alone do not reflect the way in which
a task is done or the time needed to do a task in comparison with
most people (who have little or no difficulty with a task in
everyday life).
They have also interpreted the impact of the disability with
reference to the general population and not to one’s peer group.
This has worked against gifted and talented (high IQ) individuals
with LDs, although the new ETS (2007) Guidelines now refer to
gifted/LD individuals.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERPRETATION OF THE ADA
BARTLETT v. THE NEW YORK STATE
BOARD OF LAW EXAMINERS (2001)
 Bartlett,
who had received accommodations in
law school, was initially denied accommodations
on the bar examination because
 She
had successfully completed a Ph.D. and law
school.
 Many of her scores on the psychoeducational
evaluation were average.
 The
case reached the U.S. Supreme Court and
was remanded back to the original court.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERPRETATION OF THE ADA
BARTLETT v. THE NEW YORK STATE
BOARD OF LAW EXAMINERS (2001)

The court concluded that Bartlett had a significant
functional limitation in reading and in her ability to work.
She did not read in the way that “most people do.”
 Her lack of fluency and automaticity were consistent with the
problems experienced by adults with reading disorders.
 The lengths to which she went to avoid reading and writing
were evidence of how limited she was.
 Her use of compensatory strategies did not correct, mitigate, or
improve her slow reading speed.
 Her use of compensatory strategies led to fatigue, which slowed
her even more.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERPRETATION OF THE ADA
BARTLETT v. THE NEW YORK STATE
BOARD OF LAW EXAMINERS (2001)
The court concluded that the “average person standard”
was not meant to be specific to test scores, because many
tests were not designed to assess skills in adults.
 Rather, the standard is not being able to complete tasks
“in the way that most people do.”
 An evaluation must include evidence of limitations in
everyday activities; test scores alone are insufficient to do
this.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERPRETATION OF THE ADA



Nonetheless, testing agencies and educational institutions have
become increasingly conservative when applying the ADA
guidelines, even for individuals with documented LD/ADHD and
a history of accommodations.
As an example, most people in medical school are above average
and do not fall below the “average person” standard.
Consequently, obtaining accommodations for LD or ADHD on the
USMLE is extremely difficult, and obtaining accommodations
“lower level” entrance exams has become more difficult.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
KEY POINTS FOR OBTAINING
ACCOMMODATIONS
For developmental disorders, symptoms must have been
present in childhood, even if they did not become
functionally limiting until later in life.
 The client must be disabled in comparison with most
people.

Impaired scores must be below the level of most people.
 Gifted/LD individuals have a far harder time qualifying.

There must be evidence of educational impact, seen in
grades and/or standardized test scores.
 Simply having a disorder does not mean it is disabling.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
KEY POINTS FOR OBTAINING
ACCOMMODATIONS
Ask the client how s/he completes tasks affected by the
LD/ADHD and document this in the report. It is
especially important to document how the disability
affects the client in everyday life.
 Obtain information from instructors and professors
showing how the LD/ADHD is affecting the client in
class.
 If the client has been receiving accommodations and has
good grades, state that s/he has done well because of
having been accommodated, extensively tutored,
medicated, at great emotional cost, etc.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
KEY POINTS FOR OBTAINING
ACCOMMODATIONS
Always complete testing with the person taking any
needed medication, as this is how s/he will be completing
the examination.
 Support test data with qualitative observations of how the
client completes the measures. Show that the disability
affects him/her in multiple settings.
 Specify exactly how much extended time is needed (i.e.,
50% or 100%) and make it reasonable, based on the
degree of disability It may also be necessary to specify
for which sections of the test this applies.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
KEY POINTS FOR OBTAINING
ACCOMOMDATIONS

When recommending extended time, state how the client
will make use of that time (e.g., rereading material,
applying compensatory metacognitive strategies, using
imagery), based on the client’s report, observations, and
potential compensatory strategies.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
FINAL THOUGHTS ON DISABILITY
DETERMINATION
Colleges and even post-graduate programs are often more
open to providing accommodations than are high-stakes
testing organizations.
 Nonetheless, one must be realistic when the problems are
mild or when individuals are gifted, particularly because
of inconsistent interpretation of the ADA.
 It is reasonable to consider that the requirements for entry
into certain professions should be more stringent.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
FINAL THOUGHTS ON DISABILITY
DETERMINTION
 Uniform
determination of disability will prevent
individuals from being denied accommodations at
a later point.
 College (and even high school) students should be
counseled realistically about the chances for
accommodations, if they are considering medical
school.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ACCOMMODATIONS
AND
INTERVENTIONS
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ACCOMMODATIONS FOR
SCHOOL

Testing Accommodations
Extended time (50% to 100%)
 Individual or small group testing
 Extra breaks
 Laptop computer for writing tests and/or note-taking
 Calculator
 Reader/audio format/use of technology for tests
 Scribe (amaneuensis)
 Alternate examination format
 Specific written examination format

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ACCOMMODATIONS FOR
SCHOOL
 Class
accommodations
 Textbooks
in audio form
 Preferential seating
 Permission to record lectures
 Note-taker
 Copies of overheads/PowerPoints
 Proofreading assistance
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ACCOMMODATIONS FOR
SCHOOL
 Program
 Course
accommodations
substitution
 Foreign
language
 Mathematics
 Priority
registration
 Reduced course load
 Extended time line for graduation
 Access to tutorial and other support services
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ACCOMMODATIONS FOR THE
WORKPLACE
The reality of obtaining accommodations is different
from being eligible for accommodations.
 Employers may find a way to reject a client who selfdiscloses a learning disability or ADHD and requests
accommodations during an interview.
 It is better to obtain the job, “sweat it out,” and
demonstrate one’s value to the workplace before
requesting accommodations.
 Implementation of accommodations may be facilitated by
a psychologist, vocational counselor, or job coach.

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
ACCOMMODATIONS FOR THE
WORKPLACE










Computer technology for reading, writing, and scheduling
Books and technical manuals in audio form
Dictation services
Written instructions
Note-taking services at meetings
Breaking assignments into smaller pieces, with deadlines for each
Handling only one project at a time
Individual office
Modification of job demands
Changing positions
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
SOFTWARE AND ASSISTIVE
TECHNOLOGY

Reading

Books in audio form
Recording for the Blind and Dyslexic; www.rfbd.org
 Bookshare.org
 Library services for the disabled



Kurzweil 3000
Writing
Texthelp Read and Write Gold
 Word Q
 Dragon Naturally Speaking or Via Voice for dictation

AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
SOFTWARE AND ASSISTIVE
TECHNOLOGY
 Writing
and organization: Inspiration
 Universal design for instruction used by all
students
 Specific
programs, such as Blackboard, that present
information and permit tests to be taken on the web
 Broader use of the Internet for posting class schedules,
syllabi, PowerPoints, and handouts
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERVENTION
Medication
 Evidence-based intervention for reading

Fluency and comprehension
 Phonological awareness
 Automaticity of decoding and single-word reading
 Intensity is key, particularly if the deficit is longstanding


Tutoring, to remediate weaknesses, develop study skills,
and work on specific subjects
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
INTERVENTION
 Coaching
for problems with executive functioning
(ADHD), including the use of technology
 Psychotherapy
 Self development and growth
 Bibliotherapy
 Support
AACN June 2008
groups
R. L. Mapou, Ph.D., ABPP-CN
OTHER RECOMMENDATIONS
 Additional
evaluations (medical, neurological,
sleep, speech-language)
 Vocational/career counseling
 Legal advice or advocacy
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE EXAMPLES
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
38-year-old male with veterinary degree. unable to pass
licensing exam. History of problems with reading and
attention.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
BEHAVIORAL RATING SCALES
Wender Utah Rating Scale Total score: 9 (-)
Parents’ Rating Scale
Total score: 7 (-)
Barkley’s Childhood ADHD Rating Scale
Score
Self
Mother
Inattentive Symptoms
2 (-)
4 (-)
Hyperactive/Impulsive Sx. 9 (-)
7 (-)
Total Symptoms
11 (-)
11 (-)
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
BEHAVIORAL RATING SCALES
T-score
CAARS Scale
Self
Inattention/Memory Problems 54
Hyperactivity/Restlessness
61
Impulsivity/Emotional Lability 45
Problems with Self-Concept
51
DSM-IV Inattentive Sx
61
DSM-IV Hyper.-Imp. Sx
59
DSM-IV ADHD Sx Total63
62
ADHD Index
54
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
T-score
Wife
56
55
55
58
61
60
56
CASE FF
BEHAVIORAL RATING SCALES
T-score
BRIEF-A Scale
Self
Inhibit
68*
Shift
48
Emotional Control
43
Self Monitor
46
Behavioral Regulation Index 51
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
T-score
Wife
65*
62
51
56
58
CASE FF
BEHAVIORAL RATING SCALES
T-score
BRIEF-A Scale
Self
Initiate
61
Working Memory
71*
Plan/Organize
64
Task Monitor
56
Organization of Materials
48
Metacognition Index
61
T-score
Wife
57
63
56
55
52
57
Global Executive Composite
58
AACN June 2008
57
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
INTELLECTUAL SKILLS
WAIS-III
Verbal IQ: 108
Verbal Comprehension Index: 96
Performance IQ: 124
Perceptual Organization Index: 130
Verbal subtest scores ranged from 7 to 17, Performance subtest
scores ranged from 10 to 17.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LANGUAGE SKILLS
AUDITORY PHONLOGICAL AWARENESS
WJ3COG Subtest/Cluster STD
Sound Blending
98
Incomplete Words
110
Phonemic Awareness
102
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ACADEMIC SKILLS
WJ-III Reading Subtest/Cluster
Word Attack
Letter-Word Identification
Basic Reading Skills
AACN June 2008
STD
96
(6 errors)
111(2 errors)
105
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ACADEMIC SKILLS
WJ-III Writing Subtest
Spelling of Sounds
Spelling
Writing Fluency
STD
109
102
101
(1 error)
WJ-III Summary Score
STD
Phoneme/Grapheme Knowledge 100
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LANGUAGE SKILLS
COMPREHENSION
WAIS-III Measure AASS
Vocabulary
11
Gaps in his word knowledge
COMPREHENSION
WJ3ACH Subtest/Cluster
Understanding Directions
Oral Comprehension
Listening Comprehension
AACN June 2008
STD
107
100
104
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ATTENTION
SPAN FOR VERBAL INFORMATION
Measure
Raw
STD/AASS
WAIS-III Digit Span Forwards
8 digits
(17)
CVLT-II, Trial 1
7 words
WJ3COG Memory for Sentences
102
WMS-III Logical Memory 1st Rec.
12
Reported that he has always been good with phone nos.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LANGUAGE SKILLS
PRODUCTION
Measure
Boston Naming Test-Total
Boston Naming Test-With
phonemic cuing
COWAT-Letters F,A,S
COWAT-Animals
WJ3COG Subtest
Rapid Picture Naming
AACN June 2008
Raw score T-score
58/60
50
60/60
18 words
21
STD
112
R. L. Mapou, Ph.D., ABPP-CN
24
45
CASE FF
ACADEMIC SKILLS
WJ-III Reading Cluster
Reading Fluency
STD
90 (0 errors)
Nelson Denny Reading Test
Reading Rate
Comprehension, Timed
Comprehension, Extended Time
Total Time: 32 minutes
37/38 questions correct.
%ile
6
6
78
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ACADEMIC SKILLS
WJ-III Math Subtest/Cluster STD
Math Fluency
94 (1 error)
Calculation
120
Math Calculation Skills
Not reported
Missed one problem with fractions, but got algebra.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ACADEMIC SKILLS
WJ-III Summary Scores
Academic Skills
Academic Fluency
AACN June 2008
STD
112
91
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ATTENTION
ALERTNESS-GENERAL OBSERVATIONS
Awake and alert
FOCUSED ATTENTION/PROCESSING SPEED
WAIS-III Measure
AASS/STD
Digit Symbol-Coding
10
Symbol Search
11 (1 error)
Processing Speed Index 103
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ATTENTION
FOCUSED ATTENTION/PROCESSING SPEED
Measure
Raw score
T-score
Trail Making, Part A
18 seconds
56
Trail Making, Part B
45 seconds
52
Digit Vigilance-Time
441 seconds 39
Digit Vigilance-Errors 0
64
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ATTENTION
SUSTAINED ATTENTION
IVA Continuous Performance Test
Full Scale Response Control Quotient (RCQ)
Auditory RCQ
Auditory Prudence
Auditory Consistency
Auditory Stamina
Visual RCQ
Visual Prudence
Visual Consistency
Visual Stamina
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
STD
67
66
68
77
86
77
69
97
94
CASE FF
ATTENTION
SUSTAINED ATTENTION
IVA Continuous Performance Test
Full Scale Attention Quotient (AQ)
Auditory AQ
Auditory Speed
Auditory Vigilance
Auditory Focus
Visual AQ
Visual Speed
Visual Vigilance
Visual Focus
AACN June 2008
STD
100
102
111 (542 ms)
105 (100%)
87
103
109 (379 ms)
106 (100%)
90
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
ATTENTION
MENTAL MANIPULATION/DIVIDED ATTENTION
WAIS-III Measure
Raw
STD/AASS
Digit Span Backwards
7 digits
(17)
Arithmetic
11
Letter-Number Sequencing 6-7 items 17
Working Memory Index
130
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
PLANNING AND PROBLEM SOLVING
Tower of LondonDX
Total Move Score
106
Total Correct Score
114 (7/10)
Total Rule Violation Score
82 (1 violation on #4)
Total Time Violation Score
64 (2 over 60 secs.)
Total Initiation Time
112
Total Execution Time
94
Total Problem-Solving Time
90
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
PLANNING AND PROBLEM SOLVING
D-KEFS 20 Questions Test
AASS
Initial Abstraction Score
10
Total Questions Asked
11
Total Weighted Achievement Score 12
Generally systematic, but weak on the first.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
FLEXIBILITY OF THIKING/USE OF FEEDBACK
WCST Measure
Raw STD %ile
Categories
6
>16
Total Errors
22
88
Perseverative Errors
10
86
Non-perseverative Errors
12
88
Perseverative Responses
11
86
Failure to Maintain Set
0
>16
Trouble shifting categories on F, N, then C. After that, OK.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING SKILLS,
AND REASONING ABILITIES
ORGANIZATION
California Verbal Learning Test-II
Semantic Clustering z-score: 0.5
Serial Clustering z-score: 2
Recalled the words in order
WMS-III Logical Memory
Some details out of order. Lost context of the first story.
Rey-Osterrieth Complex Figure Test Copy
Generally organized
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
REASONING
WAIS-III Measure
AASS
Similarities
7 (Missed several easy)
Comprehension
13
Picture Completion
12
Matrix Reasoning
17
Picture Arrangement
13
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
VISUOSPATIAL SKILLS
CONSTRUCTION
Measure
Raw score AASS
Rey-Osterrieth-Copy
31/36
9
WAIS-III Block Design
15
Careless errors on Rey-Osterrieth.
Completed all Block Designs correctly and quickly.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LEARNING AND MEMORY-VERBAL
California Verbal LT-II Total
z-score
Trials 1-5
62
62 (T)
Trial 1
7
0
Trial 5
15
1
List B
5
-0.5
Short Delay-Free
14
1
Short Delay-Cued
14
0.5
Long Delay-Free
15
1
Long Delay-Cued
14
0.5
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LEARNING AND MEMORY-VERBAL
California Verbal LT-II Total
z-score
Total Repetitions
3
0
Total Intrusions
0
1
Recognition-Total Hits
Total False Positives
AACN June 2008
16
0
0.5
1
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LEARNING AND MEMORY-VERBAL
WMS-III Measure
AASS
Logical Memory I Recall Total
13
Logical Memory I Learning Slope 13
Logical Memory II Recall Total
14
Logical Memory Retention: 95% 14
Logical Memory I Thematic Total 11
Logical Memory II Thematic Total 14
Logical Memory II Recognition–A: 14/15 B: 15/15
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LEARNING AND MEMORY-VISUAL
WMS-III Measure
AASS
Family Pictures I Recall Total
15
Family Pictures II Recall Total
15
Family Pictures Retention: 100% 12
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
LEARNING AND MEMORY-VISUAL
Rey-Osterrieth Recall Total AASS
Immediate
27.5/36 13
20 Minute Delay
27.5/36 13
WAIS-III Dig. Sym. Inc. Learning Total
Paired Recall
7/9
Free Recall
8/9
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
%ile
>50
>50
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
DIAGNOSES
784.61 Reading disorder
314.9
ADHD, Not otherwise specified
854.0
S/P traumatic brain injury, severity unknown
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
RECOMMENDATIONS
50% additional time on the licensing examination
Specialized training to improve reading fluency and
comprehension
Medical H.E.L.P. program at Marshall University
Tutoring, to improve study skills
Get sufficient sleep
Books on improving study skills and cognitive skills
Books on ADHD in adults
Compensatory strategies for attentional problems
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE FF
OUTCOME
Granted double time on the licensing exam, based on an
initial summary letter.
Do not know if he passed.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
43-year-old male shop teacher. History of problems with
attention, organization, work production, and dysthymia.
At risk of losing his teaching job.
BEHAVIORAL RATING SCALES
Wender Utah Rating Scale Total score: 51 (+)
Parents’ Rating Scale
Total score: 12 (+)
Barkley’s Childhood ADHD Rating Scale
Score
Self
Mother
Hyperactive/Impulsive Sx. 20 (+)
9 (-)
Inattentive Symptoms
15 (+)
10 (-)
Total Symptoms
35 (+)
19 (-)
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
BEHAVIORAL RATING SCALES
T-score
CAARS Scale
Self
Inattention/Memory Problems 77
Hyperactivity/Restlessness
51
Impulsivity/Emotional Lability 58
Problems with Self-Concept
62
DSM-IV Inattentive Sx
85
DSM-IV Hyper.-Imp. Sx
52
DSM-IV ADHD Sx Total69
70
ADHD Index
59
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
T-score
Wife
74
50
65
68
71
64
65
CASE CC
BEHAVIORAL RATING SCALES
T-score
BRIEF-A Scale
Self
Inhibit
62
Shift
66
Emotional Control
61
Self Monitor
64
Behavioral Regulation Index 66
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
T-score
Wife
72
66
57
75
68
CASE CC
BEHAVIORAL RATING SCALES
T-score
BRIEF-A Scale
Self
Initiate
66
Working Memory
76
Plan/Organize
82
Task Monitor
71
Organization of Materials
74
Metacognition Index
78
T-score
Wife
73
73
83
73
76
80
Global Executive Composite
76
AACN June 2008
75
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
UTAH CRITERIA FROM INTERVIEW
Persistent motor hyperactivity
Attentional difficulties
Affective lability
Disorganization, inability to complete tasks
Hot temper, explosive short-lived outbursts
Impulsivity
Emotional overreactivity
Yes
Yes
No
Yes
Yes
Yes
Yes
PROPOSED ADULT ADHD CRITERIA FROM INTERVIEW
(Barkley et al (2008)
Six out of nine symptoms endorsed as problems
Impairment reported at work and, to a lesser extent, at home and
during past schooling.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
INTELLECTUAL SKILLS
WAIS-III
Full Scale IQ: 143
Verbal IQ: 137
Verbal Comprehension Index: 142
Performance IQ: 142 Perceptual Organization Index: 145
All but Digit Symbol were above average.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
ACADEMIC SKILLS
WJ-III Reading Subtest
Letter-Word Identification
Reading Fluency
STD
115
119
WJ-III Writing Subtests STD
Spelling
128
Writing Fluency
131
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
ACADEMIC SKILLS
WJ-III Math Subtest/Cluster
Math Fluency
Calculation
Math Calculation Skills
WJ-III Summary Scores
Academic Skills
Academic Fluency
AACN June 2008
STD
112
120
121
STD
128
125
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
ACADEMIC SKILLS
Nelson Denny Reading Test %ile
Reading Rate
94
Comprehension, Timed
99
Total Time: 18 minutes
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
ATTENTION
FOCUSED ATTENTION/PROCESSING SPEED
WAIS-III Measure
AASS/STD
Digit Symbol-Coding
10
Symbol Search
18
Processing Speed Index Not reported
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
ATTENTION
FOCUSED ATTENTION/PROCESSING SPEED
Measure
Raw score
T-score
Trail Making, Part A
20 seconds
53
Trail Making, Part B
30 seconds
67
Digit Vigilance-Time
290 seconds 48
Digit Vigilance-Errors 1
58
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
ATTENTION
SUSTAINED ATTENTION
Test of Variables of Attention
Reaction Time
Variability
Percent Omission Errors
Percent Commission Errors
ADHD Score
AACN June 2008
Score
365 ms
74 ms
0
2.16
-1.46
R. L. Mapou, Ph.D., ABPP-CN
STD
84
89
101
114
CASE CC
ATTENTION
SPAN FOR VERBAL INFORMATION
Measure
Raw
WAIS-III Digit Span Forwards
8-9 digits
CVLT-II, Trial 1
11 words
WJRCOG Memory for Sentences
WMS-III Logical Memory 1st Rec.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
STD/AASS
(14)
118
10
CASE CC
ATTENTION
RESISTANCE TO INTERFERENCE
Consonant Trigrams Raw z-score
Total Correct
33/42 -0.9
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
ATTENTION
MENTAL MANIPULATION/DIVIDED ATTENTION
WAIS-III Measure
Raw
STD/AASS
Digit Span Backwards
4-7 digits (14)
Arithmetic
13
Letter-Number Sequencing
7 items
19
Working Memory Index
128
Consonant Trigrams
Total Counted
AACN June 2008
Raw
21.7
R. L. Mapou, Ph.D., ABPP-CN
z-score
1.9
CASE CC
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
PLANNING AND PROBLEM SOLVING
Tower of LondonDX
Total Move Score
120
Total Correct Score
118 (7/10)
Total Initiation Time
148
Total Execution Tim
104
Total Problem-Solving Time 88
Total Time Violation Score 78 (2/10 exceeded 1 min.)
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
PLANNING AND PROBLEM SOLVING
D-KEFS 20 Questions Test
AASS
Initial Abstraction Score
14
Total Questions Asked
13
Total Weighted Achievement Score 14
Sometimes made questions more complicated. Lost track
of what he had asked once.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
ORGANIZATION
California Verbal Learning Test-II
Semantic Clustering z-score: 3
Serial Clustering z-score: -2
Rey-Osterrieth Complex Figure Test Copy
Made good use of the organization to guide his copy.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
EXECUTIVE FUNCTIONS, PROBLEM-SOLVING
SKILLS, AND REASONING ABILITIES
REASONING
WAIS-III Measure
AASS
Similarities
16
Comprehension
14
Picture Completion
14
Picture Arrangement
16
Matrix Reasoning
18
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
LANGUAGE SKILLS
COMPREHENSION
WAIS-III Measure
Vocabulary
AASS
17
WJ3ACH Subtest/Cluster
Understanding Directions
Oral Comprehension
Listening Comprehension
AACN June 2008
STD
121
117
121
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
LANGUAGE SKILLS
PRODUCTION
Measure
Boston Naming Test-Total
COWAT-Letters F,A,S
COWAT-Animals
Raw score
60/60
69 words
47
T-score
61
68
79
Could go on at length and in great detail when recounting
his history.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
VISUOSPATIAL SKILLS
CONSTRUCTION
Measure
Raw score AASS
Rey-Osterrieth-Copy
35/36
13
WAIS-III Block Design
19
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
LEARNING AND MEMORY-VERBAL
California Verbal LT-II Total
z-score
Trials 1-5
74
74 (T)
Trial 1
11
1.5
Trial 5
16
1.5
List B
11
2
Short Delay-Free
16
1.5
Short Delay-Cued
16
1.5
Long Delay-Free
16
1.5
Long Delay-Cued
16
1
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
LEARNING AND MEMORY-VERBAL
California Verbal LT-II Total
z-score
Total Repetitions
3
0
Total Intrusions
1
0.5
Recognition-Total Hits
Total False Positives
AACN June 2008
16
0
0.5
1
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
LEARNING AND MEMORY-VERBAL
WMS-III Measure
AASS
Logical Memory I Recall Total
11
Logical Memory I Learning Slope 17
Logical Memory II Recall Total
13
Logical Memory Retention: 94% 13
Logical Memory I Thematic Total 10
Logical Memory II Thematic Total 12
Logical Memory II Recognition–A: 14/15 B: 15/15
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
LEARNING AND MEMORY-VISUAL
WMS-III Measure
AASS
Family Pictures I Recall Total
12
Family Pictures II Recall Total
12
Family Pictures Retention: 98%
8
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
LEARNING AND MEMORY-VISUAL
Rey-Osterrieth Recall Total AASS
Immediate
18/36 10
20 Minute Delay
17.5/36 10
WAIS-III Dig. Sym. Inc. Learning Total
Paired Recall
5/9
Free Recall
8/9
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
%ile
25
>50
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
DIAGNOSES
314.00 ADHD, predominantly inattentive type
300.4
Dysthymia, based on prior diagnosis
300.02 Rule out generalized anxiety disorder
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
RECOMMENDATIONS
Treatment with psychostimulant medication
Coaching
An assistant to help with materials logistics for class
Cognitive-behavioral therapy for ADHD and anxiety
Books on ADHD
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN
CASE CC
OUTCOME
Started on Adderall with good results, but would forget to take it.
Switched to Adderall XR, with better results, but still seeing the need
for a short-acting dose later in the day.
Started working with a coach. Included wife to address marital
issues.
Began to look for a cognitive-behavioral therapist.
Improvement seen in classroom performance
Given another year to show continued improvement.
AACN June 2008
R. L. Mapou, Ph.D., ABPP-CN