Attention-deficit hyperactivity disorder (ADHD) is

characterized by developmentally inappropriate

levels of:

• Inattention
• Hyperactivity
• Impulsivity
ADHD behaviors are developmentally
inappropriate, pervasive, chronic, and
result in considerable impairment in
social and academic functioning.
 History of ADHD
Heinrich Hoffman, a German psychiatrist, authored a widely-published
children’s book of short stories in 1844

“Fidgety Phillip”

“Johnny Look-in-the-Air”

“The Story of Cruel Frederick”

“The Story of Little Suck a

Thumb”

“The Dreadful Story of Pauline

and the Matches”

Fidgety Phil, often seen as an allegory for ADHD. Illustration from a book written by
physician Heinrich Hoffmann.
Courtesy of Project Gutenberg.
Thome & Jacobs, 2004
Prevalence
• Prevalence estimates vary depending on method
used, geographic region, age targeted, and rater

• Prevalence of ADHD estimated at 8.7% (Froehlich

et al., 2007)

• More common in boys than girls

• Symptom presentation may reduce as individual

becomes older
Impairment
• Peer relationships
• Adult relationships
• Sibling relationships
• Academic Progress
• Self-esteem
• Group functioning
• Associated problems
What are the Current Guidelines?
U.S. Department of Education (2003): “The criteria set forth by the fourth edition of the DSM-
IV are used as the standardized clinical definition to determine the presence of ADHD”

Pelham, Fabiano, & Massetti (2005): “Diagnosing ADHD is most efficiently accomplished with
parent and teacher rating scales”

American Academy of Child and Adolescent Psychiatry (2007): “Evaluation . . . Should consist
of clinical interviews with the parent and patient, obtaining information about the patient’s
school or day care functioning…”

American Academy of Pediatrics (2011): “The primary care clinician should determine that
DSM-IV-TR criteria have been met… Information should be obtained primarily from reports
from parents or guardians, teachers…”

DSM-V is now used – modifications include moving age of onset specifier from 7 to 12 years of
age; for older adolescents and adults only 5 symptoms are required; clinician now reports on
presentation and severity
 Other Commonalities
• Must assess for impairment in functioning across
settings.

• Should evaluate whether comorbidities are present.

• All emphasize the use of DSM criteria in assessment.

DSM-IV Definition for Attention Deficit/
Hyperactivity Disorder
A. Six Symptoms of either Inattentive or Hyperactive/Impulsive
(1) Inattention:
• often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• often has difficulty sustaining attention in tasks or play activities
• often does not seem to listen to what is being said to him or her
• often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
• often has difficulties organizing tasks and activities
• often avoids or has difficulties engaging in tasks that require standard mental effort
• often loses things necessary for tasks or activities
• is often easily distracted by extraneous stimuli
• often forgetful in daily activities

(APA, 2013)
DSM-IV Definition for Attention Deficit/
Hyperactivity Disorder
(2) Hyperactivity-Impulsivity:
•often has difficulty playing or engaging in leisure activities quietly
•is always "on the go" or acts as if "driven by a motor”
•often talks excessively
•often blurts out answers to questions before the questions have been completed
•often has difficulty waiting in lines or awaiting turn in games or group situations
•often interrupts or intrudes on others (e.g. butts into other's conversations or games)
•often runs about or climbs inappropriately
•often fidgets with hands or feet or squirms in seat
•leaves seat in classroom or in other situations in which remaining seated is expected

(APA, 2013)
DSM-V Definition for Attention-Deficit/
Hyperactivity Disorder-Concentrations
Predominantly Inattentive Concentration: Criterion (1) is met but not
criterion (2) for the past six months

Predominantly Hyperactive-Impulsive Concentration: Criterion (2) is met

but no criterion (1) for the past six months

Combined Concentration: Both criteria (1) and (2) are met for the past six
months
What is NOT Evidence-based
Medical Tests

Allergy Tests

CAT/PET scans, MRI scans

Asking the child about symptoms

Evidence-based Assessment of
ADHD Symptoms
There are a number of well-developed, validated, and useful
measures for identifying the presence of ADHD symptoms.

Many of these are in the form of parent and teacher rating

scales.
(Pelham, Fabiano, & Massetti, 2005)
Sampling of ADHD Rating Scales
Swanson, Nolan & Pelham (SNAP) Rating Scale
(Atkins, et al., 1985, Atkins et al., 1988; Gaub & Carlson, 1997; MTA Cooperative Group, 1999; Pelham & Bender, 1982)

ADHD Rating Scale

(DuPaul et al., 1991,1997; DuPaul, Anastopoulos et al., 1998; Gomez et al., 1999;Power et al., 1998)

Disruptive Behavior Disorders Rating Scale

(Pelham, et al., 1992; Pelham, Evans et al., 1992)

Vanderbilt Rating Scale

(Wolraich, et al., 1998, 2003)

ADHD Symptom Checklist-4

(Gadow & Nolan, 2002; Gadow & Sprafkin, 1997; Gadow et al., 2001; Mattison et al., 2003; Sprafkin et al., 2001, 2002)
Sampling of Other Rating Scales
Child Behavior Checklist/Teacher Report Form
(Achenbach & Rescorla, 2001; Anastopoulos, et al., 1993; Barkley et al., 2000; Ostrander, et al., 1998)

Behavioral Assessment Scale for Children

(Ostrander et al., 1998; Reynolds & Kamphaus, 2002)

Conners Parent and Teacher Rating Scales

(Conners et al., 1998 a,b; Goyette et al., 1978; Roberts et al., 1981)

IOWA Conners Rating Scale

(Atkins et al., 1989; Loney & Milich, 1982; Milich et al., 1982; Pelham et al., 1989)
Common Factors Across Rating Scales
• Parent and Teacher Versions
• Based on DSM classification system
• Use a Likert Scale for ratings
• All have evidence of reliability and validity; psychometric soundness.
• Effective at discriminating between clinical and non-clinical groups.
• Sensitive to behavioral and pharmacological treatment effects.
Limitations of Rating Scales
Provide idea of frequency and/or severity of symptoms, but
no information on context.

“Often does not seem to listen when spoken to directly.”

Typically do not provide information on degree of impairment

due to symptoms.
Diagnostic Interviews
Structured Interviews
• Diagnostic Interview for Children and Adolescents – Revised
• Diagnostic Interview Schedule for Children

Semi-Structured Interviews
• Kiddie Schedule for Affective Disorders and Schizophrenia
• Child and Adolescent Psychiatric Assessment
Limitations of Diagnostic
Interviews
• Limitations are similar to those of rating scales.

• Also very costly in terms of patient and clinician time.

• Limited incremental validity.

Diagnostic Criteria (cont.)
[symptoms] persisted for at least 6 months to a degree that is maladaptive and
inconsistent with developmental level.

Some H-I or Inatt. symptoms that caused impairment were present before age 12.

Some impairment from the symptoms present in two or more settings.

There must be clear evidence of clinically significant impairment in social, academic, or

occupational functioning.
(APA, 2013)
Once a diagnosis is established, the focus should shift to the
rest of the assessment process including:

• Identifying impaired areas of functioning

• Operationalizing target behaviors within these domains
• Conducting a functional analysis of the antecedents, settings, and
targets of the target behavior(s)
• Implementing treatment and constructing measures to monitor and
evaluate treatment progress
(Pelham, Fabiano, & Massetti, 2005)
Presenting Problems (complete one page for each problem; continue on back if necessary). Begin by giving a brief explanation of how antecedents and
consequences affect behavior, and explain that you will be asking about antecedents, behaviors and consequences, all defined very specifically and
objectively.

Problem (define specific behavioral target from the Impairment Rating Scale):

Homework not completed within expected time.

When was the problem first noted, and by whom? (Include age/grade, sudden or gradual, noticed personally or brought to attention by someone else)
First noticed in second grade. The teacher sent home notes stating seatwork was incomplete and needed to be
completed at home.

How often does the problem occur, and in what settings? What is the intensity/severity of the behavior?

-Home This problem occurs on an almost daily basis at home. Generally, it takes 4-5 times as long to
complete the work as it should. We are often surprised by unfinished long-term projects, which send us
scrambling to the store at 8:00 at night (i.e.,to buy posterboard or markers for his projects).
-School Some of the same problems occur at school because the unfinished work gets sent home to be completed.
-With peers N/A
-Other (describe) N/A

What are the typical antecedents to the behavior? Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time
of day, event), or does it appear to happen for no reason? What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic)?
Command to get started on homework; Peter is more resistant if the homework includes writing; He appears to
get the work done faster if it is done right after school rather than later in the evening; problem is
worse is parents are rushed.

What typically happens after the behavior occurs? What are the typical consequences? What have the parents tried to do to modify consequences and
what have been the results? How consistent have the parents’ reactions been?
Peter avoids having to concentrate on and complete his work; parents get very frustrated and upset;
homework time often includes multiple arguments/shouting matches between the parent and Peter; schoolwork
incomplete; have tried time outs and grounding and it does not work.

Current level of competency/strengths related to target behavior:

Peter is good at math – these assignments tend to get done quicker; Can persist in a homework activity if
it is really engaging (e.g., searching for different types of leaves for a science project).
Example of Teacher Progress Monitoring Measure

23/27 = 87%

See http://ccf.buffalo.edu; www.jimwrightonline.com; www.directbehaviorratings.com

Summary and Recommendations
There is considerable psychometric information available to support ADHD
assessments.

Diagnostic procedures for ADHD can be conducted relatively easily using evidence-
based methods.

•Parent and Teacher Rating Scales

•Clinical interview to determine onset of symptoms and rule out other potential diagnoses.

•Structured diagnostic interviews for ADHD do not add incremental validity for assessments.
Summary and Recommendations
Clinicians and consumers should be mindful of incremental validity.

Assessments should emphasize an accounting of key domains of functioning, focusing

on areas of competency and impairment.

Assessments should emphasize a careful analysis of the context of impaired behaviors

•Antecedents
•Consequences
•Settings

Focus of assessment activities is weighted toward those that facilitate treatment

planning.
Select Areas for Target
Improvement &
Defining Goals Identification
Review the student’s current behavior Select Target behaviors
• 3-5 is a rule of thumb
Involve all school staff who work directly
with the student
Operationally define target
behaviors
Key domains
• Improving peer relations
• Improving academic productivity Set criteria for behavioral goals
• Improving classroom rule- • Baseline
following
• Guesstimate
• Archival data
Identify specific behaviors to facilitate
progress toward goals
Creating the DRC
Reward Menu
Child Reward Form
Child’s Name: Michael
Date:

Daily Rewards:
Level 3 (50-74% positive marks): 15 min. of T.V. or pick 1
snack
Level 2 (75-89% positive marks): 30 min. of T.V. or both of
Level 3
Level 1 (90-100% positive marks): 45 min. of T.V. or choose
dessert and stay up 15 extra min.

Weekly Rewards:
Level 3 (50-74% positive marks): Choose dinner on Saturday

Level 2 (75-89% positive marks): Go out to lunch with Mom

or Dad
Level 1 (90-100% positive marks): Sleepover and movie with
 Practical Parenting
• Attention and Praise- Planned Ignoring-
• “Catch children being good.”
• Comment on appropriate behavior.
• Balanced attending between
siblings/others.
Time out/ Punishment/
Grounding-
Only effective in the context of
positive parenting strategies. Time
out from positive reinforcement
More/longer duration is not always
better. Should be used to suppress
negative behavior rather than a
reaction to it.
Deliberately ignore minor,
inappropriate behaviors.
Especially if the behaviors are
attention-seeking! Attend to and
return to appropriate behavior
Premack Contingencies
“Grandma’s Rule”
and Transitional
Warnings- Help children
know about and prepare for
transitions/changes in
routine.
Effective Requests and Commands
Bad Commands
• Issued when it is unclear whether the child is attending
• Contain multiple steps
• Vague
• Issued as a question
• Unclear phrasing (Let’s . . .)
• Extended for a long period of time
• Repeated without consequences
Good Commands
• Issued once attention is obtained
• Issued in manageable steps
• Specific
• Issued as a command/instruction
• Use clear phrasing
• Limited to the present
• Followed by consequences for both compliance (e.g., praise) and noncompliance (e.g.,