Richie, a 7-year-old boy, was referred for a neuropsychological assessment for possible ADHD. Testing found that while his general intellectual functioning was in the average to high average range, he showed weaknesses in attention, processing speed, and working memory consistent with ADHD. Rating scales completed by his mother also indicated significant inattentive and hyperactive behaviors meeting criteria for the combined presentation of ADHD. The treatment plan developed involved medication with methylphenidate, behavioral management training for parents and teachers, and cognitive rehabilitation therapy to target Richie's weaknesses and manage his ADHD symptoms. Close monitoring was recommended to evaluate the effectiveness of the multi-pronged intervention approach.

1. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
ADHD
NEUROPSYCHOLOGICAL ASSESSMENT
CASE PRESENTATION
Alana T. Kristen
ResearchGate: https://www.researchgate.net/profile/Ilona_T_Kristen2
LinkedIn: https://www.linkedin.com/in/alana-kristen-
47b34943/?originalSubdomain=ca

2. Introduction
Nature of the problem:
• ADHD is a neurobehavioral developmental disorder of
childhood that is characterized by developmentally
inappropriate levels of
• Hyperactivity
• Impulsivity
• Inattention

3. Subtypes of ADHD:
• Attention Deficit Hyperactivity Disorder – Predominantly Inattentive Type
• Attention Deficit Hyperactivity Disorder – Predominantly Hyperactive-
Impulsive Type
• Attention Deficit Hyperactivity Disorder – Combined
• New subtype: Sluggish Cognitive Tempo

4. Epidemiology:
• ADHD is considered to be the most common and diagnosed
psychiatric disorder in children, with prevalence ratings
ranging from 3% to 7% of the school aged children
• ADHD occurs more often in males than females, estimates of
rations vary significantly
• Ranges from 2:1 to 9:1 have been reported with the gender
differences less pronounced for the inattentive type of ADHD
• Accounts for a large number of referrals to pediatricians, family
physicians and child mental health professionals – estimated
around 40%
• It is considered to be a chronic disorder, with 30% to 50% of
individuals diagnosed with ADHD in childhood continue to
have symptoms into adulthood.
• Have high comorbidity with other psychiatric disorders
(Diagnostic and Statistic Manual of Mental Disorders [4th ed.]

5. Controversies and Unresolved Issues:
• What is normal versus clinical?
• The issue involving the diagnosis of ADHD, inattentive type.
• ADHD diagnosis and age.

6. CASE STUDY:• Richie is a 7 year old right-handed male who was brought to my
office by his mother to evaluate for possible ADHD symptoms.
Richie attends his first grade in a public elementary school. His
mother is employed as a math teacher in a community based college
and his father is an automobile mechanic.
While pregnant with Richie, mother described her attitude as
depressed and moody. In addition the mother reported to have
smoked 1.5 packages of cigarettes within the first 1 months of
pregnancy and approximately half pack a day for the next 2 months
before quitting . She have also reported to have moderately consumed
alcohol while at the first month of her pregnancy.
There was no diagnostic history of severe mental illness within
Riches family.

7. I. Initial Interview
I have decided to interview Richie and his mother in the same day, separately
( the waiting time between two separate interviews was 45 minutes).
Interviewing parent:
• I will use semistructured interview
Rationale for using semistructured interview:
• The interview will focus on the specific complaints about the child’s
psychological adjustment and any functional parameters.
• However, the interview will also provides the phenomenological data that
rating scales cannot capture
• Although storable data will be obtained, the small details and
nuances of parental observation will interact with my acquired
knowledge (from, research, readings, workshops etc.) – this will
support my final diagnostic conclusions.
• ( Barkley,
2006)

8. Important areas of evaluation would include:
• Demographic information (age of the family members; child’s date of
birth; parents names and address; and occupations; the child’s school,
teacher and physician) – obtained at the outset of the appointment.
• Child related information
• Major referral concerns: Specific questions about:
-child behavior and history of the problem
-history of other medical conditions

9. Important areas of evaluation continue:
• School related information
• Details about the parents, other family members and community
resources that might be available to the family
• Parental history of psychopathology
• Psychosocial status
• Parental stress, marital discord,
Note: The choice of the assessment tools I will employ in the
latter session will be contingent upon the information collected
in the interview phase.

10. (Sample illustrating some of the questions I would ask Richie’s
mother):
• 1. When the problems were first noticed or reported?
• 2. What parenting strategies do parents employ when Richie
misbehave?
• 3. Are they any current family circumstances that are related to
the Richie’s problems severity? (such as intramerital conflict,
divorce or family illness)
• 4. What are Richie’s relationships with his peers?

11. Child Interview:
Why it is important?
• Help the clinician to correct any misinterpretations that the child might
have about why she or he is seeing the mental health professional (e.g.,
“I’m crazy” etc.)
• Provide valuable information about child’s internalistic problems (such as
mood states and feelings)
• Indicative of child’s motivation to participate in the therapy process
• Help establish therapeutic alliance
(Barkley, 2006)

12. Sample of the questions I would ask Richie:
• Do you ever find that you have been sitting in class, and suddenly
you realize that your teacher has been talking and you have no idea
what the teacher is talking about?
• Does it ever seem to you to you longer to complete your school work
than compared to other kids?
• Is there anything that worries you a lot?
• Is there anything that makes you angry?

13. • What did interview data revealed:
• Richie’s Behavior History
Richie’s teacher indicated that he exhibits difficulties focusing, sustaining attention
and has encountering ongoing classroom problems. His teacher reported that
Riche is always fidgeting in his seat, throws items at other students and frequently
leave his seat during classroom instruction. He was placed on discipline plan and
his behavior was reportedly improved. Richie school grades are “hardly
satisfactory” and his daily performance is inconsistent. Mother stated, “one day he
comes home with excellent on his worksheet, 4 day latter he doesn’t even try to
complete the work sheet, and that’s the way it goes.”
Richie’s behavior problems were initially reported in kinder garden and have
continued troughs his first grade. Richie has been found climbing the roofs of the
houses, running into the street without looking. When Riche misbehaved, his
parents usually employed physical and verbal punishment to enforce discipline.
Rewards for good behavior included play time and money. In describing his peer
relationships, mother indicated that Richie had always good friends in the
neighborhood but they quickly become irritated with his aggressive behavior. The
mother as well reported aggressive outbursts’; however she also stated that her son
is “generally a good child.”

14. Richie has been seeing by an outpatient counselor to address his behavior
problems at home and school. He was recently evaluated by an occupational
therapist who reported difficulties in the fine motor skills.
During the initial interview, there were no indicative signs of motor
retardation, agitation or gait difficulties. Speech was within a normal limit,
there was no indication of difficulties with world fluency, neologisms, or
auditory comprehension. Riches affect was appropriate; his thoughts flowed
logically with no evidence of hallucinations or delusions. However, Richie
showed signs of responding to extraneous stimuli and had to be redirected
numerous times. When he didn’t found a particular task appealing, he lost
interest quickly.

15. II. Assessment Stage
According to Fishmen (2005) the assessment is problem oriented (not
undertaking as a mere exercise in applying assessment techniques), -
designed to answer questions not only about the diagnosis (ADHD) but
about the factors underlying the development and the maintenance of the
presented problem (in Whitefield and Edwards, 2009).
Combinations of tools should be used.

16. • Behavior checklist and Rating Scales for ADHD:
Generally used for initial screening purposes
• Advantages:
• Cost and time effective (most could be completed in
less than 15 minutes)
• because they are completed retrospectively reactivity is
not a concern
• Disadvantages:
• might be affected by the accuracy of the observer
• subjective (rating scales discourage complete
confidence in their reliability).
Rating scale should be selected based on multiple aspects, including their
psychometric properties, ability to screen for comorbid conditions,
completion time, cost, accessibility and the need of self report (Madaan,
2008)

17. Connors Rating Scales (CRS):
• the only scale that provides normative data for preschool children (to age
3 years)
• can be re-administered, which could help monitor treatment response
• additional utility in initial assessments, particularly when comorbidities
are suspected (Vanderbilt scale serves this function as well).

18. Assessment tools administered to Richie:
• ADHD Parent Rating Scale
• Wechsler Intelligence Scale for Children Fourth Edition
• Continuous Performance Test (CPT)
• CPT requires the patient to sit at a computer terminal
and press keys on the keyboard in response to visual
images or stimuli that appear on the screen.
• Scorers calculate the rate of missed cues and
erroneous responses. Individuals with ADHD tend
to make more errors on the test than people who
do not have the condition.
• Additional Information: CPT & ADHD |
eHow.com
http://www.ehow.com/about_6556867_cpt-
adhd.html#ixzz14Hke3JwQ

19. • Wide Range Assessment of Memory and Learning (WRAML-2; Sheslow
& Adams. 2003) – objective assessment of memory functions
• Cognitive Functioning Tasks
• Tactual Performance Test
Madaan V., DaughtonJ., Lubberstedt B., Mattai A., Vaughan B., Kratochvil J (2008).
Assessing for the efficacy of treatments for ADHD. CNS Drugs 22, 4

20. Advantages of CPTs:
• Increased objectivity
• Time efficient (can be taking within 15 minutes)
• Have increased sensitivity for detecting inattention
in the absence of explicit hyperactivity and /or
impulsivity
• can help monitor the treatment
• Observing a child taking CPT can also provide
information about the motor activity and response to
commands

21. Neuropsychological Test Findings:
• Results from research involving neuropsychological
testing has often suggested that children with ADHD have
problems;
• in inhibiting behavioral responses,
• with working memory,
• with planning and organization,
• with verbal fluency,
• with perseveration,
• In motor sequencing,
• with other frontal lobe functions.

22. Laboratory Tests used to assess ADHD conditions:
• Blood work
• Urinalysis
• Chromosome studies
• EEG’s
• MRIs
• Computerized tomography (CT) scans.
Some of these studies have demonstrated such differences
in ADHD patients such as altered Encephalographic
(EEG) activity (greater slow wave, reduced fast wave),
reduced cerebral blood flow to the striatum, or diminished
orienting galvanic skin responses.

23. • However, it has been suggested that none of this
laboratory measures are of significant value in the
diagnostic process of ADHD as yet
• Such laboratory studies should not be used routinely in
the evaluation of children with ADHD and when used to
be interpreted within the contest of the overall
assessment.
• Only when the medical and developmental history of
physical exams suggest that a treatable medical problem
such as (e.g., seizure disorder) exists, or that a genetic
syndrome is a possibility, should this laboratory
procedures be recommended
(Barkley, 2008).

24. What the test scores revealed for Richie:
• The ADHD Parent’s Rating Scale:
This scale was employed by Richie’s Mother to determine
his problematic behavior at home. Richie scored on this
scale was 21 which placed him in the 99th percentile, with
his mother specifically accentuating problems with
restlessness, disturbing other children and failing to finish
things. Fidgeting and distractibility have been also noted.
• General Intellectual Information:
The Wechsler Intelligence Scale for Children (WISC-IV)
was administered to Richie to assess general intellectual
abilities. Richie performed very well on the subsets of
Verbal Comprehension and Perceptual Reasoning. Although
his IQ was 109 (in the high average range), in subtests
looking at the Processing Speed and Working Memory, he
consistently scored in the low average range of intellectual
functioning. He appeared to have difficulties in the areas
requiring non-distractible attention span for good
performance.

25. • Continuous Performance Test and Wide Range Assessment of Memory
and Learning 2:
On CPT’s (visual/nonverbal part) Richie showed difficulties with
inattention marked by the large number of commission errors and
difficulties of identifying targets and non-targets. On CPT’s Auditory-
Verbal part. Richie performed in the high average on both of the Controlled
Oral Fluency Tests.
The WRAML 2 memory test indicated that Richie’s overall immediate
verbal auditory memory was average, however his immediate visual
memory was in the low average range.
• Sensory/Tactile:
In the Tactual performance Test (Reitan, 1979), Richie showed average
performance when using his dominant right hand and was in high average
range using his non dominant hand. Both hands and the total time were also
in the average range. On the Line Bisecton Task There was no indication
for hemi-inattentions or hem-neglect.

26. Case Conceptualization and Diagnosis ADHD:
Results of neuropsychological testing indicated that Richie's general
intellectual functioning is in the Average, high average range . He
showed particular strengths in the areas of verbal related
knowledge, fluency and reasoning, in addition to nonverbal fluid
reasoning and good motor integration skills. This optimistic
findings could help explain why Richie's teachers often remarked
how successful he can be once he “settles down and focuses on his
work”. In fact, it is quite possible that Richie's overall intellectuals
functioning's are underestimated because of the weaknesses in
mental and motor speed, and working memory. It has been
suggested that weaknesses in this areas are often secondary to
difficulties with inattention and concentration.
Richie's Neuropsychological Tests revealed that he has indicate many
strengths. It is important to continuously communicate this
strengths to the parents to engage them in establishing appropriate
treatment plan and encourage their child to continue master his
areas of weakness.

27. III. Treatment Plan
Guiding concepts and relevant research:
• Methods of treatment for ADHD often involve some combination of
behavior and cognitive modification, lifestyle changes counseling and
medication
• Combination of Medical Treatment and Behavior Management is suggested
to be some of the most effective ADHD management strategies, followed by
medication alone.
• Research also cautious that while medication has been shown to improve
behavior when taking over short period of time, they have not been shown to
alter long term outcomes of ADHD.
Jensen P., Garcia J., Glied S. (2004). Cost effectiveness of
ADHD treatments: findings from the multimodal treatment study of children with ADHD. The American Journal of
Psychiatry 162, 9.

28. OPTIONS FOR INTERVENTIONS IN THE
TREATMENT OF ADHD:

29. Treatment Continues:
In Richie's case I have decided upon implementing multiple treatment strategies.
It has been suggested that combination of treatment strategies contributes to
favourable long term outcomes in ADHD (Madaan V, 2008)
The treatment will consist of biological, psychosocial, and cognitive rehabilitation
interventions
• Cognitive - behaviour management
• Medication – Methylphenidate (Ritalin) , stimulant drug
• Typically the goal to reduce impulsivity and hyperactivity and improve attention abilities
• Psychosocial treatment focuses on broader issues (improving
academic performance, decreasing disruptive behavior, and
improving social skills)
• Structure play, home and school environment
• Parental management (PMT) training
• Cognitive Rehabilitation therapy (involves structured activities
designed to improve cerebral functioning and teach
compensation techniques).
• Mindfulness training for children (optional alternative)
(American Academy of Pediatrics, 2000;
Sohlberg, 1989).

30. Effectiveness of the intervention:
• Because both parents and teachers had implemented the program
with care and understanding, no further intervention was offered
• However, this is NOT always the case (E.g., in Richie’s case if his
mother was unable to follow the behavior management procedures or
was unwilling to attend the therapy session the outcomes would
substantially differ)
Note: That is why it is always important to assess the family
functioning and to note potential family disruptions that would need
attention to help parents more effectively manage their child
diagnosed with ADHD