Richie, a 7-year-old male, was referred for a neuropsychological assessment for possible ADHD. Testing found strengths in verbal abilities but weaknesses in processing speed and working memory consistent with inattention. Rating scales completed by Richie's mother found symptoms in the 99th percentile. A treatment plan was developed using a multimodal approach including medication, behavioral management training for parents, and cognitive rehabilitation exercises. Close monitoring of the family's ability to implement interventions was also advised to maximize outcomes.

1. 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.  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.

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