Eng- A: Evidence-Based Assessment for Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD): Evidence-Based Assessment

I. Introduction to ADHD

  • Definition: Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. It is characterized by developmentally inappropriate symptoms of inattention and hyperactivity/impulsivity.

  • Diagnostic Criteria (DSM-5 TR, APA, 2022): (Based on American Psychological Association [APA], 2013; APA, 2022)

    • (a) Symptom Count: Six symptoms of inattention and/or six symptoms of hyperactivity/impulsivity are required for children. For adults, only five symptoms per domain are required.

    • (b) Onset: Symptoms must be present before the age of 12.

    • (c) Functioning in Multiple Settings: Symptoms must impact functioning in at least two settings.

    • (d) Impairment: Symptoms must cause impairment.

    • (e) Differential Diagnosis: Symptoms are not better attributed to another mental disorder.

  • **Prevalence: ** * Children (6-18 years worldwide): Approximately 5\% (Faraone & Biederman, 2005; Kessler et al., 2006; Polanczyk et al., 2015).

    • Adults: Reportedly lower than in children.

  • **Gender Bias: ** * Childhood: Significant gender-biased prevalence rate of approximately 3:1 favoring males (Skogli et al., 2013).

    • Adolescence/Adulthood: Differences decrease during adolescence and are lower in adulthood (Das et al., 2012).

  • Heritability:

    • Highly heritable, with estimates of about .8 (Frazier & Youngstrom, 2006; Gizer et al., 2009; Nikolas & Burt, 2010).

    • Children with a first-degree relative with ADHD are four to five times more likely to be diagnosed.

  • **Presentations (Subtypes): ** * Predominantly Inattentive

    • Predominantly Hyperactive-Impulsive

    • Combined Presentation

    • Note: There is limited stability and evidence of prescriptive utility in specific presentations (Lahey et al., 2005; Pelham, 2001).

II. Impact of Undiagnosed and Untreated ADHD

  • Public Health Outcomes: Implicated in numerous important public health outcomes (Cortese & Tessari, 2017; Dalsgaard et al., 2015; Gudjonsson et al., 2009; Hamed et al., 2015; Lichtenstein et al., 2012; Quinn & Madhoo, 2014) such as:

    • Increased job instability

    • Obesity

    • Increased mortality due to accidents

    • Higher incarceration rates

    • Substance use disorders

  • Comorbidity: Individuals with ADHD experience increased comorbidity rates compared to those without ADHD.

    • Youth with ADHD are five times more likely to develop disruptive, learning, anxiety, and depressive disorders (Angold et al., 1999).

    • Co-occurrence of Depression: Associated with greater functional impairment, longer and more severe depressive episodes, and higher rates of suicidality and hospitalizations than either disorder in isolation (Biederman et al., 2008; Chronis-Tuscano et al., 2010; Daviss, 2008; Reid et al., 2015).

III. Evidence-Based Assessment (EBA)

  • Importance: Essential for accurate assessment and early intervention, mitigating negative outcomes (Pritchard et al., 2012).

  • Benefits: Demonstrated accuracy and efficiency, keeping assessment costs low and reducing waitlists (Zhou et al., 2018).

  • Complicating Factors:

    • Phenotypic Heterogeneity: Significant variability in presentation, leading to differences in comorbidity profiles (Barkley, 2013; Garner et al., 2013).

    • Developmental Change Over Time:

      • Hyperactivity and impulsivity symptoms are most salient in early childhood but decline in middle and late childhood (Olson, 2002).

      • Inattention symptoms emerge and become more noticeable during later childhood, especially with school entry (Hart et al., 1995; Lahey et al., 2005).

      • Key inattentive symptoms (distractibility, difficulty sustaining attention) tend to persist into adolescence and adulthood, while many adults "outgrow" hyperactivity (Martel, Eng et al., 2021; Martel, Goh et al., 2021).

      • Roughly 50\% of childhood ADHD cases continue into adulthood (Faraone & Biederman, 2005; Kessler et al., 2006).

IV. Case Studies Illustrating Assessment Across the Lifespan

  • Childhood Case (Violet, 9 years old; Babinski et al., 2018):

    • Presenting Concerns: Referred for group behavioral treatment due to ADHD and interpersonal impairment. Previous diagnoses included ADHD combined type, generalized anxiety disorder, social anxiety disorder. Struggled with peer relationships (rejection, bullying), emotion regulation (labile mood), noncompliance at home, and academic initiation.

    • Prior Treatment: Selective serotonin reuptake inhibitors and play therapy (terminated).

    • Diagnostic Assessment:

      • Semi-structured Disruptive Behavior Disorders Interview: Mother reported criteria for ADHD combined presentation, but not Oppositional Defiant Disorder (ODD).

      • Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children (mood and anxiety modules) with Violet and mother. Anxiety symptoms were not pervasive enough for an anxiety disorder diagnosis.

      • Additional Specific Measures (Pre- and Post-treatment): Disruptive Behavior Disorders Rating Scale, Screen for Child Anxiety and Related Disorders, Short Mood and Feelings Questionnaire, Impairment Rating Scale.

      • Note: Broad and narrowband assessment was conducted, but school difficulties were not evaluated.

    • Conclusion: ADHD combined presentation was the primary driver of impairment across school, home, and peer settings, contributing to anxiety and oppositionality. Risk factors included significant peer rejection, inconsistent parental discipline, parental psychopathology, and elevated home stress. Comprehensive treatment (parent support, social skills) was suggested. School functioning evaluation needed further clarification.

  • Adulthood Case (Brian, 32 years old; Puente & Mitchell, 2016):

    • Presenting Concerns: Difficulties with executive functioning (concentration, forgetfulness, task initiation/completion, organization, planning, time management). Impairments at home and work.

    • Assessment Procedures (under DSM-IV):

      • ADHD-Specific Instruments:

        • Conners’ Adult ADHD Rating Scale (CAARS) – self- and informant-report (wife).

        • Conners’ Adult ADHD Diagnostic Interview for DSM-IV.

      • Findings:

        • Brian and wife endorsed elevations on CAARS: Inattention/Memory Problems, DSM Inattention Symptoms, DSM Total ADHD Symptoms.

        • Wife also endorsed: Impulsivity/Emotional Lability, Problems with Self-Concept, DSM Hyperactivity/Impulsivity Symptoms.

        • Brian endorsed all nine inattention symptoms and five of nine hyperactivity/impulsivity symptoms on the diagnostic interview.

      • Broadband Interview (to rule out comorbidity): Structured Clinical Interview for DSM-IV Axis I Disorders.

      • Findings: Brian endorsed inattentive symptoms and symptoms consistent with generalized anxiety disorder, which was determined to be secondary to ADHD.

    • Conclusion: Diagnosed with DSM-IV ADHD, predominantly inattentive presentation. Treatment focus on behavioral strategies for managing executive function and anxiety secondary to ADHD, though executive function was not formally evaluated.

V. Choice of Measures for ADHD Assessment

  • General Recommendations: Due to high heterogeneity and comorbidity, assessment should generally include:

    • Broadband Measures: To screen for co-occurring difficulties and alternative explanations.

    • ADHD Symptom-Specific Scales: Administered to multiple informants (parents/teachers for children; client/other informant for adults).

    • Impairment Assessment: To identify how symptoms impact day-to-day functioning (either as part of another measure or separately).

  • Recommended Measures (Table 1):

    • Purpose: Broadband Rating Scales

      • Children: ASEBA, BASC-3

      • Adults: ASEBA

    • Purpose: ADHD-Specific Scales

      • Children: ADHD-RS-5, Conners-3

      • Adults: BAARS-IV, CAARS

    • Purpose: Treatment Response

      • Children: ADHD-RS-5, Daily Report Cards

      • Adults: Needs more research

VI. Instrument Selection and Predictive Utility

  • Broadband vs. Narrowband Instruments: Reviews suggest differences exist, though much literature focused on DSM-IV.

    • Vaughn et al. (1997) found no differences between BASC and Child Behavior Checklist (CBCL) parent/teacher versions for diagnosing ADHD, but Teacher Report Form (TRF) of CBCL was better at identifying youth without ADHD.

    • Angello et al. (2003) found BASC parent/teacher versions differentiated youth with/without ADHD, and between inattentive/combined presentations. Conners’ Rating Scale-Revised (CRS-R) uniquely differentiated ADHD from mood issues.

    • Chang et al. (2016) found similar diagnostic performance between CBCL/TRF Attention Problems scale and CRS-R.

  • Narrowband Rating Scales: Useful and time-efficient.

    • ADHD Rating Scale-5 Home and School Versions (ADHD-RS-5; DuPaul et al., 2016):

      • Popular and normative-based.

      • Accuracy: 68\% for parent report, 84\% for teacher report in differentiating youth with/without ADHD (Angello et al., 2003).

      • Differentiates ADHD subtypes (Pelham et al., 2005).

      • Predictive ability: A subset of four items on ADHD-RS-5 at baseline predicted mental health difficulties 5 years later (Martel, Goh et al., 2021).

    • Conners’ Third Edition (Conners-3; Conners, 2008):

      • Popular narrowband scale.

      • Accuracy: 78\% for parent report, 76\% for teacher report, 73\% for self-report in differentiating youth with/without ADHD (Kao & Thomas, 2010).

    • Both ADHD-RS-5 and Conners-3, along with CBCL and BASC, show sensitivity to treatment effects (pharmacological and behavioral), making them efficient for monitoring (Collett et al., 2003; Pelham et al., 2005).

VII. Best Validated Broadband Measures

  • Importance: Critical for screening ADHD-specific symptoms and other psychopathology.

  • Achenbach System of Empirically Based Assessment (ASEBA; Achenbach, 2009):

    • Measures for children and adults using multiple informants.

    • CBCL has good reliability, convergent, and discriminative validity for DSM-oriented scales (Nakamura et al., 2009).

    • CBCL and TRF are useful for predicting internalizing and externalizing disorders compared to Youth Self Report (Salbach-Andrae et al., 2009).

    • Parent- and teacher-reported Attention Problems subscales on CBCL and TRF are better at identifying youth with ADHD than general scales like Externalizing Problems (Hudziak et al., 2004).

    • Attention Problems subscale is useful for combined presentations but less so for predominantly inattentive presentations (Jarrett et al., 2018).

  • Behavior Assessment System for Children, Third Edition (BASC-3; Reynolds & Kamphaus, 2015):

    • Self, parent, and teacher forms up through age 25.

    • High internal consistency, good test-retest reliability, age- and sex-specific norms.

    • Clinical Utility: Youth with ADHD rated higher on Hyperactivity and Attention Problems subscales (Zhou et al., 2018).

    • High scores on Executive Functioning and Learning Problems subscales combined with low scores on Functional Communication and Resilience subscales can identify youth with ADHD beyond Attention Problems and Hyperactivity subscales.

    • Overall, broadband scales are cost-effective and efficient for differentiating ADHD and screening for other psychopathology.

VIII. Best Validated ADHD-Specific Measures with Impairment Information

  • ADHD-RS-5:

    • Items map directly to the 18 DSM ADHD symptoms.

    • Assesses six domains of impairment: familial relations, peer relations, academic functioning, behavioral functioning, homework functioning, and self-esteem.

    • High internal consistency, adequate test-retest reliability, inter-rater reliability, and criterion validity (Acosta-Rodas et al., 2019; Alexandre et al., 2018).

  • Conners-3:

    • Assesses ADHD symptoms and related problems like executive functioning, ODD, and conduct disorder.

    • Very good test-retest reliability and internal consistency; interrater reliability coefficients range from .52 to .94 (Conners, 2008).

  • Adult Measures (for adults, similar to ADHD-RS-5 and Conners-3):

    • CAARS (Conners et al., 1999)

    • Barkley Adult ADHD Rating Scale-IV (BAARS-IV; Barkley, 2011)

    • Note: While psychometrically strong, these adult rating scales are vulnerable to malingering, necessitating other informant reports (Dvorsky et al., 2016; Silverman, 2012; Taylor et al., 2011).

IX. Developmental Differences and Multiple Informant Integration

  • Requirement for Multiple Informants: ADHD is unique in requiring multiple informants, though also considered for personality disorders (Alexander et al., 2017).

  • Integration Challenges: Little empirical work on how to integrate information when informants disagree.

  • Children (ages 6-12):

    • Parent and teacher reports should be averaged.

    • This approach outperformed OR or AND algorithms in predicting longitudinal outcomes like social skills and academic performance (Martel et al., 2015; Martel, Markon, & Smith, 2017; Martel, Eng et al., 2021).

  • Adolescents and Adults:

    • When self- and informant reports are inconsistent, other informant reports should be prioritized.

    • Informant reports may be more related to objective forms of impairment, such as executive function (Martel, Nigg, & Schimmack, 2017).

    • Empirical evidence and qualitative suggestions support prioritizing informant reports in adolescents (Sibley et al., 2012a, 2012b, 2019).

  • Self-Report Utility:

    • Useful for identifying potential internalizing symptoms and areas of risk parents may not be aware of (e.g., covert delinquency, substance use, sexual behaviors).

    • Useful for planning interventions targeting specific symptoms and impairment, even for individuals not meeting full ADHD criteria.

    • Measures like BASC-3, ASEBA, and Conners-3 offer self-report forms for certain ages (BASC-3 self-report starts at age 6).

X. Executive Functioning (EF) and Neuropsychological Assessment

  • Not Diagnostic: Historically conceptualized as an EF disorder (Nigg, 2001), but recent meta-analyses show EF deficits have poor sensitivity and specificity for predicting ADHD diagnosis (Willcutt et al., 2005).

  • Comorbidity with EF Deficits: Children with anxiety, ODD, autism spectrum disorder (ASD), and other psychopathology also exhibit EF deficits (Pennington & Ozonoff, 1996).

  • Attention Tasks: Even attention tasks like Conners’ Continuous Performance Test (CPT) only inconsistently predict ADHD cases (Jarrett et al., 2018).

  • EF Subtypes: Support is lacking for EF as a diagnostic criterion or an EF subtype within ADHD (Frick & Nigg, 2012). The number of subtypes found depends on the number of tasks included (Fair et al., 2012; Roberts et al., 2017).

  • Predictive Utility: EF deficits in children with ADHD clearly predict academic difficulties and are useful in comprehensive psychoeducational evaluations to aid in personalized interventions (Martel, 2020; Willoughby et al., 2017).

  • Classroom Observations: Can be helpful in challenging differential diagnosis cases but often not practical due to cost-effectiveness and confidentiality concerns.

XI. Assessment for Comorbid Learning Problems (LDs)

  • High Comorbidity: ADHD is often comorbid with learning disabilities, with children with ADHD being three to four times more likely to have LDs than typically developing peers (DuPaul & Volpe, 2009).

  • Association Drivers: Inattentive symptoms, deficits in working memory and processing speed, and multiple genes implicated in both disorders (Paloyelis et al., 2010; Rabiner et al., 2000; Rapport et al., 2008; Shanahan et al., 2006).

  • Ruling out LDs: Should be done using achievement and intelligence testing, parent- and teacher-report, and/or academic records.

  • IQ Profiles: ADHD and LD share similar IQ profiles with deficits in working memory and processing speed, but these scores are not diagnostic.

  • When to Test: Intelligence and achievement tests should only be completed if there is a specific concern about learning or if requested by caregivers or schools, as they are costly and time-consuming.

  • Integration: IQ profiles should be combined with other information from rating scales, observations, and clinical interviews to identify strengths and weaknesses for treatment planning (Calderon & Ruben, 2008; Martel, 2020).

XII. Measure Sensitivity to Developmental Change in Symptoms

  • Trajectories: A wealth of research on ADHD symptom trajectories across the lifespan, from typical development to persistent ADHD (Franke et al., 2018).

  • Assessment Methods in Trajectory Studies: Majority use diagnostic interviews or broadband scales; few use narrowband measures for repeated symptom capture.

  • Identified Trajectories: Döpfner et al. (2015), Sasser et al. (2016), and Walton et al. (2017) identified three distinct developmental trajectories (low, medium, high symptom).

    • Measures varied: German-based ADHD Symptom Checklist (Döpfner et al., 2015), Diagnostic Schedule Interview for Children (Sasser et al., 2016), Development and Well-Being Assessment Interview (Walton et al., 2017).

  • Variations: Not all studies find the same trajectories; results differ when modeling hyperactivity/impulsivity separately from inattention or considering gender. No studies have examined race/ethnicity.

  • Methodological Variation: Differences across studies are due to sample types/sizes, assessment points, predictors, and diagnostic procedures.

  • Future Need: Further work is needed to evaluate normative symptom trajectories across development, gender, and race/ethnicity, and to empirically evaluate developmental sensitivity of measures to normative changes (Martel et al., 2012 suggests decreasing importance of hyperactive/impulsive symptoms in adulthood).

XIII. Evaluation of Treatment Efficacy

  • Importance of Continued Assessment: Assessment should not end after diagnosis; continued tracking of ADHD symptoms and impairment is essential for ensuring treatment effectiveness and functional improvement.

  • Tracking Methods for Children:

    • ADHD-RS: For children with clinically significant ADHD symptoms, reliable change can be tracked (Szomlaiski et al., 2009).

    • General Functioning: For children with symptoms no longer clinically significant, tracking general functioning is more reliable than ADHD symptom change (Karpenko et al., 2009).

    • Functional Assessment Tracking: Clinicians should collaborate with caregivers to identify target behaviors.

    • Daily Report Cards (DRC): A well-studied, time-efficient method for teachers to communicate progress to caregivers and clinicians. Sensitive to both medication and psychosocial treatment effects (Pelham et al., 2002).

  • Tracking Methods for Adults: Less standardized and studied methods for personalized treatment goals.

    • Future Directions: Wearable technology and daily mobile surveys of symptoms might be more accurate than in-visit measures for treatment monitoring (Surman et al., 2022; I. C. Wong et al., 2019).

XIV. Future Directions in ADHD Assessment

  • Adult ADHD Diagnosis: Clinicians report lack of confidence (Schneider et al., 2019).

    • Adults require five symptoms/domain (vs. six for children), and DSM-5 includes adult-specific symptom language.

    • Research needed to determine if different symptom sets are needed for adults (e.g., "runs about" and "difficulty playing quietly" less relevant; Martel et al., 2015).

    • Symptoms like restlessness and emotion dysregulation might be more developmentally appropriate for adults and aid in differentiation (Hirsch et al., 2018; Wender et al., 2001).

    • Rigorous evaluation of developmental differences and changes in symptom expression from preschool to adulthood is lacking.

  • Adolescent Girls and Women: Understudied and potentially underidentified.

    • Lower rates of comorbid disruptive behavior disorders and higher rates of internalizing problems (Chronis-Tuscano et al., 2010; Hinshaw et al., 2022).

    • Preliminary research suggests ADHD symptoms fluctuate cyclically with the menstrual cycle, starting at puberty (Roberts et al., 2018).

    • Adolescent girls with ADHD may experience increased depression and impairment (Eng et al., In Press).

    • Assessments may need to be sensitive to reproductive and menstrual cycle phases.

  • Race and Ethnicity: Heavily understudied area.

    • Race and ethnicity are social constructs, but group differences are likely related to social/systemic factors (racism, healthcare access, SES; Flanagin et al., 2021) and risk markers (lower birth weight, maternal education, household income; Cénat et al., 2021).

    • Prevalence: Equivocal results.

      • Some studies suggest higher prevalence in Black children than White children (Cuffe et al., 2005; Danielson et al., 2018).

      • Other research found no differences (A. W. Wong & Landes, 2022) or reversed effects (higher rates in White vs. Black adolescents; Shi et al., 2021).

    • Underdiagnosis: ADHD may be underdiagnosed in Black children (Coker et al., 2016), despite Black mothers rating symptoms higher than White mothers (Barrett & DuPaul, 2018).

    • Black children may exhibit more symptoms but are diagnosed less often, possibly due to parental effects and treatment accessibility (Miller et al., 2009).

    • Other racial/ethnic groups are less studied (Chung et al., 2019; Collins & Cleary, 2016; Getahun et al., 2013; Kapke et al., 2019; Shi et al., 2021; A. W. Wong & Landes, 2022).

    • Causes of Disparities: Numerous factors include problem recognition, cultural stereotypes/biases in raters/clinicians, care-seeking tendencies (Coker et al., 2016), fear of stigma, and racial discrimination.

    • Solutions: Multipronged approach needed, including culturally sensitive and appropriately normed assessment protocols, addressing knowledge gaps, facilitating trusting relationships, and determining if ADHD criteria need modification for cultural context. Professionals need wider understanding of cultural variations and competence in various models of illness, behavior, bias, family dynamics, and developmental issues (Kagitcibasi, 2005).

XV. Summary of Current Evidence-Based Procedures

  • Necessity: Narrow- and broadband ratings are needed to assess ADHD and common comorbidity.

  • Learning Concerns: Consideration of academic achievement, IQ, and executive function assessment in cases with concerns about learning problems.

  • Developmental Phase: Crucial for integrating multiple informant data.

    • Childhood: Parent and teacher reports should be averaged (ages 12 and below).

    • Adulthood: Other informant reports should be prioritized over self-ratings when inconsistent, with separate consideration of self-report for comorbid internalizing problems.

  • Future Research: Critical need for research on:

    • Sensitivity of symptom ratings to developmental change over time and treatment response.

    • Validity of measures for historically understudied populations (adults/adolescents, girls/women, non-Caucasian races/ethnicities).