Evidence-based assessment/Attention deficit hyperactivity disorder (assessment portfolio)/extended version

What is a "portfolio"?
For background information on what assessment portfolios are, click the link in the heading above.

Does all of this feel like TMI? Click here to go to a condensed version.

Diagnostic Criteria of ADHD in youth
ICD-11 Diagnostic Criteria
 * General Definition:
 * Attention deficit hyperactivity disorder is characterized by a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity, with onset during the developmental period, typically early to mid-childhood. The degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation expected for age and level of intellectual functioning and significantly interferes with academic, occupational, or social functioning. Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility and problems with organization. Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in structured situations that require behavioural self-control. Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences. The relative balance and the specific manifestations of inattentive and hyperactive-impulsive characteristics varies across individuals, and may change over the course of development. In order for a diagnosis of disorder the behaviour pattern must be clearly observable in more than one setting.
 * Predominantly Inattentive Presentation:
 * All definitional requirements for attention deficit hyperactivity disorder are met and inattentive symptoms are predominant in the clinical presentation. Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility and problems with organization. Some hyperactive-impulsive symptoms may also be present, but these are not clinically significant in relation to the inattentive symptoms.
 * Predominantly Hyperactive-Impulsive:
 * All definitional requirements for attention deficit hyperactivity disorder are met and hyperactive-impulsive symptoms are predominant in the clinical presentation. Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in structured situations that require behavioural self-control. Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences. Some inattentive symptoms may also be present, but these are not clinically significant in relation to the hyperactive-impulsive symptoms.

Base rates of youth ADHD in different populations and clinical settings
This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled, and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rates of adolescent depression that they are likely to see in their clinical practices.


 * To find prevalence rates across multiple disorders, click here.

Psychometric properties of screening instruments for youth ADHD
The following section contains a list of screening and diagnostic instruments for ADHD. The section includes administration information, psychometric data, and PDFs or links to the screenings.
 * Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
 * For a list of more broadly-reaching screening instruments, click here.

Screening and diagnostic instruments for attention deficit hyperactivity disorder
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent

Likelihood ratios and AUCs of screening measures for (insert portfolio name)

 * For a list of the likelihood ratios for more broadly reaching screening instruments, click here.

Note: All studies with one exception used structured or semi-structured clinical interviews to establish diagnosis of ADHD. The exception, the Sprafkin & Gadow study (2007), used a combination of CBCL rating scales, clinician review, and clinician consensus to confirm ADHD diagnosis. “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000).

Interpreting ADHD screening measure scores

 * For information on interpreting screening measure scores, click here.
 * Also see the page on likelihood ratios in diagnostic testing for more information

Gold standard diagnostic interviews

 * For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic interviews for ADHD
****Depression instruments are placeholders Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Severity interviews for ADHD
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Process phase
The following section contains a brief overview of treatment options for ADHD and list of process and outcome measures for ADHD. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Process measures

 * CBCL Attention Problems Subscale
 * Could be used on a weekly basis to track changes in ADHD symptomotology. T-scores from this measure could also be recorded on a weekly basis to determine if reliable and clinically significant changes in ADHD symptoms are occuring. The CBCL Attention Problems Subscale has repeatedly demonstrated good-to-excellent convergence with diagnostic interviews for diagnosing ADHD. The CBCL Attention Problems Subscale is a scale on the CBCL, which is readily available at the Finley Clinic.


 * Daily Report Card
 * Several scholars have pointed out that it is equally important to track changes in the functional behaviors that a child with ADHD engages in, in addition to their ADHD symptoms, to capture the full range of adaptive changes that are made by children with ADHD throughout the course of treatment. The daily report card is a mechanism by which such adaptive behavioral changes can be tracked. When implementing the daily report card, problematic child behaviors at home and at school are targeted for change. Rewards are offered to the child for reaching daily and weekly goals for reducing maladaptive behaviors and increasing adaptive behaviors. Parents and Teachers track child behaviors on a daily basis and provide feedback to one another and the child with behavior frequency counts and/or daily "grades" on how well the child behaved. Daily report cards are a mainstay of cognitive-behavioral and behavioral modification evidence-based intervention strategies for ADHD, and they are highly recommended for tracking child treatment outcomes. Instructions for creating a daily report card are attached in Appendix 1.

Outcome and severity measures
This table includes clinically significant benchmarks for ADHD specific outcome measures


 * Information on how to interpret this table can be found here.
 * Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
 *  For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks,  see here.

Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.

Search terms: [ADHD or CONNERS or DBD] AND [clinical significance OR group means] in PsycINFO

Treatment

 * Please refer to the Wikipedia page on Attention Deficit Hyperactivity Disorder for more information on available treatment for ADHD or go to Effective Child Therapy for a curated resource on effective treatments for ADHD.

Executive summary
1. If intervening with children ages 4-5, behavior therapy should be the first line of treatment.

2. If intervening with children ages 6-11, behavior therapy should be the first line of treatment, in conjunction with medication.

3. If intervening with children ages 12-18, medication should probably be the first line of treatment, though behavior therapy could be used in combination.

4. Three types of therapeutic interventions have well established evidence-bases:


 * a. Behavioral Parent Training Interventions
 * b. Behavioral Classroom Management Interventions
 * c. Behavioral Peer interventions involving recreational peer groups (e.g. summer camps)

5. If considering a classroom management intervention:


 * a. Academic and Cognitive-Behavioral Interventions are most effective in changing academic outcomes
 * b. Cognitive Behavioral and Contingency Management Interventions are most effective in changing behavioral outcomes

Clinical practice guidelines
Published by the American Academy of Pediatrics in 2011.


 * Preschool-aged children (ages 4–5)
 * Primary care clinicians should prescribe evidence-based parent and/or teacher-administered behavior therapy as the first line of treatment, and may prescribe methylphenidate if behavioral interventions are not effective.


 * Elementary-aged children (ages 6–11)
 * Primary care clinicians should prescribe FDA-approved medications for ADHD and/or evidence based parent and teacher administered behavior therapy. Preferably, both medication and behavior therapy will be prescribed.


 * Adolescents (ages 12–18)
 * Primary care clinicians should prescribe FDA approved medications for ADHD with the assent of the adolescent and may prescribe behavior therapy as a treatment for ADHD, preferably both.

Behavioral therapies
These meet the American Academy of Pediatrics and American Psychological Association Task Force criteria for well-established evidence-based treatments. Descriptions and effect sizes are taken from the American Academy of Pediatrics' guidelines and Pelham & Fabiano's review article.


 * Behavioral Parent Training
 * Behavior modification principles provided to parents for implementation in home settings. Typical outcomes include improved compliance with parental commands, improved parental understanding of behavioral principles, high levels of parental satisfaction with treatment.
 * Median effect size: 0.55


 * Behavioral Classroom Management
 * Behavior-modification principles provided to teachers for implementation in classroom settings. Typical outcomes include improved attention to instruction, improved compliance with classroom rules, decreased disruptive behavior, improved work productivity, and improved academic achievement.
 * Median effect size: 0.61


 * Behavioral Peer Interventions
 * Interventions focused on peer interactions/relationships. These could include group-based interventions provided weekly and include clinic-based social skills training used either alone or concurrently with behavioral parent training and/or medication. Typical outcomes are more mixed with these interventions. Some clinical-office based interventions have produced minimal effects, while some studies of behavioral peer intervention coupled with behavioral parent training found positive effects on parental ratings of ADHD symptoms. No studies of this type of intervention reveal differences on social functioning or parental ratings of social behavior. Behavioral Peer Interventions implemented in peer group/recreational settings (e.g. summer camps) have the most evidence of being effective.
 * Median effect size: None reported, effect sizes found are considered moderate.

School based interventions
Findings from a review by DuPaul and colleagues.


 * Associated with greater effects on academic outcomes
 * Academic — interventions focus primarily on manipulating antecedent conditions via things like peer tutoring, computer-aided instruction, and organizational skills.
 * Combined academic and contingency management interventions.


 * Associated with greater effects for behavior outcomes
 * Contingency management — interventions use reinforcement and punishment.
 * Cognitive behavioral — interventions focus on development of self-control skills and reflective problem-solving strategies.