Evidence based assessment/Attention deficit hyperactivity disorder (assessment portfolio)
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|Steps 1-2: Preparation phase|
|Steps 3-5: Prediction phase|
|Steps 6-9: Prescription phase|
|Steps 10-12: Process/progress/outcome phase|
- 1 Demographic information
- 2 Diagnosis
- 3 Treatment
- 4 Process and outcome measures
- 5 References
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 rate of ADHD that they are likely to see in their clinical practice.
|Setting (Reference)||Base Rate(s)||Demography||Diagnostic Method||Best Recommended For|
|Meta-Analysis of worldwide prevalence of Child/Adolescent ADHD||6.1% (parent rating)
7.1% (teacher rating)
10.5% (ages 3-5)
11.4% (ages 6-12)
8.0% (ages 13-18)
|Worldwide, Ages 3-18||Multiple, but each focused on DSM-IV criteria|
|Epidemiological NHIS (US CDC, 2011)||8.4% (Overall)
2.1% (ages 3-5)
8.4% (ages 6-11)
11.9% (ages 12-17)
10.3% (southern region of US)
|USA Nationally Representative, Ages 3-17||Parent-report of whether child had ever been diagnosed|
|Child and Adolescent Epidemiological National Survey of Children's Health (US CDC, 2007)||9.5% (overall)
1.5% (ages 3-5)
9.1% (ages 6-11)
12.4% (ages 12-17)
15.6% (North Carolina)
|USA Nationally Representative, Ages 4-17||Parent-report of whether child had ever been diagnosed|
|Adolescent Epidemiological National Comorbidity Survey-Adolescent Supplement||8.7%||USA Nationally Representative, Ages 13-18||CIDI 3.0 structured diagnostic interview|
|Johnston County, North Carolina Sample||15.5%||Representative Sample of Johnston County School Children, North Carolina, Ages 6-12||Combined parent and teacher report (NTRS and DISC) with DSM-IV criteria|
|North Carolina Community Sample||0.9% (3-month prevalence)
4.1% (estimated by age 16)
|Sample drawn from 11 counties in Western NC, Ages 9-16||CAPA structured diagnostic interview|
|High-Risk Community Sample||14.3%||Sample recruited at Durham, NC, Seattle, Nashville, and Central Pennsylvania sites. Sample was followed longitudinally and identified as at high risk for externalizing disorders in kindergarten. 50% African American, ages 12-15||Diagnostic Interview Schedule for Children (DISC)|
|Meta-Analysis of Clinical Samples||38%||Ages 6-90||Structured Diagnostic Interviews|
|Meta-Analysis of Clinical Samples||23%||Ages 6-90||Clinical Evaluations|
|Teacher-Reported Prevalence of ADHD||5.25% (overall)
5.58% (elementary schoolers)
3.53% (middle schoolers)
7.1% (one county in rural NC)
|USA Nationally Representative, Ages 5-14||Teacher report of number of children who have been identified with ADHD in their class|
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
- Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
- Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
- a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
- b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
- f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
- Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
- Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
- a. Often fidgets with or taps hands or feet or squirms in seat.
- b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
- c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
- d. Often unable to play or engage in leisure activities quietly.
- e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
- f. Often talks excessively.
- g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
- h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
- i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
- 314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.
- 314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.
- 314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.
- Specify if:
- In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning.
Specify current severity:
- Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
- Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
- Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent
|Screening Measure (Primary Reference)||AUC||LR+ Score||LR- Score||Clinical generalizeability||Study description|
|Child Behavior Checklist (CBCL) - Attention Problems T-Score||.84 (N=187)||6.92 (>55)||0.19 (<55)||Somewhat High||Utilized sample ages 6-18 recruited from local pediatricians, psychiatrists, and community advertisements. Included 95 children who met criteria for ADHD. 70 of these children also met criteria for ODD/CD.|
|12.2 (>60)||0.41 (<60)|
|47 (>65)||0.53 (<65)|
|34 (>70)||0.66 (<70)|
|Child Behavior Checklist (CBCL) - Attention and Aggression Problems T-Score||Boys: .86 (N=111)||10.2 (>55)||0.41 (<55)||Somewhat High||Utilized sample ages 6-18 which consisted of 219 brothers and sisters of children who were referred to a hospital pediatric unit for ADHD or other symptoms. Half of these siblings had brothers and sisters who had ADHD, half did not.|
|Girls: 0.90 (N=108)||11.2 (>55)||0.35 (<55)|
|Teacher Response Form (TRF) - Attention Problems T-Score||Not reported (N=184)||3.66 (>70)||0.73 (<70)||Somewhat High||Utilized sample ages 5-12 years referred to a research clinic for assessment of ADHD. 108 children were ultimately diagnosed with ADHD, while 76 were not. LR's are calculated for discriminating between those two groups.|
|Teacher Response Form (TRF) - Attention and Aggression Problems T-Score||Not reported (N=184)||4.33 (>70)||0.89 (<70)||Somewhat High|
|Composite International Diagnostic Interview (CIDI) 3.0||Adolescent Reported: .57 (N=321)||8.36 (when classified positive by CIDI)||0.86 (when classified negative by CIDI)||Moderate||Utilized the NCS-A sample of 10,148 adolescents aged 13-17 and their parents.|
|Parent Reported: .71 (N=321)||9.67 (when classified positive by CIDI)||0.56 (when classified negative by CIDI)|
|Disruptive Behavior Disorder Rating Scale (DBDRS) - Parent Report (Pelham et. al, 1992)||0.78 (N=232)||5.06 (Endorsed ≥ 6 symptoms of inattention or hyperactivity)||0.20 (<9) (Endorsed < 6 symptoms of inattention or hyperactivity)||Somewhat High||Sample consisted of 232 ethnically diverse children ages 5-10 with (n = 121) and without (n=111) ADHD recruited through advertisements at school and through self-help groups.|
|Disruptive Behavior Disorder Rating Scale (DBDRS) - Teacher Report (Pelham et. al, 1992)||0.63 (N=232)||1.97 (Endorsed ≥ 6 symptoms of inattention or hyperactivity)||0.24 (Endorsed < 6 symptoms of inattention or hyperactivity)||Somewhat High|
|Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS)||Not reported||4.79 (Endorsed ≥ 6 symptoms of inattention or hyperactivity)||0.38 (Endorsed < 6 symptoms of inattention or hyperactivity)||Moderate||Sample consists of 582 children ages 5-15 recruited through schools in Oklahoma. Sample includes children screened as "high risk" for ADHD and "low risk" for ADHD.|
|Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS)||Not reported||2.91 (Positive risk score)||0.657 (Negative risk score)||Moderate||Sample consisted of 370 children ages 5-15 recruited though schools in Oklahoma. Sample was representative community sample.|
|Conners Rating Scale (Revised) - Long Form Parent Report (Conners, 1997)||Not reported||15.33 (>93rd percentile)||0.09 (<93rd percentile)||Moderate||Data come from normative sample of 2482 children ages 3 to 17 across the United States and Canada. LRs here discriminate ADHD from Non-Clinical.|
|Conners Parent Rating Scale-48 (CPRS-48) Impulsive-Hyperactive Subscale T-Score (Conners, 1990)||Not reported||1.26 (>70)||0.79 (>70)||Somewhat High||Utilized sample ages 5-12 years referred to a research clinic for assessment of ADHD. 108 children were ultimately diagnosed with ADHD, while 76 were not. LR's are calculated for discriminating between those two groups.|
|Conners Teacher Rating Scale-39 Hyperactivity Subscale T-Score (Conners, 1990)||Not reported||5.2 (>70)||0.53 (<70)||Somewhat High|
|Conners Teacher Rating Scale (Revised) - Long Form (Conners, 1997)||Not reported||8.66 (>93rd percentile)||0.24 (<93rd percentile)||Moderate||Data come from normative sample of 1973 children ages 5 to 17 across the United States and Canada. LRs discriminate ADHD from non-clinical.|
|ADHD Symptom Checklist-4 (ADHD-SC4) - Parent Report||Not reported||1.45 (Endorsed ≥ 6 symptoms of inattention or hyperactivity)||0.70 (Endorsed < 6 symptoms of inattention or hyperactivity)||Somewhat High||Data come from sample of 207 children ages 5-17 years old who were referred to psychiatric outpatient service with variety of emotional and behavioral disorders.|
|ADHD Symptom Checklist-4 (ADHD-SC4) - Teacher Report||Not reported||1.53 (Endorsed ≥ 6 symptoms of inattention or hyperactivity)||0.60 (Endorsed < 6 symptoms of inattention or hyperactivity)||Somewhat High|
|ADHD RS-IV - Home (DuPaul et. al, 1998b)||Not reported||1.63 (>80th percentile)||0.35 (<80th percentile)||Moderate||Sample of 2000 children ages 5 to 18 years old from geographically representative normative base.|
|ADHD RS-IV - School (DuPaul et. al, 1998b)||Not reported||4.5 (>80th percentile)||0.42 (<80th precentile)||Moderate|
|Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID)||0.83 (N=225)||4.14 (Diagnosis of ADHD on MINI-KID)||0.16 (No Diagnosis of ADHD on MINI-KID)||MISSING||Sample of 225 children and adolescents ages 6-17 which included 190 outpatients and 36 controls, recruited from South Florida psychiatric center.|
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).
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.
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
|Intervention type||Effect size|
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.
Process and outcome measures
Severity and outcome
|Measure||Diagnostic category||Cut Scores*||Critical Change
|Benchmarks Based on Published Norms|
|Conners 3-Teacher Rating Scale T-Scores||ADHD Inattentive||36||74||57||11||10||5.6|
|Conners 3-Parent Rating Scale T-Scores||ADHD Inattentive||37||72||58||10||10||5.6|
|Benchmarks Based on ADHD Samples|
|Disruptive Behavior Disorders Rating Scale||1.4||8.6||5.7||12||10||0.9|
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
- 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.
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