State of the Art Assessment and

Treatment of ADHD: A Workshop

for Psychologists in the Trenches
Georgia Psychological Associa=on Annual Mee=ng
Augusta, GA
April 16, 2016
William L. Buchanan, Ph.D., ABPP
Board Cer)fied in Clinical Psychology
doc4add@mindspring.com

North Point Psychology, LLC (678) 624-0310, ex. 0

3534 Old Milton Parkway fax: (678) 624-0258
Alphare>a, Georgia 30005 www.NorthPointPsychology.com
Russell Barkley (2013). Taking Charge of ADHD –
Third Edi4on. NY: Guilford. Chapter 1, first
paragraph:

“A>enOon-deficit/hyperacOvity disorder, or ADHD, is a

developmental disorder of self-control. It consists of
obvious problems with a>enOon span, impulse control,
and acOvity level. But…the disorder is also reflected in
impairment in will or the capacity to control the child’s
own behavior rela@ve to the passage of @me, that is,
to keep future goals and consequences in mind. It is
not…just a ma>er of being ina>enOve and
overacOve.” (p. 19)
2
What is ADHD?
• A>enOon Deficit HyperacOvity Disorder
• ADHD is a biological, neurological, mostly geneOc condiOon
that people are born with, live with, and die with.
• There is no cure – it must be managed (similar to diabetes).
• ADHD is not acquired and it is not caused by inadequate or
bad parenOng (although parenOng can make the symptoms
worse or help make the symptoms more manageable).

3
Different names for ADHD
ADHD has been present for hundreds of years and has had many different names:

•  A>enOon deficits chapter in medical •  Minimal Brain DysfuncOon (MBD)

textbook by Melchior Adam Weikard, •  Hyperkinesis
published in German, 1775
•  HyperkineOc Syndrome
•  “Diseases of a>enOon” in medical
textbook by Scodsh physician Alexander •  HyperacOvity
Crichton, 1798 •  A>enOon Deficit Disorder (ADD)
•  “Fidgety Phil” described by German •  A>enOon Deficit HyperacOvity Disorder
physician Heinrich Hoffman, 1865 (ADHD)
•  PostencephaliOc Behavior Disorder •  “bad kid,” “out of control child,” etc.
•  (1917 – 1918 epidemic)
•  “Poor kid, bad parents”
•  Minimal Brain Damage

4
 ADHD Sta=s=cs
•  Worldwide prevalence is 4.5 to 5.5% of all children and 3.5 to 4.5% of all
adults have ADHD.
•  Approximately 9.5% of U.S. children 4 - -17 years of age (6.4 million) have
been diagnosed with ADHD as of 2011 (CDC).
•  40 to 60% of all ADHD individuals are undiagnosed.
•  Boys (13.2%) are more likely than girls (5.6%) to be diagnosed with
ADHD. (RaOo: about 2.4 to 1).
•  13.2% of boys have ADHD – that’s about 1 or 2 ADHD boys in every
classroom.
•  85% of individuals with ADHD have Combined PresentaOon.
5
ADHD doesn’t just run in families – it gallops!

6
ADHD Sta=s=cs
•  40% of children who have ADHD have at least one parent who has ADHD
•  57% of individuals with ADHD will have offspring with ADHD.
•  50% of children who have ADHD also have sleep problems.
•  Parents of a child who has ADHD are three Omes as likely to separate or
divorce as parents of non-ADHD children
•  Teenagers with ADHD have almost four Omes as many traffic citaOons as
their non--ADHD peers.
•  Teens with ADHD have four Omes as many car wrecks and are seven Omes
more likely to have a second accident.
•  Over 10,000 scienOfic papers and over 100 textbooks have been wri>en
on ADHD.
7
DSM II, III, III-R
Diagnos(c and Sta(s(cal Manual (DSM) published by the American Psychiatric AssociaOon.

•  DSM--II (1968) HyperkineOc ReacOon of Childhood

•  DSM--III (1980) A>enOon Deficit Disorder (ADD)

with or without HyperacOvity, also Residual Type

•  DSM--III-R (1987) A>enOon Deficit HyperacOvity

Disorder (ADHD) – no types
8
DSM-IV, DSM-5
Diagnos(c and Sta(s(cal Manual (DSM) published by the American Psychiatric AssociaOon (ApA).

•  DSM--IV (1994) ADHD with Types:

•  Predominately Ina>enOve Type
•  Predominately HyperacOve/Impulsive Type
•  Combined Type

•  DSM--5 (2013) ADHD with PresentaOons:

•  Predominately Ina>enOve PresentaOon (PIP)
•  Predominately HyperacOve/Impulsive PresentaOon (PHIP)
•  Combined PresentaOon (CP) 9
 DSM-5 InaVen=on Criteria for ADHD
•  1. InaDen@on: Six or more symptoms of ina>enOon for children up to age 16, or five or more for
adolescents 17 and older and adults; symptoms of ina>enOon have been present for at least 6
months, and they are inappropriate for developmental level:

•  Olen fails to give close a>enOon to details or makes careless mistakes in schoolwork, at work, or
with other acOviOes.
•  Olen has trouble holding a>enOon on tasks or play acOviOes.
•  Olen does not seem to listen when spoken to directly.
•  Olen does not follow through on instrucOons and fails to finish schoolwork, chores, or duOes in
the workplace (e.g., loses focus, side-tracked).
•  Olen has trouble organizing tasks and acOviOes.
•  Olen avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of
Ome (such as schoolwork or homework).
•  Olen loses things necessary for tasks and acOviOes (e.g. school materials, pencils, books, tools,
wallets, keys, paperwork, eyeglasses, mobile telephones).
•  Is olen easily distracted
•  Is olen forgenul in daily acOviOes. 10
 DSM-5 Hyperac=vity / Impulsivity Criteria
for ADHD
•  2. Hyperac@vity and Impulsivity: Six or more symptoms of hyperacOvity-impulsivity for
children up to age 16, or five or more for adolescents 17 and older and adults; symptoms
of hyperacOvity-impulsivity have been present for at least 6 months to an extent that is
disrupOve and inappropriate for the person’s developmental level:

•  Olen fidgets with or taps hands or feet, or squirms in seat.

•  Olen leaves seat in situaOons when remaining seated is expected.
•  Olen runs about or climbs in situaOons where it is not appropriate (adolescents or adults
may be limited to feeling restless).
•  Olen unable to play or take part in leisure acOviOes quietly.
•  Is olen "on the go" acOng as if "driven by a motor".
•  Olen talks excessively.
•  Olen blurts out an answer before a quesOon has been completed.
•  Olen has trouble waiOng his/her turn.
•  Olen interrupts or intrudes on others (e.g., bu>s into conversaOons or games). 11
 Barkley (2013)
Impulsiveness and HyperacOvity seem to be part of the same problem –
impairment in behavioral inhibi@on.

“Even what we call problems with a>enOon at Omes seem to be problems with
inhibiOng behavior – inhibiOng the urge to do something a child would rather
be doing than the task at hand. So when we say that children with ADHD have a
short a>enOon span, we really mean they have a short interest span.” (p. 53)

“So it seems that all three problems thought to be the primary symptoms of
ADHD – a>enOon, impulsiveness, and hyperacOvity – can be reduced to a delay
in the development of inhibi@on of behavior and of persistence toward goals
and the future more generally.” (p. 54) 12
DSM-5 Criteria for ADHD – cont.
•  In addiOon, the following condiOons must be met:

•  Several ina>enOve or hyperacOve-impulsive symptoms were present before

age 12 years.
•  Several symptoms are present in two or more sedng, (such as at home, school
or work; with friends or relaOves; in other acOviOes).
•  There is clear evidence that the symptoms interfere with, or reduce the quality
of, social, school, or work funcOoning.
•  The symptoms are not be>er explained by another mental disorder (such as a
mood disorder, anxiety disorder, dissociaOve disorder, or a personality
disorder). The symptoms do not happen only during the course of
schizophrenia or another psychoOc disorder.
13
DSM-5 Presenta=ons for ADHD
Based on the types of symptoms, three presentaOons of ADHD can occur:

•  Combined Presenta@on (CP): if enough symptoms of both criteria ina>enOon and

hyperacOvity-impulsivity were present for the past 6 months

•  Predominantly InaDen@ve Presenta@on (PIP): if enough symptoms of ina>enOon,

but not hyperacOvity-impulsivity, were present for the past six months

•  Predominantly Hyperac@ve-Impulsive Presenta@on (PHIP): if enough symptoms of

hyperacOvity-impulsivity but not ina>enOon were present for the past six months.
(Usually very young children)

•  Because symptoms can change over Ome, the presentaOon may change over Ome as
well. (No longer “Types”).
14
 5 Types of AVen=on
•  Focused ADen@on: The ability to keep one's a>enOon focused while compleOng a parOcular task. Children who have
difficulty with focused a>enOon are olen described as daydreaming and preoccupied with other acOviOes instead of
the assigned task. Focused a>enOon refers to the intensity of the a>enOonal process at any given moment.
Example: Instead of doing class work, the child stares out the window.
•  Selec@ve ADen@on: The opposite of distracObility; the ability not to be distracted by extraneous events. Children who
have difficulty with selecOve a>enOon are distracted easily by minor noises or movement . They are unable to
prioriOze and select what is most important to pay a>enOon to in their immediate environment.
Example: Although the teacher may be standing at the front of the room and speaking, the child is paying a>enOon to
the classmate next to him. (“Squirrel!”)
•  Divided ADen@on: The ability to divide one's a>enOon so that one can complete two tasks simultaneously.
Example: The child has difficulty listening to a teacher while simultaneously taking notes.
•  Sustained ADen@on: Persistence; the ability to remain on task for a sufficient amount of Ome to saOsfactorily complete the
task. Sustained a>enOon refers to the length of Ome one has focused a>enOon.
Example: The child is unable to complete 20 minutes worth of mathemaOcs homework without gedng off task.
•  Vigilance: Wakefulness and readiness to respond. Normal vigilance is required for adequate a>enOon.
15
Example: Instead of listening to the teacher, the child puts her head down on the desk and sleeps during class.
 Concentra=on Deficit Disorder
(previously Sluggish Cogni=ve Tempo)
•  A second a>enOon disorder has been proposed by Russell Barkley, which is separate and disOnct from ADHD.
“Primarily a disorder of vigilance” or “Disorder of mind wandering.”
•  Researchers have found the most salient symptoms of CDD:

Daydreaming Lethargic
Trouble staying alert / awake UnderacOve
Mentally foggy / easily confused Slow moving / sluggish
Stares a lot Slow to complete tasks
Lost in thoughts Drowsy / sleepy appearance
Spacey / mind is elsewhere ApatheOc / withdrawn
Does not process quesOons or explanaOons Lacks iniOaOve/effort fades
accurately
•  Note: A cogniOve component and a behavioral competent; i.e., “HypoacOve.” 16
CDD
•  Barkley has concluded that CDD is NOT a disorder of execuOve funcOoning, but
ADHD is massively so (i.e., CDD is more of a pure a>enOon / concentraOon
disorder).
•  59% of individuals with CDD also meet criteria for ADHD, mostly PIP.
•  CDD has less heritability than ADHD, and somewhat greater contribuOon from
environmental factors; e.g.:
•  Prenatal alcohol exposure
•  Treatment side effect from leukemia

There is no official diagnosOc criteria for CDD, but Barkley indicates that if a parent endorses 3
or more symptoms listed earlier, the child reaches the 93rd percenOle (i.e., 1.5 standard
deviaOons above the mean; T = 65).
In the case of an adult, Barkley suggests 5 or more symptoms.
h>p://www.russellbarkley.org/factsheets/SluggishCogniOveTempo.pdf
Also see Chapter 17, p. 435 (2015). 17
Proposed Diagnos=c Criteria of Adult ADHD
Six or more which have persisted for six months or more that is maladapOve and
inconsistent with developmental level:

1. Olen easily distracted by extraneous sOmuli.

2. Olen make decisions impulsively.
3. Olen has difficulty stopping acOviOes or behavior when they should do so.
4. Olen starts a project or task without reading or listening to direcOons
carefully.
5. Olen shows poor follow through on promises of commitments they make to
others.
18
Proposed Criteria for Adult ADHD - cont.
6. Olen has trouble doing things in their proper order or sequence.
7. Olen more likely to drive a motor vehicle much faster than
others (excessive speeding). (If person has no driving history,
subsOtute: “Olen has difficulty engaging in leisure acOviOes or
doing fun things quietly.”)
8. Olen has difficulty sustaining a>enOon in tasks or leisure
acOviOes.
9. Olen has difficulty organizing tasks and acOviOes.

Barkley, 2008. 19
Causes of ADHD
•  UnderacOvity in frontal lobes
•  Reduced cerebral blood flow to frontal and striatal regions
•  Smaller prefrontal lobe and striatal regions, especially on right side
(Hynd and others).
•  “The striatum, together with the hippocampus, is one of the most
vulnerable regions in the brain” (Journal of Neurotrauma, March 2000).
Buchanan’s pondering: Are a>enOon & EF most fragile abiliOes?
Note: A>enOon and EF in elderly with demenOa are “first to go.”
•  GeneOcs: ADHD risk of offspring with ADHD is 57%
•  MonozygoOc twins 81% concordance rate; DizygoOc twins 29%.
20
Underac=vity of the Brain in ADHD
Buchanan’s pondering: Is behavioral hyperacOvity a
compensa@on for the brain’s under-arousal? Is this why
sOmulants decrease hyperacOvity?

Teaching analogy:

Driving back from vacaOon on downtown connecter (I-85/75)

at 2:00 a.m. and you are dead Ored. What do you do?
21
 Striatum
Caudate and Putamen
Striatum is the subcorOcal
part of the forebrain and
a criOcal component of
the reward system.
FuncOonally, the striatum
coordinates mulOple
aspects of cogniOon,
including motor and
ac@on planning,
decision-making,
mo@va@on,
reinforcement, and
reward percep@on.
22
 DSM-6 (20??)

Executive Function Disorder?

Executive Function Deficit

Disorder?
23
Execu=ve Func=ons
•  Most common definiOon: “Those •  Effort / Persistence
mental abiliOes needed to sustain •  Planning
problem solving toward a goal.” •  Organizing
•  “Those capabiliOes that enable a •  Problem Solving
person to engage successfully in •  Working Memory
independent, purposeful, self-
serving behavior.” Lezak, 1995, p. 42 •  Managing emoOons and frustraOons
•  Monitoring
•  AdjusOng acOons based on
•  Focusing (Barkley: Pre-EF) environmental feedback
•  Focused and Sustained A>enOon
•  Time management
•  InhibiOon •  Past, Present, Future
•  Impulse Control •  CompleOng / Follow Through
•  IniOaOon / AcOvaOon 24
Execu=ve Func=ons: Making a PB&J Sandwich

1.  Focus / Pay a>enOon: “I’m hungry.”

2.  Problem solve: “I can fix a PB&J.”
3.  AcOvaOon: “Get up and go to kitchen.”
4.  Plan: “I need peanut buMer, jelly, bread, knife, plate.”
5.  Organize: “Put on counter.”
6.  Effort / Persistence: “Don’t give up.”
7.  Sustained A>enOon: “Don’t get distracted.”
8.  Impulse Control: “I’ll play Xbox later, aRer my PB&J.”
25
 Execu=ve Func=ons: Making a PB&J Sandwich
9.  Working memory: “Where’s the plate?”
10.  Managing emoOons: “This is taking too long.”
11.  Plan: “I beMer clean up too.”
12.  Organize: “Take plate and knife to sink, then dishwasher; bread
and peanut buMer to cabinet; jelly to refrigerator.”
13.  AcOvaOon / Effort
14.  Sustained A>enOon: “Don’t get distracted.”
15.  Impulse Control: “I’ll play Xbox in a minute.”
16.  CompleOng: “Anything else I need to do?”
26
 Execu=ve Func=ons: Doing Homework
1.  Listen to the teacher.
2.  Write down the assignment accurately & completely.
3.  At locker -- remember, plan, and organize. (What will I
need tonight to complete my HW – for every class?)
4.  Put everything needed in backpack.
5.  Take home.
6.  At home – remember: HW tonight.
7. IniOate HW – get materials out of backpack.
8. Plan and organize at desk. 27
 Execu=ve Func=ons: Doing Homework
9.  Do Math – focus, impulse control, problem solving, manage
frustraOon, make correcOons based on feedback,
persistence, follow through, etc.
10.  Put in notebook, put up math materials.
11.  Do Science, put in notebook, put up science materials.
12.  Etc. – repeat for each class.
13.  Have backpack ready to go in the morning.
14.  Take backpack to school.
15.  At locker, get what I need for class. 28
Execu=ve Func=ons: Doing Homework

16. Turn in homework.

17. Etc. – repeat for each class.

Note: a child can do 90% of these and sOll get a zero.

29
30% Rule
The execuOve funcOons of ADHD children lag behind their same age peers by about
30%. So a 10 year old child with ADHD has the execuOve funcOons ability of the
average 7 year old child. (2013, p. 37)

Age : EF
6 : 4 Buchanan’s pondering: Since the frontal lobe conOnues to
9 : 6 develop unOl the mid-20s, is the maximum EF for an ADHD
10 : 7 adult about equal to the EF of a 17 year old?
12 : 8
15 : 10
18 : 12 Buchanan’s pondering: If 30% is Average (Moderate),
20 : 14 is Mild ADHD = 10 to 20%?
24 : 16 is Severe ADHD = 40 to 50%?
25 : 17 30
ADHD and Time, according to Barkley (2013):

“The disorder is also reflected in impairment in will or the capacity to

control the child’s behavior rela@ve to the passage of @me, that is, to
keep future goals and consequences in mind.” (2013, p. 19)
“ADHD is not just hyperacOvity or distracObility of the moment…, but a
relaOve impairment in how behavior is organized and directed toward
the tomorrows of life.” (2013, p. 26)
“…the behavior of those with ADHD is focused on the moment, not on
the ‘laDers’ of life.” (2013, p. 26)
“…inability to look toward the future and to regulate their own
behavior.” (2013, p. 27)
31
ADHD and Time, according to Barkley (2013):
“The inability to inhibit behavior and consider the later consequences of one’s
acOons.” (2013, p. 35)
“Altered sense of @me.” (2013, p. 58)
“Nearsighted to the future.” (2013, p. 58)
“Blind to @me or the future.” (2013, p. 58)
“Future Neglect Syndrome” (2013, p. 58)
“A disorder of future-directed behavior.” (2013, p. 26)
“Temporal myopia or @me blindness.” (2015, p. 422)
“Without a sense of the future, it is hard to defer gra@fica@on.” (2013,p. 59)
Buchanan’s pondering: “Future Deficit Disorder??”
Buchanan’s pondering: “Is this deficit of the future the reason it is so for hard for
ADHD individuals to ‘shil gears’?” (e.g., pudng on shoes and gedng out of the car;
Get off the computer!). 32
Time Blindness: Prisoner of the Now
“What is the wise thing to do?” Specifically:

•  “In light of my past experience, current circumstances, and

future hopes and dreams, what is the wise thing for me to
do?”
•  This quesOon does not compute in the ADHD brain! From:
Andy Stanley
North Point Community Church
“Ask It” Series
January 5, 2014
33
 Time Blindness: Prisoner of the Now
•  Dr. Russell Barkley: “Children with ADHD are delayed in their development of their
ability to use an internal sense of @me and of the future to guide their current
behavior. Because they do not have the same capacity to sense and use Ome as normal
children, they can not respond to demands that involve Omelines and preparaOon for the
future as well as others can….They are less sensi@ve to mental informa@on about @me
but are more sensi@ve to things that are occurring around them in the ‘now‘.” (2013, p.
162)

•  Consequences! What consequences?

•  In light of the current situaOon, Hindsight + Foresight = Wisdom.
•  Lack of Hindsight + Lack of Foresight = ADHD behavior, being totally focused on the NOW
•  Now, this moment, this second, is all there is. Lives for the micro-moment. Can’t see,
imagine or realisOcally consider beyond this moment. (Can give lip service to future
consideraOons, but doesn’t truly “get it.”) 34
 Time Blindness: Prisoner of the Now
•  Time Blindness is being blind to hindsight, blind to foresight, and
only seeing the “now.”
•  Individuals (especially children) with ADHD are “Prisoners of the
Now.”
•  “Being blind to my past experience, current circumstances, and
future hopes and dreams, what will I… oops, there it is!”
•  Hard to “shil gears,” i.e., transiOon from one acOvity to another.
Paradoxically, can get “hyper--focused” – “needs a crowbar.”
•  ADHD individuals need external references to @me. (2013, p 162)
35
ADHD: a Disorder of Self-Control
•  Lack of Hindsight + Lack of Foresight (Prisoner of the Now)
•  Poor Working Memory
•  Poor Impulse Control (“disinhibited”)
•  Poor FrustraOon Tolerance
•  Poor EmoOonal RegulaOon

•  i.e., A Disorder of Self--Control

•  Barkley (2015, Chapter 3): “Emo@onal Dysregula@on is a Core Component of ADHD.”
•  “If there is no sense of the future, there is no choice to be made and
therefore no self-control because there is no need for it.” (2015, p. 411).
36
Self-control as Defined by Barkley
•  “Self-control is a response (or series of responses) by the individual that
funcOons to alter the probability of their subsequent response to an event
and in so doing thereby changes the likelihood of a later consequence related
to that event.” (2015, p. 410)
•  “In other words, self-control is any acOon by an individual directed toward
changing one’s behavior and therein altering future rather than merely
immediate consequences.” (p. 410)
•  Execu(ve func(ons “comprise the principal classes of behavior on which we
engage for purposes of self-regula(on (changing our current behavior so as to
change our future.) An execuOve act is any acOon one takes that funcOons to
modify one’s own behavior so as to likely change one’s future outcome. EFs
represent a specific type or class of self-control.” (p. 410)
37
Symptoms of Emo=onal Impulsiveness

Barkley: “Problems with inhibi@on of behavior are highly associated with

problems with inhibi@on and self-regula@on of emo@on.” (2015, p. 92)
•  ImpaOent
•  Quick to anger
•  Easily frustrated
•  Overreacts
•  Easily excited
•  Loses temper *
•  Touchy / easily annoyed *
* Overlaps with ODD
(Can not self-soothe) 38
Thus, ADHD includes:
• DSM: ina>enOon, impulsivity and hyperacOvity

• Disorder of execuOve funcOoning

Time blindness, prisoner of the now, disorder of future-
directed behavior
• Disorder of self-control
EmoOonal dysregulaOon is a core component

• Also, Adult ADHD and CDD 39

Barkley and The Self (2012) p. 28-29
“Strikingly absent from most views of EF…is a role of the self in these
models. In my view, the conscious self IS the central execuOve. Each
of us develops a conscious sense of self, and it is this conscious self
that is serving as the execuOve. It is through our self-awareness/self-
consciousness that our values and wants are consciously known to us,
our goals (values or what we wish to pursue) are chosen by us, and
the strategies that we will employ in these pursuits are selected by us.
Who chooses? I do. What is to be valued and pursued? What I choose
to do. How is it to be pursued? The way I decide to it. The “I” has
been almost enOrely jedsoned from cogniOve theories of EF, replaced
by some unknown, undefined central execuOve holed up in some
penthouse office suite in the frontal lobes.”
40
Barkley and Free Will (2012) p. 29
“This conscious capacity to consider who and what we are, what we
will value, and how and when it will be pursued originates in our self-
awareness. It is the seat of human free will as philosophy has noted
(our freedom to choose among various goals over various Omes
periods and the means to a>ain those goals).”
“Freedom or free will is a conscious generaOon of and consideraOon
of the variety of opOons available to that individual over the longer
term as capable of being conceived by the individual. It also includes
the selecOon of which goals to pursue, how to pursue them, and
when to do so. This acOve agency of the self exists in philosophy but
seems to be lost to or intenOonally avoided by the field of
neuropsychology.”
41
Comorbidity
•  OpposiOonal Defiant Disorder > 50% (range: 45% to 84%)
•  Conduct Disorder 15%
•  Anxiety Disorders 25 to 50%
•  Depression 33% (25% of depressed children have ADHD)
•  Depression + ADHD + ODD/CD is highest risk for suicide.
•  Learning Disability 35 to 40%
•  OCD (not higher in ADHD, but 51% children, 36% adolescents with OCD have ADHD)
•  Tics / Toure>e’s Disorder 10% (50 to 70% of people with Tics have ADHD) “Contrary to
clinical lore, sOmulant treatment did not lead to an increase in Ocs.” (2015, p. 154)
•  AuOsm Spectrum Disorder (30 to 80% of ADS have ADHD)
•  AddicOons – ADHD alone is a risk factor. Meta-analysis sOmulants treatment “does not
increase risk of later drug abuse, but may not provide a protecOve factor.” 42
ADHD and Bipolar Disorder
•  Children with BP have high rates of ADHD (40 to 90%). ADHD most olen
diagnosed first.
•  ADHD olen have trouble going to sleep; only BP has a true decreased need for
sleep (less than 6 hours a day).
•  BP talk over the examiner, use more words and have an increased rate and
volume of speech (pressured speech); not so extreme in ADHD (about 20%).
•  BP may have flight of ideas, grandiosity and psychosis; not ADHD.
•  Bipolar has more agitaOon; ADHD has more anxiety.
•  “SOmulants are not instrumental in the development of BD.” (2015), p. 150
•  “Once mood is stable, sOmulants can be combined with mood stabilizers
without causing relapse of mania.” (p. 151) MTA: no evidence that sOmulants
caused mood destabilizaOon. 43
44
The Importance of a Differen=al Diagnosis

45
46
 Neuropsychological Assessment adds NOTHING
to the assessment of Execu=ve Func=oning in
ADHD
Tests of ExecuOve FuncOoning have li>le, if any, discriminaOve power
in assessing ADHD (WCST, Halstead Category Test, Stroop Color-Word
Test, NEPSY-2, Tower tests, Maze tests)
“Most people with ADHD do not exhibit clinical impairment of EF
test baDeries” (2015, p. 407)
“EF tests and EF ra@ngs are not significantly correlated with each
other, or if significant, they are so poorly related that they share less
than 10% of their variance, leading reviewers to conclude that these
methods do not assess the same construct.” (2015, p. 407)
47
 The Problem with EF Tests (2012b, p. 13-16)
•  Most tests to assess EF were not originally designed to measure EF.
•  No consensus definiOon of EF exists that can be used as the standard for determining the
validity of EF tests.
•  The structured clinical sedng is ill suited to assessing self-regulaOon across Ome and its use
in novel situaOons.
•  TradiOonal tests of EF cannot evaluate the cross-temporal nature of EF as used in daily life
because of their small window of sampling behavior (5 to 30 minutes per test).
•  Some of the most important features of EF are not captured by EF tests.
•  EF tests do not directly evaluate self-regulaOon.
•  EF tests do not capture the social funcOons of EF; such as reciprocity, cooperaOon, and social
exchange.
•  EF tasks are contaminated by mulOple non-EF cogniOve processes.
•  EF tests have very low or no ecological validity. 48
Neuropsychological Assessment adds NOTHING
to the assessment of Execu=ve Func=oning in
ADHD
The missing component is the linkage between EF and Social
Func@oning (Barkley, 2012, p. 23)

“This requires some neuropsychological capacity to sense the

future or later desired outcomes, that is, to construct
hypotheOcal futures, par@cularly for social
consequences.” (2015, p. 411)

RaOngs of EF in daily life acOviOes or direct observaOon of EF

performance in natural sedngs are found to be superior to EF
tests in detecOng impairment. 49
Social Executors
Eslinger (1996) found ExecuOve FuncOons (in PreFrontal Cortex) contain “social
executors”:
1) Social self regula@on: manage the iniOaOon, rate, intensity and duraOon of
social interacOons
2) Social self-awareness: insight into oneself and the impact of one’s behavior
on others in a social sedng
3) Social sensi@vity: the ability to understand another’s perspecOve, point of
view, or emoOonal state (similar to empathy)
4) Social salience: regulaOon of somaOc and emoOonal states that impart a
sense of meaningfulness to social situaOons and to specific individuals within
the situaOon
Barkley, 2012, p. 24
50
 5 Part Assessment of ADHD
1)  5 measures of Short-term Focused A>enOon
2)  ConOnuous Performance Tests (CPTs) for Sustained A>enOon
3)  RaOngs Scales for ADHD and ExecuOve FuncOoning
4)  Clinical Interviews – paOent and collaterals
5)  Developmental, Medical, Academic and Family History

However, since the more than 80% of people with ADHD have at least one
other DSM diagnosis, the best assessment is a full psych evaluaOon that
includes emoOonal and personality tests, and for youth (preK to college),
intellectual and academic tesOng (30 to 40% will have a learning disability).
51
1) 5 Measures of Short-term Focused AVen=on

• Trail Making Test, Parts A and B (from the Halstead Reitan

Neuropsychological Ba>ery)

• Cancella@on Tests (Diamond, 592, Random A’s)

• Each take about “a minute or two” – Can the person get

focused?

• All are Omed, and measure visual scanning and a>enOon.

52
Trail Making Test
• Timed test (in seconds). Norms available and can generate Standard
Scores or T-scores
• Part A is a learning task; i.e., a “warm up” for Trails B
• Part B is a measure of Divided A>enOon and ability to shil cogniOve
set.
• Part B is the “single best measure” for detecOng brain damage if you
only have a minute or two.
• Child version (ages 9 to 14) and Adult version (ages 15 and up).
• h>p://reitanlabs.com/Trail_Making_Tests_Tucson_AZ.html
53
54
55
Cancella=on Tests
• Timed test norms available for most ages
• Omissions vs. Commission errors
• Need to observe the individual’s visual tracking pa>ern
• First two are structured (rows and columns), last one is
random (Wechsler scales are reversed)
• These tests have a ton face validity and parents “get it.”
• May have “false negaOve” with high IQ individuals
56
57
58
59
60
61
2) Con=nuous Performance Tests (CPTs)
for Sustained AVen=on
•  Test of Variables of ADen@on (TOVA) (www.tovatest.com)
•  Uses Standard Scores (comparable to IQ and Academic scores)
•  Developed by neurologist

•  Quo@ent ADHD System (h>p://www.quoOent-adhd.com/)

•  Unique method of presenOng data, but able to evaluate how one
does every 30 seconds.
•  First objecOve assessment of motor movements via moOon sensors.
•  Developed by Harvard neurologists at McLean Hospital
•  First ADHD assessment cleared by the FDA. 62
63
TOVA Scores
However, this makes no sense
The TOVA Company labels the because it uses standard scores.
scores: Thus, I relabeled the scores:

•  Omission Errors •  Focused A>enOon

•  Commission Errors •  Impulse Control
•  Response Time •  Response Time
•  RT Variability •  Consistency of A>enOon
(i.e., Sustained A>enOon)

64
Response Speed Variability
“This distracObility is also well documented by studies of
response-Ome distribuOons using simple and choice
response-Ome tasks. These almost uniformly show that those
with ADHD have a slower and more variable response style
than controls (Lijffijt, et al., 2005), and this increased
variability in response @me occurs because those with ADHD
become more distracted and disengaged from the task
(Adams, Roberts, Milich, & Fillmore, 2011; Spencer et al.,
2009).” In Barkley, 2015, p. 66.
65
66
67
68
69
70
71
72
73
74
75
76
77
3) Ra=ngs Scales for ADHD and
Execu=ve Func=oning
•  Connors - 3 Parent and Teacher RaOng Scales
•  BASC-3 Parent, Teacher and Self-report
•  ADHD RaOng Scale - 5 (DuPaul, 2016, Guilford Press)
•  Child Behavior Checklist (CBCL, Achenbach) (h>p://aseba.org/)
•  SNAP Checklist (in Barkley and Murphy, 2005).

•  Home SituaOon QuesOonnaire (in Barkley and Murphy, 2005).

•  School SituaOon QuesOonnaire (in Barkley and Murphy, 2005).

•  Connors Adult ADHD RaOng Scale (CAARS)

•  Barkley Adult ADHD RaOng Scale – IV (BAARS-IV) 2011 78
3) Ra=ngs Scales for Execu=ve Func=oning

• Barkley Deficits in Execu(ve Func(oning Scale –

Children and Adolescents (BDEFS-CA) 2012
• Barkley Deficits in Execu(ve Func(oning Scale (BDEFS)
2011
• Behavior Ra(ng Inventory of Execu(ve Func(oning –
Second Edi(on (BRIEF-2) 2015
• Comprehensive Execu(ve Func(oning Inventory (CEFI)
79
ADHD Ra=ng Scale - 5 (DuPaul, 2016)
• Permission to photocopy
• Child version (5-10) and Adolescent version (11-17)
• Home and School Symptoms Scales
• English and Spanish versions
• Scales: Ina>enOon, HyperacOvity/Impulsivity
• Reliable Change Index (RCI) = Pos>reatment Score –
Pretreatment score / Standard Error of Difference
80
Connors Adult ADHD Ra=ng Scale (CAARS)

• The CAARS provides a mulOple-informant assessment with

self-report (CAARS–S) and observer raOngs (CAARS–O).
Both address the same behaviors and contain idenOcal
scales, subscales, and indices. Long, short, and screening
versions are available for each.

• Ina>enOon/memory Ina>enOve Symptoms

• HyperacOvity/restlessness HyperacOve/Impulsive
• Impulsivity/EmoOonal Lability Total
• Problems with Self-Concept
81
Barkley Adult ADHD Ra=ng Scale – IV
(BAARS-IV) 2011
• Ages 18 – 89
• Permission to photocopy
• Self Report and Observer Report
• Current Symptoms Form & Childhood Symptoms
Form
• Scales: Ina>enOon, HyperacOve, Impulsive, Total
ADHD, Sluggish CogniOve Tempo (SCT/CDD)
82
Barkley Deficits in Execu=ve Func=oning Scale –
Children and Adolescents (BDEFS-CA) 2012
Ages 6-11, 12-17
Permission to photocopy
Observer RaOngs
Short (20), Long (70), and Interview forms

Self-Management to Time
Self-OrganizaOon/Problem Solving
Self-Restraint
Self-MoOvaOon
Self-RegulaOon of EmoOons
EF Summary Score
ADHD-EF Index 83
Barkley Deficits in Execu=ve Func=oning
Scale (BDEFS) 2011
•  Ages 18-81
•  Permission to photocopy
•  Self Report and Observer Report
•  Short (20) and Long (89) forms

•  Self-Management to Time
•  Self-OrganizaOon/Problem Solving
•  Self-Restraint
•  Self-MoOvaOon
•  Self-RegulaOon of EmoOons
•  Total EF Summary Score
•  ADHD-EF Index 84
Behavior Ra=ng Inventory of Execu=ve
Func=oning – Second Edi=on (BRIEF-2) 2015
• Ages 5 to 18
• Parent, Teacher and Self Report forms
• English and Spanish forms
• Ten clinical scales: Inhibit, Self Monitor, Shil, EmoOonal
Control, IniOate, Task CompleOon, Working Memory, Plan/
Organize, Task Monitor, OrganizaOon of Materials
• Three validity scales: Inconsistency, NegaOvity, Infrequency
• Four broader Indexes Behavioral RegulaOon Index, EmoOon
RegulaOon Index, CogniOve RegulaOon Index , and Global
ExecuOve Composite.
• BRIEF-A Adult (18 to 90) and BRIEF-P Preschool versions (2 to
5) (neither second ediOon) 85
Comprehensive Execu=ve Func=oning
Inventory (CEFI)
•  Parent, Teacher and Youth Self Report (12-18), 90 items, ages 5 to 18

•  Full Scale Score

•  ADen@on - measures how well a youth can avoid distracOons, concentrate on tasks, and sustain a>enOon
•  Emo@on Regula@on - measures a youth's control and management of emoOons
•  Flexibility - describes how well a youth can adapt to circumstances, including problem solving ability
•  Inhibitory Control - reflects a youth's control over behavior or impulses
•  Ini@a@on - describes a youth's ability to begin tasks or projects without being prompted
•  Organiza@on - describes how well a youth manages personal effects, work, or mulOple tasks
•  Planning - reflects how well a youth develops and implements strategies to accomplish tasks
•  Self-Monitoring - describes a youth's self-evaluaOon of his/her performance or behavior
•  Working Memory - measures how a youth keeps important informaOon in mind in order that he/she know
what to do and how to do it, including remembering important things, instrucOons, and steps 86
 Empirically Supported, Promising and
Unsupported Treatments of ADHD
• Chapter 13 in Science and Pseudoscience in Clinical Psychology
– Second Edi(on edited by Sco> Lilienfield, Lynn & Lohr (2015)
• Empirically Supported - SOmulants, Behavior Therapy,
CombinaOon, some non-sOmulants
• Promising – Self directed IntervenOons, Peer directed
IntervenOons, Neurofeedback, CogniOve, Dietary, NutriOonal
• Unsupported Treatments – AnOdepressants, RestricOons of
sugar and sweeteners, Sensory IntegraOon IntervenOons,
Play Therapy
87
S=mulant Drugs to Treat ADHD
•  Adderall and Adderall XR •  Metadate and Metadate ER
•  Concerta •  Methylin and Methylin ER
•  Daytrana (patch) •  Quillivant XR (Liquid)
•  Dexedrine •  Ritalin, Ritalin SR, Ritalin LA
•  Focalin and Focalin XR •  Vyvanse

Note: SOmulants are water soluble.

88
 Two Classes of S=mulants
Methylphenidate (MPH) •  Quillivant XR (Liquid)
deriva@ves:
•  Ritalin, Ritalin SR, Ritalin LA Amphetamine (AMPH) salt
•  Concerta deriva@ves
•  Daytrana (patch) (dextroamphetamine):
•  Focalin and Focalin XR •  Adderall and Adderall XR
•  Metadate and Metadate ER •  Dexedrine
•  Methylin and Methylin ER •  Vyvanse 89
Short-ac=ng S=mulants (approx 4 hours)

•  Ritalin (Methylphenaidate)
•  Dexedrine
•  Methylin
•  Metadate
90
Medium-ac=ng S=mulants (6-8 hours)

• Adderall • Methylin ER
• Focalin • Dexedrine
• Ritalin SR Spansules
• Metadate ER • Daytrana (patch)
91
Long-ac=ng S=mulants (10-14 hours)

•  Concerta (Oros Delivery System)

•  Vyvanse
•  Adderall XR
•  Focalin XR
•  Ritalin LA
•  Quillivant XR (Liquid Methylphenadate)
•  Daytrana (patch)
92
Six delivery systems for S=mulants
Five Ps (plus L)
•  Pills
•  Pump - Concerta (Oros Delivery System)
•  Pellets - Dexedrine Spansules
•  Patch - Daytrana
•  Prodrug - Vyvanse
•  Liquid - Quillivant XR (Liquid Methylphenadate)
Bonus Tip: How to swallow a pill 93
S=mulants and the Brain
•  ADHD involves widespread frontal •  “…trea@ng ADHD with medica@on
hypoacOvity may result in a greater normaliza@on
•  Frontal-striatal-cerebellar regions of brain development, known as a
underlie ADHD “neuroprotec@ve effect”…, than if the
medica@ons had never been used.
•  Striatum: Caudate nucleus, Putamen This makes some sense given that
clinically effec@ve doses of s@mulants
increase brain ac@vity in the very
•  Barkley: “29 studies to date have regions that have been found to be
noted that brain development of underac@ve in the various func@onal
children treated with s@mulant neuroimaging studies…(i.e., caudate,
medica@on is closer to that of controls prefrontal cortex, cingulate and
who do not have ADHD than to cerebellum).” (2015, p. 367-368)
children with ADHD never treated
with s@mulants.” (2015, p. 367) 94
S=mulants and the Brain

•  S@mulants improve execu@ve func@oning.

•  “So such a con@nuous increase in
func@oning sustained over months or years
of development from daily medica@on use
could result in a near-normaliza@on of
func@oning.” (2015, p. 368)
•  SOmulants act through dopamine and
noradrenergic reuptake inhibitors and
agonists.
•  SOmulants increase dopamine in the
striatum, and dopamine and norepinephrine
in the hippocampus and prefrontal cortex.
95
Non-S=mulants to Treat ADHD
At least once a day, every day
• StraDera (atomoxeOne) – selecOve noradrenergic
reuptake inhibitor that leads to dopamine elevaOon
in the frontal lobe but not elsewhere.

Alpha Agonists (anOhypertensives):

• Intuniv & Tenex (guanfacine)
• Kapvay (clonidine)
The above are less effecOve than sOmulants, but work
24 hours a day. 96
Current Popular Treatment:
Stimulant + Non-stimulant

97
 Holding people with ADHD accountable
Barkley (2013, p. 70): “InteresOngly, while this understanding of ADHD
should evoke empathy, it does not mean that we should stop holding
children with ADHD accountable for their behavior. Those with ADHD are
not insensiOve to the consequences of their acOons, but they have
trouble connecOng consequences with their own behavior because of
the Ome delay between the behavior and the important delayed
consequences of those acOons. This means that to help those with
ADHD we must make them more accountable, not less so. We must
devise consequences that are more immediate, more frequent, and
more salient than they would normally be in any given situa@on. Thus
we can help them compensate for their deficit and live more normal,
funcOonal lives.” 98
 Behavioral Therapy Programs
• Your Defiant Child – Second Edi(on by Barkley (2013)
• Defiant Children – Third Edi(on: A Clinicians Manual for Assessment
and Parent Training by Barkley (2013)
• Your Defiant Teen – Second Edi(on by Barkley and Arthur Robin
(2013)
• Defiant Teens – Second Edi(on: A Clinicians Manual for Assessment
and Family Interven(on by Barkley and Arthur Robin (2014)
• The Kazdin Method for Paren(ng the Defiant Child by Alan Kazdin
(2009)
99
4 Things All Children with ADHD Need

1. Structure
2. RouOne
3. Consistency
4. Calmness
1. Calm Structure
2. Calm RouOne
3. Calm Consistency
100
 How does structure, rou=ne and consistency
work?

Teaching analogy – driving to Ellijay to give an ADHD

workshop.

Buchanan’s pondering: How much more structure,

rouOne and consistency do individuals with ADHD need
(in comparison to non-ADHD individuals)?
101
 Giving Direc=ves Correctly
1)  Make your direc@ve a statement instead of a ques@on. Olen, parents ask a quesOon instead of clearly staOng what they
want the child to do. For example, instead of saying, “Go take your bath,” the parent says, “Don’t you think it’s Ome for your
bath?” The child might genuinely believe the answer is “No.” Parents should not ask quesOons if they are not prepared to
accept the answer. Instead, give a clear statement.
2)  Make the direc@ve five words of less. Olen parents get into too much explaining. Children’s a>enOon spans are limited,
and the longer a parent spends giving explanaOons and details, the more lost the child gets and the more the child tunes the
parent out. Thus, direcOves need to be short and to the point. For example, “Go take your bath,” “Turn off the computer,”
and so on. When you’ve said the sixth word, you’ve said too much.
3)  Tell the child what to do instead of what not to do. Parents frequently get into the habit of saying, “Don’t do that!” The
trouble with this is that kids get sick of hearing the word “don’t” as much as parents get sick of saying it. “Don’t” is negaOve.
It is much be>er to be posiOve by telling the child what to do instead of what not to do. For example, if a child is running
through the house, instead of saying, “Don’t run in the house,” say, “Slow down, walk.” You can always say it posiOvely - it
just takes pracOce.
4)  When giving direc@ves, stay calm and unemo@onal. Parents olen mistakenly believe that if they become emoOonal by
raising their voice it will provide the necessary emphasis for children to know they really mean business. Instead, what it
does most olen is escalate hosOlity and negaOvity. Parents must model for children what they want their children to do.
Upset parents will not be effecOve when telling their children to calm down. Becoming emoOonal when dealing with a child’s
misbehavior is like trying to put out a fire by pouring gasoline on it! The best way to discipline is to give direcOves in a
business-like manner, one which is respecnul, calm, unemoOonal and in control. 102
Getting emotional with a person
with ADHD is like trying to put
out a fire by pouring gasoline
on it.

103
 Giving Praise – Catch them being good (8:1)
1)  You’re so much fun to be 9)  Way to go - that’s great! really good.
around!
10)  Good for you! 21)  Give it a try.
2)  You get be>er at that every day.
11)  You’re a joy to watch. 22)  There you go!
Way to go!
12)  That’s be>er than I ever did. 23)  Go for it!
3)  Hang on a second while I call
Sports Illustrated - they’ll want a 13)  You handled that beauOfully! 24)  Just do it!
picture of this. 14)  That’s incredible! 25)  What have you got to lose?
4)  I’m going to brag about this. 15)  You just taught me something I 26)  That’s worth a trophy right
That’s great! didn’t know. there.
5)  I look up to you! 16)  You’re a joy to be with. 27)  I’m so happy you’re my son
6)  That’s really terrific! 17)  You are very special to me. (daughter).
7)  That was thoughnul. 18)  What super effort! 28)  I’m so happy I am your mon
(dad).
8)  This is a tremendous 19)  I enjoy our Ome together.
improvement. 29)  I love your smile.
20)  Keep that up and you’ll be
30)  You’re going to make it! 104
105
 Buchanan’s Home Study Hall
1. Pick a designated @me that home study hall is to be completed every day, Sunday through Thursday (or Monday
through Friday, whichever is works best for the family). NOTE: The earlier in the day, the beDer, provided there is
adequate supervision. If the child is later than usual coming home, then the home study hall should start ASAP
upon arrival. A general guideline is the child should do a minimum of ten minutes of academic work at home every
school night per grade (i.e., grade X 10 = length of home study hall). Of course, this must be tailored to each child,
depending on how far behind the child is academically, the demands of the teachers, the ability of the child, etc.
2. The student must be sijng at a desk, with knees under and the chair pulled up to the desk (standing desk okay).
3. The desk must be clear of all other items. Only academic material may be on the desk.
4. The desk must be facing the wall, free of distracOons.
5. There is to be no television, phone calls, etc. during home study hall (low volume music is okay).
6. The home study hall is to be for the en@re @me period. For example, if home study hall is for an hour, 60 full
minutes must be used doing something academic. If the student says, "I have no home work", the student sOll must
do something academic during that 60 minutes and may not leave the desk unOl the enOre 60 minute period is
completed. If the child “finishes” his or her homework before the end of the designated Ome, then the child should
read the next chapter, re-read the last chapter, recopy class notes, outline the chapter, study for next week’s test,
work on the project due in two weeks, etc. (Breaks ok, but Ome stops).
7. There is to be no interrup@ons during the home study hall. Any Ome wasted will be paid back at a ra@o of 2
to 1. For example, if the student goes to the bathroom and takes four minutes, the student pays back eight minutes
of addiOonal study Ome. 106
 Daily Report Card
•  Six Columns: Subject, tonight’s homework, HW turned in, classwork
completed, behavior okay, teacher signature.
•  HW turned in, classwork completed, behavior okay are yes/no, NOT
progressive scale. (The child did it or not!)
•  Con@ngency: IF all YES for all subjects, AND Home Study Hall completed for
the day, THEN can have electronic entertainment.
•  Daily report card is like a “@cket” to a movie theater – no Ocket, not
admission.
•  Parents show empathy and support: “Darn! I was
really hoping to you could ____ tonight.”

•  Giraffe story 107

 Extended Time of Tests??
•  Barkley (2013): “It is not clear that giving children or adults with
ADHD extra @me for examina@ons at school or in taking professional
exams as adults actually benefits them. They may wind up just
wasOng the extra Ome they are given, rather than using it to full
advantage to review their work, look for mistakes to correct, or tackle
harder problems they iniOally passed over.” (p. 43)

•  IF slow processing speed on Wechsler, slow fluency on academic

tests, slow response @me of TOVA, etc., then consider extended Ome
(“Ome and a half”), but NOT merely for having ADHD. 108
 Academic Strategies (1 of 8)
•  Teachers and Parents need to be on the same page and cooperaOvely
work together
•  Frequent communicaOon with parents (in agenda book or email) DAILY
COMMUNICATION: IF-THEN Con@ngency
•  IEP / 504 for students in public schools
•  Quiet room with less distracOons for tests
•  Post all HW/assignments on internet at least a week ahead
•  Give noOce before changing tasks
•  Allow HW and assignments to be turned in later and sOll get credit (e.g.,
can sOll get a grade of “C” aler X number of days)
109
 Academic Strategies (2 of 8)
•  Post assignments and grades on internet quickly
•  Seat the child front and center, facing forward. Do not use tables
with children facing each other.
•  “Catch the child being good.” Give frequent praise for on--task
behavior.
•  Discuss the behavior in private rather than calling the child out in
front of the class
•  Have the child sit next to a well--behaved role model
•  Increase the distance between desks, if possible
•  Allow the student to stand or walk about 110
 Academic Strategies (3 of 8)
•  Break long assignments into smaller segments, each with a deadline
•  Shorten assignments or work periods
•  Pair wri>en instrucOons with oral instrucOons
•  Set a Omer for 10--minute intervals and have the student get up and
show the teacher the work
•  Have a peer assist the child in note taking
•  Have the teacher ask quesOons to encourage parOcipaOon
•  Enlist the child to help present the lesson
•  Cue the child to stay on task with a private signal; e.g., a gentle tap
on the shoulder 111
 Academic Strategies (4 of 8)
•  Schedule a five--minute period for the child to check over work
before turning in assignments
•  Have a teacher or older student assist the child with packing
backpack, reviewing what is needed for HW
•  Have the teacher ignore minor inappropriate behavior
•  Allow the student to play with paper clips or doodle
•  Designate a place in advance where to let off steam
•  Adjust assignments so that they are not too long or too hard
•  Develop a behavior contract with the student and parents (share
info about what works at home or vice versa) 112
 Academic Strategies (5 of 8)
•  Have the teacher use clear verbal signals, such as “Freeze,” “This is
important,” or “One, two, three…eyes on me”
•  Allow the student to earn the right to daydream for 5--10 minutes by
compleOng the assignment
•  Use a flashlight or a laser pointer to illuminate objects or words to pay
a>enOon to
•  Illustrate vocabulary words and science concepts with drawings or
pictures
•  Allow the child to run errands, to hand out papers to students, clean off
bookshelves, or to stand at Omes while working
•  Give the child a fidget toy in class to increase concentraOon
•  Slot in short exercise breaks between assignments 113
Academic Strategies (6 of 8)
•  Give the child a standing desk or an air-filled rubber disk to sit on so he
can wiggle around
•  Give advanced noOce about upcoming projects and reports
•  Stand next to the student to make sure that the assigned task is begun
quickly
•  Present all assignments and due dates verbally and visually
•  Photocopy pages for students so they do not have to rewrite math
problems
•  Keep sample math problems on the board
•  Allow use of a calculator for class -- and homework
•  Give review summaries for math exams 114
 Academic Strategies (7 of 8)
•  Send weekly progress reports home if not online.
•  Regularly check desk and notebook for neatness, encourage
neatness rather than penalize sloppiness
•  Allow student to have extra set of books at home
•  Give assignments one at a Ome
•  Assist student in sedng short term goals
•  Break down tasks to smaller units
•  Do not penalize for poor handwriOng if visual-motor deficits are
present
•  Encourage learning of keyboarding skills 115
Academic Strategies (8 of 8)
•  Allow student to tape record assignments or homework
•  Praise compliant behavior
•  Provide immediate feedback
•  Ignore minor misbehavior
•  Use teacher a>enOon to reinforce posiOve behavior
•  Use "prudent" reprimands for misbehavior (i.e. avoid lecturing or
criOcism)
•  Acknowledge posiOve behavior of nearby student
•  Supervise student closely during transiOon Omes 116
 Combined Treatments
Behavior Therapy meet the APA Task Force Criteria as an EST for:
•  Parent Training
•  Classroom Con@ngency Management
•  Summer Treatment Programs
However, Behavior Therapy is rarely sufficient to “normalize” children.
Furthermore, treatment effects are usually limited to the period when
treatment is acOvely implemented. There is no evidence that behavioral
treatment produces long-term change (neither does insulin).

Therefore, combined treatments (BT + meds) are the standard of care.

117
 Advantages of Combined Treatment

•  May have complimentary effects, each addressing

the weaknesses of the other.
•  May amplify each other.
•  More cost-effec@ve.

(Lilienfield, chapter 13)

118
 Treatment of Adults with ADHD
•  CBT Treatments are for Adult ADHD are empirically
supported treatments
•  ADHD is not a disorder of “knowing what to do;” it is a
disorder “not doing what you know.”
•  In other words, ADHD is less a disorder of a7en)on and
more of a disorder of inten)on. (2015, p. 760)
•  Do more with less (Content, that is) – be>er to cover less
and “lock in” more
•  Focus on the “Point of Performance” – i.e., real world 119
 Mary Solanto CBT for Adult ADHD (2011)

•  Book includes treatment manual – 12 Sessions

•  Session 1 – Making peace with the diagnosis and commidng to acOon
•  Sessions 2 to 6 – Time Management
•  Sessions 7 to 9 – Gejng Organized
•  Sessions 10 to 11 – Projects
•  Session 12 – looking to the future
•  Op@onal session – Gedng to bed, gedng up and gedng to work on
Ome
120
 Dr. Mary Solanto – Mantras
•  “Complete large projects by dividing it into smaller, more manageable parts.”
•  “If you’re having trouble gedng started, then the first step is too big!”
•  “Do all things in order of priority.”
•  “Out of sight, out of mind.”
•  “A place for everything.”
•  “Everything in it’s place.”
•  “What you don’t do today won’t go away – it will just be much harder tomorrow!”
“Commandments” of Planner Use
•  Thou shalt have one planner and one planner only.
•  Thou must carry thy planner with thee at all (mes.
•  Thou shalt enter every appointment and task into thy planner.
•  Thou shalt consult thy planner every morning, every midday, and every evening!”
121
 Promising Treatments of ADHD
“The jury is s@ll out.”

•  Self directed Interven@ons - self monitoring and self reinforcement

•  Peer directed Interven@ons - peer tutoring
•  Neurofeedback
•  Cogni@ve Treatment – early results were ineffecOve
•  Dietary restric@on of arOficial food coloring and preservaOves meta-analysis
found 33% responded to some degree to dietary intervenOons; 8% to food color
effects – only found in parent reports (not blind)
•  Nutri@onal – Omega 3 fa>y acids
122
 Unsupported Treatments of ADHD
An@depressants – although limited effecOveness found, all
carry black box warning for suicide, slow onset, requires daily
dosing – thus, there is insufficient jusOficaOon for using

Restric@ons of sugar and sweeteners

Sensory Integra@on Interven@ons (used by 90% of OTs)

Play Therapy (don’t use with externalizing disorders) 123

 Russell Barkley ADHD and EF References

• (2013). Taking Charge of ADHD – Third Edi(on. New York: Guilford.

• (2010). Taking Charge of Adult ADHD. New York: Guilford.

• (2015). AMen(on Deficit Hyperac(vity Disorder: A Handbook for

Diagnosis and Treatment – Fourth Edi(on. New York: Guilford.

• (2012). Execu(ve Func(ons: What They Are, How They work, and Why
They Evolved. New York: Guilford. 124
 Russell Barkley Assessment References
•  (2011). Barkley Adult ADHD Ra(ng Scale – IV (BAARS-IV). New York: Guilford.

•  (2011). Barkley Deficits in Execu(ve Func(oning Scale (BDEFS for Adults). New York:
Guilford.
•  (2012b). Barkley Deficits in Execu(ve Func(oning Scale – Children and Adolescents
(BDEFS-CA). New York: Guilford.

•  (2011). Barkley Func(onal Impairment Scale (BFIS). New York: Guilford.

•  (2012). Barkley Func(onal Impairment Scale – Children and Adolescents (BFIS-CA).
New York: Guilford.

•  (2005) AMen(on-Deficit Hyperac(vity Disorder, Third Edi(on: A Clinical Workbook.

With Kevin Murphy. New York: Guilford. 125
 Russell Barkley Treatment References
•  (2013). Your Defiant Child – Second Edi(on. New York: Guilford.
•  (2013). Defiant Children - A Clinician's Manual for Assessment and Parent
Training - Third Edi(on. New York: Guilford.
•  (2013). Your Defiant Teen – Second Edi(on. New York: Guilford. With Arthur
Robins.
•  (2014). Defiant Teens: A Clinician's Manual for Assessment and Family
Interven(on – Second Edi(on. New York: Guilford. With Arthur Robins.
•  (2016). Managing ADHD in School – The Best Evidence-Based Methods for
Teachers. New York: PESI Publishing and Media.
•  h>p://www.russellbarkley.org/factsheets/ADHD_School_AccommodaOons.pdf
126
 Adult ADHD References and Suggested Readings

•  Russell Barkley. (2010). Taking Charge of Adult ADHD. New York: Guilford.

•  Russell Ramsey and Anthony Rostain (2015). The Adult ADHD Tool Kit. NY:
Routledge.

•  Steven Safren, Susan Sprich, Carol Perlman, and Michael O>o. (2015). Mastering
Your Adult ADHD: A Cogni(ve-Behavioral Treatment Program. NY: Oxford.

•  Mary Solanto. (2011). Cogni(ve-Behavioral Therapy for Adult ADHD: Targe(ng

Execu(ve Dysfunc(on. NY: Guilford.
127
 Other References and Suggested Readings
•  Thomas Brown (2013). A New Understanding of ADHD in Children and Adults:
Execu(ve Func(on Impairments. NY: Routledge.
•  George DuPaul and Gary Stoner. (2014). ADHD in the Schools – Third Edi(on. NY:
Guilford.
•  Edward Hallowell and John Ratey (2011). Driven to Distrac(on (Revised):
Recognizing and Coping with AMen(on Deficit Disorder. NY: Anchor.
•  Joyce Cooper--Kahn and Laurie Dietzel (2008). Late, Lost, and Unprepared: A
Parents' Guide to Helping Children with Execu(ve Func(oning. NY: Woodbine
House.
•  Sco> Lilienfield, Steven Lynn and Jeffrey Lohr (Eds.). (2015). Science and
Pseudoscience in Clinical Psychology – Second Edi(on. NY: Guilford. Chapter 13 is
on ADHD. 128