name: title class: title-slide, left, middle background-image: url(images/daftpunktocat-thomas.gif) background-position: right background-repeat: no-repeat background-size: contain background-color: var(--usc-black) .pull-left[ # A.D.H.D. ## Neuropsychological assessment for diagnostic clarification and treatment planning ### Joey W. Trampush, Ph.D., Della Martin Assistant Professor of Psychiatry and the Behavioral Sciences ### Ashraf Elmashat, M.D., Clinical Professor of Psychiatry and the Behavioral Sciences, Associate Medical Director of Keck Outpatient Psychiatry and Behavioral Health Services ### Department of Psychiatry and the Behavioral Sciences ### 2021-12-21  ] --- name: hello class: middle, center background-color: var(--near-black) ## Hello. ??? Our department has grown since 2018 --- class: middle, center background-color: var(--near-black) .bg-near-light-green.b--dark-green.ba.bw2.br3.shadow-5.ph4.mt5[ If you cannot explain something in simple terms, you don't understand it. .tr[ — Richard Feynman (probably) ]] .center[] .footnote[[source](https://twitter.com/proffeynman/status/1370595934191591430)] ??? Richard Feynman was an American theoretical physicist, known for his work in the path integral formulation of quantum mechanics, the theory of quantum electrodynamics, the physics of the superfluidity of supercooled liquid helium, as well as his work in particle physics for which he proposed the parton model.-Wikipedia --- class: middle What do we know about .big[ADHD]? .footnote[ [<svg aria-hidden="true" role="img" viewBox="0 0 496 512" style="height:1em;width:0.97em;vertical-align:-0.125em;margin-left:auto;margin-right:auto;font-size:inherit;fill:currentColor;overflow:visible;position:relative;"><path d="M165.9 397.4c0 2-2.3 3.6-5.2 3.6-3.3.3-5.6-1.3-5.6-3.6 0-2 2.3-3.6 5.2-3.6 3-.3 5.6 1.3 5.6 3.6zm-31.1-4.5c-.7 2 1.3 4.3 4.3 4.9 2.6 1 5.6 0 6.2-2s-1.3-4.3-4.3-5.2c-2.6-.7-5.5.3-6.2 2.3zm44.2-1.7c-2.9.7-4.9 2.6-4.6 4.9.3 2 2.9 3.3 5.9 2.6 2.9-.7 4.9-2.6 4.6-4.6-.3-1.9-3-3.2-5.9-2.9zM244.8 8C106.1 8 0 113.3 0 252c0 110.9 69.8 205.8 169.5 239.2 12.8 2.3 17.3-5.6 17.3-12.1 0-6.2-.3-40.4-.3-61.4 0 0-70 15-84.7-29.8 0 0-11.4-29.1-27.8-36.6 0 0-22.9-15.7 1.6-15.4 0 0 24.9 2 38.6 25.8 21.9 38.6 58.6 27.5 72.9 20.9 2.3-16 8.8-27.1 16-33.7-55.9-6.2-112.3-14.3-112.3-110.5 0-27.5 7.6-41.3 23.6-58.9-2.6-6.5-11.1-33.3 2.6-67.9 20.9-6.5 69 27 69 27 20-5.6 41.5-8.5 62.8-8.5s42.8 2.9 62.8 8.5c0 0 48.1-33.6 69-27 13.7 34.7 5.2 61.4 2.6 67.9 16 17.7 25.8 31.5 25.8 58.9 0 96.5-58.9 104.2-114.8 110.5 9.2 7.9 17 22.9 17 46.4 0 33.7-.3 75.4-.3 83.6 0 6.5 4.6 14.4 17.3 12.1C428.2 457.8 496 362.9 496 252 496 113.3 383.5 8 244.8 8zM97.2 352.9c-1.3 1-1 3.3.7 5.2 1.6 1.6 3.9 2.3 5.2 1 1.3-1 1-3.3-.7-5.2-1.6-1.6-3.9-2.3-5.2-1zm-10.8-8.1c-.7 1.3.3 2.9 2.3 3.9 1.6 1 3.6.7 4.3-.7.7-1.3-.3-2.9-2.3-3.9-2-.6-3.6-.3-4.3.7zm32.4 35.6c-1.6 1.3-1 4.3 1.3 6.2 2.3 2.3 5.2 2.6 6.5 1 1.3-1.3.7-4.3-1.3-6.2-2.2-2.3-5.2-2.6-6.5-1zm-11.4-14.7c-1.6 1-1.6 3.6 0 5.9 1.6 2.3 4.3 3.3 5.6 2.3 1.6-1.3 1.6-3.9 0-6.2-1.4-2.3-4-3.3-5.6-2z"/></svg> @brainworkup](https://github.com/brainworkup) [<svg aria-hidden="true" role="img" viewBox="0 0 512 512" style="height:1em;width:1em;vertical-align:-0.125em;margin-left:auto;margin-right:auto;font-size:inherit;fill:currentColor;overflow:visible;position:relative;"><path d="M459.37 151.716c.325 4.548.325 9.097.325 13.645 0 138.72-105.583 298.558-298.558 298.558-59.452 0-114.68-17.219-161.137-47.106 8.447.974 16.568 1.299 25.34 1.299 49.055 0 94.213-16.568 130.274-44.832-46.132-.975-84.792-31.188-98.112-72.772 6.498.974 12.995 1.624 19.818 1.624 9.421 0 18.843-1.3 27.614-3.573-48.081-9.747-84.143-51.98-84.143-102.985v-1.299c13.969 7.797 30.214 12.67 47.431 13.319-28.264-18.843-46.781-51.005-46.781-87.391 0-19.492 5.197-37.36 14.294-52.954 51.655 63.675 129.3 105.258 216.365 109.807-1.624-7.797-2.599-15.918-2.599-24.04 0-57.828 46.782-104.934 104.934-104.934 30.213 0 57.502 12.67 76.67 33.137 23.715-4.548 46.456-13.32 66.599-25.34-7.798 24.366-24.366 44.833-46.132 57.827 21.117-2.273 41.584-8.122 60.426-16.243-14.292 20.791-32.161 39.308-52.628 54.253z"/></svg> @brainworkup](https://twitter.com/brainworkup) [<svg aria-hidden="true" role="img" viewBox="0 0 512 512" style="height:1em;width:1em;vertical-align:-0.125em;margin-left:auto;margin-right:auto;font-size:inherit;fill:currentColor;overflow:visible;position:relative;"><path d="M326.612 185.391c59.747 59.809 58.927 155.698.36 214.59-.11.12-.24.25-.36.37l-67.2 67.2c-59.27 59.27-155.699 59.262-214.96 0-59.27-59.26-59.27-155.7 0-214.96l37.106-37.106c9.84-9.84 26.786-3.3 27.294 10.606.648 17.722 3.826 35.527 9.69 52.721 1.986 5.822.567 12.262-3.783 16.612l-13.087 13.087c-28.026 28.026-28.905 73.66-1.155 101.96 28.024 28.579 74.086 28.749 102.325.51l67.2-67.19c28.191-28.191 28.073-73.757 0-101.83-3.701-3.694-7.429-6.564-10.341-8.569a16.037 16.037 0 0 1-6.947-12.606c-.396-10.567 3.348-21.456 11.698-29.806l21.054-21.055c5.521-5.521 14.182-6.199 20.584-1.731a152.482 152.482 0 0 1 20.522 17.197zM467.547 44.449c-59.261-59.262-155.69-59.27-214.96 0l-67.2 67.2c-.12.12-.25.25-.36.37-58.566 58.892-59.387 154.781.36 214.59a152.454 152.454 0 0 0 20.521 17.196c6.402 4.468 15.064 3.789 20.584-1.731l21.054-21.055c8.35-8.35 12.094-19.239 11.698-29.806a16.037 16.037 0 0 0-6.947-12.606c-2.912-2.005-6.64-4.875-10.341-8.569-28.073-28.073-28.191-73.639 0-101.83l67.2-67.19c28.239-28.239 74.3-28.069 102.325.51 27.75 28.3 26.872 73.934-1.155 101.96l-13.087 13.087c-4.35 4.35-5.769 10.79-3.783 16.612 5.864 17.194 9.042 34.999 9.69 52.721.509 13.906 17.454 20.446 27.294 10.606l37.106-37.106c59.271-59.259 59.271-155.699.001-214.959z"/></svg> brainworkup.io](https://brainworkup.io) ] .pull-right[] ??? ## 80HD - PATS preschool study --- class: center, middle ### First pub (2003) .pull-left[  ] .pull-right[  ] --- class: center, middle ### Cognitive Development in Preschoolers At-Risk for ADHD .pull-left[  ] .pull-right[  ] ??? #### Notes - note - note --- class: center, middle, section ## Full Circle ...  [ADHD AHRQ Update 2022](https://effectivehealthcare.ahrq.gov/products/adhd-update/systematic-review-2018) --- class: center, middle, section .frame[ ### Developmental Trajectory of ADHD ] -- This is the model of ADHD from which I work ...  ??? #### Notes - note - note --- class: section middle center ## Clinical ADHD .red[vs.] Cognitive ADHD .pull-left[ ### inattention ### hyperactivity ### impulsivity ] .pull-right[ ### attentional fluency ### stimulus-boundedness ### emotion regulation ] --- class: center, middle, f2 `Executive Dysfunction in ADHD` Three core areas ... --- class: center middle .big[1.] ## attentional fluency --- class: middle, center ### **Attentional Fluency** = Working Memory + Processing Speed How .fat-font[much] and how .fat-font[fast] ... .left.pull-left[ #### Working Memory - Verbal WM - Maintaining verbal information in conscious awareness - Fluently retrieving information from LTM - Nonverbal WM - "Mind's eye" - "Episodic future thinking" ] .left.pull-right[ #### Processing Speed/Variability - Regulating alertness - Sustaining effort during repetitive, boring tasks - Adjusting processing speed - Completing tasks - Maintaining performance consistency ] ??? - EFT: this is why planning is impaired --- name: devsci class: center, middle #### Working Memory #### Dopamine Genes #### Remission of ADHD .pull-left[] .pull-right[] --- class: center, middle ### GWAS of Working Memory Grant Currently funded by NIMH to conduct large-scale genome-wide association study (GWAS) of working memory in >25,000 people & >70,000 WM phenotypes & >293,000,000 genetic variants .pull-left[  ] .pull-right[  ] ??? - interested in students to work on project --- name: rtsd class: bottom, left .left-column[ ### RTSD as a biomarker of lifelong ADHD - Reaction time variability - Response (in)consistency - Attentional drift - slow RTs - Impulsive responding - fast RTs ] .right-column[  ] --- class: center, middle background-color: var(--near-black) .big[2.] ## stimulus-boundedness --- **Stimulus-boundedness in ADHD**: -- >...is an inappropriate response to a salient or nonsalient environmental or internal stimulus during cognitive/neuropsychological testing. Environmentally dependent behaviors occur often and cannot be easily redirected and/or environmental dependency makes task completion very difficult, e.g.: -- >- environmental dependency (e.g., picking up a pen from the table and writing/fidgeting) -- >- excessive attention to irrelevant objects (e.g., picking up objects from floor) -- >- closing in on a stimulus or being distracted by adjacent stimuli -- >- overtalkativeness, expressing everything that comes to mind .footnote.small.red[NIH EXAMINER Behavior Rating Scale] ??? - stems from frontal lobe damaged pts --- class: center, middle background-color: var(--near-black) .big[3.] ## emotional & affective ## regulation --- name: bell class: left, middle, fullscale background-image: url(https://gifs.joelglovier.com/crying/laughing-crying.gif) background-position: 50% 50% background-size: 100% ## Emotional Control .pull-left[ > **Emotion** 🔥 > > **(Dys)Regulation** > > in **ADHD** > > > Not part of DSM/ICD diagnostic criteria > > .big[BUT] ... ] ??? This is recognized on most rating scales e.g., brown --- **Managing Frustration and Modulating Emotions in ADHD** (Brown Executive Function/Attention Scales) -- >Individuals w/ ADHD often have difficulty with regulating emotional reactions .yellow[**to the extent that they take over much of what the individuals are thinking or doing**]. -- >Although the DSM-5 does not recognize any symptoms related to emotion management as an aspect of ADHD, many with the disorder describe chronic difficulties managing: -- >- frustration, anger, worry, disappointment, desire, and other emotions -- >- excessive irritability, sensitivity to criticism, overwhelming nervousness and worry, and unhappiness -- >- They find it very difficult to put their emotions into perspective and get on with what they need to do. --- class: center, middle ## Case Presentation  --- class: middle, center # "Scout" ### Identifying Information <style> #id { font-family: 'Alegreya', 'Spectral', 'STKaiti', serif; } </style> <style> .emphasized { table-layout: auto; width: 100%; color: black; font-size: 1.5em; font-family: 'Roboto Condensed', 'Metrophobic', 'Aldrich'; break-inside: avoid; } </style> | | | |--------------------------|--------------------------------------------------------------------| | **Age:** | 10-years, 1-month | | **Sex:** | Female | | **Ethnicity:** | White/Caucasian | | **Handedness:** | Right | | **Education:** | 4th Grade | ??? - 874. Scout - 875. SL --- class: middle, left ### Reason for Referral * Scout presented for neuropsychological evaluation to determine her cognitive, academic, and emotional strengths and weaknesses. * Referred by her parents for behavioral and academic concerns, including: - behavioral immaturity - defiance - attention/executive problems - reading/learning difficulties * Purpose of eval was (shockingly) to clarify diagnoses and assist with educational and treatment planning --- class: middle ### Background - Scout requires frequent redirection and strong reinforcements and consequences in order to manage her behavior. - She defies parent requests, engages her parents and sister in frequent arguments and periodic acts of aggression, and commits serious rule violations (e.g., lying, stealing). - Parents struggle with discipline and feel frustrated. - Behaviorally, she acts "immature" and will throw unprovoked tantrums. --- class: middle #### ...continued - Parents describe Scout as having a "lack of executive functioning skills," including an unawareness for how loud she is talking, "squeals" to annoy people, has poor body and voice control, and is defiant. - She is forgetful; e.g., forgetting a set of instructions "two-seconds later" such as her nightly bedtime routine. - Scout has only recently started to .fat-font[look both ways before crossing the street] consistently --- class: middle #### ...continued - Scout has a tendency to impulsively say things to others that are not true. - For example, for unbeknownst reasons, she told folks that her .fat-font[dog had died], which was untrue. - She has been accused of stealing on multiple occasions, behavior her mother said started to emerge around age 6. - She has allegedly .fat-font[stolen money] multiple times, stolen her mothers shampoo, her grandmother's lipstick, and her sister's belongings. - She has been accused of stealing money from a friends house ($50), an accusation Mrs. Scout feels is very much unfounded. --- class: middle #### ...continued - In a separate incident, last year, she told her school psychologist/therapist her older sister "parents me" and that her parents "spank" her when she gets in trouble. - She returned to class and repeated it to her teacher. - A report was filed with child protective services (CPS) and the investigation was tabled. - Her mother sometimes wonders if Scout has a "conscious" about the things she does and way she behaves at times. --- class: middle ## Relevant History ### Developmental/Medical - Product of a planned, 42-week pregnancy (11 days late) delivered via .fat-font[planned home birth]. - Preg notable for Rh incompatibility - She was delivered after 4.5 hours of labor weighing 7 lb., 2 oz. - Mom described it as "a short but intense natural delivery" that required the umbilical cord to stay connected until it was done pumping blood from mom to baby. --- class: middle #### ...continued - S/p delivery complications included mild jaundice without phototherapy. - Major developmental milestones (e.g., standing, walking, uttering first words, speaking in short sentences) were reached within expected time frames. - Tantrums, loud screaming, and irritability emerged within the first four years as a toddler. - Mom concerned with Scout's eating habits, as she can be a picky eater and is underweight. --- class: middle #### ...continued - Mom has had concerns with Scout's poor posture/musculoskeletal stability and is accident prone ("she's falling and tripping all the time"). - Bites her finger nails throughout the day - Gets chronic blood noses - Scout is far sighted and has prescription eye glasses for reading, but does not like to wear them and .fat-font[refuses] to do so at times. - Paternal family psych history of .fat-font[ADHD] and .fat-font[dyslexia] --- class: middle ### Academics - Fourth grade in a public elementary school - School is excruciatingly challenging for Scout much of the time. - She gets "lost" doing her schoolwork and constantly feels overwhelmed. - She sometimes refuses to turn in her assignments and/or tests because she either didn't start them, didn't finish them, or didn't understand what was expected of her. - She daydreams a lot in school and is always worrying about what everyone thinks. - IEP for reading and attention problems since end of 2nd grade --- class: middle #### ...continued - She has to "log out" of class for tutoring each day on Zoom. - She "hates" being singled out everyday to leave class for an hour to work with her reading tutor. - She is supposed to keep a reading log of her IEP work but won't do it. - Even at home, Scout gets frustrated when doing her homework, yet will not let her mother help her. --- class: middle #### ...continued - The cumulative impact of her school difficulties has crushed Scout's self-esteem and feelings of competency. --- class: middle ### Behavioral/Emotional/Social - At one point in second grade (~2019), Scout .fat-font[threatened to kill herself] in what seemed to be related to her feelings of school inadequacy. - She began seeing the school counselor for therapy - Scout recalls seeing her therapist at school and found it to be helpful. - She has not seen any other outside counselor or psychologist. - Scout relates well to her peers and is quite social. --- class: middle #### ...continued Per mom: >"She has tendency to lie, to make up little fibs to look smarter, more cool, or get attention. Then her friends find out its not true and they get upset with her. >Or, Scout interrupts them when they are talking, she wants to change the rules to the game. >She loves talking to and hanging out with adults, but loves playing with younger kids because she is in control. They look up to her and Scout can be the 'mommy.' She usually wants to be the leader of her peer group." >"Scout has a huge heart! She cares strongly for the family dog-he is the only one that can help her calm down. They sleep together every night. >She has a strong energy. People love talking with her, think she's funny and engaging. Scout loves giving compliments (whether they are genuine or she knows that it will make them like her more) again though... a strength. She has a lot of empathy for her peers/friends when they get hurt or are left out. She has been praised from teachers for her sweet nature." --- class: middle ### Family - Lives with her biological parents and older sister (14 yo) - Mom graduated from high school and is employed in the entertainment industry - Dad has an MFA and is employed in the film industry - Her parents work opportunities were reduced during the early part of the COVID-19 pandemic and struggled financially for a while, but are now back on track and working steadily. - Scout and her sister get along okay most of the time, but not always. >"They love each other but have a very competitive relationship. When they get along... it's beautiful ... when they fight... it's all tears." --- class: middle #### ...continued Mom made this comment about some of Scout's behavior at home: > "Scout does odd things sometimes... like she doesn't think. For instance, pulled on her curtains and make the support come off the wall (9 years old); use a marker and write all over her dresser (9 years old); come in my room and take clothing or jewelry without asking then lie that she took it; .fat-font[not flush her toilet for days]; has to be reminded to brush her teeth; puts chewed gum on her bookshelf; the list goes on. And Dad and I get upset with her so much we can see .fat-font[it's wearing on her spirit]." --- class: middle ## Behavioral Observations ### Testing - Scout was seen in-person @ PBHS @ UPC, evaluated across two 4-hour testing sessions scheduled a week apart - Brought several stuffed dolls (Yoda) and various other items (her "blanky") with her from home. - Physically, Scout is exceptionally tall (>90th percentile in height), thin, pretty - Interpersonally, she is friendly and engaging, and it was easy to establish rapport --- class: middle #### ...continued - Spontaneous language is easy to elicit from her, as she is talkative and social, and hyper-expressive. - Receptive language comprehension is variable. - She unknowingly .fat-font[confabulates a lot] (i.e., makes up words and phrases that are unique to her mental lexicon such as "fratten" and "confrunkled" and "quimping"). - She uses "filler words" a lot such as "umm yeah," as if she goes blank for a second when trying to think of what to say and loses her train of thought briefly. - Fine-motor dexterity is an area of weakness, as is .fat-font[motor persistence]; she stood up constantly during testing because it was hard for her to sit still seated for extended periods of time. --- class: middle ### Child Interview - Scout expressed wide ranging but predominantly negative feelings about everything we discussed over two days of testing. - Very open and honest about her school difficulties. - "hates" having to leave Zoom everyday for an hour to work with her reading tutor. It makes her feel bad about herself and she wants no part of her IEP. - Said her peers "make fun of me for my IEP." She said her teacher "hates me" and "won't call on me" on Zoom. - "panics" before all of her tests because she is usually unprepared/didn't study. --- class: middle ### Child Interview cont... - Openly said she can be a .fat-font["very naughty child"] and is "only good about 1 day a week." - Gets "excluded" by her friends sometimes, and said, "sometimes I feel like I"m not good enough." - Has a "boyfriend" named Hank who is "cute, funny and puts a smile on my face." - Loves her dog "Franky" who is "the only one who is nice to me." --- name: gauss1 class: middle center background-size: contain ### Distribution of Scores: _Population-level Interpretation_ <div class="figure"> <img src="images/plot_narrow.png" alt="Statistical classification of neuropsychological test scores in the general population." width="50%" /> <p class="caption">Statistical classification of neuropsychological test scores in the general population.</p> </div> --- class: animated slideInRight fadeOutLeft 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Impression - F90.2 Attention-deficit/hyperactivity disorder, combined type - F81.0 Specific reading disorder (decoding and fluency) - F81.81 Disorder of written expression (spelling) - F43.25 Adjustment Disorder with mixed disturbance of emotions and conduct - Rule out Oppositional defiant disorder - Rule out Conduct disorder - Rule out Disruptive mood dysregulation disorder - Rule out Developmental coordination disorder (dyspraxia) --- class: center, middle ## Referral to Dr. Elmashat ... --- class: center, top background-size: contain `Postscript` ### Follow-Up from Mom ...  ??? - mom emailed about 2-3 months later --- name: snoop class: middle, right, lbc background-image: url(https://gifs.joelglovier.com/favs/snoop-turning-the-wheel-big.gif) background-color: #FFFFFF background-size: auto .lbc.pull-right[ "There are three ways to ultimate success: The first way is to be kind. The second way is to be kind. The third way is to be kind." ] ??? - Mr Rogers [](https://jasonstcyr.com/2019/11/27/building-trust-have-you-been-kind-today/)