The Role of Neuropsychological Assessment in the Functional Outcomes of Children with ADHD

Tele-Neuropsychology: From Science to Policy to Practice

OBJECTIVE

The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t).

METHOD

We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access.

RESULTS

The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology.

CONCLUSIONS

More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access.

Evidence-Based Assessment for Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects individuals from all life stages, genders, and races/ethnicities. Accurate assessment of ADHD across different populations is essential as undiagnosed ADHD is associated with numerous costly negative public health outcomes and is complicated by high comorbidity and developmental change in symptoms over time. Predictive analysis suggests that best-practice evidence-based assessment of ADHD should include both ADHD-specific and broadband rating scales from multiple informants with consideration of IQ, academic achievement, and executive function when there are concerns about learning. For children under age 12, parent and teacher ratings should be averaged. For adolescents and adults, informant reports should be prioritized when self- and other-report are inconsistent. Future research should provide more stringent evaluation of the sensitivity of measures to treatment response and developmental change over time as well as further validate measures on historically understudied populations (i.e., adults, women, and racial/ethnic minorities).

College students who believe they have ADHD report more neuropsychological deficits than non-ADHD peers

Objective: Attention-deficit/hyperactivity disorder (ADHD) diagnosis in college students has been associated with poor academic outcomes and greater neuropsychological and emotional difficulties. The present study sought to determine whether college students who believe they have ADHD report more neuropsychological deficits than non-ADHD peers. Method: College students (N = 1,520) completed a confidential online survey designed to explore ADHD beliefs and subjective neuropsychological impairment. MANOVA was used to examine the association between ADHD beliefs and neuropsychological symptoms. LSD post hoc analysis was used to examine pairwise comparisons across groups. Results: College students who believe they have ADHD reported more neuropsychological deficits than those without ADHD and similar levels of neuropsychological impairment as peers with a self-reported diagnosis of ADHD. Conclusion: Results show a statistically and clinically significant relationship between ADHD belief and neuropsychological impairment among college students. These findings highlight the need for qualified ADHD assessment in college students who believe they have ADHD.

Generalizable prediction of childhood ADHD symptoms from neurocognitive testing and youth characteristics

Childhood attention-deficit/hyperactivity disorder (ADHD) symptoms are believed to result from disrupted neurocognitive development. However, evidence for the clinical and predictive value of neurocognitive assessments in this context has been mixed, and there have been no large-scale efforts to quantify their potential for use in generalizable models that predict individuals' ADHD symptoms in new data. Using data drawn from the Adolescent Brain Cognitive Development Study (ABCD), a consortium that recruited a diverse sample of over 10,000 youth (ages 9-10 at baseline) across 21 U.S. sites, we develop and test cross-validated machine learning models for predicting youths' ADHD symptoms using neurocognitive abilities, demographics, and child and family characteristics. Models used baseline demographic and biometric measures, geocoded neighborhood data, youth reports of child and family characteristics, and neurocognitive tests to predict parent- and teacher-reported ADHD symptoms at the 1-year and 2-year follow-up time points. Predictive models explained 15-20% of the variance in 1-year ADHD symptoms for ABCD Study sites that were left out of the model-fitting process and 12-13% of the variance in 2-year ADHD symptoms. Models displayed high generalizability across study sites and trivial loss of predictive power when transferred from training data to left-out data. Features from multiple domains contributed meaningfully to prediction, including neurocognition, sex, self-reported impulsivity, parental monitoring, and screen time. This work quantifies the information value of neurocognitive abilities and other child characteristics for predicting ADHD symptoms and provides a foundational method for predicting individual youths' symptoms in new data across contexts.

Can We Expand the Pool of Youth Who Receive Telehealth Assessments for ADHD? Covariates of Service Utilization

BACKGROUND

During the COVID-19 pandemic, telehealth became widely utilized for healthcare, including psychological evaluations. However, whether telehealth has reduced or exacerbated healthcare disparities for children with Attention-Deficit/Hyperactivity Disorder (ADHD) remains unclear.

METHODS

Data (race, ethnicity, age, insurance type, ADHD presentation, comorbidities, and distance to clinic) for youth with ADHD (Mage = 10.97, SDage = 3.42; 63.71% male; 51.62% White) were extracted from the medical record at an urban academic medical center. Three naturally occurring groups were compared: those evaluated in person prior to COVID-19 (n =780), in person during COVID-19 (n = 839), and via telehealth during COVID-19 (n = 638).

RESULTS

Children seen via telehealth were significantly more likely to be older, White, have fewer comorbid conditions, and live farther from the clinic than those seen in person.

CONCLUSIONS

The current study suggests that telehealth has not eliminated barriers to care for disadvantaged populations. Providers and institutions must take action to encourage telehealth use among these groups.

Explaining the Prospective Association of Positive and Negative Parenting Behaviors and Child ADHD Symptoms: Pathways Through Child Executive Function and Reward Responsivity

Objective: Parenting behavior is a well-established correlate of offspring ADHD. However, little is known about how parenting exerts its effects on offspring ADHD symptomatology. We examined whether prospective associations between positive and negative parenting behaviors and child ADHD symptoms are mediated by deficits in child executive function (EF) and reward responsivity (RR). Method: One hundred and thirty-five children with and without ADHD were assessed across two Waves, when children were mean ages 6 and 8 respectively. Children completed tasks on EF, and parents completed questionnaires about their parenting behaviors and their children's RR and ADHD symptoms. Results: Negative parenting behavior at Wave 1 was indirectly associated with offspring ADHD symptoms at Wave 2 via offspring EF. Conclusion: Individual differences in EF, but not RR, during early childhood may constitute a potential pathway by which negative parenting behaviors exerts its effects on subsequent offspring ADHD symptomatology. Treatment implications are discussed.

Attention deficit in children with attention deficit hyperactivity disorder at primary school age measured with the attention network test (ANT): A protocol for a systematic review and meta-analysis

Background

Attentional deficits are among the most bothersome symptoms of attention deficit hyperactivity disorder (ADHD). To date, the neurological basis of attentional deficits has not been fully described according to the diagnostic criteria. ADHD may result from deficits in various attributes of attention. There is no specialist neuropsychological diagnostic method that allows reliable distinction between primary attention disorders in the etiology of ADHD and secondary problems that may arise due to co-morbidities. This protocol aims to systematically review the literature to evaluate patterns of attention common to school-age children either diagnosed with ADHD or at high risk of ADHD, as measured by the neuropsychological attention network test (ANT).

Methods

Our search strategy will consist of electronic databases (PubMed, PsychInfo, Web of Science, EMBASE, and Cochrane Library) and hand searching. Both prospective cohort studies and prospective studies of intervention effects will be included, provided they used the ANT. The primary output variable will be attention deficits. Screening and eligibility will be done independently by two reviewers based on pre-specified eligibility criteria. Data extraction will be based on a pre-pilot data extraction form and conducted by two authors independently. The risk of bias will be assessed by two authors independently. The rating of the certainty of the entire body of evidence will be evaluated using the GRADE approach. Any discrepancies identified at any stage of the review will be resolved by discussion or/and consultation with another reviewer. We plan a narrative synthesis of findings and a quantitative meta-analysis if the data allow.

Discussion

The research will identify patterns of neuropsychological ANT results characteristic of both school-age children diagnosed with ADHD and those at high risk of having ADHD. Our results could be used to check whether the pattern of a child’s performance in the ANT corresponds to the characteristic pattern of the results of children with ADHD. At present, the ANT is used only in research; the results of this review will serve as a useful benchmark. Hopefully, in the future, it will be possible to use the ANT in the wider diagnosis of ADHD.

Systematic review registration

PROSPERO: CRD42021249768.

Training a machine learning classifier to identify ADHD based on real-world clinical data from medical records

The diagnostic process of attention deficit hyperactivity disorder (ADHD) is complex and relies on criteria sensitive to subjective biases. This may cause significant delays in appropriate treatment initiation. An automated analysis relying on subjective and objective measures might not only simplify the diagnostic process and reduce the time to diagnosis, but also improve reproducibility. While recent machine learning studies have succeeded at distinguishing ADHD from healthy controls, the clinical process requires differentiating among other or multiple psychiatric conditions. We trained a linear support vector machine (SVM) classifier to detect participants with ADHD in a population showing a broad spectrum of psychiatric conditions using anonymized data from clinical records (N = 299 participants). We differentiated children and adolescents with ADHD from those not having the condition with an accuracy of 66.1%. SVM using single features showed slight differences between features and overlapping standard deviations of the achieved accuracies. An automated feature selection achieved the best performance using a combination 19 features. Real-world clinical data from medical records can be used to automatically identify individuals with ADHD among help-seeking individuals using machine learning. The relevant diagnostic information can be reduced using an automated feature selection without loss of performance. A broad combination of symptoms across different domains, rather than specific domains, seems to indicate an ADHD diagnosis.

External Validation of BMT-i Computerized Test Battery for Diagnosis of Learning Disabilities

Background: Learning disabilities (LDs) are a major public health issue, affecting cognitive functions and academic performance for 8% of children. If LDs are not detected early and addressed through appropriate interventions, they have a heavy impact on these children in the social, educational, and professional spheres, at great cost to society. The BMT-i (Batterie Modulable de Tests informatisée, or "computerized Adaptable Test Battery") enables fast, easy, reliable assessments for each cognitive domain. It has previously been validated in children ages 4-13 who had no prior complaints. The present study demonstrates the sensitivity of the BMT-i, relative to reference test batteries, for 191 children with cognitive difficulties. Materials and Methods: These 191 subjects were included in the study by the 14 pediatricians treating them for complaints in five cognitive domains: written language [60 (cases)]; mathematical cognition (40); oral language (60); handwriting, drawing, and visuospatial construction (45); and attention and executive functioning (45). In accordance with a predefined protocol, the children were administered BMT-i tests first, by their pediatricians, and reference tests later, by specialists to whom the BMT-i test results were not disclosed. Comparison of BMT-i and reference test results made it possible to evaluate sensitivity and agreement between tests. Results: For each of the five domains, the BMT-i was very sensitive (0.91-1), and normal BMT-i results were highly predictive of normal results for specialized reference tests [negative likelihood ratio (LR-): 0-0.16]. There was close agreement between BMT-i and reference tests in all domains except attention and executive functioning, for which only moderate agreement was observed. Conclusion: The BMT-i offers rapid, reliable, simple computerized assessments whose sensitivity and agreement with reference test batteries make it a suitable first-line instrument for LD screening in children 4-13 years old.

Psychological and neuropsychological underpinnings of attention-deficit/hyperactivity disorder assessment

The identification and diagnosis of attention-deficit/hyperactivity disorder (ADHD) is extremely important in order to help change the trajectory of an individual's life outcomes. A review of the current state of evidence-based assessment of ADHD is dominated by the DSM-5's conceptualization of behaviorally-oriented diagnostic criteria. This assumption that the DSM-5's method for identifying ADHD is the gold standard underlies the research base that evaluates the incremental validity of measures and methods for diagnosing it. That is, when evaluating whether a measure is useful in the identification of ADHD, the 'right answer' is based on the DSM-5's behaviorally-oriented definition. An alternative model for considering the fact that ADHD is a neurodevelopmental disorder, with its roots in executive dysfunction, is proposed. Using neuropsychological and cognitive tests to identify executive functioning problems can be combined with rating scales and interviews to diagnose ADHD in a way that does not ascribe entirely to a behavioral definition of the disorder.

Transforming pediatric neuropsychology through video-based teleneuropsychology: an innovative private practice model pre-COVID-19

Objective

In pediatric neuropsychology multiple barriers such as long wait times until an appointment, insurance coverage, and limited providers who are bilingual/bicultural or who sub-specialize in pediatric neuropsychology, often slow families from receiving diagnoses and interventions in a timely and affordable manner. This paper focuses on increasing accessibility through the development of a video-based, pediatric teleneuropsychology (TeleNP) practice model that was developed in a private practice 2 years before the COVID-19 pandemic.

Method

‘Design thinking’ methodology to problem-solving was utilized to innovate the traditional neuropsychology practice model in under-served areas who may have limited financial and healthcare resources. The practice model approach to include a virtual diagnostic clinic with increased patient and provider efficiency was created to enhance accessibility for patients and sustainability for providers.

Results

Video-based TeleNP screenings were conducted for 67 children with developmental (i.e., attention deficit hyperactivity disorder, autism spectrum disorder) and language disorders, as well as concussion and psychiatric diagnoses. Additional comorbidities were identified in 65.6% of children. Follow-up data approximately 2 months later revealed 98.5% of children were receiving new interventions as a result of the video-based TeleNP assessment.

Conclusion

Video-based TeleNP benefits the consumer as it can reduce wait times, decrease family financial burden (i.e., travel and parent time off work), expedite referrals for interventions, and provide geographically under-served populations access to providers who are linguistically and culturally responsive. For providers, this model revealed improvements with direct implications for cost-saving, thereby facilitating long-term economic sustainability within a private practice healthcare marketplace.

Pediatric neuropsychological evaluation via telehealth: Novel models of care

Objective: As the coronavirus pandemic extends across the globe, the impacts have been felt across domains of industry. Neuropsychology services are no exception. Methods for neuropsychological assessments, which typically require an in-person visit, must be modified in order to adhere to social distancing and isolation standards enacted in an effort to slow the pandemic. How can providers continue to meet the needs of patients referred for neuropsychology evaluations, while respecting federal and state guidelines for safety and ethical mandates? We offer a novel, tiered model of care, successfully implemented in response to mandated social distancing, in a large, pediatric neuropsychology program.Method: We describe the considerations and challenges to be addressed in transitioning a large neuropsychology department to a new model of care, including triaging referrals, developing -or rediscovering - types of services to meet the needs of a virtual patient population, and helping patients, parents, and providers to adjust to these new models.Conclusions: Lessons learned as a function of rapid changes in care models have implications for the field of neuropsychology as a whole as well as for future flexibility in meeting the needs of pediatric patients and their families.

Facilitating Transitions to Adulthood in Pediatric Brain Tumor Patients: the Role of Neuropsychology

PURPOSE OF REVIEW

Transition-age patients with history of a pediatric brain tumor are at significant risk for difficulties transitioning to adulthood. We review current transition models and the potential role of neuropsychology in the transition process for adolescent and young adult brain tumor survivors.

RECENT FINDINGS

Several recently developed healthcare transition models include consideration of patients' cognitive and functional capacities, yet currently available transition readiness tools are limited in scope and do not possess adequate normative data across pediatric medical populations. We explore the potential utility and added benefit of systematically incorporating neuropsychology in the transition process for pediatric brain tumor survivors. The literature supports increased evaluation and intervention targeted at psychosocial barriers to transition. Based on these findings, we propose a family-centered and multidisciplinary care model that promotes both medical and broader psychosocial transition processes. Neuropsychology is ideally suited to assess the wide-ranging areas encompassed in transition readiness and to facilitate the transition process.

Attentional profile of adolescents with ADHD in virtual-reality dual execution tasks: A pilot study. APPLIED NEUROPSYCHOLOGY-CHILD 2020;11:81-90. [PMID: 32400210 DOI: 10.1080/21622965.2020.1760103]

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is highly prevalent in children and adolescents, with estimated prevalence ranges from 5.9 to 7.1% globally and 1 to 6.8% in Spain. This has commonly been associated with deficits in attention threads and executive functions. This paper aims to study the cognitive-executive performance of adolescents between the ages of 17 and 23 with an ADHD diagnosis, relative to a control group. The total sample consisted of 120 male participants who were given the Nesplora Aquarium test. Dual execution tasks assessed attention, response speed, and inhibition capability. When comparing the experimental and control groups, statistically significant differences were detected in processing speed, selective attention, and cognitive inhibition [general execution (T_correct_n) (p = 0.008), attention arousal (T_omission_n) (p = 0.008), and processing speed (T_correctreactime_mean) (p = 0.008)]. We demonstrate that a new virtual reality tool, designed to measure attention in people over the age of 16 years, is effective at measuring attention and working memory. In addition, item difficulty and discrimination values were also acceptable.

Slow Processing Speed and Sluggish Cognitive Tempo in Pediatric Attention-Deficit/Hyperactivity Disorder: Evidence for Differentiation of Functional Correlates

The association between slow processing speed and sluggish cognitive tempo (SCT), a phenotype described within attention-deficit/hyperactivity disorder (ADHD) samples over the past decade, remains unclear. We examined whether SCT and processing speed predict different functional correlates within children and adolescents with ADHD. Participants were 193 clinically-referred youth meeting DSM ADHD criteria without comorbid conditions (mean age = 9.9 years, SD = 2.5; age range 6-16). The incremental utility of SCT and processing speed to predict (1) adaptive functioning and (2) academic achievement, after controlling for age, sex, medication status, and ADHD symptom burden, was assessed using hierarchical multiple regressions. SCT symptoms significantly predicted adaptive functioning, accounting for 6% of the variance, but did not predict academic achievement. Processing speed did not add incrementally to the prediction of adaptive functioning, but did predict academic achievement, accounting for 4% of the variance. Results suggest that SCT and processing speed differentially predict functional abilities not accounted for by ADHD symptom burden.

Preschool Inhibitory Control Predicts ADHD Group Status and Inhibitory Weakness in School

Objective

Discriminative utility of performance measures of inhibitory control was examined in preschool children with and without ADHD to determine whether performance measures added to diagnostic prediction and to prediction of informant-rated day-to-day executive function.

Method

Children ages 4-5 years (N = 105, 61% boys; 54 ADHD, medication-naïve) were assessed using performance measures (Auditory Continuous Performance Test for Preschoolers-Commission errors, Conflicting Motor Response Test, NEPSY Statue) and caregiver (parent, teacher) ratings of inhibition (Behavior Rating Inventory of Executive Function-Preschool version).

Results

Performance measures and parent and teacher reports of inhibitory control significantly and uniquely predicted ADHD group status; however, performance measures did not add to prediction of group status beyond parent reports. Performance measures did significantly predict classroom inhibitory control (teacher ratings), over and above parent reports of inhibitory control.

Conclusions

Performance measures of inhibitory control may be adequate predictors of ADHD status and good predictors of young children's classroom inhibitory control, demonstrating utility as components of clinical assessments.

Comorbidity of reading disabilities and ADHD: Structural and functional brain characteristics

Reading disabilities (RD) and attention-deficit/hyperactivity disorder (ADHD) are two of the most common developmental disorders. RD and ADHD frequently co-occur, which raises questions about how the disorders interact and to what extent they can be differentiated. To date, the underlying neural mechanisms leading to RD-ADHD comorbidity (COM) are not understood. In this study, structural and functional magnetic resonance imaging (fMRI) were combined with comprehensive behavioral testing in order to characterize the behavior, brain structure, and neural correlates of executive function, phonological processing and reading fluency in 60 children with clinical diagnoses of RD, ADHD, or COM, and controls. Whole-brain analyses of variance were performed on cortical thickness values and on the data of the three fMRI tasks to investigate overall group differences. To validate these findings, a region of interest analysis was performed in regions that have previously been shown to exhibit group differences in children with RD or ADHD using the same paradigms. The neuroimaging results demonstrated structural and functional atypicalities for COM in regions that are frequently associated with deficits in children with isolated ADHD or RD. A combination of shared and distinctive brain alterations between the clinical groups was identified, supporting the multiple deficit model for ADHD, RD, and its comorbidity.

The Influence of Demographic and Child Characteristics on Referral for Neuropsychological Evaluation

Objective

A number of studies have documented the benefits of neuropsychological evaluation as a tool for understanding brain-behavior relationships in various childhood disorders; however, little is known about the process by which children are referred for neuropsychological evaluation. From a systems perspective, it is important to understand whether there are identifiable referral patterns, and if so, how being aware of such patterns could shape the behavior of providers making those referrals. We aim to examine child characteristics that influence referral for neuropsychological evaluation.

Methods

Retrospective chart review of 773 children who received neuropsychological evaluation and were diagnosed with autism, attention-deficit/hyperactivity disorder, and/or anxiety was completed. Children were divided into groups based on referral source (professional or caregiver) and compared on demographic, behavioral, and medical characteristics.

Results

Overall, professionals were more likely than caregivers to refer children for neuropsychological evaluation. Though standardized measures suggested children referred by professionals and caregivers were similar, their clinical presentation appears to be different (i.e., those referred by professionals had more comorbidities and were more likely to be prescribed psychotropic medication than those referred by caregivers). Also, children with public insurance were more likely to be referred by a professional than by their caregiver.

Conclusions

Findings highlight the important role of professionals in identifying “at-risk” children and supporting families through the process of receiving further evaluation when indicated. This information can be used to create a more efficient system for evaluating children and developing treatment plans, providing neuropsychologists with direct information to share with referral sources.

Occupational Status Is Compromised in Adults With ADHD and Psychometrically Defined Executive Function Deficits

OBJECTIVE

Problems related to executive function (EF) are frequently reported in adults with ADHD. However, only a subgroup of patients show deficits on common neuropsychological tests designed to measure EF. We investigated whether this subgroup also had higher levels of functional impairments, including unemployment, than the ADHD group without such deficits.

METHOD

We defined executive function deficit (EFD) from selected tests from the Delis-Kaplan Executive Function System (D-KEFS) and assessed ADHD symptoms and psychiatric comorbidity with the use of questionnaires in 79 ADHD patients and 77 controls (IQ above 80 in both groups).

RESULTS

In the ADHD group, 24.3% had EFD. This subgroup showed significantly higher frequency of unemployment, more reading and writing problems, lower IQ scores, and more self-reported ADHD symptoms in childhood than the ADHD subgroup without EFD.

CONCLUSION

These findings indicate that it may be possible to identify individuals at risk of functional impairments, and emphasizes the importance of effective treatment programs targeting EF.

Involvement of family environmental, behavioral, and social functional factors in children with attention-deficit/hyperactivity disorder

BACKGROUND

The objective of this study was to investigate relationships among family environmental characteristics, behavior problems, and social function impairments in children with ADHD.

METHODS

Among children from four primary schools in Shantou city of China, 132 who were diagnosed with ADHD were selected and 138 typically developing children were recruited from the same schools. These children were evaluated using the self-designed questionnaire, FES-CV, CPRS, CTRS, and WFIRS-P for familial environment, behavioral problems, and social function impairment measures. In addition, children's behavioral problems and functional impairments were evaluated using self-established field behavior observation method. Logistic regression model was used to estimate ORs and 95% CIs for ADHD risk with family environmental factors.

RESULTS

In the unconditional logistic model, ADHD risk in children was increased with parents' worse educational level, occupational status, and emotional stability with trend. Children with ADHD had lower scores on most subscales of FES-CV (P<0.01) but higher scores on Conflict subscale (P<0.001). Children with ADHD showed impairments on all the six WFIRS-P subscales tests (all P<0.001), and higher scores on the CPRS and CTRS scale subscales representing behavioral symptoms (all P<0.001 except Somatic Complaints), and more behavioral problems and functional impairments.

CONCLUSION

Compared with typically developing children, children with ADHD had worse family environment. Family characteristics especially parents' emotional unstability, lower education levels, and worse occupation status may increase ADHD risk in children. In addition, the behavioral problems and social functional impairments may interact with adverse family environmental factors in children with ADHD. Therefore, early interventions with focus onto the compromising factors can be useful for improving the social-behavioral functions of children with ADHD.

Clinical and functional correlates of processing speed in pediatric Attention-Deficit/Hyperactivity Disorder: a systematic review and meta-analysis

It is well established that processing speed is negatively impacted in children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD). Unfortunately, exactly how processing speed vulnerabilities manifest in daily functioning has not been well established. To support clinical care of youth with ADHD, it is important to better understand the functional consequences and relevant outcomes associated with processing speed deficits. This systematic review and meta-analysis sought to identify the association between processing speed and clinical or functional correlates among children or adolescents diagnosed with ADHD. A total of 409 abstracts were screened, of which, 60 full-text articles were identified as potentially relevant, and 8 of these studies met inclusion criteria. Domains evaluated across these studies included reading skills, mathematics skills, written expression, anxiety, self-appraisals of competence, and adaptive functioning. Six studies reported an association between processing speed and reading skills, allowing for meta-analysis. Processing speed difficulties among youth with ADHD appear strongly associated with several clinical and functional correlates including weaker academic skills, poorer adaptive skills, increased self-reported anxiety, and overestimates of social competence. Meta-analytic results for studies reporting the association between processing speed and reading skills indicate a medium overall weighted mean effect size (r = 0.33, 95% CI = 0.28 -0.39) with minimal heterogeneity (I² = 0.17). Clinical implications of these findings, limitations in the current knowledge base, and suggestions for future research are discussed.

Attention Functioning Among Adolescents With Multiple Learning, Attentional, Behavioral, and Emotional Difficulties

Attention-deficit/hyperactivity disorder (ADHD) is characterized by high levels of inattention, hyperactivity, and impulsivity; however, these symptoms can result from a variety of reasons. To obtain a comprehensive understanding of the various difficulties of individuals with ADHD, especially when co-occurrence difficulties are present, it is essential to combine neuropsychological and subjective assessment tools. In the present field study the authors investigated a group of adolescents with multiple deficits (MD) using neuropsychological and subjective measures. Teachers' ratings verified extremely high levels of symptoms of oppositional behavior, inattention, hyperactivity-impulsivity, social problems, and emotional problems in this group. As expected, MD group participants showed decreased abilities to maintain attention on task for a long period of time, focus attention and effectively inhibit adjacent distractors, and resist conflicting irrelevant information. Importantly, although significant differences in the attention measures were observed at the group level, not all MD participants displayed deviant performance. Thus, we conclude that the heterogeneous group of adolescents with MD comprises individuals with primary attention deficits as well as those with other nonattentional deficits that show equivalent behavioral symptoms. Using neuropsychological tools can be useful in differentiating between different core deficits and in guiding appropriate interventions.

"Why am I so stuck?": A Collaborative/Therapeutic Assessment Case Discussion

Assessors from 3 continents worked together on a single multimethod case study. Their goal was to hold the client at the center and forefront of their attitudes and thinking as each assessor focused on a specific measure or group of measures. The adult client requested a neuropsychological assessment and completed a full battery of cognitive measures as well as the MMPI-2, the Rorschach, and the Wartegg. A basic tenet of collaborative/therapeutic assessment holds that the client is a full partner in the assessment process; he or she is also seen as the final arbiter of the usefulness of the ideas derived. With that in mind, the client worked with the lead assessor to create 6 questions she wished answered by the assessment. Feedback and discussion occurred in a number of ways: through discussion sessions with the lead assessor that included extended inquiry; individualized letters from the other assessors, each addressing her 6 questions; a summary letter from the lead assessor; and a metaphorical, therapeutic story that stressed key findings from the assessment. Results converged powerfully, with similar findings from each assessor. The client stated that she felt heard and understood in the process, even by individuals who she had never met personally.

ADHD inattentive symptoms mediate the relationship between intelligence and academic performance in children aged 6-14

OBJECTIVE

Fluid intelligence and the behavioral problems of attention-deficit/hyperactivity disorder (ADHD) are related to academic performance, but how this association occurs is unclear. This study aimed to assess mediation and moderation models that test possible pathways of influence between these factors.

METHODS

Sixty-two children with ADHD and 33 age-matched, typically developing students were evaluated with Raven's Colored Progressive Matrices and the spelling and arithmetic subtests of the Brazilian School Achievement Test. Dimensional ADHD symptomatology was reported by parents.

RESULTS

Our findings suggest that fluid intelligence has a significant impact on academic tests through inattention. The inattentive dimension was the principal behavioral source of influence, also accounting for the association of hyperactive-impulsive manifestations with school achievement. This cognitive-to-behavioral influence path seems to be independent of diagnosis related group, and gender, but lower socioeconomic status might increase its strength.

CONCLUSION

Fluid intelligence is a relevant factor in the influence of ADHD behavioral symptoms on academic performance, but its impact is indirect. Therefore, early identification of both fluid intelligence and inattentive symptoms is of the utmost importance to prevent impaired academic performance and future difficulties in functioning.

Incremental validity of neuropsychological assessment in the identification and treatment of youth with ADHD

Comprehensive neuropsychological assessments for youth with ADHD allow for thorough consideration of co-occurring disorders and provide targeted recommendations for treating ADHD and comorbid conditions. This study offers a preliminary evaluation of the added value (compared to routine care) associated with neuropsychological assessment in the identification and treatment of ADHD in youth ages 3-17 years. First we describe a novel measure developed to evaluate broad-based outcomes for youth with ADHD following neuropsychological assessment. Next we compare parent ratings of child symptoms and quality of life between two groups of youth with ADHD: those who have recently received neuropsychological assessments (NP+), and those who have not (NP-). Participants were surveyed again 5 months after baseline to assess changes in symptoms, quality of life, and service utilization. While both groups experienced significant improvements in behavioral/emotional symptoms, the NP+ group had greater initiation of parent behavior management training and special education services and greater initiation of medication management over the follow-up period, compared with the NP- group. Satisfaction with neuropsychological assessment was high overall but slightly decreased over the course of the follow-up period. The findings offer preliminary support for the incremental efficacy of neuropsychological evaluation in the diagnosis and management of ADHD.

Clinical utility of the Colorado Learning Difficulties Questionnaire

BACKGROUND AND OBJECTIVE

Behavioral disorders are highly comorbid with childhood learning disabilities (LDs), and accurate identification of LDs is vital for guiding appropriate interventions. However, it is difficult to conduct comprehensive assessment of academic skills within the context of primary care visits, lending utility to screening of academic skills via informant reports. The current study evaluated the clinical utility of a parent-reported screening measure in identifying children with learning difficulties.

METHODS

Participants included 440 children (66.7% male), ages 5.25 to 17.83 years (mean = 10.32 years, SD = 3.06 years), referred for neuropsychological assessment. Academic difficulties were screened by parent report using the Colorado Learning Difficulties Questionnaire (CLDQ). Reading and math skills were assessed via individually administered academic achievement measures. Sensitivity, specificity, classification accuracy, and conditional probabilities were calculated to evaluate the efficacy of the CLDQ in predicting academic impairment.

RESULTS

Correlations between the CLDQ reading scale and reading achievement measures ranged from -0.35 to -0.65 and from -0.24 to -0.46 between the CLDQ math scale and math achievement measures (all P < .01). Sensitivity was good for both reading and math scales, whereas specificity was low. Taking into account the high base rate of reading and math LDs within our sample, the conditional probability of true negatives (96.2% reading, 85.1% math) was higher than for true positives (40.5% reading, 37.9% math).

CONCLUSIONS

Overall, the CLDQ may more accurately predict children without LDs than children with LDs. As such, the absence of parent-reported difficulties may be adequate to rule out an overt LD, whereas elevated scores likely indicate the need for more comprehensive assessment.