This week’s blog was contributed by Jeremy Sharp, PhD, licensed psychologist and clinical director at the Colorado Center for Assessment & Counseling and the host of the Testing Psychologist Podcast. Dr. Sharp earned his undergraduate degree in experimental psychology from the University of South Carolina and earned his master’s degree and doctorate in counseling psychology from Colorado State University. He specializes in psychological and neuropsychological evaluation of children and adolescents and provides private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. He lives in Fort Collins, Colorado with his wife (also a therapist) and two kids. 

The past 18 months have been a rollercoaster for all of us. It seems like a lifetime ago when we got the news that my then-seven and eight-year-old children would NOT be going back to school after spring break in March 2020. I remember thinking, “Okay, we can get through this for a couple of months...things will be back to normal in the fall.” But no! Things were definitely NOT back to normal in the fall for us or for most families in the U.S.  

There are many implications for kids being out of school or partially attending school for the better part of a year. I’d like to focus on the implications for practitioners who may be seeing increased referrals for issues like ADHD and learning issues. 

Although some data suggest that mental health utilization (both psychotherapy and assessment) went down during the pandemic, this frankly does not match the anecdotal evidence from around the country. It seems like every practitioner I talk to is completely full—with longer waitlists than ever. Our practice has seen a huge increase in referrals for assessment of ADHD and learning disorders, and I think there is a direct link to the pandemic. Here are a few reasons why: 

1. Instability in the environment. Kids do well with stable, consistent environments. Speaking for myself, other parents, and practitioners around the country, there was very little stability or consistency over the past year. Here are just a few examples of environmental changes: kids transitioning from in-school to in-home learning, parents transitioning to working from home, parents transitioning to being an in-home teacher, and cancellation of after-school programs and activities. Many families experienced variation or reduction in income. Marginalized groups and lower-income families may have experienced food insecurity. The list goes on and on. Increased instability = increased anxiety, acting out, distraction, or withdrawal. 

2. Parents getting a firsthand look at kids’ behavior and academic skills. During the pandemic, many parents transitioned into the role of in-home teacher or a facilitator of education. For those parents who previously relied primarily on teacher comments or conferences to gauge their kid’s academic performance, this was an eye-opening experience. Parents suddenly got to see just how distractible, unfocused, fidgety, and (sometimes) disruptive our kids could be throughout the school day. If any parents of kids with ADHD were in denial about their children’s symptoms, those symptoms quickly became clear. Were they likely worsened by the instability mentioned above? Definitely. But many parents acknowledged and sought support once their kids were home all day trying to learn. 

3. Parents being more burned out than usual. Not only were kids under more stress, but parents were also struggling during the pandemic. As mentioned previously, the world was turned upside down for us, too! It was challenging to juggle work (if you were still employed), finances, kids being home, spouses suddenly being home together more than usual, and any number of other things. When parents get stressed, it’s easy to focus on the negative or undesirable aspects of your child’s behavior. These might include not sitting still, interrupting the teacher, not doing their work, blurting things out, and so forth. Even if these behaviors are occurring with typical frequency, a stressed-out parent may notice them more often and perceive them to be more severe. 

4. Increased variability in learning. Again, structure is important. In addition to the big-picture environmental instability discussed earlier, the academic realm itself was quite variable for many kids. Teachers absolutely did their best to develop and implement remote learning options. And yet, many children ended up with multiple platforms or websites to navigate. Many did not have stable internet access, which disrupted video and audio delivery. The remote school day typically looked different than the in-person school day, with many kids completing their work more independently than before. For kids with attention concerns, this was a recipe for disaster. 

Related post: Jeremy Sharp on Trauma-Informed Assessment 

All of these factors created quite a dilemma. Yes, many clinicians have seen increased referrals for ADHD evaluations, but how does one evaluate ADHD with so many environmental influences? These are just a few strategies that we’ve employed: 

1. Conduct a more thorough intake. Our intakes now include explicit questions to gauge the impact of the pandemic. We ask about changes to the family routine, including parent work schedules, parent involvement in learning, kids’ reactions to the pandemic in general, loss of sports or after-school activities, and the timeline of in-person vs. remote learning. 

2. Pay more attention to history. With a neurodevelopmental disorder like ADHD, history is always important. It should not just emerge out of nowhere. But with many parents now seeing longstanding or acute symptoms of ADHD firsthand, this factor is more important. In the past, we may have gotten by with documenting symptoms within the last year and going on our way with a diagnosis. Now, we must look further back. Were these symptoms present prior to the pandemic? Are they only happening during academic times? Do they vary based on in-person vs. remote learning?  

3. Be less confident. Principle 5 of the American Psychological Association’s guidance on psychological teleassessment during the COVID-19 crisis explicitly states that we should widen our confidence intervals when making conclusions and clinical decisions. This is incredibly important. Most evaluations over the past 18 months have a big, metaphorical asterisk beside the results that says, “We are not as confident in these results as we typically are. Here’s our best guess.” We’ve gotten over the fear of saying, “This is unclear right now,” and have no shame about asking families to come back in 6–12 months for a brief, updated assessment. 

In summary, there are many things for us to consider as we see increased referrals for ADHD testing. We must take environmental factors into account, acknowledge that parents and kids are more stressed out than usual, know that certain groups have less access to resources than others, and generally be more diligent and less confident in diagnostic results. It’s a thrilling time, as my colleague Dr. A. Jordan Wright says, to “be brave” with our work as we navigate challenging circumstances to do our best in helping these families. 

 

Catch up with the Testing Psychologist podcast online, via Apple Podcasts, Google Podcasts, or on Spotify. 

 

 

Do you see students or clients with symptoms like restlessness, excessive talking, or difficulty staying on task? Sometimes, it can be difficult to know if the behaviors are age-appropriate and typical or if they might be signs of ADHD–the primary developmental disorder of executive function.

Find out quickly with the new BRIEF2 ADHD Form.

Using results from the BRIEF2, the gold-standard instrument for assessing executive function, the BRIEF2 ADHD Form takes a three-step approach to predict the likelihood of an ADHD diagnosis. This knowledge helps parents, clinicians, and educators get children and adolescents ages 5 to 18 years the supports they need—both in and out of the classroom.

Scoring is quick and straightforward, and existing BRIEF2 scores (or PARiConnect results) can be used–there’s no need to retest. Scores are first plotted alongside skylines of scores from children and adolescents known to have ADHD to help evaluators get an at-a-glance view of how their clients’ and students’ ratings compare.  Next, using classification statistics and an evidence-based approach, scores from the BRIEF2 Working Memory and Inhibit scales are used to predict the likelihood of ADHD and determine likely subtype. Finally, specific responses on individual BRIEF2 items are compared to DSM-5™ ADHD criteria.

Results from the BRIEF2 ADHD Form can help professionals develop Individual Education Plans and provide academic interventions and accommodations and help get students on the path to success.

Coming to PARiConnect this summer!

College can be difficult even for the most prepared of students. For those struggling with an undiagnosed learning difficulty, it can be overwhelming. They may have poor coping skills, increased levels of stress, executive functioning and working memory deficits, low self-esteem, and even significant academic, interpersonal, and psychological difficulties.

The worst part? They don’t know why.

The new Kane Learning Difficulties Assessment™ (KLDA™) is a tool that screens college students for learning difficulties and ADHD to give them the answers they need.

According to a National Council on Disability report, up to 44% of individuals with an attention deficit disorder were first identified at the postsecondary level. The KLDA screens college students for learning difficulties and ADHD as well as other issues that affect learning, such as anxiety, memory, and functional problems like organization and procrastination. It identifies those who should seek further assessment, so they can get the help they need to succeed in college.

The KLDA measures academic strengths and weaknesses in key areas, including reading, listening, time management, writing, math, concentration and memory, organization and self-control, oral presentation, and anxiety and pressure.

It is useful for all levels of postsecondary education, including vocational schools, technical colleges, community colleges, 4-year colleges and universities, and graduate schools.

The KLDA is a self-report form that can be completed with paper and pencil or online via PARiConnect. Administration takes just 15 minutes, and no special training is required to administer or score.

Scoring and reporting is completed exclusively through PARiConnect. A Student Feedback Report is generated for students that provides them with a comparative sense of their academic skills in relation to their peers. A Score Report is generated for the test administrator.

For students, knowing that are at risk for a learning difficulty, ADHD, or other issue that affects learning—and getting the help they need—can be a first step toward academic success. For more information or to order the KLDA, visit the product page.

 

Though several sources agree that attention deficit/hyperactivity disorder (ADHD) is is on the rise, new numbers question how much. According to a recent study published in JAMA Pediatrics, diagnoses of ADHD increased 24 percent in Southern California over the past 10 years, bringing to issue previous estimates.

 As part of the study, doctors reviewed the charts of children treated at the Kaiser Permanante Southern California physician’s group from 2001 to 2010 – 842,830 children in all. They found that in 2001, 2.5 percent of children age 5 to 11 were diagnosed with ADHD, but that number increased to 3.1 percent in 2010.

The Centers for Disease Control and Prevention (CDC) estimates that about 9.5 percent of children age 4 to 17 have ADHD. Researchers in the California study believe their estimate gives a more accurate picture of the rate of ADHD in Southern California because they reviewed actual medical records, rather than relying on parents to respond to telephone surveys, which is how the CDC got its number. Furthermore, the majority of ADHD diagnoses in the California study were made by specialists using strict Diagnostic and Statistic Manual of Mental Disorders (DSM-IV) diagnoses. This complicates previous estimates, as new research found that only 38 percent of primary care physicians actually use the DSM-IV for diagnosing ADHD.

A great deal of research over the years has focused on the devastating effects of bullying on the mental health of its victims. However, a recent study also suggests that children with mental disorders such as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and depression are much more likely to engage in bullying behavior toward others.

Lead author Dr. Frances Turcotte-Benedict, a Brown University masters of public health student and a fellow at Hasbro Children’s Hospital in Providence, presented the findings at the American Academy of Pediatrics’ national conference in New Orleans on October 22. Turcotte-Benedict and her colleagues reviewed data provided by parents and guardians on mental health and bullying in the 2007 National Survey of Children’s Health, which included nearly 64,000 children ages 6 to 17 years.

In the survey, 15.2 percent of children were identified as a bully by their parent or guardian. Children with a diagnosis of depression or ADHD were three times as likely to be identified as bullies; children diagnosed with ODD were identified as bullies six times more often than children with no mental health disorders. The study found no noticeable differences between boys and girls—both were at increased risk for bullying when a mental health disorder was present.

Traits associated with ODD, such as aggression and revenge-seeking, appear to be clear risk factors for bullying. The connection between bullying and ADHD may be less obvious. “Even though, by definition, these children [with ADHD] aren’t angry or aggressive toward their peers, they do display traits that would increase the likelihood of having impaired social interactions,” explains Dr. Steven Myers, a professor of psychology at Roosevelt University in Chicago, in an October 22 interview with the Huffington Post. “If you’re not really thinking through the consequences of your actions on the playground, you might not have the self-monitoring or restraint to hold back from bullying.”

“These findings highlight the importance of providing psychological support not only to victims of bullying, but to bullies as well,” concludes Turcotte-Benedict. “In order to create successful anti-bullying prevention and intervention programs, there certainly is a need for more research to understand the relationship more thoroughly, and especially, the risk profile of childhood bullies.”

What do you think? Should bullying prevention programs do more to address the mental health problems of the bully? PAR wants to hear from you, so leave a comment and join the conversation!

According to an eleven-year-long study by a group of Canadian researchers, it appears that the youngest students in a class are more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) than peers born at other points in the year.

The study, conducted by University of British Columbia researchers and headed up health research analyst Richard Morrow, finds that children born the month of the school’s cut-off date were more likely to receive an ADHD diagnosis than those born just a month later. After studying nearly 930,000 children in British Columbia, which has a cut-off date for enrollment of December 31, it was found that boys born in December were 30 percent more likely to be given an ADHD diagnosis than those born in January. Girls with December birthdays were 70 percent more likely to receive this diagnosis than those born in January. Furthermore, boys and girls with December birthdays were 41 percent and  77 percent more likely, respectively, to be treated with prescription medication for ADHD than those born the following month.

While researchers believe their analyses show a relative-age effect in the diagnosis and treatment of children age 6-12 years, they warn that these findings raise concerns about the potential for overdiagnosis and overprescribing in the youngest students because the lack of maturity in younger students may be misinterpreted as symptoms of ADHD. ADHD is currently the most commonly diagnosed neurobehavioral disorder in children.

For more information on this study, visit the Canadian Medical Association Journal.

Guidelines from the American Academy of Pediatrics released in October suggest that attention deficit hyperactivity disorder can be diagnosed and treated in children as young as age 4, two years younger than the previous minimum age set by AAP a decade ago.

Mark Wolraich, the lead author of the ADHD clinical practice guidelines and a professor of pediatrics at the University of Oklahoma Health Sciences Center, told the Wall Street Journal recently that ADHD in a preschool-aged child is very different from the typically active behavior seen in most young children (www.online.wsj.com, October 17). A child with ADHD often doesn’t play well with other children, is prone to accidents, and is overactive much of the time. “It's not the environmental things like parties triggering it,” Dr. Wolraich says.

According to the new guidelines, behavior management should be the first approach for treating preschool-aged children. But when behavioral interventions aren’t enough, the guidelines suggest that doctors consider prescribing methylphenidate (commonly known by the brand name Ritalin) for preschool-aged children with moderate to severe symptoms.

Other key recommendations include assessing children for other conditions that might coexist with ADHD, such as oppositional defiant and conduct disorders, anxiety, and depression.

“Treating children at a young age is important,” asserts Dr. Wolraich, “because when we can identify them earlier and provide appropriate treatment, we can increase their chances of succeeding in school.”

For more information, or to request a complete copy of the guidelines, visit www.aap.org.

What do you think about the new ADHD guidelines? Will they affect your practice? Join the conversation—leave a comment now!