Clinical Reasoning in the Assessment and Intervention Planning for Attention-Deficit/Hyperactivity Disorder

Abstract

The purpose of this article is to provide the reader with insight into the clinical reasoning involved in the assessment and intervention planning for a child with Attention-Deficit/Hyperactivity Disorder. The reader will be guided through the authors’ conceptualization of this case, and suggestions for intervention in the classroom will be discussed.

Keywords

Attention-Deficit/Hyperactivity Disorder ADHD psychopathologies and symptomologies school-based assessment intervention diagnosis

Introduction and Theoretical Framework

Today’s inclusive classrooms incorporate students with a number of exceptional learning needs. Students may have difficulties in academic, social, emotional, behavioral, or adaptive domains and may require support and remediation to maximize their development. One of the more common childhood diagnoses is Attention-Deficit/Hyperactivity Disorder (ADHD). Indeed, with a prevalence rate ranging from 5% (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007) to 16% (Rowland et al., 2015), the number of children identified with ADHD in a typical elementary classroom of 30 students may range between two and five students. However, these numbers may not account for students who are not formally identified as having ADHD or who present with subthreshold symptomology. Thus, it is important to understand how to recognize, identify, and support these children’s learning and developmental needs within the school setting. The goal of this article is to not only demonstrate the importance of undertaking an assessment process by way of a scientifically supported theoretical framework, but also to provide the reader with insight into the clinical reasons relative to both assessment and intervention planning for a child with ADHD.

Theoretical frameworks provide a foundation from which a practitioner is able to make appropriate clinical decisions. This article primarily takes a scientist-practitioner approach to working with children, which is based on the understanding that practicing psychologists should be aware of, and competent in, both research and clinical practice (Jones & Mehr, 2007). As such, the authors apply an evidence-based approach to assessment and diagnosis, allowing standardized testing, as well as other collateral evidence to guide our conceptualization process. We bring in evidence to provide a solid conceptual foundation of ADHD, as well as an applied focus that incorporates an understanding of the child’s day-to-day reality. Our intervention suggestions are guided by evidence-based research into effective school-based programming and planning, with careful consideration of the realities of typical life in a busy school environment and the demands of a classroom teacher.

Importantly, we also incorporate a strengths-based approach to our clinical work; we seek to understand not only a child’s areas of difficulty, but also the areas in which he or she excels (Climie, Mastoras, McCrimmon, & Schwean, 2013). Building on the principles of positive psychology (e.g., Climie & Mastoras, 2015), this approach allows for a more well-rounded view of the child whereby a balanced approach incorporates children’s abilities in the assessment and intervention process (Climie & Henley, 2016; Climie & Mastoras, 2015). Together, the authors believe that incorporating a scientist-practitioner model in conjunction with a strengths-based approach to working with children with ADHD will allow for an accountable and realistic conceptualization of a child and his or her environment.

Disorder Characteristics

ADHD is a neurodevelopmental disorder characterized by persistent difficulties with inattention and/or excessive hyperactivity-impulsivity that significantly impacts daily functioning in multiple settings (American Psychiatric Association [APA], 2013). Many children with ADHD have a combined presentation (60%; Biederman, Mick, & Faraone, 2000), consisting of six or more symptoms in both areas of inattention and hyperactivity-impulsivity (see Figure 1). However, some children with ADHD have a predominantly inattentive presentation (30%), which is more often seen in girls with ADHD and can be easily missed due to less overt disruptiveness (Moldavsky, Groenewald, Owen, & Sayal, 2013). Boys are more often diagnosed with ADHD than girls (2:1 ratio in childhood), with an approximately equal gender ratio in adulthood (Nussbaum, 2012). Minimally, symptoms must be present for 6 months across two settings (e.g., home and school).

Figure 1.

Behavioral symptoms of ADHD.

Presentation of ADHD symptoms frequently begins in childhood (before 12 years of age) and must be differentiated from normative development levels, resulting in added challenges of accurate diagnosis before the age of 5 years (Sonuga-Barke, Koerting, Smith, McCann, & Thompson, 2011). ADHD is now recognized as a lifelong condition, with up to 80% of those diagnosed as children continuing to meet diagnostic criteria as adolescents and adults and at least 90% of individuals having some form of lifelong impairment in one or more domains (Biederman et al., 2000). Outward signs of hyperactivity-impulsivity tend to decrease with age, but symptoms of inattention generally remain (Dopfner, Hautmann, Gortz-Dorten, Klasen, & Ravens-Sieberer, 2015) throughout the lifespan.

ADHD is acknowledged to be primarily related to deficits in executive functioning (EF; Barkley, 2014). EFs are the higher order cognitive processes that enable us to plan, organize, multi-task, and flexibly manage our emotions and actions and are recognized as key contributors to daily impairments (Brown, 2008). They are associated with academic (Barbaresi, Katusic, Colligan, Weaver, & Jacobsen, 2007) and occupational underachievement (Küpper et al., 2012), emotion regulation (Anastopoulos et al., 2010), social relationships (Barkley, 2014), and a variety of physical health concerns (e.g., smoking, obesity; Nigg, 2013).

ADHD often co-occurs with other psychiatric conditions and functional impairments, including motor disorders (e.g., developmental coordination), autism spectrum disorder, and substance use disorders (Brown, 2009). In particular, ADHD is highly comorbid (40%-50%) with disruptive behavior disorders such as Oppositional Defiant Disorder and Conduct Disorder (Barkley, 2014), as well as mood/anxiety disorders (15%-30%; DuPaul, Gormley, & Laracy, 2013), and learning disabilities (45%; DuPaul et al., 2013).

Case Presentation

Reason for Referral

Billy was referred for a psychoeducational assessment by his school learning team to better understand his learning needs. His classroom teacher noted concerns regarding Billy’s attention and focus, as well as his learning and retention of math facts and processes. His mother, Mrs. Jones, reported that Billy’s pediatrician requested a psychoeducational assessment to query the possibility of a diagnosis of ADHD.

Based on the limited information provided in the referral question, it appears as though there are two components to this assessment — Billy’s attentional concerns and his academic abilities in the area of mathematics. The link between attentional concerns and academic underachievement is well documented (e.g., Barkley, 2014). Some of the key EF deficits commonly associated with ADHD (e.g., working memory) are known to impact mathematical ability (Bull & Scerif, 2001; Raghubar, Barnes, & Hecht, 2010), so it will be important to gain a better understanding of Billy’s cognitive profile, including his EF abilities, as well as his areas of strength and weakness.

Background Information

Billy is an 8-year-old boy who is currently enrolled in an inclusive Grade 3 classroom. He resides with his mother and father, as well as two younger siblings, ages 4 and 2 years. The following section outlines information collected from three different sources: Billy’s mother, Billy’s teacher (Ms. Smith), and Billy himself. Collection of information from multiple sources allows for a clearer understanding of the presenting concerns and may help the examiner to determine if any party presents with unintentional bias.

Interview With Billy’s Mother

Mrs. Jones reported primary concerns with Billy’s attention and disruptive behavior at home and in the classroom. She questioned if his behaviors were due to boredom, learning difficulties, or some other clinical condition, such as ADHD. Mrs. Jones related that Billy often makes careless mistakes on homework (e.g., simple spelling errors, addition instead of subtraction), particularly if he is rushing through his work so he can play video games. She also indicated that Billy has difficulty completing tasks (e.g., cleaning his room) as he is easily distracted and forgets what he was supposed to be doing. She stated that, although he has regular morning and bedtime routines, Billy requires constant and repeated reminders to start and finish each task. Further, when he is preoccupied with his current activity (e.g., reading or playing something of interest), it can be hard to get his attention to listen to instructions. Billy has difficulties with organizing his materials at home as he often misplaces his belongings. He also struggles to stay seated during mealtimes during which he is particularly fidgety. Although Billy is not overly active at home, Mrs. Jones stated that he often seems quite restless and that he constantly needs to touch different items when he is out in public. She also reported that Billy is overly talkative about his interests, has trouble waiting for his turn while playing games, frequently interrupts others during conversations, and often acts before thinking about the consequences.

Mrs. Jones noted that her son has displayed attentional concerns since he started kindergarten, which has negatively impacted his life at home, at school, and in social situations. She stated that his teachers have expressed concerns regarding Billy’s ability to perform to his full academic potential due to his inattentive behaviors, such as making careless mistakes on classwork, as well as his impulsivity and disruptive behaviors that frequently annoy his peers. Of particular concern is Billy’s math performance which is impacted by his poor attention to detail and his lack of focus during lessons.

Developmental history

Although Billy was born late at 42 weeks, via emergency C-section, the pregnancy was healthy with no drug or alcohol use. His birth weight was 9 lbs., 10 ozs., with an Apgar score of 9. He was jaundiced at birth, with a hospital stay of 3 days. Mrs. Jones reported no concerns with Billy’sattainment of early developmental milestones.

Medical history

Billy’s last medical exam indicated no physical health concerns, aside from eczema, and he is currently not taking any medications. Recent hearing and vision screenings were reported to be normal. There was no reported history of head trauma or other serious injuries.

Psychiatric history

Billy’s maternal uncle was diagnosed with ADHD in childhood and took medication regularly. His father experienced reading difficulties in school but was never assessed for ADHD. No concerns were noted with Billy’s mood or emotion regulation.

Interview With Billy’s Teacher

His current Grade 3 teacher provided information regarding Billy’s classroom behaviors and academic strengths and weaknesses. She was quick to state that Billy is a friendly and engaging child who works very hard in all subject areas. However, Ms. Smith reportedthat Billy often demonstrates inconsistent performance in class and has difficulty focusing. She described him as fidgety and often needing to move about the classroom. As well, he frequently blurts out answers and interrupts his peers’ work.

Academically, Ms. Smith is concerned about Billy’s ability to retain math concepts from day to day. Although he tries hard and seems to grasp the skills one day, Billy struggles to retain or recall the information when necessary. In addition, he has not yet developed automaticity with simple math facts, so he spends much of his time working out basic problems rather than focusing on more advanced questions. In writing, Ms. Smith reported that the quality and quantity of Billy’s independent writing is not always strong, but that he has good ideas and can produce strong work if someone works with him to keep him on task. Billy’s reading is generally at grade level and, although he does not particularly enjoy reading, his reading and comprehension are adequate. Billy had additional reading support over the past year and showed improvement in this area. Ms. Smith noted that there are no significant social or behavioral concerns, other than his impulsive interrupting of others.

Interview With Billy

A brief interview was conducted with Billy prior to the start of the assessment. Billy reported that he generally enjoys school and that he likes his teacher. He stated that he would like to be a scientist when he grows up, as he enjoys doing experiments in class. His favorite subjects are Science and Art, and he also likes recess. He reported that Social Studies is hard and that he does not always like Math as sometimes he “gets numbers mixed up". At home, he likes to play video games, go swimming, and play baseball. Billy reported that he has two good friends at school in his class whom he enjoys playing with at recess.

Gathering information about the child’s daily functioning in multiple settings from multiple reporters using multiple methods can help to enhance the overall understanding of the child. Obtaining detailed examples of how the child’s attentional difficulties present at home and at school from parent and teacher interviews highlight levels of symptoms and impairments. In addition, a review of the child’s school file, specifically current and past report cards with particular attention to the teacher comments of child behavior, not just achievement, may reveal patterns of difficulties associated with ADHD. Concurrently, the child should have a full physical examination to rule out medical conditions that may be associated with attention problems (e.g., hearing impairment, sleep dysfunctions, seizures). As ADHD has a strong genetic component and may be associated with developmental or environmental problems (e.g., low birth weight, prenatal substance exposure), it is important to gather a thorough background history.

Assessment Protocol

Although the assessment protocol for ADHD may be somewhat variable depending on the referral question, location of assessment (e.g., school, private clinic), and clinician, for the purpose of this case study, a number of pertinent information sources and test measures will be used. Given the school context, this case study will include a review of the school file, classroom observations, cognitive and academic testing, and completion of behavior and EF rating scales by parents and teacher.

Review of School File

Academically, report cards from Grades 1 and 2 indicate that Billy was reading and writing slightly below grade level, was easily distracted, and struggled to work in groups and complete assignments. He had more difficulty with mathematics, and it was repeatedly noted that he seemed to forget information quickly; for example, he struggled to memorize his basic math facts and could only get through the first one or two steps when problem solving before he required help to complete the rest of the problem.

Classroom Observation

Billy was observed within the classroom for three 30-min periods while he participated in a small group Language Arts project, a Mathematics lesson requiring individual desk work, and a Science class requiring small group participation. The Behavior Observation of Students in Schools (BOSS; Shapiro, 2011; an interval recording procedure) was used to record on- and off-task behaviors, specifically Billy’s engagement with academic tasks. He displayed significant off-task verbal and motor behaviors and was actively engaged in the task less than 30% of the time. Billy continually left his desk to wander around the classroom or to engage in conversations with peers, played with objects instead of completing desk work, frequently interrupted peers when they were speaking, and was unable to engage in a writing task for longer than 30 seconds without teacher support. Although he was able to refocus his attention when given verbal cues, Billy quickly became distracted again.

Intellectual Assessment

The Wechsler Intelligence Scale for Children–5th edition (WISC-V; Wechsler, 2014) was administered to gain a comprehensive understanding of Billy’s cognitive intelligence. A Full Scale Intelligence Quotient (FSIQ) is derived from the combined results of seven core subtests. The WISC-V also provides five factor-based index scores: Verbal Comprehension (VCI), Visual Spatial Reasoning (VSI), Fluid Reasoning (FRI), Working Memory (WMI), and Processing Speed (PSI). Canadian norms were used to score this measure.

Billy generally performed in the Average to High Average range, although there were some significant discrepancies in his composite scores (30 point spread between highest and lowest scores), resulting in an overall FSIQ score not being reported. Billy demonstrated strengths on the VSI and FRI domains, with scores in the High Average range (88th and 81st percentiles, respectively), indicating that his ability to work with visual problems and on problem-solving tasks is slightly above his same age peers. His PSI score was also in the High Average range (79th percentile), indicating that he is generally able to process information quickly and accurately. Although his VCI score was slightly lower, it still fell within the Average range (58th percentile), indicating that Billy is able to reason with verbal information at the expected level. However, his WMI score was significantly lower than his other scores, falling within the Low Average range at the 21st percentile. This lower WMI score indicates that Billy may have difficulty retaining and manipulating information in his short-term memory, a process requiring attention, concentration, and sustained mental effort.

Academic Achievement

Billy completed the Wechsler Individual Achievement–3rd edition (WIAT-III; Wechsler, 2009) to gain an understanding of his academic abilities in reading, mathematics, written expression, and oral language. His reading abilities were Low Average to Average, with no significant issues with sight word reading (27th percentile), phonetic understanding (25th percentile), reading aloud (27th percentile), or reading comprehension (21st percentile). His writing skills were also relatively Average, with sentence composition (25th percentile) and essay composition (55th percentile) falling within the Average range and spelling slightly lower (14th percentile) due to an overemphasis on phonetics. Scores within Oral Language were in the Average range (Listening Comprehension–34th percentile; Oral Expression–55th percentile). In contrast, Billy demonstrated difficulties with mathematics. Specifically, his rote math and problem-solving abilities were both within the Borderline range (3rd percentile) and his ability to complete timed addition (12th percentile; below average), subtraction (7th percentile; borderline), and multiplication (5th percentile; borderline) questions were below the expected level for his grade.

Behavioral Functioning

The Conners-3 Rating Scale (Conners-3; Conners, 2008) was completed by Billy’s mother and his current teacher to gain an understanding of Billy’s behavioral functioning. Ms. Smith reported clinically significant concerns withinattention, hyperactivity/impulsivity, and EF. She also endorsed at-risk concerns with learning problems. In particular, Ms. Smith indicated the presence of nine out of nine hyperactive/impulsive symptoms and six out of nine inattentive symptoms; thus, her ratings indicated that the diagnostic criteria for ADHD Combined presentation were met. Ms. Smith’s ratings also indicated that Billy’s problems often impair his academic functioning and occasionally impair his social relationships. No significant concerns related to defiance, aggression, or peer relations were noted on this scale, and Ms. Smith’s ratings on the anxiety and depression screener items did not indicate a need for further investigation in these areas.

Mrs. Jones’ ratings were fairly consistent with Ms. Smith’s. Mrs. Jones noted clinically significant levels of inattention and EF, and at-risk levels of hyperactivity/impulsivity and learning problems. Her ratings indicated the presence of five out of nine hyperactive/impulsive symptoms and seven out of nine inattentive symptoms; thus, Mrs. Jones’ ratings indicated that the diagnostic criteria for ADHD Inattentive presentation were met and that the ratings for an ADHD Combined presentation were nearly met (i.e., the requirement of six of nine hyperactive/impulsive symptoms). Mrs. Jones’ ratings also indicated that Billy’s problems often impair his academic functioning and occasionally impair his social relationships and home life. No significant concerns with aggression or peer relations were noted, and ratings on the anxiety and depression screener items did not indicate a need for further investigation.

Together, these reports indicate significant inattention and hyperactive/impulsive concerns. When considering both home and school environments, the presence of these behaviors are at a level significant enough to interfere with academic and social functioning.

Executive Function

Mrs. Jones and Ms. Smith each completed the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000). Mrs. Jones endorsed significant difficulties in several EF domains, including Billy’s ability to initiate (e.g., independently beginning a task), plan/organize tasks (e.g., homework, overwhelmed by large assignments, poor written work), monitor his behavior (e.g., check for mistakes, awareness of others), and WM (e.g., trouble finishing tasks, easily distracted). Ms. Smith also endorsed significant concerns in several EF domains, including planning, organizing, self-monitoring, and WM. Borderline concerns about Billy’s ability to inhibit, shift, and initiate responses were also noted at school.

Evidence-based assessment practices for diagnosing ADHD include symptom rating scales, structured interviews, domain-specific impairment measures, and behavioral observations (Pelham, Fabiano, & Massetti, 2005). The most efficient assessment method is obtaining information through both parent and teacher rating scales (Pelham et al., 2005), and the Conners-3 demonstrates among the strongest psychometric properties in the realm of ADHD diagnostic instruments (Johnston & Mah, 2008). Discrepancies between parent and teacher ratings commonly occur (e.g., Antrop, Oosterlaan, Roeyers, & Van Oost, 2002), and when this occurs, the assessor must consider a variety of explanatory factors including different situational demands (e.g., more distractions at school than at home), different internal resources (e.g., child is more fatigued after school) and external supports (e.g., more structure and routine provided in one setting than the other), and different developmental norms and expectations (e.g., parents of one child vs. teachers in a class of 30 students).

Behavioral observations alone should not be relied upon to confirm or rule out ADHD, particularly when the child is seen in a novel, high adult-to-child ratio, and controlled environment (e.g., meeting a new clinician in an office), as the child’s behavior in such settings is not necessarily representative of their daily functioning. However, observations completed in natural settings (e.g., BOSS in classrooms) may provide a useful understanding of the child’s day-to-day functioning in a comfortable and familiar environment. As well, these naturalistic observations may identify specific target behaviors for intervention goals.

Finally, studies exploring the utility of EF rating scales, such as the BRIEF, have shown promise in identifying EF deficits common with children displaying ADHD symptoms (Jarratt, Riccio, & Siekierski, 2005). These instruments may be particularly useful for providing additional insight into the underlying challenges that an individual child is experiencing (e.g., individual weakness in planning or organization) and may allow teachers to have a better understanding of what aspects of EF a child may need support so as to be successful.

Cognitive performance measures, such as versions of the continuous performance tests or neuropsychological and EF standardized tests, have limited evidence to support their ability to predict or discriminate ADHD (Toplak, Bucciarelli, Jain, & Tannock, 2008). In particular, scores on these measures often produce high rates of false negative diagnoses; that is, children with ADHD often score within the normal range on these measures due to the novel and engaging tasks within a controlled testing environment that are associated with the nature of these measures. Similarly, standardized cognitive and academic testing, such as the WISC-V and WIAT-III, is not required to make an ADHD diagnosis but may be useful to determine whether a learning disorder is present and to better understand patterns of individual strengths and weaknesses. However, it is also important to not rely on subscale scores on cognitive tests (e.g., WMI) as a definitive indication of ADHD.

Diagnostic Conclusion

Given the information presented above, several diagnoses were considered. First, it was determined that Billy meets criteria for a diagnosis of ADHD Combined presentation, given his reported symptoms in both the inattentive and hyperactive/impulsive domains. More specifically, behavior ratings at home and school indicate clinically significant impairment, and classroom observations confirmed a number of behavioral challenges related to ADHD. In addition, EF ratings by his mother and teacher highlighted a number of areas in which Billy’s EF abilities are compromised, including planning, organizing, and WM. His cognitive profile also indicated a specific area of difficulty within the WM domain.

Challenges in the area of mathematics were also identified. Therefore, a concurrent diagnosis of a specific learning disorder with impairment in mathematics is indicated. Billy demonstrated numerous math difficulties, including retention of math facts, problem solving, application of skills, and retention of math-related information. These deficits have been present for a number of years, despite remedial attempts, and appear to be linked to his reduced WM capacity. Interventions should focus on addressingthe behaviors associated with ADHD as well as building math skills, with consideration of Billy’s WM profile.

Intervention Planning

One of the most critical components of any psychological assessment is the identification of relevant interventions and strategies that enhance the child’s competencies while targeting areas of need across multiple domains. This intervention planning approach is particularly important given that a child with ADHD must show impairment in multiple settings. Additionally, it is crucial that any intervention or recommendation be evidence-based with empirically supported research verifying its utility and effectiveness for individuals with ADHD. Specifically, the following section highlights recommendations within the areas of attention, WM, and mathematics.

ADHD Support

Children with ADHD may receive support at home and at school in a number of ways. His teachers can develop an individual program plan that addresses Billy’s attention and learning needs while emphasizing his strengths. Designing and implementing classroom supports for children with ADHD focuses on evidence-based academic skill instruction and behavior management interventions, such as contingency contracting, token reinforcement and response cost systems, goal-setting, cognitive-behavioral management strategies, computer-assisted instruction, peer tutoring, task and instructional modifications, and specific instructional strategies. Programs that target EF deficits, such as the Homework, Organization, and Planning Skills (HOPS) for middle school students, facilitate homework management and organization of materials (Langberg et al., 2012). Computer-assisted instruction allows children with ADHD to learn academic material on the computer in a multi-sensory, segmented, immediate-feedback format (Mautone, DuPaul, & Jitendra, 2005), while peer tutoring has been found to improve prosocial and classroom behavior, along with academic performance (Greenwood, Maheady, & Delquadri, 2002). Finally, a high level of communication between home and school is essential to foster consistency between settings.

Billy’s parents may wish to deepen their understanding of their son’s diagnosis by accessing research-based information so that they are best able to support their son. Specifically, information about ADHD may be accessed through organizations such as the Center for ADD/ADHD Advocacy (CADDAC) or Children and Adolescents With Attention Deficit Hyperactivity Disorder (CHADD). Additionally, Billy’s parents may seek training in parenting skills specific to ADHD, which will help them apply behavioral strategies targeting their son’s ADHD symptoms. Behavioral parent training is an evidence-based intervention for ADHD that teaches strategies to manage child behaviors based on operant conditioning principles (i.e., antecedents and consequences to change behavior; Antshel, 2015). Techniques to help support the child’s environment (e.g., visual aids and task checklists), enhance parental commands/instructions, positive reinforcement to increase desired child behavior (e.g., praise, child-centered play, token reward charts), and consequences to set limits on inappropriate child behavior (e.g., ignoring whining, time-out to calm down, loss of privileges) are included. Many of these techniques are transferable to the school setting as well.

Finally, use of stimulant medication is a common evidence-based intervention and is often recommended for individuals aged 6 years and above (American Academy of Pediatrics, 2011). Common stimulant medications for ADHD include methylphenidate-based (e.g., Ritalin, Concerta) and amphetamine-based (e.g., Adderall, Vyvanse) prescriptions. Long-acting preparations (i.e., duration of action is 8-12 hr) are recommended as they eliminate the need for midday dosing at school. Benefits of medication include significant improvements in ADHD symptoms; however, common side effects include appetite suppression and insomnia.

Working Memory

It will be important to recognize that Billy’s WM is an area of personal weakness that may impair his ability to follow instructions and completemath assignments or multi-step tasks. Although it is difficult to improve core cognitive abilities (e.g., WM) directly, it is possible to provide compensatory strategies.. For example, it may be beneficial to teach Billy verbal rehearsal strategies, such as repeating instructions back in his own words, to ensure comprehension and retention. Targeted teaching of memory strategies, such as chunking, verbal rehearsal, and verbal imagery, may also be helpful, as well as the use of memory aids, such as outlines, organizers, personal planner, number lines, multiplication grids, calculators, and other visual tools. Finally, especially as it relates to mathematics, it may be useful to provide Billy with adequate examples of a novel concept or to demonstrate step-by-step methods for solving problems or explaining relationships so that he is able to work through problems in multiple ways; thus, giving him more problem-solving tools.

Mathematics

It will also be important to enhance Billy’s rote mathematics skills, as well as his problem-solving skills. For example, access to computer-assisted math programs may encourage Billy to build his basic skills in a game-like manner. In addition, providing him with checklist reminders for math algorithms that he has trouble with (e.g., steps for completing subtraction with carrying), keeping a notebook with examples/models of different processes to use as a reference, and using mnemonics where possible may also be helpful. It will also be important to teach Billy specific EF-related strategies, such as checking his work for errors and working through word problems in a systematic manner. Finally, taking the opportunity to show him that math is present in all subjects and connecting math to real-life experiences may reinforce the importance of building these skills.

Building on Strengths

Finally, it is important to acknowledge and enhance Billy’s current strengths. For example, it would be useful to help him learn to use his strong conceptual and fluid reasoning abilities by providing him with meaningful activities that involve problem solving and predicting conclusions. Because of his strong visual spatial abilities, Billy may benefit from being allowed substitutelanguage-based projects with more hands-on projects. He can be encouraged to build on his interpersonal skills by placing him in leadership and coaching roles. Having him read to a Grade 1 student orbe assigned as a buddy/mentor for a new student may reinforce positive sense of self. Lastly, encouraging Billy’s participation within structured community-based activities may foster his self-esteem and support EF development.

Conclusion

This article provides a single case study of a child with ADHD and related concerns. It is important to remember that each child with ADHD presents with unique strengths and weaknesses and that taking a “one size fits all” approach to a heterogeneous disorder is not appropriate. Thus, to best conceptualize the essence of what is most central to a child’s developmental strengths and needs, it is imperative to not rely solely on test administration, but to also gather reliable and valid information from multiple sources using multiple methods. This process reflects a scientist-practitioner approach to effectively integrate quality assessment data, supported by research knowledge and evidence, and reinforced with clinical experience and insight regarding the multifaceted context of the child. Providing evidence-based, timely, and accurate assessment and diagnosis of ADHD may allow a child to receive necessary supports to ensure that they are best supported in the classroom environment.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Emma A. Climie is an assistant professor and registered psychologist in the School and Applied Child Psychology program in the Werklund School of Education at the University of Calgary. She is also the lead researcher for the Carlson Family Research Award in ADHD. She directs the Strengths in ADHD lab and her research interests include strengths-based approaches to children and the impact of knowledge, stigma, and physical activity on the mental health of children.

Janet W.T. Mah is a clinical child psychologist and research lead of the Provincial ADHD Program at BC Children’s Hospital, and is a clinical faculty member in the Department of Psychiatry at the University of British Columbia. In addition to her clinical roles in diagnostic assessments and behavioural parent interventions for ADHD, her research focuses on innovative psychosocial interventions for ADHD, social-cognitions related to engagement and adherence, and mental health literacy and stigma among cultural groups.

Cheryl Y. Chase is a registered psychologist employed by the Calgary Board of Education and maintains a private practice focusing on psychoeducational assessments and trauma therapy. She is also a sessional instructor in the School and Applied Child Psychology program in the Werklund School of Education at the University of Calgary, teaching courses on trauma and resilience, psychosocial interventions for children with ADHD, and academic, cognitive, and social-emotional assessment.

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