Clinical practice guidelines on cognitive impairment and ADHD-Assessment and Management

ADHD is a common disorder seen in children and adolescents. It is one of the most common disorders diagnosed in childhood and affects children across populations. In about 5% of cases, it progresses to adulthood and may manifest as adult ADHD. Boys are more commonly affected than girls. The ratio of boys to girls affected is 3:1 to 5:1, most of which is attributed to biological factors such as differences in male and female biology along with hormonal factors, but there may be other psychosocial and parenting factors such as child-rearing practices where boys are allowed to be behaviorally less inhibitive and physically more active as compared to girls. The condition is associated with deficits in basic cognitive processes like attention and higher abilities like planning and organization, with varying degrees across children. Cognitive impairments contribute to significant dysfunction in ADHD. Although the prevalence of ADHD in adulthood is reported to be about 4–5% of the population, not much research is available on ADHD in adults.[1,2] This paper primarily deals with cognitive dysfunctions in children and adolescents with ADHD. SYMPTOMS OF ADHD Process of developing these guidelines and their scope These guidelines have been developed by reviewing the available literature on cognitive impairment and cognitive assessment in ADHD. Only reviews and meta-analyses or synthesis papers of multiple meta-analyses or position papers and white papers have been reviewed. For India data, a specific search has been done for the published work of the centers, institutes, and professionals long associated with the research work on ADHD, especially in neurocognitive assessment and intervention. The findings in the clinical guidelines below are based on a combination of the findings of the studies reviewed above and the clinical experience of all authors writing the paper. The findings have been posited in a manner that shall be clinically useful for the busy clinician and from an academic and research standpoint. The scope of these guidelines is to serve to guide clinicians in the assessment of cognitive impairment in ADHD, and while these are general guidelines, every case must be assessed individually [Table 1].Table 1: Clinical symptoms of ADHDCOGNITIVE IMPAIRMENTS SEEN IN CHILDREN WITH ADHD More recently, it has become clear that whereas ADHD is associated at the group level with a range of cognitive impairments, no single cognitive dysfunction characterizes all children with ADHD. Patients with this syndrome do not fit into any one category and are present with widely differing co-occurring disorders including varying cognitive profiles. Cognitive impairments constitute secondary features that often accompany the disorder and need to be considered as part of a comprehensive clinical formulation and multidisciplinary treatment plan. For a comprehensive plan of intervention, cognitive deficits need to be considered.[3,4] The types of cognitive deficits seen generally in children with ADHD are as follows : Attention deficits Sustained Attention: Difficulty maintaining focus over extended periods, especially on tasks that require prolonged mental effort (e.g., classroom activities, homework). Selective Attention: Problems filtering out distractions and focusing on relevant information, resulting in being easily distracted by external stimuli. Divided Attention: Challenges in managing multiple tasks simultaneously, often leading to incomplete or poorly done tasks. Processing speed deficits Slow Cognitive Processing: Reduced speed in processing information, which can affect the ability to complete tasks efficiently and keep up with peers in fast-paced environments. Reaction Time: Slower reaction times, impacting activities that require quick responses, such as sports or timed academic tasks. Executive functioning deficits Working Memory: Difficulty holding and manipulating information in mind for short periods, affecting tasks like following multistep instructions or solving problems. Inhibition Control: Challenges in suppressing impulses, leading to behaviors such as interrupting others, difficulty waiting their turn, and acting without thinking. Cognitive Flexibility: Problems shifting attention between tasks or adjusting to new rules, which can lead to difficulties in adapting to changing situations or perspectives. Planning and organization deficits Task Initiation: Difficulty starting tasks, often leading to procrastination or avoidance. Organization: Problems organizing thoughts, materials, and tasks, resulting in disorganized workspaces, forgotten assignments, and missed deadlines. Time Management: Challenges in estimating time needed for tasks, leading to poor time allocation and inability to meet deadlines. Memory deficits Short-Term/Working Memory: Issues with retaining information for short durations, affecting ongoing tasks like remembering instructions or recalling recent events. Long-Term Memory: Difficulty with the retrieval of stored information, impacting the ability to recall learned material and apply it in different contexts. Emotional regulation deficits Emotional Control: Difficulty managing emotions, leading to frequent mood swings, frustration, and difficulty coping with stress. Motivational Deficits: Problems with intrinsic motivation, often requiring external rewards or stimuli to initiate and complete tasks. Language and communication deficits Verbal Fluency: Difficulty retrieving words, leading to struggles with expressive language and slower conversational exchanges. Pragmatic Language: Challenges in using language appropriately in social contexts, affecting the ability to follow conversational rules and interpret social cues. Note: Similar cognitive impairments may also be present in Adult ADHD but may be significantly affected by the presence of comorbid psychiatric disorders like depression, bipolar disorder, personality disorders, and other comorbidities unlike in childhood ADHD. The current guidelines focus only on child and adolescent ADHD. We recommend the assessment of development, intellectual functioning, cognitive abilities, and learning problems in that order because each of the first-level domains helps understand the subsequent domains better. Children with ADHD will have specific developmental delays Developmental skill repertoire is a good indicator of intellectual levels and cognitive abilities, especially in young children. For example, cognitive maturity can be understood from motor abilities, language and communication skills, and social and emotional skills. Therefore, a thorough developmental assessment is necessary for ADHD. There could also be clinically significant developmental conditions that limit cognitive functioning. However, there is not much research in this area as compared to the focus given to other comorbid conditions, like externalizing disorders (e.g., conduct disorder, oppositional and defiant disorder), internalizing disorders (e.g., anxiety) and other psychiatric disorders (e.g., mood disorders, substance use disorder). Since ADHD is a neurodevelopmental disorder, it shares many neurobiological, neuropsychological, and clinical features with other neurodevelopmental disorders, especially autism spectrum disorder, and global developmental delay/intellectual disability. Therefore, persons with ADHD, especially children, should be examined for specific developmental delays or deficits rather than ignoring them as features of ADHD. In this regard, pertinent clinical questions are: what is the nature of developmental delays and how to assess and intervene the same? [Refer to Figure 1].Figure 1: Screening developmental problems in ADHDRecent studies have indicated that persons with ADHD can at least have mild delays or deficits or deviations in specific domains like motor coordination, language processing, pragmatic communication, socialization/interpersonal, and adaptive behavior. It should not be assumed that all these problems are secondary to ADHD, and assessment or intervention is carried out only after the ADHD symptoms are resolved. Rather, it is important to note that clinically significant developmental deficits were 2 to 7 times as common in children with ADHD as in non-ADHD children. It implies that the specific developmental delays are not a consequence of ADHD but independently occur, maybe due to the same neurobiological mechanism that mediates the ADHD symptoms. Specific deficits (e.g., language and interpersonal skills) may interact with the other impairments responsible for ADHD to make the disorder more severe and more disabling. Therefore, the identification of developmental problems is necessary for a detailed assessment, program planning, referrals, and the prediction of the course and prognosis.[5] For children below the age of 15 years, the Developmental Screening Test, Vineland Social Maturity Scale, or any other standardized, culturally appropriate tests can be used to identify gross developmental problems. It is better to avoid paper–pencil or computer-based specific cognitive tests under the age of 4 years. If needed, cognitive assessment should be restricted to developmental assessments in which there are specific subscales for cognitive assessment (e.g. Developmental Assessment for Indian Infants; Bayley Scales of Infant and Toddler Development). The assessment report should inform the nature of the developmental problems (i.e., delay, deficit, or deviation), the affected domains (e.g., single or multiple), and the permanence of the condition (e.g., transient or global) and link all of these to intervention plan including appropriate referrals. It is preferable to repeat the developmental assessments at 6-month intervals if the child is below 5 years of age because development during this period is diffused yet rapid, and intellectual disability or other specific developmental difficulties are difficult to ascertain without any evidence of stable deficits. Intellectual impairments in ADHD could be a function of core symptoms and also an artifact of testing Most intelligence tests are long and require focused and sustained attention of the individuals to perform adequately. Some tests may require planning and specific problem-solving skills to achieve the tasks. Furthermore, the individual’s motivation is also important. Given that the deficits in these areas are characteristic of ADHD, they can affect global intellectual capacities. Therefore, it is not surprising that meta-analyses have found low IQ in children with ADHD as compared to nonclinical controls. Since most studies have not included persons with IQs below 80, it is difficult to comment on how common borderline intelligence or intellectual disability is in ADHD.[6] Nonetheless, the relevant clinical questions are: does the individual have a below-average intellectual functioning (i.e. borderline functioning or intellectual disability)? Are the intellectual impairments a function of the core symptoms of ADHD? How to check the artifact of testing? Which measures are best suited for intellectual assessment in ADHD? [Table 2].Table 2: Summary of guidelines on intellectual functioning in ADHDHow to differentiate between low IQ and cognitive deficit typical of ADHD? It is easy to understand how inattention, impulsivity, and low motivation affect test performance. However, it is also true that those with low intelligence may also show less interest and become easily distracted if presented with a complex task. Therefore, a thorough developmental history must be taken to identify clinically significant delays (see the first statement on developmental delays for specific guidelines). If the developmental delays are significantly subaverage in two or more important areas, the diagnosis of global developmental delay or intellectual disability should be considered as per the chronological age cutoff. Furthermore, clinical observations must be validated by appropriate developmental or intelligence measures. Clinical history should always precede psychometric assessment and not vice versa. Concerning the assessment measures, it is preferable to use developmental and adaptive behavioral measures for children under 5 years of age. Those measures will yield developmental and social quotients, respectively. The test quotients can be interpreted the same way as the intelligence quotient to identify the severity of the developmental delay. For children aged 6 and above, age-appropriate intelligence scales can be administered. For further details on the intelligence scales, Appendix 2 in the Indian Psychiatric Society’s clinical practice guidelines on intellectual disability can be referred to.[7] It is preferable to start the intellectual assessment with non-speed performance tests (e.g. Gessell’s Drawing Test, Progressive Matrices), understand how basic cognitive processes affected the test performance, and proceed with global intelligence scales (e.g. Wechsler’s scales or Binet scales with contemporary norms) that contain both verbal and nonverbal items and timed and untimed items. Otherwise, a child’s poor performance on an intelligence scale is not necessarily due to intellectual impairment but unsuitability of the test for the individual (i.e., artifact of the test). To illustrate further, a child may find it difficult to sustain attention as the complexity of items increases on speed tests. Conversely, with adequate breaks and appropriate reinforcement, the child may complete a complex test like progressive matrices. Notwithstanding these, IQ assessment should not be used as a standalone method. Rather, it should be complemented with developmental measures (especially, for children below 5 years) and adaptive behavioral assessment (a rule applicable for any age group) because impairments in both will suggest intellectual impairments. Conversely, a relatively better performance on adaptive behavior measure than on an intelligence scale may denote the adverse effects of cognitive impairments on global intelligence. If the results of the non-speed tests and adaptive behavioral measures match, an appropriate diagnostic code should be used to highlight the intellectual level. Regarding the effects of ADHD symptoms on intelligence scores, studies indicate that inattentive and the combined subtypes, compared with the normative sample, show lower IQ scores on global intelligence scales (e.g., Wechsler’s scales). However, the ADHD combined type was better on dynamic tests (i.e., novel problem-solving tasks).[8] Therefore, tests that measure rule-learning to solve problems progressively (e.g. Progressive Matrices) must be a part of the assessment. 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