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The Brown ADD Scales

Article · January 1996

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Thomas E Brown
Yale University
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Thomas E. Brown, Ph.D.
ADHD: DSM-IV and Beyond
Yale University School of Medicine

Assessment of Shifts in Conceptualizing ADHD

Executive Function ♦ 1968 Hyperkinetic Disorder of childhood
Impairments in ADHD: ♦ 1980 Attention Deficit Disorder
• With or without hyperactivity
The Brown ADD Scales • Residual type recognized
♦ 1987 ADHD (only combined symptoms)
Thomas E. Brown, PhD ♦ 1994 AD/HD–3 types
Department of Psychiatry
♦ 2000 AD/HD (impaired executive function)
Yale Medical School

ADHD Symptoms Overlap With

2 ADHD Symptom Sets
“Executive Functions” (EF)
♦ Hyperactive-impulsive ♦ Wide range of central control
symptoms: impaired ability processes of the brain
to inhibit
♦ “Inattention” symptoms: ♦ Connect, prioritize, and
impairments in multiple integrate cognitive functions–
cognitive functions moment by moment
♦ Symptoms of “inattention” ♦ Like conductor of a
usually most persistent symphony orchestra
and most problematic

Executive Functions Often

Characteristics of ADHD Symptoms
Impaired in ADHD
♦ Dimensional, not “all-or-nothing” Executive Functions
• Everyone sometimes has some
impairments in these functions;
in ADHD: chronic, severe impairment Organizing, Focusing, Regulating Managing Utilizing Monitoring
prioritizing, sustaining alertness, frustration working and self-
and focus, and sustaining and memory regulating
♦ Situational variability: “If I’m interested” activating shifting effort, and modulating and action
to work focus to processing emotions accessing
• Most persons with ADHD have a few tasks speed recall
activities where ADHD impairments
are absent
1. 2. 3. 4. 5. 6.
Activation Focus Effort Emotion Memory Action
ADHD looks like willpower problem, but it isn’t!
Brown TE. Manual for Attention Deficit Disorder Scales for Children and Adolescents; 2001.
Thomas E. Brown, Ph.D.
ADHD: DSM-IV and Beyond
Yale University School of Medicine

1. Organize, Prioritize, and Activate 2. Focus, Shift, and Sustain Attention

♦ Difficulty organizing tasks, ♦ Loses focus when trying to listen
materials or plan
♦ Difficulty estimating time, ♦ Easily distracted–internal/external
prioritizing tasks
♦ Forgets what was read, needs
♦ Trouble getting started on work to re-read

Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents, Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents,
and Adults; 2000. Brown TE. Manual for Attention Deficit Disorder Scales for and Adults; 2000. Brown TE. Manual for Attention Deficit Disorder Scales for
Children and Adolescents; 2001. Children and Adolescents; 2001.

3. Regulating Alertness, Effort, 4. Manage Frustration,

and Processing Speed Modulate Emotion
♦ Difficulty regulating sleep and (Not included in DSM-IV criteria)
alertness
♦ Emotions impact thoughts, actions
♦ Quickly loses interest in task, too much
especially longer projects; doesn’t ♦ Frustration, irritations, hurts, desires,
sustain effort worries, etc., experienced “like
♦ Difficult to complete task on time, computer virus”
especially in writing–“slow modem” ♦ “Can’t put it to the back of my mind”
Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents, Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents,
and Adults; 2000. Brown TE. Manual for Attention Deficit Disorder Scales for and Adults; 2000. Brown TE. Manual for Attention Deficit Disorder Scales for
Children and Adolescents; 2001. Children and Adolescents; 2001.

5. Utilize Working Memory,

6. Monitor and Self-Regulate Action
Access Recall
♦ Difficulty holding one or several things (Not just hyperactive/impulsive behavior)
“on line” while attending ♦ Difficulty controlling actions, slowing
to other tasks self and/or speeding up as needed
♦ Difficulty “remembering to remember” for tasks
♦ Inadequate “search engine” for ♦ Doesn’t size up ongoing situations
activating stored memories, integrating carefully
these with current info to guide current ♦ Hard to monitor and modify own
thoughts and actions actions to fit situation/aims
Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents, Brown TE. Attention-Deficit Disorders and Comorbidities in Children, Adolescents,
and Adults; 2000. Brown TE. Manual for Attention Deficit Disorder Scales for and Adults; 2000. Brown TE. Manual for Attention Deficit Disorder Scales for
Children and Adolescents; 2001. Children and Adolescents; 2001.
Thomas E. Brown, Ph.D.
Yale University School of Medicine
EF Development and Demands
♦ EF capacity develops through
childhood, into adolescence and
beyond; it is not fully present in
early childhood
♦ Environmental demands for EF
increase with age, from preschool
through adulthood
♦ EF impairments often are not
noticeable by age 7
How Can ADHD Be Assessed?
♦ When ADHD was seen as just a
disruptive behavior disorder in
childhood, diagnosis was based
on observing overt behavior
♦ EF impairments of ADHD are
largely cognitive, covert, and not
easily observed
♦ EF are complex, interactive, and
not easily isolated for capture in
laboratory measures
Ask the Patients!
♦ Because EF impairments of ADHD
are so complex and largely covert
• Assessment of impairment requires
extensive self-report data from patient
& family about relevant history,
especially complex everyday tasks
• Compare these data with profiles
of ADHD, normal development and
other disorders
ADHD: DSM-IV and Beyond
When Are ADHD
Impairments Noticeable?
♦ Some are obvious very early and
are noticeable in preschool years
♦ Some are not noticeable until
middle elementary or junior high
♦ Some are not apparent until child
leaves home to go to college or later
Problems in Assessment
of Executive Functions
♦ EF modulate and control other
functions
♦ Single function = pooled outcome
of multiple sub-functions
♦ EF are reciprocally dependent
♦ Complex, everyday tasks are more
sensitive diagnostic indicators
Query Functioning for Tasks
Not intrinsically interesting
Useful and/or necessary
Complex, self-managed
-Organizing homework -Cleaning house
-Driving in traffic -Utilizing feedback
-Managing money -Explaining clearly
-Allocating time -Completing chores
-Interacting mutually -Sequencing tasks
-Reading for comprehension (not self-chosen)
Thomas E. Brown, Ph.D.
ADHD: DSM-IV and Beyond
Yale University School of Medicine

Comparisons of WISC/ WAIS-III WISC-

WISC-III Index Discrepancies
Index Scores to Assess ADHD VCI/POI v. FDI/PSI
Index Scores [VCI, POI] less sensitive to Children 8-8-12 years
problems in
attention, memory, processing speed 70
60
50
40
vs percent of Ss
30 ADHD (n=130)
20 Normal (n=2,200)
10
Index Scores [WMI, (FDI), PSI] 0
15 points 30 points
more sensitive to these problems VCI or POI - FDI or PSI

Comparison of CMS Story Memory vs VIQ - Story Memory in ADHD & Normals
VIQ by age groups
Children 8-12 years 80
70
60
60
50
50 ADHD-15 pts
percent of Ss 40
Normal-15 pts
40 30
ADHD-30 pts
percent of Ss 30 20
Normal-30 pts
ADHD (n=70) 10
20 Normals (n=94)
0
10 8-12 yr 13 - 16 16 - 19 16 - 69
0 age group
15 points 30 points
VIQ - Story Memory discrepancy

ADHD Is a Complex Disorder Often Other Psychiatric Disorders

Complicated by Comorbidity Often Accompany ADHD
♦ In 50-70% of cases, ADHD is further
complicated by one or more
additional psychiatric or learning
disorders
♦ Not only is it possible to have
another disorder with ADHD, it is
2 to 5 times more likely in lifetime
than for those without ADHD 70% of children with ADHD had at least one psychiatric
Pliszka SR, et al. ADHD with Comorbid Disorders; 1999. Brown TE. Attention-Deficit
disorder in addition to ADHD.
Disorders and Comorbidities in Children, Adolescents, and Adults; 2000. (MTA, 1999)
Thomas E. Brown, Ph.D.
ADHD: DSM-IV and Beyond
Yale University School of Medicine

Other Disorders Often Found w/ADHD LD in ADHD Children

♦ Specific Learning Disorders Clinical Sample of ADHD Children:
(Reading, Math, Written Exp., Speech/Lang) Reading LD 27%
♦ Substance Use Disorders Math LD 31%
♦ Dysthymia, Major Depressive Disorder Written Expression LD 65%
One or more LD 70%
♦ Obsessive-Compulsive Disorder
(Mayes, Calhoun, Crowell, 2000)
♦ Developmental Coordination Disorder Epidemiological Sample:
♦ Central Auditory Processing Disorder CDC National Health Interview Study:
♦ Tourette’s Disorder 50% of children ADHD-diagnosed children
are also identified as having LD
♦ Asperger’s Disorder
(Pliczka, Carlson & Swanson, 1999; Brown, 2000) (CDC, 2002)

How Is ADHD Related to Comorbid

Disorders?
♦ ADHD:developmental impairment of
executive functions that organize and
regulate many specific functions of
mind cf: impaired orchestra conductor
♦ Comorbidity: ADHD with 1 or more
specific mental functions also impaired
cf: orchestra player(s) + conductor
impaired
Assessment for ADHD
♦ Clinical interview with patient (conjoint)
♦ ADHD Rating Scale (multiple reporters)
♦ DSM-IV Diagnostic Criteria (multi-rater)
♦ Comparisons of IQ Index Scores
♦ Story Memory Test vs Verbal IQ
♦ Screening for comorbid disorders
♦ Integration and weighting of relevant
data

Key Points

♦ ADHD is a complex cognitive disorder

affecting all age groups, both genders
♦ ADHD=developmental impairment of EF
♦ Dimensional; Chronic, but not constant
♦ Not easily assessed by observation
♦ Usually complicated by other disorders
♦ Often responsive to medication treatments

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