Kevin O Brien, Ph.D., ABPP-Cn

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1 Aerospace Medical Association Meeting: Pay Attention! ADHD in Civil Aviation (May 16, 2013) Neuropsychological Evaluation of ADHD: Recent FAA Revisions Kevin O Brien, Ph.D., ABPP-Cn Arizona Neuropsychology, P.C N. Hayden Road, Suite 106 Scottsdale, AZ (480)

2 Disclosure Information 84 th Annual AsMA Scientific Meeting Kevin P. O Brien, Ph.D. I have no financial relationships to disclose. I will not discuss off-label use and/or investigational use in my presentation

3 SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS: Revised January 2013 Protocols for P & P s, SSRI, Alcohol & Substance Abuse/Dependence, Potential Neurocognitive Impairment and ADHD/ADD were reviewed and revised by The FAA Neuropsychology Working Group: Robert Elliott, Ph.D., ABPP-CN, SP Gary Kay, Ph.D. Jeffrey Moore, Ph.D. Randy Georgemiller, Ph.D., ABPP-CP Carlos Porges, Ph.D., ABPP-RP, and Dan DaSilva, Ph.D. Chris Front, Psy.D. served as the facilitator.

4 What is Role of Neuropsychologist? 1) Consultative (work with AME/FAA) 2) Augments, does not replace, medical decision-making 3) Provides objective data regarding neurocognitive functioning 4) Required by FAA in cases where history of ADHD or ADD and/or psychostimulant medication use are an issue

5 Testing means different things in Medicine and Neuropsychology Physicians order a test or tests to assess a specific function or blood level (e.g., thyroid series, glucose tolerance, cholesterol, creatinine) A neuropsychological examination includes tests but does not rely on any single test. There is no one neuropsychological test that is a marker for any neurological/psychological/psychiatric condition. Neuropsychological evaluation relies on: Pattern of test performance How a test score fits with other similar test results, history, brain imaging, other medical information and collaterals.

6 ADHD: Three Types per DSM-IV* 1. Inattentive 2. Hyperactive-Impulsive 3. Combined ** FAA does not use DSM-IV; Uses CFR s/far s **

7 ADHD: Common Themes 1. Individuals with a DSM-IV diagnosis of ADHD who are enrolled in an aviation school and want to fly 2. Bright individuals who took meds for ADHD as a child for lackluster (or not) academic performance 3. General aviation pilots who were Rx d psychostimulants for focus issues, daytime fatigue or sleepiness, etc.

8 ADHD: Diagnostic Pitfalls 1. Many with DSM-IV diagnoses had evals that were based on cursory workup that did not include interview of parents or teachers. 2. Many given DSM-IV diagnoses to justify Tx with a psychostimulant. 3. Many with true history of ADHD are fit to fly. 4. Psychostimulants are currently not allowed by FAA (despite demonstrated effectiveness in Air Force sorties).

9 CFR s / FAR s* , 207 & 307-Mental: (c) No other personality disorder, neurosis, or other mental condition that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved finds- CFR: Code of Federal Regulations FAR: Federal Aviation Regulations

10 CFR s / FAR s* , 207 & 307-Mental: (c)(1) Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or (c)(2) May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

11 CFR s / FAR s* , 209 & 309-Neurologic: (b) No other seizure disorder, disturbance of consciousness, or neurologic condition that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved finds-

12 CFR s / FAR s* , 209 & 309-Neurologic: (b)(1) Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or (b)(2) May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

13 SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD (January 2013) Who may perform: Clinical psychologist who is boardcertified (ABPP or ABPN) or: Board eligible in clinical neuropsychology (has training and background to qualify for application to either Board)

14 SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD (January 2013): Core Test Battery: WAIS-IV Overall intellectual abilities Trail Making A Sustained attention Trail Making B Alternating attention Category Test OR Wisconsin Card Sorting Test AND Stroop Test Executive functioning PASAT Speed of mental processing & mental endurance

15 SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD (January 2013): Core Test Battery (continued): TOVA-8 or CPT-II or IVA Continuous performance tests that require visual and/or auditory vigilance WMS-IV subtests, Rey AVLT, CVLT-II Verbal memory WMS-IV subtests, BVMT-R or Rey Complex Figure Visual memory BNT, COWAT and Semantic Fluency - Language tests

16 SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD (January 2013): Core Test Battery (continued): Finger Tapping Test Manual motor speed Grooved Pegboard or Purdue Pegboard Visual motor ( eye-hand coordination ) MMPI-2 (and others if needed) Psychological/emotional functioning

17 SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD (January 2013): Core Test Battery (continued): Additional Testing if problems are noted on tests of reading or math Additional Testing if any other areas of concern are identified by the neuropsychologist

18 SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR ADHD OR ADD (January 2013): Q: Is additional testing in the future required? A: If eligible for unrestricted medical certification, no additional testing would be required. However, pilots found eligible for Special Issuance will be required to undergo periodic reevaluations. The letter authorizing special issuance will outline required testing (and scope).

19 How to Find a Neuropsychologist Directory of members Listed by state Providers: Listed alphabetically OR by State * List includes both neuropsychologists and psychologists who conduct CS-AE

20 Thank You!

21 SUPPLEMENTAL SLIDES: DSM-IV Criteria for ADHD: Inattentive Criterion A (1): six (or more) of the following symptoms of inattention: a) Often fails to give close attention to details b) Difficulty sustaining attention in tasks or play c) Often does not seem to listen d) Often does not follow thru/fails to finish e) Often has difficulty organizing tasks/activity f) Often avoids/dislikes tasks involving sustained mental exertion g) Often loses things necessary for tasks etc h) Often easily distracted by extraneous stimuli i) Often forgetful in daily activities

22 SUPPLEMENTAL SLIDES: DSM-IV Criteria for ADHD: Impulsive-Hyperactive Criterion A (1): six (or more) of the following symptoms of hyperactivityimpulsivity: a) Often fidgets with hand or feet or squirms b) Often leaves seat in classroom or other situation c) Often runs about or climbs excessively or (in adults) subjective feelings of restlessness d) Often has difficulty playing in activities quietly e) Often on the go /acts as if driven by a motor f) Often talks excessively g) Often blurts out answers/responds before Q s completed h) Often has difficulty awaiting turn i) Often interrupts or intrudes on others

23 SUPPLEMENTAL SLIDES: DSM-IV Criteria for ADHD: Inattentive Criterion B: Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. Criterion C: Some impairment from the symptoms is present in two or more settings (e.g., school, work, home). Criterion D: There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. Criterion E: The symptoms do not occur exclusively during the course of another mental disorder.

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