Empirically Informed Attention-Deficit/hyperactivity Disorder Evaluation with College Students
Reilley, Sean P., Journal of College Counseling
Attention-deficit/hyperactivity disorder (ADHD) is both an underdiagnosed and a misdiagnosed problem on college campuses, leading to pronounced academic and psychosocial difficulties. Counselors encounter diagnostic criteria that are child oriented, long lists of differential diagnoses, high rates of coexisting disorders, and no definitive tests for ADHD. This article reviews research findings concerning adults with ADHD, outlines empirical solutions for meeting diagnostic challenges, and provides new effect size data for selecting screening instruments.
Attention problems are frequent complaints of college students presenting for counseling. Isolating the magnitude, range, and basis of student inattention is critical for effective therapeutic intervention but is frequently complicated. College maladjustment may result in transient attention problems that are specific to the classroom. Longer lasting and more pervasive attention difficulties may emerge as secondary features of psychiatric or medical conditions, or these difficulties may reflect a chronic attention syndrome, attentiondeficit/hyperactivity disorder (ADHD). Undiagnosed ADHD is a significant problem on college campuses and, paradoxically, is one that is compounded by erroneous self-diagnoses by students seeking treatment (Roy-Byrne et al., 1997; Searight, Burke, & Rottneck, 2000). In the pages to follow, a primer on adult ADHD evaluation is presented as a resource for college counselors.
Counselors, like other helping professionals, frequently lack advanced training in adult ADHD. A variety of factors, including paperwork and case management demands, frequently preclude extensive reading in this area. The primary aim of this primer is to enhance counselors' awareness of the types of difficulties encountered when evaluating college students for possible ADHD. A secondary aim is to offer empirically based suggestions drawn from ADHD studies of community and college adults to enhance the evaluation process, including selection of ADHD rating scales and behavioral measures.
An Overview of Adult ADHD and the DSM-IV-TR Criteria
ADHD is a neuropsychological disorder with sets of hyperactive-impulsive and/ or inattentive symptoms. This disorder is one of the most common mental health illnesses among children, with a 3% to 5% prevalence rate (American Psychiatric Association [APA], 2000). Of children with ADHD, 60% to 70% continue to have significant attention problems as adults, and 30% to 50% continue to meet criteria in the Diagnostic and Statistical Manual for Mental Disorders, text revision (DSM-IV-TR; APA, 2000) for ADHD (Searight et al., 2000; Wender, 1995).
Many practitioners believe the vast majority of adults with ADHD are undiagnosed (Adler & Cohen, 2003). At a college level, epidemiological data are lacking. Retrospective, clinic-based chart reviews and surveys of ADHD symptoms yield prevalence estimates ranging from 2% to 11% of the college population (DuPaul et al., 2001; Heiligenstein, Conyers, Berns, Miller, & Smith, 1998; Weyandt, Linterman, & Rice, 1995). The exact prevalence number is difficult to calculate given methodological differences in identification of ADHD in these studies. In addition, Roy-Byrne et al. (1997) indicated that approximately one half to two thirds of adults with self-diagnosed ADHD failed to meet DSM-IV-TR criteria. Therefore, counselors contend with significant rates of erroneous self-diagnoses as well as high rates of undiagnosed ADHD in a college population. As a consequence, counselors' mastery of the DSM-IV-TR criteria is essential for successfully navigating an ADHD evaluation (Attention Deficit Disorder Association, 2000; Dulcan & Workgroup on Quality Issues, 1997).
Within the DSM-IV-TR typology, an ADHD diagnosis is tenable if developmentally inappropriate attention problems meet the following criteria: (a) had onset before age 7, (b) have persisted in a maladaptive form in at least two settings for 6 months, and (c) are not better accounted for by another disorder. In making an ADHD diagnosis, counselors must specify a subtype according to whether a minimum of six inattentive symptoms (ADHD, Primarily Inattentive Type), six hyperactive-impulsive behaviors (ADHD, Primarily Hyperactive/Impulsive Type), or criteria for both clusters (ADHD, Combined Type) are met. In cases in which a student's attention problems emerged before age 7, but her or his current symptoms fail to meet the quantity, duration, or multiple-setting criteria, a diagnosis of ADHD, In Partial Remission, is used. If it is questionable whether the age of onset criterion is met, and her or his current symptoms fail to meet full ADHD criteria, a diagnosis of ADHD, Not Otherwise Specified, may be used. At first glance, the application of the DSM-IV-TR criteria for ADHD may seem straightforward. However, as outlined in the next section, counselors also need to be aware of the frequent difficulties faced when attempting to apply the DSM-IV-TR criteria.
Challenges in Applying the DSM-IV-TR Criteria for ADHD to Adults
Counselors should be aware that the DSM-IV-TR criteria for ADHD are entirely child focused. No adults were included in the clinical field trials used to establish these criteria. As a result, the DSM-IV-TR lacks sufficient examples of the changes in ADHD symptoms by adulthood (DuPaul et al., 2001). Also, there are significant discrepancies among professionals regarding adult criteria for functional impairments, especially in social and occupational domains. The following paragraphs provide a synopsis of the developmental and possible gender differences in ADHD symptom presentation to assist counselors with placing the child-oriented DSM-IV-TR criteria into an adult context.
Knowledge of the changes in ADHD symptoms by adulthood is a crucial first step in successfully applying the DSM-IV-TR criteria. Historically, ADHD has been viewed as a disorder primarily involving hyperactive-impulsive symptoms, which have been associated with male-oriented academic and behavioral difficulties (Nadeau & Quinn, 2001). Boys are more likely to be referred for ADHD testing and 4 to 9 times more likely to receive an ADHD diagnosis, especially the Hyperactive-Impulsive subtype (APA, 2000). Overt hyperactive motor symptoms common in boys (e.g., running or climbing excessively) are substantially reduced by adulthood (Pary, Lewis, Matuschka, & Lippmann, 2002; Stern, Garg, & Stern, 2002). When present in adults, hyperactive symptoms are frequently subtler in their behavioral manifestation, such as internal feelings of restlessness or tension (Weyandt et al., 1995). Some impulsive behaviors, such as blurting out socially inappropriate, rude, or insulting comments, are similar to childhood behaviors. Others, such as traffic violations, frequent changes in employment, or short-lived romantic relationships, take more adult-oriented forms (Murphy & Gordon, 1998).
Inattentive symptoms, in contrast, remain fairly stable into adulthood and are reported in more than 90% of adults with ADHD (Searight et al., 2000; Stern et al., 2002). Inattentive girls are less likely to be referred for an ADHD evaluation during primary school because their behavior is often less disruptive to parents and teachers. As a consequence, women with ADHD are frequently diagnosed in their later adolescent to college-age years. Inattention in both women and men may be expressed as significant disorganization, tardiness at work, or difficulties with household affairs, such as paying bills on time (Adler, Kessler, & Spencer, 2003; Stern et al., 2002).
Empirically Supported Solutions for Applying the DSM-IV-TR Criteria for ADHD to Adults
Although the empirical research literature details difficulties in applying the DSM-IV-TR criteria with adults, it also provides potential solutions for these problems. Five core DSM-IV-TR issues are subsequently discussed in relation to college ADHD evaluations. These include (a) documenting the frequency of ADHD symptoms, (b) assessing direct impairment in functioning, (c) establishing a childhood onset of symptoms, (d) evaluating for similar psychiatric and medical disorders or coexisting conditions, and (e) documenting the severity of symptoms relative to an ADHD population. Potential solutions for counselors are provided for each of these issues with the goal of enhancing the accuracy of ADHD evaluations.
Documenting the Frequency of ADHD Symptoms
First, the DSM-IV-TR criteria for ADHD require counselors to evaluate the frequency and persistence of student's attention problems for the past 6 months. Decisions regarding inappropriate symptom occurrences (i.e., "often" in the DSM-IV-TR) are difficult to make given their subjectivity (Burns, Gomez, Walsh, & de Moura, 2003). ADHD rating scales have dealt with this problem through two different scaling techniques. One method entails students rating the frequency of each DSM-IV-TR symptom using a rating scale that directly incorporates the diagnostic nomenclature of "often," such as never, sometimes, often, or very often. Alternatively, a frequency count system can be used for specific time frames (e.g., never, 1 to 2 times, or 3 to 4 times in the past day or week). Counselors can modify both approaches to include current frequency estimates as well as those over longer time frames, such as the DSM-IV-TR criterion of 6 months.
Demonstrating Direct Impairments Due to ADHD Symptoms
Second, the DSM-IV-TR criteria for ADHD require counselors to document direct impairments in the student's functioning in two or more settings as a result of current ADHD symptoms (Burns et al., 2003). Self-report scales for this purpose can be found in Barkley and Murphy (1998). In addition, counselors can use grade point averages and current performance in classes as indicators of academic impairment (Barkley & Murphy, 1998). These should be confirmed with the college or university registrar following a signed release of information from the student. Murphy and Gordon (1998) recommended full academic and test histories be obtained, if possible, for corroborating and understanding the student's academic history. Dysfunction is also required in at least one other nonacademic setting such as marked social, home, or occupational difficulties. Nadeau (1997) has developed an ADD Workplace Questionnaire, and Barkley and Murphy (1998) provided both a Social History Form and a Work Performance Rating Scale for obtaining questionnaire-type ratings from students, significant others, and/or employers for these areas.
Documenting a Childhood Onset of ADHD Symptoms
Third, the DSM-IV-TR criteria for ADHD require counselors to provide evidence of a childhood onset of ADHD symptoms. Providing this type of evidence for college adults without an existing ADHD diagnosis can be complicated. One third of college adults seeking evaluation for ADHD were not formally diagnosed as children, and as many as 40% do not actively recall childhood hyperactivity prior to age 7 (Heiligenstein et al., 1998). To meet the age of onset criterion, retrospective reports of childhood ADHD symptoms are obtained in an interview. However, aspects of these reports are often incomplete or inaccurate, especially in an unstructured interview (Barkley & Murphy, 1998; Zucker, Morris, Ingram, Morris, & Bakeman, 2002). Consequently, counselors are encouraged to use semistructured interviews and structured questionnaires, such as those discussed hereafter, in screening for a history of ADHD symptoms.
Semistructured interview guides, including the Conners' Adult ADHD Diagnostic Interview for DSM-IV (Epstein, Johnson, & Conners, 2001) and the Brown ADD Diagnostic Form (Brown, 1996a), may enhance retrospective data collection. In addition, structured questionnaires, such as the Wender Utah Rating Scale (Wender, 1995) and the Childhood Symptoms Scale (Barkley & Murphy, 1998), are helpful for inquiries about childhood behaviors as well as for obtaining scores to compare with ADHD samples. Corroborating selfreport information with collateral sources, such as parents and school report cards, should be strongly considered (Murphy & Gordon, 1998).
Evaluating Psychiatric and Medical Conditions That Resemble or Coexist With Adult ADHD
Fourth, the DSM-IV-TR criteria for ADHD require counselors to demonstrate that the student's current attention problems are not better accounted for by another disorder. This means that counselors need to ascertain whether the student's current symptoms are primary to ADHD, secondary to other psychiatric or medical conditions, or due to ADHD and a second coexisting condition. ADHD in adults is frequently mistaken for psychiatric conditions that have secondary attention symptoms similar to ADHD (Adler et al., 2003; Searight et al., 2000). Perhaps more common is the presence of ADHD and a second psychiatric or mental disorder (Wender, 1995). Approximately 30% to 60% of college students who complete an ADHD evaluation qualify for a diagnosis of ADHD and a psychiatric disorder (Heiligenstein et al., 1998). Adler and Cohen (2003) indicated the comorbidity rates for adult ADHD are highest for mood (19% to 37%), anxiety (25% to 50%), and alcohol (32% to 53%) or substance abuse disorders involving illicit drugs, including marijuana and cocaine (8% to 32%). Learning disorders (20%), especially those involving auditory processing components, are also common (Barkley & Murphy, 1998). The practical implications of these data are that routine screening for a competing or coexisting psychiatric or mental disorder is needed. Use of a broad outpatient screening instrument, especially an instrument using DSM-IV-TR criteria such as the Psychiatric Diagnostic Screening Questionnaire (Zimmerman, 2002), will enhance the screening process for ADHD.
In addition to psychiatric comorbidities, counselors, like other helping professionals, frequently overlook possible medical contributors. Hypothyroidism, hypertension, hepatic disease, sleep disorders, migraine headaches, post-concussive syndrome, epilepsy, and seizure disorders can mirror ADHD symptoms (Searight et al., 2000; Stern et al., 2002). A variety of medical checklists such as the Health Self-Report Form are available to screen for medical contributors (Barkley & Murphy, 1998). In addition, a routine medical referral should be considered. Stern et al. recommended a thorough medical evaluation, including a thyroid panel, serum lead level, and urine drug screen.
Use of Evaluation Measures to Document the Severity of Attention Problems
Fifth, the DSM-IV-TR criteria for ADHD require counselors to demonstrate that the student's current ADHD symptoms are present to a degree that is developmentally inconsistent for adults. This means that counselors need to evaluate the severity of a student's reported attention problems relative to those from adults with and without ADHD. In the remainder of this article, several broadband and narrowband rating scales are reviewed to assist counselors with obtaining initial data to address this issue. Finally, a review and analysis of behavioral screening measures are provided to assist counselors with corroborating self-ratings of attention problems.
Broad-and narrowband rating scales. Broad- and narrowband rating scales are the most frequently used screening instruments, in addition to a clinical interview, for making an initial ADHD diagnosis (Barkley & Murphy, 1998; Mandal, Olmi, & Wilczynski, 1999). The rationale underlying their usage is that the student, family member, or significant other is aware of and will provide an accurate account of the scope and severity of the student's attention problems. If the attention problems are valid, a credible screening instrument will assist the counselor with assessing the degree to which the frequency, scope, and severity of the student's attention problems deviate from age-appropriate norms.
Commonly used broadband rating scales include the Conners' Adult ADHD Rating Scales (Conners, Erhardt, & Sparrow, 1999), the Brown Adult Attention Deficit Disorder Scales (Brown, 1996b), and the Wender Utah Rating Scale (Wender, 1995). These scales can be completed by a significant other or have a separate collateral form, and they tap into symptoms beyond those required for assessment by the DSM-IV-TR. Narrowband rating scales, such as the Current Symptoms Scale (Barkley & Murphy, 1998) and the Adult Self-Report Scale-v1.1 (Adler et al., 2003), facilitate an assessment of specific DSMIV-TR symptoms within an adult context.
Although attention-rating scales are popular and freely available in some cases (Adler et al., 2003; Wender, 1995), they are not without limitations. A major issue for most rating scales is lack of psychometric validation, especially with individuals with psychiatric disorders having secondary attention problems (e.g., major depression). As such, the fallibility of scores provided by attention-rating scales should be considered when psychiatric symptoms are suspected. At a minimum, one narrowband scale that targets each of the DSM-IV-TR symptoms and at least one broadband rating scale that includes additional variables, such as mood and affect, are recommended for ADHD screening. In addition, use of behavioral screening measures such as those discussed in the following section is recommended to enhance the credibility of self-report data. These are important to routinely include in an evaluation because few attention-rating scales have items that successfully detect response sets or pervasive response bias.
Behavioral screening measures. To corroborate self-reported attention problems, practitioners are increasingly relying on behavioral screening measures from the neuropsychological literature. Preliminary reviews of adult ADHD studies by Faraone et al. (2000) and Woods, Lovejoy, and Ball (2002) indicate that individuals with ADHD exhibit a slower rate of psychomotor speed on the Digit Symbol Substitution Test (Wechsler, 1997). Sustained attention difficulties have been demonstrated using a variety of computerized continuous performance tests (Barkley & Murphy, 1998). Difficulties with short-term memory have been documented using the Digit Span Test (Wechsler, 1997) and the California Verbal Learning Test (Delis, Kramer, Kaplan, & Ober, 1987). Executive functioning difficulties have been observed on a variety of brief behavioral tasks, including the Trail Making Test (Reitan, 1958), the Stroop Color-Word Task (Stroop, 1935), and the Controlled Word Association Test (Benton, Hamsher, & Silvan, 1994).
An analysis of the effect sizes associated with these measures for a subset of the published neuropsychological data is provided in the reminder of this article. Effect sizes are increasingly being used in research because they provide a common metric for comparing the size of obtained differences between ADHD and control groups. Counselors may consider using available effect size data to determine the relative importance of various ADHD screening instruments for inclusion into a customized screening battery. Finally, counselors should be aware that many colleges and universities require comprehensive psychoeducational or neuropsychological testing in order to provide postsecondary accommodations.
Comprehensive searches of PsycINFO and MEDLINE using keywords AD/ HD, ADHD, ADD and their unabbreviated terms were conducted for publications dated 1979 to 2002. Criteria for inclusion included the following: a well-defined ADHD sample and a comparative control group, reported means and standard deviations of instruments administered, and at least five studies reporting a significant difference between ADHD and control groups for a screening measure. A total of 19 studies met these criteria. It should be noted that these studies could have been further limited to use of a particular commercial version of a screening measure. This process would have resulted in a very small pool of instruments and, thus, was not attempted. Finally, 3 studies involving computerized, continuous performance measures were omitted due to significant variability in reporting of performance variables.
Professionals need guidelines for interpreting the direction and magnitude of reported effect sizes in research articles in order to better inform their counseling practices. Effect sizes reported herein reflect a "standardized" difference in which the mean for the ADHD group is subtracted from that of the control group, and this outcome is divided by the pooled standard deviation. A value of 0 means that the screening measure had equivalent effects for both the ADHD and control group. Effect sizes greater than 0 indicate the screening measure was more effective in identifying attention problems in the ADHD group versus the control group. Conversely, effect sizes less than 0 indicate that attention problems in the control group were more reliably identified than in the ADHD group. A widely accepted approach for assessing the magnitude of effect sizes in the behavioral sciences is to use guidelines specified by Cohen (1992) wherein 0.2 is considered small, 0.5 is medium, and 0.8 is regarded as a large effect size.
As evident in Tables 1 and 2, the effect sizes for each screening measure range considerably from a low of -0.41 to a high of 1.36. There was one instance in which a given instrument failed to successfully predict attention difficulties in the anticipated direction (i.e., ADHD < Control). When mean values are computed across studies for each instrument, all yield at least medium effects using Cohen's (1992) guidelines. Specifically, the mean effect size for the Digit Symbol Test (M = 0.82, SD = 0.51) was slightly more robust than either the Digit Span Test (M = 0.58, SD = 0.36) or the California Verbal Learning Test (M = 0.65, SD = 0.18). Inspection of variability within these measures, however, reveals a more consistent effect size for the California Verbal Learning Test. For executive functioning measures, effect sizes were all in the medium range and slightly higher for the Stroop Color-Word Task (M = 0.66, SD = 0.39) and the Controlled Oral Word Association Test (M = 0.65, SD = 0.44) relative to the Trail Making Test (M = 0.51, SD = 0.44).
ADHD evaluation is a complicated process for counselors because this disorder is both underdiagnosed and misdiagnosed on college campuses. Until the advent of the DSM-V (in ongoing development), which may or may not include specific adult criteria for ADHD, college counselors, like other professionals, will have to successfully navigate a myriad of diagnostic issues. These include child-oriented diagnostic criteria (DSM-IV-TR), long lists of differential diagnoses, high rates of comorbidities, and no definitive tests for diagnosing ADHD. In conducting initial evaluations with college students for ADHD, counselors should seek medical consultation to rule out possible medical and psychiatric contributors. They should cast a wide behavioral net that includes use of broadband and narrowband attention-rating scales, as well as emotional and medical questionnaires. Counselors should conduct extensive interviews of students' academic and psychosocial background and obtain collateral information and/or ratings from significant others, parents, or employers. Furthermore, counselors should attempt to document self-ratings and collaterals' ratings of inattention, impulsivity, and hyperactivity, using behavioral screening measures after the appropriate training. On the basis of an initial analysis of effect sizes for commonly used behavioral measures, there are several choices. At present, a screening battery of several instruments is suggested in lieu of reliance on a particular measure, because comparable effect size data for clinical groups with secondary attention problems are not yet available.
References marked with an asterisk indicate studies included in the meta-analysis.
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Sean P. Reilley, Department of Psychology, Morehead State University. This article was supported, in part, by a grant from the Kentucky Statewide Experimental Program to Stimulate Competitive Research Committee. Correspondence concerning this article should be addressed to Sean P. Reilley, Morehead State University, Department of Psychology, 601 Ginger Hall, Morehead, KY 40351 (e-mail: firstname.lastname@example.org).
TABLE 1 Cohen's Effect Sizes for Working Memory and Psychomotor Speed Measures Psychological Test and Study Cohen's d Digit Span (WAIS) Biederman et al., 1993 0.39 Jenkins et al., 1998 0.52 Kovner et al., 1998 1.24 Murphy, Barkley, & Bush, 2001 0.39 Riordan et al., 1999 0.86 Seidman, Biederman, Weber, Hatch, & Faraone, 1998 0.15 Walker, Shores, Troller, Lee, & Sachdev, 2000 0.54 Digit Symbol (WAIS) Biederman et al., 1993 0.21 Klee, Garfinkle, & Beauchesne, 1986 0.70 Murphy et al., 2001 0.66 Riordan et al., 1999 1.32 Seidman et al., 1998 0.23 Silverstein, Como, Palumbo, West, & Osborn, 1995 1.31 Walker et al., 2000 1.36 California Verbal Learning Holdnack, Moberg, Arnold, Gur, & Gur, 1995 0.88 Jenkins et al., 1998 0.73 Lovejoy et al., 1999 0.71 Riordan et al., 1999 0.42 Seidman et al., 1998 0.52 Note. WAIS = Wechsler Adult Intelligence Scale-III (Wechsler, 1997). TABLE 2 Cohen's Effect Sizes Associated With Executive Functioning Measures Psychological Test and Study Cohen's d Controlled Oral Word Association Dinn, Robbins, & Harris, 2001 1.11 Jenkins et al., 1998 1.11 Johnson et al., 2001 0.15 Lovejoy et al., 1999 0.84 Murphy et al., 2001 0.39 Rapport, VanVoorhis, Tzelepis, & Friedman, 2001 0.09 Walker et al., 2000 0.87 Stroop Color-Word Task Corbett & Stanczak, 1999 0.18 Johnson et al., 2001 0.31 Lovejoy et al., 1999 1.31 Murphy et al., 2001 0.72 Rapport et al., 2001 0.85 Riordan et al., 1999 0.87 Walker et al., 2000 0.39 Trail Making Test (Part B) Gensler et al., 1993 -0.41 Johnson et al., 2001 0.44 Lovejoy et al., 1999 0.63 Rapport et al., 2001 0.58 Riordan et al., 1999 0.93 Silverstein et al., 1995 0.53 Walker et al.. 2000 0.87…
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Publication information: Article title: Empirically Informed Attention-Deficit/hyperactivity Disorder Evaluation with College Students. Contributors: Reilley, Sean P. - Author. Journal title: Journal of College Counseling. Volume: 8. Issue: 2 Publication date: Fall 2005. Page number: 153+. © 2007 American Counseling Association. COPYRIGHT 2005 Gale Group.
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