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. …