ASRS in College Students

Lenard A. Adler, on February 25, 2016

Gray et al. (2014), The Adult ADHD Self-Report Scale (ASRS): utility in college students with attention- deficit/hyperactivity disorder. PeerJ 2:e324; DOI 10.7717/peerj.324

There has been ongoing interest in the identification of ADHD in college students; many transitional adults will present with ADHD related symptoms and problems with the transition to post-secondary education and the related demands on attention and executive function. This investigation examined the utility of the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) in identifying college students at risk for ADHD. 135 college students (mean age 24 years) who were enrolled in disability service programs at their respective institutions were surveyed; all students had received a prior diagnosis of ADHD and were asked to complete all scales as if they were not on medication (59% of the students were on medication at the time of the evaluation). Students first completed the six item ASRS screener by telephone and then, several weeks later, the completed a paper version of the 18 item ASRS symptom checklist. A collateral version “other-report” of the 18 item ASRS symptom checklist, and a self-report measure of executive function (BDEFS), were also collected.

There was a modest correlation of the other-report and self-report of ASRS symptoms (r(59) = .46, p < .001) and other-report scores were significantly lower than self-report scores (F(1,57) = 8.92, p = .004). There was a moderately high correlation of student self-report of symptoms on the ASRS Screener (telephonic) and the identical six items when completed on the 18 item ASRS Symptom Checklist several weeks later (r (131) = .66, p < .001), indicating some stability of self-report of ADHD symptoms. There were moderate correlations between the total score on the ASRS screener and total executive function (BDEFS summary) scores (r (129) = .40, p < .001); correlations between total scores on 18 item ASRS symptom checklist and summary score on BDEFs were higher than seen with the screener (r (131) = .62, p < .001), indicating that a total symptom inventory of ADHD symptoms better correlates with executive function than the screening subset (which is not surprising). This study has several limitations including: 1) the subjects being asked to complete scales in the hypothetical sense of when they were not on medication (and with 3/5 students being treated for ADHD), creating the possibility of reporter bias, and 2) the study utilized a non-validated version of the other report version of the ASRS symptom checklist which was not sanctioned by WHO.

The study does highlight the utility of the ASRS symptom checklist as a self-report measure in college students; this instrument carries the advantages of being easy to use and being in the public domain. It also indicates that gathering collateral information can be helpful, but as seen in other reports, collateral reports of symptoms are often lower than self and clinician symptom scores as the informant only sees the patient for a portion of their day (home vs. work vs. social).

ADHD in Young Adults – A Longitudinal Study

Lenard A. Adler, on December 17, 2015

P, Kuntsi J. Childhood predictors of adolescent and young adult outcome in ADHD.   J Psychiatr Res. 2015 Jan 29. pii: S0022-3956(15)00022-9. doi: 10.1016/j.jpsychires.2015.01.011.


This investigation examined predictors, including a variety of cognitive measures, demographics and ADHD symptoms and impairments in 116 adolescents followed for an average of 6.6 years into early adulthood.  This study is important as it addresses the critical issue of identifying risk factors for persistence of ADHD into adulthood, which would allow in the future, targeted interventions to potentially improve remission rates.  Remission was defined if individuals no longer met DSM-IV symptom (via DIVA) or impairment (via BFIS) criteria from parental and subject interviews. Symptoms and impairments were established from periods off medication.  62% of the sample was treated with medication.  21% of the sample was found to have remitted.  A number of risk factors were identified as increasing the risk of persistence of ADHD, including higher parental reports of ADHD symptoms, lower IQ and lower socio-economic status (SES).  Medication status did not significantly influence whether a subject was classified as having remitted or persistent ADHD.  These findings of significant associations of low SES and IQ and high ADHD symptoms with persistence of ADHD into young adulthood reinforce similar findings from prior studies and should be included as some of the foci of other longitudinal studies in ADHD.

University Healthcare Provider Survey on ADHD

Lenard A. Adler, on October 29, 2015

This study provides the 2015 results of a survey of college and university health care providers (physicians, psychologists and nurses) about their knowledge about and treatment preferences concerning ADHD. The survey consisted of 37 forced choice questions, which took less than 15 minutes to complete; the overall response rate was somewhat low (8%), creating the possibility of sampling error, but never the less this is a sufficiently large sample from which interesting conclusions can be drawn. Even though about half of providers felt quite comfortable recognizing ADHD, over 90% still referred students to other providers to make an ADHD diagnosis. Over 90% of respondents felt that ADHD medication therapy was useful for treating ADHD and over 50% treated the students themselves or in consultation with a specialist. Nurse practitioners were more likely to refer students for treatment as compared to physicians. This survey highlights potential areas of improvement in the post-secondary school handling of ADHD in their students, including the potential for increased training re: diagnosis and treatment so that physicians and nurse practitioners in these settings will be more likely to diagnose and treat students in their institutions. This could lead to potential removal of barriers to care and treatment of university students with ADHD.

 

Thomas M1, Rostain A2, Corso R3, Babcock T4, Madhoo M . ADHD in the College Setting: Current Perceptions and Future Vision. Journal of Attention Disorders. 19(8):643-54, 2015. doi: 10.1177/1087054714527789. Epub 2014 Apr 17.

Symptom Manifestations and Impairments in College Students with ADHD

Anthony L. Rostain, MD MA on May 26, 2015

Gray SA, Fettes P, Woltering S, Mawjee K, Tannock R (2015). “Symptom manifestation and impairments in college students with ADHD.” Journal of Learning Disabilities.  2015 Mar 16. pii: 0022219415576523.  

This article reviews what is currently known about the cognitive and academic impairments faced by post-secondary students with ADHD and then reports on a prospective study of symptoms and functional impairments in 135 ADHD university students.   The authors point out that there is limited evidence available on the functioning of post-secondary students with ADHD, and that published studies reveal conflicting evidence.  On the one hand, several studies reporting the results of objective tests of executive functioning (EF) in this population show little differences to peers without ADHD, whereas their self-reports of EF suggest they experience impairments in day-to-day cognitive functioning.  Similarly, there are inconsistent findings regarding the academic performance of this population with some studies showing lower GPAs and higher rates of academic probation and other studies showing no differences between ADHD students and their non-ADHD peers.  However, several papers document that by self-report, post-secondary students with ADHD struggle to keep up with academic demands.

In order to learn about the nature of symptoms and impairments in college students with ADHD, the authors conducted a brief, semi-structured telephone interview with students using the 6-item version of the Adult ADHD Self-Report Scale (ASRS) during which subjects were asked to provide real-life examples of behaviors for each of the symptoms.  Qualitative interview data was analyzed along with symptoms of psychopathology, psychological distress, executive functioning, cognitive difficulties, “grit,” cognitive testing measures (IQ and neuropsychological battery), academic screening measures and self-reported GPAs.   

All subjects were attending university, were between the ages of 18-35 years (mean age 23.7), had a previous diagnosis of ADHD, were registered with student disability services at their school, and met criterion scores on the ASRS administered by phone.  Over 90% of the sample had completed at least 1 year of college and 58% was female.  About 18% had a comorbid learning disability and 51% were taking an ADHD medication (97% taking stimulants).  

Results of the study revealed that these students’ IQ scores were within the normal range and their performance on neuropsychological tests was also in the normal range.  In marked contrast, this sample reported marked impairments in EF in daily life, especially with respect to time management, organization, problem solving, self-restraint, self-motivation, and self-regulation of emotions.  Over 2/3 of the sample had scores in the 95th percentile on the Barkley Deficits of Executive Functioning Scale (BDEFS).   The subjects also reported higher rates of cognitive difficulties in daily life, high levels of distress, lower levels of “grit,” and relatively high rates of anxiety, depression, obsessive compulsive symptoms, phobias, paranoia and psychoticism compared to normal controls.  The mean GPA of the sample was 2.91 indicating acceptable to good academic progress.

The most salient aspect of the study was the qualitative descriptions provided by these ADHD students of their daily struggles with managing the demands of college life.  The major problems they cited included hyperactivity (especially fidgeting), procrastination, and difficulty wrapping up the final details of projects they’d started.  They reported trouble organizing time and materials, and often forgot to use coping strategies they had developed to overcome their difficulties.  Time management problems and psychological distress were among the most prominent themes to emerge from the content analysis.

This study clearly demonstrates the extent to which college students with ADHD encounter considerable distress in meeting academic demands largely as a result of executive functioning difficulties that are better captured by self-report than by neuropsychological testing.  It adds evidence to the argument that neuropsychological testing alone should not be used to determine eligibility for accommodations.   It also documents the reported high levels of stress, distress and psychopathology in this population and points to the need for interventions that bolster EF, particularly with respect to time management, organization and handling negative emotions (distress).   

College Students and Risky Behavior

Anthony L. Rostain, MD MA on April 9, 2015

Graziano PA, Reid A, Slavec J, Paneto A, McNamara JP, Geffken GR. “ADHD Symptomatology and Risky Health, Driving, and Financial Behaviors in College: The Mediating Role of Sensation Seeking and Effortful Control” Journal of Attention Disorders (2014) Epub ahead of print April. DOI: 10.1177/1087054714527792.


This study explores the relative contributions of “top-down” (i.e. effortful control) and “bottom up” (i.e. sensation seeking) mental processes to maladaptive risky behaviors in college students with ADHD. The authors review these constructs by pointing out that effortful aspects of self-regulation involve intact prefrontal circuits underlying executive functions whereas reactive behaviors not requiring conscious mental resources are influenced by emotional stimuli and are mediated by subcortical brain structures. Given that ADHD involves difficulties in both these domains of psychological functioning, it makes sense to explore which contribute to the onset of maladaptive risk-taking in college students with ADHD.


The authors studied 555 college students attending a southeastern university using an online survey for which they received class credit. Participants filled out standardized rating scales to assess outcomes. Of the total sample, 5.7% reported a history of an ADHD diagnosis and 10.8% reported elevated ADHD symptoms (> 1.5 SD above the mean) on an ADHD rating scale. There were two distinct patterns of risk behaviors: risky driving/financial behaviors and risky health behaviors. ADHD symptoms were highly correlated with these two factors as well as with sensation seeking and effortful control. More ADHD symptoms were associated with risky behaviors ONLY when effortful control was low. Sensation seeking was more highly associated with risky health behaviors but not risky driving/financial behaviors.


The authors note that the study’s reliance on self-report scales and measures limits its validity. ADHD individuals are known to underreport severity of symptoms. Moreover, it was not possible to detect the presence of antisocial behaviors (e.g. Conduct Disorder) that might have a greater impact on risky behaviors than ADHD symptoms. Finally, the fact that the study was conducted on a single campus may limit the generalizability of its findings to the entire population of US college students.


Despite these limitations, this paper reports interesting results suggesting that ADHD symptoms may not be as important as effortful control deficits and as high stimulus seeking in mediating the onset of risk behaviors in this population. These could be important targets for psychological therapies. It also points to the relevance of these two aspects of psychological functioning for preventive health efforts to reduce health, driving and financial risk behaviors, and for clinical approaches to dealing with patients presenting with maladaptive coping mechanisms.

Dialetical Behavior Therapy, College Students, and ADHD

Anthony L. Rostain, MD MA on March 18, 2015

J Atten Disord. 2015 Mar;19(3):260-7. DOI: 10.1177/1087054714535951
“Pilot Randomized Controlled Trial of Dialectical Behavior Therapy Group Skills Training for ADHD Among College Students”
Fleming, A.P., McMahon, R.J., Moran, L.R., Peterson, A.P., Dreessen, A.

This article reports on the results of the first randomized controlled clinical trial of treatment program for college students with ADHD. Thirty-three college students with ADHD between the ages of 18 and 24 years were randomized to receive either group administered Dialectical Behavior Therapy (DBT) supplemented by individualized week coaching phone calls or a skills handouts (SH) intervention based on a published manual for adults with ADHD. The DBT intervention consisted of eight weekly 90 minute sessions and seven weekly 10-15 minute individual coaching phone calls designed to assist participants to address key areas of difficulty. A booster session was offered to subjects during the first week of the following academic quarter. Session topics included psycho-education about ADHD, mindfulness, daily planner use, chunking tasks, prioritization, structuring the environment, using social support, managing sleep, eating and exercise, emotion regulation, and troubleshooting about skills use. The SH material topics included psycho-education about ADHD and executive functioning, organization, planning, time management, structuring the environment and stress management. Outcome measures included the Barkley Adult ADHD Rating Scale IV (symptom measurement), the Brown ADD Rating Scales (as a proxy for executive functioning), the ADHD Qualify of Life Questionnaire, the Beck Depression and Anxiety Inventories, the Fie Facet Mindfulness Questionnaire, the subject’s GPA from the academic quarter prior to each assessment point, and performance on the Conners’ Continuous Performance Task (CPT). Both groups had similar baseline measures and treatment completion rates. At the conclusion of the study, compared to the SH participants, subjects receiving DBT and coaching phone calls showed significant improvement in treatment response rates (59-65% v 19-25%) and clinical recovery rates (53-59% v 6-13%). At follow up, DBT subjects showed greater improvements in ADHD symptoms, executive functioning and mindfulness. No differences between groups were seen in comorbid symptoms, GPA or on CPT measures, although a trend toward significance was reported. Of note, subjects in the SH group did have a treatment response rate of 25% which suggests this may be a cost effective alternative. Participants in the DBT group reported that mindfulness, planning and organization were the most helpful aspects of the program. Overall, these are promising results from a small RCT of a structured group-administered skills training program for college students with ADHD. While it is important to replicate this intervention on a broader scale, these results suggest that programs of this sort should be made more widely available to this population.

ADHD in Older Adults

Lenard A. Adler, on January 9, 2015

Just as there have been concerns about the treatment and potential increased societal burden as we improve disease recognition with adolescents recently diagnosed with ADHD aging into adulthood, there are similar concerns as middle aged adults recently diagnosed with ADHD become older adults with ADHD. In fact, the largest percentage growth in stimulant prescriptions in the last year is in adults over the age of 50 years of age (Adler LA. ADHD in Older Adults. Paper Presentation at the Annual Meeting of the American Psychiatric Association, New York , New York, May 2014). However, there are special concerns re: the diagnosis and treatment of older adults which merit heightened attention.

The evidence basis for ADHD in older adults is quite small, when compared to the literature for childhood and adult ADHD. In fact a recent Pubmed search found 100 times fewer peer-reviewed publications on geriatric and older adults with ADHD, than for adult ADHD in general (Adler LA 2014).

The epidemiology of ADHD in older adults indicates:

Similar prevalence to overall adult ADHD
Some diminution in symptom severity with age – this is true through the lifespan, not just true with geriatric ADHD.
Impairment: Notable deficits in social interactions, which is larger than younger adults with ADHD
The diagnosis of ADHD in older adults is complicated by potential overlap with disorders of cognitive decline, such as Mild Cognitive Impairment (MCI).
Inattentive (IA) symptoms (relative to hyperactive-impulsive (HI) ones) increase with the transition from childhood to adulthood (Kessler RC. Arch Gen Psychiatry 2010). It is not clear that this pattern continues with the transition to older adulthood. It is also not clear if the number and burden of IA symptoms might be limited with retirement as individuals perform less cognitively challenging tasks.
The co-morbidities seen in adults with ADHD are similar to those seen in adult ADHD in general.
Symptoms also seem similar. However, there is some support in the literature for increasing rates of depression as adults with ADHD become geriatric adults.

A specific co-morbidity which must be addressed in the evaluation of adults for ADHD is Mild Cognitive Impairment (MCI). It is critical that physicians examine whether there are formal memory deficits. Deficits in MCI are more memory-related as compared with attentional issues seen in ADHD. Other potential issues in establishing this differential include that executive function deficits are somewhat less common in MCI as compared with ADHD in general (except for amnestic MCI).

The time courses of the illnesses differ with an older onset in life for MCI, while ADHD is more or less present throughout the lifespan. A MMSE may be quite helpful in establishing whether memory deficits are present, or formal neuro-psychological testing can be obtained to further delineate the presence of memory vs. attentional issues.

There are special treatment considerations for older adults with ADHD. ADHD medications should be used carefully, with regular cardiovascular monitoring and consultation with primary care physicians as all FDA approved medications for adult ADHD (sustained release stimulants and atomoxetine) have a small risk for increasing the heart rate (on the average 5 beats/minute) and blood pressure (on the average 3 mm Hg); this is especially important as geriatric adults have higher rates of cardiovascular illness and hypertension. Geriatric adults with ADHD should also be monitored for potential agitation or activating effects of the medication.

In conclusion, just as ADHD persists from the transition from adolescence into young adulthood, it also persists in the transition to older adulthood. As always, clinicians should perform careful clinical evaluations and establish appropriate treatment programs, taking into account the special issues involved with the older adults.

ADHD Success Story #6 – ADHD and College Students

Anthony L. Rostain, MD MA on March 27, 2014

Let me tell you about a success story of mine, a college student who I’ll call Carrie. Carrie is about to finish her sophomore year in college after a very, very rocky start to her college career. She was a bright, enthusiastic and vivacious high school student who managed to get by through her intelligence, her energy, and being able, at the last minute, to get her work done. She also had very supportive teachers who gave her the benefit of the doubt if she did turn in assignments late.

 

Now, Carrie thought she might have ADHD but she never went for help. She actually was kind of skeptical about it and thought she just needed to try harder. So she was active in the high school drama club and actually went off to college hoping to become a playwright someday. So, after arriving at college, Carrie became very active in one of the drama clubs on her campus. She began to stage-manage and she started hanging out with all of the drama club students and was enjoying a great deal, and contributing great deal, to the activities of that organization. She also used the same studies, strategies that she had used in high school. So she talked a lot in class but never really read all of the assignments and she’d waited until the last minute to do the reading or to turn in the papers. She found herself cramming for the exams. It turned out that she ended up spending too much time with her extracurriculars and not enough time studying.

 

So after failing two classes in her spring semester, Carrie was asked to take an academic leave of absence from her college. She came back home and was evaluated in our program and we did in fact diagnose her with ADHD. We explained to her exactly how it was that she had managed to do fine until college and that she had managed to get by until she was in this unstructured learning environment. We spent a lot of time teaching her about adult ADHD, we started her on an ADHD medication, and she began coming for weekly cognitive behavioral trainings sessions.

 

Over the course of the next few months, she began to get more and more comfortable with the diagnosis and with figuring out what she needed to do to get difficult tasks done. She managed to get a job in selling tickets in local theater company and eventually she decided to take some courses in community college. She did extremely well and she really figured that she was now ready to go back to college.

 

She went back this past year and has done exceptionally well, getting most As and a few Bs, keeping herself very organized and able to balance the lifestyle that she wants. She’s able to get the studying done that she wants, she’s able to participate in the drama club and guess what, she’s pursuing her dream of becoming a playwright and is now a full-fledged English major in good standing.

 

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