Assessing Functional Impairment in ADHD: Concerns for Validity of Self-Report

ADHD Symptomatology is Associated with Alcohol Use and Consequences via Drinking Norms

Background: Research suggests individuals with ADHD are at risk for alcohol use and related problems and are more susceptible to peer influence. Although previous research has focused on the relationship between alcohol use, related problems, and ADHD symptomatology, scant research has examined whether descriptive drinking norms (i.e., perception of others quantity of drinking) and level of alcohol use mediate this association. Objectives: Consequently, the current study tested a sequential mediation model to examine whether ADHD symptoms were associated with alcohol-related problems via drinking norms and level of alcohol use. Participants were 294 college students who completed an online survey regarding various health behaviors and mental health symptoms. Results: Path analyses were used to test the hypothesized model. Results revealed that the indirect effect from ADHD symptoms to alcohol-related problems as mediated by drinking norms and alcohol use was significant. Thus, higher ADHD symptoms were associated with greater drinking norms, which was in turn, associated with greater alcohol use, and in turn, associated with greater alcohol-related problems. Conclusions: ADHD symptoms and drinking norms may serve as risk factors for engaging in elevated alcohol use, and in turn, experiencing more alcohol-related problems. Interventions should target perceptions regarding peer alcohol use and alcohol-related problems for individuals with ADHD symptoms. Future research should explore the environment and social contexts in which individuals with ADHD symptoms are drinking in to further understand these associations.

Negotiating Normalcy: Epistemic Errors in Self-Diagnosing Late-ADHD

In this paper, I share insights from ongoing ethnographic fieldwork among adult Danes who identify as having Attention Deficit Hyperactivity Disorder (ADHD) but do not meet the clinical standards and have yet to receive a diagnosis. These individuals are particularly relevant to the ongoing debates about under- and overdiagnosis of ADHD, as their claims to the diagnosis influence and mirror societal perceptions of what is considered normal and what is seen as a condition. Despite their symptoms not strictly meeting diagnostic criteria, thus risking overdiagnosis and associated psychiatric labeling, they perceive themselves as distinct from 'normal' people. Through a critical anthropological lens, I argue that medicalizing variations in human personality represents a contemporary societal epistemic error, drawing on Gregory Bateson's work. I highlight the dynamics of diagnosis versus notions of normality in diagnosing and self-diagnosing ADHD. Understanding these dynamics is crucial for addressing concerns of overdiagnosis as well as underdiagnosis and misdiagnosis. By illuminating the complexities of diagnostic processes and their societal implications, I aim to contribute to a richer understanding of mental health discourse and practice.

The prevalence of cannabis use disorder in attention-deficit hyperactivity disorder: A clinical epidemiological meta-analysis

Studies have shown that individuals with attention-deficit hyperactivity disorder (ADHD) pose an increased risk for developing substance use disorders. Increased cannabis product accessibility and recent legislative changes have led to increased cannabis consumption, thereby increasing the risk of cannabis use disorder (CUD). The present meta-analysis explored the lifetime and current prevalence of CUD in ADHD. A systematic review was conducted using the following databases: PubMed, PsycINFO and Web of Science. A total of 14 articles were included and used to estimate the aggregate lifetime and current prevalence of CUD in ADHD alongside risk ratios comparing increased risk of CUD in ADHD versus control samples. Mixed and random-effects models indicated that lifetime and current prevalence rates of CUD in ADHD populations were 26.9% and 19.2%, respectively (although prediction intervals ranged from 12.4% to 48.8% and 5.5%-39.1%, respectively). Analysis of the risk ratios indicated that those with ADHD were at 2.85- and 2.91-times greater risk of a lifetime or current diagnosis of CUD, respectively, than those in the general population. Our findings support the need for additional research on the prevalence of CUD in those with ADHD, as well as the inclusion of CUD screening in the treatment of ADHD.

Risky driving behavior among individuals with Autism, ADHD, and typically developing persons

INTRODUCTION

Many individuals with Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) often experience difficulty with driving, including difficulty with obtaining a driver's license as well as driving safely and efficiently. Such difficulties negatively impact their ability to function independently and participate in daily activities that require driving. ASD and ADHD commonly occur co-morbidly and share many overlapping clinical features. Few studies have directly compared the nature of difficulties in driving safety outcomes between ASD and ADHD. The overarching goal of the current study was to characterize and compare self-reported driving behavior among young autistic drivers, ADHD drivers, and typically developing (TD) drivers.

METHOD

Fifty-four participants (14 ASD, 20 ADHD, 20 TD); ages 16-30) completed the Autism Spectrum Quotient and ADHD Adult Rating scale as a method of screening of symptoms. All three groups then completed the Driving Behavior Questionnaire (DBQ), which measured self-reported driving violations, driving errors, and overall risky driving behavior. The three groups of ASD, ADHD, and TD individuals were then compared regarding symptomology and driving behavior differences.

RESULTS

One-way ANOVAs indicated group differences in DBQ total scores and DBQ errors. Drivers with ADHD reported significantly greater overall risky driving behaviors and driving errors compared to ASD and TD drivers. There were no significant differences between ASD and TD drivers in reported risky driving behaviors and errors. Linear regressions indicated that among all drivers, self-reported ADHD symptoms were significantly associated with higher levels of self-reported overall risky driving and driving errors, regardless of diagnostic group.

DISCUSSION

Risky driving and driving errors may be more closely related to symptoms that are characteristic of ADHD. This has implications for individuals with ADHD and autistic individuals who often show or report higher rates of ADHD symptoms. Future studies should compare driving skills of ASD and ADHD drivers using objective measures of driving performance, such as driving simulators or on-road tests.

College students who believe they have ADHD report more neuropsychological deficits than non-ADHD peers

Objective: Attention-deficit/hyperactivity disorder (ADHD) diagnosis in college students has been associated with poor academic outcomes and greater neuropsychological and emotional difficulties. The present study sought to determine whether college students who believe they have ADHD report more neuropsychological deficits than non-ADHD peers. Method: College students (N = 1,520) completed a confidential online survey designed to explore ADHD beliefs and subjective neuropsychological impairment. MANOVA was used to examine the association between ADHD beliefs and neuropsychological symptoms. LSD post hoc analysis was used to examine pairwise comparisons across groups. Results: College students who believe they have ADHD reported more neuropsychological deficits than those without ADHD and similar levels of neuropsychological impairment as peers with a self-reported diagnosis of ADHD. Conclusion: Results show a statistically and clinically significant relationship between ADHD belief and neuropsychological impairment among college students. These findings highlight the need for qualified ADHD assessment in college students who believe they have ADHD.

Accommodation Decision-Making for Postsecondary Students with ADHD: Treating the Able as Disabled

Students with attention-deficit/hyperactivity disorder (ADHD) may be entitled to academic accommodations in postsecondary education. Disability Services Offices (DSOs) in Canada say that objective evidence of functional impairment is required prior to providing academic accommodations. This study set out to determine if postsecondary disability service providers use objective, third-party data when making accommodation decisions. Providers were asked if they would grant extra time accommodations to a fictitious prospective student. The student self-reported attention and academic problems that emerged during COVID restrictions, and that extra time helped her earn better grades and reduced her anxiety. While her neuropsychological report suggested superficial similarity to ADHD and contained accommodation recommendations, it lacked any objective evidence supporting either an ADHD diagnosis or functional impairments that would support extra time accommodation. Despite the lack of current or historical functional impairment, 100% of all DSO decision makers confirmed that they would grant extra time accommodations to this student. Results suggest that DSOs’ accommodation decisions are not based on evidence of functional impairment but rely mainly on student self-report and the recommendations of a professional. As such, the current system of determining reasonable accommodations is flawed and inequitable, offering non-impaired individuals access to supports and services that may privilege them over their similarly abled peers. Postsecondary institutions must either develop more defensible methods of disability determination or provide all students with access to accommodations to create a more equitable learning environment.

Unique considerations in the assessment of ADHD in college students

Evidence-based practice in psychology (EBPP) has long focused on treatment, but evidence-based psychological assessment (EBPA) is also crucial given the important role of accurate and reliable diagnostic practices in treatment planning. In terms of the diagnosis of attention-deficit/hyperactivity disorder (ADHD), EBPA practices are well-established for children, and more recently for adults, but for college students in particular there are special considerations that warrant attention. College students with symptoms of ADHD have some challenges that are unique, and thus the assessment and diagnosis of ADHD in these students is unique. The aim of this review is not to cover all EBPA strategies for diagnosing ADHD in emerging adult college students; rather, we will focus on the unique considerations at play in college ADHD assessment. These include (a) conceptual matters such as the appropriateness of the DSM-5 criteria for college students, the limitations of our understanding of ADHD this population because of a lack of diversity in research studies, and the issue of late-identified ADHD; and (b) practical matters, such as specific documentation needs, how to gather and interpret self- and other-report of symptoms, how to assess impairment, and alternate explanations for ADHD-like symptoms in college students.

Self-reported functional impairment in college students: relationship to noncredible reporting, ADHD, psychological disorders, and other psychological factors

INTRODUCTION

Both symptoms and functional impairment should be assessed in college students seeking evaluations for Attention Deficit Hyperactivity Disorder (ADHD). However, impairment is not specific to ADHD. Although it is well documented that self-reported symptoms can be reported noncredibly, there is less research examining credibility of self-reported impairment, and few clinicians rule out alternative causes for impairment.

METHOD

Participants (N = 428) completed self-report measures of functional impairment, sleep, perceived stress, and in an ADHD symptom measure with embedded validity indicators.

RESULTS

Noncredible reporters endorsed greater functional impairment than credible reporters in several domains, but impairment was reported at a high rate even in credible responders (N = 323) in several domains. Participants who reported prior ADHD and participants who reported prior psychiatric diagnoses reported greater impairment and higher rates of clinically significant impairment than those who reported no prior diagnoses. Few differences in reported impairment emerged between those who reported ADHD and psychiatric diagnoses. Sleep and stress accounted for significant variance in impairment, and the ADHD group reported greater impairment than the psychiatric diagnosis and no diagnosis groups after controlling for these variables.

CONCLUSIONS

Results reinforce the importance of considering the validity of, and alternative sources for, self-reported impairment in college students with ADHD concerns.

Detection of Feigned ADHD Using the MOXO-d-CPT

Objective: The objective of this study was to assess the MOXO-d-CPT utility in detecting feigned ADHD and establish cutoffs with adequate specificity and sensitivity. Method: The study had two phases. First, using a prospective design, healthy adults who simulated ADHD were compared with healthy controls and ADHD patients who performed the tasks to the best of their ability (n = 47 per group). Participants performed the MOXO-d-CPT and an established performance validity test (PVT). Second, the MOXO-d-CPT classification accuracy, employed in Phase 1, was retrospectively compared with archival data of 47 ADHD patients and age-matched healthy controls. Results: Simulators performed significantly worse on all MOXO-d-CPT indices than healthy controls and ADHD patients. Three MOXO-d-CPT indices (attention, hyperactivity, impulsivity) and a scale combining these indices showed adequate discriminative capacity. Conclusion: The MOXO-d-CPT showed promise for the detection of feigned ADHD and, pending replication, can be employed for this aim in clinical practice and ADHD research.

Accommodation decision-making for postsecondary students with ADHD: Implications for neuropsychologists

Neuropsychologists are often asked to evaluate students for attention-deficit/hyperactivity disorder (ADHD) and to provide documentation to support their requests for academic accommodations in college. Research points to the importance of multi-method, multi-informant data when evaluating ADHD and determining the need for accommodations. However, the Association on Higher Education and Disability (AHEAD) directs disability service providers to give primacy to students' self-reports and their own impressions of students' narratives over objective, third-party data when rendering accommodation decisions. The organization asserts that in many cases information from parents, teachers, and psychologists is not needed to confirm the existence of a disability or students' need for accommodations. In this article, we describe the way disability service providers are directed to evaluate accommodation requests, the limitations of these procedures, and the dangers of well-intentioned, but indiscriminate accommodation-granting. We then provide recommendations for neuropsychologists who conduct ADHD evaluations for college students in light of these professional guidelines.

American Academy of Clinical Neuropsychology (AACN) 2021 consensus statement on validity assessment: Update of the 2009 AACN consensus conference statement on neuropsychological assessment of effort, response bias, and malingering

Objective: Citation and download data pertaining to the 2009 AACN consensus statement on validity assessment indicated that the topic maintained high interest in subsequent years, during which key terminology evolved and relevant empirical research proliferated. With a general goal of providing current guidance to the clinical neuropsychology community regarding this important topic, the specific update goals were to: identify current key definitions of terms relevant to validity assessment; learn what experts believe should be reaffirmed from the original consensus paper, as well as new consensus points; and incorporate the latest recommendations regarding the use of validity testing, as well as current application of the term 'malingering.' Methods: In the spring of 2019, four of the original 2009 work group chairs and additional experts for each work group were impaneled. A total of 20 individuals shared ideas and writing drafts until reaching consensus on January 21, 2021. Results: Consensus was reached regarding affirmation of prior salient points that continue to garner clinical and scientific support, as well as creation of new points. The resulting consensus statement addresses definitions and differential diagnosis, performance and symptom validity assessment, and research design and statistical issues. Conclusions/Importance: In order to provide bases for diagnoses and interpretations, the current consensus is that all clinical and forensic evaluations must proactively address the degree to which results of neuropsychological and psychological testing are valid. There is a strong and continually-growing evidence-based literature on which practitioners can confidently base their judgments regarding the selection and interpretation of validity measures.

Concordance between the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and Clinical Assessment of Attention Deficit-Adult (CAT-A) over-reporting validity scales for detecting invalid ADHD symptom reporting

This study investigated the relationship between symptom validity scales on the Clinical Assessment of Attention Deficit-Adult (CAT-A) and the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in the context of Attention-Deficit/Hyperactivity Disorder (ADHD) evaluation. The sample comprised 140 consecutive patients referred for a neuropsychological evaluation of ADHD and were administered the CAT-A and the MMPI-2-RF and a battery of performance-based neurocognitive tests. Results indicated CAT-A/MMPI-2-RF symptom validity concordance of 51% between measures, with 38% concordant valid and 13% concordant invalid responses. Among those with discordance symptom validity results, rates of valid CAT-A/invalid MMPI-2-RF responding (41%) were more common than invalid CAT-A/valid MMPI-2-RF responding (8%). Results also indicated higher levels of ADHD symptoms among invalid responding within the CAT-A, whereas the MMPI-2-RF Cognitive Complaints scale did not differ by CAT-A validity status. Finally, symptom validity scales on both the CAT-A and MMPI-2-RF were largely discordant from neuropsychological test validity status per performance validity tests. Findings highlight the need for symptom validity testing when assessing ADHD and indicate that validity indices on broad personality assessments may assess different constructs than embedded validity indices in ADHD-specific measures.

ADHD Assessment in College Students: Psychologists’ Adherence to DSM-5 Criteria and Multi-Method/Multi-Informant Assessment

The evidence-based assessment of attention-deficit/hyperactivity disorder (ADHD) depends on adherence to Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) diagnostic criteria and reliance on multi-method/multi-informant data. Although nearly all psychologists endorse these practices, college students with ADHD may lack documentation supporting their diagnoses. We reviewed the documentation submitted by 214 undergraduates diagnosed with ADHD and receiving academic accommodations for this condition. Their clinicians also completed a checklist that described their assessment procedures. Relatively few psychologists assessed all DSM-5 criteria, based on either the psychologist’s self-reported assessment procedures (23.4%), written documentation (14.0%), or multi-method/multi-informant data (10.3%) such as educational/medical records, results of rating scales, or interviews with other informants. Psychologists were least likely to assess students’ areas of impairment or to rule out alternative causes for students’ self-reported symptoms. This lack of adherence to DSM-5 criteria and overreliance on students’ self-reports can threaten the reliability of diagnosis and the appropriateness of medication and accommodations that follow.