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Screening University Students for Possible ADHD:
Think Horses not Zebras
Allyson Harrison, Ph. D., & James Medd, M.L.I.S.,
Regional Assessment and Resource Centre, Queen's University, Kingston ON
Physicians are frequently asked to determine whether or not a never-before
diagnosed young adult may suffer from Attention Deficit Hyperactivity Disorder
(ADHD). As this is a clinical diagnosis based on both specific signs and history, it
is often difficult for clinicians to gather sufficient data in one visit to confirm all of
the DSM-IV criteria. Furthermore, other disorders and even symptom
exaggeration can make differential diagnosis challenging. This study reports on
data from a university-based ADHD screening clinic. Physicians, counsellors,
academic advisors and the Disability Services Office at a large Canadian
University were informed that any student approaching them regarding possible
ADHD could be screened at no charge in an ADHD clinic. The clinic operated on
a year-round basis, and provided a comprehensive screening assessment and
referral service.
We hypothesized that never-before diagnosed students presenting with
symptoms of ADHD were unlikely to meet full diagnostic criteria for ADHD,
and that other causes for their current symptoms might better explain their
presentation.
Purpose
Mean Scores on
CAARS Subtests
57 students aged 18-36 (20% were graduate students) were referred for a one-
hour screening appointment.
Comprehensive background information was requested prior to the initial
appointment. The screening interview was supplemented by self and observer
ratings of ADHD symptoms, evaluation of emotional functioning and
performance on a computerized vigilance test.
Students who demonstrated sufficient symptoms were referred for a full
psychoeducational assessment.
Method
Although all students reported currently elevated symptoms of ADHD, only one
met full criteria for the diagnosis. For almost all students, comprehensive
background data failed to demonstrate academic or other functional difficulties.
Reasons for their experienced symptoms included: Clinical depression/anxiety;
Substance abuse/drug seeking; Lack of study/learning skills; Lower overall
intellectual ability; ESL.
Results
Conclusions
Outcomes of screening
Lost to follow-up 19
Referred to counsellor 3
Referred to Learning Skills 14
Decided not to continuea 8
Referred for full assessment 13
57
Final diagnosis of those referred for full assessment
ADHD 1
General Anxiety Disorder 4
First episode psychosis 1
Perfectionistic and OCPD 1
PTSD 2
Avg IQ in demanding program 2
Malingering 1
ESL 1
13
aNote: Reasons not to continue included: left to complete grad school elsewhere; went back to
personal counsellor; did not want to continue if we could not provide remediation immediately;
realized from interview that ADHD unlikely.
Symptom reports on
CAARS above threshold
OBSERVER report
(N=57) T ≥ 65 T ≥ 70
Inattention symptoms 63% 47%
DSM Inattention s/o 60% 43%
DSM Hyperactivity s/o 35% 28%
DSM s/o Total 51% 43%
ADHD Index 56% 30%
SELF-report
(N=46)
Inattention symptoms 60% 45%
DSM Inattention s/o 94% 85%
DSM Hyperactivity s/o 41% 34%
DSM s/o Total 84% 70%
ADHD Index 45% 30%
Results
Note: CAARS = Conner's Adult ADHD Rating
Scales; Hyper = hyperactivity; self-conpt = self
concept; Inatt = Inattention symptoms; s/o =
symptoms. Pass=passed symptom validity test.
Fail=failed symptom validity test (eg. objective
evidence they were exaggerating symptoms in a non-
credible manner)
Post-secondary students seeking first-time assessments for ADHD are
unlikely to meet full criteria for ADHD; clinicians should suspect other
possible causes for reported symptoms. Access to historical
documentation is of assistance when making this diagnosis.
High symptom reporting alone is not sufficient to diagnose
ADHD in young adults. All DSM-IV criteria need to be
established prior to making this diagnosis.
Objective evidence of past history and current psychiatric
symptoms essential for differential diagnosis.
Some young adults are motivated to obtain the diagnosis
for access to stimulant medication or academic
accommodations.
Specialized symptom validity tests may help to identify
symptom exaggeration.
Demographics Mean SD Range
Final yr HS avg (%) 85.09 6.15 65-99
Current grade avg 69.92 8.6 50-90
N
# with prior Dx of ADHD 0
Reasons for requesting screening (not mutually exclusive)
Wanting Rx 22
Extra time for exams 15
Learning/study strategies 22
Extensions for assigned work 5
Dx to assist with academic appeal 5
Not sure what they could get 6
Just want to know for interest 6
Retrospective parent reports supporting sufficient childhood s/o(N=20)
Inattention 1
Hyperactivity/Impulsivity 3
Number who could provide evidence of substantial
impairment in 2+ areas prior to age 12
2 out of 28
0
20
40
60
80
Mean Score
CAARS Subtest
Pass (n=40)
Fail (n=6)