Handbook ADHD Studenți

College Students with ADHD
Lisa L. Weyandt • George J. DuPaul
College Students
with ADHD
Current Issues and Future Directions
Lisa L. Weyandt George J. DuPaul
Chafee Social Science Center Department of Education & Human Services
Department of Psychology Lehigh University
University of Rhode Island Bethlehem, PA, USA
Kingston, RI, USA
ISBN 978-1-4614-5344-4 ISBN 978-1-4614-5345-1 (eBook)

DOI 10.1007/978-1-4614-5345-1
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2012948683
© Springer Science+Business Media New York 2013

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To my mother, Margie (LW)
To my parents, Lawrence and Emma (GD)
Preface
Attention-deficit/hyperactivity disorder (ADHD) is a chronic disorder that affects a

significant proportion of the child, adolescent, and adult population. Over the past
several decades, hundreds of empirical studies have been conducted to illuminate
our understanding of ADHD as well as identify evidence-based strategies for assess-
ing and treating individuals with the disorder. In addition, many books have been
published to guide health professionals, educators, parents, and individuals with
ADHD in managing this disorder in home, school, and community environments.
Such guidelines have been invaluable in promoting more successful outcomes for
the ADHD population as well as translating research into practice. Unfortunately,
until recently, the challenges and needs exhibited by college students with ADHD
have been relatively neglected in the empirical literature.
Over the last decade or so, increasing numbers of research investigations have
focused on identifying the specific challenges and difficulties faced by college stu-
dents with ADHD. Research has been relatively consistent in identifying a myriad
of academic, psychological, social, and occupational deficits that characterize the
college ADHD population (Weyandt & DuPaul, 2006). The type and degree of
deficit is not surprising given that ADHD is a chronic disorder associated with
impairment across the lifespan (Barkley, Murphy, & Fischer, 2008). The challenges
faced by college students with ADHD, however, are not simply an extension of
those found by individuals with ADHD in general. Because of the unique academic
and social demands of college environments, students with this disorder encounter
difficulties that are unique to that setting and time in their lives. Our own research
has been devoted to enhancing understanding of the unique challenges encountered
by college students with ADHD as well as identifying methods to understand,
assess, and treat this population in an effective fashion.
The purpose of this book is to enhance the knowledge, assessment, and treatment
of ADHD in college students. Specifically, we comprehensively review the avail-
able research regarding college students with ADHD and translate this evidence
base into clinical/educational practice. This book is intended to meet the needs of
vii
viii Preface
health care and educational professionals working with college students with
ADHD. In addition, this book should be helpful to parents and teachers of students
with ADHD. Finally, we hope that students with ADHD will use this book to help
understand their disorder and become effective self-advocates in obtaining evi-
dence-based services.
Kingston, RI, USA Lisa L. Weyandt

Bethlehem, PA, USA George J. DuPaul
Acknowledgments
There are many individuals who assisted us in completing this book. We would like
to thank Matthew Gormley (doctoral student in school psychology at Lehigh
University), Gregory Paquin (doctoral student in school psychology at the University
of Rhode Island), Anna Salatto (undergraduate psychology major at the University
of Rhode Island), and Chelsea Schubart (undergraduate student at the University of
Rhode Island) for their contributions to the development of the text. We are espe-
cially grateful to Mr. Gormley and Ms. Schubart who invested many hours locating
research articles and preparing references for the text. We also thank our collabora-
tors on two seminal research projects discussed in this text including Kristen Carson
(Lehigh University), Sean O’Dell (Lehigh University), Joseph Rossi (University of
Rhode Island), Anthony Swentosky (University of Rhode Island), Genevieve Verdi
(University of Rhode Island), and Brigid Vilardo (Lehigh University). Finally, we
would be remiss if we did not acknowledge the dozens of college students with
ADHD as well as college student disabilities officers working with these students
from whom we have learned a great deal about the challenges and successes faced
by this population.
ix
Contents
1 Introduction and Background Information........................................... 1

Background Information Concerning ADHD ............................................ 2
Prevalence and Incidence ....................................................................... 3
Gender and Developmental Information................................................ 6
2 ADHD in Adolescents (Middle and High School) ................................. 11
ADHD in Adolescence .............................................................................. 12
Academic and Social Functioning ......................................................... 12
Associated Difficulties ........................................................................... 14
Family Functioning ................................................................................ 16
Assessment and Treatment of ADHD in High School .............................. 16
Assessment of ADHD in Adolescents ................................................... 16
Treatment of Adolescents with ADHD .................................................. 19
Transition from High School to Postsecondary Education Settings .......... 22
Conclusions ................................................................................................ 24
3 Academic, Social, and Psychological Functioning ................................ 25
Academic Functioning ............................................................................... 26
Social Functioning ..................................................................................... 27
Psychological Functioning ......................................................................... 29
Functioning in Multiple Areas ................................................................... 31
Summary .................................................................................................... 34
4 Assessment of ADHD ............................................................................... 37
Purpose and Goals of Assessment ............................................................. 37
Assessment Process ................................................................................... 38
Screening................................................................................................ 38
Multimethod Assessment ....................................................................... 39
Interpretation of Assessment Data ......................................................... 40
Design of Treatment Plan ...................................................................... 42
Evaluation of Treatment Outcome ......................................................... 43
Assessment Measures ................................................................................ 44
xi
xii Contents
Diagnostic Interview .............................................................................. 44

Self-Report Rating Scales ...................................................................... 45
Parent Rating Scales .............................................................................. 48
Tests/Direct Measures ............................................................................ 50
Measures of Functional Impairment ...................................................... 51
Archival Data ......................................................................................... 54
Assessment Challenges .............................................................................. 54
Reliability and Validity of Retrospective Reports.................................. 54
Positive Illusory Bias on Self-Report of Functioning ............................ 55
Relevant Norm Group ............................................................................ 55
Inclusion of Parents................................................................................ 56
Inclusion of Collateral Informants ......................................................... 57
Feigning of ADHD ................................................................................ 58
Case Example............................................................................................. 58
Conclusions ................................................................................................ 60
5 Psychosocial Treatment and Educational Interventions ...................... 61
Psychosocial Treatment Strategies............................................................. 62
Educational Interventions .......................................................................... 66
Educational Accommodations ................................................................... 67
Oversight of Support and Treatment Services ........................................... 71
Case Example............................................................................................. 72
Conclusions ................................................................................................ 73
6 Pharmacotherapy..................................................................................... 75
Pharmacotherapy of ADHD ....................................................................... 75
Stimulants and Pro-drug Stimulants ...................................................... 75
Non-stimulants ....................................................................................... 79
Antidepressants and Anticonvulsants .................................................... 80
Diversion of Medication ............................................................................ 82
Conclusion ................................................................................................. 85
Case Example............................................................................................. 85
7 Future Directions for Practice and Research ........................................ 87
Transition from High School and Future Research ................................... 87
Overview of ADHD in College and Future Research ................................ 89
Assessment and Future Research ............................................................... 90
Academic, Social, and Psychological Functioning and Future Research .. 92
Social and Psychological Functioning ................................................... 93
Pharmacotherapy of ADHD and Future Research ..................................... 94
Psychosocial and Educational Interventions and Future Research ............ 95
Conclusions ................................................................................................ 98
References ....................................................................................................... 101
Index ................................................................................................................ 119

About the Authors
Lisa L. Weyandt, Ph.D., is Professor of Psychology at the University of Rhode

Island. She is recognized nationally and internationally for her work with ADHD
and executive functions. Dr. Weyandt is particularly interested in the assessment
and treatment of ADHD in college students including pharmacological and non-
pharmacological interventions and clinical neuroscience. She is the author of An
ADHD Primer and The Physiological Bases of Cognitive and Behavior Disorders
and has published numerous articles and book chapters concerning ADHD.
George J. DuPaul, Ph.D., is Professor of School Psychology and Chairperson of
the Department of Education and Human Services at Lehigh University. He has
extensive experience providing clinical services to children and adolescents with
attention-deficit hyperactivity disorder (ADHD) and their families as well as con-
sulting with a variety of school districts regarding the management of students with
ADHD. He has been an author or coauthor on more than 180 journal articles and
book chapters related to ADHD. He has published seven books and two videos on
the assessment and treatment of ADHD. Currently, he is investigating the effects of
early intervention and school-based interventions for students with ADHD as well
as the assessment and treatment of college students with ADHD.
xiii
Chapter 1
Introduction and Background Information
Garrett has had difficulty paying attention since the first grade and has consistently
been described by his teachers and parents as “challenging” and “impulsive.”
Garrett’s parents were often frustrated with his below average grades and felt that
he “did not apply himself.” Garrett was evaluated by his pediatrician and diag-
nosed with attention-deficit/hyperactivity disorder (ADHD) in the 3rd grade, and he
began taking methylphenidate. He also received special educational services
throughout elementary, middle, and high school. Garrett graduated from high
school and is beginning his first semester at a university located in the northeast
region of the United States. Garrett’s parents are concerned about his poor organi-
zational skills and ability to manage on his own without the support he was accus-
tomed to receiving prior to college.
Melissa earned average grades in elementary school. In middle school and high
school, Melissa struggled to achieve average grades and was described by her teach-
ers and parents as “very forgetful” and “poorly organized.” Melissa is currently
attending a community college and is having difficulty managing her course work.
She sought the advice of a psychologist at the college’s health and counseling center
and was recently diagnosed as having ADHD: predominantly inattentive type.
Although their backgrounds are different, both of these college students are strug-
gling with attention-deficit/hyperactivity disorder (ADHD). ADHD is estimated to
affect 3–7% of the school-age population and 2–5% of the adult population (American
Psychiatric Association, 2000). Relative to what is known about ADHD in child-
hood, however, far less, empirical information is available concerning ADHD in
adults. What is clear, however, is that increasing numbers of adolescents with ADHD
are graduating from high school and many are pursuing a college education. Disability
support service offices from around the country are reporting an increase in the num-
ber of college students requesting special accommodations for ADHD, yet mental
health providers, parents, and educators are often at a loss as to how to best meet the
needs of these students. The purpose of this book is to review the research literature
about ADHD in adolescents and college students and to provide practical sugges-
tions for health care and education professionals working with adolescents transi-
tioning into college, particularly regarding how college students with ADHD can
L.L. Weyandt and G.J. DuPaul, College Students with ADHD: 1

Current Issues and Future Directions, DOI 10.1007/978-1-4614-5345-1_1,
2 1 Introduction and Background Information
best cope with the disorder. This chapter will provide a brief overview of the disorder
and include information regarding diagnostic criteria, prevalence, types of ADHD,
and developmental information.
Background Information Concerning ADHD
The core symptoms of ADHD—inattention, impulsivity, and hyperactivity—have

been recognized in children since the early 1900s (Still, 1902). The American
Psychiatric Association, however, did not formally recognize the disorder until 1968
with the publication of the second edition of the Diagnostic and Statistical Manual
of Mental Disorders (American Psychiatric Association [DSM-II], 1968). At that
time, the disorder was referred to as “hyperkinetic reaction disorder of childhood.”
The name, “attention-deficit disorder” (ADD), emerged in 1980 with the third edi-
tion of the DSM, and two subtypes were specified: ADD with hyperactivity and
ADD without hyperactivity (American Psychiatric Association, 1980). With the
publication of the revised edition of the DSM-III, ADD was changed to attention-
deficit hyperactivity disorder (ADHD) (American Psychiatric Association [DSM-
III-R], 1987). In 1994, three subtypes of ADHD were delineated in the DSM-IV,
namely, ADHD combined type, ADHD predominantly inattentive type, and ADHD
predominantly hyperactive-impulsive type (American Psychiatric Association
[DSM-IV], 1994). The DSM-IV Text Revision was released in 2000, and the diag-
nostic criteria for ADHD did not change (American Psychiatric Association [DSM-
IV-TR], 2000).
ADHD combined type is characterized by difficulties with attention and impulsiv-
ity/hyperactivity. Children and adolescents with this subtype exhibit more behavioral,
aggressive, and externalizing difficulties and experience more parental and familial
discord than those with other ADHD subtypes (Bauermeister, Matos, & Reina, 1999).
Adolescents and adults with ADHD combined type are also more likely to have been
arrested, display hostility problems, attempted suicide, and to have oppositional or
antisocial diagnoses (Murphy, Barkley, & Bush, 2002). In contrast, individuals with
ADHD predominantly inattentive type have fewer behavior problems but tend to have
more learning-related difficulties as well as internalizing disorders such as anxiety or
depression (Carlson & Mann, 2002). ADHD predominantly hyperactive-impulsive
subtype is most often associated with younger children (Lahey, Pelham, Loney, Lee,
& Willcutt, 2005), and this subtype may be an early manifestation of ADHD com-
bined type. Research findings are inconsistent concerning cognitive and neuropsycho-
logical profiles associated with each subtype, but, at present, it does not appear as
though there are distinct and reliable neuropsychological differences between the sub-
types (Shuai, Chan, & Wang, 2011; Wodka et al., 2008).
Although useful in helping to identify ADHD as well as subtypes of the disorder,
the diagnostic criteria are not without problems. In terms of adolescents and young
adults, including college students, the diagnostic criteria have serious limitations.
For example, the DSM criteria for ADHD have never been validated in adults, do
Background Information Concerning ADHD 3
not include separate symptom thresholds for adults, and fail to identify some
significantly impaired adults who are likely to benefit from treatment (McGough &
Barkley, 2004). In addition, symptom criteria are not age referenced, and some of
the criteria are developmentally inappropriate for adolescents and adults (e.g., often
leaves the classroom, has difficulty playing or engaging in leisure activities quietly),
and there are unequal numbers of criteria for the core symptoms (i.e., nine for inat-
tention, six for hyperactivity, and three for impulsivity). The DSM-V is scheduled
for publication in May 2013, and it is likely that the diagnostic criteria will be
altered for adults. In the meantime, pioneers in the field such as Russell Barkley
(2009) recommend modifying the current criteria for adults. Specifically, diagnostic
thresholds of 4 rather than 6 out of 9 symptoms have been suggested for both inat-
tention and hyperactivity-impulsivity domains (Barkley, 2009). Further, Bell (2011)
recently argued that the age of onset required by the DSM-IV-TR (symptoms prior
to age 7) be reconsidered for adults and that “early onset” and “late onset” symp-
toms be recognized by the DSM-V.
Prevalence and Incidence
Prevalence refers to the total number of cases in a given population, while incidence
refers to the number of new cases in a particular period of time. The prevalence of
ADHD is approximately 3–7% of school-age children and 2–5% of the adult popu-
lation (APA, 2000; Simon, Czobor, Bálint, Mészáros, & Bitter, 2009). ADHD con-
tinues throughout the lifespan, and recently, Swedish researchers estimated that
3.3% of older adults aged 65–80 met diagnostic criteria for ADHD based on current
and retrospective symptoms (Guldberg-Kjär & Johansson, 2009). ADHD affects all
ethnic and socioeconomic groups and is not a uniquely “American disorder.” For
example, Faraone, Sergeant, Gillberg, and Biederman (2003), in an attempt to deter-
mine the worldwide prevalence of ADHD, reviewed 50 studies—20 were studies
involving populations from the USA and 30 were non-US populations. Results
revealed that ADHD prevalence rates were similar around the world, and, depend-
ing on the criteria and informant used to diagnose ADHD, some rates were lower or
higher than those found in the USA. A recent study estimating the prevalence of
ADHD in Panamanian school children illustrates this point. Results revealed that
7.4% of the sample met the criteria for ADHD based on information provided by
teachers, parents, and the students themselves (Sanchez, Velarde, & Britton, 2010).
The incidence of ADHD has been a more controversial issue as some have ques-
tioned whether ADHD is on the rise, whether faulty diagnoses exist, or whether
clinicians are better able to diagnose the disorder compared to previous years.
Addressing this question scientifically is challenging as diagnostic criteria have
changed over the years; greater attention has been paid to the disorder by the media,
and parents, teachers, and medical personnel have become more knowledgeable
about the disorder. Studies that have attempted to sort out this issue have found that
more children in clinic settings are diagnosed with ADHD compared to a decade or
more ago (Robison, Skaer, Sclar, & Galin, 2002). Recently, the Center for Disease
Control (CDC) reported the percentage of children aged 4–17 years with a parent-
reported ADHD diagnosis (lifetime) increased from 7.8% to 9.5% during 2003–
2007, representing a 21.8% increase in 4 years. However, evidence does not support
that ADHD is being overdiagnosed, and, in fact, research suggests that the number
of children and adolescents treated for ADHD falls at the lower end of the preva-
lence range (Couzin, 2004; Merikangas et al., 2011; Sciutto & Eisenberg, 2007).
The exact prevalence of ADHD in college students is unknown, largely because
students with ADHD are not required to disclose their disability to colleges and uni-
versities. Prevalence estimates are based on (a) studies that survey large groups of
students regarding ADHD symptoms and/or (b) information from disability services
offices regarding the percentage of students receiving special services for ADHD.
Concerning the latter, the percentage of college students receiving disability support
services for ADHD varies across universities with Henderson (1999) and Guthrie
(2002) estimating that nearly two in five college students with disabilities have
ADHD or a learning disability. Wolf et al. (2009) has reported that approximately
25% of students receiving disability services are registered as having ADHD.
Several studies have been conducted in an effort to identify the percentage of
students who report clinically significant levels of ADHD symptoms. Weyandt,
Linterman, and Rice (1995) conducted the earliest investigation of self-reported
prevalence of ADHD symptoms using a sample of 770 college students who com-
pleted two ADHD symptom questionnaires (Adult Rating Scale, ARS; Weyandt
et al., 1995; and the Wender Utah Rating Scale, WURS, Ward, Wender, & Reimherr,
1993). Approximately 7% and 8% of the sample reported significant ADHD symp-
toms (scores at or above 1.5 standard deviations) on the ARS and WURS, respec-
tively, with 2.5% reporting significant symptoms on both scales. When a more
stringent criterion (i.e., 2 standard deviations) was used, prevalence of significant
ADHD symptoms dropped to 4% (ARS), 3.8% (WURS), and 0.05% (both scales).
Similar results were found by Heiligenstein, Conyers, Berns, and Smith (1998) who
administered a version of the ADHD Rating Scale (DuPaul et al., 1998) based on
DSMIII-R (APA, 1987) criteria. Nearly 500 college students at a Midwestern uni-
versity were included in the study, and approximately 4% of the students self-re-
ported symptoms that met DSM-III-R criteria for ADHD. Consistent with other
studies, older students reported fewer hyperactive-impulsive symptoms than younger
students, and there were no differences for inattention symptoms with respect to
gender, ethnicity, and educational level.
Prevalence of ADHD symptoms among college students has been investigated in
the United Kingdom as well. For example, Pope and colleagues (2007) asked
approximately 1,000 students to complete the self-report short form of the Conners’
Adult ADHD Rating Scales (CAARS; Conners, 2004), and approximately 6.9% of
the sample met the study’s threshold for ADHD. Cross-cultural comparisons have
also been conducted including a study by DuPaul, Schaughency, et al. (2001) who
compared self-report ratings from 1,209 college students from the United States,
Italy, and New Zealand. Results revealed that 2.9% of male students from the United
States were classified as having one of the three subtypes of ADHD, while 7.4% of
male Italian students and 8.1% of male students from New Zealand reported
significant ADHD symptoms. The most common subtype for males was the hyper-
active-impulsive subtype. Female students from the USA, however, reported
significantly more ADHD symptoms than female students from Italy or New
Zealand (3.9%, 0%, and 1.7%, respectively). The majority of the female partici-
pants also met diagnostic criteria for the hyperactive-impulsive subtype.
Norvilitis, Ingersoll, Zhang, and Jia (2008) assessed ADHD symptoms among
college students in China and the United States and, similar to previous studies,
found that 4.4% of American students reported significant current ADHD symp-
toms. Interestingly, slightly more (7.8%) Chinese students reported significant
ADHD symptoms. Other studies using different self-report instruments have
reported even higher percentages. For example, McKee (2008) assessed the preva-
lence of ADHD symptomology in a sample of 1,096 college students using the
CARE (College ADHD Response Evaluation, CARE; Glutting, Youngstrom, &
Watkins, 2005). Based on self-report symptoms that met or exceeded the 97th per-
centile (i.e., norm-based approach), approximately 20% of students met the criteria
for ADHD. Alternatively, when using DSM-IV criteria (i.e., criterion-based
approach), significantly fewer college students met the criteria for ADHD (7.48%).
This discrepancy in prevalence rates between normative and criterion-based
approaches has important implications for (a) the appropriateness of current diag-
nostic criteria and (b) for relying on self-report measures for the college student
population.
A comprehensive approach to studying ADHD symptomology would be to
obtain both self (student) and parental information about the student’s symptoms.
Such a study was conducted by Lee, Oakland, Jackson, and Glutting (2008) who
asked nearly 1,000 college freshmen and their parents to complete rating scales
measuring current and retrospective ADHD symptoms (CARE). Results revealed
that prevalence rates varied depending on the rater (self or parent) as well as on
student gender and race. Specifically, using self-report, approximately 1.2% of
males and 4.6% of females met diagnostic criteria for ADHD, and 8.4% of African
Americans and 2.3% of White students met DSM-IV-TR criteria. Using parental,
retrospective ratings, 5.6% of males and 1.6% of females met diagnostic criteria,
while 1.9% of African American students and 4.7% of White students received rat-
ings beyond symptom thresholds. Finally, when self and parent ratings were com-
bined, only 0.4% of males, 0% of females, 0.9% of African Americans, and 0.1% of
Whites were identified as meeting DSM-IV-TR criteria for ADHD.
Recently, several studies have suggested that college students are able to feign
ADHD symptoms, and this points to the need for thorough evaluations with this
population (Booksh, Pella, Singh, & Gouvier, 2010; Harrison & Edwards, 2010;
Sansone & Sansone, 2011; Sollman, Ranseen, & Berry, 2010). Additional informa-
tion regarding these studies will be covered in Chap. 4 concerning the assessment of
ADHD in college students.
In conclusion, prevalence studies suggest that approximately 2–8% of college
students self-report significant symptoms characteristic of ADHD. It is important to
note that these percentages do not reflect the actual percentage of college students
who have been diagnosed with ADHD, however, and ADHD symptoms are associ-
ated with other disorders as well (e.g., substance use, anxiety). Interestingly, 5% of
incoming first-year students (6.4% of men, 3.8% of women) in a large, nationally
representative survey reported having ADHD (Pryor, Hurtado, DeAngelo, Blake, &
Tran, 2010); this prevalence rate is consistent with estimates based on more com-
prehensive surveys of symptomology. Nevertheless, research is sorely needed to
determine the percentage of students attending college who have documented
ADHD that is consistent with current diagnostic criteria.
Gender and Developmental Information
Research consistently finds that boys are more likely to be diagnosed with ADHD
than girls with ratios ranging from 2:1 to 9:1 depending on the subtype of ADHD
(APA, 2000). Findings are inconclusive however, as to whether subtype differences
exist between boys and girls. For example, it is a common belief that boys are more
likely to be diagnosed with ADHD combined type and ADHD hyperactive-impulsive
subtype, and girls are more likely to have ADHD predominantly inattentive type. In
an earlier meta-analysis conducted by Gaub and Carlson (1997), it was concluded
that boys with ADHD are more likely to have problems with acting out, hyperactivity,
and aggressive behaviors (externalizing) than girls who were more likely to have
greater intellectual impairment and lower levels of hyperactivity and externalizing
behaviors. More recent studies, however, have not found a prevalence difference in
ADHD subtypes between boys and girls (Ghanizadeh, 2009; O’Brien, Dowell,
Mostofsky, Denckla, & Mahone, 2010). Recently, Fedele, Lefler, Hartung, and Canu
(2012) investigated sex differences in college students with ADHD and found that
female college students with the disorder reported higher levels of impairment in
home life, social life, education, money management, and daily living compared to
females without ADHD. Females with ADHD were also found to have higher levels
of impairment compared to male college students with ADHD. These results are
similar to those of DuPaul et al. (2006) who found that elementary school-aged girls
with ADHD exhibited greater symptom severity and impairment relative to their
female peers than did boys with ADHD relative to male peers.
In terms of developmental characteristics, DSM-IV-TR criteria require that the
onset of ADHD occurs before the age of seven (APA, 2000). Most children are
diagnosed with the disorder during elementary school years; however, research sug-
gests that symptoms are often present earlier in life, particularly during the pre-
school years. For example, preschool children with ADHD are often excessively
impulsive, active, accident prone, demanding, and aggressive (Barkley, 2008;
DuPaul, McGoey, Eckert, & Van Brakle, 2001; Suvarna & Kamath, 2009; Scahill &
Schwab-Stone, 2000).
Whether ADHD can be recognized earlier, that is, infancy has received attention
as well. Heinonen, Raikkonen and colleagues (2010), for example, followed 828
infants from birth until 56 months and found that those infants born small for
gestational age were nearly four times more likely to have significant ADHD symp-
toms at follow-up, compared to those of average gestational age. Similar studies
have reported that very low birth weight infants were also more likely to have
ADHD in young adulthood (Sanson, Smart, Prior, & Oberklaid, 1993; Strang-
Karlsson et al., 2008). Additional prenatal and postnatal risk factors for ADHD have
been identified and include maternal smoking and drug and alcohol use during
pregnancy, preterm delivery, delivery complications, and caffeine exposure
(Bekkhus, Skjothaug, Nordhagen, & Borg, 2010; Linnet et al., 2003). Recently,
however, Sarah Ball and colleagues at the Harvard School of Public Health
collected information from a large sample of women regarding their smoking habits
during pregnancy and then followed the offspring into young adulthood. Contrary
to expectations, findings did not support a relationship between maternal smoking
during pregnancy and ADHD (Ball et al., 2010).
During the elementary school years, children with ADHD continue to struggle
with problems with inattention, hyperactivity, and impulsivity and are at greater
than average risk for developing social and behavioral problems. Compared to their
peers without the disorder, children with ADHD are more likely to earn poorer
grades, exhibit poor organizational skills, perform more poorly on tasks that require
fine motor skills, and use school-based services than children without the disorder
(Ek, Westerlund, Holmberg, & Fernell, 2011; Lavasani & Stagnitti, 2011; Loe &
Feldman, 2007). Children with ADHD are also more likely to have repeated a grade,
been placed in special education classes, and receive tutoring (Biederman, Petty,
Clarke, Lomedico, & Faraone, 2011). Estimates of coexisting learning disabilities
vary across studies (e.g., 20% to 30%), but recently, Yoshima and colleagues
reported that approximately 50% of boys and girls with ADHD in their study also
had a learning disability in reading (Yoshimasu et al., 2010). In addition to learning
problems, children with ADHD are at greater risk for developing behavioral and
emotional disorders such as conduct disorder, oppositional-defiant disorder, major
depression, and anxiety disorders (Faraone, Biederman, & Monuteaux, 2002; Geller
et al., 2003).
It was once commonly believed that children would outgrow ADHD with the
onset of adolescence; however, longitudinal studies indicate that most children with
ADHD continue to display significant symptoms throughout adolescence and into
adulthood (Barkley, Murphy, & Fischer, 2008; Biederman et al., 2011; Langley
et al., 2010). The nature of the symptoms tends to change however, with overt
hyperactivity decreasing and symptoms of internal or mental restlessness increasing
(APA, 2000; Weyandt et al., 2003). Problems with inattention and impulsivity tend
to persist throughout adolescence and are associated with increased risk of aca-
demic, social, and behavioral difficulties. Indeed, numerous studies have reported
that adolescents with ADHD have higher rates of detention and expulsion and rela-
tively low rates of high school graduation. They are also more likely to exhibit high
levels of antisocial behavior and substance use and abuse problems (Barkley,
Fischer, Edelbrock, & Smallish, 1990; Ek et al., 2011; Langley et al., 2010). Both
boys and girls with ADHD are more likely to develop conduct disorder, which is
associated with an increased risk of psychiatric and sexual problems (Frick & Nigg,
2012; Monuteaux, Faraone, Gross, & Biederman, 2007). A hallmark of adolescence

is the legal right to drive an automobile, and, unfortunately, studies have found that
adolescents with ADHD are more likely to be involved in traffic accidents and
receive speeding citations and license suspensions (Barkley, Murphy, DuPaul, &
Bush, 2002; Fischer, Barkley, Smallish, & Fletcher, 2007).
Although the outcome of ADHD in adolescence, as described, looks unfavor-
able, studies have shed light on factors that are associated with a more positive
outcome. Specifically, those with less severe ADHD symptoms are less likely to
abuse substances and less likely to engage in antisocial behavior than those with
more severe ADHD symptoms. In addition, adolescents with ADHD who have been
treated with stimulant medication are less likely to develop substance abuse prob-
lems compared to children and adolescents who had not been treated with stimu-
lants (Barkley, Fischer, Smallish, & Fletcher, 2003; Biederman, Wilens, Mick,
Spencer, & Faraone, 1999).
Family factors such as socioeconomic status (SES) and parental pathology have
also been associated with outcome in adolescence (Hechtman, 1993; Murray et al.,
2008). Specifically, SES appears to be a protective factor with better outcomes asso-
ciated with middle to higher SES (Copeland, Shanahan, Costello, & Angold, 2009).
Maternal depression is also associated with increased risk of ADHD in children,
and maternal pathology in general is associated with disruptive behavior problems
in children with ADHD (i.e., oppositional-defiant behavior) (Counts, Nigg, Stawicki,
Rappley, & von Eye, 2005; Sciberras, Ukoumunne, & Efron, 2011). Recently, Foley
(2011) found that families of children with ADHD reported significantly higher
levels of family dysfunction that families without children with ADHD. Several
factors are predictive of a better prognosis in adolescence, and these include intel-
ligence, emotional stability, and social skills functioning (Weiss & Hechtman,
1993). Given these findings, the importance of early identification and intervention
for children with ADHD is crucial.
Less empirical information is available concerning ADHD in adults, but in
recent years, researchers have begun to provide a clearer picture of adults with
this disorder. Overall, studies have found that most adults with ADHD do not
have a college degree and they tend to hold manual labor positions such as car-
penters, plumbers, painters, or mechanics (Mannuzza, Klein, Bessler, Malloy, &
Hynes, 1997; Surman et al., 2010). Similarly, Halmøy and colleagues (2009)
found only 24% of adults with ADHD were employed compared to 79% of adults
without the disorder, and adults with ADHD are more likely to be fired from jobs
(Barkley, Fischer, Smallish, & Fletcher, 2006). Prospective follow-up studies
have found that adults with ADHD, like adolescents with the disorder, are at
greater risk for educational underachievement, substance use/abuse, and antiso-
cial behavior (Barkley, Fischer, Smallish, & Fletcher, 2004; Barkley et al., 2008;
Mannuzza & Klein, 2000). Nevertheless, a growing percentage of high school
students with ADHD are pursuing college, and the remainder of this book will
focus on what is known about this unique population of students.
In the chapters to follow, information will be presented concerning ADHD in
adolescents with a focus on the high school population. Next, what is known about
the academic, social, and psychological functioning of college students with ADHD
will be reviewed. Chapters 4 and 5 will cover assessment methods and psychoso-
cial/educational treatments for college students with ADHD, respectively.
Pharmacological approaches will be reviewed in Chap. 6, and information regard-
ing prescription stimulant misuse on campuses will be included. Lastly, Chap. 7 will
offer suggestions for future directions in research and practice regarding college
students with ADHD.
Chapter 2
ADHD in Adolescents (Middle and High School)
As discussed in Chap. 1, ADHD is a chronic disorder that typically begins early in

life (Barkley, 2006). In fact, according to DSM criteria, one must exhibit impair-
ment from symptoms during childhood (i.e., before the age of 12 years old)
(American Psychiatric Association, 2013). Thus, the typical course is for symptoms
to impair functioning as early as preschool with continued difficulties through ele-
mentary and secondary school (Barkley, Murphy, & Fischer, 2008). Young children
with ADHD are likely to experience problems with development of appropriate
social interactions, delayed growth in early literacy and math skills, as well as higher
than average risk for accidental injuries (DuPaul, McGoey, et al., 2001; Lahey et al., 1998).
Problems interacting with parents and preschool/day-care teachers may also arise
because of the increased risk for development of oppositional-defiant disorder
(ODD) and later conduct disorder (CD) (Lahey et al., 2004).
Upon entering elementary school, children with ADHD typically exhibit multi-
ple behavioral and academic challenges that impair school and home functioning.
Approximately 76% of preschoolers with ADHD will continue to exhibit clinically
significant symptoms of the disorder (Lahey et al., 2004). Children with the disorder
are likely to experience significant academic underachievement that may lead to
provision of special education services and/or grade retention (Barkley, 2006;
DuPaul & Stoner, 2003). Social difficulties often include verbal and physical aggres-
sion, peer rejection, lack of friends, and/or affiliation with younger or more aggressive
peers (Hoza, 2007). Noncompliance and defiance of authority figure commands
are frequent concomitants, and, in fact, over 50% will exhibit ODD or early CD
(Barkley, 2006). Referral for school services and/or community-based treatment
(e.g., psychotropic medication, psychosocial intervention) is common for this age
group. Given the chronicity of ADHD, it is not surprising that 70–80% of elemen-
tary school-aged children will continue to exhibit the disorder in adolescence
(Barkley, Fischer, Edelbrock, & Smallish, 1990).
The purpose of this chapter is to provide an overview of ADHD in adolescence,
particularly as it is manifested during the high school years and transition to
postsecondary education. First, research on symptoms and impairment during

12 2 ADHD in Adolescents (Middle and High School)
adolescence is reviewed with an emphasis on school functioning. Next, possible

comorbid disorders that may arise during adolescence are discussed. Finally, assess-
ment and treatment of ADHD among high school students are reviewed briefly with
a focus on how best to support these students as they transition to college.
ADHD in Adolescence
As children with ADHD progress into and through adolescence, the absolute
frequency of inattention, impulsive, and hyperactive symptoms decreases; however,
the same is true for their non-ADHD peers. Stated differently, there is a negative
linear trend to ADHD symptom trajectory for teens with and without ADHD. Thus,
adolescents with ADHD continue to show marked differences in symptoms relative
to their peers even though symptom frequency is diminishing (Barkley et al., 2008).
As a result, the vast majority of children with ADHD followed into adolescence
continue to meet full diagnostic criteria for the disorder (Barkley, 2006). For exam-
ple, Bussing, Mason, Bell, Porter, and Garvan (2010) followed an ethnically diverse
sample of 94 children (5–11 years old) with ADHD for 8 years and found 56% of
the children continued to exhibit clinically significant symptoms in adolescence.
Diagnostic outcome was consistent across gender, race, and SES. Langley et al.
(2010) obtained similar results with a United Kingdom sample wherein 69.8% of
126 children with ADHD followed longitudinally into adolescence met full criteria
for ADHD 5 years later.
Academic and Social Functioning
As is the case for younger children, adolescents with ADHD typically experience
significant academic and/or social impairment. Kent and colleagues (2011) recently
conducted the most comprehensive investigation of academic impairment among
high school students with ADHD using data from the Pittsburgh ADHD Longitudinal
Study. Parent and teacher ratings as well as school archival data were collected on
an annual basis through the high school years for two demographically similar sam-
ples including 326 boys with and 213 boys without childhood ADHD. Relative to
their classmates, high school students with ADHD exhibited significant academic
impairment across multiple measures including significantly lower GPA, lower
class placement (e.g., remedial vs. honors level classes), and higher rates of course
failure. Further, students with ADHD were reported by teachers to turn in a
significantly lower percentage of assignments and were significantly more likely to
be absent or tardy from class. As a result, adolescents with ADHD were over eight
times as likely to drop out of school. Similarly, Barkley et al. (2008) and Galéra
et al. (2009) found that adolescents with ADHD were more likely to experience one
or greater grade retentions and fail to graduate from secondary school relative to
ADHD in Adolescence 13
non-ADHD peers. One possible reason for compromised academic functioning in

this population is that adolescents with ADHD typically exhibit significantly poorer
executive functioning skills (e.g., working memory, planning, impulse control)
compared to controls (Shur-Fen Gau & Shang, 2010). Specifically, Shur-Fen Gau
and Shang found that 279 11- to 17-year-old adolescents with ADHD along with
their 108 unaffected siblings showed several deficits relative to 173 unaffected con-
trols with respect to shorter backward digit span, more shift errors on a dimensional
shift test, shorter span length on a spatial span test, less successful strategy use and
more total errors on a spatial working memory test, and fewer problems solved on a
cognitive problem-solving test. Presumably, the combination of these deficits could
compromise academic achievement.
Given the chronicity of academic achievement difficulties in the ADHD
population, it is not surprising that the most salient predictors of high school func-
tioning are measures of previous school functioning. Using longitudinal data from
the Multimodal Treatment of ADHD (MTA) study (MTA Cooperative Group,
1999), Langberg, Molina, Arnold, Epstein, and Altaye (2011) examined school
and family variables at the elementary age level that may serve as predictors of
grades and achievement test scores among high school students with ADHD.
Langberg et al. found that homework management and teacher-rated classroom
performance in elementary school, as well as parent education level, were the best
predictors of high school grades for students with ADHD. Alternatively, child IQ,
early symptoms of inattention, teacher-rated elementary school classroom perfor-
mance, receipt of special education, and family income best predicted standardized
achievement test scores. Thus, the school difficulties exhibited by adolescents with
ADHD typically appear early in their academic careers and are both multifaceted
and chronic.
Although not studied as extensively as educational functioning, social impairment
(i.e., peer relationship difficulties) found among younger children with ADHD also
is evident for adolescents with the disorder. For example, Sibley, Evans, and Serpell
(2010) examined peer functioning and social cognition in a sample of 27 young
adolescents with ADHD and a comparison sample of 18 adolescents without ADHD
(M age = 12 years old in both samples). Adolescents with ADHD were significantly
more likely to evidence peer relationship difficulties based on parent report of social
functioning and peer ratings of liking. Further, participants with ADHD exhibited
significantly more difficulties with two out of three social cognitive skills, specifically
with social comprehension and problem-solving abilities. Interestingly, perfor-
mance on social comprehension and problem-solving tasks predicted parent ratings
of social functioning above and beyond the effects of gender, attesting to the
importance of social cognition in development of age-appropriate peer relations.
Adolescents with ADHD also are more likely than their non-ADHD peers to report
bullying others and to be victimized by bullies (Timmermanis & Wiener, 2011).
Although specific predictors of bullying others have not been identified, Timmermanis
and Wiener found lower levels of teen-perceived social support and higher levels
of parent-reported social difficulties significantly predicted peer victimization in a
sample of 40 adolescents with ADHD.
In addition to difficulty with peer relationships, adolescents with ADHD may

experience significant difficulties getting along with teachers and adult authority
figures in the school setting. Although specific investigations of teacher-student
interactions and relationships have not been conducted with this population,
several studies have shown middle and high school teachers to report significantly
elevated behavioral and social difficulties for students with ADHD (e.g., Barkley
et al., 1990). Further, adolescents with ADHD are at higher than average risk for
school suspensions and expulsions (Barkley et al., 2008). Although this is indirect
evidence, elevated behavior ratings and school disciplinary rates indicate that
teachers perceive students with ADHD to be significantly disruptive to classroom
and school activities presumably negatively impacting teacher-student relations.
It is important to note that most longitudinal studies following children with
ADHD into adolescence have included predominantly male samples. The general-
izability of obtained findings to adolescent girls is therefore limited. Nevertheless,
those few studies that have included adequate numbers of females have found girls,
similar to boys with ADHD followed into adolescence to show significant impairment
across domains of functioning. In fact, Owens, Hinshaw, Lee, and Lahey (2009)
followed a sample of young children with ADHD into their teenage years with only
16.4% of girls showing positive adjustment across several areas of functioning relative
to 86.4% of girls in a comparison sample. Thus, as is the case for boys, most girls
with ADHD do not “grow out of” their symptoms and continue to experience social
and academic impairment.
Associated Difficulties
ADHD is often associated with other psychological difficulties and psychiatric

comorbidities in adolescence (Barkley et al., 2008). Among the most common asso-
ciated problems are significantly higher levels of antisocial behavior, criminal activ-
ity, and substance use relative to non-ADHD controls (Langley et al., 2010).
Meta-analytic findings indicate that adolescents with ADHD are about twice as
likely than youth without ADHD to use nicotine and other substances but not alco-
hol and are two to three times more likely to develop disorders of abuse/dependence
for nicotine, alcohol, marijuana, and cocaine (Lee, Humphreys, Flory, Liu, & Glass,
2011). In a large epidemiological study of over 10,000 14- to 16-year-olds in Iceland,
adolescents meeting symptom criteria for ADHD were approximately eight times
more likely than peers to use LSD or cocaine and about seven times as likely to use
mushrooms or amphetamines (Gudjonsson, Sigurdsson, Sigfusdottir, & Young,
2012). Further, Gudjonsson et al. found that ADHD symptoms predicted cigarette
smoking, alcohol use, and illicit substance use above and beyond effects of anxiety,
depression, and antiestablishment attitude with a large, significant linear trend asso-
ciating ADHD symptoms with polysubstance use. This increased risk for substance
use and abuse is consistent across a range of demographic characteristics (e.g., age,
sex, race; Lee et al., 2011) but may be accounted for, in part, by comorbid ODD or
ADHD in Adolescence 15
CD (Harty, Ivanov, Newcorn, & Halperin, 2011) and history of childhood maltreatment
(DeSanctis et al., 2008). Interestingly, most studies have not found a connection
between stimulant medication treatment and increased risk for substance use (e.g.,
Harty et al., 2011). The association between cigarette smoking and ADHD appears
to be mediated, in part, by school adjustment particularly at the middle school level
(Flory, Malone, & Lamis, 2011; Glass & Flory, 2010).
Adolescents with ADHD may also be at increased risk for internalizing disorders.
Chronis-Tuscano et al. (2010) conducted a longitudinal study examining risk for
depression and suicidal behavior in adolescence in a sample of 125 children with
ADHD and 123 demographically matched comparison peers. Children with ADHD
were identified with the disorder between the ages of 4 and 6 years old; all children
were followed through age 18. Based on diagnostic interviews with youth and par-
ents, individuals with ADHD were over four times as likely as comparison children
to meet diagnostic criteria for depression by age 18 and were nearly four times as
likely to have attempted suicide. Girls were at higher risk for both outcomes than
boys, and concurrent child emotional and behavioral problems between ages 4 and
6, as well as maternal depression, predicted later teen depression and suicidal behav-
ior. The importance of comorbid disorders, especially symptoms of internalizing
disorder, at an early age for predicting later emotional and behavioral outcomes has
been supported relatively consistently across the literature. For example, Harty,
Miller, Newcorn, and Halperin (2009) found that children with ADHD + CD exhib-
ited significantly higher levels of physical aggression in late adolescence compared
to those with ADHD alone, while children with ADHD + ODD exhibited significantly
higher levels of verbal aggression in late adolescence. Both comorbid groups
displayed more anger than children diagnosed with ADHD alone. Thus, children
with ADHD and comorbid disruptive behavior disorders appear to be at higher risk
for emotional dysregulation difficulties in adolescence than do children with ADHD
in isolation (Harty et al., 2009).
In addition to risk for internalizing and externalizing disorders, ADHD in adoles-
cence may disrupt other important areas of functioning. Specifically, teens with this
disorder may be more likely to engage in early sexual behavior relative to their non-
ADHD peers (Galéra et al., 2010). This is not surprising given that impulse control
problems are core ADHD symptoms. Galéra and colleagues found that the risk for
early sexual behavior is particularly acute when teens exhibit both ADHD and high
levels of CD symptoms. Adolescents with ADHD also have been found to experience
a significantly higher rate of dental caries (i.e., cavities) compared with age-matched
controls (Blomqvist, Ahadi, Fernell, Ek, & Dahllöf, 2011). In fact, Blomqvist et al.
found that only 6% of teens with ADHD in their sample were caries-free compared to
29% in the control group. Finally, several independent research groups have found a
significantly higher frequency of motor vehicle accidents and moving violations
among teens with ADHD relative to comparison peers (Barkley, 2004; Weiss &
Hechtman, 1993). Unlike other associated difficulties, driving risks do not appear to
be moderated by the presence or absence of comorbid conditions; stated differently, it
appears that the core cognitive and behavioral deficits comprising ADHD are the pri-
mary predictors of poor driving outcomes in this population (Barkley et al., 2008).
Family Functioning
There are surprisingly few studies that have examined family functioning among
adolescents with ADHD. Those investigations that have been conducted had
identified all of the challenges experienced by families with younger children with
ADHD with difficulties magnified by parent-teen conflict that may be common in
many families of adolescents, even those without psychiatric difficulties.
The combination of ADHD and all of the possible associated comorbidities and
functional difficulties present significant costs to the educational system and com-
munity at large. In fact, the mean cost per student with ADHD to school districts is
$5,007 annually (in 2010 dollars) above and beyond the cost associated with general
education. Given a mean ADHD prevalence rate of approximately 5% of the US
population, this annual per student cost translates to a total national cost of $13.4
billion per year (Robb et al., 2011). When costs associated with mental health ser-
vices and juvenile justice system are factored in, the annual cost per individual is
$40,000 (Jones & Foster and Conduct Problems Prevention Research Group, 2009).
Thus, efforts to identify and treat adolescents with ADHD are critical from mental
health, educational, and economic standpoints.
Assessment and Treatment of ADHD in High School
Very little research has specifically examined assessment and treatment of ADHD
among high school students. Those studies that have been conducted generally indi-
cate that many of the same procedures used with preadolescent children may be
appropriate for identifying and treating ADHD in adolescents. Alternatively, assess-
ment and intervention strategies must be modified to account for important develop-
mental and contextual differences associated with the adolescent age group and the
high school setting. A brief, general overview of assessment and treatment proce-
dures follows including a discussion of developmental and contextual factors that
must be considered in working with teens with ADHD.
Assessment of ADHD in Adolescents
The assessment of ADHD involves collection of multiple measures across several

respondents to determine whether (a) an individual’s behaviors are consistent with
DSM criteria for the disorder (including the presence of functional impairment),
(b) there are competing hypotheses (e.g., presence of another disorder) for the
apparent ADHD behavioral symptoms, (c) if any comorbid disorders are present,
and (d) what treatment strategies are warranted to address the individual’s
difficulties. Measures typically include diagnostic interview with a parent as well
Assessment and Treatment of ADHD in High School 17
as possibly a teacher, behavior rating scales completed by parent(s) and teacher(s),

and archival records related to academic and behavioral functioning (e.g., school
records, reports of prior psychoeducational evaluations) (Barkley, 2006; Sibley,
Pelham, Molina, et al., 2011). School-based assessment should also include direct
observation of student behavior in classroom and other relevant school settings
(e.g., cafeteria, playground) (DuPaul & Stoner, 2003). Individual evaluation of
cognitive abilities and/or academic achievement on norm-referenced measures
may be helpful in documenting functional impairment but are not considered criti-
cal to the diagnosis of ADHD (Barkley, 2006; DuPaul & Stoner, 2003). Direct
testing of attention and impulse control (e.g., continuous performance test (CPT))
may be helpful in some cases; however, scores on individual assessments like CPTs
may yield high false-negative rates (Barkley, 1991).
Once assessment data are gathered, the clinician must interpret these data to
reach diagnostic decisions as well as develop a treatment plan that directly addresses
symptomatic behaviors and relevant functional impairments. For diagnosis, clini-
cians compare assessment data to DSM criteria for ADHD and other disorders that
may underlie apparent ADHD symptomatology (e.g., generalized anxiety disorder)
or are comorbid with ADHD (e.g., oppositional-defiant disorder). For the diagnosis
of ADHD, it is particularly critical to establish symptomatic behaviors as chronic,
significantly excessive for the individual’s sex and age, and cross-situational (i.e.,
present in both home and school). Further, symptomatic behaviors must be associ-
ated with significant impairment in academic, social, or occupational functioning.
Assessment data can also guide treatment decisions based on severity of ADHD,
presence/absence of comorbid disorders, nature and degree of functional impairment,
as well as availability of community resources to deliver services (DuPaul & Stoner,
2003). Functional behavior assessment data are critical to the development of
school-based behavioral strategies by identifying antecedent and/or consequent
events that maintain behavior and that can be modified by parents, teachers, and/or
other school personnel (DuPaul & Ervin, 1996). Finally, an individual’s response to
prior interventions can be very helpful in determining the next course of action. For
example, if a classroom-based behavior modification program has been imple-
mented and only leads to partial success, then more intensive behavioral intervention
may be necessary and/or adjunctive treatments (e.g., individualized academic
instruction) may be warranted.
Although assessment of ADHD in adolescents generally includes the aforemen-
tioned measures and procedures, important modifications are necessary to account
for developmental and contextual factors (Sibley, Pelham, Molina, et al., 2011). First,
in order to increase an adolescent’s motivation to participate in a diagnostic evalua-
tion and, eventually, treatment, it is important to include methods and measures that
provide the teenager with input into the assessment process. For example, the adoles-
cent could be interviewed regarding symptomatic behavior as well as academic and
social functioning. Alternatively, youth could be asked to complete self-report behav-
ior ratings. These measures not only provide input and enhance motivation but also
could provide helpful insight into possible symptoms of internalizing disorders (e.g.,
depression, anxiety). It is important to note, however, that youth with ADHD do not
typically provide accurate report regarding their ADHD symptomatology or their

self-esteem. In fact, several studies have demonstrated that children and adolescents
with ADHD exhibit a positive illusory bias when completing self-appraisal ratings
such that ratings of functioning are especially elevated in those areas of functioning
most at deficit (Hoza, Pelham, Dobbs, Owens, & Pillow, 2002). For this reason, self-
report ratings of ADHD symptoms and functional impairment should be interpreted
with caution (Barkley, 2006; DuPaul & Stoner, 2003).
Some assessment methods, especially direct observations of behavior, are
difficult, if not impossible, to conduct in high school settings. Collecting direct
observation data in an unobtrusive fashion in a typical high school classroom is rela-
tively disruptive to classroom ecology and may provide skewed findings. Our expe-
rience is that most high school students can readily determine that they are being
observed and their behavior may change accordingly. Further, collection of behav-
ior ratings from teachers may be unwieldy given the potential number of teachers
involved with a given student and their potential relative unfamiliarity with that
student. Specifically, the feasibility of obtaining behavior ratings from six or more
teachers may be limited, and, even when these are available, it may be challenging
to interpret the data if there are inconsistent reports across teachers. For this reason,
it often is recommended to obtain ratings from teachers of two or three core aca-
demic subject areas (e.g., English, math, science) rather than an entire team of
teachers (DuPaul & Stoner, 2003; Evans, Allen, Moore, & Strauss, 2005). Although
research is necessary to support this assumption, students are presumably more
likely to exhibit disruptive behaviors and educational impairment in the most chal-
lenging core academic subjects as opposed to minor subject areas like physical edu-
cation, music, or art. Thus, if a clinician can obtain ratings from only one teacher,
then it should be a core academic teacher with whom the adolescent struggles the
most (Sibley, Pelham, Molina, et al., 2011).
Adolescence can be a challenging developmental period for many individuals,
not just those with ADHD or other emotional/behavioral disorders. Two typical
challenges associated with adolescence are highly relevant and potentially problem-
atic for teens with ADHD. First, parents and teachers increasingly expect adolescents
to function independently in terms of self-care, educational activities/assignments,
and conformity with rules and legal obligations. Second, adolescents typically spend
more time with peers than with family members or teachers; peer acceptance and
pressure to conform with peer group standards become paramount. Adolescents with
ADHD may be even more likely than typically developing teens to experience
significant challenges with independent functioning and peer acceptance given the
self-regulation deficits and peer rejection often associated with the disorder. Thus,
assessment measures should tap these potential areas of challenge by exploring pos-
sible difficulties with organizational skills, homework completion, self-care, conduct
problems, peer acceptance status, and social skills. In fact, Sibley, Pelham, Molina,
et al. (2011) found assessment of functional impairment to be of greater value than
evaluation of ADHD symptoms in identifying adolescents with the disorder.
Functional challenges may be the primary areas of concern above and beyond ADHD
symptoms and, thus, should be targeted directly by treatment strategies.
Treatment of Adolescents with ADHD
The most widely studied and efficacious interventions for ADHD include psychotropic,
chiefly CNS stimulant, medication and behavioral strategies implemented in home
and school settings (Barkley, 2006; Weyandt, 2006a). Additional treatment approaches
may include school–home notes or daily behavior report cards (e.g., Fabiano &
Pelham, 2003), social relationship interventions (e.g., Pfiffner & McBurnett, 1997),
organizational skills training (Evans, Langberg, Raggi, Allen, & Buvinger, 2005),
and academic interventions (DuPaul & Stoner, 2003). Presumably, most of these
strategies are used individually or in combination to treat adolescents with ADHD;
however, there are far fewer treatment outcome studies in this age group relative to
intervention investigations in younger children and preadolescents.
In contrast to the dozens of studies of stimulant medication for treating children
with ADHD and lesser but growing literature investigating stimulant therapy in
adults with the disorder, there have been few controlled investigations of stimulants
in adolescents with ADHD. Nevertheless, those few studies that have been conducted
provide strong support for stimulant efficacy in this age group. Evans and colleagues
(2001) conducted the most comprehensive controlled study of methylphenidate in
treating adolescents with ADHD, to date. A sample of 45 teenagers with ADHD (M
age = 13.8) participated in a 6-week double-blind, placebo-controlled trial of 3 doses
of methylphenidate while attending a summer treatment program (STP). Statistically
significant improvements for multiple outcomes were obtained with one or more
dosages of methylphenidate relative to placebo. Improvements were found for teacher
ratings of ADHD symptoms and oppositional-defiant behavior, direct observations
of classroom on-task and disruptive behavior, productivity and accuracy on assigned
classwork, and completion of homework. The majority of adolescents exhibited at
least moderate (i.e., effect size ³ 0.50) on at least one methylphenidate dosage for
nearly all measures. Interestingly, the greatest gains were evident for improvements
between placebo and the lowest dosage (i.e., 10 mg) with higher dosages accounting
for only minimal incremental improvement, at least at the group level. The results of
the Evans et al. study are very consistent with similar findings of behavioral and
academic improvement associated with stimulant treatment in preadolescent chil-
dren (for review, see Conners, 2002). Alternatively, a significant percentage (ranging
from 9% to 60%) of adolescents in this study did not show moderate improvement
for one or more measures, suggesting that teens with ADHD often will require treat-
ment beyond stimulant medication.
As is the case for pharmacotherapy, few controlled studies of psychosocial inter-
vention for adolescents with ADHD have been conducted. Of those few investiga-
tions, most have evaluated upward extensions of treatments that are efficacious for
younger children, such as parent training in behavior modification. In a seminal
study of three family therapy approaches for teenagers with ADHD, Barkley,
Guevremont, Anastopoulos, and Fletcher (1992) recruited 61 12- to 18-year-olds
(M age = 13.6–14.2 depending on treatment group) who were randomly assigned to
behavior management training, problem-solving and communication training, or
structural family therapy. Treatments were delivered across 8–10 weekly sessions
with assessment data on teen and family functioning collected prior to intervention,
right after intervention sessions ended, and then at a 3-month follow-up. In contrast
to hypothesized superiority for behavior management training and problem-solving
and communication training relative to structural family therapy, significant
improvements were found for all three treatment groups. Specifically, participants
exhibited fewer symptoms of internalizing and externalizing disorders as well as
improved school functioning, while mothers reported lower levels of depression,
and mother-teen interactions improved with respect to conflict, negative communi-
cation, and anger. For the most part, these improvements were maintained 3 months
after treatment ended. Unfortunately, individual response to treatment was minimal
as only 5–30% of participants showed reliable change and even fewer (i.e., 5–20%)
were normalized or recovered with treatment. The limited positive response to
treatment is not surprising given the relative brevity of intervention and the multi-
ple, chronic functional impairments exhibited by adolescents with this disorder.
Thus, it is unclear whether behavior modification interventions implemented by
parents of teens with ADHD are as successful as similar treatment strategies with
younger children.
Two recent, uncontrolled studies have examined the effects of psychosocial treat-
ment delivered in the context of STP for adolescents with ADHD. Sibley, Pelham,
Evans, et al. (2011) conducted a pilot study of a package of psychosocial interven-
tions (e.g., daily behavior report card, behavior tracking system, academic instruc-
tion, and organizational skills training) to address academic, behavioral, and social
functioning in 19 teenagers with ADHD (M age = 14.06) attending STP. Nearly all
(82.4–94.7%) participants were reported by parents, counselor, or teacher to have
improved at least somewhat after completing the treatment program. Improvements
were noted in multiple domains including conduct problems, adult-directed defiance,
social functioning, inattention/disorganization, mood/well-being, and academic
skills. Sibley, Smith, Evans, Pelham, and Gnagy (2012) found similar improve-
ments for a separate sample of 34 adolescents with ADHD (M age = 13.88) wherein
between 63% and 90.9% of participants showed improved functioning across aca-
demic, behavioral, and social domains following STP. Of course, these findings are
limited by the lack of a comparison group to control for history, maturation, and
treatment expectancy effects. Further, given that multiple treatment components
were included in the STP, it is unclear which component(s) was causally related
to improved outcomes.
Several smaller scale studies have evaluated the efficacy of various intervention
strategies implemented in high school settings. Most of these investigations have
employed self-regulation strategies either alone or in combination with academic
strategy instruction or positive reinforcement. Graham-Day, Gardner, and Hsin
(2010) examined the effects of self-monitoring alone and self-monitoring plus rein-
forcement on the on-task behavior of three 10th grade students with ADHD. All
three students were taught to use self-monitoring in the context of a study hall
specifically for students with disabilities. Students were provided with 15 opportu-
nities during a 20-min period to indicate whether they were paying attention or not
using an individual checklist (i.e., circle “yes” if paying attention or circle “no” if
not paying attention). Students were cued to self-monitor using a variable 2-min
schedule via audiotaped chimes. A self-monitoring plus reinforcement condition
was also included wherein students compared their on-task checklist to that of an
independent observer. If student and observer ratings were off by one or fewer
responses, then the entire study hall class received reinforcement (e.g., candy). Two
of the three students showed reliable increases in on-task behavior with self-moni-
toring alone, while the third student only exhibited reliable improvement when
group reinforcement was added to self-monitoring. Similar improvements in on-
task behavior were found for five 13- to 16-year-old adolescents with ADHD in the
context of completing homework (Axelrod, Zhe, Haugen, & Klein, 2009). In the
latter study, self-monitoring in 3-min or 10-min fixed intervals was paired with indi-
vidual reinforcement (e.g., access to extra television or video-game time) when stu-
dent responses matched an independent observer with 80% or greater accuracy.
The self-regulated strategy development (SRSD) model of strategy instruction
has been used to address deficits in reading recall and expository writing in high
school students with ADHD. SRSD involves explicit instruction in cognitive strate-
gies relevant to a specific skill area until mastery is achieved (Harris & Graham,
1996). Specifically, strategy instruction is scaffolded to enable students to use the
strategy independently and effectively while also encouraging students to self-mon-
itor and manage their use of the strategy on their own. Johnson, Reid, and Mason
(2011) taught three ninth grade students with ADHD to use a multicomponent read-
ing comprehension strategy (i.e., think before reading, think while reading, think
after reading (TWA)) following the SRSD model. Prior to reading, students are
taught to think about what they know and what they want to know about the specific
subject matter covered in the text. They also are encouraged to consider the author’s
purpose in writing the text. Next, students are encouraged to link what they are read-
ing to any prior knowledge they may have on the topic, to think about their reading
speed, and to carefully reread any text that is unclear. Finally, after completing the
reading assignment, students are taught to identify main ideas and to summarize the
content of the reading by retelling what they have learned. The TWA strategy was
taught across five lessons using the SRSD model. Steps to TWA were introduced
and modeled by the instructor, followed by guided practice by the student. Scaffolded
practice involved instructor prompts and feedback when needed. Finally, students
independently practiced using the TWA strategy independently while self-monitor-
ing their accurate use of the strategy. All three students in the Johnson et al. investi-
gation showed improved social studies expository text recall, with specific
improvement in the number of main ideas percentage of supporting details recalled.
Recall gains were maintained 2 and 4 weeks following the end of intervention.
Jacobson and Reid (2010) obtained similar positive effects on the persuasive
essay writing of three high school students with ADHD. SRSD was used to teach
two strategies to plan and organize ideas for persuasive writing. For planning the
essay, students were taught to STOP (suspend judgment, take a side, organize your
idea, and plan more while you write). For organizing their ideas, students were
instructed to use the mnemonic DARE (develop topic sentence, add supporting
ideas, reject possible arguments for the alternative view, and end with a conclusion).
The effects of strategy instruction were examined in the context of a multiple
baseline across participants design. Increases in number of essay elements, length,
planning time, and holistic quality of the essays were noted across all three students
with gains maintained 3 weeks after termination of instruction.
Transition from High School to Postsecondary Education Settings
Given the ubiquitous and sometimes serious academic and/or social deficits experi-
enced by adolescents with ADHD, it is not surprising that they are at significantly
higher risk than their peers for dropping out of school, with one recent estimate indi-
cating that students with ADHD were eight times as likely to drop out as students
without the disorder (Kent et al., 2011). At least one longitudinal study found between
30% and 40% of adolescents with ADHD may drop out of high school (Barkley,
Fischer, Smallish, & Fletcher, 2006). Above and beyond ADHD symptom severity,
the risk for dropout may be related to lower cognitive abilities, deficient reading
skills, lower SES, frequent marijuana use, and limited paternal contact, particularly
for adolescents in urban environments (Trampush, Miller, Newcorn, & Halperin,
2009). Thus, a significant percentage of adolescents with ADHD will not be eligible
for postsecondary education because they did not graduate from high school.
Adolescents with ADHD who graduate from high school are significantly less
likely to go for postsecondary education than their non-ADHD counterparts. In their
longitudinal follow-up of a sample of individuals with ADHD followed from child-
hood to young adulthood, Barkley and colleagues (2006) found only 21% of partici-
pants with ADHD ever attended college as compared with 78% of a comparison
control group. Similar lower than average rates of college attendance have been
found in other longitudinal studies following children with ADHD into adulthood
(e.g., Weiss & Hechtman, 1993).
Those adolescents with ADHD who attend college or other postsecondary educa-
tion setting appear to have milder difficulties, at least during the initial transition
phase, than individuals with ADHD who do not attend college. Nelson and Gregg
(2012) collected self-report ratings of anxiety and depression from high school stu-
dents with ADHD who were transitioning to college and from college students with
ADHD. Interestingly, transitioning students with ADHD reported significantly fewer
anxiety and depression symptoms than did college students with the disorder. Perhaps
this finding indicates that students with milder ADHD and functional impairments
are able to attend college; however, once they are there, anxiety and depression
symptoms increase as the students encounter educational and/or social difficulties.
High school students with ADHD who seek to attend college or another postsec-
ondary education setting clearly face challenges not encountered by their non-ADHD
classmates. Thus, this population requires support prior to, during, and after the tran-
sition from high school to college. Unfortunately, we were unable to locate a single
study examining strategies to aid in this critical transition for students with ADHD.
Transition from High School to Postsecondary Education Settings 23
Several authors have provided suggestions, albeit without empirical support, that
may be helpful in supporting students transitioning to postsecondary education.
DuPaul and Stoner (2003) suggest that students with ADHD should have regular
meetings with their school guidance counselor beginning in middle school to aid
students in planning for their long-term future. Regular meetings are particularly
critical given that individuals with ADHD typically are not future oriented (Barkley,
2006). In particular, it may be important for counselors to guide students in identify-
ing academic interests and strengths to aid in this planning process. DuPaul and
Stoner caution that this early, intensive planning should not prematurely “pigeon-
hole” students into one track (e.g., college preparatory courses) relative to another
(e.g., vocational education) but rather should encourage students to develop an
interest area that may help motivate them to continue schooling.
Schwiebert, Sealander, and Bradshaw (1998) provide several suggestions for
school counselors working with high school students with ADHD to aid in the tran-
sition to postsecondary education. Counselors should first advocate for students to
have a comprehensive psychoeducational evaluation that focuses extensively on
academic history and functioning. A report based on this evaluation should identify
specific academic needs and provide detailed recommendations for how these would
be addressed at the college level. This evaluation may be critical in obtaining neces-
sary accommodations and related support services in college. Secondly, school
counselors should assist students with ADHD in taking appropriate college-bound
coursework. This will ensure that students will have taken all necessary courses,
thus preventing possible roadblocks to college admission.
High school counselors should help students with ADHD to prepare a transition
file that may be helpful in obtaining appropriate support services and accommoda-
tions in college (Schwiebert et al., 1998). This transitional file should include, for
example, high school transcripts, ACT and/or SAT scores, diagnostic report and
treatment recommendations, copies of any IDEA or 504 educational plans, student
writing sample (e.g., personal statement, essay), evidence of participation in extra-
curricular activities and/or honors received, and copies of letters and applications to
colleges completed by the student.
The student should also be assisted in evaluating possible colleges, particularly
with respect to the availability and quality of support services for students with dis-
abilities (Schwiebert et al., 1998). The counselor may help the student investigate
what documents will be needed to qualify for support services at various colleges
along with other important information (e.g., how many credit hours will qualify for
full-time student status). Specific support services that could be investigated include
availability of special orientation sessions; alternative testing options; the degree to
which disability staff advocate for student needs with faculty; availability and qual-
ity of tutoring and academic support; opportunity to use recorded textbooks; possi-
ble course substitution options; assistance with study, test-taking, and note-taking
skills; availability of note-taking services; assistance with managing schedule and
time; possible extensions of assignment deadlines; and technological assistance
(Richard, 1992).
Finally, students should be assisted in developing self-advocacy skills (Schwiebert

et al., 1998). Counselors may guide students through practice exercises and role-
play scenarios where students need to self-identify ADHD and request support or
accommodations. Students may also be guided in writing letters requesting special
considerations based on their ADHD. Counseling students in understanding their
ADHD and its impact on their lives, particularly on educational functioning, may
motivate students to accept training in time management and self-care skills that
will be critical to success in college.
Conclusions
ADHD is a chronic disorder that is associated with significant academic, social, and
psychological impairment into adolescence and beyond for most individuals with
the disorder. High school students with ADHD frequently experience difficulties
meeting academic expectations (e.g., completing assignments accurately and on
time) and, as a result, obtain significantly lower GPAs than their non-ADHD peers.
Students with ADHD are at significantly higher risk for dropping out of school and
not obtaining postsecondary education. Further, adolescents with this disorder may
experience notable difficulties making and keeping friends and are at risk for join-
ing deviant peer groups that engage in delinquent behavior. There is also increased
risk for alcohol, nicotine, and illicit substance use particularly when symptoms of
other disruptive behavior disorders (e.g., CD) are present. Early sexual behavior and
driving difficulties (e.g., vehicular accidents) are also more likely to be exhibited by
adolescents with ADHD relative to their typically developing peers.
Given the possible multiple impairments associated with ADHD in high school,
it is imperative that adolescents with this disorder are identified and provided with
effective treatment support. Assessment of the disorder involves collection of data
regarding current and past behavioral, academic, social, and psychological func-
tioning using multiple respondents and measures. A comprehensive evaluation of
ADHD must account for important developmental factors associated with adoles-
cence as well as contextual factors related to the high school environment. Treatment
strategies include behavioral interventions at home and school possibly combined
with psychotropic medication (e.g., stimulants). Interventions directly targeting
areas of academic and social impairment are also needed. Unfortunately, there are
few studies specifically examining treatment strategies for high school students with
ADHD. Those studies that have been conducted support the use of self-monitoring
of behavior as well as self-regulated strategy development in improving on-task
performance, reading comprehension, and writing. However, these studies are lim-
ited by small sample size and restricted external validity. There are also no studies,
to date, examining the impact of educational accommodations in the high school
setting nor have specific strategies for supporting students transitioning from high
school to college been investigated. Clearly, more research attention needs to be
paid to this important developmental phase, particularly if college success is to be
maximized for students with ADHD.
Chapter 3
Academic, Social, and Psychological
Functioning
As discussed in Chap. 1, increasing numbers of high school students with ADHD

are attending college, and approximately 25% of college students who receive
disabilities services are identified with ADHD (Wolf, 2001; Wolf, Simkowitz, &
Carlson, 2009). Relative to children and adults with ADHD, however, research
studies regarding the college student population are scarce. The purpose of this
chapter is to review available information concerning the academic, social, and
psychological functioning of college students with ADHD.
As discussed in Chap. 2, studies that have followed children with ADHD into
adolescence have revealed that adolescents with ADHD are at risk for poor aca-
demic achievement, more likely to drop out of high school, and are less likely than
their peers without ADHD to attend and complete college (Barkley, 1998a; Murphy,
Barkley, & Bush, 2002; Wolf, 2001; Trampush, Miller, Newcorn, & Halperin,
2009). Recently, Julie Schweitzer and her colleagues from the University of
California, Davis, found that nearly 33% of students with ADHD either drop out of
high school or delay high school graduation, a rate that is nearly twice that of stu-
dents with no psychiatric disorder (Breslau, Miller, Joanie Chung, & Schweitzer,
2011). Given that most high school students with ADHD do not pursue college, it
has been suggested that college students with ADHD differ from their peers that do
not attend college in several ways, including possessing higher cognitive abilities,
better coping skills, and past experience with school success at the grade-school
level which serve as “protective factors” for these students (Glutting, Youngstrom,
& Watkins, 2005). Although empirical research in this area is scant, preliminary
studies do not support the concept of “protective factors.” For example, studies
have found that the IQ of college students with ADHD does not differ significantly
from college students without ADHD—that is, their intelligence is not significantly
higher or significantly lower than peers without ADHD (Weyandt, Mitzlaff, &
Thomas, 2002). What remains unknown, however, is whether the IQ of high school
students with ADHD who did not attend college differs from those who attended
college. In addition, contrary to popular perception, research does not support the

26 3 Academic, Social, and Psychological Functioning
idea that college students with ADHD have superior divided attention skills and are
better at “dual tasking” (Linterman & Weyandt, 2001). Nevertheless, more research
is clearly warranted to explore the ways in which college students who pursue
college differ from those with ADHD who do not pursue college.
Academic Functioning
Several studies have investigated the academic performance of college students

with ADHD, and findings have been mixed. For example, Sparks, Javorsky, and
Philips (2004) found that the GPA for students with ADHD (M = 2.7) was similar to
students without ADHD (M = 2.9), and furthermore, 83% of the students with ADHD
received average (“C”) or above average grades in required foreign language
courses. Most studies, however, have found that college students with ADHD have
lower GPAs and more academic-related problems (e.g., academic probation)
(Heiligenstein, Guenther, Levy, Savino, & Fulwiler, 1999). Recently, Advokat,
Lane, and Luo (2011) surveyed 92 college students with ADHD and compared their
ratings to students without the disorder. Results revealed that college students with
ADHD had lower GPAs, lower ACT (American College Testing) scores, and
students with ADHD withdrew from significantly more classes than students
without ADHD. Interestingly, the study habits of students with and without ADHD
did not differ in this study, but students with ADHD reported that they were worse
than other students at completing assignments. Other studies, however, have found
that ADHD symptoms are negatively correlated with levels of study habits, study
skills, and academic adjustment (Norwalk, Norvilitis, & MacLean, 2009). Some
research has even found that students with ADHD score lower than students with
and without learning disabilities in the areas of time management, concentration,
selection of main ideas, and test-taking strategies based on their ratings on the
Learning and Study Strategies Inventory (LASSI; Weinstein, & Palmer, 2002;
Reaser, Prevatt, Petscher, & Proctor, 2007). These findings suggest that learning and
study strategies differ between students with ADHD compared to students with
other types of disabilities and therefore the tradition of using similar academic
interventions for these students may not be as effective as developing specific strat-
egies for college students with ADHD.
The reasons why college students with ADHD tend to perform more poorly in
courses and to have more academic problems are largely unknown and warrant fur-
ther investigation. It is plausible that cognitive factors such as impairments in execu-
tive function may play a role in academic problems. Gropper and Tannock (2009),
for example, found working memory impairments in a small (16) group of students
with ADHD and suggested this finding was related to the students’ lower academic
performance. Recently, our research team (Weyandt et al., under review) found that
college students performed significantly more poorly on an executive function self-
report measure, the BRIEF (Behavior Rating Inventory of Executive Function).
However, differences did not emerge between college students with and without
Social Functioning 27
ADHD on another task thought to measure executive function (California Verbal

Learning Test, CVLT). Other studies, also however, have not found executive function
deficits in college students with ADHD compared to those without the disorder, and
therefore, the role of cognitive factors remains unclear (Advokat, Martino, Hill, &
Gouvier, 2007; Weyandt, Rice, Linterman, Mitzlaff, & Emert, 1998). Prevatt, Proctor,
Baker, Garrett, and Yelland (2011) recently found that college students with ADHD
showed difficulties estimating how much time it would take to complete a task, errors
made, and retrospective estimates of how much time it actually took to complete the
task. These findings, although preliminary, suggest time management may be an
issue for college students with ADHD and would likely impact academic perfor-
mance. In addition, Weyandt and colleagues (2003) found that college students with
ADHD reported significantly higher levels of internal (mental) restlessness than col-
lege students without the disorder which could also negatively impact concentration
and consequently academic performance. Heiligenstein et al. (1999), however, sug-
gested that academic impairment in college students with ADHD may be related to
external factors such as specific difficulty with academics at a particular university,
loss of family structure and support as a function of living away from home, and lack
of individualized education. Indeed, social and psychological factors likely play a
role in the success or failure of all college students, and perhaps, this is especially
true in those with ADHD.
Social Functioning
A number of studies have attempted to examine the social functioning of college

students with ADHD including areas such as coping, adjustment, and the use of alcohol
and illicit substances. For example, Meaux, Green, and Broussard (2009) found that
peer relationships were described as a helpful coping factor by college students with
ADHD, as were medication, planning, use of alarm clocks and reminder methods,
removal of distractions, and internal self-talk. Other studies have asked college students
to reflect on their childhood and to identify factors that helped them cope prior to
arriving at college such as caring parents and teachers, active teaching styles, and
cognitive strategies to help with focusing (Bartlett, Rowe, & Shattell, 2010). Recently,
Wilmshurst, Peele, and Wilmshurst (2011) found that college students with ADHD
who were doing well academically and emotionally reported significantly higher levels
of parental, emotional, and academic support than their non-ADHD peers.
Several studies have reported adjustment difficulties in a number of areas among
college students with ADHD. Norwalk et al. (2009), for example, reported that stu-
dents who rated themselves as having higher levels of ADHD symptoms also
reported higher levels of academic adjustment problems, lower GPAs, poorer study
skills, and lower levels of career-making decisions. Similar findings have been
found regarding lower GPA and academic concerns (Blase et al., 2009; Rabiner,
Anastopoulos, Costello, Hoyle, & Swartzwelder, 2008; Shaw-Zirt, Popali-Lehane,
Chaplin, & Bergman, 2005). Students with ADHD also have more on-the-job
difficulties than their non-ADHD peers (Shifrin, Proctor, & Prevatt, 2010).
Specifically, college students with ADHD are more likely to receive lower work
performance evaluations and to be fired from their jobs. Some studies suggest that
college students with ADHD report a lower quality of life relative to their non-
ADHD peers (Grenwald-Mayes, 2002), while other studies have not found a differ-
ence between social satisfaction in freshmen and sophomores with ADHD compared
to their peers without ADHD (e.g., Rabiner et al., 2008). It remains unknown, however,
whether social functioning changes over time for students with ADHD and longitu-
dinal studies are desperately needed to address this issue. Perceptions of college
students with ADHD have been addressed in terms of the perceptions of peers and
professors toward these students. In general, preliminary studies suggest that
college students without ADHD describe college students with the disorder more
negatively than positively (Chew, Jensen, & Rosen, 2009). In contrast, professors’
knowledge of the disorder was remarkably accurate and was not influenced by the
number of years taught, the type of college or university, or prior experience with a
student with ADHD (Vance & Weyandt, 2008).
Perhaps one of the most provocative areas of research concerns substance use
among college students with ADHD. As reviewed in Chap. 1, several follow-up
studies have found that adolescents and adults with ADHD are at greater risk for
substance use and abuse. Only a handful of studies, however, have explored this
issue in college students with ADHD. Upadhyaya and colleagues (2005) were
among the first to examine the relationship between ADHD symptoms, medication
treatment, and substance use patterns among 334 college students. Results revealed
that college students who reported significant symptoms of ADHD were more
likely to engage in substance use (tobacco use, marijuana, alcohol) than students
without ADHD symptoms. Similar findings were reported by Blase et al. (2009)
who also found college students with ADHD were more likely to use substances.
Weyandt et al. (2009) found that 21.3% of college students with ADHD who par-
ticipated in their study had been written up for alcohol-related offenses in the dor-
mitories, 2.8% were written up for drug offenses, and 9% reported being arrested
at least once due to alcohol, drug, or other offenses. Recently, however, Janusis and
Weyandt (2010) reported that college students with ADHD were less likely to use
alcohol than students without the disorder. Factors that might influence whether
students with ADHD choose to use alcohol are the subject of recent investigations.
For example, Rodriguez and Span (2008) found a strong relationship between
ADHD symptoms, frequency of drinking alcohol, and anticipation of hangover
effects. Specifically, findings revealed that students with ADHD who did not
anticipate hangover symptoms were significantly more likely to use alcohol than
students who did anticipate hangover effects. Wilens and colleagues (2011) explored
whether executive function deficits were predictive of tobacco and substance use
in young adulthood, and contrary to expectations, results did not support such a
relationship. Clearly more research is needed in this area, but overall, studies sug-
gest that college students with ADHD are at risk for using substances such as
tobacco, alcohol, and marijuana.
Psychological Functioning 29
Psychological Functioning
The psychological functioning of college students with ADHD is a recent area of

study, and the literature in this area includes studies investigating college students
who have been diagnosed with ADHD and college students with self-reported
symptoms of ADHD.
Regarding students who have been diagnosed with ADHD, research suggests
that these students are more likely to report lower self-esteem ratings compared to
students without the disorder (Canu & Carlson, 2007; Dooling-Litfin, & Rosén,
1997; Shaw-Zirt et al., 2005). In addition, based on research by Kern, Rasmussen,
Byrd, and Wittschen (1999), college students with ADHD are more likely to be
“confrontive” and “aggressive” than college students without ADHD. They also
tend to be more independent and less rule focused and less likely to be influenced in
a positive or negative manner by corrective feedback. Interestingly, in the Kern et al.
study, all students were in good academic standing with the university, suggesting
that aggressive and confrontive personality characteristics of students with ADHD
did not negatively influence their academic performance.
Psychological impairment has also been studied with college students with
ADHD. For example, Heiligenstein et al. (1999) investigated psychological func-
tioning in 26 college students with previous ADHD diagnoses compared to students
without ADHD. Findings revealed that college students with ADHD did not show
evidence of psychological impairment on the inventory of common problems
(Hoffman & Weiss, 1986) compared to students without ADHD. Weyandt et al.
(1998), however, found that college students with ADHD reported greater psycho-
logical distress than control students on the Global Severity Index of the Brief
Symptom Inventory (BSI, Deragotis, 1992). Likewise, Heiligenstein and Keeling
(1995) in an earlier study found significant impairments in college students who
sought treatment at a university medical center and were subsequently diagnosed
with ADHD. The most common presenting problems for students in this study were
ADHD symptoms (55%), mood symptoms (21%), academic underachievement
(14%), and nonspecific learning disability (10%). Forty-five percent of students
reported no psychiatric comorbidities. Of the students who reported comorbid prob-
lems, difficulties included depressive disorders (26%), drug or alcohol abuse or
dependence (26%), legal difficulties (12%), anxiety disorders (5%), learning dis-
abilities (2%), and eating disorders (2%).
Issues with comorbidity, namely, depression, anxiety, and learning problems, have
been reported by other studies, including Rabiner and colleagues (2008) who found
higher rates of depression and learning problems in college students with ADHD.
Richards, Rosén, and Ramirez (1999) investigated differences in psychological func-
tioning in a sample of college students with diagnosed ADHD, ADHD symptoms
only, and control participants. Both the diagnosed ADHD and ADHD symptom
groups scored higher on the Symptom Checklist 90-Revised (SCL-90-R; Tennen,
Affleck, & Herzberger, 1985) compared to the control group supporting a relationship
between ADHD symptoms and psychological difficulties. Recently, however, Nelson
and Gregg (2012) investigated anxiety and depression symptoms among transitioning
students with ADHD and did not find significant impairments in these students. It is
difficult to ascertain why results across studies are inconsistent, but it is plausible that
student factors (e.g., age, sex, and treatment history) may influence the results as well
as methodological factors associated with each study. For example, the studies
often differ in the type of strategy they use to measure psychological impairment
(e.g., interview, self-report, type of instrument), and this could influence the findings.
In general, however, research suggests that college students with ADHD are at risk
for having additional psychological issues including depression, anxiety, learning
problems, and psychological distress. It is important to note that although students
with ADHD may perform with the normal range compared to a standardization
sample, they may still perform more poorly than their college peers.
Studies examining the relationship between ADHD symptomology and psycho-
logical variables are more numerous than studies with college students with docu-
mented ADHD. The findings, however, are similar to studies with college students
diagnosed with ADHD in that results have been inconsistent across investigations.
For example, Ramirez et al. (1997) found that students who reported significant
ADHD symptoms endorsed high scores on the psychoticism scale of the SCL-90-R
and reported more difficulties with anger. Similarly, Theriault and Holmberg (2001)
investigated whether ADHD symptomatology was associated with relationship
aggression using the conflict tactics scales (CTS2; Straus, Hamby, Boney-McCoy,
& Sugarman, 1996). Specifically, participants were asked to indicate how often they
engaged in various behaviors in conflict situations with their significant other in the
last 12 months. The results (based on a 7-point Likert scale) indicated that individuals
with ADHD symptoms were as likely to negotiate and no more likely to psychologi-
cally aggress toward a romantic partner. More recently, however, Wymbs and col-
leagues (2012), using data from the Pittsburgh ADHD Longitudinal Study, compared
the level of verbal aggression and violence reported by young adult males (18- to
25-year-old) with childhood ADHD to demographically similar males without
ADHD histories. Findings revealed that males with a history of childhood ADHD,
especially those with conduct problems persisting from childhood, were more likely
to be verbally aggressive and violent with romantic partners than males without
histories of ADHD or conduct problems.
College students who report significant levels of ADHD symptoms also appear to
have difficulty with decision-making and are more likely to report feelings of regret
about their decisions (Norvilitis, Sun, & Zhang, 2010; Schepman, Weyandt, Schlect,
& Swentosky, 2012). Interestingly, difficulties with career decision-making, social
and academic difficulties, and study skills are characteristic of college students with
high ADHD symptoms in the United States and in other countries (e.g., China)
(Norvilitis et al., 2010). On a related note, research has found that college students
who report significant levels of ADHD symptoms are also more likely to report lower
levels of life satisfaction (Gudjonsson, Sigurdsson, Eyjolfsdottir, Smari, & Young,
2009). These findings are consistent with studies with college students with docu-
mented ADHD who have also reported lower levels of life satisfaction.
Driving-related problems are also exhibited by college students with ADHD.
Woodward, Fergusson, and Horwood (2000) measured the degree to which attention
Functioning in Multiple Areas 31
difficulties at age 13 were associated with driving outcomes at age 21 in a

longitudinal sample of 1,265 New Zealanders. Analyses revealed that elevated
attention difficulties were related to statistically significant increases in involve-
ment in motor vehicle accidents, drinking and driving, being arrested for drinking
and driving, driving without a license and/or registration, engaging in street racing,
police contact for a driving offense, and total traffic violations later in life. These
findings are similar to those of Barkley, Murphy, DuPaul, and Bush (2002) who
found that college students with ADHD received more overall driving citations,
speeding violations, and license suspensions and revocations and were involved in
more motor vehicle accidents as the driver than those without ADHD. Richards,
Deffenbacher, and Rosén (2002) also examined the driving behavior of students
with high self-reported symptoms of ADHD in a sample of introductory psychology
students. Results indicated that these students reported more driving anger and more
aggressive behavior while driving, took more risks while driving, and were involved
in a greater number of motor vehicle accidents.
A handful of studies have attempted to identify factors predictive of ADHD
symptomatology. For example, Kaas, Wallace, and Vodanovich (2003) explored
whether boredom proneness and sleep disorders were predictive of ADHD symp-
toms using the Adult Behavior Checklist (ABCL; Barkley & Murphy, 1998), Athens
Insomnia Scale (AIS; Soldatos, Dikeos, & Paparrigopoulos, 2000), Boredom
Proneness Scale (BPS; Farmer & Sundberg, 1986), and the Epworth Sleepiness
Scale (ESS; Johns, 1992). Findings indicated that sleep disturbances and boredom
proneness were significant predictors of ADHD symptoms. Higher sensation-seek-
ing behavior and drug use have also been associated with higher levels of ADHD
symptomology (Hines & Shaw, 1993; Janusis & Weyandt, 2010).
Functioning in Multiple Areas
Given the various areas of functioning affected by ADHD, studies that examine
multiple deficits in a comprehensive fashion are important in promoting fuller
understanding of how the disorder affects college students. Weyandt, DuPaul, and
colleagues (under review) recently completed one of the few comprehensive inves-
tigations of multiple areas of functioning in college students with ADHD. Two
samples of students participated in this study including 24 young adults with ADHD
(M age = 20.2; SD = 1.2) and 26 without ADHD (M age = 20.0; SD = 1.2). Students
with ADHD met DSM-IV-TR criteria for ADHD on the basis of student and parent
report, while students without ADHD did not meet these same criteria. The two
samples were comprised primarily of males and individuals from White non-Hispanic
descent (see Table 3.1). Also, students from all four class levels were included.
The ADHD and non-ADHD samples were equivalent with respect to age, year in
college, gender ratio, ethnicity, and parents’ level of education; however, as expected,
statistically signi fi cant and large differences were evident with respect to
self-reported ADHD symptoms. In fact, Cohen’s d effect sizes indicated that group
differences in ADHD symptoms were 2.5 SD units or greater. Multiple measures
Table 3.1 Participant demographic information for college students with and without ADHD
Typical college students
ADHD (n = 24) (n = 26) c2 or t
Age in years (SD) 20.17 (1.20) 20.00 (1.17) 0.497
Year in college 2.224
Freshman 3 (13%) 5 (19%)
Sophomore 7 (30%) 6 (23%)
Junior 3 (13%) 7 (27%)
Senior 10 (44%) 8 (31%)
Gender 0.384
Male 15 (62.5%) 14 (54%)
Female 9 (37.5%) 12 (46%)
Ethnicity 4.724
White non-Hispanic 20 (91%) 25 (81%)
African American 1 (4.5%) 0 (0%)
Hispanic 0 (0%) 3 (11%)
Asian/Pacific Islander 1 (4.5%) 1 (4%)
Indian 0 (0%) 1 (4%)
Father’s level of 2.669
education
Less than HS 0 (0%) 0 (0%)
HS diploma or 6 (26%) 6 (23%)
equivalent
Some college 2 (9%) 3 (11%)
Bachelor’s degree 10 (43%) 7 (27%)
Graduate degree 5 (22%) 9 (35%)
Training program or 0 (0%) 1 (4%)
certificate
Mother’s level of 3.695
education
Less than HS 1 (4%) 0 (0%)
HS diploma or 3 (12.5%) 3 (11%)
equivalent
Some college 5 (21%) 4 (15%)
Bachelor’s degree 9 (37.5%) 8 (31%)
Graduate degree 6 (25%) 9 (35%)
Training program or 0 (0%) 2 (8%)
certificate
Conners’ Adult ADHD
Rating Scales
Inattention/memory 82.25 (7.57) 42.81 (7.24) 18.836*
problems
Hyperactivity/ 60.00 (11.07) 38.38 (5.59) 8.817*
restlessness
ADHD symptoms total 75.17 (10.05) 39.15 (7.39) 14.517*
ADHD index 58.04 (7.51) 36.12 (4.98) 12.255*
*p < 0.001
Functioning in Multiple Areas 33
70 d= d=
2.08 2.10 d=
d= 1.49
60
1.68
50
40
T-Score
ADHD
30
Control
20
10
0
BRIEFF BRI BRIEF Meta BRIEF GE SCL-90-RGSI
Measure
Fig. 3.1 Differences in executive and psychological functioning: college students with and without
ADHD. Cohen’s d effect size differences between college students with and without ADHD for
T-scores on the Behavior Rating Inventory of Executive Function (BRIEF), Behavioral Regulation
Index (BRI), Metacognition Index (Meta), and Global Executive Composite as well as on the
Global Severity Index (GSI) of the Symptom Checklist 90-Revised (SCL-90-R) (Adapted from
“The Performance of College Students with and without ADHD: Neuropsychological, Academic,
and Psychosocial Functioning” by L.L. Weyandt, G.J. DuPaul, G. Verdi, J.S. Rossi, A. Swentosky,
B.A. Vilardo, S.M. O’Dell, & K.M. Carson, 2012, manuscript under review)
were obtained from both samples including self-report of executive, social, academic,
and psychological functioning; direct testing of verbal learning and short-term
working memory; assessment of attention and impulse control; and self-report of
emotional expression and functioning.
Results indicated statistically significant group differences in executive functioning,
study and organizational skills, psychological symptoms, and social functioning.
Specifically, college students with ADHD obtained significantly higher (i.e., indicative
of greater deficit) T-scores on the Behavior Regulation Index, Metacognition Index,
and Global Executive Composite of the Behavior Rating Inventory of Executive
Function-Adult Version (BRIEF-A; Roth, Isquith, & Gioia, 2005). Although mean
T-scores on these scales were only in the mildly impaired range relative to the
BRIEF-A normative sample, these scores were 1.68 SDs or greater above scores
obtained by students in the non-ADHD sample (see Fig. 3.1). A similar statistically
significant and large (Cohen’s d = 1.49) group difference was found for mean T-score
on the Global Severity Index of the Symptom Checklist-90-Revised (SCL-90-R;
Derogatis, 1986). Again, students with ADHD were only mildly impaired on this
measure of psychological functioning in comparison with the SCL-90-R normative
sample; however, the gap in functioning relative to their non-ADHD peers was large.
Large, statistically significant group differences were also found for self-report of social
functioning when in the student work role as well as for study and organizational
skills (see Fig. 3.2). Not surprisingly, students without ADHD reported a higher level
of academic functioning relative to those with ADHD; this group difference was in
100 d = 0.69
80 d = 0.88
60
Score
d = 2.06
40 ADHD
Control
20
0
SAS-SR Acad Perf Study & Org
Skils
Measure
Fig. 3.2 Differences in social and academic functioning: college students with and without
ADHD. Cohen’s d effect size differences between college students with and without ADHD for
scores on the Social Adjustment Scale-Self-Report work role subscale (SAS-SR), Academic
Performance Rating Scale-Self (Acad Perf), and study and organizational skills ratings (Study and
Org Skills) (Adapted from “The Performance of College Students with and without ADHD:
Neuropsychological, Academic, and Psychosocial Functioning” by L.L. Weyandt, G.J. DuPaul, G.
Verdi, J.S. Rossi, A. Swentosky, B.A. Vilardo, S.M. O’Dell, & K.M. Carson, 2012, manuscript
under review)
the moderate range (Cohen’s d = 0.69). In contrast to these significant and large
group differences, very few if any differences were found on direct measures of
verbal learning, working memory, attention, and impulse control.
The results of the Weyandt and DuPaul et al. (under review) study have important
clinical implications. For example, these data provide compelling evidence of moder-
ate to large differences in numerous important areas of functioning between college
students with ADHD and the general student population. Thus, diagnostic assessment
of college students suspected of ADHD should focus not only on symptom presenta-
tion but should also include measures of impairment across areas of functioning criti-
cal to success in college. Ideally, these measures would include relevant norm groups
(i.e., other college students) so that impairment in the college setting can be assessed
more specifically. In addition, treatment of college students with ADHD should not
focus exclusively on reduction of ADHD symptoms, but rather should be directed to
improvement in academic, executive, psychological, and social functioning.
Summary
In summary, available research suggests that college students with ADHD are more
likely to encounter academic, social, and psychological difficulties than college students
without the disorder. In addition, it is important to note that although some college
Summary 35
students with ADHD may appear to be functioning within the normal range on
standardized instruments, they may be functioning relatively poorly compared to
their college student peers. Additional studies are warranted as, relative to the child
and adolescent literature, studies involving college students are scant. Future studies
are needed to better understand the types of academic impairments college students
with ADHD are likely to experience, and the development of prevention and inter-
vention methods is essential to help increase the likelihood that these students will
succeed in college. Well-designed studies are also needed to explore the social and
psychological functioning of college students with ADHD, and similar to academic
interventions, empirically supported treatment approaches need to be available for
these students. Currently, universities offer accommodations for students with doc-
umented ADHD; however, accommodations are not empirically supported treat-
ments. Studies are desperately needed to develop valid and reliable interventions
for college students with ADHD.
Chapter 4
Assessment of ADHD
Given the prevalence (i.e., 5%; Pryor, Hurtado, DeAngelo, Blake, & Tran, 2010) of
ADHD in the college population and legal mandates to provide services and accom-
modations for students with disabilities, college-based (e.g., counseling center) and
community-based clinicians are increasingly called upon to conduct ADHD evalu-
ations (Pazol & Griggins, 2012). Comprehensive psychological and educational
assessment procedures are necessary to identify college students with ADHD and to
ascertain those support services and/or interventions that may optimally address
symptoms and functional deficits. This chapter describes the purpose and goals of
assessment as well as a five-stage process for comprehensive evaluation that empha-
sizes a data-based decision-making approach. A multimethod assessment protocol
is described including diagnostic interviews; self-report rating scales; other-report
rating scales; tests of attention, impulse control, and neuropsychological function-
ing; archival data; and measures of academic, social, and occupational functioning.
Specific challenges to the assessment process (e.g., feigning of ADHD) are addressed
in detail. This chapter concludes with an illustrative case example.
Purpose and Goals of Assessment
The primary purpose of psychological assessment of college students suspected of

having ADHD is to identify whether the disorder is present and what other disorders
may either better explain apparent ADHD symptoms or may be comorbid with
ADHD (Cellucci, Remsperger, & McGlade, 2007). Thus, the first goal is to provide
a comprehensive diagnostic formulation that best explains difficulties that students
may be experiencing. Although diagnosis is an important outcome, assessment must
address other equally important goals (Parker & Benedict, 2002). Specifically, assess-
ment data should be used to plan support services and formulate treatment plans.
Stated differently, evaluation outcomes should help clinicians to individualize services
and interventions to meet the specific needs of college students with ADHD.

38 4 Assessment of ADHD
Table 4.1 Assessment of ADHD process

Process step Purpose
Screening Establish presence of some ADHD symptoms to determine
whether additional evaluation is necessary
Multimethod assessment Collect comprehensive data on symptoms as well as
psychological, social, educational, and, possibly,
occupational functioning across settings, measures, and
respondents
Interpretation of results Evaluate assessment data in context of DSM-V criteria to
reach diagnostic decisions
Treatment planning Use assessment data to plan and implement necessary
support services as well as psychosocial, educational,
and/or medical interventions
Evaluate treatment outcome Periodically collect assessment data to establish whether
intervention(s) lead to symptom reduction and enhanced
functioning. Make adjustments to intervention plan and
support services based on data
Finally, assessment should not end with diagnosis and the formulation of a treatment
plan but should continue such that intervention effectiveness can be examined.
A final goal for assessment is to determine whether treatment and support services
are reducing symptoms and enhancing functioning. Data should be used to make
treatment decisions including when and how services should be modified over time.
Assessment Process
The process of assessing ADHD in college students should be conducted in the

context of a data-based decision-making approach. As has been described for
younger children and adolescents, assessment is undertaken not simply to arrive at
a diagnosis but more importantly is focused on addressing problems and challenges
that students are facing with respect to possible symptoms and functional deficits
(Anastopoulos & Shelton, 2001; DuPaul & Stoner, 2003). We believe that a five-
step process is necessary to comprehensively address diagnostic and treatment
goals. The steps include screening of ADHD, multimethod assessment of ADHD,
interpretation of assessment data, treatment planning, and evaluation of treatment
outcomes (see Table 4.1).
Screening
Upon referral for academic, behavioral, and/or social difficulties, students should
be screened for possible ADHD symptoms. In other words, ADHD should be
considered as a viable hypothesis for student difficulties that could be related to
Assessment Process 39
inattention and/or hyperactivity-impulsivity. The most cost-efficient screening

method is to have students complete a brief rating scale regarding the presence and
severity of current ADHD symptoms (e.g., Conners Adult ADHD Rating Scale-
Screening Form; Conners, Erhardt, & Sparrow, 1999). Alternatively, Reilley (2005)
suggests the use of behavioral screening measures such as tests of attention (e.g.,
computerized continuous performance tests), cognition (e.g., verbal learning/
memory tests), psychomotor speed (e.g., digit symbol tests), and neuropsychologi-
cal functioning. In a systematic review of the literature, Reilley found moderate
effect size differences between adults with ADHD and controls on several screen-
ing measures; however, no data regarding sensitivity and specificity were pre-
sented. Also, it is important to note that use of direct tests as screening measures is
less efficient than self-report ratings.
If self-report ratings cross a specific threshold (e.g., 90th percentile for individu-
al’s sex and age) for inattention or hyperactive-impulsive symptoms, then additional
evaluation of ADHD may be warranted. Although self-report of ADHD symptoms
may yield both false positives (i.e., students identified with ADHD through screen-
ing who do not have the disorder) and false negatives (i.e., students with ADHD
who are not identified by screening), this is most likely the most cost- and time-
efficient screening method (Smith & Johnson, 2000).
Multimethod Assessment
If screening indicates that ADHD may be present, then a comprehensive evaluation

should be conducted using multiple methods including (a) assessment of the fre-
quency and severity of ADHD symptoms over past 6 months using a clinical inter-
view and symptom rating scales; (b) documentation of the impact of symptoms on
multiple domains of functioning especially academic performance through inter-
view, review of archival educational and occupational records, and other reports
(e.g., parent, spouse, faculty, employer); (c) confirmation of childhood history of
ADHD through retrospective symptom ratings (from student and parent) and school
records; (d) comprehensive documentation of individual and family developmental,
medical, academic, and psychiatric histories; and (e) examination of possible
comorbid conditions (e.g., depression, anxiety disorder) (Barkley and Murphy
2006; Pazol & Griggins, 2012; Wolf, 2001; Wolf, Simkowitz, & Carlson, 2009).
Additional assessment methods could include checklists regarding behaviors asso-
ciated with ADHD (e.g., internal restlessness) as well as executive functioning (e.g.,
organizational skills, time management, and planning), interview(s) with people in
close contact with the student, measurement of how long the student can sustain
attention as well as inhibit behavior (e.g., CPT), and tests of intellectual function-
ing, cognitive processing, and academic achievement to rule out possible learning
disabilities (Levrini & Prevatt, 2012).
This multimethod assessment approach is very similar to that described for
children and adolescents (e.g., Anastopoulos & Shelton, 2001; Barkley, 2006);
however, there are important modifications relevant to the needs of college students.
Specifically, the inclusion of reports from others (e.g., roommates, romantic part-
ners) may be helpful in assessing current symptoms and functional impairments.
Further, evaluation of executive and psychosocial functioning is critical given the
emphasis on independent self-care and completion of assigned responsibilities in
this population.
Despite the consensus that a multimethod evaluation approach is optimal, few
studies have actually examined the utility of this approach from an empirical
perspective. In fact, we were able to find only one study examining multimethod
assessment of ADHD in a college sample. Robeva, Penberthy, Loboschefski, Cox,
and Kovatchev (2004) investigated the combination of Wender Utah Rating Scale
(WURS) scores with two electroencephalogram (EEG) indices (consistency index
and alpha-blocking index) in identifying ADHD or non-ADHD status in a small
sample (n = 6) female college students. Bayesian analyses were used to assess the
probability of ADHD following each assessment method. Although classification
accuracy for any single measure was <85%, the combination of measures correctly
classified all participants. Although the results of this study are promising, conclu-
sions regarding multimethod assessment are limited by the small, single-gender
sample and the atypical battery of measures used (in contrast to the more typical
combination of clinical interviews, student and parent rating scales, and direct
behavioral measures as described previously) (DuPaul, Weyandt, O’Dell, &
Varejao, 2009).
Interpretation of Assessment Data
The results of the evaluation are interpreted primarily in reference to DSM criteria
for ADHD and other disorders. First, the clinician must look for evidence indicating
the significant presence of at least four symptoms of inattention or at least four
symptoms of hyperactivity and impulsivity. In order for a symptom to be considered
clinically significant, the behavior must (a) occur persistently for at least 6 months,
(b) be evident to a degree that is inconsistent with the student’s developmental level
(i.e., late adolescence–young adulthood), and (c) directly impact daily social and
academic/occupational activities. Typically, symptom presence and significance are
established through student and/or parent responses on the diagnostic interview and
symptom rating scales. The latter are particularly helpful in documenting the degree
to which symptomatic behaviors are inconsistent with a student’s developmental
level as rating scale scores can be compared with normative data. Various thresh-
olds for clinical significance on rating scales have been recommended; however,
most experts use a 93rd or 95th percentile cut point (Anastopoulos & Shelton, 2001;
Barkley, 2006). Given that college settings present unique demands and expecta-
tions upon a relatively high-functioning segment of the population, normative data
based on the general adult population may result in relatively conservative ADHD
identification rates (McKee, 2008). Self-report ratings of college students with
ADHD may actually be in the mildly impaired or even normal range relative to
general population norms; however, when these ratings are compared with those
obtained from college students without ADHD, large differences may be evident
(Weyandt, DuPaul et al., under review). Thus, it may be beneficial to use ratings that
provide college student normative data in order to definitively characterize the
significance of ADHD symptoms. Unfortunately, very few measures provide
specific college-based norms.
Second, the clinician must establish that several significant ADHD symptoms
were present by the age of 12, in accordance with DSM-V criteria. This information
can be gleaned from parent and student response to symptom history questions on
the diagnostic interview. Further, retrospective ratings of childhood ADHD symp-
toms can be obtained from the student and parent. The significance of symptoms on
retrospective ratings could be established by comparing scores with childhood
norms. Finally, archival data such as educational records or prior psychoeducational
evaluation reports can be helpful in documenting a childhood history of ADHD
symptoms.
Third, symptoms must be evident in two or more settings. For children and ado-
lescents, this criterion is evaluated in a relatively straightforward fashion by exam-
ining evidence for ADHD symptoms across home and school. For college students,
this criterion is a bit more challenging to evaluate; however, the clinician can con-
sider parent report as evidence for symptoms in the home setting, while student
self-report or report from others in the college environment can establish symptom-
atic presence at school. If the student is employed, it is possible to obtain employer
report regarding symptoms in the work environment.
A critical diagnostic criterion requires ADHD symptoms to clearly interfere with
or reduce the quality of academic, social, or occupational functioning. Here, the
clinician must consider self- or other-report ratings of social relationships, executive
functioning, study skills, and/or academic performance. If available, cognitive, aca-
demic, or neuropsychological test scores can be considered. Course grades and
overall grade point average (GPA) are helpful in evaluating whether academic per-
formance is compromised. Of course, subjective judgments must be made when
deciding what level of performance is needed to establish impairment. For example,
what GPA level is necessary to establish impairment? Would failing grades be
required or would impairment be evident with passing grades that are lower than
what the student obtained in high school? Unfortunately, there are no clear guide-
lines for impairment thresholds, and the clinician must rely on experience and logic
(e.g., student considered impaired if two or more “D” grades are obtained in a given
semester) in reaching such decisions.
Next, diagnostic interview and symptom rating scales should be consulted in rul-
ing out other disorders in accounting for symptomatic behaviors. DSM-V criteria
specifically identify schizophrenia, other psychotic disorders, mood disorders,
anxiety disorders, personality disorders, and dissociative disorder as conditions to
consider as possible rule-outs. The fact that some of these disorders (e.g., depression,
anxiety disorder) may occur along with ADHD in a significant percentage of
individuals complicates differential diagnosis.
Finally, the specific subtype of ADHD should be identified, primarily based on

the pattern and number of symptoms in the attention and hyperactive/impulsive
categories. Once again, diagnostic interview and symptom rating scale data should
be consulted. The DSM-V includes two variations of inattentive presentation, pre-
dominately inattentive presentation and inattentive presentation (restricted), the lat-
ter of which is sometimes referred to in the literature as sluggish cognitive tempo.
Barkley (2011) has presented data supporting the contention that sluggish cognitive
tempo or ADHD, inattentive presentation (restricted) is a separate and distinct dis-
order from other forms of ADHD. Whether this is actually a separate disorder or a
subtype of ADHD needs to be explored via research; however, it is possible that
inattention presentation (restricted) may have particular relevance for cognitive and
executive functioning impairment in college students.
Design of Treatment Plan
Clinicians must use assessment data not only to make diagnostic decisions but, of
equal import, to identify support services and treatment strategies that will best
meet the needs of students. Although no empirical guidelines exist to guide the
treatment planning process, there are salient factors that should be considered based
on clinical experience. Clinicians should consider the overall severity of ADHD
symptoms and degree to which critical areas of functioning (e.g., academic perfor-
mance) are impaired when planning treatment. The more severe the symptoms and/
or impairment, the more that intensive support services and treatment components
(including medication) may be necessary.
The presence of comorbid disorders (e.g., mood disorder, anxiety disorder,
learning disabilities) will necessitate inclusion of interventions to directly address
symptoms of other disorders. For example, if a student is found to have both
ADHD and LD, specific educational accommodations and tutorial support will
typically be needed to address learning challenges above and beyond any support
related to ADHD.
Many college students with ADHD will have received various support services
and/or treatment during their childhood and adolescence. Clinicians should con-
sider the student’s prior response to specific treatments in developing a plan for the
college environment. Parent and student report of prior treatment response as well
as archival data (e.g., educational records, reports from prior psychoeducational,
medical, or psychiatric evaluations) can be helpful in establishing a history of
treatment response. In cases where prior or current treatment has a strong record of
positive response, then there may be no need to make significant changes other
than adding components that may address any new challenges encountered in the
college environment.
Finally, the pattern of a student’s academic strengths and weaknesses can inform
treatment decisions particularly in relation to educational accommodations, support,
or supplemental instruction. Educational records, reports from prior psychoeducational

evaluations, and results from current cognitive, neuropsychological, or academic
achievement tests may be helpful in this regard.
Clinicians need to collaborate with students with ADHD in designing and
planning support services and intervention (Parker & Benedict, 2002). Collaboration
should take a problem-solving focus where the clinician interprets assessment
results for the student, and these are used to identify strengths that can be used to
enhance treatment as well as weaknesses that are directly addressed by support
strategies and interventions. In particular, the clinician and student should focus on
the question “What steps can be taken to ameliorate problems?” (Parker & Benedict,
p. 9). If students understand the nature of the challenges that need to be addressed
and are full participants in designing a support and intervention plan, then they
presumably will be motivated to follow through on prescribed procedures.
Evaluation of Treatment Outcome
Following implementation of support services and intervention, data should be

collected periodically to assess changes in ADHD symptoms and functioning (aca-
demic, social, and/or occupational). Anastopoulos and Shelton (2011) describe an
eight-step outcome evaluation process that includes determining desired treatment
outcomes, determining criteria for success, selecting methods of evaluation, collect-
ing baseline data, determining the integrity of intervention, measuring outcomes,
determining treatment efficacy and cost/benefit analysis, and continuing, modify-
ing, or replacing treatment based on outcome data. Although this eight-step process
was designed for treatment evaluation with children and adolescents, the same steps
may be applicable for evaluating intervention in the college setting. During the ini-
tial stages of treatment and support, data should be collected relatively frequently
(e.g., weekly) so that adjustments to treatment components can be made when nec-
essary. Once the plan is relatively stable, then reassessment can be conducted on a
monthly basis or at the end of each semester.
The specific measures used to assess treatment response will vary across indi-
viduals as a function of the primary areas of concern and the nature of the
intervention(s) and support services. For example, DuPaul et al. (2012) used the
ADHD Index from the CAARS-Short Form and the Metacognition Index from the
Behavior Rating Inventory of Executive Functioning-Adult Version (BRIEF-A;
Roth, Isquith, & Gioia, 2005) to evaluate the effects of lisdexamfetamine dimesy-
late for a sample of college students with ADHD (see Chap. 6 for more details).
These two measures were chosen because the ADHD Index provided a brief,
focused assessment of ADHD symptoms, while the Metacognition Index tapped
possible changes in working memory, planning and organization, task monitor-
ing, and organizing of materials. The latter are considered critical to academic
success in college.
Assessment Measures
Comprehensive assessment of ADHD in college students requires multiple measures

and methods across several respondents. Specific measures include diagnostic inter-
views with the student and parent; current and retrospective symptom ratings from the
student, parent, and possibly others (e.g., roommate, professors); tests of attention,
impulse control, verbal memory, and neuropsychological functioning; assessment of
possible functioning in key domains (e.g., academic and social); and archival data
regarding academic functioning and previous diagnostic evaluations. Each of these
assessment components is described in detail along with examples of specific measures
in each category (Table 4.2). The measures receiving the most substantive empirical
attention have been student self-report and parent-report symptom ratings; therefore,
these assessment strategies are discussed in greater detail than other methods.
Diagnostic Interview
Diagnostic interviews with the student and parent(s) provide critical data with respect
to current symptoms of ADHD as well as symptoms of other emotion and behavior
disorders; information regarding developmental, educational, medical, and family
Table 4.2 ADHD assessment measures

Type of assessment measure Examples
Diagnostic interview Adult interview (Barkley & Murphy, 2006)
Student self-report ratings-current symptoms CAARS, ASRS, BADDS, CARE,IRS,
SCL-90-R, ASSIST
Student retrospective ratings WURS
Parent ratings-current symptoms CARE, BADDS
Other informant ratings-current symptoms AISRS
Parent ratings-childhood symptoms Childhood Symptoms Scale
Tests/direct measures CCPT-II, CVLT, TOVA
Measures of functional impairment WIAT-III, BRIEF-A, LDA, LASSI,
SAS-SR, QLI, SRS, DBRS
Archival data Grade transcripts, prior psychological/
psychiatric reports
Note. CAARS Conners Adult ADHD Rating Scales, ASRS Adult ADHD Self-Report Scale,
BADDS Brown Attention Deficit Disorder Scales, CARE College ADHD Response Evaluation
System, IRS Internal Restlessness Scale, SCL-90-R Symptom Checklist 90-Revised,
ASSIST Alcohol, Smoking, and Substance Involvement Screening Test, WURS Wender Utah
Rating Scale, AISRS Adult ADHD Investigator Symptom Rating Scale, CCPT-II Conners
Continuous Performance Test-II, CVLT California Verbal Learning Test, TOVA tests of variables
of attention, WIAT-III Wechsler Individual Achievement Test, BRIEF-A Behavior Rating Inventory
of Executive Function-Adult Version, LDA Learning Difficulties Assessment, LASSI Learning and
Study Strategies Inventory, SAS-SR Social Adjustment Scale-Self-Report, QLI Quality of Life
Inventory, SRS Sexual Risk Survey, DBRS Driving Behavior Rating Scale
Assessment Measures 45
histories; and description of current and prior treatments to address presenting

difficulties. Thus, a comprehensive interview will include detailed questions designed
to address these important aspects of a student’s current and past functioning. It is par-
ticularly critical that students and parents independently provide specific information
regarding the presence, frequency, and severity of symptoms of ADHD and other dis-
orders in the context of DSM criteria. Because ADHD is a chronic disorder that first
appears in childhood (i.e., prior to the age of 12), reports regarding both current and
childhood symptoms are necessary. Although structured psychiatric interviews are
available (e.g., Structured Clinical Interview for DSM Disorders; First, Spitzer, Gibbon,
& Williams, 1996), these may be cumbersome and time-consuming for typical clinical
practice. In our experience, a semi-structured interview (e.g., Barkley & Murphy, 2006)
may be optimal in balancing the need for specific, comprehensive information regard-
ing symptoms with an appropriate level of flexibility to accommodate clinical practice.
For more details regarding the diagnostic interview in the context of adult ADHD
evaluation, readers should consult Murphy and Gordon (2006).
Self-Report Rating Scales
Students should complete self-report rating scales that assess current and childhood
symptoms of ADHD as well as current symptoms of other emotion and behavior
disorders.
Current Symptoms
Several rating scales provide reliable and valid data regarding self-report of ADHD
symptoms in adults. For example, the Conners Adult ADHD Rating Scales (CAARS;
Conners, et al., 1999) provide frequency ratings for the DSM-IV-TR (American
Psychiatric Association, 2000) symptoms of ADHD. The CAARS is comprised of
three different versions—long, short, and screening—each of which can be com-
pleted by self or observer report. The 30-item screening form is ideal for diagnostic
purposes as it contains a 12-item ADHD Index and three ADHD symptom scales
(inattention, hyperactive-impulsive, and total) based on DSM-IV-TR criteria.
Although the CAARS has adequate reliability and validity, at least one study has
shown that this measure does not adequately discriminate between ADHD and other
adult psychiatric disorders (Van Voorhees, Hardy, & Kollins, 2011). Thus, it may be
best viewed as an initial screener that must be supplemented with other measures to
aid in differential diagnosis.
A similar, albeit shorter, self-report measure is the Adult ADHD Self-Report
Scale (ASRS; Kessler et al., 2005) that includes 18 items corresponding to DSM-
IV-TR symptoms of ADHD. Respondents indicate the frequency of each symptom
on a four-point Likert scale. The ASRS has demonstrated adequate reliability and
validity in clinical samples (e.g., Adler et al., 2006). Further, the ASRS was found
to significantly discriminate between college students with ADHD receiving psy-
chotropic medication, college students with ADHD not receiving treatment, and
students without ADHD (Garnier-Dykstra, Pinchevsky, Caldeira, Vincent, & Arria,
2010). The Brown Attention Deficit Disorder Scales (BADDS; Brown, 2001)
include an adult version (i.e., 18 years old and up) that is comprised of 40 items
assessing five categories of ADHD-related impairments in executive functioning
(organizing, prioritizing, and activating to work; focusing, sustaining, and shifting
attention to tasks; regulating alertness, sustaining effort, and processing speed;
managing frustration and modulating emotions; and utilizing working memory and
accessing recall). Like the CAARS, the ASRS and BADDS are best viewed as
screening measures that should be supplemented with additional rating scales and
other measures in a comprehensive evaluation.
The most widely studied assessment measure for the college population is the College
ADHD Response Evaluation System (CARE; Glutting, Sheslow, & Adams, 2002).
CARE includes a 90-item self-report inventory focused on ADHD symptoms and related
behavioral/functioning difficulties that may be experienced by college students with this
disorder. The CARE system was developed to aid in screening and evaluation as well as
to identify specific areas of weakness that can be targeted for intervention.
Several studies have examined the psychometric properties of CARE ratings. For
example, Glutting, Monaghan, Adams, and Sheslow (2002) examined the factor struc-
ture, internal consistency, and 1-year predictive validity of CARE ratings in a sample
of 680 first-year college students and their parents at several northeastern universities.
Principal axis factor analysis with oblique rotation resulted in three factors for student
ratings including student-rated inattentiveness, student-rated hyperactivity, and stu-
dent-rated academic time-management problems. Internal consistency estimates
(coefficient alphas) for two of the factors were adequate (i.e., ³0.70) but less than
adequate for the student-rated hyperactivity factor (a = 0.69). The predictive validity
of student ratings may be limited as multiple regression analyses indicated that stu-
dent symptom ratings did not contribute to end-of-freshman-year GPA prediction.
Two additional studies examined the structure and psychometric properties of
the CARE. Glutting, Youngstrom, and Watkins (2005) used the standardization
sample for this measure (N = 1,080 first-year college students and their parents) to
examine whether the factor structure of symptom reports varied as a function of
respondent (parent or student) or student gender. Exploratory and confirmatory fac-
tor analyses indicated a 3-factor structure (inattention, impulsivity, and hyperactiv-
ity) for student reports and a 2-factor structure (inattention and hyperactivity/
impulsivity) for parent reports. Factor structure was consistent across genders.
Konold and Glutting (2008) examined the degree to which trait and method vari-
ance contributed to measurement of ADHD symptoms using the CARE. A corre-
lated trait-correlated method confirmatory factor analysis was used with the CARE
standardization sample indicating that parent ratings were superior measures of
internalizing symptoms while student ratings were better for assessing externalizing
symptoms. Further, method and source variance contributed more than trait variance
to ADHD symptom ratings as has been found for parent and teacher ratings of
younger children (Gomez, Burns, Walsh, & Hafetz, 2005).
Relative to other assessment measures for the college student population, the
CARE has received a good deal of empirical attention and appears to be a reliable
and valid measure of ADHD symptoms in this age group. Nevertheless, this mea-
sure is limited by use of an agree/disagree response format rather than a Likert
scale allowing for more responses along a continuum (e.g., “not at all,” “some-
times,” “often,” “very often”) that is more typical for ADHD rating scales with
younger age groups (DuPaul et al., 2009). Further, the standardization sample is
limited by a relatively low response rate (approximately 36% according to Glutting,
Sheslow, et al., 2002) and the collection of data during freshman orientation (i.e.,
before respondents were actually college students). Thus, the degree to which stan-
dardization data can be generalized to the college population as a whole may be
limited. It is also noteworthy that a three-factor structure has been found consis-
tently for this instrument, perhaps indicating that it may be important to assess
attention, impulse control, and hyperactivity separately in college students (Proctor
& Prevatt, 2009).
Another self-report rating scale specifically developed for the college popula-
tion may aid in examining hyperactivity separate from other ADHD dimensions.
Weyandt and colleagues (2003) developed the Internal Restlessness Scale (IRS)
to assess symptoms of mental restlessness that may be manifestations of hyperac-
tivity in this age group. In the first of two study phases, IRS ratings were com-
pared for 20 students with ADHD relative to 20 students without ADHD. As
expected, college students with ADHD reported significantly higher frequency of
internal restlessness symptoms relative to their non-ADHD counterparts. In a sub-
sequent phase of this study, a randomly selected sample of 477 students com-
pleted IRS ratings to assess the factor structure of this measure. A principal axis
factor analysis followed by promax rotation indicated four factors (internal dis-
tractibility, internal restlessness, internal impulsivity, and internal disorganiza-
tion). Further, 4-week test-retest reliability for the total IRS score was 0.80. Thus,
the IRS appears useful for the assessment of ADHD in college students; however,
more research is needed because it has been examined in the context of a single
study at one university.
Self-report ratings of psychopathological symptoms beyond ADHD should also
be included for the dual purpose of differential diagnosis and assessment of possible
comorbid disorders. For example, the Symptom Checklist 90-Revised (SCL-90-R;
Derogatis, 1986) is a 90-item self-report questionnaire assessing psychopathologi-
cal symptoms including somatization, obsessive-compulsive, interpersonal sensitiv-
ity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.
This scale also includes three global indices: Global Severity Index (GSI), Positive
Symptom Total (PST), and Positive Symptom Distress Index (PSDI). The SCL-
90-R has been shown to have adequate reliability and validity. The discriminant
validity of the SCL-90-R in the college ADHD population was demonstrated by
Richards, Rosén, and Ramirez (1999) who investigated differences in psychological
functioning in a sample of college students with confirmed ADHD, ADHD by self-
report only, and without ADHD. Both ADHD groups scored significantly higher
than the control group on every SCL-90 scale except for paranoid ideation which
was equivalent across all three groups.
A final area of potential difficulty that should be explored using self-report is the
use and abuse of alcohol and illicit substances. Probably the most comprehensive
self-report measure is the Alcohol, Smoking, and Substance Involvement Screening
Test (ASSIST; WHO ASSIST Working Group, 2002). This measure has been used
extensively to evaluate drug use and dependency. The ASSIST includes ten items
tapping frequency of use of various substances as well as dependency and impair-
ment as a function of using substances. The reliability and validity of this measure
is adequate, and the ASSIST has been found to discriminate between ADHD and
controls in a male adolescent population (Szobot et al., 2007).
Retrospective Symptoms
According to DSM-V criteria, ADHD is a disorder of childhood onset with impair-

ing symptoms appearing by age 12. Thus, data are needed to document a significant
childhood history. One way to accomplish this is by having students complete ret-
rospective ratings of childhood ADHD symptoms. Unfortunately, there are few rat-
ing scales constructed specifically for this purpose, and there is scant research
documenting the psychometric properties of retrospective symptom ratings.
Wierzbicki (2005) assessed psychometric properties of the Wender Utah Rating
Scale (WURS; Ward, Wender, & Reimherr, 1993) in a college student sample.
A convenience sample of 111 college students enrolled in an introductory psychol-
ogy course completed the WURS on two occasions four weeks apart. The scale was
found to have reasonable internal consistency (>0.87) but relatively modest test-
retest reliability (r = 0.68). WURS ratings were moderately correlated with mood
symptoms on the Beck Depression Inventory (Beck, Steer, & Brown, 1996). The
WURS appears to have some utility for the assessment of ADHD in college
students; however, more research is needed because it has been examined in
the context of a single study at one university. Further, the degree to which retro-
spective ratings provide accurate reflections of childhood symptoms is unclear.
Parent Rating Scales
As is the cases for student self-report, parents should complete rating scales that assess
student exhibition of current and childhood symptoms of ADHD. Parent ratings are
particularly critical with respect to child symptoms as they may have a more accurate
recollection of child functioning and difficulties than do students, themselves.
Current Symptoms
The CARE assessment system (Glutting, Sheslow, et al., 2002) described previ-
ously for student self-report also includes parent ratings of current symptoms and
functioning. Specifically, parents are asked to complete 44 items regarding ADHD
symptoms and related behavioral/functioning difficulties. Glutting, Monaghan,

et al. (2002) examined factor structure, internal consistency, and predictive valid-
ity of CARE parent ratings. As was the case for CARE self-report ratings, three
factors were identified: parent-rated inattentiveness, parent-rated hyperactivity,
and parent-rated impatience. It should be noted that Glutting et al. (2005) found a
two-factor structure for CARE parent ratings that conformed to DSM symptom
dimensions of inattention and hyperactivity-impulsivity. As for internal consis-
tency, coefficient alphas for the three factors found in the Glutting, Monaghan,
et al. (2002) study were adequate (i.e., ³0.70). The contribution of CARE scores
in predicting end-of-freshman-year grade-point average (GPA) was examined
using bivariate correlations as well as multiple regression analyses that controlled
for predictive contributions of Scholastic Aptitude Test (SAT) scores. Results
indicated that CARE parent ratings, particularly inattentiveness, contributed
significant variance (approximately 7%) in prediction of freshman year GPA over
and above SAT scores (Glutting, Monaghan, et al., 2002). This evidence of pre-
dictive validity is in contrast to the lack of predictive value of CARE self-report
ratings in this same study. Finally, as mentioned previously, a correlated trait-
correlated method confirmatory factor analysis with the CARE standardization
sample indicated that parent ratings were superior measures of internalizing
symptoms, while student ratings were better for assessing externalizing symp-
toms (Konold & Glutting, 2008).
Parent ratings on the CARE appear to provide reliable and valid perceptions
regarding current ADHD symptoms and related difficulties in college students.
However, some of the same limitations noted for CARE self-report ratings are
applicable. Specifically, ratings limited by use of an agree/disagree response format
rather than a Likert scale allowing for more responses along a continuum of symp-
tom frequency. Further, the standardization sample is limited by a relatively low
response rate (approximately 36% according to Glutting, Sheslow et al., 2002) and
the collection of data during freshman orientation (i.e., before respondents were
actually college students). The degree to which standardization data for CARE par-
ent ratings can be generalized to the college population as a whole may be limited
(DuPaul et al., 2009).
Although not a parent-report measure, it is worth noting that clinician symptom
report ratings have been studied for use in evaluating ADHD in adults. The Adult
ADHD Investigator Symptom Rating Scale (AISRS; Spencer, Adler, et al., 2010)
includes 18 items that are directly adapted from DSM-IV-TR symptoms for ADHD.
In addition to the items, clinicians can use prompts for each item to increase
confidence in obtained responses. Items are scored on a four-point Likert scale
related to symptom severity (i.e., ranging from none to severe). Spencer and col-
leagues found the AISRS to have adequate internal consistency as well as good
convergent and discriminant validity in comparison with other measures.
Specifically, the AISRS was found to correlate highly with the investigator rating
version of the CAARS, to have a factor structure that conforms with DSM symp-
tom dimensions, to yield scores that are stable over time, and to demonstrate sen-
sitivity to medication effects. Thus, the AISRS may be a useful adjunct to student
self-report and parent report of symptoms.
Retrospective Symptoms/Functioning
As is the case for student self-report, it is critical to obtain parent perceptions of

childhood ADHD symptoms in order to establish childhood onset of symptoms and
impairments as per DSM-V criteria. For example, Barkley and Murphy (2006) pro-
vide a brief rating (i.e., the Childhood Symptoms Scale) of the 18 DSM-IV-TR
ADHD symptoms that parents can complete with respect to their child’s behavior
when between the ages of 5 to 12. Unfortunately, although parent retrospective
symptom ratings are frequently recommended (e.g., Murphy & Gordon, 2006), we
were unable to locate any empirical studies delineating the psychometric properties
of retrospective rating scales. In the absence of supporting research, clinicians must
exercise caution in interpreting parent retrospective ratings.
Tests/Direct Measures
Multimethod assessment of ADHD in college students may also include direct

testing and measurement of attention, impulse control, working memory, and
neuropsychological functioning. Some measures recommended in the clinical
literature include the Conners Continuous Performance Test-II (CCPT-II;
Conners, 2000), the Digit Span Test (Wechsler, 1997), and the California Verbal
Learning Test (CVLT; Delis, Kramer, Kaplan, & Ober, 1987). Given putative
deficits in executive functioning associated with ADHD, tests such as the trail-
making test (Reitan, 1958), Stroop color-word task (Stroop, 1935), and the con-
trolled word association test (Benton, Hamsher, & Silvan, 1994) have been
recommend (Reilley, 2005).
Although at least one investigation found moderate effect sizes (Cohen’s
d ³ 0.50) between college students with ADHD relative to controls on scores from
these tests (Reilley, 2005), most studies have found either small or no differences.
For example, Weyandt et al. (1998) compared a group of students diagnosed with
ADHD students to a group of students with developmental reading disorder as
well as a control group. Groups were compared on self-report measures of current
and childhood ADHD symptoms, as well as various tests of executive functioning
including a computerized version of the Tower of Hanoi, tests of variables of
attention (TOVA; Greenberg, 1997), the Wisconsin Card Sorting Test (Grant &
Berg, 1948), and the Ravens Standard Progressive Matrices (Raven, Court, &
Raven, 1992). Findings revealed that the group with developmental reading dis-
order made significantly more errors on the Wisconsin Card Sorting Test than the
control group; however, no differences were found between the groups on any of
the other neuropsychological measures. In a subsequent study, Weyandt, Mitzlaff,
and Thomas (2002) compared scores on the TOVA and the freedom from distract-
ibility factor of the Wechsler Adult Intelligence Scales-Revised (WAIS-R;
Wechsler, 1981) between college students with and without ADHD. Although
students with ADHD made more errors of omission than the nondisabled
comparison group, no differences between groups were found on the WAIS-R

freedom from distractibility factor, errors of commission on the TOVA, mean
response time, or variability. Similarly, Linterman and Weyandt (2001) found no
differences between college students with and without ADHD in the ability to
maintain divided attention. More recently, Semrud-Clikeman and Harder (2011)
found no group differences on a battery of neuropsychological measures between
college students with ADHD relative to a non-ADHD comparison group.
Alternatively, some neuropsychological data, primarily related to impulse con-
trol, predicted writing mechanic skills in this sample. Finally, Weyandt and col-
leagues (under review) found no differences in CVLT scores between college
students with ADHD and a non-ADHD comparison group.
As was the case for TOVA scores, studies examining ADHD versus non-
ADHD group differences in CCPT performance have yielded mixed results, at
best. Advokat, Martino, Hill, and Gouvier (2007) found college students with
ADHD to obtain more omission errors and higher levels of variability on the
CCPT compared to students without ADHD. However, no further group differ-
ences were found for remaining CCPT scores. Similarly, Weyandt et al. (under
review) found college students with ADHD to exhibit greater variability in
standard error of reaction time on the CCPT-II relative to comparison students
without ADHD.
Given the nonexistent or scant differences in test performance between college
students with and without ADHD, clinicians should interpret neuropsychological
test findings with caution. A strict interpretation of test scores may result in false-
negative diagnostic decisions wherein college students with ADHD based on other
measures may go undetected by direct tests of attention, impulse control, and execu-
tive functioning. Certainly, no single test or combination of direct assessment mea-
sures should be used to make diagnostic decisions. Alternatively, these tests may
help identify cognitive and behavioral strengths and weaknesses that can be incor-
porated into treatment and support plans.
Measures of Functional Impairment
In addition to evaluation of symptoms of ADHD and other psychopathological dis-

orders, comprehensive assessment will include measures of student functioning in
important areas including academic, social, occupational, and other (e.g., driving)
domains. Assessment of functioning is important for at least two reasons. First,
DSM-V criteria for ADHD require symptoms to be associated with significant func-
tional impairment. Thus, data regarding functioning is critical for accurate diagnos-
tic decision-making. Second, knowledge regarding student functioning will inform
intervention planning in terms of what areas should be targeted for support and
intervention as well as providing baseline data to evaluate treatment efficacy. Most
currently available assessment techniques rely on student self-report, although
direct testing is possible in the educational domain.
Multiple measures are available to assess academic performance and associated

activities (e.g., study skills) in college students. First, direct tests of educational achieve-
ment can be used to assess student performance across major academic areas in rela-
tion to representative, standardization samples of adults. For example, The Wechsler
Individual Achievement Test (WIAT-III; Psychological Corporation, 2009) can be
used to assess reading, math, written language, and oral language skills. The WIAT-
III includes 16 subtests with normative data for individuals ranging from 4 to
50 years old. The main advantages of a norm-referenced achievement test like
the WIAT-III are the strong standardization of content, process, and normative data.
Alternatively, test content may not have a direct relevance for college students, and
specific norms for college students are not provided. Nevertheless, an achievement
test like the WIAT-III may be helpful in characterizing students’ academic status
relative to similar-aged peers as well as to pinpoint areas of educational strength and
weakness that may be relevant for intervention planning.
Student academic functioning can also be assessed using self-report measures.
The Learning Difficulties Assessment (LDA; Kane, Walker, & Schmidt, 2011) is a
web-based self-report survey of perceived difficulties in reading, writing, spelling,
math, listening, concentration, memory, organizational skills, sense of control, and
anxiety that has norms for college students. The LDA is designed to identify indi-
vidual learning strengths and weaknesses, provide students with information about
their perceived skills relative to their peers, and identify individuals who may be at
risk for LD and ADHD. In particular, the LDA may be a useful supplement to aca-
demic achievement testing in allowing comparison of perceived strengths and weak-
nesses to objective assessment of educational functioning.
It is also important to assess study and organizational skills as part of the ADHD
evaluation given that students with this disorder frequently report struggling in this
area relative to college students without ADHD (Advokat, Lane, & Luo, 2011). The
Learning and Study Strategies Inventory, college version (LASSI; Weinstein &
Palmer, 2002) is a psychometrically sound questionnaire that assesses student per-
ceptions of study and organizational skills. The LASSI includes 77 items that yield
several subscale scores: information processing, selecting main ideas, test strategies,
motivation, self-testing, concentration, time management, and study aids. Reaser,
Prevatt, Petscher, and Proctor (2007) found LASSI scores to significantly discrimi-
nate among college students with ADHD only, LD only, and no disorder; however,
scores were not significant predictors of academic achievement. Thus, self-report of
study and organizational skills may be helpful from a diagnostic and treatment plan-
ning perspective, but may not be directly predictive of academic functioning.
According to DSM-V criteria, ADHD symptoms could also be related to impair-
ment in social functioning. Assessment in this domain primarily relies upon self-
report. The Social Adjustment Scale-Self-Report (SAS-SR; Weissman, 1999) is a
54-item scale assessing behaviors in six aspects of life, including work (i.e., paid,
student, homemaker), social and leisure activities, relationships with extended fam-
ily, role as spouse, role as parent, role within family, and an overall mean score. All
of these subscales are certainly relevant to social functioning of college students;
however, only the work role subscale has been found to discriminate between
college students with and without ADHD (Weyandt et al., under review). Another
option is the Quality of Life Inventory (QLI; Frisch, 1994) that assesses self-percep-
tions of friendships, social activities, and quality of relationships. The QLI includes
32 items that yield subscale scores and an overall quality of life score. Unfortunately,
this measure has not been examined specifically in the college ADHD population,
so its value as a diagnostic measure is unclear.
Occupational functioning can be assessed in at least two ways. First, some self-
report measures include factors or subscales that address specific aspects of job-
related behaviors or functioning. For example, the SAS-SR includes subscales
tapping self-perceptions of social functioning the context of various work roles.
Second, students can be interviewed regarding their job history and performance.
Barkley and Murphy (2010) provide an interview format that asks respondents
about the number of jobs held, number of times fired, number of times quit due to
boredom, number of times quit due to conflict with employer, degree of trouble get-
ting along with coworkers, and number of times disciplined due to behavior or
substandard work. Although this interview has not been studied specifically with
the college ADHD population, Barkley and Murphy have found it to be sensitive to
occupational functioning deficits among adults with ADHD.
Beyond assessment of possible functional impairment, there are two other
areas of risk that should be examined in a comprehensive ADHD evaluation.
Given that individuals with ADHD have been found to engage in riskier sexual
behavior than their peers (e.g., Barkley, Murphy, & Fischer, 2008), assessment of
sexual risk behavior may be important not for diagnostic purposes but for
identification of students who may need support in making changes in this area.
The Sexual Risk Survey (SRS; Turchik & Garske, 2009) is a 23-item question-
naire that assesses the frequency of self-reported risky sexual behaviors (e.g.,
vaginal sex without a condom, sex while intoxicated or using illicit substances)
over the previous 6 months. The SRS has adequate internal consistency and crite-
rion-related validity with the college population (Fulton, Marcus, & Payne, 2010),
although its specific use in the context of an ADHD evaluation has not been
investigated.
A second area of risk for college students with ADHD is in driving behavior.
As discussed in prior chapters, adolescents and young adults with ADHD are
significantly more likely to be cited for moving vehicle infractions and to be
involved in vehicular accidents and with greater damage than their non-ADHD
peers (e.g., Barkley, Guevremont, Anastopoulos, DuPaul, & Shelton, 1993).
Thus, past and current student driving behavior should be assessed. The Driving
Behavior Rating Scale (DBRS; Barkley, Murphy, & Kwasnik, 1996) is a self-
report measure to assess perceived driving habits in relation to safe driving prac-
tices (e.g., using directional signals before turning). The DBRS contains 20 items
and yields a total score that has been correlated with parent report on this same
measure as well as with adverse driving outcomes (e.g., Barkley, Murphy,
DuPaul, & Bush, 2002).
Archival Data
Information from student educational and medical records is important in

documenting a history of impairment related to possible ADHD symptoms as well
as indicating current areas of strength and weakness. At a minimum, records regard-
ing high school and collegiate GPA should be obtained, across academic subject
areas if possible (i.e., current transcript). Although grades are subject to possible
teacher or professor bias, they possess substantial face validity as indicators of aca-
demic success. Further, high-stakes decisions (e.g., graduation, access to scholar-
ships, and placement on the dean’s list or academic probation) are based on grades,
so these are critical data for examining possible academic impairment related to
ADHD. In addition to transcripts, reports from prior psychoeducational, psychiat-
ric, or medical evaluations can be helpful in establishing a history of ADHD and/or
related disorders as well as providing a context for assessing current educational
and psychosocial strengths and weaknesses. Finally, archival records (e.g., medical
records) can also include helpful information regarding receipt and response to prior
treatments.
Assessment Challenges
Assessment of ADHD in college students presents several challenges that clinicians

need to consider proactively in order to increase the likelihood of making reliable
and valid diagnostic decisions. Challenges include the reliability and validity of
retrospective reports, possible positive illusory bias influencing self-ratings of func-
tioning, selection of appropriate norm group for standardized measures, inclusion of
collateral informants (e.g., parents, friends) as respondents, and possible feigning
of ADHD by students without the disorder.
Reliability and Validity of Retrospective Reports
One of the major challenges in diagnosing ADHD in adults is the need to collect
historical data to establish childhood onset (i.e., by age 12) of clinically significant
symptoms. As described previously, clinicians rely primarily on retrospective report
from students and parents regarding childhood history of ADHD symptoms and asso-
ciated impairment. Ideally, retrospective reports would be supplemented by archival
data (e.g., prior psychological, educational, or psychiatric evaluations); however, such
data are not always available. Fortunately, there is some evidence that maternal report of
childhood symptoms of mental disorders is generally reliable and is not differentially
affected by the child’s age or gender (Kentgen, Klein, Mannuzza, & Davies, 1997).
Assessment Challenges 55
However, Kentgen et al. reported the accuracy of maternal retrospective report to

diminish with intervals beyond 6 months. A more recent investigation casts additional
doubt regarding the accuracy of retrospective symptom report. Miller, Newcorn, and
Halperin (2010) found older adolescents and young adults with ADHD as well as
their parents to have limited accuracy in recall of childhood ADHD symptoms.
Further, adult and parent perspectives regarding past symptoms were significantly
associated with reports regarding the severity of current symptoms. Therefore,
although it is important to obtain retrospective report of childhood symptoms to estab-
lish childhood onset of ADHD, clinicians must interpret these reports with caution as
retrospective reports may have limited accuracy and be influenced by the severity of
current symptom presentation (i.e., report of childhood symptoms may be inflated or
deflated depending on current symptom severity).
Positive Illusory Bias on Self-Report of Functioning
Hoza and colleagues have conducted several research investigations establishing that
children with ADHD exhibit a positive illusory bias (i.e., inflated ratings) when report-
ing on their own behavior and functioning (e.g., Hoza, Pelham, Dobbs, Owens, &
Pillow, 2002). This positive illusory bias is particularly prominent when children with
ADHD are asked to report on their academic, social, or physical competence, with
significantly inflated ratings in those areas where by other measures they have their
greatest difficulties (Hoza et al., 2004). This tendency to inflate self-ratings of compe-
tence is not restricted to children with ADHD. In fact, at least one study has shown
positive illusory bias in self-report ratings of work and driving performance in a sam-
ple of 103 college students with ADHD compared to 94 of their peers without ADHD
(Prevatt et al., 2012). Given that clinicians rely primarily on self-report of functioning
as part of a diagnostic evaluation of ADHD, these ratings must be interpreted with
caution particularly if students are reporting above average functioning in a given
area. Ideally, self-ratings of functioning should be supplemented with archival data
(e.g., grade transcripts) and/or ratings from others (e.g., parents) in order to minimize
the possible influence of positive illusory bias on diagnostic decisions.
Relevant Norm Group
Many of the standardized measures described previously have adequate and repre-
sentative norms for adults; however, most do not include separate norms for college
students. In fact, only a few self-report instruments (e.g., CARE, Internal Restlessness
Scale) used a college student normative sample; no direct tests of symptomatic or
related functioning have specific college student norms. The lack of separate norms
for college students is potentially problematic because at least one study has shown
large psychosocial deficits for college students with ADHD when compared with
their fellow students without the disorder; however, when compared with norms
based on the general adult population, scores for the students with ADHD were in the
average or mildly impaired range (Weyandt et al., under review; see Chap. 3). Thus,
if clinicians are assessing whether ADHD symptoms are associated with significant
impairment, different decisions may be reached depending on the normative referent
group. Specifically, students with ADHD may obtain scores in the average range
based on general population norms such that impairment does not appear to be pres-
ent. Alternatively, these same students may actually be experiencing impairment
relative to the college student population, and this may go undetected when using
general adult population norms. We recommend that, whenever possible, student
performance should be compared to the performance of the general college popula-
tion as the latter is the most relevant norm group. Unfortunately, very few measures
(e.g., CARE, IRS) include norms for the college student population.
A related issue is whether to base diagnostic decisions on normative compari-
sons or relative to criteria for the disorder. McKee (2008) compared diagnostic out-
comes for a large sample (N = 1,096) of college students using a norm-referenced
versus criterion-referenced approach. Self-report ratings of ADHD symptoms were
obtained on the CARE with clinical significance determined by surpassing the 97th
percentile (i.e., norm-referenced approach) and by symptom number thresholds
based on DSM criteria (i.e., criterion-referenced approach). Approximately 20% of
the sample was identified as ADHD using the norm-referenced approach, while
7.48% was identified using diagnostic criteria. These results suggest that it may be
more conservative to use a criterion-referenced approach to diagnosis with self-
report ratings, whereas the norm-referenced approach may be more liberal.
Clinicians are advised to use both approaches (i.e., norm-referenced and criterion-
referenced) when interpreting symptom self-ratings especially if only adult general
population norms are available. Clearly, scores from any single self-report are
insufficient for making a diagnosis, and these must be interpreted in the broader
context of other assessment data from clinical interviews, parent reports, and infor-
mation about functional impairment.
Inclusion of Parents
Given aforementioned potential limitations of student self-report as well as need for

historical information regarding childhood onset of impairing symptoms, clinicians
have been advised to include parent report when assessing young adults suspected
of ADHD (Murphy & Gordon, 2006; Pazol & Griggins, 2012; Wolf, 2001; Wolf
et al., 2009). As discussed previously, parent ratings may have greater value than
self-ratings for predicting freshman year GPA (Glutting, Monaghan, et al., 2002).
Alternatively, Katz, Petscher, and Welles (2009) found that student ratings of cur-
rent and childhood ADHD symptoms were significantly higher than informant rat-
ings (with more than 50% of informants being a parent) in a sample of 190
self-referred college students. Of course, one of the reasons why student ratings
Assessment Challenges 57
were higher could be that they were self-referred and therefore more likely to report
significant symptoms than students who are referred for evaluation by a variety of
sources, including parents. Katz et al. further found that impairment was relatively
equivalent for those students identified as ADHD by one source as for those stu-
dents identified by two sources. Thus, disagreement among respondents regarding
presence and severity of ADHD and related impairment does not necessarily mean
that the diagnosis should not be made. Rather, Katz et al. suggest that clinicians use
diagnostic interviews to explore reasons for discrepancies between student and par-
ent report, and rating scale and interview data be simultaneously considered to help
reach diagnostic interpretations.
Inclusion of Collateral Informants
Another option to supplement self-report data is to obtain reports of current and past
symptoms from collateral informants, such as roommates, faculty, and/or significant
others (Parker & Benedict, 2002). Unfortunately, the inclusion of collateral infor-
mants in assessment of ADHD in college students has received almost no empirical
attention. Approximately 44% of the informants included in the Katz et al. (2009)
study were significant others or friends of the students being evaluated. As noted
previously, Katz and colleagues found self-report ratings of current symptoms to be
significantly higher than informant report. Despite potential disagreement among
sources, Katz et al. recommend inclusion of informant report with explicit explora-
tion of reasons for any discrepancy in symptom and/or impairment ratings. Of
course, students need to provide informed consent for clinicians to obtain ratings
from others and need to be assured that obtained information will be handled in a
confidential fashion.
As discussed in Chap. 2, teacher behavior ratings are critical in the comprehen-
sive evaluation of high school students suspected of ADHD. Unfortunately, we
were unable to locate a single study of college faculty ratings being used for
ADHD assessment purposes. Presumably the lack of faculty ratings is due to the
limited contact that professors have with students. Further, there is some evidence
that college faculty view ADHD with a degree of skepticism. In fact, a sample of
university professors rated ADHD among the lowest acceptable disabilities for
educational accommodations (Buchanan, St. Charles, Rigler, & Hart, 2010).
Interestingly, a higher percentage of older faculty relative to middle-aged and
younger professors identified ADHD as a disability that warrants instructional
accommodations. The latter finding is consistent with the results of Vance and
Weyandt (2008) who found professors were knowledgeable about ADHD.
Nevertheless, clinicians should be aware of possible negative biases toward
ADHD as a disability when obtaining professor input. It may be important to
provide faculty with education about ADHD and related disorders to increase
awareness and attenuate misguided bias.
Feigning of ADHD
Given the prominence of symptom self-report in the assessment of ADHD among

college students as well as the access to educational accommodations and psychotro-
pic medication associated with the diagnosis, there is concern that students may feign
symptoms in an attempt to “look ADHD.” Several studies have shown that college
students can exaggerate symptoms as well as exhibit low effort and/or simulate
ADHD symptoms on diagnostic tests (Booksh, Pella, Singh, & Gouvier, 2010; Suhr,
Hammers, Dobbins-Buckland, Zimak, & Hughes, 2008; Sullivan, May, & Galbally,
2007). In the most comprehensive investigation on this phenomenon, to date,
Sollman, Ranseen, and Berry (2010) found that self-report symptom rating scales
were particularly susceptible to faking. Further, deliberate underperformance on tests
of attention and impulse control may be related more to motivation than feigning.
Symptom validity tests (SVTs) have been recommended to address concerns regard-
ing feigning of ADHD (Sollman et al., 2010). SVTs are cognitive measures that are
specifically designed to detect malingering and lack of effort during an assessment.
Examples include the Digit Memory Test (DMT; Hiscock & Hiscock, 1989), the Letter
Memory Test (LMT; Schipper, Berry, Coen, & Clark, 2008), and the Test of Memory
Malingering (TOMM; Tombaugh, 1997). Two separate studies conducted with inde-
pendent samples of college students found that all three of these SVTs showed moder-
ate sensitivity to feigning along with high specificity for ADHD (Jasinski et al., 2011;
Sollman et al., 2010). Specificity rates were particularly robust when failure was
detected on two or more SVTs (Jasinski et al.). Thus, in addition to a comprehensive
evaluation of current and past diagnostic status as well as behavioral, cognitive, and
emotional functioning, clinicians should consider using one or more SVTs in an ADHD
evaluation (Sollman et al.). The latter may be critical in detecting when symptoms are
being feigned or exaggerated on self-report or objective tests of ADHD.
Case Example
Colin was a 19-year-old White male in his sophomore year at a private, 4-year univer-
sity who sought a psychological evaluation due to problems focusing on school- or
work-related activities as well as diminishing motivation across time on most tasks.
As a first step in the evaluation, Colin was interviewed using the Barkley and Murphy
(2006) semi-structured interview. He reported that he has always had trouble focusing
on and completing academic work in a timely fashion. Further, he was identified as a
learning disability in elementary school and received special education services,
specifically for writing difficulties, for a few years. Colin’s grades have ranged from
“A’s” to “C’s” depending on his interest in the subject matter. In three college semes-
ters, Colin has already had to drop three courses because of failing grades.
With respect to DSM-IV-TR criteria for ADHD, Colin reported exhibiting seven
of the nine inattention symptoms and eight of the nine hyperactivity-impulsivity
symptoms both currently and as a child. Further, he reported these symptoms to
Case Example 59
significantly interfere with his educational activities, social interactions with peers,
romantic relationships, driving, and management of daily responsibilities.
Specifically, he is easily distracted and has significant problems remembering and
completing assignments. In contrast, he will perform well on tests. In the social
domain, he reported “driving others nuts” because he has difficulties seeing things
from others’ perspectives. In fact, his roommate had recently moved out because
Colin was so difficult to get along with.
A telephone interview with his parents corroborated many of these same con-
cerns especially childhood symptoms of inattention (8 out of 9) and hyperactivity-
impulsivity (7 out of 9). They reported fewer current symptoms relative to Colin’s
report but acknowledged that they are not in frequent contact with him and therefore
are not able to observe many of the difficulties he reports experiencing at college.
Both Colin and his parents reported that his inattentive and hyperactive-impulsive
symptoms began when he was very young (i.e., prior to the age of 7) but that he was
able to get through public school with parental support and supervision. In fact, both
he and his parents describe theirs as a close family (Colin has one older sister, age
22) and that he had a “good upbringing.” Family history was negative for ADHD
and psychiatric disorders among immediate and extended relatives.
Colin did not report significant current symptoms of any other psychopathologi-
cal disorder (e.g., anxiety or mood disorders); however, both he and his parents
stated that he exhibited most of the symptoms of oppositional-defiant disorder when
he was in elementary and middle school. Colin reported having 5–10 alcoholic
drinks per week with no other recreational drug use.
Colin completed the CAARS-screening version with respect to current ADHD
symptoms. Scores were in the clinically significant (i.e., greater than 95th percen-
tile for his age and gender) range on the DSM-IV inattentive symptoms
(T-score = 87), DSM-IV hyperactive/impulsive symptoms (T-score = 69), and
DSM-IV ADHD symptoms total (T-score = 85) subscales. Alternatively, his
CAARS ADHD Index score was only mildly elevated (T-score = 57). Colin also
completed the SCL-90-R to assess other areas of psychopathology. Although the
general symptom index on this measure was mildly elevated (T-score = 60), all sub-
scale scores including those related to anxiety disorder and depression were in the
normal range (i.e., T-score < 60). His parents completed the Childhood Symptoms
Scale-Other Report Form (Barkley & Murphy, 2006) with all nine inattentive
symptoms and two hyperactive-impulsive symptoms reported to be present often
when Colin was between 5 and 12 years old.
Colin’s performance on the CCPT-II was variable with clinically significant
score for commission errors (T-score = 71), mildly elevated scores for detectability
or d’ (T-score = 63), and hit reaction time for interstimulus interval change
(T-score = 63). All other CCPT-II scores, including for omission errors, were in the
normal range (i.e., T-score < 60).
As noted previously, Colin reported significant academic and social difficulties
in association with his inattentive and hyperactive-impulsive symptoms. Self-report
of executive functions on the BRIEF-A was in the mildly elevated range especially
for the working memory (T-score = 66) subscale and on the Metacognition Index
(T-score = 61). His GPA at the time of the evaluation was 2.0, and he had already
dropped one course during the current semester due to failing performance. With
respect to social skills, Colin’s ratings on the SAS-SR were in the clinically
significant range for both work role (T-score = 74) and social and leisure (T-score = 65)
subscales. Finally, Colin was asked to complete the DMT as a check on symptom
validity, and his score on this measure was not indicative of malingering (i.e., sup-
porting the validity of ADHD symptom report and test performance).
The student interview, parent interview, self-report ratings of current symptoms,
parent report of childhood symptoms, and performance on the CCPT-II were consistent
in indicating that Colin had ADHD combined type. Specifically, both current and child-
hood symptoms met DSM-IV-TR criteria for frequency, severity, and age of onset.
Further, interview, rating scale, and archival data indicated that he suffered clinically
significant impairment to academic and social functioning in association with ADHD
symptoms. Also, ADHD symptoms could not be accounted for on the basis of other
mental health disorders, malingering, or feigning. As a result of the evaluation, Colin
was referred to the college student disability office for possible educational accommo-
dations and academic support. Further, he was urged to contact his physician to explore
the possible use of CNS stimulant medication to manage his ADHD symptoms. Finally,
he was referred to the university counseling center for possible cognitive-behavior
therapy to help him manage daily activities and increase focus on academic tasks.
Conclusions
The comprehensive assessment of ADHD in college students is best accomplished

when viewed in the context of a five-stage process including screening, multimethod
assessment, interpretation of assessment data, design of intervention plan, and evalu-
ation of intervention outcome. Multiple assessment methods and respondents should
be used including diagnostic interviews with the student and parent(s), self-report
symptom ratings, childhood symptom ratings from parent(s), and indicators of pos-
sible academic and social impairment (e.g., grade transcripts, self-report ratings of
social skills). Care must be taken to assess the presence of other disorders that could
either better account for apparent ADHD symptoms or be comorbid with ADHD.
Given possible risks for feigning ADHD in this population, symptom validity tests
may be an important component of the evaluation. Finally, as exemplified by our
five-stage approach, the assessment process must not end with a diagnostic decision
but must be tied directly to treatment planning and evaluation.
Chapter 5
Psychosocial Treatment and Educational
Interventions
The primary nonmedical treatments for children and adolescents with ADHD are
behavior modification strategies implemented in home and school settings along
with educational interventions and supports (for review, see Chap. 2). In similar
fashion, college students with ADHD can receive psychosocial treatment, primarily
in the form of cognitive-behavior therapy, along with educational interventions and
accommodations. The purpose of this chapter is to describe psychosocial treatment
and educational interventions for college students with ADHD. We review the avail-
able literature supporting the efficacy of these approaches with this population.
Because treatment can be delivered across university and community settings, we
also discuss the need for oversight and management of students’ treatment. The
specific role of college disability services in providing case management is described.
A case example is provided to illustrate how treatment components can be inte-
grated in an effective fashion.
Ideally, psychosocial treatment and educational interventions/accommodations
should be provided in the context of a comprehensive support program for college
students with ADHD. Components of an effective ADHD support program include
disability documentation standards and screening procedures, provision of services
and programs possibly including psychosocial treatment and/or academic tutoring,
and accommodations in instructional and testing practices (Javorsky & Gussin,
1994; Wolf, 2001). We described appropriate screening and assessment (i.e., dis-
ability documentation) strategies in Chap. 4. The intervention approaches discussed
in this chapter represent the steps that should be taken, following diagnosis, to
implement an effective support program for college students with ADHD.
Before discussing treatment strategies specific to the college ADHD population,
it is worthwhile to review methods typically recommended and used to treat ADHD
in adults. A variety of psychosocial treatment approaches have been recommended
for adults with ADHD including individual counseling, group treatment, family and
marital/couple counseling, vocational counseling, coaching, and use of assistive
technology (Murphy, 2006). A major component of initial treatment is to thoroughly
explain the nature and implications of an ADHD diagnosis while helping the adult
to reframe the past and instill hope for the future (i.e., focus on ways to meet the

62 5 Psychosocial Treatment and Educational Interventions
challenges of ADHD in everyday life) (Murphy, 2006). It is important to note that

there has been very little empirical study of psychosocial treatment for adults with
ADHD. In fact, Ramsay and Rostain (2007) found only eight treatment outcome
studies for adult ADHD with only three of these employing randomized clinical
trials. Given that the empirical literature supporting treatment of adult ADHD,
including college students with this disorder, is relatively scant in comparison to
treatment of child and adolescent with ADHD, much of the information we describe
here is based on expert recommendations and conceptual notions of effective treat-
ment, and empirical studies are needed to verify their validity. Thus, practitioners
are advised to employ caution when implementing psychosocial and educational
treatments for the college student population.
Psychosocial Treatment Strategies
Several nonmedication (i.e., psychosocial) treatment approaches have been recom-

mended for treating ADHD and related impairments among college students.
Suggested interventions have included cognitive-behavior therapy (CBT), individ-
ual counseling, stress reduction strategies, anger management, and promotion of
self-care (e.g., proper sleep and nutrition habits) (Wolf, Simkowitz, & Carlson,
2009). Some or all of these interventions could be part of a comprehensive college-
based support program administered through a student disability office and/or
university counseling center (Javorsky & Gussin, 1994). Alternatively, psychoso-
cial intervention could be provided by a community-based therapist (Wolf et al.,
2009). Regardless of setting, psychosocial treatment is directed at three key target
areas: (a) increasing motivation to complete college-related responsibilities in a
timely fashion; (b) improving self-regulation skills in academic, social, and occupa-
tional contexts; and (c) reducing or preventing significant symptoms of comorbid
emotional or behavioral disorders (e.g., mood disorder).
Unfortunately, very few empirical studies, to date, have investigated the effects
of psychosocial interventions on the symptoms or associated functional impair-
ments of college students with ADHD. This is not surprising given the lack of
research, in general, regarding psychosocial treatment of ADHD in adults. As noted
previously, in their literature review, Ramsay and Rostain (2007) found only eight
treatment outcome studies with the adult ADHD population, and only three of
these involved randomized clinical trials. Although we were able to locate several
conceptual descriptions of psychosocial treatments including coaching (Swartz, Prevatt,
& Proctor, 2005) and logotherapy (i.e., therapy, based on existential philosophy, that
teaches individuals that they are free to choose for themselves; Schulenberg, Melton,
& Foote, 2006), very few empirical beyond qualitative reports of individual case
studies (e.g., Swartz et al., 2005) were found.
The most widely recommended psychosocial treatment approach for college stu-
dents with ADHD is cognitive-behavior therapy (CBT). CBT does not directly
address the symptoms of ADHD but rather is designed to ameliorate the cognitive,
Psychosocial Treatment Strategies 63
Fig. 5.1 Typical case conceptualization for cognitive-behavior therapy with college students with
ADHD (Adapted from “Cognitive Behavior Therapy for College Students with Attention-Deficit/
Hyperactivity Disorder” by J.R. Ramsay & A.L. Rostain, 2006, Journal of College Student
Psychotherapy, 21, pp. 11–12)
emotional, and behavioral ramifications of ADHD symptomatology (e.g., procrastination

in completing academic assignments). For the purposes of CBT, clinicians must
develop a case conceptualization in order to understand challenges faced by stu-
dents with ADHD from the student perspective. Figure 5.1 displays the key ele-
ments of a typical case conceptualization as described by Ramsay and Rostain
(2006). The combination of ADHD-related difficulties and relevant developmental
challenges (e.g., increased expectations for organization and time management)
may lead students to adopt maladaptive core beliefs, particularly with respect to
inadequacy (e.g., “I am not a good student”). Maladaptive cognitions, in turn,
increase anxiety and elicit compensatory strategies to reduce anxiety (e.g., procras-
tination of challenging assignments). Over time, this maladaptive cycle may per-
vade thoughts, feelings, and behaviors in daily college life. Thus, the primary goals
of CBT are to help students recognize this cycle and adopt coping, problem-solving
strategies to circumvent this maladaptive process.
Ramsay and Rostain (2006) provide a detailed overview of CBT for college
students with ADHD. Specifically, they outline steps for clinicians to follow in
implementing CBT across an academic semester (see Table 5.1). In the early stages
of the semester, clinicians should help students identify relevant goals for therapy
regarding both academic challenges (e.g., increase study time) and other college life
activities (e.g., decrease alcohol use). In formulating goals, it is helpful to consider
student motivation for participation in treatment; in particular, the degree to which
students are ready to make changes in their lives will dictate the relative feasi-
bility of possible goals. Students are supported in understanding the linkages
among cognitions, emotions, and behaviors in relation to the challenges they face.
For example, when given a challenging assignment, a student may have maladap-
tive thoughts (“I always fail on difficult, long-term assignments”) that are associ-
ated with unpleasant emotions (e.g., anxiety). Anxiety may lead students to engage
in maladaptive compensatory strategies such as procrastination. Once students
come to recognize such patterns, clinicians guide them in using a coping, problem-
solving approach to making small, feasible changes in their routines and activities.
As students practice the coping, problem-solving approach, clinicians review
the relative success of therapeutic homework and support ongoing use of these
Table 5.1 Steps to cognitive-behavior therapy (CBT) for college students with ADHD
Stage of semester CBT steps
Beginning of 1. Identify specific therapy goals for semester related to academic issues
semester and other aspects of college life (e.g., social activities)
2. Discuss student motivation for participating in therapy
3. Elicit details of cognitive, emotional, and behavioral experiences of
students surrounding common difficulties (e.g., procrastination of
assigned tasks)
4. Encourage students to “start small” and make feasible changes in routines
and activities
Middle of 5. Review results from therapeutic homework. If unsuccessful, work with
semester student to collaboratively problem-solve around difficulties
6. Foster balanced, constructive thinking when students encounter
challenges (e.g., midterm exams and projects). Use cognitive restructuring
techniques to help students attain healthy yet realistic perspective on
negative outcomes
7. Address possible comorbid problems (e.g., depression) by integrating
these into case conceptualization and treatment plan
End of semester 8. Help students handle inevitable missteps in making cognitive, emotional,
and behavioral changes by supporting the use of coping and problem-
solving strategies
9. Emphasize the need to “finish strong” by using coping strategies in the
context of final exams and other end of the semester demands (e.g.,
registering for classes)
10. Terminate treatment by supporting student in appreciating successes,
encouraging student to focus on how to manage ADHD symptoms on an
ongoing basis, developing proactive strategies for relapse prevention,
and empowering students to seek additional help when needed
Adapted from “Cognitive Behavior Therapy for College Students with Attention-Deficit/
Hyperactivity Disorder” by J.R. Ramsay & A.L. Rostain, 2006, Journal of College Student
Psychotherapy, 21, pp. 13–17
strategies in anticipating mid-semester challenges (e.g., midterm exams, increased

workload) (Ramsay & Rostain, 2006). If students encounter difficulties in imple-
menting coping strategies, clinicians work with students to use a problem-solving
approach to identifying and remediating roadblocks. Cognitive restructuring strate-
gies may help students to adopt healthy, realistic perspectives on negative outcomes
(e.g., “I am angry with myself for not having done a better job on this assigned
paper; however, this is my most difficult course and I put more effort into this paper
than I have for prior assignments”). Clinicians should assess students for comorbid
disorders (see Chap. 4) and integrate appropriate treatment strategies for associated
difficulties into CBT, if possible.
As the end of the semester approaches, students should be prepared to handle
inevitable missteps in making changes in their daily lives by supporting them in
the ongoing use of coping and problem-solving strategies (Ramsay & Rostain,
2006). Given the increased academic (e.g., final exams) and social (e.g., end of
year events) demands that are typically encountered at the end of the semester,
clinicians should support students in finishing the semester strongly by redoubling
Psychosocial Treatment Strategies 65
efforts to use coping strategies. It is also important to prepare students for termina-
tion of CBT by helping them to appreciate the successes achieved during the course
of the semester as well as proactively plan for possible relapse. In particular, stu-
dents should be empowered to seek additional help during the semester break and/
or in subsequent semesters.
Although CBT has great face validity for treatment of college students with
ADHD, we were unable to find a single empirical study of its use with this popula-
tion. Safren and colleagues (2010) conducted the best available study of CBT for
treatment of adult ADHD. This was a randomized clinical trial comparing CBT to
an attention-matched comparison group that received relaxation training with edu-
cational support. The sample was comprised of 86 adults with ADHD (M
age = 43 years old) who completed 12 individual sessions of CBT or the comparison
condition. Results indicated significantly greater reductions in ADHD symptoms
and concomitant increases in clinician ratings of improvement for patients in the
CBT condition relative to the comparison group. In fact, 67% of the CBT group
exhibited a positive treatment response based on improvement in ADHD symptoms
relative to only 33% of the comparison treatment group. Treatment gains were
maintained at 6- and 12-month follow-up assessment phases. These promising
findings are tempered by the fact that this study did not examine outcomes specific
to college students (e.g., academic and social functioning) and, in fact, employed a
sample whose average age was significantly older than the typical college popula-
tion. Further, all participants were receiving medication throughout the CBT trial.
Thus, the degree to which obtained CBT success can be generalized to college stu-
dents with ADHD, particularly those not receiving medication, is limited.
Another commonly recommended intervention for college students with ADHD
is known as coaching. As is the case for CBT, coaching is not focused on reduction
of ADHD symptoms per se but rather “involves helping students deal with aspects
of their disability that interfere with academic performance and coping with aspects
of the college experience, such as procrastination, lack of concentration, ineffective
self-regulation, poor planning, anxiety, social incompetence, or time management”
(Swartz et al., 2005, p. 648). The ADHD coach develops a collaborative relation-
ship with the student in order to help develop strategies and self-confidence with
respect to executive functioning skills (e.g., time management). Swartz et al. describe
the coaching process as involving several steps including an initial meeting to set
expectations, structure meeting content and schedule, as well as set long-term goals
along with objectives for the first week of coaching. Weekly objectives (i.e., short-
term, attainable outcomes) related to each long-term goal are set at the end of each
coaching session and evaluated at the beginning of each subsequent meeting.
Coaches can chart progress on weekly objectives so that students receive visual
feedback regarding progress toward goal attainment. Students and coaches agree on
rewards and consequences for session attendance and progress toward goals (e.g.,
payment to coach if session is missed or weekly objective is not attained). Coaches
generally guide and support students in using a systematic problem-solving approach
toward attaining goals that involves discussion of challenges or obstacles to goal
attainment, identifying possible strategies for circumventing challenges or obsta-
cles, changing consequences for actions, evaluating the effectiveness of strategies

on a weekly basis, and making changes to strategies as necessary.
As is the case for CBT, very little research has been conducted on ADHD coaching,
in general, with only two studies of this intervention for college students with
ADHD. Swartz et al. (2005) presented uncontrolled case study data for a female
college student with ADHD who showed improvements in self-reported study strat-
egies, increased study time, and receipt of desired course grade following 8 weeks
of ADHD coaching. Prevatt, Lampropoulos, Bowles, and Garrett (2011) examined
the impact of between-session assignments in ADHD coaching for a larger sample
(N = 13) of college students with ADHD. Results indicated that progress in coaching
sessions for these 13 students was significantly related to three aspects of between-
session assignments: (a) coach’s rating of the quality of students’ between-session
assignments during treatment, (b) students’ positive attitude toward between-session
assignments, and (c) the perceived usefulness of those assignments. Further,
treatment gain scores (as measured by therapist rating of student motivation and
work) were significantly related to student motivation to please their parents. These
findings support the use of between-session assignments in the context of ADHD
coaching and also highlight factors related to assignments and coaching interactions
that are potentially most useful. Unfortunately, conclusions regarding the efficacy
of ADHD coaching for the college population are limited due to the lack of experi-
mental controls and the small samples used in these two investigations.
Educational Interventions
Educational interventions involve providing students with training in specific

content-area skills (e.g., skills directly taught in a course); instruction in ways to
organize course materials and tasks, study for tests, and/or take class notes; and
ongoing support in implementing strategies or practicing newly acquired academic
skills. Thus, interventions are designed to enhance student skills and knowledge in
content areas and/or in ways to support their own learning. A variety of educational
interventions are possible for students with ADHD; however, most recommended
strategies have focused on providing instruction in study/organization skills and/or
methods to enhance comprehension of lecture and reading material. As was the case
for psychosocial interventions, very few empirical studies have examined the
efficacy of specific educational or academic interventions for the college ADHD
population. In fact, we were able to find only two published studies of educational
intervention for college students with ADHD either alone or in combination with
learning disabilities (LD).
Allsopp, Minskoff, and Bolt (2005) developed, implemented, and evaluated a
model for delivering course-specific strategy instruction to 46 college students with
disabilities, including 18 students with ADHD with or without LD. A mixed meth-
ods quasi-experimental design was used wherein strategy instruction was individu-
alized for each student based on specific learning needs as well as prior empirical
support for a strategy designed to meet those needs. For example, to enhance a
Educational Accommodations 67
student’s reading comprehension, the RAP paraphrasing strategy was used that
involved R-read a paragraph; A-ask what the main ideas are; and P-put the ideas
into your own words (Schumaker, Denton, & Deshler, 1984). Between one to three
strategy sessions, each of which lasted 1 to 2 h, were provided over the course of a
single semester. Statistically significant increases in grade point average (GPA)
were found with a mean effect size of 0.55, indicating an increase of approximately
one-half standard deviation with treatment. Improvements were larger for those stu-
dents who were on academic probation prior to intervention. Further, interview
responses from students found two factors related to improvement including inde-
pendent use of strategies and supportive relationship between student and instructor.
Conversely, two factors were related to no improvement including student aca-
demic/cognitive skills deficits and emotional/medication-related issues. In other
words, students who had more severe comorbid conditions were less likely to
respond to intervention. Although these results are promising regarding the salutary
effects of individualized academic strategy instruction, conclusions are tempered by
the lack of a control or comparison condition in this study.
Computer technology (e.g., assistive software) appears to have great potential in
meeting the academic needs of college students with ADHD. Hecker, Burns, Elkind,
Elkind, and Katz (2002) examined assistive software programs for enhancing the
reading skills of 20 students with attention disorders (i.e., ADHD) who attended a
private college for individuals with learning and related disorders (including ADHD).
An AB case study design was used with participants serving as their own controls.
Student performance in a required English course was compared for unassisted (base-
line or A phase) versus assistive software (intervention or B phase) conditions.
Participants reported less fatigue and distraction when using the assistive software,
and the treatment condition was associated with enhanced reading rate and less time
to complete reading passages. Unfortunately, no changes in reading comprehension
were obtained. Similar to the Allsopp et al. (2005) study, some of these results are
promising; however, conclusions are limited by the lack of experimental control as
well as the minimal impact of treatment on reading comprehension.
Educational Accommodations
The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation
Act require colleges and universities to provide reasonable adjustments to academic
and related programs to qualified students with disabilities including those with
ADHD. These adjustments typically are referred to as accommodations. Educational
accommodations are distinct from interventions in that the former do not involve
training to improve student skills or knowledge. Rather, accommodations are
changes to educational practice that mitigate the impact of a disability, in this case
ADHD, on student access to the curriculum (Harrison, Bumford, Evans, & Owens,
under review). Although specific accommodations are based on the needs and
impairment exhibited by individual students, typical recommendations for students
with ADHD include providing extra time or breaks during tests, allowing use of
spell-check for word processing during examinations, placing students in distrac-

tion-free environments during tests, providing someone to take notes during class
lectures, and extending assignment deadlines (Wolf, 2001; Wolf et al., 2009).
It is helpful to think about accommodations in the context of four categories
including presentation, response, timing/scheduling, and setting (Harrison et al.,
under review; Tindal & Fuchs, 2000). Presentation accommodations involve chang-
ing the way that academic instruction, assignments, or evaluation is presented to
students. An example of a presentation accommodation is describing course assign-
ments both orally and in writing (Javorsky & Gussin, 1994). See Table 5.2 for addi-
tional presentation accommodations.
There are two possible ways to provide response accommodations. One would
involve changes in the manner in which students are asked to respond to instruction,
assignments, and/or test items. An alternate format for exams (e.g., oral vs. written)
is a frequently recommended response accommodation (Javorsky & Gussin, 1994).
Another way to provide a response accommodation is to allow students to use a
device (e.g., calculator, digital recorder) as an aid in responding to instruction,
assignments, or exams (see Table 5.2 for additional response accommodations).
Timing/scheduling accommodations can take one of three forms. One possibility
is to change the amount of time allowed for completion of a test or assignment.
Extended (e.g., double) time on exams is a frequently recommended example
(Javorsky & Gussin, 1994; Wolf et al., 2009). Another timing/scheduling accom-
modation is to alter the time allotted for the presentation of a lecture or instruction.
A final variant of this type of accommodation is to change the schedule or time
framework for an assignment or test. For example, students with ADHD may be
allowed to complete parts of an exam in a piecemeal fashion over several hours or
days (see Table 5.2 for additional timing/scheduling accommodations).
Setting accommodations involve alterations to the setting where students com-
plete tests or assignments. A common recommendation is to allow students with
ADHD to take tests in relatively quiet classrooms away from their non-ADHD peers
and other possible distractions (Javorsky & Gussin, 1994; Wolf, 2001; Wolf et al.,
2009). See Table 5.2 for additional setting accommodation recommendations.
Similar to what has been found for children and adolescents with ADHD and
related behavior disorders (Harrison et al., under review), very little empirical
research has evaluated the efficacy of recommended accommodations in enhancing
academic and class performance of college students with ADHD. In an unpublished
dissertation study, Clifton (2007) examined the accommodation of preferential (i.e.,
closer to instructor) seating in the context of two studies. In the first study, a sample
of 350 college students, 43 of whom reported a diagnosis of ADHD, were allowed
to choose their seats in two separate classes. Grades were negatively correlated with
seating distance (i.e., the lower the grades, the farther the seat was from the instructor),
and this relationship was stronger for students with ADHD. Interestingly, however,
the correlation between seating distance and grades was outweighed by the negative
correlation between class absences and grades. In a second study, Clifton randomly
assigned 76 students, only four of whom reported an ADHD diagnosis, to one of
three seating conditions (near, middle, and far distance) for one lecture session.
Educational Accommodations 69
Table 5.2 Possible educational accommodations for college students with ADHD
Accommodation
type Possible accommodation
Presentation 1. Describe course assignments both orally and in writing
2. Start lectures with review of previous lecture and topic overview for the
current class session
3. Emphasize main ideas and critical concepts both orally and in writing (e.g.,
using fonts in different colors on Powerpoint); review main ideas at the end
of class session
4. Speak clearly and at a pace that allows students to follow content and keep
up with note-taking; pause regularly for student questions
5. Taking notice of and responding to signs of student confusion (e.g., facial
expressions or verbal inquiries) with clear explanations and/or supportive
assistance
6. Allow time at end of lecture class sessions for discussion and question-and-
answer opportunities
7. Provide students with exam guides that present examples of test format and
content
8. On exams, avoid using complex sentences (e.g., double negatives) and
incorporating questions within questions
9. On exams, give students sufficient blank space or allow additional exam
booklets for those students who have large handwriting
Response 1. Provide an alternate format (e.g., oral vs. written) for exams
2. Allow students to use a device (e.g., calculator, clicker response system) as
an aid in responding to instruction, assignments, or exams
3. Accept a variety of possible responses (e.g., oral, typewritten) to exam questions
4. Provide student with opportunity to clarify or rephrase an exam question to
ensure understanding prior to student answering the question
5. Provide students with options (e.g., research project, class presentation) for
demonstrating mastery of course objectives
6. Allow students to use spell-checker for word processing during exams
7. Provide students with class notes or allow someone else to take notes
during lectures
8. Allow students to speak quietly to themselves during exams as this may
assist them in maintaining attention and recalling information
Timing/ 1. Provide extra (e.g., double) time on exams
scheduling 2. Give course syllabus to students four to six weeks before the semester and,
if possible, discuss syllabus and course requirements with students prior to
start of semester
3. Allow students to complete parts of exams or course assignments in
piecemeal fashion over a period of time
4. Extend time for completion of course requirements
5. Provide students with opportunities to meet to discuss any questions or concerns
regarding lecture material, assigned readings, and/or course assignments
6. Advise students to register for challenging courses in the morning rather
than in afternoon or evening
7. Advise students to enroll for a reduced courseload, and select courses that
meet more frequently for shorter periods of time (e.g., 50-min class sessions)
8. Extend time for completion of degree requirements
(continued)
Table 5.2 (continued)

Accommodation
type Possible accommodation
Setting 1. Allow students to complete exams in quiet classrooms away from other
students and other possible distractions
2. During class sessions, attempt to eliminate or reduce possible auditory and
visual distractions (e.g., outside noise)
Note. Accommodation recommendations are cited from Javorsky & Gussin, 1994; Wolf, 2001;
Wolf, Simkowitz, & Carlson, 2009
Students completed a brief quiz after the lecture to test their comprehension.
Students sitting near the front of the class obtained higher grades than those sitting
farther away; however, this was a relatively small effect (Cohen’s d effect size = 0.2
for mean quiz scores between students seated near vs. far distance) and not statisti-
cally significant. Although Clifton interpreted these findings as supportive of
preferential seating as an accommodation, the specific effects for students with
ADHD are unclear given that very few students in his sample were diagnosed with
this disorder.
As described previously, a commonly recommended timing/scheduling accom-
modation for students with ADHD is to provide extended time on tests. This accom-
modation presumes that students benefit from extra time due to their distractibility
and/or related cognitive deficits. In the only known empirical study of this accom-
modation with college students, Lindstrom and Gregg (2007) assessed performance
on the Scholastic Aptitude Test (SAT) in reading for students without disabilities
(n = 2,476) tested under standard time conditions relative to students with disabili-
ties (n = 2,476; 959 of whom had ADHD with or without LD) tested with extended
time. Approximately 80% of the students with disabilities were provided time and a
half, while the remaining 20% received double time. Several analyses were con-
ducted to establish factorial invariance across the two groups that indicated that SAT
measured the same underlying construct of reading performance across samples and
that students in both groups responded to items in a similar manner. Although SAT
reading scores were significantly lower in the disability sample, providing extra
time did not appear to affect measurement or response pattern to test items. In other
words, provision of extra time did not alter what the test measures in any significant
way. Unfortunately, these findings do not provide specific information whether this
accommodation enhances test performance for students with ADHD.
In addition to the lack of empirical scrutiny regarding the efficacy of educational
accommodations, it also appears that many college students with ADHD do not
have access to and/or use accommodations on a consistent basis. As part of a larger
survey regarding college students’ attitudes their fellow students with ADHD,
Chew, Jensen, and Rosén (2009) asked 30 students diagnosed with ADHD about
their access to and use of educational accommodations.
Specifically, students were asked whether they felt that sufficient accommo-
dations had been offered and, if so, whether they used those accommodations.
Oversight of Support and Treatment Services 71
Only 40% of students reported that the university had offered suf fi cient
accommodations. Less than half (45%) of those receiving sufficient accommo-
dations reported actually using them. Students were asked for reasons why they
did not use accommodations, and responses varied from students being unaware
of possible accommodations, students’ desire to be the same as their fellow
students even if it takes longer, as well as students’ feeling that accommodations
were unnecessary or that their symptoms had improved to the point where they no
longer desired accommodations.
Oversight of Support and Treatment Services
Given the variety of support and treatment services that may be necessary for col-
lege students with ADHD, it is likely beneficial to have one person serving in the
role of case manager. Specifically, at least one person needs to be aware of all ser-
vices that are being provided to the student as well as monitor the implementation
and relative success of these services. The presence of a case manager is particularly
important for college students with ADHD who no longer are able to fully rely on
parent or guardian support. Indeed, the college years represent the first time that
they must independently manage their daily lives, including their own treatment.
Although it is possible to train students to serve as their own case managers, a uni-
versity student disabilities staff member or a university-based or community-based
therapist may be more ideal choices for this role.
Regardless of who serves as case manager, there are several activities that are
critical to this role. First, the case manager should work with the student to identify
all services currently received to address the student’s ADHD. With student permis-
sion, the case manager should have regular (e.g., monthly) communication with all
professionals working with the student. This would include mental health, educa-
tional, and medical professionals. Second, the case manager should assist the stu-
dent in collecting data regarding the effects of support and treatment services.
Training students in data-based decision-making may be helpful in this regard.
Third, the case manager can guide students in serving as their own advocates in
terms of (a) obtaining services that are needed but not currently provided and (b)
working with service providers to ensure that outcomes are maximized (e.g., asking
for changes to treatment if the latter is not successful). Unfortunately, there aren’t
extensive data on case management for college students with ADHD; however, the
data that are available suggest that case management is either absent or less than
ideal. For example, Baverstock and Finlay (2003) surveyed 50 undergraduate stu-
dent health centers in the United Kingdom to ascertain who provides medical
support to students with ADHD. Their results indicated that general practitioners
either alone or in conjunction with other health professionals managed medical care
for the vast majority of students; however, 87% of these physicians had not received
any training specific to management of ADHD.
Case Example
Megan is a 21-year-old White female who is completing her senior year at a highly
competitive, private university. She was diagnosed with ADHD in 5th grade (age 10)
following some difficulties with both academic and social functioning. Over the years,
she has been treated with a variety of psychotropic medications including methylpheni-
date and mixed amphetamine salts. Currently, she takes 30 mg lisdexamfetamine dime-
sylate (LDX) on a daily basis. Although LDX appears to attenuate her ADHD symptoms
to some degree, Megan continues to experience significant difficulties with concentra-
tion during academic activities, being disorganized in her daily life, being on time for
appointments and classes, forgetting assignments or appointments, and interrupting
others during conversations. In fact, she and her mother report Megan to display nearly
all of the symptoms of ADHD on a regular basis. As a result, Megan is experiencing
significant difficulties in many phases of her life including educational functioning,
management of her finances, social relationships, and driving.
To address these difficulties, Megan recently began working with the university
office of student disabilities to formulate a support plan. The latter includes educa-
tional instruction and accommodations. Specifically, she receives direct instruction
in study and organization skills from a disabilities office staff member on a weekly
basis. This instruction helps Megan to plan and monitor study sessions, take notes
on assigned readings, and prepare for exams and long-term assignments. Further,
she is provided with coaching on organizing her daily schedule, setting up her envi-
ronment to cue her regarding appointments and classes (e.g., through her cell
phone), and managing her finances. The student disabilities office has also opened
communication with Megan’s instructors to (a) inform them of her ADHD-related
difficulties, (b) implement accommodations, and (c) monitor her academic progress
over the course of the semester. A variety of accommodations have been arranged
for Megan, and these are based on individualized course requirements and needs.
For example, one of Megan’s courses (British History) is a large lecture course
wherein her instructor has agreed to implement many of the presentation accom-
modations listed in Table 5.2. Alternatively, for Megan’s lab-based course in organic
chemistry, she has worked with her instructor to modify response requirements (see
Table 5.2). The specific components of this educational support and accommoda-
tion plan will be modified based on Megan’s academic progress or lack thereof over
the course of the semester.
Given the interpersonal struggles related to her ADHD that Megan is encountering,
the university student disabilities officer (who also served as Megan’s case manager)
referred her to the university counseling center. Following a thorough assessment of
Megan’s psychological functioning (which confirmed her diagnosis of ADHD
combined type), her therapist outlined a course of CBT to address her impulsive
behavior in social situations as well as ameliorate her organization and time-management
difficulties. Megan and her therapist collaboratively developed short- and long-term
goals related to reducing the frequency of her interruptions during conversations as
well as increasing the frequency of her participation in social activities that did not
Conclusions 73
involve alcohol. Her therapist guided Megan in the development and practice of
a problem-solving approach to coping with these difficulties. For example, she
followed three steps prior to and during conversations: (a) prior to starting a
conversation, she reminds herself to count to 3 before speaking; (b) while others are
talking, she reminds herself to make eye contact and recognize facial behaviors
associated with the speaker finishing talking; and (c) count to 3 before responding.
Megan was assigned homework between each weekly session and collected periodic
data to document the degree to which the coping strategies worked. Although Megan
showed progress following ten CBT sessions over the course of the semester, she
and her therapist agreed to meet again at the beginning of the next semester to assess
whether continued treatment was necessary.
Conclusions
The primary nonmedical approaches to support and treatment of college students

with ADHD include psychosocial treatment (i.e., CBT and ADHD coaching), edu-
cational interventions, and educational accommodations. In contrast to medication
treatment that is primarily directed toward reduction of ADHD symptoms, the three
nonmedical approaches address critical functional impairments (e.g., academic
underachievement) commonly associated with ADHD. For most students, the com-
bination of these three approaches will likely be necessary to ameliorate the wide
variety of difficulties that they may experience in independent, daily living. Because
multiple professionals typically are involved in providing support and treatment
services, one of these professionals should serve as a case manager. The latter would
ensure that students are receiving appropriate services and that service providers are
working toward goals in a similar fashion and help students to advocate for them-
selves in obtaining needed services.
It is also important to help students locate resources that help them understand
ADHD as well as provide information that students can use in daily living. The
website for the Children and Adults with ADHD (CHADD) organization contains
accurate information on the disorder as well as its assessment and management
(http://www.chadd.org). There are also several helpful books for adults with ADHD.
For example, Levrini and Prevatt (2012) provide many practical suggestions, many
of which are evidence-based, for adults with ADHD to manage their daily lives.
Using many of the same principles employed in CBT and ADHD coaching, Levrini
and Prevatt guide adults with ADHD in a problem-solving approach to setting goals,
managing time and space, improving social interactions, using incentives to enhance
behavior change, and self-advocacy in obtaining necessary services. They also pro-
vide specific suggestions for improving study skills that are empirically based and
practical (see Table 5.3).
Unfortunately, there is a substantial gap between recommended services and
empirical research documenting the efficacy and effectiveness of these services. We
were able to find only a handful of studies examining psychosocial and educational
Table 5.3 Strategies to improve study skills

1. Study in small chunks of time (20–50 min) followed by breaks rather than long hours
2. Pick a good place to study where you won’t be distracted
3. Figure out your optimal time of day to study
4. Start with difficult material and then reward yourself by switching to easier content
5. Make sure you understand assignment and plan your time accordingly
6. Don’t study in bed; sit in a comfortable chair
7. Make sure you study (even if it is a little bit) every day
8. Reward yourself after studying for a specified period of time
9. When it’s appropriate, work with study partners
10. Study early and often (spread out your work rather than cram)
Note. From “Succeeding with Adult ADHD: Daily Strategies to Help You Achieve Your Goals and
Manage Your Life” by A. Levrini and F. Prevatt, 2012, Washington, DC: American Psychological
Association, pp. 154–155
intervention for college students with ADHD. Further, those studies that are avail-
able have employed relatively weak research designs with respect to threats to inter-
nal and external validity. In addition, very little is known regarding the extent to
which recommended services are actually provided to college students with ADHD.
For example, we do not know the answers to basic questions such as the percentage
of college students with ADHD who receive educational interventions, educational
accommodations, and/or psychosocial treatment (e.g., CBT). If the success of college
students with ADHD is to be maximized, it will be critical for the field to document
the extent to which various nonmedical services are provided as well as the relative
efficacy and effectiveness of recommended treatment approaches.
Chapter 6
Pharmacotherapy
The previous chapter covered educational and psychosocial interventions for

ADHD, and although complimentary or alternative treatments are sometimes advo-
cated (Hurt, Arnold, & Lofthouse, 2011), the effectiveness of these approaches is
highly questionable and generally lacks empirical support (Weyandt, 2006b; Willis,
Weyandt, et al., 2011). The focus of this chapter is on the use of medications to treat
ADHD in the college student population. This chapter begins with a review of dif-
ferent types of medications that are available for the treatment of ADHD, discusses
the relatively few studies that have examined pharmacotherapy in college students
with this disorder, and concludes with information concerning the misuse (diver-
sion) of prescription stimulant medication among college students.
Pharmacotherapy of ADHD
A variety of medications are available to treat ADHD including stimulants, non-

stimulants, antidepressants, and, less commonly, medications used to treat other
conditions such as anticonvulsant medications. The most frequently prescribed
medication for college students with ADHD is psychostimulants. Examples of psy-
chostimulants used in the treatment of ADHD are found in Table 6.1.
Stimulants and Pro-drug Stimulants
Psychostimulants are medications that increase the activity of the central nervous
system. Although the exact mode of action of psychostimulants is not understood,
numerous studies suggest that they serve to increase functioning of one of the brain’s
important neurotransmitter systems, dopamine (Spencer, Bonab, et al., 2010;
Swanson, Baler, & Volkow, 2011). Dopamine plays a critical role in the brain’s
attention and motivation/reward systems and likely interacts with other neurotrans-

76 6 Pharmacotherapy
Table 6.1 Examples of psychotropic medications used in the treatment of ADHD

Stimulants
Amphetamine salts Adderall
Dexmethylphenidate Focalin
Dextroamphetamine Dexedrine
Methylphenidate Concerta, Metadate, Methylin, Ritalin
Prostimulant
Lisdexamfetamine dimesylate Vyvanse
Non-stimulant
Atomoxetine Strattera
Antidepressants SSRIs
Sertraline Zoloft
Fluoxetine Prozac
Antidepressants tricyclics
Imipramine Tofranil
Desipramine Norpramin
Anticonvulsants
Oxcarbazepine Trileptal
Carbamazepine Tegretol
mitters within these systems (Weyandt, 2006a). Several studies suggest that the cen-
tral nervous system of individuals with ADHD is under-aroused rather than
over-aroused, and stimulants serve to balance the activity of this system (Negrao,
BiPath, van der Westthuizen, & Viljoen, 2011). Cognitively, stimulants improve
one’s ability to focus, to inhibit impulsive responding, and to sustain attention over
time (Anderson & Baldwin, 2000; Abikoff & Hechtman, 1996; Castellanos, Kelly,
& Milham, 2009; Rubia et al., 2009). Recently, Paul Wender and colleagues (2011)
from the University of Utah, School of Medicine, conducted a 1-year trial of a
stimulant medication (methylphenidate) in adults with ADHD and found that symp-
tom severity decreased by 80% and most adults showed marked improvement in
psychosocial functioning as well. In addition, Bejerot, Ryden, and Arlinde (2010)
found that 80% of adults with ADHD treated with stimulants continued to show
symptom improvement at 6-month to 9-month follow-up. Furthermore, the use of
stimulants appeared safe as blood pressure remained unchanged after 2 years, and
severe adverse side effects or drug abuse were not detected in this sample of adults.
Recently, Olfson and colleagues examined associations between cardiovascular
events in approximately 170, 000 youth ages 6–21 years with ADHD treated with
methylphenidate and amphetamines. Results revealed that cardiovascular events
were rare and not associated with stimulant use (Olfson et al., 2012). It is important
to note, however, that psychostimulants can cause serious complications with indi-
viduals with underlying cardiac problems, and therefore, individuals should have a
thorough physical examination before taking psychostimulants.
Further evidence supporting the effectiveness of medication in the treatment of
ADHD stems from neuroimaging studies conducted with children and adults.
Pharmacotherapy of ADHD 77
Specifically, the brain activity of individuals with ADHD has been measured prior
to and after administration of stimulant medication in a number of studies.
Interestingly, studies have found reduced areas of blood flow and energy use (i.e.,
glucose metabolism) in several areas of the brain associated with attention and self-
regulation in individuals with ADHD, and following the administration of medica-
tion, blood flow and energy use increase in these regions (Langleben et al., 2002;
Lou, Henriksen, & Bruhn, 1984; Moll, Heinrich, Trott, Wirth, & Rothenberger,
2000; Rubia et al., 2009; Schweitzer et al., 2003; Shafritz, Marchione, Gore,
Shaywitz, & Shaywitz, 2004; Volkow et al., 2002). Collectively, these studies sup-
port that ADHD is characterized by differences in brain functioning that appears to
be altered or improved, albeit temporarily, by stimulant medications.
Stimulants are the most frequently prescribed medications for college students
with ADHD (as is true for children and adolescents with ADHD) (Baverstock &
Finlay, 2003; Zito et al., 2003). Indeed, over a decade ago, Wilens, Spencer, and
Biederman (1998) described stimulants as the “first line of therapy” for young
adults, and, a few years later, Staufer and Greydanus (2005) recommended stimu-
lants as an effective treatment specifically for the management of ADHD in college
students. Despite the recommendation of stimulant medications as a first line of
treatment for young adults with ADHD, and that most college students with ADHD
take prescription stimulants (Advokat, Lane, & Luo, 2011), double-blind, placebo-
controlled studies examining the effectiveness of these medications with college
students are rare. In fact, to date, the only systematic and empirical study to investi-
gate the effectiveness of a stimulant in the treatment of ADHD in college students
was conducted by Weyandt, DuPaul, and colleagues (DuPaul et al., 2012).
Specifically, we studied the effects of the pro-drug stimulant, lisdexamfetamine
dimesylate (LDX), on the academic, social, and psychological functioning of
college students with ADHD, as well as the effectiveness at reducing ADHD
symptomatology. LDX is referred to as a pro-drug stimulant because it is tagged
with the amino acid lysine that prevents the metabolism of the drug until it enters
the gastrointestinal tract. Once it enters the gastrointestinal tract, LDX is converted
to dextroamphetamine, which is responsible for the drug’s activity. Although the
specific mode of action is unknown, dextroamphetamine is believed to block the
reuptake of dopamine and norepinephrine; hence, more of these neurotransmitters
are available for communication among brain cells.
Along with our colleagues, we studied a total of 24 college students with
ADHD and 26 without the disorder from two different institutions (DuPaul et al.,
2012). As described in Chap. 3, the two student groups exhibited large differ-
ences in ADHD symptoms (see Table 3.1) and moderate to large differences in
executive, psychological, academic, and social functioning (see Figs. 3.1 and
3.2). Over a 5-week period, students with ADHD participated in a no-drug
baseline, placebo, or 30, 50, and 70 mg of LDX per day. Information was
collected in a double-blind fashion concerning students’ ADHD symptoms,
neuropsychological, and psychosocial functioning. The same measures were
collected over the course of 1 week for college students without ADHD who
were not receiving medication.
65
60
CAARS T-Score
55
Inatt/Mem
Hyp/Restless
50
Self-Concept
ADHD Index
45
40
BL P 30-mg 50-mg 70-mg
LDX Dosage
Fig. 6.1 Self-report ratings of ADHD across dosage conditions. Standardized T-scores for
self-report ratings on the Conners Adult ADHD Rating Scale (CAARS) across baseline (BL),
placebo (P), and three active lisdexamfetamine dimesylate (LDX) dosage conditions for 24 college
students with ADHD. From “Double-Blind, Placebo-Controlled, Crossover Study of the Efficacy
and Safety of Lisdexamfetamine Dimesylate in College Students with ADHD” by G.J. DuPaul,
L.L. Weyandt, J.S. Rossi, B.A. Vilardo, S.M. O’Dell, K.M. Carson, G. Verdi, and A. Swentosky,
2012, Journal of Attention Disorders, 16, p. 212 (Copyright 2012 by Sage Publications. Reprinted
with permission)
Results revealed that most participants reported clinically significant reductions

in ADHD symptoms; however, large differences remained in neuropsychological
functioning between ADHD and control participants. Specifically, LDX led to
significant reductions in self-reported ADHD symptoms relative to both baseline
and placebo conditions (see Fig. 6.1). In addition, LDX was associated with sub-
stantial improvement in executive functioning, including task management, plan-
ning, organizational skills, study skills, and working memory (see changes in
metacognition in Fig. 6.2). Significant, but smaller, improvements were found for
psychosocial functioning. Reliable change indices (RCI; Jacobson & Truax, 1991)
were calculated to determine individual response to placebo and active LDX con-
ditions for self-reported ADHD symptoms and executive functioning. RCIs indi-
cated 86% of college students with ADHD exhibited a positive response in terms
of ADHD symptoms, and 73% showed a positive response in terms of executive
functioning to at least one LDX dosage condition (see Fig. 6.3). It is important to
note that although substantial improvements were found, college students with
ADHD did not improve to the point of “normalization” and indeed remained at a
disadvantage (i.e., at least one standard deviation difference) relative to the control
participants (see Fig. 6.4). Therefore, it is critical that pharmacotherapy be aug-
mented with effective psychosocial and academic treatments for college students
with ADHD.
70
65
60
BRIEF T-Score
55 Behav Reg
Metacognition
50 Global Exec
45
40
BL P 30-mg 50-mg 70-mg
LDX Dosage
Fig. 6.2 Self-report ratings of executive functioning across dosage conditions. Standardized
T-scores for self-report ratings on the Behavior Rating Inventory of Executive Function (BRIEF)
across baseline (BL), placebo (P), and three active lisdexamfetamine dimesylate (LDX) dosage
conditions for 24 college students with ADHD. From “Double-Blind, Placebo-Controlled,
Crossover Study of the Efficacy and Safety of Lisdexamfetamine Dimesylate in College Students
with ADHD” by G.J. DuPaul, L.L. Weyandt, J.S. Rossi, B.A. Vilardo, S.M. O’Dell, K.M. Carson,
G. Verdi, and A. Swentosky, 2012, Journal of Attention Disorders, 16, p. 212 (Copyright 2012 by
Sage Publications. Reprinted with permission)
Non-stimulants
In 2002, the FDA approved the non-stimulant medication, atomoxetine (Straterra™)

for the treatment of ADHD in children and adults. Atomoxetine targets the neu-
rotransmitter norepinephrine and reportedly makes more of this neurotransmitter
available to brain cells (Garnock-Jones & Keating, 2009; Seneca et al., 2006). A
substantial number of studies have found atomoxetine is effective for treating ADHD
symptoms in children and adults (Adler et al., 2009; Surman et al., 2010; Vaughan,
Fegert, & Kratochvil, 2009). For example, atomoxetine has been found to improve
ADHD symptoms, academic performance, and classroom behavior in children with
the disorder (Mendez, Singh, Harrison, Huang, Jin, & Cho, 2011; Waxmonsky et al.,
2010). It is also associated with improvements in self-esteem, emotional well-being,
and overall quality of life of children with ADHD (Wehmeier et al., 2011).
Atomoxetine has also been found to be a safe and effective treatment for adults with
ADHD and is associated with improved work performance (Santosh, Sattar, &
Canagaratnam, 2011; Wigal et al., 2010). The use of atomoxetine with the college
student population, however, has not been investigated.
100
90
80
70
60
Percentage
50
ADHD Index
BRIEF Metacog
40
30
20
10
0
Placebo 30-mg 50-mg 70-mg Any LDX
Dosage Condition
Fig. 6.3 Percentage of positive responders (RCI 1.96) across dosage conditions. Percentage of
positive responders to placebo and lisdexamfetamine dimesylate (LDX) based on individual
reliable change index (RCI) scores for the Behavior Rating Inventory of Executive Function
(BRIEF) Metacognition Index and the ADHD Index from the Conners Adult ADHD Rating
Scale. From “Double-Blind, Placebo-Controlled, Crossover Study of the Efficacy and Safety of
Lisdexamfetamine Dimesylate in College Students with ADHD” by G.J. DuPaul, L.L. Weyandt,
J.S. Rossi, B.A. Vilardo, S.M. O’Dell, K.M. Carson, G. Verdi, and A. Swentosky, 2012, Journal
of Attention Disorders, 16, p. 215 (Copyright 2012 by Sage Publications. Reprinted with
permission)
Antidepressants and Anticonvulsants
In addition to stimulants, pro-drug stimulants, and non-stimulants, antidepressants

including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepres-
sants (see Table 6.1) have been used in the treatment of ADHD in adults, although
there is a dearth of information concerning their use in college students with ADHD
(Faigel, 1995; Javorsky & Gussin, 1994; Kollins, 2008). SSRIs are believed to exert
their effects by targeting the brain neurotransmitter, serotonin. Specifically, SSRIs
tend to block the reuptake of serotonin making more of it available for use by brain
cells during communication, while tricyclic antidepressants target serotonin and
norepinephrine. Improvement in symptoms is also associated with longer-term
changes to neurons (i.e., changes in receptors) (Weyandt, 2006a). Antidepressants
may be useful for individuals with ADHD who do not respond to other types of
medication or have coexisting depression, anxiety, or addiction problems (Spencer
& Biederman, 2002). Tricyclic antidepressants may take 4–6 weeks to influence
3.5
2.5
Cohen's d Effect Size
1.5 ADHD Index

BRIEF Metacog
0.5
0
Placebo 30-mg 50-mg 70-mg Lowest
Effective
Dose
Dosage Condition
Fig. 6.4 Magnitude of differences between ratings of participants with ADHD during medication
conditions and non-ADHD controls. Cohen’s d effect size differences between college students with
ADHD receiving placebo and lisdexamfetamine dimesylate and unmedicated college students with-
out ADHD for the Behavior Rating Inventory of Executive Function (BRIEF) Metacognition Index
and the ADHD Index from the Conners Adult ADHD Rating Scale. From “Double-Blind, Placebo-
Controlled, Crossover Study of the Efficacy and Safety of Lisdexamfetamine Dimesylate in College
Students with ADHD” by G.J. DuPaul, L.L. Weyandt, J.S. Rossi, B.A. Vilardo, S.M. O’Dell, K.M.
Carson, G. Verdi, and A. Swentosky, 2012, Journal of Attention Disorders, 16, p. 215 (Copyright
2016 by Sage Publications. Reprinted with permission)
symptom improvement and are associated with greater adverse side effects than
SSRIs and are therefore rarely prescribed relative to the other medications available
for ADHD. Studies that have compared the effectiveness of stimulants versus anti-
depressants in the treatment of ADHD have found that stimulants show greater
efficacy in terms of symptom reduction and improvement in functioning (Faraone
& Glatt, 2010).
Anticonvulsants, more commonly known as antiseizure medications, also have
been recommended, but less commonly, in the treatment of ADHD (see Table 6.1).
For example, Davids, Kis, Specka, and Gastpar (2006) reported that the antiseizure
drug, oxcarbazepine, was well tolerated by adults with ADHD and effective at reduc-
ing ADHD-related symptoms. It is critical to note, however, that antidepressant and
anticonvulsant medications have not been approved by the FDA for the treatment of
ADHD and are used off-label. In addition, no double-blind, placebo-controlled stud-
ies of these medications have been conducted with college students with ADHD.
In summary, a variety of medications are available for the treatment of ADHD in

college students, but only stimulants, one pro-drug stimulant (LDX), and one non-
stimulant (atomoxetine) have been approved by the FDA for the treatment of ADHD.
Other medications are used off-label and include antidepressants and anticonvul-
sants. Unfortunately, studies regarding the use of these medications with the college
student ADHD population are virtually nonexistent. Authors Weyandt and DuPaul
conducted the only double-blind, placebo-controlled study investigating the effec-
tiveness of LDX with college students with ADHD, and results supported the effec-
tiveness of this medication in improving ADHD symptoms, executive functioning,
study/organizational skills, symptoms of psychological disorders, and social perfor-
mance at least in terms of the student role (DuPaul et al., 2012). Although several
types of medications are used to treat ADHD, in general, research suggests that
stimulant medications are the most efficacious at improving ADHD symptoms and
functional impairments.
Diversion of Medication
Diversion, or the nonmedical use of prescription medication for purposes other than
prescribed, also referred to as recreational use, illicit use, misuse, or abuse, has
become an issue on college campuses in recent years. In fact, according to Fortuna,
Robbins, Caiola, Joynt, and Halterman (2010), the nonmedical use of prescription
medications by adolescents and young adults has surpassed all illicit drugs except
marijuana. Studies have consistently revealed that a substantial percentage of col-
lege students are using prescription stimulants without a valid prescription and they
are doing so for both academic and recreational purposes. For example, in one of
the first studies of prescription stimulant misuse, Babcock and Byrne (2000) distrib-
uted a 10-question survey (yes/no format) designed to measure nonmedical use of
prescription stimulants to all students (1,401) attending a public, 4-year college in
the northeast region of the United States. Nearly 300 surveys were completed, and
participant ages ranged from 18 to 51, with a median age of 21. Results revealed
that approximately 16% of the students reported that they had taken Ritalin™
(methylphenidate) for “fun,” and 53% reported knowing a student who had taken
Ritalin™ for “fun.” Approximately 2% of the sample had a valid prescription for
Ritalin™. More recently, Weyandt and colleagues (2009) surveyed students at a
university located in the northeast and found that 7.5% of the sample reported using
stimulants without a prescription within the past 30 days, 60% reported knowing
students who misuse stimulants, 50% agreed or strongly agreed that prescription
stimulants were “easy to get on this campus,” and 21.2% of participants indicated
they had occasionally been offered prescription stimulants from other students.
Additional studies have yielded similar results (e.g., McCabe, Knight, Teter, &
Wechsler, 2005; Rabiner et al., 2009; Sharp & Rosén, 2007; Teter, McCabe,
Cranford, Boyd, & Guthrie, 2005; White, Becker-Blease, & Grace-Bishop, 2006).
Recently, Tuttle, Scheurich, and Ranseen (2010) explored the prevalence of ADHD
Diversion of Medication 83
and medication diversion in medical students. The authors found that 5.5% of nearly
400 medical students reported being diagnosed with ADHD and most (72%) were
diagnosed as adults. Meanwhile, 10% of the nearly 400 students reported using
stimulants for nonmedical purposes. Wilens and colleagues (2008) conducted a sys-
tematic review of the diversion literature and concluded that lifetime rates of diver-
sion ranged from 5% to 35% of college students.
Motivations for misusing prescription stimulants appear quite clear. In essence,
the main reasons students report for using stimulants without a prescription include
(a) to help with concentration, attention, and focusing; (b) to improve academic
performance; and (c) for recreational purposes (e.g., to stay awake while consuming
alcohol or other substances) (Arria et al., 2008; DeSantis, Webb, & Noar, 2008;
Hall, Irwin, Bowman, Frankenberger, & Jewett, 2005; Teter et al., 2005; White
et al., 2006). Recently, Looby and Earleywine (2011) studied the arousal level and
cognitive performance of college students who thought they were receiving meth-
ylphenidate when in fact they received a placebo. Findings revealed that partici-
pants reported feeling significantly more aroused and stimulated than control
participants; however, their cognitive performance did not differ. These findings
suggest that subjective mood may be implicated in prescription stimulant misuse
among college students.
In terms of identifying students who may be at greater risk for medication diver-
sion, studies have found that nonmedical use of stimulants tends to be higher among
college students who have lower grade point averages, are White, members of fra-
ternities or sororities, use a greater number of illicit substances, and attend colleges
in the northeast region of the United States (Advokat, Guidry, & Martino, 2008;
Dussault & Weyandt, 2011; Jardin, Looby, & Earleywine, 2011; Kroutil et al., 2006;
McCabe et al., 2005; White et al., 2006; Wilens et al., 2008). Research also suggests
that college students who report problems with inattention are at greater risk for
using stimulants without a prescription (Arria et al., 2008; Wilens et al., 2008).
Indeed, it has recently been reported that students who misuse prescription stimu-
lants are 7 times more likely to have significant ADHD symptoms than students
who do not misuse prescription stimulants (Peterkin, Crone, Sheridan, & Wise,
2011). In addition, psychological variables may predict students who are at greater
risk for misusing stimulants. For example, Low and Gendaszek (2002) found that
students who endorsed high ratings on a sensation-seeking measure (Sensation-
Seeking Scale; Zuckerman, Eysenk, & Eysenk, 1978) were more likely to misuse
prescription stimulants, while student ratings on a perfectionism scale
(Multidimensional Perfectionism Scale; Frost, Marten, Lahart, & Rosenblate, 1990)
were not associated with prescription stimulant misuse. Recently, Dussault and
Weyandt (2011) and Weyandt et al. (2009) found a relationship between stimulant
misuse and degree of psychological distress and internal restlessness reported by
college students. Lastly, Dussault and Weyandt (2011) and Rabiner et al. (2009)
found that stimulant misuse among college students was associated with impulsivity
and use of other substances. With regard to gender differences, some studies report
higher rates of nonmedical stimulant use among male compared to female college
students (e.g., Low & Gendaszek, 2002; Teter et al., 2005; McCabe et al., 2005);
however, other studies have not found significant differences between males and
females (e.g., Carroll, McLaughlin, & Blake, 2006; Hall et al., 2005; Kroutil et al.,
2006; Sharp & Rosén, 2007; White et al., 2006).
Whether students with ADHD are more or less likely to abuse stimulants during
college is unclear. In a recent review of the literature, Wilens et al. (2008) concluded
that both individuals with and without ADHD misuse stimulant medications.
Preliminary findings also suggest that college students with ADHD who are pre-
scribed stimulants for the first time while in college have significantly higher rates
of stimulant misuse, as well as rates of alcohol and other drug use (Kaloyanides,
McCabe, Cranford, & Teter, 2007). Upadhyaya and colleagues (2005) also found
that college students with ADHD who were taking prescription stimulant medica-
tion were more likely to use other drugs than students without ADHD. Upadhyaya
and colleagues (2005) reported that 25% of college students prescribed stimulants
for ADHD reported using stimulants to “get high” and 29% reported sharing or sell-
ing their stimulants to someone else. Given that some students with ADHD appear
to be using their prescription medication for recreational purposes, Faraone and
Upadhyaya (2007) have recommended that college students be prescribed medica-
tions that have less potential for abuse such as LDX. Indeed, DuPaul et al. (2012)
found a decrease in use of substances among college students with ADHD while
they were taking LDX.
In terms of type of stimulants likely to be misused, Ritalin™ appears to be
misused four times more often than Concerta™, and among Ritalin™ abusers,
intranasal use has been reported more often than oral use (Dupont, Coleman,
Bucher, & Wilford, 2008). Why Ritalin™ is misused more often than Concerta™
is difficult to interpret, but it may be that the former is more readily available to
college students. In fact, research has found that the primary source of prescrip-
tion stimulants tends to be other students (Barrett, Darrendeau, Bordy, & Pihl,
2005; McCabe & Boyd, 2005). Garnier and colleagues (2010) recently reported
that among nearly 500 college students prescribed a medication, nearly 36%
diverted a medication at least once, and the most commonly diverted medication
was ADHD related (61.7%). In most cases, students reported sharing their medi-
cation rather than selling it (33.6% and 9.3%, respectively). To help reduce the
rate of sharing of medication, it is possible that transdermal systems (i.e., medica-
tion patches) could be useful with the college student population although, to
date, studies of the transdermal system have only been conducted with children
(Pelham et al., 2011).
In summary, misuse of prescription stimulants is a problem on college campuses,
and both students with and without ADHD have been found to misuse these medi-
cations. The main motivations appear to be academic and recreational. Although the
findings are preliminary, it appears as though students who are at greater risk for
diversion include those who are White, members of sororities and fraternities, have
lower GPAs, attend colleges in the northeast, and have higher levels of psychologi-
cal distress, internal restlessness, anxiety, inattention, and impulsivity. Clearly, more
research is warranted in this area to better understand risk factors and ways to reduce
the likelihood of medication diversion on college campuses.
Case Example 85
Conclusion
A variety of medications are available to treat ADHD including stimulants,

non-stimulants, prostimulant, antidepressants, and, less commonly, medications
used to treat other conditions such as anticonvulsant medications. The most fre-
quently prescribed medication for college students with ADHD is psychostimu-
lants. Although the use of psychostimulants in the treatment of ADHD in children
is well established, there is a dearth of studies examining their effectiveness in the
college student population. To date, only one double-blind, placebo-controlled
study investigating the effectiveness of LDX with the college student population has
been conducted. Given that increasing numbers of students with ADHD are attending
college, effective treatment methods play a crucial role in increasing the likelihood
of success in these students. Future research using rigorous design is needed to further
explore the role of pharmacotherapy for college students with ADHD. In addition,
studies are needed to develop effective nonpharmacological interventions for this
population, especially when considering the diversion problem on college campuses.
Lastly, success in college is not simply based on academic performance but is mul-
tifaceted and includes areas such as psychological, neuropsychological, and social
functioning. Research is needed to answer basic questions about college students
with ADHD regarding each of these areas of functioning and to examine how func-
tioning may change over time and/or with treatment. Pharmacotherapy is the most
widely used form of treatment for college students with ADHD and will likely con-
tinue to play a critical role in the treatment of these students in the future.
Case Example
Alex (a 21-year-old White male college senior) participated in the Weyandt and
DuPaul research project investigating the effects of a stimulant medication, LDX, on
college students with ADHD (DuPaul et al., 2012). As part of the process, an extensive
diagnostic interview was conducted with Alex and with his mother. In addition,
Alex underwent five assessment sessions that covered various aspects of his psycho-
logical, academic, and behavioral functioning while he was taking different dosages
of LDX. After the initial baseline phase, Alex received weekly dosages of placebo,
50-mg, 70-mg, and 30-mg tablets, respectively. Alex’s results are as follows.
Based on the results of the diagnostic interview, which screened for inattentive
and hyperactive behaviors, as well as a variety of mood and emotional disorders,
Alex had clinically elevated levels of inattention symptoms (i.e., ADHD, predomi-
nantly inattentive type). He did not meet the criteria for any other mood or
emotional disorders.
A direct assessment of Alex’s memory and attention was completed on a weekly
basis, and the findings indicated that while he was taking the 30-mg dosage, he did
not experience significant inattentive or hyperactive behaviors. While Alex was taking
the 50-mg and placebo dosages, he experienced moderate inattentive/hyperactive

behaviors; some inattentive or hyperactive behaviors were exhibited while he was
taking the 70-mg dosage. Based on these findings, the 30-mg dosage was the most
effective dose for Alex in terms of memory and attention.
With respect to psychological functioning, while taking the 30-mg and placebo
dosages, Alex reported no elevated levels of psychological distress on any of the mea-
sures completed. While taking the 50- and 70-mg dosages, however, Alex reported
some psychological distress on the measures, and therefore, the 30-mg and placebo
dosages appeared to be the most effective in terms of psychological functioning.
Consistent with other areas assessed, Alex reported that while he was taking the
30-mg dosage, he was achieving good grades in classes and felt he was socially well
adjusted. Alex did not provide information regarding his academic performance
while taking the 50- and 70-mg dosages; however, he did report that he was
experiencing difficulties interacting with others in his work (i.e., study) role. Finally,
while taking the placebo dosage, Alex reported that he was achieving good grades
in classes but that he was experiencing some difficulties related to his work role,
however, not to the degree that he had reported during the 50- and 70-mg dosages.
Therefore, based on the data collected, the 30-mg dosage appeared the most
effective at improving Alex’s academics and social adjustment.
With regard to behavior and emotional functioning, Alex rated himself as expe-
riencing difficulty planning and organizing academic work while taking the 30-mg
dosage but having strong emotional control. While taking the placebo and 50-mg
dosages, Alex also rated himself as having control over his emotions, but noted that
he experienced difficulties with study and organizational skills. Additionally, while
Alex was taking placebo, he reported experiencing the least amount of flat affect
throughout the week. Finally, while taking the 70-mg dosage, Alex rated himself as
having strong emotional control and planning and organizational skills. Alex also
indicated that he experienced the most flat mood during this phase, however. Therefore,
although the 70-mg dosage was most effective in treating Alex’s planning and organi-
zational skills, the placebo was most effective in terms of Alex’s emotional state.
In summary, the 30-mg dosage of LDX appeared to be the most effective across
the measures Alex completed. A report was sent to Alex and his primary care physi-
cian, recommending that he must continue the treatment with LDX and begin with
the 30-mg dosage.
Chapter 7
Future Directions for Practice and Research
Students with ADHD experience multiple challenges in the college environment

including possible academic, social, psychological, and occupational impairment.
Thus, as discussed throughout this book, it is important to identify college students
who may have this disorder, assess symptoms and functioning in a comprehensive
fashion, and provide treatment to address ADHD, related disorders, and functional
impairments. Although increasing clinical and research attention has addressed the
challenges and needs faced by the college ADHD population, significant gaps
remain between what is known about ADHD in college settings and what informa-
tion is needed to optimize outcomes for students with the disorder. The purpose of
this chapter is to review the main findings discussed in previous chapters and to
offer suggestions for practice and future research.
Transition from High School and Future Research
ADHD is a chronic disorder that is associated with significant academic, social, and
psychological impairment into adolescence and beyond for most individuals with
the disorder. High school students with ADHD typically have difficulties with a
variety of academic expectations (e.g., completing long-term assignments, perform-
ing at expected levels of tests) and, consequently, obtain significantly lower grades
than their classmates. ADHD also is associated with a significantly higher risk for
dropping out of school and not obtaining postsecondary education. As for social
functioning, secondary school students with ADHD may have problems making
and keeping friends and could be at higher than average risk for joining deviant peer
groups that engage in antisocial behavior. Adolescents with this disorder also can be
prone to alcohol and/or substance use especially when comorbid conduct problems
are present. Additional risks include early sexual behavior and driving difficulties
(e.g., moving vehicle violations, vehicular accidents).
Because ADHD is associated with so many critical risks in adolescence, it is
important to identify students with this disorder, assess their functioning in multiple

88 7 Future Directions for Practice and Research
areas (e.g., psychological, academic, and social), and provide the necessary supports
and interventions to enhance their chances for successful outcomes. It is especially
critical to assist students with ADHD in making the transition to life after high
school whether they pursue postsecondary education or employment. Unfortunately,
as noted in Chap. 2, little research has specifically examined the treatment (including
medication) for high school students with ADHD. Those few investigations that
have been conducted support the use of self-monitoring of behavior as well as
self-regulated strategy development in improving on-task performance, reading
comprehension, and writing.
Given the lack of research on treatment, educational support, and transition
planning for high school students with ADHD, there are several critical areas for
future investigation. First, most extant studies have been limited by small samples and
an almost exclusive focus on White, male, middle-class students. Thus, randomized
controlled trials with larger, more heterogeneous (i.e., in terms of gender, race, and
socioeconomic status) are sorely needed. Second, even though educational accom-
modations (e.g., extra time on tests) frequently are recommended to address
academic deficits, very few controlled investigations have examined their efficacy
(for review, see Harrison, Bumford, Evans, & Owens, under review). The impact of
commonly recommended educational accommodations on academic achievement
should be studied, particularly in general education classrooms where most students
with ADHD are placed. In a similar fashion, efficacy trials examining psychosocial
and academic interventions for high school students are necessary to guide clinicians
and school personnel in supporting those with ADHD. Given the variety and chro-
nicity of difficulties experienced by adolescents with ADHD, outcome studies
should be conducted over longer time periods (e.g., entire school year) rather than
2–3 months as is typical for the school-based intervention literature (DuPaul, Eckert,
& Vilardo, under review).
A final critical area for investigation is the development and evaluation of specific
strategies for supporting students with ADHD transitioning from high school to
college. Pre-, peri-, and post-transition strategies should be developed and evaluated
in terms of psychological, academic, and social adjustment to the college setting.
Pre-transition strategies might include students working with their high school guid-
ance counselors to prepare for postsecondary education. This process should involve
several steps such as (a) identifying colleges or universities that not only match stu-
dent academic interests and competencies but also have a track record for meeting
the needs of students with disabilities including ADHD; (b) guiding students in
preparing applications including writing support for required essays; (c) preparing
students to take college entrance exams (i.e., SAT or ACT) and helping students to
advocate for appropriate accommodations on these tests, if necessary; and (d) linking
students to in-school or community-based services that provide instruction and ongo-
ing support in the development of important school survival skills (e.g., note-taking,
preparing for exams, organization of school tasks and materials). Peri-transition planning
could involve specific orientation programming provided by staff associated with
university student disabilities offices. Orientation programming could make students
aware of student disability office requirements (e.g., evaluation to confirm disability
Overview of ADHD in College and Future Research 89
status), possible educational accommodations available, as well as information about

important support systems on campus (e.g., counseling center, writing support program).
Post-transition planning could include comprehensive evaluation of student’s psycho-
logical, academic, and social functioning as well as ongoing monitoring of progress
in the context of a support and intervention plan. Although anecdotal evidence and
the face validity of transition planning may provide support for these services,
controlled studies of pre-, peri-, and post-transition strategies are sorely needed to
optimize successful outcomes for college students with ADHD.
Overview of ADHD in College and Future Research
As discussed in Chap. 1, ADHD is estimated to affect 3–7% of the school-age

population and 2–5% of the adult population (American Psychiatric Association,
2000). Children and adolescents with ADHD are at increased risk for psychosocial
problems and academic underachievement, including dropping out of school. In recent
years, however, increasing numbers of adolescents with ADHD are graduating from
high school, and many are pursuing a college education.
The actual percentage of college students with ADHD is unknown, however,
largely because students with ADHD are not required to disclose their disability to
colleges and universities. As discussed in Chap. 1, the percentage of college
students receiving disability support services for ADHD varies across universities
with Henderson (1999) and Guthrie (2002) estimating that nearly two in five
college students with documented disabilities have ADHD or a learning disability.
Wolf (2009) has reported that approximately 25% of students receiving disability
services are registered as having ADHD. A substantial number of college students
(e.g., 4–8%), however, appear to struggle with ADHD symptoms (DuPaul,
Schaughency, et al., 2001; Heiligenstein, Conyers, Berns, & Smith, 1998; Pope
et. al, 2007; Weyandt, Linterman, & Rice, 1995), suggesting that the actual percent-
age of students with ADHD may be closer to DSM estimates. Indeed, 5% of incom-
ing first-year students (6.4% of men, 3.8% of women) for Fall 2010 in a large,
nationally representative survey reported having ADHD (Pryor, Hurtado, DeAngelo,
Blake, & Tran, 2010). Given these findings and unanswered questions, future
research is needed to determine not only the percentage of students with ADHD
who are registered with Disability Service Programs but also the percentage of
college students at large who have documented ADHD, and their symptoms are
consistent with current diagnostic criteria.
In addition, research is needed to better understand whether gender differences
exist among college students with ADHD. Lee, Oakland, Jackson, and Glutting
(2008), using self-report instruments, found that approximately 1.2% of males and
4.6% of females met diagnostic criteria for ADHD; however, when self- and parent
ratings were combined, only 0.4% of males and 0% of females met the criteria for
the disorder. Information is also sorely lacking with regard to prevalence differences
across ethnic groups. For example, Lee and colleagues found that 8.4% of African
Americans and 2.3% of White students met DSM-IV-TR criteria when relying on
self-report; however, when parental, retrospective ratings were also considered,

0.9% of African Americans and 0.1% of Whites were identified as meeting
DSM-IV-TR criteria for ADHD. Information is virtually nonexistent, however,
regarding gender and ethnicity information among college students diagnosed with
ADHD, and future studies should attempt to clarify these issues.
Assessment and Future Research
Three subtypes of ADHD are described in the DSM, namely, ADHD combined
type, ADHD predominantly inattentive type, and ADHD predominantly hyperac-
tive impulsive type (American Psychiatric Association, 2000). These categories,
although useful, are problematic in a number of ways. For example, the diagnostic
criteria have not been validated in adults; they do not include separate symptom
thresholds for adults and fail to identify some significantly impaired adults who are
likely to benefit from treatment (McGough & Barkley, 2004). In addition, symptom
criteria are not age referenced, and some of the criteria are developmentally inap-
propriate for adolescents and adults (e.g., often leaves the classroom, has difficulty
playing or engaging in leisure activities quietly), and there are unequal numbers of
criteria for the core symptoms (i.e., nine for inattention, six for hyperactivity, and
three for impulsivity). Fortunately, the latter three limitations will be addressed by
DSM-V criteria that include symptom descriptions for adults as well as additional
impulsivity items.
These limitations have direct implications for practice and for future research.
For example, with regard to assessment, the question arises whether clinicians
should modify the current criteria (i.e., require fewer symptoms) when evaluating
adults suspected of having ADHD as recommended by Barkley (2009). A related
issue is whether age of onset be modified to reflect “early onset” and “late onset”
symptoms as suggested by Bell (2011).
In Chap. 4, we describe the comprehensive assessment of ADHD in college stu-
dents in the context of a five-stage process including screening, multi-method
assessment, interpretation of assessment data, design of intervention plan, and evalu-
ation of intervention outcome. As is the case for assessment of children and adoles-
cents, multiple assessment methods across respondents (i.e., students and parents)
should be used including (a) assessment of the frequency and severity of ADHD
symptoms over the past 6 months using a clinical interview and symptom rating
scales; (b) documentation of the impact of symptoms on multiple domains of
functioning especially academic performance through interview and review of archi-
val educational and occupational records and other report (e.g., parent, spouse,
faculty, employer); (c) confirmation of childhood history of ADHD through retro-
spective symptom ratings (from student and parent) and school records; (d) compre-
hensive documentation of individual and family developmental, medical, academic,
and psychiatric histories; and (e) examination of possible comorbid conditions
(e.g., depression, anxiety disorder) (Barkley, 2006; Pazol & Griggins, 2012; Wolf,
Assessment and Future Research 91
2001; Wolf, Simkowitz, & Carlson, 2009). In addition, indices of possible academic
and social impairment (e.g., grade transcripts, self-report ratings of social skills) are
important components of a comprehensive evaluation. Recent studies have high-
lighted possible feigning of ADHD symptoms among college students. Therefore,
symptom validity tests (e.g., Test of Memory Malingering [TOMM]; Tombaugh,
1997) should also be included in the evaluation. Finally, our five-stage evaluation
process emphasizes that that assessment does not end with a diagnostic decision but
provides critical data for treatment planning and evaluation. In particular, the impact
of intervention on psychological, academic, and social functioning should be
monitored so that treatment decisions are not based solely on symptom reduction.
Important strides have been made in recent years to develop and evaluate assessment
methods for use in the college population. Nevertheless, there are several critical
areas for future investigation. First, reliable and valid measures specifically for
screening for ADHD in college students need to be developed with particular atten-
tion paid to the positive and negative predictive powers of these measures. In other
words, to what degree do screening measures identify students who definitely have
ADHD as well as reliably identify students who definitely don’t have ADHD?
Second, standardization samples comprised of college students need to be used in
the development of both symptom self-report ratings as well as measures of func-
tional impairment (e.g., academic and social performance). Currently, the College
ADHD Response Evaluation System (CARE; Glutting, Sheslow, & Adams, 2002)
is the only symptom rating scale that contains specific normative data for college
students. Third, symptom and impairment rating scales need to be developed and
field-tested for completion by collateral informants (e.g., parents, roommates,
friends, significant others, and, possibly, college faculty). At present, ADHD
assessment relies heavily on self-report which can be limited in many ways
including the possibility of student feigning of symptoms. Fourth, although there
are several instruments available to assess functional impairment (e.g., Learning
and Study Strategies Inventory [LASSI]; Weinstein & Palmer, 2002) specifically in
college students, additional college-based measures need to be developed to evaluate
social, academic, and occupational functioning in this population. It is particularly
critical to develop direct measures of functioning that do not rely exclusively on
student self-report.
In addition to development and psychometric evaluation of assessment measures
specifically for college students, research can also help enhance the evaluation
process. For example, many experts (e.g., Barkley, 2006) recommend a multiple
method and respondent approach to assessment of ADHD in adults; however, very
little empirical attention has been given to this approach. Research could help
determine the optimal combination of measures and respondents to reach reliable
and valid diagnostic decisions. From a feasibility perspective, studies may also help
identify cost- and time-efficient assessment protocols that are diagnostically sensitive
while also manageable in most clinical settings. Further, not only is it important to
continue investigating the degree to which various measures are sensitive to
treatment effects in college students with ADHD, but it is also critical to examine
the treatment validity of assessment instruments (Nelson & Hayes, 1979).
Specifically, to what degree do scores on an assessment measure lead to adoption

and development of intervention strategies that are ultimately associated with effective
outcomes? This question lies at the heart of the treatment design process.
Some of the assessment challenges that we identified in Chap. 4 lead directly to
potential research initiatives. Currently, ADHD assessment in adults relies on retro-
spective report of childhood symptoms and functioning typically by parent and/or
self-report. Extant data indicate that retrospective recall, particularly by students
themselves, may have limited reliability and validity in terms of accurately reflecting
child and adolescent functioning. Thus, the development of methods and measures
that document childhood functioning in adults in a psychometrically sound fashion
could enhance diagnostic decision-making. Another assessment challenge that
requires investigation is the degree to which college students with ADHD exhibit a
positive illusory bias when reporting on their functioning. At least one study (Prevatt
et al., 2012) indicates that college students are similar to children with ADHD in
exhibiting this bias. Additional studies are needed to confirm this bias and assess the
extent to which this bias may affect self-report ratings in this population.
Academic, Social, and Psychological Functioning

and Future Research
Preliminary studies suggest that college students with ADHD are more likely than
their peers to have lower GPAs, lower ACT (American College Testing) scores, and
more academic-related problems such as higher course withdrawals and being placed
on academic probation (Advokat, Lane, & Luo, 2011; Blase et al., 2009; Heiligenstein,
Guenther, Levy, Savino, & Fulwiler, 1999; Rabiner, Anastopoulos, Costello, Hoyle,
& Swartzwelder, 2008; Shaw-Zirt, Popali-Lehane, Chaplin, & Bergman, 2005).
Others have found that students with ADHD are more likely to have problems with
study habits, study skills, and academic adjustment (Norwalk, Norvilitis, & MacLean,
2009) as well as difficulties with time management, concentration, selection of main
ideas, and test-taking strategies (Reaser, Prevatt, Petscher, & Proctor, 2007; Weinstein
& Palmer, 2002). The reasons for these problems are unknown, however, and studies
are needed to further clarify the role of cognitive and environmental factors. For
example, preliminary studies suggest that impairments in executive function, includ-
ing organizational skills, may play a role in academic problems (e.g., Gropper &
Tannock, 2009; Weyandt et al., in press), and other studies suggest time and internal
restlessness may be problematic for college students with ADHD (Prevatt, Proctor,
et al., 2011; Weyandt et al., 2003).
Heiligenstein et al. (1999), however, suggested that academic impairment in
college students with ADHD may be related to external factors such as specific
difficulty with academics at a particular university, loss of family structure and
support as a function of living away from home, and lack of individualized educa-
tion. Indeed, social and psychological factors likely play a role in the success or
failure of all college students, and perhaps this is especially true in those with
Academic, Social, and Psychological Functioning and Future Research 93
ADHD. Recently, Wilmshurst, Peele, and Wilmshurst (2011) found that college
students with ADHD who were doing well academically and emotionally reported
significantly higher levels of parental, emotional, and academic support than their
non-ADHD peers. Clearly, more research needs to be conducted to better understand
the specific academic needs of college students with ADHD and to determine whether
these needs differ from those of college students with other types of disabilities.
Social and Psychological Functioning
Several studies suggest that college students with ADHD are at greater risk for adjust-
ment difficulties in a number of areas. For example, students who rated themselves as
having higher levels of ADHD symptoms also reported greater academic adjustment
problems, lower GPAs, poorer study skills, and lower levels of career-making deci-
sions (Norwalk et al., 2009). Students with ADHD also have more on-the-job
difficulties such as lower work performance ratings and being fired than their non-
ADHD peers (Shifrin, Proctor, & Prevatt, 2010). Some studies suggest that college
students with ADHD report a lower quality of life relative to their non-ADHD peers
(Grenwald-Mayes, 2002). Preliminary findings also indicate that peers and professors
view college students with ADHD more negatively than positively (Chew, Jensen, &
Rosen, 2009). Whether these perceptions affect social interactions is unknown, how-
ever, and it is also unknown whether social functioning changes over time for students
with ADHD. Longitudinal studies are desperately needed to address these issues.
A number of studies have attempted to examine the social functioning of college
students with ADHD with respect to coping, adjustment, and the use of alcohol and
illicit substances. For example, Meaux, Green, and Broussard (2009) found that
peer relationships were described as a helpful coping factor by college students with
ADHD, as were medication, planning, use of alarm clocks and reminder methods,
removal of distractions, and internal self-talk. Caring parents and teachers, active
teaching styles, and cognitive strategies to help with focusing have also been
identified by students with ADHD as factors that have improved their coping abili-
ties (Bartlett, Rowe, & Shattell, 2010). With regard to substance use, college stu-
dents who report significant symptoms of ADHD appear more likely to engage in
substance use (tobacco use, marijuana, alcohol) than students without ADHD symp-
toms (Blasé et al., 2009). Alternatively, college students with documented ADHD
may be less likely to use alcohol than students without the disorder (Janusis &
Weyandt, 2010). This area is wide open to research, and future studies are needed to
clarify whether college students with ADHD are indeed more likely to use and/or
abuse substances as well as factors that may be related to substance use or abuse.
As discussed in Chap. 3, students with ADHD are more likely to report lower
self-esteem ratings compared to students without the disorder and are at greater risk
for problems with depression, anxiety, aggression, and psychological distress com-
pared to students without ADHD (Canu & Carlson, 2007; Dooling-Litfin, & Rosén,
1997; Heiligenstein & Keeling, 1995; Kern, Rasmussen, Byrd, & Wittschen, 1999;
Rabiner et al., 2008; Richards, Rosén, & Ramirez, 1999; Shaw-Zirt et al., 2005;
Weyandt et al., 1998). A number of studies have also found that college students
with ADHD are more likely to be involved in driving-related problems such as
motor vehicle accidents, drinking and driving, being arrested for drinking and driving,
driving without a license and/or registration, engaging in street racing, police
contact for a driving offense, and total traffic violations later in life (Barkley,
Murphy, DuPaul, & Bush, 2002; Woodward, Fergusson, & Horwood, 2000). What
remains unexplored, however, are factors that increase the likelihood of driving
problems with these students as well as methods that may improve the driving record
of students with ADHD.
Again, more studies are needed to further explore the psychological functioning
of college students with ADHD, and ideally longitudinal studies would be con-
ducted to follow these students over time. Information is also needed regarding
types of services these students are receiving, whether some are more effective than
others, and whether early interventions would impact functioning across college
years. For example, pharmacotherapy is regarded by many as a first line of treat-
ment for college students with ADHD, but information is lacking regarding the
effectiveness of interventions used in isolation or in conjunction with pharmaco-
therapy (e.g., counseling, skills training, academic accommodations).
Pharmacotherapy of ADHD and Future Research
As discussed in Chap. 6, a variety of medications are available to treat ADHD

including stimulants, prostimulants, non-stimulants, antidepressants, and, less
commonly, medications used to treat other conditions such as anticonvulsant medi-
cations. The most frequently prescribed class of medication for college students
with ADHD is psychostimulants, and thousands of studies attest to the effectiveness of
psychostimulants at improving ADHD symptomatology. Although psychostimulants
affect the dopamine system of the brain, the specific mode of action of this drug
remains under investigation (Spencer, Adler, et al., 2010; Swanson, Baler, & Volkow,
2011; Weyandt, 2006a). In addition, despite the recommendation of stimulant medica-
tions as a first line of treatment for young adults with ADHD, and that most college
students with ADHD take prescription stimulants (Advokat et al., 2011), double-
blind, placebo-controlled studies examining the effectiveness of these medications
with college students are rare. Although our work investigating the effectiveness of
LDX in improving ADHD symptomatology found 86% of participants reported
reductions in ADHD symptoms, large differences remained in neuropsychological
functioning between ADHD participants and control participants even with LDX.
Thus, additional studies are essential . For example, replication studies are needed
and ecologically valid studies that explore executive functioning performance in the
classroom and everyday living are needed. In addition, research is needed to com-
pare the effectiveness of LDX compared to other medications used in the treatment
of ADHD in college students.
Psychosocial and Educational Interventions and Future Research 95
A related issue concerns nonmedical use of prescription medication for purposes

other than prescribed, also referred to as recreational use, illicit use, misuse or abuse,
or diversion. Fortuna, Robbins, Caiola, Joynt, and Halterman (2010) reported that
the nonmedical use of prescription medications by adolescents and young adults
has surpassed all illicit drugs except marijuana. College students without ADHD
report using prescription stimulants for both academic and recreational purposes.
(e.g., McCabe, Knight, Teter, & Wechsler, 2005; Rabiner et al., 2009; Sharp &
Rosén, 2007; Teter, McCabe, Cranford, Boyd, & Guthrie, 2005; Weyandt et al.,
2009; White, Becker-Blease, & Grace-Bishop, 2006). Wilens and colleagues (2008)
conducted a systematic review of the diversion literature and concluded that lifetime
rates of diversion ranged from 5% to 35% of college students.
Students who may be at greater risk for medication diversion include those with
lower grade point averages, of White ethnicity, members of fraternities or sororities,
those who use a greater number of illicit substances, and those who attend colleges
in the northeast region of the United States (Advokat, Guidry, & Martino, 2008;
Dussault & Weyandt, 2011; Jardin, Looby, & Earleywine, 2011; Kroutil et al., 2006;
McCabe et al., 2005; White et al., 2006; Wilens et al., 2008). Research also suggests
that students who misuse prescription stimulants are 7 times more likely to have
significant ADHD symptoms than students who do not misuse prescription stimu-
lants (Peterkin, Crone, Sheridan, & Wise, 2011). Psychological variables such as
high sensation seeking, internal restlessness, and higher rates of impulsivity may
also predict students who are at greater risk for misusing stimulants (Dussault and
Weyandt, 2011; Low & Gendaszek, 2002; Rabiner et al., 2009; Weyandt et al.,
2009). Future studies are needed to explore whether intervention programs (e.g.,
education about risks of stimulant abuse) would curtail the misuse of prescription
stimulants on college campuses.
Whether students with ADHD are more or less likely to abuse stimulants during
college is unclear. In a recent review of the literature, Wilens et al. (2008) concluded
that both individuals with and without ADHD misuse stimulant medications.
Preliminary findings also suggest that college students with ADHD who are pre-
scribed stimulants for the first time while in college have significantly higher rates
of stimulant misuse, as well as higher rates of alcohol and other drug use
(Kaloyanides, McCabe, Cranford, & Teter, 2007). The primary source of prescrip-
tion stimulants tends to be other students (Barrett, Darrendeau, Bordy, & Pihl, 2005;
McCabe & Boyd, 2005). Clearly, more research is warranted in this area to better
understand risk factors and ways to reduce the likelihood of medication diversion on
college campuses.
Psychosocial and Educational Interventions and Future Research
The primary non-pharmaceutical approaches to support and treatment of college

students with ADHD include psychosocial treatment (i.e., cognitive-behavior
therapy [CBT] and ADHD coaching), educational interventions, and educational
accommodations. In contrast to medication treatment that is primarily directed

toward reduction of ADHD symptoms, the three non-pharmaceutical approaches
address critical functional impairments (e.g., academic underachievement)
commonly associated with ADHD. CBT is designed to reduce the cognitive,
emotional, and behavioral rami fi cations of ADHD symptomatology (e.g.,
procrastination in completing academic assignments) by directly addressing
maladaptive beliefs (e.g., “I am not a good student”) that may result from the
combination of ADHD and developmental challenges (e.g., increased expecta-
tions for organization and time management) associated with college (Ramsay &
Rostain, 2006). Maladaptive cognitions, left unchecked, increase anxiety and
lead to compensatory strategies to reduce anxiety (e.g., procrastination of challeng-
ing assignments) that are successful in the short term, but detrimental to student
success over the long term. Thus, the primary goals of CBT are to help students
recognize this cycle and adopt coping and problem-solving strategies to counteract
this maladaptive process.
ADHD coaching involves assisting students to cope with the impact of their
symptoms on academic performance and on completing daily responsibilities asso-
ciated with the college experience (Swartz, Prevatt, & Proctor, 2005). The coaching
process involves several steps including an initial meeting for the coach and student
to set collaborative expectations, structure meeting content and schedule, as well as
formulate long-term goals (Swartz et al., 2005). Weekly objectives (i.e., short-term,
attainable outcomes) related to each long-term goal are set at the end of each coaching
session and evaluated at the beginning of each subsequent meeting. Coaches can
help students to chart progress on weekly objectives as well as select rewards and
consequences for session attendance and progress toward goals. The primary
approach is to assist students in using a systematic problem-solving approach toward
attaining goals that involves discussion of challenges or obstacles to goal attainment,
identifying possible strategies for overcoming challenges or obstacles, changing
consequences for actions, evaluating the effectiveness of strategies on a weekly
basis, and making changes to strategies when needed.
Educational interventions involve providing students with training in specific
content-area skills (e.g., math or writing skills); direct instruction in strategies to
organize course materials and tasks, study for tests, and take class notes; and ongoing
support in using newly acquired strategies or academic skills. Most of the recom-
mended educational interventions include providing instruction in study/organization
skills and/or methods to enhance comprehension of lecture and reading material
(Allsopp, Minskoff, & Bolt, 2005; Hecker, Burns, Elkind, Elkind, & Katz, 2002).
Support plans for college students with ADHD typically include educational
accommodations that involve changes to educational practice that mitigate the
impact of a disability, in this case ADHD, on student access to the curriculum
(Harrison, Bumford, Evans, & Owens, under review). Although specific
accommodations are based on the needs and impairment exhibited by individual
students, typical recommendations for students with ADHD involve changes in
presentation (e.g., providing guides with examples of test format and content),
response requirements (e.g., allow oral or written exam answers), timing/scheduling
Psychosocial and Educational Interventions and Future Research 97
(e.g., provide extra time to complete exams), and setting (e.g., allow student to
complete exam in a distraction-free setting) (Wolf, 2001; Wolf et al., 2009).
Practitioners should consider using the combination of psychosocial and
educational strategies to address the wide variety of difficulties that college students
with ADHD may experience in independent, daily living. Because multiple university-
and community-based professionals typically are involved in providing support and
treatment services, one of these professionals would ideally serve as a case manager.
The latter would ensure that students are receiving appropriate services, service
providers are working toward goals in a similar fashion, and students are able to
advocate for themselves in obtaining necessary services.
As described in Chap. 5, there is a substantial gap between recommended services
and empirical research documenting the efficacy and effectiveness of these services.
At a descriptive level, very little is known regarding (a) what psychosocial treatment
and educational services are recommended for college students with ADHD and (b)
the extent to which recommended services are actually provided. Specifically, the
percentage of college students with ADHD who receive educational interventions,
educational accommodations, and/or psychosocial treatment (e.g., CBT) needs to
be addressed. Further, whether the type of interventions and accommodations that
are recommended and received are effective, and does type of intervention vary
by type of postsecondary institution (e.g., 2-year community college vs. 4-year
university) and by other demographic variables (e.g., geographic region)? In similar
fashion, how often are treatment and support services overseen by a case manager
(as we recommended in Chap. 5)? And if a case manager is present, who typically
serves in this role? Are university-based personnel (e.g., student disabilities office
director) more likely to serve as case managers, or is this role more typically filled by
community-based professionals (e.g., clinical psychologist)?
In addition to basic descriptive research, experimental studies are sorely needed to
document the relative efficacy and effectiveness of recommended treatment
approaches. First, efficacy studies of specific psychosocial and educational interven-
tions should be conducted using sample sizes that provide sufficient statistical power
as well as including random assignment to appropriate control conditions (e.g., group
that controls for therapist or educator attention). Similarly controlled efficacy studies
should examine outcomes associated with each of the four types of educational accom-
modations (i.e., presentation, response, timing/scheduling, and setting). Second,
treatment outcome should be documented not only with respect to reductions in
ADHD symptoms or improvement in psychological functioning but should also focus
on measuring possible changes in academic and social functioning. Third, because
students with ADHD may have other psychiatric or learning disorders, the possibility
of differential treatment response as a function of comorbidity should be examined.
For example, are certain educational interventions more helpful for students with
comorbid ADHD and LD relative to other interventions that may be most helpful
for students with ADHD. Fourth, the degree to which psychosocial or educational
interventions normalize psychological, academic, and social functioning should be
assessed by comparing treatment outcomes for students with ADHD to functioning
for peers without ADHD. As we found in our study of LDX (DuPaul et al., 2012), it
is possible for treatment to lead to large, clinically significant improvements in symptoms

and functioning while still leaving students with ADHD at significant deficit relative
to their non-ADHD classmates. Thus, it would be important to know whether psycho-
social or educational interventions could lead to significant improvement that brings
students with ADHD closer to the normal range of functioning. Fifth, given that it is
unlikely for a single intervention approach to sufficiently address the many challenges
faced by students with ADHD, studies examining various treatment combinations
(e.g., psychosocial plus educational intervention; combined psychosocial, educational,
and medication treatment) are necessary to identify how best to optimize treatment
plans for this population. These investigations should also attempt to identify predic-
tors of response to intervention; this may aid in determining subgroups of students
that respond differently to varying combinations of treatment strategies. Finally,
experimental or quasi-experimental studies should evaluate the degree to which hav-
ing a case manager improves student academic, social, and/or psychological outcomes.
Although using a case manager to facilitate and coordinate services has significant
face validity, empirical data are needed to assess whether a case manager actually
enhances the probability of treatment success.
Conclusions
Attention-deficit hyperactivity disorder (ADHD) is a chronic disruptive behavior

disorder associated with long-term impairment in educational attainment, occupa-
tional status, and social relationships, as well as increased risk for psychopathology
and legal difficulties (Barkley, Murphy, & Fischer, 2008; Mannuzza, Klein, Bessler,
Malloy, & Hynes, 1997). Individuals identified as having ADHD in childhood
are significantly less likely to graduate from high school, and significantly fewer
(20–21%) go on to postsecondary education relative to their non-ADHD peers
(68–78%; Barkley et al.). For those children and adolescents with ADHD who do
attend college, they are at increased risk for obtaining a significantly higher percent-
age of D and F grades, withdrawing from a significantly greater percentage of
courses, and not completing their degree programs relative to control individuals
without ADHD (Weyandt & DuPaul, 2006).
The significantly lower rate of college degree attainment among young adults
with ADHD has critical implications for the long-term financial and mental health
status of this population and for society at large. For example, many studies have
documented that individuals with a bachelor’s degree earn two to four times as
much as high school graduates across the lifespan (e.g., Baum, Ma, & Payea, 2010;
Kantrowitz, 2007). In most Western cultures, life satisfaction, happiness, and general
mental health are strongly correlated with socioeconomic status (e.g., Mossakowski,
2008). Thus, individuals with bachelors or advanced degrees generally report higher
levels of life satisfaction and happiness (Smith, 1982), participate more in community
life (e.g., voting), and engage in healthier lifestyles than high school graduates or
students who drop out (Baum et al.).
Conclusions 99
Table 7.1 Practical suggestions for college students with ADHD

Attend a university with good support services for students with ADHD
Register with Disability Support Services (DSS)
Use accommodations provided by DSS
Use a system for organization and stay organized, for example, iPhone application
Tape record lectures with professors’ permission
Establish a relationship with a student in each class with whom you can share and compare notes
Meet with teaching assistants for additional help
Review lecture notes daily
Break studying into smaller segments and avoid “marathon” study sessions as well as cramming
Review graded exams and papers with professors
Meet regularly (at least twice a semester) with an academic advisor
Begin working on assignments in advance
Join an ADHD support group
Use services offered at the Health and Counseling Center
Use services provided on campus such as writing centers and tutors
Set the alarm on the other side of the room, not next to the bed
In this book, we have illustrated how the difficulties experienced by college

students with ADHD are not only an extension of the challenges these young adults
faced as adolescents but are often times compounded by the increased responsibili-
ties and expectations for independent living associated with the university environment.
We believe that the chances for success are optimized by students receiving compre-
hensive evaluations of their psychological, academic, and social functioning and by
their receipt of psychosocial, educational, and/or medical treatments. Unfortunately,
current assessment and intervention approaches are primarily based on extrapolations
of successful strategies for children and adolescents with ADHD or based on
strategies that may work for other populations (e.g., students with LD). Nevertheless,
this book provides practitioners, researchers, and students with ADHD the best
available information on how this disorder is manifested, assessed, and treated in
postsecondary settings. We close with practical suggestions for students with ADHD
and/or professionals who work with this population that may help promote successful
outcomes (see Table 7.1).
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Index
A self-regulation strategies, 20–21

Academic functioning SRSD model, 21
internal (mental) restlessness, 2 STP, 19, 20
lower GPAs and ACT, 26 strategy instruction, 22
working memory impairments, 26 TWA strategy, 21
Academic performance, 26–27, 29, 34, 39, 52, Adult ADHD Investigator Symptom Rating
83, 90 Scale (AISRS), 49
Academic, social, and psychological AISRS. See Adult ADHD Investigator
functioning, 92–94 Symptom Rating Scale (AISRS)
ADHD. See Attention-deficit hyperactivity Alcohol, Smoking, and Substance Involvement
disorder (ADHD) Screening Test (ASSIST), 48
ADHD Self-Report Scale (ASRS), 45–46 Antidepressants and anticonvulsants
Adolescents antiseizure medications, 81
academic and social functioning LDX, 82
academic impairment, 12 SSRIs, 80
behavior ratings and school disciplinary Archival data, 54
rates, 14 ASRS. See ADHD Self-Report Scale (ASRS)
MTA study, 13 Assessment, 90–92
peer relationship, 13–14 case examples, 58–60
assessment challenges
challenges, 18 feigning, 58
developmental and contextual factors, inclusion of collateral informants, 57
17 inclusion of parents, 56–57
measures, 16 positive illusory bias on self-report, 55
school-based, 17 relevant norm group, 55–56
self-report ratings, 18 reliability and validity, retrospective
family functioning, 16 reports, 54–55
psychological difficulties design, treatment plan, 42–43
diagnostic criteria, 15 evaluation, treatment outcome, 43–44
early sexual behavior, 15 goal, 37
symptom criteria, 14 interpretation, assessment data
social difficulties, 11 behavior, 40
transition from high school to diagnostic criterion, 41–42
postsecondary education, 22–24 symptoms of inattention, 40–41
treatment measures
Evans study, 19 archival data, 54
family therapy approaches, 19–20 diagnostic interviews, 44–45
Current Issues and Future Directions, DOI 10.1007/978-1-4614-5345-1,
120 Index
Assessment (cont.) B
functional impairment, Behavior
51–53 aggressive, 6
parent rating scales, 48–50 antisocial, 7–8, 14
self-report rating scales, 45–48 classroom, 79
tests/direct, 50–51 54-item scale, 52
multimethod, 39–40 school-based, 17
screening, 38–39 suicidal, 15
steps, 38 T-scores, 33
ASSIST. See Alcohol, Smoking, and Behavioral disorder, 18, 62
Substance Involvement Screening Behavior Rating Inventory of Executive
Test (ASSIST) Function (BRIEF), 26
Attention-deficit disorder (ADD), 2 BRIEF. See Behavior Rating Inventory of
Attention-deficit hyperactivity disorder Executive Function (BRIEF)
(ADHD)
academic functioning, 27–28
ADD, 2 C
BRIEF-A normative sample, 33 California Verbal Learning Test (CVLT), 50
CARE, 5 CARE. See College ADHD Response
case example, 72–73 Evaluation System (CARE)
clinical implications, 34 CBT. See Cognitive-behavior therapy (CBT)
core symptoms, 2 CCPT-II. See Conners Continuous
description, 1 Performance Test-II (CCPT-II)
diagnosis, children, 6 Cognitive-behavior therapy (CBT)
DSM-III-R criteria, 4 case conceptualization, 63
DSM-IV Text Revision, 2 coaching sessions, 66
DSM-V, 3 description, 62–63
“dual tasking”, 26 maladaptive cycle, 63
educational accommodations randomized clinical trial, 65
(see Educational semester approaches, 64–65
accommodations) steps, 63, 64
educational interventions (see Educational weekly objectives, 65
interventions) College ADHD Response Evaluation System
executive vs. psychological functioning, (CARE), 46–47
33 Colleges, 89–90 See also Attention-deficit
family factors, 8 hyperactivity disorder (ADHD)
gender differences, 6 College students. See Attention-deficit
group differences, 33 hyperactivity disorder (ADHD)
incidence, 3–4 Conners Continuous Performance Test-II
learning disabilities, 7 (CCPT-II), 50
participant demographic information, Coping, 25, 27, 63–65, 73, 93
32 CVLT. See California Verbal Learning Test
prenatal and postnatal risk factors, 7 (CVLT)
prevalence
college students, 4–5
older adults, 3 D
prospective follow-up studies, 8 Diagnostic interviews, 44–45
“protective factors”, 25 Digit Memory Test (DMT), 58
psychological functioning, 29–31 Digit Span Test, 50
SCL-90-R, 33 Disability support services (DSS), 1, 89, 99
social functioning, 28–29 Diversion of medication
social vs. academic functioning, 34 motivations, misusing prescription, 83–84
strategies to improve study skills, 74 psychological distress and internal
support and treatment services, 71 restlessness, 83
Index 121
10-question survey, 82 The Learning and Study Strategies Inventory,

Ritalin™ abusers, 84 college version (LASSI), 52
DMT. See Digit Memory Test (DMT) The Learning Difficulties Assessment (LDA), 52
The Driving Behavior Rating Scale (DBRS), 53 Letter Memory Test (LMT), 58
DSS. See Disability support services (DSS) Lisdexamfetamine dimesylate (LDX), 77
LMT. See Letter Memory Test (LMT)
E
Educational accommodations M
The Americans with Disabilities Act Mental health, 1, 16, 60, 71, 98
(ADA), 67 MTA study. See Multimodal Treatment of
categories, 68 ADHD (MTA) study
possible educational accommodations, 69–70 Multimethod assessment, 39–40
SAT, 70 Multimodal Treatment of ADHD (MTA)
timing/scheduling accommodations, 68, 70 study, 13
Educational interventions
AB case study design, 67
quasi-experimental design, 66 N
RAP paraphrasing strategy, 67 Non-stimulants, 79–80
Educational treatment, 9, 62, 88
Emerging adulthood, 7, 22, 28, 40
P
Parent rating scales
F current symptoms, 48–49
Feigning, 58 retrospective symptoms/functioning, 50
Functional impairment, 51–53 Pharmacotherapy, 94–95
antidepressants and anticonvulsants, 80–82
case examples, 85–86
G diversion of medication, 82–84
Global Severity Index (GSI), 47 LDX, 85
GPA. See Grade-point average (GPA) non-stimulants, 79–80
Grade-point average (GPA), 49 stimulants and pro-drug stimulants, 75–79
GSI. See Global Severity Index (GSI) Positive illusory bias on self-report, 55
Positive Symptom Distress Index (PSDI), 47
Positive Symptom Total (PST), 47
H PST. See Positive Symptom Total (PST)
High school. See Attention-deficit Psychological functioning
hyperactivity disorder (ADHD) anxiety and depression symptoms, 30
career decision-making, 30
driving-related problems, 30–31
I psychiatric comorbidities, 29
Inclusion of collateral informants, 57 psychoticism scale, 30
Inclusion of parents, 56–57 sleep disturbances and boredom proneness,
Internal Restlessness Scale (IRS), 47 31
Intervention. See Educational interventions Psychosocial and educational interventions,
95–98
Psychosocial functioning, 40, 76–78
L Psychosocial treatment. See Psychosocial
LASSI. See The Learning and Study Strategies treatment strategies
Inventory, college version (LASSI) Psychosocial treatment strategies
LDA. See The Learning Difficulties CBT (see Cognitive-behavior therapy
Assessment (LDA) (CBT))
LDX. See Lisdexamfetamine dimesylate interventions, 62
(LDX) problem-solving approach, 63–64
122 Index
Q Stimulants and pro-drug stimulants

QLI. See Quality of Life Inventory (QLI) cardiovascular events, 76
Quality of Life Inventory (QLI), 53 dopamine, 75–76
‘first line of therapy’, 77
LDX, 77
R psychostimulants, 75–79
RAP paraphrasing strategy, 67 RCIs, 78
RCIs. See Reliable change indices (RCIs) self-report ratings, 78, 79
Relevant norm group, 55–56 STP. See Summer treatment program (STP)
Reliability and validity, retrospective reports, Stroop color-word task, 50
54–55 Summer treatment program (STP), 19, 20
Reliable change indices (RCIs), 78 Support and treatment services, 71
Symptom Checklist 90-Revised (SCL-90-R), 47
S
SAT. See Scholastic Aptitude Test (SAT) T
Scholastic Aptitude Test (SAT) scores, Test of Memory Malingering (TOMM), 58
49, 70 Tests/direct measures, 50–51
SCL-90-R. See Symptom Checklist Think after reading (TWA) strategy, 21
90-Revised (SCL-90-R) TOMM. See Test of Memory Malingering
Screening, 38–39 (TOMM)
Selective serotonin reuptake inhibitors Transition from high school to postsecondary
(SSRIs), 80 education, 87–89
Self-regulated strategy development (SRSD) attendance, 22
model, 21 dropout, 22
Self-report rating scales regular meetings, 23
current symptoms self-advocacy skills, 24
ASRS, 45–46 self-port ratings, 22
ASSIST, 48 specific support services, 23
CARE, 46–47 TWA strategy. See Think after reading (TWA)
SCL-90-R, 47 strategy
retrospective symptoms, 48
SES. See Socioeconomic status (SES)
The Social Adjustment Scale-Self-Report W
(SAS-SR), 52 WAIS-R. See Wechsler Adult Intelligence
Social functioning Scales-Revised (WAIS-R)
peer relationships, 28–29 Wechsler Adult Intelligence Scales-Revised
substance use, 29 (WAIS-R), 50
Socioeconomic status (SES), 8 Wechsler Individual Achievement Test
SRSD model. See Self-regulated (WIAT-III), 52
strategy development Wender Utah Rating Scale (WURS), 48
(SRSD) model WIAT-III. See Wechsler Individual
SSRIs. See Selective serotonin reuptake Achievement Test (WIAT-III)
inhibitors (SSRIs) WURS. See Wender Utah Rating Scale (WURS)

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College Students with ADHD

Lisa L. Weyandt • George J. DuPaul

ISBN 978-1-4614-5344-4 ISBN 978-1-4614-5345-1 (eBook)

Library of Congress Control Number: 2012948683

© Springer Science+Business Media New York 2013

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Attention-deficit/hyperactivity disorder (ADHD) is a chronic disorder that affects a

Kingston, RI, USA Lisa L. Weyandt

1 Introduction and Background Information........................................... 1

Diagnostic Interview .............................................................................. 44

References ....................................................................................................... 101

Index ................................................................................................................ 119

Lisa L. Weyandt, Ph.D., is Professor of Psychology at the University of Rhode

L.L. Weyandt and G.J. DuPaul, College Students with ADHD: 1

Background Information Concerning ADHD

The core symptoms of ADHD—inattention, impulsivity, and hyperactivity—have

Prevalence and Incidence

Gender and Developmental Information

2012; Monuteaux, Faraone, Gross, & Biederman, 2007). A hallmark of adolescence

As discussed in Chap. 1, ADHD is a chronic disorder that typically begins early in

L.L. Weyandt and G.J. DuPaul, College Students with ADHD: 11

adolescence is reviewed with an emphasis on school functioning. Next, possible

Academic and Social Functioning

non-ADHD peers. One possible reason for compromised academic functioning in

In addition to difficulty with peer relationships, adolescents with ADHD may

ADHD is often associated with other psychological difficulties and psychiatric

Assessment and Treatment of ADHD in High School

Assessment of ADHD in Adolescents

The assessment of ADHD involves collection of multiple measures across several

as possibly a teacher, behavior rating scales completed by parent(s) and teacher(s),

typically provide accurate report regarding their ADHD symptomatology or their

Treatment of Adolescents with ADHD

Transition from High School to Postsecondary Education Settings

Finally, students should be assisted in developing self-advocacy skills (Schwiebert

As discussed in Chap. 1, increasing numbers of high school students with ADHD

L.L. Weyandt and G.J. DuPaul, College Students with ADHD: 25

Several studies have investigated the academic performance of college students

ADHD on another task thought to measure executive function (California Verbal

A number of studies have attempted to examine the social functioning of college

The psychological functioning of college students with ADHD is a recent area of

difficulties at age 13 were associated with driving outcomes at age 21 in a

Functioning in Multiple Areas

Purpose and Goals of Assessment

The primary purpose of psychological assessment of college students suspected of

L.L. Weyandt and G.J. DuPaul, College Students with ADHD: 37

Table 4.1 Assessment of ADHD process

The process of assessing ADHD in college students should be conducted in the

inattention and/or hyperactivity-impulsivity. The most cost-efficient screening

If screening indicates that ADHD may be present, then a comprehensive evaluation

Interpretation of Assessment Data

Finally, the specific subtype of ADHD should be identified, primarily based on

Design of Treatment Plan

or supplemental instruction. Educational records, reports from prior psychoeducational

Evaluation of Treatment Outcome

Following implementation of support services and intervention, data should be

Comprehensive assessment of ADHD in college students requires multiple measures

Table 4.2 ADHD assessment measures

histories; and description of current and prior treatments to address presenting

Self-Report Rating Scales

According to DSM-V criteria, ADHD is a disorder of childhood onset with impair-

Parent Rating Scales

symptoms and related behavioral/functioning difficulties. Glutting, Monaghan,

As is the case for student self-report, it is critical to obtain parent perceptions of