DSM-5 and Other Symptom Thresholds for ADHD: Which Is the Best Predictor of Impairment in College Students?

Short form Conners' Adult ADHD Rating Scales: Factor structure and measurement invariance by sex in emerging adults

INTRODUCTION

The short version of the Conners' Adult ADHD Rating Scales (CAARS-S:S) is a self-report measure used to identify symptoms of Attention Deficit/Hyperactivity Disorder (ADHD) during adulthood. However, its psychometric properties specifically in emerging adults, or the transitional age group between adolescence and adulthood, remain understudied. This study aimed to validate the factor structure of the CAARS-S:S in a sample of emerging adults.

METHOD

The CAARS-S:S measure was completed by adults (n = 591) aged 18 to 29 located in English-speaking countries, including Australia, Canada and the United States. Confirmatory factor analysis was used to test a four-factor model of Inattention/Memory Problems, Hyperactivity/Restlessness, Impulsivity/Emotional Lability and Problems with Self-Concept, as well as the model's invariance by sex. Sex was also included as a covariate in the model to examine differences in males' and females' scores on each factor.

RESULTS

Overall, the four-factor structure fit the data and was invariant across males and females. All factors demonstrated high internal reliability (average ωt and α = .86). It was observed that males tended to score higher on Inattention/Memory Problems while females scored higher on Problems with Self-Concept.

CONCLUSION

This research establishes the psychometric properties of the CAARS-S:S, placing greater confidence in using it to screen for ADHD symptoms in emerging adults living in a Westernized cultural context. The detailed findings of this research, implications for the use of the CAARS-S:S in this age group and potential future directions for examining the properties of the measure are discussed.

ADHD and Psychological Need Fulfillment in College Students

OBJECTIVE

Self-determination theory suggests that the satisfaction and frustration of basic psychological needs-autonomy, competence, relatedness-are uniquely associated with overall well-being. Undergraduates with attention-deficit/hyperactivity disorder (ADHD) experience more academic-related impairment and are less likely to graduate. Thus, well-being is important to understand and aim to improve in these students.

METHOD

Students at four universities (N = 2,197) completed a survey and reported previous diagnoses, ADHD symptoms, and psychological need satisfaction and frustration. Group differences were explored via t-tests; associations were explored via structural equation modeling.

RESULTS

The ADHD group reported lower satisfaction and higher frustration across all psychological needs. Inattention and hyperactivity/impulsivity were uniquely associated with aspects of need fulfillment beyond the impact of comorbid symptoms. Sex differences emerged such that women with ADHD had the lowest overall need satisfaction.

CONCLUSIONS

Addressing need fulfillment, both satisfaction and frustration, in interventions with undergraduates with clinical/subclinical levels of ADHD may optimize treatment effectiveness.

Adult-Onset ADHD: A Critical Analysis and Alternative Explanations

Attention deficit/hyperactivity disorder (ADHD) is characterized as a neurodevelopmental disorder. However, data from several recent studies suggest that there may be adults who meet current criteria for ADHD, yet did not experience symptoms until adulthood (i.e., "adult-onset ADHD"). This systematic review evaluated and synthesized the empirical evidence on adult-onset ADHD to answer the question: Is the extant literature strong enough to evaluate adult-onset ADHD? Nine studies met strict inclusion/exclusion criteria. Results suggest that the methodologies of the extant studies were not strong enough to evaluate adult-onset ADHD. Insufficient methodologies provide presently unclear information about the nature of late-onset symptoms. These symptoms seem to exist but their source could be (1) adult-emergent symptoms that were previously surpassed due to lower environmental demands/supportive facilitators, (2) mimics that were not properly assessed, or (3) childhood-onset symptoms that were not detected earlier due to failure to come to clinical attention. Future directions, clinical recommendations, and limitations of the literature and the current review are discussed.

Feasibility and Acceptability of an Internet-Based Intervention for Young Adults with ADHD

Internet-based interventions (IBIs) to treat psychological disorders are available, but accessibility to these to treat attention-deficit/hyperactivity disorder (ADHD) in young adult populations is quite limited. The current study examined the feasibility of a proposed IBI for ADHD and participant perceptions regarding treatment acceptability and credibility, and outcome expectancy. Participants (N = 235; aged 18-35) with a prior ADHD diagnosis were recruited through Amazon's Mechanical Turk (MTurk) and were provided with a proposed IBI and explanatory outlines of treatment module content. Participants in the cross-sectional study were randomly assigned to either a tailored (i.e., targeted content modules), minimal (i.e., presented overall fewer and non-targeted modules), or full (i.e., all possible modules) condition. Results demonstrated moderate IBI acceptability among participants in the tailored and full conditions. The majority of participants preferred IBI over face-to-face (F2F) treatment, and most individuals who preferred F2F treatment also considered an IBI to be an acceptable treatment modality. Lack of significant mean differences between the tailored and full conditions on several of the main outcomes of interest (e.g., perceptions of acceptability) suggests that implementation of either method of treatment could prove effective. Differences based on treatment length and relevance, and biological sex were also explored. Implications, limitations, and future directions are discussed.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s41347-022-00256-4.

Acute Effects of Physical Exercise on Cognitive and Psychological Functioning in College Students with Attention-Deficit/Hyperactivity Disorder

We sought to elucidate the acute effects of high-intensity interval training (HIIT) among college students with and without attention-deficit/hyperactivity disorder (ADHD). Participants were age- and sex-matched across ADHD (n = 18) and non-ADHD groups (n = 18) and both groups completed baseline (non-HIIT) and experimental sessions (HIIT). We examined within- and between-subject effects on a continuous performance task (CPT) and self-reported ADHD and internalizing symptomatology. We found that the degree of improvement on ADHD and depressive symptomatology, as well as processing speed and response variability following HIIT was significantly greater for the ADHD group than the comparison group. Further investigations such as randomized controlled trials focusing on the chronic effects of sustained HIIT interventions are needed to substantiate the potential feasibility and efficacy of HIIT as an intervention. HIIT may be a useful adjunct to psychosocial and/or pharmacological treatments for college students with ADHD because it: (a) yields immediate, acute improvements in executive functioning, ADHD, and mood; (b) promotes improved physical and mental health; (c) poses a relatively low risk of deleterious effects in apparently healthy college students. Even with the need for additional research, current data suggest a single, brief, high-intensity bout of aerobic exercise can yield immediate significant short-term improvements. These improvements may enhance functioning and improve outcomes for college students with ADHD.

Unique considerations in the assessment of ADHD in college students

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

Psychometric Properties of the Weiss Functional Impairment Rating Scale: Evidence for Utility in Research, Assessment, and Treatment of ADHD in Emerging Adults

Objective: The current study examines psychometric properties of the Weiss Functional Impairment Rating Scale (WFIRS), a measure of adult ADHD-related impairment. It is a self-report questionnaire that provides a metric of overall life impairment and domain-specific dysfunction. Method: Using data from a large (N = 2,093), multi-institution sample of college students and including a subsample of collateral informants (n = 262), a series of analyses were conducted. Results: The WFIRS demonstrated robust internal reliability, cross-informant agreement on par or superior to other measures of ADHD symptomatology and impairment, and concurrent validity. The WFIRS was not shown to be uniquely associated with ADHD, as internalizing symptoms also associated with the total and domain scores. Conclusion: The use of the WFIRS in identifying ADHD-related impairment in emerging adults appears to be psychometrically supported, and will prove useful to clinicians and researchers.

Invariance of ADHD Symptoms Across Sex and Age: a Latent Analysis of ADHD and Impairment Ratings from Early Childhood into Adolescence

A population-based longitudinal sample of 489 twin pairs was assessed at six time points over ten years to examine the measurement invariance and stability of attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as the developmental relations between inattention (IN), hyperactivity-impulsivity (HI), and multiple aspects of functional impairment. Parent ratings of ADHD symptoms and functional impairment were obtained in preschool and after the completion of kindergarten, first, second, fourth, and ninth grades. Results of the temporal and sex invariance models indicated that parent ratings of the 18 ADHD symptoms function in the same manner for females and males from early childhood into adolescence. In addition to establishing this prerequisite condition for the interpretation of longitudinal and between-sex differences in the IN and HI symptom dimensions, cross-lagged models indicated that both IN and HI were associated with increased risk for both concurrent and future overall, social, and recreational impairment, whereas only IN was uniquely associated with later academic impairment. Taken together, the current results demonstrate that IN and HI are highly stable from preschool through ninth grade, invariant between females and males, and indicative of risk for impairment in multiple areas, thereby providing strong support for the validity of the symptom dimensions among both sexes.

Validation of the French Version of the Weiss Functional Impairment Rating Scale-Self-Report in a Large Cohort of Adult Patients With ADHD

Objective: To analyze the psychometric properties of the French version of the Weiss Functional Impairment Rating Scale-Self Report (WFIRS-S) in a large clinical sample of adults with ADHD. Method: Patients (N = 363) were diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria. Psychometric properties of the French version of the WFIRS-S were tested including construct validity with a confirmatory factor analysis, internal structural validity with Cronbach's alpha coefficient, external validity by correlations with the Beck Depression Inventory-II (BDI-II), and the EuroQol five-dimension (EQ-5D) questionnaire. Results: The confirmatory factor analysis found the following: root mean square error of approximation (RMSEA) = 0.061, 90% confidence interval (CI) = [0.058, 0.063]; comparative fit index (CFI) = 0.67. Cronbach's alpha coefficient was .91. Correlations with EQ-5D descriptive index, visual analogue scale (VAS) scores, and BDI-II scores were -0.48, -0.55, and 0.53, respectively. Conclusion: The French version of the WFIRS-S is a psychometrically acceptable self-reported questionnaire for the multi-domain evaluation of functional impairments in adults with ADHD, for research and clinical purposes.

Cigarette and e-cigarette use and social perceptions over the transition to college: The role of ADHD symptoms

Cigarette and electronic cigarette (e-cigarette) use prevalence increases during adolescence and peaks in young adulthood, with substantial increases during the transition from high school to college especially more recently for e-cigarette use. It is important to identify the underlying factors that serve as risk factors for tobacco use and social perceptions about cigarette and e-cigarette use. It is unknown whether attention-deficit/hyperactivity disorder (ADHD) symptoms are associated with social perceptions about tobacco or increased tobacco use during the high school to college transition. This three timepoint prospective longitudinal study evaluates the reciprocal relationship between ADHD symptoms and social perceptions about tobacco as well as the frequency of cigarette and e-cigarette use in a sample of 150 high school seniors (Mage = 18.25, 66.0% female, 65.3% White) across the transition to college. ADHD symptoms in high school predicted increases in e-cigarette use during the first semester of college, and this association maintained through the end of the first year. ADHD symptoms predicted changes in social perceptions about cigarette and e-cigarette use after the transition to college. ADHD symptoms were predicted by social perceptions about e-cigarettes at the beginning of college. Understanding the psychosocial mechanisms underlying the pathways from ADHD symptoms to e-cigarette use may advance tobacco use etiology and prevention efforts, which is important considering the rapid growth in e-cigarette use among emerging adults. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Positive alcohol expectancies mediate associations between ADHD behaviors and alcohol-related problems among college students

An increasing percentage of college students report being affected by ADHD behaviors, and this population is at increased risk of experiencing negative consequences associated with alcohol consumption. However, specific factors motivating alcohol consumption and contributing to negative outcomes among these individuals are not well understood. Recent work suggests alcohol expectancies may interact with ADHD behaviors to influence negative drinking-related outcomes among those with elevated inattention and/or hyperactivity-impulsivity. Seven-hundred-forty emerging adults (M age = 19.13 [SD = 2.25] years; 72.1% female; 85.8% Caucasian) enrolled in two public universities in the Southeast and Midwest USA completed the Brief Comprehensive Effects of Alcohol Survey (B-CEOA) and provided self-reports of ADHD symptoms and drinking-related outcomes. Multiple mediation analyses were conducted to evaluate effects of ADHD behaviors (i.e., hyperactivity-impulsivity, and inattention) and related impairment in major life domains (e.g., social interactions, occupational and educational activities, fulfillment of daily responsibilities) on drinking-related outcomes via positive and negative alcohol expectancies, controlling for sex, age, co-occurring oppositional behaviors, and data collection site. Inattention, hyperactivity-impulsivity, and impairment directly predicted both personal and social problems consequent to alcohol use. Effects of ADHD behaviors and impairment on drinking-related personal and social problems were partially mediated by positive expectancies. Findings are consistent with and extend prior work supporting a role of positive alcohol expectancies in alcohol-related negative outcomes among college students experiencing mild to moderate symptoms of ADHD.

Exploring DSM-5 ADHD criteria beyond young adulthood: phenomenology, psychometric properties and prevalence in a large three-decade birth cohort

BACKGROUND

There are still uncertainties on the psychometric validity of the DSM-5 attention deficit hyperactivity disorder (ADHD) criteria for its use in the adult population. We aim to describe the adult ADHD phenotype, to test the psychometric properties of the DSM-5 ADHD criteria, and to calculate the resulting prevalence in a population-based sample in their thirties.

METHOD

A cross-sectional evaluation using the DSM-5 ADHD criteria was carried out in 3574 individuals from the 1982 Pelotas Birth Cohort. Through receiver operator curve, latent and regression analyses, we obtained parameters on construct and discriminant validity. Still, prevalence rates were calculated for different sets of criteria.

RESULTS

The latent analysis suggested that the adult ADHD phenotype is constituted mainly by inattentive symptoms. Also, inattention symptoms were the symptoms most associated with impairment. The best cut-off for diagnosis was four symptoms, but sensitivity and specificity for this cut-off was low. ADHD prevalence rates were 2.1% for DSM-5 ADHD criteria and 5.8% for ADHD disregarding age-of-onset criterion.

CONCLUSIONS

The bi-dimensional ADHD structure proposed by the DSM demonstrated both construct and discriminant validity problems when used in the adult population, since inattention is a much more relevant feature in the adult phenotype. The use of the DSM-5 criteria results in a higher prevalence of ADHD when compared to those obtained by DSM-IV, and prevalence would increase almost threefold when considering current ADHD syndrome. These findings suggest a need for further refinement of the criteria for its use in the adult population.