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Section 18
Case Study: Diagnostic Issues in Adult ADHD

Question 18 | Test | Table of Contents

Presenting Problems/Client Description
Cathy is a 24-year-old woman who had recently been dismissed from medical school. She sought a second opinion regarding possible ADHD, as well as help with a legal appeal for readmission to her school. A previous neuropsychological assessment had documented deficits in executive functions and processing speed. However, her poor performance was attributed to her extreme anxiety. Cognitive behavioral treatment was recommended, and academic accommodations (such as extra time for tests) were denied. Even with the recommended intervention, she still could not complete exams or manage her work load and was eventually asked to leave. During the interview, Cathy reported lifelong distractibility, as well as miscellaneous chronic signs of neurocognitive difficulties. For example, on a symptom checklist she indicated long-standing problems with planning and switching between tasks, poor word retrieval and fine-motor control, and general forgetfulness. Sadness, stress, and anxiety were also checked. History review found delays in walking and toilet training (motor and self-control), as well as chronic struggles in school. She had repeated first grade because of poor behavioral regulation and academic delays. Her grades in middle school and high school varied greatly (A–D), and she performed least well in classes that required detailed attention to rules (i.e., math and foreign languages). Nevertheless, she then earned strong Scholastic Aptitude Test scores and was accepted at a competitive college. In college her grades still fluctuated, but she persevered and eventually gained admission to medical school. Family history was significant for diagnosed ADHD and learning disabilities in both of her siblings, as well as clinical depression and alcoholism in her extended family. Many other family members were accomplished professionals.

Case Formulation
Some may think Cathy is unlikely to have ADHD because she is highly educated. However, this syndrome exists in all educational and socioeconomic contexts. Her presentation was typical of adults who have ADHD in that she was self-referred, complained of chronic disorganization and problems with attention, had a history of diagnostic ambiguity, and sought help because of an acute problem in school or the work world. Her legal needs were also not unusual; in this population they can range from requests for academic services (e.g., time accommodations) to criminal defense (e.g., diminished competence in sentencing decisions). Her personal history suggested the required childhood onset of her ADHD type symptoms (i.e., behavioral difficulties and academic variability), and she reported some of the more frequently associated developmental delays (e.g., late walking and toilet training). History review had indicated that her core symptoms, although diminished from childhood levels (especially for motor overactivity), had remained fairly constant irrespective of her mood/anxiety state. Thus emotional issues did not seem to account for her cognitive difficulties. Her family neuropsychiatric history included many of conditions commonly seen in this population (i.e., ADHD/LD, depression, and alcoholism). Last, the previous neuropsychological evaluation had found deficits typically seen in ADHD but assumed incorrectly that the presence of anxiety disorder ruled out concurrent ADHD.

When these findings were taken together, an ADHD diagnosis seemed probable. That is, Cathy reported core ADHD symptoms that were lifelong and still disruptive (and recalled appropriate developmental changes), reported associated personal and family history, and described good physical health. Ordinary diagnostic needs may have been met with the addition of formal ADHD scales, symptom checklists (regarding alternative or comorbid psychiatric conditions), review of DSM-IV criteria (regarding her childhood and current life), and limited objective neuropsychological testing (e.g., CPT). When combined with the interview and history, such data are often sufficient to establish a diagnosis or the need for preliminary treatment of other conditions. However, because there were legal needs and a conflicting evaluation, a new neuropsychological evaluation was indicated. In this forensic context more objective documentation of previous and current functional problems was also required. As a result her parents were sent the WURS questionnaire, and past report cards and evaluations were requested. Some evaluators would also include formal tests of motivation/malingering when evaluating for accommodations based on ADHD, but I consider this approach biased against this specific diagnosis.

Assessment Findings
Cathy’s grade school report cards documented chronic variable academic performance and behavior control problems. Teacher comments mentioned poor attention and peer group difficulties. Her childhood level of ADHD and associated symptoms on the WURS, as recalled by her parents, fell in ranges that were above those of normal control individuals but consistent with either ADHD or depression. However, they indicated high levels of most core ADHD symptoms, while denying symptoms associated with major academic or social difficulties. She denied major sadness during childhood but did report sufficient symptoms during childhood to meet ADHD/Predominantly Inattentive type criteria on the DSM-IV. Currently, Cathy met five of the necessary six inattentive DSM-IV criteria and also met three hyperactive-impulsive criteria: that is, she was not clearly a primarily inattentive or hyperactive/ impulsive or combined type but had high levels of symptoms overall. I use the ADHD/NOS designation for this situation and have found that this diagnosis as well as the primarily inattentive type are especially common in adults.

Consistently with the argument that measures normed for adults are more sensitive than the existing DSM-IV criteria, Cathy’s level of symptoms on two adult ADHD self-report scales were highly significant, especially for inattention and cognitive problems. Both her depression and anxiety scale scores were only mildly elevated, suggesting minimal impact on her cognition. On interview she further clarified that her anxiety and depression were largely triggered by her chronic inability to perform up to expectations, an explanation often heard in this population. Her performance on the Conners’ CPT indicated a 99% probability of attention disorder, with Markedly Atypical scores on omissions, commissions, and variability. Thus objective findings were remarkably consistent with the neuropsychological literature regarding ADHD and validated her subjective experience of problems. On the Wechsler Adult Intelligence Scale-4th Edition (WAIS-IV), Cathy earned Very Superior range scores on all IQ measures, indicating that she is highly intelligent and has fairly equal verbal and spatial-manipulative reasoning ability. Significant variability, however, was seen in subtests (Very Superior to Deficient) and Index scores (Very Superior to Low Average), indicating disruption in her cognition. Moreover, the two Index scores that are most consistently associated with ADHD, Working Memory and Processing Speed, were also significantly below her other indices (Verbal Comprehension and Perceptual Organization). Academic skills, as assessed via the Woodcock-Johnson III, ranged from Low Average to Superior, with High Average skills cluster and Low Average fluency cluster. Thus her performance in most skill areas was significantly below expectations for her intellect and fell in markedly weak ranges compared to that of the population when she was required to perform quickly (especially for reading). When there was no time constraint, her Reading Comprehension was Superior. Thus the need for academic accommodations was objectively supported.

Additional neuropsychological testing found deficits in abilities primarily mediated by the same frontal brain system implicated in ADHD: that is, she again showed disturbed executive functions (in inhibition, sequencing, and switching), as well as poor visual-motor integration and planning, and weak memory (both verbal and visual, likely secondary to her poor initial attention). Importantly, the unique pattern of this profile was not particularly consistent with the previously diagnosed anxiety disorder.

Outcome and Prognosis
Cathy was delighted to have her diagnostic suspicions confirmed and eagerly sought pharmacotherapy and psychoeducation. She responded well to these more targeted treatments; becoming better able to manage her time and actions. Her medical school, however, would not reverse their previous decision. She still needs to mourn this lost opportunity and redefine her goals. Both can be prolonged and difficult processes in adults who have previously spent years struggling to find an appropriate career fit.
- Wasserstein, Jeanette; Diagnostic Issues For Adolescents And Adults With ADHD; Journal of Clinical Psychology; May 2005; Vol. 61 Issue 5, p 535

Personal Reflection Exercise #4
The preceding section contained information about a case study concerning diagnostic issues in adult ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article Reference:
Cohen, E., & Kalanthroff, E. (2019). Visuospatial processing bias in ADHD: A potential artifact in the Wechsler Adult Intelligence Scale and the Rorschach Inkblots Test. Psychological Assessment, 31(5), 699–706.

Kofler, M. J., Sarver, D. E., Austin, K. E., Schaefer, H. S., Holland, E., Aduen, P. A., Wells, E. L., Soto, E. F., Irwin, L. N., Schatschneider, C., & Lonigan, C. J. (2018). Can working memory training work for ADHD? Development of central executive training and comparison with behavioral parent training. Journal of Consulting and Clinical Psychology, 86(12), 964–979.

Stanton, K., Forbes, M. K., & Zimmerman, M. (2018). Distinct dimensions defining the Adult ADHD Self-Report Scale: Implications for assessing inattentive and hyperactive/impulsive symptoms. Psychological Assessment, 30(12), 1549–1559.

QUESTION 16
In what way was Cathy’s presentation typical of adult clients with ADHD? To select and enter your answer go to Test.

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