Lorraine E. Wolf

Adults with ADHD. An overview.

Abstract: Attention‐Deficit Hyperactivity Disorder (ADHD) is a common, genetically transmitted neurological disorder, with onset in childhood, probably mediated by decreased brain dopaminergic functioning. The first author was one of the earliest to describe the persistence of symptoms into adulthood. Prevalence and natural history data suggest that of the 3 to 10% of children diagnosed with ADHD, one‐ to two‐thirds (somewhere between 1 and 6% of the general population) continue to manifest appreciable ADHD symptoms into adult life. This paper describes how ADHD in adults can be readily diagnosed and treated, despite resembling or coexisting with other psychiatric disorders. The Wender Utah diagnostic criteria address adult characteristics of the disorder. Informant and patient interviews and rating scales are used to determine the psychiatric status of the patient as a child, make a retroactive diagnosis of childhood ADHD, and establish the current diagnosis of the adult. Stringent diagnosis is key to determining effective treatment. Dopamine agonist stimulant medications appear to be the most effective in treating ADHD. About 60% of patients receiving stimulant medication showed moderate‐to‐marked improvement, as compared with 10% of those receiving placebo. The core symptoms of hyperactivity, inattention, mood lability, temper, disorganization, stress sensitivity, and impulsivity have been shown to respond to treatment with stimulant medications. Non‐dopaminergic medications, such as the tricyclic antidepressants and SSRIs have generally not been useful in adults with ADHD in the absence of depression or dysthymia. Pemoline is no longer appoved for use in these patients, despite early favorable reports. Appropriate management of adult patients with ADHD is multimodal. Psychoeducation, counseling, supportive problem‐directed therapy, behavioral intervention, coaching, cognitive remediation, and couples and family therapy are useful adjuncts to medication management. Concurrent supportive psychosocial treatment or polypharmacy may be useful in treating the adult with comorbid ADHD.

College Students with ADHD and Other Hidden Disabilities

Abstract: Nearly 25 years of special education law have enabled many qualified students with disabilities to graduate from college preparatory high school programs and enter institutes of higher education. The Americans with Disabilities Act enacted by Congress in 1990, the Individuals with Disabilities Education Act of 1975, and Section 504 of the Rehabilition Act of 1973 all mandate special education services for students with disabilities. A parallel nationwide rise is being reported in the numbers of students with disabilities on college campuses. The greatest increase is seen in students with so‐called hidden disabilities such as learning disabilities, ADHD, and psychiatric disabilities. These students face a number of obstacles once they are admitted to college. Many factors, some intrinsic to the student and others extrinsic to the campus, moderate success in higher education. Overlapping or multiple diagnoses, psychological distress, poor social and interpersonal skills, persisting cognitive deficits (especially in the area of executive functioning), and alcohol abuse are important factors that must be understood as institutions of higher education strive to promote access and provide effective support services on their campuses.

Wisconsin Card Sorting deficits in the offspring of schizophrenics in the New York High-Risk Project

It has been suggested that performance on the Wisconsin Card Sorting Test (WCST) may be an indicator of vulnerability to schizophrenia. WCST deficits have been demonstrated in schizophrenic patients and their relatives, but not as yet in their offspring. This study aimed to further establish the indicator potential of WCST deficits by analyzing data collected as part of the New York High-Risk Project (NYHRP), a longitudinal study of attention, cognition and clinical functioning in the offspring of schizophrenic (HRSz, n=73), affective disordered (HRAff, n=61) and normal comparison (NC, n=120) parents. Parental Research Diagnostic Criteria diagnoses were established by semi-structured interview (SADS-L). WCST testing was carried out when offspring were in their mid-20s. HRSz subjects performed significantly more poorly on the WCST than HRAff and NC subjects. High-risk subjects who developed psychotic symptoms prior to or shortly after testing did not differ significantly from HRSz subjects who did not become ill. Thus, WCST performance in the offspring of schizophrenics resembles that of schizophrenic patients and may distinguish HRSz from offspring at risk for nonschizophrenic illness. WCST deficits may be a specific familial indicator of vulnerability, but appear not to distinguish between those subjects at risk for schizophrenia who do or do not become ill.

Adult ADHD. Concluding thoughts.

Abstract: This concluding paper raises some final questions and issues that the authors feel should receive more emphasis in future research on ADHD in adults. One significant problem for our field is the upward extension of child‐based models and approaches without proper adaptation to adults. With adults differing patterns of comorbidity and symptom heterogeneity pose new conceptual, diagnostic, and treatment challenges. As an illustration, we review ten common presenting complaints in adults and their link to the underlying core ADHD deficits of hyperkinesis, inattention, and impulsivity. While these core symptoms are often overt problems in children, in adults subtler executive dysfunction appears. Even though the growing consensus is that ADHD is a disorder of executive functions (EF), the details of the EF/ADHD connection remain unclear and may be far more complex in adults. That complexity is mirrored in the widening anatomic representation of EF, extending beyond the frontal lobes into the subcortex and other nonfrontal regions. More research will be needed to follow the developmental trajectory of executive dysfunction in ADHD over the life cycle and tie this to the developmental neuropsychology of EF. Psychosocial context and nongenetic familial influence are also critical variables that need greater consideration when characterizing and measuring ADHD symptoms in adults. Finally, until we have reached consensus on adult subject selection, we may not be able to enhance diagnostic rigor or expand our conceptual framework for understanding the underlying pathophysiology of ADHD in adults.

Innovative Programming to Support College Students with Autism Spectrum Disorders

The percentage of students who have autism spectrum diagnoses who are attending college has dramatically increased in recent years. The Centers for Disease Control estimate that 1:88 people are on the autistic spectrum, and that this number will likely continue to increase (CDC, MMWR Surveill Summ 58 (ss-10), 2012). When the authors first began presenting to providers of disability services in 2001, Asperger’s syndrome and other autism spectrum disorders (ASD) were not well-known diagnoses. Over the years, it has become clear that all colleges and universities now have seen a rise in the numbers of these students. One recent article estimated the prevalence of ASD in college students to be between 0.7 and 1.9 % (Autism, 15, 683–701, 2011), which roughly parallels the incidence referenced above. Because of the increasing numbers of students diagnosed with ASD attending college, campuses are often unsure how to best serve this population (Students with Asperger syndrome: A guide for college personnel. Shawnee Mission, KS: Autism Asperger).