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.
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.
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
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.
In what way was Cathy’s presentation typical of adult clients with
ADHD? Record the letter of the correct answer the .