by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (civilian) and Medical Director, Family Health Clinic, Wright-Patterson Medical Center in WPAFB, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US government.
Innov Clin Neurosci. 2011;8(8):10–13
This ongoing column is dedicated to the challenging clinical interface between psychiatry and
primary care—two fields that are inexorably linked.
Funding: There was no funding for the development and writing of this article.
Financial disclosures: The authors have no conflicts of interest relevant to the content of this article.
Key words: Attention deficit hyperactivity disorder, ADHD, faking, stimulant abuse
Abstract: Attention-deficit hyperactivity disorder is a common malady in the general population, with up to 8.1 percent of adults meeting criteria for this syndrome. In the college setting, the diagnosis of attention deficit hyperactivity disorder may offer specific academic advantages. Once the diagnosis is assigned, the prescription of stimulant medication may provide additional secondary gains through misuse and/or diversion. For example, these drugs may be used by college consumers to increase alertness, energy, academic performance, and athletic performance. Stimulants may also decrease psychological distress, alleviate restlessness and weight concerns, and be used for recreational purposes. According to the findings of five studies, the symptoms of attention deficit hyperactivity disorder can be believably faked, particularly when assessed with attention deficit hyperactivity disorder symptom checklists. Thus, the faking of attention deficit hyperactivity disorder is a realistic concern in both psychiatric and primary care settings.
Attention deficit hyperactivity disorder (ADHD) is a fairly common psychiatric malady in the general population. According to the National Comorbidity Survey Replication study, the prevalence of this disorder in the adult United States population is 8.1 percent. While we were not able to locate any prevalence data in primary care samples, one might assume that there are even higher rates in these settings based upon impulsivity and its relationship to accidents and poor adherence with general medical care. While this disorder is generally viewed as a potential limitation in life, particularly with regard to relationships, academics, and employment, in a university setting, the diagnosis of ADHD may offer some potential advantages. In this edition of “The Interface,” we discuss the academic advantages of such a diagnosis, present the empirical evidence regarding whether or not an individual can feign ADHD symptoms, and discuss additional reasons, other than academic, why one might do so.
ADHD: An Academic Advantage?
Because a number of college campuses make special accommodations for students with ADHD, the diagnosis of this disorder may result in various academic benefits. For example, depending on the institution, academic accommodations for ADHD might include additional time to complete assignments and tests, elimination of spelling penalties, advantageous seating in the classroom, testing environments that are free from distractions, reduced homework loads, audio recording of lectures, use of books on tape, access to professors’ notes, and additional clarification of directions. Given these academic benefits, there could be an impetus to feign or simulate the symptoms of ADHD.
Can ADHD Symptoms Be Feigned?
To “make a long story short” as the saying goes, according to the available research, the symptoms of ADHD can be readily feigned, particularly when symptoms are assessed with checklists. These are the conclusions of the five available studies that we located in the PsycINFO and PubMed databases, and they report consistent findings.
In the earliest study that we could locate, Quinn examined two groups of college students, one group with ADHD (n=16) and the other group consisting of prepared malingerers (n=44). Upon testing for ADHD, malingerers were able to successfully fake positive scores on a scale for childhood and current symptoms (i.e., the ADHD Behavior Rating Scale), but not on the Integrated Visual and Auditory Continuous Performance Test.
In a 2007 publication, Fisher examined the ability of college students to fake test results on two individual ADHD assessments. When given the ADHD Behavior Checklist and the College ADHD Response Evaluation, feigners were able to simulate ADHD outcomes on 77 and 93 percent of items, respectively. Neither scale was more successful than the other in preventing false positives.
In a 2007 Canadian study, Harrison et al examined 70 college students (35 controls and 35 fakers) and compared them with 72 individuals in an archival database with a confirmed diagnosis of ADHD. In this study, while the researchers found some differences among the subgroups in their responses to the Conners’ Adult ADHD Rating Scale and the Woodcock Johnson Psychoeducational Battery-III, they concluded that the symptoms of ADHD could be easily fabricated, particularly when the diagnosis is based solely on symptom-checklist data.
In a 2008 study, Frazier et al divvied up 98 college students into the following three study groups: controls, ADHD simulators, and reading-disorder simulators. In this study, there were no specific ADHD measures to fake; in other words, the simulation of an ADHD diagnosis was not actually tested. However, the three study groups showed identifiable patterns/differences on the Validity Indicator Profile and the Victoria Symptom Validity Test, suggesting that fakers of ADHD might be detected using these measures.
In a 2010 study, Booksh et al divided 110 college students into controls and malingerers. Like the Harrison et al study, these groups were then compared to an archival sample of 56 students who were previously diagnosed with ADHD. The researchers administered nine different assessments; at least four of these measures were designed to explore the diagnosis of ADHD. At the end of the study, the researchers concluded that, “…[we] failed to find consistent significant performance differences between individuals with ADHD and those simulating…” As a result of these findings, the authors emphasize the importance of obtaining diagnostic information from multiple sources, including self report, objective assessment, observational assessment, and/or reports by others.
In the final research article that we were able to locate, Sollman et al divided 80 college students into the following three study groups: controls (n=14), fakers (n=30), and students with genuine ADHD (n=29). One of the most interesting aspects of this study was the clarity in the procedure section of this report regarding the actual training of the faker group. Fakers were given only five minutes to read through a brief clinical scenario, peruse internet information that was presented as a pseudo-webpage, and take notes. Following this brief training, all participants took an extensive battery of tests (12 in all). Like the previous researchers, investigators found that symptom checklists (e.g., the ADHD Rating Scale, Conners’ Adult ADHD Rating Scale-Self-Rating Form Long) were particularly susceptible to faking.
What can we conclude from these studies? First, ADHD symptom checklists are easily faked. Second, fairly sophisticated testing materials are required to demonstrate inconsistencies in testing that would indicate the feigning of ADHD symptoms. While the assessment for inconsistencies is reassuring, one wonders if the required administration expertise, time, and expense of these tests can be feasibly undertaken in a college setting with large numbers of students. Third, according to the data by Sollman et al, it takes very little time for an individual to prepare for the defeat of an ADHD testing measure.
Prevalence of Prescription Stimulant Misuse on Campuses
Given an incorrect or feigned diagnosis of ADHD, a clinician might then provide a prescription for stimulant medication. According to the findings of a recent university study, about one-third of college students who were legitimately prescribed a medication diverted that medication at least once in their lifetime. Not surprisingly, nearly two-thirds of these diverted medications were related to the treatment of ADHD. These data echo the impression of Judson and Langdon, who state that illicit prescription stimulant use is increasing on all college campuses.
In terms of the prevalence of prescription stimulant misuse, Hall et al found that 13 to 14 percent of college students reported illicit use, and DeSantis et al found that 34 percent reported illicit use. In keeping with these findings, Weyandt et al found that 7.5 percent of college students reported the illicit use of a prescription stimulant in the preceding 30 days, and McCabe et al found that 5.4 percent reported illicit usage in the preceding year. Despite some variances, these data indicate that illicit prescription stimulant use is reported by a significant minority of college students.
Why Do College Students Abuse Prescription Stimulants?
College students may abuse prescription stimulants for a number of reasons. These include enhancing alertness and improving energy levels, increasing attention,15 improving academic performance, alleviating psychological distress or restlessness, partaking for recreational purposes, bettering athletic performance,[17,18] and addressing weight concerns. These drugs also have a known street value and may be used as a source of income. According to Arria et al, prescription stimulant use frequently occurs in the context of perceived low harmfulness. These rationales for stimulant use are listed in Table 1.
ADHD affects a significant minority of the general population. While traditionally thought of as a psychological liability, the diagnosis of ADHD may offer some academic advantages in the college environment. According to available studies, ADHD can be realistically portrayed through feigning. Fakers are most likely to be successful on symptom checklists for ADHD. In addition to the potential academic benefits of a diagnosis of ADHD, the subsequent prescription of stimulants may confer additional secondary gains. For example, diversion is not uncommon among those prescribed these specific types of drugs, and up to one-third of college students report the illicit use of prescription stimulants. When illicitly used, user rationales include improved alertness, energy, attention, and academic and athletic performance as well as alleviation of psychological distress, restlessness, and weight concerns. These drugs may also be used for recreational purposes and as a source of income. Whether in the psychiatric setting or primary care setting, the diagnosis of ADHD must be carefully undertaken through the integration of a number of sources of information and sophisticated psychological testing, when available. Only then should medication be thoughtfully considered.
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