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Prevalence and Impact of ADHD in College Students

Larry Culpepper, MD, MPH

Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts

Prevalence of ADHD in College Students

ADHD is present in approximately 9% of US children and adolescents and almost 4.5% of adults.1,2 With about half of the cases persisting into adulthood, up to 8% of the US college population reports having significant ADHD symptoms.3 Enrollment in higher education by these students has risen dramatically since a series of laws were passed requiring educational accommodations for individuals with disabilities (including ADHD).4

Unfortunately, college students with ADHD generally have poor academic outcomes. Compared with their nondisabled peers, undergraduates with ADHD have lower grades, a greater rate of academic probation, and lower rates of class attendance.3 Students with disabilities, including those with ADHD, also have lower graduation rates overall (AV 1AV 1)5; however, these students may graduate at the same rate if they take advantage of special education accommodations.6

Despite the availability of such accommodations, fewer than one-fourth of eligible students seek those services in college.7 While staff at elementary and high schools are required by law to identify and provide services for students with disabilities, the responsibility to obtain special accommodations in college lies with students.7

Neurobiology of ADHD

Further exploration of ADHD and its impact on the college population is best informed by an understanding of the neurobiology and the symptomatology of the disorder. ADHD is partially caused by a structural abnormality in the brain that affects executive functioning (eg, focusing, planning, organizing, and sequencing).8 Brain abnormalities have been demonstrated via numerous imaging studies in individuals with ADHD. The consistent findings are that those with ADHD have smaller brain volumes in both the cerebral and cerebellar regions, independent of sex and medication status, and that volumetric abnormalities persist with age.9 In addition, ADHD is highly heritable at a rate of 76% and involves a complex mechanism of several genes.10 The symptoms and presentation of ADHD may vary depending on the genetic composition of the individual. The evidence clearly shows that ADHD is a genetically inherited condition present from birth, with a significant impact on brain structure and volume.

Impact of Executive Function Impairment

Given the pervasive nature of brain dysfunction in ADHD and that the abnormalities affect the areas of the brain that govern executive function, the fact that impairment occurs in multiple settings (eg, home, school, work, and social settings) is not surprising. College affords students new freedom and greater autonomy as well as more responsibility and higher expectations than before. High school students operate within a highly structured environment, but college students, especially those living at a residential campus, must create that structure for themselves. Undergraduates are responsible for organizing themselves, showing self-control, setting priorities, and completing tasks over entire semesters instead of several hours or day to day. Academic expectations are higher—less time is spent in the classroom, more time is spent studying alone, and some classes are much larger with less personal attention than in high school. Social life on campus can also provide new temptations that may prove difficult to resist.

Brown11 has developed a cognitive model of ADHD structured around 6 areas of executive function: activation, focus, effort, emotion, memory, and action (AV 2AV 2). Although these areas typically work together harmoniously, the impairment caused by ADHD negatively impacts each of these functions.

More

Activation. Activation involves organizational skills, and college students with problems in this area will exhibit inconsistent academic performance. For example, they will have difficulty organizing their assignments and keeping track of notes and handouts. They will also procrastinate and have difficulty prioritizing tasks, which will lead to problems in deciding on which homework to do and when and in completing long-term assignments on time.

Focus. Focus involves not only initial focus but also maintaining focus and appropriately shifting attention between tasks. A student with ADHD may be hyperfocused and excel on one assignment but then perform very poorly on other assignments, or do very well in one class for the first half of the semester and then lose focus, signifying an inconsistent academic performance. This student is also easily distracted by social and daily priorities, which may lead to neglecting long-term assignments. Focus is a problem in other settings as well, such as driving. Adults with ADHD tend to have histories of multiple car accidents compared with those without ADHD, perhaps because of this lack of focus.12

Effort. Another area of executive dysfunction is inconsistency of effort and difficulty in sustaining effort and alertness. This difficulty can lead to incomplete assignments, poor study habits, poor sleep hygiene, frequent drowsiness, and erratic day-to-day schedules. The overall effect is a seeming lack of motivation in the classroom and in interactions with professors and other personnel. Impairment in this area may also result in slow processing, despite considerable effort, and increased time to complete tasks such as tests or written assignments.

Emotion. Many young adults with ADHD find it difficult to manage their emotions. They may be easily overwhelmed emotionally and have a low threshold for frustration, which in turn leads to increased irritability and angry outbursts, the inability to accept another’s point of view, and the tendency to argue constantly. Because these young adults may be perceived as being moody and insensitive to others, which then can lead to decreased social interactions and increased rates of depression and anxiety, they may have difficulty forming and maintaining close personal relationships.

Working memory. ADHD can lead to impairment in working memory. College students with ADHD have chronic difficulty holding and processing new information, which may impair their ability to complete complex course assignments and participate coherently in class discussions. Working memory dysfunction may also lead to difficulty in finishing tests and in organizing their thoughts for written assignments.

Action. College students with ADHD also often have challenges in monitoring and self-regulating their actions. Self-regulation is required to complete classroom assignments as well as to function adequately in classroom and social situations. These students have difficulty following directions and will often act impulsively, perhaps by interrupting others and acting inappropriately in small group settings. This lack of self-regulation is tied to the student’s lack of insight into how he or she is perceived by other students and faculty.

Call to Action

A number of effective treatments and interventions can help college students with ADHD achieve their educational and life goals, but students need to be aware of and be motivated to take advantage of the available disability programs. Clinicians and university personnel are in a position recognize undiagnosed ADHD in undergraduates and encourage those students, as well as those who have an ADHD diagnosis, to seek out and use the university and community provided resources and services.

For Clinical Use

 

  • Recognize that students with ADHD commonly have co-occurring learning disorders and poor educational outcomes
  • Be aware that ADHD has a significant impact on executive function, which negatively affects undergraduates’ academic and social functioning
  • Watch for undiagnosed ADHD and encourage students with ADHD to use disability services on campus and in the community

 

Abbreviations

ADHD = attention-deficit/hyperactivity disorder

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References

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