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Recognizing and Diagnosing ADHD in College Students

Larry Culpepper, MD, MPH

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

ADHD Presentation in College Students

By the time they reach college, many young adults with ADHD have already been diagnosed. Students may disclose that they have ADHD in their college application, and those who do are then eligible to receive accommodations specifically designed for students with ADHD.

Other college students, however, may have ADHD that was never recognized and formally diagnosed; they often tend to be women and tend to have the inattentive subtype of ADHD.1 Frequently, these students have not paid attention or performed well in primary and secondary schools, yet their behavior was never recognized by parents, teachers, or doctors as possibly being related to ADHD. However, when these undiagnosed students enter postsecondary schools, the demands of higher education and the newfound independence of the collegiate lifestyle may exacerbate the disorder and lead to disease recognition. Undergraduates need self-control and organizational skills to set priorities and complete long-term tasks. Because external structure is minimal in college and the academic and social spheres are constantly competing for students’ attention, students must impose order on the inconsistency of campus life, which is especially difficult for those with ADHD. These students display symptoms of inattention, hyperactivity, and impulsivity (AV 1AV 1).2,3

During the admissions process, cues that a student may have undiagnosed ADHD include incomplete, inconsistent, or late applications, which may result from executive functioning impairment experienced by young adults with ADHD. (For more information about the impact of executive dysfunction on students, see "Prevalence and Impact of ADHD in College Students."

Signs of ADHD during the school year may include social difficulties and interpersonal conflicts, substance use, financial problems, injuries and driving accidents, and poor academic performance, such as late assignments, erratic performance, disorganized work, and absenteeism.4 College faculty and officials are in a position to recognize these signs of ADHD, help students receive a proper assessment, and aid clinicians in evaluating and diagnosing the student (AV 2AV 2). Informant reports from parents or high school teachers, which must be obtained with the student’s permission, can also aid in the diagnostic process. Because ADHD is highly heritable,2 other members of the student’s family may also be affected by the condition.

Consistently and objectively evaluating ADHD symptomatology is the key to assessing the disorder. Using rating scales can greatly help in initially assessing students for ADHD as well as in reliably documenting and tracking ADHD symptoms in response to treatment. Several rating scales are now available, many of which students can complete themselves and then submit to their clinician, including:

In addition to conducting assessments, examining the student’s behavior in the context of the DSMcriteria will also help to make an accurate diagnosis.5 An ADHD diagnosis requires the presence of ≥ 6 symptoms of inattention or hyperactivity/impulsivity that were present before 7 years of age, are present in ≥ 2 settings, cause functional impairment, and are not attributable to another psychiatric disorder.5 Although the criteria focus on childhood presentations, those symptoms can be adapted for and applied to adults (see AV 1AV 1). Students may meet most, but not all, criteria for ADHD, particularly the criterion that specifies that the ADHD symptoms must be present before the age of 7 years. Faraone et al6 found that adults who met all criteria except age at onset still experienced functional impairment, psychiatric comorbidity, and familial transmission comparable to those who met all ADHD criteria. The revision of the ADHD criteria to be published in the DSM-5 may present alternative approaches for making a valid and reliable diagnosis in adults.

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Common Comorbidities in ADHD

All patients with ADHD, including college students, are likely to have other psychiatric conditions.7 Disorders that are often comorbid with ADHD include:

  • Anxiety and depressive disorders
  • Drug or alcohol abuse
  • Antisocial, oppositional defiant, conduct, and/or personality disorders
  • Autism spectrum disorder
  • Sleep disorders
  • Learning disabilities

College students, specifically, tend to have sleep difficulties. ADHD also often co-exists with learning disabilities and may require an additional educational evaluation for these difficulties. When completing the differential diagnosis, many of the aforementioned conditions share symptomatology with ADHD (AV 3AV 3)8 and should be ruled out before an ADHD diagnosis is confirmed.

Summary

College students with undiagnosed ADHD tend to have poor academic performance, social and financial problems, frequent absenteeism, and a higher-than-usual number of driving incidents and interpersonal conflicts. Recognition by college personnel and proper evaluation and consistent follow-up by clinicians can help college students with ADHD get the treatment that they need in order to thrive in an academic setting. In evaluating a student for ADHD, informant reports, school records, assessment scales, and the DSM criteria should be used to make a definitive diagnosis. Although the DSM criteria were originally developed to assess children for ADHD, college students’ behaviors can be evaluated in this context as well. Additionally, ADHD commonly co-occurs with and may be mistaken for other psychiatric disorders, so completing a differential diagnosis is necessary.

Once ADHD is confirmed, a number of effective treatment options can be implemented, and rating scales should be used consistently to objectively measure response to treatment.

For Clinical Use

 

  • Recognize the signs and symptoms of ADHD in college students
  • Use informant reports, school records, assessment scales, and the DSM criteria to assess college students for undiagnosed ADHD
  • Be aware that other disorders commonly co-occur with and share symptomatology of ADHD
  • Consistently use rating scales during follow-up visits to objectively measure treatment response

 

Abbreviations

ADHD = attention-deficit/hyperactivity disorder
DSM = Diagnostic and Statistical Manual of Mental Disorders

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References

  1. Biederman J, Faraone S. The Massachusetts General Hospital studies of gender influences on attention-deficit/hyperactivity disorder in youth and relatives. Psychiatr Clin North Am. 2004;27(2):225–232.
  2. Kooij SJJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry. 2010;10:67.
  3. Goodman DW. The consequences of attention-deficit/hyperactivity disorder. J Psychiatr Pract. 2007;13(5):318–327.
  4. Blase SL, Gilbert AN, Anastopoulos AD, et al. Self-reported ADHD and adjustment in college: cross-sectional and longitudinal findings. J Atten Disord. 2009;13(3):297–309.
  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
  6. Faraone SV, Biederman J, Spencer TJ, et al. Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry. 2006;163(10):1720–1729.
  7. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–723.
  8. Searight HR, Burke JM, Rottnek F. Adult ADHD: evaluation and treatment in family medicine. Am Fam Physician. 2000;62(9):2077–2086.