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Treating ADHD: Addressing the Needs of College Students

Larry Culpepper, MD, MPH

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

Paul King, MD

Parkwood Behavioral Health System, Olive Branch, Mississippi

Being a college student with ADHD is difficult, and getting the appropriate care (whether on or off campus) can be a complicated road to navigate. Students can face many barriers such as being misdiagnosed, remaining undiagnosed, and experiencing delays in consulting with a doctor or receiving a proper assessment. Lack of communication between campus faculty and community physicians may also hinder the health care process. To help assess and meet the needs of students, parents, and health care providers, we held two roundtable meetings with campus and community clinicians at The University of Mississippi in Oxford. This activity presents the experiences and advice shared by clinicians at those roundtables.

Identifying ADHD in College Students

AV 1. College Students With ADHD and Problems in Class (00:41)

College students with undiagnosed ADHD have symptoms that manifest in a variety of ways (AV 1). Meeting attendees stated that, for example, many undergraduate students with unmanaged ADHD have trouble in class, are involved in driving accidents, and are late to appointments; they also may be disruptive and prone to fighting or violence and may abuse alcohol. Students with these types of problems may be referred by college personnel to the school’s Student Health Services for evaluation. Alternatively, students themselves may seek guidance from counselors or Student Health Services because they are aware of an inattention problem that has gone unrecognized or undiagnosed, or they may be completely confused as to why they are not achieving their academic goals. Some students even exhibit compensatory strategies for combating undiagnosed ADHD, such as being overly organized, which could lead to a misdiagnosis of OCD. Sleep dysfunction is also a common problem in ADHD and could be the presenting complaint.

Some disorders commonly co-occur with ADHD or may be mistaken for ADHD. For example, students with undiagnosed ADHD may already have received a diagnosis of anxiety, depression, or bipolar disorder and may be taking medications that are not alleviating their symptoms. Additionally, untreated ADHD may cause problems that can lead to alternate diagnoses, such as problems forming intimate relationships or problems leading to school failure, which can result in depression. Instead of (or besides) ADHD, some students have ODD or impulse control problems, including aggressive behavior. These conditions, while primarily childhood disorders, commonly persist into the late teenage years and may never have been diagnosed because they were attributed to basic immaturity. Alcohol and substance abuse may also complicate the picture and are more common in those with ADHD who are untreated. Because depression, anxiety, bipolar disorder, ODD, impulse control disorders, OCD, sleep dysfunction, and many other disorders either can occur with or be mistaken for ADHD, clinicians should always assess patients for these disorders when ADHD is suspected.

AV 2. Nonmedical Use of Stimulants by College Students With and Without ADHD (00:44)

Data from Arria et al1

Unfortunately, diversion is a common problem with ADHD medications (AV 2)1 and some students may seek an ADHD diagnosis in order to obtain medications such as stimulants. Some students may want to supplement their income by selling the medication, while others without ADHD may take the medication to enhance their concentration while studying, especially during final exams. Conversely, some students may take the medication in an attempt to self-medicate what they believe is undiagnosed ADHD.

Misdiagnosis or missed diagnosis of ADHD has a resounding effect around the college campus, affecting classroom pupil instruction, student activities and organizations, resident life, Student Health Services, and campus security. Currently, many college campuses need procedures (via an overseeing organization) by which faculty or campus staff can refer students whom they suspect have ADHD for evaluation so that students can get the necessary assessment and care.

Diagnosing ADHD

Diagnosing ADHD can be difficult, time-consuming, and costly. Using a combination of personal interaction, clinical judgment, standard procedures, informant reports, diagnostic criteria, and objective, measurement-based tools can aid in the evaluation process. At The University of Mississippi, students who are suspected of having ADHD are given a battery of tests, some of which focus on learning disabilities, to confirm the diagnosis and assess potential comorbidities. A formal ADHD assessment and diagnosis is required to get special on-campus and in-classroom accommodations and could take several months. If necessary, students may be referred to community clinicians who could then work with on-campus resources to effectively manage the condition.

For practicing clinicians to understand the larger clinical picture and the full impact of a patient’s symptoms, a thorough patient history should be taken. Clinicians should screen for inattention, comorbidities, problems in school, delinquencies, suicidality, and drug misuse/abuse. Also ask patients if they can provide reports by informants (eg, their parents or teachers) or if you can have their permission to get informant reports to obtain additional information about their symptoms and behaviors, which can be helpful in securing an ADHD diagnosis. Be sure to detail this history in the patient’s record to document the baseline status and use as a reference point for future visits. This documentation can also be used to help the student obtain special on-campus accommodations.

AV 3. DSM-IV-TR Criteria for ADHD (abbreviated version)

Based on the DSM-IV-TR2
Abbreviations are defined before the References

ADHD diagnostic criteria. The DSM criteria for ADHD were initially developed for children, and not all criteria may apply to adults (AV 3).2 For example, some students will not recall the prevalence of ADHD symptoms when they were younger, so they may not meet the full criteria for ADHD even though they have the disorder. In this event, getting informant reports from family members could greatly help.

If they are available, informants may at first report a precipitating event without realizing that the patient has exhibited symptoms indicative of ADHD over a long period of time. For example, an informant may report that a patient was functioning normally until she lost her job, but, upon further questioning, may conclude that the patient was never quite fully functional but always managed to get by. Former teachers may be able to provide accounts of childhood behavior and scores on college entrance examinations, and pediatricians may be contacted for medical histories. Clinicians should probe informants for as many details as possible to get a truly accurate clinical picture and determine if ADHD diagnostic criteria are met.

Using questionnaires. Some meeting attendees stated that they use the Vanderbilt ADHD Diagnostic Teacher Rating Scale, a 55-item scale that rates ADHD symptoms and screens for some comorbidities, although this tool was originally developed for children. Another commonly used tool is the Adult ADHD Self-Report Scale, an 18-item self-report scale based on the DSM-IV-TR criteria that places symptoms in context to gather more accurate information about frequency and severity. This assessment is also available in an interactive online format.

More

When administering questionnaires, be sure to use a printout of the scale that does not feature the scores and their meanings. This will help to elicit genuine responses from students. Clinicians can also refer patients online to complete a questionnaire, such as the interactive ASRS. Students can then bring the printed results to their next clinical visit. This will save time during the appointment, and patients have a hard copy of the questionnaire for their own records. One downside to using online tools is that respondents can research the “right” answers to get an ADHD diagnosis, if desired.

Meeting attendees agreed that clinicians should take the time required to adequately assess students for ADHD and should use all available resources to make the diagnosis. However, if they have considerable time constraints or are not comfortable making an ADHD diagnosis, then they should not do it and should refer the patient to another clinician.

Managing ADHD

Once a student has been diagnosed with ADHD, treatment can begin. First, patient education about the disorder is paramount—the more students understand, the more likely they are to be involved in their treatment. Students should also be made aware of resources where they can find additional information, including campus, community, and online resources.

If medication is prescribed, the patient should be educated about the importance of adherence and the dangers of diversion. Keep in mind that medication nonadherence is common for various reasons. Some patients may not like the way medication makes them feel, eg, “controlled,” and others may think that their ADHD has resolved and that they no longer need medications. In some cases, parents may object to medication for their child, but the final decision is the adult student’s. Parents and students can be educated about the safety of newer ADHD medications and the benefits of treatment.

Students with ADHD should also be educated about their rights. These include on-campus and in-classroom accommodations as specified by the Americans with Disabilities Act of 1990 (ADA) and privacy rights as established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for services obtained in the community. HIPAA’s privacy rights only extend to protect students’ health information by covered entities, or health care providers; whereas, students’ health service records (and related privacy rights) held by an institution may be considered education records, which then fall under the Family Education Rights and Privacy Act (FERPA). These rules and rights may be further modified by state law, so researching the Student Health Services at a particular institution may be the best source of information for these student-related legal issues.

The key to the successful treatment of ADHD is self-management, which can be encouraged in several ways:

  • Have students keep a log of their medication-taking and their symptoms to bring to each clinical visit
  • Instruct patients on how to take their medication and what to do if friends or parents ask to have any pills
  • Help students get organized by using a weekday planner or other organizational tools
  • Give students a list of strategies to help them succeed at college

Systemic Issues in Diagnosing and Treating ADHD

In diagnosing and treating college students with ADHD, several systemic issues need to be overcome. For example, college personnel need to be educated about the disorder and its presenting behaviors so that they can better identify students and refer students for assessment.

Clinicians need to be aware of the costs of assessments and medications. Many students see clinicians in the community, especially as they can remain on their parents’ insurance plans until age 26 years. Some insurance providers, however, consider ADHD a childhood disorder and will not pay for treatment in people over the age of 18 years. Others may classify an ADHD evaluation as an educational assessment, which is a noncovered service. In such cases, clinicians supporting an appeal of the denial of coverage may be helpful.

Communication between university and community clinicians needs to be enhanced to provide more effective and comprehensive treatment to students with ADHD. Community clinicians may not be familiar with the procedures for screening and accommodating those with ADHD as well as with on-campus ADHD resources.

For more information about diagnosing and managing ADHD in college students, go to ADHDKnowledge.com. You can also refer your college-aged patients to this site to take the ASRS and to get ADHD information.

For Clinical Use

 

  • Use a combination of personal interaction, clinical judgment and procedures, informant reports, diagnostic criteria, and objective, measurement-based tools to diagnose ADHD
  • Educate students with ADHD about the disorder and provide resources for further information
  • Educate students with ADHD about the importance of medication adherence and the dangers of medication diversion
  • Foster mutual communication between university and community medical professionals

 

Abbreviations

ADHD = attention-deficit/hyperactivity disorder
ASRS = Adult ADHD Self-Report Scale
DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
OCD = obsessive-compulsive disorder
ODD = oppositional defiant disorder

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References

  1. Arria AM, Caldeira KM, O’Grady KE, et al. Nonmedical use of prescription stimulants among college students: associations with attention-deficit/hyperactivity disorder and polydrug use. Pharmacotherapy. 2008;28(2):156–169. PubMed
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.