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Recognizing and Addressing Barriers to the Effective Management of ADHD in College Students

Larry Culpepper, MD, MPH

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

Between 2% and 8% of college students report clinically significant symptoms of ADHD, but many are not diagnosed or treated.1 Individuals with untreated ADHD are less likely to finish college and more likely to have academic problems compared with students without ADHD, signaling a need for effective diagnosis and management by clinicians.1

ADHD symptoms may go unnoticed until college for a number of reasons:

  • students and parents may think symptoms are part of the student’s personality rather than a medical condition
  • college requires more self-organization and self-management than high school does, and ADHD symptoms may surface when students lose the parental support and control that may have helped them manage difficulties before college
  • coursework and studying are more intense in college than in high school, and the symptoms may become apparent when the student is among a higher-performing peer group.

College students with ADHD symptoms may need the support of college personnel to help them recognize their symptoms and seek appropriate treatment. For clinicians to diagnose and effectively manage ADHD in college-aged patients, barriers such as students’ and clinicians’ negative perceptions about the disorder and its treatment must be overcome.

Barriers to Diagnosing ADHD in College Students

Students, parents, and even clinicians may recognize the symptoms of ADHD but may avoid an official diagnosis for various reasons, including fear of stigma and concern about misuse of medication. Other diagnostic barriers include a difficult-to-diagnose population as well as a complex ADHD presentation.

Fear of stigma. ADHD is prone to stigma because people may associate the symptoms with being a childhood-behavioral problem, having a lack of focus, or being lazy rather than with a legitimate medical condition. Students want to fit in and be independent and may not want to seek help and appear as though they are asking for allowances. These desires may be combined with poor self-esteem and a lack of social skills,2 causing self-stigmatization if students add an ADHD diagnosis to their list of perceived problems. The misuse of ADHD medication by college students without ADHD also contributes to stigmatizing ideas about the disorder—students who actually have ADHD could be perceived as trying to deceive clinicians just to get a prescription. Health care providers and university personnel can help remove the stigma of ADHD by providing education and support.

Misuse of stimulants. Prescription stimulants, a common treatment for ADHD, are commonly misused on college campuses, possibly due to their wide availability and their perceived connection with increased academic performance. Over a 4-year collegiate experience, almost two-thirds of students are offered prescription stimulants for nonmedical use, usually by friends with a prescription (AV 1).3 Some college students who are using ADHD medication without a prescription may actually have ADHD that was never diagnosed.

AV 1. Opportunity and Use of Prescription Stimulants in College Students (00:26)

Data from Garnier-Dykstra et al3

Clinicians may be reluctant to formally diagnose ADHD because of concerns about prescribing controlled substances. While diversion is a serious issue with potential for real harm (eg, medical, legal), it should not be used as a rationale to withhold an accurate diagnosis and effective treatment.

Stimulant misuse includes obtaining and using ADHD medication without a prescription through illegal sharing, selling, purchasing, or stealing. Most students who use ADHD medication without a prescription obtain it for free from another student,4 thereby decreasing the motivation for a student with ADHD symptoms to seek care from health services.

Two of the most abused prescription stimulants are amphetamine/dextroamphetamine and methylphenidate, with amphetamine/dextroamphetamine surpassing methylphenidate as the most commonly misused agent.5 Among college students, self-reported motives for misuse included improving concentration, helping to study, and increasing alertness, while nonacademic reasons included getting high and experimenting.6 Although 76% of students misusing stimulants reported perceived academic improvement,7 it is unclear whether using stimulants actually does improve school performance in students without ADHD.

A survey7 discovered that stimulant misusers are 7 times more likely to be symptomatic for ADHD than those who do not misuse. Therefore, some college students’ misuse may be a form of self-treatment for undiagnosed ADHD. Clinicians can help by screening students for ADHD using a scale such as the Adult Self-Report ADHD scale, providing a formal diagnosis when needed and initiating proper treatment. Other rating scales can also help to confirm a diagnosis of ADHD in this population.

Diagnostic ambiguity. An ADHD diagnosis relies on a thorough patient history, informant reports, review of school records, and questionnaires that assess symptoms, such as distractibility, impulsivity, and restlessness, which began in childhood and continue into adulthood.1 One barrier to diagnosing college students can be the lack of available teachers who can inform the clinician about the student as fully as an elementary or high school teacher could. When parent reports are obtained, discordance between parent and student perceptions may be apparent. Additionally, many diagnostic instruments and criteria used in this population are ambiguous because they are geared to assess symptoms in children rather than young adults.

AV 2. Prevalence of Risky Behaviors in Adults With Self-Reported ADHD Diagnosis (00:24)

Data from Biederman et al8

Dysfunctional behaviors. Another potential barrier to diagnosing college students with ADHD is that they may display other dysfunctional behaviors, such as substance use or reckless driving,1 that can obscure their underlying condition. Adults diagnosed with ADHD have shown more impairment than adults without ADHD in areas such as tobacco addiction, recreational drug use, arrests, and speeding tickets (AV 2).8 These behaviors can become the focus of concern for clinicians and overshadow ADHD as the real cause.

Comorbid psychiatric disorders. Along with dysfunctional behaviors, co-occurring psychiatric disorders may also obfuscate ADHD in college students. Depression, anxiety, substance use, oppositional defiant disorder, personality disorders, sleep problems, and learning disabilities are common in adults with ADHD.9 Symptoms of these disorders can complicate the clinical picture and make it difficult for the clinician to recognize and diagnose ADHD, but objective scales can help differentiate ADHD from comorbid mental health disorders and substance abuse.

Managing College Students Diagnosed with ADHD

When college students receive a diagnosis of ADHD, they may pose distinct management challenges because of the risk of medication abuse. In fact, those students with greater dysfunction and more behavioral disturbances—who may benefit the most from appropriate treatment—can be the very patients about whom clinicians have the most concern about diversion and misuse of ADHD medication. Clinicians can offer treatment plans that minimize the dangers and help students learn effective strategies to manage their ADHD symptoms.

AV 3. Prescription and Diversion Rates Among 483 College Students (00:28)

Data from Garnier et al5
Abbreviations are defined before the References

Educate patients about the dangers of diversion. Among college students with ADHD and a stimulant prescription, over 60% have diverted the medication, compared with diversion rates of 6% to 35% for other medications (both psychotropic and nonpsychotropic) (AV 3).5 Students may think they are helping friends when they share their medication, but the students who receive diverted medication miss the important education that comes with proper treatment. They may ignore adverse effects to achieve their desired results, whether real or perceived, and they are also at risk for harmful drug interactions and dependence. Illicit users who take prescription stimulants by alternate routes (eg, intranasally) increase their risk of harm because the pharmacokinetics of drugs can change when not taken as intended.6

More

Clinicians must educate their college-aged patients with ADHD about the dangers of diversion as well as the legal ramifications of illicit prescription sharing. Studies5,10 have shown that students who divert their medications tend to have conduct or substance use problems. A review11 identified illicit methylphenidate users as more likely to be white, male, in a fraternity, and using other illegal substances. Knowing who is most at risk for misuse and diversion enables clinicians to provide the necessary education and additional monitoring to those patients who need it.

Provide treatments that are less likely to be misused. Educating patients about the dangers of diversion can help clinicians reduce the likelihood of misuse, but prescribing alternate treatments can also help. When treating ADHD, long-acting, extended-release stimulant formulations and nonstimulants are less likely to be misused or diverted for recreational purposes than short-acting, immediate-release stimulants.12

AV 4. Recognizing a Patient at Risk for Prescription Misuse (02:40)

Nonmedication interventions, such as ADHD coaching or using study aides or other accommodations, may also help college students with ADHD manage their responsibilities (AV 4). (See the ADHD Clinicians’ Toolbox for fact sheets, medication guides, resources, and patient logs.)

Monitor medication use. Along with treating ADHD and providing education about the disorder and its treatment, clinicians should take additional steps to monitor medication use and response. Prescription drug monitoring programs can help clinicians identify patients who are diverting or misusing their medication.12 Watching for behavior changes by meeting more frequently and using rating scales can also help clinicians spot problems that may arise from improper treatment adherence. Another option is to limit the quantity of medication prescribed or the number of refills, when warranted, so that patient contact is more frequent.

Conclusion

Clinicians face distinct barriers to the recognition, diagnosis, and management of ADHD in college students. Students and parents may not recognize symptoms until the pressures of college and the lack of parental support make academic achievement more challenging. For some students with undiagnosed ADHD, misusing prescription stimulants may appear to be a viable option for controlling symptoms and helping them concentrate, but they risk dangerous drug interactions and dependence. Other psychiatric conditions, such as depression and anxiety, or substance abuse can obscure the underlying problem of ADHD. By developing a therapeutic relationship with student patients, clinicians can accurately assess for and diagnose ADHD, recognize those at risk for diverting or misusing their medication, provide education about adherence, and monitor and support them throughout the pressures of college life.

Clinical Points

  • Screen students who misuse prescription stimulants for ADHD
  • Work with college administration and health care providers to reduce the stigma associated with an ADHD diagnosis and provide support services for students with ADHD
  • Consider alternate treatments, such as nonstimulants, extended-release medications, and nonpharmacologic coping strategies for students at risk for diversion

Drug Names

amphetamine/dextroamphetamine (Adderall, Adderall XR, and others), methylphenidate (Concerta, Ritalin, and others)

Abbreviations

ADHD = attention-deficit/hyperactivity disorder
FDA = US Food and Drug Administration

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References

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