How Can We Improve Outcomes for College Students with ADHD?
College students with ADHD face a unique set of challenges — increased academic and social demands; diminished support; and elevated risk for anxiety, stress, and mood disorders — that often lead to adverse outcomes. Historically, colleges have seldom focused on services for students with ADHD — a trend that is changing given increased interest in this group. Today, colleges are crafting ADHD-specific services, while researchers are continuing to uncover factors behind success in college for this population.
College students with ADHD represent a distinct and auspicious yet overlooked population. The assumption that this group, by virtue of its acceptance into higher education alone, needs no special support for managing ADHD symptoms has prevailed for far too long. Given the unique factors that influence the college experience for students with ADHD — from academic and social challenges to treatment adherence — this population merits dedicated attention from clinicians, educators, families, and institutions of higher education themselves.
Improving outcomes for college students with ADHD requires a multi-pronged approach. Many colleges and universities across the U.S. do provide services of varying degrees, including recruitment into innovative programs that target specific areas of impairment with attention deficit hyperactivity disorder (ADHD or ADD). At the same time, a growing body of literature has sought to understand other factors — like increased parental involvement — that contribute to success in college for students with ADHD.
College Students with ADHD: Trends and Challenges
The population of college students with ADHD has increased substantially in the past 20 years — from roughly 2 percent of the student body to about 11.6 percent1. In other words, roughly 1 in 9 college students today has an ADHD diagnosis.
ADHD in college is also associated with a range of challenges. According to clinical psychologist Arthur Anastopoulos, college freshmen with ADHD encounter a “perfect storm” of increased interpersonal and cognitive demands alongside decreased parental involvement and support, all with lingering executive function challenges and symptoms of inattention and impulsivity/hyperactivity2. Other hurdles common to college students with ADHD include:
- Academic impairments: Less college readiness3, lower GPA, fewer credits earned per semester, higher risk for discontinuous matriculation than among college peers without ADHD4; lower rates of degree attainment than among peers without ADHD5
- Social impairments6
- Comorbidities, including significant rates of anxiety and mood disorders7
- Higher levels of school disengagement and emotional difficulties than among peers without ADHD8
What we know about ADHD in adolescence does not necessarily reflect the experience of many college students with ADHD, who likely performed better in high school and demonstrate higher ability levels than do their peers with ADHD who don’t attend college (one study found that college students with and without ADHD have relatively higher average IQs9). They also experience different stressors than do same-age peers with ADHD who do not pursue college.
While college students with ADHD may benefit the most from on-campus resources and supports, data shows that these students use these services at alarmingly low rates. Less than a quarter of these students use disability services, and only about a third have used tutoring services.4
In addition, adherence to ADHD medications in college is actually quite low, averaging roughly 50 percent10. This means that a college student with ADHD takes their prescribed medication about once every two or three days. Medication adherence also follows a curvilinear pattern, where medication is taken at higher rates at the beginning and end of a semester.10
For all these reasons, we must continue to investigate how to best support college students with ADHD.
College Students with ADHD: Improving Outcomes
ADHD Services and Programs
Innovative programs and interventions that attend to the unique challenges of college students with ADHD are showing promising results.
1. SUCCEEDS ADHD Clinic
The SUCCEEDS ADHD Clinic (Students Understanding College Choices – Encouraging and Executing Decisions for Success11), founded at the University of Maryland at College Park in 2018 and with a second location now at the University of Illinois at Chicago, aims to help college students with ADHD with academic and/or mental health difficulties. The program was created to address ADHD-specific deficits (in areas like executive functioning and self-regulation) that have been largely excluded from university services and accommodations.
Students in the program undergo an initial evaluation that identifies domains of focus — be it academics, substance dependency help, anxiety, or another issue — and that informs their individualized treatment plan for the semester. The program also offers organizational skills training — covering areas like prioritizing, goal setting, and routines — as well as weekly group sessions, individualized academic and mental health coaching, and guided study hall sessions. Parental involvement is a factor, but the degree of involvement varies across patients.
SUCCEEDS is first and foremost a clinical service for these students, but the program also serves as an opportunity for research. Findings in a study12 involving a small portion of the roughly 50 clinic participants show that more than half reported clinically significant changes in organizational skills. All of the participants with moderate levels of mood disorder at baseline reported clinically significant changes in symptoms. And half of the students with elevated levels of alcohol use reported changes in use by the end of the program.
Preliminary evidence suggests that SUCCEEDS is an effective method for addressing the distinct and wide-ranging difficulties experienced by college students with ADHD. That said, SUCCEEDS has also illuminated several important considerations, including the sheer complexity of patient cases. For anyone with ADHD, comorbidity tends to be the rule, not the exception. Individualized treatment plans, as well as program content overall, must therefore take into consideration comorbid conditions and challenges. Future directions for the program include, but are not limited to, further expansion across colleges, creating tiered levels of care, and implementing more standardized parental involvement.
2. Organization, Time Management, Planning (OTMP) Interventions
Skill and knowledge-building interventions may also help students with ADHD succeed in college, as demonstrated by a pilot study13 of a largely behavioral-based intervention program for these students across two public universities.
The 8-week program focuses on OTMP and study skills, as these most directly relate to the executive function deficits associated with ADHD and to the demands of college. Skills covered in the weekly in-person group sessions include planning with calendars, creating task list systems, studying and note-taking, and addressing procrastination. Some of the program’s sessions also focus on psychoeducation, where participants learn more about and discuss ADHD.
At the program’s end, the 30 participants tended to report improvement in inattention, in overall ADHD symptoms, and in OTMP skills compared to baseline measures. Participants also generally reported satisfaction with the intervention and had a very high attendance rate (87 percent rate for weekly sessions). The program thus holds promise for targeting ADHD-specific challenges and improving outcomes in college for students with ADHD.
The Role of Parents
Parenting significantly impacts the trajectory of a child and adolescent with ADHD, even into adulthood. It is well established that, with ADHD, a positive parent-child relationship can lead to adaptive outcomes, whereas the opposite can lead to adverse outcomes.
Children and teens with ADHD are at a greater risk for harsh and inconsistent parenting. Compared to non-ADHD peers, adolescents with ADHD experience less monitoring and supervision from parents and more frequent arguments with them as well14. These interactions put these teens at higher risk for comorbid difficulties15, including oppositional defiant behaviors, substance abuse, anxiety, and mood disorders. On the other hand, parenting that involves more responsiveness, higher levels of warmth, and more knowledge of and involvement in activities has been linked to fewer negative outcomes.16
Research also shows that higher levels of authoritarian parenting (a harsher, overly punitive style) and lower levels of authoritative parenting (which is widely accepted as the optimal parenting approach), is associated with negative outcomes, and especially in emerging adulthood. Authoritarian parenting is linked to acute ADHD symptoms and the internalization of symptoms, which include stress and anxiety17. However, higher levels of parental warmth, involvement and autonomy-granting may buffer against mood disorders and ADHD symptoms in college18. Parents of college students with ADHD, therefore, may be in a unique position to provide particularly valuable support, even from a distance.
Findings from a recent study on parental support for college students with ADHD and its influence on symptoms and impairments are mostly in line with this existing literature. The study’s “high ADHD” group (those who reported a previous diagnosis of ADHD and/or identify with five or more DSM-5 symptoms) reported lower levels of trust with parents, poor quality of communication, and higher levels of alienation with parents compared to students in the “no ADHD” group. The study found that, overall, a low level of parent trust was related to more impairment. Higher levels of alienation, meanwhile, were also related to higher levels of impairment and more anxiety, stress, and negative emotions. A closer, more trusting relationship with parents, it appears, may protect against poor outcomes in college for students with ADHD.
Stimulant Misuse on College Campuses
For college students with ADHD, taking prescribed stimulants and other ADHD medications as directed is correlated with success. But the nonmedical use of stimulants is a significant issue on college campuses, with prevalence rates roughly ranging between 5 percent and 10 percent19. This trend may be rooted in universal college stressors today.
Over time, college freshmen especially are arriving onto campuses with higher GPAs and more attention (and stress) toward academics, but less attention on emotional health20. How does this relate to stimulants? The average college student believes that stimulant medication provides academic benefit21. Interestingly, research on nonmedical stimulant use among college students without ADHD suggests an expectancy effect — in other words, the data shows no actual link between stimulants and improved neurocognition in students without ADHD22. In fact, some research shows that stimulant misuse is associated with a drop in GPA in students who do not have ADHD.23
Clearly, not all college students misuse stimulants. Research shows that the individuals at risk for misusing are those who self-report problems with procrastination and/or time management; who use other substances; and who believe that stimulant misuse is rampant on campus.
Stimulant Misuse Prevention Efforts
An ongoing project at New York’s Syracuse University has revealed some insights into addressing stimulant misuse on college campuses.
The prevention program involves more than 400 freshmen without ADHD, half of whom are undergoing a brief intervention that targets misuse risk-factors like time-management problems, procrastination, and perceived stimulant benefit. Analysis reveals that, compared to controls, the intervention group saw a lower rate of stimulant misuse (about 4 percent prevalence versus 11 percent) during their first semester in college24. This group also saw a reduction in positive expectations for stimulants.
Interestingly, procrastination and time management interventions had negligible impact on participants, which raises questions about refocusing the program on successful interventions – namely, motivational interviewing and challenging expectations on stimulants. Ultimately, however, participants positively rated the intervention experience overall.
College Students with ADHD: Conclusions
College students with ADHD are increasingly common, and increasingly navigating stressors that are unique to them. While college disability services are one solution, only a minority of college students with ADHD seek these services. Innovative care models and targeted interventions for these students show promise in increasing the necessary skills for college success and in improving symptoms of ADHD and its comorbidities. Research also shows that a strong parent-child relationship may improve outcomes in college — and beyond.
College Students with ADHD: Next Steps
- Read: 6 Ways to Smooth the Transition from High School to College
- Read: Managing ADHD Medication in College
- Guide: Choosing Your Dream College: Criteria for Students with ADHD
The content for this article was derived with permission from the “Improving Outcomes for College Students with ADHD” symposium presented by Kevin Antshel, Ph.D., Anne Stevens, Ph.D., Michael Meinzer, Ph.D., and Will Canu, Ph.D, as part of the 2021 APSARD Annual Virtual Meeting.
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3 Canu, W. H., Stevens, A. E., Ranson, L., Lefler, E. K., LaCount, P., Serrano, J. W., Willcutt, E., & Hartung, C. M. (2020). College Readiness: Differences Between First-Year Undergraduates With and Without ADHD. Journal of learning disabilities, 22219420972693. https://doi.org/10.1177/0022219420972693
4 Gormley, M. J., DuPaul, G. J., Weyandt, L. L., & Anastopoulos, A. D. (2019). First-Year GPA and Academic Service Use Among College Students With and Without ADHD. Journal of attention disorders, 23(14), 1766–1779. https://doi.org/10.1177/1087054715623046
5 Kuriyan, A. B., Pelham, W. E., Jr, Molina, B. S., Waschbusch, D. A., Gnagy, E. M., Sibley, M. H., Babinski, D. E., Walther, C., Cheong, J., Yu, J., & Kent, K. M. (2013). Young adult educational and vocational outcomes of children diagnosed with ADHD. Journal of abnormal child psychology, 41(1), 27–41. https://doi.org/10.1007/s10802-012-9658-z
7 Arthur D. Anastopoulos, George J. DuPaul, Lisa L. Weyandt, Erin Morrissey-Kane, Jennifer L. Sommer, Laura Hennis Rhoads, Kevin R. Murphy, Matthew J. Gormley & Bergljot Gyda Gudmundsdottir (2018) Rates and Patterns of Comorbidity Among First-Year College Students With ADHD, Journal of Clinical Child & Adolescent Psychology, 47:2, 236-247, DOI: 10.1080/15374416.2015.1105137
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10 Gray, W. N., Kavookjian, J., Shapiro, S. K., Wagoner, S. T., Schaefer, M. R., Resmini Rawlinson, A., & Hinnant, J. B. (2018). Transition to College and Adherence to Prescribed Attention Deficit Hyperactivity Disorder Medication. Journal of developmental and behavioral pediatrics : JDBP, 39(1), 1–9. https://doi.org/10.1097/DBP.0000000000000511
11 Meinzer, M. C., Oddo, L. E., Garner, A. M., & Chronis-Tuscano, A. (2020). Helping college students with attention-deficit/hyperactivity disorder SUCCEED: A comprehensive care model. Evidence-Based Practice in Child and Adolescent Mental Health, 1-17.
12 Lauren E. Oddo, Anna Garner, Danielle R. Novick, Michael C. Meinzer, Andrea Chronis-Tuscano. (2021) Remote Delivery of Psychosocial Intervention for College Students with ADHD during COVID-19: Clinical Strategies, Practice Recommendations, and Future Considerations. Evidence-Based Practice in Child and Adolescent Mental Health 6:1, pages 99-115.
13 Cynthia M. Hartung, Will H. Canu, Judah W. Serrano, et al. (2020). A new organizational and study skills intervention for college students with ADHD. Cognitive and Behavioral Practice. https://doi.org/10.1016/j.cbpra.2020.09.005.
15 Garcia, A.M., Medina, D. & Sibley, M.H.(2019). Conflict between Parents and Adolescents with ADHD: Situational Triggers and the Role of Comorbidity. J Child Fam Stud 28, 3338–3345. https://doi.org/10.1007/s10826-019-01512-7
16 Howard, A. L., Strickland, N. J., Murray, D. W., Tamm, L., Swanson, J. M., Hinshaw, S. P., Arnold, L. E., & Molina, B. (2016). Progression of impairment in adolescents with attention-deficit/hyperactivity disorder through the transition out of high school: Contributions of parent involvement and college attendance. Journal of abnormal psychology, 125(2), 233–247. https://doi.org/10.1037/abn0000100
17 Stevens, A.E., Canu, W.H., Lefler, E.K. et al. (2019). Maternal Parenting Style and Internalizing and ADHD Symptoms in College Students. J Child Fam Stud 28, 260–272. https://doi.org/10.1007/s10826-018-1264-4
18 Meinzer, M.C., Hill, R.M., Pettit, J.W. et al. (2015). Parental Support Partially Accounts for the Covariation Between ADHD and Depressive Symptoms in College Students. J Psychopathol Behav Assess 37, 247–255. https://doi.org/10.1007/s10862-014-9449-7
19 Teter, C. J., McCabe, S. E., LaGrange, K., Cranford, J. A., & Boyd, C. J. (2006). Illicit use of specific prescription stimulants among college students: prevalence, motives, and routes of administration. Pharmacotherapy, 26(10), 1501–1510. https://doi.org/10.1592/phco.26.10.1501
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21 Arria, A. M., Geisner, I. M., Cimini, M. D., Kilmer, J. R., Caldeira, K. M., Barrall, A. L., Vincent, K. B., Fossos-Wong, N., Yeh, J. C., Rhew, I., Lee, C. M., Subramaniam, G. A., Liu, D., & Larimer, M. E. (2018). Perceived academic benefit is associated with nonmedical prescription stimulant use among college students. Addictive behaviors, 76, 27–33. https://doi.org/10.1016/j.addbeh.2017.07.013
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24 Kevin M. Antshel, Theresa Parascandola, Lea E. Taylor & Stephen V. Faraone (2021) Achievement goal orientation and stimulant misuse in college students, Journal of American College Health, 69:2, 125-133, DOI: 10.1080/07448481.2019.1656635
Updated on June 9, 2021