Kevin Antshel, PhD, ADHD in AdultsNot every child with ADHD will matriculate to a four-year college, although the numbers are increasing. For example, a follow-up survey on post-secondary trajectoires of high school students with ADHD histories (N = 364) showed that 30% of the ADHD sample were currently in pursuit of a four-year degree; this figure was 9% higher than previously reported data from a comparable sample in 20061. Thus, more children with ADHD are becoming college students with ADHD. College students seeking on-campus ADHD evaluations and ADHD treatment and are also increasing in prevalence. The most recent data from the Association of University and College Counseling Center Directors (AUCCCD) annual survey, completed by 518 college counseling center directors, suggests that approximately 9% of the students seen during the 2014-2015 academic year presented at their counseling centers with concerns specifically related to ADHD2. To put this in perspective, this means that depending upon the size of the college, college counseling centers are seeing anywhere from 1 to 775 students per year with concerns specifically related to ADHD2. It is not possible to know which students the college counseling centers are not seeing and certainly there are plenty of students not seeking counseling centers for ADHD related concerns. Thus, the AUCCCD data likely represents an underestimate of the number of college students with concerns specifically related to ADHD.

College students with ADHD face significant difficulties in the college academic environment and are at greatly increased risk of poor academic achievement and failure. Clinical recommendations for working with college students with ADHD include (a) a combined approach of pharmacotherapy and psychosocial interventions, typically CBT; (b) meeting with the college student more than once per week, generally by having both group CBT and individual CBT interventions operating concurrently, (c) integrate clinical services with other providers on campus (e.g., Office of Disability Services, Counseling Center, etc.) in an attempt to improve and integrate service provision; (d) specifically target treatment adherence, including a discussion of how to handle stimulant diversion requests; (e) incorporate a discussion of emerging adulthood themes such as identity exploration, feeling-in-between adolescence and adulthood, setting realistic and optimistic life goals, and becoming independent from parents; and (f) consider adopting more of a “chronic” model for treating ADHD in college students (e.g., following students over their entire four year experience rather than treating for one semester)3.

In addition to treating college students with ADHD on campus, another issue that is present on college campuses is the college students that may be motivated to over report ADHD symptoms and malinger ADHD. College students have several incentives to over-report ADHD symptoms. A substantial number of students seek stimulant medication, most often with the intent to enhance academic performance4. Prevalence rates for stimulant misuse are the highest in college students (17%) compared to all other populations5. In addition to obtaining stimulant medication, some college students seek an ADHD diagnosis for the accompanying academic accommodations (e.g., extended time for examinations, etc.), also in the hope of improving grades6. Still others may seek an ADHD diagnosis as an external attribution for perceived academic failures7. Given these incentives, it is not surprising that elevated rates of ADHD malingering exist in college students8. Despite this, no existing strategies to detect ADHD malingering in college students have adequate sensitivity and specificity9. Given concerns about students feigning symptoms in order to acquire medication and/or academic accommodations along with the great difficulty in detecting ADHD malingering, it is not surprising that the vast majority of university health professionals are not comfortable diagnosing ADHD, with over 90% referring students off campus for ADHD evaluations10.

Our knowledge of ADHD in the college student population is nascent and we know far less about ADHD in this population compared to ADHD in children and adolescents. Increasing numbers of college students have ADHD diagnoses and are seeking on campus treatment services. Similarly, college students have several clear incentives to malinger ADHD symptoms. Given the difficulties in detecting ADHD malingering, the overwhelming majority of university health professionals refer students off campus. Researchers and clinicians should continue to develop more effective ADHD treatment options, including those designed to reduce stimulant diversion/misuse. Likewise, better understanding how to accurately detect ADHD malingering in this population is important for reducing public health costs for unwarranted assessments, backlogging an already significantly limited psychological resource on college campuses2 and creating an unfair advantage (e.g., receipt of inappropriate academic accommodations).
 

References
1. Kuriyan AB, Pelham WE, Jr., Molina BS, et al. Young adult educational and vocational outcomes of children diagnosed with ADHD. Journal of abnormal child psychology. 2013;41(1):27-41.
2. Association for University and College Counseling Center Directors. The Association for University and College Counseling Center Directors Annual Survey. Indianapolis, IN: AUCCCD; 2015.
3. He A, Antshel KM. Cognitive Behavioral Therapy for Attention Deficit / Hyperactivity Disorder (ADHD) in College Students: A Review of the Literature. Cogn. Behav. Pract. In press.
4. DeSantis AD, Webb EM, Noar SM. Illicit use of prescription ADHD medications on a college campus: a multimethodological approach. Journal of American college health : J of ACH. 2008;57(3):315-324.
5. Benson K, Flory K, Humphreys KL, Lee SS. Misuse of stimulant medication among college students: a comprehensive review and meta-analysis. Clinical child and family psychology review. 2015;18(1):50-76.
6. Williamson KD, Combs HL, Berry DT, Harp JP, Mason LH, Edmundson M. Discriminating among ADHD alone, ADHD with a comorbid psychological disorder, and feigned ADHD in a college sample. The Clinical neuropsychologist. 2014;28(7):1182-1196.
7. Suhr J, Wei C. Symptoms as an Excuse: Attention Deficit/Hyperactivity Disorder Symptom Reporting as an Excuse for Cognitive Test Performance in the Context of Evaluative Threat. Journal of Social and Clinical Psychology. 2013;32(7):753-769.
8. Suhr J, Hammers D, Dobbins-Buckland K, Zimak E, Hughes C. The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation. Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists. 2008;23(5):521-530.
9. Musso MW, Gouvier WD. “Why is this so hard?” A review of detection of malingered ADHD in college students. Journal of attention disorders. 2014;18(3):186-201.
10. Thomas M, Rostain A, Corso R, Babcock T, Madhoo M. ADHD in the College Setting: Current Perceptions and Future Vision. Journal of attention disorders. 2015;19(8):643-654.

Kevin Antshel, PhD

About Kevin Antshel, PhD

Kevin Antshel, PhD is the Director of the Clinical Psychology Program and ADHD Lifespan Treatment, Education, and Research Program at Syracuse State University. He is also Associate Professor of Psychology at Syracuse State University, and Adjunct Associate Professor in Psychiatry at SUNY Upstate Medical University.