Kevin Antshel, PhD, ADHD in AdultsAccording to statistics released in 2014 by the National Student Clearinghouse Research Center1, nearly 1 in 3 college students will drop out in their first year of college. While there are a variety of possible reasons (e.g., financial, etc.) for this sobering statistic, this finding highlights that transitioning to college can be challenging for a significant proportion of adolescents. For adolescents with ADHD, this transition period can be especially demanding. Adolescents with ADHD often move away from a structured environment (e.g., interventions and accommodations occurring at school, parent involvement, etc.) to the less structured environment of the college campus and greater demands for functional independence (e.g., managing medication without the involvement of parents).

A recently published qualitative study by Schaefer and colleagues2 addresses stimulant medication adherence in college freshmen with ADHD, a part of this transition towards independence. In this study, 10 second-semester college freshmen with ADHD (7 males, 3 females) were interviewed using a semi-structured interview guided by the Health Belief Model (HBM), a theory developed to explain health behavior decision-making3.

Using a Likert scale from 0 (not at all controlled) to 10 (fully controlled), college freshmen with ADHD reported having moderate ADHD control (M = 6.1, SD = 2.7). Using a similar Likert scale from 0 (parents not at all involved) to 10 (parents completely involved), college freshmen with ADHD reported that in high school, parental involvement was moderate (M = 6.8, SD = 3.0) yet in college, parental involvement decreased to low levels (M = 2.8; SD = 3.5). Medication barriers identified by the majority of surveyed college freshmen with ADHD included not feeling like taking the medication, difficulty adhering to a fixed medication schedule, difficulties obtaining a refill on time and that the medication interfered with other activities.

Six different themes (presented here in descending order) emerged from the qualitative interviews and were reported by the majority of the 10 freshmen. The theme that was unanimously raised by all freshmen with ADHD related to volitional non-adherence to stimulants. The reasons for this non-adherence were varied yet could be grouped into inaccurate disease beliefs (“outgrew my ADHD”), perceived lower academic demands (“light academic day and no need to take my stimulant”) and medication side effects. While the authors did not explicitly make this link, volitional non-adherence to daily stimulant medication prescriptions sets the stage for stimulant diversion / misuse. By having “extra” medication available, the possibility of stimulant diversion is increased. Consistent with this notion, a second theme that emerged from the interviews was centered on perceived pressure from peers to share stimulant medications. A third theme that emerged from the interviews was that poor ADHD self management had negative implications for academic performance. A fourth theme was that increased social support was needed. The last two themes related to being ill-equipped for the abrupt transition to independence and reluctance to use non-medication management strategies (e.g., failure to use of Office of Disability Services secondary to stigma).

The authors concluded by offering a number of clinical strategies for improving the transition to college for adolescents with ADHD. While not mentioned in the Schaefer et al. study, others have developed programs tailored towards helping adolescents with ADHD transition from high school to college. For example, the Accessing Campus Connections and Empowering Student Success (ACCESS) program developed by Anastopoulos and colleagues4 includes weekly group therapy and individual mentoring. Group treatment sessions address ADHD knowledge (e.g., including medication knowledge), behavioral strategies (e.g., how to access resources on campus) and cognitive skills (e.g., how think adaptively). ACCESS is currently being tested in a randomized controlled clinical trial study after initial pilot data were encouraging.

By virtue of their college student status, college students with ADHD have had higher academic success during elementary, middle and high school and likely have better coping skills and higher general abilities than individuals with ADHD from the general population. (In support of this view, the average age of ADHD diagnosis for the 10 college freshmen was 15.7 years in the Schaefer et al. qualitative study.) At the same time, college students with ADHD are likely to experience a different set of stressors than young adults with ADHD who are not enrolled in college. In this way, college students with ADHD may represent a distinct category of individuals with ADHD who face a distinct set of challenges. Efforts, like those of Schaefer et al., to understand how best to improve the transition of adolescents with ADHD to college are a clinically important topic.

College students, both with and without ADHD, are in the developmental period of “emerging adulthood,” a period of time between 18-25. Emerging adulthood consists of five dimensions: identity exploration (e.g., trying out different career goals), feeling-in-between adolescence and adulthood, possibilities (e.g., setting optimistic life goals), self-focus (e.g., becoming independent from parents), and instability (e.g., uncertainty and stress from exploring life options)5. The Schaefer et al. study did not use emerging adulthood as a framework for understanding the qualitative interview responses from the freshmen with ADHD. However, several of the emerging adulthood dimensions can be observed in the identified themes and individual freshmen responses.

In sum, the Schaefer et al. study provides meaningful information about stimulant medication adherence, an important aspect of the transition to college for adolescents with ADHD. In addition to providing useful information about how to best facilitate a smooth transition to college, the Schaefer et al. study also intimates that efforts to improve stimulant medication adherence (and therein lessen stimulant diversion) are sorely needed for college students with ADHD.
 

References
1. Center NSCR. First-Year Persistence Rate of College Students Declines. 2014; http://nscnews.org/first-year-persistence-rate-of-college-students-declines/. Accessed February 20, 2017.
2. Schaefer MR, Rawlinson AR, Wagoner ST, Shapiro SK, Kavookjian J, Gray WN. Adherence to Attention-Deficit/Hyperactivity Disorder Medication During the Transition to College. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2017.
3. Cummings KM, Jette AM, Rosenstock IM. Construct validation of the health belief model. Health Educ Monogr. 1978;6(4):394-405.
4. Anastopoulos AD, King K. A Cognitive-Behavior Therapy and Mentoring Program for College Students With ADHD. Cogn Behav Pract. 2015;22:141-151.
5. Arnett JJ. Emerging adulthood. A theory of development from the late teens through the twenties. The American psychologist. 2000;55(5):469-480.

Kevin Antshel, PhD, ADHD in AdultsOccupational impairments are one of the most common outcomes for adults with ADHD. As a function of ADHD symptoms and associated problems such as psychiatric comorbidities and executive function impairments, adults with ADHD often experience difficulties finding and maintaining jobs and are at increased risk for being unemployed or underemployed. Given the variety of outcomes that are associated with occupational functioning (e.g., quality of life, socioeconomic status and subsequent healthcare access, etc.), efforts to understand ADHD in the occupational setting represent a clinically significant topic. Despite being an environment in which adults with ADHD spend considerable time, very few existing studies have considered how the occupational environment impacts ADHD.

A very recently published paper1 fills this void and examines how young adults with ADHD perceive their occupational environment and the extent to which this environment influences their ADHD symptoms. Using a qualitative research design, one of the primary research questions that the authors investigated was the extent to which certain occupational settings are a better fit for young adults with ADHD. The participants in this study all were young adults with well defined ADHD that was diagnosed in childhood. All participants were ascertained from the Multimodal Treatment Study of ADHD (MTA)2 and were approximately 24 years of age at the time of their qualitative interview.

The majority of young adults with ADHD reported a connection between occupational environments and ADHD symptoms. While certain work environments intensified ADHD symptoms, other work environments ameliorated symptoms. The importance of the “goodness of fit” between occupational environment and person was a consistent theme that emerged from the qualitative interviews. A view that problems were environmental, not personal, helped to reduce feelings of inadequacy. The young adults with ADHD commonly reported that a highly stimulating environment provided the best person-environment fit. A highly stimulating environment was further operationalized as consisting of some of these elements: stressful work that is novel and requires multitasking, working in a busy and fast-paced environment, completing work that is physically demanding or hands-on in nature, and/or working on tasks that are intrinsically interesting.

The authors concluded that ADHD symptoms are occupationally context-dependent; work environments may either increase or decrease ADHD symptoms dependent upon the “goodness of fit”1. The authors further assert that future research should consider the effectiveness of occupational “fit” as a potential intervention. In my own clinical experiences, I can relate that person-environment fit indeed has a salient impact upon symptom and functioning levels. As I commonly tell parents of children with ADHD, “there is no better intervention than a great teacher who understands your child”. These recently published data suggest that the same principles may hold for young adults, albeit with a different environmental context. This paper is important and reinforces the notion that context “matters”. Rather than ADHD being static, it is more accurate to view ADHD as dynamic and an interaction between the person and the environment.

Similar research has been published in outlets that are likely not familiar to mental health professionals. In the entrepreneur literature, several recent papers have been published on the association between entrepreneurship and having an ADHD diagnosis3 or elevated ADHD symptoms4,5. These research groups have demonstrated positive relationships between ADHD and entrepreneurial intentions (commitment to performing a behavior that is necessary to start a business venture) and the link between ADHD and entrepreneurial orientation (generally considered to be the level of innovation, creativity, proactiveness and risk-taking that an individual possesses). These three studies as well as a case study6 suggest that it is hyperactivity-impulsivity symptoms, not inattention symptoms, that are positively linked to entrepreneurship. Similar to the MTA ADHD researchers described above, these entrepreneurship investigators also concluded that the functional outcomes associated with ADHD are dynamic and context-dependent.

While these entrepreneur data are interesting, much research remains to be done regarding the association between ADHD and entrepreneurship. For example, the existing studies have methodological constraints (e.g., the variance of entrepreneurial orientation explained by ADHD symptoms is low, common method bias [relying exclusively on self-report], etc.). Likewise, these entrepreneurship papers have considered entrepreneurial orientation and intention, not entrepreneurial success. Thus, future work should consider the extent to which individuals with ADHD experience successful outcomes as entrepreneurs. For example, in which industry and contexts/situations (e.g., managing finances, developing a new product, marketing, etc.) might individuals with ADHD experience entrepreneurial success? My suspicion is that there will be no, “one size fits all” conclusions. In other words, the entrepreneurship success is context-dependent and varies widely among adults with ADHD. The exciting part of this line of investigation, however, is the seismic shift in focus: conventional workplace liabilities associated with ADHD may emerge as abilities in an entrepreneurship context.
 

References
1. Lasky AK, Weisner TS, Jensen PS, et al. ADHD in context: Young adults’ reports of the impact of occupational environment on the manifestation of ADHD. Social science & medicine. 2016;161:160-168.
2. MTA Collaborative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Archives of general psychiatry. 1999;56(12):1073-1086.
3. Dimic N, Orlov V. Entrepreneurial Tendencies Among People with ADHD. International Review of Entrepreneurship. 2014;13:187-204.
4. Thurik R, Khedhaouria A, Torrès O, Verheul I. ADHD symptoms and entrepreneurial orientation of small firm owners. Applied Psychology: An International Review. 2016;65:568-586.
5. Verheul I, Block J, Burmeister-Lamp K, Thurik R, Tiemeier H, Turturea R. ADHD-like behavior and entrepreneurial intentions. Small Business Economics. 2015;45:85-101.
6. Wiklund J, Patzelt H, Dimov D. Entrepreneurship and psychological disorders. Frontiers of Entrepreneurship Research. 2014;34:50-59.

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.