Anthony_Rostain_AIA_15_Bzb6ml.png.jpgGray SA, Fettes P, Woltering S, Mawjee K, Tannock R (2015). “Symptom manifestation and impairments in college students with ADHD.” Journal of Learning Disabilities.  2015 Mar 16. pii: 0022219415576523. [Epub ahead of print]  

This article reviews what is currently known about the cognitive and academic impairments faced by post-secondary students with ADHD and then reports on a prospective study of symptoms and functional impairments in 135 ADHD university students.   The authors point out that there is limited evidence available on the functioning of post-secondary students with ADHD, and that published studies reveal conflicting evidence.  On the one hand, several studies reporting the results of objective tests of executive functioning (EF) in this population show little differences to peers without ADHD, whereas their self-reports of EF suggest they experience impairments in day-to-day cognitive functioning.  Similarly, there are inconsistent findings regarding the academic performance of this population with some studies showing lower GPAs and higher rates of academic probation and other studies showing no differences between ADHD students and their non-ADHD peers.  However, several papers document that by self-report, post-secondary students with ADHD struggle to keep up with academic demands.

In order to learn about the nature of symptoms and impairments in college students with ADHD, the authors conducted a brief, semi-structured telephone interview with students using the 6-item version of the Adult ADHD Self-Report Scale (ASRS) during which subjects were asked to provide real-life examples of behaviors for each of the symptoms.  Qualitative interview data was analyzed along with symptoms of psychopathology, psychological distress, executive functioning, cognitive difficulties, “grit,” cognitive testing measures (IQ and neuropsychological battery), academic screening measures and self-reported GPAs.   

All subjects were attending university, were between the ages of 18-35 years (mean age 23.7), had a previous diagnosis of ADHD, were registered with student disability services at their school, and met criterion scores on the ASRS administered by phone.  Over 90% of the sample had completed at least 1 year of college and 58% was female.  About 18% had a comorbid learning disability and 51% were taking an ADHD medication (97% taking stimulants).  

Results of the study revealed that these students’ IQ scores were within the normal range and their performance on neuropsychological tests was also in the normal range.  In marked contrast, this sample reported marked impairments in EF in daily life, especially with respect to time management, organization, problem solving, self-restraint, self-motivation, and self-regulation of emotions.  Over 2/3 of the sample had scores in the 95th percentile on the Barkley Deficits of Executive Functioning Scale (BDEFS).   The subjects also reported higher rates of cognitive difficulties in daily life, high levels of distress, lower levels of “grit,” and relatively high rates of anxiety, depression, obsessive compulsive symptoms, phobias, paranoia and psychoticism compared to normal controls.  The mean GPA of the sample was 2.91 indicating acceptable to good academic progress.

The most salient aspect of the study was the qualitative descriptions provided by these ADHD students of their daily struggles with managing the demands of college life.  The major problems they cited included hyperactivity (especially fidgeting), procrastination, and difficulty wrapping up the final details of projects they’d started.  They reported trouble organizing time and materials, and often forgot to use coping strategies they had developed to overcome their difficulties.  Time management problems and psychological distress were among the most prominent themes to emerge from the content analysis.

This study clearly demonstrates the extent to which college students with ADHD encounter considerable distress in meeting academic demands largely as a result of executive functioning difficulties that are better captured by self-report than by neuropsychological testing.  It adds evidence to the argument that neuropsychological testing alone should not be used to determine eligibility for accommodations.   It also documents the reported high levels of stress, distress and psychopathology in this population and points to the need for interventions that bolster EF, particularly with respect to time management, organization and handling negative emotions (distress).   

Anthony L. Rostain, MD MA

About Anthony L. Rostain, MD MA

Dr. Rostain is Director of Education, Department of Psychiatry, Professor of Psychiatry and Professor of Pediatrics at the Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia. He is immediate past President of APSARD, the American Professional Society of ADHD and Related Disorders, and is on the Advisory Board of ADHD in Adults.com.