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Adherence to ADHD Medication in College Freshmen

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.

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.