OR WAIT 15 SECS
Before adolescents with attention-deficit/hyperactivity disorder (ADHD) head off to college and away from home, many for the first time, their pediatricians need to initiate frank discussions about how ADHD will affect them both academically and in their daily living and to help them plan a successful transition to what lies ahead.
According to those who track college graduation rates in the United States, there is a 50% to 60% chance that a college-bound adolescent will not have a successful college experience; in other words, a significant number of students are at risk for leaving college before they graduate.1 Although individuals with attention-deficit/hyperactivity disorder (ADHD) are less likely than others to attend college, an increase in the number of college students with ADHD has been observed in recent years.2 Because ADHD frequently has an adverse impact on a teenager’s academic, social, and psychological functioning, there is reason to expect that those with ADHD might have problems adapting when they enter into college life. This, in turn, can lead to higher college dropout rates among students with ADHD than among those without the disorder.3
When asked about their transition to college, most students with ADHD report it to be “somewhat to very challenging.”4 Only a small percentage of students with ADHD rate the transition as “not very challenging,” but this group credits the rigorous demands of their high schools and the opportunities in high school to practice advocating for themselves as the reasons for their success. Students with ADHD often find the transition to college difficult because they were not prepared to advocate for themselves and to meet the increased academic expectations at college. In addition, they report that they have trouble accepting their differences/disability and fulfilling the many demands of the college experience.4
Given the growing cost of college and the serious economic problems facing many families, these aborted college experiences create a significant financial burden, not to mention an emotional toll, on both students and parents. Parents are now insisting that students maximize the educational opportunities made possible by their financial sacrifice. Students from families who are struggling to make tuition payments cannot afford the luxury of reduced course loads or taking additional semesters to graduate. Some colleges are now setting firmer time limits on how long a student may take to complete a degree. Instead of encouraging the 5-year plan that a number of students have adopted, some colleges are pushing for the 4-year, 8-semester plan, an approach not allowing for as many stops and starts as in the past. Teenagers with ADHD will need to acclimate more quickly and be successful from the beginning or run the risk of being unable to graduate within these new, tighter parameters.5
GETTY IMAGES / OJO IMAGES / CHRIS RYANWhy is successfully completing college such a problem in the first place? Ironically, adolescents’ specific high school experiences may contribute to the difficulty. Most teenagers today lead structured lives and get very little practice making decisions about how to manage their time and life in general. The typical adolescent attends school every day from around 7:30 AM to 3:30 PM, participates in some activity such as a club or sport before dinner, eats dinner, and then may engage in other structured activities or complete homework. Most teenagers have well-meaning parents who have established rules for what needs to happen when. The protectiveness and anxiety of these parents may have led them at times to take over their child’s responsibilities and make things happen in an effort to have their teenager avoid stress and failure. In addition, the secondary education system itself may have become part of the problem. Daily assignments, weekly tests, manageable reading assignments, few independent long-range assignments, and teachers who may encourage, direct, control, remind, prod, and sometimes even nag their students to perform all foster dependence. It is, therefore, not surprising that succeeding on their own at college is so challenging for adolescents.
Transition planning, however, can make a big difference in helping teenagers with ADHD be ready for what lies ahead in college. The treating pediatrician can play a significant role in assisting patients with ADHD to ensure that this transition goes smoothly. So, how can this be accomplished? Several factors are beneficial to the transition process. These include: helping students with ADHD gain knowledge about ADHD and how it will affect them at college, helping them develop self-management/self-determination skills, and encouraging them to use the college’s resources.
Gaining a fuller understanding of ADHD and its ramifications are important factors in its successful management. Although the parents of patients with ADHD may have pursued this information for their children in the past, as young adults their children will need to take responsibility for their disorder and find out as much as they can. By having a detailed discussion with their teenaged patients on how ADHD can affect them at college and what they can do about it, pediatricians can help these patients take the first steps on the road to success. With this goal in mind, it is useful to discuss the following areas with teenaged patients with ADHD. Some books that cover these topics also have been included in an additional reading list (see “Additional Resources”).
Daily living. The transition from attending high school and living at home to starting college or university studies while living away from home is among the most challenging of transitions for many students; however, it is especially challenging for young adults with ADHD. Parents of a student with ADHD typically provide considerable support for their son or daughter throughout that child’s adolescence-including daily reminders about taking medication; frequent prompts to get to bed on time, get up on time, and plan work schedules; and to stay on top of studies.6 When parents drive away after dropping their son or daughter off at college, they take their organizational skills with them and leave their child completely on his/her own, sometimes for the first time. Although many students with ADHD may relish this initial taste of freedom, many quickly find themselves floundering and experience great difficulty managing their daily routines.
Adolescents with ADHD need to be encouraged to spend the time they have left before going off to college to work on these areas. Sometimes that means helping their parents see the benefits of letting go and thus allowing their teenagers to learn to function on their own. This is where the pediatrician may play a pivotal role.
Academic differences. Students with ADHD have little to no experience in handling the more difficult coursework and the freedom and responsibilities they will encounter at college. College is dramatically different from high school with no adults to prod a teenager and help structure his or her life. Academic expectations are more challenging than those in high school. These differences are at odds with the core symptoms seen in students with ADHD, particularly poor executive functioning, which affects both time management and organizational skills. College students face unlimited possibilities for how to spend their time, and may experience increased academic demands that most have not had in high school, even if they have taken advanced placement classes. Add to this mix an irregular class schedule, professors who do not take attendance or assign and grade daily homework, only a few tests during the semester that cover hundreds of pages of reading, and complex long-term assignments that the student must have the self-discipline to complete. By highlighting the need for good executive functioning skills at college, the pediatrician can call attention to an area that has been found to be critical to academic success. In advising these young patients with ADHD, the idea of working with a coach or academic or peer tutor can also be suggested, emphasizing how such personal support can help them achieve their goals.
For some very bright students with ADHD, high school may not have been a challenge. As a result, they may have been able to excel without much sustained effort. These students will inevitably discover that their last-minute approach to preparing for tests or writing papers will not work at college. In this setting, some will become confused and depressed. In addition to lacking the important time management and study skills needed at college, these students have no experience needing or asking for help. They often view these first academic problems as a sign of personal failure and end up in a cycle of hiding their mistakes from family members and friends. They may work more diligently, but still fail to achieve, regardless of degree of effort. If an adolescent’s pediatrician knows this to be the case, the physician can help the patient avert this situation by pointing out how different college is from high school, how the student’s ADHD will affect him or her, and encouraging the use of campus resources when needed.
Only one-third of college students who received special education services in high school seek such formal accommodations in college. Many of these students do not use all the resources available to them, according to a report from the National Longitudinal Transition Study.7 Another study also has shown that students with disabilities can graduate at the same rate as their nondisabled peers if they access support.8 Many adolescents with ADHD understand the value of a college education in terms of increased income, cultural and family enrichment, and even better health as life progresses.9 Most, however, are unaware that they might need to self-disclose their disability and ask for the appropriate resources to be able to graduate on time. By having a discussion that includes questions about each patient’s strengths and weaknesses, preferred learning style, passions, and hopes for the future, pediatricians can help these students assess their capabilities and ascertain where they will need support. This self-knowledge is often the first step to self-advocacy.
In addition, pediatricians can encourage their patients with ADHD to:
To find out more about how a coach can help students with ADHD achieve success, visit www.edgefoundation.org, a national nonprofit organization that provides coaching for students with ADHD. This organization also offers a free care package for the parents of teenagers or college students with ADHD that might prove helpful to the parents of your patients.10
Attention-deficit/hyperactivity disorder is a complex disorder and patients will need a complex solution to ensure success. Treatment for ADHD is often described as being multimodal-comprised of many different components-and encompassing all aspects of daily life. Pediatricians of these patients may need to point out that ADHD affects not only the students’ academic performance but also their relationships, emotions, and day-to-day activities such as eating, sleeping, and getting enough exercise. This is a lot to consider for such patients, but to foster success at the college level, these teenagers with ADHD will need to address their disorder and begin to take charge of their own care. The latter includes the use of medication, meaning that they need to become more knowledgeable about their medication and its effects. It is also important to discuss how taking medication might improve other aspects of daily life such as organization, time management, and relationships, in addition to academics.
Treatment issues to be discussed with patients with ADHD who are going off to college include: the decision to continue or even begin medication therapy at college; determining whether their current medication regimen is effective; a plan for developing communication strategies to convey their concerns back to you as their pediatrician once they are away at college; and how they will get their prescriptions filled on campus. Now is the time for pediatricians and their college-bound patients with ADHD to work together to develop a medication regimen that will lead to a practical daily schedule. Encouraging patients to take their medication consistently so that it will be effective for studying and reading assignments is often critical to a successful transition.
Over the last decade, several medications have been approved that make the treatment of ADHD easier and more effective. These newer medications are all longer-acting preparations in a variety of formulations and delivery systems (Table). Such once-a-day preparations provide the individual with ADHD a means of reducing symptoms throughout the day and into the early evening, while eliminating the need for a multiple-dose regimen that is difficult for those with ADHD to remember. In addition, longer-acting medications have fewer adverse effects, particularly the mood swings or “crash” seen in some patients as a short-acting medication is wearing off.11,12
Young adults on stimulant medications, particularly those living in dormitory or other communal settings, need to be reminded about several issues regarding these medications. First, they should be cautioned not to give or sell any of their ADHD medications to their friends or to others who ask for it. Not only does this reduce the amount of medication that they have for their own personal use, but it could also endanger the health of the other person.
In addition, it is important that patients understand that their medication is a controlled substance. Under federal law, ADHD medications are schedule II substances, and even giving these medications away can result in a drug distribution charge. Further, if patients use up their medication more quickly than prescribed or lose it, they will not be able to receive a new prescription until the end date of the current prescription. It may take some time to get a new prescription and have it filled, so students should be reminded to plan accordingly, especially around exam time. Finally, pediatricians should remind patients that, by law, these medications need to be kept in the original bottles and suggest that students carry their medications with them at all times to prevent theft.
As students with ADHD pursue their college careers, they must do so in environments that are less structured and supportive than the ones they experienced in high school. This opportunity for growth and maturation is important, leading students with ADHD to work on their own to achieve balance and structure in their lives. Discussing ways to maintain good emotional and mental health, including how to deal with stress and how to get the emotional support through individual or group therapy or attending peer support groups on campus, is critical. The lifestyle of many college students often fails to include good living habits such as eating a nutritionally sound, well-balanced diet with meals spaced evenly throughout the day; getting enough sleep; exercising regularly; and avoiding drugs and alcohol. Pediatricians can take this opportunity to reinforce the need for maintaining healthy habits.
The overall message of this article is one that urges pediatricians to hold deliberative discussions with college-bound patients with ADHD as early as possible in the college transition process. These discussions should encourage self-determination and the acquisition of independent living skills. By engaging college-bound students in this process, pediatricians are providing them the greatest opportunity to achieve success in college as well as in life. Given the trusting relationship that exists with these patients, pediatricians are likely in the best position to impart the critical information needed to ensure their successful transition to college.
1. Knepper PR. Beginning Postsecondary Students Longitudinal Study Second Follow-up Data Analysis System (DAS) BPS:96/01. Beginning postsecondary students in 2001 by disability status and learning disability status [CD-ROM]. NCES 2003159. Alexandria, VA: National Center for Education Statistics, U.S. Department of Education; 2003. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2003159. Published March 13, 2003. Accessed July 12, 2013.
2. Henderson C. College Freshmen with Disabilities, 2001: A biennial statistical profile. Washington, DC: American Council on Education, HEATH Resource Center; 2001.
3. US Department of Education. Identifying and treating attention deficit hyperactivity disorder: a resource for school and home. How does ADHD affect school performance? http://www2.ed.gov/rschstat/research/pubs/adhd/adhd-identifying_pg4.html. Modified February 13, 2009. Accessed July 12, 2013.
4. Quinn P, Maitland TE. Ready for take off: preparing teens with ADHD/LD for college. Presented at: Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) 24th Annual International Conference on ADHD; November 10, 2012; San Francisco, CA.
5. University of North Carolina at Chapel Hill. 2012–2013 Undergraduate Bulletin. Academic procedures. http://www.unc.edu/ugradbulletin/procedures1.html. Accessed July 12, 2013.
6. Brown TE. Attention Deficit Disorder. The Unfocused Mind in Children and Adults. New Haven, CT: Yale University Press; 2005. http://yalepress.yale.edu/yupbooks/excerpts/brown_attention.pdf. Accessed July 12, 2013.
7. Newman L, Wagner M, Cameto R, Knokey AM. The post-high school outcomes of youth with disabilities up to 4 years after high school: a report from the National Longitudinal Transition Study-2 (NLTS2). NCSER 2009-3017. http://www.nlts2.org/reports/2009_04/nlts2_report_2009_04_complete.pdf. Published April 2009. Accessed July 12, 2013.
8. Jorgensen S, Fichten C, Havel A, Lamb D, James C, Barile M. Students with disabilities at Dawson College: success and outcomes. Final report presented to PAREA. http://adaptech.dawsoncollege.qc.ca/cfichten/PAREA_2k3.pdf. Published Spring 2003. Accessed July 12, 2013.
9. Porter K. The value of a college degree. ERIC Digest. http://www.ericdigests.org/2003-3/value.htm. Published 2002. Accessed July 12, 2013.
10. Edge Foundation. The ADHD Parent Care Package: Support and Encouragement for Parents of Teens and Young Adults with ADHD.https://edgefoundation.org/parents/free-parent-care-package/. Accessed July 12, 2013.
11. Kolar D, Keller A, Golfinopoulos M, Cumyn L, Syer C, Hechtman L. Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. 2008;4(2):389-403.
12. Cascade E, Kalali AH, Weisler RH. Short-acting versus long-acting medications for the treatment of ADHD. Psychiatry (Edgmont). 2008;5(8):24-27.
DR QUINN is a developmental pediatrician in Washington, DC. She is a founding board member of the EDGE Foundation and a paid consultant and speaker for Noven and Shire Pharmaceuticals.
Subscribe to Contemporary Pediatrics to get monthly clinical advice for today's pediatrician.