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The Clinical Priority of ADHD
in Higher Education

By Steven Iacono, LISW-CP

Marie was a freshman starting her first semester of college majoring in social work. For many years she had been able to “get by” academically. It’s not that she couldn’t do the work, but it had always been a struggle. Compared with her peers, it seemed to take longer for her to get projects done. Her parents supplied a lot of support and oversight. They made sure she remembered to put her essays in her book bag, inquired about what homework needed to be done, and generally provided structure for her studies. Her 4th grade teacher had commented to her parents that she might have some type of attention problem; however, since her grades were good, they did not pursue any type of evaluation. They also disregarded her tendency to procrastinate heavily and to become easily distracted. They reasoned that kids always try to avoid doing their chores and homework.    

Marie was popular, though frequently tangential and impulsive in conversation. Her friends often joked about how she could talk for hours and how she “had no filter on her mouth.” In high school they playfully teased about her habit of constantly misplacing her cell phone. College quickly became daunting for Marie. Her parents were no longer there to oversee her studies; it was all up to her now. She had to juggle her time between friends, studying, trying to join a sorority, projects, laundry, exercising, holding down a part-time job, and many other daily tasks. Everything seemed equally important; trying to prioritize and devote enough hours to each became harder and harder.

Her first exams were crushing. Soon, she found herself failing two classes and began to think she was not smart enough for college. Her mood diminished. Fortunately, she visited her campus counseling center and met with a clinician who informed her that she reported many typical symptoms of ADHD. Marie told her parents and at first they were skeptical. However, after learning more about this condition they realized that it might actually explain a lot of her behaviors over the years. After receiving a full assessment she was diagnosed with ADHD. She started taking medication to improve her ability to concentrate and attended a weekly workshop offered at the counseling center to address her time management deficits.

Symptoms and Statistics

Marie’s story is fictional, but what she went through is common to tens of thousands of college freshman every year. ADHD is known to have a prevalence of 4.4% among the adult population of the United States (Kessler et al., 2006). It is a condition that can impact the academic, employment, psychological, and social functioning of college students. In conjunction with the developmental transitions and other rigors of college life, it has the potential to impact whether students complete their degree program. Adults with ADHD are known to have exceptionally high rates of comorbidity including anxiety (47.1% prevalence), mood disorders (38.3%), and substance use (15.2%) (Kessler et al., 2006).

Students with this condition have been noted to have lower levels of self-esteem and generally lesser social skills along with more adjustment issues (Shaw-Zirt, Popali-Lehane, Chaplin, & Bergman, 2005; Dooling-Liftin, & Rosèn, 1997). A meta-analysis of several studies regarding vehicle accidents calculated an overall increased risk factor of 1.88 for persons who have ADHD (Jerome, Segal, & Habinski, 2006). They are also noted to frequently have more speeding tickets and more accidents involving bodily injury (Barkley, Murphy, & Kwasnik, 1996). Because of the prevalence and broad impact of this condition, one might expect that college and university counseling centers would provide a range of assessment and treatment services for students who have it, but this does not appear to be the case.

This author conducted two studies that gathered data from counselors in 134 randomly selected colleges and universities offering four-year degrees across the United States regarding their views about ADHD. The results reflect a general lack of interest and service provision. When asked to rate their comfort level working with students who have ADHD, 36% acknowledged being either not comfortable or only somewhat. Forty-one percent rated their interest working with students with ADHD as being either not interested or only somewhat. An additional 15% indicated that they would prefer not to work with these students at all if given a choice.

Training and education are extremely important in the provision of mental health services. The author’s studies found that 72% of all counselors rated their formal graduate training regarding ADHD as being poor or only somewhat adequate. Most had never attended a continuing education conference or seminar pertaining to this condition or received any in-house training about it. This led to the finding that seven out of 10 counselors do not routinely screen their new clients for this condition. Jennifer Cross, MS, LPC, CHC, a campus counselor, noted, “There are a few aspects of this condition that make it a silent issue. Most clinicians have limited exposure to it during graduate school, so they might not realize what they’re missing. It can be hard to identify. Several other conditions such as anxiety, depression, and even certain medical problems can imitate some of the symptoms of ADHD. Also, there is still the mistaken belief that it would have most likely been identified in childhood if it were truly present.”

The author’s experience has been that ADHD is often viewed as a “yes/no” condition; it’s either present or it’s not. But the reality is that it’s a spectrum just like many other disorders. Those who are on the more severe end of the spectrum do frequently get identified in childhood, but the more mild to moderate cases can be overlooked; this becomes a significant issue when students are confronted with college-level academic requirements.

Social workers often hold unique positions in college counseling centers because they are employed in a variety of roles. The following are four primary roles in which they can impact the provision of services to students who have ADHD:

• Counselors. As noted, ADHD as a condition does not appear to receive much screening, assessment, or treatment. Individual clinicians can rectify these oversights. Even if they don’t believe that they have the knowledge and skills to provide treatment, simply screening for it and then connecting students to appropriate resources can be greatly beneficial.
• Advocates. Many campus counseling center personnel are not aware of the prevalence of this condition; informing coworkers and faculty can greatly reduce this knowledge deficit. Additionally, they can engage in outreach and education with the greater campus to dispel misinformation and stigma.
• Case managers. Social workers in case management positions are growing in popularity in campus counseling and general medical clinics. Their ability to link students to on-campus resources (e.g., disability registration offices, tutoring) and off-campus resources (e.g., specialists, psychological testing) put them in a position to greatly influence student academic success.
• Educators. Campus counselors often hold adjunct professorships and lecturer roles. By teaching their students about ADHD, they can make a change over time in the way in which future clinicians view this condition.

The assessment and treatment of ADHD on college campuses has evolved into a hot-button issue. High levels of medication abuse, legal liability for prescribing these medications, stigma about this condition, its level of comorbidity, and other factors impact the provision of services. However, there is an ethical and professional imperative not to overlook something that one does not know much about. Not being interested in working with students who have ADHD, or not learning much about this condition in graduate school, cannot be an excuse to provide less service. It could be argued that due to the high level of comorbidity, prevalence, and the academic and personal struggles that often accompany it, that students with this condition need even more time, consideration, and resources.

— Steven Iacono, LISW-CP, is coordinator of special services at the University of South Carolina.

References

Barkley, R. A., Murphy, K. R., & Kwasnik, D. (1996). Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics, 98(6), 1089-1095.

Dooling-Liftin, J. K., & Rosén, L. A. (1997). Self-esteem in college students with a childhood history of Attention Deficit Hyperactivity Disorder. Journal of College Student Psychotherapy, 11(4), 69-82.

Jerome, L., Segal, A., Habinski, L. (2006). What we know about ADHD and driving risk: A literature review, meta-analysis and critique. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 15(3), 105-125.

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., et al. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716-723.

Shaw-Zirt, B., Popali-Lehane, L., Chaplin, W., & Bergman, A. (2005). Adjustment, social skills, and self-esteem in college students with symptoms of ADHD. Journal of Attention Disorders, 8(3), 109-120.