ADHD in college students

OBJECTIVE: According to the American Psychiatric Association, 3% to 7% of the school-age population has ADHD and many children continue to display significant symptoms throughout adolescences and adulthood. Relative to the childhood literature, less is known about ADHD in adults, especially college students with ADHD. The principle purpose of this review articles is to summarize the major research findings concerning ADHD in the college student population with regard to prevalence of symptoms, neuropsychological and psychological functioning. Overall, findings suggest that college students with ADHD are at greater risk for academic and psychological difficulties, and they perform similar to non-ADHD controls on many neuropsychological tasks. These findings are preliminary, however, and are tempered by the small number of studies that have been conducted as well as the methodological limitations of these studies. CONCLUSION: Future research using larger sample sizes, rigorous assessment criteria, and a longitudinal design is needed to better understand the psychological, academic, and neuropsychological functioning of college students with ADHD. Studies are also needed to elucidate the effects of pharmacological and nonpharmacological effects of treatment on the functioning of college students with this disorder.     

The Effectiveness of Cultural Adjustment and Trauma Services (CATS): Generating Practice-Based Evidence on a Comprehensive, School-Based Mental Health Intervention for Immigrant Youth

A collaborative study of Cultural Adjustment and Trauma Services (CATS), a comprehensive, school-based mental health program for traumatized immigrant children and adolescents, was conducted to generate practice-based evidence on the service delivery model across two school districts. Program effectiveness was assessed by testing whether client functioning and PTSD symptoms improved as a result of 7 separate service elements. An array of clinical services including CBT, supportive therapy, and coordinating services were provided to all students, and an evidence-based intervention for trauma, TF-CBT, was implemented with a subset of students. Greater quantities of CBT and supportive therapy increased functioning, while greater quantities of coordinating services decreased symptoms of PTSD. TF-CBT services were associated with both improved functioning and PTSD symptoms, although TF-CBT was implemented with fidelity to the overall comprehensive service model rather than the structured intervention model. Results suggest the comprehensive school-based model was effective, though different service components affected different student outcomes. Implications of these findings for immigrant mental health interventions and implementing structured evidence-based practices into community mental health programs are discussed. Suggestions are made for future research on existing mental health practices with immigrants.     

Developmental Context and Treatment Principles for ADHD Among College Students

Attention-deficit/hyperactivity disorder (ADHD) affects between 2 and 8?% of college students. ADHD is associated with impaired academic, psychological, and social functioning, and with a wide array of negative outcomes including lower GPAs, graduation rates, and self-reported quality of life. The college environment often brings decreased external structure and increased availability of immediate rewards, presenting added demands for behavioral self-regulation—an area in which students with ADHD are already vulnerable. Despite the significant impact of ADHD in college and the unique challenges presented by the college context, virtually no treatment development research has been conducted with this population. In order to provide a framework to guide intervention development, this comprehensive review integrates research from three key domains that inform treatment for college students with ADHD: (1) functional impairment associated with ADHD among college students, (2) etiology of ADHD and the developmental context for ADHD among emerging adults (age 18–24), and (3) treatment outcome research for ADHD among adolescents and adults. A detailed set of proposed treatment targets and intervention principles are identified, and key challenges associated with treatment development in this population are discussed.     

A New Organizational and Study Skills Intervention for College Students with ADHD

The transition to college can be very challenging for individuals with ADHD. Increased task and life demands happen in tandem with deficits in time management, study skills and habits, and delaying rewards to achieve longer-term goals. Cognitive-behavioral treatment (CBT) holds promise for targeting these and related challenges. Psychosocial interventions exist for the general population of adults with ADHD, but not college students. Importantly, an intervention designed for college students should be manageable in terms of time and cost. We developed such an intervention specifically for college students with ADHD; organizational, time management, and planning (OTMP) skills were the focus of this largely behavioral treatment, as these most directly relate to the executive function deficits characteristic of ADHD and to the demands of college. Academic study skills and psychoeducation regarding ADHD and medication management were also included. The intervention was tested with 30 undergraduate, post-baccalaureate, and graduate students (57% biological males; M age 22.6; 83.3% White/Non-Hispanic) from two public universities in the U.S. Participants completed a battery of self-report measures of ADHD symptoms, impairment, and OTMP skills pre- and post-treatment. Most participants reported a past diagnosis of ADHD (n = 23; including possible comorbidity), with all others reporting at least 5 pre-treatment symptoms of inattention (M for all participants = 6.3). The manualized intervention consisted of 6 group therapy sessions and 2 individual sessions. Results suggested that this new treatment has promise, with t-tests comparing pre- and post-intervention scores indicating significant improvements in inattention symptoms, total ADHD symptoms, self-concept impairment, total impairment, and use of organization, time management, and planning skills. In addition, participants generally reported satisfaction with the intervention and had a very high attendance rate. Future studies of this new intervention should include a randomized controlled trial, the collection of objective outcome measures, and a more diverse sample.     

Adjustment, social skills, and self-esteem in college students with symptoms of ADHD

Many studies of ADHD have shown that the problems associated with the disorder continue into adolescence and beyond for 10% to 60% of patients. The present study assesses several aspects of college adjustment, social skills, and self-esteem in a nonreferred sample of college students meeting criteria for a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of ADHD. Twenty-one undergraduate students with symptoms of ADHD are compared to 20 students without significant ADHD symptoms, who match the ADHD students on age, gender, and grade point average. Students with ADHD symptoms show decreased functioning in several areas of college adjustment as well as lower levels of self-reported social skills and self-esteem. The results also suggest that the relation between ADHD and college adjustment is partially mediated by self-reported levels of self-esteem.     

Yoga,Mindfulness, and Meditation Interventions for Youth with ADHD: Systematic Review and Meta-Analysis

Attention-deficit/hyperactivity disorder (ADHD) is a chronic developmental disorder affecting 3–7% of children. In light of the growing utilization of yoga, mindfulness, and meditation in ADHD populations and potential benefits it has on ADHD symptoms, executive function deficits, and social functioning, we sought to evaluate these interventions for youth with ADHD. The primary aim of this review paper is to identify the efficacy of these programs for the treatment of youth with ADHD through a systematic review and meta-analysis. A systematic literature search was conducted in the following electronic databases: PsychINFO, ERIC, PubMed, and MEDLINE. Studies were included in the meta-analytic review if participants were between 5–17 years old, had a diagnosis of ADHD or met symptom threshold on psychometrically-validated measure of ADHD symptoms, was a treatment outcome study, and was published in a peer-reviewed English-language journal. The effect sizes of eleven studies demonstrate that yoga, mindfulness-based interventions, and/or meditation had a statistically significant effect on the outcomes of ADHD symptoms, hyperactivity, and inattention (parent and teacher report), as well as parent-child relationship, executive functioning, on-task behavior, parent stress, and parent trait-mindfulness (p?<?0.05). The effect sizes range from small to large effects across these outcomes. Considerable risk for bias was found across studies. Given significant methodological limitations of the literature, positive effect sizes found in studies should be interpreted with caution; these interventions should not be considered first-line interventions for ADHD. However, preliminary findings suggest yoga, mindfulness, and meditation may be beneficial for youth with ADHD, but extensive research is required to validate the efficacy of these interventions.     

Cross-cultural comparison of ADHD symptoms among Japanese and US university students

Problems related to attention, hyperactivity, and impulsiveness are known to impact social, academic, and vocational success. When the problems begin in childhood and lead to impaired functioning, the syndrome is identified as attention-deficit/hyperactivity disorder (ADHD). Symptoms of the syndrome persist into adolescence and adulthood for many individuals, but less is known about characteristics of adults compared to children, especially adults attending university. Furthermore, there is little cross-national and cross-cultural research. This study compared DSM-IV-TR ADHD symptoms of US university students (N=271) to Japanese peers (N=712). Comparison of group means on a DSM-IV-TR-based checklist indicated that Japanese students reported more problems with inattention (and overall ADHD symptoms) but not hyperactive-impulsive symptoms. Although differences were statistically significant, effect sizes were small, indicating that for practical purposes, the students reported similar levels of symptoms. Japanese students reported higher rates of meeting or exceeding symptom counts that comprise diagnostic criteria for ADHD, but differences were quite small. Using DSM-IV-TR thresholds, 5.70% of US students and 6.27% of Japanese students reported enough symptoms to meet the cut-off for inattentive, hyperactive/impulsive, or combined type during childhood. With regard to recent problems, 2.66% of US students and 4.52% of Japanese students reported enough symptoms to meet the cut-off for one of the three subtypes. Comparisons using other methods of calculating rates are also provided. This research adds to the limited knowledge of ADHD symptoms in university students across countries and it supports the view that ADHD is not merely a cultural construct. This study is among the first to identify potential attention problems in Japanese university students.     

Callous-Unemotional Traits are Uniquely Associated with Poorer Peer Functioning in School-Aged Children

This study examines externalizing symptoms (attention-deficit/hyperactivity disorder [ADHD], conduct problems, and callous-unemotional [CU] traits) in relation to domains of peer functioning (social competence, loneliness, and close friendship quality), with a specific focus on the role of CU traits. One hundred twenty-four elementary students (grades 3–6; 45% boys) completed multiple measures of peer functioning, and teachers completed measures of externalizing symptoms and social competence. After controlling for demographic variables and other externalizing symptoms, CU traits were significantly associated with poorer peer functioning across all variables except for demands of exclusivity in close friendships. ADHD symptoms were also uniquely associated with poorer social functioning across a number of variables. In contrast, conduct problems were at times associated with better social functioning after controlling for the effects of other externalizing problems. These findings bolster the importance of developing and evaluating social skills interventions for children displaying elevated CU traits.     

Clinical Change Mechanisms in the Treatment of College Students With ADHD: Trajectories and Associations With Outcomes

The purpose of this study was to evaluate trajectories of response for the three theorized mechanisms of clinical change (knowledge, behavioral strategies, and adaptive thinking) associated with the Accessing Campus Connections and Empowering Student Success (ACCESS) intervention for college students with attention-deficit/hyperactivity disorder (ADHD) and their association with treatment outcomes. Participants included 250 college students comprehensively diagnosed with ADHD randomly assigned to ACCESS or to a delayed-treatment control who completed ratings at baseline, end of active treatment, and end of the maintenance phase of treatment (after two semesters). Growth mixture models (GMMs) were used to evaluate trajectories. Participants in ACCESS made significant gains in the use of behavioral strategies and trajectories were associated with large effect size improvements in measures of symptoms and functioning. Participants also made improvements in ADHD knowledge. However, only the knowledge trajectory with rapid improvement displayed significantly better outcomes. Only one trajectory group showed improvement in adaptive thinking with most ACCESS participants remaining stable across time. However, adaptive thinking trajectories were strongly related to both symptom and functional outcomes. ACCESS is associated with large gains in two of the three theorized clinical mechanisms of change, behavioral strategies and ADHD knowledge. Rapid improvement in behavioral strategies was associated with robust improvement in symptoms and functioning. Although improvements in the third mechanism, adaptive thinking, were small, they were strongly associated with outcomes demonstrating the importance of a cognitive-behavioral approach in treating college students with ADHD.     

Hoarding Disorder and a Systematic Review of Treatment with Cognitive Behavioral Therapy

Until recently, compulsive hoarding has been treated as a type of obsessive-compulsive disorder with mixed results. Little research exists on the efficacy of behavioral interventions specifically designed to treat hoarding disorder, and most existing research is limited with regard to the numbers of participants, their ethnic and cultural diversity, and study replication; therefore, the generalizability of findings is limited. This article reviews the prevalence of hoarding disorder, cognitive behavioral therapy treatment approaches, and measurement of symptoms. A systematic review compares the efficacy of various CBT methods, with particular attention to comparing therapy that is traditionally used to treat OCD with those designed specifically to treat hoarding disorder. Only clinical studies using CBT interventions designed to treat hoarding associated with OCD or hoarding disorder were included. Studies included participants of all ages, and articles were published in peer-reviewed journals. Case studies were excluded. After a comprehensive search and removing duplicates from databases and references, 65 articles were reviewed, of which 12 met criteria for review. Preliminary results demonstrate improvement in hoarding symptoms with CBT interventions that are both for OCD and those designed to specifically treat hoarding disorder; however, when compared to each other, the efficacy of these treatments is inconclusive, thus more research is needed.     

A Review of Factors that Promote Resilience in Youth with ADHD and ADHD Symptoms

The vast majority of research on youth with ADHD has focused on risk factors and describing the types of impairment individuals with ADHD experience. However, functional outcomes associated with ADHD are heterogeneous, and although many youth with ADHD experience significant negative outcomes (e.g., school dropout), some are successful in multiple domains of functioning (e.g., pursue and graduate college). There is a growing body of literature supporting the existence of factors that protect youth with ADHD from experiencing negative outcomes, but there is no published synthesis of this literature. Accordingly, the goals of this review are to conceptualize risk–resilience in the context of ADHD using a developmental psychopathology framework and to systematically review and critique evidence for promotive and protective factors in the context of ADHD. The literature search focused specifically on resilience in the context of ADHD symptoms or an ADHD diagnosis and identified 21 studies, including clinic, school, and community samples. Findings of promotive and/or protective factors are summarized across individual, family, and social–community systems. Overall, we know very little of the buffering processes for these youth, given that the study of promotive and protective factors in ADHD is in its infancy. The strongest evidence to date was found for social- and family-level systems. Specifically, multiple longitudinal studies support social acceptance as a protective factor, buffering against negative outcomes such as poor academic performance and comorbid depressive symptoms for youth with ADHD. There was also compelling evidence supporting positive parenting as a promotive factor. In terms of individual-level factors, positive or modest self-perceptions of competence were identified as a promotive factor in multiple studies. Future directions for research that will catalyze the study of resilience with ADHD are provided, and the potential for targeting protective mechanisms with intervention and prevention is discussed.     

Evaluating the Effectiveness of a Group CBT for Parents of ADHD Children

Improvements in parenting skills do not necessarily lead to improvements in child and parent outcomes for children with attention deficit and hyperactivity disorder (ADHD). Cognitive factors such as parental cognitions and parenting self-efficacy may influence such outcomes. Clinical research on the effects of cognitive-behaviour therapy (CBT) on parental cognitions, parenting self-efficacy and mental health in Chinese parents of children with ADHD is lacking. This quasi-experimental study intended to assess the effects of a culturally attuned group CBT treatment on the mental health and quality of life of Chinese parents aged 26–58 years, with children with ADHD in Hong Kong. Participants in the experimental group received group CBT and standard treatment and their counterparts in the control group received standard treatment. Primary outcome variables of mental health and quality of life and process variables including parenting stress, parenting efficacy and dysfunctional attitudes were measured at baseline, post-treatment and 3-month follow-up. Data were analysed using 2?×?3 ANCOVAs, Cohen’s d statistics and multiple mediation analyses. Group by time interactions were found for most outcome variables. Effect size statistics indicated that group CBT had small to moderate effects on most outcome variables at post-treatment and follow-up assessments. The effect of CBT on mental health was mediated by the reduction in parenting stress and the effect of CBT on quality of life was mediated by the reductions in parenting stress and dysfunctional attitudes. Given its potential benefit, it is worth considering incorporating this group CBT programme into interventions for Chinese parents with ADHD children.     

Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms

The purpose of the present study was to examine the potential efficacy, patient acceptability, and feasibility of a novel, cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. Thirty-one adults with ADHD and stable psychopharmacology for ADHD were randomized to CBT plus continued psychopharmacology or continued psychopharmacology alone. Assessments included ADHD severity and associated anxiety and depression rated by an independent evaluator (IE) and by self-report. At the outcome assessment, those who were randomized to CBT had lower IE-rated ADHD symptoms (p < .01) and global severity (p < .002), as well as self-reported ADHD symptoms (p < .0001) than those randomized to continued psychopharmacology alone. Those in the CBT group also had lower IE-rated and self-report anxiety (p's < .04), lower IE-rated depression (p < .01), and a trend to have lower self-reported depression (p = .06). CBT continued to show superiority over continued psychopharmacology alone when statistically controlling levels of depression in analyses of core ADHD symptoms. There were significantly more treatment responders among patients who received CBT (56%) compared to those who did not (13%) (p < .02). These data support the hypothesis that CBT for adults with ADHD with residual symptoms is a feasible, acceptable, and potentially efficacious next-step treatment approach, worthy of further testing.     

Introduction to special series on college students with ADHD: psychosocial issues, comorbidity, and treatment

Increasing empirical attention has been focused on college students with ADHD in recent years. In this special series, five studies are included that address psychosocial issues, comorbidity, and treatment of college students with ADHD. The nature and results of each study are briefly described. This special series of articles significantly advances our knowledge of critical issues with respect to psychosocial functioning, alcohol/substance use, comorbidity, and treatment of ADHD in college students.     

Interventions to Address the Academic Impairment of Children and Adolescents with ADHD

There exists a strong link between ADHD and academic underachievement. Both the core behavioral symptoms of ADHD and associated executive functioning deficits likely contribute to academic impairment. Current evidence-based approaches to the treatment of ADHD (i.e., stimulant medication, clinical behavior therapy and classroom behavioral interventions) have demonstrated a robust impact on behavioral variables such as attention and disruptive behavior within classroom analogue settings; however, their efficacy in improving academic outcomes is much less clear. Although surprisingly few treatment outcome studies of ADHD have attempted to incorporate interventions that specifically target academic outcomes, the studies that are available suggest that these interventions may be beneficial. The state of the treatment literature for addressing academic impairment in children and adolescents with ADHD will be reviewed herein, as well as limitations of current research, and directions for future research.     

Engagement With Personalized Feedback for Emotional Distress Among College Students at Elevated Suicide Risk

Depression and suicidal ideation have substantially increased among college students, yet many students with clinically significant symptoms do not perceive their distress as warranting mental health services. Personalized feedback (PF) interventions deliver objective data, often electronically, comparing an individual’s reported symptoms or behaviors to a group norm. Several studies have shown promise for PF interventions in the context of mood and depression, yet little is known regarding how, and for whom, mood-focused PF interventions might be best deployed. The primary aim of this study was to examine the sociodemographic, clinical, and treatment-seeking factors associated with reviewing PF reports on emotional distress among college students (N = 1,673) screening positive for elevated suicide risk and not receiving mental health treatment. Results indicated that PF engagement was greatest among those with higher depression scores, and those reporting privacy/stigma concerns as barriers to treatment. Sexual minority students were more likely to review their PF than heterosexual students. Taken together, PF interventions may be a useful tool for engaging those with greater clinical acuity, and those hesitant to seek in-person care. Further research is warranted to examine the circumstances in which PF interventions might be used in isolation, or as part of a multitiered intervention strategy.     

A conceptual model of child psychopathology: implications for understanding attention deficit hyperactivity disorder and treatment efficacy

Highlights the desirability of using a theoretical framework for guiding the design and evaluation of therapeutic interventions for children with attention deficit hyperactivity disorder (ADHD). A general conceptual model is introduced and used to evaluate ADHD treatment outcome research. Treatments designed to target the substrate level (pharmacological interventions) result in broad, robust improvement in both core and peripheral areas of functioning. Those targeting hypothesized core features of the disorder (i.e., attention, impulsivity-hyperactivity) produce corresponding improvement in core and peripheral outcome measures with the exception of studies employing cognitive-behavior therapy. Those targeting peripheral features of the disorder effect change only in corresponding peripheral areas of functioning. Implications for clinical practice are discussed, and an alternative conceptual model of ADHD is introduced and compared with existing models.     

The relationship between ADHD symptoms and driving behavior in college students: The mediating effects of negative emotions and emotion control

Previous research has shown a relationship between attention deficit-hyperactivity disorder (ADHD) symptoms and driving anger and adverse driving outcomes. Moreover, adults with ADHD symptoms express their emotions in more aggressive ways, indicating a lack of emotion control. The present study surveyed 246 college students to examine the relationship among ADHD symptoms, negative emotions, emotion control, and driving anger and safe driving behavior. Mediating effects of negative emotions and emotional control on the relationship between ADHD symptoms and self-reported driving anger and safe driving behavior were also examined. Both negative emotions and emotion control were significant mediators of the relationship between ADHD symptoms and driving anger, but not safe driving behavior. Mediation was stronger for ADHD-Hyperactive/Impulsive symptoms than for ADHD-Inattention symptoms. These results may provide some insight on how to design training programs for individuals with ADHD symptoms to increase driving safety.     

The relationship of compliance with inattention and hyperactivity/impulsivity

The aim of the study was to investigate the relationship between Attention Deficit Hyperactivity Disorder (ADHD) inattention and hyperactivity/impulsivity symptoms in predicting compliance. It was hypothesised that inattention symptoms are a better predictor of compliance than hyperactivity/impulsivity. There were two different groups of participants: 367 college students (both males and females) and 89 male prisoners. All participants had completed the Gudjonsson Compliance Scale (GCS) and the DSM-IV-TR (Screening) Checklist for adult ADHD symptoms. Significant correlations emerged between compliance and ADHD symptoms, but the correlations were higher for inattention than hyperactivity/impulsivity among both samples. This was confirmed by multiple regression analyses (hierarchical), which showed that the variance in compliance explained by ADHD inattention versus hyperactivity/impulsivity symptoms increased from 2% to 8% for college students and 8% to 24% for prisoners after entering inattention into the model (hyperactivity/impulsivity was entered first in the regression models). The findings suggest that inattention is a more powerful predictor of compliance than hyperactivity/impulsivity. This is a novel and an important finding.     

Co-occurring Mental Health Problems and Peer Functioning Among Youth with Attention-Deficit/Hyperactivity Disorder: A Review and Recommendations for Future Research

It is well established that children and adolescents with attention-deficit/hyperactivity disorder (ADHD) frequently experience co-occurring mental health problems in addition to difficulties in their peer relationships. Although substantial research has focused on the extent to which peer functioning contributes to subsequent co-occurring mental health problems, much less research has considered how co-occurring mental health problems affect peer functioning domains. Therefore, the purpose of this review is to examine the effect of co-occurring mental health problems on the peer functioning of youth with ADHD. The impact of co-occurring externalizing (i.e., oppositional defiant disorder, conduct disorder) and internalizing (i.e., anxiety, depression) symptoms are reviewed, with a focus on whether these co-occurring symptoms exacerbate, attenuate, or have no effect across peer domains of social skills/competence, peer status, and friendship among youth with ADHD. Drawing from a developmental psychopathology framework, this review then draws attention to relevant causal processes and developmental cascades (including social-cognitive, affective, and family and parenting factors) in offering promising avenues for future work.