- The neural structures underlying executive functioning are among the latest to mature, which means that most college students spend the majority of their time in college with an executive system under construction.
 - A key process in this maturation, myelination, is the process in which the neural axons are encased with a fatty sheath that facilitates their speed of neural impulse transmitting. Until this process of myelination is complete, emerging adults are more vulnerable to errors in self-regulation, especially when the task demands are high, which is exactly what is happening to college students with ADHD.

Executive Function Development

 - MRI results indicate that myelination of the dorsal lateral prefrontal cortex (DLPFC) continues throughout the early twenties. The DLPFCi s particularly involved in response inhibition and planning—core areas of executive functioning deficit among many individuals with ADHD.
 - Diffusion Tensor Imaging (DTI) data showed that myelination of the frontostriatal circuit continue to improve through the age of 21 in tasks involving response inhibition, interference control, set shifting,  and working memory.
 - All the tasks described above are part of the impaired areas of the "cool" executive functions of ADHD. The late maturation of brain tissues related to them implies a developing and immature stage of such functions among college students with ADHD.

"Cool" Executive Functions

 - Neuroimaging research suggests that adolescents show greater activity than adults in the nucleus accumbens, a brain area related to difficulty in inhibition and responses to delayed rewards. However, more researches using fine scientific strategies such as the C-DT behavioral paradigm should be conducted with emerging adults as participants to figure out the relationship between this area and ADHD among college students.
 - Questionnaire-based investigations have suggested that the development of long-term reward motivation and the ability to plan and anticipate for future events may continue throughout emerging adulthood.
 - Further behavioral and neuroimaging research using active reward contingencies is needed in order to better understand the maturation of delay aversion throughout emerging adulthood.


"Hot" Executive Functions

 - Researches have shown that socio-emotional context plays a powerful role in decision-making processes among adolescents and emerging adults. Under contexts of high socio-emotional arousal (i.e.peer existence), the executive function system of adolescents and emerging adults may be overwhelmed by their motivational (reward-seeking) system.
 - This may lead to a decreased ability in making reward-related decisions and regulating behavior in high-demand contexts.
 - With the high degree of social interacted needed in most college settings, the effects of such socio-emotional contexts becomes particularly profound. For those with ADHD, this brings another difficulty for them to cope with college life and study, both of which require high level of decision-making and self-regulating abilities.

Socio-Emotional Context 

 - For most students who experience the shift into emerging adulthood during their college, this experience brings the a marked loss of parental supervision and structure, and a corresponding dramatic increase in independence in academic work, social activity, substance use, and daily life rhythms. This new environment demand high organizational skills and long-term planning, while at the same time provides more immediate, short-term rewards. Thus, executive demands increase just as contextual support for effective executive control decreases.
 - For college students with ADHD, these increased demands on executive control occur at a time of ‘‘double deficit’’ in self-regulation. 
 - First, individuals with ADHD tend to have poorer executive functioning and a stronger aversion to delay in reward than those without ADHD.
 - Second, their executive functioning and motivational systems are not yet fully mature and are particularly susceptible to the effect of high socio-emotional arousal.
 - Thus, college students with ADHD are more susceptible to executive failures in college than their peers do. This gives the implication that effective intervention for ADHD among college students must lean more heavily on moderating the self-regulation demands of the environment, including increasing external support and decreasing challenging contextual factors.

"Double Deficit" in Self-Regulation

The transition from adolescence to adulthood involves important biological and sociological changes. For students with ADHD, such changes may impose a "double deficit" on them in response inhibition, long-term reward motivation, and self-regulation. This provides explanations on why college students with ADHD is a special group of subjects to study and what psychological treatment may be the most efficient for this population.


Colby College

According to the APA, 3-7% of school-age children have ADHD, and many display significant symptoms throughout adolescence. However, there is little known about the symptomology of ADHD in adolescence and adulthood, particularly in college-aged populations. This article is designed to summarize major research findings about ADHD in college-aged populations, including prevalence of symptoms, psychological functioning, and potential influence on academic performance. Findings suggest college students with ADHD are at greater risk for academic and psychological difficulties, but these findings are merely preliminary.

ADHD in College Students

Fleming, A. P., & McMahon, R. J. (2012). Clinical Child and Family Psychology Review, 15(4), 303-329. https://doi.org/10.1007/s10567-012-0121-z 

Developmental Context and Treatment Principles for ADHD Among College Students 

- Prior to the 1970s, ADHD was believed to be a childhood disorder that was outgrown with the onset of puberty. 
- Longitudinal research suggests that the majority of children and adolescents diagnosed with ADHD display symptoms into adulthood.
- It is estimated that ADHD symptoms affect 2-4% of the college student population.

The purpose of this review is to summarize research findings of ADHD in college student populations, including:
- The prevalence of ADHD symptoms in this population.
- The results concerning the psychological and neuropsychological functioning of college students with ADHD.

ADHD in College Students: Introduction

- Students with ADHD are not required to report to student disability support services, therefore the actual number of college students with ADHD is speculative.
- In general, approximately 25% of students receiving disability support services receive support for ADHD, increasing substantially since 1975.
- In a preliminary study of the percentage of college students who report clinically significant levels of ADHD symptoms, findings suggested 7-8% of participants experience significant ADHD symptoms.
- Collectively, studies suggest that approximately 2-8% of college students self-report clinically significant symptoms associated with ADHD, although these numbers do not reflect the actual percentage of college students with documented ADHD.

ADHD in College Students: Results: Prevalence of ADHD and ADHD Symptoms in College Students

Academic Performance:
- Preliminary studies suggest that college students with ADHD tend to have significantly lower GPAs, and report more academic problems than their neurotypical counterpart.
- College students with ADHD are more likely to be on academic probation, and are less likely to attend and graduate from college. 
- The underlying factors that contribute to poorer academic performance in college students with ADHD  are poorly understood, but may be related to impaired organizational skills, study skill deficits, deficits in executive functioning, and other cognitive deficits.
- Students who self-reported high symptoms of ADHD used significantly fewer academic coping behaviors, were less organized, less methodical, and procrastinated significantly more.
- Not all studies, however, indicate that college students with ADHD are at an increased risk for academic problems, indicating contradictions in preliminary research.

Psychological Functioning:
- The findings on psychological functioning have been fairly inconsistent, with some studies reporting that they experience greater psychological distress, and others not supporting these findings, indicating additional contradictions.
- One study suggests that students with ADHD reported other comorbid disorders, such as depressive disorders, anxiety disorders, substance dependency/abuse disorders, or eating disorders.
- However, a different study suggests that, although students with ADHD had significantly lower GPAs, they did not differ from their neurotypical counterparts with regard to psychosocial functioning.

ADHD in College Students: Results: Academic and Psychological Functioning

- Similar to other areas of research with college students with ADHD, the literature concerning neuropsychological functioning is sparse.
- One study indicated that contrary to popular belief that those with ADHD have superiors divided attention skills, college students with ADHD and their neurotypical counterpart performed similarly on tasks of divided attention performance.

Neuropsychological functioning in college students with ADHD symptoms:
- Several studies have compared the neuropsychological functioning of college students who self-report high and low ADHD symptoms, many of which reveal very little significant results.
- In summary, little information is available concerning the neuropsychological functioning of college students with ADHD.
- Findings are mixed with respect to performance on specific neuropsychological tests, and additional studies with larger sample sizes are needed to further explore this topic.

ADHD in College Students: Neuropsychological Findings

Although the empirical study of ADHD in a college student population is in “relative infancy,” this particular review supports several tentative conclusions:
- Approximately 2-8% of college students in the US report clinically significant levels of ADHD symptoms, and the prevalence of these symptoms vary across genders and fluctuates depending on the criteria for clinical significance.
- There is preliminary evidence that self-reported symptoms vary across countries, but these are the results of a single study.
- It is unclear how many college students with disabilities have diagnosed ADHD, although preliminary estimates place this figure at about 25%, and the number of students with ADHD is likely to vary significantly across universities.
- College students with significant ADHD symptoms obtain a lower GPA and are less likely to graduate than their neurotypical peers.

Equivocal findings have been found regarding the psychological functioning of college students with significant ADHD symptoms.

Conclusions based on the available literature (as of 2006) are tempered by the small number of studies that have been conducted as well as significant limitations of those investigations that have been completed.

ADHD in College Students: Summary and Future Research Directions

Approximately 6% of first-year college students report having been diagnosed with ADHD in their life. Students with ADHD may be more susceptible to certain risk factors that could potentially affect their academic performance, but the current literature is limited on just how much of an effect it has. The existing longitudinal studies on ADHD follow children into adulthood, but tend to neglect college-age people with ADHD, and the studies do not explore the long-term academic impact of a diagnoses. 

This longitudinal study follows college students with and without an ADHD diagnosis over the course of four years, to explore their academic performance trajectories, as well as identifying predictors of academic performance over time to inform future intervention development. Findings suggested that college students with ADHD obtained significantly lower GPAs compared to their non-ADHD peers, and in addition, only a few predictors of academic outcomes for students with ADHD were identified, including parent educational attainment and receipt of academic support services.

Academic trajectories of college students with and without ADHD: predictors of four-year outcomes

Research on ADHD in college students began in the 1990s and has been steadily increasing in recent years. Accumulating research suggest that college students with ADHD experience less academic success and greater psychological and emotional difficulties, and use substances at higher rates. However, conclusions drawn from this body of research may not be representative of the wider population of students with ADHD. This literature review expands upon the growing body of research on ADHD in college students, and touches upon the results of existing studies.

What do we really know about ADHD in college students?

Procrastination is often acknowledged in therapeutic treatment of ADHD, but it is not officially seen as an ADHD-related symptom. As a result, little is known about the role of procrastination in symptomology of ADHD. This study aims to explore the relationship between procrastination and ADHD-related symptoms of inattention, hyperactivity, and impulsivity in undergraduate college students. Results indicated that only inattention was correlated with general procrastination, as well as susceptibility to temptation.

The relation between procrastination and symptoms of attention-deficit hyperactivity disorder (ADHD) in undergraduate students

 - College students with ADHD tend to show lower social skills and social adjustments than peers matched on age, gender, and GPA.
 - Inattentive symptoms among male college students have been found to be associated with delayed dating onset, lower comfort and assertiveness in heterosocial situations, and lower ratings from female classmates
 - Students with ADHA are evaluated as more ‘‘confrontive’’ and ‘‘aggressive,’’ more independent, less rule-focused, and less influenced by corrective feedback by their peers.
 - College students with ADHD also report poorer parent-child relationships.
 - Some research show that increased contact with students with ADHA can raise their peers' rating on those individuals, which implies the possible efficiency of peer normalization.
 - Negative judgements may result from negative social experiences college students get from the ADHD peers, as numbers of such comments grow over time, highlighting the importance of early intervention.

ADHD in College Students: Results: Social Functioning

 - College students with ADHD report lower confidence in their own career decision-making ability and lower job performances. 
 - Main areas of impairment include: (1) performance of assigned work, (2) management of daily responsibilities, and (3) management of time and work-related deadlines.
 - Interventions targeted at improving students' academic functioning may also be helpful in improving their occupational functioning.

ADHD in College Students: Results: Occupational Functioning



 "Cool" executing functioning:
 - Students with ADHD show poorer working memory performance than normal controls, which is also associated with lower GPAs. However, the same relationship does not show in response inhibition or divided attention, suggesting that cool’’ executive function deficits contribute to ADHD-related impairment in some, but not all, college students.
 - In addition, only about 50 % of adolescents and adults with ADHD show impaired performance on tests of response inhibition, further decreasing the likelihood of this pathway alone to count all cases of ADHD among college students.
Hot" executive functioning:
 - Further research is needed to clarify the connection between delay aversion and ADHD-related functional impairment among emerging adults and adults.


ADHD in College Students: Relation to the etiology of ADHD

ADHD in College Students: Developmental Context for ADHD in College

 - The unique developmental and contextual challenges for college students with ADHD, their similarity to both adults (independent of external control) and adolescents (a still-maturing executive function system and heightened vulnerability to the effects of social-emotional arousal on decision making) suggest the need of an intervention uniquely tailored for this population.
 - Although stimulant medication is an effective treatment for ADHD, they are intolerable or ineffective for up to 50% of adults with ADHD, and most adults who do respond to medication still experience significant deficits in executive control and other areas of functioning.
 - Researches suggest that psychosocial interventions are feasible, acceptable, and decrease core symptoms and/or functional impairment among adults who use stimulant medication and those who do not. Leveraging contextual support also seems to be an important component of effective intervention with college students.

ADHD in College Students: Possible treatments

 - This section discusses some intervention targets along with corresponding treatment principles/approaches for each target. Due to the lack of treatment development efforts in this area, it also proposes some feature research directions for ongoing investigations.
 - A principle-based approach in which assessment of key proximal behavior targets and key underlying areas of deficit guides the application of appropriate interventions may be most useful to flexibly respond to the varied presentations in ADAD within college students.

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