ADHD Does Not Go Away When They Go to College

Thought that kid with ADHD with his frequent prescriptions and sassy attitude would get off your schedule when he got into college? Actually, he needs you and your advice even more now that he will be managing more on his own.

You are one of the important relationships in the patient’s life that it is usually better not to shake up – not with all the other changes happening after high school graduation. This is a scary time for him without his usual supports and scary for you as well in that you will have less contact with your patient, less direct feedback from parents and teachers, and lower overall ability to supervise (compared with your role with younger children and adolescents). All the good communication you should have developed over his childhood will now pay off as a higher level of trust is required and appropriate now that your patient is a young adult.

It is not just you who will be getting less feedback –students get less frequent feedback on their performance as well. Some might not realize that their symptoms interfered with their academic functioning until they see their grades at the end of first semester. They might think everything is great, in complete denial that their symptoms are not well controlled.

Managing medicines is tricky for them as well as for you. ADHD symptoms make it more challenging for these kids to remember to take their medication. I talk to them in advance about establishing a new routine that takes into account their varying class schedules, privacy, and medication theft concerns.

Recommend that they use a pill tray marked with days of the week and times, and fill it weekly, so they can remember which pills they have already taken or missed.

In addition, work with them to adjust their medication to their new schedules. In high school, kids with ADHD typically take a long-acting stimulant that covers 10 hours. In college, some days may start at noon and others at 7 a.m., and many run until 3 a.m. I have quite a few college kids who switch to short-acting stimulants to take advantage of greater dosing flexibility. That way, they can more effectively control when they study, eat, and sleep. Ensuring enough and regular sleep and eating is harder, but also critical to college success.

Also consider switching some college students to a medication formulation that is more difficult to snort or sell or give to other students. Forms that are more difficult to abuse include OROS controlled-release methylphenidate (Concerta, Ortho McNeil Janssen); lisdexamfetamine (Vyvanse, Shire Pharmaceuticals); atomoxetine (Strattera, Eli Lilly); extended-release guanfacine (Intuniv, Shire); and long-acting clonidine (Kapvay, Shionogi Pharma). Although OROS methylphenidate and lisdexamfetamine are first-line medicines for ADHD, these others may be useful and may keep a risk taker from getting into trouble.

I have a very frank and honest discussion with kids with ADHD before they leave for college. I tell them they have to protect their supply of medications. If someone else steals their pills or they give them away, I tell them I am not able to prescribe more. Kids take this seriously – if they do lose some of their medication, they come crawling into my office saying: "Please, you have to believe me. I lost four of them. Please let me have another prescription." I also address the very real risks for injury and death if someone for whom these medications were not intended takes them inappropriately. I tell them this is just one more of the big responsibilities of adulthood.

Help these kids with suggestions on safe and private storage of their medication. They may be sharing a bathroom and are almost certainly sharing living space in college, so they need a way to hide their stimulants or lock them up. For example, you can suggest they purchase a fake shaving cream can from a joke store, one that includes a hidden compartment on the bottom.

If you haven’t already, counsel your patients with ADHD about the enormous risks of driving without being on their medicine. The dangers are similar to those of driving while intoxicated with alcohol. That is a very sobering thought – automobile crashes are the No. 1 reason a young person dies in this country.

Interactions with alcohol and other substances that college students may use is another very real risk for patients taking stimulants for ADHD. Even excessive caffeine intake can be risky, as stimulant medication already increases the likelihood for cardiac arrhythmia.

Long-term studies now show that young adults appropriately treated for ADHD with medication are somewhat more likely to experiment with illegal drugs, but less likely to become addicted to them. Your patients should be accustomed to discussions with you about potential side effects, and this is one of them. The success orientation of most college students should help when counseling them about the potential social as well as physical problems of caffeine, alcohol, and illegal substances. And don’t forget to provide collegiate athletes with a letter about their medicines to avoid problems when they are drug tested.

Prepare your patients with ADHD for a greater need to organize their academic work in college. This can be tricky for them because ADHD interferes with executive functioning. And the older you are, the more of an executive you really need to be. A college student needs to organize his own class schedule, manage homework, and figure out how much time to dedicate to studying. A student with ADHD might be a "man of the moment" and not even consider studying on Monday for an examination for a class he has only on Fridays.

Kids with ADHD are likely to have made it into college with a lot more guidance (or nagging!) from parents or teachers about organization than average.

The good news is that many colleges now offer assistance with organization and study skills for freshmen. You can do a great service by suggesting they research which schools offer these accommodations before they apply and take advantage of these accommodations when they arrive. If formal support is not available, older students can be hired to help a freshman navigate the new challenges of college.

ADHD does not often "travel alone." Learning disabilities and mood disorders are the most common comorbidities.

It is unlikely that a new learning disability will be discovered during college. Most of your patients will already know if they are a slow reader or weak in math and have been helped in earlier parts of their education. College, in many ways, is more forgiving than high school because students have more flexibility to choose classes that align with their strengths.

Students may be unaware, however, that they can request front and center seating in lecture halls or classrooms to help them stay focused as well as extended time, tutoring, and a class scribe, recorded classes, or lecture note transcripts – great resources for kids with ADHD whether they have learning disabilities or not.

Monitor your patients with ADHD for new onset or worsening of the common comorbidities of mood disorders, particularly depression, anxiety, and tic disorders. The likelihood for these conditions to emerge continues to rise throughout adolescence.

Use a standard screening tool at each visit for college-age patients, one that looks for these mood disorders and any suicidality. The stress of college pressure and loneliness is hard on any kid but, combined with the academic weaknesses and predisposition to depression found with ADHD, can be fatal. I prefer an online instrument that patients can complete before coming home from college for a break, such as the CHADIS system.

Teenagers and young adults are more honest about providing potentially negative or sensitive information about themselves to a computer compared with a paper questionnaire, and especially compared with a face-to-face conversation with a doctor. Interestingly, they are more honest and elaborate more on risk behaviors when online, even though they know their physician is going to see the information.

If you are not in a good position to manage your college-aged patients yourself, help them transition to an adult care provider proficient in the management of ADHD. Family physicians often are a better choice than internists because they care for children and are more likely to have experience treating ADHD. But make this decision only if you must, as continuing your long term relationship and support can make a big difference at this delicate transition. Besides, you then get to see them grown up and share in their success!

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. Dr. Howard disclosed that she is cocreator of CHADIS. E-mail her.

Thought that kid with ADHD with his frequent prescriptions and sassy attitude would get off your schedule when he got into college? Actually, he needs you and your advice even more now that he will be managing more on his own.

You are one of the important relationships in the patient’s life that it is usually better not to shake up – not with all the other changes happening after high school graduation. This is a scary time for him without his usual supports and scary for you as well in that you will have less contact with your patient, less direct feedback from parents and teachers, and lower overall ability to supervise (compared with your role with younger children and adolescents). All the good communication you should have developed over his childhood will now pay off as a higher level of trust is required and appropriate now that your patient is a young adult.

It is not just you who will be getting less feedback –students get less frequent feedback on their performance as well. Some might not realize that their symptoms interfered with their academic functioning until they see their grades at the end of first semester. They might think everything is great, in complete denial that their symptoms are not well controlled.

Managing medicines is tricky for them as well as for you. ADHD symptoms make it more challenging for these kids to remember to take their medication. I talk to them in advance about establishing a new routine that takes into account their varying class schedules, privacy, and medication theft concerns.

Recommend that they use a pill tray marked with days of the week and times, and fill it weekly, so they can remember which pills they have already taken or missed.

In addition, work with them to adjust their medication to their new schedules. In high school, kids with ADHD typically take a long-acting stimulant that covers 10 hours. In college, some days may start at noon and others at 7 a.m., and many run until 3 a.m. I have quite a few college kids who switch to short-acting stimulants to take advantage of greater dosing flexibility. That way, they can more effectively control when they study, eat, and sleep. Ensuring enough and regular sleep and eating is harder, but also critical to college success.

Also consider switching some college students to a medication formulation that is more difficult to snort or sell or give to other students. Forms that are more difficult to abuse include OROS controlled-release methylphenidate (Concerta, Ortho McNeil Janssen); lisdexamfetamine (Vyvanse, Shire Pharmaceuticals); atomoxetine (Strattera, Eli Lilly); extended-release guanfacine (Intuniv, Shire); and long-acting clonidine (Kapvay, Shionogi Pharma). Although OROS methylphenidate and lisdexamfetamine are first-line medicines for ADHD, these others may be useful and may keep a risk taker from getting into trouble.

I have a very frank and honest discussion with kids with ADHD before they leave for college. I tell them they have to protect their supply of medications. If someone else steals their pills or they give them away, I tell them I am not able to prescribe more. Kids take this seriously – if they do lose some of their medication, they come crawling into my office saying: "Please, you have to believe me. I lost four of them. Please let me have another prescription." I also address the very real risks for injury and death if someone for whom these medications were not intended takes them inappropriately. I tell them this is just one more of the big responsibilities of adulthood.

Help these kids with suggestions on safe and private storage of their medication. They may be sharing a bathroom and are almost certainly sharing living space in college, so they need a way to hide their stimulants or lock them up. For example, you can suggest they purchase a fake shaving cream can from a joke store, one that includes a hidden compartment on the bottom.

If you haven’t already, counsel your patients with ADHD about the enormous risks of driving without being on their medicine. The dangers are similar to those of driving while intoxicated with alcohol. That is a very sobering thought – automobile crashes are the No. 1 reason a young person dies in this country.

Interactions with alcohol and other substances that college students may use is another very real risk for patients taking stimulants for ADHD. Even excessive caffeine intake can be risky, as stimulant medication already increases the likelihood for cardiac arrhythmia.

Long-term studies now show that young adults appropriately treated for ADHD with medication are somewhat more likely to experiment with illegal drugs, but less likely to become addicted to them. Your patients should be accustomed to discussions with you about potential side effects, and this is one of them. The success orientation of most college students should help when counseling them about the potential social as well as physical problems of caffeine, alcohol, and illegal substances. And don’t forget to provide collegiate athletes with a letter about their medicines to avoid problems when they are drug tested.

Prepare your patients with ADHD for a greater need to organize their academic work in college. This can be tricky for them because ADHD interferes with executive functioning. And the older you are, the more of an executive you really need to be. A college student needs to organize his own class schedule, manage homework, and figure out how much time to dedicate to studying. A student with ADHD might be a "man of the moment" and not even consider studying on Monday for an examination for a class he has only on Fridays.

Kids with ADHD are likely to have made it into college with a lot more guidance (or nagging!) from parents or teachers about organization than average.

The good news is that many colleges now offer assistance with organization and study skills for freshmen. You can do a great service by suggesting they research which schools offer these accommodations before they apply and take advantage of these accommodations when they arrive. If formal support is not available, older students can be hired to help a freshman navigate the new challenges of college.

ADHD does not often "travel alone." Learning disabilities and mood disorders are the most common comorbidities.

It is unlikely that a new learning disability will be discovered during college. Most of your patients will already know if they are a slow reader or weak in math and have been helped in earlier parts of their education. College, in many ways, is more forgiving than high school because students have more flexibility to choose classes that align with their strengths.

Students may be unaware, however, that they can request front and center seating in lecture halls or classrooms to help them stay focused as well as extended time, tutoring, and a class scribe, recorded classes, or lecture note transcripts – great resources for kids with ADHD whether they have learning disabilities or not.

Monitor your patients with ADHD for new onset or worsening of the common comorbidities of mood disorders, particularly depression, anxiety, and tic disorders. The likelihood for these conditions to emerge continues to rise throughout adolescence.

Use a standard screening tool at each visit for college-age patients, one that looks for these mood disorders and any suicidality. The stress of college pressure and loneliness is hard on any kid but, combined with the academic weaknesses and predisposition to depression found with ADHD, can be fatal. I prefer an online instrument that patients can complete before coming home from college for a break, such as the CHADIS system.

Teenagers and young adults are more honest about providing potentially negative or sensitive information about themselves to a computer compared with a paper questionnaire, and especially compared with a face-to-face conversation with a doctor. Interestingly, they are more honest and elaborate more on risk behaviors when online, even though they know their physician is going to see the information.

If you are not in a good position to manage your college-aged patients yourself, help them transition to an adult care provider proficient in the management of ADHD. Family physicians often are a better choice than internists because they care for children and are more likely to have experience treating ADHD. But make this decision only if you must, as continuing your long term relationship and support can make a big difference at this delicate transition. Besides, you then get to see them grown up and share in their success!

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. Dr. Howard disclosed that she is cocreator of CHADIS. E-mail her.

Thought that kid with ADHD with his frequent prescriptions and sassy attitude would get off your schedule when he got into college? Actually, he needs you and your advice even more now that he will be managing more on his own.

You are one of the important relationships in the patient’s life that it is usually better not to shake up – not with all the other changes happening after high school graduation. This is a scary time for him without his usual supports and scary for you as well in that you will have less contact with your patient, less direct feedback from parents and teachers, and lower overall ability to supervise (compared with your role with younger children and adolescents). All the good communication you should have developed over his childhood will now pay off as a higher level of trust is required and appropriate now that your patient is a young adult.

It is not just you who will be getting less feedback –students get less frequent feedback on their performance as well. Some might not realize that their symptoms interfered with their academic functioning until they see their grades at the end of first semester. They might think everything is great, in complete denial that their symptoms are not well controlled.

Managing medicines is tricky for them as well as for you. ADHD symptoms make it more challenging for these kids to remember to take their medication. I talk to them in advance about establishing a new routine that takes into account their varying class schedules, privacy, and medication theft concerns.

Recommend that they use a pill tray marked with days of the week and times, and fill it weekly, so they can remember which pills they have already taken or missed.

In addition, work with them to adjust their medication to their new schedules. In high school, kids with ADHD typically take a long-acting stimulant that covers 10 hours. In college, some days may start at noon and others at 7 a.m., and many run until 3 a.m. I have quite a few college kids who switch to short-acting stimulants to take advantage of greater dosing flexibility. That way, they can more effectively control when they study, eat, and sleep. Ensuring enough and regular sleep and eating is harder, but also critical to college success.

Also consider switching some college students to a medication formulation that is more difficult to snort or sell or give to other students. Forms that are more difficult to abuse include OROS controlled-release methylphenidate (Concerta, Ortho McNeil Janssen); lisdexamfetamine (Vyvanse, Shire Pharmaceuticals); atomoxetine (Strattera, Eli Lilly); extended-release guanfacine (Intuniv, Shire); and long-acting clonidine (Kapvay, Shionogi Pharma). Although OROS methylphenidate and lisdexamfetamine are first-line medicines for ADHD, these others may be useful and may keep a risk taker from getting into trouble.

I have a very frank and honest discussion with kids with ADHD before they leave for college. I tell them they have to protect their supply of medications. If someone else steals their pills or they give them away, I tell them I am not able to prescribe more. Kids take this seriously – if they do lose some of their medication, they come crawling into my office saying: "Please, you have to believe me. I lost four of them. Please let me have another prescription." I also address the very real risks for injury and death if someone for whom these medications were not intended takes them inappropriately. I tell them this is just one more of the big responsibilities of adulthood.

Help these kids with suggestions on safe and private storage of their medication. They may be sharing a bathroom and are almost certainly sharing living space in college, so they need a way to hide their stimulants or lock them up. For example, you can suggest they purchase a fake shaving cream can from a joke store, one that includes a hidden compartment on the bottom.

If you haven’t already, counsel your patients with ADHD about the enormous risks of driving without being on their medicine. The dangers are similar to those of driving while intoxicated with alcohol. That is a very sobering thought – automobile crashes are the No. 1 reason a young person dies in this country.

Interactions with alcohol and other substances that college students may use is another very real risk for patients taking stimulants for ADHD. Even excessive caffeine intake can be risky, as stimulant medication already increases the likelihood for cardiac arrhythmia.

Long-term studies now show that young adults appropriately treated for ADHD with medication are somewhat more likely to experiment with illegal drugs, but less likely to become addicted to them. Your patients should be accustomed to discussions with you about potential side effects, and this is one of them. The success orientation of most college students should help when counseling them about the potential social as well as physical problems of caffeine, alcohol, and illegal substances. And don’t forget to provide collegiate athletes with a letter about their medicines to avoid problems when they are drug tested.

Prepare your patients with ADHD for a greater need to organize their academic work in college. This can be tricky for them because ADHD interferes with executive functioning. And the older you are, the more of an executive you really need to be. A college student needs to organize his own class schedule, manage homework, and figure out how much time to dedicate to studying. A student with ADHD might be a "man of the moment" and not even consider studying on Monday for an examination for a class he has only on Fridays.

Kids with ADHD are likely to have made it into college with a lot more guidance (or nagging!) from parents or teachers about organization than average.

The good news is that many colleges now offer assistance with organization and study skills for freshmen. You can do a great service by suggesting they research which schools offer these accommodations before they apply and take advantage of these accommodations when they arrive. If formal support is not available, older students can be hired to help a freshman navigate the new challenges of college.

ADHD does not often "travel alone." Learning disabilities and mood disorders are the most common comorbidities.

It is unlikely that a new learning disability will be discovered during college. Most of your patients will already know if they are a slow reader or weak in math and have been helped in earlier parts of their education. College, in many ways, is more forgiving than high school because students have more flexibility to choose classes that align with their strengths.

Students may be unaware, however, that they can request front and center seating in lecture halls or classrooms to help them stay focused as well as extended time, tutoring, and a class scribe, recorded classes, or lecture note transcripts – great resources for kids with ADHD whether they have learning disabilities or not.

Monitor your patients with ADHD for new onset or worsening of the common comorbidities of mood disorders, particularly depression, anxiety, and tic disorders. The likelihood for these conditions to emerge continues to rise throughout adolescence.

Use a standard screening tool at each visit for college-age patients, one that looks for these mood disorders and any suicidality. The stress of college pressure and loneliness is hard on any kid but, combined with the academic weaknesses and predisposition to depression found with ADHD, can be fatal. I prefer an online instrument that patients can complete before coming home from college for a break, such as the CHADIS system.

Teenagers and young adults are more honest about providing potentially negative or sensitive information about themselves to a computer compared with a paper questionnaire, and especially compared with a face-to-face conversation with a doctor. Interestingly, they are more honest and elaborate more on risk behaviors when online, even though they know their physician is going to see the information.

If you are not in a good position to manage your college-aged patients yourself, help them transition to an adult care provider proficient in the management of ADHD. Family physicians often are a better choice than internists because they care for children and are more likely to have experience treating ADHD. But make this decision only if you must, as continuing your long term relationship and support can make a big difference at this delicate transition. Besides, you then get to see them grown up and share in their success!

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. Dr. Howard disclosed that she is cocreator of CHADIS. E-mail her.