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Diagnosing ADHD

What do these college-bound students have in common?

Jan never did any homework while attending her large public high school, but she was bright and had an excellent memory. Her teachers and parents often said things to her like, “You’re so smart. If only you would work harder, you could be the top student in your class.” Nonetheless, she was able to get good enough grades to be accepted into a highly ranked large state university.

Norah was an artistic and forgetful girl whose room was always a disaster. She did her homework with other classmates or her older sister, who helped her stay on task. She got excellent grades at her small all-girls religious school. She was accepted into a prestigious private university.

Ned always turned his homework in late, but the teachers in his small private school made allowances because he participated so well in class. He had a high grade point average, outstanding test scores and was accepted into an Ivy League university.

Since [kids with inattentive ADHD] don't themselves realize that they have an actual deficit, they can't explain what's going on.

All of these students had Attention Deficit Hyperactivity Disorder, and had had it from childhood, although it was never officially diagnosed. They had mostly inattentive symptoms rather than the more familiar pattern of hyperactivity and impulsivity.

Students with the hyperactive type of ADHD are the ones you commonly think about when you hear the diagnosis of ADHD. They fidget and squirm in their seats, talk nonstop and are in constantly in motion. They are impulsive and act without regard for consequences. Thus, these students will cause enough disruption at home or school to get their condition diagnosed way before college.

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Kids with inattentive ADHD may not be noticed by teachers. They have difficulty focusing but also have innate deficits in what's called "executive functioning," which involves skills such as organizing, planning complex actions and being able to look forward and anticipate consequences. They might be easily distracted, miss details and forget things. They also have difficulty processing information as quickly and accurately as others.

When children with inattentive symptoms face situations that are difficult and can't figure out a way to manage it, they tend to shut down and just avoid the situation. They may feel too ashamed to ask for help. Since they don't themselves realize that they have an actual deficit, they can¹t explain what's going on.

People are often surprised to hear that ADHD can be undetected until the college years, but it happens much more often than you'd think. Elementary and high schools provide significant structure and support so students with milder types of ADHD can succeed academically despite their deficits. In contrast, the college environment provides them with very little structure and accountability.

In high school, classes are held every day. They are small enough so that teachers know each student. The deadlines for homework assignments are short, and students get constant feedback about how they are performing. Parents are notified if the student begins to slip, and remedial action can be taken.

It¹s much easier for students to fall between the cracks when they get to college. Freshmen frequently take large lecture courses, where attendance is not taken. They spend much less time attending classes compared to high school, so they need to be able to structure their time in between classes more independently and effectively.

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In certain classes, grades may hinge on just a few exams. In other classes, students may be given weeks to read large volumes of material and write long papers that will determine most of their grade. Therefore, students with ADHD can and often do procrastinate to a much greater degree than they could get away with in high school.

The first information the parent may have about a child¹s school problems often comes when the child arrives home ... with news that he's on academic probation.

Parents of college students are rarely notified when their children are struggling academically. Privacy laws prevent colleges from sending grades home to parents without the student's permission, even though the parents are footing the tuition bills. Thus, the first information the parent may have about a child¹s school problems often comes when the child arrives home at the end of the first or second semester with news that he's on academic probation.

If you recognize your child in the above vignettes, the first step is to learn more about ADHD. You can start by checking out the CHADD (Children and Adults with Attention Deficit Hyperactivity) website. A good book to look at is Driven to Distraction by Edward M. Hallowell.

Then consider having your child evaluated by a psychiatrist or behavioral pediatrician who specializes in the disorder, before he leaves for school. If he has the diagnosis, you can discuss the type of supports he needs, including medications, counseling and perhaps extra support from his school.

When I see such students, I start with helping them understand the way their brain functions. By the time they get to my office, they and their parents can be quite demoralized, frustrated and angry with each other. Understanding that their child is not “lazy, crazy or stupid,” can go a long way to ease tensions and build self-esteem.

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The next step is to help the student learn how to manage their disorder in a college setting. They may need to take medications such as stimulants. They do better with smaller classes and assistance like tutoring. Many colleges these days have learning centers where they can get help.

But no matter how much you try to avoid problems, inattentive ADHD often doesn’t show up until after a semester of failure. This can’t always be prevented, despite your best efforts.

If it happens, don’t panic. As I tell my patients, you are gathering data about yourself, so everything you go through gives you a better idea about what supports you need in order to function as best you can.

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