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ow! Look at that! the nursing student exclaimed upon seeing her postpartum patients large hemorrhoids. The student was immediately escorted from the patients room by her instructor and she received a severe reprimand for making inappropriate, unprofessional comments in front of a patient. How could she be so insensitive and impulsive? Comments such as these and other unpredictable, unreliable behaviors placed this student in jeopardy of failing her clinical rotation. In a follow-up counseling session, the student revealed that she had attention deficit hyperactivity disorder (ADHD). Although she was in good academic standing in her course work, her behavior pattern made her appear weak and not bright. Her written work was sloppy and unorganized; she needed the maximum amount of time allowed for a paperand-pencil test; would interrupt others speaking in class; or would lay her head down on her desk when bored. At age 21, the student continued to receive prescribed Ritalin, but she didnt like to take it: Its not who I am when Im on Ritalin. Im not me. This true scenario typifies the efforts of college-age students who have struggled through their academic lives with a unique, but not rare, disorder.

The Nursing Student With Attention Deficit Hyperactivity Disorder

Martha J. Bradshaw, PhD, RN Judith Schurr Salzer, MS, MBA, RN

Attention deficit hyperactivity disorder (ADHD) in college-age students presents a complex challenge of coping with academic coursework, refining life skills, and addressing self-limitations. Behaviors that characterize ADHD are particularly problematic for nursing students, especially when the student has difficulty with behaviors that exemplify executive functioning. The authors discuss symptoms and treatments associated with the diagnosis of ADHD and evaluation and interventions for college students, based on guidelines from the Americans With Disabilities Act. Nursing faculty can facilitate academic success by recognizing the problem in nursing students and implementing strategies useful for selfmanagement of ADHD.

The Diagnosis of Attention Deficit Hyperactivity Disorder

Over half of the children diagnosed with ADHD have symptoms that persist into adolescence and adulthood.1 Because the problem has been so well identified and addressed, these children continue academic studies through adolescence and are showing up as college students with more frequency. The Diagnostic and Statistical Manual of Mental DisordersFourth

Edition (DSM-IV), published in 1994 by the American Psychiatric Association, provides specific diagnostic criteria for ADHD. Individuals must have had 6 or more of the symptoms listed for at least 6 months in either the inattention or hyperactivity-impulsivity category. The symptoms must be to a degree that is maladaptive and inconsistent with developmental level,2 must have been present before 7 years of age, and must be present in two or more settings, such as at school or work and at home. In addition, clear evidence of significant impairment in social, academic or occupational functioning2 must exist independent from any other psychiatric or developmental disorder. Symptoms typical of inattention include failure to pay attention to details, difficulty sustaining attention, failure to listen, failure to follow through, difficulty organizing, avoidance of sustained mental effort, losing things, distractibility, and forgetful-

ness. Figure 1 displays symptoms commonly seen in ADHD.

ADHD in Adults
There is agreement among experts that, for many people, ADHD is a lifelong problem with characteristics that change with the onset of maturity. It is estimated that 30% to 70% of those with ADHD in childhood will continue to experience symptoms that affect their functioning during adulthood.3-5 Attempts to establish
Authors affiliations: Associate Professor and Interim Chair, Department of Undergraduate Studies (Dr Bradshaw), Assistant Professor, Department of Advanced Practice (Ms Salzer), School of Nursing, Medical College of Georgia, Augusta, Ga. Corresponding author: Martha J. Bradshaw, PhD, RN, Associate Professor, School of Nursing, Medical College of Georgia, Augusta, GA 30912 (mbradsha@mail.mcg.edu).

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Hyperactivity Fidgeting Inability to remain seated Inappropriate running or climbing Difficulty in engaging in quiet activities High activity level Excessive talking Inattention Failure to pay attention to details Difficulty sustaining attention Failure to listen Failure to follow through Difficulty organizing Avoidance of sustained mental effort Losing things Distractibility Forgetfulness Impulsivity Blurting out answers Difficulty waiting turn Interrupting others Figure 1. Typical ADHD symptoms.

adapt to changing situations. Individuals who use executive functions well are more independent and purposeful in their behaviors, especially those who are goal-directed and are selfcontrolling.4 Typical skills associated with executive function that are needed in nursing students include patient care planning, setting outcome goals, flexibility, initiating and sustaining action, and accepting and monitoring feedback. Growing consensus supports the belief that a lack of inhibition may be the central feature of adult ADHD.7 The inability to control immediate responses and monitor behavior are primary indicators of a lack of inhibition. Adults with ADHD are often poorly organized and unable to prioritize appropriately, focusing on minor tasks while important ones are not completed.7 Clearly, given the subtlety and subjectivity of symptoms, assessment of the adult with possible ADHD is challenging.

college students, especially in a program with the rigor of nursing. Many college students with disabilities choose to complete 2-year rather than 4-year degrees, and even fewer of these students seek postgraduate degrees.3 Students with ADHD are at risk for academic failure in any program or major.6 Once in college, the level of selfresponsibility and independence increases the challenges for students with ADHD. Many lack the prerequisite knowledge, skills, and confidence needed for success. Thus they are at a high risk for failure and attrition. This problem was first addressed through the Individual Disabilities Education Act, Section 504, in 1975, and refined through the Americans With Disabilities Act in 1990.8 Figure 2 lists the typical deficits in college students with ADHD. These are categorized as academic and social/emotional deficits.

ADHD in the Nursing Student

The nursing student with ADHD emerges as a problem student when she or he has difficulty with course expectations: identifying and completing assignments, locating pertinent information in the course syllabus, following spoken directions, or remembering items from orientation. This same student may exhibit difficulties in the clinical experience, such as not being fully prepared, being unorganized, having difficulty setting priorities, or not retaining or applying relevant information to a specific patient. Faculty should be alert to the early signs and offer guidance or advisement early in the school term. In some cases, the student may merely have problems with time management or poor preparation skills. In other cases, the student may have ADHD, perhaps previously undiagnosed.

Learning Disorder or ADHD?

normative data on college students with ADHD revealed that the degree of typical symptoms is relatively modest, suggesting the hyperactivity, impulsivity, and other symptoms decline with age.6 However, using the same symptoms classification that is used with children causes the young adult college student to score below the level for a diagnosis of ADHD, while still having problematic symptoms. The hyperactivity demonstrated by children may be replaced by a generalized restlessness or difficulty relaxing during adulthood.7 Impaired academic achievement often is demonstrated in adults with ADHD as an inability to adequately sustain attention, organize study time, or manage distractions in the academic environment. Thus, the diagnosis of ADHD in some college students is missed. Cognitive deficits that persist into early adulthood predominately are in the area of executive functioning rather than in language and comprehension areas.3 Executive functions, which are mental activities involved with self-control and goal-directed behavior, enable an individual to engage in planning and problem solving and A diagnostic overlap between ADHD and learning disorder (LD) exists for several reasons. Each problem has similar symptoms and history, making the differential diagnosis difficult. ADHD is different from LD in that ADHD includes impulsive behaviors, related to neurological correlates, not under the students control. Some college/university guidelines regarding the identification of and assistance for students with learning disorders will usually have a definition for ADHD that is separate from learning disability (Randall Butterbaugh, personal interview, June 27, 2002). Faculty must determine their academic institutions definitions as they seek to identify a problem with the student and develop a subsequent plan.

College Students With ADHD

Young adults with ADHD are progressing in college at higher numbers than in previous years. This is in part due to early diagnosis and management of the problem, with academic guidance and thorough supervision. Students with ADHD constitute only a small percentage of upper division

Assessment, Findings, and Strategies

Colleges and universities should have systematic guidelines for identifying students with ADHD, in compliance with Section 504 and the Americans With Disabilities Act.8 These guidelines can serve as a basis for working with qualified students to bring about academic success. This success is

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Academic deficits Attention Planning Organization Memory Higher-order conceptual thinking Self-expression Social/emotional deficits Impulsivity Deficient friendship/social skills Shyness Conversational difficulties Temper and emotional instability Low self-confidence/self-esteem Figure 2. Typical deficits in college students with ADHD.

based on timely recognition and management of the students learning needs, as well as agreement by the student and faculty to participate in the prescribed plan. In general, learning assistance services are provided as long as there is documentation to support the students request. During the application process, the student may self-identify that she or he has a learning disorder or ADHD. The disability cannot have any bearing on admissions decisions. 8 Some students choose to self-identify once admitted. The most common assistance or accommodations provided are a quiet private room for tests, scheduled breaks during a test, or more time on objective exams or in completing assignments. A student cannot request these accommodations because she or he believes it will help with coursework; documentation of ADHD must be provided to receive this assistance. It is much more challenging for the student, faculty, and school when ADHD never has been identified, properly evaluated, or prescribed interventions implemented. Thus, the problem of ADHD may first be identified when a student is in academic jeopardy. This is unfortunate because valuable time and effort are lost, and the student often is discouraged about his or her ability to be successful in a health professions program. It is critical for faculty to be knowledgeable of characteristics of this problem (see Figures 1 and 2) and the appropriate steps to initiate interventions. Schools

or faculty groups should periodically review the institutions guidelines regarding identification of a student with ADHD and appropriate steps for academic support. In the event ADHD is suspected in a student, the instructor should begin the process carefully and with sensitivity to the students feelings. A student with a previously unrecognized and undiagnosed learning problem likely may receive such comments from an instructor with anger, denial, or dismay. The trust relationship between the faculty member and the student is now at risk. The instructor must proceed with care in advisement and encouraging the student to seek evaluation to confirm or rule out any learning disorder. Furthermore, the discussion about a possible learning disorder comes at a time when the student is having difficulty with nursing coursework, either in the didactic or clinical setting. The anxiety and defeat the student is feeling now is multiplied. Suggested openings in to the topic include, You really seem to be struggling in this class. Have you ever considered being evaluated to see if there might be additional strategies or techniques that you might be able to use to improve your course work? In those instances in which a faculty member speaks to a student about the possibility of a learning problem, the student may acknowledge a history of ADHD. Students may divulge having been fully evaluated and may know of a prescribed plan for learning assistance. Some students continue to receive Ritalin. However, a student may admit to not taking the Ritalin or not seeking academic assistance in hopes that the learning problem has been conquered or outgrown. Many students in situations such as these develop very successful coping and study skills that yield positive academic accomplishments in pre-nursing courses. Faced with the challenges in the nursing curriculum, students must adapt or learn new strategies for success. A previously undiagnosed ADHD problem may manifest itself after entry into a nursing program because external factors may influence or aggravate troublesome neurocognitive behaviors.6 Transferring into the nurs-

ing program, separation from family or social support, or schedule demands are influential factors that have a negative impact on previously successful coping skills, thus making the ADHD more evident. In addition, deficient executive functions impede the students ability to listen to a lecture, organize the information, and relate it to previously acquired knowledge. Faculty can work with the student on refining study skills or developing new ones, as well as pointing out the behaviors essential for professional nursing. Areas to emphasize are those critical elements common in executive functioning and professional nursing: resistance to distraction (ie, focusing on the task at hand), questioning and reading comprehension, self-regulation, and self-description.4 The student deserves formal guidance, as this is the only means by which the student can receive the type and level of assistance appropriate for the designated problem. Faculty are obligated to point out to a student that, in order to receive legitimate, effective assistance, the student must meet with the designated individual in the school, college, or university who will examine the students history, the learning disorder evaluation, and final diagnosis. The instructor can tell the student how to initiate the process, but only the student should initiate the evaluation process itself. If the instructor actually initiates the process, she or he is placed in a situation of liability, either by diagnosing a disability without proper training or violating a student confidentiality. The student should bring documentation of previous diagnostic evaluations and medical records that show related diagnoses and treatment, including medication. Some colleges and universities have student assistance programs with experienced personnel skilled at evaluating, advising, and diagnosing a range of student learning disorders, including ADHD. The recommendation from such program or testing center is sent to a designated individual in academic administration at the students school. These services may be less available at the community college level, which further compounds the problem for students and faculty. A student may choose to re-

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ceive testing and evaluation through a private source, such as a psychologist. The student and family may feel this provides more anonymity, but the cost is five or six times greater than the services provided through the university system. This evaluator follows the same procedure of sending a recommendation to university academic administration. The nursing student with ADHD needs ongoing support and consideration from faculty. If special testing procedures are to be implemented, faculty should provide the measures while bringing as little attention to the situation as possible. The student may need to spend time with a clinical instructor learning how to best organize clinical written work or how to better manage time in order to provide complete patient care. Often, some helpful suggestions from faculty will direct a student toward improved self-management skills.

Issues for Students With ADHD and Nursing Faculty

Initiating Academic Support
Timing is critical if the nursing student is going to be successful in coursework and clinical performance. Early self-identification and provision of an accommodation plan is ideal. Unfortunately, the problem may gain attention once the student fails one or two exams, or receives an unsatisfactory clinical evaluationany instance in which the student is at risk of failing the program. If the student then discloses a history of ADHD and initiates the process, the time from initial processing, through testing, evaluation, prescriptive plan, and return of recommendations to faculty can be lengthy. During this time, the students problem behaviors persist and the needed level of learning is not taking place. Additionally, the student carries the burden of guilt, discouragement, and uncertainty, which further affect learning and performance. Once faculty receive recommendations, a semesters worth of coursework may have been completed with minimal (or not successful) results. The faculty and school are under no obligation to the student prior to or without a diagnosis.

If a student who eventually receives a diagnosis of ADHD and accommodations are recommended fails a course during this process, the failing grade should be upheld. Individual deans and administrative faculty need to decide whether or not to allow the student to continue in the program, repeating the course and engaging in recommendations accordingly. Similarly, the student with a known diagnosis of ADHD who does not self-identify and take advantage of available accommodations has no recourse when academic difficulties, especially course failure, occur. The situation is the same for the student with a new diagnosis of ADHD who receives recommendations but does not seek assistance that is offered. Another interesting and challenging issue is the student who wishes to be tested and would comply with recommendations, but does not have financial means to pay for the extensive appraisal. A counselor knowledgeable about this process can help the student and family examine insurance benefits for this process, as part of mental health evaluation. Students who have health benefits provided through the Veterans Administration might qualify for this testing, based on specific criteria. Vocational rehabilitation also may pay for the evaluation.

chotherapy in addition to pharmacotherapy. With education about their disorder, students are often able to develop compensatory strategies. Making lists and using computerized schedules improves planning and organization. Clearing the desk or working surface from clutter and facing the desk away from a window or door decreases unnecessary distractions. Breaking projects down into pieces that are manageable and assigning a deadline to each piece increases the probability of success in completing the project.

Conclusion
It is imperative for the nursing student to receive timely, thorough, and appropriate assessment and diagnosis of any learning disability. Diagnostics used for the purpose of identifying processing deficits such as in ADHD should focus on executive functioning skills needed for nurses and nursing students. The treatment plan for a nursing student with ADHD should be individualized and include education about ADHD and consideration of pharmacotherapy, teaching cognitive strategies, and individual or group counseling. Personal accountability, timely and appropriate evaluation and advisement, and support from faculty will direct the college student toward becoming a successful professional nurse.

Interventions for ADHD

Treatment of adults with ADHD does not differ significantly from that of children. Stimulants are the most commonly used category of drugs, and drug therapy is typically used in conjunction with behavioral or psychotherapy. Adults with ADHD can benefit from learning about their disorder and how to develop self-management strategies.7 Education should include information on the increased risk of adults with ADHD for drug and alcohol dependence. Marital counseling, individual counseling, and self-help groups are often valuable in assisting individuals to modify problem behaviors and establish a more productive life-style. College students with ADHD are likely to benefit from cognitive-behavioral skills training and psy-

Acknowledgment
The authors thank Dr. Randy Butterbaugh, Director of Student Affairs, Medical College of Georgia and Dr. Margo Habiger, Liaison for Regents Center for Learning Disorders, University of Georgia, for the information they provided for the manuscript. References
1. Heilingenstein E, Conyers L, Berns A, Miller M. Preliminary normative data on DSM-IV attention deficit hyperactivity disorder in college students. J Am Coll Health. 1998;46(4):185-189. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. 3. Wolf LE. College students with ADHD

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and other hidden disabilities. Ann N Y Acad Sci. 2001;931:385-395. 4. Lesaca T. Executive functions in parents with ADHD. Psychiatric Times 2001; 18(11):4. Available at: http://www. psychiatrictimes.com/p011117.html. Accessed August 7, 2002. 5. Barkley RA, Murphy KR, Bush T. Time

perception and reproduction in young adults with attention deficit hyperactivity disorder. Neuropsychol. 2001;15(3): 351-360. 6. Heilingenstein E, Guenther G, Levy A, Savcino F, Fulwiler J. Psychological and academic functioning in college students with attention deficit hyperactiv-

ity disorder. J Am Coll Student Health. 1999;47(4):181-186. 7. Searight HR, Burke JM, Rottnek F. Adult ADHD: Evaluation and treatment in family medicine. Am Fam Physician. 2000;62(9):2077-2086, 2091-2092. 8. Americans with Disabilities Act P.L. 101336, Federal Register, 42 USC 12101: 1990.

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