Supporting ADHD Students in Higher Education
We need to talk about ADHD
As I'm writing this piece, it was only recently, on Monday 6th February 2023, that a parliamentary debate took place for the government to review the management and funding for ADHD assessments for both children and adults.
It’s part of the growing recognition of this neurodevelopmental condition and the potential impact and consequences of undiagnosed and unsupported ADHD. Support might include medication, therapy, education/workplace adjustments, social support and advocacy.
Last year, in April 2022, the UK Adult ADHD Network (UKAAN) published a consensus statement ‘to provide an informed understanding of the impact of ADHD on the educational (or academic) outcomes of university students and highlight an urgent need for timely access to treatment and management.’
This blog piece aims to increase awareness and understanding of the condition, and to share some work we’ve been doing at the University of Sheffield to support ADHD students.
What or who do you think of when you hear ADHD?
So, I'm a woman in my 40s of Chinese heritage, with a postgraduate education, working as a professional… might it surprise you that I also have ADHD?
As a lifelong condition, ADHD and its challenges can bite harder when faced with big transitions and major life events. Particularly if it’s gone under the radar in childhood. The more overt symptoms of intense external hyperactivity and impulsivity may be easier to spot by a teacher or a parent. Yet those children who have internalised hyperactivity (e.g. having a restless mind) or fall towards a more inattentive presentation (e.g. being a daydreamer and zoning out in class) are often missed. Pragmatically speaking they weren’t disrupting the rest of the class or household!
Dependent on the types and persistence of symptoms coupled with how they interfere or impair at least 2 areas of an individual’s functioning, a diagnosis of ADHD is currently categorised into 3 subtypes:
ADHD-PI, i.e. predominantly inattentive type where symptoms include disorganisation, distractibility, and forgetfulness
ADHD-PH, i.e. predominantly hyperactive type where symptoms include restlessness, fidgeting, difficulty remaining seated
ADHD-C, i.e. combined type where there's roughly an equal mix of inattentive and hyperactive symptoms
The term ‘ADD’ is now medically outdated, and ADHD can be viewed as a neurodivergent spectrum condition to describe the same underlying brain differences that can manifest as a range of symptoms that have varying degrees of severity.
Doesn’t everyone have a bit of ADHD?
ADHD symptoms are relatable to a lot of people. However, with ADHD, they are more intense, severe and occur more frequently. They have a significant impact on day-to-day functioning.
There is growing research highlighting structural and biochemical brain differences and genetic factors contributing to the ADHD brain vs a neurotypical brain. It’s a chronic condition and ways to manage difficulties associated with the symptoms are more effective with an understanding of these brain differences.
A deficit of attention?
There’s ongoing debate as to whether the term 'ADHD' - that is, attention deficit hyperactivity disorder -, accurately reflects the condition. It's a bit of a misnomer since it’s not so much a lack of attention, rather a difficulty in channelling often a vast amount of attention to tasks or situations in a proportionate and timely manner.
So, maybe not so much ‘Attention Deficit'.
Difficulty in directing attention or ‘mind-wandering’ can lead to: ‘hyperfocus’ on high interest subjects or tasks (think persistence and the ability to turn projects around or learn new subjects in a relatively short space of time while very little else can be attended to); ingenious lateral thinking; and spontaneous resourcefulness especially when faced with emergency situations.
On the flip-side it can feel impossible to direct attention to the growing mountain of low interest tasks and jobs which might include tangible, messy 'doom piles', i.e. the accumulation of objects or paperwork that become too overwhelming to deal with; as well as to day-to-day self care activities such as preparing meals and taking a shower.
Paradoxically it's often the case that ADHDers want to do certain tasks but can't. The struggle is real (and neuroscientifically based) when it comes to task initiation and the ability to switch between tasks.
What about ‘Hyperactivity’? This is often thought of as an externally visible symptom but in fact can also manifest internally, such as having a racing mind and having an internal sense of restlessness. It often comes with frequent spells of burn-out and shut-down, so during these times ADHD can seem quite the opposite of physical/external hyperactivity.
There can also be a misattribution of the term ‘Disorder’ to the character of the person e.g. ‘They’re disordered’, ‘I’m disordered’, rather than its clinical meaning of how a set of problems significantly impairs an individual’s daily life. I wonder if the stereotypical view of ADHD as ‘unruly, bad behaviour’ reinforces this misattribution.
The term 'ADHD' also doesn’t quite convey the challenges with a range of other executive functions such as working memory, prioritisation and emotional regulation; as well as sensory sensitivities.
And another thing - the neurobiological basis of the condition isn’t clear from the term ADHD; rather, it implies it’s a behavioural disorder which has implications for negative societal attitudes towards ADHD individuals with systemic knock-on effects such as (social) treatment/punishment.
When you’ve met one person with ADHD, you’ve met one person with ADHD
As ADHD intersects with an individual’s other characteristics, beliefs and experiences I believe that this can lead to different ways the condition presents, and how it’s then interpreted by the self and others (including medical professionals).
ADHD is highly heritable so if your parents are also ADHD, certain ways of being within the home might not feel as unacceptable compared to when you're 'out there.' These factors are additionally influenced by intra- and inter-cultural values, as well as systemic ones including overt and internalised social privilege: I’m looking at you capitalism, white privilege and patriarchy.
As a result, there’s likely an impact on how an ADHD person might respond to and manage the arbitrary rules, demands and expectations of a neurotypical world.
There is debate around pathologising neurodivergence because of how 'negative' symptoms might be exacerbated by constraints set by societal factors. If we frame a neurodivergence such as ADHD as a contextually driven condition, can we call it brain difference or a neurotype, rather than a clinical disorder?
As it stands, ADHD is a condition that presents very real challenges in our society for those affected. With diagnosis, there can be benefits of an explanation and validation for day-to-day difficulties as well as pathways for support and medication. With these in place, the outcomes and quality of life for an ADHD person has the potential to be much improved.
Hopefully, as we shift to greater awareness, education and research; we'll see positive and inclusive changes more broadly.
Unconscious bias
Access to assessment and healthcare is likely subject to unconscious bias notably in relation to racial and gender disparities. Studies indicate that children of colour are less likely to receive a diagnosis of ADHD and their symptoms may be taken to form a diagnosis of a ‘disruptive behaviour disorder’, that is, ‘bad behaviour’, which means these children might not access the right support and treatment, so are further marginalised and disenfranchised compared to their white counterparts.
Significantly, ADHD often presents differently in females and non-binary people compared with males (or, rather, the stereotypical presentation of ADHD in males). These are also populations where ADHD is likely to be highly undiagnosed. This may mean that when ADHD is overlooked, an individual might be treated for another condition (such as anxiety, depression or borderline personality disorder) when it’s possible that the root cause is ADHD or that ADHD co-exists with the other condition.
Masking and coping mechanisms
ADHD that's missed earlier in life may also be due to an ADHD person 'masking' their symptoms and it’s likely that they're not even aware of the symptoms of ADHD.
Masking might stem from a fear of judgement or punishment for the ‘weird’ things they do or why they ‘can’t just do things’ or ‘be like everyone else’; a sense of shame about their symptoms; internalised societal expectations e.g. to be a ‘good girl who sits still’; or other previous trauma associated with being 'different'.
ADHDers diagnosed or not, may have (unknowingly) developed coping mechanisms to deal with day-to-day tasks. Where it can become problematic for ADHD individuals is when coping mechanisms no longer work or become unavailable e.g. due to changes in circumstances, and/or if they lead to ill health, addiction, accidents, relationship breakdowns or breaking the law.
For example, if an ADHD person functions in a chronic hyper-aroused, flight-or-flight, always-on-the-go state this can lead to burn out. With a brain that’s constantly seeking novelty and stimulation since dopamine availability in the brain is cited as low and a contributory factor to ADHD, there’s often a difficulty in directing attention to the 'right' tasks and to switch one's focus on or off.
ADHD can look like low motivation, procrastination or rumination over negative thoughts, yet also creativity, enthusiasm and high energy.
With symptoms of distractibility and procrastination in the mix, seemingly moderately-to-highly organised and average-to-high achieving individuals are, behind the scenes, engaging in compensatory almost obsessive-like behaviour of extreme effort to attain the outcomes of a ‘normal person’.
University life and ADHD
When we think about students starting university, this major life transition often means the loss of structure and routine that home and school may have provided. There’s a greater demand on general life tasks (often of low interest) in addition to the social and, of course, academic demands.
There’s a vast amount of ‘stuff’ grabbing your attention: from settling into a new home, unpacking and organising clothes and belongings in your room; to managing the relationships with the people you live with in your new halls and with those you meet on your course; to navigating a university campus and possibly a new city or country; to the array of societies you could join; to whom you should bank with; to what to buy at the supermarket; to making sure you get to lectures and so much more...
The transition to university is often challenging for anyone and requires more executive functioning such as focus, organisation and planning. Therefore it can feel much more difficult and overwhelming for an ADHD individual especially if they aren’t aware of their ADHD. This may lead to a sense of not managing and embracing independence ‘like other people’ and can contribute to low self-esteem, anxiety and low mood.
Without recognition of difficulties and additional support in place, life at university can become an accumulation of struggle after struggle with a detrimental effect on one's self-concept, mental health and academic outcomes.
We can do more to understand, recognise and support students struggling with ADHD.
ADHD Peer Support Sessions for Students at The University of Sheffield
The potential negative impact of ADHD on mental health is clear and research shows that ADHD is highly co-morbid with mental health diagnoses. This knowledge was the springboard for our work at the Student Mental Health, Counselling and Therapies Service towards delivering peer support sessions for ADHD students at the University of Sheffield during the winter term of 2022.
It was conceived to mark ADHD Awareness month, as a one-off offer consisting of 2 online sessions (to offer students a choice of dates) in October 2022 with a view to gauge interest and uptake.
The idea of setting up an ADHD peer support group resonates with eminent ADHD clinician Dr. Ned Hallowell’s notion of 'Vitamin C[onnect]'. This conceptualises his view that connecting with other ADHDers is an important part of enhancing wellbeing with ADHD. It also links in with the theme for October 2022’s ADHD Awareness month: ‘understanding a shared experience’.
Myself and my co-facilitator for the sessions are therapists from the Student Mental Health, Counselling and Therapies Service. Therapeutic skills in conjunction with previous experience facilitating groups contributed to the style of delivery. Our personal and professional experience of ADHD also informed our approach.
Considerations for an ADHD-informed support group
Given the access and wait issues for ADHD assessment and thinking about students seeking more information to start a path towards assessment, we felt it was important to state in our comms and promo that having a medical diagnosis to attend sessions isn’t required, so it's ok to attend if you're self diagnosed or suspect you might have ADHD.
With memory issues and forgetfulness being common symptoms of ADHD, we emailed reminders for the sessions a few days before and on the morning of the session.
As facilitators we briefly shared our experience of ADHD as part of the introduction in the sessions as we felt this would help convey a sense of empathy and allyship.
As the sessions were online, we were keen for attendees to engage and participate and also respectful that they may feel more comfortable keeping cameras and microphones off.
As the perception of time can also be a challenge for a lot of people with ADHD, we emphasised that it was OK to arrive late for the session and to leave early.
Given ADHDer's tendency to interrupt others (which might be a symptom of impulsivity or a way to cope with poor working memory) we encouraged participants to mute microphones when others were speaking and to use the 'raise hand' button for online interaction.
We suggested that participants could note down questions/comments or add to the chat box without having to hold them in mind as they were waiting their turn to speak, again this factors in the challenges of poor working memory.
We also encouraged participants to complete a feedback form as soon as possible by providing a link to the form in the chat box at the end of the session. We also schedule-sent emails, with the link, to all participants at the end time of the session while the experience was still relatively front-of-mind.
There was an emphasis that the space wasn't for crisis support (we posted a link in the chat box for crisis support resources if needed) and on maintaining confidentiality.
Initial review and developments
Given the demand for the sessions (we had around 60 registrants for the 2 sessions) and limited spaces (we capped capacity at 15 attendees per session) and in light of positive feedback from the students who attended, we delivered 2 further sessions during the remainder of the winter term.
In response to specific feedback, we ran an in-person as well as an online session. Additionally, for the final session we included a psycho-education segment for the first 20 minutes of the 90 minute session. As facilitators, we gave a short talk covering a definition of ADHD, diagnosis pathways and current university support.
Feedback from and demand for the sessions indicated a continued need for a specific ADHD support group. Over the course of the sessions, students discussed ADHD-related topics such as diagnosis journeys, procrastination/task activation, time management, self-care and sleep issues.
Collaborative work and moving forward
Our colleagues at the Disability and Dyslexia Student Services (DDSS) have been delivering ADHD workshops. These address specific study issues for ADHD students.
We decided to look at blending the offer between services and are currently jointly running focus groups for students as a way to engage them to shape future support sessions. The focus groups will also help to add to our understanding and implementation of ADHD-informed considerations.
With the 2 services working together, this is with a view to jointly running monthly support sessions with a core peer support element. These sessions are likely to continue to be offered both online and in-person with a short psycho-education segment at the start of the session presented by the facilitators (ideally one from each service). We are also looking at other ways this segment might be delivered; for example, by a student, through the use of a video, or by inviting guest speakers in.
It’s also a great opportunity and learning experience working across services with our Student Mental Health Counselling and Therapies Service collaborating with the DDSS.
At present, we are close to finalising details for forthcoming ADHD support sessions for the remainder of this academic year 2022/23 with a view to move onto the next phase of planning for the new academic year in the coming months.
About the author
Ella Parker is a BACP registered and accredited psychotherapist. She works as a counsellor and clinical supervisor for the Student Mental Health, Counselling and Therapies Service at The University of Sheffield.
She is late diagnosed ADHD, mum to 2 boys and a lucky black cat, keen lifter of weights and had a previous life working in the advertising industry.
