Background: Increasing numbers of adolescents and college students are presenting with
complaints of symptoms suggestive of attention deficit hyperactivity disorder (ADHD; Harrison,
Edwards & Parker, 2007). These individuals have often not been previously evaluated for ADHD
during childhood, which can complicate assessment. This is further compounded by the lack of a
consistent pattern on neuropsychological testing as well as the lack of rating scales with adequate
diagnostic sensitivity and specificity to ADHD (Harrison et al., 2007). The differential for symptoms
of inattention and hyperactivity is broad and includes ADHD, non-ADHD psychiatric disorders that
mirror ADHD and malingering of ADHD symptoms for secondary gain. The purpose of this paper is to
explore these diagnostic categories and discuss diagnostic challenges for ADHD in this age group.
Methods: A review of the literature was conducted utilizing MEDLINE and PsycINFO searches.
Keywords included ADHD, attention deficit hyperactivity, adolescent, college, university, assessment,
diagnosis, diversion, malinger and feign. A total of 46 papers primarily targeting adolescents and
college student populations are included in this review.
Results: 46 articles were published in peer-reviewed journals describing ADHD symptoms in
adolescents and college students. The articles were all published in or after 1991. All participants had
either symptoms of ADHD or a diagnosis of ADHD with diagnostic assessments ranging from
clinical interviews, neuropsychological assessment and use of rating scales.
Discussion and Conclusions: Initial diagnosis of ADHD in adolescent and young adult populations is
challenging. Childhood histories can be useful in identifying ADHD in older adolescents and college
students, including history of executive functioning deficits, social skill deficits, increased emotional
problems, early development concerns, behavioral problems, and family history of ADHD. It is
important to evaluate carefully for comorbidities and other causes of ADHD symptoms, including
depression, anxiety, bipolar disorder, disruptive mood dysregulation disorder, sleep disorders, medical
disorders, and substance abuse etiologies. If non-ADHD psychiatric disorders are present, it may be
worthwhile to treat these disorders first. Finally, there are increasing concerns for malingering of
ADHD symptoms for secondary gain, particularly to obtain stimulant medications for academic and
recreational purposes. Unfortunately, ADHD symptoms can be feigned on self-report instruments,
clinical interviews, and objective testing. Clinicians should utilize a combination of strategies to ensure
the accuracy of diagnosis, including clinical interviews that emphasize early childhood history and
current academic performance, as well as objective and validity tests that are able to discriminate
between ADHD and malingered symptoms. Prescribers should also establish routine clinic practices to
reduce diversion such as requiring regular appointments, conducting periodic urine drug screens, using
prescription monitoring services, and delaying initial stimulant prescriptions until an ADHD diagnosis
is thoroughly established.