NURSE EDUCATOR

Volume 28, Number 4 pp 161-165

2003; Lippincott Williams & Wilkins, Inc.

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 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

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.

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-

NURSE EDUCATOR Volume 28, Number 4 July/August 2003

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

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.

Figure 1. Typical ADHD symptoms.

162

ADHD in the Nursing Student

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.

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.

College Students
With ADHD

Assessment, Findings,
and Strategies

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

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

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

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.

NURSE EDUCATOR Volume 28, Number 4 July/August 2003

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-

NURSE EDUCATOR Volume 28, Number 4 July/August 2003

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-

163

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.

164

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.

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-

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.

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.
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