Thought that kid with ADHD with his frequent prescriptions and sassy attitude would get off your schedule when he got into college? Actually, he needs you and your advice even more now that he will be managing more on his own.
You are one of the important relationships in the patient’s life that it is usually better not to shake up – not with all the other changes happening after high school graduation. This is a scary time for him without his usual supports and scary for you as well in that you will have less contact with your patient, less direct feedback from parents and teachers, and lower overall ability to supervise (compared with your role with younger children and adolescents). All the good communication you should have developed over his childhood will now pay off as a higher level of trust is required and appropriate now that your patient is a young adult.
Dr. Barbara J. Howard
It is not just you who will be getting less feedback –students get less frequent feedback on their performance as well. Some might not realize that their symptoms interfered with their academic functioning until they see their grades at the end of first semester. They might think everything is great, in complete denial that their symptoms are not well controlled.
Managing medicines is tricky for them as well as for you. ADHD symptoms make it more challenging for these kids to remember to take their medication. I talk to them in advance about establishing a new routine that takes into account their varying class schedules, privacy, and medication theft concerns.
Recommend that they use a pill tray marked with days of the week and times, and fill it weekly, so they can remember which pills they have already taken or missed.
In addition, work with them to adjust their medication to their new schedules. In high school, kids with ADHD typically take a long-acting stimulant that covers 10 hours. In college, some days may start at noon and others at 7 a.m., and many run until 3 a.m. I have quite a few college kids who switch to short-acting stimulants to take advantage of greater dosing flexibility. That way, they can more effectively control when they study, eat, and sleep. Ensuring enough and regular sleep and eating is harder, but also critical to college success.
Also consider switching some college students to a medication formulation that is more difficult to snort or sell or give to other students. Forms that are more difficult to abuse include OROS controlled-release methylphenidate (Concerta, Ortho McNeil Janssen); lisdexamfetamine (Vyvanse, Shire Pharmaceuticals); atomoxetine (Strattera, Eli Lilly); extended-release guanfacine (Intuniv, Shire); and long-acting clonidine (Kapvay, Shionogi Pharma). Although OROS methylphenidate and lisdexamfetamine are first-line medicines for ADHD, these others may be useful and may keep a risk taker from getting into trouble.
I have a very frank and honest discussion with kids with ADHD before they leave for college. I tell them they have to protect their supply of medications. If someone else steals their pills or they give them away, I tell them I am not able to prescribe more. Kids take this seriously – if they do lose some of their medication, they come crawling into my office saying: "Please, you have to believe me. I lost four of them. Please let me have another prescription." I also address the very real risks for injury and death if someone for whom these medications were not intended takes them inappropriately. I tell them this is just one more of the big responsibilities of adulthood.
Help these kids with suggestions on safe and private storage of their medication. They may be sharing a bathroom and are almost certainly sharing living space in college, so they need a way to hide their stimulants or lock them up. For example, you can suggest they purchase a fake shaving cream can from a joke store, one that includes a hidden compartment on the bottom.
If you haven’t already, counsel your patients with ADHD about the enormous risks of driving without being on their medicine. The dangers are similar to those of driving while intoxicated with alcohol. That is a very sobering thought – automobile crashes are the No. 1 reason a young person dies in this country.
Interactions with alcohol and other substances that college students may use is another very real risk for patients taking stimulants for ADHD. Even excessive caffeine intake can be risky, as stimulant medication already increases the likelihood for cardiac arrhythmia.