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As many as 25% of students at certain colleges say they have misused attention deficit hyperactivity disorder (ADHD) medication at some point, earning Ritalin and Adderall nicknames like "study buddies," "smart drugs," and "Stanford steroids."

But new research suggests that many college students who misuse stimulants aren't doing so to turn that A-minus into an A. Rather, these students may be struggling to survive the semester due to attention problems or even undiagnosed ADHD.

ADHD experts have suspected for years that a subset of students who misuse stimulants might actually be self-medicating. Now, there's some evidence to support the hunch, thanks to a pair of studies published in recent months.

"I do think there's probably a subset of students who use [stimulant] drugs without a prescription that probably do have undiagnosed ADHD, and this is one way that they try to deal with [it]," says David Rabiner, PhD, an associate research professor of psychology and neuroscience at Duke University, in Durham, N.C.

[ pagebreak ]The typical stimulant abuser

College students who misuse stimulants are sometimes perceived to be go-getters who want to clock even longer hours in the library. (Mock newspaper the Onion recently "reported" that Adderall received an honorary doctorate from Harvard for contributions such as allowing students to work "for 19 uninterrupted hours at a time.")

The media portrays this as "normal college student behavior—kind of the work-hard, play-hard mentality," Rabiner says.

This may be partially true; the percentage of students who say they took a stimulant in the past year is greater at highly competitive universities than at all colleges nationwide, for instance. But, in reality, users are also more likely than nonusers to have a low GPA and be heavy partiers, according to a 2005 survey of students at more than 100 colleges across the country.

Many students try to compensate for other bad habits (like binge drinking) by taking these drugs, says Amelia Arria, PhD, director of the Center on Young Adult Health and Development at the University of Maryland School of Public Health, in College Park. "Typically, the scenario is that [students] have had a history of alcohol and marijuana use and [prescription] drug use comes into play a little bit later," she explains.

And a small group of students use stimulants themselves as a recreational drug. A 2009 survey, led by Rabiner, of 3,400 undergraduates at two universities found that 6% of students said their most common reason for taking stimulants, which can have cocaine-like effects when snorted or injected, was to get high. More than half said they used the drugs mostly as a study aid.

From this and other surveys, it seems college students often misuse ADHD drugs to get by academically amid the distractions of college life.

Indeed, many students who use stimulants without a prescription report having problems with completing assignments and other tasks that require focus. Although attention problems can themselves be a side effect of alcohol and drug use, experts say some students may have undiagnosed ADHD.
Next Page: How many are self-medicating?

[ pagebreak ]How many are self-medicating?

It's hard to say precisely how widespread ADHD symptoms are among stimulant misusers, but experts generally agree that the rate is probably greater than that in the general population, which is about 5%.

In two separate studies published earlier this year, researchers surveyed students at East Coast universities.

One study, led by Arria—and funded by Ortho-McNeil-Janssen, the makers of the stimulant Concerta—found that 17% of stimulant misusers had ADHD symptoms, compared with about 9% of the group of nonusers. The rate of ADHD symptoms among misusers was much higher in the other study, 71%, compared to only 10% of nonusers.

"These studies definitely suggest that among the kids using stimulants, an appreciable portion may have ADHD," says Stephen Faraone, PhD, director of child and adolescent psychiatry research at SUNY Upstate Medical University, in Syracuse. "This calls on campuses to be alert as to whether there is untreated ADHD." Faraone currently receives research support and consulting fees from Shire Development, the makers of extended-release Adderall, and in the past his research has been funded by companies including Ortho-McNeil-Janssen and Eli Lilly, which makes the stimulant Strattera.

But, he says, "There is a wide range between 17% and 71%." Differences between campuses and the groups that were sampled could explain some of the discrepancy, he adds.

College may bring out previously unrecognized attention problems. For one, students with undiagnosed ADHD might have been able to manage until university and its higher demands, Arria says.

The myriad challenges and distractions of college, not just drinking and partying, can trigger "context-specific ADHD," says Lawrence Diller, MD, an assistant clinical professor of pediatrics at the University of California–San Francisco, who is in private practice in Walnut Creek, CA.

In fact, a 2010 study by Rabiner and his colleagues found that freshmen who reported having attention problems their first semester were more likely to take up stimulant misuse by the end of their sophomore year, even if they were not heavy drinkers and users of marijuana or other drugs.

However, drinking and drug abuse can also bring on ADHD-like symptoms. "We're all affected in our attention capacity if we're not following a healthy lifestyle," Arria says.
Next Page: Should Ritalin abusers really get an Rx?

[ pagebreak ]Should Ritalin abusers really get an Rx?

There's no need to rush prescriptions to people already misusing ADHD drugs. "What we don't want to do is to think that [undiagnosed] ADHD is the primary reason why people are using prescription stimulants nonmedically," Arria says.

In fact, if students aren't carefully diagnosed, she says, clinicians could miss other common problems—like drug and alcohol abuse. Arria adds that many clinicians insist on doing a full assessment on students who are not abusing other drugs and alcohol, including getting a history of symptoms and reports from teachers, to know if they have ADHD.

For students who really do have undiagnosed ADHD, misusing stimulants can make the problem worse. Self-treatment "is a way of delaying treatment, which is not a good thing," Faraone says. "People just think they need it to study for a test [but] in order for treatment to work, medicine has to be taken every day on a regular schedule."

For anyone, misusing stimulants can cause headaches, irritability, reduced appetite, and trouble falling asleep. What's more, people who truly have ADHD often also experience depression and anxiety. Self-treatment won't fix those complications, Faraone says.

Whether or not they're misusing stimulants, students who suspect they might have undiagnosed ADHD should visit a doctor or campus health services for a thorough evaluation. (Likewise, parents who worry that their child has undiagnosed attentional problems should urge him or her to consult a professional.)

This may require going off-campus for help. Unfortunately for students, many college counseling or health centers do not offer ADHD evaluation. "Assessment of ADHD and very time-consuming and it requires an expert, and often counseling centers have generalists," says Denise Hayes, PhD, former president of the Association for University and College Counseling Center Directors.

The lack of access to thorough evaluation "may make it more likely for students who think they can benefit from some ADHD drugs to go to their peers looking for it," Rabiner says.