Difficulties faced by university students with self-reported symptoms of attention-deficit hyperactivity disorder: a qualitative study

Attention-deficit hyperactivity disorder (ADHD) has as its major symptoms inattention, impulsivity, and hyperactivity [1]. The prevalence rates of ADHD have been increasing over the past decades [2]. The revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes diagnostic criteria for adult ADHD, which differ from those for childhood ADHD [1]. The DSM-5 includes more developmentally expansive criteria and is expected to have a marked impact on the diagnosis and treatment of adult ADHD. A cross-national study of 11,422 adults in the United States and Europe reported that the prevalence of adult ADHD was approximately 3.4% and was significantly higher in higher-income than in lower-income countries (4.2% vs. 1.9%, respectively) [3]. Approximately 2–8% of university students have clinically significant ADHD symptoms [4]. Furthermore, studies in South Korea found that approximately 1.1% of adults had significant ADHD symptoms [5], and 7.6% of university students had ADHD [6].

Adults with ADHD have a lower quality of life than those without ADHD [7]. Similarly, college students with ADHD have a lower quality of life than do students without ADHD [8]; they have been shown to be more depressed and anxious, to be more easily angered or to suppress emotion, to have achieve less academically, and to be poorly supported in their relationships with their friends [9, 10]. ADHD symptoms have a negative impact on many aspects of life, including self-esteem, academic functioning, social functioning, and parent–child relationships [8, 11, 12]. Adults with ADHD are vulnerable to addiction; ADHD is often accompanied by addictive disorders [13] that are closely associated with sleep problems, leading to impairment in daily life [14].

In addition, adults with ADHD may experience frustration, depression, anxiety, difficulty in controlling emotions, interpersonal problems, and, in severe cases, personality disorders. They may often receive negative feedback from those around them and may exhibit suicidal behavior in response to repeated failures [4, 9, 10, 15‐18]. Attending university is a particularly important period that affects future careers and overall social life; it is particularly challenging because of the adjustment to the new, unstructured environment that university students must make [19]. University students with ADHD experience a variety of academic, psychological, social, and mental problems [20]. Since university students with ADHD tend to have reduced life satisfaction and greater subjective pain than those without ADHD [21], there is a great need for ADHD treatment and interventions that support this vulnerable student cohort.

Although studies have been conducted to identify the support needs of university students with ADHD [18, 20], most of this research has focused on the experiences of students living in the United States, with little attention paid to diverse ethnic groups. To date, only a few studies have been conducted in Asia, making it difficult to generalize the findings to cross-national populations. The particular cultural demands faced by Korean university students, including the pressure to find a job and high parental expectations, may lead to difficulties such as mental health-related and self-centered behavioral problems [22, 23]. Given the low number of adults diagnosed with ADHD in Korea, the scarcity of related studies, and limited information about adult ADHD among the Korean population [10, 24], multifaceted studies and clinical approaches are needed to help Korean university students who have ADHD symptoms. To adequately address and evaluate the difficulties that such students experience, the condition must be explored from their perspective. Therefore, the present study aimed to investigate the difficulties experienced by Korean university students with ADHD symptoms so as to provide the basic data needed to develop appropriate interventions.

The present study aimed to analyze the difficulties experienced by university students with ADHD symptoms. A total of 12 eligible students were interviewed and four themes emerged during the analysis. The first theme was lack of a daily routine. University students with ADHD symptoms did not implement their plans well because of their inattention, impulsivity, and the lack of regularity within their daily lives. Hyperactivity, which is common in pediatric patients with ADHD, decreases markedly with age, such that superficial activity is maintained at a relatively reasonable level in adult patients with ADHD [30]. However, the present study shows that certain ADHD-related difficulties persist into adulthood, including impulsivity, inattention, difficulty in controlling emotions, and inability to systematize [15, 18]. In addition, previous studies have indicated that university students with ADHD symptoms have irregular sleeping hours and lower sleep quality [18, 31], and eat irregular meals or occasionally partake in binge eating [31, 32]. These observations are consistent with the results of the present study. Many studies have shown that university students with an ADHD tendency or diagnosis have more difficulties with alcohol, smoking, and internet and smartphone addiction than do other students [6, 22, 26, 33, 34]. These outcomes further support the theory that university students with ADHD symptoms lack structure in their daily lives. Therefore, attention, support, and other appropriate interventions would help these students manage their daily life schedule, including their sleeping and eating behaviors, while coaching programs or organizational skills intervention programs may help them manage their time more efficiently [35, 36].

The second theme was unsatisfactory academic performance and achievement. Even if the students made plans to study in advance, they failed to prioritize and complete tasks. This resulted in unsatisfactory academic performance and achievement. The students made efforts to overcome these problems, but their concentration waned with lack of interest, and they struggled with repeated failures. Previous studies have reported that such students have difficulty planning and completing tasks as a result of procrastination or indecision, and thus do not manage their time well [37, 38]. Other studies have reported that university students with ADHD symptoms have low academic performance as a result of difficulties with concentrating on their studies and completing assignments, worries about studying and having high test anxiety, and not applying appropriate learning strategies, which all lead to problems with adjusting to university life [4, 9, 16‐18, 21, 39]. Such difficulties in adjusting to university life can extend to difficulties in social functioning in adulthood. For example, these students may fail to secure employment or may find only low income employment [3, 40]. Therefore, programs promoting academic strategies and time management skills should be implemented to help these students improve their academic performance and educational achievements. As in previous studies, working memory training or self-monitoring can be applied to support their learning [41, 42]. In addition, our results indicate that these students should be encouraged to concentrate on their areas of interest, as this strategy might help them to better select and adapt to their future jobs.

The third theme was unskilled interpersonal relationships. The participants reported having extreme reactions in interpersonal relationships and experienced difficulties in forming and maintaining relationships as a result of this impulsivity. Previous studies have shown that university students with ADHD have higher levels of anger and greater difficulty in controlling emotions than their peers; therefore, these students often express anger in socially unacceptable ways [10, 33]. Furthermore, studies have reported that university students with ADHD tend to be more aggressive or confrontational in stressful situations than their peers; therefore, they often experience difficulties in forming relationships with other people [4, 10]. Since ADHD is associated with certain characteristics, such as inattentiveness and impulsivity, individuals diagnosed with ADHD tend not to pay enough attention to the feelings and desires of others, often interfering in a criticizing and controlling way, and causing conflict, disappointment, and distrust [10]. Research indicates that anger and aggressiveness negatively impact interpersonal relationships [43]. The establishment of self-identity and formation of personal relationships are important developmental tasks for university students. The lack of social skills in patients with ADHD is already known, but until now, the mechanisms leading to such difficulties have remained obscure; this study provides an understanding of why social skills are lacking. Impaired interpersonal competence can cause serious psychological maladjustment and low self-esteem, which have serious effects on life satisfaction [21]. It is, thus, important for college students with ADHD to be educated about how to express their negative feelings more healthily (rather than expressing extreme anger or displaying avoidance), to learn interpersonal skills, and to consider the effects that their ADHD symptoms can have on their relationships with others.

The final theme was continuous worry. This study found that although university students with ADHD symptoms tried to overcome these tendencies, they had high levels of self-distrust as a result of perpetually repeating cycles involving obsessing over past events and worrying about future failures. This can reduce their expectations for the future, gradually exacerbating their negative functioning. Previous studies have reported that university students with ADHD tendencies demonstrate a poorer adjustment to university life, exhibiting higher rates of depression and anxiety and lower than usual self-esteem and self-efficacy [6, 10, 21, 30, 44]. Patients with ADHD are known to have very poor tolerance for stress and dysfunctional coping styles [45]. As they are often inefficient and have difficulty adjusting to major life obligations, such as academic studies or occupations, these individuals are more likely than the general population to experience stress-causing negative life events [46, 47]. They may be very worried about repeated failures, the negative feedback they receive as a result of low academic performance, and interpersonal difficulties. These students are also more easily distracted. Time management is very important for enhancing self-efficacy and academic performance among university students [19]. Therefore, students should be taught effective time management skills to help them perform tasks efficiently and achieve a good work-life balance.

The final theme, the extent to which these students constantly worry about past mistakes and potential future ones, is important in this study. As a result of their history of repeated negative experiences and failed efforts, they come to distrust themselves and their ability to achieve their goals, which leads to further demoralization, loss of motivation, and progressive worsening of their functioning over time. Therefore, when providing interventions, it is necessary to repeatedly reduce negative feedback and to reinforce positive motivation for the future; this is an important implication arising from this study.

In summary, university students with ADHD symptoms have difficulties coping with repeated cycles of negative thoughts and worries, irregular lifestyles as a result of poor time management, dissatisfaction with academic performance and interpersonal relationships, and self-dissatisfaction. Although individual or group cognitive-behavioral therapy, mindfulness training, and coaching [20], may be helpful, it is necessary to consider the social and cultural environment of the subject based on the results of this study when applying and developing programs appropriate for them. To help these students live a healthy lifestyle at university, they should be properly diagnosed and educated about ADHD, how to prevent worrying, how to express emotions healthily, and how to effectively manage time. Social awareness of adult ADHD should also be enhanced.

This study has several limitations. First, the subjects were Korean university students; therefore, caution must be applied when generalizing these results to adults from other countries, cultures, and age groups. Further studies of university students or adults from different populations are needed. Second, participants were selected on the basis of self-reported ADHD symptoms; the experiences of and findings related to those formally diagnosed with ADHD or receiving ADHD treatment may differ. The findings of this study need to be captured and quantified using standardized rating instruments, and replicated in larger samples with fully diagnosed students. Despite these limitations, we believe that this study is important because it is the first to analyze difficulties from the perspective of Korean university students with ADHD symptoms. In addition, this study highlights the importance of developing intervention programs for such university students.

When the difficulties experienced by Korean university students with ADHD symptoms were analyzed, four main themes were identified, including lack of a regular daily routine, unsatisfactory academic performance and achievement, unskilled interpersonal relationships, and an ongoing tendency to worry. Students were aware of these difficulties and tried to overcome them by self-discipline. However, their self-esteem was lowered as a result of repeated cycles of inattentiveness and impulsivity. Therefore, to improve their experiences, university students with ADHD symptoms must develop insight into their diagnosis and be educated about ways to stop worrying and to effectively manage time. It is also important for universities to provide students with access to resources for life management.