Illustration by Michael Morgenstern

Objectivity is hard to find when it comes to diagnosing ADHD. "It would be nice if we could do a blood test, but it's just not that black and white," says Student Health physician Lauren Johnson. She says an ADHD diagnosis entails a comprehensive evaluation, including a family history and a record of childhood symptoms. "We're sticklers for having documentation before we're willing to initiate medication or refill medication." The condition "is genetic, it's biological," she adds. "It's not something that just showed up last week." 

At Duke Student Health and at other institutions, the number of ADHD students is on the rise, says Johnson, both in the categories of students seeking an initial ADHD diagnosis and those aiming to maintain treatment after having been diagnosed before beginning college. Kollins observes that a hike in the number of students seeking a diagnosis is one thing; an actual increase in prevalence would be something else. "It means that there are more people who have heard about the disorder and/or the treatment. And they think it could explain the impairments they are facing." That is, students not succeeding as they anticipated might arrive at the conclusion that ADHD issues—and not, say, bad study habits—are holding them back. "Or," he concedes, "it might be a quick way to get some cognitive-enhancing drugs."

If students are diverting those drugs to their peers, they're violating the terms of the Duke Student Health "Controlled Medication Contract." Among other terms, the contract provides that students "will not ask for or accept" medications from other providers while receiving medication from Student Health; that they will "not share, sell, or trade" medications; and that they understand that excuses of running out early, losing a prescription, or spilling medication won't entitle them to a prescription refill.

Even with such strict language, diversion is hardly uncommon. According to Rabiner's survey, in the past six months 65 percent of ADHD students at Duke were asked by other students for their medication; most were asked multiple times. Some gave or sold their ADHD medication to a peer—a few on multiple occasions—and two students reported having their medication stolen.

Sarah, a 2008 Duke graduate, who was diagnosed with an attention disorder in her junior year, can identify with many of those scenarios—including the sense that she was lagging behind her peers in a high-pressure Duke environment. "In contrast to high school, getting good grades at Duke required a more complete understanding of the material, not only memorization," she says. "I had no clue how to manage my time. I would spend the majority of my time sitting in front of books, but daydreaming or thinking about other things. I would also spend excessive amounts of time making to-do lists or trying to catch up and get organized."

Sarah (not her real name) takes Adderall almost daily. It's useful for her, she says, because it allows her to exist in a distraction-free zone. Now and again, she notes, she needs to get off the Adderall to escape the zone and to follow a more easygoing routine.

To college students, for whom odd sleeping and eating habits are the norm, the side effects are no big deal, Sarah says. And illicit pill-popping is no big deal either. "You'll hear people say, 'I have a huge paper due tomorrow. This is going to be an Adderall night.' People don't feel guilty about it. It's not hidden." Sarah says that as a student, she was "asked a lot" to give out some of her Adderall; she was offered $15 for just one pill. She says she's refused the offers but jokes, "I could have made a lot of money."

The drugs prescribed for a diagnosed ADHD condition, counterintuitively, help slow down hyperactive individuals. In ADHD brains, says Kollins, dopamine function is abnormally inactive. Dopamine largely controls someone's ability to inhibit responses; the lack of that ability translates into impulsivity, hyperactivity, and inattention. For ADHD individuals, at least in theory, elevating levels of dopamine "normalizes" attention and inhibitory control. So, far from replicating the caffeine buzz of coffee or an energy drink like Red Bull, ADHD medication places the ADHD individual in a zone where he or she is calmer and more focused.

The main differences among the various medications hinge on whether they are based on amphetamine or methylphenidate. According to Kollins, these compounds operate slightly differently on the brain. Amphetamine is more potent, so physicians prescribe more controlled doses. There's no evidence that any one compound works better than another for treating ADHD. A number of the stimulants are designed for slow release, with the effects lasting six to twelve hours. Others are in and out of the body's system in three or four hours.

There's a lot of debate around the question of whether the drugs work in the same way for those with and without ADHD, Kollins says. Either population, though, will see side effects. "If you take a reasonable dose of an amphetamine or methamphetamine product, you are going to be able to stay awake longer; in fact, it might impair your sleep. It's going to decrease your appetite. If you reach a certain point with a dose, it is going to make you jittery. You are going to get a bump in your heart rate and your blood pressure. The magnitude of the change is going to depend on how much you take and exactly what product you take."

Beyond concerns over side effects, there's reason to doubt, according to Rabiner, whether ADHD students find their medications helpful in terms of the ultimate aim—success in college. In another Web survey, still unpublished, he and his colleagues found that while "most students with ADHD appeared to be making satisfactory adjustments in college," they also reported having "lower GPAs, heightened concerns about academic performance, and … more depressive symptoms, social concerns, emotional instability, and substance use."

The medications probably do improve attention and reduce impulsivity in children and adults with ADHD, Rabiner says. And they probably promote short-term gains in children's academic performance—the basis on which they are prescribed. "What has been harder to document at the group level is that this treatment leads to improvements in meaningful real-world outcomes. As a crude analogy, it is sort of like studies showing that certain medications may reduce blood pressure but have no impact ultimately on mortality rates."

Rabiner's earlier survey shows that a lot of students who use ADHD drugs illicitly are also drawn to other substances: 24 percent reported using cocaine and 67 percent, marijuana. Problem drinking, too, is linked with the use of the drugs.

"The feeling is that if you take Adderall, you can stay up longer and you are not going to pass out when you are out drinking," says Kollins. "Well, that may be a perceived benefit, but then we get mentions of Adderall being in somebody's system when they show up with alcohol poisoning at the emergency room." Officials involved with student health worry that the illicit use of ADHD drugs can mask other problems, including depression, sleep disorders, and drinking to excess, that should be addressed in other, more medically sensible, ways.