Editorial: Advances in the social determinants of health for college students with ADHD

problems (14). New Zealand students with ADHD spent less 5me with friends than non-ADHD peers, despite 5me with friends being associated with higher self-esteem (16). Notably, ADHD presenta5on was impacted by social determinants. In Ethiopia, students from rural communi5es were 4.49 5mes more likely to screen high for ADHD than peers from urban centers. Compared to students whose mothers had acended college, those students whose mothers could not read/write were more than twice as likely to screen high for ADHD; and students with a history of childhood infec5on were significantly more likely to screen high for ADHD than those without (13).Most papers in this special issue relied on screening ques5onnaires or self-reported ADHD diagnosis rather than comprehensive clinical evalua5ons. However, not all individuals scoring highly on a screening measure will meet diagnos5c criteria for ADHD. Furthermore, screening ques5onnaires rarely consider childhood behaviors, leaving uncertainty as to whether ADHD's childhood onset criterion is met. Last, the sensi5vity and specificity of a single measure is generally too low to be adequate for clinical decision-making (20). At the same 5me, young adults' narra5ves illuminate the difficulty ohen faced obtaining an ADHD evalua5on, including high expense, long wait lists, referral difficul5es, and lack of connec5on with the healthcare provider (21). In addi5on, s5gma surrounding ADHD may limit young people's engagement with service providers. In all papers, par5cipants were acending a 4-year college/university, yet community college students with ADHD also struggle (22), and may face addi5onal stressors (23) that amplify the impact of ADHD on func5oning. To our knowledge, there are no studies on prevalence of ADHD or experiences of students with ADHD acending voca5onal training schools; this is an area for future research.Shihing from an impairment to strengths-based framework is recommended. For example, New Zealand students with ADHD spent more 5me at university than students without ADHD, which was associated with higher self-esteem (16). Scholars have proposed ways in which ter5ary ins5tu5ons can develop the necessary infrastructure to support neurodivergent students (24,25). Beyond expanding mental health and educa5on supports through wellness centers or disability services (24), supports could be systema5cally integrated into courses (e.g., instruc5ons in mul5ple formats; chunking of assignments) (25), likely benefiang all students, but par5cularly those with ADHD. Ryder and colleagues (15) showed that despite students with ADHD having higher test anxiety and lower self-efficacy, their sta5s5cs performance did not differ from non-ADHD peers. This may be essen5al to communicate to students with ADHD, given the rela5ons between self-efficacy and academic performance and internalizing psychopathology (26). Similarly, instructors may benefit from learning how ADHD impacts students' academic func5oning. Students with ADHD perceive rela5onships with faculty to be worse than students without ADHD, which in turn is related to lower self-efficacy and student engagement (27). Faculty efforts to improve their understanding of students' experiences and to adopt neuroinclusive pedagogical prac5ces (28) may go some way to mi5gate these outcomes.Hearing directly from students themselves is essen5al. Mpetha Jr. and colleague's ( 14) study presented powerful narra5ves of students' lived experiences, and in doing so, iden5fied poten5al treatment targets. Considering these students' experiences, shame, and internalized beliefs of self-doubt and defec5veness are likely impera5ve to address in a therapeu5c context (29). Group treatment may be par5cularly beneficial in highligh5ng to students that they are not alone in their experiences (30).Inclusive research prac5ces, including establishment of community advisory boards and codesign of research studies by neurodiverse post-secondary students is also essen5al (31). Community-based par5cipatory research built on a founda5on of mutual respect, equality, and collabora5on offers real poten5al for greater understanding of ADHD, its related challenges, and individuals' strengths (32).Last, post-secondary students with ADHD may have comorbid diagnoses or cogni5ve profiles that impact their academic outcomes, use of coping strategies, and treatment response. In par5cular, research on Au5sm Spectrum Disorder (ASD) or ASD-like traits and twice-excep5onal status is lacking, and are important areas for future research.Campuses must develop becer resources for students with ADHD. Low cost, accessible assessments are an essen5al first step. Ter5ary educa5on providers need to develop infrastructure for screening and assessing college students for ADHD. Many students have no history of clinical evalua5on, especially those from historically marginalized, disinvested, or resource-constrained communi5es (30,33). Yet, ins5tu5ons commonly require formal documenta5on of a diagnosis to access services. One of the South African par5cipants stated that the lack of a diagnos5c evalua5on (due to unaffordable cost) made it hard to explain their behavior to peers (14). Notably, girls/women and people of color are underdiagnosed, misdiagnosed, or receive their diagnoses later than White boys/men, which is linked to poorer outcomes (34,35). It is important that educators and clinicians are acuned to these issues, and how current diagnos5c tools may contribute to these dispari5es, to help ensure these differences in health outcomes are not perpetuated.Accommoda5ons (36) and psychotherapeu5c interven5ons should be culturally-tailored (37), adapted for folks with ADHD (38,39,40), and developed with input from students (41). In addi5on, neurodivergent-affirming approaches may result in greater student engagement and outcome effec5veness. ADHD remains a highly s5gma5zed neurotype (42,43). Kassaw and colleagues (13) hypothesized s5gma interacts with ADHD behaviors to exacerbate impairment. Individuals may mask their behaviors (44), refrain from seeking healthcare (45), or choose not to disclose their diagnosis (21,45). Students may be reluctant to inform their instructors and/or peers or seek out accommoda5ons due to fear of nega5ve evalua5on or differen5al treatment (46). Psychoeduca5on and des5gma5za5on efforts for campus communi5es are needed. In addi5on,Deleted: symptoms parents have a role in helping students transi5on to college, while increasing their adult child's autonomy (47). Parents (and in turn the parent-adult child rela5onship) (48) may benefit from psychoeduca5on that ADHD is a neurodevelopmental disorder, and ADHD behaviors do not represent characterological flaws.This special edi5on presents four papers from around the globe that highlight commonali5es and local nuances in ADHD presenta5on and impairment among post-secondary students. It is a call to ac5on for researchers from around the world to not only inves5gate group level differences, but to consider contextual and cultural factors that modulate outcomes, and represent avenues for novel and effec5ve supports.