When Intelligence Masks Impairment: Academic Transition as the Precipitating Context for ADHD Diagnosis in a High-Functioning Student

Introduction

This case report presents a representative case of late-identified attention deficit hyperactivity disorder (ADHD) in a high-functioning engineering student, used as a vehicle to examine how diagnostic thresholds, intellectual masking, and multimodal treatment interact in a college population.

ADHD is a common neurodevelopmental disorder, with the current global prevalence of the condition estimated to be 5.3% among children and 2.5% among adults.¹ College settings have become especially crucial in understanding this disorder. ADHD diagnoses among US college students have seen a marked increase during the last decade, with estimates showing a prevalence rate of 14-15% in the 2024-2025 academic year, a stark increase from 4-8% in the previous decade.² It is still not clear whether this phenomenon indicates the underreporting of ADHD among college students, where their problems go unnoticed until they are exposed to higher education’s increased reliance on self-directed study.^3,4 Alternatively, the increased rates may represent a lower threshold of diagnosing due to rising academic and social pressures.⁵ In either case, it bears great consequences for the medical field. Underdiagnosis can lead to serious disability and increased mortality, while overdiagnosis can misinterpret ordinary behavior as a disorder.⁶ It becomes even harder for those who possess above-average intellectual ability since successful structured testing may not uncover their real attention disorders until academic demands outpace their ability to compensate.^7,8

According to DSM-5-TR, the criteria for ADHD, Predominantly Inattentive Presentation, include a consistent inability to sustain focus for at least six months.⁹ This may manifest in activities such as listening to lectures, engaging in discussions, or reading lengthy texts.⁹ Additionally, Criterion D requires that such symptoms impair social, academic, or occupational functioning in some way.⁹ In cases like these, this criterion may not be met until the environment demands more than the individual is capable of coping with.⁹ ADHD can be considered from the perspective of a continuous distribution rather than as a dichotomous state where individuals either do or do not have the disorder.¹⁰ Thus, attentional abilities and executive functioning may be better understood as existing along a spectrum.¹¹ The threshold at which these differences become functionally impairing is shaped by the individual’s social and environmental context.¹² The same attentional profile may therefore be considered subclinical in one setting and pathologic in another.

This case report aims to illustrate how late-identified ADHD presents in a high-functioning adult and to underscore the role of family medicine physicians in recognizing, diagnosing, and managing ADHD when it is first identified in adulthood, especially when it is provoked by higher academic demands such as the college setting.

Case Presentation

The patient is a 20-year-old man who studies mechanical engineering at the university level and who presented for attentional difficulties. The patient had no previous personal history of generalized anxiety or mood disorders. He did endorse a history of situational test anxiety associated with insomnia, which was well managed with propranolol as needed. This treatment did not aid his attentional difficulties. He had never undergone testing for ADHD, although there was a family history of this condition on both sides of his family through cousins. The patient consumed six to eight alcoholic drinks a week and marijuana once a month, both in social settings.

In high school, the patient performed well academically. He attributed this success to the structured nature of high school, where classes were brief and there were constant changes of subjects as well as various activities which ensured that no one task would require him to concentrate for too long. However, once he went to college, all this structure vanished, and he found himself unable to concentrate during lecture and study sessions. He also had difficulty initiating and completing assignments despite great interest in the subject matter, and he endorsed a tendency to cycle between tasks without completing any one of them. The challenges continued despite his implementing academic strategies such as the Pomodoro technique, a time-management system in which individuals work intently for 25 minutes followed by a 5-minute break. He also placed his phone in a separate room to reduce distractions while studying, but he still struggled to focus.

Because of his difficulties in college, the patient sought medical evaluation for his attentional problems. He was referred for neuropsychological testing by his family medicine physician. His testing showed an IQ score of 116 by the Wechsler Adult Intelligence Scale test, which placed him into the high-average intelligence level, with other tests revealing high level of processing speed and reasoning. Behavioral observations of parents and the BRIEF-2 questionnaire showed the ADHD composite score of 70, two standard deviations above the normal range of 0-50. This score indicated clinically significant problems, including difficulties in regulating attention, initiating actions, planning and effortful persistence. Impulsivity and Behavioral Dysregulation subscales fell within the average range (T-scores < 65), which, per BRIEF-2 norms, does not meet the threshold for clinically significant executive dysregulation in those domains; had these scores also exceeded 65-70, a Combined Presentation diagnosis may have been indicated instead. These findings are consistent with a diagnosis of ADHD, Predominantly Inattentive Presentation. Other conditions considered included mood and anxiety disorders, but the patient had no symptoms of mood disturbance or generalized anxiety. His alcohol and marijuana use did not meet criteria for a substance use disorder.

Management was a combination of non-pharmacological and pharmacological treatments. Non-pharmacologic treatment involved training in executive functioning skills, academic strategies, environmental manipulation to minimize distractions, and academic accommodations such as additional time on tests and an exam environment with reduced stimuli. At the same time, the patient was administered amphetamine salts, which showed positive results: his grade point average increased from 3.11 without medication to 3.70 on medication within one semester.

Discussion

This case is important not because of its complexity but rather because it simply demonstrates how attention-related problems can be hidden from view. The recognition and management of ADHD in college students with high intellectual functioning, as in our patient, can respond well to multidisciplinary treatment.

The American Academy of Pediatrics (AAP) has developed clinical practice guidelines for the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) among children and adolescents; yet no such clinical practice guidelines have been formulated for adults. Although professional consensus efforts have tried to fill this void, no formal clinical practice guidelines for adult ADHD have been established thus far.¹³ As a result, there is a greater burden on individual clinicians to apply individualized evidence to adult presentations.

For family medicine physicians, this case illustrates a presentation that is both common and commonly missed. ADHD is the most commonly encountered neurodevelopmental conditions in primary care settings, however, its detection in high-functioning adults may be inconsistent.^8,14 Contrary to patients diagnosed with ADHD in childhood who come to adult care services with already formed treatment plans, adults presenting with the disorder for the first time necessitate a more structured approach to diagnosing the disorder which involves exclusion of other conditions such as mood and anxiety disorders, assessment of functional impairment in non-educational settings, and consideration of how intellectual functioning might have been masking the condition for years. ADHD is within the scope of family practice, although individual providers may choose to refer to behavioral health specialists for this care. The AAFP has created tools and guidelines for the treatment of ADHD by family medicine physicians.¹⁵ It is essential for primary care physicians interested in treating this condition to be familiar with the use of screening instruments, referral procedures, and treatments available for adults with ADHD. One such screening instrument is the WHO-developed Adult Attention-deficit/hyperactivity disorder Self-Report Scales (ASRS), which has been shown to be both highly sensitive (91%) and highly specific (96%) for ADHD in adults.¹⁶

In this case, arriving at the correct diagnosis required careful exclusion of competing explanations, a process that reflects broader tensions in how modern societies identify and respond to neurodevelopmental differences. The patient showed no generalized anxiety disorder or mood disturbances, and his situational test anxiety with pre-examination insomnia was limited in scope and unlikely to account for his pervasive attentional difficulties. His alcohol and marijuana use did not meet criteria for a use disorder, consistent with patterns reported among the majority of US college students.¹⁷ Though substance use is believed to sometimes serve as an inadvertent coping mechanism for undiagnosed ADHD, it did not confound the clinical picture here.¹⁸ What remained, once these alternatives were set aside, was a presentation fully consistent with ADHD. The contrast between his above average performance on structured tasks and his severe real-life executive dysfunction illustrates precisely why this condition is so easily missed: the clinical setting, much like the highly structured classroom, can itself become a compensatory scaffold that masks the very deficits it is meant to detect. Identification of ADHD in K-12 settings in the United States is largely determined by Section 504 of the Rehabilitation Act and the Individuals with Disabilities Education Act (IDEA), but federal law allows states to determine their own procedures for identification, leading to wide variation in identification rates between districts.¹⁹ In college, students themselves are responsible for self-identifying to a disability services office and providing clinical documentation to receive accommodations, creating a reactive system that is not well-suited to serve students who have never linked their struggles to a treatable condition.²⁰ This raises a broader question whether the American educational environment may conceal an individual’s ADHD symptoms through large, unindividualized classes where the individual’s performance may get little attention until failure.

Comparison across peer nations

The approach to neurodevelopmental differences in the education system varies considerably across peer nations. Finland emphasizes smaller class sizes and individualized support for those with attentional differences.²¹ In the United Kingdom, schools are legally required to identify and support pupils with special educational needs, including ADHD, through a formalized framework overseen by designated Special Educational Needs Coordinators who coordinate individualized support plans — a proactive, school-embedded model of identification that stands in contrast to the American approach of waiting for academic failure.²² Australia formally recognizes ADHD under disability law and mandates reasonable educational adjustments, though access gaps persist.^23,24 In Japan, by contrast, cultural expectations around conformity and behavior can lead individuals to mask neurodivergent traits, at the cost of increased anxiety and social exclusion.²⁵ Taken together, these international comparisons underscore that the American academic environment may be positioned both to hide inattentive ADHD in its early stages and to expose it suddenly at the point of college entry.

The role of educational demand in late diagnosis

The current case corroborates the claim that the cutoff point for diagnosing a functional impairment is not fixed, as it shifts depending on the circumstances.¹² Indeed, the emergence of ADHD symptoms is more likely among college students, who must balance higher performance pressure with less structured learning environments.³ This pattern is perhaps most striking among medical students, a population defined by high academic achievement and professional identity — precisely the traits that render ADHD most invisible. A 2025 systematic review of medical students across several countries found ADHD prevalence rates as high as 38.9% on validated screening tools compared to as low as 1.7% on self-report alone: a gap the authors attribute in part to a lack of recognition among high-achieving students who may never connect their impairments to a treatable condition.²⁶ The review further noted that unrecognized ADHD in medical training carries downstream consequences, such as increased medical errors, burnout, and difficulties in residency progression.²⁶ This suggests that the professional stakes of delayed diagnosis extend well beyond academic performance. Accommodations during clinical rotations are substantively different from past academic accommodations, from extended test time to modified call schedules and clinical workflow modifications.²⁷ Timely diagnosis ensures trainees can access these supports during the clerkship years, which will shape the rest of their careers.

Intellectual giftedness and diagnostic masking

With the patient’s IQ of 116, making an ADHD diagnosis can be especially difficult. Giftedness reduces the apparent deficits in attention observed through standardized neuropsychological testing because the performance of gifted students in such tasks tends to be overestimated in comparison to their functional impairment.^7,8 Having a high IQ does not negate an ADHD diagnosis. Other studies have shown that high-IQ children with ADHD manifest academic achievement problems and family history rates equivalent to those seen among ADHD groups of average IQ individuals, contradicting the theory that these patients are simply bored and under-stimulated.²⁸ ADHD cognitive characteristics appear even more prominent in the context of having higher-than-average general intelligence since the disparity between potential and actual performance becomes greater in this regard.⁸ Because of his ability to compensate through intellectual strengths, treating this patient required consideration of a fundamental question: is the goal of ADHD treatment to optimize an individual’s potential, or merely to prevent societal disruption? The latter model intervenes only at the point of breakdown, leaving untreated those who appear to function well, but fall short of their potential.

Balancing overdiagnosis and undertreatment

Any attempt at addressing late identification of ADHD in an otherwise high-functioning individual is bound to confront the issue of overdiagnosis and the problem of undertreatment. The risk of ADHD diagnosis increases more than two times among the youngest compared to the oldest children in a particular grade, highlighting how differences in child development can lead to some ADHD diagnoses.⁵ One meta-analysis estimated that for every individual using medication without a formal diagnosis, three patients with a diagnosis who might benefit do not receive medication.¹⁰ Another review found varied reasons for declining or stopping medical treatment, including stigmatization, side effects, and a belief that treatment was unnecessary.²⁹ In this context, there is a significant danger associated with undertreatment. While there is not data focused specifically on college and medical students, we know that adults face a different set of complications of ADHD than children, with ADHD in adulthood being associated with a 2.07-fold increase in mortality.³⁰ In particular, adults with ADHD face up to a 47% increased risk of serious transport accidents compared to non-ADHD controls, a risk reduced by approximately 58% with stimulant medication.³¹ Furthermore, college students with ADHD report significantly higher rates of risky sexual behavior than their neurotypical peers across all four years of college, with alcohol and cannabis use further compounding this risk in both medicated and unmedicated groups.³² Therefore, the right course of action should involve timely, evidence-based intervention.

Conclusion

On its surface, this case is unremarkable, with no comorbid conditions, no unusual medical history, and no serious academic failure until the patient’s compensatory resources were finally exhausted. This case shows us that a high-functioning, intellectually capable college student can suffer from a neurodevelopmental disorder whose effects remain invisible until environmental demands exceed his capacity to compensate. First, intelligence does not protect an individual from ADHD; it may simply conceal it. Second, fears about overdiagnosis at the population level should not translate into underdiagnosis in individual cases, with real morbidity consequences of undertreatment for adults and college-aged students. Finally, this case raises a question that extends beyond diagnosis: when we treat ADHD in a gifted individual, are we intervening to optimize an individual’s potential, or merely to prevent societal disruption? For family medicine physicians, the more immediate question may be simpler: are we asking? It may be worth integrating routine ADHD screening into our practice with tools such as the ASRS.¹⁶