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Am Fam Physician. 2021;104(2):141-151

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Approximately 19 million students attend college in the United States. Although they are generally healthy, about 20% of youth have special health care needs, including asthma, diabetes mellitus, and learning, mental health, and substance use disorders. Physicians can facilitate the transition of a youth to an adult model of health care by using structured processes to orient the youth to self-care before entry into college. Stimulant medications are effective for treatment of students with attention-deficit/hyperactivity disorder, but physicians should monitor for signs of drug diversion. Learning disorders may manifest with emotional or physical symptoms and are managed in a multidisciplinary fashion. Depression, anxiety, sleep problems, and posttraumatic stress and eating disorders are common in this population and can affect school performance. Screening and/or interventions for obesity, depression, anxiety, violence, nicotine use, and substance use are effective. Immunizations for influenza, human papillomavirus, meningococcus, and pertussis are crucial in this high-risk population. Lesbian, bisexual, gay, transgender, and queer students have unique health care needs.

Approximately 19 million full- and part-time students were enrolled in U.S. colleges in 2018.1 Although they are generally healthy, many of these individuals have special health care needs such as asthma, diabetes mellitus, mental health concerns, and learning disorders. Understanding and managing the needs of this dynamic population involve addressing the unique psychosocial stressors related to this life transition that manifest before and while attending college. Common self-reported medical conditions among college students are presented in Table 1.2

ConditionFrequency (%)Comment
Allergies53Usual care generally applies; however, self-care of these conditions may be a new experience for some students
Cold/upper respiratory infection37
Orthopedic injury10
Stomach/gastrointestinal illness10
Urinary tract infection9
Mental health and lifestyle conditions
 Anxiety24Overall, 33% of students reported being diagnosed with a mental health condition; 26% of students report receiving mental health counseling
 Attention-deficit and attention deficit/hyperactivity disorders8
 Posttraumatic stress disorder5
 Acne26Usual care generally applies
 Gastroesophageal reflux4
 Diabetes mellitus2
 Heart/vascular disorder2

Transition to College

College students are often assuming responsibility for their health care for the first time; however, the transition from a childhood model of care to an adult model of care is often given a lower priority than other transitions that students are experiencing.3 Approximately 20% of U.S. youth have special health care needs.4 Although many children and adolescents have taken steps to comanage their diseases, most of these youth do not receive a structured transition to an adult care model,5 and the situation is complicated by poor care coordination.3 Students may have to reconcile recommendations from multiple sources of care, such as an ongoing childhood physician and a new clinician at college if living away from home. Physicians may perceive that youth are poorly informed regarding their own health care matters. Simultaneously, some physicians may be poorly informed about patients' childhood conditions that continue into adulthood, such as cerebral palsy and cystic fibrosis.5 Problems with this transition result in declines in treatment adherence, increased emergency department use, and increased hospitalizations.3 Improved adherence to health care, better patient experience, and increased appropriate use of ambulatory services are reported with structured health care transition visits that prepare the student for self-care and help to transfer the student to the adult model of care6 (Table 2).

Meet privately with the patient for part of the visit
Prepare youth and family for transition by encouraging chronic condition management responsibilities (knowledge of conditions, treatments)
Assess readiness for transition and develop transition plan
Implement transition plan with provision of medical records (visits, tests, reports) to patient and family and care coordination with receiving practice
Anticipatory guidance
 Awareness of counseling services
 Chronic health conditions
 College/occupational plans
 Food security
 Functional independence and community inclusion (for students with disabilities)
 Health insurance
 Legal matters (power of attorney, advance medical directive)
 Medical decision-making/privacy at age of majority (state-specific)
 Nutrition and fitness
 Pocket card or electronic medical record of conditions, medications, and immunizations
 Public service (voting rights, selective service)
 Sexuality and relationships
 Substance use, smoking, and vaping

Health Care Coverage

Under the Patient Protection and Affordable Care Act (ACA), students younger than 26 years have four options for qualifying health coverage: coverage under a parent's insurance plan, school-offered health plans, marketplace plans, and Medicaid and the Children's Health Insurance Program.7 Despite these options, 72% of college students and recent college graduates indicate that finding health care coverage remains difficult, and 1.6 million students remain uninsured.8

A parent's insurance plan may be the least expensive option, but it may also limit confidentiality for the young adult because notices of service are sometimes sent to the primary enrollee. Participation in one of the other three options results in bills and explanations of benefits being sent directly to the student. Many school-offered plans do not provide coverage during summer breaks and may leave the student uninsured if other options are not pursued.

Under the ACA, all but the school-offered health plans are regulated by the Department of Health and Human Services. These plans are required to provide the following coverage without an annual or lifetime limit: ambulatory services; emergency services; hospitalization; laboratory tests; maternity and newborn care; mental health care, including substance use treatment; prescription medications; and rehabilitation services.7 Copays for these services vary widely.

Institutions of higher education vary with regard to testing, immunization, and prevention practice, depending on state law and exemption practices, in their health care resources and responses to the COVID-19 pandemic.9

Common Learning and Mental Health Issues

The learning and mental health needs of college students remain a growing concern. College counseling center directors report an increase in the number of students who arrive on campus already taking a psychotropic medication,10 with at least 40% of these directors reporting increases compared with the previous five years of depression and anxiety disorders, learning disorders, sexual assault, and crisis issues requiring immediate responses.11 In colleges, most health center visits (60%) are to primary care clinics, whereas a smaller proportion of these visits (13%) are to mental health clinics.11 Students in higher education are protected by the Americans with Disabilities Act and Section 504 of the Rehabilitation Act12; however, the ACA does not support costs associated with diagnosis and treatment of learning disorders.13 Students should meet with their college office of disabilities to understand school policies and resources and to self-advocate regarding insurance requirements.14

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