The Educational Pathway

Imagine everyone's got a bit of chewing gum on their head and, in order to understand a question, they write it down on a little piece of paper and put it on the chewing gum. It sticks and you can read the question in your head and write down the answer. Well, regardless of how easy the answer is, I will pick it up, put it on my chewing gum and it will fall off, because my chewing gum is not sticky, and I will pick it up, put it on, it'll fall off, and I will have to proper push it into the chewing gum for it to stay there.

As well as managing the core symptoms of ADHD, those with persisting symptoms often experience impairment throughout other areas of their lives. Indeed, functional problems in at least two life areas are required to meet diagnostic criteria for ADHD. This module is on the topic of education, which is especially important in adolescence as it paves the way for later employment.

Young people experience several changes during their years of education. They may change school when they move from junior to secondary school, and again after GCSE examinations. At this stage some may seek employment, while others will go on to study for A-levels or other qualifications such as diplomas or BTECs. They may pursue training through NVQ or apprenticeship schemes to gain the experience required for skilled occupations (e.g. electrician, plumbing, catering). Still others attend further education establishments to pursue academic goals at university or college. After this, some go on to complete post-graduate studies.

Between 16-18 years teenagers undergo important educational transitions and make decisions about their future careers. For those who continue to study, achieving their academic potential continues to be a struggle and some will opt out of further education and enter the job market with mixed success. Indeed, ADHD has been associated with a number of negative educational outcomes, including being less likely to graduate from College or High School [1] (see Figure 1). It has been associated with educational underachievement including lower exam-grade attainment, repeating academic years, higher rates of school drop-out, greater remedial support and/or special education, and a history of suspension or expulsion [1-5]

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The risk of academic failure is greatest for those whose ADHD symptoms are unidentified. Too many ADHD children, especially those with predominantly attentional problems, still fall under the radar. Those attending selected private educational establishments, and/or whose impairments are minimised due to high levels of parental support, may also be missed. Their difficulties may become more apparent in secondary school when they are expected to work more autonomously and manage a larger and more complex workload.

Academic Progress

In younger children, the transition to middle school has been shown to hinder and even briefly reverse the decline in symptoms that may be seen with age [6], and equivalent educational transitions may arise during the teenage years when moving to secondary school, college or university.

During adolescence, hyperactive and impulsive symptoms often remit earlier than symptoms of inattention. This may parallel a narrowing of the curriculum when young people select fewer subjects of interest to study and hence may perform better. Thus young people may appear to improve as their ADHD presentation becomes less overt. Nevertheless persisting (perhaps sub-threshold) symptoms may remain and cause disruption to others (e.g. by constant fidgeting, confrontational behaviour, speaking out without thinking, talking too much and/or ‘acting the clown’). Behavioural disturbances of this nature are most likely to lead to sanctions such as detention and internal exclusion from lessons. Persistent, severe disruption, oppositional behaviour and/or emotional outbursts may result in school exclusions and, for some, expulsion.

Unsurprisingly, frequent suspensions and/or permanent exclusion significantly disrupt a young person's education. Compared with their peers, ADHD children are 100 times more likely to be permanently excluded from school; research suggests that 39% of ADHD children receive fixed-term exclusions from school and 11% are excluded permanently [7]. These exclusions, together with impairment in school performance and the need to re-sit exams and/or repeat years, can mean that these young people take longer than their peers to graduate or to gain qualifications.

Excluded children are commonly schooled in Pupil Referral Units (PRUs), and around 75% of PRU children have special educational needs, many of whom have difficulties associated with ADHD [8]. Ironically, many ADHD children benefit from the PRU system, which provides smaller class sizes, greater individual attention, minimisation of noise/distraction, greater structure and individual education plans and/or self-development plans. Other children with severe ADHD impairment and additional special educational needs will attend special schools, which provide a similar learning environment but with peers at a more equal academic level.

Academic Performance

Students are expected to attend class punctually, sit still, focus on the topic, take notes, collaborate with peers in group exercises, and work quietly without disturbing others.

Symptoms of inattention, which are most likely to persist, mean that young people often struggle to maintain their focus on tasks and sustain attention in class. They are easily distracted and experience interruption to their train of thought. This interferes with their ability to express themselves in a logical and coherent way. They may become preoccupied with lots of thoughts and ideas that are peripheral or unrelated to the topic. This flooding of thoughts or ideas may be functional in terms of creativity but it is tiring and often described as a ceaseless mental activity.

Loss of focus is most likely to occur when engaged in 'tedious' or repetitive tasks, or those with complex concepts that are difficult to understand. In response, the young person with ADHD may 'switch off' and start to 'daydream' or doodle. This may be perceived as a lack of effort. Children attending large, mainstream, comprehensive schools with characteristic large classes including children of mixed ability, will struggle more than children who are fortunate to attend selective, private education, which typically provides smaller class sizes and greater teaching support for a more academically homogenous group.

I was always bright. I was never slower than other students. I was always just as quick and clever as the top of the class but I couldn't put it on paper.

Poor organization skills are a major problem throughout higher education. The issue, however, is that children with ADHD 'can't' as opposed to the (erroneous) perception that they 'won't' organise themselves and do the work. This is frustrating for all parties, and leads to anxiety for the student, feelings of embarrassment and failure, and negative comparisons of self to others.

These problems increase in adolescence as young people take greater responsibility and autonomy in their school work and career, and are often expressed by them arriving in class without the correct books or kit. Outside of class students are expected to organise their time so they complete homework assignments and meet course deadlines.

Due to their ADHD symptoms, learning and revision skills do not come naturally to the young person with ADHD as it takes sustained effort and motivation to cope with work demands. Furthermore, they have to apply themselves against a backdrop of increasing educational demands and expectations, with timetables becoming more complex, examinations more important, and greater autonomy being expected of them. Most likely they will receive less parental support in preparing for the school day, travelling to and from school, and with homework.

School and Classroom Interventions

Research has suggested that lifetime ADHD symptoms are a key predictor of academic performance (as measured by GCSE performance, GCSE entries, and GCSE weighted score) [9]. While supported or special education may enable students with ADHD to get more out their lessons, these young people are disadvantaged in test and exam situations as they may sacrifice accuracy for speed or use the time inefficiently. Co-morbid difficulties such as anxiety will further exacerbate symptoms and impair performance.

Teachers usually have an awareness of how basic cognitive ability or 'intelligence' relates to academic performance, but they may be less aware of how ADHD hampers academic performance.

I used to have this little card thing. If I wanted to go out for a break I'd show it to the teacher and I used to be able to leave the class and go up to the [inclusion] room.

Those with special educational needs and/or ADHD may be entitled to special arrangements in examinations. Guidelines are set by the Joint Council for Qualifications and it is not the difficulty per se that gives the right to special arrangements, rather the extent to which the difficulty might impair the child in an exam situation. For young people with ADHD, common recommendations include a prompter, supervised breaks/rest periods, and extra time (which may range from 10-25%). Other potential arrangements, depending on circumstances, may be the use of computers or word processors.

In addition, classroom provisions can be made. The NICE guidelines [10] recommended that behavioural interventions could be provided in the classroom, by teachers trained in the management of ADHD, to help children and young people with ADHD. Evidence from expert opinions and clinical experience of respected authorities suggests that classroom interventions may particularly help to reduce off-task behaviours if they are provided as part of a multimodal treatment plan. Indeed, a review of the literature identified a need to provide psychoeducational information about ADHD in educational establishments, including information about management strategies that can be implemented in the classroom (see Box 1) [11].

Box 1: Recommended classroom interventions and management strategies for treating ADHD in adolescence [11]
  • Provide psychoeducational information, environmental and management strategies adapted for this developmental age group, e.g., use of a Weekly Report Card instead of a Daily Report Card; tickets or certificates of achievement can be issued to reward good behaviour and/or achievement; report tickets can be awarded for breaking predetermined rules; teach study skills, including test-taking strategies; implement homework completion sessions; reward systems can be extended to introduce longer-term rewards (the accumulation of several small rewards can be exchanged for a larger desired reward).
  • Establish regular sessions attended by parents, teachers and counsellors initially to identify the child's needs and formulate an intervention plan and subsequently to monitor and evaluate the progress of the intervention programme (including addressing any obstacles that may arise).
  • Implementation of individualised programmes if the child does not respond to standard treatment, e.g., provision of one-to-one support, remedial and/or revision sessions, if appropriate.

If young people with ADHD are to reach their potential and achieve academic success, educational establishments need to develop greater awareness about ADHD and how this may impede academic progress. Indeed for the first time, NICE guidelines included representation from education on the Guideline Development Group, which emphasises the importance of joint working with the educational sector for this patient group. In particular, children who receive fixed-term exclusions from school should be assessed for ADHD, and this could be introduced through greater involvement of Special Educational Needs Co-ordinators (SENCOs) and referrals to educational psychologists. The provision of school and classroom interventions may support many young people to succeed in mainstream education.

Key Points from Module 4

Box 2: Key points from Module 4 - ADHD and Education
  • ADHD is associated with educational underachievement including lower exam-grade attainment, repeating academic years, higher rates of school drop-out, greater remedial support and/or special education, and a history of suspension or expulsion.
  • Symptoms of inattention, which are most likely to persist, mean that young people often struggle to maintain their focus on tasks and sustain attention in class.
  • Poor organisational skills are a major problem throughout higher education.
  • As they grow up, symptomatic remission of hyperactivity and impulsivity, together with a narrowing of the curriculum, means their academic skills may superficially appear to have improved.
  • ADHD children may benefit from selective private or special educational systems which typically provide smaller class sizes and greater teaching support for a more academically homogenous group.
  • ADHD students may be entitled to special arrangements in examinations such as a prompter, supervised breaks/rest periods and extra time.
  • Classroom interventions that are provided as part of a multimodal treatment plan are considered by expert groups to be beneficial.

References

[1] Barkley, R.A., Murphy, K.R., & Fischer, M. (2007). ADHD in adults: What the science says. New York: The Guilford Press.

[2] Barbaresi, W.J., Katusic, S.K., Colligan, R.C., Weaver, A.L., Jacobsen, S.J. (2007). Long-Term School Outcomes for Children with Attention-Deficit/Hyperactivity Disorder: A Population-Based Perspective. Journal of Developmental and Behavioral Pediatrics, 28(4), 265–273.

[3] Bauermeister, J. J., Shrout, P. E., Ramirez, R., Bravo, M., Alegria, M., Martinez-Taboas, A., et al. (2007). ADHD correlates, comorbidity, and impairment in community and treated samples of children and adolescents. Journal of Abnormal Child Psychology, 35(6), 883–898.

[4] Biederman, J., Faraone, S. V., Taylor, A., Sienna, M.,Williamson, S., & Fine, C. (1998). Diagnostic continuity between child and adolescent ADHD: findings from a longitudinal clinical sample. Journal of the American Academy of Child and Adolescent Psychiatry, 37(3), 305–313.

[5] Frazier, T. W., Youngstrom, E. A., Glutting, J. J., & Watkins, M. W. (2007). ADHD and achievement: metaanalysis of the child, adolescent, and adult literatures and a concomitant study with college students. Journal of Learning Disabilities, 40(1), 49–65.

[6] Langberg, J.M., Epstein, J.N., Altaye, M., Molina, B.S.G., Arnold, L.E., & Vitiello, B. (2008). The Transition to Middle School is Associated with Changes in the Developmental Trajectory of ADHD Symptomatology in Young Adolescents with ADHD. Journal of Clinical Child and Adolescent Psychology, 37(3), 651–663.

[7] O’Regan, F. (2009). Persistent disruptive behaviour and exclusions. ADHD in Practice, 1(1), 8-11.

[8] Department for Children, Schools and Families. (2008). Back on track: a strategy for modernizing alternative provision for young people. Command Paper; Cm 7410.

[9] Birchwood, J., & Daley, D. (2012). Brief report: The impact of Attention Deficit Hyperactivity Disorder (ADHD) symptoms on academic performance in an adolescent community sample. Journal of Adolescence, 35(1), 225-231.

[10] National Institute for Health and Clinical Excellence (NICE). (2009). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. NICE Clinical Guideline 72. London.

[11] Young, S., & Amarasinghe, J.M. (2010). Practitioner Review: Non-pharmacological treatments for ADHD: A lifespan approach. Journal of Child Psychology and Psychiatry, 51(2), 116–133.

Further Reading and Useful Resources

Young, S., Murphy, C.M., & Coghill, D. (2011). Avoiding the ‘twilight zone’: Guidance and recommendations on ADHD and the transition between child and adult services. BMC Psychiatry. 11:174, dx.doi.org/10.1186/1471-244X-11-174

Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A Psychological Guide to Practice, Second Edition. Chichester: John Wiley & Sons.

Young, S. (2013). The ‘RAPID’ cognitive behavioral therapy program for inattentive children: preliminary findings. Journal of Attention Disorders, 17(6), 519-526.

Young, S., Fitzgerald, M., & Postma, M.J. (2013). ADHD: making the invisible visible An Expert White Paper on attention-deficit hyperactivity disorder (ADHD): policy solutions to address the societal impact, costs and long term outcomes, in support of affected individuals, www.europeanbraincouncil.org/pdfs/ADHD%20White%20Paper_15Apr13.pdf

Special exam arrangements: jcq.org.uk/exams_office/access_arrangements/

ADHD and the school day: www.addiss.co.uk/schoolreport.pdf

Practical advice for dealing with ADHD in schools (for parents and teachers): www.education-support.org.uk/parents/special-education/adhd/