ADHD in High School
Literature includes references to ADHD dating back to 1775. In 1845, a German physician wrote a children’s book, Fidgety Phil. The descriptions of the main character match almost exactly the criteria included in The Diagnostic and Statistical Manual of Mental Disorders, first published in 1952. Now in its fifth edition, the DSM-5 diagnostic criteria state:
- Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity for ≥6 months to a degree that is inconsistent with the developmental level.
- Several symptoms were present before the age of 12.
- Several symptoms must be present in two or more settings (i.e., at home, school, or work; with friends or relatives; in other activities).
- Symptoms interfere with or reduce the quality of social, academic, or occupational functioning
- Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication, or withdrawal).
If we have established criteria, then why do school teams have such difficulty specifying how a particular student is impacted and what interventions, remediation, and/or supports are needed?
ADHD isn’t homogeneous. It looks different for everyone, both in terms of brain function and impairment. Related to brain development, prior to age 12, children are more likely to present as hyperactive. At age 13, children are more likely to present as inattentive or combined type. Symptoms may fluctuate daily, making diagnosis and impact statements difficult to summarize. Symptoms may overlap with an array of other mental and physical health concerns, such as anxiety, depression, sleep disorders, brain injury, or thyroid functioning.
How does this affect my student’s learning?
- Attentional capacity: the amount of information that can be held temporarily in memory
- Working memory: hold AND to manipulate information in some way (auditory and/or visual)
- Sustained attention: remain focused for a prolonged period of time
- Selective attention: stay focused in the presence of distractors
- Response inhibition: stop oneself from doing something
- Cognitive flexibility: shift and to refocus on another stimulus or task
- Processing speed: the time it takes to complete simple tasks
How does this affect my student’s emotional regulation, social communication, and friendships?
- Impatience/impulsivity with friends and peers
- “Overreacting” or “underreacting” in response to strong emotions
- Needs more time to regulate and to return to normal after heightened feelings
In the high school classroom, the combination of inattention and difficulty with inhibition control looks like…
- Difficulty listening to lectures
- Difficulty starting/finishing an assigned task
- Difficulty remaining in seat
- Difficulty working collaboratively with peers
- Difficulty completing chores
- Difficulty completing self-care tasks
- Difficulty making and keeping friends
- Prospective memory (i.e., "when I get home, I need to...")
- Issues with time
- Preferential seating: One of the most commonly written classroom accommodations. However, on its own, it’s not a particularly useful strategy. It can be helpful when it’s part of a broader combination of accommodations
- Testing in a separate location: This is dependent upon a student’s distractibility. Some need the direct support of an adult to sustain attention or to return to task.
- Noise canceling headphones: Can be very helpful in reducing environmental noise
- Extended testing time: The most common accommodation in IEPs and 504s. Research is mixed. Executive functioning deficits mean students with ADHD don’t make good use of time. However, if a student with ADHD also has reading comprehension difficulties, they are more likely to benefit from additional time
Interventions vs Accommodations
Both are helpful, but interventions generally lead to better long-term outcomes. Common examples in teaching notetaking vs providing a copy of teacher notes and organizational training vs helping organize a binder. Consider social skills training combined with real-world reminders and feedback in real time. Cognitive/behavioral training helps to build organization, planning, compensatory strategies to manage distractibility, building flexible thinking and problem solving. Parents may need support to help establish rules, set expectations, create home routine, and to better implement positive reinforcement. Outside of the school setting, some studies suggest that daily cardio exercise helps attention and memory. Also important is sleep hygiene to improve bedtime resistance, falling asleep, staying asleep, waking up on time, and to reduce feeling sleepy during the day. Better sleep = better emotional/behavioral regulation and better working memory.