How well do you really understand ADHD?
After years of debate, dispute and scepticism, few people today question the existence of attention deficit hyperactivity disorder (ADHD). Although the condition is widely perceived to be a modern epidemic, anthropologists now believe it may have been around since prehistoric times, when adventurous, restless, impulsive spirits would have made for excellent hunter-gatherers. Unfortunately these traits are less helpful in the 21st-century classroom, where it is estimated that half a million schoolchildren in the UK are affected by ADHD.
In primary schools, ADHD tends to manifest itself through hyperactivity, a short attention span and impulsive behaviour. If ADHD is undiagnosed and unsupported, by the time a student reaches young adulthood the condition can lead to academic difficulties, anxiety, depression, self-harm, increased risk of substance misuse and offending. The statistics are stark:
l Some 40 per cent of pupils with ADHD are given fixed-term exclusions and 11 per cent of these young people go on to be excluded permanently.
l The Youth Crime Action Plan identifies ADHD as one of the primary risk factors in criminal offending during childhood.
l Almost half of people with ADHD suffer from long-term mental health problems.
l Research suggests that as many as one in five of those with ADHD will attempt suicide at some point in their lives.
Yet with early diagnosis and good management, there's no reason that children with ADHD can't go on to achieve great things and live happy, fulfilled lives. In fact, channelled in the right way, those very characteristics with the potential to create mayhem in the classroom can form the foundations for adult success - read what comedian Rory Bremner has to say on the subject (see panel, page 36). ADHD doesn't correlate with low intelligence, just low attainment. We need to tackle the myths around the condition, starting with the five misconceptions below.
Myth 1 ADHD is bad behaviour
Although bad behaviour is usually what prompts a diagnosis of ADHD, the behaviour is a symptom of an underlying cognitive impairment.
People with ADHD have poor regulation of dopamine, a transmitter in the brain linked to learning, memory and motivation. Studies have also shown that the areas of the brain responsible for controlling excitability, impatience and impulse are underdeveloped in those with the condition.
Bad behaviour is not an inevitable result - many children with ADHD are perfectly compliant. But imagine how it feels to be a four-year-old with ADHD arriving in the classroom. A hyperactive nervous system makes it impossible for you to sit still. Concentration and focus are difficult. Poor memory skills make it hard to take in instructions. Repeated failure and censure erode your natural love of learning.
In essence, the classroom and school environment can become a source of stress for these pupils: the bad behaviour that is widely perceived as "being" ADHD is actually their response to this stress.
Myth 2 ADHD is a solo diagnosis
In 70 per cent of cases, ADHD occurs alongside another condition, for example autism, dyslexia, dyspraxia, Asperger's syndrome or sensory processing disabilities. It is estimated that 40 per cent of children with autism have the disorder. And approximately 25 per cent of children with ADHD also have dyslexia.
Myth 3 ADHD results from bad parenting
The latest research suggests that ADHD is actually a genetic condition that is 80 per cent heritable. Many parents of a child with ADHD have been found to have the condition themselves (often undiagnosed), and siblings are four or five times more likely to have it than other children.
However, the severity of a child's symptoms will depend on a combination of genetic potential, environmental factors and their early life. In short, bad parenting doesn't help. Parenting a child with ADHD requires a unique set of skills, but help for parents is often hard to come by.
Myth 4 ADHD affects only children
ADHD is a lifelong condition, making it a huge issue for the whole education sector, from nurseries to sixth-form colleges and beyond. Symptoms of hyperactivity tend to diminish in a person's late teens. However, research suggests that up to 60 per cent of adults with ADHD will still behave impulsively, lack focus and struggle with working memory.
This potential lifelong impact increases the moral imperative to ensure that children are diagnosed early and equipped with the knowledge and skills to self-manage their condition into adulthood. Without this support, sufferers will have an increased risk of school failure, mental health difficulties and problems accessing further education or employment.
Myth 5 Medication is the answer
All too often, medication is the only support available for children with ADHD. There is overwhelming evidence that psychostimulant medication alleviates symptoms, moderating impulsive and inattentive behaviours and resulting in improved school performance. However, as many as 80 per cent of teenagers become non-compliant with medication by the age of 15, so alternative and longer-term solutions must also be sought.
Children with ADHD, and their parents, need to be trained to understand how their brains work differently and what strategies they can use to manage the condition. Guidelines from the National Institute for Health and Care Excellence (Nice) suggest that medication should be reserved for those with the most severe symptoms, and a greater focus placed on family support, group-based interventions and cognitive behavioural therapy. Even pharmaceutical companies agree that ADHD medication should not be the only treatment.
The worry is - in the context of overstretched NHS resources and cuts to mental health services - where is the crucial support going to come from? Here are five things schools can do for ADHD sufferers.
1 Provide better training for teachers
The challenge for teachers is to distinguish between inappropriate behaviour and behaviour resulting from ADHD. This can be even harder in girls with ADHD, who are likely to be inattentive but compliant. The current ratio of boy-to-girl diagnosis is 4:1, but research suggests that many girls with ADHD pass under the radar until adolescence, when they frequently present with mental health problems such as self-harm.
At the ADHD Foundation, we believe that training Reception and Year 1 teachers to better identify ADHD
behaviour would make the greatest difference to the long-term well-being of affected children. Intervention within the first year of starting school can transform a child's educational prospects - at the moment the average age of diagnosis is 9.
2 Be proactive about getting help
The gradual dismantling of local authority control of schools in England and the support network this used to provide - including educational psychologists, social workers and behaviour support services - is leaving a vacuum that schools are struggling to fill. They are going to have to embrace the culture of buying in specialist support services if the needs of pupils with ADHD are going to be met in the future.
3 Work closely with parents
Parenting a child with ADHD is extremely challenging; remember that a high proportion of these parents are likely to have ADHD themselves.
A collaborative partnership between school and home provides the most effective support, with parents and teachers sharing approaches, strategies, stories and successes. Offer parenting programmes and work with parents on learning strategies, so the whole family can support their child's academic attainment and reinforce behaviour messages at home. When the pupil does something well or behaves in a way that is conducive to cooperative learning, make the effort to call or write to parents to inform them of their child's achievements.
4 Provide curriculum and exam support
Focus on the positives and take a personalised approach to the curriculum for pupils with ADHD. Just as pupils mustn't be allowed to use their condition as an excuse for poor behaviour, schools must not use it as a reason for underachievement.
Individuals with ADHD often excel in sport and the arts - physical activity and creativity are also good outlets for hyperactivity and can have a positive effect on behaviour. A personalised or alternative curriculum (designed with the individual's strengths in mind) will give pupils the greatest possible chance of success.
Performance anxiety in exams is often a major stumbling block for pupils with ADHD and can lead to poor test results. When pupils are taking exams, de-stress the situation by breaking down what they need to learn into bite-sized chunks. Learning posters for the bedroom wall will help to improve their ability to remember key information.
5 Make your teaching ADHD-friendly
Read all the available information on your pupils with ADHD - their profiles, personal learning plans and so on - so that you understand how the condition affects them and can differentiate appropriately.
Make sure you know the difference between unintentional ADHD behaviours and unacceptable behaviour. Draw attention to the actions that are conducive to learning through repeated praise and encouragement - structure and routine can also reduce anxiety. Sit affected pupils at the front of class, away from distractions such as windows and doors, use movement in your lesson plans as much as possible and have spare copies of any pupil-friendly learning plans and timetables so that you can constantly remind them about lesson objectives and homework. Try not to rely on verbal instruction: support tasks with clear written instructions and ask the pupil, in an encouraging way, to repeat back what they need to do.
A common mistake is to let pupils with ADHD get away with bad behaviour, but it does young people no favours to let them think that the school rules don't apply in their case. They have to learn how to self-regulate so that they can manage their ADHD in the future. Always explain choices and consequences so that the pupil understands they are personally responsible for any sanctions imposed.
Dr Tony Lloyd is chief executive of the ADHD Foundation
A helping hand
The ADHD Foundation provides support for young people with ADHD across the UK, improving their life chances by working with individuals, their families, doctors, the youth justice system and teachers. For more information, go to www.adhdfoundation.org.uk
The ADHD Foundation is a Comic Relief-funded project. Red Nose Day will take place on 13 March and the money raised will help to fund projects like this in the UK and Africa. To find out more and to order your free schools fundraising resource pack, visit www.rednoseday.comtes
ADHD and me
The many talented, high-profile individuals with ADHD show that those affected by the condition can lead happy and successful lives. Here, comedian Rory Bremner and Paralympic judo hopeful Jonathan Drane share their experiences.
Rory Bremner: I've lived with ADHD all my life. It's just taken me most of my life to realise it.
I assumed I was normal. I thought that taking on too much, getting distracted, and being impetuous, hyperactive and inattentive were symptoms of my frantic life, not the cause.
A glimpse at my school reports is enough to confirm that I was always this way.
"I'm a bit of a chameleon," I told a therapist once. "Then you shouldn't sit on a patchwork quilt," he replied. Genius. I realised later that he was the well-known psychiatrist Arthur Hyatt Williams.
Similar, although less original, analogies have been applied: tuning into lots of channels simultaneously, mind like a pinball machine, flibbertigibbet and so on. All of them fit.
For a child in class, such mental overload and so many distractions make it almost impossible to settle and learn, and each failure or reprimand damages the self-esteem.
Yet, by the same token, a constantly shifting mind is incredibly creative: making connections, jumping boundaries, chasing thoughts. Attention deficit? Attention surfeit, more like. As a comedian, ADHD is my best friend and my worst enemy. It launches flights of imagination but hinders the organisation of them (or me). Oysters produce pearls when a foreign object invades their shell. Do I really want to be cured?
Jonathan Drane: My diagnosis was the result of exhaustive efforts by my mother, who was desperately trying to keep her son in a school that seemed content with the perception that I was "just another disruptive child".
In retrospect, it troubles me that there was not a protocol before and after I was diagnosed. However, at the age of 15, when I was finally armed with a diagnosis, the school had no choice but to allow greater flexibility and a partial lifting of the stigma attached to my behaviour. As a result, this gave my family some time to manage me and prepare for the rapidly diminishing opportunity left for my education.
I believe that my experiences have made me robust. That is not to say that I'm not anxious - far from it - but, in a sense, my childhood conditioned me to expect certain things. Perhaps having been so frequently defined by my errors became my stage for proving those people wrong. And I am always poised with a funny story to tell about just how wrong I can get things.
Sport has been a great way of helping me to self-regulate my ADHD. And although I am now losing my sight, it hasn't stopped me from achieving a place in the Team GB Paralympics team. I aim to compete in Brazil in 2016.
Read this guide for more practical more advice on teaching students affected by ADHD.