Introduction
According to the Diagnostic and statistical manual of mental disorders: DSM-5 (American Psychiatric Association, 2013), which is the most commonly used diagnostic manual in the United States, Attention Deficit Hyperactivity Disorder (ADHD) is a “neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity” (p. 32). Inattention and disorganization include difficulties with staying on task, listening, and losing things, more frequently than others in that age or developmental level. Hyperactivity-impulsivity includes compulsive moving, fidgeting, challenges with staying seated, interrupting others, and difficulty with waits—once again, more than it is normal for that specific age or developmental level. According to the manual, during the early years, there is frequent overlap between ADHD and disorders such as oppositional defiant disorder and conduct disorder. Many times, ADHD will continue into adulthood, causing difficulties in social, academic and occupational functioning (American Psychiatric Association, 2013).
ADHD in adolescents is relatively a common phenomena: 5%–10% of adolescents in the US are diagnosed with ADHD (Centers for Disease Control, 2013 in Sibley, Altszuler, Morrow & Merrill, 2014); However, the efficacy of today’s primary treatments and approaches is not high enough to prevent 38% of the adolescents with ADHD to drop out from high school (Barkley et al., 2002 in Sibley, Altszuler, Morrow & Merrill, 2014). This lit review aims to answer two questions: What contributes to the low academic results of adolescents with ADHD, and what is the efficacy of the methods that are being used today to help them with their academic struggle.
This lit review explores these questions through the lens of a strengths-based framework, reviewing the history of the definition of ADHD, providing an updated view of ADHD, examining the specific academic challenges that adolescents with ADHD experience and how the education system and family systemically contribute to their struggle with ADHD. The review then continues to explore the efficacy of today’s pharmaceutical and psychosocial treatments for adolescents with ADHD and ends with a conclusion.
Theoretical Framework
The two very different lenses through which this lit review explores the challenges of ADHD in adolescents and its treatments are the medical approach that is behind the DSM and the strengths-based approach. In the center of the therapies that are built on strength-based approaches is the guiding principle that emphasizing and cultivating the client’s strengths facilitates a change in the client’s negative pattern of thinking, feeling and behaving. These changes can occur since the focus is shifting the attention of the client away from the problem which allows the personal story to change by acknowledging personal strengths, talents and skills (Seligman, 1988; Snyder, & Lopez, 2006 in Bowles, 2013).
This strengths-based approach moves away from the more common medical approach in psychology that revolves around problems and pathologies and sees the solution for these in focusing on these problems and exploring them in detail:
Psychology is typically viewed as a pathology-focused profession. Individuals seek psychological support when something is wrong or when there is an issue that needs to be ‘solved.’ Graduate-level psychology programmes emphasize courses in child and adolescent disorders, child psychopathology and clinically-based interventions for psychological disorders. Much research effort and focus are devoted to understanding how and why individuals experience distress and what can be done to ameliorate these concerns. (Climie & Henley, 2016).
Even though it is essential to understand the challenges and the difficulties that the client faces and categorization of the symptoms such as in the DSM V might be very helpful. A lot is lost if the focus is only on the negative, while the successes and strengths are not discussed and not celebrated. For example, in the case of psychoeducational assessments of children in schools, the results of these assessments will affect the way that the children view themselves, as well contribute to the way that their parents and their teachers view them. Adverse reports often lead to parents’ discouragement and contribute to feelings of helplessness in the teachers since they do not actually include enough information of what can be done to help their students (Buckley & Epstein, 2004; Lebeer et al., 2012 in Climie & Henley, 2016). These negative effects tend to have the opposite results of what was intended: Learning and development tend to be inhibited (Lebeer et al., 2012 in Climie & Henley, 2016). In fact, research shows that when compared to problem-focused assessments, strengths-based assessment (SBA) is the preferred type of approach; It leads to higher parent satisfaction, fewer missed appointments, and better academic outcomes for students (Cox, 2006 in Climie & Henley, 2016). Although the evidence for the efficacy of strengths-based approach is ample, and while during the past two decades, a more person-focused positive view has been implemented when working with individuals, this is approach is still very much in the sidelines (Seligman & Csikszentmihalyi, 2000; Tedeschi & Kilmer, 2005 in Climie & Henley, 2016).
The History of the Definition It is important to remember that like all other mental disorders, ADHD is merely a definition, a cluster of statistical symptoms combined to give a group of phenomenon a name, to make it easier to provide a clear and effective treatment. The definitions of mental disorders are very much dependant on the people who created them, on the culture, the location, and the period when the definition was made. Definitions tend to change with time, and the fifth edition of the DSM is very much different than the first edition.
Crosby and Lippert (2017) emphasize the significant changes in perception and understanding of what we know today as ADHD and the way it is reflected in the many names that it had. The first definition in use was “brain-injured child syndrome” (p. 9). We can see that at the beginning it was more viewed as a children-related disorder, heavily emphasizing the defect. Gradually, the medical community shifted from viewing ADHD as a result of a defective brain, moving from “minimal brain damage” to “minimal brain dysfunction” and then to “hyperactive child syndrome.” Only in 1980, the mental health community renamed it “attention deficit disorder” (ADD), and seven years later it changed once again to “attention-deficit hyperactivity disorder” (ADHD), which is still in use today (Matthews, Nigg, & Fair in Crosby & Lippert, 2017).
Beyond the DSM: A Fresh Look at ADHD
The language we use can influence the way we see the world, and the word “deficit” within today’s definition of ADHD seems to create some confusion around understanding what ADHD means. To say that there is a “deficit” of attention for those with ADHD misses the point entirely (Hallowell & Ratey in Crosby & Lippert, 2017). There is plenty of attention present in the experience of ADHD; The challenge is not with a lack of it, but with the fact that it tends to follow whatever is most interesting at the moment. Actions and attention tend to gravitate towards activities that promise the most significant short-term reward, thus making it extremely difficult to focus on whatever feels boring, even if there is a long-term reward for doing these activities.
Crosby and Lippert (2017) suggest that because of the mental health field’s own biases, “the diagnostic criteria for ADHD highlight what your attention’s biased against, what it moves away from. It’s largely missing the other side of this—what your attention’s biased toward, what it moves to.” (p. 10). If someone with ADHD cannot focus on doing their homework, or pay their bills, or wash the dishes, it is not because they are lazy, or lack of motivation; Their attention tends merely to shift from doing tasks that might feel tedious and not exciting, towards what feels like fun and easy in the moment: Watching their favorite TV show, playing video games, or being on Facebook on their phones. What happens is that the actions that people with ADHD will take will be based on their attention, and this way, an important bill that needs to be paid might be forgotten in favor of playing the guitar for example (Crosby & Lippert, 2017). Needless to say, the consequences of this extremely strong urge to procrastinate and avoid following through with what feels would be a long of effort of sustaining attention on mundane activities, might lead to very real negative consequences: Poor academic or workplace performance, conflicts with family members or the partner, and lower self esteem (Crosby & Lippert, 2017; Sibley, Altszuler, Morrow & Merrill, 2014).
What makes the efforts of attention and action regulation in ADHD even more difficult, is the fact that are multiple stages of the regulation, with each stage presenting its challenges. The fours stages of attention and action regulation according to Crosby and Lippert (2017) are: Starting, sustaining, shifting and stopping. So if for example, an adolescent with ADHD needs to do their homework, there are a few different stages that they need to navigate successfully. First they need actually to start, before due date, then they need to sustain the attention and not to get distracted, then they need to shift to other things that need to be done, and stop doing the task on time, when they need for example leave home to make it on time to an appointment.
ADHD in Adolescents Even though historically ADHD was viewed as a childhood disorder, the consensus now is that ADHD also affects adolescents and adults (Molina et al., 2009; Wolraich et al., 2005 in Sibley, Altszuler, Morrow & Merrill, 2014). The symptoms of this neurodevelopmental disorder look similar in adolescents as in other ages: They often include signs of higher levels of inattention than their peers, overactivity, and low impulse regulation (APA, 2013 in Sibley, Altszuler, Morrow & Merrill, 2014). While all ages share similar challenges with ADHD, the impact of ADHD on Adolescents can be seen mostly in the academic functioning domain (Robin, 1998; Wolraich et al., 2005 in Sibley, Altszuler, Morrow & Merrill, 2014). Sibley, Altszuler, Morrow & Merrill (2014) list the many academic impairments that adolescent students with ADHD are experiencing when compared to their peers that do not struggle with challenges of ADHD: Lower performance on standardized achievement tests (Barkley et al., 1991 in Sibley, Altszuler, Morrow & Merrill, 2014), lower number of assignment completion (Barkley, Anastopoulos, Guevremont, & Fletcher, 1991; Kent et al., 2011; Weiss & Hechtman, 1993 Sibley, Altszuler, Morrow & Merrill, 2014), lower course grades (Barkley, Fischer, Smallish, & Fletcher, 2006; Kent et al., 2011), higher rate of absence from school (Barbaresi, Katusic, Colligan, Weaver, & Jacobsen, 2007 in Sibley, Altszuler, Morrow & Merrill, 2014), higher rate of being late to classes (Kent et al., 2011 in Sibley, Altszuler, Morrow & Merrill, 2014), as well as higher likelihood of suspension due to disciplinary incidents (Barkley, Fischer, Smallish, & Fletcher, 2002 Sibley, Altszuler, Morrow & Merrill, 2014). These many challenges lead to the typical outcome of failing in classes (Barkley et al., 1991, 2002, 2006; Kent et al., 2011 in Sibley, Altszuler, Morrow & Merrill, 2014), which in turn puts adolescents with ADHD at a much higher risk of high school dropout (Barbaresi et al., 2007; Barkley et al., 2006; Kent et al., 2011 in Sibley, Altszuler, Morrow & Merrill, 2014): Some estimate that up to 38% students with ADHD, or in other words one in three will dropout of high school as a result of academic failure (Barkley et al., 2002 in Sibley, Altszuler, Morrow & Merrill, 2014).
To better understand the high impact that ADHD has in on students in high schools, it is equally important to explore the systemic academic structures that might be contributing to these unfortunate outcomes. Although the first signs of academic struggle of individuals with ADHD starts in childhood (Barkley et al., 2006; Fischer, Barkley, Fletcher, & Smallish, 1993; Langberg et al., 2011; Lee & Hinshaw, 2006; Miller & Hinshaw, 2010 in Sibley, Altszuler, Morrow & Merrill, 2014), the challenges seem to intensify after transitioning to secondary school (Langberg et al., 2008 in Sibley, Altszuler, Morrow & Merrill, 2014). While advancing in their journey in school, students are beginning to face new requirements and learning environments; In middle and high school, as opposed to elementary school, adolescents are required to participate in multiple classes every day, when the majority of the academic work is expected to be done outside of school (Eccles, 2004 in Sibley, Altszuler, Morrow & Merrill, 2014). The amount of attention and time given to individual students subsides as well (Benner & Graham, 2009 in Sibley, Altszuler, Morrow & Merrill, 2014) at the time when increased expectations of independence from the students by their parents lead to less homework supervision and academic support (Cooper, Lindsay, & Nye, 2000 in Sibley, Altszuler, Morrow & Merrill, 2014). Since these structures and trajectories gradually increase the importance of the skills that are required for self-disciplined independent studies, it is not surprising that students with ADHD that have challenges with attention and action regulation find themselves in a vacuum; While the pressure increases, they have found themselves with less and less supervision and support.
Given the vast significance that academic performance has on the lives of adolescents, their self-esteem, the relationships with their parents, as well as further success in life, it is crucial to understand ADHD better, and to examine the current ways to treat ADHD critically; 38% of academic failure can be viewed as red flag pointing to the possibility that today’s theoretical frameworks of treating ADHD in adolescents might be outdated, or just were never efficient enough. Furthermore, one might say, that today’s western education system is setting students with ADHD to failure and that even if the best treatments will be identified and implemented, there is still a dangerous systemic problem with prevention of academic failure with this population.
Treatment The treatments for ADHD can be categorized into two main categories: pharmaceutical treatments and psychosocial treatments. The National Institute of Mental Health Multimodal Treatment of ADHD Study (The MTA Cooperative Group, 1999 in Prevatt & Levrini, 2015) found that psychosocial treatments, when combined with medication, showed the best results for individuals with ADHD.
Pharmaceutical Treatments Since medication is the most commonly used method of treating ADHD in adolescents, it is crucial to review the long-term efficacy of the medical treatment that is associated with academic performance. Langberg & Becker (2012) reviewed studies that were published since 2000 that followed youth with ADHD for three years or longer. They focused on several academic areas: School grades, achievement test scores, and grade retention. Although the studies they reviewed showed a correlation between long-term medication use and improvements in standardized achievement scores, they found that the size of these improvements was insignificant and that the educational and clinical benefits were questionable. Furthermore, beyond the low levels of success of the pharmaceutical approach, Dosreis & Myers (2008) talk about the widespread reluctance of parents to medicate their children who struggle with ADHD, mainly because of the stories they hear about the possible side effects of the medication. These two studies raise a question: If there is such a large gap between the most widely used method to support adolescents with ADHD and the actual low results, as well as the high resistance of the parents with going this route, why is it still the default way to treat ADHD, or at least, why is it not enhanced more by other more effective treatments.
Psychosocial Treatments
While directly affecting the brain chemistry of an individual with ADHD through pharmaceuticals, mainly stimulants, is the most commonly used method of treating ADHD in adolescents, other non--medical methods are being explored as well and are showing promising results. In a study conducted by Schultz, Evans, Langberg, & Schoemann (2017), a multisite clinical trial of Challenging Horizons Program (CHP), a year-long afterschool program that trained adolescents with ADHD in academic and interpersonal skills, showed that the students that attended more than 80% of the sessions showed significant reductions in academic impairment and problem behaviors: They showed medium to substantial benefits in disruptive behaviors, organization, homework performance, and grades compared to students who did not participate in the program. Moreover, the results were still present for six months after the end of treatment ended. There is ample evidence for the positive results that cognitive behavior therapy (CBT)–oriented treatment had, helping individuals with ADHD with learning to regulate their attention and to improve their skills of time management, organization, and planning (Antshel, Faraone, & Gordon, 2012; Mongia & Hechtman, 2012; Ramsay & Rostain, 2006; Safren, Perlman, Sprich, & Otto, 2005; Solanto et al., 2010; Torrente et al., 2012 in Prevatt & Levrini, 2015). ADHD coaching is a variant of CBT that targets precisely the challenges of ADHD.
Conclusion
ADHD is a neurodevelopmental disorder that causes significant academic impairments for adolescents. Even though that in many ways today’s education system sets adolescents with ADHD to failure (Sibley, Altszuler, Morrow & Merrill, 2014), the most widely used approach is to try and fix the problem after it occurs with the help of medications, instead of preventing it in the first place. This approach does not prevent the very high rate of high school dropout among adolescents with ADHD, which is not surprising in the light of the fact the default treatment via pharmaceuticals by itself was found to be not sufficient enough (Langberg & Becker, 2012).
Sasha Raskin, MA, is an international #1 bestselling co-author , the founder and CEO of Go New , a transformational education program, a life, and business coach and a psychotherapist in Boulder, CO. He is working on a P.h.D in Counseling Education and Supervision and is an adjunct faculty at the Contemplative Counseling master’s program at Naropa University, from which he also graduated. Sasha has been in the mental health field for more than 10 years, worked with youth at risk, recovery, mental health hospitals, and coached individuals, couples, families, startups, and groups. He has created mindfulness stress reduction and music therapy programs within different organizations. Whether it’s in person or via phone/video calls, Sasha uses cutting-edge, research-based techniques to help his clients around the world to thrive.
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