Learning support for students with ADHD

Chris Derrington
Attention Deficit (Hyperactivity) Disorder (ADHD) was once believed
to affect children only. Estimated to be found in around 5% of the
population, it is now recognised that up to 80% of school-age
children with an ADHD identification will continue to present
indicators in adolescence, and between 30% and 65% will be
affected in adulthood (Barkley, 1990). Inevitably, this has
implications for educators working in the post-16 sector and, as
more young people access further and higher education, it is likely
that they will come across greater numbers of students with
identified (or unidentified) ADHD. Most studies have found that
individuals with ADHD (hereafter ADDers) have average or above
average intelligence, but the nature of their difficulties is such that
they tend to under-achieve academically (Hinshaw, 1994; Cooper
and Bilton, 2002). This has implications for student support
services across all universities. In the FE sector, there is increasing
pressure to make vocational provision available for disaffected (and
behaviourally challenging) students from the age of 14. Although
some of the general advice found in books about ADHD in children
will be applicable and relevant to the needs of the young adult,
there are some developmental characteristics of ADHD which have
implications for those who support students in FE and HE settings.
Teenage years can be particularly challenging for ADDers. This
paper will explore the nature and indicators of ADHD and suggest
ways in which students can be supported and encouraged to
overcome some of the difficulties that are likely to confront them in
order to achieve their true potential.

Background
The earliest official diagnosis of attention disorder is usually
attributed to George Still (a British physician), whose description in
The Lancet was published more than a hundred years ago. He
explained the condition in terms of 'a defect in moral control'. This
suggested that sufferers had insufficient moral fibre to control their
inattention. What we refer to as ADHD today has been described by
many different terms over the intervening years. In the UK, there
was (until fairly recently) a preference among practitioners for the
World Health Organisation term Hyperkinetic Syndrome, whereas
in the USA, Attention Deficit Disorder (ADD) predominated. The
combination of attention deficit and hyperactivity disorders into a
single syndrome known as ADHD is now recognised by both
international classifications of mental disorders: The American
Psychiatric Association (APA) and the World Health Organisation
(WHO). It is regarded as a medical diagnosis applied to children and
adults who present behavioural symptoms of:

inattention

impulsiveness and

hyperactivity

to an extent that significantly interferes with relationships and their

ability to learn. The nature and effects of these broad indicators are
described below.
What causes ADHD?
By the middle of the twentieth century, the focus had shifted away
from theories of moral deficiency to the view that biological
antecedents (those outside the individual's control) were
responsible. In the UK, there was some reluctance within medical
and educational circles to accept ADHD as a bona fide neurological

condition, and the perception that this was being used to label or
excuse children exhibiting poor, learned behaviour prevailed.
Theories that suggested inadequate parenting skills as a possible
cause for ADHD have since been refuted by studies (e.g. Barkley
1990) which concluded that a childs ADHD was more likely to result
in ineffective parenting (through exhaustion, frustration and
demoralisation) rather than the other way round. Without
recognition and effective support, ADDers are likely to develop low
self-esteem, which in turn only exacerbates their emotional,
behavioural and cognitive difficulties.
Unquestionably, ADHD is a complex condition (which affects males
more than females) and there is no simple explanation, despite a
significant amount of international research attempting to isolate
the causes. In this sense, ADHD is multi-dimensional. Barkley
(1997) suggests that ADDers have problems in inhibiting their
behavioural responses because of a neurological dysfunction in the
frontal lobes of the brain. Influenced by Vygotsky's theory
concerning the relationship between overt behaviour and
internalised speech, he suggests that behavioural self-control is
exerted through a process of self-talk, and that this is one of the
executive functions of the brain that is impaired. Other executive
functions such as concentration, working memory, time-awareness,
hindsight and foresight, emotional regulation and motivation are
also affected according to this theory of cognitive dysfunction.
Research studies involving neuro-imaging techniques such as MRI
(magnetic resonance imaging) and CT (computerised tomography)
reveal links between ADHD and certain abnormalities in the
development of striatal regions of the brain, which control
movement and behaviour. In particular, low levels of activity in the
neurotransmitters in the frontal lobes are characteristic of ADDers.

There is also evidence to suggest that ADHD can be inherited.

Traditional methods used to establish whether or not a type of
neurodiversity has a genetic component include ascertaining the
prevalence among family members. In the case of behavioural
disorders it can be difficult to isolate genetic determinants from
learned behaviour. It could be argued, for example, that adult
ADDers may find the demands of parenting more difficult to manage
and this could impact on the behaviour of their children. According
to Tannock (1998), studies over the past thirty years consistently
reveal a higher incidence of ADHD among biological relatives (not
just parents) of children who are ADDers than in those relatives of
children who are not. Furthermore, both twin and adoption studies
tend to support the heredity argument; further evidence has found
that genes in the dopamine system (a neurotransmitter in the
brain) are implicated in ADHD (Thompson, 1993).
Other studies of environmental variables such as diet and food
additives suggest that although there may be some links, there is
no evidence in terms of causality.
Current theory, therefore, suggests that although the primary cause
of ADHD is a biological (neurological) one, this interacts with
psychosocial factors in the individuals social, cultural and physical
environment which, in turn, leads to behavioural manifestations.
Cooper and Bilton (2000) describe ADHD as a biopsychosocial
condition. This perspective enables its management to be more
effective through a combination of strategies rather than
concentrating on one approach i.e. medication.
Overlap with other types of neurodiversity

It has been suggested that up to 70% of ADDers are neurodiverse

in another way as well (Kewley,1999). Additional difficulties may be
related to anxiety disorders, such as obsessive-compulsive disorder,
panic attacks, depression or bi-polar disorder (sometimes referred
to as manic depression). In other cases, indicators overlap with
those of Tourettes Syndrome, Aspergers Syndrome, dyslexia and
speech and language difficulties, which makes an accurate
assessment of ADHD more difficult. It is also interesting to note that
approximately 60% of boys identified with the combined or
hyperactive sub-type of ADHD will go on to develop conduct or
oppositional defiant disorders by the time they reach adolescence
(Barkley, 1990). In these cases, persistent patterns of anti-social,
aggressive and volatile behaviour go well beyond the challenging
behaviours often associated with adolescence.

How is ADHD identified?

Because of the complications described above, some ADDers may
be identified well before the age of five, but others can go through
childhood without it being formally identified at all. ADHD can only
be identified officially by a specialist physician or psychiatrist
(although educators, GPs, psychologists and parents all have an
important part to play in the assessment process). Identification can
be made at any age and it is never too late to consider ways of
effectively managing ADHD in later life, including the use of
medication. Research in the USA suggests that medication is almost
as effective in adult ADDers as it is with children, although it is
thought to have little impact on memory.
Sub-types

Although ADHD is now referred to as a single condition, it can

present in different ways and the Diagnostic and Statistical Manual
4 (updated 2000) produced by the American Psychiatric
Association (APA) identifies three sub-types, with diagnostic
criteria for each. The sub-types are:
- mainly hyperactive/impulsive
- mainly inattentive
- the combined sub-type.
The pattern of difficulties may vary widely from one individual to the
next, but females are more likely to be affected by the mainly
inattentive sub-type and the combined sub-type is considered to be
the most challenging form of the disorder. Generally, hyperactivity
declines with age and adults are more likely to display fidgety and
restless behaviour rather than gross motor hyperactivity. Attention
problems, on the other hand, are thought to remain constant and
the effects of executive function problems, including self-regulation,
are likely to be intensified over time as the pressures of adult life
unfold. For example, adolescents who may have been used to a
highly structured home and school life, where decisions have been
made for them, can suddenly find themselves unable to cope; their
difficulties might only emerge once they enrol at college and have
to make their own decisions.
In order for an identification of ADHD to be made, individuals must
present with at least of six out of nine specific indicators, which
have been present from an early age and which are exhibited in two
or more different settings. [See page 22 above.]
How to help and support student ADDers

In contrast to other learning differences, ADHD involves

performance rather than skills; student ADDers may already
possess the necessary academic skills they need to succeed. The
problem they have is in accessing the skills on demand and
continuing to implement them over time; what they require is
support in accessing and utilising them. As Barkley (1997) points
out, student ADDers often know what they should do or should have
done, but this provides little consolation to them, little influence
over their behaviour, and often much irritation to others. As already
suggested, low self-esteem is a common feature of student ADDers
because of the messages that they have received in the past. Selfimage is a reflection of others perceptions; someone who is told
often enough that they are lazy, stupid and unreliable will eventually
adopt that self-perception. Students with low self-esteem may also
unconsciously protect their ego by belittling and putting others
down, refusing to trust others and testing out relationships by
challenging those who are trying to help them.
Inattention
As mentioned above, attention difficulties arise from dysfunction of
the prefrontal cortex. The most basic trait is a lack of focused
attention.1
It is not that ADDers do not attend - they just attend to everything!
All stimuli impinge on their senses with equal potency and because
they are so easily distracted by external stimuli, it may appear that
they are not listening, even when being spoken to directly. Student
ADDers appear to satiate quickly on tasks and will shift from one
uncompleted activity to the next, make careless mistakes and
hand in work of very variable standard and quality. There may be
difficulties with note-taking and completing directed tasks.
Although it should be pointed out that ADDers can devote intense levels of
attention to something if it interests them (hyperfocusing) (Javorsky, 1994)
1

Students may also be distracted by their own internal thoughts.

This can give the impression of day-dreaming and appearing
oblivious. Psychologists refer to this process as tangential thinking,
where thoughts spring from one topic to another. Tangential
thinking can be extremely advantageous when exploring ideas or
during multi-task activities, but can easily lead to procrastination.
Shorter, more frequent assignments are likely to yield more success
than long-term projects, but multiple choice tests or activities can
present student ADDers with additional challenges; they may
experience problems in making decisions because they can justify
several possible answers. Such students also get bored very quickly
and respond better to variations in teaching styles. Tutors and
mentors need to vary their voice level and the pace of delivery. A
sharply focused lecture using a multi-sensory approach is more
likely to keep the student ADDer engaged and interested.
There are some practical strategies that can help students in taught
sessions. Tutors or mentors could help the student identify and be
more aware of the things that they find distracting, and help
provide them with strategies that will help them resist impulses and
distractions. Seating arrangements could take account of this and
even headphones may be helpful to dampen extraneous
environmental noise. Conversely, it can be helpful to identify times
and places where the student is more focused. If the student is
taking medication such as Ritalin, it should be possible to determine
the optimal times for focused study i.e. before the dose has begun
to wear off. This is sometimes referred to as the window of efficacy.
Those who teach or support student ADDers should use frequent
eye contact, always allow time for the student to tune in to the
message or instruction being given, especially where this is related
to assignments and deadlines, and check that the student has

received and understood the direction. Critical pieces of information

will need to be emphasised more than once.
Impulsiveness
Impulsive behaviour is caused by difficulties with the brains
executive functions, which are planning and forethought, and the
inhibition of impulsive responses. Student ADDers may therefore
often appear to act on a whim, without considering the
consequences or learning from past experiences. Physical
impulsiveness may lead to an increase in risk-taking behaviours
such as dangerous driving, substance abuse, gambling or
involvement in extreme sports. These students may appear to lack
body awareness and may be more prone to accidents than others.
Impulsive behaviour can also be manifested in the way that ADDers
communicate. The individual may talk too much in social situations,
have a tendency to finish other peoples sentences, and be prone to
butting in and interrupting. On the other hand, these students may
shine during verbal presentations. Verbal impulsiveness also means
that students may say thoughtless or rude things without realising
the damaging effect this can have on relationships. Emotional
impulsiveness is displayed through intolerance and impatience with
others and sudden mood swings, including angry outbursts. These
students may need help and support in terms of self-awareness so
that they are able to recognise these characteristics and learn how
to read social signals.
Hyperactivity
As ADDers grow older, gross motor hyperactivity becomes less
apparent. This is possibly a result of social conditioning, but adult
ADDers often learn to channel their energies and hyperactive
tendencies positively by engaging in occupational or leisure

activities that satisfy this need. Some highly successful creative or

business people who seem to thrive on stressful work demands and
who display boundless energy and little need for sleep, may fall into
this category. If sufficiently motivated, students with high levels of
energy can be extremely successful even though their success is
sometimes achieved in unorthodox ways. Others may need
encouragement to take up some kind of energetic hobby or sport
that will help to burn off their excess energy. Hyperactivity also
includes continuous bodily movements. Students who exhibit
restlessness and fidgety behaviour may well be unaware that their
continuous drumming or tapping of fingers or agitated and
repetitive movement of legs is distracting to others around them;
they can be taught relaxation exercises. Where long periods of
study or concentration are required, tutors should be encouraged to
integrate stretch breaks into the session as student ADDers may
complain of feeling trapped in a confined space.

Memory and organisation

ADDers are reported to have difficulties in using their working
memory. In other words, they have problems in holding information
over a short period of time and are less able to use hindsight
(retrospective functioning) and foresight (prospective functioning).
This can be frustrating for those working with and supporting
students who do not seem able to adapt their actions in the light of
past mistakes or to read warning signs effectively. Without
appropriate support, student ADDers may forget which lectures they
should be attending or turn up without the necessary paperwork or
equipment. They are also liable to miss appointments such as
tutorials and deadlines for assignments.

Adult ADDers also have problems with saliency: that is, being able
to discern what is most important. This can be highly frustrating for
the student throughout periods of revision and during exams. Trying
to start work on assignments can be an excruciating experience and
it is little wonder that these students have trouble meeting
deadlines. Concept mapping may help the student to navigate and
cope with projects and assignments by producing a more tangible
and visual format; it is also helpful to negotiate an easily achievable
and concrete starting point. It may also help the student to focus on
tangible, short-term steps rather than long-term plans.
Organisational props such as using colour-coded ring-binders or
notebooks for each subject area can be helpful and students could
be encouraged to use daily reminder schedules or To do lists. The
most important tasks should be highlighted or listed in order of
priority and the student should be reminded to check this at regular
intervals. Students could also be encouraged to record or
programme reminders on their computer, mobile phone, MP3 player
or personal dictaphone.
Students who are on medication for ADHD may simply forget to
take it; college or university life may be the first time they have
been solely responsible for administering this. It is also worth
mentioning here that adult ADDers often experience problems with
financial management and this may be an area of support that
students will require.
Time management
Evidence from colleges in the USA suggests that student ADDers
suffer from chronic time management problems. Although this can
be partly explained by difficulties with other executive functions,

research has shown that children like this are less able to estimate
time than other children. It is unsurprising, therefore, that some
students simply lose track of time. Tutors and mentors could
support students by providing frequent reminders about how much
time is left to complete tasks. During periods of private or individual
study, it might be helpful to encourage the use of an hourly alarm
on their phone or watch to help keep track of time.
The coaching model
Across the USA, colleges are beginning to introduce coaching
services adapted from private practice to support student ADDers,
and this is an approach that might be more widely adopted to
support students in colleges and universities in the UK. Coaching is
designed to help students reframe their understanding of
themselves as capable and reliable individuals. The role of the
ADHD coach could include some or more of the following:

Setting ground rules: it is important to reach agreement on the

type of feedback the student wants

Asking succinct questions to help the student stop and reflect

Encouraging problem-solving skills

Providing encouragement and working on self-belief

Monitoring progress against targets by regular phone calls or emails

Prompting the student to verbalise the directions or reminders

they will need later to carry out a task

Encouraging the student to draw upon past experiences for

insights, or look ahead and anticipate barriers.

Positive aspects of ADHD

ADHD is often considered in a very negative sense. Some tutors (as

well as parents) may find themselves locked into a cycle of
negativity and may benefit from considering strategies such as reframing (Molnar and Lindquist, 1989). This technique involves
finding a new and positive way of thinking about a students
difficulties. Many characteristics associated with ADHD are also
linked to creativity and success. An example of re-framing is shown
below:

Negative perception

Re-framed perception

Impatient

Goal orientated

Day dreamer

Imaginative

Distractible

A high level of
environmental
awareness

Impulsive

Able and willing to take

risks
Individuals with ADHD can achieve success due to their:

Visionary imaginations and ability to see the big picture

Creativity and inventiveness

Risk-taking behaviour which can produce important discoveries

Ability to process information and make broader observations

Ability to hyper-focus

High levels of energy

Good negotiation skills

Intuition and ability to come up with quick solutions to problems.

Generally, student ADDers can experience a range of difficulties

working within conventional systems, but it is important that these
adaptive characteristics are not overlooked. With appropriate
accommodations and teaching, students can be successful in
academic programmes, including medicine and education, and in a
range of vocational courses (Teeter, 1998; Richards, 1999).

References
American Psychiatric Association (2000) Diagnostic and statistical
manual of mental disorders (4th ed.) Washington, DC: Author
Barkley, R (1997) ADHD and the nature of Self Control
New York: Guildford
Barkley, R (1990) A Handbook for Diagnosis and Treatment
New York: Guildford
Cooper, P and Bilton, K (eds) (2000) ADHD: Research, Practice and
Opinion London: Whurr.
Cooper, P and Bilton, K (2002) Attention Deficit/Hyperactivity
Disorder: A Practical Guide for Teachers London: David Fulton
Hinshaw, S (1994) Attention Deficits and Hyperactivity in Children
Thousand Oaks CA: Sage
Kewley, G D (1999) Attention Deficit Hyperactivity Disorder:
recognition, reality and resolution London: David Fulton
Molnar, A and Lindquist, B (1989) Changing Problem Behaviour in
Schools San Francisco: Jossey Bass

Richards, I C (1999) Inclusive schools for pupils with emotional and

behavioural difficulties Support for Learning 14, 99-103.
Tannock, R (1998) ADHD: advances in cognitive, neurobiological
and genetic research Journal of Child Psychology and Psychiatry
39,1,65-99.
Teeter, P A (1998) Interventions for ADHD: Treatment in
Developmental Context

New York: Guildford

Thompson, R (1993) The brain: A Neuroscience primer

New York: Freeman
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mental and behavioural disorders. Diagnostic criteria for research.
Geneva: Author