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Attention Deficit Hyperactivity Disorder: Aspects of School Achievement

ADHD AND SCHOOL ACHIEVEMENT Attention Deficit Hyperactivity Disorder: Aspects of School Achievement Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) are characterized by developmentally discordant inattention and hyperactivity/impulsivity (HI) across multiple settings (American Psychiatric Association, 2013). Students with ADHD may exhibit academic underachievement, decline in the quality of interpersonal relationships (e.g. peers and teachers), and difficulties controlling behavior in academic settings as a result of the core symptoms (Harpin, 2005). Evidence suggests that the primary disability associated with ADHD is in the executive functioning associated with self-regulation and behavior (Barkley, 2006). Executive Functioning and ADHD Executive functions such as working memory, internalization of speech, self-regulation of affect/motivation/arousal, and reconciliation are associated with the behavioral inhibition and self-regulation concordant in ADHD through the processes that they support. Working memory supports various abilities such as: holding information saliently, hindsight and foresight, selfawareness, sense of time, and keeping rule-governed behavior salient. Internalization of speech supports description and reflection, self-questioning, implementation of rules, and reading comprehension. Self-regulation of affect/motivation/arousal supports emotional regulation, application of objectivity, perspective taking, and delaying gratification for long-term goals. Reconciliation supports analysis and synthesis of behavior and events, fluency related to behavior and verbal tasks, and behavioral simulations (Barkley, 1997).

Deficits in these areas of executive functioning make it difficult for students with ADHD to inhibit task-irrelevant responses, execute goal-directed responses, sustain persistence in pursuit of a goal, re-engage after distractions and control behavior from what one has learned previously (Barkley, 1997). The inattention and HI and the concomitant difficulties associated

ADHD AND SCHOOL ACHIEVEMENT with school may result from deficits in these areas of executive functioning. These difficulties may manifest as less time on task compared to peers, disruptive classroom behavior, poor persistence on academic tasks, greater distractibility, and inattentiveness in classroom settings (DuPaul & Stoner, 2004; Barkley, 2006). Support for these deficits in executive functions are

related to the findings that students with ADHD have difficulties with work accuracy, homework completion, organization, and time management skills (Power, Werba, Watkins, Angelucci, & Eiraldi, 2006). By looking at ADHD through a framework of deficit in behavioral inhibition and selfregulation, we may be able to examine the association between ADHD and school success/failure with greater accuracy. ADHD may have a profound affect on a students school related outcomes such as academic achievement, peer relationships, and overall educational outcome (e.g., graduation rates, college pursuance). ADHD may also hinder a students productivity and ability to learn in academic settings. Academic Achievement and ADHD The majority of students with ADHD have difficulties with academic achievement. By studying academic achievement we are able to better understand how the disorder and deficits in executive function may affect the processes of learning in academic arenas from pre-school to high school and beyond. When compared to students without a formal diagnosis, students with ADHD may have significant academic underachievement and poor academic performance (Loe & Feldman, 2007; Barkley, 2006). As such, these difficulties are what might bring the child to the attention of school psychologists, parents, or teachers for the first time. These difficulties in academic achievement are evident in the grades that students with ADHD receive. Students with ADHD may be at risk for lower grades overall (Barkley, 2008). In

ADHD AND SCHOOL ACHIEVEMENT general, students with ADHD receive more failing grades compared to controls (Barkley, Fischer, Edelbrock, & Smallish 1990; Youngstrom, Glutting, & Watkins, 2007). Areas where grades are commonly impacted by ADHD are math and reading (DuPaul and Stoner, 2004).

Although less studied, students with ADHD in High School are more likely to have lower overall grade point averages, lower levels of class placement (remedial vs. honors) and higher rates of class failure (Kent et al., 2011). In a longitudinal study, adolescents with childhood ADHD had an average grade point average (GPA) of 2.75, which was lower than the control of 3.0 (Molina et al. 2009). Other studies report a larger 0.6 GPA difference (Barkley, 2006). GPA can have a profound affect on college admissions. On standardized tests of academic achievement, Frazier et al., (2007) reported the results from a meta-analysis indicating a moderate to large discrepancy on standardized measures of academic achievement between individuals with ADHD and typical controls (weighted d=0.71). With scores on standardized tests showing deficits compared to controls in reading, math, writing and spelling, with the largest effect sizes on reading measures. This may suggest that ADHD has a global affect on a students attainment of academic achievement with regard to subject matters. It is possible that ADHD may negatively impact measure of academic achievement. Academic Course Preschool is often the first academic setting where students with ADHD noticeably deviate from their peers academically (Spira & Fischel, 2005). DuPaul, McGoey, Eckert, and Vanbrackle (2001) examine preschoolers with ADHD, and note that conceptual development and general cognitive abilities are already statistically lower than controls this early on in their educational development. As students with ADHD progress into later schooling, (e.g.

ADHD AND SCHOOL ACHIEVEMENT elementary, middle, and high school) differences in grades and scores on academic achievement start to become more prominent and differentiated towards specific academic areas such as arithmetic, spelling and writing (Daley & Birchwood, 2010). Interestingly enough, Frazier et al., (2007, 2004) report that the associated magnitude of the difference compared to controls may decrease as the students age and progress through school. It is unclear whether this reduction is attributable to symptom reduction or school drop-

out associated with ADHD as students age. This decrease however does not appear to resolve the academic underachievement associated with childhood ADHD, being also of consequence for students in high school, college, vocational schools and adulthood, suggesting that these academic difficulties continue. This is concurrent with the view that ADHD is a chronic condition that age alone does not reduce (Barkley, 1997). Factors in Academic Achievement A factor that may influence academic achievement of students is the severity of ADHD symptoms. Children who exhibit a greater number, severity, and pervasiveness of behaviors congruent with ADHD were often more likely to achieve academically at a level below what their IQ would predict (Barry, Lyman, & Klinger, 2001). Longitudinal studies have shown that parental, teacher, and maternal ratings are associated with worse academic outcomes (DuPaul, Volpe, Jhendra, Lutz, & Lorah, 2004). Students who have more severe ADHD have may have poorer outcomes academically when compared to students with lesser forms of ADHD (Barkley, 2006). Another factor that may influence academic achievement is the academic skills of students with ADHD. Daley and Birchwood (2010) suggest that many of the academic difficulties faced in school-aged children with ADHD begin in preschool. This is especially

ADHD AND SCHOOL ACHIEVEMENT important because it is where students gain many of the foundations necessary for academic skills, such as organization, ability to sit in a classroom, attend to subject material, time

management and the beginnings of literacy. DuPaul et al., (2001) also observed a deviation from the control in academic skills of preschoolers with ADHD. Furthermore, parental homework management of children with ADHD is also positively associated with academic achievement into elementary school (Langberg, Molina, Arnold, Epstein, & Hetchman, 2011). Parental homework management may be a way for parents act as the executive function engineers and support the academic skills of their children with ADHD. Grade Retention and Dropout Given the academic difficulties associated with ADHD, it is not surprising that students with ADHD may be at increased risk for a host of negative academic outcomes, one of which is absenteeism. Students with ADHD miss more school than students without ADHD (Kent et al., 2011). This is not surprising considering the time management difficulties those students with ADHD may display as a result of deficient executive functioning. Barbaresi and colleagues (2007) report a 2.4-day difference in the number of absences compared to control per academic year. Compounded over 12 years of schooling, this pattern of absence and tardiness can lead to less academic exposure. Perhaps one of the most poignant outcomes of students with ADHD is the grade retention and dropout rates. Students with ADHD are three times more likely to be retained a grade (Kent et al., 2010), and estimates suggest that 30% of students with ADHD are retained at least one grade for poor academic performance (Smith et al., 2007; DuPual & Stoner, 2004). One longitudinal study found that students with ADHD are eight times more likely to drop out during high school (Kent et al., 2010). Barkley (2006) estimates that 10-40% of these students fail to

ADHD AND SCHOOL ACHIEVEMENT graduate high school. It should be noted that Beiderman et al., (2004) identified a relationship between executive functioning deficits and ADHD combined, are a better predictor of academic outcomes than ADHD alone. Intelligence and Executive Functioning

One factor that may help explain the academic difficulties that students with ADHD may face is the relationship between ADHD and intelligence, as measured by intelligence quotients (IQ). The preponderance of evidence shows that there is a negative relationship between ADHD and IQ (for a review see Frazier et al., 2007). Typically, those who have who have more severe ADHD symptoms have lower scores on standardized measures of IQ compared to control (Tillman, Bohlin, Sorensen, & Lundervold, 2009). The size of this relationship ranges from 7 to 15 standard score points (Barkley, 1998). Fraizer et al., (2004) also report a medium effect size (d=0.61) with an average 9-point difference between students with ADHD and controls. Controversy exists within the IQ discrepancy in regard to whether it is a feature of the disorder or a secondary consequence. For example, Barkley (1997) and Tannock (1998) report that people with ADHD have lower working memory and impaired executive functioning. Many executive functions (e.g. processing speed and working memory) are directly and indirectly measured on the full-scale IQ scores of a standardized test, suggesting that the measure of IQ may be reduced as a secondary consequence of the deficits in executive functioning and working memory. This is essentially questioning whether or not full-scale IQ is a valid measure of intellectual abilities in someone with ADHD, thus making it more of a measurement issue. However, Tillman et al., (2009) report that differences in fluid intelligence are not fully mediated by these deficits in executive functions. Thus, people with ADHD may have lower levels of fluid intelligence, even when the executive functioning deficits are controlled, and the

ADHD AND SCHOOL ACHIEVEMENT discrepancy in executive function may not result in a decrease in fluid intelligence. Contrasting this conclusion however, Tillman et al., (2009) claim that deficits in crystalized intelligence appear to be mediated by these differences in executive functioning. This may suggest that crystalized intelligence deficits are a secondary consequence to the deficits in executive functioning, while reduced fluid intelligence is a feature of ADHD. Patterns in Special Education

Many students with ADHD receive special education services as a result of the associated concomitant academic and cognitive deficits. ADHD is estimated to affect at least two million students in the United States (Forness & Kavale, 2002). Many students with ADHD receive some sort of school service, with an estimated 30-40% being placed in one or more special education program (Barkley, 2006). A student with ADHD is three to seven times more likely to receive special education services than a student without ADHD (LeFever, Villers, Morrow, & Vaughn, 2002; Forness and Kavale, 2002). Classification rates under the Individuals with Disabilities Education Improvement Act (IDEA) for students with ADHD vary, and are often related to comorbidity. Under IDEA, a classification of Other Health Impairment (OHI) is the traditional classification for students with ADHD due to the provisions for disorders that involve attention problems. Unsurprisingly, students with ADHD represent the largest group who receive services under OHI (Grice, 2002). Because of the comorbidities associated with ADHD, many students receive services under other classifications. In a national sample, 65% of students with ADHD were classified under OHI (Schnoes, Reid, Wagner, & Marder, 2006; Forness & Kavale, 2002). Unsurprisingly, 50% are classified under Specific Learning Disability, which is to be expected considering that as much of 90% of students with ADHD have a learning disability depending on the method used

ADHD AND SCHOOL ACHIEVEMENT (Barkley, 2006). Many students were also dual classified or classified under other areas with

classification of 58% for emotional disability, 21% for mental retardation, 20% specific learning disability, and 4.5% for speech language impairment (Schnoes et al., 2006). Similar studies confirm these numbers (Forness & Kavale, 2002). These classification rates also represent another aspect of ADHD - the accompaniment with various comorbidities. Pure ADHD, that is, ADHD that is not accompanied with other disorders, is uncommon. In clinic samples, eighty percent of Children with ADHD have a second disorder, and more than 60% with have two or more disorders (Smith et al., 2007). In community samples, the numbers of second disorder ranges from 30-40% (Barkley, 2006). The most commonly comorbid disorder with ADHD is Oppositional Defiant Disorder (ODD), cooccurring in 55% of children with ADHD. Mood disorders such as anxiety are also often seen (25%) along with depression (20-30%). Learning disabilities (LD), Tourettes, tic disorders, speech language impairment, are all also commonly seen alongside ADHD (Smith et al. 2007). An important point to note is that any of these disorders in isolation (without comorbidity with ADHD) can negatively affect school success, either through academic access or behavioral difficulties. ADHD is often seen with many of these disorders, thus making it difficult to parcel out the specific influences that ADHD alone has on school outcomes. However, DuPual et al. (2004) concluded that the association with academic problems appears to be specific to ADHD related symptoms, while behavior difficulties appear to relate with externalizing comorbidities such as ODD and conduct disorder (CD) as well as other internalizing comorbidities such as depression. Students with comorbidity such as ODD/ tend to have poorer social and academic outcomes (Barkley, 2006).

ADHD AND SCHOOL ACHIEVEMENT A dual model pathway of ADHD and ODD/CD may help explain the way that ADHD affects academic achievement. Rapport, Scanlan, and Denny (1999) hypothesize that ADHD predisposes to academic underachievement through high comorbidity with ODD and CD, however, they act in separate ways respectively. ADHD may impact academics through its


associated cognitive deficits in intelligence, attention, and working memory. ODD/CD and other comorbid disorders may negatively affect the students work productivity. This may be evidenced by poor academic outcomes for students with more inattentiveness than hyperactivity (Faraone, Biederman, & Weber, 1998). Settings and Services Most students with ADHD are served in regular classrooms, accounting for an average of 65% of the school day. Students with ADHD are less likely than other students receiving special education services to spend the majority of the day in the general education classroom (Schnoes et al, 2006). This may be the effect of ODD and other comorbidities associated with the behavior of ADHD. Two thirds of students with ADHD receive some sort of non-academic service. Over 55% receive some sort of service involving behavior management and/or interventions. Students with ADHD are more likely than other special education students to receive social work services, behavioral interventions, and family counseling/training (Schnoes et al, 2008). ADHD students are 91% more likely to receive academic services than special education students without ADHD. The most common is progress monitoring by a special education teacher, followed by tutoring, and learning strategies instruction (Schnoes et al., 2006). These types of academic services may also include strategic seating, modified assignments (e.g., shorter assignments, frequent breaks), individualized instruction, cooperative learning (e.g., peer tutoring), behavioral

ADHD AND SCHOOL ACHIEVEMENT modification interventions, and specialized consultation for teachers and parents (DuPaul & Stoner, 2002). School Related Social Relationships Students with ADHD may be characterized as more impulsive, intrusive, excessive, disorganized, engaging, aggressive, intense, and emotional. As a result of this, they may be viewed as disruptive and aversive to people in their social circles (Wehmeier, Schacht, &


Barkley, 2010). It is of little surprise that teachers view students with ADHD as more stressful to teach (Greene, Beszterczey, Katzenstein, Park, & Goring, 2002). Put bluntly, peers do not like students with ADHD. Hosa (2007) discusses how inattention limits the ability to acquire social skills through observational learning and the ability to attend to social skills makes it difficult to learn effective social cues. Similarly, HI contributes to unrestrained and overbearing social behavior that may make children socially aversive to peers. These social impairments result in poor social and communication skills, compared to controls (Wehmeier et al., 2002). These social impairments may appear to begin in preschool and continue even through to high school (Thorell & Rydell, 2008). The result is an impaired ability to participate in social exchanges, and up to 70% of children with ADHD may have no close friends by third grade. Children with ADHD are rated lower on social preference, are less well-liked, and more likely to be rejected by peers. This leads to the possible conclusion that adolescent students with ADHD may be more likely to be bullied or become bullies themselves (Wehimer et al., 2010). Conclusion ADHD is a disorder associated with deficits in executive functioning. These deficits in executive functions are associated with the lack of behavioral inhibition and self-regulation in ADHD. Students with ADHD may be at risk for a host of negative outcomes related to school

ADHD AND SCHOOL ACHIEVEMENT success. Academic achievement, peer rejection, higher dropout rates, and reduced intelligence


are only some of the factors that may negatively impact an ADHD students ability for success in school. These factors may reduce options in the future and limit their ability to reach their potential.



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