Attention Deficit Hyperactivity Disorder and School Problems

Earl J. Soileau Jr.

Attention deficit hyperactivity disorder (ADHD) has now been defined as a neurodevelopmental disorder that causes hyperactivity, impulsive behavior, and attention problems. The recent change in labeling underscores that while the disorder begins in childhood it can persist through adulthood for some people. As many as 10% of school children are affected with this disorder; however, the prevalence and incidence of those who have been diagnosed as adolescents and young adults (AYAs) are not clear. In AYAs with ADHD, the ratio of males to females is between 2 and 3 to 1. The evidence suggests that there is a lowered percentage of AYAs who meet diagnostic criteria.¹ Regardless, data are clear that many negative outcomes exist for those left untreated in the AYA years.² Treatment can provide enormous benefit and it is important for providers to have a clear understanding of the risks and benefits of treatment, as well as practical strategies to approach both the evaluation and management of this common disorder. In addition, clinicians should be aware that although school difficulties during adolescence and young adulthood may be the result of ADHD, one should also consider the possibility of learning disabilities, school phobias, avoidance, and other academic performance problems.

ATTENTION DEFICIT HYPERACTIVITY DISORDER

ADHD is characterized by the presence of the three major symptoms that include the following:

Difficulty maintaining focus and paying attention
Struggles with controlling impulsive behavior
Troubles with hyperactivity

Often this cluster is evident in early childhood and persists throughout the child’s life course. These major symptoms make it difficult for an adolescent or young adult to get along with others, make and maintain relationships, remember what they have learned, complete school work in a timely fashion, meet school and work deadlines, communicate with teachers and parents, organize their lives, resolve disagreements, and follow rules. Many individuals with ADHD have difficulty with the developmental tasks of adolescence and young adulthood such as developing independence, identity formation, and making career decisions. As would be expected, these failures often result in low self-esteem and depressive symptoms.²,³ If motor overactivity or hyperactivity is present initially, this high activity level tends to subside in early adolescence. In contrast, impulse control and inattentive symptoms during childhood persist in 60% to 80% of adolescents and upward of 50% continue to meet diagnostic criteria for ADHD into adulthood.⁴,⁵ For many adults, mental overactivity or restlessness is a common manifestation. When motor overactivity is present in early adolescence, many will become normally active or underactive in adulthood.⁶,⁷,⁸ Impulse control tends to improve during the middle adolescent years and resolves in many. Difficulty in the cognitive domains, for example, working memory, memory organization, perseverance in tasks, and distractibility, appears to continue in most, but not all. Young adults tend to continue to have difficulty in the cognitive domains, but may not be as symptomatic if they are occupied in jobs they find interesting and enjoyable. Among college students, these cognitive challenge requirements increase rather than decrease and most young adults become more symptomatic throughout the college years.

Etiology

At present, the etiology of ADHD is not clear, although studies suggest that ADHD results from a combination of genetic and environmental factors. Twin studies suggest a high heritability in ADHD with estimates near 80%.⁹,¹⁰ Molecular genetic studies reveal that there are likely multiple gene systems that affect core symptoms.¹¹ Clearly, the environment plays a role and is superimposed on the genetic backdrop. For instance, there is evidence to suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD. There is also evidence to suggest that individuals who have suffered a brain injury show some similar behaviors to those with ADHD.

Advances in brain imaging technology have shown structural and functional brain differences between individuals with and without ADHD.¹²,¹³ Longitudinal brain imaging studies have shown that ADHD is characterized by a delay in structural brain maturation; although the brain matures in a normal pattern, it is delayed about 3 years.¹²,¹³ This delay is associated with regions of the brain involved in thinking, attention, and planning.¹³ Further studies using brain imaging and cognitive evaluation may help clarify how this disorder develops.

Diagnosis and Assessment

The diagnosis of ADHD is based on a clear picture of the adolescent or young adult’s current function and history of difficulties. The provider should consider gathering information from three sources, that is, home, school, and the adolescent or young adult.¹⁴,¹⁵ The parent, significant other, or close friend represents one source of information from the home and social sphere. To assess behavior in the school or work setting, information is gathered from teachers, employers, coaches, or coworkers. Clinicians should conduct a separate interview with adolescent or young adult as it allows the young person to self-report problems and concerns that they
have been experiencing and it allows the clinician to identify signs or symptoms consistent with ADHD or suggestive of other serious comorbid disorders.

It is important for the provider to carefully evaluate descriptions of the problem(s) and to characterize the symptoms. The provider should determine if the symptoms occur frequently, interfere with functioning, and appear to be acute or chronic. Often it is helpful to seek out specific examples of such difficulties, for example, inability to complete homework or difficulty organizing simple tasks, to mention a few.

The evaluation should include a review of the medical and mental health history, psychosocial, and family histories.

Complete Medical History

A complete medical history, including prenatal exposures to tobacco, drugs, alcohol, perinatal complications or infections, developmental delay, central nervous system infection, head trauma, recurrent otitis media, and current or past medication use, should be determined. The history should include an exploration of hearing or visual impairments, sleep disturbances, thyroid abnormalities, and neurologic or cognitive impairments. This will help to distinguish ADHD from other medical conditions.

In addition, a review of current or past substance use should be determined.

It is particularly important to obtain a dietary history (i.e., appetite, picky eating), history of sleep patterns, and family cardiac history and cardiac review of systems before initiation of pharmacotherapy to avoid attributing preexisting problems to medications.

Family history of similar behaviors is important because ADHD is highly heritable. In addition, family history of other mental disorders can be helpful in determining the nature of comorbid disorders.

Questionnaires

Typically, representatives from all three domains are not present at the clinical encounter when assessing the adolescent or young adult, which requires the provider to rely on the use of some type of written report from the teacher or employer. Reliable standardized measures are available that enhance an accurate diagnosis (Table 71.1). Parents, teachers, and employers report their observations using various formats, and responses can be used to elucidate discussion as well as provide required documentation. In addition, there are self-report versions for AYAs to complete to ensure accurate and confirming information for each core domain. For young adults, documentation may be required by universities and athletic associations such as the National College Athletic Association, so that they can provide supportive classroom modifications and allow for the use of medication. It is important for the clinician to remember that questionnaires and checklists are used as collateral information, but by themselves do not make a diagnosis.

TABLE 71.1 Paper -and -Pencil Instruments for ADHD Screening

ADHD Evaluation Instrument	Target Age	Cost	Source
Brown ADD Scales for Adolescents	Validated for Adolescents	Yes	http://www.pearsonclinical.com/education/products/100000456/brown-attention-deficit-disorder-scales-brownaddscales.html?Pid=015-8029-240
Vanderbilt ADHD Teacher Rating Scale	Validated for 6-12 y	No	http://peds.mc.vanderbilt.edu/VCHWEB_1/rating˜1.html
Conners Wells Adolescent Self-Report Sclales	Validated for Adolescents	Yes	Amazon.com, ADD Wearhouse.com
World Health Organization ADHD Self-Report Scale (ASRS)	Validated for 18-44 y	No	http://www.hcp.med.harvard.edu/ncs/asrs.php
Wender Utah Rating Scale for ADHD in Adults	Validated for over 18 y	No	Click to access Wender%20Utah%20Rating%20scale%20for%20ADHD.pdf

The accepted standard for diagnosis remains the clinical interview. The interview delineates a persistent pattern of ADHD symptoms for more than 6 months and should use information from two or more informants who have exposure to the patient in at least two of the three domains.¹⁴,¹⁵ Older AYAs may present for evaluation alone. For older youth, it may be difficult to obtain written reports or completed questionnaires from a teacher, employer, or parent, but it is an important component to confirm the diagnosis. Objective observers such as teachers, parents, or employers will see the older adolescent in limited situations such as in the classroom or home, and their input must be interpreted within this context. In these extreme cases where adult informants in key domains are not available, the use of peer observation may be helpful.

Differential Diagnosis

A number of disorders and factors may produce symptoms similar to those of ADHD; however, these are usually suggested by a thorough history and physical examination.

Medical

Medical conditions that may have similar clinical features or presentation to ADHD include hearing or visual impairment, lead poisoning, thyroid abnormalities, traumatic brain injury, sleep disorders (e.g., obstructive sleep apnea, restless-leg/periodic limb movement disorder), and medication effects (e.g., albuterol). Unlike the persistent symptoms of ADHD, the symptoms of an alternative condition may fluctuate with the disease course or exposure to medication. Neurologic or developmental conditions must also be considered, particularly learning disabilities and cognitive impairments, which can impair academic functioning and interfere with attending and task completion in school.

Mental Health

Mental illnesses such as depression (impairments in the ability to concentrate and in motivation), anxiety disorder (poor attention), bipolar disorder (impulsive or overactive behaviors and distractibility), oppositional defiant disorder (ODD), conduct disorder, obsessive compulsive disorder, posttraumatic stress disorder, and adjustment disorder may mimic or co-occur with ADHD. Problems with substance abuse, particularly cannabis and alcohol, can also mimic ADHD symptoms. Given that ADHD is characterized by an early onset of symptoms, it is important to assess the circumstances that prompt the adolescent or young adult and/or their families to seek assessment, particularly if there is not a history of ADHD symptomatology in the past.

Psychosocial and Environmental Factors

Stressful home environment or an unsuitable educational environment can cause symptoms that may mimic ADHD or co-occur with it. In contrast to ADHD alone, these behaviors often occur only in one setting as opposed to being present in a number of different settings.

Physical Examination

The physical examination of most AYAs with ADHD will be normal. However, the examination is necessary to exclude other conditions in the differential diagnosis of ADHD. Important aspects of the examination include:

Measurement of height and weight. Height and weight should be plotted on a growth chart for each individual. This will offer important information about the adolescent’s growth, which may be affected by ADHD. It is not clear that medication has a major impact on growth.
Measure vital signs (heart rate and blood pressure). This is important information as stimulant medications are likely to result in modest increases in heart rate and blood pressure.
Assessment of dysmorphic features
A complete neurologic examination, including assessment of neurocutaneous abnormalities as well as vision and hearing

Laboratory Studies

Laboratory evaluation may be helpful in the evaluation of other conditions that may be suggested by the history and physical examination. Likewise, electroencephalography and brain imaging may be indicated if there are symptoms or findings suggestive of another diagnosis. Professional practice guidelines do not recommend any specific laboratory studies or imaging before initiating ADHD medications in the absence of other symptoms.

Barriers to Evaluation

There are many barriers to the diagnosis and treatment of ADHD, including time required, use of multiple professionals and visits, as well as psychological testing. The key is to provide an efficient and comprehensive evaluation to ensure that the adolescent or young adult and family are not left untreated due to lengthy wait times for other professionals to conduct psychological or neuropsychology testing. Psychological, neuropsychological, and/or academic testing is not required to make a diagnosis of ADHD; however, these evaluations may be helpful in making a diagnosis and/or delineating comorbidities. In an effort to be efficient, the provider is encouraged to first screen for common comorbidities, and after a diagnosis is made and treatment initiated, subsequent referral for further diagnostic testing may be necessary. Since the adolescent or young adult may present due to a crisis situation in school such as failing multiple classes or behavioral problems that are precipitating suspension or expulsion, it is important for the clinician to evaluate all information presented including family history, the increased challenges in the to adolescent or young adult’s life, reasons why this concern has not been diagnosed in the past, as well as comorbid conditions, that is, depression, anxiety, substance use, learning disabilities, or bipolar disorder.

CURRENT DIAGNOSTIC CRITERIA

The diagnostic criteria for ADHD have been modified in the Diagnostic Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). In the DSM-5, ADHD is now included in the section on Neurodevelopmental Disorders, as this better reflects the way ADHD is currently conceptualized. The clinician should be aware that the inattentive or hyperactive/impulsive symptoms must be present prior to age 12 and adolescents who are >17 years can meet diagnostic criteria with 5 instead of 6 symptoms from the inattentive and hyperactivity/impulsivity categories, which must be present for >6 months.

The requirement that there be clear evidence that symptoms interfere with two domains, for example, social, academic, or occupational remains unchanged, but treatment should not be withheld because dysfunction does not exist in two life areas. In cases where interference of two domains is not present, diagnostically this can be accurately labeled as “Other Specified ADHD” or “Unspecified ADHD” depending on whether the dysfunction does not exist in the other domain, or if it is not uncovered as part of the assessment, respectively.

The ADHD diagnosis must be specified as mixed, primarily inattentive or primarily hyperactive, and impulsive. The severity rating of mild, moderate, or severe is optional. For those AYAs who have previously met diagnostic criteria, but some of these symptoms are no longer present, a notation of partial remission should be used.

Objective Testing

Recently, the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System was approved by the US Food and Drug Administration (FDA) and takes about 15 to 20 minutes. This testing calculates ratios of theta to beta brain waves given off each second where the ratios are significantly higher in ADHD individuals. There is no widespread clinical experience with this diagnostic tool, but data suggest that combination of NEBA and the clinical evaluation together is superior to the clinical evaluation alone.¹⁶ The FDA approval specifies that it is not to be used as a stand-alone diagnostic tool but as part of a clinical evaluation.¹⁶

Comorbidities

It is well established that ADHD frequently co-occurs with other psychiatric disorders. As many as 60% of AYAs with ADHD experience one or more of these comorbidities. Learning disorders are common as well as depressive, anxiety, and substance use disorders. Bipolar affective spectrum disorders are less common, but cause much more difficulty in many spheres of life and have many overlapping ADHD symptoms. ODD symptoms are common in younger adolescents with ADHD. ODD symptoms somewhat abate with pharmacotherapy, but those with ODD and emerging conduct disorders may be a subset of ADHD youth who have much more difficulty with accepting authority and following rules. Those youth with these comorbid disorders usually have increased family conflict, substance misuse, school failure, and truancy. Therefore, clinicians should be prepared to see a wide range of psychiatric symptoms when managing patients with ADHD.

If comorbidities are not apparent at diagnosis or a poor response to treatment is noted, the provider should examine for the presence of a comorbid condition that may be exacerbating ADHD symptoms or whether these symptoms are masking a different disorder. At times, there will be symptoms of anxiety or depression that appear to be related to the struggle with functional impairments of ADHD and may resolve when ADHD is effectively treated. If these other symptoms do not remit, consider the possibility of an independent psychiatric, neurodevelopmental, or other behavioral disorder.

MANAGEMENT

Management of ADHD can be broadly separated into two components: environmental and pharmacologic. Frequently, patients and their families have tried to adapt their environment before seeking outside help. Adapting or modifying the school and home environments may better allow for the completion of work and retention of material. Both are a powerful adjunct to medication use. Modification of the adolescent’s or young adult’s environment in combination with psychotherapy can provide improvements in concentration, organization, as well as coping. Medication use typically provides improved cognitive functioning in key areas: input information, increased task efficiency and completion, as well as retention.¹³ Finally, for those patients with comorbid conditions including mood and anxiety symptoms, psychotherapy
as well as psychotropic medication may be necessary to improve overall functioning.

Educational Modifications

Typically, it is necessary to provide modifications for most students with ADHD. In school settings this can be accomplished with minimal disruption to the student, but requires extra effort and support from school personnel. Common modifications include allowing extended time for completion of tests and projects, preferential seating so that the field of view between student and teacher is minimized, individual instruction, and provision of lecture notes. Because independent note taking can be very difficult for AYAs with ADHD, it is common for teachers to copy and provide their notes that have been used on overheads, whiteboards, or electronic screens, so that copying by the student is not required. Alternatively, other students who are proficient in taking notes could be asked to share their notes with the student with ADHD. Recording lectures may also be helpful. Finally, a quiet testing environment may also be required for some patients with ADHD to accurately assess their knowledge as they may be easily distracted by ambient classroom noise and activity.

Behavioral and Psychological Interventions

Helping the adolescent or young adult to cope with symptoms of anxiety, depression, and obsessive worrying through behavioral therapies may also improve academic performance as well as reduce the burden of ADHD symptoms. Behavioral and psychotherapeutic interventions, that is, counseling, behavioral modification, and psychotherapy are most helpful if they are targeted to the needs of the individual with ADHD.

While behavior modification may be challenging in adolescents, there is increasing evidence that cognitive behavioral therapy (CBT) improves functioning among AYAs with ADHD.¹⁷,¹⁸ CBT is goal-directed and focuses on changing specific thoughts and patterns of behavior to obtain competency in particular situations. Successful behavioral interventions that have yielded significant improvement in ADHD outcomes when used as an adjunct to medication incorporate components that include psychoeducation, organizing/planning, coping with distractibility, and adaptive thinking elements. Two additional optional, but helpful, components include targeting strategies to reduce procrastination and relationship skill enhancement.¹⁹

Navigating Legal Rights

There are legal provisions available that ensure ADHD students’ academic achievement is similar to students without these difficulties. In the United States, Title II of the Americans with Disabilities Act 504 modifications, Individuals with Disabilities Education Act, and the potential for an individualized education plan are all available to these students and their parents, if requested. However, the implementation and execution of these laws and policies may vary from school district to school district. At the college level, typically an Office for Students with Disabilities exists and can be helpful. Parents must advocate for their adolescent or young adult in order to ensure that all legal rights are afforded to their son or daughter. Young adults may also enlist other significant adults to navigate their legal rights within the school environment.

PHARMACOLOGIC TREATMENT OF ADHD