Adolescence

In addition to the universal stressors of life, adolescents also face specific mental health challenges. The significant number of life transitions and changes in physical, emotional and social contexts that occur in this life stage, make adolescence a particularly vulnerable period for the development of mental health problems. The World Health Organisation (2021a) contends that globally, an estimated 14 percent of adolescents aged 10-19 have experienced a mental health condition such as anxiety, depression or behavioural disorders. Adolescents with mental health challenges have a more complex and difficult developmental pathway than neurotypical individuals (Kaplan, 2004) which complicates the already complex task of navigating adolescence.

Attention Deficit Hyperactivity Disorder 

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013b) conceptualises Attention Deficit Hyperactivity Disorder (ADHD) as a neurodevelopmental disorder that has its onset in early childhood. ADHD is the most common childhood neurodevelopmental disorder and while the prevalence of ADHD is difficult to precisely determine, current research suggests that between 1 and 7% of school aged children have the disorder (Thapar & Cooper, 2016; APA, 2013b; Wicks-Nelson & Israel, 2015). ADHD affects males and females of all intelligence levels and from every socioeconomic and cultural background (APA, 2013b). ADHD is a multifaceted, heterogeneous disorder that has widespread, pervasive effects on an individual’s functioning and development. The primary features of ADHD are inattention and hyperactivity-impulsivity and are thought to be present from two years of age and continue into adolescence and to a lesser degree into adulthood. Behavioural symptoms resulting from hyperactivity include fidgeting, constant movement, incessant talking, tapping, and frustration with boredom or sitting still. Symptoms of impulsivity can manifest in behaviours such as interrupting conversations, risk-taking and acting without thinking of the consequences (Wicks-Nelson & Israel, 2015).

Evidence of Symptoms 

ADHD is visible in cognitive, behavioural and social symptoms during adolescence, however, the presentation of ADHD symptoms can change in severity and type when individuals reach adolescence. According to DSM-5 (APA, 2013b) the cognitive deficits of adolescents with ADHD are exemplified by a lack of academic achievement and inattentive symptoms such as poor listening skills, disorganisation, inability to filter out external or unimportant stimuli, poor memory, difficulty focussing on or completing mundane tasks and making careless errors. According to Wicks-Nelson and Israel (2015), the secondary features of ADHD include motor incoordination, poor academic achievement, sleep issues, poor executive function, adaptive behaviour deficits, and negative social interactions and typically continue into adolescence and across an individual’s lifespan. Hyperactivity can present differently in high school. Adolescents with ADHD may present with less hypermobility but more anxiety or an inability to relax (Kaplan, 2004).

Impact on the Individual and Interactions

The impact of ADHD on an adolescent’s functioning and development is profound. The pervasive nature of ADHD has potentially long-term and far-reaching impacts on an individual’s entire lifespan including their health, education, occupation and interaction with the criminal justice system (Wicks-Nelson & Israel, 2015). Adolescents with ADHD face many academic difficulties in high school and many fail to master the developmental tasks of emotional and behavioural autonomy (Geldard et al., 2019). Research has established the link between poor academic performance and ADHD. Approximately two-thirds of primary school-aged children with ADHD also have a learning disability or another coexisting disorder (Cantwell, 1994). Up to 30% of adolescents with ADHD have repeated a grade and 40% have special education programs in place. 30% fail to finish high school or go on to tertiary education (Barkley & Murphy, 2006).

The behavioural functioning of adolescents with ADHD is often the first indication they are not tracking along a neurotypical developmental pathway (Wicks-Nelson & Israel, 2015). An adolescent with ADHD will display some or all of the following behaviours; not listening when spoken to, difficulty paying attention and completing tasks, making careless errors, daydreaming, disorganisation and avoiding activities requiring sustained mental effort. Adolescents with ADHD may appear more immature, take more risks, suffer more physical injuries and negative behavioural consequences at school because they lack the self-regulation skills of their same age peers. Deficits in adaptive behaviour may become more evident throughout high school and failure to learn everyday skills such as organisation of belongings and time management is an indication of the impacts of ADHD on an individual’s development and functioning (Werner & Smith, 2001).

Cognitively, adolescents with ADHD score an average of nine points lower than their same aged peers on tests of intelligence (Barkley & Murphy, 2006; Frazier et al., 2004). It is estimated that 25–35% will have a coexisting learning or language problem (Pliszka et al., 1999), and approximately 10% have been reported to have reading disabilities (Shaywitz & Shaywitz, 1991). Adolescents with ADHD also have approximately 30% less executive functioning skills than is considered normal. Ultimately, by late adolescence individuals with ADHD will only develop 75-80% of the executive functioning capacity of their neurotypical peers. This reduced cognitive functioning manifests as poor memory and processing abilities and requires that adolescents with ADHD be supported to plan and complete tasks at school. Studies found significant differences in academic performance of children with and without ADHD, particularly in problem solving, recall of facts and performance on normative assessments such as NAPLAN. Children with ADHD-I or predominantly inattentive symptoms can be overlooked. Too often ADHD is associated with child hyperactivity only and inadequate consideration is given to inattentiveness, cognitive impairment and emotional dysregulation.

Physiologically, ADHD brains are anatomically and functionally different. Individuals with ADHD have been found to have a greater number of general health problems such as asthma, physical injuries and sleep issues (Wicks-Nelson & Israel, 2015) resulting in long-term societal impacts such as, increased risk of obesity, diabetes, heart disease as well as anxiety and depression. Impulsive behaviours and motor incoordination also place adolescents at greater risk of accidental injury and lead to conflict with parents and disruption to family relationships (Barkley & Murphy, 2006).

The social-emotional impacts of ADHD are pervasive. Although not all adolescents with ADHD have social-emotional problems, research suggests that at least half of them do. At school, adolescents with ADHD suffer higher rates of peer rejection, bullying and social isolation than their neurotypical peers. Intrusive, overbearing behaviours of interrupting, aggression, incessant talking and hypermobility can alienate their peers. Inattentive symptoms such as social withdrawal and failure to listen to others may also cause them to be left out or ostracised. As a result of their poor social functioning, adolescents with ADHD may suffer low self-esteem, and are at increased risk of developing internalising and externalising disorders such as anxiety, depression and Oppositional Defiance Disorder (Rucklidge & Tannock, 2001). In the wider community context, adolescents with ADHD have been found to engage in more criminal behaviour and substance abuse than their neurotypical peers (Kaplan, 2004).

Suggested Intervention

The following mental health interventions for adolescents with ADHD have a pragmatic focus, are evidenced based and contextually relevant to a high school environment. The GRIP Framework (Commonwealth of Australia, 2007) and an ecosystems perspective requires the GO to gather data from multiple contexts and sources, such as the adolescent, their teachers, parents, and any allied health professionals they may have worked with in the past. Psychometric assessments assist the GO to determine an individual’s overall IQ (WISC; Moura et al., 2019), ADHD symptoms (Conners, 2008 ASRS vi.i self-report and the SNAP-IV with parents and teachers) and comorbid depression and anxiety symptoms (Screen for Child Anxiety Related Emotional Disorders – SCARED; Muris et al., 1998) A search of school behaviour and academic records will offer a comprehensive picture of the adolescent’s functioning in different contexts and their strengths and vulnerabilities. The GO may identify specific problems or compromised functioning in multiple domains, which would indicate possible psychopathology (APA, 2013b). In response, a referral to a doctor for assessment for ADHD is appropriate. A combination of stimulant medication and psychosocial interventions in multiple contexts yields the best outcomes for adolescents with the disorder (APA, 2013b). The presentation of ADHD symptoms and the cognitive and psychosocial strengths and weaknesses of people with ADHD vary widely, therefore the Student Support Plan should contain individualised strategies and interventions. Psychosocial interventions for adolescents with ADHD should focus on the core ADHD symptoms of inattention, hyperactivity and impulsivity and support executive functioning. Involvement of teaching staff and use of strategies such as visual timetables and concrete materials may free up working memory and allow adolescents to process information more efficiently and better understand tasks.

The Student Support Plan should include support strategies for adolescents with symptoms of inattention such as checklists to track task completion, preferential seating, allowing extra time to complete tasks and assessments, withdrawal to a quieter area for assessment, use of assistive technology to reduce written work, providing a copy of notes or audio recordings and assisting the student to underline, circle, or highlight key terms on reading material. Strategies to support disorganisation should be included such as study skills and time management strategies, assistance to create a daily routine and a school assignment calendar, check-ins with the teacher after doing the first few problems to ensure correct steps are followed, organisation skills to assist in prioritising assignment goals, organising desk and workspaces, sorting papers into coloured folders, using a daily assignment book and checking it before they leave for home. Strategies to support hyperactivity and impulsivity include movement breaks and using fidget toys such as stress balls when tempted to call out or walk around.

In conclusion, the mental health challenges of ADHD can cause adolescents to have trouble with mastering developmental tasks, and result in maladaptive behaviour. The interventions and supports provided by a Guidance Officer should aim to assist young people to find new and better ways to proceed adaptively along their developmental pathway and successfully deal with the demands of high school life.