How can the secondary mainstream classroom be more inclusive for pupils with ADHD?

Claire Pass, MA Education, Leadership and Management; Co-Founder and Director, Dragonfly: Impact Education, UK

Creating an effective learning environment means paying attention to both the macro-culture – across the whole school – and the micro-culture(s) of the individual classroom (Moore et al., 2017). This article will consider how both the macro- and micro-cultures of the school impact pupils with attention deficit hyperactivity disorder (ADHD) and the implications of this for the learning environment. It will begin from the standpoint that to be effective, the learning environment must be inclusive and meet the needs of all learners. This is problematic when many of the characteristics of ADHD manifest as behavioural problems, which can hinder the learning of a class (Moore et al., 2017). While positive relationships are central to effectively supporting these pupils, teaching pupils with ADHD is associated with high levels of stress in teachers, which may adversely affect both these relationships and the learning environment as a whole (Moore et al., 2017). Recent research has also shown teacher beliefs about ADHD to be ambivalent, which in turn affects the teaching strategies employed (Boon, 2020). There are evidence-based psychosocial interventions such as classroom behaviour management strategies that are often not implemented in school settings, highlighting the need to close the research-to-practice gap in this area (DuPaul et al., 2020), and with a worldwide prevalence of seven per cent (Boon, 2020), the need for a greater understanding of ADHD on the ground in schools is becoming increasingly pressing.

Context

ADHD can be categorised into three subtypes: predominantly impulsive, predominantly inattentive or a combination of both. Most cases are diagnosed in children aged six to 12, and diagnoses are often accompanied by secondary conditions such as sleep and anxiety disorders (NHS, 2021), as well as impairments in social and academic functioning, atypical motivation and aggressiveness (Boon, 2020). These secondary factors in and of themselves can have an impact on a child’s ability to thrive both in and out of the school context. 

The diagnostic criteria for ADHD, as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013), include symptoms such as having a short attention span, making careless mistakes in schoolwork, being unable to persevere with tasks, being unable to listen to instructions, difficulties with organisation, being unable to sit still, fidgeting, calling out and excessive talking. While this is not an exhaustive list, it gives an indication of the challenges faced by both education staff and the students themselves. The implications for the importance of schools and classroom-based staff in addressing the needs of pupils with ADHD are highlighted by Tegtmejer (2019), who describes ADHD as ‘primarily a classroom diagnosis’ (p. 240) because so many of the diagnostic criteria reference classroom-specific behaviours, schoolwork and homework. This also highlights the significance of teacher education and training around ADHD, as their reports about and perceptions of behaviours will influence the diagnostic procedure (Boon, 2020).

In the recent past, ADHD has been regarded by many as a social problem, with its status as an actual condition even being questioned by a prominent psychiatrist; it is not surprising, then, that education staff have sometimes demonstrated knowledge of ADHD founded in inaccurate information – for example, the belief that it reflects family situations or upbringing (Boon, 2020). With the aim of improving teachers’ understanding of ADHD, Boon (2020) synthesised data from magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) that demonstrates that people with ADHD have significant differences in both structure and processes in their brains, supporting the argument that ADHD as a condition is indeed biological, rather than sociological.

Some of the anatomical differences in the brains of people with ADHD were found in those areas of the brain connected to mental processing, attention, movement and motivation: reduced basal ganglia volume, reduced thalamic volume, reduced cortical thickness in grey matter, differences in the corpus callosum and differences in the thickness of white matter. The fMRIs revealed that different circuitry within the brain was activated during task processing, reward anticipation and self-regulation. These differences marked out people with ADHD as being distinct from neurotypical individuals and also from individuals with other neurological diagnoses.

Challenges

According to Gaastra et al. (2020), because of the prevalence of the condition, ‘practically every teacher will teach a student with ADHD’ (p. 2). However, despite the fact that NICE recommends that only teachers with specific training should provide behavioural interventions in the classroom (Moore et al., 2017), there is a lack of knowledge about and practice of evidence-based strategies specific to ADHD (Moore et al., 2017; DuPaul et al., 2020). 

In one study it was revealed that education staff worked to support students through classroom management strategies (CMS) and by ensuring that work was pitched appropriately to engage and motivate pupils (Moore et al., 2017). This is in contrast to attitudes in the past, where educators valued the withdrawal of pupils with ADHD from the classroom, and is perhaps indicative of the influence of national policy (Moore et al., 2017). Although staff aimed to used inclusive strategies, it was found that they were not evidence-based approaches and were not ADHD-specific, with many secondary school teachers reporting that they ‘do not provide additional support for students with ADHD symptoms’ (Gaastra et al., 2020, p. 1). In many cases, strategies that staff deemed to be the most effective were in direct contrast to the evidence base about effective strategies; this is perhaps because the more individualised CMSs increase workloads and demands on time in an already time-poor context, thus influencing staff perceptions of effectiveness (Gaastra et al., 2020).

This combination of a lack of training, additional workload implications and the pressure on staff to balance their time between the needs of different pupils with a range of varying needs in a classroom situation could be why Tegtmejer (2019) describes ADHD as posing more of a challenge than other conditions for schools.

Strategies

As the prefrontal cortex, shown to have a thinner thickness of grey matter in pupils with ADHD, is still developing during adolescence, interventions that target executive functions, such as working memory, planning and impulse control, can make a significant difference (Boon, 2020) and positively impact on the behaviours associated with ADHD that affect academic achievement, behaviour and relationships.

Other individualised ADHD-specific strategies that could be implemented include support with the self-monitoring of behaviour and academic outcomes, daily report cards, physical activity or ‘movement breaks’, or exit cards (Moore et al., 2017. These are all elements of the macro-culture of the school and would need to emerge from a cohesive top-down approach, despite being individual interventions.

The ‘Universal Design for Learning’ (UDL) has also been identified as a potentially effective approach that is ADHD-inclusive (Boon, 2020), although perhaps by its very nature not ADHD-specific. The principle of universal design originated in architecture, when buildings were designed to be accessible for all. It was applied to education in the 1990s by the Centre for Applied Special Technology (CAST) and, although it acknowledges that additional support might still be needed for those with significant needs, it aims to make learning accessible to all, so while there are no specific modifications for special educational needs, the design ensures that no pupil is left unable to access the learning environment or the learning itself (CAST, 2017; Evmenova, 2018; Hazmi and Ahmad, 2018). 

The three main elements to UDL are ‘what’ (knowledge), ‘how’ (skills) and ‘why’ (motivation) (CAST, 2017), and it utilises the redundancy principle by presenting knowledge in a variety of different ways, using multiple methods of motivating and engaging pupils and by providing multiple ways for pupils to show what they have learned (Evmenova, 2018). Rather than differentiated resources, differentiated instruction, modelling and scaffoldingProgressively introducing students to new concepts to suppor are at the centre of UDL, and teachers are encouraged to anticipate potential barriers to learning by mapping out the variability of learners in their classes and proactively planning for potential difficulties to build in effective support and scaffolding. In this sense, planning becomes about designing the instruction and delivery of the lesson to reduce or remove barriers to learning, rather than planning the content of the lesson (Evmenova, 2018; Hazmi and Ahmad, 2018).

When examining the micro-culture of the individual classroom within the school, Boon (2020) concludes that clear classroom rules and expectations, a structured environment and routines, and being seated near the front of the class and near to behavioural role models are all beneficial for pupils with ADHD, highlighting the interplay between consistent whole-school routines and behaviour practices and the culture within the classroom. In 2019, Tegtmejer highlighted six strategies often used by staff to manage ADHD behaviour in the classroom: structure and clarity; ignoring; supporting active participation; extra time and attention; shields – such as screens for isolated learning; and repeated small messages and physical contact, such as gently touching the shoulder. When analysing these CMSs, he pointed to the fact that rigidly structured instruction led to frequent interruptions, disrupting the flow of the lesson. He argued that ‘the widespread idea that ADHD calls for firmly structured instruction and close management should be challenged’ (p. 251), supporting the notion that a flexible approach to instruction and well-established routines are beneficial. He also noted that the CMS of ignoring was a much-used strategy because it is already an established technique for maintaining the flow of a lesson, but that as the number of pupils with ADHD rises it is becoming increasingly relied upon, perhaps suggesting that a wider range of CMSs are needed.

There are several CMSs that are helpful to pupils with ADHD and they can be categorised into antecedent, consequence-based and self-regulation CMSs (Gaastra et al., 2020). Antecedent CMSs (those that proactively aim to avoid specific behaviours through planning seating arrangements, task choices, etc.) are often viewed as the most effective by education staff and are reported as being the most used and applied to pupils who display challenging behaviour. Consequence-based CMSs (occurring after the behaviour – for example, praise or a sanction) and self-regulation (student self-monitoring to improve self-control) are seen as less effective and used less often, although the evidence base highlights that although antecedent CMSs improve attainment, it is the consequence-based and self-regulation CMSs that actually improve classroom behaviour (Gaastra et al., 2020).

To conclude, the high prevalence of ADHD pupils in mainstream classrooms has left a gap in teacher knowledge that needs to be addressed on both a whole-school level – with policies and processes for ADHD being led centrally – and on an individual CPD level. While this is a demand on training time, it has been demonstrated that teachers who respond appropriately to the needs of pupils with ADHD do not have to deal with as many behavioural issues (Gaastra et al., 2020), and so this may be time well spent.