Childhood School Performance in Adults Diagnosed with Attention-Deficit/Hyperactivity Disorder

Abstract

Objective:

Children with ADHD often tend to underperform in school. This partial study aimed to find out if the school experience of adults with higher ADHD symptomatology differs from those with lower and no ADHD symptomatology.

Method:

Based on the results of ASRS questionnaires, the respondents were divided into three groups (low, medium, and high) according to the manifested ADHD symptomatology. We explored their school experiences by looking at their grades for behavior at school, notes regarding their attendance, school expulsion, and other school experiences.

Results:

Children with higher ADHD symptomatology were significantly more likely to be expelled, receive notes for bad behavior, disturbing or forgetting as well as receive reprimands from teachers.

Conclusion:

Our results show that children with increased ADHD symptomatology experience more difficulties with school behavior, they are frequently reprimanded, and they do receive more negative feedback regarding their attendance and tardiness from teachers.

Keywords

adult ADHD school performance school problems

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) is a lifelong neurodevelopmental condition that is most commonly diagnosed in childhood (3%–7%) and can persist into adulthood (2%–4%) (Weyandt & DuPaul, 2008). Its symptoms are categorized under the Hyperactive-Impulsive (HI), Inattentive (I), and mixed or combined categories (C). It is also now divided into childhood ADHD and adulthood ADHD. In childhood, the most common manifestation of the disorder is HI and C, both of which can create problems for the individual in the school and work setting (American Psychiatric Association, 2013). Studies show that children with ADHD are at higher risk of academic difficulties (Weyandt & DuPaul, 2008).

Given the prevalence of ADHD, almost up to 1 in every 20 children is potentially facing difficulties regarding ADHD symptomatology and, thus consequent school difficulties. The association between academic attainment and ADHD among school-aged children (6–16) was replicated among younger children as well; younger children with ADHD are at higher risk of even preschool failure and, thus losing the opportunity to socialize and be exposed to pre-academic conditions. It can be therefore assumed that they will struggle in school settings as well. There is still a lack of interventions aimed at behavior management in schools that would help these at-risk children (McGoey et al., 2002). Early ADHD assessment and management can be a way to help with trajectories that lead to poorer achievement and lower school engagement which is prevalent from middle childhood to early adolescence if left unmanaged (Zendarski et al., 2021). Although some ADHD symptomatology changes as children grow up, severe academic difficulties are also observed in high school. Students with ADHD were more likely to drop out or have higher rates of course failure and lower GPA. Their attendance was associated with a higher level of absence and tardiness, and according to teachers’ reports they had lower performance in their assignments and were less likely to reach their potential (Kent et al., 2011).

Overall, students with ADHD have more special education needs, poorer attendance, and lower literacy attainment compared to controls (May et al., 2021). Children with ADHD often struggle with reading which inevitably leads to worsened school performance, as reading is fundamental for successful school outcomes and is associated with increased school achievements. (Roberts et al., 2020). ADHD has been associated with poorer school performance on academic tasks and non-academic related issues like behavioral problems (Tamm et al., 2021). Children with ADHD were also found to experience higher levels of peer interaction problems, such as peer rejection and peer victimization. Difficulties regarding friendship maintenance can lead to poor social adjustment and worsened social skills (Kok et al., 2016).

Regarding the HI presentation of this disorder in children, there is a robust positive correlation between externalizing behavior and strong impulsivity (Barkley et al., 1997). Inattention was a more predictive variable of academic functioning than sluggish cognitive tempo (Mayes et al., 2022). Furthermore, inattention is associated with emotional problems (Han et al., 2020).

Longitudinal studies have found that individuals with untreated ADHD often performed worse academically than non-ADHD individuals. The main factor in the longitudinal data associated with good outcomes was multimodal treatment (pharmacological and psychotherapeutic combined). When properly diagnosed and treated, according to the data, the individual will show significant improvements in school and work (Arnold et al., 2020). A study from Denmark has also confirmed the positive correlation between ADHD treatment in children and positive outcomes in school, along with the adverse outcomes noted if treatment is stopped (Keilow et al., 2018). Worsened academic achievement was even more prevalent among individuals that were not taking medication(Arnold et al., 2020). Overall, medication seems to have more positive than adverse effects when reported by teachers as well (Lee, 2008).

Barnard-Brak et al. (2011) also note the importance of examining the coexisting disorders that often manifest together with ADHD, as they may also impact academic underachievement. And ADHD was also associated with psychopathological problems such as anxiety and depression (Visser et al., 2020)

Furthermore, the genetic component of ADHD was examined and showed an overlap between ADHD and academic achievement. It is therefore recommended to include data about educational attainment when studying ADHD (de Zeeuw et al., 2014). Apart from genetic explanation, another reason for worsened academic achievement may be because visual motor integration, motor coordination, and visual perception are linked with academic achievement in early school children. Children with ADHD tend to underperform due to the aforementioned underdeveloped skills, and thus, this reflects academic underachievement (Carames et al., 2022). One recommendation is earlier assessment and early educational correcting programs (Brook & Boaz, 2005).

Gut et al. (2012) showed that the effect of ADHD symptomatology on achievement could be mediated by academic motivation. Their research highlights the importance of academic motivation and its role in the school performance of children with ADHD (Gut et al., 2012). On the one hand, this was confirmed by Martin (2012), who showed that the promotion of personal best scores for students plays a positive role in their academic achievement, and their promotion should be more utilized (Martin, 2012). On the other hand, a Swedish study showed that self-perception of academic competence did not play a significant role. In this longitudinal study stability of symptoms affected children from 6th through 11th to 12th grade. They concluded that ADHD casts a “long shadow” on academic achievement (Scholtens et al., 2013). Perceived control was also non-significant in a study conducted by Martin et al. (2017); however, they did show that self-efficacy and relational support play a significant and vital role. Therefore it is necessary to identify factors that help with motivation and underly the processes that can narrow the achievement gap (Martin et al., 2017).

A popular “strategy” for parents with children with ADHD seems to be delayed school entry, as parents hope it will result in improved academic attainment. However, no meaningful association was found between children with ADHD who had delayed school entry and children with ADHD who did not have delayed school entry. The only meaningful association was when delayed school entry was accompanied by medication; this was, however, also due to increased symptoms of inattention over time. Therefore it seems that delayed school entry does not seem to be a beneficial strategy for children with ADHD (Barnard-Brak et al., 2017).

Aside from academic performance, grades are also allocated in the Czech Republic based on school behavior. One of the main aspects of cognitive functioning impaired in individuals with ADHD is executive functioning. There is a clear association between ADHD and executive function deficits (Lambek et al., 2011). A recent cross-national study looking at knowledge of ADHD in school teachers and how to work with children with this disorder is very high in the Czech Republic, thus showing that teachers are aware of the phenomena (Sciutto et al., 2016). No recent studies in the Czech Republic have assessed ADHD retroactively and its relation to school performance, and thus we present the first study to do so.

This partial study aimed to find out if the school experience of adults with higher ADHD symptomatology differs from those with lower and no ADHD symptomatology. School experience is essential both for personal development as well as professional development. Educational achievements are based on both knowledge and often on behavior as well. Disciplinary problems, repetition of the school year, and lower grades from behavior are supposed to be symptoms of school failure.

Methodology

The professional polling and statistics agency STEM/MARK recruited the respondents from a Czech National Panel. The questioning was done through a computer-assisted web interviewing method and led to an original sample of N = 1,518. Based on the ASRS questionnaires, the respondents were divided into three groups (low, medium, and high) according to the manifested ADHD symptomatology. In particular, we divided the respondents into terciles based on their sum of markers (scoring above the given threshold for each of the screening questions, range 0–5) and sum of responses for screening questions (range 5–30). Because both approaches could disagree, we selected only participants assigned into the first, second, or third tercile by both methods. This led to the final sample N=1,147. We explored their school experiences by looking at their grades for behavior at school, notes regarding their attendance, school expulsion, and other school experiences. For this, we constructed a set of questions that asked about the following: their grade for behavior (in the Czech school system, behavior is graded on a scale 1–3. 1—very good, 2—acceptable, and 3—unacceptable (frequent misbehavior and behavior that is not in accordance with the school rules)), we asked them if they were ever expelled from school—this means conditional expulsion for a certain period of time. We then explored their behavior during school by asking them whether they were ever written a note for bad behavior, for disturbing them during the classroom, or for forgetting (homework or school supplies). Lastly, we also asked whether they were ever reprimanded (by the headmaster), which means that their behavior broke the school’s conduct in a way that the headmaster had to be notified. In the Czech school system, all of these notes and reprimands are written down along with other grades that the students receive, and parents have to be notified about this and have to sign them—a way of checking that they were told about their child’s behavior at school. For a more detailed description of the methodology, see Vňuková et al. (2021). The data were analyzed with the statistical software R (R Core Team, 2022). We tested the independence between each school experience and the severity of ADHD using χ² analysis

Results

The research sample consisted of 1,518 respondents from the Czech Republic. The sample included 766 males and 752 females aged 18 to 65 years (average age 4.56, SD = 13.64). The education level corresponded with national statistics. The sample had 291 respondents who graduated university (19%), 572 respondents with high school diplomas (38%), and 655 respondents from lower secondary or vocational schools without high school diplomas (43%).

The chi-squared analysis between ADHD symptomatology and school difficulties showed the following results (Table 1).

Table 1.

χ² analysis.

	Elementary school					Lower high school
	ADHD type					ADHD type
Type of difficulties	Low	Medium	High	Chi-sq	p-Value	Low	Medium	High	Chi-sq	p-Value
Lower behavior grade	3.00	5.60	4.80	3.77	.152	5.40	7.50	8.80	3.51	.173
Expelled	0.00	0.50	1.50	7.32	.026	0.20	0.00	1.80	12.02	.002
Notes for bad behavior	4.60	7.20	12.10	14.89	.001	4.20	7.50	14.30	25.60	.000
Notes for disturbing	7.60	12.50	22.80	36.44	.000	7.00	10.70	22.80	42.65	.000
Notes for forgetting	5.20	6.40	26.80	97.04	.000	2.80	6.90	26.10	114.24	.000
Nothing	82.60	75.20	54.00	74.51	.000	81.40	75.20	52.60	75.47	.000
Reprimand	8.80	13.60	16.50	10.87	.004	8.80	14.10	19.50	18.24	.000

Bold indicates the significant p-values.

There are significant differences among school difficulties and the intensity of ADHD symptomatology. This is across the elementary school as well as lower high school. Children with more increased ADHD symptomatology were significantly more likely to be expelled, receive notes for bad behavior, disturbing or forgetting, and receive reprimands from teachers. Overall, the higher the ADHD symptomatology, the more school difficulties the children faced. The school difficulties were found regardless of age, and students with more increased ADHD symptomatology struggled in elementary and lower high school. The results suggest that children with higher ADHD symptomatology are more likely to be forgetful, restless, and misbehave—which then gets written down by their teachers. The only variable that did not turn out to be significant was worsened grades for behavior. Although there are group differences, they did not reach statistical significance.

Discussion

Respondents with higher symptoms of ADHD declared significantly more school problems than those who scored low. The result was expected and is in line with the literature on ADHD. Typical educational institutions require students to follow the rules regulating behavior among students, students’ behavior toward teachers, and school tasks. In the Czech Republic, one additional caveat is that behavior is graded and thus plays a part in the final grade and classical academic performance. For students with symptoms of ADHD, it is usually difficult to follow strict rules all over the school areas and time. School behavioral problems can have long-term negative consequences for an educational and working career. Even in places where behavior is not graded, such as in the US school systems, an ADHD diagnosis is associated with a significantly lower grade point average, but only when students are untreated (Frazier et al., 2007). In general, one importtakeawayaway from previous literature is that teachers with long experience can also help to ameliorate the behavior and outcomes of students with ADHD in the classrooms (Bussing et al., 2003; DuPaul, 2007) Low-grade conduct, reprimands, school year repetition, or expulsion from school may strongly limit further study paths. That is why the violation of the school rules due to misunderstanding or attention problems should be addressed by teachers or specialists working with ADHD students. As previously mentioned, the study by Sciutto et al. (2016) has shown that school teachers in the Czech Republic are well aware of ADHD in the classroom and what signs to look at. The administration of ADHD medication and psychotherapy is also recommended for people of all ages with ADHD symptoms, especially younger individuals, so that there are better lifestyle outcomes from early on.

One limitation that could have been looked at is past anxiety, which can often be misdiagnosed as childhood ADHD. Furthermore, anxiety is also a comorbidity in ADHD, and it is necessary to assess whether the school dysfunction is more from the ADHD symptoms or the anxiety (Di Lonardo Burr & LeFevre, 2021).

Overall, our results show that children with increased ADHD symptomatology experience more difficulties with school behavior, are more frequently reprimanded, and receive more negative feedback regarding their attendance and tardiness from teachers. This might consequently lead to worsened school attainment. Based on our results, we recommend early ADHD screening and improved education of teachers and school workers about the association between ADHD and possible school problems. Such raised awareness can positively affect teachers’ approach and, subsequently, their way of evaluating children.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support: GAČR—1811247S, Cooperatio Program, research area: Psychology.

ORCID iD

Martina Vňuková

Author Biographies

Martina Vňuková is a resercher at the First Faculty of Medicine Charles University. Her focus is Health psychology and Lifestyle.

Filip Děchtěrenko was the head statistician for the grant project titled ADHD and time perception. Currently he is lecturing at the department of psychology in the college of polytechnics Jihlava.

Simon Weissenberger is a researcher and a lecturer of psychology.

Martin Anders is the associate professor and the head of department of Psychiatry of First Faculty of Medicine Charles University and General University hospital.

Radek Ptáček is the profssor of Medical Psychology at Charles University. He was the main lead of the grant titled: ADHD and time perception.

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