Strategies for ensuring positive transition for individuals with attention-deficit/hyperactivity disorder

2.1 Inattention

The greatest difficulty that individuals with ADHD demonstrate is the inability to sustain attention or persist at tasks and to resist distractions while doing so (Fischer et al., 2005; Nigg & Barkley, 2014). Failure to sustain attention often leads to a host of complaints by parents, teachers, and even co-workers, who frequently indicate that the individual is easily distracted, does not listen, and cannot concentrate. Research examining the inattention domain has corroborated such complaints through demonstrations of increased off-task behavior, less persistence in performing tedious functions, and less likelihood of returning to an activity once distracted (e.g., Borger & van der Meere, 2000; Fischer et al., 2005), behaviors that are not observed in those with other disabilities or psychiatric conditions (e.g., Swaab-Barneveld et al., 2000).

Overall, inattention in ADHD is characterized by behaviors such as becoming easily distracted by extraneous stimuli; failing to pay close attention to details; making careless mistakes in school or work; difficulty sustaining attention during lectures, lengthy readings, or conversations; appearing as not listening when spoken to directly; trouble following through with instructions and completing school or work assignments; difficulty organizing tasks (exemplified by poor management of sequential tasks, disorganization, poor time management, and meeting deadlines); avoiding tasks that require sustained mental effort; and displaying frequent forgetfulness for daily activities. It is not uncommon for others to misinterpret the inability of individuals with ADHD to sustain attention and, therefore, concentrate effort to complete tasks as “laziness, irresponsibility, or failure to cooperate” (APA, 2013, p. 63). Such public perceptions can undermine the mental and physical health of individuals with ADHD when these individuals also question the legitimacy of their disabilities and, as a result, fail to seek treatment, rehabilitation, or accommodations (both postsecondary and workplace). Individuals with ADHD also are affected by stigma, and they may develop compensatory strategies to mask their difficulties but suffer from the stress and constant effort of trying to maintain a socially acceptable façade (APA, 2013).

2.2 Hyperactive-impulsive behavior

A second area of behavioral difficulty that individuals with ADHD may experience is inhibiting impulses. Simply stated, individuals with ADHD may not possess the ability to stop a behavior once they are ready to engage in that behavior. This inability means that an individual with ADHD may move about constantly, including at inappropriate times, or make hasty, “in the moment” decisions that may result in negative consequences. Over time, hyperactivity declines by adolescence or adulthood, symptoms may be expressed more as restlessness rather than excessive, uncontrollable behaviors (Nigg & Barkley, 2014). On the other hand, impulsivity appears to remain elevated over time but is usually displayed more as improper decision-making/problem-solving (Fischer et al., 2005).

Hyperactivity-impulsivity is characterized by behaviors such as frequent fidgeting, hand tapping, or inability to sit still; leaving seats in classroom or workplace situations when expected to remain in place; feeling restless; frequent inability to quietly engage in play or leisure activities; inability or discomfort with remaining still for extended periods of time such as in restaurants or in lengthy work meetings; talking excessively; difficulty waiting; blurting out answers before questions have been completed; and interrupting others who are speaking or intruding into or taking over what others are doing without permission (APA, 2013). Some research points to the notion that hyperactivity-impulsivity in ADHD can be thought of as a heightened valuation of a reward rather than a pure inability to inhibit behaviors (Sagvolden, Russell, Aase, Johansen & Farshbaf, 2005). That is, the notion of receiving an immediate reward (e.g., receiving $25 now) possesses a higher influence relative to a delayed reward (e.g., receiving $200 in a week). In such a mechanism, behaviors tend to center on a more impulsive style.

2.3 Comorbid psychiatric conditions

Individuals with ADHD often have other, co-occurring disabling conditions. In fact, up to 44% of children with ADHD have at least one other disorder; and 43% have at least two or more additional disorders (Wilcutt et al., 2012). Such rates also are true for adults with ADHD (Barkley, Murphy & Fischer, 2008). Comorbid conditions include anxiety disorders, mood disorders, substance use disorders, and antisocial and other personality disorders (e.g., Loeber, Burke & Pardini, 2009; Molina & Pelham, 1999; Shatz & Rostain, 2006). If untreated, psychiatric comorbidities can amplify the difficulties that individuals with ADHD experience in social interactions, education, and employment.

2.4 Developmental course

Depending on the number and severity of symptoms and the degree to which they impair social or occupational functioning, ADHD may be diagnosed as mild, moderate, or severe. As children with ADHD develop into adolescents, they may experience marked impairment in social and vocational functioning. For example, in comparison to their peers, adolescents with ADHD score lower on standardized tests (despite the fact that they have the cognitive abilities to score higher), have higher absenteeism rates, are at greater risk for dropping out of high school, and are less likely to pursue postsecondary education (DuPaul, Weyandt & Janusis, 2011). Those who do pursue postsecondary education earn lower grade point averages (GPAs) than their peers and demonstrate higher dropout and academic probation rates. As adults, individuals with ADHD often demonstrate increased adverse health outcomes, including fewer friends, social impairments, impulsive decision-making, driving risks and motor vehicle accidents, disturbances in sleep, substance use disorders, difficulties in romantic relationships, and increased rates of criminal activity (O’Driscoll, Heary, Hennessey & McKeague, 2012; Nigg, 2013).

2.5 Epidemiology

Although population estimates vary, most indicate that the prevalence of ADHD in school-aged children and adolescents is between 5% and 12% (APA, 2013; Rowland et al., 2015). Among adults, the prevalence of ADHD ranges from 2.5% to 5% (Barkley, 2012). ADHD is more common in male than in females; however, females with ADHD are more likely than males to present with inattentive features (APA, 2013). Though it has been suggested that the prevalence of ADHD has risen, it is unclear whether a true growth in prevalence exists or is the result of other factors such as changes in diagnostic criteria, increased public awareness, greater access to services, policy changes in special education, and the influence of the pharmaceutical industry on diagnostic practices (Centers for Disease Control and Prevention [CDC], 2014; Polanczyk et al., 2007). However, in a recent analysis, no evidence was found to support the notion that rates of ADHD are increasing in the population when standard diagnostic procedures were used (Erskine et al., 2014). Regardless of any real or supposed increase in the rates of ADHD, recent data from the National Survey of Children’s Health indicates that the proportion of children who have ever been diagnosed with ADHD increased from 7.8% in 2003 to 9.5% in 2007, then to 11.0% in 2011 (CDC, 2014).

5.1 Intervention in schools

Early intervention and service provision throughout primary and secondary education are hallmarks of effective treatment for children and youth with ADHD and can facilitate better outcomes in adulthood (DuPaul et al., 2011). The most commonly used interventions are a combination of pharmacological and non-pharmacological interventions. FDA approved psycho-stimulants (e.g., methylphenidate) are the most commonly prescribed medications. Doses of medication are titrated (adjusted) to achieve maximum benefit with minimal adverse effects. Non-pharmacological interventions include evidence-based parent- or teacher-administered behavioral strategies that focus on attention management training, conflict resolution skills, compliance training, and social skills training (e.g., Barkley, 2013; Jenson, Rhode, & Reavis, 2009; Rhode, Jenson & Reavis, 2010). In research conducted in the Netherlands by Stoutjestijk (2016), positive behavior reinforcement combined with emotional support was the pedagogical strategy found to result in the greatest improvements in behavioral functioning. Based on this finding, the author recommended that emotional support be incorporated into all interventions used with students with ADHD. Home-school communication between teachers and parents or adult guardians is critical to ensure that these strategies are consistently implemented in both settings. Likewise, partnerships among teachers, parents, and school psychologists (who recommend strategies) are critical.

School-based transition planning for individuals with ADHD should begin as early as possible (ideally before the required age of 16). Because symptoms of ADHD can have a negative impact on educational and social outcomes, it is vital for educational teams to determine what instructional and educational experiences will help the individual prepare for the transition from school to adult life. When becoming involved in the transition process, VR professionals can help the individuals with ADHD invest in their future by encouraging them to play a key role in planning their own career paths. This assistance may include, but is not limited to, discussions with teachers, school support staff, career centers, community members, and other health care professionals to request additional help or learning accommodations, goals, and/or classroom structure. Throughout the school year, VR professionals and transition specialists must encourage the individual with ADHD to meet with school support team members to monitor progress, receive emotional support and encouragement, and make appropriate changes when necessary.

5.2 Ensuring long-term success through counseling and guidance

As has been indicated, deleterious effects of ADHD are often evident in adult populations. To that end, emotional support and employment assistance may be necessary on a long-term basis to ensure long-term success. Counseling and guidance is a service that is provided by the state-federal VR professionals to all clients throughout the VR process, and emphasizes emotional support, encouragement, and rapport-building. This relationship is based on mutual bonds and respect, equality, agreed upon tasks, and support of clients in identifying and pursing their self-determined goals. Wadsworth and Harper (2007) provided helpful recommendations for counseling individuals with ADHD in a manner that increases the likelihood of a strong working alliance. First, the focus of counseling should be on empowering individuals with ADHD to manage their symptoms and functional difficulties. Due to long histories of academic and vocational failures and troublesome relationships, adults with ADHD may experience self-blame, frustration, and helplessness. Consequently, they may avoid situations that historically have been problematic. Rehabilitation professionals should assist the individual to reframe such negative experiences as symptoms of their disorder rather than personal failures. Essentially, VR professionals should engage the individual using cognitive behavioral therapy (CBT) approaches that aim to change negative or irrational thought patterns that get in the way of staying on task or getting things done (Solanto, 2011).

Second, it is recommended that structured, directive counseling approaches are used rather than insight-oriented, non-directive approaches (Wadsworth & Harper, 2007). Counseling approaches should focus on establishing clear guidelines regarding the rehabilitation process, the importance of being on time for appointments, and both the rehabilitation consumer’s and counselor’s responsibilities. At times, the consumer may perceive the VR professional as too controlling. To counter this negative perception, the VR professional can emphasize that the rehabilitation consumer is an equal partner who has the final say regarding service options and rehabilitation goals. This emphasis, if repeatedly stated and coupled with questions about what the consumer’s preferences are, could assuage the consumer’s perception of the VR professional as being too controlling. Wadsworth and Harper (2007) also delineated ADHD symptoms that may be observable in counseling sessions and cautioned VR professionals not to misinterpret these as disinterest, lack of motivation, uncooperativeness, defiance, and/or immaturity. Examples of these symptoms include long pauses in speech, stopping in the middle of a sentence, forgetting what they were saying, asking the rehabilitation counselor to repeat what she or he was saying, staring into space rather than looking at the rehabilitation counselor, interrupting the rehabilitation counselor when he or she is speaking, and wandering around or leaving the VR professional’s office.

5.3 Planning for college, career, and beyond

Depending on the timing of involvement, VR professionals will want to make sure that an individual who is benefitting from an Individualized Education Plan (IEP) and/or 504 plan in high school documents the nature and extent of such services prior to graduation. Colleges, vocational training programs, and workplace environments may require such records for review before they provide similar types of accommodations and/or services. It is important for VR professionals to collaborate with the educational team to identify goals and services necessary to make the transition. To be optimally effective, VR professionals must develop measurable post-secondary goals (e.g., “After high school, Sergio will enroll in courses at Bay Harbor College” or “Arthur will attend skills training courses in auto mechanics at Ocean Community College”). In addition to setting measurable goals, VR professionals should work with the individual with ADHD to develop a transition assessment portfolio that records data and maintains ongoing dialogue between the individual, case managers, and other relevant individuals.

At this stage, it is vital that VR assessment and planning take an individualized approach, especially due to the heterogeneity of individuals with ADHD. Essential to designing and implementing individualized supports and services for individuals with ADHD, rehabilitation professionals should create as many opportunities for the individual to exert control through choice making (allowing an individual to select an activity among several alternatives) and preference (those activities that are most appealing to the individual) into the rehabilitation process. Once the individual has identified naturally rewarding activities, the VR professional should co-develop with the client a specific support plan (i.e., individualized plan for employment [IEP] that includes: (a) individualized instruction, (b) functional programming, (c) data-based instruction provided within a structured environment, (d) emotional support and encouragement, and (d) collaboration with families and other service providers. Such support plans should focus on those characteristics of social skills, behavioral regulation, and academic and/or employment skills needed to support the individual with ADHD to be successful in his or her chosen path to employment and other adult roles.

5.4 Postsecondary support

As the number of individuals with ADHD attending colleges and universities grows, so too does the need for postsecondary supports. Postsecondary supports and accommodations that have been identified as instrumental to the academic success of students with ADHD include course specific strategic instruction for academic achievement, assistive software programs for enhancing reading compression, extended time on tests in distraction-free environments (e.g., testing centers), books on tape, and note taking assistance (DuPaul et al., 2011).

In addition to the aforementioned array of services, ADHD coaching for improving executive functioning skills and enhancing self-regulation has received increasing attention in recent years (e.g., Field, Parker, Sawilowsky & Rolands, 2013). The focus of coaching is on the development of specific executive functioning skills such as goal setting, confidence building, organizing, problem solving, and persistence at completing tasks. ADHD coaches work with students to set goals based on an accurate self-awareness of their ADHD, its symptoms, and how symptoms affect their thoughts and behaviors. In goal-setting, coaches foster goal achievement by helping students to develop greater self-awareness by teaching strategies to stop, reflect, and take action. They also work with students to identify both individual and environmental factors that support or restrict goal achievement and work with them to develop strategies to activate supportive factors and ameliorate restrictive factors. The student with ADHD, who is held accountable for achieving her or his goals and directs this process. However, ADHD coaches offer suggestions and guidance, set structure, provide support, and help students implement strategies for skill building.

5.5 Job development and placement

Once all services on the IPE have been completed, the next step is job development and placement. As is true of all VR services, job development and placement assistance is highly individualized and takes into consideration each individual client’s unique preferences, skills, ambitions, and needs. However, several issues for providing this service to individuals with ADHD warrant consideration:

The need for on-going emotional support and encouragement from the VR professional during the highly stressful period of searching for, finding. and beginning a new job cannot be overstated.

5.6 Accommodation planning

In accommodation planning with individuals with ADHD, the first steps are to review accommodations they have used in secondary and postsecondary classrooms, evaluate their satisfaction with these accommodations, and determine if accommodations they found to be satisfactory can be implemented or adapted for implementation for the specific jobs. Then additional accommodations can be explored as necessary. A variety of accommodations that employers can easily implement to address work-related problems and improve the job performance of workers with ADHD have been recommended (see Adamou et al., 2013). These accommodation ideas include: (a) providing a private office or workstation that is located in a quiet area to limit distractions; (b) developing a buddy system whereby co-workers help individuals with ADHD remain focused; (c) allowing productive movements at work and encouraging employees with ADHD to remain active throughout to day to limit hyperactive impulses; (d) providing alarms, structured notes, and/or regular supervision to improve time management; and (e) delegating more tedious tasks to co-workers or providing incentives for task completion.