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Open Journal of Psychiatry, 2017, 7, 71-78
http://www.scirp.org/journal/ojpsych
ISSN Online: 2161-7333
ISSN Print: 2161-7325
DOI: 10.4236/ojpsych.2017.72007 April 18, 2017
Importance of Early Intervention and Special
Educational Support for High School Students
with Attention-Deficit/Hyperactivity Disorder
Takuji Inagaki1*, Rei Wake2
1Faculty of Education, Shimane University, Matsue, Japan
2Faculty of Medicine, Shimane University, Izumo, Japan
Abstract
Aim: The present study aimed to investigate problems relating to education,
past situations and treatments in high school students with attention-
deficit/
hyperactivity disorder (ADHD) and to discuss appropriate considerations.
Methods:
Participants were 6 students who were diagnosed with ADHD a
c-
cording to Diagnostic and Statistical Manual of Mental Disorders IV, Text
Revision (DSM-IV-TR) criteria.
Results:
In total, 6 cases of high-school st
u-
dents with ADHD showed dominantly inattention features. They had notably
not been diagnosed with ADHD or received appropriate special support ed
u-
cation until they were of high-
school age, although they had clearly shown
characteristic features of the disorder from childhood. As a result, they had
decreased motivation to study and showed indolence, and suffered from low
self-esteem.
Conclusion: This case report suggests that early diagnosis of
ADHD and early intervention with special support education are of great i
m-
portance. To support these students, better ed
ucational and medical support
systems are warranted.
Keywords
ADHD, High-School Students, Special Educational Support
1. Introduction
Although attention-deficit /hyperactivity disorder (ADHD) is widely recognized
as a childhood disorder, for the majority of children, symptoms persist through
adolescence and into adulthood. ADHD has significant negative effects on edu-
cational functioning and academic performance of children. High school stu-
dents with ADHD frequently experience academic difficulties and have lower
How to cite this paper:
Inagaki, T.
and
Wake
, R. (2017) Importance of Early In-
tervention and Special Educational Support
for High School Students
with Attention-
Deficit/Hyperactivity Disorder
.
Open Jour
-
nal of Psychiatry
,
7
, 71-78.
https://doi.org/10.4236/ojpsych.2017.72007
Received:
January 12, 2017
Accepted:
April 15, 2017
Published:
April 18, 2017
Copyright © 201
7 by authors and
Scientific
Research Publishing Inc.
This work is licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
T. Inagaki, R. Wake
72
self-esteem than students without ADHD. Although they have had learning dif-
ficulties or behavioral problems in childhood, many of students with ADHD
may have been previously undiagnosed. Therefore, for early recognition of the
disorder and prevention of long-term negative outcomes, it is important to iden-
tify the factors in childhood that lead to the persistence of ADHD and associated
impairment. It is also required that high-school students be provided with the
academic supports and services that they require. Special support education is
important to foster positive long-term outcomes and prevent the decrease in
their self-esteem. The following is a report of 6 high-school students with ADHD
who were not appropriately diagnosed and treated.
2. Material and Method
We consecutively experienced six high-school students who were diagnosed with
ADHD according to Diagnostic and Statistical Manual of Mental Disorder IV.
Text Revision (DSM-IV-TR) criteria (American Psychiatric Association 2000)
[1] in the psychiatry unit of Shimane University Hospital from 2013 to 2015.
These 6 cases were selected out of 22 high-school students who came to our
psychiatry unit during same period. They were free of neurological and cardi-
ovascular diseases, and chronic diseases such as cancer or diabetes mellitus. We
used the ADHD-Rating Scale IV (ADHD-RS IV) to define inattentiveness, hy-
peractivity/impulsiveness, and combined diagnostic subtypes of ADHD [2]. We
fully preserved their anonymity in the case description. We investigated their
academic challenges, past situations and treatments, current symptoms, and ca-
pability for social adaptation and discussed appropriate considerations regarding
support systems for their future.
3. Cases Presentation
Table 1 indicates the clinical characteristics of the students. Table 2 shows their
clinical features and histories. Their main complaints were decline in academic
performance and forgetfulness. Almost all of them experienced some degree of
difficulty in school in the past. Of the total, 5 were male. In total, 5 cases out of
the 6 students predominantly revealed inattentive behavior and 1 showed a
mixed pattern (hyperactive and inattentiveness). The following is a brief de-
scription of the past histories and clinical characteristics of the 6 cases of stu-
dents with ADHD.
Case 1: Problematic behaviors were not addressed in childhood, other than in
learning composition. After attending high school, he showed tiredness, forget-
fulness regarding homework, and gradually worsening academic performance.
He had not received educational support in the past.
Case 2: Both hyperactivity behaviors and inattentiveness began in child-
hood. He also experienced difficulties of in learning math. He did not receive
special educational support or appropriate medical care. He experienced bul-
lying in childhood. Smartphone (internet) addiction and sleep rhythm disord-
er persist.
T. Inagaki, R. Wake
73
Table 1. The clinical characteristics of the students with ADHD.
Age 18 years old male 16 years old male 16 years old male 15 years old male 18 years old male
16 years old female
Introducer School counselor Psychiatrist (-) (-) (-) Pediatrician
Full IQ FIQ:80 (WAIS-III) FSIQ:110 (WISC-IV) FIQ:110 (WAIS-III) FIQ:130 (WISC-III) (-) FSIQ:90 (WISC-IV)
First
diagnosis
of ADHD
This time This time 2 years before 7 years before This time 3 years before
Diagnosis by
DSM-IV-TR Inattentive type Inattentive type Inattentive type Combined type Inattentive type Inattentive type
Prognosis Graduated from
high school
Dropped out of
school → Transferred
to another high school.
Dropped out of
school → Transferred
to another high school.
Stayed in
same grade.
Stayed in
same grade.
Dropped out of
school →
Transferred
to another high
school.
Table 2. The clinical features and past histories of the students.
Age 18 years old male 16 years old male 16 years old male 15 years old male 18 years old male
16 year
s
old female
Chief
Complaints
Decline of academic
impairment.
Forgetfulness.
Decline of academic
impairment.
Forgetfulness.
Second opinion
for diagnosis
as ADHD.
Decline of
academic
impairment.
Decline of
academic
impairment.
Forgetfulness.
Decline of
academic
impairment.
Forgetfulness.
Infant age
Restlessness.
Frequently losing.
Restlessness.
Impulsiveness.
Short temper.
Elementary
school age
Difficulty
in composition.
Difficulty in
concentration and
time keeping.
Restlessness.
Difficulty in
concentration.
Damage of
bullying,
A poor memory. Difficulty
in studying.
Junior high
school age
Inattention.
Difficulty in math
and communication.
Difficulty in putting
in order.
Short temper.
Damage
of bullying.
Decrease in
motivation
to study.
Clumsiness.
Decrease in
motivation
to study.
High
school age
Decrease in
motivation to study.
Difficulty
in putting away.
Decline of academic
impairment.
Nonattendance
to school.
Nonattendance
to school. Short
temper. Violence.
Nonattendance
to school.
Difficulty in
putting away.
Nonattendance
to school.
Defiance to
the family.
Learning
disabilitiy
(+)
Composition, math,
science and reading.
(+)
Composition and
math.
(+)
Math. (−) (+)
Fine work.
(+)
Composition
and math.
Past special support
intervention (−) (−) (−) (-) (−) Special
support class.
Bothered feelings Anguish for
his ability.
Anguish for his
ability. Low
self-esteem.
Discontent for
previous diagnosis.
Anguish for his
ability. Low
self-esteem.
Anxiety for the
future. Low
self-esteem.
Unwilling
to go to school.
Victim of bullying (−) (+) (+) (+) (−) (−)
Comorbidity (−) (+) Anxiety (+) Anxiety (+)
Depressive mood (+) Anxiety (−)
Internet addiction (−) (+) Mobile phone (−) (+) Mobile phone (+) Mobile phone (+) Mobile phone
Sleep disturbance (−) (+) (−) (+) (+) (+)
T. Inagaki, R. Wake
74
Case 3: He was diagnosed as ADHD at another psychiatric clinic before; how-
ever, he was not convinced of the validity of the diagnosis and discontinued
psychiatric clinic sessions and drug therapy.
Case 4: Although he was diagnosed with ADHD and started treatment in
childhood, he did not receive special educational support. As a result, treatment
and clinic visits were discontinued. He experienced bullying in elementary
school. Smartphone (internet) addiction and sleep rhythm disorder persist.
Case 5: He had shown forgetfulness from childhood, and experienced difficul-
ties with organization and planning. He also showed little emotion when he told
a lie. He had not received special educational support.
Case 6: She had difficulty in learning and showed poor study skills since ele-
mentary school. She experienced increased academic impairment, with lower
grade-point averages, placement in lower-level classes, and failure in more
courses. Medication and special educational support were provided when she
reached junior-high school age, but did not continue. Smartphone (internet) ad-
diction and sleep rhythm disorder persist. We advised all of them to make a
schedule everyday and to keep their sleep rhythm.
4. Discussion
Characteristic features of the cases are as follows:
1) In total, 5 of the 6 cases (cases 1, 2, 3, 5 and 6) were diagnosed with ADHD
with inattentiveness, and in Case 4, the diagnosis was mixed-type ADHD. Also,
4 cases (cases 1, 2, 3 and 5) were diagnosed for the first time at high-school age.
The diagnosis was first given at our psychiatry unit. The other two cases had
been previously diagnosed and received ADHD medication therapy.
2) Although some behavioral and academic problems had been observed since
childhood in 5 of the cases, the students had not received appropriate education-
al and/or medical support. Only 1 case (case 6) received academic intervention
such as modified assignments and slower-paced instruction in a special-support
class. Also, 5 of the students (cases 1, 2, 3, 5 and 6) showed some degree of
learning disability.
3) In total, 3 cases (cases 2, 3 and 4) had experienced bullying by classmates.
Almost all of them had negative feelings about themselves and low self-esteems.
4) Comorbidities of depressive mood and/or anxiety appeared in 4 cases (cas-
es 2, 3, 4 and 5). Furthermore, in 4 cases, the students suffered sleep disturbance
(day and night rhythm reversal) with smartphone (internet) addiction (cases 2,
4, 5, and 6).
5) Clinical courses: The convalescence of Case 1 suggested graduation from
high-school to university. Cases 2, 3, and 6 had many absences from school and,
transferred to another high school. Cases 4 and 5 remained in the same grade.
ADHD is generally the most common neuropsychiatric and neurobehavioral
disorder beginning in childhood. The symptoms of ADHD include inattention,
hyperactivity, impulsivity, disorganization, and academic and behavioral diffi-
culties [3] [4]. We reported 6 cases of high-school students with ADHD, predo-
T. Inagaki, R. Wake
75
minantly of the inattentive type. One of the important problems from almost all
of these cases were that they had not been diagnosed with ADHD and received
appropriate special educational support until they were of high-school age, even
though they had clearly developed the characteristic clinical features in child-
hood. Therefore, they had difficulty learning and experienced several behavioral
and academic problems. As a result, they had decreased motivation to study and
exhibited behavioral problems, felt distressed, and had low self-esteem.
The intensity of hyperactive behaviors in children may subside with age;
however, the characteristics of inattentiveness, organizational dysfunction, and
impulsivity often persist [5]. Numerous follow-up studies have confirmed the
persistence of ADHD symptoms into adulthood [6]. However, the inattentive-
dominant type of ADHD is not as apparent in its clinical course compared with
the hyperactive-dominant type. In this case report, 5 of the 6 cases were not
found to have exhibited the characteristic symptoms in childhood.
The disorder often impairs behaviors essential for adaptive functioning, in the
academic, social, and psychological realms. As a result, ADHD has a significant
negative impact on scholastic functioning and academic performance. Some
students with ADHD are unable to take notes during lectures and do a poor job
planning and completing schoolwork and studying for exams, and thus the per-
sistence of ADHD symptoms and associated disorders may be negatively corre-
lated with the individual’s satisfaction with school life.
As for comorbidities, cognitive and emotional problems are well documented
in ADHD. ADHD is associated with reduced executive functioning (e.g., work-
ing memory, response inhibition, and organization). In addition, ADHD is often
associated with poor emotional and mood regulation, and irritability. Therefore,
people with ADHD may have interpersonal-communication problems, in addi-
tion to adjustment difficulties [5]. There are serious consequences of ADHD in
childhood and adulthood in terms of functional outcomes, and it has been sug-
gested that early recognition and intervention for ADHD and comorbid mental
disorders is important for improving future outcomes [7] [8].
In adolescents, mood disorders and substance-use problems can complicate
the clinical course of ADHD. Of the total, 2 cases presented in this report
showed mood disturbance and/or anxiety. The severity of ADHD and comor-
bidity results in widely varying courses of treatment, and many students discon-
tinue treatment in adolescence and adulthood [5].
Furthermore, the comorbidity of learning disorder (difficulty) (LD) can also
complicate the clinical course of ADHD.A large proportion of patients were pre-
viously undiagnosed with respect to ADHD, although many of them had been
recognized as having learning difficulties in childhood [7]. The comorbidity of
LD and ADHD is relatively high with approximately 31% - 45% of students with
ADHD having LD as well [5] [9].
Therefore, appropriate support, such as special educational support, may be
essential to ensure positive long-term outcomes. High schools are required to
provide students who have a disability with appropriate academic adjustments
T. Inagaki, R. Wake
76
and auxiliary aids and services in order to allow them equal participation in
educational programs. Several academic accommodations are possible: addition-
al time for exams, distraction-free examination rooms, deadline flexibility, note-
taking services, tutoring, alternative formats for exams, and adaptive equipment
and technology [10]. Many students should receive more than one type of aca-
demic intervention such as extra time for tests and modified assignments, slow-
er-paced instruction, progress monitoring, and case management [11].
Brook
et al.
[3] examined 308 students aged 12 - 18 years who had been diag-
nosed with ADHD and LD, and reported that 34% of them reported being se-
verely stressed when going to school and sitting in class. Their complaints were:
tiredness and excessive need for sleep, frequent quarrelling with their friends,
feeling different from other classmates, and having low self-esteem. Their grades
were low on average; 94% reported feeling despair regarding their own ability
and academic achievement, and 53% reported feeling that their teachers don’t
understand them or their difficulties. Their frustration increases their anxiety,
depression, and mood instability, and hence negative social interactions, and
there is an absence of strong relationships. As a result, they feel decreasing self-
esteem, different from and inferior to their classmates [3]. Consequently, they
may develop a mood disorder.
In terms of addiction, ADHD is clearly associated with unhealthy behaviors
and outcomes, including smoking, illicit substance use, accidents and injuries,
obesity, and even attempting suicide [5]. In some cases, students with ADHD
may be at higher risk of adopting certain problematic behaviors such as internet
addiction and alcohol-related problems than those without ADHD. In this re-
port, 4 students showed internet addiction (smartphone addiction) with sleep
rhythm disturbances. There have been few investigations of the association be-
tween inattentiveness in adolescents and smartphone use, but a relationship be-
tween playing computer games, internet addiction, and inattentiveness has been
described. Zheng
et al.
[12] investigated the prevalence of inattentiveness among
middle school students and found it to be considerable, and inattentiveness in
adolescents was significantly associated with the amount of time spent on enter-
tainment on the mobile phone each day and night. In this report, 3 students
were found to have disturbed sleep (with the day and night rhythms reversed),
probably resulting from internet addiction, including computer games.
Prognosis is very important. High school students with ADHD are also signif-
icantly more likely to be absent or tardy and are more than eight times more
likely to drop out of school than their peers without ADHD [13]. They are sig-
nificantly more likely to withdraw from a course [11]. They also experience dif-
ficulties completing school work and have significantly lower grades, score sig-
nificantly lower on standardized tests, and experience higher rates of special
education placement, grade retention, and school dropout compared to students
without ADHD [11] [14]. These patients were associated with dropping out of
school and having fewer years of education [7]. Of the primary manifestations of
ADHD, inattentiveness appears to be a key factor influencing achievement
T. Inagaki, R. Wake
77
among students; this symptom is associated with decreased academic and social
adjustment, poor study skills, and more depressive symptoms. These symptoms
resulted in increasing likelihood of failing courses and ultimately dropping out
of school. In this report, 3 of the students dropped out of school. Individuals
with ADHD may suffer reduced self-esteem, perhaps secondary to peer rejection
or academic or occupational difficulties [5].
Therefore, it is important to identify the factors in childhood that lead to the
persistence of ADHD and associated impairment for early detection and preven-
tion of long-term negative outcomes [4]. Consequently, special educational
support for these students is very important. There is, however, little data re-
garding special educational services provided to high-school students with
ADHD. Although some evidence supports academic interventions, including in-
structional modification, self-monitoring, and social-skills training, which may
improve academic performance, unfortunately few studies have examined school
services for high-school students with ADHD in detail [11]. Leslie
et al.
[15]
found that 15 - 17-year-old with ADHD received fewer school-based services
than 11 - 12-year-old students. Murray
et al.
[11] reported that school gradua-
tion rates were significantly lower at schools attended by those with ADHD
compared to schools attended by those without ADHD.
In addition, some educational support programs are important to prepare
them for adult life with suitable skills and occupation and, for increasing self-
esteem. Notably, recent prospective data indicate that early childhood attention
problems prospectively predict adolescent academic failure and work disability
[5].
5. Conclusion
In total, this case report suggests that the early diagnosis of ADHD and early in-
tervention of special educational support are important. In order to support
these students, better educational and medical support systems are warranted.
Conflict of Interest
The authors state that the there are no conflicts that relate to this research.
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