Risk and protective factors associated with successful transition to high school in youth with ADHD: a prospective cohort study

© 2017 Dr. Nardia Jane ZendarskiIntroduction: Limited research has examined the transition to high school in adolescents with ADHD, despite this period being a critical determinant of future schooling. This thesis aims to describe school functioning in adolescents with ADHD at an academic, social-emotional and school engagement level and to identify risk and protective factors that are predictive of differing levels of functioning as well as trajectories of social-emotional functioning over the transition and their impact on early high school functioning. Methods: This is a prospective cohort study of adolescents (n=130) with ADHD in the first and third years of high school. Primary outcomes included: (1) academic achievement (National Assessment Program-Literacy and Numeracy (NAPLAN) five test domains); (2) social-emotional functioning and trajectories of functioning (parent and teacher-reported Strengths and Difficulties Questionnaire (SDQ)) and (3) school engagement (self-rated attitudes toward school and recorded suspensions). A broad range of adolescent, family and school risk and protective factors were examined in relation to key outcomes including: child IQ, working memory, ADHD symptom severity, behavioural problems, peer victimisation, family functioning, parent mental health, family socioeconomic status (SES) as well as school SES, sector and location. Analyses: Mean scores on outcomes were compared to state benchmarks or normative data using t-tests. Multivariable regressions analyses were used to model risk and protective factors associated with each transition outcome. Results: Academic achievement: Adolescents with ADHD performed below the state average across all NAPLAN test domains and 40% achieved scores below the national minimum standard in one or more areas (e.g. writing and spelling). Higher IQ and SES were associated with better scores. Gender differences were not observed with the exception of writing, where girls outperformed boys. Modifiable factors associated with poorer academic outcomes on individual domains included symptoms of inattention, peer victimisation and poor family management. Social-emotional functioning (SEF): Adolescents exhibited poorer SEF across multiple domains (e.g. internalising symptoms, externalising problems and peer problems) in comparison to norms. The strongest modifiable factors on these three domains were middle childhood SEF on the domain being examined and parent-rated ADHD symptoms. Additional factors varied by domain; concurrent sleep problems, age (younger) and gender (girl) were associated with higher internalising problems; parent mental health problems and peer problems were associated externalising problems. Three trajectories (never, intermittent and persistent) of SEF were identified for internalising, externalising and peer problems. Compared to the never trajectory, children with persistent internalising and externalising trajectories had poorer maths achievement and more school suspensions. School engagement: Adolescents with ADHD in the first year of high school were less motivated and less connected to peers in comparison to state data. There were high rates of suspension across the first and third year of high school in comparison to peers (21% vs 6%, p<.01). Modifiable factors associated with poor attitudes toward school included adolescent depression and poor family management. The risk of suspension increased for adolescents who exhibited higher levels of conduct and hyperactivity symptoms and lower intelligence. Higher family SES and attending an independent school decreased this risk. Conclusion: Findings highlight the large achievement gap and increased risk for adolescents with ADHD in this critical period. Most adolescents will require additional support and intervention and difficulties are likely to be multifaceted spanning multiple domains of functioning. A tailored rather than standard approach to improving outcomes is needed for most students with ADHD. Optimising educational outcomes for all students with ADHD will require both health and educational experts to work together to target potentially modifiable variables associated with poor functioning. Findings point toward a review of current evidence-based interventions addressing modifiable variables that could be adapted, piloted and then rigorously trialled in Australian adolescents with ADHD in early high school