ADCET Podcast: Supporting Students with ADHD in the Tertiary Sector

Michele Toner outlines common challenges faced by students with ADHD in the tertiary sector and provides practical strategies for supporting students to overcome these challenges and achieve their academic goals.

The tertiary sector presents many challenges for students with ADHD. For those enrolling straight from school, the move requires the transition from a highly structured to a relatively unstructured environment. Whilst this can be liberating at first, the novelty soon wears off as the work builds up. For mature age students, challenges are different, as they are often juggling several commitments, including children and full-time work. Either way, students can become overwhelmed and feel tempted to withdraw. But there is much that can be done to make tertiary study ADHD-friendly. Ideally, changes need to occur on two fronts – the university/TAFE and the student. While the support available at university and TAFE is significant, students with ADHD need to learn the best way to utilise what is on offer and need support in developing self-awareness and self-advocacy. They are often reluctant to seek support for fear of stigma.

Michele Toner OAM has been supporting people with ADHD since 1995, starting her coaching practice in 2009. Her PhD investigated Uni students with ADHD. She is a faculty member of the ADD Coach Academy in New York where she trains coaches. Michele works to promote ADHD Awareness. She held inaugural board positions for ADHD Australia, and The Australian Association of ADHD Professionals (AADPA). She is Chair of the Board at ADHD WA and member of their Professional Advisory Body. In 2017 she co-authored “The ADHD Go-to-Guide” with Professor Desiree Silva. Michele was awarded an OAM in 2021 for her work in ADHD.

Watch the original webinar: https://www.adcet.edu.au/resource/10844/adcet-webinar-supporting-students-with-adhd-in-the-tertiary-sector

Transcript

DARREN BRITTEN: Hi everyone, and welcome back to another episode of the ADCET podcast. This podcast: Supporting Students with ADHD in the Tertiary Sector, is the audio adaptation of a webinar presented by Dr Michele Toner OAM in February 2022. You’ll hear Dr Toner outline common challenges faced by students with ADHD in the tertiary sector as well as provide practical strategies that can help to overcome these challenges. We hope you take something meaningful from this important presentation.

MICHELLE TONER: Hello everyone, and thank you, Darlene. I'm so glad you still remember the presentation. We were talking recently, and one of my most endearing memories of that presentation was the two support dogs who had a fight, and one of them was a dog in training and unfortunately, the other one was quite a seasoned operator and he just ignored the little upstart who was trying to have a go at him. Yes, it was a lovely day, I really enjoyed presenting that day. So, I want to thank you all very much for the invitation, first of all, to talk about ADHD which is a topic very close to my heart and also to thank so many of you for turning up. I do know that you do wonderful work with students at universities and TAFE’s across the country and I'm always very relieved when I know that students are registered for support with, you know, for their ADHD. I know how busy you are. And I do know that you've got a lot busier around the COVID period. And certainly, COVID has brought ADHD to the fore for many, many people who were dealing with its symptoms quite successfully. Pardon me, I have a bit of a tickle in my throat, it's all the talking I do. So, I know that your workload has really grown because ADHD and other mental health conditions have really come to the fore and are taking up a lot of your time. So I guess what I wanted to start with, and I know that there are many of you on this call who know a lot about ADHD and some of you will know more than I do, so please, I want to respect that and I hope that I can give a broad understanding of the most important things as I see them for students with ADHD. So, I'm going to start by just addressing some of the myths and stigma that surrounds ADHD that actually prevents students coming to you for support. It surprises and pains me that sometimes I'll be working with a student and they'll say, "Oh, no, I want to try to do this my way. I don't want any unfair advantage and I don't want to be singled out and embarrassed." And very often, it's because things haven't gone as well as they could have, support wise, in the secondary sector. And I don't mean that at all, to be criticism of teachers, I have enormous respect for teachers, but know that they are very limited by what the curriculum authorities will allow them to do. So, when students come to university, I really have to persuade them it'll be very meaningful and they'll get a huge amount of support. But the kinds of things that people with ADHD are dealing with on a constant basis is that people believe that ADHD isn't real, that they're making excuses for bad behaviour, and, you know, there are so many research studies about ADHD, it is the most researched condition, mental health condition in children, and with adults it's fast getting up there. But this one study was really interesting where they did MRI studies on 3000 students, children with ADHD, and found great differences in the maturation of their brains, that the brains matured later than their non ADHD peers, and also, that when they matured, they matured differently. So, the regions that developed were different. Now, brain imaging is not a diagnostic tool for ADHD, but it's really important to note that it shows differences, very clear differences. I notice I don't have the reference to that study and I will provide it later and they could probably put it up with the video. So, students with ADHD can be up to two years or sometimes even more in emotional maturation behind their non ADHD peers. So, they get to university or TAFE, they're sort of 17 and sometimes younger in the TAFE system, but, you know, they sort of are not as emotionally mature. Now that counts in their favour often, in the tertiary sector, because they're not forced to socialise with their same age peer group and very often, they'll get along better with people who are older or younger. Another myth that persists is that ADHD is over diagnosed and I would say that many, many people, if we did a poll I would hazard a guess, that many people would agree with that, even those who are fairly knowledgeable about ADHD, because it's a narrative that the media have trotted up so often. Now, what we know in WA is, because WA for a long time was the leading prescriber of stimulant medication for ADHD and this resulted in a parliamentary inquiry and the government keeping reports on how many people use stimulant medication in Western Australia. They stopped doing reports in 2017, but it's important to note that in Western Australia, if you use stimulant medication, you are required to sign a form, giving the government permission to keep de-identified data about your usage. So what they found, and the reason they stopped in 2017, was that they found in fact that out of the possible 5% percent of children who could have ADHD, and that is a conservative estimate, and the 4% of adults who have ADHD, 1.6% of children are treated with stimulant medication and 0.7% of adults are treated with stimulant medication. And of course, people with ADHD could be diagnosed and choose not to have stimulant medication, so I'm not saying that only 1.6 are diagnosed, but it would be unlikely that the rest would be diagnosed but not using medication. So, we know that ADHD is quite under diagnosed, and that would be some of the reason that people are coming to the fore with COVID and getting diagnosed, where they might have been managing before. So the government's stopped counting pills and spending money in 2017 because they realised the over diagnosis was not an issue. However, the media still continued to report it as such. The other myth that people have is that ADHD medications are addictive and they create substance abuse and this is a huge issue and trotted out by the opponents of ADHD and, you know, there are a lot of people who are anti-ADHD, and unfortunately, a lot of those vocal people reside in Western Australia so we've had to become very tough. But there was an international consensus statement, you know, working in this area recently, and in 2020, they released this consensus statement and they stated that stimulant medication does not lead to substance use disorder. It actually protects against substance use disorder in children with ADHD, because people who are undiagnosed with ADHD are very prone to self diagnosis with alcohol, with cigarettes and with illegal substances. So, we know that people who work in the area of substance abuse, who are educated about this, screen people who are presenting with substance abuse disorders, screen them for ADHD and treat them for the ADHD, which often makes quite a difference. Just on that note, another research study that is currently underway in Western Australia, at the Perth Children's Hospital, they started screening children who presented with suicide attempts and found that 60% of those children had undiagnosed ADHD, and once the ADHD was identified and treated, it really improved their outcomes. So, what exactly is ADHD for those of you who don't know? It is a developmental disorder and it has three core symptoms. And the core symptoms are inattention, hyperactivity and impulsivity. Now, people talk about what the difference might be between ADD and ADHD, and less so at the moment, but some people still talk about ADD and ADHD, and in previous versions of the diagnostic and statistic manual, we used to refer to ADD, which was the ADHD without hyperactivity, and ADHD. At the moment, they're all called ADHD with three subtypes: there's the predominantly inattentive, the predominantly hyperactive impulsive and then the most commonly diagnosed subtype is the combined subtype, people who have symptoms of both. At the moment, for someone to be diagnosed as an adult, they need to prove that they had some symptoms of ADHD before the age of 12, and this can be quite a stumbling block because people look at school reports, people often don't have their school reports, so, psychiatrists will often say, you know, bring a family member along so that they can tell me about how you were talking too much in class or never getting your work done, and teachers were always saying, you could have done better if you tried harder. The other thing to remember is that the symptoms have to show poor functioning. So, they need to show that they are messing with the lives of people with ADHD. And for your students who have come out since COVID, they possibly were managing before the demand on their executive functioning became so great. And one of the important things to know is that ADHD, the most common problems are executive function impairments, which I'm going to talk about briefly, and also to remember that ADHD rarely comes alone. As my clients say, ADHD always brings a friend. Just one point on the childhood onset of below 12 years, there is a growing body of research and opinion about the adult De Novo ADHD, so that people are being diagnosed as adults without having had any symptoms before they were adults, and the debate is whether they had enough scaffolding in place, or their functioning enabled them to put enough strategies in place to prevent the executive functions from being a problem until there was no more to give and they come to the fore. So, whether it is that, whether it was always there and it is coming to the fore, or whether it was never there and suddenly it is presenting, I always say, when doctors tell me that some people outgrow their ADHD, I'll say, "That's fine until they have their first baby" because that is a very hard thing to plan for. So, ADHD never comes alone. I'm mindful that dyslexia isn't called dyslexia anymore, but most people refer to it, so I think it's a learning difficulty with specific difficulties in reading or writing or mathematics or speech. So what we do call them these days doesn't really matter, everyone knows that they exist as this. And most people with ADHD will have a learning difficulty such as dyslexia, dyspraxia, and that actually makes their ADHD harder to deal with. The other thing that they can also present with is a coexisting condition of a mental health condition, and so, that really complicates their issues. Straight ADHD is a lot easier to deal with than ADHD that is complicated, medicinally and also sort of practically on an everyday level. And something to remember, is not only do these conditions coexist, they interact and make each other worse. So when someone with anxiety and ADHD could start to get anxious, and then that ADHD hyper focus kicks in on the anxious thoughts and then the rumination becomes much more of a problem. So they, you know, the conditions all have to be treated. So really, universities and TAFEs are not only just a test of people's knowledge in a certain area, they also are a test of people's executive functioning, and I'm sure many of you are familiar with what executive functions are. They are the management system of the brain, Thomas Brown calls them, and Russell Barkley talks of those elements of self control that allow us to sustain action and problem solving towards a goal, and he calls them the Swiss Army Knife of mental faculties. And that reminded me of when my son was little, he had a Fisher Price Swiss Army Knife, and he called it his salami knife. So, I put that in because sometimes I still call it a salami knife, just in case I did. If anyone Googles, looks on YouTube for videos by Thomas Brown or Russell Barkley, you will find a huge wealth of information about ADHD and executive functions. So this is Thomas Brown's model, and essentially, the executive functions all work together, and they sort of, work in the frontal cortex of the brain, and they are the organiser, the director, the managing director of a company, the managing director of your brain, the conductor of the orchestra. So, if you think of an orchestra without a conductor, you know, they may be actually quite good sometimes depending on their musicality and their teamwork, but they could be quite diabolical sometimes. Pardon me, that's a lozenge to keep me from coughing. But there would be a bit of inconsistency, and so too you will find people with ADHD with those executive function impairments. There's a lot of inconsistency, so their conductor sometimes goes out for a smoke break or falls asleep at the job, and so things just don't happen the way they should. And the problems that they will experience are with organising, and if you think about at the tertiary sector, they need to be able to organise their materials, organise what they need, organise where they need to be. They need to be able to prioritise and decide which assignment to start earlier, or if two lectures clash, which one they're going to attend in person and which one they're going to listen to, and when you've got ADHD, whatever captures your attention becomes your priority. So they have to design their environment so that the correct things capture their attention. Getting started is a huge problem for people with ADHD. Now, focus is an issue, there is no deficit of attention in people with ADHD, that is a total misnomer. The problem they have is focusing on the right thing at the right time, and then sustaining that attention. So, as I'm talking, there's someone using a power tool in the building next door, I know you can't hear them, but if you could, it would be very hard for you to focus on what I was saying and lock out that noise that you were hearing. And people will with ADHD will hear the clock ticking, the lawn mower outside and find it very hard to block that out and focus on what they need to. They'll find it hard not to get distracted. So they'll start working on something and then go, ’oh, that reminds me of something else’, and before they know it, they're working on something that's not really what they're meant to be doing that day. So their attention drifts, and then what is ultimately frustrating is, it's hard for them to shift their attention. So, whilst they may have great difficulty getting started on a task, they also have great difficulty stopping. So if they start an assignment and they've got three assignments due, but all they can do is focus on the first assignment and find it really hard to shift their attention between the three assignments, that's going to cause all sorts of problems for them. People with ADHD often become very cognitively fatigued because they're having to work a lot harder on doing everything than other people. Students will tell you, ‘I'll get the same mark as one of my mates, but I worked five times harder to get the same result, and he's not smarter than me, I just have to work harder’. So sustaining that effort is really hard. They get bored, and if they're not interested in something, it's like sticking needles in their eyes, getting them to do it. And they're very often, they're not always have a slow processing speed. And if you look at psychometric testing of students with ADHD, there are often lower scores in working memory and processing speed, though not always. So, that's often a flag for people. Psychometric testing is also not a diagnostic tool for ADHD, but it gives you a good overall picture. Another area that people with ADHD struggle is the area of emotions and managing their emotions. So they feel very strong emotions and they interfere and make it difficult for them to actually focus on what they need to focus on. They can have outbursts of anger or intense sadness and worry about feeling rejected or having done the wrong thing, and then of course, there's working memory. So, people with ADHD can have great long-term memories, but their short-term memory is often very challenging for them, and we'll talk later about externalising working memory. And then monitoring their actions, self-regulation, having the ability to pause and think before they do something. So, when you look at those problems, ADHD can seem benign because people will say, ‘yeah but everyone has those problems’, ‘everyone's forgetful sometimes’, ‘everyone forgets things sometimes’, ‘everyone usually does the wrong prioritising sometimes’, and what people need to understand is that those problems occur in a frequency and intensity for people with ADHD that causes huge problems in their lives. Another thing that occurs is that people with ADHD can have islands of excellence. So they could have superb working memories, or they could be excellent at something. They could be wonderful verbal processers and be obviously intelligent, and then people assume that they should be able to do, if they can do this higher order thinking so easily, well, they should be able to remember the date their assignment’s due, right? But they can't. It is their biggest challenge. So, when you're thinking about someone with ADHD, remember those trivial things that the average population can do, someone with ADHD can't, that's their biggest challenge. And also, there is inconsistency, which frustrates people around them, but if it frustrates you, imagine how it feels for the person with ADHD. And so people with ADHD are often working on these two levels of functioning, there's this one level where they're smart, engaged, and in tutorial, you know, the tutor thinks, ‘oh, this is going to be my distinction student’ and they’re verbally processing well, but then there's this other side of their brain that has to follow through, that has to execute their great ideas, that needs to actually do the things that they know they need to do, that needs to help them organise and shift focus. And people with ADHD sometimes know, I mean, of course they know they've got to pay their bills on time. When the time comes to doing it, they forget about the severity of not paying their bills on time. So, we know that tertiary students will often take longer to complete courses, they have higher dropout levels, they get overwhelmed, and this is where it's so important that they're engaged in your services because halfway through semester they find themselves behind on everything and then instead of going to help, this feeling of being overwhelmed, they paralyse because they don't know where to start, they feel ashamed. And so, rather than go and see someone for help, they'll often quit, and that is a huge shame because universities and TAFEs can be very ADHD friendly. And my PhD thesis was a qualitative study of students with ADHD at university, and developed a theory. And what the theory was about, they're developing empowerment and how they learned to work with their ADHD and make university, mine was university but it also applies to TAFE, make it work for them and find their way of doing things. So, the kinds of work that you do is, you know, this cartoon of Leunig's with the person drinking correction fluid to try how to change themselves is so touching to me because people with ADHD, they're judged as lazy, people think they don't try hard enough, if they tried hard enough they could do better, and it's very hard for them to explain how hard it is to do things. So, difficulty getting started is common and, you know, not finishing tasks, is also common, and these are tasks within their capability. Sometimes they can't see an entry point, and it's really important to help them find that entry point, and sometimes they can't get started because they need to do the perfect start or they know that they can't do it perfectly, and so they'll put it off until they think they can. And these are the students who will research and research and research and research and never write anything, and the night before the assignment is due, they haven't started writing it, but they know a lot in their heads and they can't articulate that. So what they need to do in order to get started is dot point, turn their assignment into a series of dot points. If you were to start this assignment now, what's the first thing you would do? Or what are the first five things you would do? And instead of saying, research the topic, be specific, find five research papers and just read those, and then if you need more later you can. And if it's a TAFE assignment just, you know, read the first five questions, do the first five questions and don't worry about the whole assignment. It's very helpful for them to work with, what we call in coaching, a body double. So if there's someone else working alongside them, that helps them to work, and they needn't necessarily be working on the same thing. And I know at Curtin and other universities where they have their ADHD groups, those students will form a study group where they're not studying the same discipline, but they'll meet and work together on their various assignments. And many people make good use of a website called Focusmate where they look at focus session with a stranger somewhere in the world and say, right, for the next hour, I'm doing this and find that they can be very productive in that way. So, I've got this little focus formula that I teach students and it's got four steps and the first is to plan what you're going to do - what are the first five things that you need to do for this assignment?, and have them visible so that they become your priority. And then set up what do you need to do to get this assignment started? What documents do you need? What website do you need open? Do you need your course outline? And then sprint, set a 30 minute timer and get as much done in that 30 minutes as you possibly can. When the 30 minutes is up, don't force your brain to stop as the Pomodoro Technique recommends, because if you're focused, keep going, you may never get that focus back. But make sure you’re focused on the right thing and you haven't gone down a rabbit hole, and do as many sprints as you can when you're focused. And the final step is the brain dump: When you do need to stop? Ask yourself, when I come back what will my next step be? And if you write that down, that note to your future self, for example, then when you come back it'll be easier to get started again. And that knowledge makes it easier to stop. People with ADHD need to externalise their working memory. So, the working memory is like a kitchen work bench where you're cooking a recipe and you've got all the ingredients laid out and you're halfway through, and while you had your back turned, your cat jumped on the kitchen bench and pushed some stuff off, and when you turn back it's gone and you're not sure what was there to start with. And so you lose your place and you've got to go back to the recipe. What was it I needed again? And where was I? And what have I done? And people with ADHD are constantly doing that. They're constantly going back to the beginning and: Where am I? Where was I? So they've got to find a way to externalise their working memory instead of remembering 65 things at once, write them down. And there'll be great resistance amongst people with ADHD: Don't tell me to keep a diary; I hate keeping a diary; No, Michelle, no, no, no, no, no, don't tell me to do that because I can keep a diary for a week but after that, I can't. So, when we are coaching someone with ADHD, we work hard to find their version of an external working memory. Could be Evernote, it could be a diary, it could be PostIt notes, and you know, my clients have very varying versions of their external working memory. Pardon me. And I always say to someone if they tell me, I don't need to write that down, I will remember that, I will always say with love, I'm sorry, but I know you're lying, so you have to write it down somewhere. Where's it going to be? The other thing that people have is this total time blindness. So, they have difficulty judging the passage of time. If they're doing something they love it feels like five minutes when it was actually much longer than that, and they're in deep trouble with their partner because they haven't done the chores they were meant to do. It literally feels like five minutes to them. They also have great difficulty predicting time required, and they use best case scenarios. So they'll look at their assignment and go, ‘yeah, I can do that in a day’, and sometimes they can. You know, people, and this works against them, people with ADHD will pull the hat out of the bag at the 11th hour and do it because they can't overthink it, they can't be a perfectionist, but that's not sustainable, and particularly, when they have three assignments due. They show up late, you know being late is something that people with ADHD lose their jobs for. They know they've got to be on time, but it is something that they really struggle with and we do a lot of coaching around what exactly makes them late. And of course they miss deadlines because they underestimate what they've got to do or they forget the deadline. "Oh yes. Did I have that? Oh yes. I had that assignment." And I'll say, "What assignments have you got coming up?", "Yeah, I got a few coming up, but they're not for a couple of weeks." And I'll say, "Well, let's just check your course outline." "Oh my gosh, they're due next week. I thought I had so much time." So, the golden rules, there are a couple of golden rules with ADHD. Aside from externalising your working memory, you've got to make time visible. So, people need to get a planner and put their due dates on that planner so they can see their time as opposed to a list, which is just a list of words. So they need to have that long term planner of the overview of what's coming up, and then also, to have a look at their week. And you know, this is a very full week, but you know, this could be appointments. This is not for a student, actually. This could be studying I've got to do, this would be a job I've got, and assigning the time to do those things, because when they do that, they might realise that studying, this was my only opportunity for getting that assignment done, but on Monday, I thought I had a week to do it, and so I didn't do it on Monday, and so I'm sitting up all of Thursday night. So making time visible is really important, and it can be an electronic version of a calendar as well. Focusing, as we said, focus is a real issue. So people will, they're very good at the big picture, people with ADHD. In fact, they're the ones that you want when you looking to brainstorm. Their brains are idea generators and they can see beyond where other people see. One of my clients was an oil and gas engineer, and his boss said that he could see the oil and gas platform before it was built, before it was designed and conceived. He could see it in his head. They can also be very good at detail. So when they get into the detail of a task, they can do a fantastic job. What they can't do easily is move between the two. So, when they're sitting in big picture, it's oh yeah, I'm going to do this assignment and I'm going to answer these questions, or I'm going to do this interview and I'm going to, you know, and I'm going to interview this person, but they're not actually scoping the task and asking themselves, what are the things that I'm required to do for this task? What are the steps required? Because then, that'll help them to get started, but also it will stop them from getting lost in detail on one point of the task. So, if they've got a list of five things that they know they need to do and they keep those visible, then they're going to be mindful that they've got to cover all five instead of getting lost in one thing. So, they go down rabbit holes. And what happens is that they're still working, "I wasn't on Facebook, Michelle, I was still doing uni work but it wasn't the assignment that was due today. And it was just an interesting aside to what I needed to do." And so if they have that mindfulness alert of a beeper or a buzzer going off every 30 minutes, they can learn to stop, make sure that they're still focused on the right thing and then get back to work. And if they're not, bring themselves back to the right thing. So when you think about this, how exhausting is it for someone with ADHD? They can't just sit down and do an assignment. In order for them to do some work, there are at least 10 things that they need to do before they get started. So they've got to get ready to get ready. There's always an extra step. So, when you bear all of this in mind, I know that you all have compassion for the students you work with, but many people don't and many lecturers don't understand. So it's really important to convey that to them as well. Transitions are very difficult. So, transitioning from home to uni or TAFE, transitioning from TAFE back to uni can be very hard. And so, what students often find useful for them is a launch pad. So when it's time to leave somewhere, everything that they need to take with them is in one spot of the house. So get everything ready for TAFE and uni, leave it at your front door. In the morning, you just need to wake up, get dressed and go, instead of, "Okay, where was that? What do I need? Oh, but my brain's still here and I'm playing with my cat. Oh, but I really need to focus on uni. What is it I need to do today?" Very, very hard for them. So, they have to set aside time. And we talk about book ends, at the end of their day, to look at your next day and go, what will I need to set up for tomorrow? What do I need to take with me? Let me put it on my launch pad now. What reminders do I need tomorrow for appointments that I have? Let me set them up now. What time do I need to leave? Let me check Google Maps now. Because otherwise they're doing all of that five minutes before their lecture starts. And one other thing that's really important is that they need reminders at the point of performance, they need them where they need them. So for example, if a client, a student needs to remember that they have a tutorial at three o'clock in the afternoon and they live 40 minutes from university, they don't want the reminder at half past three or quarter to three. They want the reminder after their morning lecture, if there's a long gap. They need a reminder at 10:00 am that says, don't go home today, you've got a lecture at three o'clock, you've got tutorial that you can't miss. So they need to think about what reminders am I going to need and where will I need them? So, they need to pause, which is a challenge that they have because hindsight and forethought do not come easily to someone with ADHD. So, they need to pause, What do I need in this moment to remember, to do the task I set out to do? And that is a really important thing to work with them as well. 

DARREN BRITTEN: Thanks for listening to this ADCET podcast. We hope that you learned something new about making tertiary education more accessible and inclusive for students with disability. You can keep up to date with our future webinars and podcasts by signing up for our fortnightly newsletter at our website: adcet.edu.au/newsletter.

Thanks again for listening to this podcast from the Australian Disability Clearinghouse on Education and Training. Supporting you, supporting students.