Mental Health Challenges of Young People with ADHD Symptoms: Teachers’ Perspectives and Strategies

Abstract

(1) Background: Many mental health conditions either start or become apparent in childhood or adolescence. This paper reports on aspects of a study which explored the perspectives of 12 teachers from independent secondary schools in Western Australia on how the mental health and wellbeing of students exhibiting symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) can be fostered within classrooms. Specifically, the focus here was on mental health challenges faced by students with ADHD symptoms and the strategies teachers employ to support their mental wellbeing. (2) Methods: A qualitative approach was taken to the study’s design and the data analysis. Teachers responded to a survey with four open-ended questions, and then participated in individual, semi-structured interviews. (3) Results: The analysis led to the generation of four themes relating to students’ mental health challenges, as well as comprehensive strategies used by teachers to address these. (4) Conclusions: The findings indicated that adolescents with ADHD, regardless of a formal diagnosis, experience significant difficulties with their mental health and academic achievement as a result of their ADHD symptoms, but also that the participant teachers employed a wide range of strategies to assist these students, including those that target their specific mental health challenges and those that are holistic and support their wellbeing more generally.

1. Introduction

The World Health Organization’s (WHO) Constitution states, health is “a state of complete physical, mental and social well-being” [1] (p. 1, emphasis added). Supporting the mental health and emotional wellbeing of young people is paramount, given that many mental health conditions either start or become apparent in childhood or during adolescence [2,3,4,5,6]. Solmi et al. [6] reported the results of a large-scale meta-analysis in which 14.5 years was identified as the peak age for the onset of mental health disorders.

In Australia, the Young Minds Matter survey evaluated the mental health of children and young people from over 6300 Australian families across a decade-and-a-half. Results indicated that one in seven (14%) young people has a mental disorder and as many as one in five (20%) has mental health difficulties [7]. Some of these child and adolescent mental disorders are prevalent and have a “very high adverse impact” [8] on the everyday lives of those affected. Of the adolescents surveyed between 1998 and 2013/14 for Young Minds Matter, 11% reported engaging in deliberate self-harm, and approximately 8% reported having considered suicide at some point in the 12 months prior to the survey [7].

Poor mental health also has negative effects on young people’s education. A direct relationship has been found between wellbeing and educational attainment [9,10,11] and, even after shared-risk factors have been considered, longitudinal associations between mental health and academic performance in children and adolescents remain [10]. Students with mental disorders not only have poorer results in every test domain in Australia’s NAPLAN (National Assessment Program—Literacy and Numeracy), but gaps in their achievement increase over the years, such that by Year 9 (14 years of age), those with a mental disorder are about 1.5 to 2.8 years behind their peers with no mental disorders [11].

1.1. Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most commonly presenting childhood and adolescent psychiatric conditions worldwide [12,13,14], with a prevalence rate of 7.8% in Australian children and adolescents [8]. It is also the most frequent neurodevelopmental disorder encountered in child and adolescent mental health services [15]. Research examining the prevalence of ADHD among children and adolescents of different races demonstrates its significant variability [16], including, for example, among children and adolescents in Iran [17,18], Arab countries [19], Africa [20], Australia [8], China, Hong Kong, and Taiwan [21,22], Spain [23], and the USA [14,24]. In a recent comprehensive review, which included meta-analyses, Popit et al. [13] concluded “the overall prevalence of ADHD in register studies was 1.6%, 95% CI [0.9; 3.0], in survey studies was 5.0%, 95% CI [2.9; 8.6], in one-stage clinical studies was 4.2%, 95% CI [2.9; 6.0], and in two-stage clinical studies was 4.8%, 95% CI [4.0; 5.8]” (p. 18). This high variability tends to be attributable not to geographical location, but rather to methodological characteristics, including diagnostic criteria, source of information, and the impairment requirement for the diagnosis [25,26,27]. Others [28,29,30] also highlight the dynamic and diverse cultural practices and beliefs that contribute to differences in prevalence rates of ADHD, including that ADHD may stem from sociocultural factors that are most common in American/Western societies; whether symptoms are perceived as problematic by parents and teachers, especially in conformity to rules; parenting-related factors such as behavioural and academic expectations; and if ADHD is seen as a valid medical diagnosis.

ADHD is reported more frequently in males than in females, with a ratio of approximately 2:1 in children [25,31,32]. A diagnosis of ADHD requires that several symptoms are present before the age of 12 years; there is age-inappropriate inattention and/or hyperactivity-impulsivity which persists for at least 6 months; at least six of the listed symptoms of inattention and/or six of the listed symptoms of hyperactivity and impulsivity are present; and that symptoms are interfering with functioning in two or more contexts (for example, home, school or elsewhere) [31,32,33,34].

Based on the symptoms shown, ADHD can be categorised as predominantly inattentive, predominantly hyperactive-impulsive, or combined presentation [31,32]. The ways in which ADHD presents, as well as the severities of its symptoms, vary considerably across individuals [33,35], and there can be differing expressions of symptoms within different contexts [34]. Thus, the risk of having ADHD can be deemed to fall on a continuum of distribution in the population [35]. These factors mean that some adolescents with ADHD-related challenges require support, despite their symptoms not being severe enough to meet the threshold for a formal diagnosis [32,36,37].

‘Externalising’ symptoms are related to conduct and actions, while ‘internalising’ symptoms are related to thoughts and emotions. In general, girls present more with inattentiveness and internalising symptoms, whereas boys display more hyperactivity and/or impulsivity and other externalising symptoms [38,39]. It is important to note that due to gender and referral biases, ADHD is underdiagnosed, or diagnoses are delayed, in girls, and therefore, it is undertreated in this cohort [38,39].

ADHD Symptoms, Mental Health and Academic Underachievement

While this paper focuses on mental health, there is a well-documented link between emotional and behavioural challenges and academic underachievement. Research has recognized the importance of emotional regulation in ADHD and how this has a serious impact on the educational performance and achievement of children and adolescents with ADHD [40]. Impulsive outbursts, shows of frustration, and instances of conflict frequently arise in classrooms because of the individual’s feelings of inadequacy to retain information, build upon previously learned concepts (which is essential for long-term academic success), and organize, manage, and complete tasks within time frames (without fully understanding them). This often creates a cycle of academic underperformance and leads to further emotional distress in the school environment [41].

In comparison to their neurotypical peers, children with ADHD are five times more likely to have depression and three times more likely to suffer from anxiety disorders [33]. In Western Australia, a longitudinal study [42] found that adolescents with ADHD symptomatology were more likely to fare poorly over an extended period in terms of their mental health. ADHD symptomatology was found to make a significant, unique contribution to predicting scores for all the subscales measured (general wellbeing, depression, and worry—frequency and amount), over and above age. Substantial effect sizes suggested that ADHD symptomatology contributed in the longer term to 13% of score variance in depression scores and 8% of score variance in overall wellbeing levels [42]. Young people with ADHD also commonly experience emotional dysregulation, including difficulties in controlling their emotions, overreacting emotionally, and frustration [31,32,43]. This interacts with socio-cognitive impairments and inappropriate behaviour [44] to have a significant socio-emotional effect.

Adolescents with ADHD experience serious negative consequences academically, both in their performance at school and their overall academic attainment [31,32,45,46,47]. According to DuPaul and Langberg [48] children and adolescents with ADHD experience significantly lower standardized achievement scores and school grades and are retained in school year levels at higher rates in comparison to their same-age peers. In fact, the impact of ADHD on academic achievement is greater than that of serious physical health issues [49]. A review [45] and study [50] both demonstrated a significant relationship between ADHD and academic performance, while Evans et al. [51] stated that impairment in learning at school is one of the most noteworthy difficulties experienced by adolescents with ADHD. Further, a review [52] of two major studies [53,54] suggested that “poor educational outcomes were primarily attributable to ADHD” (p. 329). Lawrence et al.’s study [55] on the academic trajectories of secondary school students found that, by Year 9 (14 years of age), students with ADHD were on average 2.5 years behind in reading, 3 years behind in numeracy, and 4.5 years behind in writing, compared to their peers without a mental disorder. As a result of academic underachievement and large attainment gaps, adolescents with ADHD are also less likely than their typically developing peers to complete their schooling or go on to tertiary education [56,57].

1.2. Human Rights and Inclusive Education

Inclusion is predicated on the notion of human rights, enshrined in the milestone document, the Universal Declaration of Human Rights. This was drafted and signed by multinational representatives, including those from Australia, and proclaimed by the United Nations General Assembly on 10 December 1948 [58]. These human rights include Article 26, “Everyone has the right to education” [58] (p. 7). Australia was also one of the original signatories to the United Nations Convention on the Rights of Persons with Disabilities [59], which describes individuals with disabilities as “those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others” (p. 4). Parties to the Convention agreed inter alia that persons with disabilities should be able to access inclusive education.

In Australia, rights to inclusion are also enshrined in law. The Disability Discrimination Act [60] was passed by the Federal Government in 1992 and has been amended numerous times, with Compilation No. 38 showing amendments to the law in force up to October 2023. The Act makes specific provision for Education under Section 22 [60]. The obligations of education providers under the Act are clarified by the Australian Disability Standards for Education 2005 [61]. Definitions of disability under these Standards include “(f) a disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction; or (g) a disorder, illness or disease that affects a person’s thought processes, perception of reality, emotions or judgment or that results in disturbed behaviour” [61] (p. 7). As ADHD is a neurodevelopmental disorder, Australians with ADHD are entitled by law to inclusion from a disability perspective, which includes the right to inclusive education.

1.3. Teachers’ Roles in Supporting Students’ Wellbeing

As primary carers, parents and guardians are ultimately responsible for their children’s wellbeing. The reality, however, is that most young people attend school and spend most of their day there. Teachers see students frequently and often for a significant amount of time, depending on the schooling level and subject timetables, and thus are well placed to play a central role in supporting students’ mental health [7,9,62,63,64,65,66].

Despite a substantial need for mental health services for young people [8], there is a distinct lack of access to these services and certainly to timely access in Australia, with long waiting lists for assessment and treatment being common [2,62]. A significant proportion of those who are fortunate enough to be in contact with services will not receive adequate levels of support [2]. In fact, only 11.6% of children with an identified mental disorder, including ADHD, have sufficient contact with health professionals for it to meet criteria for minimally adequate treatment [67]. These barriers to care result in further reliance on teachers for mental health support.

In Australia, in addition to inclusion requirements enshrined in law, there are also obligations placed on teachers to support students’ diverse learning needs and wellbeing. These are set out in the Australian Professional Standards for Teachers [68], in The Alice Springs (Mparntwe) Education Declaration [69], and in policies from state or territory education departments. These further underscore the importance of teachers’ roles in fostering the mental health and emotional wellbeing of students.

1.4. The Present Study

This paper reports on specific aspects of a qualitative study which was conducted to explore the perspectives of secondary school teachers on supporting the mental health of students with ADHD symptoms. The participant teachers were encouraged to share their experiences of teaching students with any inattentive or hyperactive symptoms, whether those students were formally diagnosed with ADHD or not. The following Research Questions are addressed in this report on the study:

• What are teachers’ perspectives on the mental health challenges experienced by secondary school students with ADHD (diagnosed or undiagnosed) in classroom settings?
• What strategies do teachers employ to support these students’ mental health challenges?

2. Materials and Methods

2.1. Framework, Paradigm and Methodology

Qualitative research aims to distil, describe and draw conclusions about “the lived experiences of real people in real settings” [70]. While quantitative research can be used to produce broad insights or analysis of outcomes, it could be argued that it cannot capture and represent complex issues such as human interactions, or the impacts of disorders on individuals’ lives, as fully as qualitative research does [71,72,73].

The conceptual framework underpinning the present study was inclusive education, the mental health needs of students with ADHD symptomatology, and the perspectives of their teachers. To this end, this study adopted a constructivist paradigm. Within a constructivist view, there is not a single, indisputable or knowable reality (ontology); instead, participants and researchers are co-constructors of understandings (epistemology) about multiple realities based on each participant’s subjective interpretation of the context under study, as well as the researcher’s analysis of shared aspects and thematic patterns [70].

The present study employed thematic analysis [74,75,76] to analyse the teachers’ responses, specifically Braun and Clarke’s [75] well-known reflexive thematic analysis in which the researcher takes an active role in analysing and interpreting data to reflect patterns of shared meaning, or themes [74]. In summary, the six phases utilised are familiarisation with the data; generation of initial codes; searching for themes; reviewing of themes; defining and naming of themes; and production of the report [75].

As seen in these phases, themes are developed as a result of coding which aims to “provide a coherent and compelling interpretation of the data, grounded in the data” [74] (p. 848, latter emphasis added). Therefore, rather than starting with a pre-determined set of codes and working to match data elements with these, an inductive coding approach is used. In inductive coding, single words or short descriptions (codes) are assigned to phrases in the data to capture each idea communicated, allowing the dataset itself to determine which codes emerge. Clarke and Braun [76] aptly describe codes as "the smallest units of analysis that capture interesting features of the data” (p. 297). The codes are then grouped, via an iterative process, to elucidate patterns of meaning and construct themes to represent them.

2.2. Participants

Teachers and Heads of Learning Area, including those involved in pastoral care, in secondary schools in Western Australia, were the target population for this study. The aim was to recruit participants with a diverse range of subject areas and years of teaching experience. Invitations to participate in the study were issued to teachers via the researchers’ professional networks. No incentives were offered for participation.

Twelve teachers responded to invitations and consented to participation. Their ages ranged from 34 to 62 years (average age: 49.7 years), and their teaching experience varied from 4 to 30 years (average years of experience: 20 years). Ten of the 12 participating teachers were female, while two were male. All were working in, or had very recently worked in, independent secondary schools in a metropolitan setting in Perth, Western Australia (secondary schools in Western Australia cater to students in Years 7 to 12, ages 11 to 18 years). Two of the participants were teachers at the same school, while the remaining 10 participants all taught at different schools. A very wide range of teaching subject areas were represented by the participants. Among them, two were Heads of Learning Area (Subject Heads), two were Level 2 Senior Teachers, one was Head of Students, and one was an experienced teacher who was currently employed as a Pastoral Care Consultant. See

Table 1. Profile of the study participants.

Participant	School Type	Role	Teaching Years	Age (Years)	Gender
Mei	Secondary Metropolitan	Head of Learning Area, Teacher	20	59	F
Lauren	Secondary Metropolitan Alternative Education	Senior Teacher Level 2, Pastoral Care	26	48	F
Nick	Secondary Metropolitan	Teacher	4	34	M
Debbie	Secondary Metropolitan	Teacher	7	59	F
Amber	Secondary Metropolitan	Teacher	21	48	F
Angela	Secondary Metropolitan	Head of Students, Teacher	24	46	F
Chris	Secondary Metropolitan	Senior Teacher Level 2	25	51	M
Sophie	Secondary Metropolitan	Teacher	27	53	F
Natalie	Secondary Metropolitan	Teacher	19	42	F
Mandy	SSENBE1 Metropolitan	Pastoral Care Consultant	20	44	F
Donna	Secondary Metropolitan	Head of Learning Area, Teacher	18	50	F
Lynn	Secondary Metropolitan	Teacher	30	62	F

¹ School of Special Educational Needs: Behaviour and Engagement.

for a profile of the participating teachers. Note: pseudonyms have been used.

2.3. Data Collection Procedure

This study was reviewed and approved by The University of Western Australia Human Ethics Committee (Reference: 2023/ET000996), and all participants provided their informed consent online before participating in this study.

The data collection process was completed in two stages. The first stage involved participant teachers completing a Qualtrics survey, which comprised a demographic information section (school type, current role, subject areas, age, gender, years of teaching experience), and then four open-ended questions, with no specified word limits:

• Please reflect upon one or more situations in which you have encountered a student with symptoms of attention-deficit disorder (with or without a formal diagnosis) in your classroom. How prepared did you feel to support their mental health and emotional wellbeing needs? Can you describe your experiences in detail?
• With respect to the situations you have described, what are some of the specific strategies you adopted in an effort to accommodate the mental health needs of these students?
• How prepared do you feel to address the specific mental health and emotional wellbeing needs of students with attention-deficit symptomatology (with or without a formal diagnosis)? Can you describe your experience in detail?
• What is your perspective on the needs of both practicing and beginning teachers (in any respect, including, for example, professional development, resourcing) to feel better prepared to support the mental health and emotional wellbeing of students with attention-deficit symptomatology (with or without a formal diagnosis)?

The second stage involved each of the participant teachers engaging in an individual semi-structured interview with the principal researcher, either online via video-conferencing (Microsoft Teams meeting) or in person if preferred by the participant. Eight participants were interviewed online, and four chose the in-person option. The interviews comprised four open-ended questions, interwoven with the open-ended Qualtrics questions from the first stage, since these conversations were also intended to provide an opportunity to expand upon or clarify aspects of participants’ answers to the online questions. Where explanation was not needed, the researcher allowed participants to share their experiences and perspectives freely. As a result, the length of the interviews varied, with an average duration of 34 min. Regardless of interview length, all participants were asked the same four open-ended questions:

• How significant would you say the impact of ADHD is in classrooms, compared to other difficulties?
• What mental health challenges would you say you have seen in students with ADHD?
• What else do you think needs to be done or could be done to enhance teachers’ abilities to support the mental health needs of students with ADHD in classrooms?
• When a student has been referred for diagnosis and doctors or psychologists have suggested interventions and supports, have you found any barriers to putting these in place?

Although the interview questions referred to students with ADHD, participants were reminded in the interviews that the intention was to include those exhibiting ADHD symptoms, with or without a formal diagnosis.

All the interviews were recorded with consent from the participants, and the video/audio files were processed by commercial transcription software to generate draft interview transcripts. The principal researcher checked these transcripts thoroughly, cross-checking with the video/audio files to ensure that these representations of the interview contents for the datasets were as accurate as possible. Finally, the checked and edited transcripts were sent out individually to the respective participants to review as a final step in the quality control process.

2.4. Analysis

In line with Braun and Clarke’s [75] thematic analysis approach, the entire dataset was inductively and reflexively examined. In the familiarization phase, the data, made up of the written responses to the Qualtrics questions as well as the interview transcripts, were reviewed several times. Next, generation of codes via inductive coding took place via a meticulous process of highlighting phrases and assigning descriptive word(s) to these (as per the coding sample in Figure A1 in Appendix A).

Once it was clear that all relevant codes regarding mental health challenges experienced by students with ADHD symptomatology had been assigned, these codes were grouped together by similar or related types. Thereafter, the codes were checked repeatedly to refine the groupings and four themes were identified. Composite narratives, aligning with the four identified themes, were then generated from the coded data, using the teachers’ exact words to the extent possible, to represent the mental health challenges of students with ADHD symptoms as witnessed by the teachers. The intention of this process was not only to represent the data with fidelity, but also to express the teachers’ perspectives summarized via a composite teacher ‘voice’ in each instance.

During the analysis, it also became apparent that the many strategies the teachers had described in their responses and interviews had commonalities or were related by their intended outcomes. Therefore, inductive coding, theme generation and refinement processes were used to link patterns of meaning and elucidate these strategies and teachers’ employment of them. This resulted in a two-pronged presentation of strategies: those that specifically addressed the mental health challenge themes depicted in the composite narratives were set out, followed by those that were holistic in nature, organized within a second set of themes.

2.5. Trustworthiness and Rigour in the Present Study

This study comprised many elements in line with the criteria for a positive evaluation of trustworthiness in qualitative research. In terms of Credibility, transcription software was first used to produce drafts of participant interviews. These were crosschecked with the recordings where any parts were unclear and corrected as needed. The checked drafts were shared with the participants so that all had the opportunity to make any further corrections for accuracy, and they were also provided with the draft article prior to publication. The participants’ words were used verbatim to the extent possible, both in constructing the composite narratives, and via extensive direct quotes in reporting the results. A list of pseudonyms was provided to indicate all the teachers whose words were incorporated into each composite narrative. All interviews were conducted by the same researcher for consistency of questioning and interaction, and all took place over approximately 1 month, to give as specific a timeframe as possible for capturing teachers’ views.

Looking to elements of Transferability, throughout the reporting of this study the authors sought to provide “thick description” [77] (p. 316), and thus sufficient detail to allow readers to make informed evaluations about the relevance of this study’s findings, as well as research-to-practice implications for their own contexts.

As for Dependability, all interviews were conducted one-on-one for privacy reasons, and to encourage honest and full accounts from participants. Pseudonyms were used for teacher names to maintain the participants’ confidentiality, and care was taken not to present any very specific information that might identify a teacher or school. Each stage of the data collection and analysis process was carried out with an emphasis on thoughtfulness and reflexivity, and the researchers sought to ensure that the analytic processes aligned with the overarching framework and methodology of the overall study.

With regard to Confirmability, an extensive audit trail was maintained throughout the study. All raw and original data were saved, as well as all coding and versions of the results thereafter.

3. Results

The first part of the results is supported by four composite narratives depicting teachers’ perspectives on the mental health challenges experienced by students with diagnosed or undiagnosed ADHD, while the second part reports on the strategies that teachers use to support these students.

3.1. Teacher Perspectives on the Mental Health Challenges Faced by Students with ADHD Symptoms

The composite narratives presented here were constructed to illustrate the four themes that arose from the data analysis and were intended to ‘give voice’ to the perspectives of these teachers regarding the mental health impacts of ADHD on their students. They were generated directly from the interview transcripts and, therefore, they consist almost exclusively of the teachers’ own words, with minimal linking phrases.

3.1.1. Theme 1: Feeling Anxious

The first theme concerned teachers’ observations of students with ADHD symptoms who experience a great deal of anxiety. This tends to co-exist with, and feed into, a cycle of mental health difficulties. Teachers noted that these students’ anxiety can be exacerbated by several factors. Some will fall behind in their schoolwork, due to their inability to focus, then worry to the extent of ruminating, leading to further anxiety. Others will be unable to manage their time, will overthink their work and concerns, and sometimes even overwork themselves if they have perfectionist tendencies, resulting in more stress and anxiety. Another negative impact of their perceived pressure to be perfect is that students get fixated on aspects of their work, which teachers termed becoming ‘stuck’ or ‘stuckness’. This was an evocative way to describe how these students are unable to proceed as needed: some cannot get started on work, some focus on the wrong aspects, while others cannot manage to complete it. This first narrative illustrates elements of Theme 1, in the words of Mandy, Nick, Amber, Angela and Natalie (See Figure 1).

3.1.2. Theme 2: Feeling Different

The second theme related to teachers’ perspectives that some students feel ‘fractured’, i.e., ‘broken’, as though there is something wrong with them because they have ADHD symptoms. Many of them have experienced academic failure, or at least lowered academic achievement, and know they are not performing as well as their friends and peers. They have also often been subjected to years of negative feedback at school, including criticism of their behaviour or disorganisation, or being told they are not reaching their potential. This combination of academic struggles and negative experiences can make them feel like they are failures as people. Teachers described how these students’ lack of success and the negative impacts on their self-esteem can lead to them suffering from shame. Elements of Theme 2 are depicted within this second narrative, in the words of Lauren, Lynn, Chris, Natalie, Sophie and Angela (See Figure 2).

3.1.3. Theme 3: Feeling Frustrated

The third theme pertains to teachers’ descriptions of students who, the teachers reasoned, were experiencing distress due to their difficulties with learning and mental health, and who tended to ‘act out’ as a result. Teachers were generally understanding, even sympathetic, towards students who behaved defiantly towards them. This defiance could include challenging teachers on their teaching methods, yelling, refusing to do any work, leaving the classroom, distracting other students, or causing other types of disruption in the classroom. The teachers variously explained this defiance as appearing to be a defence mechanism used by students to mask that they were struggling with work, or a manifestation of their distress or frustration. They also highlighted how frustration appeared to be a key factor in the mental health challenges of students with ADHD symptoms, and that it seemed to be caused primarily by a feeling of failure. This third narrative depicts elements of Theme 3, in the words of Lynn, Mandy, Mei, Natalie, Angela, Sophie, Debbie and Nick (See Figure 3).

3.1.4. Theme 4: Feeling Helpless

The fourth theme involved teachers’ perspectives on students who have faced many challenges because of their ADHD symptoms and feel either overwhelmed or defeated. The teachers felt there was a learned helplessness at play, because many students had experienced years of negative comments and feedback and were now losing hope in their ability to achieve, as their low self-worth became ingrained. Teachers also described students who felt a sense of hopelessness because they were unable to cope with their work, due to their poor ability to focus, or had become overwhelmed and were thus underperforming and falling behind, adding to their feelings of failure. These students would often end up in a negative spiral of not seeing the point in carrying on. Teachers also reported that even students who were doing well, but who struggled with getting work done due to their ADHD symptoms, would sometimes decide it was all too much and give up. This final narrative encapsulates elements of Theme 4, in the words of Donna, Angela, Sophie, Debbie, Amber, Nick and Natalie (See Figure 4).

3.2. Teacher Strategies to Support the Mental Health of Students with ADHD Symptoms

During coding and the subsequent refining and theme generation stages, it became apparent that the strategies the participant teachers employed to support the mental health of students with ADHD symptoms were both comprehensive and extensive. Many were holistic approaches, while others were targeted responses to the particular mental health challenges their students with ADHD symptoms faced.

3.2.1. Specific Strategies Which Target Students’ Mental Health Challenges

Numerous strategies were identified which related directly to the specific mental health challenges that teachers described in their students with ADHD symptoms. Since these targeted strategies were distinct from holistic approaches taken, examples of these are outlined here separately, organised in line with the four themes and narratives already presented.

As covered within the Feeling Anxious theme, some students experience a great deal of anxiety, which can lead to depression, and they worry or overthink their concerns. They also struggle with feeling ‘stuck’, i.e., an inability to start their schoolwork or to complete it, or problems with getting hyper-focused on one part only, which can be related to difficulties in regulating perfectionist tendencies. Natalie (19 years’ experience) shared that she assisted these students by “negotiating what they can do in class and agreeing on what they can catch up on at home if they need to take it slow”. She pointed out that being given that option helped to relieve pressure on students and gave them a “sense of control [which] can ease anxiety”.

There are also students with ADHD symptoms who have experienced failure and have low self-esteem, as per the theme Feeling Different. They can even feel as if something is wrong with them, which can lead to shame. To support students with these struggles, teachers tended to focus on positives. For example, Chris (25 years’ experience) favoured “reminding them that [ADHD] does come with superpowers… the lateral thinking, the speed of thinking”. Angela (24 years’ experience) emphasized “teaching a student that… they are a wonderful person, they have different skills”. Lauren (26 years’ experience) had found that, “Often a purposeful job or peer tutoring another student… [would] support their belief in themselves and their ability to achieve success”.

When attempting to provide support to students whose mental health challenges fell within the theme Feeling Frustrated, teachers encountered students whose behaviour was likely a manifestation of the distress they were experiencing as a result of long-term or multiple difficulties, as well as frustration. Some of these students were disruptive or overtly defiant. Describing which strategies were helpful in this context, Debbie (7 years’ experience) recalled one of her students, and commented, “there is some aggression because I think they get frustrated and it comes out… he’d walk around and he’d come back and he’d be better. He would just have to get that tension out of his system”. Sophie (27 years’ experience) reflected on her approach with one of her disruptive students, saying, “I think because I’m trying to show respect and kindness to him… he’s working really hard to try… But where he’s getting in a lot of trouble in other classes and at recess, he’s behaving really, really well in my class”.

Finally, in cases where students feel overwhelmed or feel like giving up, as found in the theme Feeling Helpless, Nick (4 years’ experience) described taking a flexible approach in attempting to support a student through such difficulties:

[A] lot of managing that overwhelm is… ‘just give me something’… ‘Right, what can we do? How can we [bridge] that gap between supporting you with your overwhelm and you still being able to provide some sort of evidence of learning, even if it’s not all of it… let’s just readjust this assignment a little bit’.

3.2.2. Holistic Strategies Which Support the Mental Health of Students with ADHD

Four themes, with sub-themes, relating to holistic mental health support for students with ADHD symptoms emerged via the analysis (see

Table A1. Themes, sub-themes and illustrative quotations.

Theme 1: Building Relationships
Sub-themes	Illustrative Quotations
Importance	I put the relationship first with all of my students… knowing them well and figuring them out, you know, building that connection is just important. (Angela, 24 years’ experience) I think one of the things… in all teaching is relationship building with the student… [it] is always a key towards much more engagement in whatever lessons you prepare thereafter. (Mei, 20 years’ experience)
Trust	I will coach staff sometimes rather than step in because I’m a stranger to kids a lot sometimes. And I know relationship is a lot more powerful, when we have that relationship to de-escalate kids with trust. (Mandy 20 years’ experience) Having that good relationship with her has really supported the strategies that I can implement with her because she trusts me and we can look at that and I’ve set and developed a study plan for her for all of our classes because of that trust relationship. (Donna, 18 years’ experience) [After chatting to a student of concern] we had a better working relationship and he started trusting me with when he was feeling overwhelmed with his work instead of acting out. (Natalie, 19 years’ experience) Those little quiet check-ins at a time that’s appropriate… so that they know that I’m aware, which means they know I’ve got their back… it’s like, “Oh, someone cares how I’m doing, someone cares about results and how I get it”… Yeah, because the pressure’s lifted, just someone cares, you know? (Natalie, 19 years’ experience) So in the end it wasn’t the educational factor that we were more concerned with… sometimes the fundamental thing is just making a child feel loved and accepted. (Mei, 20 years’ experience)
Theme 2: Seeing Individuals
Sub-themes	Illustrative Quotations
Recognising each student’s point of need	We meet her at the point where she is rather than try to drag her to the point that we expect her to be. (Mei, 20 years’ experience) I think that’s just how I treat all students, especially when they’re doing it tough… It’s just about trying to sit down and meet the person at their point of need, where they are right then. (Chris, 25 years’ experience) [I prioritise] catering for students needs in a variety of ways that are relevant for their situation. (Donna, 18 years’ experience)
Engaging students via their interests	So I think making that connection based on their interest, based on things that really fascinate them. And these are students, they are people like any one of us, so knowing another person, knowing what a person likes… their preferences and all that. And working along those lines always helps. (Mei, 20 years’ experience) A kid last year was like, “Oh, I can’t do it. I’ve got ADHD”. I’m like, “No, that just means you’re working in hard mode. Come on, you’re a gamer. Let’s go, gamer”. (Natalie, 19 years’ experience)
Showing compassion and understanding	If you’re showing kind of compassion and care towards them and understanding of their situation, they try their best. (Sophie, 27 years’ experience) Seeing the student as someone who honestly wanted to learn and make the ‘green’ choices but had difficulty with control over their output was important. (Lauren, 26 years’ experience) Also having conversations with the student to know that actually their behaviour is normal. (Donna, 18 years’ experience) Approaching each student as an individual human being… It’s about respect for students and… unconditional personal regard… if the ADHD has got in the way and things haven’t been working well, [reminding students] that we still like them and respect them as human beings. (Chris, 25 years’ experience) It’s like, “I see you as a person, not just a student, not just a kid who doesn’t get it. We’re going to openly talk about what you need.” (Natalie, 19 years’ experience) Having that conversation with the student, not singling them out… never ever mentioning their diagnosis and really making them feel seen and heard I think is really important and they all really support that mental health. (Donna, 18 years’ experience) I’ll always say to all of the students, “if you need help, if you need support, let me know”. (Angela, 24 years’ experience) Even if the things aren’t helping that much, the fidgets or the cushions, the idea that I see these kids, that I care about their experience, that it’s a way of acknowledging their experience [by providing these things]. And all of that stuff contributes to feeling seen and heard and understood. (Sophie, 27 years’ experience)
Seeing the broader context	I think often it’s bigger picture stuff. So if they come into your class and they’re having a bad day, it’s unpicking what else has gone on. (Angela, 24 years’ experience) You can read the room, you know. You can see where they’re at. But then you can also do that one-on-one with a kid… [and have] chats about personal emotional struggles with the work or outside influences affecting their focus. (Natalie, 19 years’ experience) In a secondary situation, you’ve got them for 40 min a day. You don’t know what happened in the last class, you don’t know what’s going to happen in the next class… So you just have to deal with what you’ve got at that moment. (Lynn, 30 years’ experience) [They don’t] come to school with a fresh plate. They come into school after breakfast, after the morning routine… you know, not being able to find their shoes and being yelled at… All of those things come into school in the morning and most kids brush them off because that’s just life, but a student with ADHD may not be able to do that as easily. (Lynn, 30 years’ experience)
Theme 3: Reducing Stigma
Sub-themes	Illustrative Quotations
Consistent approaches for all students	I’ll actually have conversations with my ADHD kids if I’m having to call them out, and I’ll just say… “I’m giving you a leeway, but you can’t push it… because then what’s happening is if I let you just have free rein because of this, then other people are going to feel like it’s unfair when I call them out… So I’m not attacking you, but I am going to have to keep it consistent”. (Natalie, 19 years’ experience) [It’s important to have] a very clear and consistent, I guess, management approach with perhaps some specific mechanisms in place for those students that, you know, they’ve got a timeout card. (Lynn, 30 years’ experience)
Using discreet cues	One kid [with] ADHD and anxiety… was afraid to put his hand up… if he’s feeling overwhelmed or he needs help, he will put an orange highlighter… on top of the pencil case… so I’m like, “cool, I’ve got the orange highlighter cue… that’s fine. I’ve got your back”. (Natalie, 19 years’ experience) [I have a] traffic light cups [system] so students don’t need to raise their hand for help but can still signal clearly that (green) they are going fine with the set task, (orange) need help but can keep working, (red) are stuck and can’t do anything without my help. (Natalie, 19 years’ experience) [I use] some sort of verbal cue or visual cue that’s been agreed to between you so that they have an out. (Lynn, 30 years’ experience)
Inclusive approaches	I provide a set of wiggle cushions and a jar of fidgets in my room… Many students enjoy using these things which removes any stigma attached to who uses them and why… in my classroom, anyone can use them… So it stops them from being unique. It’s like, oh, they see, oh, lots of people use these things, not just me. And the other kids see, oh, it’s not just the weird special kids that use this, this is also enjoyable for us. (Sophie, 27 years’ experience)
Sharing own diagnosis	And with my own diagnosis… I let the kids know actually. As part of my get-to-know-you things… “I’m going to tell you guys something, and I don’t expect you guys to share this back, but I have ADHD”… by saying, “Oh, this is something about me, it’s not all of who I am, I’m also an English teacher”… it’s just setting the tone. (Natalie, 19 years’ experience) Every day, we kind of look at things around kindness, respect, and inclusion… so I disclosed that I have an autism diagnosis… we were talking about the idea of invisible disabilities, that sometimes you don’t know what’s going on with someone… So I think yeah that just created community and understanding… So that helps I guess with all of their mental health. (Amber, 21 years’ experience)
Theme 4: Providing Safe Spaces
Sub-themes	Illustrative Quotations
Feeling of safety	We do get to chat with them and… I think it’s critical actually to the girls feeling a sense of belonging and feeling connected to the school… when there is a connection and they’re feeling safe and secure in our spaces, sometimes they’ll disclose things in our classrooms… I’m not talking mandatory reporting sort of stuff. (Angela, 24 years’ experience) Building a safe place where whatever is going on with them is okay and human allows for better and honest working relationships. (Natalie, 19 years’ experience) Providing a safe, inclusive space, without shame or judgement, benefits everyone. It also greatly reduces disruptions and behaviour problems from students. Getting in trouble for things students can’t easily control or modify causes these students a lot of stress and shame. (Sophie, 27 years’ experience)
Physical ‘safe space’	Sometimes what they need is actually a safe space away from the noise and all that’s happening in the classroom… So we do have learning support staff in where there is a room that they can actually go to and collect themselves… That helps. I think creating that safe space, creating that acceptance, just switched off from the intensity for a while and coming back does help. (Mei, 20 years’ experience) Students were given time out cards they could use if experiencing anxiety or stress and they could go to student services for up to 20 min. (Debbie, 7 years’ experience) But at our school, if a kid is struggling with those things and they’re getting in trouble and they’ll talk with the psych[ologist] and one of the deputies and they’ll get a [card] and there’s… a little chill out zone… they get a 15 min time out. The card allows them to go and just sit there… and the chaplain or the psych will pop their head out… “Do you need anything?”—“No”. And they can just sit there and they bring themselves back down, so it’s pretty great self-regulation there. (Natalie, 19 years’ experience)

in Appendix A, which presents the four themes and their sub-themes, with illustrative quotations given for each).

Theme 1: Building Relationships

The first holistic strategy theme, Building Relationships, appeared to be at the heart of how these teachers approached supporting their students with ADHD symptoms and mental health challenges. The sub-themes identified here were Importance and Trust.

Teachers emphasised the importance of getting to know their students well, as this led to developing trust between them, which enabled them to help students better. For Angela (24 years’ experience), “figuring them out, you know, building that connection is just important”, while Mei (20 years’ experience) found that relationship building “is always a key towards much more engagement”. Donna (18 years’ experience) found that “[h]aving that good relationship with [a student] has really supported the strategies that I can implement with her because she trusts me”. Natalie (19 years’ experience) shared that after establishing a better working relationship with one of her students through conversation, “he started trusting me with when he was feeling overwhelmed with his work instead of acting out”.

Theme 2: Seeing Individuals

The second theme, Seeing Individuals, refers to teachers adapting approaches to what is most relevant for a particular student. Sub-themes identified were as follows: Recognising each student’s point of need; Engaging students via their interests; Showing compassion and understanding; Seeing the broader context.

As Chris (25 years’ experience) put it, “It’s just about trying to sit down and meet the person at their point of need, where they are right then”. Teachers also talked about the value of using students’ interests to engage them. Mei (20 years’ experience) felt it was helpful to engage with students by knowing what fascinates them, “making that connection based on their interest… their preferences and all that”. They also emphasized showing they care about their students. In Sophie’s experience (27 years), students try their best “[if] you’re showing kind of compassion and care towards them and understanding of their situation”. For Chris (25 years’ experience) “[i]t’s about respect for students and… unconditional personal regard… if the ADHD has got in the way… [reminding them] that we still like them and respect them as human beings”. Another important aspect was viewing problems within the broader contexts of their students’ lives and factors outside of their particular classroom that might also be impacting their mental health. As Angela (24 years’ experience) put it, “I think often it’s bigger picture stuff. So if they come into your class and they’re having a bad day, it’s unpicking what else has gone on”.

Theme 3: Reducing Stigma

The third theme, Reducing Stigma, highlights the importance of teachers treating all students in their classes fairly, irrespective of whether they have ADHD symptoms and mental health difficulties. Sub-themes identified were as follows: Consistent approaches for all students; Using discreet cues; Inclusive approaches; Sharing own diagnosis.

Teachers felt taking consistent approaches was part of being careful not to cause resentment from neurotypical peers by giving those with ADHD-related behavioural difficulties too much leeway. Lynn (30 years’ experience) emphasized “a very clear and consistent, I guess, management approach with perhaps some specific mechanisms in place for those students”. Another strategy teachers employed was avoiding drawing negative attention to those with ADHD, for example by having discreet cues to signal the need for help. Natalie (19 years’ experience) described this cue used by one of her students: “if he’s feeling overwhelmed or he needs help, he will put an orange highlighter… on top of the pencil case…”, while Lynn (30 years’ experience) will make use of “some sort of verbal cue or visual cue that’s been agreed to between you so that they have an out”. A further strategy to reduce stigma was reported by Sophie (27 years’ experience), who said, “I provide a set of wiggle cushions and a jar of fidgets in my room… Many students enjoy using these things which removes any stigma attached to who uses them and why…”. Some teachers found that sharing their own diagnosis of neurodiversity was helpful for reducing stigma. Natalie (19 years’ experience) said, “And with my own diagnosis… I let the kids know actually… by saying, ‘Oh, this is something about me, it’s not all of who I am, I’m also an English teacher’… it’s just setting the tone”.

Theme 4: Providing Safe Spaces

The final theme, Providing Safe Spaces, refers to both abstract and literal spaces where students with ADHD and mental health challenges can feel safe. Sub-themes identified were Feeling of safety and Physical ‘safe space’.

Teachers described the importance of having classrooms where students felt comfortable being themselves. In Sophie’s (27 years’ experience) view, “[p]roviding a safe, inclusive space, without shame or judgement, benefits everyone. It also greatly reduces disruptions and behaviour problems from students”. The value of having a literal ‘safe space’ for students, i.e., quiet areas or supportive venues in schools where students who were experiencing mental health difficulties could regulate themselves or access support from pastoral care staff, was also reported by the teachers. Mei (20 years’ experience) described that in her experience, “[s]ometimes what they need is actually a safe space away from the noise and all that’s happening in the classroom… So, we do have learning support staff in where there is a room that they can actually go to and collect themselves”.

4. Discussion

The current paper reports on two aspects of a qualitative study which sought the perspectives of secondary school teachers on supporting the mental wellbeing of their students with ADHD symptoms. First, teachers’ perspectives were sought on the mental health challenges experienced by secondary school students with ADHD (diagnosed or undiagnosed) in classroom settings. Second, the strategies teachers employ to foster the mental wellbeing of such students were explored. Overall, the findings indicated that teachers observed their students facing numerous, significant mental health difficulties as a result of their ADHD symptoms and the knock-on impacts thereof, but also that teachers used a wide range of strategies to assist these students, including those that targeted their specific mental health challenges and those that were holistic and supported their wellbeing more generally. The qualitative approach taken in this study provided a wealth of detail regarding the human perspectives that lie behind the figures reported in other studies. Depth of experiences was revealed and documented, including the complexity of the mental health difficulties with which these students contend in relation to their learning, and for which teachers attempt to provide support with the aim of fostering their wellbeing.

4.1. Teachers’ Views on the Mental Health Challenges Faced by Students with ADHD Symptoms

The participant teachers spoke both passionately and compassionately about the mental health difficulties they observed in their students with ADHD symptoms. Thematic analysis [74,75,76] resulted in four themes which encapsulated the students’ mental health challenges, as observed by the teachers: Feeling Anxious, Feeling Different, Feeling Frustrated, Feeling Helpless. These themes were presented as four composite narratives, constructed using the teachers’ words linked together to provide a collective teacher ‘voice’ in each case. The intention was for each narrative to serve as an illustration of a particular theme, allowing the impact of the teachers’ perspectives to permeate through these retellings of their experiences. Their vivid accounts of the difficulties they witnessed in their students made it clear that students with ADHD symptoms are either at risk of or already experiencing serious mental health problems. The teachers’ perspectives also served to bring to the fore the human face of the statistics about mental health conditions and their real impacts on these adolescents’ lives.

The narrative for Theme 1, Feeling Anxious, depicted teachers’ perspectives on students with ADHD symptoms who struggle with anxiety, overthink their concerns and worry a lot (i.e., they are stressed, but also ‘stuck’ because they have difficulties in starting or completing schoolwork, often exacerbated by perfectionist tendencies which further contribute to their anxiety). Next, the narrative for Theme 2, Feeling Different, illustrated teachers’ observations of students who feel like failures and, as the teachers put it, as if they are “broken” (i.e., fractured in some way due to their ADHD symptoms and struggles). These students have often not achieved academic success and have had years of negative feedback from staff who lack understanding of the challenges they face from their ADHD symptoms, resulting in low self-worth and feelings of shame. Subsequently, the narrative for Theme 3, Feeling Frustrated, sketched out teachers’ experiences of students who display externalising or disruptive behaviour, often as a manifestation of distress, or resulting from a build-up of frustration due to their difficulties with learning and mental health. Such students were described as using defiance towards teachers as a type of defence mechanism or to mask how frustrated or upset they feel. Finally, the narrative for Theme 4, Feeling Helpless, exemplified teachers’ descriptions of students with ADHD symptoms who end up with a kind of learned helplessness, where they do just enough and no more, because they have lost hope in experiencing success. This narrative also depicted students who feel hopeless because they become overwhelmed with their learning struggles and feel like giving up entirely.

The findings reported here thus affirm and elaborate upon what is already clear in the literature: that adolescents with ADHD symptoms, regardless of a formal diagnosis, are far more likely than neurotypical peers to experience significant mental health difficulties, including anxiety or depression [33,42], as well as academic underachievement [11,55,56,57]. Additionally, the findings affirm the consensus in the literature that young people cannot learn effectively without good mental health [9,10,11].

It is hoped, however, that these findings also shed further light on the reasons why young people with ADHD symptoms often struggle with school engagement and do not fare well academically. First, the results indicate that there are complex, interrelated effects between the mental health challenges and educational difficulties experienced by students with ADHD symptomatology. For example, there can be interplay between factors such as anxiety, frustration, and emotional distress, with knock-on negative effects on learning. Another example is where learned helplessness, or even hopelessness, can result from long-term academic difficulties and negative feedback impacting mental health. As per the findings, these individual factors may not only interact, but also compound one another to produce a negative cycle or even downward spiral effects. This interplay of factors is particularly apparent in the first theme, Feeling Anxious, for example. The narrative illustrating this theme described students who worry a great deal about their schoolwork, which further impacts their ability to focus but can even, at times, result in school refusal, causing them to fall further behind in their work, which then heightens their anxiety, leading ultimately to overwhelm.

4.2. Teachers’ Strategies to Support the Wellbeing of Students with ADHD Symptoms

Teachers proffered a comprehensive range of strategies that they used in classrooms to foster the mental wellbeing of students with ADHD symptomatology. Some addressed specific mental health challenges experienced by these students, including strategies for those experiencing high levels of anxiety and who are feeling ‘stuck’; for those with low self-esteem and feelings of failure; for those who are frustrated or distressed and express defiance; and for those who feel overwhelmed or hopeless.

The teachers also noted numerous general strategies that are important for providing environments that support all students exhibiting ADHD symptomatology, irrespective of their specific manifestations or particular mental health difficulties. These more holistic strategies were represented within four overarching themes that emerged from the analysis—Building Relationships, Seeing Individuals, Reducing Stigma and Providing Safe Spaces—along with their respective sub-themes. In summary, teachers emphasised the importance of building good teacher–student relationships involving trust; recognising each student’s point of need; engaging students via their interests; showing compassion and understanding; using a consistent approach for all students; agreeing upon discreet cues for students to alert teachers to difficulties; allowing all students to make use of supportive measures; and helping students to feel safe in classrooms as well as providing physical quiet spaces for self-regulation.

The teachers talked about all their strategies throughout their interviews, as well as in their written answers to open-ended questions. It was, therefore, unsurprising that many of the strategies the teachers used were interrelated. For example, making the effort to build relationships and trust with students, which are part of a holistic strategy, enabled teachers to support their self-esteem or frustration with targeted strategies more effectively, as students were then more willing to engage with these supports. In addition, some strategies, such as the holistic strategy of Seeing Individuals, were useful in supporting students who were struggling with more than one mental health difficulty (e.g., anxiety as well as low self-esteem, or in cases where there was a cycle of negative impacts).

Several of the strategies align with requirements for teachers that are set out in Australian education policies, such as The Alice Springs (Mparntwe) Education Declaration [69] and the Australian Professional Standards for Teachers [68]. This suggests that, overall, these teachers are providing a good standard of mental wellbeing support for their students. Turning to the first theme, in terms of strategies which come under Building Relationships, a number of studies have found that good relationships between teachers and students have positive outcomes for students, including those with ADHD symptomatology [78,79,80]. Such studies affirm this to be a sound general approach taken by these teachers. For strategies contained within the second theme, Seeing Individuals, knowing students and recognizing individual students’ needs are strategies reflected in various policy frameworks [68,69]. Similarly, Evidence for Learning [81] recommends that teachers “know and understand students and their influences” (p. 6). A systematic review of qualitative research on school context and symptoms of ADHD found that it was “[p]articularly salient…to explore individual pupil needs and motivations in relation to the classroom” [82] (p. 96). Thus, from these perspectives, teachers showing understanding, striving to meet students’ specific needs, as well as using students’ interests to engage them, are all constructive approaches. Relating to strategies from the third theme, Reducing Stigma, teachers using these are indeed adopting an inclusive approach, by interacting with all students in a consistent manner, by normalizing the use of classroom supports, and by being willing to share their own diagnoses with students. This is important since a meta-synthesis review of children and adolescents’ experiences of their ADHD [83] found that stigmatization is one of the negative factors that can impact interactions with others. Findings from a systematic review [84] focused on ADHD symptoms and teacher–student relationships included that if teachers display rejection of students with ADHD, this “poses a risk factor for not only school failure, but also peer exclusion…leading to low self-esteem and loneliness” (p. 146). As Toye et al. [85] note regarding teachers’ roles in inclusion of children with ADHD in mainstream schools, “Whilst policy mandates inclusion, it is teachers’ behaviour that determines its success” (p. 184). Finally, the fourth theme, Providing Safe Spaces, included strategies which help students to feel safe in classrooms, as well as the provision of supportive physical spaces for students to retreat to when stressed. Feeling safe is a key component of a state of positive mental wellbeing [62].

4.3. Implications for Practice

The findings indicated that the mental health challenges faced by students with ADHD symptoms and their educational difficulties are often interrelated and may have complex effects on one another. Some students experience negative cycling or even downward spirals as problems interact with and compound one another. These outcomes have implications for secondary school teachers and schools, because they highlight the scale and the depth of these students’ struggles, and thus the consequent burdens on teachers. Due to the prevalence of ADHD, every classroom in Australia is likely to contain at least one student with ADHD, while in disadvantaged areas, this rises to approximately 75% of classrooms having at least two students with ADHD, owing to the higher prevalence seen in disadvantaged families [55]. There will be additional numbers of students experiencing difficulties with ADHD symptoms whose impairment is just below the diagnostic threshold, yet still significant enough to affect their engagement with and success in school. In terms of this neurodevelopmental disorder alone, these numbers of students with ADHD symptoms and mental health impacts represent an onerous load on teachers, who will be teaching and assessing these students, as well as providing mental wellbeing support.

The findings also show that the teachers who participated in this present study made use of an extensive range of strategies to support the mental health of students with ADHD symptoms, including those that targeted their particular mental health needs. Given that most of the teachers were very experienced, with an average of 20 years’ teaching experience, this raises the question of whether graduate or inexperienced teachers would be similarly capable of providing such an array of strategies. If not, a further question arises as to the implications this might have with respect to the burdens on teachers to provide these supports, as well as the possible impacts on students in their classrooms.

On a more positive note, the comprehensive set of strategies that the teachers in this study were employing could reasonably be assumed to be useful in supporting students beyond the cohort with ADHD symptoms. This would include those with other mental disorders or comorbid diagnoses. Approximately one in seven students is affected by a mental disorder [11], and comorbidities are common in individuals with ADHD [55,86,87]. In addition, since the majority of these strategies were holistic, these would have the advantage of being valuable for fostering the general mental wellbeing of all students in a class.

4.4. Limitations

The present study’s limitations relate primarily to its sample and localized scope. There were 12 teacher participants in this study, only from independent schools and one geographical area. However, this relatively small sample size was amply mitigated by the fact that these teachers were from 11 different schools, represented a range of ages, seniority and years of teaching experience, and held the expertise of nearly 20 teaching subjects between them. It should be noted that, while the current proportions of teachers in Australian secondary schools are 61.4% female versus 38.6% male [88], this sample comprised 83.3% female to 16.7% male teachers. Despite this ratio, given that responses to the questions posed in this study are unlikely to attract gender-specific biases (i.e., that both male and female teachers are likely to have confronted similar issues in their classrooms), the impact of this sample attribute is likely to have been minimal.

Convenience sampling was employed, and all of the teachers were from schools in the Independent sector. This is a limiting factor but, on the other hand, since all 12 teachers were from Independent schools, this represents a specific context and might serve to increase the relevance or applicability of the study’s findings to others in this sector. Another limiting consideration is that the majority of the participants in this study had decades of teaching experience, which means they were not necessarily representative of teachers in general, or of newly qualified teachers. Nevertheless, it could be argued that, as these teachers used many strategies but still described the great impact of mental health struggles associated with ADHD seen in their students, their accounts serve to underscore the gravity of the problem that is likely to exist in other contexts. These could include the classrooms of early career teachers who have not yet built a significant repertoire of strategies for dealing with these problems, or those of under-resourced schools. Therefore, in a sense, the findings of the present study highlight even more powerfully the negative mental health experiences of students with ADHD symptoms and how these can impact their learning on a daily basis.

In terms of scope, it must be noted that this study was confined to a particular geographical area: that of Perth, Western Australia. The representativeness of a sample and the location of the research have implications for the transferability of a study’s findings to other contexts, but the researchers sought to counter this by providing sufficient detail, or “thick description” [77] (p. 316), throughout the reporting of this study, to allow readers to make informed evaluations of the applicability of the findings to their own contexts.

There were also limitations due to interacting aspects inherent in this study’s context, which could not be controlled for. First, it was not possible to take account of other comorbid conditions which the students described in the data might have had in addition to their ADHD symptoms, and which might have contributed to the mental health challenges they experienced. Second, strategies that teachers use in classrooms, whether general or specific, will all interact. Thus, while this study was focused on strategies of a mental health support nature, there will be effects at play from other approaches too, including those intended primarily to support the academic performance of such students.

These limitations notwithstanding, this study contributes to the literature by providing rich insights into the complex mental health challenges of students with ADHD symptoms, interacting effects between their learning and mental health, and the strategies that teachers are already employing to support these particular students. It is hoped that the findings will highlight the experiences of students with the most prevalent mental health disorder in schools, to inform future approaches and policy decisions, as well as to provide pointers to guide future research in this area.

4.5. Directions for Future Research

Although the findings of the current study give a detailed view of teachers’ perspectives on how students with ADHD symptoms present in class and their learning and mental health challenges, it would be valuable to conduct qualitative research with a more diverse sample of teachers from a wider range of schools, including government public schools in metropolitan and rural regions. Teachers who are in their first year post-graduation could potentially face unique difficulties responding to students with ADHD and, therefore, could be a point of focus for future research. This would improve the generalisability of the findings. Research could also be conducted with students with ADHD symptoms to voice what they perceive to be their most serious challenges in terms of the mental health impacts of their ADHD symptoms, and their suggestions for better ways in which teachers and schools can support their wellbeing and, consequently, their learning. While the teachers who participated in this study provided a wealth of qualitative data and perspectives, exploring students’ lived experiences and insights would complete the overall picture and might serve to reinforce findings as reported here. These might also provide new perspectives on the problems, which would contribute to the generation of further, more refined solutions.

Future research could also focus on obtaining a clearer picture of the mental health difficulties experienced by young people with sub-diagnostic-threshold ADHD symptoms in classroom contexts. Many of the teachers’ perspectives given in the present study involved students without formal diagnoses of ADHD, who nevertheless faced challenges from their symptoms and mental health problems. At least 5% of children are just under the diagnostic threshold for ADHD, because they do not meet all of the criteria for such a diagnosis [89]. These students will, nevertheless, experience substantial challenges and need support [31,36,37,49,62,89]. A complicating factor in the provision of such support is that funding eligibility is only assessed for those with a diagnosis. This means that those who do not meet the formal criteria, but still have difficulties, are not eligible for assistance in schools, such as via teacher aides. Research on this sub-clinical cohort could allow funding policies to be re-evaluated, should a need for an extension of assistance be demonstrated in well-controlled empirical research.

The present study focused on students with ADHD symptoms and mental health. Every class, however, will include students with a variety of different capabilities and challenges. Future research is needed to evaluate the mental health challenges, and severity thereof, of those with other neurodevelopmental disorders, mental health conditions and difficulties. This would undoubtedly be tricky to undertake due to the prevalence of comorbidities between mental health disorders. It would, however, be useful to see what impacts on mental health there are from other, less prevalent, conditions and whether similar or novel strategies are currently used, or needed, to support students with those other conditions.

5. Conclusions

This paper reports on the mental health challenges of students with ADHD symptoms and the strategies teachers use to support these students’ wellbeing. The literature contains primarily facts and figures from quantitative data relating to the poor mental health outcomes from ADHD [33,42] and this disorder’s negative impacts on academic achievement [11,55,56,57]. This qualitative study, therefore, adds value by providing rich detail about the significant, interrelated mental health difficulties that these students face, the knock-on negative impacts they experience on their learning, and the negative cycles of difficulties that may affect such students. This study’s findings also highlighted the comprehensive strategies that teachers employ to support the mental wellbeing of students with ADHD symptomatology in their classrooms. As the prevalence of ADHD is not declining [7,8,90], there is need for a clear focus to be placed on tackling the mental health crisis in adolescents and its complex negative effects on learning. Despite the best efforts of teachers, these are clearly still being played out in schools across Australia on a daily basis.