ADHD, PDB and School Exclusion: The Lost and the Cost

The exclusion of children from the school environment, either on a fixed-term or a permanent basis, is a disciplinary tool used in primary and secondary schools throughout the United Kingdom. Such exclusion is usually instigated following an infringement of the school’s behavioural policy where precipitating factors may include physical assault, verbal abuse, threatening or racist behaviour, bullying, theft, or sexual misconduct (Department for Children, Schools and Families, 2009). The overriding aim of any exclusion policy is to deter misbehaviour, thereby fostering a safe and productive academic environment.

Pupils with special educational needs (SEN) are more likely to be permanently excluded than pupils without SEN (Department for Children, Schools and Families, 2009). While the term SEN covers a range of physical and neurological conditions, from cystic fibrosis to hearing impairment, it may also include children with psychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder (ODD), and others, all of which may be characterized by disruptive behaviour (CHADD, 2005).

In this article, I will examine the role of underlying behavioural disorders in school exclusion and specifically explore the potential role of ADHD in disruptive behaviours. The over-arching intent of this effort is to encourage continued debate among all stakeholders in this important issue that affects children and impacts their potential and incurs a significant societal cost.

During the 2010/2011 academic year in England, there were 304,370 fixed-term exclusions and 5,170 permanent exclusions from primary, secondary, and special schools (Department for Children, Schools and Families, 2012).

Persistent disruptive behaviour – The need for a definition

”Persistent disruptive behaviour” is a term that is widely used in the exclusion process, although there is no standardized definition that appears to have been agreed upon. Indeed, the literature review demonstrated that the term has been used to cover a spectrum of behaviours, from calling-out in class, annoying/distracting other students, and general attention seeking, to more aggressive actions.

For both, fixed and permanent types of exclusion, “persistent disruptive behaviour” was most commonly cited as the reason for exclusion, accounting for 24.1% of fixed-term exclusions and 32.9 of permanent exclusions in 2010/2011 (Department for Children, Schools and Families, 2012). .
In current practice, persistent disruptive behaviour appears to be applied to a range of pervasive and to some extent predictable, consistently inappropriate behaviours rather than one-off actions such as a physical or verbal assault or damage of property. However, if the definition varies from school to school, it follows that there may be significant variation in the criteria being applied when making the decision to exclude a pupil, and this may make interpretation of inter-school comparisons of exclusion statistics difficult. The data presented in Figure 3 show the incidence of permanent exclusion attributable to persistent disruptive behaviour across a number of LEAs in England. LEAs were selected solely on the basis of data availability. Disruptive behaviour was repeatedly listed among the most common reasons for permanent exclusion. However, no definition of the term was provided by any LEA.

School Exclusions: The Role of Behavioural Disorders and ADHD

\ADHD is one of the most common childhood neurodevelopmental disorders, estimated to affect between 3% and 9% of school-age children and young people in the United Kingdom (NICE, 2009). A recognized neurobehavioural disorder (American Academy of Paediatrics, 2000), ADHD is typically characterized by symptoms such as “failure to give close attention to schoolwork,” an “inability to listen when spoken to directly” or “follow through on instructions” and a “tendency to leave a classroom without permission” (Table 2; DSM-IV; American Psychiatric Association [APA], 2000). Such symptoms closely resemble the types of disruptive behaviours associated with school exclusion. If symptoms are manifested over a prolonged period of time, these behaviours may place a child at risk of exclusion, especially if the underlying cause of these behaviours is not recognized and appropriately managed.

There is a high rate of co-occurrence, or co morbidity, between CD, ODD, and ADHD. A nationally representative sample of 10,438 5- to 15-year-olds taken from the 1999 British Child Mental Health Survey revealed 35% co morbidity (DSM-IV diagnosis) between ADHD, CD, and ODD (Maughan et al., 2004). In the US, the National Institute of Mental Health’s (NIMH) collaborative multimodal treatment study of children with ADHD (MTA Co-Operative Group, 1999) reported that 40% of children with ADHD had comorbid ODD and 14% were diagnosed with comorbid CD.

Considering the relatively high prevalence of ADHD among school-age children in the United Kingdom, it is plausible that many children excluded from schools for disruptive behaviour are showing symptoms of unidentified, untreated, or poorly managed ADHD. Although the relationship between ADHD and school exclusion has not been well studied in the scientific literature to date, available evidence suggests that rates of exclusion are indeed higher among children who have been diagnosed with ADHD than in the general school-age population (Daniels & Porter, 2007). A survey of 526 UK families, conducted by the Attention Deficit Disorder Information and Support Service (ADDISS) in 2006, revealed that 11% of children with ADHD were permanently excluded from their school. This is considerably higher than the permanent exclusion rate of 0.1% reported from the general population (Department for Children, Schools and Families, 2009). It is also interesting to note that the problem of exclusion is not unique to school-age children; exclusion of pre-school children with ADHD from kindergarten or summer camp also has been reported (Ghuman et al., 2009).Unrecognized ADHD may, at least in part, also help to explain the disproportionate rates of school exclusion among boys. Compared with girls, boys are over-represented in terms of both fixed-term and permanent exclusions, these being almost three times higher for fixed-term exclusions and 3.5-times higher for permanent exclusions (Department for Children, Schools and Families, 2009). Published studies demonstrate that ADHD diagnosis rates are higher among males than females, and that girls are at a lower risk for disruptive behaviour disorders. Boys are more prone to hyperactive behaviour than girls who are more likely to be inattentive, as shown in a combined analysis of two studies of 522 children with and without ADHD (Biederman et al., 2002). Girls with ADHD were 2.2 times (95% confidence interval = 1.2–4.0) more likely to be primarily diagnosed as inattentive, than boys with ADHD (Biederman et al., 2002). Other studies also suggest that the prevalence of ADHD is higher among males than females; male to female ratios range from 6:1 to 10:1 in clinical samples and from 2:1 to 3:1 in no referred community samples (Barkley, 1998; Gershon, 2002). Moreover, ODD appears to be more common in boys during childhood but equally common among girls and boys during adolescence (APA, 2000). While this may account for lower rates of school exclusion among girls, conversely, it may also precipitate under-identification and under-referral of girls with ADHD for appropriate treatment.

The Impact of School Exclusion

Some reports suggest that school exclusion and educational underachievement are closely linked. A 1998 report published by the New Policy Institute showed that only a minority of permanently excluded pupils return to full-time mainstream education (New Policy Institute [NPI], 1998). The reintegration of pupils into the mainstream school setting was examined in a postal survey of English LEAs (GHK Consulting, 2004). Among pupils who had been permanently excluded from their previous school, rates of reintegration varied considerably between LEAs for the period 2002 to 2003. In primary schools (n = 38), reintegration was attempted for 23% to 100% of excluded children and in secondary schools (n = 43) the range was 31% to 100%. Reintegration was deemed successful in 82% and 75% of primary and secondary schools attempting the process although there was no standardized definition of success, and LEAs operated according to their own criteria (GHK Consulting, 2004). Barriers to the reintegration of permanently excluded pupils may have included the reluctance of a school to take excluded pupils and a lack of commitment when receiving these children, home and family issues, limited support in schools and learning and behavioural problems (GHK Consulting, 2004).

Educational underachievement as a consequence of school exclusion has also been linked to unemployment and long-term dependency on benefits (Ofsted, 1995). There is also an association between school exclusion and crime. In a survey of 343 young people excluded from school across six LEAs in England (1988–1998), 117 had no recorded offences prior to permanent exclusion but acquired a record of offending following exclusion, and 5% of respondents engaged in criminal activities in the same month that they were permanently excluded (Berridge et al., 2001).

Exclusion has also been associated with antisocial behaviour and can have serious effects on the child’s relationships with family members, peers, and school friends. The containment of excluded children within the same referral unit may help to reinforce poor behaviours due to peer influence. In extreme cases, exclusion can precipitate a breakdown in family relationships (Wright et al., 2005). Furthermore, findings from the Edinburgh Study of Youth Transitions and Crime, a study of truancy, school exclusion and substance misuse in a cohort of 4300 young people who started secondary school in Edinburgh in 1998 show that excluded pupils report a significantly higher incidence of illegal drug use, underage drinking and smoking than non-excluded pupils (McAra, 2004). The same 2004 study by McAra also demonstrated that illegal drug use was significantly higher (p < .001) among excluded versus non-excluded children, rising from 23% to 57% in the third year, compared with 7% and 31% among non-excluded students. Alcohol and smoking followed a similar trend and by the third year, 44% and 43% of excluded children were engaging in these activities, compared with 23% and 17% of non-excluded children (p < .001 for both comparisons).

Finally, but importantly, school exclusion has significant financial consequences for the schools as well as the communities that are impacted. Costs are primarily derived from managing the exclusion process and providing replacement education for the excluded child and social services. The transfer, in 2007, of budgetary responsibility for exclusions to schools has meant that many have lost revenue. In 2008, schools in Nottingham reportedly paid almost £200,000 of funding to the city council for the alternative education of permanently excluded pupils, usually at a pupil referral unit (Greenwell, Nottingham Evening Post, 2009). Financial penalties linked to permanent pupil exclusions totalled £4.4 million in 2008 (The Daily Telegraph, 2008). The penalties ranged from £1,500 to £10,000 per permanently excluded pupil and were issued by nearly one third of LEAs in England. The report argued that such fines exerted unfair pressure on head teachers to avoid permanent exclusion and may have accounted for a rise in fixed-term exclusions as a less costly alternative. Governmental statistics from 1996 to 1997 demonstrated that the cost of excluding pupils from schools in England was an estimated £81 million compared with approximately £34 million if they had continued with full-time mainstream schooling (NPI, 1998). More recent interim data from the Welsh Assembly Government, published in the National Behaviour and Attendance Review (NBAR, 2008), estimated the cost of permanent exclusion at £300,000 per child. Although full details were not provided in the final report, the interim report attributed this figure to social care, probation, providing alternative education, and loss of future employment prospects, as well as costs to the community as a whole.

The role of the teacher in the exclusion process

It is clear that the school and its teachers are at the centre of the inclusion/exclusion issue. From all perspectives, the underlying aim of any disciplinary approach is to understand and cater to the unmet needs of the individual child, by recognizing and addressing the underlying cause of the behavioural problem. This is by no means an easy task for those at the “front-line” of education, given the demands placed on their time and attention on a day-to-day basis. Class sizes in the United Kingdom, particularly those in primary schools, are among the largest in the world, with an average of 24.5 students compared with the international average of 21.5 (Organisation for Economic Co-operation and Development, 2008). This “over-crowding” of the classroom and a general lack of resources can mean that teachers struggle to provide individualized care and as a result, behavioural disorders may go undetected and untreated. NICE recognizes that schools and teachers are currently ill-equipped to offer at-risk children the specialist management and teaching strategies from which they could stand to benefit (NICE, 2009), adding that symptoms like inattentiveness, hyperactivity, and impulsivity are not necessarily definitive signs of ADHD and that it takes training and experience to make the distinction.
Greater awareness of behavioural disorders among educators, instituting guidelines around the use of appropriate screening tools (within the boundaries of local legislation), and modifying existing school exclusion criteria to include appropriate screening recommendations may be of some value. Such measures will not only prove beneficial to the child in question, but are also likely to demonstrate that the attendant burdens and costs of school exclusions to the impacted families, the schools, and the wider community will be considerably better managed if not significantly reduced as a consequence. Considering ADHD as a common disruptive behaviour, there are some studies which have demonstrated the effectiveness of some school-based. Considering ADHD recognition and management programs has been reported. One such study conducted in the UK by Sayal and colleagues (2006) looked at whether educating teachers about ADHD improved their recognition of the disorder in the classroom. After specialized training, the proportion of children identified by teachers as having probable ADHD increased from 3.2% to 4.1% of all pupils (p < .05). This increase was accompanied by improved correlation between teacher recognition and a diagnostic algorithm (from 32% before training to 50% afterwards; p < .05). The authors concluded that a brief educational intervention for teachers could help to improve the identification of undiagnosed children with ADHD in the community.


Exclusion from school— widely used as a disciplinary tool in the UK—can have a lasting and often detrimental impact not only on the child, but also their families and carers, their schools, and even the community as a whole. Persistent disruptive behaviour accounts for a high proportion of fixed-term and permanent school exclusions in the United Kingdom, but consensus is currently lacking regarding a clear definition for the term. Some students excluded for persistent disruptive behaviour may be showing symptoms of an undiagnosed behavioural disorder, in particular the condition of ADHD with or without co morbid ODD and CD. Fixed-term disciplinary exclusion could, therefore, represent the first opportunity to detect such disorders. Early intervention by the school/teacher and subsequent screening and diagnosis by a medical professional may help many children to realise their full potential by preventing disruptive behaviours from becoming persistent. Diagnosis may in turn, help to circumvent the avoidable burdens of multiple fixed-term exclusions or even permanent exclusion. Improving the level of training received by teachers will also help to identify children at risk of behavioural disorders before the problem escalates further.

Fin O’Regan Jan 2015
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