A combination of medication and behavioral interventions tends to yield the greatest improvement in social skills and school performance for students with ADHD.
ADHD is a disruptive behavior disorder characterized by levels of inattention, impulsivity, and overactivity that are well beyond what is expected and appropriate for a given student's sex and age. Students with ADHD may have difficulty concentrating on schoolwork, frequently interrupt conversations or activities, and have difficulty remaining seated when required to do so. Approximately 3%-7% of school-age children in the United States have this disorder. Children with ADHD typically first exhibit symptoms of this disorder during their preschool or early elementary school years, and it is highly likely that these symptoms will continue throughout their lives. Boys are three times more likely to be diagnosed with ADHD than girls.
There are three subtypes of ADHD: individuals who exhibit problems only with inattention and concentration (ADHD Predominantly Inattentive Type); individuals who exhibit problems only with hyperactivity and impulsivity (ADHD Predominantly Hyperactive-Impulsive Type); and individuals who exhibit problems in both areas (ADHD Combined Type). ADHD is not a learning disability nor is it a manifestation of bad parenting or an impoverished environment; however, other behavioral and emotional problems and many learning disorders include symptomatic behaviors that may mimic ADHD. A trained mental health professional must conduct a thorough evaluation to ensure an accurate diagnosis.
It is likely that students differ with respect to the specific underlying cause of their ADHD symptoms. There is growing evidence that these symptoms are at least partially caused by genetic factors. Specifically, the brains of individuals with and without ADHD may differ with respect to the balance of certain chemicals, referred to as neurotransmitten, as well as the size and operation of specific brain components such as the prefrontal cortex. Further, other biological factors such as ptegnancy and birth complications and environmental toxins (e.g., early lead exposure and prenatal exposure to alcohol and tobacco smoke) are thought to cause ADHD symptoms in some individuals.
Although genetic and biological factors account for ADHD symptoms to a large degree, environmental factors-such as the nature of classroom tasks and the behavior management style at home and school-also affect the expression of the disorder. Although these factors do not directly cause ADHD, they can make symptoms better or worse. In general, it is best to view this disorder as having both biological and environmental influences, thereby indicating that both medical and psychosocial treatments could be helpful.
The inattentive, impulsive, and hyperactive behaviors that compose ADHD often lead to significant academic and social difficulties that affect how a student functions at home and at school. Students with ADHD frequently do not achieve their academic potential, may be at higher than average risk for grade retention and school drop out, and are less likely to pursue postsecondary education. Because achievement problems are highly related to rates of inattention and disruptive behavior, the academic underachievement of students with ADHD most likely represents a performance problem rather than an ability deficit. About 25% of children with ADHD also have learning disabilities.
Individuals with ADHD typically have difficulties making and keeping friends, primarily because of their higher levels of verbal and physical aggression. Family relationships can become problematic because students with ADHD are less likely to follow through on parental directives and are more likely to argue with adults. Approximately 50%-60% of individuals with ADHD exhibit significant symptoms of other disruptive behavior disorders including oppositional defiant disorder (ODD) and conduct disorder (CD). Thus, interventions not only must address ADHD-related behaviors but also must focus on improving academic and behavioral functioning.
Although most students with ADHD experience many difficulties in elementary school, these problems typically increase and worsen in middle level and high schools because of unique secondary school practices. Specifically, secondary school students must learn the expectations and meet the standards of multiple teachers. In addition, they must coordinate a more complex time schedule that involves changing classes frequently throughout the day and the year. Further, there is a greater emphasis on independently completing long-term assignments and more freedom to organize materials and prepare homework assignments. The peer group becomes particularly important for secondary school students, which potentially compounds the social relationship problems associated with ADHD. Finally, students are expected to develop long-term goals and develop career interests. Because of their impulsivity, students with ADHD typically focus on the present and have great difficulty realistically envisioning their long-term future. Multiple intervention strategies must be used across the secondary school years to address these difficulties.
The two most effective interventions for reducing the symptomatic behaviors of ADHD are central nervous system (CNS) stimulant medications and behavior modification procedures. Although most adolescents respond positively to medication, the combined use of medication and behavioral interventions tends to yield the greatest improvement in their social skills and school performance.
Medication. CNS stimulants include methylphenidate (Ritalin, Concerta, Metadata), dextroamphetamine (Dexedrine), and mixed amphetamine compound (Adderall). Numerous studies have found that stimulants enhance attention, reduce impulsive behavior, and increase academic productivity among the majority of children and adolescents who are treated. For the most part, side effects are relatively benign and include appetite reduction, insomnia, headaches, and stomachaches. In very rare cases, motor or vocal tics may develop. Contrary to popular lore, stimulants are just as effective for adolescents as they are for younger children with ADHD. Further, adolescents who are treated with stimulant medication are at no higher risk for substance abuse than are untreated individuals. In fact, some research indicates that medicated students are less likely to abuse substances than students with ADHD who are not receiving medication (Wilens, Faraone, Biederman, & Gunawardene, 2003). There are anecdotal reports of adolescents possibly abusing stimulant medications, presumably after obtaining the latter from students with ADHD, so it may be prudent to have a school nurse or administrator dispense medication during the school day and to include these drugs as part of the school's overall drug and alcohol policy.
Several other psychotropic medications are available for those children who do not respond to stimulants or who experience significant side effects. These include atomoxetine (Strattera), bupropion (Wellbutrin), and clonidine (Catapres). The response to medication varies among individuals and requires ongoing monitoring to determine the optimal medication and dosage. Further, medication should always be used in combination with academic and behavioral interventions. It is advisable to have the school nurse and the school psychologist stay current with research related to medication and provide information to other staff members about this topic.
Behavioral interventions. There are two types of behavioral interventions-classroom and schoolwide-that can be implemented in secondary school settings. Classroom behavioral interventions involve systematic changes to antecedent events-activities occurring prior to a target behavior-or consequent events-activities that follow a target behavior. The most effective treatment plans are those that include a balance between antecedent-based and consequence-based procedures. Such interventions as behavioral contracts (e.g., earning privileges for appropriate school behavior) are particularly effective when they are used consistently in both the home and the school settings. There is some evidence that self-monitoring and self-evaluation strategies can be effective for adolescents with less severe ADHD symptoms. Self-monitoring may be particularly helpful in enhancing organization skills.
Schoolwide positive behavior support plans have the advantage of helping all students, not just those with ADHD, comply with school rules and engage in appropriate social interactions. Typically, these plans include a three-tiered disciplinary model ranging from schoolwide strategies for all students, specialized group strategies for at-risk students, and individualized interventions for students exhibiting high-risk behavior. Because of the severity of their behavior difficulties, students with ADHD may require the full range of interventions in this model. Other treatments that may benefit students with ADHD include academic interventions (e.g., direct instruction in areas of deficit) and training in note taking, study skills, and test-taking strategies.
The diagnosis of ADHD does not by itself qualify a student for special education services. However, many students with ADHD will meet criteria for an educational disability (such as being other health impaired or having a learning disability or a socialemotional disorder) and may benefit from the services of special education to address learning and behavior factors that interfere with school performance. If academic progress is limited or behavioral difficulties are present, parents or school personnel can request an evaluation by the special education team to determine eligibility and the need for these services.
Section 504 plans may also benefit some students with ADHD. Federal law mandates these plans for individuals with a physical or mental impairment that interferes with a major life activity, such as learning. A 504 plan for a student with ADHD might provide extra time (or no time limits) during testing or testing in a quiet space to compensate for distractibility. Again, if learning or behavior problems interfere with the school progress of a child with ADHD, parents or school personnel can request that the school provide a Section 504 evaluation.
Throughout the course of an academic year, principals must deal with many issues that affect the lives of students. The more that principals know about the unique characteristics of different populations, the better they will be prepared to provide an environment that serves all students. Principals should work with school nurses, school psychologists, and the special education staff to gather additional information about ADHD.
Wilens, T. E., Faraone, S. V., Biederman, J., & Gunawardene, S. (2003). Does stimulant therapy of Attention Deficit/Hyperactivity Disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 11(1), 179-185.
* ADHD in the schools: Assessment and intervention strategies (2nd ed.). G. DuPaul & G. Stoner, 2003. New York: Guilford.
* Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). R. Barkley. 1998. New York: Guilford.
* Behaviorally effective school environments. M. Shinn, H. Walker, & G. Stoner (Eds.). 2002. Bethesda, MD: National Association of School Psychologists.
* An ADHD Primer. L Weyandt. 2001. Boston: Pearson, Allyn, and Bacon.
* Efficacy of a school-based treatment program for middle school youth with ADHD. S. Evans, J. Axelrod, & J. Langberg. 2004. Behavior Modification, 28, 528-547.
* Helping the Student With ADHD in the Classroom. Bethesda, MD: National Association of School Psychologists. Retrieved July 15, 2004q, at www .naspcenter.org/pdf/special%20needs%20template.pdf
* Homework success for children with ADHD: A family-school intervention program. T. Power, J. Karustis, & D. Habboushe. 2001. New York: Guilford.
* Taking charge of ADHD: The complete, authoritative guide for parents (rev, ed.). R. Barkley. 2000. New York: Guilford.
Challenging Horizons, http://chprogram.jrnu.edu
National Resource Center on ADHD, www.help4adhd.org.
George J. DuPaul, a professor in and coordinator of the school psychology program at Le high University in Bethlehem, PA, is involved in empirical studies of school-based interventions for students with ADHD and related disorders. George P. White, a former middle level principal and school superintendent, is a professor and the coordinator of the educational leadership program at Lehigh University. He has developed a program to prepare future principals to lead legally defensible inclusive learning environments for all students.
Copyright National Association of Secondary School Principals Oct 2004
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