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Principal Leadership Magazine, Vol. 5, Number 2, October 2004
Counseling 101 Column
An ADHD Primer
A combination of medication and behavioral interventions
tends to yield the greatest improvement in social skills and school performance
for students with ADHD.
By George J. DuPaul and George P. White
Topics: ADD/ADHD |
George J. DuPaul, a professor
in and coordinator of the school psychology program at Lehigh 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.
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.
Possible Causes
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 neurotransmitters, as well as the size
and operation of specific brain components such as the prefrontal cortex.
Further, other biological factors such as pregnancy 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.
Characteristics
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.
School Inspections
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.
Effective Interventions
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, Metadate), 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.
Accommodations
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 social-emotional 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.
Summary
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. PL
Reference
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 Case Study
Barry, a 12-year-old seventh-grader, was diagnosed with ADHD-Combined Type
when he was in the second grade and experienced chronic difficulties with
inattentive, impulsive, and highly active behavior throughout most of his
school career. Since elementary school, Barry received a psychostimulant medication, methylphenidate, to reduce his
ADHD symptoms. Although this treatment was effective in helping Barry control
his attention and behavior in the classroom, he continued to have problems
organizing his materials, keeping track of assignments, and being prepared
for class.
His middle school team met with the school psychologist and guidance counselor
to discuss how to help Barry with his organizational skills. They decided
to use a self-monitoring strategy that would help Barry track his class preparation
activities (e.g., being in his seat when class began, stopping other activities
when class instruction started, having pen or pencil on his desk, having
a notebook or textbook available and open, and completing homework). A checklist
of these behaviors was created for this purpose. The school psychologist
met with Barry before school on three occasions to help him with organizational
skills, train him to use the self-monitoring procedures, and provide him
with an opportunity to practice the specific skills. As part of the training,
Barry was taught to set goals with respect to being prepared for class and
to evaluate how well he met these goals on a daily basis.
When training was complete, Barry first used the self-monitoring strategy
in the subject area he had the most difficulty with: English. For the two
weeks before beginning to use the self-monitoring strategy, Barry’s English
teacher indicated that he had successfully completed about 53% of the required
class preparation behaviors. After the second day of self-monitoring training,
Barry increased his completion rate to 75%. Within a few days of using this
strategy, Barry met 100% of the expected behaviors. Barry’s other team teachers
helped him use these skills in all of his classes. Given his consistent performance,
the school team decided to phase out the self-monitoring checklist with the
expectation that Barry would continue to monitor his behavior on a less formal
basis. Barry remained relatively consistent in being prepared for his classes
for the remainder of the year.
This case study demonstrates the effectiveness of combining a medical intervention,
which for Barry was methylphenidate, with a classroom-based strategy, such
as self-monitoring, to treat students with ADHD. One important element in
Barry’s success was the unified and consistent support of his entire team
of teachers. Because ADHD is a chronic disorder, it should be assumed that
students like Barry will require a combination of interventions throughout
their school years.
Identifying Students With ADHD
Students should be evaluated for possible ADHD if they exhibit chronic (for
more than six months) problems with inattention, impulsivity, or excessive
physical activity.
No single test, questionnaire, or source of information (parent, teacher,
or student) is sufficient for the accurate diagnosis of ADHD. Current best
practice in evaluating students for ADHD requires the use of multiple assessment
methods and sources of information that include diagnostic interviews with
parents, teachers, and students; behavior rating scales that are completed
by parents and teachers; and data (e.g., report card grades and test scores)
that indicate whether a student is impaired by ADHD symptoms.
- Psychologists
or physicians conducting ADHD assessments must ensure that diagnostic decisions
are made based on DSM-IV criteria and should also consider alternative hypotheses
for a student’s inattentive, impulsive, and hyperactive behavior (e.g., symptoms
caused by other learning, behavioral, or emotional disorders).
- The
diagnostic decision must take into account all relevant information from
the student’s school, home, and community sources. The diagnosis should never
be made without input from both parents and teachers.
- The
evaluation should not end with the diagnosis but rather should lead to the
design of effective interventions. This type of assessment considers environmental
factors that trigger and reinforce specific behaviors.
- Assessment
information should be collected periodically to determine whether interventions
are working and whether changes in treatment are necessary.
Strategies for Students With ADHD
The most effective strategies for promoting school success in students with
ADHD include both proactive strategies—procedures that are implemented before
the student becomes disruptive or experiences failure—and reactive approaches—procedures
that are used after a student exhibits a specific behavior.
- The
most effective reactive procedure is a written behavioral contract that specifies
what the student is expected to do (i.e., responsibilities) and what the
student will get if responsibilities are met (i.e., privileges at home or
school).
- Whenever
possible, students with ADHD should be taught to monitor and evaluate their
own behavior, particularly if they have been successful with more intrusive
interventions, such as medication or behavioral contracts.
- Classroom
interventions for students with ADHD are most effective when implemented
in schools that employ schoolwide behavior support
plans for all students.
- Instruction
in effective ways to take notes, study for tests, and complete homework should
be provided either during or after school.
- Students
with ADHD typically do not understand the connection between their school
performance and their long-term futures. In-school group sessions coordinated
by a school counselor or a school psychologist can help students understand
their aptitudes and interests, develop long-term goals, and appreciate the
importance that school success will have in meeting their long-term goals.
ADHD Resources
Print:
- 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, 2004,
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.
Internet: