School-Based Interventions for Students with ADHD

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Preventative and efficacious intervention services are warranted for those children who, because of deficiencies associated with the symptoms of ADHD, are at risk of school failure and increased potential for the development of more severe behavior problems. Effective interventions are those interventions that are not specific to the diagnosis, per se, but to the individual needs of the child (DuPaul, Eckert, & McGooey, 1997; DuPaul & Ervin, 1996). More specifically, effective interventions are developed through careful assessments that are functional in nature and lead to the selection of intervention strategies that are proactive and closely monitored for their success. Unfortunately, current practice does not always mirror empirically derived best practices, and this also is true for intervention services for students with ADHD.

Educational assessment and intervention services employed for students with ADHD typically include traditional special education, pharmacological interventions (e.g., methylphenidate), and/or behavioral interventions (e.g., time-out) (Reid, Maag, Vasa, & Wright, 1994). In this article, we will describe the current status of school-based service delivery practices for students with ADHD, highlighting the need for a more proactive and preventative model. Next, we will present an alternative model.

Current Practices

Researchers have pointed to a general lack of information regarding "the type of services students with ADHD are receiving, the extent to which these students are identified under existing handicapping categories, and the type of placement or educational treatments they receive" (Reid, Maag, & Vasa, 1994, p. 118). In part, this is due to the fact that children with ADHD are a heterogeneous population in need of an individualized approach to treatment (DuPaul & Ervin, 1996; DuPaul et al., 1997).

According to the 1999 Rules and Regulations regarding the 1997 amendments to the Individuals with Disabilities Act (IDEA), students with ADHD may qualify for special education services under existing categories. Alternatively, these students may qualify for services through the requirements of section 504 of the Rehabilitation Act of 1973 (Section 504) and its implementing regulation in 34 CFR Part 104. It is important to note, however, that "no child is eligible for services under the Act merely because the child is identified as being in a particular disability category. Children identified as ADD/ADHD are no different, and are eligible for services only if they meet the criteria of one of the disability categories, and because of their impairment, need special education and related services" (Federal Register, 1999, Part II, p. 12543). A student is eligible for services under IDEA or Section 504 solely on the fact their disability results in an educational impairment that entitles them to those services and not on the basis of the diagnosis alone. Despite over a decade of debating the merit of including ADHD as a separate disability category, the 1997 amendments to IDEA upheld the position that children with ADHD, like other children, are eligible for special education services only under existing categories. For example, students with ADHD qualify under the category of "other health impairment" (OHI) when the presence of ADHD adversely affects academic performance.

Studies indicate that students with ADHD are referred for special education at high rates, with 50% (range, 44.8%–66.8%) eligible and receiving special education services (e.g., Bohline, 1985; Sandoval & Lambert, 1984–85). In one survey, Reid and colleagues (1994) obtained specific demographic information and examined the presence of other disabilities, type of placements and related services, academic achievement, and interventions employed for students with ADHD. Reid et al. (1994) reported that in one school district serving 14,229 students, 136 students were clinically diagnosed with ADHD, and 57% (n = 77) of those diagnosed were receiving special education services. When students who were not identified under IDEA were considered, the vast majority of students with ADHD spent most if not all of their time in general education classrooms. These statistics mirror the current practices of inclusion in which over 80% of students served through IDEA spend time in general education settings (U.S. Department of Education, 1990). Thus, general education teachers must know how to assist the needs of students with ADHD effectively in inclusive settings. Unfortunately, teachers reported they lacked the knowledge and skills to do so (Reid et al., 1994).

When approaches to interventions were considered, 90% of students with ADHD (including 47% who were not receiving special education services through IDEA) were medicated (Reid et al., 1994). Of those medicated, 94.3% received at least one dosage at school, yet, according to reports from school nurses, in 50.9% of these cases there was no physician contact regarding monitoring. These findings are not surprising given recently reported findings from regional and national databases that indicate "on average, there has been a 2.5-fold increase in the prevalence of methylphenidate treatment of youth with ADD between 1990 and 1995" and, "in all, approximately 2.8% (or 1.5 million) of U.S. youths aged 5 to 18 were receiving this medication in mid-1995" (Safer et al., 1996, p. 1084).

According to the empirical literature, both pharmacological (e.g., stimulant medication) and behavioral interventions (e.g., contingency management, token reinforcement, response cost, etc.) have been found to reduce symptoms of ADHD while enhancing behavior control and academic performance for a majority of children (Barkley, 1998; DuPaul & Eckert, 1997; MTA Cooperative Group, 1999a). However, individual differences in response to various treatments and/or their combinations or potencies have been noted (Whalen & Henker, 1991). Furthermore, the degree to which comorbid disorders/disabilities are present may impact the success of interventions and warrant multimodal approaches to treatment (Barkley, 1998). In these cases, the need for classroom intervention is markedly increased. According to a recent, large-scale, 14-month, comparative study conducted by a national consortium of researchers, "medication management, alone or combined with intensive behavioral treatment, was superior to behavioral treatment and community care in reducing ADHD symptoms; but only combined treatment showed consistently greater benefit than community care across other outcome domains (disruptive and internalizing symptoms, achievement, parent-child relations, and social skills)" (MTA Cooperative Group, 1999b, p. 1088). According to the MTA Cooperative Group (1999b), "conclusions suggest the relative strength of medication-based interventions across 14 months of treatment for ADHD-related symptoms and the modest superiority of combined treatment for both oppositional/aggressive symptoms and specific functional domains" .