Factors affecting school-aged children with attention deficit hyperactivity disorder include clinically significant impairment in social, academic, or occupational functioning.

 Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed psychiatric condition in children, affecting between 3% and 5% of school-age children, or at least 2 million children. Boys are four to nine times more likely to be diagnosed than girls.1

There is a great deal of debate about the true incidence, diagnosis, and proper treatment of ADHD. During the 1990s, there was a several-fold increase in the number of stimulant prescriptions for children.2 Experts have posed a chicken-and-egg question: are there more prescriptions because diagnostic tools are improved and there is greater awareness of the problem, or do adults have less patience with children who are active and more demanding today compared with 20 years ago? A Web site developed by school nurses who have worked with children diagnosed with ADHD3 provides a critique of the current diagnostic criteria and discusses concerns about labeling children with the ADHD diagnosis and medicating them to change their behavior.

Another confounding factor is the similar characteristics of children with ADHD and gifted students who are bored with the level of instruction.

In mid 2000, the American Academy of Pediatrics (AAP) published a clinical practice guideline for the diagnosis and evaluation of the child with ADHD.2 This guideline supports use of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 1994) to ensure a more accurate diagnosis and to decrease variations in how the diagnosis is made. The DSM-IV criteria call for the following:

  • Either six or more symptoms of inattention that have persisted for at least 6 months, are maladaptive and inconsistent with developmen- tal level, and/or
  • Six or more of hyperactivity- impulsivity that have persisted for at least 6 months, as above
  • Impairment from symptoms is present in more than one setting; for example, not only at school
  • Clinically significant impairment in social, academic, or occupa- tional functioning
  • Behavior cannot be attributed to another disease such as a mood disorder, anxiety, or personality disorder1,2

The health care provider evaluating the child to make an ADHD diagnosis must rely on reports from parents, caregivers, and teachers since even a 30-minute office visit rarely offers an opportunity to assess the child’s behaviors.2 This in itself can result in cyclical collection of purely subjective data from one person: the teacher; 40% of the time, the teacher tells the parent a medical referral is needed to evaluate classroom behavior problems.4 Thus, the responsible parent takes the child to the health care provider, who then, according to the AAP, needs to gather evidence from the child’s teacher.2 The teacher has the potential to have a great influence on the child’s diagnosis, but research shows that teachers are not necessarily knowledgeable about ADHD and the variety of treatment options.4

It is essential that while a diagnosis of ADHD is being considered, other potential causes of behavioral changes are also explored. Childhood sleep disorders such as sleep-disordered breathing and restless legs syndrome can interrupt sleep, resulting in daytime behaviors of sleep deprivation that mimic ADHD. Interestingly, habitual snoring is present in 33% of children with ADHD compared with 9% to 11% of other children.5 Psychiatric conditions may also coexist with ADHD.

Public School Classrooms Today
Children who are easily distracted and do not pay attention to detail, fidget or squirm when required to sit at a desk for periods of time, or cannot seem to keep their mouths shut to “work quietly” will have trouble in a traditional classroom setting. Teacher-driven referrals are triggered when students do not follow classroom rules or complete required tasks and are considered disruptive to other students.1

There are tremendous pressures in classrooms nationwide today. The No Child Left Behind Act (NCLB) requires public schools to be publicly accountable for student performance. This mandate has translated into standardized testing, resulting in pressure on students to do well on these achievement tests. NCLB requires that all public elementary and secondary school students must be held to the same challenging academic content and achievement standards. “Out-of-level testing,” which has traditionally been used for students with special needs such as ADHD who take standardized tests for a grade level below the grade to which they are assigned, is no longer an acceptable means for meeting the assessment or accountability requirements of NCLB. All students with special needs should be provided with accommodations so they can be held to the same standards for content and achievement as all other students in the grade in which the special needs student is enrolled.6

Standardized test results are made public, and schools that fail to meet “Adequate Yearly Progress” criteria are sanctioned. Each state determines its own approach to a school improvement plan and corrective actions. Not only do these reports affect the climate in the classroom, in which many teachers now feel as if they have to “teach to the test,” but the scores have an impact on the community at large because school quality affects property values.1,7,8 Given this educational climate, it is no wonder that teachers are less able to deal with disruptive students in the classroom, and students who feel stressed are more likely to act out.

What the Law Says About Meeting the Needs of Students with ADHD

There are two federal mandates that address services provided to children with special needs. The Individuals with Disabilities Education Act (IDEA) may or may not cover a particular child’s ADHD under the category of “other health impairment”; an individualized, comprehensive assessment of each child must be done. If a child is eligible under IDEA, an individualized education program (IEP) is developed that includes goals, benchmarks, objectives, and interventions to meet the student’s needs.

Section 504 of the Rehabilitation Act of 1973 has different criteria—a student with ADHD who does not meet the IDEA criteria may be eligible for services under Section 504 and vice versa. Section 504 was established to ensure a “free appropriate education” for all children with a physical or mental impairment that “substantially limits one or more major life activities” (US Department of Education, 2003). Parents and school districts may have very different ideas about a child’s behavior, whether a problem exists, and whether a child should be placed into a special educational program. Parents have the right to challenge a school’s decision that a child is not eligible for either of these programs and there are many parent advocacy groups established to help parents through this process.

Pharmacotherapy for ADHD
The mainstay of drug therapy has been methylphenidate or other stimulants that block the reuptake of dopamine, which have been described as effective for 75% to 90% of children with ADHD. The most powerful effects are improved attention and reduced physical hyperactivity and impulsivity.9 A newer drug, atomoxetine, is not a stimulant nor is it a controlled substance. It is a selective norepinephrine reuptake inhibitor. Atomoxetine is more effective than placebo in clinical studies for treating ADHD, but is not significantly superior to methylphenidate. American Family Physician’s regular feature STEPS, covering the safety, tolerability, effectiveness, price, and simplicity of featured drugs, recommends that atomoxetine be considered only as an alternative for patients who have not responded to methylphenidate.10

While studies show behavioral improvement with medication, there is no clear evidence that pharmacotherapy improves academic achievement. Research has shown improvement in academic measures such as completing more work assignments and being more accurate in assigned work, but not on academic achievement tests.4

Behavioral Management
Snider et al4 surveyed teachers to determine what interventions were most commonly used with students with ADHD. These include communicating with parents through parent-teacher conferences (87%); notes or phone calls to the home (82%); daily reports on the child’s behavior (75%); and consequences for misbehavior (78%).

Note that none of these provide positive reinforcement for children when they are successful, nor are individualized interventions described. The AAP9 describes four effective behavioral techniques that provide rewards for appropriate behavior and consequences for inappropriate behavior. It is important to remember that ADHD has little to do with children’s innate intelligence; it is a behavioral description.

Positive reinforcement provides rewards or privileges when children behave appropriately. To be meaningful, the reward should be individualized to the child.

Time-out removes children from a situation in which inappropriate behavior occurs and puts them in a location without positive reinforcement. Sending children to their rooms is not usually an effective location for this technique because most children can find enjoyable things to do in their room. The goal is to teach children that the consequences for misbehaving are to be removed from activities they enjoy.

Response cost withdraws rewards or privileges as a consequence when children misbehave. If they are told that the privilege, such as using the computer or watching television, will be withheld, consistent follow-through is essential for success no matter how much the children protest.

Token economy is a system by which positive behavior earns tokens, and negative behavior takes tokens away. Tokens can be as simple as stars on a white board, stamps on a sheet, or checkers. This method is particularly effective for bright children, as they learn the “value” of appropriate behavior in this token economy. Children can trade tokens for rewards after a given period of time. In the beginning, the reward may occur at the end of a day, and as they progress, the reward may be offered at the end of a week.

Establishing a regular routine is also important. Place a big clock in the child’s room and design charts for chores and tasks on which a mark or sticker can be placed for tangible evidence of successful completion. Display the chart prominently, such as on the refrigerator door.

When giving verbal instructions, be sure you have the children’s attention first, and ask them to repeat the instructions so you can clarify any misunderstandings.

For each behavioral approach to have a chance at success, it must be used consistently everywhere the child goes. That means the parents and teacher must communicate openly so that there is no confusion about the school behavior rules and the home behavior rules, particularly when starting this type of intervention.

Tips for the Classroom
Managing a classroom with one or more child with ADHD is extremely challenging. Before a formal diagnosis is made, children with ADHD are at least as frustrated as the adults who are trying to deal with them. They have been told they have been bad, and what they do is wrong. An important first step is to change the language from the black and white, positive and negative, to a less judgmental approach of whether behavior is appropriate or inappropriate. Next, recognize what is unique about a particular child with ADHD. Ask what helps them calm down and focus on a task. If children are easily distracted, their seat should be away from windows, which can provide a multitude of distractions outdoors. Keep the classroom door closed if possible to reduce the temptation to watch who may be walking by in the hall. If they are particularly kinesthetic, provide tools and activities that can keep their hands busy, such as a small bean bag or exercise ball they can squeeze in their hands. Provide an opportunity for physical activity at regular intervals; particularly with younger children who may or may not have ADHD, it is unrealistic to expect that they can sit still at their desks for long periods of time.

Begin with the most complex concepts early in the day when children are likely to be most fresh and less distracted. Break large tasks into smaller pieces. Provide instructions for one activity or assignment at a time, and make eye contact with students whose attention is likely to wander. Remember that children with ADHD may need to hear things more than once, not because of a lack of intelligence, but because of an inability to focus.

Have fun, be creative, and use games as an instructional tool. Games that allow children to get up and move around help dissipate the energy that causes the squirming and continuous motion that is often seen in children with ADHD.11,12

Perhaps most important, look for the moments in school and at home when the child is a star and can be showered with genuine positive feedback. Children with ADHD may try your patience and make getting through a normal day challenging. The frustration that occurs can be a filter through which you cannot see the special talents and gifts the child has. Working to see them will make it easier to see the child behind the ADHD diagnosis, and improve self-esteem that will help him achieve success and be more happy and productive in school.

Patricia Carroll, RRT, RN, BC, CEN, MS, owns Educational Medical Consultants in Meriden, Conn, and is the health care coordinator for Shelter NOW in Meriden.

1. US Department of Education. Identifying and treating attention deficit hyperactivity disorder. A resource for school and home. August 2003. Washington, DC. Available at: http://www.ed.gov/officesosers/osep [NOT FOUND].
2. American Academy of Pediatrics Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder: Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170.
3. Webb JT, Latimer D. ADHD and children who are gifted. 1993. Available at: http://www.kidsource.com/kidsource/content/adhd_and_gifted.html. Accessed February 29, 2004.
4. Snider VE, Busch T, Arrowood L. Teacher knowledge of stimulant medication and ADHD. Remedial and Special Education. 2003;24:46-56.
5. Montgomery GL. ADHD and pediatrics. Sleep Review. 2002;3(3):58-61;65.
6. US Department of Education: Title I Directors’ Conference February 2003. Available at: http://www.ed.gov/admins/lead/account/standassess03/edlite-index.html. Accessed February 29, 2004.
7. Connecticut Voices for Children. Connecticut Kidslink, January 29, 2001. Available at: www.ctkidslink.org. Accessed February 29, 2004.
8. Superintendent’s Community Advisory Council. SCAC Minutes, January 13, 2004. Available at: http://www.fcps.k12.va.us/Superintendent/scac/min_011304.htm. Accessed February 29, 2004.
9. American Academy of Pediatrics Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108:1033-1044.
10. Lynch T. Atomoxetine for ADHD. Am Fam Physician. 2003;68:1827-1828.
11. Hallowell EM, Ratey JJ. Fifty tips on the classroom management of attention deficit disorder. 1992. Available at: http://www.hypos.ch/articles/hallowell_school.htm[NOT FOUND]. Accessed February 29, 2004.
12. US Department of State: Standards of learning tests in Virginia and the No Child Left Behind Act. Available at: http://www.state.gov/m/dghr/flo/rsrcs/pubs/19998.htm. Accessed February 29, 2004.