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ADHD Goes to School: Providing Teachers and Parents with Specific Management Strategies
by Russell A. Barkley, Ph.D., ABPP

4 CE Hours - $99

Last revised: 09/12/2015

Course content © copyright 2015 by Russell A. Barkley, Ph.D., ABPP All rights reserved.


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Learning Objectives

This is an intermediate-level course intended to provide mental health professionals with a variety of evidence-based methods for addressing school adjustment issues. After completing this course, mental health professionals will be able to:

The materials in this course are based on the book “Managing ADHD in School: The Best Evidence-Based Methods for Teachers” by R. A. Barkley (2016), published by PESI, Eau Claire, Wisc. The course contains the most accurate information available to the author at the time of writing. The scientific literature on ADHD grows daily, and new information may emerge that supersedes these course materials. This course will equip clinicians to be able to advise parents and teachers on the most effective methods for managing the symptoms of ADHD and associated impairments in children and teens with ADHD in school settings.

Outline

Introduction

Education is the most prevalent domain of impaired major life activities associated with ADHD in children and teens, with more than 90% of those affected having significant problems functioning effectively in this setting. School is also the most seriously impaired domain relative to all other domains such as family, peer, and community functioning. Mental Health professionals therefore are routinely called upon to advise families and educators on the most appropriate methods for managing ADHD related symptoms, behavioral problems, and academic performance difficulties in school settings.

What is ADHD? Just the Facts

This section provides a brief review of the symptoms, associated cognitive deficits, demographics, and etiology of Attention Deficit Hyperactivity Disorder (ADHD) as taken from other courses by Dr. Barkley (on this website). It is not intended as a substitute for the information in the other courses. Course participants are encouraged to take those other courses for more extensive knowledge about ADHD. The research supporting the information provided below can be found in other courses by Dr. Barkley as well as in the latest edition of his handbook on ADHD.2

ADHD is a neurodevelopmental condition that consists of developmental delays or deficiencies in at least two types of neuropsychological abilities. These two dimensions are inattention and hyperactive-impulsive symptoms.3 The disorder is classified as neuro-developmental because the scientific evidence for the substantial role of neurological and genetic causes in ADHD is now overwhelming and irrefutable (see Causes of ADHD below). ADHD is considered to be neuro-developmental because it is primarily the result of a delay or lag in the development of specific mental abilities. Those deficits are largely due to delays and/or dysfunctioning in the maturation of the brain areas that underlie those abilities. Such brain maldevelopment seems to arise largely from genetics but can also occur as a consequence of damage or other disruptive influences experienced by the child or teen at any time during development, most often during prenatal brain formation.

The symptoms of ADHD are dimensional in that they reflect the extreme end of a continuum of normal or typical human ability in these two areas. Therefore, children and teens with ADHD have a disorder that:

Symptoms of ADHD

The general nature of the symptoms most often evident in children and teens with ADHD include:

Inattention:

Hyperactivity-Impulsivity:

To warrant a diagnosis of ADHD, these symptoms must occur at least often, to a degree that is excessive for the child’s age. The child or teen has to have a majority of the symptoms (six or more) on either list. Several symptoms must have developed in childhood (before 12 years of age). These symptoms must have persisted for at least the past six months, must occur in two or more settings (home, school, work, community), and must lead to impaired functioning in major life activities, such as social (family, peers, community), academic, or occupational activities. Only a small percentage of children will meet all of these conditions, making those who do, more problematic than 92%-95% of the child or adolescent population in these respects.

Deficient Mental Abilities that Contribute to the Symptoms

I and many other clinical researchers conceptualize these symptoms as involving deficits in these mental abilities, often referred to as executive functions:4

If you noticed a recurring theme here, it is that ADHD interferes with thoughts, actions, words, motivations, and emotions aimed at organizing behavior across time and preparing for the future instead of just reacting to the moment. To act impulsively, fail to persist, and be distractible is to be nearsighted to the future – to be preoccupied by moments and so be blind to time. The aforementioned cognitive deficits will then disrupt the student’s executive functioning (EF) in daily school activities. Therefore, deficient executive functioning in daily life will be evident in problems with:

The vast majority of children and teens meeting research diagnostic criteria for ADHD fall in the bottom 7% of the population in each of these major areas of executive functioning in daily life.5 It is easy to see how such deficits would produce a myriad of difficulties with functioning in educational settings that typically place a premium on these EF abilities.

Demographic Facts about ADHD

Setting Factors that Influence ADHD Severity

Children and teens with ADHD may show significant fluctuations in the severity of their symptoms across diverse situations or settings. In general, symptoms of ADHD may often be worse in settings or tasks that:

All of these settings demand executive functioning and self-regulation. Of course, the symptoms of ADHD can improve in settings that involve factors that are the opposite of those above. Specifically, these best-case situations may involve fun activities, highly stimulating or interesting tasks (e.g., video games), lots of movement (e.g., gym, recess, sports), frequent rewards or feedback, highly supervised settings, working in small teams with peers rather than independently, working one-on-one with an adult, highly novel settings, where supervisors speak briefly but back up their rules with consequences, and where there is little or no pressure to wait for things.

Causes of ADHD

As discussed above, ADHD is known as a neurodevelopmental disorder. That is because its chief causes exist in the broad realms of genetics and neurology rather than in the domain of social causes.

Genetics. ADHD is a highly inherited disorder. For instance, if a parent has the diagnosis, their children are six to eight times more likely to have the disorder (35%-54%). If a child has ADHD, their biological brother or sister is three to five times more likely to have the condition (25%-35%). Their biological mother is three to four times more likely to have ADHD, and their biological father is five to six times more likely to have it. If an identical twin has ADHD, the other twin will be ADHD in 75%-90% of cases. All this clearly shows the genetic (heritable) nature of ADHD.

The degree to which individual differences in genes among people contributes to individual differences in their ADHD symptoms is 65%-80%. In other words, up to 80% of the differences among people in their degree of ADHD symptoms is due to differences in their genetic makeup. This is higher than the genetic contribution to temperament and personality traits, depression, anxiety, antisocial behavior, and even intelligence. It is only slightly less than the genetic contribution to variation among people in their height

Research currently suggests that there may be as many as 25 to 44 genes involved in causing ADHD. Note that these are not different kinds of genes from those seen in typical people. There is no specific disease gene or genes for ADHD such as may be seen in Tay Sachs or other severe neurological disorders. What is involved in ADHD are different versions of the same genes seen in typical people. For instance, children with ADHD may have a longer version of a gene than that seen in a typical child – this is often known as tandem repeats. For instance, typical children may get four or five copies of a certain gene side-by-side, while children with ADHD may have seven or more copies, thus creating a longer version of this gene. Such variations in gene length and repetition are called polymorphisms. The different version of the gene in cases of ADHD leads to different proteins and other chemicals, and those lead to different structural changes in the brain. And those differences create differences in the brain’s functioning – sometimes different enough to create ADHD.

This explanation does not mean that all 25 or more risk genes need to have atypical versions in order to create the disorder; only a subset could well cause it. It does mean that cases of ADHD will vary in which genes led to their particular case of the disorder. For instance, as a hypothetical example, it may be that just five to eight genes from among this pool are needed to be different so as to cause a case of ADHD to emerge. But which subset of this risk pool of ADHD genes that differs in any individual case may not be the same subset of genes that caused another case of the disorder. This further means that similar-appearing symptomatic cases of the disorder could still have different underlying genetics for their disorder. Those differences could lead to either subtle or even important differences in the nature of their disorder (some are more impulsive, others more inattentive), in the risks for other disorders (such as depression, learning disorders, smoking or other substance abuse), in the consequences from the disorder (driving impairments, criminal behavior), and even responsiveness to different ADHD medications or other treatments.
Understanding the genetics of ADHD also helps us to understand why ADHD may be more likely to be affiliated with some other psychiatric disorders, as they may share the same or similar underlying genes. Some of the risk genes for ADHD, for instance, have been found in reading disorders, autistic spectrum disorders, and bipolar disorder, while other genes are shared with oppositional defiant disorder, conduct disorder, and even nicotine dependence and alcoholism.
Because ADHD is a disorder that falls along a continuum or dimension, and because it is inherited, one can see signs of an ADHD phenotype within a family having the genetic form of the disorder. That is to say that parents and siblings of a child with ADHD may be more likely to manifest some milder forms of the symptoms or traits of the disorder even if they don’t meet all of the requirements for receiving a diagnosis of it. [Note: the same is true in autistic spectrum disorders, which are also strongly genetically influenced.]

While most cases of ADHD are genetic and involve inheritance of the genes contributing to ADHD from parent to child, new cases of ADHD can arise in a family due to genetic mutations in ADHD-risk genes that occur in the parent’s eggs or sperm. These mutations get passed along to the children, creating a new line of ADHD risk in the family even though the parents do not have the disorder or any elevated risk for it.

Neurology. Hundreds of research studies employing a variety of methods for measuring brain structure, functioning, development, and connectedness (networks) now support the conclusion that ADHD is largely a neurologically caused disorder. At least five to six brain regions are reliably linked to the disorder. These brain regions can be seen in Figure 1, below. They are the prefrontal cortex, the anterior cingulate cortex (at the midline of the frontal lobes), the frontal section of the corpus callosum (the splenium), the basal ganglia, and the cerebellum (mostly the central vermis region). Less certain is whether or not the thalamus is involved. Interestingly, evidence suggests that the right side of the brain in some or most of these regions may be somewhat more involved in creating ADHD than the left. But both sides of these regions appear to be involved in the disorder. In general, the brains of children and teens with ADHD are about 3%-10% smaller globally in gray matter (the material on the outside layer of the brain). But these five specific brain regions appear to be even smaller – about 15%-30% smaller than normal for age.

Figure 1. (A) Diagram of the human brain - regions involved in ADHD are the prefrontal cortex, anterior cingulate cortex, striatum, cerebellum, and corpus callosum (splenium or anterior aspect). (B) The dopamine system of the brain – a neurotransmitter system influenced by certain ADHD medications. (C) The norepinephrine system of the brain – a neurotransmitter system affected by other ADHD medications. From ehp.niehs.nih.gov

Developmental research finds the brain to be two to three years delayed in its development in these regions, especially the prefrontal lobes, and to be 10%-30% less active than in typical comparison cases. More recently, fine-grained neuro-imaging methods have revealed defective microstructures in the subcortical (white matter) neural networks that connect these brain regions to each other. These methods make the maturational deficiencies in ADHD even more obvious in the interconnectedness (networks) of these structures than was evident in studies of just surface gray matter. While the size of the entire brain may eventually become closer to normal with age, the connectedness and functioning of the neural networks is likely to remain deficient into adulthood for many cases, though not for all cases. There is no doubt now that ADHD is of neurologic origin, hence its classification as a neurodevelopmental disorder.

You can now understand why ADHD is both genetic and neurological. The genes involved in causing ADHD are genes that build and operate certain regions and networks in the brain during development. Different versions of genes involved in ADHD compared to typical people result in differences and even deficiencies in these structures and their functioning. ADHD is therefore a neuro-genetic disorder in many cases.

But ADHD can also arise from non-genetic sources, as shown in Figure 2 below. Most of these are conditions or factors that can potentially interfere with brain growth and functioning, especially in the ADHD-related brain regions mentioned above. For example, it is now known that when a mother smokes tobacco or drinks alcohol beyond a certain amount during her pregnancy, she increases the risk for ADHD in her unborn child two to three times greater than the typical risk (Fetal Alcohol Syndrome and Exposure, FASD in Figure 2). This is likely the result of these substances having a toxic effect on brain development. Other pregnancy complications may do much the same, abnormally altering brain development. These include conditions such as the number of maternal infections during pregnancy, delivery complications (Perinatal hazards in Figure 2), degree to which the baby was born substantially premature (Low Birth Weight, LBW in Figure 2), degree of severe stress to which the mother was exposed during pregnancy, extent of abuse of other drugs besides tobacco and alcohol during pregnancy, and other factors. A smaller percentage of ADHD cases may be due to brain injuries suffered after the child is born. This can include diseases, brain trauma, tumors, stroke, or even poisoning, such as with lead or pesticide exposure (Lead in Figure 2).

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Figure 2. Etiologies of ADHD

Most recently, some research shows that these environmental risk factors can interact with the ADHD risk genes discussed above to further heighten a child’s risk for ADHD. This is illustrated in Figure 3. For instance, if a mother passes one of the major ADHD risk genes to her child and she smokes during that pregnancy, the risk for ADHD in her child is magnified two to three times greater than would have been the case from either the risk gene or maternal smoking alone (evidence of a risk gene by environmental interaction). In summary, about 60%-70% of cases of ADHD are likely due to inheritance or genetic factors. Another 20%-25% arise from pregnancy complications that may adversely affect brain development or that interact with ADHD risk genes to do so. The remaining 5%-10% may arise from injuries to the brain sustained after birth.

Notice here that there is no compelling evidence that social factors, such as parenting or educational environment, have been found to cause ADHD. The degree of evidence against such explanations is now so compelling that no reputable scientist working in this field gives them any credence at this time. This does not mean that social factors are unimportant; just that they are not important in explaining the initial causes of ADHD. They are still important in determining how impaired someone with ADHD will be in specific situations. Social factors are also important in influencing what the risk to a child will be for other psychiatric disorders known to be due in part to these social factors (anxiety, depression, oppositional behavior, conduct disorder, etc.). And surely you will recognize that social environmental factors determine how much access to care children get for treating their ADHD, and the quality of that care, including in the school setting.

Figure 3: ADHD as a risk gateway from multiple prenatal and early developmental risk factors and amplifying risk for a wide range of outcomes related to cascading effects of poor self-control throughout life. From Nigg, J. T and Barkley, R. A. (2013); Attention deficit hyperactivity disorder; in E. J. Mash and R. A. Barkley (Eds.), Child Psychopathology (3rd ed.). New York: Guilford Press. Copyright 2013 by Guilford Press. Reprinted with permission.

Research has now ruled out the likelihood that dietary substances such as sugar or food preservatives and additives cause ADHD. However, some children may be sensitive to food colorings enough to induce or mildly worsen their ADHD symptoms but such effects are found in a minority of children and often when they are preschoolers, not when they are teens or adults. Anti-oxidants have not been found to be linked to ADHD and thus taking food supplements that increase them in the body seem unlikely at this time to benefit children with ADHD. Iron deficiencies have been found in some studies in children with ADHD but this finding is not reliable across studies and it is not clear that iron supplements would be helpful for management of the disorder in these cases. ADHD does not arise from watching TV excessively, using computers too frequently, or playing video games. Although the degree of TV viewing in the early preschool years was correlated to a small degree with inattention in some studies, other studies completely failed to replicate that finding. And the direction of causation is also unclear here. We know that children with ADHD like to watch TV more than typical children so ADHD could be leading to more TV viewing. The disorder is certainly associated with increased use of the Internet or video games, but these don’t cause ADHD, rather ADHD predisposes children to excessive electronic media use. For instance, children with short attention spans would rather play a fast-paced exciting video game than read for pleasure; they would rather watch TV than exercise; they would rather use the Internet or social media on their smartphones to socialize with others, even strangers, than interact in person with neighborhood or school-based peers.

As you can see from the above review, ADHD is a neurodevelopmental disorder of attention, inhibition, and executive functioning that largely arises from neurological and genetic origins.

General Principles for Managing the Executive Function (EF) Deficits in ADHD

As noted above, children and teens with ADHD have serious deficits in their executive functioning and self-regulation. In dealing with these deficits, there are several basic principles that must be kept in mind in constructing specific interventions for the educational problems of these individuals. Here are the principles that underlie the effective management of ADHD-related EF deficits in the schools.7

Externalize Information

If the process of regulating behavior via internally represented forms of information (e.g. working memory or the internalization of self-directed behavior) is impaired or delayed in those with ADHD and EF deficits, then those students will be best assisted by “externalizing” those forms of information. The provision of physical representations of such information will be needed within the school setting at the point of performance. Since covert or private information is weak as a source of stimulus control, making that information overt and public may assist with the strengthening of control of behavior via that information. Make the information physical and place the physically represented information outside of the child just as it was in earlier development. Internal forms of information generated by the executive system, if they have been generated at all, appear to be extraordinarily weak in their ability to control and sustain behavior toward the future in those with EF deficits. That behavior remains largely under the control of the salient aspects of the immediate context. So, make the information external again.

The solution to this problem is not to nag those with ADHD-related EF difficulties to simply try harder or remember what they are supposed to be working on or toward. Instead, the solution is to fill the immediate context with physical cues comparable to the internal counterparts that are proving ineffective. In a sense, clinicians treating those with EF deficits must beat the environment at its own game. Whenever possible, minimize sources of high-appealing distractors that may subvert, distort, or disrupt task-directed mentally represented information and the behavior it is guiding. In their place should be cues, prompts, and other forms of information that are just as salient and appealing, yet are directly associated with or are an inherent part of the task to be accomplished. Such externalized information serves to cue the individual to do what they know.

If the rules that are understood to be operative during educational or occupational activities, for instance, do not seem to be controlling the child‘s behavior, they should be externalized. They can be externalized by posting signs about the school environment and its rules and having the student frequently refer to them. Having the student verbally self-state these rules aloud before and during individual work performances may also be helpful. One can also record these reminders on a digital recorder that the student listens to through an earphone while working.

Externally Represent or Remove Gaps in Time

Figure 4. Time Escapes ADHD Children

The organization of an individual’s behavior both within and across time is one of the ultimate disabilities rendered by ADHD. EF deficits create problems with time, timing, and timeliness of behavior such that they are to time what nearsightedness is to spatial vision. They create a temporal myopia in which the individual’s behavior is governed even more than normal by events close to or within the temporal now and the immediate context rather than by internal information that pertains to longer term, future events. This helps us to understand why students with EF deficits make the decisions they do, short-sighted as they seem to be to others around them. If one has little regard for future events, then much of one’s behavior will be aimed at maximizing the immediate rewards and escaping from immediate hardships or aversive circumstances, without concern for the delayed consequences of those actions. Those with deficient EF could be assisted by making time itself more externally represented, by reducing or eliminating gaps in time among the components of a behavioral contingency (event, response, outcome). Caregivers and others can also help to bridge such temporal gaps related to future events.

Another solution is to reduce or eliminate the problematic time-related elements of a task when feasible. The elements should be made more contiguous. Rather than telling the child that a project must be done over the next few days, week, or month, assist her with doing a step a day toward that eventual goal so that when the deadline arrives, the work has been done, but done in small daily work periods with immediate feedback and incentives for doing so.

Externalize Motivation

The EF theory of ADHD also hypothesizes that a deficit will exist in the internally generated and represented forms of motivation needed to drive goal-directed behavior. Complaining to these children about their lack of motivation (laziness), drive, will power, or self-discipline will not suffice to correct the problem. Pulling back from assisting them to let the natural consequences occur, as if this will teach them a lesson that will correct their behavior, is likewise a recipe for disaster. Instead, artificial means of creating external sources of motivation must be arranged at the point of performance in the context in which the work or behavior is desired.

For instance, the provision of artificial rewards, such as tokens, may be needed throughout the performance of a task or other goal-directed behavior when there is little or no immediate consequences associated with that performance. Such artificial reward programs become for the person with ADHD-related EF deficits what prosthetic devices are to the physically disabled, allowing them to perform more effectively in some tasks and settings with which they otherwise would have considerable difficulty. The motivational disability created by EF deficits makes such motivational prostheses essential for most children deficient in EF.

The methods of behavior modification are particularly well suited to achieving these ends. Many techniques exist within this form of treatment that can be applied to children with ADHD related EF deficits. What first needs to be recognized is that (1) internalized, self-generated forms of motivation are weak at initiating and sustaining goal-directed behavior; (2) externalized sources of motivation, often artificial, must be arranged within the context at the point of performance; and (3) these compensatory, prosthetic forms of motivation must be sustained for long periods. If the external motivation is removed, the behavior will not be further sustained and the individual will regress to more erratic goal-directed behavior with less ability to sustain actions toward tasks and goals.

In general, there are two reasons to do behavior management for anyone: for informational training and for motivational sustaining. The former is done for individuals who have not yet acquired a skill. Once the skill is taught through behavioral or other pedagogical methods, those methods can be withdrawn and the behavior sustained presumably by contact with the natural contingencies. But in EF disorders such as ADHD, the issue is not ignorance or lack of knowledge of a skill; the problems are with the skill’s timing and execution at key points of performance and with the self-motivation needed to sustain the performance. Behavioral treatments can provide the motivational or behavior-sustaining assistance needed. Removing the external motivation after improvement in task performance will result in a loss of motivation and a return to the baseline state of limited self-motivation and an inability to sustain actions toward goals.

By equating EF with self-regulation (SR), and by viewing the SR of emotion as described by Gross as but a specific form of a more generalized process of SR, the EF theory of ADHD illustrates at least five vectors through which EF/SR can influence goal-directed activities:

In attempting to assist students in rehabilitating or at least compensating for their EF deficits, these five vectors offer opportunities in which clinicians can strive to improve such deficits. While this can be done by directly working with the student, it is likely to be greatly assisted by advising caregivers to assist the individual with these five pathways of SR. Modifying the “point of performance,” as further discussed below, readily fits into the situation modification vector of SR. Various cognitive behavioral therapies may prove useful at the re-appraisal pathway. The point here is not to map out all possible ways by which these five vectors of SR could be used to boost EF in those with EF deficits, but to make clinicians cognizant that such pathways are available.

Related to this idea of motivational deficits accompanying EF disorders such as ADHD is the literature on self-regulatory strength and the resource pool of effort (will power) associated with activities of SR. There is abundant literature on this topic that has been overlooked by neuropsychologists studying EF, yet it has a direct bearing on EF given that EF is viewed as SR. As nicely summarized by Bauer and Baumeister (2011),8 research indicates that each implementation of EF (working memory, inhibition, planning, reasoning, problem-solving, etc.) depletes this limited resource pool temporarily such that protracted use of EF may greatly deplete the available pool of effort. This can result in students being less capable of SR (EF) in subsequent situations or in immediately succeeding time periods. They are thus more likely to experience problems or fail outright in their efforts at EF/SR and their resistance to immediate gratification. Such temporary depletions may be further exacerbated by stress, alcohol or other drug use, illness, or even low levels of blood glucose.

Research also indicates what factors may serve to more rapidly replenish the resource pool. These include:

Some research further suggests that the actual capacity of the resource pool may be boosted by routine physical exercise and by routine practicing of tasks involving self-regulation daily for two weeks.

Make Problem-Solving Manual

Children with ADHD cannot hold information in mind or manipulate mental information as well as other children. That means that mental problem-solving is difficult for them. To assist them, try to think of ways to make the problem, or parts of the problem, physical in various ways so that the child can manipulate the parts of the problem manually to facilitate mentally held information. For instance, if they have mental arithmetic to do, let them have some marbles, a number line, an abacus, or some other way to physically count and manipulate the information to help them solve the math problems. If the child has a written essay to do, encourage them to use 3x5 file cards and to write a different idea on each card as the ideas come to mind. Just have them think and free associate to the assigned topic. As each idea is stated, have them write it down on a separate card. Now the child can take these “idea cards” and reorganize them into a possible essay on that topic. I am sure you can think of other ways to do this for a child or teen with ADHD. Remember, it’s not the method, but the principle that should be emphasized here: make solving problems manual work and not just mental work.

Intervene at the Point of Performance in Natural Settings

Given the above principles, clinicians should likely reject most approaches to intervention for students with ADHD related EF deficits that do not involve helping them with an active intervention at the point of performance. Once-per-week tutoring is unlikely to succeed with the student with deficient EF without efforts to insert accommodations at key points of performance in natural settings to address the impaired domains of educational activities. This is not to say that extensive training or retraining of EF, as with working memory training, may not have some short-term benefits. Such practice has been shown to increase the likelihood of using working memory and of boosting the SR resource pool capacity in normal individuals, at least temporarily (Bauer & Baumeister, 2011).

Approach ADHD and its EF Deficits as a Chronic Condition

The foregoing review of the etiologies of ADHD lead to a much more general implication: The approach taken to its management must be the same as that taken in the management of other chronic medical or psychiatric disabilities. Diabetes is an analogous condition to many forms of EF deficits. At the time of diagnosis, all involved must realize that there is currently no cure for the condition. Still, multiple means of treatment can provide symptomatic relief from the deleterious effects of the condition, including taking daily doses of medication and changing settings, tasks, and lifestyles. Immediately following diagnosis, the clinician works to educate the patient and family on the nature of the chronic disorder, and then designs and implements a treatment package for the condition. This package must be maintained over long periods to maintain the symptomatic relief that the treatments initially achieve. Ideally, the treatment package, so maintained, will reduce or eliminate the secondary consequences of leaving the condition un­managed. However, each patient is different and so is each instance of the chronic condition being treated. As a result, symptom breakthroughs and crises are likely to occur periodically over the course of treatment that may demand re-intervention or the design and implementation of modified or entirely new treatment packages. Changes to the environment that may assist those with the disorder are not viewed as somehow correcting earlier faulty learning or leading to permanent improvements that can permit the treatments to be withdrawn. Instead, the more appropriate view of psychological treatment is one of designing a prosthetic educational environment that allows the student to better cope with and compensate for the disorder going forward. Behavioral and other technologies used to assist people with ADHD related EF deficits are akin to artificial limbs, hearing aids, wheel chairs, ramps, and other prostheses that reduce the handicapping impact of a disability and thus allow the individual greater access to and better performance of their major life activities. Those methods provide the additional social and cultural scaffolding around the student with EF deficits so that performance in that specific setting can be more effective.

10 Specific Principles for Managing ADHD

Based on the principles reviewed in the previous section for addressing EF deficits in children and teens with ADHD, one can develop 10 specific rules that need to be followed in setting up any program to address those deficits. They are:

  1. Rules and instructions provided to children with ADHD must be clear, brief, and often delivered through more visible and external modes of presentation than is required for the management of normal children. Stating directions clearly, having the child repeat them out loud, having the child utter them softly to themselves while following through on the instruction, and displaying sets of rules or rule-prompts (e.g. stop signs, big eyes, big ears for “stop, look, and listen” reminders) prominently throughout the classroom are essential to proper management of ADHD children. Relying on the child’s recollection of the rules as well as upon purely verbal reminders is often ineffective.
  2. Represent time and time periods externally (physically). Children with ADHD are less capable of using their sense of time to manage their current behavior and get work done in time, over time, and on time. When short time intervals of an hour or less are required to do work, then represent that time period using a clock, kitchen timer, counting device or other external means to show the child how much time they have left and how quickly it is passing. The large (1-ft.) clock at addwarehouse.com can serve this purpose. Or just use a spring-loaded kitchen cooking-timer placed on the child’s desk. For longer time periods, break the work down into shorter periods with smaller work quotas and allow the child to take frequent breaks between these shorter work periods.
  3. Consequences used to manage the behavior of ADHD children must be delivered swiftly and more immediately than is needed for normal children. Delays in consequences greatly degrade their efficacy for children with ADHD. As will be noted throughout this chapter, the timing and strategic application of consequences with children with ADHD must be more systematic and is far more crucial to their management than for normal children. This is not just true for rewards, but is especially so for punishment, which can be kept mild and still effective by delivering it as quickly upon the misbehavior as possible. Swift, not harsh, justice is the essence of effective punishment.
  4. Consequences must be delivered more frequently, not just more immediately, to children with ADHD in view of their motivational deficits. Behavioral tracking, or the ongoing adherence to rules after the rule has been stated and compliance initiated, appears to be problematic for children with ADHD. Frequent feedback or consequences for rule adherence seem helpful in maintaining appropriate degrees of tracking to rules over time.
  5. The type of consequences used with children with ADHD must often be of a higher magnitude, or more powerful, than that needed to manage the behavior of normal children. The relative insensitivity of children with ADHD to response consequences dictates that the methods chosen for inclusion in a behavior management program must have sufficient reinforcement value or magnitude to motivate children with ADHD to perform the desired behaviors. Suffice it to say, then, that mere occasional praise or reprimands are simply not enough to effectively manage children with ADHD.
  6. An appropriate and often richer degree of incentives must be provided within a setting or task to reinforce appropriate behavior before punishment can be implemented. This means that punishment must remain within a relative balance with rewards or it is unlikely to succeed. It is therefore imperative that powerful reinforcement programs be established first and instituted over one to two weeks before implementing punishment in order for the punishment, sparingly used, to be maximally effective. Often children with ADHD will not improve with the use of response cost or time out if the availability of reinforcement is low in the classroom and hence removal from it is unlikely to be punitive. “Positives before negatives” is the order of the day with children with ADHD. When punishment fails, this is the first area that clinicians, consultations, or educators should explore for problems before instituting higher magnitude or more frequent punishment programs.
  7. Those reinforcers or particular rewards which are employed must be changed or rotated more frequently with ADHD than normal children given the penchant of the former for more rapid habituation or satiation to response consequences, apparently rewards in particular. This means that even though a particular reinforcer seems to be effective for the moment in motivating child compliance, it is likely that it will lose its reinforcement value more rapidly than normal over time. Reward menus in classes, such as those used to back up token systems, must therefore be changed periodically, say every two to three weeks, to maintain the power of efficacy of the program in motivating appropriate child behavior. Failure to do so is likely to result in the loss of power of the reward program and the premature abandonment of token technologies based on the false assumption that they simply will not work any longer. Token systems can be maintained over an entire school year with minimal loss of power in the program provided that the reinforcers are changed frequently to accommodate this problem of habituation. Such rewards can be returned later to the program once they have been set aside for a while, often with the result that their reinforcement value appears to have been improved by their temporary absence or unavailability.
  8. Anticipation is the key with children with ADHD. This means that teachers must be more mindful of planning ahead in managing children with this disorder, particularly during phases of transition across activities or classes, to insure that the children are cognizant of any shift in rules (or consequences) that is about to occur. It is useful for teachers to take a moment to prompt a child to recall the rules of conduct in the upcoming situation, repeat them orally, and recall what the rewards and punishments will be in the impending situation before entering that activity or situation. Think ahead, think aloud is the important message to educators here. By themselves, such cognitive self-instructions are unlikely to be of lasting benefit, but when combined with contingency management procedures, they can be of considerable aid to the classroom management of ADHD children.
  9. Children with ADHD must be held more publicly accountable more often for their behavior and goal-attainment than normal children. The weaknesses in executive functioning associated with ADHD result in a child whose behavior is less regulated by internal information (mental representations) and less monitored via self-awareness than is the case in normal children. Addressing such weaknesses requires that the child with ADHD be provided with more external cues about performance demands at key points of performance in the school, be monitored more closely by teachers, and be provided with consequences more often across the school day for behavioral control and goal attainment than would be the case in normal children.
  10. Behavioral interventions, while successful, only work while they are being implemented and, even then, require continued monitoring and modification over time for maximal effectiveness. One common scenario is that a student responds initially to a well-tailored program, but then over time, the response deteriorates; in other cases, a behavioral program may fail to modify the behavior at all. This does not mean behavioral programs do not work. Rather, such difficulties signal that the program needs to be modified. It is likely that one of a number of common problems occurred (e.g., rewards lost their value, program was not implemented consistently, program was not based on a functional analysis of the factors related to the problem behavior).

Classroom Management: Basic Considerations

Consider the recommendations throughout the remainder of this book as you would a food buffet – choose from among these various methods those you find most suitable for the child or teen with ADHD you have in mind to help. I begin with some basic features of the classroom and teaching style that can help improve the school functioning of children and teens with ADHD. In reviewing these, keep in mind an important distinction between proactive and reactive teaching methods. Many suggestions below are examples of proactive teaching and behavior management. They are in contrast to the customary reactive approach many teachers take with ADHD students. Here, a change is made to a classroom situation or the curriculum or a plan is set up in advance of any problem occurrence. It is done in order to reduce the likelihood of such problems happening in upcoming situations. Proactive teaching also increases the probability that appropriate behavior and school performance are likely to occur. After reading, you will likely agree that proactive methods are superior to reactive methods in dealing with students with ADHD as the former actually reduces or even prevents the likelihood that a problem will arise in a situation. The latter only deals with it after it has occurred.

Peer Tutoring

Evidence clearly demonstrates that when students with ADHD work in dyads with their peers in order to learn new material, they are more likely to concentrate and to learn that material more quickly than if they just listen to a classroom lecture. This is known as peer tutoring.15 It essentially involves the following brief steps:

  1. Create, discuss and distribute scripts (work sheets based on the concept or skill you are teaching).
  2. Teach any new concepts and skills to class as you normally would.
  3. Provide initial instructions for the work that is to be done.
  4. Break the class up into dyads (pairs).
  5. Have one student in each dyad be the “tutor.” That student is to teach the other student in the pair what it was the teacher just taught in her lecture and what is contained on the worksheet. This student-tutor then quizzes their partner on the material.
  6. You should move around or circulate in the classroom during this time, supervising behavior, and coaching the dyads as needed.
  7. Be sure to alternate who plays the tutor/student roles in the dyad for the next task or assignment.
  8. Re-organize the class into new dyads daily or weekly so that the same children are not working together in the same pair for too long.
  9. Graph or post quiz results on a bulletin board at the front of the class.

Increasing Incentives and Rewards for Good Behavior and Performance in Your Classroom

As noted in previous sections, students with ADHD have far less self-motivation than do other students, meaning they will not be able to persist for as long as others in doing work for which there is no immediate reward or consequence. It was shown that to help make up for this intrinsic motivation deficit, teachers need to provide more “external’ or artificial consequences to students with ADHD when work is to be done. Here we present numerous ways to do this:

Figure 5. Attention Training System

Daily Behavior Report Cards and Behavior Contracts

Two of the most effective tools for helping to improve the behavior and school performance of children with ADHD are daily behavior report cards, also known as note-home cards, and behavior contracts. Both are additional methods of proactive teaching and behavior management first addressed above in Classroom Management: Basic Considerations.

Daily Behavior Report Cards

Any behavior recording system, or report card, must be set up according to certain rules if it is to be maximally effective.

  1. Daily goals must be stated in a positive manner.
  2. The card specifies both behavioral and academic goals.
  3. The targets are to be a small number of goals.
  4. The teacher provides quantitative feedback – usually a numerical rating or grade
  5. The feedback is provided at the end of each class period.
  6. There is to be regular daily communication with parents (the card goes home each school day for review by the parents).
  7. Consequences are established at home and are tied to the student’s school behavior and performance. Parents essentially set up a home token system in which a list of privileges is created and a point value or cost is assigned to each. The tokens or points earned from the daily report cards are to be spent for these privileges.
  8. Solicit parental cooperation before starting.
  9. Get student input into the goals especially with older children and teens.
  10. Review the card weekly for any necessary modifications.

The boxes below contain instructions that can be shared with parents about a daily behavior report card, how to implement it, and the kinds of cards teachers and parents can create for use with a student with ADHD.

 

Parent-teacher Handout for Using a Daily School Behavior Report Card

A daily school behavior report card involves having the teacher send home an evaluation of your child’s behavior in school that day, which can be used by you to give or take away rewards available at home. These cards have been shown to be effective in modifying a wide range of problems with children at school. Due to their convenience and cost effectiveness and the fact that they involve both the teacher(s) and parents, they are often one of the first interventions you should try if behavior problems at school are occurring with your child. The teacher reports can consist of either a note or a more formal report card. We recommend the use of a formal behavior report card like those shown at the end of this handout. The card should list the “target” behavior(s) that are to be the focus of the program on the left-hand side of the card. Across the top should be numbered columns that correspond to each class period at school. The teacher gives a number rating reflecting how well the child did for each of these behaviors for each class period. Some examples are provided at the end of this handout.

How the Daily Report Card Works

Using this system, teacher reports are typically sent home on a daily basis. As the child’s behavior improves, the daily reports can be reduced to twice weekly (Wednesdays and Fridays), once weekly, or even monthly, and finally phased out altogether. A variety of daily report cards may be developed and tailored for your child. Some of the behaviors targeted for the program may include both social conduct (shares, plays well with peers, follows rules) and academic performance (completes math or reading assignments). Targeting low academic performance (poor production of work) may be especially effective. Examples of behaviors to target include completing all (or a specified portion of) work, staying in the assigned seat, following teacher directions, and playing cooperatively with others. Negative behaviors (e.g., aggression, destruction, calling out) may also be included as target behaviors to be reduced by the program. In addition to targeting class performance, homework may be included. Children sometimes have difficulty remembering to bring homework assignments home. They may also complete their homework but forget to return the completed work to school the next day. Each of these areas may be targeted in a school behavior report card program.

It is recommended that the number of target behaviors you work on be kept to about four or five. Start out by focusing on just a few behaviors you wish to change, to help maximize your child’s success in the program. When these behaviors are going well, you can add a few more problem behaviors as targets for change. We recommend including at least one or two positive behaviors that the child is currently doing well with, so that the child will be able to earn some points during the beginning of the program.

Typically, children are monitored throughout the school day. However, to be successful with problem behaviors that occur very frequently, you may want to have the child initially rated for only a portion of the school day, such as for one or two subjects or classes. As the child’s behavior improves, the card can be expanded gradually to include more periods/subjects until the child is being monitored throughout the day. In cases where children attend several different classes taught by different teachers, the program may involve some or all of the teachers, depending on the need for help in each of the classes. When more than one teacher is included in the program, a single report card may include space for all teachers to rate the child. Alternatively, different report cards may be used for each class and organized in a notebook for children to carry between classes. Again, the card shown at the end of this handout can be helpful because it has columns that can be used to rate the child by the same teacher at the end of each subject, or by different teachers.

The success of the program depends on a clear, consistent method for translating the teacher’s reports into consequences at home. One advantage of school behavior report cards is that a wide variety of consequences can be used. At a minimum, praise and positive attention should be provided at home whenever a child does well that day at school, as shown on the report card. With many children, however, tangible rewards or token programs are often necessary. For example, a positive note home may translate into television time, a special snack, or a later bedtime. A token system may also be used in which a child earns points for positive behavior ratings and loses points for negative ratings. Both daily rewards (e.g., time with parent, special dessert, television time) and weekly rewards (e.g., movie, dinner at a restaurant, special outing) may be included in the program.

Advantages of the Daily Report Card

Overall, daily school behavior report cards can be as or even more effective than classroom-based behavior management programs, with effectiveness increased when combined with classroom-based programs. Daily reports seem particularly well suited for children because the children often benefit from the more frequent feedback than is usually provided at school. These programs also give parents more frequent feedback than would normally be provided by the child. As you know, most children, when asked how their school day went, give you a one-word answer, “Fine,” which may not be accurate. These report card programs also can remind parents when to reward a child’s behavior, and forewarn parents when behavior is becoming a problem at school and will require more intensive work. In addition, the type and quality of rewards available in the home are usually far more extensive than those available in the classroom, a factor that may be critical with children who need more powerful rewards.

Aside from these benefits, daily school report cards generally require much less time and effort from your child’s teacher than do classroom-based programs. As a result, teachers who have been unable to start a classroom management program may be far more likely to cooperate with a daily report card that comes from home.

Despite the impressive success of report card programs, the effectiveness of the program depends on the teacher accurately evaluating the child’s behavior. It also hinges on the fair and consistent use of consequences at home. In some cases, children may attempt to undercut the system by failing to bring home a report. They may forge a teacher’s signature or fail to get a certain teacher’s signature. To discourage these practices, missing notes or signatures should be treated the same way as a “bad” report (i.e., child fails to earn points or is fined by losing privileges or points). The child may even be grounded for the day (no privileges) for not bringing the card home.

Some Examples of Daily School Report Cards

Several types of school behavior report cards that rely on daily school behavior ratings will be discussed here. Two examples are provided at the end of this handout. These are the cards we recommend most parents use if they want to start a school behavior report card quickly. One card is for classroom behavior, the other is for recess behavior. Use whichever card is most appropriate for the problems your child is having at school. Two sets of each card are provided so that you can make photocopies of that page and then cut the page in half to make double the number of cards.

Notice that each card contains five areas of potential behavior problems that children may experience. For the class behavior report card, columns are provided for up to seven different teachers to rate the child in these areas of behavior or for one teacher to rate the child many times across the school day. We have found that the more frequent the ratings, the more effective is the feedback for the children and the more informative the program is to you. The teacher initials the bottom of the column after rating the child’s performance during that class period to ensure against forgery. If getting the correct homework assignment home is a problem for some children, the teacher can require the child to copy the homework for that class period on the back of the card before completing the ratings for that period. In this way, the teacher merely checks the back of the card for the child’s accuracy in copying the assignment and then completes the ratings on the front of the card. For particularly negative ratings, we also encourage teachers to provide a brief explanation to you as to what resulted in that negative mark. The teachers rate the children using a 5-point system (1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor).

The child takes a new card to school each day. These can be kept at school and a new card given out each morning, or you can provide the card as your child leaves for school, whichever is most likely to be done consistently. As soon as the child returns home, you should immediately inspect the card, discuss the positive ratings first with your child, and then proceed to a neutral, businesslike (not angry!) discussion with your child about any negative marks and the reason for them. Your child should then be asked to formulate a plan for how to avoid getting a negative mark tomorrow. You are to remind your child of this plan the next morning before your child departs for school. After the child formulates the plan, you should award your child points for each rating on the card and deduct points for each negative mark. For instance, a young elementary school aged child may receive five chips for a 1, three for a 2, and one chip for a 3, while being fined three chips for a 4 and five chips for a 5 on the card. For older children, the points might be 25, 15, 5, –15, and –25, respectively, for marks 1–5 on the card. The chips or points are then added up, the fines are subtracted, and the child may then spend what is left of these chips on the privileges on the home reward menu.

Another daily report card program is provided for dealing with behavior problems and getting along with others during school recess periods or free time periods each day. Again, two cards are provided on the page so that you can make photocopies of the page and cut the pages in half to double the number of cards. The card is to be completed by the teacher on recess duty during each recess or free time period. It is inspected by the class teacher when the child returns to the classroom, and then should be sent home for use, as above, in a home chip/point system. The classroom teacher should also be instructed to use a “think aloud–think ahead” procedure with the child just prior to the child’s going out for recess or free time. In this procedure, the teacher (1) reviews the rules for proper recess behavior with the child and notes that they are written on the card, (2) reminds the child that he/she is being watched by the teacher on recess duty, and (3) directs the child to give the card immediately to the recess monitor so the monitor can evaluate the child’s behavior during recess or free time.

As these cards illustrate, virtually any child behavior can be the target for treatment using behavior report cards. If the cards shown here are not suited for your child’s behavior problems at school, then design a new card with the assistance of your therapist, using the blank cards provided at the end of this handout. They do not take long to construct and can be very helpful in improving a child’s school behavior and performance.

From Defiant Children. Copyright 1997 by The Guilford Press.

 

Daily School Behavior Report Card

Child’s Name________________________________________________________ Date________

Teachers:

Please rate this child’s behavior today in the areas listed below. Use a separate column for each subject or class period. Use the following ratings: 1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor. Then initial the box at the bottom of your column. Add any comments about the child’s behavior today on the back of this card.

Class periods/subjects:
1
2
3
4
5
6
7
Behaviors to be rated:

Class participation

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Performance of class work

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Gets along well with other children

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Quality of homework, if any given

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Teacher’s initials:
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Place comments below or on back of card
From Defiant Children. Copyright 1997 by The Guilford Press.

 

Daily Recess and Free Time Behavior Report Card

Child’s Name________________________________________________________ Date________

Teachers:

Please rate this child’s behavior today during recess or other free time periods in the areas listed below. Use a separate column for each recess/free time period. Use the following ratings: 1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor. Then initial at the bottom of the column. Add any comments on the back.

Class periods/subjects:
1
2
3
4
5
6
7
Behaviors to be rated:

Keeps hands to self; does not push, shove

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Does not tease others

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Follows recess/free time rules

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Gets along well with other children

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Does not fight or hit

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Teacher’s initials:
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Place comments below or on back of card
From Defiant Children. Copyright 1997 by The Guilford Press.

 

Daily School Behavior Report Card

Child’s Name________________________________________________________ Date________

Teachers:

Please rate this child’s behavior today in the areas listed below. Use a separate column for each subject or class period. Use the following ratings: 1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor. Then initial the box at the bottom of your column. Add any comments about the child’s behavior today on the back of this card.

Class periods/subjects:
1
2
3
4
5
6
7
Behaviors to be rated:

 

___
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Teacher’s initials:
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Place comments below or on back of card
From Defiant Children. Copyright 1997 by The Guilford Press.

Behavioral Contracts

Instead of a behavior report card, teachers can set up an in-class behavior contract.18 These contracts should contain the following elements:

It is helpful to have the student sign the contract and for a copy of the contract to be posted in a visible location near the student so he or she can make reference to it throughout the class period.

Externalizing Information and Time

Recall from the above discussion of EF deficits that children and teens with ADHD have very poor working memory. That means that they cannot hold as much information in mind or for as long as other students. They are also less likely to call up such information from memory and keep it consciously in mind when they are entering class periods or during a change in a situation from a prior activity to the next or to a new one. Since “internal” or mental information is not very effective at guiding an ADHD student’s behavior, it is helpful to boost working memory by placing key pieces of information in the student’s visual or other sensory fields in that work location. Putting such information in a physical form in the visual field of the student is called “externalizing” the key information and cues. This section briefly reviews some ways that teachers can help “externalize” critical pieces of information about the situation and any time intervals that may be important for that situation, class, or work period. This is another example of a form of proactive teaching and behavior management.

Make Rules Obvious and in Physical Form

Make Time Obvious or Physical

As noted in a previous chapter, children and teens with ADHD cannot manage or guide their behavior based on their sense of time. So teachers should not rely on a child’s subjective sense of time, which is impaired in children with ADHD. As suggested earlier, “externalize” time. Essentially, this means using some external timekeeping device in the child’s workspace to help children with ADHD see how much time they have to do something, and then how much of it has passed and how much is left as they complete their work. To do this, you can use clocks, timers, watches, recorded time signals, etc., anything to show how much time they have to do an assignment. For example, you can use the Time Timer,20 which is a timer device that is an 8 in. x 8 in. clock with a red dial that signals a time period of up to one hour (see Figures 6 and 7). When a child has deskwork to do within a set time period, you can set this clock to that time period. The time available shows up in red on the clock face and as time passes, the amount of red exposed decreases until time us up and a signal sounds to indicate the end of the work period.

Figure 6. Time Timer

Of course, digital timers can also be found on the Internet, such as the My Time Activity Timer.21

Figure 7. My Time Activity Timer

You can also download a variety of online stopwatches and timer apps for a tablet, iPad, or smartphone at: online-stopwatch.com/classroom-timers. These include traditional clock faces, time bombs, cartoon characters running races, virtual hourglasses, etc.

Helping Children Improve Self-Awareness

As you learned above, children and teens with ADHD are less aware of their own behavior than are typical students because they do not monitor their ongoing behavior as well or as often as do those other students. Research does not show any definitive means by which teachers can improve the self-awareness or self-monitoring of students with ADHD. But here are some methods that have been used by clinical researchers and others to try to do so.22

Figure 8. MotivAider

Transition Planning

Children and teens with ADHD, as noted previously, have trouble not only with working memory (remembering the rules that apply in a given situation) but also with self-monitoring of their own behavior. Both of these problems conspire along with their inattentiveness to pose frequent problems when the student is transitioning from one activity, class period, or classroom to the next one on their daily schedule. As a result, problem behaviors can often occur during or just after such transitions. To help address this situation, it is recommended to use a method called transition planning. This is to be discussed with the child before it is put into use. Essentially, here is what the student is to do BEFORE starting a new activity, class subject, or even entering a new classroom:

  1. Before the child enters a new situation (next class, recess, going to lunch room) have him or her STOP!
  2. The teacher then reviews two or three rules the child needs to obey in this new situation.
  3. The child then repeats those rules back, out loud.
  4. The teacher explains what the incentive or reward is to be in that situation for obeying those rules (tokens, time on the computer, extra play time, etc.).
  5. The teacher then establishes with the child what the punishment is to be if a rule is broken.
  6. The teacher then assigns the child an immediate instruction to do or activity to start. For instance, the teacher can say “Go to your desk, get out your math book, and turn to chapter X and start reading.”
  7. The child then enters the new situation, and follows your plan.
  8. The teacher is to reward the student frequently throughout the new activity.
  9. At the end of that situation, the teacher speaks briefly with the student to evaluate her success (or failure).

A teacher can also augment or replace this procedure with a 3x5 in. file card on which are written the rules the child is to follow routinely when entering this new situation, class subject, or classroom. That way, the child has the “externalized” rules written on the card to take with him to keep in view on his desk throughout the period.

Too often, teachers allow students to go through these transitions unassisted. Then when problems develop, the teachers are forced to react to this situation, usually with discipline. The proactive behavior management outlined above is far superior to reactive management at creating a better day for both ADHD student and teacher.

Potential Disciplinary Methods

Before implementing any of the ideas or methods listed below, a teacher should check with the school principal or school district on their policies concerning any guidelines or regulations pertaining to discipline or punishment. That said, here are some methods that can serve as forms of punishment for student misbehavior.

Tips for Teen Management

Some of what follows has already been discussed above for children with ADHD. But other methods here have been developed specifically for use with teens with ADHD in school settings.

Smart Pen.jpg

Figure 9. Smart Pen

Medications Used to Manage ADHD

Between 40% and 80% of children and teens with ADHD are likely to be taking an ADHD medication as part of their treatment by a physician. It is therefore helpful for educators to know the types of medications their students with ADHD are likely to be taking, how the drugs work, and what the side effects are likely to be. Children taking medication are likely to be more responsive to the behavioral methods used to manage ADHD-related school problems and the combination of those methods with medication often results in far greater improvement than when either form of treatment is used alone.

There are two basic categories of ADHD medicines that are approved by the Food and Drug Administration for use with children and teens – stimulants and non-stimulants. Both have to be taken daily. They all control the symptoms of ADHD only as long as your student takes the medications. They produce no enduring positive effects on your student’s ADHD if they stop taking them. Ceasing the use of medication often results in a return of the ADHD symptoms back to their pre-treatment levels. Think of these medicines as you would insulin with a diabetic. Insulin does not cure diabetes, but it does manage it so long as it is used, and if used properly, for most people. But if your student stops the medication the underlying problem and its symptoms will return.

Both types of ADHD medications typically work by increasing the amount of two (or more) chemicals in the brain known as neurotransmitters. Those chemicals are involved in permitting nerve cells to communicate with each other so the brain can function effectively. More specifically, these drugs increase just how much of these chemicals are residing outside of the nerve cells. That can increase the activity of adjacent nerve cells. The two neurotransmitters are dopamine and norepinephrine. By causing nerve cells to express more of these neurochemicals, or by keeping the nerve cells from pulling these chemicals back into the cell once they have been released, they increase the communication that occurs between nerve cells in regions of the brain that are related to directly causing ADHD. In short, increasing these brain chemicals in these regions lets that brain area function better, and sometimes even normally. Also, recent studies show that children who have taken these medications (especially the stimulants) are likely to have brain development that is closer to normal than children with ADHD who have not taken the medication – a phenomenon known as neuroprotection.

Types of Stimulants and their Actions

There are two basic types of stimulants currently marketed in the U.S. – methylphenidate (MPH) and amphetamine (AMP). These stimulants act in the brain to mainly increase the amount of dopamine available for use outside the nerve cells. Yet they can, to a smaller extent, increase the amount of norepinephrine outside the nerve cells as well. AMP does this mainly by increasing the amount of dopamine that is produced and expressed from the nerve cell when it is activated. To a lesser extent, it may also block the transport system by which the dopamine is normally re-absorbed back into that nerve cell after being released. That can result in more dopamine being left outside the cell to continue to function. MPH mainly acts by preventing this re-absorption of dopamine. That is why it is known as a transport or re-uptake blocker.

Both AMP and MPH have the potential to be abused because they increase dopamine in regions of the brain known as reward centers. Stimulating those centers can lead to an increased likelihood of addiction to drugs that do so. But ADHD medications are very unlikely to do this when taken by mouth and swallowed, as prescribed. They certainly can do so when they are sniffed through the nose as a powder or injected into a blood vein in a solution, such as when mixed with water. Because of this potential for drug abuse, the Drug Enforcement Administration in the U.S. has classified these stimulants as Schedule II Controlled Substances along with other potentially addictive drugs. This classification places limits on how much of the drugs can be produced annually, how the drugs are to be prescribed, how they are to be stored in pharmacies, and how they are to be dispensed and otherwise monitored in the U.S.

There are up to five different methods by which these two drugs are delivered into the body. These five methods are described in the Box below. The methods differ in how long they maintain the blood levels of the drug in the body, and so in the brain. There are hundreds of studies on the safety and effectiveness of these stimulants and delivery systems.

The Five Stimulant Delivery Systems

The five different delivery systems are the 5 Ps – pills, pumps, pellets, patches, and pro-drug. The various brand names of ADHD medicines you will hear about are either one form or another of MPH or AMP and involve one of these delivery systems:

  • Pills: These are the original versions of these medicines that have been available for many decades. The first versions of AMP were discovered in the 1930s while the first version of MPH was discovered in the 1950s. In pill form, these medications are absorbed quickly, usually within 15-20 minutes, after being taken by mouth and swallowed. They can reach their peak level in the blood (and so in the brain) in 60-90 minutes usually, and may last three to five hours in controlling the symptoms of ADHD in most people. That was their problem. If you wanted to control the symptoms of ADHD across the waking day of say 14-16 hours, you had to give these medications two to four times per day or more. The inconvenience that posed for people having to take these drugs is obvious, not to mention the fact that many had to remember to take these drugs so often they frequently forgot to do so. These and other problems with these immediate release pills led pharmaceutical companies to explore better ways to get the medicines into the body and keep them active there longer. The brand names you are likely to hear about for these pills are Ritalin® (MPH, a mixture of d-MPH and l-MPH), Focalin® (just d-MPH), Dexedrine® (d-AMP), Benzedrine® (l-AMP), and Adderall® (a mixture of the d- and l-AMP forms or salts).
  • The Pump: Then came the invention of an ingenious water-pump system for delivering these drugs into the body and keeping them in the blood stream longer. The brand name for this system is Concerta® and it contains MPH. It is a capsule-appearing container with a small laser-drilled hole on one of its long ends. Inside there are two chambers. One chamber contains a paste-like sludge of MPH, and the other chamber is empty. There is also powdered MPH coating the outside of the capsule. Now, here is the neat part: when you swallow the capsule, the powder goes right to work just as it would in the pill form of MPH described above (i.e., Ritalin). That gives just enough time for the capsule to start to absorb water from your stomach (and later your intestines). The water is absorbed through the wall of the pump in a continuous, even flow into the empty chamber. As that chamber fills up, it presses against the other chamber that contains the MPH paste. That pressure then squeezes the MPH paste out of the hole in the capsule. It is designed to do that continuously for 8-12 hours or more. The end result is that many people, especially children, only need to take one capsule a day, and not the usual two or three (or more) they would have to take using the regular pills discussed above. The capsules come in various size doses of course so that physicians can adjust the dose to better suit the individual needs and responses of their ADHD patients. One problem though is that some older children and teens may need a longer course of medication each day than what this provides. To deal with that issue, some physicians use the pills of MPH or AMP toward the end of the day. They do this to get an extra three to five hours of treatment with medication after the Concerta® may lose its beneficial control of ADHD symptoms. Even so, you just have to love the human ingenuity that led to the discovery of this delivery system.
  • The Pellets: At around the same time as the water-pump method was being invented, chemical (pharmacological) engineers were modifying a method that uses time-release pellets to create a way to keep medicines in the body and blood stream longer than the pills. This method had been used for years with some cold medicines, like the old Contac brand. But the system had to be modified in various ways for use with MPH and AMP. Now we have time-release pellets for both of these stimulants. Little beads of the drug are coated in such a way that some dissolve immediately after being swallowed, others dissolve one, two, three, or more hours later. This means that the drug can be more gradually activated and absorbed into the blood stream across 8-12 hours for most people. Here is another ingenious delivery system. It has the added advantage that if someone simply cannot or does not want to swallow the capsule that contains these pellets, they can open the capsule (pull it apart) and sprinkle it on a teaspoon of applesauce, yogurt, or other food and swallow it that way. It does not change the way the drug will work in the body, typically. You may have heard of these delivery systems by the brand names of Ritalin LA® (MPH), Focalin XR® (d-MPH), Medadate CD® (MPH), and Adderall XR® (AMP) here in the U.S. Again, there are different sizes (doses) to these capsules to permit a physician to adjust the dose for each individual to their optimum level. Like the water-pump method above, these time-release pellet systems sometimes have to be supplemented late in the day with a regular or immediate-release pill version of the same drug. That permits even longer symptom control if necessary. Some research exists that shows that this pellet system gives a little better control of ADHD symptoms in the morning than afternoon hours. In contrast, the pump system above provides a bit better control in the afternoon than morning hours. Both delivery systems provide good control of ADHD symptoms across the day but not at exactly the same hours of the day. This can be an issue sometimes in deciding which delivery system may be better for someone depending on when they need the greatest control of their ADHD symptoms during the day.
  • The Patch: The next invention of a delivery system for the stimulants was FDA-approved just a few years after the two above (pump and pellet). It is a patch with an adhesive coating that is applied directly to the skin, such as on the back of one’s shoulder or on the buttocks. The patch contains MPH. When applied to the skin, the MPH is absorbed through the skin and gets into the blood stream by that means. So long as you wear the patch, MPH is being delivered into the body for as many hours during the day as one wants to do so. Because the stimulants can cause insomnia or trouble falling asleep, the patch needs to be removed several hours before bedtime to permit the drug left in the body to be broken down and removed without adversely affecting the onset of sleep. This delivery system used to go by the brand name Daytrana® (MPH), but the patent on the device is up for sale and may be purchased by another company and renamed in the future. Here is another clever invention for getting the stimulants into the blood stream and keeping them there for a sufficient time to control the symptoms of ADHD across most of the waking day. It has the advantages of not needing to be swallowed and of delivering the medicine into the blood stream as long as you are wearing the patch that day. Of course, the disadvantage is that you have to remember to take the patch off well before you want to go to sleep. Another problem is that 15%-20% of people experience a skin rash at the site of the patch and may need to stop using the patch for this reason. As with the drugs above, the patch comes in different doses to better adjust the amount of the drug to each individual.
  • The Pro-Drug: In 2008, another delivery system received FDA-approval for use with adults with ADHD, and that system goes by the brand name of Vyvanse® (a form of AMP). Approval came later for using the drug with children and teens. Here is yet a further example of human inventiveness. One of the problems with the immediate release pills as well as the pellet systems discussed above is that they have the potential to be abused. That is usually done by crushing and inhaling the powder from the pills or the crushed beads from the pellet systems. That powder can also be mixed with water and injected into a blood vein. Whether snorted through the nose or injected into a vein, the stimulants get into the blood very quickly and so into the brain very rapidly. It is this rapid invasion of the brain by the drug and nearly as rapid decrease in certain brain regions that creates the “rush” or euphoria that people can experience with stimulants delivered in this fashion. This does not occur from the oral ingestion of the drug. This problem led a small biotech company near Albany, NY to invent a method in which the AMP (d-amphetamine) is locked up so that it cannot be activated unless it is in the human stomach or intestines. They achieved this by bonding a lysine compound to the d-AMP. This bonding of an active drug to another compound alters its typical pattern of activation and is called a pro-drug by the FDA. In this form, the AMP is inactive and will remain so until it is swallowed. Then, in the stomach and intestine and its blood supply, there is a chemical that naturally occurs there that splits the lysine from the d-AMP. Then the d-AMP can go to work and be absorbed into the blood stream. The drug is designed in such a way that the d-AMP lasts 10-14 hours, typically. This delivery system greatly reduces the likely abuse potential of this version of AMP while providing for the desired longer time course of action from a single dose.

Side Effects of Stimulants

The most common side effects people experience when taking a stimulant (MPH or AMP) are listed below in their descending order of likely occurrence:

These stimulants also increase heart rate and blood pressure slightly, but generally no more so and often less so than if you had just climbed a half-flight of stairs. You may have heard claims that these drugs increase the sensitivity to or risk for abusing other drugs, especially other stimulants. The vast majority of research does not support this claim. People who have taken ADHD medications such as these stimulants for years, including children growing up with ADHD, were found to be no more likely to abuse drugs than were those not being treated. In fact, in a few studies they were found to be less likely to do so, probably because the ADHD medication was controlling their impulsiveness.

You may have also heard that these drugs, especially the stimulants, might increase the likelihood of sudden death, usually from heart block (heart stops beating). In rare cases, strokes have occurred in people taking these drugs. While some people have died while taking a stimulant, these cases always involve other extenuating factors that alone can account for the sudden death. Those reasons include things like a history of structural heart defects along with engaging in vigorous exercise just preceding the death. The available evidence actually shows that people on stimulants have a somewhat lower likelihood of sudden death than the general population (which is one to seven people per 100,000 per year, depending on age). This is probably because physicians routinely screen for heart problems before starting people on stimulants and, if discovered, usually do not use these medications. So those with the greatest likelihood of having heart problems if they took a stimulant are not prescribed them. Even so, physicians have been cautioned not to put people on stimulants if they have a history of sudden death in their family or a history of structural heart abnormalities, major arrhythmias, or other major cardiac problems. It also makes sense not to treat people with clinically or morbidly high blood pressure with a stimulant for the obvious reason that it can make the situation even more risky for them. The risk to otherwise healthy children and teens with ADHD is not significant if there is any increased risk at all.

Atomoxetine – A Non-stimulant

In 2003, the FDA approved the first non-stimulant drug for the management of child, teen, and adult ADHD, and the first new drug for ADHD in more than 25 years. That drug was Atomoxetine (ATX), under the brand name Strattera®. This was the most studied ADHD drug before receiving FDA approval that has ever been brought to market. Randomized and double-blinded studies were done involving more than 6,000 patients worldwide to thoroughly study the effectiveness, side effects, and safety of this medication. Now, like the stimulants above, millions of people worldwide take this medication for management of their ADHD.

As noted above, AMP acts in the brain by increasing the amount of dopamine that is produced and expressed from the nerve cell when it is activated. To a lesser extent, it may also block the transport system by which the dopamine is normally re-absorbed back into that nerve cell after being released. MPH mainly acts by preventing this re-absorption of dopamine and so is known as a transport or re-uptake blocker. Atomoxetine, in contrast, works by blocking the re-absorption of norepinephrine once it has been released. Like, MPH, it is a re-uptake blocker, but it blocks the re-uptake of a different neuro-chemical; that is norepinephrine. But some research shows that by doing this, ATX does result in an increase in dopamine outside nerve cells in certain parts of the brain, such as the frontal cortex.

ATX also differs from the stimulants, however, in that it does not affect the brain centers that are likely to be related to drug addiction or abuse. This is why the drug is called a non-stimulant. It is also why it is not classified as a controlled substance in the U.S. Research shows that the drug has a very low potential for abuse. That means it is not preferred or liked by known drug addicts more than other psychiatric drugs such as anti-depressants, which is to say addicts like it very little. The different means by which it acts in the brain can result in a different profile of potential side effects and adverse reactions, and possibly somewhat different benefits from this drug than what one sees with the stimulants.

ATX is nearly as effective for managing ADHD symptoms as are the stimulants, but not quite. The same percentage of patients appears to positively respond to both these classes of drugs (stimulants and non-stimulants), averaging about 75% of people responding. However, some studies suggest that while 50% of people respond positively to both types of medications, 25% may respond better to a stimulant than to ATX while the remaining 25% may respond better to ATX than to one of the stimulants. In other words, some people are unique responders who do better on one type of ADHD drug than on another. We should not be surprised at this given that not all people are biologically identical especially in the organization and functioning of their brains. Some studies suggest that ATX may not produce quite as much improvement in ADHD symptoms as do the stimulants. But for some adults, the degree of improvement is sufficient to effectively manage their disorder while not necessarily producing the same types of side effects that one might get with a stimulant. Also, stimulants have the potential to be abused or diverted for such abuse to others who were not prescribed the drug. ATX does not adversely affect anxiety, may even reduce it significantly, does not worsen tics or nervous habits, and does not typically result in insomnia.

The issue that physicians face in daily practice with ADHD patients is therefore not which drug works better, but which drug is best suited to which individual patient given their unique profile of characteristics. Having many different drugs, just like having many different delivery systems, lets physicians better tailor their treatment to the uniqueness of each patient. Your student can expect, however, that with ATX it will take longer to adjust it to the right dosage than is the case with a stimulant. That is because it takes longer for the body to adjust to the side effects of drugs like ATX. And that is why physicians like to leave patients on a particular dosage a bit longer than they might with a stimulant before adjusting the dosage upward.

Side Effects of Atomoxetine

The most common side effects for ATX are:

Although ATX can also increase heart rate and blood pressure, it does so less than the stimulants discussed above. There is an exceptionally rare chance of liver complications that occur once in every million people treated (four cases out of 4.5 million treated to date). This seems to result from a very rare auto-immune reaction to the drug in which the body’s immune system attacks and inflames the outer layers of the liver. More recently, two of these cases were discounted as being due to other factors not related to the drug. So the risk for this side effect is now about one in every 2-3 million people being treated. But to be safe, people with a history of liver damage or other liver problems may want to avoid using ATX.

The package insert for ATX contains a warning of a possibility of increased suicidal thinking from this drug, but not suicide attempts, and only in children. This side effect is highly questionable given the lack of rigor with which the information on which it is based was collected in the initial clinical trials for this drug. This problem of increased suicidal thinking was not found for teens and adults with ADHD taking ATX. Also, recent research has found that people with ADHD who are off medication have a far higher rate of suicidal thinking and attempts than do those who are taking either ATX or a stimulant medication. These findings suggest that taking these medicines for ADHD may actually reduce the risk for suicidal thinking and attempts.

Anti-Hypertensive Drugs

Two other medicines are sometimes used to treat adult ADHD, but they should be considered “last choice” medicines to be used only if the other ADHD medicines are not proving satisfactory. Both originated as drugs used to treat high blood pressure, called anti-hypertensive drugs. One is clonidine, and works as an alpha-adrenergic enhancer. Some nerve cells in the brain have little portholes on them called alpha-2 receptors. These drugs seem to act to reduce or close off these portholes and that results in stronger or more effective nerve signals in those cells. At low dosages, this drug appears to stimulate inhibitory systems in the brain. The FDA approved an extended-release version of clonidine, clonidine ER (Kapvay®), in 2010 as a treatment for ADHD in children ages 6-17 years. But as noted above, physicians can use it “off-label” outside of this age range, such as for adults with ADHD. It can be used alone or combined with stimulants. The drug is not as effective as the other ADHD medicines discussed above. So it is sometimes used to treat ADHD when it co-exists with other disorders such as conduct or antisocial problems or irritability and anger. It can also treat tic disorders, sleep disturbances, and may reduce anxiety.

Regular clonidine is fast-acting. But the extended-release version approved for ADHD can last much longer. The most common side effect of clonidine is sedation, which tends to subside with continued treatment. It can also result in reduced blood pressure, called hypotension, and sometimes results in complaints of dry mouth, vivid dreams, depression, and confusion. Unlike other ADHD medicines, this one cannot be stopped abruptly. It requires slow tapering over several days to weeks. The drug should not be used if your student is taking beta-blockers or calcium channel blockers. Experts recommend that anyone using these drugs for treating ADHD have their blood pressure monitored when starting or when tapering off clonidine and when dosages are being increased.

Another anti-hypertensive drug used for ADHD management is guanfacine. In 2009, the FDA approved an extended-release version, guanfacine ER (Intuniv®) for the treatment of ADHD in people 6-17 years of age. Again, physicians can use it with adults off-label if they think it essential to do so. The drug can be given alone or in combination with either of the stimulant medicines discussed above, as monotherapy, or as adjunctive treatment with stimulants.

There may be some advantages of guanfacine over clonidine. These include less sedation, a longer duration of action, and less risk of cardiovascular problems.

This drug can result in minor decreases in blood pressure and pulse rate. Other side effects include sedation, irritability, and depression. Again, this medication probably is not as effective as the stimulants or ATX discussed above. Its benefit may be in helping to treat coexisting disorders with ADHD, such as anger and aggression, and in reducing highly impulsive or hyperactive behavior.

You and your student should be aware that there is very little research on using these two anti-hypertensive drugs to treat ADHD in adults. That is why they were FDA approved mainly for children, on which more research was available. Because of the lack of research, these drugs are considered last choice options for managing adult ADHD. The other ADHD medicines above should be tried first.

Conclusion

The management of ADHD in educational settings requires as a prerequisite that mental health professionals be knowledgeable about the nature of the disorder, its symptoms, the deficits in executive functioning associated with it (both cognitive and in daily adaptive functioning), as well as its demographics and etiologies. With this information in mind, especially the nature of the EF deficits inherent in ADHD, professionals can proceed to tailor a suite of intervention methods for a specific child or teen from a wide array of more than 80 methods of behavior management and classroom accommodation. All of these methods are grounded in a set of 10 overarching principles of management which themselves are grounded in the nature of EF and its deficits in ADHD.

References and Evidence Base

Barkley, R. A. (Ed.) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th edition). New York: Guilford.

Barkley, R. A., Shelton, T. L., Crosswait, C., Moore­house, M., Fletcher, K., Barrett, S., et al. (2000). Multi-method psycho-educational intervention for preschool children with disruptive behavior: Preliminary results at post-treatment. Journal of Abnormal Child Psychiatry and Psychology, 41, 319-332

Bowman-Perrott, L., Davis, H., Vannest, K., Williams, L., Greenwood, C., & Parker, R. (2013). Academic benefits of peer tutoring: A meta-analytic review of single-case research. School Psychology Review, 42, 39-55.

Cooper, H., Robinson, J. C., & Patall, E. A. (2006). Does homework improve academic achievement? A synthesis of research, 1987-2003. Review of Educational Research, 76, 1-62.

DuPaul, G.J., Eckert, T.L., & Vilardo, B. (2012). The effects of school-based interventions for attention-deficit hyperactivity disorder: A meta-analysis 1996-2010. School Psychology Review, 41, 387-412.

DuPaul, G. J., Ervin, R. A., Hook, C. L., & McGoey, K. E. (1998). Peer tutoring for children with attention deficit hyperactivity disorder: Effects on classroom behavior and academic performance. Journal of Applied Behavior Analysis, 31, 579–592.

DuPaul, G.J., Jitendra, A.K., Volpe, R.J., Tresco, K.E., Lutz, G., Vile Junod, R.E., Cleary, K.S., Flammer, L.M., & Mannella, M.C. (2006). Consultation-based academic interventions for children with ADHD: Effects on reading and mathematics achievement. Journal of Abnormal Child Psychology, 34, 633-646.

DuPaul, G. J., & Stoner, G. (2014). ADHD in the schools (3rd ed.). New York: Guilford.

DuPaul, G.J. & Weyandt, L.L. (2006). School-based interventions for children and adolescents with Attention-deficit/Hyperactivity Disorder: Enhancing academic and behavioral outcomes. Education & Treatment of Children, 29, 341-358.

Evans, J. H., Ferre, L., Ford, L. A., & Green, J. L. (1995). Decreasing attention deficit hyperactivity disorder symptoms utilizing an automated classroom reinforcement device. Psychology in the Schools, 32, 210–219.

Evans, S. W., Pelham, W., & Grudberg, M. V. (1994). The efficacy of notetaking to improve behavior and comprehension of adolescents with attention deficit hyperactivity disorder. Exceptionality, 5(1), 1–17.

Fabiano, G.A., Pelham, W.E.Gnagy, E.M., Burrows-MacLean, L., Coles, E., Chacko, A.,Wymbs, B.T., Walker, K.S., Arnold, F., Garefino, A., Keenan, J.K., Onyango, A.N.,Hoffman, M.T., Massetti, G.M., Robb, J.A., (2007), The single and combined effects of multiple intensities of behavior modification and methylphenidate for children with Attention Deficit Hyperactivity Disorder in a classroom setting. School Psychology Review, 36, 195-216.

Fabiano, G.A., Pelham, W.E., Karmazin, K., Kreher, J., Panahon, C.J., & Carlson, C. (2008). A group contingency program to improve the behavior of elementary school students in a cafeteria. Behavior Modification, 32, 121-132.

Fabiano, G. A., Vujnovic, R. K., Pelham, W. E., Waschbusch, D. A., Massetti, G.M., Pariseau, M. E., Naylor, J., Yu, J., Robins, M., Cronefix, T., Greiner, A. R., & Volker, M. (2010). Enhancing the effectiveness of special education programming for children with attention deficit hyperactivity disorder using a daily report card. School Psychology Review, 39, 219-239.

Gast, D. C., & Nelson, C. M. (1977). Time-out in the classroom: Implications for special education. Exceptional Children, 43, 461–464.

Gordon, M., Thomason, D., Cooper, S., & Ivers, C. L. (1990). Nonmedical treatment of ADHD/hyperactivity: The attention training system. Journal of School Psychology, 29, 151–159.

Hoff, K. E., & DuPaul, G. J. (1998). Reducing disruptive behavior in general education classrooms: The use of self-management strategies. School Psychology Review, 27, 290–303.

Hoza, B. & Smith, A. L. (2015). Is aerobic physical activity a viable management strategy for ADHD? The ADHD Report, 23(2), 1-5.

Jurbergs, N., Palcic, J. L., & Kelley, M. L. (2008). School-home notes with and without response cost: increasing attention and academic performance in low-income children with attention-deficit/hyperactivity disorder. School Psychology Quarterly, 22, 358-379.

Jurbergs, N., Palcic, J. L., & Kelley, M. L. (2010). Daily behavior report cards with and without home-based consequences: improving classroom behavior in low income, African American children with ADHD. Child and Family Behavior Therapy, 32, 177-195.

Kelley, M. L. (1990). School–home notes: Promoting children’s classroom success. New York: Guilford Press.

Mautone, J. A., DuPaul, G. J., & Jitendra, A. K. (2005). The effects of computer-assisted instruction on the mathematics performance and classroom behavior of children with ADHD. Journal of Attention Disorders, 9, 301–312.

McGoey, K. E., & DuPaul, G. J. (2000). Token reinforcement and response cost procedures: Reducing the disruptive behavior of preschool children with ADHD. School Psychology Quarterly, 15, 330–343.

Meyer, K. (2007). Improving homework in adolescents with attention-deficit/hyperactivity disorder: Self vs. parent monitoring of homework behavior and study skills. Child and Family Behavior Therapy, 29, 25-42.

Nelson, J.R., Benner, G.J., & Mooney, P. (2008). Instructional practices for students with behavioral disorders: Strategies for reading, writing, and math. New York: Guilford.

Ota, K. R., & DuPaul, G. J. (2002). Task engagement and mathematics performance in children with attention deficit hyperactivity disorder: Effects of supplemental computer intervention. School Psychology Quarterly, 17(3), 242–257.

Owens, J.S., Holdaway, A.S., Zoromski, A.K., Evans, S.W., Himawan, L.K., Girio-Herrera, E., & Murphy, C.E. (2012). Incremental benefits of a daily report card intervention over time for youth with disruptive behavior. Behavior Therapy, 43, 848-861.

Pagani, L., Tremblay, R., Vitaro, F., Boulerice, B., & McDuff, P. (2001). Effects of grade retention on academic performance and behavioral development. Development and Psychopathology, 13, 297-315.

Pfiffner, L. J. (2011). All about ADHD: The complete practical guide for classroom teachers (2nd Edition). New York: Scholastic.

Pfiffner, L., & DuPaul, G. J. (2015). Treatment of ADHD in school settings. In R. A. Barkley (Ed.) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th edition). New York: Guilford.

Pontifex, M. B., Saliba, B. J., Raine, L. B., Picchietti, D. L., & Hillman, C. H. (2013). Exercise improves behavioral, neurocognitive, and scholastic performance in children with attention-deficit/hyperactivity disorder. The Journal of Pediatrics, 162, 543-551.

Power, T. J., Karustis, J. L., & Habboushe, D. F. (2001). Homework success for children with ADHD: A family–school intervention program. New York: Guilford Press.

Reid, R., Trout, A.L., & Schartz, M. (2005). Self-regulation interventions for children with attention deficit/hyperactivity disorder. Exceptional Children, 71, 361-377.

Sheridan, S.M., Welch, M., & Ormi, S.F. (1996). Is consultation effective? A review of outcome research. Remedial and Special Education, 17, 341-354.

Spencer, V. G. (2006). Peer tutoring and students with emotional or behavioral disorders: A review of the literature. Behavioral Disorders, 31, 204-222.

Web Resources:

Ldonline.org

Chadd.org

Help4adhd.org

Caddra.ca

Teachadhd.ca/teaching-children-with-adhd

A fine website chock full of ideas on curriculum development for ADHD students and behavior management strategies. What is Teach ADHD.ca?

“The TeachADHD project began at Brain and Behaviour Research program at The Hospital for Sick Children and has evolved through the hospital’s Community Health Systems Resource Group’s “Teach for Success” initiative. The project’s mission is to make available to teachers relevant educational material stemming from current ADHD research in order to improve the learning outcomes of all students. It is the intention of TeachADHD to present only information that is supported by substantiated research. All materials developed for this project have been evaluated by teachers for its educational relevance.” Information was developed using multiple organizations including school systems around Toronto, the Hospital for Sick Children Brain and Behavior section, TVOntario, and others.

This subpage is a fine review of medications, from the Canadian perspective

British Columbia Department of Education

Resources from Sandra Reif

Successful Schools

National Association of School Psychologists

Child Development Institute, LLC

National Association of Special Education Teachers – Classroom Management of ADHD

Resources at HelpGuide

US Dept. of Education and US Dept. of Education ADHD Teaching

Intervention Central

Additude Magazine

New Ideas

About ADHD

Education World

Teaching Channel

Provides videos for helping teachers with classroom management problems with ADHD students.

Ideas for Teaching Children with ADHD – Leah Davies, M.Ed.

Endnotes

Note 1. Dr. Barkley is a Clinical Professor of Psychiatry at the Virginia Treatment Center for Children and Virginia Commonwealth University Medical Center, Richmond, VA. (Go back)

Note 2. In Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press. (Go back)

Note 3. For the exact symptom wording see the Diagnostic and Statistical Manual for Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association, 2013. (Go back)

Note 4. See Dr. Barkley’s course on executive functioning. See also Barkley, R. A. (2015). Executive functioning and self-regulation as an extended phenotype: Implications of the theory for ADHD and its treatment. In Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed., pp. 405-434). New York: Guilford Press. (Go back)

Note 5. Barkley, R. A. (2012). Barkley Deficits in Executive Functioning Scale – Children and Adolescents (p. 112). New York: Guilford Press. (Go back)

Note 6. See Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford Press. (Go back)

Note 7. From Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed., pp. 405-434). New York: Guilford Press. And Barkley, R. A. (2012). Executive functions: What they are, How they work, and Why they evolved. New York: Guilford Press. (Go back)

Note 8. Bauer, I. M. & Baumeister, R. F. (2011). Self-regulatory strength. In K. Vohs & R. Baumeister (Eds.), Handbook of Self-Regulation (2nd ed.) (pp. 64-82). New York: Guilford Press. (Go back)

Note 9. Sheridan, S.M., Welch, M., & Ormi, S.F. (1996). Is consultation effective? A review of outcome research. Remedial and Special Education, 17, 341-354. (Go back)

Note 10. Pagani, L., Tremblay, R., Vitaro, F., Boulerice, B., & McDuff, P. (2001). Effects of grade retention on academic performance and behavioral development. Development and Psychopathology, 13, 297-315. (Go back)

Note 11. Cooper, H., Robinson, J. C., & Patall, E. A. (2006). Does homework improve academic achievement? A synthesis of research, 1987-2003. Review of Educational Research, 76, 1-62. (Go back)

Note 12. Hoza, B. & Smith, A. L. (2015). Is aerobic physical activity a viable management strategy for ADHD? The ADHD Report, 23(2), 1-5. (Go back)

Note 13. Mautone, J. A., DuPaul, G. J., & Jitendra, A. K. (2005). The effects of computer-assisted instruction on the mathematics performance and classroom behavior of children with ADHD. Journal of Attention Disorders, 9, 301–312. (Go back)

Note 14. Fabiano, G.A., Pelham, W.E.Gnagy, E.M., Burrows-MacLean, L., Coles, E., Chacko, A.,Wymbs, B.T., Walker, K.S., Arnold, F., Garefino, A., Keenan, J.K., Onyango, A.N.,Hoffman, M.T., Massetti, G.M., Robb, J.A., (2007), The single and combined effects of multiple intensities of behavior modification and methylphenidate for children with Attention Deficit Hyperactivity Disorder in a classroom setting. School Psychology Review, 36, 195-216. (Go back)

Note 15. See DuPaul & Stoner, 2012; Spencer 2006. Bowman-Perrott, L., Davis, H., Vannest, K., Williams, L., Greenwood, C., & Parker, R. (2013). Academic benefits of peer tutoring: A meta-analytic review of single-case research. School Psychology Review, 42, 39-55. (Go back)

Note 16. McGoey, K. E., & DuPaul, G. J. (2000). Token reinforcement and response cost procedures: Reducing the disruptive behavior of preschool children with ADHD. School Psychology Quarterly, 15, 330–343. (Go back)

Note 17. Gordon, M., Thomason, D., Cooper, S., & Ivers, C. L. (1990). Nonmedical treatment of ADHD/hyperactivity: The attention training system. Journal of School Psychology, 29, 151–159. The device can be purchased at Gordon Diagnostic Systems (gerbertechnology.com) or at the addwarehouse.com. (Go back)

Note 18. See DuPaul, G. J., & Stoner, G. (2014). ADHD in the schools (3rd ed.). New York: Guilford Press. (Go back)

Note 19. Adapted from R. A. Barkley (2013). Defiant Children: A Clinician’s manual for Assessment and Parent Training (3rd edition). New York: Guilford Press. (Go back)

Note 20. specialneedsessentials.com. See also: additudemag.com (Go back)

Note 21. additudemag.com/ (Go back)

Note 22. Hoff, K. E., & DuPaul, G. J. (1998). Reducing disruptive behavior in general education classrooms: The use of self-management strategies. School Psychology Review, 27, 290–303. (Go back)

Note 23. Available at addwarehouse.com (Go back)

Note 24. Gast, D. C., & Nelson, C. M. (1977). Time-out in the classroom: Implications for special education. Exceptional Children, 43, 461–464. (Go back)

Note 25. Evans, S. W., Pelham, W., & Grudberg, M. V. (1994). The efficacy of notetaking to improve behavior and comprehension of adolescents with attention deficit hyperactivity disorder. Exceptionality, 5(1), 1–17. (Go back)

Note 26. Meyer, K. (2007). Improving homework in adolescents with attention-deficit/hyperactivity disorder: Self vs. parent monitoring of homework behavior and study skills. Child and Family Behavior Therapy, 29, 25-42. (Go back)

 

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