Introduction to the Problem
The perplexing question for educators and parents over the years has been to find suitable strategies that could help them in handling students with attention deficit hyperactivity disorder (ADHD). ADHD involves the display of developmentally inappropriate levels of inattention, impulsivity, and overactivity resulting in functional impairment across two or more settings (American Psychiatric Association [APA], 1994). ADHD affects about 3 to 7 percent of the school-age population (APA, 1994). This number represents about two million students of the United States school systems (Snead, 2005).
ADHD occurs much more often in boys than in girls. Traditionally, females tend to be at lower risk of ADHD than males; however, studies have indicated that young females also may be at increased risk of remaining undetected and untreated (Bussing, & Gary, 2001).One commonly offered explanation for lower rates of detection and treatment females is that ADHDmay be less obvious to parents and is therefore, less likely to prompt help-seeking behavior (Lahey et al., 1988).
Students with ADHD are at a higher than average risk for academic underachievement, conduct problems, and social relationship difficulties, as a function of the core symptoms of ADHD (Barkley, DuPaul, & McMurray, 1990). The disorder is chronic for most individuals and requires long-term treatment (Weiss& Hechtman,1993).
The Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) explained that in ADHD, the essential feature is a persistent pattern of inattention and/or hyperactivity–impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development (p. 78).
Background of the Study
ADHD affects about 3 to 7 percent of the school-age population (APA, 2000). Small strategies and simple interventions do not meet the needs of students challenged by ADHD. A deeper understanding of the symptoms posed by a student’s ADHD must be understood in order to better treat and thus help the student to overcome the effects of ADHD.
Various approaches are available for meeting the educational needs of ADHD students who exhibit a wide spectrum of behaviors. Understanding best practices is imperative for educators in order to better addresseach student’s needs. The role of the public school system in the process of recognition and treatment of ADHD merits special reflection. Schools operate under several legal mandates potentially applicable to students with ADHD. Educators in public schools are required under Section 504 of the 1973 Rehabilitation Act to detect and provide appropriate accommodation services to students with functional impairments in major life activities such as learning (Reid& Katsiyannis, 1995). Although the interpretation of Section 504 is left to the discretion of individual states, this law has been applied increasinglyto students with ADHD (Reid& Katsiyannis, 1995). Furthermore, students with ADHD may qualify for special education services if they have learning disabilities (Office of Special Education, 1992).
The No Child Left BehindAct provides the conceptual framework for identifying intervention strategies for students with ADHD. One factor thatcontributes to the urgency of understanding successful intervention strategies for students with ADHD is within the laws of NCLB. Snead (2005) citedfour basic principles of concentration of NCLB: (a) stronger accountability for results; (b) increased flexibility and local control; (c) expanded options for parents; and (d) an emphasis on teaching methods that have been proven to work. Snead concentrated on the fourth principle as it relates directly to teaching methods that are potentially helpful for students with ADHD. In this study best practices and strategies that are effective for the students with ADHD without losing their interest were examined.
ADHD is not a new phenomenon. The ADHD acronym has been the common label used to describe students with a specified symptom cluster (Anastopoulous & Shelton, 2001). Anastopoulos and Shelton stated that the first published cases of students with symptom clusters similar to those used in the ADHD diagnostic categories appeared in the middle 1800s. Still (1902) reported that students whose behaviors included overactivity and inattention in childhood and persisted over time were significantly developmentally different from their age-appropriate peers.
ADHD students have “volitional inhibitions” that result in behavioral deficits as well as “defects in moral control,” which likely result from neurological difficulties (Anastopoulos & Shelton, 2001, p. 341). The DSM-I did not list any developmentally significant guidelines to distinguish ADHD or its symptoms, whereas the DSM-II did include a section titled “Behavior Disorders of Childhood and Adolescence,” which listed the criteria for Hyperkinetic Reaction of Childhood (Anastopoulos & Shelton, 2001, 341). The DSM-III labeled a cluster of symptoms as “Attention Deficit Disorder with Hyperactivity,” thus inserting the change in focus to inattention as the hallmark feature of this newly emerging disorder at the time. Another profound change in the DSM-III was that it identified impulsivity as a major component in the disorder as it is noted alongside inattention and hyperactivity for the first time (Anastopoulos & Shelton, 2001). The DSM-IV has many new features in the identification of ADHD symptoms, including 18 symptom descriptors, with nine inattention symptoms and nine in the hyperactivity-impulsivity component (Anastopoulos & Shelton, 2001).
The literature suggestedthat middle childhood is a period when students have the most difficulty managing ADHD (Carroll et al., 2006). For instance, students with ADHD have symptoms of inattention, hyperactivity, and impulsivity (Sutcliffe, Bishop, & Houghton, 2006). Moreover, if ADHD goes untreated between the ages of 6 and 12, more serious problems such as “low-self-esteem, depression, oppositional defiant disorder, mood disorder, and conduct disorder” may develop (Parker, 2005, p. 25). Teachers should knowthe signs and symptoms of ADHD so they can make appropriate referrals. Early interventions may save the student and family from much hardship and frustration in the future.
About80%of students with ADHD continue symptoms of “over activity, inattention, and impulsivity,” into their teenage years (Parker, 2005, p. 26). Alexander-Roberts (2006) added that some adolescents who were hyperactive as students became hypoactive (spacey or lethargic) as teenagers. Some of them also developed a need for immediate gratification, were easily distracted, had poor peer relationships, and had low self-esteem (Alexander-Roberts, 2006). Furthermore, adolescents with ADHD showed higher rates of substance abuse issues compared to their non-ADHD peers (Parker, 2005). Again, if elementary school teachers would refer students appropriately for ADHD screening in the early years, then students might receive services during childhood to help manage ADHD throughout childhood, adolescence, and adulthood.
ADHD affects students in myriad ways. Not only is it troublesome for the individual student diagnosed with the disorder, but it may also cause a disruption for other students in the classroom as well. “Students with ADHD often have low self-esteem, are labileemotionally and prone to temper outbursts, and have low frustration tolerance” (Alexander-Roberts, 2006, p. 12). ADHD affects a child’s behavioral, emotional, academic, and social skills (DuPaul & Weyandt, 2006). Furthermore, students with ADHD often display elevated rates of “gross motor activity and fidgeting, negative verbalizations, and various other off-task behaviors different from students without ADHD” (DuPaul & Weyandt, 2006, p. 293), which can be disruptive to classmates. ADHD affects the student at home, in school, in peer relationships, and in virtually all aspects of life.
Students diagnosed with ADHD not only lack in social skills, but also suffer academic performance as well. They have “higher dropout rates, increased frequency of failing grades, and poor academic outcomes compared to youth without ADHD” (Barron, Evans, Baranik, Serpell, & Buvinger, 2006, p. 137). According to Parker (2005), students with some type of mental health disorder, such as ADHD, have “difficulty making and keeping friends, withdrawal from social activities,” and are often late to or absent from school (p. 189).
Furthermore, youth with ADHD “often exhibit co-morbid behaviors such as depression, anxiety, oppositional defiant disorders, and compulsive behaviors” (Reid, Trout,& Schartz, 2005, p. 361). In fact, more than half of all students with ADHD display significant symptoms of oppositional defiant disorder (ODD) and conduct disorder (DuPaul & Weyandt, 2006). Conduct disorders might make it difficult for teachers to recognize the signs and symptoms of ADHD, but ODD and conduct disorders also make it more important to be able to distinguish between ADHD and other childhood disorders.
It is a challenge for some students with ADHD to pay attention in class, follow rules, exert self-control, think about consequences before acting, interact appropriately in games and sports, and develop meaningful relationships with others (Parker, 2005). ADHD affects each individual differently (Alexander-Roberts, 2006) and interventions should apply according to each child’s specific needs.
Teachers play a pivotal role in the lives of many students. “They teach and manage them every day, often identify them as in need of further assistance, and become involved in monitoring and treatment plans” (Lauth, Heubeck, & Mackowiak, 2006, p. 386). Teachers may also be the first to recognize students with ADHD because of the increased demand of concentration in the classroom as well as being able to compare students with each other (Lauth et al., 2006). It may be likely that a teacher is the first person to recognize symptoms of ADHD and thus need to discuss the symptoms with the family. A student diagnosed with ADHD may not only have difficulties in the classroom with inattention, hyperactivity, and impulsivity, but these symptoms “are often associated with troublesome interpersonal relationships with family members” as well (Holmberg & Hjern, 2006, p. 664). The behavioral outcomes from these symptoms cause marital disturbances, conflict between siblings, and parents to feel depressed, blame themselves, and feel socially isolated (Alexander-Roberts, 2006).
An estimated 4.4 million students in the United States have ADHD (Centers for Disease Control and Prevention [CDC], 2005). Of those, 2.5 million take stimulant medication in order to help manage the disorder (CDC. 2005). Each year, health insurance providers in the United States spend about $3.3 billion dollars on health-care costs associated with ADHD (Parker, 2005). Furthermore, Doherty, Frankenberger, Fuhrer, and Snider(2000) found, “There had been a nearly 700% increase in the methylphenidate (Ritalin) production over the time period from 1990 to 1997” (p. 39). Moreover, “90% of the Ritalin was being consumed in the United States for the treatment of ADHD” (Doherty et al., 2000, p. 39).
Overall, ADHD either directly or indirectly affects individuals, families, and communities. Not only do students with ADHD lag behind their peers in a variety of ways, but it also puts an emotional and financial burden on families as well as impacting our society. The literature revealed a variety of interventions thatmight help students with ADHD, their families, teachers, and their classmates.
The literature suggested assorted types of interventionsmight be effective when professionals work with individuals with ADHD. The most well known approach in helping students manage ADHD is the use of stimulant medication (Reid et al., 2005). According to Parker (2005), there have been “more than 200 controlled double-blind studies of stimulant use in students with ADHD, [and] the findings are well documented that these medicines improve attention span, self-control, behavior, fine motor control, and social functioning” (p. 59). On the other hand, researchers documentedthat medication alone is not the most effective intervention in treating ADHD, but when combined with behavior management and educational accommodations medication can be effective (Reid et al., 2005).
Doherty et al. (2000) conducted a survey of middle/junior high and high school students who took stimulant medication in order to manage ADHD. Of the 925 students questioned, all reported themedication helped them with social and behavioral aspects, “but were less sure if it helped them academically” (p. 51). Another study found that “pharmacological interventions produced beneficial effects for some individuals with ADHD; however, psycho-stimulant medications, the class of drugs most frequently used, have not been demonstrated to enhance the academic productivity for many students with ADHD” (Gureasko-Moore, DuPaul, & White, 2006, p. 160).
Moreover, students reported that they took their medication because they felt that their parents and peers liked them better when they were on medication, even though they experienced some side effects such as appetite reduction and insomnia (Doherty et al., 2000; Gureasko-Moore et al., 2006).Other side effects students reported included headaches, fatigue, and developing some type of tic (Doherty et al., 2000).
Much controversy surrounds using stimulant medication in the treatment of ADHD, especially on youth. In fewer than two decades, there has been a nearly 700% increase in methylphenidate (Ritalin) production, the psychostimulant most often prescribed for treatment of ADHD in the U.S. (Doherty et al., 2000; Rafalovich, 2005). One aspect of this problem that needs further study is to explore attitudes and beliefs among elementary school teachers regarding the use of stimulant medication in the treatment of ADHD.
Self-Monitoring and Recording
Students who are diagnosed with ADHD may find it beneficial to use self-monitoring and recording in order to help manage symptoms of inattention, hyperactivity, and impulsivity. Self-monitoring can be used alone or in addition to stimulant medication. According to Reid et al. (2005), self-regulation is defined as “a number of methods used by students to manage, monitor, record, and/or assess their behavior or academic achievement” (p. 362). Such interventions can create meaningful advancements in “student-on-task behavior, academic productivity and accuracy, and reduction of inappropriate or disruptive behaviors,” Reid et al. explained (p. 373).
According to Reid et al. (2005), “ADHD is not a disorder of knowing what to do, but of doing what one knows” (p. 362); therefore, “a combination of medication, behavior modification, school accommodations, and ancillary services” (p. 362) can be effective in the treatment of ADHD. Another purpose of this research is to explore what accommodations school teachers have used and will continue to use in the treatment of ADHD.
Teachers can play a vital role as resource persons for students with ADHD and their families (Parker, 2005). For instance, they can refer families to therapists and doctors who may be able to diagnose and/or treat their child for ADHD, as well as give families information about ADHD. In addition, teachers can educate themselves on how to include a student with ADHD in the classroom and intervene not only on the microlevel (individual), but on the mezzolevel (classroom) as well.
Contingency management is one of the most common behavioral interventions for students with ADHD (Harlacher, Roberts, & Merrell, 2006). Contingency management is a reward system that clearly states expectations and identifies reinforces for not only the student with ADHD, but also every student in the class (Harlacher et al., 2006).
Therapy balls are also becoming popular in elementary schools. They give students opportunities to move around as well as strengthen their back and abdominal muscles (Harlacher et al., 2006). Lastly, it is extremely important for teachers to choose interesting and engaging lesson plans so that students who have difficulty paying attention can benefit from the instruction (Harlacher et al., 2006). It is also helpful if teachers make contracts for students to sign so that students might aim to complete their homework on time.
Along with choosing interesting and engaging lesson plans, teachers can implement a peer-tutoring program (Harlacher et al., 2006). Students who teach often learn and retain information better compared to students who do not teach or tutor. Additionally, students who are on the receiving end of the teaching have a chance to give feedback to their peers. This intervention is especially beneficial for students with ADHD, not only for academic purposes but for developing appropriate social skills as well (Harlacher et al., 2006).
Teachers can set up a peer-mentoring program in their school. The teacher should ask for volunteers from a variety of classrooms and match them with students who have ADHD. The teacher should clarify the expectations and guidelines of the program and continually check in with all students to make sure each pair is benefiting from the program. A peer-mentoring program may raise children’s self-esteem and self-confidence and improve their social skills (Harlacher et al., 2006).