An educational evaluation assesses the extent to which a child's symptoms of ADHD impair his or her academic performance at school. The evaluation involves direct observations of the child in the classroom as well as a review of his or her academic productivity.

Behaviors targeted for classroom observation may include:

Problems of inattention, such as becoming easily distracted, making careless mistakes, or failing to finish assignments on time; Problems of hyperactivity, such as fidgeting, getting out of an assigned seat, running around the classroom excessively or striking out at a peer; Problems of impulsivity, such as blurting out answers to the teacher's questions or interrupting the teacher or other students in the class; and More challenging behaviors, such as severe aggressive or disruptive behavior.

Classroom observations are used to record how often the child exhibits various ADHD symptoms in the classroom. The frequency with which the child with ADHD exhibits these and other target behaviors are compared to norms for other children of the same age and gender. It is also important to compare the behavior of the child with ADHD to the behaviors of other children in his or her classroom.

It is best to collect this information during two or three different observations across several days. Each observation typically lasts about 20 to 30 minutes.

In order to receive special education and related services under Part B of IDEA, a child must be evaluated to determine (1) whether he or she has a disability and (2) whether he or she, because of the disability, needs special education and related services. The initial evaluation must be a full and individual evaluation that assesses the child in all areas related to the suspected disability and uses a variety of assessment tools and strategies. As discussed in the section on Legal Requirements (above), a child who has ADHD may be eligible for special education and related services because he or she also meets the criteria for at least one of the disability categories, such as specific learning disability or emotional disturbance. It is important to note that the assessment instruments and procedures used by educational personnel to evaluate other disabilities-such as learning disabilities-may not be appropriate for the evaluation of ADHD. A variety of assessment tools and strategies must be used to gather relevant functional and developmental information about the child.

An educational evaluation also includes an assessment of the child's productivity in completing classwork and other academic assignments. It is important to collect information about both the percentage of work completed as well as the accuracy of the work. The productivity of the child with ADHD can be compared to the productivity of other children in the class.

Once the observations and testing are complete, a group of qualified professionals and the parents of the child will review the results and determine if the child has a disability and whether the child needs special education and related services. Using this information, the child's IEP team, which includes the child's parents, will develop an individualized educational program that directly addresses the child's learning and behavior. If the child is recommended for evaluation and determined by the child's IEP team not to meet the eligibility requirements under IDEA, the child may be appropriate for evaluation under Section 504.

Medical Evaluation

A medical evaluation assesses whether the child is manifesting symptoms of ADHD, based on the following three objectives:
To assess problems of inattention, impulsivity, and hyperactivity that the child is currently experiencing; To assess the severity of these problems; and To gather information about other disabilities that may be contributing to the child's ADHD symptoms.

Part B of IDEA does not necessarily require a school district to conduct a medical evaluation for the purpose of determining whether a child has ADHD. If a public agency believes that a medical evaluation by a licensed physician is needed as part of the evaluation to determine whether a child suspected of having ADHD meets the eligibility criteria of the OHI category, or any other disability category under Part B, the school district must ensure that this evaluation is conducted at no cost to the parents (OSEP Letter to Michel Williams, March 14, 1994, 21 IDELR 73).

In May 2000, the American Academy of Pediatrics (AAP) published a clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with ADHD. The guideline, developed by a committee comprised of pediatricians and experts in the fields of neurology, psychology, child psychiatry, child development, and education, as well as experts in epidemiology and pediatrics, is intended for use by primary care clinicians who are involved in the identification and evaluation process. The recommendations are designed to provide a framework for diagnostic decisionmaking and include the following:

• Medical evaluation for ADHD should be initiated by the primary care clinician. Questioning parents regarding school and behavioral issues, either directly or through a pre-visit questionnaire, may help alert physicians to possible ADHD.

• In diagnosing ADHD, physicians should use DSM-IV criteria.

• The assessment of ADHD should include information obtained directly from parents or caregivers, as well as a classroom teacher or other school professional, regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment.

Evaluation of a child with ADHD should also include assessment of co-existing conditions such as learning and language problems, aggression, disruptive behavior, depression, or anxiety.

What Are the Treatment Options?

Although at present no cure for ADHD exists, there are a number of treatment options that have proven to be effective for some children. Effective strategies include behavioral, pharmacological, and multimodal methods.

Behavioral Approaches

Behavioral approaches represent a broad set of specific interventions that have the common goal of modifying the physical and social environment to alter or change behavior (AAP, 2001). They are used in the treatment of ADHD to provide structure for the child and to reinforce appropriate behavior. Those who typically implement behavioral approaches include parents as well as a wide range of professionals, such as psychologists, school personnel, community mental health therapists, and primary care physicians. Types of behavioral approaches include behavioral training for parents and teachers (in which the parent and/or teacher is taught child management skills), a systematic program of contingency management (e.g. positive reinforcement, "time outs," response cost, and token economy), clinical behavioral therapy (training in problem-solving and social skills), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, development of problem-solving strategies, self-reinforcement) (AAP, 2001; Barkley, 1998b; Pelham, Wheeler, & Chronis, 1998). In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behavior. Of these options, systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained individuals have been found to be highly effective (Abramowitz, et al., 1992; Carlson, et al., 1992; Pelham & Hoza, 1996). A later study conducted by Pelham, Wheeler, and Chronis (1998) indicates that two approaches-parent training in behavior therapy and classroom behavior interventions-also are successful in changing the behavior of children with ADHD. In addition, home-school interactions that support a consistent approach are important to the success of behavioral approaches.

The use of behavioral strategies holds promise but also presents some limitations. Behavioral strategies may be appealing to parents and professionals for the following reasons:

Behavioral strategies are used most commonly when parents do not want to give their child medication; Behavioral strategies also can be used in conjunction with medicine (see multimodal methods); Behavioral techniques can be applied in a variety of settings including school, home, and the community; and Behavioral strategies may be the only options if the child has an adverse reaction to medication.

The research results on the effectiveness of behavioral techniques are mixed. While studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy (Pelham & Fabiano, 2001), it is difficult to isolate its effectiveness. The multiplicity of interventions and outcome measures makes careful analysis of the effects of behavior therapy alone, or in association with medications, very difficult (AAP, 2001). A review conducted by McInerney, Reeve, and Kane (1995) confirms that the effective education of children with ADHD requires modifications to academic instruction, behavior management, and classroom environment. Although some research suggests that behavioral methods offer the opportunity for children to work on their strengths and learn self-management, other research indicates that behavioral interventions are effective but to a lower degree than treatment with psychostimulants (Jadad, Boyle, & Cunningham, 1999; Pelham, et al., 1998).

Behavior therapy has been found to be effective only when it is implemented and maintained (AAP, 2001). Indeed, behavioral strategies can be difficult to implement consistently across all of the settings necessary for it to be maximally effective. Although behavioral management programs have been shown to enhance the academic performance and behavior of children with ADHD, followup and maintenance of the treatment is often lacking (Rapport, Stoner, & Jones, 1986).

In fact, some research has shown that behavioral techniques may fail to reduce ADHD's core characteristics of hyperactivity, impulsivity, and inattention (AAP, 2001; U.S. Department of Health and Human Services [DHHS], 1999). Conversely, one must consider that the problems of children with ADHD are seldom limited to the core symptoms themselves (Barkley, 1990a). Children frequently demonstrate other types of psychosocial difficulties, such as aggression, oppositional defiant behavior, academic underachievement, and depression (Barkley, 1990a). Because many of these other difficulties cannot be managed through psychostimulants, behavioral interventions may be useful in addressing ADHD and other problems a child may be exhibiting.

Pharmacological Approaches

Pharmacological treatment remains one of the most common, yet most controversial, forms of ADHD treatment. It is important to note that the decision to prescribe any medicine is the responsibility of medical-not educational-professionals, after consultation with the family and agreement on the most appropriate treatment plan. Pharmacological treatment includes the use of psychostimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers (NIMH, 2000). Stimulants predominate in clinical use and have been found to be effective with 75 to 90 percent of children with ADHD (DHHS, 1999). Stimulants include Methylphenidate (Ritalin), Dextroamphetamine (Dexedrine), and Pemoline (Cylert). Other types of medication (antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers) are used primarily for those who do not respond to stimulants, or those who have coexisting disorders. The results of the Multimodal Treatment Study (MTA), which are discussed in further detail in the next section, confirm research findings on the use of pharmacological treatment for patients with ADHD. Specifically, the study found that the use of medication was almost as effective as the multimodal treatment of medication and behavioral interventions (Edwards, 2002).

Administering Medication at School
Develop a plan to ensure that medication is administered in accordance with doctor's recommendation Include this plan in the child's IEP Maintain child and parent rights to medical confidentiality

Researchers believe that psychostimulants affect the portion of the brain that is responsible for producing neurotransmitters. Neurotransmitters are chemical agents at nerve endings that help electrical impulses travel among nerve cells. Neurotransmitters are responsible for helping people attend to important aspects of their environment. The appropriate medication stimulates these underfunctioning chemicals to produce extra neurotransmitters, thus increasing the child's capacity to pay attention, control impulses, and reduce hyperactivity. Medication necessary to achieve this typically requires multiple doses throughout the day, as an individual dose of the medication lasts for a short time (1 to 4 hours). However, slow- or timed-release forms of the medication (for example, Concerta) may allow a child with ADHD to continue to benefit from medication over a longer period of time. Doctors, teachers, and parents should communicate openly about the child's behavior and disposition in order to get the dosage and schedule to a point where the child can perform optimally in both academic and social settings, while keeping side effects to a minimum. If it is determined that the child should receive medication during the school day, it is important to develop a plan to ensure that medication is administered in accordance with the plan. Such a plan would be an appropriate component of the child's IEP. In addition, schools must ensure that the child's and parent's rights to medical confidentiality are maintained.

Although the positive effects of the stimulant medication are immediate, all medications have side effects. Adjusting the dosage of the medicine can diminish some of these side effects. Some of the more common side effects include insomnia, nervousness, headaches, and weight loss. In fewer cases, subjects have reported slowed growth, tic disorders, and problems with thinking or with social interaction (Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995). Medication also can be expensive, depending upon the medicine prescribed, the frequency of administration, and the subsequent frequency of refills. Stimulant medicines do not "normalize" the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers (DHHS, 1999). Nonetheless, the American Academy of Pediatrics (AAP) finds that at least 80 percent of children will respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who do not respond to one medication may have a positive response to an alternative medication, and concludes that stimulants may be a safe and effective way to treat ADHD in children (AAP, 2001).

In January 2003, a new type of nonstimulant medication for the treatment of children and adults with ADHD was approved by the FDA. Atomoxetine, also known as Straterra, may be prescribed by physicians in some cases.

Multimodal Approaches

Research indicates that for many children the best way to mitigate symptoms of ADHD is the use of a combined approach. A recent study by the NIMH-the Multimodal Treatment Study of Children with ADHD (MTA)-is the longest and most thorough study of the effects of ADHD interventions (MTA Cooperative Group, 1999a, 1999b). The study followed 579 children between the ages of 7 and 10 at six sites nationwide and in Canada. The researchers compared the effects of four interventions: medication provided by the researchers, behavioral intervention, a combination of medication and behavioral intervention, and no-intervention community care (i.e., typical medical care provided in the community).

Multimodal intervention improves:

Academic performance Parent-child interaction School-related behavior and reduces . . . Child anxiety Oppositional behavior

Of the four interventions investigated, the researchers found that the combined medication/behavior treatment and the medication treatment work significantly better than behavioral therapy alone or community care alone at reducing the symptoms of ADHD. Multimodal treatments were especially effective in improving social skills for students coming from high-stress environments and children with ADHD in combination with symptoms of anxiety or depression. The study revealed that a lower medication dosage is effective in multimodal treatments, whereas higher doses were needed to achieve similar results in the medication-only treatment.

Researchers found improvement in the following areas after using a multimodal intervention: child anxiety, academic performance, oppositional behavior, and parent-child interaction. Positive results also were found in school-related behavior when multimodal treatment is coupled with improved parenting skills, including more effective disciplinary responses, and appropriate reinforcements (Hinshaw, et al., 2000). These findings were replicated across all six research sites, despite substantial differences among sites in their samples' sociodemographic characteristics. The study's overall results appear to apply to a wide range of children and families identified as in need of treatment services for ADHD (NIMH, 2000). Other studies demonstrate that multimodal treatments hold value for those children for whom treatment with medication alone is not sufficient (Klein, Abikoff, Klass, Ganeles, Seese, & Pollack, 1997).

In October 2001, the AAP released evidence-based recommendations for the treatment of children diagnosed with ADHD. Their guidelines state that:

• Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition;

• The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management;

• The clinician should recommend stimulant mediation and/or behavioral therapy as appropriate to improve target outcomes in children with ADHD;

• When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and the presence of coexisting conditions; and

• The clinician should periodically provide a systematic followup for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers, and the child.

The AAP report stressed that the treatment of ADHD (whether behavioral, pharmacological, or multimodal) requires the development of child-specific treatment plans that describe not only the methods and goals of treatment, but also include means of monitoring over time and specific plans for followup. The process of developing target outcomes requires careful input from parents, children, and teachers as well as other school personnel where available and appropriate. The AAP concluded that parents, children, and educators should agree on at least three to six key targets and desired changes as requisites for constructing the treatment plan. The goals should be realistic, attainable, and measurable. The AAP report found that, for most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances (AAP, 2001).

Top