There is increasing evidence that many children with attention-deficit/hyperactivity disorder (ADHD) engage in high rates of behavior and to such a marked degree that their academic, behavioral, and /or interpersonal functioning is inhibited. Wolraich, Hannah, Pinnock, Baumgaertel and Brown asked teachers of children in kindergarten through fifth grade to rate their students in regard to their school functioning.1 Of children who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for ADHD, predominantly inattentive type, 72% were reported to have academic difficulties and 33% had behavior problems, and of those who were rated by their teachers to meet the criteria for the predominantly hyperactive /impulsive type, 24% were reported to have academic problems, and approximately 73% were rated as having problems with behavior. In addition, it has been documented that children with ADHD, particularly those who are aggressive, have serious problems in their social interactions with peers and are more likely to be disliked, ignored, or actively rejected than their peers.2·3 It has also been estimated that of children who are diagnosed with ADHD, 35% have learning disabilities.4 Thus, children with ADHD are at risk for school failure, academic and vocational underachievement, and /or rejection from their peer group.5·6-7 Since most children with ADHD experience significant difficulty conforming to the expectations established by schools, whether academic, social, or behavioral, schools must play a critical role in providing behavioral support, academic support, or both for children with ADHD.
LAWS THAT AFFECT THE SERVICES PROVIDED THROUGH THE PUBLIC SCHOOLS
There are two primary laws that have an impact on the services provided by public schools: Section 504 of the Rehabilitation Act of 1973, and the Individuals with Disabilities Act (IDEA). In 1991, the Department of Education confirmed that ADHD could be considered within the scope of the Education for All Handicapped Children Act, which was reauthorized in June 1997 as the Individuals with Disabilities Act (IDEA). Depending on the circumstances, a child can be considered for services under IDEA as other health impaired; emotionally disturbed; or learning disabled. IDEA is a funding statute based on a categorical approach (ie, categories of disabilities) and funds a portion of the costs for educating children with disabilities.8 Under IDEA, schools are responsible for identifying and evaluating children who are suspected of having disabilities and who may need special education services under an individualized education plan (IEP).
The specific criteria for diagnosing a learning disability may vary from state to state. The child can be identified with a learning disability based on a processing disorder and a significant discrepancy between ability and achievement in any one or a combination of seven domains: oral expression; listening comprehension; written expression; basic reading skills; reading comprehension; mathematics calculation; and mathematics reasoning. A school psychologist usually completes all or a portion of the testing for a learning disability.
Another category under which children with ADHD may qualify for special education services is an emotional disturbance. The child must demonstrate at least one of the following to such a marked degree and for an extended time period that the child's educational performance is impaired: an inability to learn which cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression; or a tendency to develop physical symptoms or fears associated with personal or school problems. A comprehensive evaluation that meets federal and state requirements must be completed before diagnosing an emotional disturbance. Consequently, a physician's statement determining anxiety in a patient is insufficient for certification of an emotional disturbance. For a child with ADHD to qualify for special education services as "other health impaired," the child must have written documentation of a diagnosis of ADHD by an appropriate professional, and there must be documented evidence that the child has limited alertness that impairs his or her school functioning.
Parents can initiate the referral process if their child is doing poorly in one of the domains of functioning, academic, behavioral, and /or social. To make a referral, it is recommended that the parent or legal guardian write a letter to the principal indicating their concern for their child's academic, behavioral, or social functioning. Sending a copy of mis letter to the child's pediatrician and the school system's director of special education is also recommended. The principal or another school representative will convene a meeting to consider die request for an evaluation. At this meeting, the committee may recommend interventions to be implemented by the student's teachers and other school personnel.
If a child continues to struggle despite interventions and modifications, the committee may recommend a comprehensive evaluation. This evaluation will be completed at school expense. A multidisciplinary team or group must evaluate the child, and the evaluation must be both comprehensive and objective. The initial evaluation can only take place with informed consent from the parent or legal guardian. Public schools must conduct and pay for this evaluation whether ADHD is a medical or educational diagnosis.
For example, if a public school system requires an assessment by a medical professional in order to diagnose ADHD before determining eligibility under IDEA, the school would be required to pay for the assessment when the team recommends the assessment. If, on the other hand, the public school determines that ADHD is an educational diagnosis, die school psychologist can complete the assessment and make the diagnosis. The team is not required to accept a diagnosis that is made by an outside source. The team may refuse to provide services, but this refusal must be justified by an evaluation.8
After the evaluation has been completed, the team reviews all data to determine if the child is eligible for special education services under IDEA. One cannot automatically assume eligibility for services based solely on the ADHD diagnosis. If this team of professionals and the child's parents determine that a child is eligible for special education services through one of the recognized handicaps in the federal IDEA guidelines, the team will develop an IEP to address the child's deficit areas, which can include academic, behavior, social functioning, and/or adaptive functioning.
Once the child is eligible for special education services, the team will meet at least one time during each school year to write or modify the child's 1ER The team can meet more frequently if parents or school personnel believe the child's program is not appropriately meeting his or her needs. These meetings will continue throughout the child's years in school or until the child is no longer eligible for special education services. In order to determine that a child is no longer eligible for special education services, the school must reevaluate him or her, and the child must no longer meet the eligibility criteria as outlined under the IDEA guidelines. Schools are not required to reevaluate every 3 years unless an evaluation is needed for intervention planning. This team of professionals is also responsible for writing a transition plan for a child who receives services under IDEA. This plan will assist the student when transitioning from the school environment to a post-secondary environment (eg, college or career). It is recommended that transition planning begin when the student is in the elementary or middle school grades; however, the plan should begin no later than 14 years of age. In doing so, most schools will attach an individual transition plan to the IEP.
When a child does not qualify for special education services under IDEA, he or she may qualify for services under Section 504 of the Rehabilitation Act. Section 504 is a non-discrimination statute and applies to all public and private organizations that receive federal financial assistance. The law prohibits discrimination against any person with a disability. ADHD is considered a disability under 504 when a person is substantially limited in a major life activity.8 Failure to learn in school is considered a major life activity; thus, schools cannot fail to provide an education that is comparable to the child's peers if he or she qualifies under 504 guidelines. Possible accommodations for the child with ADHD under Section 504 include reduced class size, tutoring, modifications in homework and classwork assignments, behavior management strategies, notetakers, and adaptations in non-academic areas (eg, music class, physical education).
If there are concerns that a child's rights have not been protected, there are procedural safeguards whereby a parent may challenge the deäsion(s) of the assessment, support, or IEP teams. Each school system is required to provide each parent with written documentation of these procedural safeguards and their rights to due process.
THE SCHOOL'S RESPONSIBILITY
Behavioral interventions are a strong component of school treatment for children with ADHD, particularly children with the hyperactive-impulsive or combined types. The 1997 amendments to IDEA mandates that IEP teams use a functional behavior assessment and behavior intervention plan that include positive behavioral interventions for students with disabilities when problem behaviors provoke consideration of a change in placement, which includes expulsion and suspension.9 A child with ADHD who is being served under IDEA and exhibits chronic behavior problems would fit into this category. However, schools are strongly encouraged to avoid waiting for a child to meet IDEA certification regulations before positive behavioral supports are implemented. It has been demonstrated that schools could dramatically reduce discipline rates when research-validated practices that promote positive behaviors are implemented across total school environments.10
For example, one Kentucky school decreased students' hours in in-school suspension by 61% during its first year of using a schoolwide positive behavior support plan. Their plan included staff consistency, schoolwide appraisal of predictable problems and solutions, dearly defined and taught expectations in problem areas of the school (eg, cafeteria, hallways), and reinforcement for desired behavior.11
However, when these positive behavioral support systems are insufficient for the student to function in the school setting, a functional behavioral assessment is needed. The functional behavioral assessment is a process whereby problem behaviors are analyzed in relation to the antecedent and consequent events that may explain why the problem behavior occurs. This process is referred to as an a-b-c analysis. In this process, the behavioral specialist examines the antecedents (triggers) that predict the behavior will or will not occur, the behavior itself, and the consequences that follow die behavior (positive or negative). By using this approach, the team can determine the function of the behavior (eg, selfregulation, attention, escape) and then be able to develop a behavioral intervention plan, crisis management plan, or both, that will assist the child to function within the school environment.
Behavioral interventions in the school setting typically include three types of strategies: prevention, teaching, and, responding.12 Preventive strategies may include the physical arrangement of classroom space, positively stated and posted classroom rules, well-developed and developmentally appropriate content and delivery of lessons, the use of routines and schedules, and schoolwide behavior plans. One of the most effective prevention strategies is when students are actively engaged in academic instruction that is matched to their abilities.
Teaching strategies to students are critical to a behavioral intervention plan; however, the teacher often overlooks this phase of the intervention plan. This strategy involves the identification of an alternative skill (replacement behavior) that will replace the problem behavior but allow the student to still have his or her needs met. After the alternative skill has been identified, the student is taught when and how to use the skill, and the teacher reinforces the newly learned skill,
There are a number of approaches used to teach new skills, which may include modeling, coaching, and practicing. An example of an alternative skill to blurting out answers would be to teach the child to raise a card to request to give a verbal response. The child might then earn time to leave the classroom to read in the office as the reinforcement for the alternative behavior. Thus, the child has learned an alternative skill that still allows for his or her needs to be met. When teaching a new skill, the teacher must begin where the student is and gradually work up to the desired level of classroom behavior.
Responding strategies follow the student's behavior. When effective strategies are used, negative behaviors can be reduced or eliminated, and positive behaviors can be increased. Responding strategies include reinforcing positive behaviors, providing mild forms of punishment for negative behaviors, using response cost and token economy systems of behavior management, and implementing daily report cards or behavioral contracts. A daily report card is an effective tool for schools to use when targeting several behaviors for improvement. It typically targets 3 to 5 behaviors that are broken down into specific, measurable goals that will result in improved behavior and academic performance when consistently monitored and reinforced. For additional information on the use of daily report cards for students with ADHD, contact William Pelham, PhD, at the Center for Children and Families at the University of Buffalo.
Responding strategies should follow a hierarchy approach to decision making from the least restrictive intervention (eg, nonverbal strategy such as proximity control) to the highest restrictive intervention. For example, when a nonverbal technique does not work to manage behavior, the teacher would select a verbal technique that moves from more child control (eg, verbal praise to an adjacent peer) to more teacher control (eg, direct command to child demonstrating misbehavior).
The third level of intervention would involve specific consequences for dealing with disruptive behavior, with corporal punishment having no place in a school setting. Response cost systems are typically a good responding strategy for the child demonstrating chronic behavior problems when nonverbal and verbal interventions are inadequate to change or redirect behaviors. A response cost system includes the loss of a reinforcer that is contingent upon an undesired behavior. Undesirable side effects (eg, aggression, escape) are reduced more with response cost systems than with other forms of punishment.13 Punishments such as expulsion or suspensions of more than 10 days in a school year cannot be used for a child receiving services under IDEA unless the IEP team has proven that the behavior is not a manifestation of the student's disability.14
INTERVENTION WITH SOCIAL INTERACTION PROBLEMS
Numerous studies have documented that children with ADHD exhibit high rates of social dysfunction and are frequently disliked, ignored, or rejected by their peers.15-3 Parents often report that their child does not receive invitations to birthday parties, that he or she only plays with younger children, that he or she is not invited a second time to peers' homes, or that he or she is unable to maintain friendships. With this population of children, it is recognized that the child typically has knowledge of social skills but is unable to perform those skills at the appropriate time. Consequently, typical social skills training that occurs in the office setting has demonstrated limited success.
Schools that conduct social skills training programs should carefully assess the individual needs of each student before selecting a curriculum. Components of most social skills programs include modeling by the teacher or through videos, children role-playing real-life situations, and then instructors providing feedback to the child. To improve generalization to other settings, homework assignments are frequently given so that the parent can reinforce the social skill when demonstrated at home. Coaching the child on when he or she should use a skill increases the likelihood that a child will be able to generalize the skills to other settings. This type of intervention could be included in the IEP or behavior intervention plan.
SCHOOL-SPONSORED PARENT EDUCATION PROGRAMS
Although laws do not require that schools provide parent training to its families, many schools are providing mis intervention to parents of children who exhibit disruptive behaviors. In a 1year follow-up study, Strayhorn and Weidman reported significantly improved school behavior for children whose parents received parent training when compared to those in a control group.18 In addition, the combined treatment of behavioral intervention and medication is more effective than either treatment alone. By training parents in behavior management techniques and instructing them on the use of home-school incentive programs, parents can have greater influence on treatment outcomes and are better informed on the activities and behaviors that occur in school. Parent education programs should be behavioral-based and focus on strategies that improve behavior and compliance in children who demonstrate high rates of disruptive behavior, and the programs should not hold to the premise that the child's problems are solely the result of poor parenting skills.16
To manage the symptoms of ADHD effectively, communication, support, and cooperation among all professionals and parents are critical to the child's success in school. Each person on the child's team is instrumental in the success of interventions; no one person should bear full responsibility. With periodic feedback given to the physician by the teacher on the child's classroom functioning, management can be more successful. This communication can be delivered through various ways, such as phone calls, faxing weekly behavioral checklists, or attendance at school meetings. In addition, the daily report card is an excellent way to provide information to physicians while simultaneously intervening for a behavior change.
On occasion, however, there may be a child who is unable to function in the school environment despite the implementation of research-validated behavioral strategies and regular communication among team members. When this occurs, teachers must acknowledge the need for outside assistance. Referrals to outside sources should follow procedures developed by school administrators, and one team member should not make unilateral referral decisions. This may help to prevent one professional from overstepping his or her professional boundaries of conduct. Although the type of communication between physician, teacher, and parent may vary, the communication must occur to ensure success for the child in the school setting.
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