![](media/image1.png){width="5.999305555555556in"
height="3.8131944444444446in"}

Identifying and Treating\
Attention Deficit\
Hyperactivity Disorder:

**A Resource for School and Home**

**2003**

Identifying and Treating\
Attention Deficit\
Hyperactivity Disorder:

**A Resource for School and Home**

**2003**![](media/image2.png){width="1.4423611111111112in"
height="1.2097222222222221in"}![](media/image3.png){width="1.2645833333333334in"
height="1.2833333333333334in"}

This report was produced under U.S. Department of Education Contract No.
HS97017002 with the American Institutes for Research. Kelly Henderson
served as technical representative for this project.

**U.S. Department of Education\
**Rod Paige\
*Secretary*

**Office of Special Education and Rehabilitative Services\
**Robert H. Pasternack\
*Assistant Secretary*

**Office of Special Education Programs\
**Stephanie Lee\
*Director*

**Research to Practice Division\
**Louis C. Danielson\
*Director*

August 2003

This report is in the public domain. Authorization to reproduce it in
whole or in part is granted. While permission to reprint this
publication is not necessary, the citation should be: U.S. Department of
Education, Office of Special Education and Rehabilitative Services,
Office of Special Education Programs, *Identifying and Treating
Attention Deficit Hyperactivity Disorder: A Resource for School and
Home,* Washington, D.C., 20202.

To order copies of this report,

**write to:** ED Pubs, Education Publications Center, U.S. Department of
Education, P. O. Box 1398,\
Jessup, MD 20794-1398;

or **fax** your request to: (301) 470-1244;

or **e-mail** your request to: edpubs@inet.ed.gov.

or **call** in your request toll-free: 1-877-433-7827 (1-877-4-ED-PUBS).
If 877 service is not yet available in your area, call\
1-800-872-5327 (1-800-USA-LEARN). Those who use a telecommunications
device for the deaf (TDD) or a teletypewriter (TTY), should call
1-800-437-0833.

or **order online** at: www.ed.gov/pubs/edpubs.html.

This report is also available on the Department's Web site at:
www.ed.gov/offices/OSERS/OSEP/.

On request, this publication is available in alternate formats, such as
Braille, large print, audiotape, or computer diskette. For more
information, please contact the Department's Alternate Format Center at
(202) 260-9895 or (202) 205-8113.

CONTENTS

[Identifying and Treating Attention Deficit Hyperactivity Disorder: A
Resource for School and Home
1](#identifying-and-treating-attention-deficit-hyperactivity-disorder-a-resource-for-school-and-home)

[What Causes ADHD? 2](#what-causes-adhd)

[How Do We Identify ADHD? 3](#how-do-we-identify-adhd)

[Legal Requirements for Identification of and Educational Services for
Children With ADHD
5](#legal-requirements-for-identification-of-and-educational-services-for-children-with-adhd)

[Behavioral Evaluation 6](#behavioral-evaluation)

[Educational Evaluation 7](#educational-evaluation)

[Medical Evaluation 8](#medical-evaluation)

[What Are the Treatment Options? 9](#what-are-the-treatment-options)

[Behavioral Approaches 9](#behavioral-approaches)

[Pharmacological Approaches 10](#pharmacological-approaches)

[Multimodal Approaches 12](#multimodal-approaches)

[How Does ADHD Affect School Performance?
13](#how-does-adhd-affect-school-performance)

[Helpful Hints 13](#helpful-hints)

[Tips for Home 14](#tips-for-home)

[Tips for School 15](#tips-for-school)

[References 16](#references)

# Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home

We have all had one of these experiences at one time or another. Perhaps
it was at the grocery store, watching frustrated parents call their
children's names repeatedly and implore them to "put that down." Maybe
it was a situation at school with a child who could not seem to sit
still and was always in motion. Maybe we noticed a child who appears
always to be daydreaming in class---the student who will not focus on an
activity long enough to finish it. Possibly the child is bored with a
task, seemingly as soon as it has begun, and wants to move on to
something else. We all puzzle over these challenging behaviors.

Attention Deficit Hyperactivity Disorder (ADHD) has many faces and
remains one of the most talked-about and controversial subjects in
education. Hanging in the balance of heated debates over medication,
diagnostic methods, and treatment options are children, adolescents, and
adults who must manage the condition and lead productive lives on a
daily basis.

+-----------------------------------------------------------------------+
| What is ADHD?                                                         |
+-----------------------------------------------------------------------+
| -   Definition                                                        |
|                                                                       |
| -   Core Categories                                                   |
|                                                                       |
| -   Comorbidity                                                       |
|                                                                       |
| -   Social Impact                                                     |
|                                                                       |
| -   Prevalence                                                        |
+-----------------------------------------------------------------------+

Attention Deficit Hyperactivity Disorder (ADHD) is a neurological
condition that involves problems with inattention and
hyperactivity-impulsivity that are developmentally inconsistent with the
age of the child. We are now learning that ADHD is not a disorder of
attention, as had long been assumed. Rather, it is a function of
developmental failure in the brain circuitry that monitors inhibition
and self-control. This loss of self-regulation impairs other important
brain functions crucial for maintaining attention, including the ability
to defer immediate rewards for later gain (Barkley, 1998a). Behavior of
children with ADHD can also include excessive motor activity. The high
energy level and subsequent behavior are often misperceived as
purposeful noncompliance when, in fact, they may be a manifestation of
the disorder and require specific interventions. Children with ADHD
exhibit a range of symptoms and levels of severity. In addition, many
children with ADHD often are of at least average intelligence and have a
range of personality characteristics and individual strengths.

Children with ADHD typically exhibit behavior that is classified into
two main categories: poor sustained attention and
hyperactivity-impulsiveness. As a result, three subtypes of the disorder
have been proposed by the American Psychiatric Association in the fourth
edition of the *Diagostic and Statistical Manual of Mental Disorders
(DSM-IV):* predominantly inattentive, predominantly
hyperactive-impulsive, and combined types (Barkley, 1997). A child
expressing hyperactivity commonly will appear fidgety, have difficulty
staying seated or playing quietly, and act as if driven by a motor.
Children displaying impulsivity often have difficulty participating in
tasks that require taking turns. Other common behaviors may include
blurting out answers to questions instead of waiting to be called and
flitting from one task to another without finishing. The inattention
component of ADHD affects the educational experience of these children
because ADHD causes them to have difficulty in attending to detail in
directions, sustaining attention for the duration of the task, and
misplacing needed items. These children often fail to give close
attention to details, make careless mistakes, and avoid or dislike tasks
requiring sustained mental effort.

Although these behaviors are not in themselves a learning disability,
almost one-third of all children with ADHD have learning disabilities
(National Institute of Mental Health \[NIMH\], 1999). Children with ADHD
may also experience difficulty in reading, math, and written
communication (Anderson, Williams, McGee, & Silva, 1987; Cantwell &
Baker, 1991; Dykman, Akerman, & Raney, 1994; Zentall, 1993).
Furthermore, ADHD commonly occurs with other conditions. Current
literature indicates that approximately 40--60 percent of children with
ADHD have at least one coexisting disability (Barkley, 1990a; Jensen,
Hinshaw, Kraemer, et al., 2001; Jensen, Martin, & Cantwell, 1997).
Although any disability can coexist with ADHD, certain disabilities seem
to be more common than others. These include disruptive behavior
disorders, mood disorders, anxiety disorders, tics and Tourette's
Syndrome, and learning disabilities (Jensen, et al., 2001). In addition,
ADHD affects children differently at different ages. In some cases,
children initially identified as having hyperactive-impulsive subtype
are subsequently identified as having the combined subtype as their
attention problems surface.

These characteristics affect not only the academic lives of students
with ADHD, they may affect their social lives as well. Children with
ADHD of the predominantly hyperactive-impulsive type may show aggressive
behaviors, while children of the predominantly inattentive type may be
more withdrawn. Also, because they are less disruptive than children
with ADHD who are hyperactive or impulsive, many children who have the
inattentive type of ADHD go unrecognized and unassisted. Both types of
children with ADHD may be less cooperative with others and less willing
to wait their turn or play by the rules (NIMH, 1999; Swanson, 1992;
Waslick & Greenhill, 1997). Their inability to control their own
behavior may lead to social isolation. Consequently, the children's
self-esteem may suffer (Barkley, 1990a).

In the United States, an estimated 1.46 to 2.46 million children
(3 percent to 5 percent of the student population) have ADHD (American
Psychiatric Association, 1994; Anderson, et al., 1987; Bird, et al.,
1988; Esser, Schmidt, & Woemer, 1990; Pastor & Reuben, 2002; Pelham,
Gnagy, Greenslade, & Milich, 1992; Shaffer, et al., 1996; Wolraich,
Hannah, Pinock, Baumgaertel, & Brown, 1996). Boys are four to nine times
more likely to be diagnosed, and the disorder is found in all cultures,
although prevalence figures differ (Ross & Ross, 1982).

## What Causes ADHD?

ADHD has traditionally been viewed as a problem related to attention,
stemming from an inability of the brain to filter competing sensory
inputs such as sight and sound. Recent research, however, has shown that
children with ADHD do not have difficulty in that area. Instead,
researchers now believe that children with ADHD are unable to inhibit
their impulsive motor responses to such input (Barkley, 1997; 1998a).

It is still unclear what the direct and immediate causes of ADHD are,
although scientific and technological advances in the field of
neurological imaging techniques and genetics promise to clarify this
issue in the near future. Most researchers suspect that the cause of
ADHD is genetic or biological, although they acknowledge that the
child's environment helps determine specific behaviors.

Imaging studies conducted during the past decade have indicated which
brain regions may malfunction in patients with ADHD, and thus account
for symptoms of the condition (Barkley, 1998a). A 1996 study conducted
at the National Institutes for Mental Health (NIMH) found that the right
prefrontal cortex (part of the cerebellum) and at least two of the
clusters of nerve cells known collectively as the basal ganglia are
significantly smaller in children with ADHD (as cited in Barkley,
1998a). It appears that these areas of the brain relate to the
regulation of attention. Why these areas of the brain are smaller for
some children is yet unknown, but researchers have suggested mutations
in several genes that are active in the prefrontal cortex and basal
ganglia may play a significant role (Barkley, 1998a). In addition, some
nongenetic factors have been linked to ADHD including premature birth,
maternal alcohol and tobacco use, high levels of exposure to lead, and
prenatal neurological damage. Although some people claim that food
additives, sugar, yeast, or poor child rearing methods lead to ADHD,
there is no conclusive evidence to support these beliefs (Barkley,
1998a; Neuwirth, 1994; NIMH, 1999).

## How Do We Identify ADHD?

Although toddlers and preschoolers, on occasion, may show
characteristics of ADHD, some of these behaviors may be normal for their
age or developmental stage. These behaviors must be exhibited to an
abnormal degree to warrant identification as ADHD. Even with older
children, other factors (including environmental influences) can produce
behaviors resembling ADHD.

The criteria set forth by the fourth edition of the *Diagnostic and
Statistical Manual of Mental Disorders* *(DSM-IV)* are used as the
standardized clinical definition to determine the presence of ADHD (see
DSM-IV Criteria for ADHD). A person must exhibit several characteristics
to be clinically diagnosed as having ADHD:

**Severity.** The behavior in question must occur more frequently in the
child than in other children at the same developmental stage.

**Early onset.** At least some of the symptoms must have been present
prior to age 7.

**Duration.** The symptoms must also have been present for at least 6
months prior to the evaluation.

**Impact.** The symptoms must have a negative impact on the child's
academic or social life.

**Settings.** The symptoms must be present in multiple settings.

The specific DSM-IV criteria are set forth in the following chart.

+-----------------------------------------------------------------------+
| ***DSM-IV Criteria for Attention Deficit/Hyperactivity Disorder***    |
|                                                                       |
| > A. According to the DSM-IV, a person with Attention                 |
| > Deficit/Hyperactivity Disorder must have either (1) or (2):         |
| >                                                                     |
| > \(1\) Six (or more) of the following symptoms of **inattention**    |
| > have persisted for at least 6 months to a degree that is            |
| > maladaptive and inconsistent with developmental level:              |
| >                                                                     |
| > **Inattention**                                                     |
| >                                                                     |
| > \(a\) often fails to give close attention to details or makes       |
| > careless mistakes in school work, work, or other activities         |
| >                                                                     |
| > \(b\) often has difficulty sustaining attention in tasks or play    |
| > activities                                                          |
| >                                                                     |
| > \(c\) often does not seem to listen when spoken to directly         |
| >                                                                     |
| > \(d\) often does not follow through on instructions and fails to    |
| > finish schoolwork, chores, or duties in the workplace (not due to   |
| > oppositional behavior or failure to understand instructions)        |
| >                                                                     |
| > \(e\) often has difficulty organizing tasks and activities          |
| >                                                                     |
| > \(f\) often avoids, dislikes, or is reluctant to engage in tasks    |
| > that require sustained mental effort (such as schoolwork or         |
| > homework)                                                           |
| >                                                                     |
| > \(g\) often loses things necessary for tasks or activities (e.g.,   |
| > toys, school assignments, pencils, books, or tools)                 |
| >                                                                     |
| > \(h\) is often easily distracted by extraneous stimuli              |
| >                                                                     |
| > \(i\) is often forgetful in daily activities                        |
| >                                                                     |
| > \(2\) Six (or more) of the following symptoms of                    |
| > hyperactivity-impulsivity have persisted for at least 6 months to a |
| > degree that is maladaptive and inconsistent with developmental      |
| > level:                                                              |
| >                                                                     |
| > **Hyperactivity**                                                   |
| >                                                                     |
| > \(a\) often fidgets with hands or feet or squirms in seat           |
| >                                                                     |
| > \(b\) often leaves seat in classroom or in other situations in      |
| > which remaining seated is expected                                  |
| >                                                                     |
| > \(c\) often runs about or climbs excessively in situations in which |
| > it is inappropriate (in adolescents or adults, may be limited to    |
| > subjective feelings or restlessness)                                |
| >                                                                     |
| > \(d\) often has difficulty playing or engaging in leisure           |
| > activities quietly                                                  |
| >                                                                     |
| > \(e\) is often "on the go" or often acts as if "driven by a motor"  |
| >                                                                     |
| > \(f\) often talks excessively                                       |
| >                                                                     |
| > \(g\) often blurts out answers before questions have been completed |
| >                                                                     |
| > \(h\) often has difficulty awaiting turn                            |
| >                                                                     |
| > \(i\) often interrupts or intrudes on others (e.g., butts into      |
| > conversations or games)                                             |
| >                                                                     |
| > B. Some hyperactive-impulsive or inattentive symptoms that caused   |
| > impairment were present before age 7 years.                         |
| >                                                                     |
| > C. Some impairment from the symptoms is present in two or more      |
| > settings (e.g., at school \[or work\] and at home).                 |
| >                                                                     |
| > D. There must be clear evidence of clinically significant           |
| > impairment in social, academic, or occupational functioning.        |
| >                                                                     |
| > E. The symptoms do not occur exclusively during the course of a     |
| > Pervasive Developmental Disorder, Schizophrenia, or other Psychotic |
| > Disorder and are not better accounted for by another mental         |
| > disorder (e.g., Mood Disorder, Anxiety Disorder, Disassociative     |
| > Disorder, or a Personality Disorder).                               |
| >                                                                     |
| > **Attention Deficit/Hyperactivity Disorder, Combined Type:** if     |
| > both Criteria A1 and A2 are met for the past 6 months.              |
| >                                                                     |
| > **Attention Deficit/Hyperactivity Disorder, Predominantly           |
| > Inattentive Type:** if Criterion A1 is met but Criterion A2 is not  |
| > met for the past 6 months.                                          |
| >                                                                     |
| > **Attention Deficit/Hyperactivity Disorder, Predominantly           |
| > Hyperactive-Impulsive Type:** if Criterion A2 is met but Criterion  |
| > A1 is not met for the past 6 months.                                |
+-----------------------------------------------------------------------+

Source: American Psychiatric Association: *Diagnostic and Statistical
Manual of Mental Disorders,* Fourth Edition.\
Washington, DC, American Psychiatric Association, 1994.

# Legal Requirements for Identification of and Educational Services for Children With ADHD

Two important federal mandates protect the rights of eligible children
with ADHD---the Individuals with Disabilities Education Act (IDEA) and
Section 504 of the Rehabilitation Act of 1973 (Section 504). The
regulations implementing these laws are 34 CFR sections 300 and 104,
respectively, which require school districts to provide a "free
appropriate public education" to students who meet their eligibility
criteria. Although a child with ADHD may not be eligible for services
under IDEA, he or she may meet the requirements of Section 504.

The requirements and qualifications for IDEA are more stringent than
those of Section 504. IDEA provides funds to state education agencies
for the purpose of providing special education and related services to
children evaluated in accordance with IDEA and found to have at least
one of the 13 specific categories of disabilities, and who thus need
special education and related services. Attention Deficit Hyperactivity
Disorder may be considered under the specific category of "Other Health
Impairment" (OHI), if the disability results in limited strength,
vitality, or alertness, including a heightened alertness to
environmental stimuli that results in limited alertness with respect to
the educational environment and that is due to chronic or acute health
problems.

Under IDEA, each public agency---that is, each school district---shall
ensure that a full and individual evaluation is conducted for each child
being considered for special education and related services. The child's
individualized education program (IEP) team uses the results of the
evaluation to determine the educational needs of the child. The results
of a medical doctor's, psychologist's, or other qualified professional's
assessment indicating a diagnosis of ADHD may be an important evaluation
result, but the diagnosis does not automatically mean that a child is
eligible for special education and related services. A group of
qualified professionals and the parent of the child determine whether
the child is an eligible child with a disability according to IDEA.
Children with ADHD also may be eligible for services under the "Specific
Learning Disability," "Emotional Disturbance," or other relevant
disability categories of IDEA if they have those disabilities in
addition to ADHD.

After it has been determined that a child is eligible for special
education and related services under IDEA, an IEP is developed that
includes a statement of measurable annual goals, including benchmarks or
short-term objectives that reflect the student's needs. The IEP goals
are determined with input from the parents and cannot be changed without
the parents' knowledge. Although children who are eligible under IDEA
must have an IEP, students eligible under Section 504 are not required
to have an IEP but must be provided regular or special education and
related aids or services that are designed to meet their individual
educational needs as adequately as the needs of nondisabled students are
met.

Section 504 was established to ensure a free appropriate education for
all children who have an impairment---physical or mental---that
substantially limits one or more major life activities. If it can be
demonstrated that a child's ADHD adversely affects his or her
learning---a major life activity in the life of a child---the student
may qualify for services under Section 504. To be considered eligible
for Section 504, a student must be evaluated to ensure that the
disability requires special education or related services or
supplementary aids and services. Therefore, a child whose ADHD does not
interfere with his or her learning process may not be eligible for
special education and related services under IDEA or supplementary aids
and services under Section 504.

IDEA and Section 504 require schools to provide special education or to
make modifications or adaptations for students whose ADHD adversely
affects their educational performance. Such adaptations may include
curriculum adjustments, alternative classroom organization and
management, specialized teaching techniques and study skills, use of
behavior management, and increased parent/ teacher collaboration.
Eligible children with ADHD must be placed in regular education
classrooms, to the maximum extent appropriate to their educational
needs, with the use of supplementary aids and services if necessary. Of
course, the needs of some children with ADHD cannot be met solely within
the confines of a regular education classroom, and they may need special
education or related aids or services provided in other settings.

+-----------------------------------------------------------------------+
| Components of a Comprehensive Evaluation                              |
+-----------------------------------------------------------------------+
| -   Behavioral                                                        |
|                                                                       |
| -   Educational                                                       |
|                                                                       |
| -   Medical                                                           |
+-----------------------------------------------------------------------+

A diagnosis of ADHD is multifaceted and includes behavioral, medical,
and educational data gathering. One component of the diagnosis includes
an examination of the child's history through comprehensive interviews
with parents, teachers, and health care professionals. Interviewing
these individuals determines the child's specific behavior
characteristics, when the behavior began, duration of symptoms, whether
the child displays the behavior in various settings, and coexisting
conditions. The American Academy of Pediatrics (AAP) stresses that since
a variety of psychological and developmental disorders frequently
coexist in children who are being evaluated for ADHD, a thorough
examination for any such coexisting condition should be an integral part
of any evaluation (AAP, 2000).

### Behavioral Evaluation

Specific questionnaires and rating scales are used to review and
quantify the behavioral characteristics of ADHD. The AAP has developed
clinical practice guidelines for the diagnosis and evaluation of
children with ADHD, and finds that such behavioral rating scales
accurately distinguish between children with and without ADHD (AAP,
2000). Conversely, AAP recommends **not** using broadband rating scales
or teacher global questionnaires in the diagnosis of children with ADHD.
They suggest using ADHD-Specific rating scales including:

*CPRS-R:L-ADHD Index*\
(Conners Parent Rating Scale---1997\
Revised Version: Long Form, ADHD Index Scale)

*CTRS-R:L-ADHD Index\
*(Conners Teacher Rating Scale---1997\
Revised Version: Long Form, ADHD Index Scale)

*CPRS-R:L-DSM-IV Symptoms\
*(Conners Parent Rating Scale---1997\
Revised Version: Long Form, DSM-IV Symptoms Scale)

*CTRS-R:L-DSM-IV Symptoms\
*(Conners Teacher Rating Scale---1997\
Revised Version: Long Form, DSM-IV Symptoms Scale)

*SSQ-O-1*

(Barkley's School Situations Questionnaire---Original Version, Number of
Problem Settings Scale)

*SSQ-O-II\
*(Barkley's School Situations Questionnaire---Original Version, Mean
Severity Scale)

(Taken from Green, Wong, Atkins, et al. (1999). *Diagnosis of Attention
Deficit/Hyperactivity Disorder.* Technical Review 3. Rockville, MD: U.S.
Department of Health and Human Services, Agency for Health Care Policy
and Research, as cited in AAP, 2000).

As with all psychological tests, child-rating scales have a range of
measurement error. Appropriate scales have satisfactory norms for the
child\'s chronological age and ability levels.

Collecting information about the child's ADHD symptoms from several
different sources helps ensure that the information is accurate.
Appropriate sources of information include the child's parents,
teachers, other diagnosticians such as psychologists, occupational
therapists, speech therapists, social workers, and physicians. It is
also important to review both the child's previous medical history as
well as his or her school records.

### Educational Evaluation

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).

# How Does ADHD Affect School Performance?

The school experience can be challenging for students with ADHD.
Students usually are identified only after consistently demonstrating a
failure to understand or follow rules or to complete required tasks.
Other common reasons for referral include frequent classroom disruptions
and poor academic performance.

Studies found that students with ADHD, compared to students without
ADHD, had persistent academic difficulties that resulted in the
following: lower average marks, more failed grades, more expulsions,
increased dropout rates, and a lower rate of college undergraduate
completion (Weiss & Hechtman as cited in Johnston, 2002; Ingersoll,
1988). The disruptive behavior sometimes associated with the disorder
may make students with ADHD more susceptible to suspensions and
expulsions. A study by Barkley and colleagues (1990b) found that
46 percent of their student study group with ADHD had been suspended and
11 percent had been expelled.

ADHD's core symptoms---inattention, hyperactivity, and
impulsivity---make meeting the daily rigors of school challenging
(Zentall, 1993). Difficulty sustaining attention to a task may
contribute to missing important details in assignments, daydreaming
during lectures and other activities, and difficulty organizing
assignments. Hyperactivity may be expressed in either verbal or physical
disruptions in class. Impulsivity may lead to careless errors,
responding to questions without fully formulating the best answers, and
only attending to activities that are entertaining or novel. Overall,
students with ADHD may experience more problems with school performance
than their nondisabled peers.

## Helpful Hints

This section highlights a few evidence-based hints for addressing the
specific learning needs of children with ADHD. More detailed information
about the effective strategies can be found in a companion guide,
*Teaching Children with Attention Deficit Hyperactivity Disorder:
Instructional Strategies and Practices.* Information regarding the
complete set of materials is available on page 21.

Numerous studies have found that positive results occur when the major
stakeholders in a student's education collaborate to address a child's
ADHD (Blazer, 1999; Bos, 1999; Bos, Nahmias, & Urban, 1999; Nahmias,
1995; Williams & Carteledge, 1997). Effective collaboration and
communication between home and school provide structure across the two
major settings in the child's life. Common rewards, reinforcement
strategies, and language help to promote consistency across settings.

Bos et al. (1999) reported that collaborative partnerships between home
and school were especially important during the initial assessment of
the child's disability and educational needs, the development of
behavior modification plans, the evaluations of medication, and the
coordination of assignments. Parents and teachers can share information
with one another if they work together to plan behavioral and academic
strategies for the student. Parents can offer information about the
child---including the child's medical history, hobbies and interests,
effective reinforcers, and behavior in other settings---that may inform
the decisions made by the teacher and other members of the IEP team. The
teacher can keep parents informed about their child's progress,
performance, and behavior in school. If the child is taking medication,
the teacher can offer feedback to parents regarding how the medication
affects the student's performance and the duration of the medicine's
effectiveness. This information also can be used to help medical
professionals make more informed decisions about the child with ADHD.

If a child exhibits patterns of disruptive or aggressive behavior, best
practice research indicates that the child may benefit from a positive
behavioral intervention plan that clearly delineates expectations and
includes positive supports. The process to develop an effective plan
should be collaborative and involve the parents and those other
individuals who are most familiar with the child.

Students also can take some of the responsibility for their educational
and behavioral adaptations. Blazer (1999) reported that students as
young as 5 years old can communicate ways to make their school
experience more pleasurable and learning easier. Student input also
helps to promote a sense of ownership and responsibility for the new
strategies and adaptations.

The following are some suggestions for practices that may be helpful for
parents and teachers working with a child with ADHD.

### Tips for Home

Caring for children with ADHD may be challenging, but it is important to
remember that these children can learn successfully. It is critical that
parents remember that some of their child's disruptive behavior is a
manifestation of the disability and that the challenge is finding ways
to help their child change the inappropriate behavior. Key to this is
remembering to focus on the need for structure and routine for your
child's daily schedule and thereby reinforcing the importance of
learning self-control and self-regulation. The following are suggestions
for parents:

-   Focus on discrete rewards and consequences for appropriate and
    inappropriate behavior:

```{=html}
<!-- -->
```
-   Tangible rewards and treats;

-   Movie night for a good week at school;

-   Removal of privileges; and

-   Time-out from reinforcing activities: the child is essentially
    removed from situations that foster inappropriate behavior.

```{=html}
<!-- -->
```
-   Set a daily routine and stick to it. Bedtime and preparation for
    school are much easier if there is a structure already in place.

-   Have tangible reminders:

```{=html}
<!-- -->
```
-   A big clock in the bedroom;

-   Charts for chores;

-   Assignment pad to record homework and a specific folder to put work
    in upon completion; and

-   Gain the child's attention before speaking to him or her. Have the
    child repeat back directions for things that are really important.

```{=html}
<!-- -->
```
-   Avoid the following:

```{=html}
<!-- -->
```
-   Repeating patterns of inappropriate behavior followed by ineffective
    punishment;

-   Administering consequences without prior warning or without the
    child understanding why he or she is receiving them; and

-   Responding inconsistently to inappropriate behaviors.

### Tips for School

A student with ADHD can present unique challenges in the classroom.
Inattention, hyperactivity, or impulsivity can be the source of
frustration, but there are ways teachers can help students with ADHD to
improve the educational experience and control the symptoms of the
disorder. It is important for teachers to be aware of coexisting
conditions such as learning disabilities, as well as reinforcing the
importance of classroom and instructional structure.

The following are tips for teachers:

-   Work on the most difficult concepts early in the day;

-   Give directions to one assignment at a time instead of directions to
    multiple tasks all at once;

-   Vary the pace and type of activity to maximize the student's
    attention; and

-   Structure the student's environment to accommodate his or her
    special needs. For example, the student can be seated away from
    potentially distracting areas (such as doors, windows, and
    computers) or seated near another student who is working on a shared
    assignment.

This guide is the first in a series of three publications that address
issues related to the instruction of children with ADHD. The two
additional guides are *A Resource Directory for ADHD* and *Teaching
Children with Attention Deficit Hyperactivity Disorder: Instructional
Strategies and Practices.* Teachers and others are encouraged to consult
these publications and to use them in conjunction with *Identifying and
Treating Attention Deficit Hyperactivity Disorder: A Resource for School
and Home.* As the documents become available, they will be listed on the
Office of Special Education and Rehabilitative Services/Office of
Special Education Programs Web site
([www.ed.gov/offices/OSERS/OSEP](http://www.ed.gov/offices/OSERS/OSEP)).

# References

Abramowitz, A. J., Eckstrand, D., O'Leary, S. G., & Dulcan, M. K.
(1992). ADHD children's responses to stimulant medication and two
intensities of a behavioral intervention. *Behavior Modification,* 16,
193-203.

American Academy of Pediatrics (2000). Clinical practice guideline:
Diagnosis and evaluation of the child with
attention-deficit/hyperactivity disorder. *Pediatrics, 105*: 5,
1158-1170.

American Academy of Pediatrics. (2001). Clinical practice guideline:
Treatment of the school-aged child with attention deficit/hyperactivity
disorder. *Pediatrics,* 108, 1033-1044. Retrieved from
[www.aap.org/policy/s0120.html](http://www.aap.org/policy/s0120.html).

American Psychiatric Association. (1994). *Diagnostic and Statistical
Manual of Mental Disorders* (4th ed.). Washington, DC: American
Psychiatric Association.

Anderson, J. C., Williams, S. C., McGee, R., & Silva, P. A. (1987).
DSM-III disorders in preadolescent children: Prevalence in a large
sample from the general population. *Archives of General Psychiatry,*
44, 69-76.

Barkley, R. A. (1990a). Attention Deficit Hyperactivity Disorder: A
Handbook for Diagnosis and Treatment. New York: Guilford Press.

Barkley, R. A. (1990b). Comprehensive evaluation of attention deficit
disorder with and without hyperactivity as defined by research criteria.
*Journal of Consulting and Clinical Psychology,* 58, 775-789.

Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and
executive functions: constructing a unifying theory of ADHD.
*Psychological Bulletin, 121*:1, 65-94.

Barkley, R. A. (September, 1998a). Attention-deficit hyperactivity
disorder. *Scientific American, 279:* 3.

Barkley, R. A. (1998b). *Handbook of Attention Deficit Hyperactivity
Disorder* (2nd ed.). New York: Guilford Press.

Bird, H. R., Canino, G., Rubio-Stipec, M., Gould, M. S., Ribera, J.,
Sesman, M., et al. (1988). Estimates of the prevalence of childhood
maladjustment in a community survey in Puerto Rico. The use of combined
measures. *Archives of General Psychiatry,* 45, 1120-1126.

Blazer, B. (1999). Developing 504 classroom accommodation plans: A
collaborative systematic parent-student-teacher approach. *Teaching
Exceptional Children,* 32, 28-33.

Bos, C. S. (1999). Home school communication. In C. Jones, H. R.
Searight, & M. A. Urban (Eds.), *Parent Articles for ADHD.* San Antonio,
TX: Communication Skill Builders.

Bos, C. S., Nahmias, M. L., & Urban, M. A. (1999). Targeting home-school
collaboration for students with ADHD. *Teaching Exceptional Children,*
31, 4-11.

Cantwell, D. P., & Baker, L. (1991). Association between attention
deficit-hyperactivity disorder and learning disorders. *Journal of
Learning Disabilities,* 24, 88-95.

Carlson, C. L., Pelham, W. E., Jr., Milich, R., & Dixon, J. (1992).
Single and combined effects of methylphenidate and behavior therapy on
the classroom performance of children with attention-deficit
hyperactivity disorder. *Journal of Abnormal Child Psychology,* 20,
213-232.

Dykman, R. A., Akerman, P. T., & Raney, T. J. (1994). *Assessment and
Characteristics of Children with Attention Deficit Disorder.* Prepared
for the Office of Special Education Programs, Office of Special
Education and Rehabilitative Services, U.S. Department of Education.

Edwards, J. H. (2002). Evidenced-based treatment for child ADHD: "Real
world" practice implications. *Journal of Mental Health Counseling,
24*:2, 126-139.

Esser, G., Schmidt, M. H., & Woemer, W. (1990). Epidemiology and course
of psychiatric disorders in school-age children: Results of a
longitudinal study. *Journal of Child Psychology and Psychiatry,* 31,
243-263.

Gadow, K. D., Sverd, J., Sprafkin, J., Nolan, E. E., & Ezor, S. N.
(1995). Efficacy of methylphenidate for attention-deficit hyperactivity
disorder in children with tic disorder. *Archives of General
Psychiatry,* 52, 444-455.

Hinshaw, S. P., Owens, E. B., Wells, K. C., Kraemer, H. C., Abikoff, H.
B., Arnold, L. E., et al. (2000). Family processes and treatment outcome
in the MTA: Negative/ineffective parenting practices in relation to
multimodal treatment. *Journal of Abnormal Child Psychology,* 28(6),
555-568.

Ingersoll, B. (1988). *Your Hyperactive Child.* New York: Doubleday.

Jadad, A. R., Boyle M., & Cunningham, C. (1999). *Treatment of Attention
Deficit/Hyperactivity Disorder. Evidence Report/Technology Assessment
No. 11.* Rockville, MD: Agency for Healthcare Research and Quality
(AHRQ); 1999. AHRQ Publ. No. 00-E005

Jensen, P. S., Hinshaw, S. P., Kraemer, H. C., Lenora, N., Newcorn, J.
H., Abikoff, H. B., et al. (2001). ADHD Comorbidity findings from the
MTA Study: Comparing Comorbid Subgroups. *Journal of the American
Academy of Child Adolescent Psychiatry,* 40(2), 147-158.

Jensen, P. S., Martin, D., & Cantwell, D. (1997). Comorbidity in ADHD:
Implications for research, practice, and DSM-IV. *Journal of the
American Academy of Child Adolescent Psychiatry*, 36(8), 1065-1079.

Johnston, C. (2002). The impact of attention deficit hyperactivity
disorder on social and vocational functioning in adults. In P.S. Jensen
and J.R. Cooper (Eds.), *Attention Deficit Hyperactivity Disorder: State
of the Science, Best Practices.* (Chapter 6, pp 1-21). Kingston, NJ:
Civic Research Institute.

Klein, R.G., Abikoff, H., Klass, E., Ganeles, D., Seese, L.M., &
Pollack, S. (1997). Clinical efficacy of methylphenidate in conduct
disorder with and without attention deficit hyperactivity disorder.
*Archives of General Psychiatry, 54,* 1073-1080.

McInerney, M., Reeve, A., & Kane, M. B. (1995). Synthesizing and
Verifying Effective Practices For Children and Youth With Attention
Deficit Disorder. Washington, DC: Chesapeake Institute.

MTA Cooperative Group. (1999a). Fourteen-month randomized clinical trial
of treatment strategies for attention-deficit hyperactivity disorder.
*Archives of General Psychiatry,* 56, 1073-1086.

MTA Cooperative Group. (1999b). Effects of comorbid anxiety, poverty,
session attendance, and community medication on treatment outcome in
children with attention deficit/hyperactivity disorder. *Archives of
General Psychiatry,* 56, 1088-1096.

Nahmias, M. L. (1995). Communication and collaboration between home and
school for students with ADHD. *Intervention in School and Clinic,* 30,
241-247.

National Institute of Mental Health (NIMH). (1999). Questions and
answers. NIMH Multimodal Treatment Study of Children With ADHD.
Bethesda, MD: NIMH.

National Institute of Mental Health. (2000). NIMH Research on Treatment
for Attention Deficit Hyperactivity Disorder (ADHD): The Multimodal
Treatment Study---Questions and Answers. \[Online\]. Available:
[www.nimh.nih.gov/events/mtaqa.cfm](http://www.nimh.nih.gov/events/mtaqa.cfm).

Neuwirth, S. (1994). *Attention deficit hyperactivity disorder.*
Bethesda, MD: National Institutes of Health (NIH). NIH Publication No.
96-3572.

OSEP Letter to Michel Williams, March 14, 1994, 21 Individuals with
Disabilities Education Law Report 73.

Pastor, P. N., & Reuben, C. A. (2002). Attention deficit disorder and
learning disability: United States, 1997-98. National Center for Health
Statistics. *Vital Health Stat, 10*(206).

Pelham W. E., & Fabiano, G. (2001). Behavior modification. *Child and
Adolescent Psychiatry Clinics of North America,* 9(3), 671-688.

Pelham, W. E., Jr., Gnagy, E. M., Greenslade, K. E., & Milich, R.
(1992). Teacher ratings of DSM-III-R symptoms for the disruptive
behavior disorders. *Journal of the American Academy of Child and
Adolescent Psychiatry,* 31, 210-218.

Pelham, W. E., & Hoza, B. (1996). Intensive treatment: A summer
treatment program for children with ADHD. In E. Hibbs & H. Jensen (Eds.)
*Psychosocial Treatment for Child and Adolescent Disorders: Empirically
Based Strategies for Clinical Practice*. New York: American
Psychological Association Press, 311-340.

Pelham, W. E., Wheeler, T., & Chronis, A. (1998). Empirically supported
psychosocial treatments for attention deficit hyperactivity disorder.
*Journal of Clinical Child Psychology,* 27, 190-205.

Rapport, M. D., Stoner, G., & Jones, J. T. (1986). Comparing classroom
and clinic measures of attention deficit disorder: Differential,
idiosyncratic, and dose-response effects of methylphenidate. *Journal of
Counseling and Clinical Psychology,* 54, 334-341.

Ross, D. M., & Ross, S. A. (1982). Hyperactivity: Current Issues,
Research, and Theory. New York: Wiley.

Shaffer, D., Gould, M. S., Fisher, P., Trautment, P., Moreau, D.,
Kleinman, M., et al. (1996). Psychiatric diagnosis in child and
adolescent suicide. *Archives of General Psychiatry,* 53, 339-348.

Swanson, J. M. (1992). School-Based Assessments and Interventions for
ADHD Students. Irvine, CA: K. C. Publishing.

U.S. Department of Health and Human Services (DHHS). (1999). *Mental
Health: A Report of the Surgeon General.* Washington, DC: DHHS.

Waslick, B., & Greenhill, L. (1997). Attention-deficit/hyperactivity
disorder. In J. M. Weiner (Ed.), *Textbook of child and adolescent
psychiatry* (2nd ed.). Washington, DC: American Academy of Child and
Adolescent Psychiatry, American Psychiatric Press, 389-410.

Williams, V. I., & Cartledge, G. (1997). Passing notes to parents.
*Teaching Exceptional Children,* 30, 30-34.

Wolraich, M. L., Hannah, J. N., Pinock, T. Y., Baumgaertel, A., & Brown,
J. (1996). Comparison of diagnostic criteria for attention-deficit
hyperactivity disorder in a county-wide sample. *Journal of the American
Academy of Child and Adolescent Psychiatry,* 35, 319-324.

Zentall, S. S. (1993). Research on the educational implications of
attention deficit hyperactivity disorder. *Exceptional Children,* 60,
143-153.