research paper on adhd in the classroom

ADHD in the Classroom: Helping Children Succeed in School

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Children with attention-deficit/hyperactivity disorder (ADHD) experience more obstacles in their path to success than the average student. The symptoms of ADHD, such as inability to pay attention, difficulty sitting still, and difficulty controlling impulses, can make it hard for children with this diagnosis to do well in school.

To meet the needs of children with ADHD, schools may offer

• ADHD treatments, such as behavioral classroom management or organizational training;
• Special education services; or
• Accommodations to lessen the effect of ADHD on their learning.

Classroom Treatment Strategies for ADHD Students

There are some school-based management strategies shown to be effective for ADHD students: behavioral classroom management and organizational training. 1

Parents report that only about 1 in 3 children with ADHD receive behavioral classroom management. 2

The behavioral classroom management approach encourages a student’s positive behaviors in the classroom, through a reward systems or a daily report card, and discourages their negative behaviors. This teacher-led approach has been shown to influence student behavior in a constructive manner, increasing academic engagement. Although tested mostly in elementary schools, behavioral classroom management has been shown to work students of all ages. 1

Organizational training teaches children time management, planning skills, and ways to keep school materials organized in order to optimize student learning and reduce distractions. This management strategy has been tested with children and adolescents. 1

These two management strategies require trained staff—including teachers, counselors, or school psychologists—follow a specific plan to teach and support positive behavior.

The American Academy of Pediatrics (AAP) recommends that the school environment, program, or placement is a part of any ADHD treatment plan. AAP also recommends teacher-administered behavior therapy as a treatment for school-aged children with ADHD. You can talk to your child’s healthcare provider and teachers about working together to support your child.

Special Education Services and Accommodations

Most children with ADHD receive some school services, such as special education services and accommodations. There are two laws that govern special services and accommodations for children with disabilities:

• The Individuals with Disabilities Education Act (IDEA)
• Section 504 of the Rehabilitation Act of 1973

The support a child with ADHD receives at school will depend on if they meet the eligibility requirements for one of two federal plans funded by IDEA and Section 504: an individualized education program (IEP) or a 504 Plan.

What are the main differences between the two Plans?

IEPs provide individualized special education services to meet the unique needs of the child.

A 504 Plan provides services and changes to the learning environment to meet the needs of the child as adequately as other students. 3

Learn more about IEP and 504 Plans [PDF – 2.75 MB]

Accommodations

IEP and 504 Plans can offer accommodations for students to help them manage their ADHD, including:

• Extra time on tests;
• Instruction and assignments tailored to the child;
• Positive reinforcement and feedback;
• Using technology to assist with tasks;
• Allowing breaks or time to move around;
• Changes to the environment to limit distraction; and
• Extra help with staying organized.

Parents of children with ADHD report receiving more services through an IEP than through a 504 plan. 2

There is limited information about which types of accommodations are effective for children with ADHD. 3 However, there is evidence that setting clear expectations, providing immediate positive feedback, and communicating daily with parents through a daily report card can help. 4

What Teachers Can Do To Help

For teachers, helping children manage their ADHD symptoms can present a challenge. Most children with ADHD are not enrolled in special education classes, but do need extra assistance on a daily basis. The National Resource Center on ADHD provides information for teachers from experts on how to help students with ADHD.

Here are some tips for classroom success.

Communication

• Give frequent feedback and attention to positive behavior;
• Be sensitive to the influence of ADHD on emotions, such as self-esteem issues or difficulty regulating feelings;
• Provide extra warnings before transitions and changes in routines; and
• Understand that children with ADHD may become deeply absorbed in activities that interest them (hyper-focus) and may need extra assistance shifting their attention.

Assignments and Tasks

• Make assignments clear—check with the student to see if they understand what they need to do;
• Provide choices to show mastery (for example, let the student choose among written essay, oral report, online quiz, or hands-on project;
• Make sure assignments are not long and repetitive. Shorter assignments that provide a little challenge without being too hard may work well;
• Allow breaks—for children with ADHD, paying attention takes extra effort and can be very tiring;
• Allow time to move and exercise;
• Minimize distractions in the classroom; and
• Use organizational tools, such as a homework folder, to limit the number of things the child has to track.

Develop a Plan That Fits the Child

• Observe and talk with the student about what helps or distracts them (for example, fidget tools, limiting eye contact when listening, background music, or moving while learning can be beneficial or distracting depending on the child);
• Communicate with parents on a regular basis; and
• Involve the school counselor or psychologist.

Close collaboration between the school, parents, and healthcare providers will help ensure the child gets the right support.

Parent Education and Support

CDC funds the National Resource Center on ADHD (NRC), a program of Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD). The NRC provides resources, information, and advice for parents on how to help their child. Learn more about their services.

How to best advocate for your child

• Understand your child’s diagnosis, how it impacts their education, and what can be done at home to help.
• Understand your child’s IEP. If you have questions, don’t be afraid to ask.
• Speak with your child’s teacher.
• When possible, obtain written documentation from teachers, administrators, or other professionals working with your child.
• Know your rights.
• Play an active role in preparing your child’s IEP or 504 Plan.
• Keep careful records, including written documentation, communication between home and school, progress reports, and evaluations.
• Try to maintain a good working relationship with the school while being a strong advocate for your child.
• Communicate any concerns you may have about your child’s progress or IEP or 504 Plan.
• Encourage your child every day, and work with your child to create a system to help with homework and other school projects. 5

What every parent should know

• School support and services are regulated by laws. The U.S. Department of Education has developed a “Know your rights” letter for parents [PDF – 181 KB] and a resource guide for educators [PDF – 956 KB]  to help educators, families, students, and other interested groups better understand how these laws apply to students with ADHD so that they can get the services and education they need to be successful.
• Healthcare providers play an important part in collaborating with schools to help children get the special services they need. Read more about the role of healthcare providers in assisting children with special needs .

More Information

• Supporting Social and Emotional Learning in School
• Learn more about education services and accommodations.
• Learn more about how to help a child with attention and learning issues.
• ADHD Toolkits for Parents and Educators
• Effective child therapy: ADHD
• The National Resource Center on ADHD.
• Evans S, Owens J, Bunford N. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology 2014 ; 43(4):527-551 [ Read overview ]
• DuPaul GJ, Chronis-Tuscano A, Danielson ML, Visser SN . Predictors of receipt of school services in a national sample of youth with ADHD. Journal of Attention Disorders Published online December 10, 2018. [ Read summary ]
• Harrison JR, Bunford N, Evans SW, Owens JS. Educational accommodations for students with behavioral challenges: A systematic review of the literature. Review of Educational Research 2013;83(4):551-97.
• Moore DA, Russell AE, Matthews J, Ford TJ, Rogers M, Ukoumunne OC, et al. School-based interventions for attention-deficit/hyperactivity disorder: A systematic review with multiple synthesis methods. Review of Education. Published online October 18, 2018.
• https://chadd.org/for-parents/individuals-with-disabilities-education-act/

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Article Contents

Conceptual framework, evolving definitions of adhd, what are the academic and educational characteristics of children with adhd, are academic and educational problems transient or persistent, what are the academic characteristics of children with symptoms of adhd but without formal diagnoses, how do treatments affect academic and educational outcomes, how should we design future research to determine which treatments improve academic and educational outcomes of children with adhd.

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Academic and Educational Outcomes of Children With ADHD

ADHD Special Issue, reprinted by permission from Ambulatory Pediatrics, Vol. 7, Number 2 (Supplement), Jan./Feb. 2007,

• Article contents
• Figures & tables
• Supplementary Data

Irene M. Loe, Heidi M. Feldman, Academic and Educational Outcomes of Children With ADHD, Journal of Pediatric Psychology , Volume 32, Issue 6, July 2007, Pages 643–654, https://doi.org/10.1093/jpepsy/jsl054

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Attention-deficit/hyperactivity disorder (ADHD) is associated with poor grades, poor reading and math standardized test scores, and increased grade retention. ADHD is also associated with increased use of school-based services, increased rates of detention and expulsion, and ultimately with relatively low rates of high school graduation and postsecondary education. Children in community samples who show symptoms of inattention, hyperactivity, and impulsivity with or without formal diagnoses of ADHD also show poor academic and educational outcomes. Pharmacologic treatment and behavior management are associated with reduction of the core symptoms of ADHD and increased academic productivity, but not with improved standardized test scores or ultimate educational attainment. Future research must use conceptually based outcome measures in prospective, longitudinal, and community-based studies to determine which pharmacologic, behavioral, and educational interventions can improve academic and educational outcomes of children with ADHD.

Problems in school are a key feature of attention-deficit/hyperactivity disorder (ADHD), often bringing the child with ADHD to clinical attention. It is important to establish the nature, severity, and persistence of these school difficulties in children with ADHD. It is also critical to learn how various treatments affect academic and educational outcomes. These findings inform clinical practice, public health, public education, and public policy. This review of academic and educational outcomes of ADHD is organized around 5 questions: (1) What are the academic and educational characteristics of children with ADHD? (2) Are academic and educational problems transient or persistent? (3) What are the academic characteristics of children with symptoms of ADHD but without formal diagnoses? (4) How do treatments affect academic and educational outcomes? (5) How should we design future research to determine which treatments improve academic and educational outcomes of children with ADHD?

We used the International Classification of Functioning, Disability, and Health (ICF) 1 as the conceptual framework for describing the functional problems associated with ADHD. The World Health Organization developed the ICF to provide a systematic and comprehensive framework and common language for describing and assessing functional implications of health conditions, regardless of the specific disease or disorder. Use of this model facilitates comparisons of health-related states across conditions, studies, interventions, populations, and countries.

In the underlying ICF conceptual framework, health conditions impact function at 3 mutually interacting levels of analysis ( Figure 1 ): body functions and structures, activities of daily living, and social participation. Problems of body functions and structures are called impairments , a more specific and narrow meaning for the term than that used in DSM-IV. 2 Problems of activities of daily living are called limitations . Problems of social participation are called restrictions. Environmental and personal factors can also affect functioning. Treatments may address the health condition directly, may be aimed at one or more domains within the levels of functioning, or may be designed to change the environment. Because of the bidirectional influences within and among these levels of analysis, treatments directed at one problem may indirectly improve problems at other levels.

Conceptual model of International Classification of Functioning, Disability, and Health.

Figure 2 applies the ICF model to school functioning in children with ADHD using the specific codes and terminology of the classification system. At the level of body functions, ADHD affects several global and specific mental functions: intellectual function; impulse control; sustaining and shifting attention; memory; control of psychomotor functions; emotion regulation; higher level cognition, including organization, time management, cognitive flexibility, insight, judgment, and problem solving; and sequencing complex movements. At the level of activities, ADHD may result in limitations in at least 2 domains relevant to this review (and other domains addressed by other chapters in this volume): (1) learning and applying knowledge, including reading, writing, and calculation; and (2) general tasks and demands, including completing single or multiple tasks, handling one's own behavior, and managing stress and frustration. Here, we will differentiate between academic underachievement , which will refer to problems in learning and applying knowledge, including earning poor grades and low standardized test scores, and academic performance , which includes completing classwork or homework. At the level of social participation, ADHD can compromise the major life area of education, including creating restrictions in moving in and across educational levels, succeeding in the educational program, and ultimately leaving school to work. Any one of these functional problems may have many contributors, including the health condition and functional problems at other levels of analysis. We will refer to the restrictions in participation as educational problems. Environmental factors relevant to outcomes in ADHD include general and special education services and policies.

Functional problems associated with attention-deficit/hyperactivity disorder using the International Classification of Functioning, Disability, and Health conceptual model.

The clinical criteria for ADHD have evolved over the last 25 years. Studies from the 1980s and 1990s often used different inclusion and exclusion criteria than were used in more recent studies. Some studies carefully differentiate between children with what we now label as ADHD-Combined subtype (ADHD-C) and attention deficit disorder or ADHD-predominantly Inattentive subtype (ADHD-I). We will address briefly the outcomes of the subtypes specifically. Many children with ADHD have comorbid conditions, including anxiety, depression, disruptive behavior disorders, tics, and learning problems. The contributions of these co-occurring problems to the functional outcomes of ADHD have not been well established. Therefore, in this review, we will consider the academic and educational outcomes of ADHD without subdividing the population on the basis of coexisting neurobehavioral problems in affected children.

Children with ADHD show significant academic underachievement, poor academic performance, and educational problems. 3–8 In terms of impairment of body functions, children with ADHD show significant decreases in estimated full-scale IQ compared with controls but score on average within the normal range. 9 In terms of activity limitations, children with ADHD score significantly lower on reading and arithmetic achievement tests than controls. 9 In terms of restrictions in social participation, children with ADHD show increases in repeated grades, use of remedial academic services, and placement in special education classes compared with controls. 9 Children with ADHD are more likely to be expelled, suspended, or repeat a grade compared with controls. 10

Children with ADHD are 4 to 5 times more likely to use special educational services than children without ADHD. 10, 11 Additionally, children with ADHD use more ancillary services, including tutoring, remedial pull-out classes, after-school programs, and special accommodations.

The literature reports conflicting data about whether the academic and educational characteristics of ADHD-I are substantially different from the characteristics of ADHD-C. 12, 13 Some studies have not found different outcomes in terms of academic attainment, use of special services, and rates of high school graduation. 14 However, a large survey of elementary school students found children with ADHD-I were more likely to be rated as below average or failing in school compared with the children with ADHD-C and ADHD–predominantly hyperactive-impulsive subtype. 15 A subset of children with ADHD-I are described as having a sluggish cognitive tempo, leading to the assumption that there is a higher prevalence of learning disorders in the ADHD-I than the ADHD-C populations. One study supporting this claim found more children with ADHD-I than children with ADHD-C in classrooms for children with learning disabilities. 16 Comparative long-term outcome studies of the subtypes in terms of academic and educational outcomes have not been conducted. 17

Longitudinal studies show that the academic underachievement and poor educational outcomes associated with ADHD are persistent. Academic difficulties for children with ADHD begin early in life. Symptoms are commonly reported in children aged 3 to 6 years, 18 and preschool children with ADHD or symptoms of ADHD are more likely to be behind in basic academic readiness skills. 19, 20

Several longitudinal studies follow school-age children with ADHD into adolescence and young adulthood. Initial symptoms of hyperactivity, distractibility, impulsivity, and aggression tend to decrease in severity over time but remain present and increased in comparison to controls. 21 In terms of activity limitations, subjects followed into adolescence fail more grades, achieve lower ratings on all school subjects on their report cards, have lower class rankings, and perform more poorly on standardized academic achievement tests than matched normal controls. 22–26 School histories indicate persistent problems in social participation, including more years to complete high school, lower rates of college attendance, and lower rates of college graduation for subjects than controls. 27–30

The subjects with ADHD in the longitudinal studies generally fall into 1 of 3 main groups as young adults: (1) approximately 25% eventually function comparably to matched normal controls; (2) the majority show continued functional impairment, limitations in learning and applying knowledge, and restricted social participation, particularly poor progress through school; and (3) less than 25% develop significant, severe problems, including psychiatric and/or antisocial disturbance. 31 It is unclear what factors determine the long-term outcomes. Persistent difficulties may be due to ADHD per se or may be due to a combination of ADHD and coexisting conditions, including learning, internalizing, and disruptive behavior disorders. The contribution of environmental factors to outcomes is also unclear.

Studies of outcome in children diagnosed with ADHD suffer from a potentially serious logical problem: circularity. 32 The clinical definition of ADHD in the DSM-IV requires the presence of functional impairment, typically defined in terms of behavior and performance at home and school. School problems are almost always present to make the diagnosis and therefore are more likely to be present at follow-up. Another problem in the use of clinic-referred samples is the selection bias in who gets referred to diagnostic clinics. One research strategy to complement the longitudinal studies of clinic-referred samples and avoid these problems is to evaluate children from community-based samples who demonstrate symptoms of ADHD but who have not necessarily been formally diagnosed with ADHD. In general, these studies find that children with symptoms of ADHD and without formal diagnoses also have adverse outcomes.

An early community-based study that charted the natural history of ADHD 33 followed subjects who were diagnosed and treated during childhood and children with symptoms and/or behavior indications who were never diagnosed or treated. Both groups were far more likely to attend special education schools and far less likely to graduate from high school or go to college than the asymptomatic controls. The magnitude of the difference was greater for the children with formal diagnosis than for those with pervasive symptoms.

Another community-based study on the relationship between symptoms of ADHD, scores on academic standardized tests, and grade retention found a linear relationship between the number of behavioral symptoms and academic achievement, even among children whose scores were generally below the clinical threshold for the diagnosis of ADHD. 34 Similar findings have been found in studies from Britain 35 and New Zealand. 36 Taken together, these findings suggest that the symptoms and associated features of ADHD are associated with adverse outcomes.

By using the ICF framework, treatments can be evaluated in terms of whether they improve body functions, including intelligence, sustained attention, memory, or executive functions; affect activities, including increasing learning and applying knowledge (such as raising standardized test scores or grades in reading, mathematics, or writing) and improving attending and completing tasks; or enhance participation, including moving across educational levels, succeeding in the educational program, and leaving school for work.

Medical Treatments

Psychopharmacological treatments, particularly with stimulant medications, reduce the core symptoms of ADHD 37 at the level of body functions. In addition, psychopharmacological treatments have been shown to improve children's abilities to handle general tasks and demands; for example, medication has been shown to improve academic productivity as indicated by improvements in the quality of note-taking, scores on quizzes and worksheets, the amount of written-language output, and homework completion. 38 However, stimulants are not associated with normalization of skills in the domain of learning and applying knowledge. 39 For example, stimulant medications have not generally been associated with improvements in reading abilities. 40, 41 In longitudinal studies, subjects demonstrated poor outcomes compared with controls whether or not they received medication. 24 , ,25 ,27 ,42–44 One caution in interpreting these findings is that it cannot be determined if outcomes would have been even worse without treatment because studies often lacked a true nontreatment group with ADHD. Another problem was attrition; subjects lost to follow-up may include those with worse outcomes. A third caution is that most children receive medication for only 2 to 3 years, 45 and it remains unclear whether steady treatment over many years would be associated with improved outcomes.

Behavior Management of ADHD

Behavioral interventions for ADHD, including behavioral parent training, behavioral classroom interventions, positive reinforcement and response cost contingencies, are effective in reducing core ADHD symptoms. 17 , ,30 ,46 However, in head-to-head comparisons behavior management techniques are less effective than psychostimulant medications 37 in reducing core symptoms. It has been shown that behavior management is equivalent or better than medication in improving aspects of functioning, such as parent-child interactions and reduction in oppositional-defiant behavior. However, the problem with this literature is that most behavior management intervention studies evaluate the impact on short-term behavior outcomes, not academic and educational outcomes. The impact of behavioral treatments on long-term academic and educational outcomes must be carefully studied.

Combined Management of ADHD

Given the chronic nature of ADHD and its impact on multiple domains of function, it is likely that multiple treatment approaches are needed. However, the impact of such combined treatments on long-term academic and educational outcomes has not been well studied. Combined treatment (medication and behavioral treatment) in the Multimodal Treatment Study of Children With ADHD was better than behavioral treatment and community care for reading achievement; however, the differences were small and of questionable clinical significance. 37 In addition, children with ADHD and co-occurring anxiety or environmental adversity derived benefit from the combination of medication and behavior management. 47, 48 We need studies to determine whether combined treatment has a larger impact on academic and educational outcomes in some subpopulations than others.

In terms of academic achievement and performance, a 2-year study comparing therapy with methylphenidate to therapy with methylphenidate plus multimodal psychosocial treatments found no advantage of combined treatment over medication alone on any academic measures. 49 The multimodal treatment included academic assistance, organizational skills training, individual psychotherapy, social skills training, and, if needed, reading remediation using phonics. In these studies, medication and/or behavior management, whether used alone or in combination, did not improve academic and educational outcomes of ADHD.

Educational Interventions and Services

The impact of remedial educational services on academic and educational outcomes is not known. Most available treatment outcome studies have not been conducted in general education classroom settings 50 and have focused on reducing problematic behavior rather than on improving scholastic status. 51 Even current rates of utilization are difficult to determine because ADHD itself is not an eligibility criterion for special education. 52 Although advocates pursued making ADHD a category of disability under the Individuals with Disabilities Education Act of 1990 (IDEA), this attempt was not successful. 53 Instead, the US Department of Education issued a policy memorandum 54 stating that students with ADHD were eligible for special education services under the Other Health Impairment category if problems of limited alertness negatively affected academic performance. Children with ADHD may qualify for special education services if they are eligible for another IDEA category, such as emotional disturbance or specific learning disability, but the children with ADHD are not disaggregated from students without ADHD in these categories. 55

Educational services are also provided to students with ADHD who do not meet IDEA eligibility requirements under Section 504 of the Vocational Rehabilitation Act of 1973 if the condition substantially limits a major life activity, such as learning. 53 Services include accommodations and related services in the general education setting, such as preferential seating, modified instructions, reduced classroom and homework assignments, and increased time or environmental modification for test taking. There is wide variability in the knowledge and application of Section 504 services among parents and educators. 53

For both special education and Section 504 services, the children most likely to obtain services are those with the most severe functional limitations. Therefore, it would be difficult to interpret associations among use of services and outcomes. There are no data regarding effectiveness of many commonly recommended accommodations, such as preferential seating, on outcomes.

The evidence that ADHD is associated with poor academic and education outcomes is overwhelming. However, studies thus far find that treatments are associated with relatively narrow improvements in core symptoms of inattention, hyperactivity, and impulsivity at the level of body functions and attending and completing tasks at the level of activities. We need prospective, controlled, and large-scale studies to investigate whether existing or new treatments will improve reading, writing, and mathematics skills; reduce grade retention; reduce expulsions and detentions; improve graduation rates; and increase completion of postsecondary education. In a literate, information-age society, these improved outcomes are vital to the economic and personal well-being of individuals with ADHD.

Because of the limitations of previous research, we recommend that future research incorporate several features. In terms of the subjects, the study must specify clear inclusion criteria, including diagnostic criteria for ADHD, subtypes, and coexisting conditions. Given the research history to date, we favor community- or school-based samples as opposed to clinic-referred samples to avoid selection bias. Studies should be conducted in general education as well as secondary school settings, given the lack of data from these settings. In terms of the outcome variables, we support use of standardized definitions of functional outcomes following the conceptualization of function provided by the ICF framework. We specifically favor repeated measures of academic achievement. Unfortunately, measures such as grades may vary across school systems. For this reason, the use of achievement tests may be preferable in large-scale studies. In addition, measures relevant to educational promotion, such as college entrance examinations, may provide more standardized information than graduation rates. In local or regional studies, other repeated measures may be possible, including analysis of portfolios. Another sensitive measure that could be collected on a continuous basis is curriculum-based measurement, 56 which involves probes of reading and math performance relative to the instructed curriculum and permits examination of relative trajectories over time as a measure of treatment outcome.

Designing convincing studies on the long-term impact of medication or behavior management on academic and educational outcomes is challenging because it is unethical to withhold standard treatments for long periods of time from an affected sample to create a control group. To circumvent this problem, we suggest large-scale studies that evaluate rates of change in the outcomes as a function of treatment strategy (or intensity) and that use statistical methods such as hierarchical linear modeling. 57 In this approach, individual students are nested in hierarchies that are defined by grade and diagnosis and also by treatment type and intensity. Repeated measures for outcomes, such as reading or math standard scores, are collected over time. The statistical methods estimate the effects of each factor—age and treatment intensity—on the rate of change. This method can demonstrate if the rate of change increases more rapidly in some groups than other groups and more rapidly than would have been predicted on the basis of status at study entry. The hierarchical linear modeling method is also helpful with differentiating rates of progress among children who adhere to treatment recommendations over long periods of time versus those who discontinue treatment after a few months or years.

We also recommend that the research strategy incorporate a 2-tiered approach. First, improvements in instruction/teaching methods, curriculum design, school physical designs, and environmental modifications should be offered to all students. We can call this phase improved universal design. Schools often try to change the child with ADHD to fit the school environment. Attempts to “normalize” behavior include pulling a child out of the classroom, perhaps applying a remedial strategy, and then putting the child back into the original setting, with the hope that the child will now be successful. 58 This strategy identifies the child as the problem, serves to isolate and potentially stigmatize the child, and precludes the exploration of environment-based solutions. 59 The advantage of universal design is that most children with ADHD are educated in general education settings. Improved universal design in the classroom could potentially benefit all children in the classroom, particularly those with ADHD. Such interventions may not decrease the differences between children with ADHD and their peers without ADHD on some measures, such as standardized test scores. However, more important is whether the children with ADHD reach a higher threshold of achievement, such as improved reading scores or higher rates of high school graduation.

The second tier for research is specific interventions for children with ADHD, layered on top of the basic reforms. These interventions can include teaching methods, new curricula, specific behavior management, and school-based intervention approaches. 60

We will focus on 6 different options that warrant further investigation in this 2-tiered research design: (1) small class size; (2) reducing distractions; (3) specific academic intervention strategies; (4) increased physical activity; (5) alternative methods of discipline; and (6) systems change.

Small Class Size

A study based in London schools of regular education students found that variations in average class size in the 25- to 35-student range are of little consequence in affecting student progress, probably because of a lack of opportunity for differences in classroom management techniques. 61 However, small classes of approximately 8 to 15 students have been beneficial for younger children and children with special needs. 62 Because children with ADHD are reported to do better with one-on-one instruction, smaller class size makes intuitive sense. Teachers perceive class size to be one of the major barriers to inclusion of ADHD students in regular education. 63 Empiric investigation on reduced class size is therefore warranted for all children, and also for children with ADHD. Small class sizes will probably result in use of innovative educational approaches that are precluded in the current system.

Reducing Distractions

Classrooms are often noisy and distracting environments. Children perform more poorly in noisy situations than do adults, and researchers have reported that the ability to listen in noise is not completely developed until adolescence or adulthood. 64–66 If an acoustic environment can be provided that allows +15 dB signal-to-noise ratio throughout the entire classroom, then all participants can hear well enough to receive the spoken message fully. 64 Accommodations in Section 504 plans often include repeating instructions and providing quiet test-taking areas that are free of distractions. Repetition of instructions alone is not likely to increase the attention of children with ADHD. Thus, methods for reducing noise and other distractions should be studied.

Specific Academic Intervention Strategies

As reviewed by Hoffman and DuPaul, 51 the so-called antecedent-oriented management strategies are good universal design features that hold promise for improving outcomes for children with ADHD. Antecedent interventions include choice making, peer tutoring, and computer-aided instruction, all reviewed below. Such strategies are proactive, support appropriate adaptive behavior, and prevent unwanted, challenging behaviors. These strategies make tasks more stimulating and provide students with opportunities to make choices related to academic work. 67 They may be particularly helpful for children with ADHD who demonstrate avoidance and escape behaviors.

Choice-making strategies allow students to select work from a teacher-developed menu. In a study of choice making with children with emotional and behavioral difficulties in a special education classroom, students demonstrated increased academic engagement and decreased behavior problems. 68 Another study demonstrated decreased disruptive behavior in a general education setting, 69 although more variable academic and behavioral performance occurred in a study of 4 students with ADHD in a general education setting. 51 A related concept is project-based learning, which capitalizes on student interests and provides a dynamic, interactive way to learn.

Studies of Class Wide Peer Tutoring, a widely used form of peer tutoring, have demonstrated enhanced task-related attention and academic accuracy in elementary school students with ADHD, 70, 71 as well as positive changes in behavior and academic performance in students without ADHD. 72 Teachers perceive time requirements of specialized interventions as a significant barrier to the inclusion of ADHD students. 63 Peer tutoring reduces the demands on teachers to provide one-on-one instruction. At the same time, it gives students with ADHD the opportunity to practice and refine academic skills, as well as to enhance peer social interactions, promoting self-esteem. Peer tutoring may be particularly effective when students are using disruptive behavior to gain peer attention. 51

Computer-aided instruction has intuitive appeal as a universal design feature and for children with ADHD because of its interactive format, use of multiple sensory modalities, and ability to provide specific instructional objectives and immediate feedback. Computer-aided instruction has not been well studied in children with ADHD. 51, 73 Studies with small numbers of subjects showed promising initial results 74, 75 but did not examine the effects on academic achievement. A small study of 3 children with ADHD that used a game-format math program found increases in academic achievement and increased task engagement. 76

Increased Physical Activity

Given that fidgeting and out-of-seat behavior are common in children with ADHD, increased use of recess and physical exercise might reduce overactivity. A study on the effects of a traditional recess on the subsequent classroom behavior of children with ADHD showed that levels of inappropriate behavior were consistently higher on days when participants did not have recess, compared with days when they did have recess. 77 A meta-analysis of studies on the effects of regular, noncontingent exercise showed reductions in disruptive behavior with greater effects in participants with hyperactivity. 78 Increased physical exercise would be beneficial for long-term health and for behavioral regulation in both children developing typically and children with ADHD.

Alternative Methods of Discipline

Many students receive suspensions or are sent to the principal's office for disruptive behavior. For those children who are avoiding work, these approaches are equivalent to positive reinforcement. Such avoidant or escape behavior could be countered with in-school as opposed to out-of-school suspensions. The use of interventions that teach children how to replace disruptive behaviors with appropriate behaviors is less punitive than suspensions and more effective in promoting academic productivity and success. 17

Systems Change

Classroom changes are unlikely to create adequate improvements without concomitant changes in the educational system. Three potential areas under the category of systems change are improved education of teachers and educational administrators; enhanced collaborations among family members, school professionals, and health care professionals; and improved tracking of child outcomes. Teacher surveys demonstrate that teachers perceive the need for more training about ADHD. 63 The optimal management of children with ADHD requires close collaboration of their parents, teachers, and health care providers. Currently there is no organized system to support this collaboration.

At the policy level, we need mechanisms to track the outcome of children with ADHD in relation to educational reform and utilization of special services. Federally supported surveys could focus on services and treatments for mental health conditions, including ADHD, and their impact on outcomes. Relevant data for the relationship of interventions and outcomes may also exist at the local and state level. Building on existing local and state databases to include health and mental health statistics could provide valuable information on this issue.

We remain ill informed about how to improve academic and educational outcomes of children with ADHD, despite decades of research on diagnosis, prevalence, and short-term treatment effects. We urge research on this important topic. It may be impossible to conduct long-term randomized, controlled trials with medication or behavior management used as treatment modalities for practical and ethical reasons. However, large-scale studies that use modern statistical methods, such as hierarchical linear modeling, hold promise for teasing apart the impact of various treatments on outcomes. Such methods can take into account the number and types of interventions, duration of treatment, intensity of treatment, and adherence to protocols. Educational interventions for children with ADHD must be studied. We recommend large-scale, prospective studies to evaluate the impact of educational interventions. These studies should be tiered, introducing universal design improvements and specific interventions for ADHD. They must include multiple outcomes, with emphasis on academic skills, high school graduation, and successful completion of postsecondary education. Such studies will be neither cheap nor easy. A broad-based coalition of parents, educators, and health care providers must work together to advocate for an ambitious research agenda and then design, implement, and interpret the resulting research. Changes in local, state, and federal policies might facilitate these efforts by creating meaningful databases and collaborations.

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Research Article

The Effects of Classroom Interventions on Off-Task and Disruptive Classroom Behavior in Children with Symptoms of Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

* E-mail: [email protected]

Affiliation Department of Clinical and Developmental Neuropsychology, University of Groningen, Groningen, The Netherlands

• Geraldina F. Gaastra, 
• Yvonne Groen, 
• Lara Tucha, 
• Oliver Tucha

• Published: February 17, 2016
• https://doi.org/10.1371/journal.pone.0148841
• Reader Comments

Children with attention-deficit/hyperactivity disorder (ADHD) often exhibit problem behavior in class, which teachers often struggle to manage due to a lack of knowledge and skills to use classroom management strategies. The aim of this meta-analytic review was to determine the effectiveness of several types of classroom interventions (antecedent-based, consequence-based, self-regulation, combined) that can be applied by teachers in order to decrease off-task and disruptive classroom behavior in children with symptoms of ADHD. A second aim was to identify potential moderators (classroom setting, type of measure, students’ age, gender, intelligence, and medication use). Finally, it was qualitatively explored whether the identified classroom interventions also directly or indirectly affected behavioral and academic outcomes of classmates. Separate meta-analyses were performed on standardized mean differences (SMDs) for 24 within-subjects design (WSD) and 76 single-subject design (SSD) studies. Results showed that classroom interventions reduce off-task and disruptive classroom behavior in children with symptoms of ADHD (WSDs: M SMD = 0.92; SSDs: M SMD = 3.08), with largest effects for consequence-based (WSDs: M SMD = 1.82) and self-regulation interventions (SSDs: M SMD = 3.61). Larger effects were obtained in general education classrooms than in other classroom settings. No reliable conclusions could be formulated about moderating effects of type of measure and students’ age, gender, intelligence, and medication use, mainly because of power problems. Finally, classroom interventions appeared to also benefit classmates’ behavioral and academic outcomes.

Citation: Gaastra GF, Groen Y, Tucha L, Tucha O (2016) The Effects of Classroom Interventions on Off-Task and Disruptive Classroom Behavior in Children with Symptoms of Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review. PLoS ONE 11(2): e0148841. https://doi.org/10.1371/journal.pone.0148841

Editor: Hanna Christiansen, Philipps University Marburg, GERMANY

Received: May 6, 2015; Accepted: January 25, 2016; Published: February 17, 2016

Copyright: © 2016 Gaastra et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This work was funded by the Nationaal Regieorgaan Onderwijsonderzoek (NRO); 411-12-241; ( http://www.nro.nl/ ); YG LT OT. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention and/or hyperactivity-impulsivity [ 1 ]. Approximately 5 to 7% of all children meet diagnostic criteria for ADHD [ 2 , 3 ], implying that on average every classroom will contain a child with ADHD. Within the classroom, children with ADHD are more inattentive (off-task) and disruptive than typically developing peers [ 4 , 5 ]. They often struggle to sustain attention to tasks and instructions, frequently talk to classmates at inappropriate times, and may call out and leave their seat without permission [ 6 ]. As a consequence, children with ADHD are at risk of academic difficulties, including underachievement, retaining grade, special educational placement, and suspension or drop-out from school [ 7 – 10 ]. Moreover, as ADHD related behaviors may disturb the learning process of classmates [ 6 ] and may elicit maladaptive behavior of both classmates and teacher [ 11 ], overall classroom functioning may decrease, both academically and socially. Campbell, Endman, and Bernfeld [ 12 ] suggested that the presence of a child with ADHD in the classroom leads to more negative interaction between teacher and students.

As teachers may be confronted daily with one or more children with ADHD in their classroom, it is important that they have confidence managing these children. General education teachers, irrespectively of their age and years of teaching experience, perceive children with ADHD as more stressful to teach than other children [ 13 ]. They report that teaching children with ADHD causes a disruption of the teaching process, a loss of satisfaction from teaching, self-doubt and increased need for support [ 13 , 14 ]. Teacher factors have a considerable impact on the achievement and behavioral outcomes of children with ADHD [ 15 ], but often teachers also seem to lack knowledge and skills to develop and implement effective classroom interventions [ 16 ]. Frequently simple management techniques are used, which can be implemented classwide and are not time-consuming [ 16 – 18 ], whereas interventions that are based on an analysis of the function of an individual child’s behavior (function-based interventions) have been proven to be more effective than non-function based interventions [ 19 ]. As many children with ADHD attend general education classrooms [ 10 ], it is important to assist teachers in their management of these children. Providing teachers with effective tools may benefit children with ADHD as well as their classmates, but moreover, may improve confidence and well-being of teachers themselves.

The problem behaviors of students with ADHD in the classroom may require treatment. The most common treatment for children with ADHD is stimulant medication [ 6 , 7 ]. Although pharmacological interventions enhance on-task behavior and academic achievement in children with ADHD [ 20 ], pharmacological interventions are limited by several factors, including possible side effects, lack of evidence of long-term effects, and compliance problems [ 21 – 25 ]. Furthermore, medical treatment may not normalize behavior and cognition in children with ADHD [ 26 , 27 ]. Because of these significant limitations, there is a need for non-pharmacological interventions, including school-based interventions.

The effectiveness of school-based interventions for ADHD was previously examined by a number of meta-analytic studies, indicating that school-based interventions improve behavioral and academic outcomes of children with ADHD [ 28 – 31 ]. DuPaul and Eckert [ 28 ] and DuPaul et al. [ 29 ] performed extensive meta-analyses of published and unpublished studies on school-based interventions for children with ADHD. The first study included 63 studies covering a period of 24 years (1971−1995) and the follow-up study included 60 studies covering a successive period of 14 years (1996−2010). Both studies indicated that school-based interventions improve behavior in children with ADHD but that effects on academic outcomes are smaller and less robust. The studies also compared different types of interventions, including academic, contingency management, and cognitive-behavioral interventions. The effects of intervention type were inconsistent between the two studies and depended on the experimental design applied (i.e., between-subjects, within-subjects, or single-subject design) and the outcomes collected (i.e., behavioral or academic outcomes). Inconsistent results were also found for moderating effects of school setting and educational placement, which may be caused by the small number of studies included for some moderator categories.

Two other meta-analytic studies describe a more narrow span of research. Purdie et al. [ 30 ] examined the effectiveness of different types of interventions, including school-based interventions, on several types of outcomes (behavioral, cognitive, social, and personal/emotional outcomes) of individuals with ADHD. The meta-analysis included eight studies on school-based interventions covering a period of eight years (1990−1998). The results showed small positive effects for school-based interventions on all types of outcomes. For cognitive outcomes, the effects were larger for school-based interventions than for other types of interventions (pharmacological, non-school-based psychological, parent training, multimodal interventions). Another meta-analysis specifically focused on studies that implemented self-regulation interventions for children with ADHD in school settings, and included 16 studies covering a period of 29 years (1974−2003) [ 31 ]. Positive effects of self-regulation interventions were found for on-task behavior, inappropriate behavior, and academic accuracy and productivity.

The present study

The present study provides a meta-analytic review of published studies on classroom interventions for ADHD covering a period of 33 years of research (1970−October 2013). The primary aim was to determine the effectiveness of several types of classroom interventions (antecedent-based, consequence-based, self-regulation, combined interventions) that can be applied by teachers in order to decrease off-task and disruptive classroom behavior in children with symptoms of ADHD. A second objective was to identify potential moderators (classroom setting, type of measure, students’ age, gender, intelligence, and medication use). As previous meta-analyses on this topic did not investigate such a wide time frame, potential moderators could be more robustly analyzed. Furthermore, it was qualitatively explored whether the identified classroom interventions also affected the behavioral and academic outcomes of classmates, which has not been addressed before. It was hypothesized that classroom interventions could have positive effects on classmates; either because of indirect effects i.e., less classroom disturbance by children with symptoms of ADHD, or because of direct effects i.e., improvement of classmates’ behavior because they also benefit from the intervention. This study will provide information on evidence-based classroom management of children with ADHD behavior, and the outcomes may be of relevance and use in the education of teachers.

There existed no protocol for this meta-analytic review. The guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed (see S1 Checklist ).

Inclusion and exclusion criteria

In order to be included in this meta-analytic review, studies had to meet the following inclusion criteria.

• The study was published in English in an academic journal. Initially, the aim was to include unpublished studies but due to limited resources and time, it was decided to restrict the meta-analytic review to published studies.
• Participants attended grades 1 through 12 (if grade was not reported, age 6 to 17 years) and had ADHD, ADD, attention deficits, or hyperactive-impulsive deficits. Furthermore, participants had an IQ of 70 or above (if IQ was reported). No restrictions were made regarding comorbid conditions and medication use. For studies examining classroom interventions for different medication dosages, placebo conditions were included in the analysis.
• In order to be able to generalize the results to the natural classroom and the general education teacher (having limited resources and limited advanced skills), the following requirements were defined. The intervention had to be implemented in the classroom by the teacher (or an experimenter who could be easily replaced by a teacher) and required no parental involvement. For example, interventions incorporating parent training or school-home notes with parent-delivered consequences were not included. The intervention had to take place in a classroom context, i.e., in the presence of a teacher and some peers of the child with symptoms of ADHD.
• Antecedent-based intervention: An intervention that manipulates antecedent conditions, such as the environment, task, or instruction (e.g., seating, music, tutoring, choice making, computer-assisted instruction).
• Consequence-based intervention: An intervention that uses reinforcement and punishment to alter the frequency of target behavior (e.g., praise, reprimands, prizes, privileges, response-cost).
• Self-regulation intervention: An intervention aimed at the development of self-control and problem-solving skills to regulate cognition and behavior (e.g., self-instruction, self-monitoring, self-reinforcement).
• The outcome measures were either teacher ratings or direct observations of off-task behavior (e.g., not attending to task or teacher, looking around), disruptive behavior (e.g., disturbing classmates, playing with objects, out of seat), and ADHD behavior (e.g., teacher rating on an ADHD rating scale) in the classroom. Measures of on-task behavior (e.g., attending to task or teacher, face directed towards work sheet) and appropriate behavior (e.g., absence of oppositional behaviors, compliance with requests) were also included, because these are by definition mutually exclusive to off-task, disruptive, and ADHD behavior. That is, a child cannot be on-task while at the same time being off-task. A reduction of off-task, disruptive, or ADHD behavior and an increase in on-task or appropriate behavior was regarded as a positive effect of the intervention. Outcome measures that were obtained outside the classroom (e.g., playground) were excluded.
• Between-subjects group design: A design that uses an intervention group and a non-intervention control group.
• Within-subjects group design (WSD): A design that applies the same intervention on each participant and assesses outcomes on at least two occasions.
• Single-subject design (SSD): A design that documents changes in behavior for an individual participant during intervention phases and non-intervention control phases. Studies using a control group but with assessments on at least two occasions, were considered to be WSD studies as this would increase the number of studies included in the same meta-analysis. In case both individual and group data (e.g., means across participants) were provided, the study was categorized as a group design study.
• Sufficient data were provided to compute effect sizes. If studies included participants both with and without symptoms of ADHD, the results had to allow disaggregation for these participants. In case of insufficient data, the authors of the relevant studies were contacted.

Search procedure

A systematic literature search was conducted to identify studies for inclusion in the meta-analytic review. First of all, electronic database searches in PsycINFO, ERIC, and Web of Science were performed until the date of October 8, 2013. A combination of search terms was used to describe participants ( ADHD , ADD , attention deficit , hyperactivity , or hyperkinetic ), interventions ( classroom , school , education , or academic , and treatment , intervention , training , strategies , therapy , or program ), and outcome measures ( classroom , school , academic , on-task , off-task , or disruptive , and functioning or behavior ). The search was restricted to the English language and in PsycINFO additionally limited to school-aged children (6 to 11 years) and adolescents (12 to 17 years). Furthermore, reference lists of relevant literature reviews and of studies included in the present meta-analytic review were checked for additional studies. All records identified by the electronic and manual searches were screened based on title and abstract. The full text of the remaining articles was used to determine eligibility for inclusion.

Coding procedure and moderating variables

Each study meeting inclusion criteria was systematically coded on several variables by the first author. Variables that were examined as potential moderators included intervention type, classroom setting, type of measure, and characteristics of participants receiving the intervention, including age, gender, intelligence, and medication use. The categories antecedent-based , consequence-based , self-regulation , and combined were used to classify intervention type. Classroom setting was defined as the classroom in which the intervention was implemented and coded as (inclusive) general education or other (e.g., special education, self-contained, resource, remedial, experimental, laboratory, hospital classroom). If an intervention was implemented in both the general education classroom and another classroom setting, it was classified as other . Type of measure was coded as teacher ratings , direct observations , or both . The mean or range of the age or grade of participants was used to create age categories for children (age 6 to 11 years; otherwise grade 1 through 5) and adolescents (age 12 to 17 years; otherwise grade 6 through 12). Gender was defined as the percentage of boys of the study samples and classified as less than 20% boys , 20 to 80% boys , or more than 80% boys . Mean IQ of participants was used to allocate samples to the IQ categories less than 90 , 90 to 110 , or above 110 . Finally, medication use was defined as the percentage of participants on medication during the study and was classified as less than 20% medicated , 20 to 80% medicated , or more than 80% medicated .

Study quality of all studies included was assessed by means of the method developed by Reichow and colleagues [ 32 , 33 ] for the evaluation of the methodological quality (i.e. rigor) of group as well as SSD studies on evidence-based practices. Both primary and secondary quality indicators were rated conform specific operational definitions. Primary quality indicators are critical for evaluating the validity of studies and are rated as high quality , acceptable quality , and unacceptable quality . Secondary quality indicators are important though not necessary elements for the validity of studies, and are rated as evidence or no evidence . Based on the ratings of primary and secondary quality indicators, an overall study quality rating was calculated ( strong , adequate , or weak ).

A random subset of 30 studies was coded by an independent second rater. Interrater reliability statistics were computed (see S1 Table ). Raters agreed between 80 and 100% ( M = 96%, κ = .94) on general study information (e.g., number of participants). For WSD studies, interrater reliability ranged from 70 to 100% agreement ( M = 92%, κ = .85, κ w = .91) for primary quality indicators and from 90 to 100% agreement ( M = 96%, κ = .89) for secondary quality indicators. For SSD studies, raters agreed between 55 and 100% ( M = 83%, κ = .76, κ w = .89) on primary quality indicators and 90 and 100% ( M = 98%, κ = .95) on secondary quality indicators. Overall agreement between raters on overall study quality across study designs was 80% (κ = .56, κ w = .71). Coding disagreements were resolved through discussion with the co-authors.

Statistical analyses

Statistical procedures were conducted using statistical software ( IBM SPSS statistics 22 ). To maintain independence between effect sizes, studies were only allowed to contribute a maximum of one effect size for each intervention category. For studies providing multiple outcomes, mean effect sizes across outcomes were computed. For SSD studies including more than one participant, mean effect sizes across participants were computed. A positive effect size indicated an improvement in behavior.

Effect sizes used for this meta-analytic review were defined as standardized mean differences (SMDs). For WSD studies, SMDs were computed as described by Becker [ 34 ]. This method allows for combining studies with and without control group in the same meta-analysis. A description of the method used for computation of effect sizes for WSDs is provided in S1 Text . For SSD studies, there is no consensus on appropriate methods for calculation of effect sizes [ 35 ]. To allow for comparison between the present study and previous meta-analyses on school interventions for ADHD, SMDs were calculated. SSD studies either reported data as descriptive statistics (means and standard deviations) or within graphs. In the latter case, data points were extracted from graphs by measuring them with the help of a ruler. The first baseline and last intervention phase were used for computation of effect sizes. Each of these phases had to consist of at least three data points to demonstrate existence or lack of an effect [ 35 ]. SMDs were computed by dividing the difference between the means of the intervention and baseline phases by the pooled standard deviation [ 36 , 37 ]. These were then corrected for small numbers of data points [ 38 ]. Because exact expressions for effect size variances of SSDs have not been derived and are formally not justified [ 35 , 39 ], standard errors and consequently statistical significance tests were not conducted for SSD studies. The distribution of effect sizes was examined separately for WSD and SSD studies. Effect sizes deviating more than two standard deviations from the mean of all effect sizes (across the studies of a particular experimental design) were recoded (i.e., Winsorized) to less extreme values. This reduced the impact of extremely large or small effect sizes on the outcomes.

Separate meta-analyses were conducted for studies employing WSDs and SSDs because effect size estimators in WSD and SSD studies are fundamentally different [ 39 ]. For the analysis of the WSD studies, macros were used that were created by Lipsey and Wilson [ 40 ]. The mean weighted effect size was computed using a random effects model [ 41 ]. Moderator analyses were conducted using mixed effects models, assuming that identifiable study characteristics act as moderator variables but that some unmeasured random effect remains [ 40 ]. Each effect size was weighted by its inverse variance. Heterogeneity was assessed by performing homogeneity tests and calculating the I 2 value. I 2 reports the proportion of total variation across studies that is due to heterogeneity rather than chance [ 42 ]. Values in the order of 25%, 50%, and 75% may be considered as low, moderate, and high, respectively. To detect publication or related bias, funnel plot asymmetry was tested using a regression method [ 43 ]. Furthermore, the fail-safe N was computed [ 44 ] in order to determine the number of studies with an effect size of zero that would be necessary to reduce the mean effect size to criterion levels of 0.20 (small effect) and 0.50 (medium effect) [ 45 ].

To determine the direct and indirect intervention effects on the classmates of participants with symptoms of ADHD, effect sizes using the same formulas as for participants with symptoms of ADHD were calculated. In case insufficient data were provided, the means of baseline and intervention phases were used to compute the percentage of change in behavior or academic performance. Because only a small number of studies provided information on classmates, the results are discussed descriptively without performing a meta-analysis.

An overview of the literature search is provided in Fig 1 . A total of 4,553 records were identified through electronic databases and an additional 230 records were identified by the manual searches. Screening of the titles and abstracts of these records resulted in 317 articles. Inspection of the full-texts of these 317 articles resulted in the exclusion of 228 articles that failed to meet inclusion criterion. An article could provide more than one effect size (study) for analysis if the article reported on multiple interventions from different categories of interventions or reported on multiple experiments. Finally, a total of 89 articles meeting inclusion criteria were considered in the present meta-analytic review, yielding to 100 studies. The list of studies included in the meta-analytic review is provided in S2 Text .

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https://doi.org/10.1371/journal.pone.0148841.g001

Study characteristics

Table 1 summarizes the major characteristics of studies included in this meta-analytic review. For each decade in the period 1970 to October 2013, there is a steady increase in the number of newly published studies on classroom interventions for children with symptoms of ADHD. The majority of studies employed SSDs (76%), whereas none of the studies solely used a between-subjects design. Of the 24 WSD studies, one third also included a control group consisting of participants with symptoms of ADHD who did not receive an intervention. A small number of studies provided information about the direct (8%) and indirect effects (3%) of classroom interventions on classmates of participants with symptoms of ADHD. Combined interventions (10%) were less often implemented than other types of interventions, whereas antecedent-based, consequence-based, and self-regulation interventions were approximately equally often implemented. Interventions were as often implemented in general education classrooms (46%) as in other classroom settings (47%). Most measures consisted of direct observations (93%), whereas only a small number of studies gathered teacher ratings (4%) or both types of outcome measures (3%). In total, 627 participants (WSDs: n = 471; SSDs: n = 156) were included in the meta-analytic review. The study samples varied between 1 and 65 participants, with the majority of studies including 10 or less participants (87%). Most studies included children (84%) and predominantly boys (74%). IQ was assessed in 27% of the studies, with most of these studies (18%) reporting a mean IQ in the average range (90−110). Medication use varied between studies, with 27% of studies not providing information about medication status of participants.

https://doi.org/10.1371/journal.pone.0148841.t001

A frequencies table of the primary, secondary, and overall quality ratings is provided in S2 Table . Regarding primary quality indicators, most WSD studies were rated as high of quality on the indicators ‘independent variable’ (i.e., description of the intervention) (92% high quality), ‘dependent variable’ (i.e. description of the outcome measure) (83% high quality), and ‘link to research question’ (100% high quality) but were rated as unacceptable of quality on ‘comparison condition’ (i.e., definition of a control group) (67% unacceptable quality). Regarding secondary quality indicators, most WSD studies showed evidence of ‘interobserver agreement’ (63% evidence) and ‘social validity’ (83% evidence) but no evidence for the other secondary quality indicators (i.e., ‘random assignment’ (8% evidence), ‘blind raters’ (25% evidence), ‘fidelity’ (33% evidence), ‘attrition’ (21% evidence), ‘generalization or maintenance’ (4% evidence), ‘effect size’ (8% evidence)). Overall, the majority of WSD studies (83%) obtained a weak rating of study quality. SSD studies were generally rated as high of quality on ‘independent variable’ (100% high quality) and ‘dependent variable’ (86% high quality) but varied in quality on the other primary quality indicators. Most SSD studies reported good ‘interobserver agreement’ (90% evidence) and showed evidence of ‘social validity’ (95% evidence). However, the majority of SSD studies showed no evidence of the other secondary quality indicators (ranging from 71 to 96% no evidence). Overall, half of the SSD studies (54%) had an adequate study quality and 43% were rated as weak.

Within-subjects design studies

For WSD studies, one outlier effect size value ( SMD = 3.51) was identified for a study implementing a consequence-based intervention. This value was Winsorized to a less extreme value of 3.00. A summary of the characteristics of each WSD study included in the meta-analysis is provided in S3 Table . Summary statistics for the moderator analyses are shown in Table 2 . For WSD studies, IQ was not included in the moderator analyses because only eight of these studies reported IQ of participants.

https://doi.org/10.1371/journal.pone.0148841.t002

Effect sizes for WSD studies ranged from −0.08 to 3.00 (Winsorized value) with a median of 0.92. The mean weighted effect size was 0.92 and reached significance (95% CI [0.59, 1.25]). Effect sizes were significantly heterogeneous ( Q T [23] = 66.80, p < .001; I 2 = 66%), indicating potential moderators. A significant effect for intervention type was found ( Q B [3] = 36.77, p < .001), with consequence-based interventions producing larger effects than antecedent-based, self-regulation, and combined interventions. Effect sizes also differed significantly for classroom setting ( Q B [1] = 4.43, p = .035), with larger effects for interventions implemented in general education classrooms than for interventions implemented in other classroom settings. No significant effect was found for type of measure ( Q B = [2] = 0.20, p = .904), age ( Q B = [1] = 1.88, p = .170), gender ( Q B [1] = 0.37, p = .543), and medication use ( Q B [2] = 0.53, p = .769). To detect publication and related bias, a funnel plot was created ( Fig 2 ). The funnel plot showed significant asymmetry ( p < .001), which seemed to be due to missing of smaller studies showing no or small beneficial effects. Fail-safe N analyses showed that 86.4 and 20.2 studies with effect sizes of zero would be necessary to reduce the mean effect size to 0.20 and 0.50, respectively.

A funnel plot showing the effect sizes of within-subjects design studies as a function of the inverse of their standard error. The vertical line indicates the weighted mean effect size ( M SMD = 0.92) and the dashed lines represent the 95% confidence limits around this mean.

https://doi.org/10.1371/journal.pone.0148841.g002

Single-subject design studies

For SSD studies, two outlier effect size values were identified for studies implementing a consequence-based ( SMD = 12.43) and self-regulation intervention ( SMD = 8.17). These values were Winsorized to a less extreme value of 7.00. A summary of the characteristics of each SSD study included in the meta-analysis is provided in S4 Table . Summary statistics for moderator examination are provided in Table 2 . Type of measure and IQ were not included in the moderator examination of SSD studies because all effect sizes were obtained for direct observations and only 19 studies reported IQ of participants. No significance tests could be performed as exact expressions for effect size variances for SSDs have not been derived and are formally not justified.

Effect sizes for SSD studies ranged from 0.42 to 7.00 (Winsorized value) with a median of 2.63. The mean weighted effect size was 3.08. Regarding intervention type, effect sizes were largest for self-regulation interventions ( M SMD = 3.61) and smallest for consequence-based interventions ( M SMD = 2.47). Regarding classroom setting, largest effects were obtained in general education classrooms ( M SMD = 3.58) and smallest in other classroom settings ( M SMD = 2.41). The examination of age as a potential moderator, resulted in a mean effect size of 3.00 for studies including children and a mean effect size of 3.39 for studies conducted in adolescents. Regarding gender, the largest effect sizes were found for mixed samples of boys and girls ( M SMD = 3.68). Finally, medication use was examined as moderator. Studies including a high proportion of participants on medication achieved largest effect sizes ( M SMD = 3.22), whereas studies with a low rate of medicated participants showed smallest effect sizes ( M SMD = 2.34).

Direct effects on classmates

Four WSD and four SSD studies provided information that could be useful for the assessment of direct effects of classroom interventions on classmates of children with symptoms of ADHD (see Table 3 ). For all four WSD studies applying antecedent-based interventions, effect sizes for behavioral outcomes of classmates were positive, ranging from 0.21 to 1.97 [ 46 – 49 ]. One of these studies also included academic performance measures of classmates and revealed an effect size of 0.64 [ 46 ]. Positive effects on classmates were also found for all four SSD studies. Two SSD studies applying an antecedent-based [ 50 ] and a self-regulation intervention [ 51 ] produced effect sizes of 1.96 and 2.53, respectively. For the other two SSD studies applying a consequence-based and a self-regulation intervention, mean class’ disruptive behavior decreased on average with 52% and 36% respectively during intervention phases as compared to baseline phases [ 52 ].

https://doi.org/10.1371/journal.pone.0148841.t003

Indirect effects on classmates

Three studies, all SSD studies, provided information showing indirect effects of classroom interventions on classmates of children with symptoms of ADHD (see Table 4 ). Positive indirect effects on behavioral outcomes of classmates were found for two out of three studies. An effect size of 1.46 was obtained for a study implementing a self-regulation intervention [ 53 ]. Two other studies applying a combined [ 54 ] and a self-regulation intervention [ 55 ] used data of different classmates and showed a behavioral improvement (34% decrease in off-task behavior) and deterioration (2% decrease in on-task behavior) respectively during intervention phases compared to baseline phases. The latter study also included classmate academic performance measures and observed an increase of 6% in academic performance during intervention phases compared to baseline phases.

https://doi.org/10.1371/journal.pone.0148841.t004

The primary aim of this meta-analytic review was to determine the effectiveness of several types of classroom interventions that can be applied by teachers in order to decrease off-task and disruptive classroom behavior in children with symptoms of ADHD. The results indicate that classroom interventions reduce off-task and disruptive classroom behavior in children with symptoms of ADHD, which is in accordance with previous meta-analyses [ 28 – 31 ]. Large effects were found for WSD studies ( M SMD = 0.92). Positive effects were also found for SSD studies ( M SMD = 3.08) but interpreting the absolute magnitude of these effects is difficult as statistical guidelines for such interpretation are lacking. It should be noted that effect sizes for WSDs and SSDs cannot be directly compared to each other as they represent different units of measurement. The obtained effect sizes were somewhat larger than those found in other meta-analyses of studies on school-based interventions for ADHD [ 28 – 31 ], which may have several causes. First, unlike the present study, DuPaul and Eckert [ 28 ] and DuPaul et al. [ 29 ] included unpublished studies. Furthermore, Purdie et al. [ 30 ] only included eight school-based studies and Reid et al. [ 31 ] specifically focused on self-regulation interventions, which resulted in a more selective overview. Finally, there were differences in the exact method of computation of effect sizes, the outcomes used, and the interventions examined.

WSD studies indicate that consequence-based interventions ( M SMD = 1.82) are more effective in reducing off-task and disruptive classroom behavior in children with symptoms of ADHD than antecedent-based ( M SMD = 0.31), self-regulation ( M SMD = 0.56), and combined interventions ( M SMD = 0.58). However, SSD studies showed largest effects for self-regulation interventions ( M SMD = 3.61) and smallest effects for consequence-based interventions ( M SMD = 2.47). The discrepancy in results between the two types of research designs may be the consequence of differences between the characteristics of participants (e.g., medication use) or the specific interventions that were implemented. Based on the present study, it can be concluded that the different classroom interventions performed had (small to large) positive effects on off-task and disruptive classroom behavior in children with symptoms of ADHD, with consequence-based and self-regulation interventions showing the strongest effects.

The results indicate that interventions implemented in general education classrooms (WSDs: M SMD = 1.30; SSDs: M SMD = 3.58) lead to a larger reduction in off-task and disruptive classroom behavior in children with symptoms of ADHD than interventions implemented in other classroom settings (WSDs: M SMD = 0.64; SSDs: M SMD = 2.41). This difference may be explained by different populations allocated to or different treatments performed in these settings. For example, the more positive effects in general education classrooms compared to other classroom settings could be explained by the fact that children with less severe symptoms of ADHD and/or less comorbidities are generally included in general education classrooms. These children may benefit more from classroom interventions than children with more severe symptoms of ADHD and/or more comorbidities, who tend to be included in special education classrooms. Furthermore, in special education classrooms there may be less room for improvement compared to general education classrooms because behavioral programs are already in place in special education classrooms.

Unfortunately, no reliable conclusions can be drawn on the influence of the type of measure used because most studies reported direct observations and only few effect sizes could be computed for teacher ratings (because either they were not reported or too few data points were available). Other studies examining the relationship between teacher ratings and observational data indicate that these two measurements of behavior are weakly to strongly correlated [ 56 , 57 ], suggesting that classroom interventions would not only improve direct observations but also improve teacher ratings. It is important that classroom interventions do not only improve behavior as measured objectively by direct observations but also improve behavior subjectively as perceived by teacher, because teachers whose efforts are rewarded may become more confident and motivated to both educate children with symptoms of ADHD and change their classroom management in favor of these children [ 58 ].

Finally, there was no clear evidence that the age, gender, and medication use of participants influenced the results. For SSD studies, intervention effects seemed to be similar for children and adolescents, and largest for studies including a mix of boys and girls. SSD studies did show a trend for a positive influence of medication on the effectiveness of classroom interventions for individuals with ADHD. However, this could not be tested statistically. For WSD studies, no moderating effects of age, gender, and medication use were found. This, however, may have been caused by a low statistical power due to the limited availability of studies in some of the categories. Intelligence as a moderator was not examined in the present study because most studies did not provide information on participants’ cognitive level. For future studies on school-based interventions, it is therefore clearly recommended to include cognitive measures as well as both genders and age groups.

The small number of studies that provided information on the effects of classroom interventions on classmates of children with symptoms of ADHD indicates positive effects on overall classroom functioning. Classmates who received the same intervention as participants with symptoms of ADHD as well as classmates who did not receive any intervention themselves, showed an improvement in behavioral and academic outcomes. This implies that classroom interventions for children with symptoms of ADHD have both direct effects on classmates, i.e., improvement of classmates’ behavior because they also benefit from the intervention, and indirect effects on classmates, i.e., profit from less classroom disturbance by children with symptoms of ADHD. Although positive effects on classmates were found for all types of classroom interventions, most studies reported on direct effects of antecedent-based interventions and indirect effects of self-regulation interventions.

Limitations

There are several factors that limit the conclusions of this meta-analytic review. First, this meta-analytic review was restricted to studies published in academic journals, which most likely has resulted in an upward bias in effect sizes. However, it is unlikely that small or negative effects would be obtained if unpublished studies would have been included, as the fail-safe N analyses for WSD studies indicate that as many as 86 studies with effect sizes of zero would be necessary to reduce the effect size to small. Furthermore, there was a trend for the smaller studies to show larger treatment effects than the larger studies, which may be due to differences in methodological quality. Examination of study quality indicates that many group and SSD studies are weak in methodological quality. For example, most group studies did not include a control group (67% unacceptable quality) and a substantial number of SSD studies had problems with demonstrating experimental control (17% unacceptable quality). This limits the interpretation of the results. Moreover, most studies employed SSDs, for which exact expressions of effect size variances have not been derived [ 35 , 39 ]. Therefore, moderator examination of SSD studies was descriptive and consequently did not allow for firm conclusions. Additionally, no statistical guidelines exist for the interpretation of effect sizes for SSD studies, which also limits the interpretation of the present findings. For WSD studies, some moderator effects may have been missed because of the low number of studies performed with regard to the effects of some moderators. Also, potential interactions between moderating variables could not be examined.

Another limitation is that potential moderators had to be analyzed using subgroup analyses instead of meta-regression analysis because the data were not normally distributed and therefore violated the assumptions for regression analysis. The use of categorical instead of continuous variables may have resulted in a loss of precision and power. Furthermore, the use of rather broad categories of classroom interventions did not allow conclusions about specific classroom interventions within these categories. Also, the outcomes applied within the studies were considerable heterogeneous. For example, some studies used a broad definition of off-task behavior (e.g., ‘not on-task’), whereas other studies defined specific types of disruptive behavior (e.g., ‘uncontrolled verbalizations’).

Finally, this meta-analytic review was restricted regarding the age and gender of participants, and type of measure. The results are most representative for boys in the age of 6 to 11 years, as only a minority of studies reported about samples including females and/or adolescents. Furthermore, the results were most often obtained from direct observation measures, reflecting objective behavior and not subjective behavior as perceived by the teacher. However, these two measurements of behavior have been found to be correlated [ 56 , 57 ], suggesting that the results of this meta-analytic review are not only applicable to objective behavior of students but may also be generalized to teachers’ experiences of students’ behavior.

Future research

The present study highlights several areas of recommended future research. First, studies on classroom interventions for ADHD have mainly focused on boys and elementary school children. As girls and adolescents with symptoms of ADHD may respond differently, there is a particular need for research on these samples. Additional factors influencing the effectiveness of classroom interventions for children with symptoms of ADHD should be further examined, because the current meta-analytic review showed considerably heterogeneous effect sizes that could not be fully explained by the investigated moderators. For example, child factors other than age and gender (e.g., cognitive dysfunctions, medication use), teacher factors (e.g., teaching experience, personality), and potential interactions between the different factors should also be taken into account. Finally, most studies evaluating classroom interventions for ADHD have employed SSDs or group designs of weak methodological quality. There is a need for higher quality studies, especially large-scale studies using randomized controlled designs, that allow for more reliable and firm conclusions.

Implications for practice

The findings of the current study are promising because they indicate that teachers can effectively implement classroom interventions to reduce off-task and disruptive classroom behavior in children with symptoms of ADHD. All types of interventions examined appeared to be effective but strongest effects were obtained for consequence-based (for WSD studies) and self-regulation interventions (for SSD studies), suggesting that teachers should consider such types of interventions in particular. The appropriateness of a specific type of intervention depends on the characteristics of the child as well as the function and meaning of his or her ADHD-related behavior [ 19 ]. Therefore, it is important that teachers consider which interventions are effective for an individual child (in contemplation with a professional such as a school psychologist or internal supervisor).

The results also indicate that classroom interventions are most effective in general education classrooms, which is promising as many children with ADHD attend such classrooms [ 10 ]. Furthermore, children with symptoms of ADHD who are on medication also benefit from classroom interventions. Therefore, teachers should not be reluctant to implement classroom interventions for children with symptoms of ADHD who already receive medical treatment for their problems, because current data do not exclude that classroom interventions provide additional improvement to medical treatment. Finally, teachers do not have to be concerned about a potential negative impact of above classroom interventions on overall classroom functioning, as the current results denote positive effects, both direct and indirect, of classroom interventions on classmates of children with symptoms of ADHD.

Because teachers often seem to lack knowledge and skills to develop and implement effective classroom interventions for children with ADHD [ 16 ], it is recommended that classroom management training is offered to teachers. Such training would not only provide teachers with effective tools for classroom management of children with symptoms of ADHD but may also improve their confidence and well-being. Consequently, such training is likely to be beneficial to children with symptoms of ADHD, their classmates, as well as their teachers.

This meta-analytic review indicates that classroom interventions reduce off-task and disruptive classroom behavior in children with symptoms of ADHD. WSD studies showed that consequence-based interventions are more effective than antecedent-based, self-regulation, and combined interventions. However, SSD studies showed largest effects for self-regulation interventions. Larger effects were obtained for children with symptoms of ADHD in general education classrooms than for those in other classroom settings. No reliable conclusions can be formulated about moderating effects of type of measure, and student’s age, gender, intelligence, and medication use. Finally, the study also indicates positive direct and indirect effects of these classroom interventions on classmates’ behavioral and academic outcomes. The results of this study may be used for educating and training teachers in dealing with children with symptoms of ADHD.

Supporting Information

S1 prisma checklist. prisma checklist..

https://doi.org/10.1371/journal.pone.0148841.s001

S1 Table. Interrater reliability.

https://doi.org/10.1371/journal.pone.0148841.s002

S2 Table. Study quality.

https://doi.org/10.1371/journal.pone.0148841.s003

S3 Table. Characteristics of Within-Subjects Design Studies Included in the Meta-Analytic Review.

https://doi.org/10.1371/journal.pone.0148841.s004

S4 Table. Characteristics of Single-Subject Design Studies Included in the Meta-Analytic Review.

https://doi.org/10.1371/journal.pone.0148841.s005

S1 Text. Computation of Effect Sizes.

https://doi.org/10.1371/journal.pone.0148841.s006

S2 Text. List of Studies Included in the Meta-Analytic Review.

https://doi.org/10.1371/journal.pone.0148841.s007

Author Contributions

Conceived and designed the experiments: YG LT OT. Performed the experiments: GFG YG LT OT. Analyzed the data: GFG YG. Contributed reagents/materials/analysis tools: OT. Wrote the paper: GFG YG LT OT.

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Understanding and Supporting Attention Deficit Hyperactivity Disorder (ADHD) in the Primary School Classroom: Perspectives of Children with ADHD and their Teachers

• Original Paper
• Open access
• Published: 01 July 2022
• volume  53 ,  pages 3406–3421 ( 2023 )

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• Emily McDougal   ORCID: orcid.org/0000-0001-7684-7417 1 , 3 ,
• Claire Tai 1 ,
• Tracy M. Stewart   ORCID: orcid.org/0000-0002-8807-1174 2 ,
• Josephine N. Booth   ORCID: orcid.org/0000-0002-2867-9719 2 &
• Sinéad M. Rhodes   ORCID: orcid.org/0000-0002-8662-1742 1  

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Children with Attention Deficit Hyperactivity Disorder (ADHD) are more at risk for academic underachievement compared to their typically developing peers. Understanding their greatest strengths and challenges at school, and how these can be supported, is vital in order to develop focused classroom interventions. Ten primary school pupils with ADHD (aged 6–11 years) and their teachers (N = 6) took part in semi-structured interviews that focused on (1) ADHD knowledge, (2) the child’s strengths and challenges at school, and (3) strategies in place to support challenges. Thematic analysis was used to analyse the interview transcripts and three key themes were identified; classroom-general versus individual-specific strategies, heterogeneity of strategies, and the role of peers. Implications relating to educational practice and future research are discussed.

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Characterised by persistent inattention, hyperactivity and impulsivity (APA, 2013), ADHD is a neurodevelopmental disorder thought to affect around 5% of children (Russell et al., 2014 ) although prevalence estimates vary (Sayal et al., 2018 ). Although these core symptoms are central to the ADHD diagnosis, those with ADHD also tend to differ from typically developing children with regards to cognition and social functioning (Coghill et al., 2014 ; Rhodes et al., 2012 ), which can negatively impact a range of life outcomes such as educational attainment and employment (Classi et al., 2012 ; Kuriyan et al., 2013 ). Indeed, academic outcomes for children with ADHD are often poor, particularly when compared with their typically developing peers (Arnold et al., 2020 ) but also compared to children with other neurodevelopmental disorders, such as autism (Mayes et al., 2020 ). Furthermore, children with ADHD can be viewed negatively by their peers. For example, Law et al. ( 2007 ) asked 11–12-year-olds to read vignettes describing the behaviour of a child with ADHD symptoms, and then use an adjective checklist to endorse those adjectives that they felt best described the target child. The four most frequently ascribed adjectives were all negative (i.e. ‘careless’, ‘lonely’, ‘crazy’, and ‘stupid’). These negative perceptions can have a significant impact on the wellbeing of individuals with ADHD, including self-stigmatisation (Mueller et al., 2012 ). There is evidence that teachers with increased knowledge of ADHD report more positive attitudes towards children with ADHD compared to those with poor knowledge (Ohan et al., 2008 ) and thus research that identifies the characteristics of gaps in knowledge is likely to be important in addressing stigma.

Previous research of teachers' ADHD knowledge is mixed, with the findings of some studies indicating that teachers have good knowledge of ADHD (Mohr-Jensen et al., 2019 ; Ohan et al., 2008 ) and others suggesting that their knowledge is limited (Latouche & Gascoigne, 2019 ; Perold et al., 2010 ). Ohan et al. ( 2008 ) surveyed 140 primary school teachers in Australia who reported having experience of teaching at least one child with ADHD. Teachers completed the ADHD Knowledge Scale which consisted of 20 statements requiring a response of either true or false (e.g. “A girl/boy can be appropriately labelled as ADHD and not necessarily be over-active ”). They found that, on average, teachers answered 76.34% of items correctly, although depth of knowledge varied across the sample. Almost a third of the sample (29%) had low knowledge of ADHD (scoring less than 69%), with just under half of teachers (47%) scoring in the average range (scores of 70–80%). Only a quarter (23%) had “high knowledge” (scores above 80%) suggesting that knowledge varied considerably. Furthermore, Perold et al. ( 2010 ) asked 552 teachers in South Africa to complete the Knowledge of Attention Deficit Disorders Scale (KADDS) and found that on average, teachers answered only 42.6% questions about ADHD correctly. Responses of “don’t know” (35.4%) and incorrect responses (22%) were also recorded, indicating gaps in knowledge as well as a high proportion of misconceptions. Similar ADHD knowledge scores were reported in Latouche and Gascoigne’s ( 2019 ) study, who found that teachers enrolled into their ADHD training workshop in Australia had baseline KADDS scores of below 50% accuracy (increased to above 80% accuracy after training).

The differences in ADHD knowledge reported between Ohan et al. ( 2008 ) and the more recent studies could be due to the measures used. Importantly, when completing the KADDS, respondents can select a “don’t know” option (which receives a score of 0), whereas the ADHD Knowledge Scale requires participants to choose either true or false for each statement. The KADDS is longer, with a total of 39 items, compared to the 20-item ADHD Knowledge Scale, offering a more in-depth knowledge assessment. The heterogeneity of measures used within the described body of research is also highlighted within Mohr-Jensen et al. ( 2019 ) systematic review; the most frequently used measure (the KADDS) was only used by 4 out of the 33 reviewed studies, showing little consensus on the best way to measure ADHD knowledge. Despite these differences in measurement, the findings from most studies indicate that teacher ADHD knowledge is lacking.

Qualitative methods can provide rich data, facilitating a deeper understanding of phenomena that quantitative methods alone cannot reveal. Despite this, there are very few examples in the literature of qualitative methods being used to understand teacher knowledge of ADHD. In one example, Lawrence et al. ( 2017 ) interviewed fourteen teachers in the United States about their experiences of working with pupils with ADHD, beginning with their knowledge of ADHD. They found that teachers tended to focus on the external symptoms of ADHD, expressing knowledge of both inattentive and hyperactive symptoms. Although this provided key initial insights into the nature of teachers’ ADHD knowledge, only a small section of the interview schedule (one out of eight questions/topics) directly focused on ADHD knowledge. Furthermore, none of the questions asked directly about strengths, with answers focusing on difficulties. It is therefore difficult to determine from this study whether teachers are aware of strengths and difficulties outside of the triad of symptoms. A deeper investigation is necessary to fully understand what teachers know, and to identify areas for targeted psychoeducation.

Importantly, improved ADHD knowledge may impact positively on the implementation of appropriate support for children with ADHD in school. For example, Ohan et al. ( 2008 ) found that teachers with high or average ADHD knowledge were more likely to perceive a benefit of educational support services than those with low knowledge, and teachers with high ADHD knowledge were also more likely to endorse a need for, and seek out, those services compared to those with low knowledge. Furthermore, improving knowledge through psychoeducation may be important for improving fidelity to interventions in ADHD (Dahl et al., 2020 ; Nussey et al., 2013 ). Indeed, clinical guidelines recommend inclusion of psychoeducation in the treatment plan for children with ADHD and their families (NICE, 2018 ). Furthermore, Jones and Chronis-Tuscano ( 2008 ) found that educational ADHD training increased special education teachers’ use of behaviour management strategies in the classroom. Together, these findings suggest that understanding of ADHD may improve teachers’ selection and utilisation of appropriate strategies.

Child and teacher insight into strategy use in the classroom on a practical, day-to-day level may provide an opportunity to better understand how different strategies might benefit children, as well as the potential barriers or facilitators to implementing these in the classroom. Previous research with teachers has shown that aspects of the physical classroom can facilitate the implementation of effective strategies for autistic children, for example to support planning with the use of visual timetables (McDougal et al., 2020 ). Despite this, little research has considered the strategies that children with ADHD and their teachers are using in the classroom to support their difficulties and improve learning outcomes. Moore et al. ( 2017 ) conducted focus groups with UK-based educators (N = 39) at both primary and secondary education levels, to explore their experiences of responding to ADHD in the classroom, as well as the barriers and facilitators to supporting children. They found that educators mostly reflected on general inclusive strategies in the classroom that rarely targeted ADHD symptoms or difficulties specifically, despite the large number of strategies designed to support ADHD that are reported elsewhere in the literature (DuPaul et al., 2012 ; Richardson et al., 2015 ). Further to this, when interviewing teachers about their experiences of teaching pupils with ADHD, Lawrence et al. ( 2017 ) specifically asked about interventions or strategies used in the classroom with children with ADHD. The reported strategies were almost exclusively behaviourally based, for example, allowing children to fidget or move around the classroom, utilising rewards, using redirection techniques, or reducing distraction. This lack of focus on cognitive strategies is surprising, given the breadth of literature focusing on the cognitive difficulties in ADHD (e.g. Coghill, et al., 2014 ; Gathercole et al., 2018 ; Rhodes et al., 2012 ). Furthermore, to our knowledge research examining strategy use from the perspective of children with ADHD themselves, or strengths associated with ADHD, is yet to be conducted.

Knowledge and understanding of ADHD in children with ADHD has attracted less investigation than that of teachers. In a Canadian sample of 8- to 12-year-olds with ADHD (N = 29), Climie and Henley ( 2018 ) found that ADHD knowledge was highly varied between children; scores on the Children ADHD Knowledge and Opinions Scale ranged from 5 to 92% correct (M = 66.53%, SD = 18.96). The authors highlighted some possible knowledge gaps, such as hyperactivity not being a symptom for all people with ADHD, or the potential impact upon social relationships, however the authors did not measure participant’s ADHD symptoms, which could influence how children perceive ADHD. Indeed, Wiener et al ( 2012 ) has shown that children with ADHD may underestimate their symptoms. If this is the case, it would also be beneficial to investigate their understanding of their own strengths and difficulties, as well as of ADHD more broadly. Furthermore, if children do have a poor understanding of ADHD, they may benefit from psychoeducational interventions. Indeed, in their systematic review Dahl et al. ( 2020 ) found two studies in which the impact of psychoeducation upon children’s ADHD knowledge was examined, both of which reported an increase in knowledge as a consequence of the intervention. Understanding the strengths and difficulties of the child, from the perspective of the child and their teacher, will also allow the design of interventions that are individualised, an important feature for school-based programmes (Richardson et al., 2015 ). Given the above, understanding whether children have knowledge of their ADHD and are aware of strategies to support them would be invaluable.

Teacher and child knowledge of ADHD and strategies to support these children is important for positive developmental outcomes, however there is limited research evidence beyond quantitative data. Insights from children and teachers themselves is particularly lacking and the insights which are available do not always extend to understanding strengths which is an important consideration, particularly with regards to implications for pupil self-esteem and motivation. The current study therefore provides a vital examination of the perspectives of both strengths and weaknesses from a heterogeneous group of children with ADHD and their teachers. Our sample reflects the diversity encountered in typical mainstream classrooms in the UK and the matched pupil-teacher perspectives enriches current understandings in the literature. Specifically, we aimed to explore (1) child and teacher knowledge of ADHD, and (2) strategy use within the primary school classroom to support children with ADHD. This novel approach, from the dual perspective of children and teachers, will enable us to identify potential knowledge gaps, areas of strength, and insights on the use of strategies to support their difficulties.

Participants

Ten primary school children (3 female) aged 7 to 11 years (M = 8.7, SD = 1.34) referred to Child and Adolescent Mental Health Services (CAMHS) within the NHS for an ADHD diagnosis were recruited to the study. All participant characteristics are presented in Table 1 . All children were part of the Edinburgh Attainment and Cognition Cohort and had consented to be contacted for future research. Children who were under assessment for ADHD or who had received an ADHD diagnosis were eligible to take part. Contact was established with the parent of 13 potential participants. Two had undergone the ADHD assessment process with an outcome of no ADHD diagnosis and were therefore not eligible to take part, and one could not take part within the timeframe of the study. The study was approved by an NHS Research Ethics Committee and parents provided informed consent prior to their child taking part. Co-occurrences data for all participants was collected as part of a previous study and are reported here for added context. All of the children scored above the cut-off (T-score > 70) for ADHD on the Conners 3 rd Edition Parent diagnostic questionnaire (Conners, 2008 ). The maximum possible score for this measure is 90. At the point of interview, seven children had received a diagnosis of ADHD, two children were still under assessment, and one child had been referred for an ASD diagnosis (Table 1 ). The ADHD subtype of each participant was not recorded, however all children scored above the cut-off for both inattention (M = 87.3, SD = 5.03) and hyperactivity (M = 78.6, SD = 5.8) which is indicative of ADHD combined type. Use of stimulant medication was not recorded at the time of interview.

Following the child interview and receipt of parental consent, each child’s school was contacted to request their teacher’s participation in the study. Three teachers could not take part within the timeframe of the study, and one refused to take part. Six teachers (all female) were successfully contacted and gave informed consent to participate.

Due to the increased likelihood of co-occurring diagnoses in the target population, we also report Autism Spectrum Disorder (ASD) symptoms and Developmental Co-ordination Disorder (DCD) symptoms using the Autism Quotient 10-item questionnaire (AQ-10; Allison et al., 2012 ) and Movement ABC-2 Checklist (M-ABC2; Henderson et al., 2007 ) respectively, both completed by the child’s parent.

Scores of 6 and above on the AQ-10 indicates referral for diagnostic assessment for autism is advisable. All but one of the participants scored below the cut-off on this measure (M = 3.6, SD = 1.84).

The M-ABC2 checklist categorises children as scoring green, amber or red based on their scores. A green rating (up to the 85th percentile) indicates no movement difficulty, amber ratings (between 85 and 95th percentile) indicate risk of movement difficulty, and red ratings (95th percentile and above) indicate high likelihood of movement difficulty. Seven of the participants received a red rating, one an amber rating, and two green ratings.

Socioeconomic status (SES) is also known to impact educational outcomes, therefore the SES of each child was calculated using the Scottish Index of Multiple Deprivation (SIMD), which is an area-based measure of relative deprivation. The child’s home postcode was entered into the tool which provided a score of deprivation on a scale of 1 to 5. A score of 1 is given to the 20% most deprived data zones in Scotland, and a score of 5 indicates the area was within the 20% least deprived areas.

Semi-Structured Interview

The first author, who is a psychologist, conducted interviews with each participant individually, and then a separate interview with their teacher. This was guided by a semi-structured interview schedule (see Appendix A, Appendix B) developed in line with our research questions, existing literature, and using authors (T.S. and J.B.) expertise in educational practice. The questions were adapted to be relevant for the participant group. For example, children were asked “If a friend asked you to tell them what ADHD is, what would you tell them?” and teachers were asked, “What is your understanding of ADHD or can you describe a typical child with ADHD?”. The schedule comprised two key sections for both teachers and children. The first section focused on probing the participant’s understanding and knowledge of ADHD broadly. The second section focused on the participating child’s academic and cognitive strengths and weaknesses, and the strategies used to support them. Interviews with children took place in the child’s home and lasted between 19 and 51 min (M = 26.3, SD = 10.9). Interviews with teachers took place at their school and were between 28 and 50 min long (M = 36.5, SD = 7.61). Variation in interview length was mostly due to availability of the participant and/or age of the child (i.e. interviews with younger children tended to be shorter). All interviews were recorded on an encrypted voice recorder and transcribed by the first author prior to data analysis. Pseudonyms were randomly generated for each child to protect anonymity.

Reflexive thematic analysis was used to analyse the data (Braun & Clarke, 2019 ). This flexible approach allows the data to drive the analysis, putting the participant at the centre of the research and placing high value on the experiences and perspectives of individual participants (Braun & Clarke, 2006 ). The six phases of reflexive thematic analysis as outlined by Braun and Clarke were followed: (1) familiarisation, (2) generating codes, (3) constructing themes, (4) revising themes, (5) defining themes, (6) producing the report. Due to the exploratory nature of this study, bottom-up inductive coding was used. Two of the authors (E.M. and C.T.) worked collaboratively to construct and subsequently define the themes using the process described above. More specifically, one author (E.M.) generated codes, with support from another author (C.T.). Collated codes and data were then abstracted into potential themes, which were reviewed and refined using relevant literature, as well as within the wider context of the data. This process continued until all themes were agreed upon.

In the first part of the analysis, focus was placed on summarising the participants’ understanding of ADHD, as well as what they thought their biggest strengths and challenges were at school. Following this, an in-depth analysis of the strategies used in the classroom was conducted, taking into account the perspective of both teachers and children, aiming to generate themes from the data.

Knowledge of ADHD

Children and teachers were asked about their knowledge of ADHD. When asked if they had ever heard of ADHD, the majority of children said yes. Some of the children could not explain to the interviewer what ADHD was or responded in a way that suggested a lack of understanding ( “it helps you with skills” – Niall, 7 years; “ Well it’s when you can’t handle yourself and you’re always crazy and you can just like do things very fast”— Nathan, 8 years). Very few of the children were able to elaborate accurately on their understanding of ADHD, which exclusively focused on inattention. For example, Paige (8 years) said “ its’ kinda like this thing that makes it hard to concentrate ” and Finn (10 years) said “ they get distracted more just in different ways that other people would ”. This suggests that children with ADHD may lack or have a limited awareness or understanding of their diagnosis.

When asked about their knowledge of ADHD, teachers tended to focus on the core symptoms of ADHD. All teachers directly mentioned difficulties with attention, focus or concentration, and most directly or indirectly referred to hyperactivity (e.g. moving around, being in “ overdrive ”). Most teachers also referred to social difficulties as a feature of ADHD, including not following social rules, reacting inappropriately to other children and appearing to lack empathy, which they suggested could be linked to impulsivity. For example, “ reacting in social situations where perhaps other children might not react in a similar way” (Paige’s teacher) and “ They can react really really quickly to things and sometimes aggressively” (Eric’s teacher). Although no teachers directly mentioned cognitive difficulties, some referred to behaviours indicative of cognitive difficulties, for example, “ they can’t store a lot of information at one time” (Eric’s teacher) and, “ it’s not just the concentration it’s the amount they can take in at a time as well” (Nathan’s teacher), which may reflect processing or memory differences. Heterogeneity was mentioned, in that ADHD can mean different things for different children (e.g., “ I think ADHD differs from child to child and I think that’s really important” —Nathan’s teacher). Finally, academic difficulties as a feature of ADHD were also mentioned (e.g., “ a child… who finds some aspects of school life, some aspects of the curriculum challenging ”—Jay’s teacher).

After being asked to give a general description of ADHD, each child was asked about their own strengths at school and teachers were also asked to reflect on this topic for the child taking part.

When asked what they like most about school, children often mentioned art or P.E. as their preferred subjects. A small number of children said they enjoyed maths or reading, but this was not common and the majority described these subjects as a challenge or something they disliked. There was also clear link between the aspects of school children enjoyed, and what they perceived to be a strength for them. For example, when asked what he liked about school, Eric (10 years) said, “ Math, I’m pretty good at that”, or when later asked what they were good at, most children responded with the same answers they gave when asked what they liked about school. It is interesting to note that subjects such as art or P.E. generally have a different format to more traditionally academic subjects such as maths or literacy. Indeed, Felicity (11 years) said, “ I quite like art and drama because there’s not much reading…and not really too much writing in any of those” . Children also tended to mention the non-academic aspects of school, such as seeing their friends, or lunch and break times.

Teachers’ descriptions of the children’s strengths were much more variable compared to strengths mentioned by children. Like the children, teachers tended to consider P.E and artistic activities to be a strength for the child with ADHD. Multiple teachers referred to the child having a good imagination and creative skills. For example, “ she’s a very imaginative little girl, she has a great ability to tell stories and certainly with support write imaginative stories” (Paige’s teacher) . Teachers referred to other qualities or characteristics of the child as strengths, although these varied across teachers. These included openness, both socially but also in the context of willingness to learn or being open to new challenges, being a hard worker, or an enjoyable person to be around (e.g., “ he is the loveliest little boy, I’ve got a lot of time for [Nathan]. He makes me smile every day, you know, he just comes out with stuff he’s hilarious”— Nathan’s teacher). The most noticeable theme that emerged from this data was that when some teachers began describing one of the child’s strengths, it was suffixed with a negative. For example, Henry’s teacher said, “ He’s got a very good imagination, his writing- well not so much the writing of the stories, he finds writing quite a challenge, but his verbalising of ideas he’s very imaginative”. This may reflect that while these children have their own strengths, these can be limited by difficulties. Indeed, Paige’s teacher said, “ I think she’s a very able little girl without a doubt, but there is a definite barrier to her learning in terms of her organisation, in terms of her focus” , which reinforces this notion.

Children were asked directly about what they disliked about school, and what they found difficult. Children tended to focus more on specific subjects, with maths and aspects of literacy being the most frequently mentioned of these. Children referred to difficulties with or a dislike for reading, writing and/or spelling activities, for example, Rory (9 years) said “ Well I suppose spelling because … sometimes we have to do some boring tasks like we have to write it out three times then come up with the sentence for each one which takes forever and it’s hard for me to think of the sentences if I’m not ready” . Linking this with known cognitive difficulties in ADHD, it is interesting to note that both memory and planning are implicated in this quote from Rory about finding spelling challenging. In terms of writing, children referred to both the physical act of writing (e.g., “ probably writing cause sometimes I forget my finger spaces ”—Paige, 8 years; “ [writing the alphabet is] too hard… like the letters joined together … [and] I make mistakes” —Jay, 7 years) as well as the planning associated with writing a longer piece of work (e.g. “ when I run out of ideas for it, it’s really hard to think of some more so I don’t usually get that much writing done ”—Rory (9 years) .

Aside from academic subjects, several children referred to difficulties with focus or attention (e.g. “ when I find it hard to do something I normally kind of just zone out ”—Felicity, 11 years, “ probably concentrating sometimes ”—Rory, 9 years), but boredom was also a common and potentially related theme (e.g. “ Reading is a bit hard though … it just sometimes gets a bit boring” —Finn, 10 years, “ I absolutely hate maths … ‘cause it’s boring ”—Paige, 8 years). It could be that children with ADHD find it more difficult to concentrate during activities they find boring. Indeed, when Jay (7 years) was asked how it made him feel when he found something boring, he said “ it made me not do my work ”. Some children also alluded to the social difficulties faced at school, which included bullying and difficulties making friends (e.g. “ just making all kind of friends [is difficult] ‘cause the only friend that I’ve got is [name redacted] ”—Nathan, 8 years; “ sometimes finding a friend to play with at break time [is difficult] ” – Paige, 8 years; “ there’s a lot of people in my school that they bully me” —Eric, 10 years).

When asked what they thought were the child’s biggest challenges at school, teachers' responses were relatively variable, although some common themes were identified. As was the case for children, teachers reflected on difficulties with attention, which also included being able to sit at the table for long periods of time (e.g. “ I would say he struggles the most with sitting at his table and focusing on one piece of work ”—Henry’s teacher). Teachers did also mention difficulties with subjects such as maths and literacy, although this varied from child to child, and often they discussed these in the context of their ADHD symptom-related difficulties. For example, Eric’s teacher said, “ we’ve struggled to get a long piece of writing out of him because he just can’t really sit for very long ”. This quote also alludes to difficulties with evaluating the child’s academic abilities, due to their ADHD-related difficulties, which was supported by other teachers (e.g. “ He doesn’t particularly enjoy writing and he’s slow, very slow. And I don’t know if that’s down to attention or if that’s something he actually does find difficult to do ” —Henry’s teacher). Furthermore, some teachers reflected on the child’s confidence as opposed to a direct academic difficulty. For example, Luna’s teacher said, “ I think it’s she lacks the confidence in maths and reading like the most ” and later, elaborated with “ she’ll be like “I can’t do it” but she actually can. Sometimes she’s … even just anxious at doing a task where she thinks … she might not get it. But she does, she’s just not got that confidence”.

Teachers also commonly mentioned social difficulties, and referred to these difficulties as a barrier to collaborative learning activities (e.g. “ he doesn’t always work well with other people and other people can get frustrated” —Henry’s teacher; “ [during] collaborative group work [Paige] perhaps goes off task and does things she shouldn’t necessarily be doing and that can cause friction within the group” —Paige’s teacher). Teachers also mentioned emotion regulation, mostly in relation to the child’s social difficulties. For example, Eric’s teacher said “ I think as well he does still struggle with his emotions like getting angry very very quickly, and being very defensive when actually he’s taken the situation the wrong way” , which suggests that the child’s difficulty with regulating emotions may impact on their social relationships.

Strategy Use in the Classroom

Strategies to support learning fell into one of four categories: concrete or visual resources, information processing, seating and movement, and support from or influence of others. Examples of codes included in each of these strategy categories are presented in Table 2 .

Concrete or visual resources were the most commonly mentioned type of strategy by teachers and children, referring to the importance of having physical representations to support learning. Teachers spoke about the benefit of using visual aids (e.g. “ I think [Henry] is quite visual so making sure that there is visual prompts and clues and things like that to help him ”—Henry’s teacher), and teachers and children alluded to these resources supporting difficulties with holding information in mind. For example, when talking about the times table squares he uses, Rory said “ sometimes I forget which one I’m on…and it’s easier for me to have my finger next to it than just doing it in my head because sometimes I would need to start doing it all over again ”.

Seating and movement were also commonly mentioned, which seemed to be specific to children with ADHD in that it was linked to inattention and hyperactivity symptoms. For example, teachers referred to supporting attention or avoiding distraction by the positioning of a child’s location in the classroom (e.g. “ he’s so easily distracted, so he has an individual desk in the room and he’s away from everyone else because he wasn’t coping at a table [and] he’s been so much more settled since we got him an individual desk” —Eric’s teacher). Some teachers also mentioned the importance of allowing children to move around the room where feasible, as well as giving them errands to perform as a movement break (e.g. “ if I need something from the printer, [Nathan] is gonna go for it for me…because that’s down the stairs and then back up the stairs so if I think he’s getting a bit chatty or he’s not focused I’ll ask him to go and just give him that break as well” —Nathan’s teacher). Children also spoke about these strategies but didn’t necessarily describe why or how these strategies help them.

Information processing and cognitive strategies included methods that supported children to process learning content or instructions. For example, teachers frequently mentioned breaking down tasks or instructions into more manageable chunks (e.g. “ with my instructions to [Eric] I break them down … I’ll be like “we’re doing this and then we’re doing this” whereas the whole class wouldn’t need that ”—Eric’s teacher). Teachers and children also mentioned using memory strategies such as songs, rhymes or prompts. For example, Jay’s teacher said, “ if I was one of the other children I could see why it would be very distracting but he’s like he’s singing to himself little times table songs that we’ve been learning in class” , and Paige (8 years) referred to using mnemonics to help with words she struggles to spell, “ I keep forgetting [the word] because. But luckily we got the story big elephants can always understand little elephants [which helps because] the first letter of every word spells because” .

Both groups of participants mentioned support from and influence of others, and referred to working with peers, the teacher–child relationship, and one-to-one teaching. Peer support was a common theme across the data and is discussed in more detail in the thematic analysis findings, where teachers and children referred to the importance of the role of peers during learning activities. Understanding the child well and adapting to them was also seen as important, for example, Luna’s teacher said, “ with everything curricular [I] try and have an art element for her, just so I know it’ll engage her [because] if it’s like a boring old written worksheet she’s not gonna do it unless you’re sitting beside her and you’re basically telling her the answers” . As indicated in this quote, teachers also referred to the effectiveness of one-to-one or small group work with the child (e.g. “ when somebody sits beside her and explains it, and goes “come on [Paige] you know how to do this, let’s just work through a couple of examples”… her focus is generally better ” – Paige’s teacher), however this resource is not always available (e.g. “ I’d love for someone to be one-to-one with [Luna] but it’s just not available, she doesn’t meet that criteria apparently ” – Luna’s teacher). Children also referred to seeking direct support from their teacher (e.g. “if I can’t get an idea of what I’m doing then I ask the teacher for help” – Paige, 8 years), but were more likely to mention seeking support from their peers than the teacher.

Thematic Analysis

In addition to summarising the types of strategies that teachers and children reported using in the classroom, the data were also analysed using thematic analysis to generate themes. These are now presented. The theme names, definitions, and example quotes for each theme are presented in Table 3 .

Theme 1: Classroom-General Versus Individual-Specific Strategies

During the interviews, teachers spoke about strategies that they use as part of their teaching practice for the whole class but that are particularly helpful for the child/children with ADHD. These tended to be concrete or visual resources that are available in the classroom for anyone, for example, a visual timetable or routine checklist (e.g. “ there’s also a morning routine and listing down what’s to be done and where it’s to go … it’s very general for the class but again it’s located near her” —Paige’s teacher).

Teachers also mentioned using strategies that have been implemented specifically for that child, and these strategies tended to focus on supporting attention. For example, Nathan’s teacher spoke about the importance of using his name to attract his attention, “ maybe explaining to the class but then making sure that I’m saying “[Nathan], you’re doing this”, you know using his name quite a lot so that he knows it’s his task not just the everybody task ”, and this was a strategy that multiple teachers referred to using with the individual child and not necessarily for other children. Other strategies to support attention with a specific child also tended to be seating and movement related, such as having an individual desk or allowing them to fidget. For example, Luna’s teacher said, “ she’s a fidgeter so she’ll have stuff to fidget with … [and] even if she’s wandering around the classroom or she’s sitting on a table, I don’t let other kids do that, but as long as she’s listening, it’s fine [with me]” .

Similar to teachers, children spoke about strategies or resources that were in place for them specifically as well as about general things in the classroom that they find helpful. That said, it was less common for children to talk about why particular strategies were in place for them and how they helped them directly.

In addition to recognising strategies that teachers had put in place for them, children also referred to using their own strategies in the classroom. The most frequently mentioned strategy was fidgeting, and although some of the younger children spoke about having resources available in the classroom for fidgeting, some of the older children referred to using their own toy or an object that was readily available to them but not intended for fidgeting. For example, Finn (10 years) and Rory (9 years) both spoke about using items from their pencil case to fiddle with, and explained that this would help them to focus. (“ Sometimes I fidget with something I normally just have like a pencil holder under the table moving about … [and] it just keeps my mind clear and not from something else ”—Rory; “ Sometimes I fiddle with my fingers and that sometimes helps, but if not I get one of my coloured pencils and have a little gnaw on it because that actually takes my mind off some things and it’s easier for me to concentrate when I have something to do ”—Finn). Henry (9 years) spoke about being secretive with his fidgeting as it was not permitted in class, “ if you just bring [a fidget toy] in without permission [the teacher will] just take it off of you, so it has to be something that’s not too big. I bring in a little Lego ray which is just small enough that she won’t notice ”. Although some teachers did mention having fidget toys available, not all teachers seemed to recognise the importance of this for the child, and some children viewed fidgeting as a behaviour they should hide from the teacher.

Another strategy mentioned uniquely by children was seeing their peers as a resource for ideas or information. This is discussed in more detail in Theme 3—The role of peers , but reinforces the notion that children also develop their own strategies, independently from their teacher, rather than relying only on what is made available to them.

Theme 2: Heterogeneity of Strategies

Teachers spoke about the need for a variety of strategies in the classroom, for two reasons: (1) that different strategies work for different children (e.g. “ some [strategies] will work for the majority of the children and some just don’t seem to work for any of them ”—Jay’s teacher), and (2) what works for a child on one occasion may not work consistently for the same child (e.g. “ I think it’s a bit of a journey with him, and some things have worked and then stopped working, so I think we’re constantly adapting and changing what we’re doing ”—Eric’s teacher). One example of both of these challenges of strategy use came from Luna’s teacher, who spoke about using a reward chart with Luna and another child with ADHD, “ [Luna] and another boy in my class [with ADHD] both had [a reward chart]… but I think whereas the boy loved his and still loves his, she was getting a bit “oh I’m too cool for this” or that sort of age… so I stopped doing that for her and she’s not missing that at all” . These quotes demonstrate that strategies can work differently for different children, highlighting the need for a variety of strategies for teachers to access and trial with children.

Some children also referred to the variability of whether a strategy was helpful or not; for example, Henry (9 years) said that he finds it helpful to fidget with a toy but that sometimes it can distract him and prevent him from listening to the teacher. He said, “ Well, [the fidget toy] helps but it also gets me into trouble when the teacher spots me building it when I’m listening…but then sometimes I might not listen in maths and [use the fidget toy] which might make it worse”. This highlights that both children and teachers might benefit from support in understanding the contexts in which to use particular strategies, as well as why they are helpful from a psychological perspective.

For teachers, building a relationship with and understanding the child was also highly important in identifying strategies that would work. Luna’s teacher reflected upon the difference in Luna’s behaviour at the start of the academic year, compared to the second academic term, “ at the start of the year, we would just clash the whole time. I didn’t know her, she didn’t know me … and then when we got that bond she was absolutely fine so her behaviour has got way better ”. Eric’s teacher also reflected on how her relationship with Eric had changed, particularly after he received his diagnosis of ADHD, “ I think my approach to him has completely changed. I don’t raise my voice, I speak very calmly, I give him time to calm down before I even broach things with him. I think our relationship’s just got so much better ‘cause I kind of understand … where he’s coming from ”. She also said, “ it just takes a long time to get to know the child and get to know what works for them and trialling different things out ”, which demonstrates that building a relationship with and understanding the child can help to identify the successful strategies that work with different children.

Theme 3: The Role of Peers

Teachers and children spoke about the role of the child’s peers in their learning. Teachers talked about the benefit of partnering the child with good role models (e.g. “ I will put him with a couple of good role models and a couple of children who are patient and who will actually maybe get on with the task, and if [Jay] is not on task or not on board with what they’re doing at least he’s hearing and seeing good behaviour ”—Jay’s teacher), whereas children spoke more about their peers as a source of information, idea generation, or guidance on what to do next. For example, when asked what he does to help him with his writing, Henry (9 years) said, “ [I] listen to what my partner’s saying… my half of the table discuss what they’re going to do so I can literally hear everything they’re doing and steal some of their ideas ”. Henry wasn’t the only child to use their peers as a source of information, for example, Niall (7 years) said, “ I prefer working with the children because some things I might not know and the children might help me give ideas ”, and with a more specific example, Rory (9 years) said, “ somebody chose a very good character for their bit of writing, and I was like “I think I might choose that character”, and somebody else said “my setting was going to be the sea”, and I chose that and put that in a tiny bit of my story ”.

Some children also spoke about getting help from their peers in other ways, particularly when completing a difficult task. Paige (8 years) said, “ if the question isn’t clear I try and figure it out, and if I can’t figure it out then… don’t tell my teacher this but I sometimes get help from my classmates ”, which suggests some guilt associated with asking for help from her peers. This could be related to confidence and self-esteem, which teachers mentioned as a difficulty for some children with ADHD. In some instances, children felt it necessary to directly copy their peers’ work; for example, Nathan (8 years) spoke about needing a physical resource (i.e. “ fuzzies ”) to complete maths problems, but that when none were available he would “ just end up copying other people ”. This could also be related to a lack of confidence, as he may feel as though he may not be able to complete the task on his own. Indeed, Nathan’s teacher mentioned that when he is given the option to choose a task from different difficulty levels, Nathan would typically choose something easier, and that it was important to encourage him to choose something more difficult to build his confidence, “ I quite often say to him “come on I think you can challenge yourself” and [will] use that language”.

Peers clearly play an important role for the children with ADHD, and this is recognised both by the children themselves, and by their teachers. Teachers also mentioned that children with ADHD respond well to one-to-one learning with staff, indicating that it is important for these children to have opportunities to learn in different contexts: whole classroom learning, small group work and one-to-one.

In this study, a number of important topics surrounding ADHD in the primary school setting were explored, including ADHD knowledge, strengths and challenges, and strategy use in the classroom, each of which will now be discussed in turn before drawing together the findings and outlining the implications.

ADHD Knowledge

Knowledge of ADHD varied between children and their teachers. Whilst most of the children claimed to have heard of ADHD, very few could accurately describe the core symptoms. Previous research into this area is limited, however this finding supports Climie and Henley’s ( 2018 ) finding that children’s knowledge of ADHD can be limited. By comparison, all of the interviewed teachers had good knowledge about the core ADHD phenotype (i.e. in relation to diagnostic criteria) and some elaborated further by mentioning social difficulties or description of behaviours that could reflect cognitive difficulties. This supports and builds further upon existing research into teachers’ ADHD knowledge, demonstrating that although teachers understanding may be grounded in a focus upon inattention and hyperactivity, this is not necessarily representative of the range of their knowledge. By interviewing participants about their ADHD knowledge, as opposed to asking them to complete a questionnaire as previous studies have done (Climie & Henley, 2018 ; Latouche & Gascoigne, 2019 ; Ohan et al., 2008 ; Perold et al., 2010 ), the present study has demonstrated the specific areas of knowledge that should be targeted when designing psychoeducation interventions for children and teachers, such as broader aspects of cognitive difficulties in executive functions and memory. Improving knowledge of ADHD in this way could lead to increased positive attitudes and reduction of stigma towards individuals with ADHD (Mueller et al., 2012 ; Ohan et al., 2008 ), and in turn improving adherence to more specified interventions (Bai et al., 2015 ).

Strengths and Challenges

A range of strengths and challenges were discussed, some of which were mentioned by both children and teachers, whilst others were unique to a particular group. The main consensus in the current study was that art and P.E. tended to be the lessons in which children with ADHD thrive the most. Teachers elaborated on this notion, speaking about creative skills, such as a good imagination, and that these skills were sometimes applied in other subjects such as creative writing in literacy. Little to no research has so far focused on the strengths of children with ADHD, therefore these findings identify important areas for future investigation. For example, it is possible that these strengths could be harnessed in educational practice or intervention.

Although a strength for some, literacy was commonly mentioned as a challenge by both groups, specifically in relation to planning, spelling or the physical act of writing. Previous research has repeatedly demonstrated that literacy outcomes are poorer for children with ADHD compared to their typically developing peers (DuPaul et al., 2016; Mayes et al., 2020 ), however in these studies literacy tended to be measured using a composite achievement score, where the nuance of these difficulties can be lost. Furthermore, in line with a recent systematic review and meta-analysis (McDougal et al., 2022 ) the present study’s findings suggest that cognitive difficulties may contribute to poor literacy performance in ADHD. This issue was not unique to literacy, however, as teachers also spoke about academic challenges in the context of ADHD symptoms being a barrier to learning, such as finding it difficult to remain seated long enough to complete a piece of work. Children also raised this issue of engagement, who referred to the most challenging subjects being ‘boring’ for them. This link between attention difficulties and boredom in ADHD has been well documented (Golubchik et al., 2020 ). The findings here demonstrate the need for further research into the underlying cognitive difficulties leading to academic underachievement.

Both children and teachers also mentioned social and emotional difficulties. Research has shown that many different factors may contribute to social difficulties in ADHD (for a review see Gardner & Gerdes, 2015 ), making it a complex issue to disentangle. That said, in the current study teachers tended to attribute the children’s relationship difficulties to behaviour, such as reacting impulsively in social situations, or going off task during group work, both of which could be linked to ADHD symptoms. Despite these difficulties, peers were also considered a positive support. This finding adds to the complexity of understanding social difficulties for children with ADHD, demonstrating the necessity and value of further research into this key area.

The three key themes of classroom-general versus individual-specific strategies , heterogeneity of strategies and the role of peers were identified from the interview transcripts with children and their teachers. Within the first theme, classroom-general versus individual-specific strategies, it was clear that teachers utilise strategies that are specific to the child with ADHD, as well as strategies that are general to the classroom but that are also beneficial to the child with ADHD. Previously, Moore et al. ( 2017 ) found that teachers mostly reflected on using general inclusive strategies, rather than those targeted for ADHD specifically, however the methods differ from the current study in two key ways. Firstly, Moore et al.’s sample included secondary and primary school teachers, for whom the learning environment is very different. Secondly, focus groups were used as opposed to interviews where the voices of some participants can be lost. The merit of the current study is that children were also interviewed using the same questions as teachers; we found that children also referred to these differing types of strategies, and reported finding them useful, suggesting that the reports of teachers were accurate. Interestingly, children also mentioned their own strategies that teachers did not discuss and may not have been aware of. This finding highlights the importance of communication between the child and the teacher, particularly when the child is using a strategy considered to be forbidden or discouraged, for example copying a peer’s work or fidgeting with a toy. This communication would provide an understanding of what the child might find helpful, but more importantly identify areas of difficulty that may need more attention. Further to this, most strategies specific to the child mentioned by teachers aimed to support attention, and few strategies targeted other difficulties, particularly other aspects of cognition such as memory or executive function, which supports previous findings (Lawrence et al., 2017 ). The use of a wide range of individualised strategies would be beneficial to support children with ADHD.

Similarly, the second theme, heterogeneity of strategies , highlighted that some strategies work with some children and not others, and some strategies may not work for the same child consistently. Given the benefit of a wide range of strategy use, for both children with ADHD and their teachers, the development of an accessible tool-kit of strategies would be useful. Importantly, and as recognised in this second theme, knowing the individual child is key to identifying appropriate strategies, highlighting the essential role of the child’s teacher in supporting ADHD. Teachers mostly spoke about this in relation to the child’s interests and building rapport, however this could also be applied to the child’s cognitive profile. A tool-kit of available strategies and knowledge of which difficulties they support, as well as how to identify these difficulties, would facilitate teachers to continue their invaluable support for children and young people with ADHD. This links to the importance of psychoeducation; as previously discussed, the teachers in our study had a good knowledge of the core ADHD phenotype, but few spoke about the cognitive strengths and difficulties of ADHD. Children and their teachers could benefit from psychoeducation, that is, understanding ADHD in more depth (i.e., broader cognitive and behavioural profiles beyond diagnostic criteria), what ADHD and any co-occurrences might mean for the individual child, and why certain strategies are helpful. Improving knowledge using psychoeducation is known to improve fidelity to interventions (Dahl et al., 2020 ; Nussey et al., 2013 ), suggesting that this would facilitate children and their teachers to identify effective strategies and maintain these in the long-term.

The third theme, the role of peers , called attention to the importance of classmates for children with ADHD, and this was recognised by both children and their teachers. As peers play a role in the learning experience for children with ADHD, it is important to ensure that children have opportunities to learn in small group contexts with their peers. This finding is supported by Vygotsky’s ( 1978 ) Zone of Proximal Development; it is well established in the literature that children can benefit from completing learning activities with a partner, especially a more able peer (Vygotsky, 1978 ).

Relevance of Co-Occurrences

Co-occurring conditions are common in ADHD (Jensen & Steinhausen, 2015 ), and there are many instances within the data presented here that may reflect these co-occurrences, in particular, the overlap with DCD and ASD. For ADHD and DCD, the overlap is considered to be approximately 50% (Goulardins et al., 2015 ), whilst ADHD and autism also frequently co-occur with rates ranging from 40 to 70% (Antshel & Russo, 2019 ). It was not an aim of the current study to directly examine co-occurrences, however it is important to recognise their relevance when interpreting the findings. Indeed, in the current sample, scores for seven children (70%) indicated a high likelihood of movement difficulty. One child scored above the cut-off for autism diagnosis referral on the AQ-10, indicating heightened autism symptoms. Further to this, some of the discussions with children and teachers seemed to be related to DCD or autism, for example, the way that they can react in social situations, or difficulties with the physical act of handwriting. This finding feeds into the ongoing narrative surrounding heterogeneity within ADHD and individualisation of strategies to support learning. Recognising the potential role of co-occurrences should therefore be a vital part of any psychoeducation programme for children with ADHD and their teachers.

Limitations

Whilst a strong sample size was achieved for the current study allowing for rich data to be generated, it is important to acknowledge the issue of representativeness. The heterogeneity of ADHD is recognised throughout the current study, however the current study represents only a small cohort of children and young people with ADHD and their teachers which should be considered when interpreting the findings, particularly in relation to generalisation. Future research should investigate the issues raised using quantitative methods. Also on this point of heterogeneity, although we report some co-occurring symptoms for participants, the number of co-occurrences considered here were limited to autism and DCD. Learning disabilities and other disorders may play a role, however due to the qualitative nature of this study it was not feasible to collect data on every potential co-occurrence. Future quantitative work should aim to understand the complex interplay of diagnosed and undiagnosed co-occurrences.

Furthermore, only some of the teachers of participating children took part in the study; we were not able to recruit all 10. It may be, for example, that the six teachers who did take part were motivated to do so based on their existing knowledge or commitment to understanding ADHD, and the fact that not all child-teacher dyads are represented in the current study should be recognised. Another possibility is the impact of time pressures upon participation for teachers, particularly given the increasing number of children with complex needs within classes. Outcomes leading from the current study could support teachers in this respect.

It is also important to recognise the potential role of stimulant medication. Although it was not an aim of the current study to investigate knowledge or the role of stimulant medication in the classroom setting, it would have been beneficial to record whether the interviewed children were taking medication for their ADHD at school, particularly given the evidence to suggest that stimulant medication can improve cognitive and behavioural symptoms of ADHD (Rhodes et al., 2004 ). Examining strategy use in isolation (i.e. with children who are drug naïve or pausing medication) will be a vital aim of future intervention work.

Implications/Future Research

Taking the findings of the whole study together, one clear implication is that children and their teachers could benefit from psychoeducation, that is, understanding ADHD in more depth (i.e., broader cognitive and behavioural profiles beyond diagnostic criteria), what ADHD might mean for the individual child, and why certain strategies are helpful. Improving knowledge using psychoeducation is known to improve fidelity to interventions (Dahl et al., 2020 ; Nussey et al., 2013 ), suggesting that this would facilitate children and their teachers to identify effective strategies and maintain these in the long-term.

To improve knowledge and understanding of both strengths and difficulties in ADHD, future research should aim to develop interventions grounded in psychoeducation, in order to support children and their teachers to better understand why and in what contexts certain strategies are helpful in relation to ADHD. Furthermore, future research should focus on the development of a tool-kit of strategies to account for the heterogeneity in ADHD populations; we know from the current study’s findings that it is not appropriate to offer a one-size-fits-all approach to supporting children with ADHD given that not all strategies work all of the time, nor do they always work consistently. In terms of implications for educational practice, it is clear that understanding the individual child in the context of their ADHD and any co-occurrences is important for any teacher working with them. This will facilitate teachers to identify and apply appropriate strategies to support learning which may well result in different strategies depending on the scenario, and different strategies for different children. Furthermore, by understanding that ADHD is just one aspect of the child, strategies can be used flexibly rather than assigning strategies based on a child’s diagnosis.

This study has provided invaluable novel insight into understanding and supporting children with ADHD in the classroom. Importantly, these insights have come directly from children with ADHD and their teachers, demonstrating the importance of conducting qualitative research with these groups. The findings provide clear scope for future research, as well as guidelines for successful intervention design and educational practice, at the heart of which we must acknowledge and embrace the heterogeneity and associated strengths and challenges within ADHD.

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The funding was provided by Waterloo Foundation Grant Nos. (707-3732, 707-4340, 707-4614).

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Emily McDougal, Claire Tai & Sinéad M. Rhodes

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Interview Schedule—Teacher

Demographic/experience.

How many years have you been teaching?

Are you currently teaching pupils with ADHD and around how many?

If yes, do you feel competent/comfortable/equipped teaching pupils with ADHD?

If no, how competent/comfortable/equipped would you feel to teach pupils with ADHD?

Would you say your experience of teaching pupils with ADHD is small/moderate/significant?

Psychoeducation

What is your understanding of ADHD/Can you describe a typical child with ADHD?

Probe behaviour knowledge

Probe cognition knowledge

Probe impacts of behaviour/cognition difficulties

Probe knowledge that children with ADHD differ from each other

Probe knowledge that children with ADHD have co-occurring difficulties as the norm

(If they do have some knowledge) Where did you learn about ADHD?

e.g. specific training, professional experience, personal experience, personal interest/research

Cognitive skills and strategies

Can you tell me about the pupil’s strengths?

Can you tell me about the pupil’s biggest challenges/what they need most support with?

When you are supporting the pupil with their learning, are there any specific things you do to help them? (i.e. strategies)

Probe internal

Probe external

Probe whether they think those not mentioned might be useful/feasible/challenges

Probe if different for different subjects/times of the day

In your experience, which of these you have mentioned are the most useful for the pupil?

Probe for examples of how they apply it to their learning

Probe whether these strategies are pupil specific or broadly relevant

Probe if specific to particular subjects/times of the day

In your experience, which of these you have mentioned are the least useful for the pupil?

What would you like to be able to support the pupil with that you don’t already do?

Probe why they can’t access this currently e.g. lack of training, resources, knowledge, time

Is there anything you would like to understand better about ADHD?

Probe behaviour

Probe cognition

Interview Schedule—Child

Script: We’re going to have a chat about a few different things today, mostly about your time at school. This will include things like how you get on, how you think, things you’re good at and things you find more difficult. I’ve got some questions here to ask you but try to imagine that I’m just a friend that you’re talking to about these things. There are no right or wrong answers, I’m just interested in what you’ve got to say. Do you have any questions?

Script: First we’re going to talk about ADHD (Attention Deficit Hyperactivity Disorder).

Have you ever heard of/has anyone ever told you what ADHD is?

(If yes) If a friend asked you to tell them what ADHD is, what would you tell them?

Is there anything you would like to know more about ADHD?

Cognition/strategy use

Script: Now we’re going to talk about something a bit different. Everyone has things they are good at, and things they find more difficult. For example, I’m quite good at listening to what people have to say, but I’m not so good at remembering people’s names. I’d like you to think about when you’re in school, and things you’re good at and things you are not so good at. It doesn’t just have to be lessons, it can be anything.

Do you like school?

Probe why/why not?

Probe favourite lessons

What sort of things do you find you do well at in school?

Is there anything you think that you find more difficult in school?

Probe: If I asked your teacher/parent what you find difficult, what would they say?

Probe: Is there anything at school you need extra help with?

Probe: Is there anything you do to help yourself with that?

Script: Some people do things to try to help themselves do things well. For example, when someone tells me a number to remember, I repeat it in my head over and over again.

Can you try to describe to me what you do to help you do these things?

Solving a maths problem

Planning your writing

Doing spellings

Trying to remember something

Concentrating/ignoring distractions

Listening to the teacher

Remaining seated in class when doing work

Working with other children in the class

Probe: Do you use anything in lessons to help you with your work?

Probe: What kind of things do you think could help you with your work?

Probe: Is there anything you do at home, such as when you’re doing your homework, to help you finish what you are doing to do it well?

Probe: Does someone help you with your homework at home? If yes, what do they do that helps? If no, what do you think someone could do to help?

Script: In this last part we’re going to talk about your time at school.

How many teachers are in your class?

Is there anyone who helps you with your work?

Do you work mostly on your own or in groups?

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McDougal, E., Tai, C., Stewart, T.M. et al. Understanding and Supporting Attention Deficit Hyperactivity Disorder (ADHD) in the Primary School Classroom: Perspectives of Children with ADHD and their Teachers. J Autism Dev Disord 53 , 3406–3421 (2023). https://doi.org/10.1007/s10803-022-05639-3

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Understanding Attention-Deficit/Hyperactivity Disorder From Childhood to Adulthood

Timothy e. wilens.

1 Clinical Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital and Harvard Medical School, Boston, MA

Thomas J. Spencer

Attention deficit/hyperactivity disorder (ADHD) is among the most common neurobehavioral disorders presenting for treatment in children and adolescents. ADHD is often chronic with prominent symptoms and impairment spanning into adulthood. ADHD is often associated with co-occurring disorders including disruptive, mood, anxiety, and substance abuse. The diagnosis of ADHD is clinically established by review of symptoms and impairment. The biological underpinning of the disorder is supported by genetic, neuroimaging, neurochemistry and neuropsychological data. Consideration of all aspects of an individual’s life needs to be considered in the diagnosis and treatment of ADHD. Multimodal treatment includes educational, family, and individual support. Psychotherapy alone and in combination with medication is helpful for ADHD and comorbid problems. Pharmacotherapy including stimulants, noradrenergic agents, alpha agonists, and antidepressants plays a fundamental role in the long-term management of ADHD across the lifespan.

INTRODUCTION AND OVERVIEW

Attention-deficit/hyperactivity disorder (ADHD) is among the most common neurobehavioral disorders presenting for treatment in children 1 , 2 . It carries a high rate of comorbid psychiatric problems such as oppositional defiant disorder (ODD), conduct disorder, mood and anxiety disorders, and cigarette and substance use disorders 3 . Across the life span, the social and societal costs of untreated ADHD are considerable, including academic and occupational underachievement, delinquency, motor vehicle safety, and difficulties with personal relationships 3 - 5 , 6 .

ADHD affects an estimated 4% to 12% of school-aged children worldwide 7 with survey and epidemiologically derived data showing that 4 to 5% of college aged students and adults have ADHD 8 . In more recent years, the recognition and diagnosis of ADHD in adults have been increasing although treatment of adults with ADHD continues to lag substantially behind that of children 8 , 9 . In contrast to a disproportionate rate of boys diagnosed with ADHD relative to girls in childhood, in adults, an equal number of men and women with ADHD are presenting for diagnosis and treatment 10 .

PSYCHIATRIC COMORBIDITY

During the past decade, epidemiological studies have documented high rates of concurrent psychiatric and learning disorders among individuals with ADHD 3 , 11 , 12 , 13 . Consistent with childhood studies, studies of ADHD adults have found high rates of childhood conduct disorder as well as adult antisocial disorders in these subjects 3 .

Mood & Anxiety

Anxiety often confounds the diagnosis and treatment of ADHD 3 , 11 , 12 . High rates of the various anxiety symptoms exist in ADHD and may manifest as social, generalized or panic-like symptoms. Similarly, ADHD increases the likelihood of having a depressive disorder by at least two-fold 8 , 14 . Interestingly, recent data suggest that stimulant treatment of ADHD over time may decrease the ultimate risk for anxiety and depressive disorders 15 .

A growing literature reports the co-occurrence of bipolar disorder and ADHD. Systematic studies of children and adolescents indicate rates of ADHD ranging from 57% to 98% in bipolar children; and conversely, rates of bipolar disorder in 22% of ADHD children and adolescents 16 . There continues to be much controversy about the validity of the concurrent diagnoses of ADHD and severe mood instability or bipolar disorder. Whereas ADHD is characterized by the typical cognitive and hyperactive/impulsive features of the disorder, bipolar disorder (BPD) is characterized by mood instability, pervasive irritability/rage, grandiosity, psychosis, cyclicity, and lack of response to structure 17 . When individuals experience both sets of symptoms, they may suffer from both ADHD and BPD 17 .

Substance Use Disorders

Combined data from retrospective accounts of adults and prospective observations of youth indicate that juveniles with ADHD are at increased risk for cigarette smoking and substance abuse (SA) during adolescence 18 . ADHD adolescents and adults become addicted to cigarette smoking at twice the rate compared to non-ADHD individuals 19 , 20 . ADHD youth disproportionately become involved with cigarettes, 19 which increases the risk for subsequent alcohol and drug use 21 . Individuals with ADHD tend to have more severe substance abuse and maintain their addictions longer compared to their non-ADHD peers 19 , 22 - 24 .

Concerns of the abuse liability of stimulants and the potential kindling of substance abuse secondary to early stimulant exposure in ADHD children have been raised. 25 These concerns are based largely on data from animal studies. 25 However, the preponderance of clinical data and consensus in the field do not appear to support such a contention. For example, in a prospective study of ADHD girls followed into adolescence, a significant reduction in the risk for SA was reported in treated compared to untreated ADHD youth 26 with no increase (or decreased) SUD risk associated with stimulant treatment into adulthood 27 .

DIAGNOSING ADHD

ADHD can be reliably diagnosed in children, adolescents, and adults 28 . Using the current guidelines, the child or adult patient must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 29 . It is important to note, however, that the DSM-IV-TR criteria for ADHD symptoms were derived from youth to age 17 years and therefore were not specifically tailored to adults and hence, may not always “fit” adults with the disorder 28 , 30 . The symptoms of the disorder are categorized as follows: inattention-difficulty sustaining attention and mental effort, forgetfulness, and distractibility; hyperactivity-fidgeting, excessive talking, and restlessness; and impulsivity-difficulty waiting one’s turn and frequent interruption of others. The DSM-IV-TR criteria also include onset by age 7, impaired functioning in at least 2 settings (home, work, school, job), and more than 6 months of duration 30 . Three subtypes of the syndrome are currently recognized: predominantly inattentive, predominantly hyperactive-impulsive, and the combined type, which is the most common and typically more severe and with more comorbidity 29 , 31 , 32 . Between 90 to 95% of adolescents and adults with ADHD manifest the inattention cluster of symptoms at least as a component of their disorder 31 . Of interest, the combined subtype of ADHD may simply represent a more severe and debilitating presentation of ADHD (e.g. more symptoms) and there may be relatively more stability of the subtype with development 32 , 33 .

To meet the diagnostic criteria for the inattentive or hyperactive-impulsive subtypes, an individual must have 6 or more of the 9 symptoms from either group of criteria (18 possible traits in all) 30 . For the combined subtype, an individual must have 6 or more inattentive symptoms and 6 or more hyperactive-impulsive symptoms. To warrant the ADHD diagnosis, symptoms must cause significant impairment. Adults diagnosed with the disorder must have had childhood onset and persistent and current symptoms, although allowance is made for incomplete persistence of full criteria (ADHD-in partial remission) or lack of clear childhood symptoms (ADHD NOS).

Of interest, whereas clinicians are concerned as to the possibility of purposely misrepresenting or over-reporting of ADHD symptoms by college students or adults, data suggest the opposite may be operant. Mannuzza et al. 34 in a prospective 16-year follow-up of children with ADHD now at a mean age of 25, found that of the 176 individuals with a well characterized past history of ADHD, only 28% of the adults through direct interviews were identified as having childhood ADHD. These data further highlight issues around the relatively poor sensitivity of recalling symptoms (and establishing the diagnosis of ADHD) by adult self-report, particularly when not anchoring symptoms in childhood.

The diagnosis of ADHD is made clinically with scales used in an ancillary manner. The patient’s symptoms, severity of impairment, possible comorbidity, family history, and psychosocial stressors may be determined during the patient and/or parent interview. In pediatric evaluations, the adolescent’s behavior and parent-child interaction are observed, and the child’s school, medical, and neurological status are evaluated 2 . A number of diagnostic and follow-up scales are available (see www.schoolpsychiatry.org ) 35 . Symptom scales used with all age groups (to assess home, school, and job performance) include, but are not limited to, the ADHD Symptom Checklist, SNAP-IV Teacher and Parent Rating Scale, Conners Rating Scales-Revised,, Brown Attention-Deficit Disorder Scales for Children, and the ADHD Symptoms Rating Scale 36 . Although these tools quantify behavior deviating from norms, they should not be used alone to make or refute the diagnosis.

Diagnosing adults involves careful querying for developmentally appropriate criteria from the DSM-IV-TR concerning the childhood onset, persistence, and current presence of symptoms 29 . Diagnostic aids are available for adult ADHD 36 , 37 . For instance, the Adult Self Report Scale, Conners Adult ADHD Scales, and Brown Attention scales for adults are among instruments available to assist in the diagnosis of ADHD 36 , 37 . For a briefer screening of adults, the World Health Organization Adult ADHD self-report scale ( Figure 1 ) can be downloaded ( www.who.org ) and has been validated as a manner of identifying those at risk for ADHD who necessitate further screening 38 .

Follow-up studies show that prominent symptoms and impairment related to the disorder persist into adulthood in approximately one-half of cases 39 , 40 . There appears to be developmental variance in the ADHD symptom profile across the life span 31 , 32 , 39 - 41 . Longitudinally derived data in ADHD youth growing up indicate that the symptom cluster of hyperactivity and impulsivity decays over time, while the symptoms of inattention largely persist 32 , 39 - 41 , 31 . In support of this notion, data derived from a group of clinically referred adults with ADHD indicate that approximately half of adults endorse clinically significant levels of hyperactivity/impulsivity, but 90% endorse prominent attentional symptoms 32 , 31 .

A substantial body of literature implicates abnormalities of brain structure and function in the pathophysiology of both childhood and adult ADHD 42 - 48 , 49 - 51 . We have known for decades that ADHD youth show impaired performance on tasks assessing vigilance, motoric inhibition, organization, planning, complex problem solving, and verbal learning and memory 52 , 53 . Prominent neuropsychologically-derived executive dysfunction is associated with learning disabilities and poorer overall prognosis over time in ADHD youth 54 . Similar findings are emerging in adults with ADHD 52 . While neuropsychological testing is not used clinically to diagnose ADHD in adults, such testing aids in identifying learning disabilities, sub average intelligence, and specific information processing deficits.

PATHOPHYSIOLOGY AND GENETICS

Neurobiology.

ADHD has been conceptualized as a disorder affecting “frontal” circuitry due to associated deficits in executive cognitive functioning. Structural imaging studies have documented diffuse abnormalities in children and adults with ADHD. A large study by Castellanos and colleagues 55 reported smaller total cerebrum, cerebellum, and the four cerebral lobes that did not change over time. A structural magnetic resonance imaging (MRI) study 56 in adults with and without ADHD also revealed a smaller anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (DLPFC). The DLPFC controls working memory that involves the ability to retain information while processing new information. These differences are thought to account for deficits in goal-directed and on task behavior in ADHD. The ACC is thought to be a key region of regulation involving the ability to focus on one task and choose between options.

Investigators have also examined the developmental pattern of cortical maturation in ADHD. Shaw and colleagues 57 reported a delay in cortical thickness among ADHD patients. The pattern of brain development, from sensorimotor to associative areas, was similar in children with and without ADHD. However, the age of peak development was delayed in those with ADHD. Using the same measure of cortical thickness data in adults, Makris and associates 58 have shown that cortical thickness is not normalized and that the areas of the brain that are affected in children with ADHD remain affected in adulthood. In this study the DLPFC, parietal areas, and ACC had thinner measures of cortical thickness in adults with ADHD than in adults without ADHD.

Functional magnetic resonance imaging (fMRI) has been used to examine brain activity during selective cognitive challenges in individuals with ADHD. One study that measures brain activity using a neuropsychological test (go/no-go) found that both youth and adults with ADHD showed attenuated activity in the frontostriatal regions of the brain that are key for inhibitory control and for attention (prefrontal cortex and caudate) 59 . Adults with ADHD also activated non-frontostriatal regions (ACC, parietal areas) moreso than controls. The amount of brain activation observed correlated closely with the degree of efficiency on the task in both children and adults with ADHD.

The results of fMRI studies were reviewed by Casey and Durston 60 who hypothesized that top-down and bottom-up control systems were affected in ADHD. They speculated that bottom-up neural systems detect the regularities and irregularities in the environment to activate the frontal brain systems to alter behavior. These systems are key regulators of maintaining sustained attention vs. shifting attention due to sensory input. Casey and Durston 60 posited that the striatum regulates what to expect (type of task), the cerebellum regulates when to expect it (timing of task), and the parietal lobe alerts one to novel or newer competing stimuli.

Interestingly, medication may normalize some of these functional deficits. Bush and colleagues published a study showing that 7 weeks of treatment with methylphenidate normalized activation in the ACC 61 . Those receiving medication showed increases in activation of the ACC and DLPFC at follow-up as compared to baseline and to those receiving placebo treatment. Hence, those areas of the brain that were underactive in adults without treatment normalized with treatment.

The neurobiology of ADHD is strongly influenced by genetic factors. As highlighted in a special issue of Science dedicated to the human genome project, ADHD is among the most recognized genetic-based disorders in psychiatry 62 . Family studies of ADHD have shown that the relatives of ADHD children are at high risk for ADHD, comorbid psychiatric disorders, school failure, learning disability and impairments in intellectual functioning 63 . Additional lines of evidence from twin, adoption and segregation analysis studies suggest that the familial aggregation of ADHD has a substantial genetic component. Twin studies find greater similarity for ADHD and components of the syndrome between monozygotic twins compared with dizygotic twins 64 , 65 . Faraone and colleagues 66 in a meta-analysis of the various studies reported on the mean heritability of ADHD. Heritability refers to the amount of genetic influence for a particular condition. A coefficient of 1 indicates an entirely genetically influenced phenomenon, while a 0 indicates no genetic influence. Depression, anxiety, panic, and even Asthma had mean heritability rates below 50%. In contrast, two of the most biologically related psychiatric disorders, schizophrenia and autism, are heritable at ~75%. ADHD falls in this higher range as well, with work by Rietveld and associates showing a mean heritability rate of 75% 67 .

As with many complex neuropsychiatric conditions, multifactorial causation is thought to be involved in ADHD; an additive effect of multiple vulnerability genes interacting with environmental influences. Pooled analyses reveal that there is not one single gene associated with ADHD 66 . The disorder is thought to result from a combination of small effects from a number of genes (polygenetic). Some of the candidate genes that have been identified thus far relate to synthesis, packaging, release, detection and recycling of dopamine or catecholamines including the post-synaptic DRD4, dopamine transporter, and SNAP 25 genes; as well as others related to other neurotransmitters such as serotonin. Clearly, more work is necessary in disentangling the relationship of candidate genes in producing specific phenocopies of ADHD, as well as response prediction to psychosocial and pharmacological intervention.

The management of ADHD includes consideration of two major areas: non-pharmacological (educational remediation, individual and family psychotherapy) and pharmacotherapy 2 . Support groups for children and adolescents and their families, as well as adults with ADHD, provide an invaluable and inexpensive environment in which individuals are able to learn about ADHD and resources available for their children or themselves. Support groups can be accessed by calling an ADHD hotline or a large support group organization (i.e. Children and adults with ADHD-CHADD, Adults with ADHD-ADDA,), or by accessing the internet.

Specialized educational planning based on the child’s difficulties is necessary in a majority of cases 68 . Since learning disorders co-occur in one-third of ADHD youth, ADHD individuals should be screened and appropriate individualized educational plans developed. Parents should be encouraged to work closely with the child’s school guidance counselor who can provide direct contact with the child as well as serve as a valuable liaison for teachers and school administrators. The school’s psychologist can be helpful in providing cognitive testing as well as assisting in the development and implementation of the individualized education plan. Educational adjustments should be considered in individuals with ADHD with difficulties in behavioral or academic performance. Increased structure, predictable routine, learning aids, resource room time, and checked homework are among typical educational considerations in these individuals. Similar modifications in the home environment should be undertaken to optimize the ability to complete homework. For youth, frequent parental communication with the school about the child’s progress is essential.

PSYCHOSOCIAL TREATMENTS

Clinicians have at their disposal a variety of psychosocial interventions for ADHD (for review see 68 , 69 ). Apart from traditional psychotherapy, which addresses underlying emotions, tutors are available to help children develop strategies for improving academic performance and interpersonal relations. Tutors can assist the child with skills in organization and prioritization, as well as act as mentors, advocates, and motivational figures.

Parent training is often conducted using the antecedent behavior consequence model, and is implemented using various methods, including small and large parent training groups, parent training with individual families, videotapes, and behavioral sessions that include children 70 . In the academic setting, virtually all children with ADHD must cope with organizational and behavioral demands and expectations. Classroom behavioral interventions often involve training the teacher in use of these methods.

Teachers can conduct individual and class-wide interventions using antecedents and/or consequence methods 71 . Antecedent interventions are based on an understanding of the range of antecedents (eg, boredom, peer provocation, unclear inconsistent rules) that precipitate behavioral problems. Antecedent/consequence interventions involve understanding antecedents to inappropriate behavior and reinforcing appropriate behavior with rewards. Consequence interventions involve the judicious use of punishment to encourage appropriate classroom behavior.

Accommodations should be considered to assist the child with ADHD. For instance, other behavioral strategies can be used in the classroom setting to facilitate attention 72 . These include placing the child with ADHD in proximity to the teacher, eliminating environmental distractions, and arranging seating in traditional rows rather than clusters. Lessons that involve novelty and stimulation in easy and repetitive tasks rather than new or difficult ones have been shown to benefit the child with ADHD. Additional interventions shown to be effective in the academic setting include peer-mediated interventions and token economies.

Exciting new work has shown that cognitive therapies 73 and cognitive behavioral therapy have been shown effective in medicated adults with ADHD who manifest residual ADHD symptoms 74 - 77 . Social skills remediation for improving interpersonal interactions and coaching for improving organization and study skills may be useful adjuncts to treatment, although there generalizeability remains debated. Little data exists for the use of neurofeedback, cerebellar training, attention or memory training, or ophthalmic manipulation for the treatment of core ADHD symptoms 71 .

PHARMACOTHERAPY

Medications remain a mainstay of treatment for children, adolescents, and adults with ADHD (see Table 1 ). In fact, NIH-funded multisite studies support that medication management of ADHD is the most important variable in outcome (for core ADHD symptoms) in context to multimodal treatment at least over the first year to two of treatment 78 - 80 . The stimulants, noradrenergic agents, and alpha agonists comprise the available agents for ADHD. The medications used in ADHD have been observed to have pharmacological responsivity across the lifespan for school-aged children, adolescents, and adult groups with ADHD.

The stimulant class medications are among first line agents for pediatric and adult groups with ADHD based on their extensive efficacy and safety data 1 . The most commonly used compounds in this class include methylphenidate-based (Ritalin, Concerta, Focalin, Metadate, Daytrana and others) and amphetamine-based (Adderall, Dexedrine, Vyvanse) formulations. Stimulants are sympathomimetic drugs which increase intrasynaptic catecholamines (mainly dopamine and norepinephrine) by inhibiting the presynaptic reuptake mechanism and releasing presynaptic catecholamines 81 . Whereas methylphenidate is specific for blockade of the dopamine and noradrenergic transporter proteins, amphetamines (in addition to blocking the dopamine and noradrenergic transporter protein) release catecholaminergic stores and cytoplasmic dopamine and noradrenaline directly into the synaptic cleft (for review see 1 , 81 ).

Given the need to additionally treat ADHD outside of academic settings (i.e. social, homework, driving) and to reduce the need for in school dosing and likelihood for diversion, there has been a shift to the extended release preparations of the stimulants. Extended release preparations diminish afternoon wear-off and rebound and appear to manifest less abuse liability compared to their immediate-release counterparts 82 , 83 . The extended release stimulants include methylphenidate (trade names: Concerta, Daytrana Patch, Focalin XR, Metadate CD, Ritalin LA) and amphetamine formulations (trade names: Adderall XR, Vyvanse). The literature suggests more similarities than differences in response to the various available stimulants 1 , 84 . However, based on different mechanisms of action and individual tolerability, some patients who lack a satisfactory response or manifest adverse effects to one stimulant may respond favorably to another. Stimulants should be initiated at the lowest available dosing once daily and increased every three to seven days until a response is noted or adverse effects emerge.

Stimulants appear to work in all age groups of individuals with ADHD. For instance, a controlled multi-site study in preschoolers showed improvement in ADHD symptoms and structured tasks; however, the response was less robust with a higher side effect burden compared to other age groups 85 . There has been a great interest in the use of stimulant treatment in adults with ADHD. There have been approximately 40 studies of stimulants demonstrating moderate efficacy 86 . Currently FDA approval is only for the extended-release preparation of stimulants in adults.

Predictable short-term adverse effects include reduced appetite, insomnia, edginess, and GI upset 87 . Elevated vital signs may emerge necessitating baseline and on-drug monitoring. Although stimulants may produce anorexia and weight loss, their effect on ultimate height remains less certain 88 , 89 . Whereas a number of studies have indicated potential growth delay earlier in treatment, normalization appears to occur with chronic treatment. Longitudinal studies suggest that the majority of ADHD youth with tics can tolerate stimulant medications 90 ; however, up to one-third of children with tics may have worsening of their tics with stimulant exposure 91 . Current consensus suggests that stimulants can be used in youth with comorbid ADHD plus tics with careful monitoring for stimulant-induced tic exacerbation.

Warnings have also highlighted potential cardiovascular adverse events. Data suggest that rates of sudden and catastrophic adverse cardiovascular effects are no higher on stimulants and nonstimulants to treat ADHD compared to the general population 92 . Based on guidelines from the American Academy of Pediatrics 93 , 94 , history and symptoms referable to structural heart disease should be queried prior to starting and during treatment with medications (see Figure 2 ) including family history of premature death, congenital heart disease, palpitations, syncopal episodes, dizziness, or chest pain 93 , 94 . Blood pressure and pulse monitoring at baseline and periodically thereafter is recommended whereas ECG monitoring is optional 93 , 94 .

Despite lingering concerns of stimulant abuse, there is a paucity of scientific data supporting that stimulant-treated ADHD individuals systematically abuse their medication 95 and the preponderance of recent data continue to suggest reductions of cigarette smoking and substance abuse associated with treatment 19 , 26 . However, data suggest that diversion of stimulants to non-ADHD youth continues to be a concern 96 , 97 . Families should closely monitor stimulant medication, and college students receiving stimulants should be advised to carefully store their medication 96 . Two studies have shown less abuse liability associated with extended-release relative to immediate release MPH 82 , 83 .

Atomoxetine

Atomoxetine is a potent norepinephrine-specific reuptake inhibitor that has been studied in youths and adults 98 , 99 . Atomoxetine has been shown to be effective in long-term use 100 . Atomoxetine has also been shown particularly useful in comorbid ADHD. In a noninferiority study in children with ADHD and tic disorder, atomoxetine reduced tic severity while improving ADHD symptoms. Children with ADHD and clinically significant anxiety responded more favorably to atomoxetine than placebo with reductions in both anxiety and ADHD scores 101 . Likewise, data in young adults with ADHD has shown that 12 week treatment with atomoxetine in recently abstinent alcoholics (4-30 days) was associated with significant reductions in ADHD and heavy drinking (not relapse) compared to placebo 102 . In clinical trials, atomoxetine is associated with nausea, GI distress, and sedation most commonly reported. Patients may rarely experience hostility, irritability, and/or suicidality. There is currently a black box warning for rare, but potentially serious, hepatitis (see http://www.strattera.com/pages/index ) 103 . While routine liver function monitoring is not recommended, careful informed consent with patients and their families can enhance vigilance for warning signs and symptoms.

Antihypertensives/alpha agonists

The antihypertensives guanfacine and clonidine are alpha-adrenergic agonists; an extended-release preparation of guanfacine is FDA approved. Whereas clonidine affects alpha receptors more broadly, guanfacine appears to be more selective for the alpha 2a receptor. Improvements in both attention and hyperactivity/impulsivity have been demonstrated with the alpha agonists 104 . The alpha agonists have been used for the treatment of core ADHD as well as associated tics, oppositional defiant behavior, aggression, and sleep disturbances, particularly in younger children 105 .

Multisite combination studies using alpha agonists and stimulants have been conducted in youth with ADHD and ADHD plus tics. Interestingly, all studies have shown that the combination was more effective than either agent alone in improving ADHD and/or tics 106 - 109 , 110 . In these studies, no clinically meaningful adverse cardiovascular events were observed 106 , 107 . Cardiovascular monitoring by ECG remains optional. Adverse effects with the alpha agonists include sedation, fatigue, mood, and the potential for rebound hypertension with abrupt discontinuation.

Several additional medications have demonstrated benefit in controlled trials, but have not been approved by the FDA for the treatment of ADHD. The antidepressant bupropion has been shown effective for ADHD in controlled trials of children 111 and adults 112 , 113 . Additionally, open trials in adolescents with ADHD and depression 114 and adults with ADHD and bipolar disorder 115 have suggested a further utility for this agent. Given its utility in reducing cigarette smoking, improving mood, lack of monitoring requirements, and general tolerability, bupropion is often used as an agent for complex ADHD patients with substance abuse or a mood disorder. Adverse events include activation, irritability, insomnia, and in rare cases, seizures.

The tricyclic antidepressants (TCAs) such as imipramine are effective in controlling abnormal behaviors and improving cognitive impairments associated with ADHD, but less so than the majority of stimulants 116 . The TCAs are particularly useful when other FDA approved agents fail and/or when oppositionality, anxiety, tics, sleep, or depressive symptoms co-occur within ADHD. Unwanted side effects include sedation, weight gain, dry mouth, and constipation. Blood levels should be measured periodically and, since TCAs prolong the cardiac repolarization, ECG monitoring is recommended but not required to screen for arrhythmia risk. TCAs can be fatal in overdose and need to be stored carefully, particularly if toddlers are in the family.

Modafinil is currently approved as treatment for narcolepsy and has been shown effective in pediatric, but not adult, trials of ADHD 117 . Modafinil has not been approved by the FDA for the treatment of ADHD due to safety concerns (rare but potentially serious erythema multiforme).

In summary, ADHD is a prevalent world-wide, heterogeneous disorder that frequently persists through adolescence into adult years. ADHD continues to be diagnosed by careful history with an understanding of the developmental presentation of normal behavior and symptoms of the disorder. ADHD has been reconceptualized as a more chronic condition with approximately one-half of children continuing to exhibit symptoms and impairment of the disorder into adulthood 39 , 40 .. Most individuals with ADHD have a comorbid disorder: including oppositional, conduct, anxiety, or mood disorders 3 , 11 , 12 .. In addition, ADHD carries with it significant impairment in academic, occupational, social, and intrapersonal domains necessitating treatment. Converging data strongly support a neurobiological and genetic basis for ADHD with catecholaminergic dysfunction as a central finding.

Psychosocial interventions such as educational remediation, structure/routine, and cognitive-behavioral approaches should be considered in the management of ADHD. Contemporary work exhibiting improved outcomes associated with specific cognitive therapies in adults with ADHD has been demonstrated. An extensive literature supports the effectiveness of pharmacotherapy not only for the core behavioral symptoms of ADHD but also improvement in linked impairments. Similarities between pediatric and adult groups in the presentation, characteristics, neurobiology, and treatment response of ADHD support the continuity of the disorder across the lifespan.

Attention-deficit/hyperactivity disorder is a heterogenous disorder that is prevalent worldwide and frequently persists from adolescence into adult years. Attention-deficit/hyperactivity disorder continues to be diagnosed by careful history with an understanding of the developmental presentation of normal behavior and symptoms of the disorder. It has been reconceptualized as a more chronic condition, with approximately half of children continuing to exhibit symptoms and impairment into adulthood. 39 , 40 Most individuals with ADHD have a comorbid disorder, including oppositional, conduct, anxiety, or mood disorders. 3 , 11 , 12 In addition, ADHD carries with it significant impairment in academic, occupational, social, and intrapersonal domains necessitating treatment. Converging data strongly support a neurobiological and genetic basis for ADHD, with catecholaminergic dysfunction as a central finding.

Psychosocial interventions such as educational remediation, structure/routine, and cognitive behavioral approaches should be considered in the management of ADHD. Contemporary work exhibiting improved outcomes associated with specific cognitive therapies in adults with ADHD has been demonstrated. Extensive literature supports the effectiveness of pharmacotherapy not only for the core behavioral symptoms of ADHD but also improvement in linked impairments. Similarities between pediatric and adult groups in the presentation, characteristics, neurobiology, and treatment response of ADHD support the continuity of the disorder across the lifespan.

Acknowledgments

This article was in part underwritten by K24 DA016264 to Timothy Wilens, MD.

Conflict of Interest Statement

Timothy Wilens, MD discloses conflicts of interest with Abbott, AstraZeneca, Eli Lilly and Co., McNeil Pharmaceuticals, Merck, the National Institutes of Health (National Institute on Drug Abuse), Novartis, and Shire. Thomas Spencer, MD discloses conflicts of interest with Cephalon, Eli Lilly and Co., GlaxoSmithKline, Janssen Pharmaceutical, McNeil Pharmaceuticals, the National Institute of Mental Health, Novartis, Pfizer, and Shire.

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ADHD: Current Research and Teaching Strategies for Reading and Writing

ADHD (attention deficit hyperactivity disorder) presents challenges that affect everyday life and learning for students as well as their teachers and parents. Much has been written and researched when it comes to the disorder, with some conclusions resulting in great debate and controversy. As research and practice continue to mine the depths of understanding ADHD, certain findings have commonly emerged:

• An estimated 3.5 percent of the student population (or 1.46 to 2.46 million children) in the United States have ADHD.
• There are three main symptoms related to ADHD: inattention, hyperactivity, and impulsivity.
• Boys are more often diagnosed with ADHD than girls, with rates of four to nine times more for boys than girls.
• Symptoms of the disorder may change as the child develops, but research indicates that the disorder persists into adulthood at some level for a significant number of people.
• There are many types of ADHD, and treatment and intervention strategies can vary among types.
• –From the

ADHD Series

• published by NASET (National Association of Special Education Teachers)

Recent research points to other findings. A comparative study of brain imaging conducted by the National Institute of Mental Health indicates that certain regions of the brain in children with ADHD may develop slower than those regions in their non-ADHD counterparts. This study implies that ADHD, at least for some children, may be due to a delay in brain development, which may change over time.

Stephen Hinshaw, a researcher at the University of California at Berkeley, has been following a study group of non-ADHD and ADHD girls. This ten-year longitudinal study is the first of its kind. (Most of the research on ADHD has been focused on boys.)

Hinshaw’s study showed that the girls with ADHD reported more problems with anxiety, depression, and eating disorders in their adolescent years than did the girls without ADHD. Other studies have shown that ADHD in girls is commonly diagnosed at a later age than in boys, often due to the fact that girls are more likely to show symptoms of inattentiveness rather than the more overt symptoms of impulsivity and hyperactivity seen in boys. As a consequence, these girls are often left unnoticed and undiagnosed until further problems emerge.

As the scientific research continues, teachers face, on a daily basis, the need to help students with ADHD succeed in their classrooms. According to NASET:

Research in the field of ADHD suggests that teachers who are successful in educating children with ADHD use a three-pronged strategy. They begin by identifying the unique needs of the child. For example, the teacher determines how, when, and why the child is inattentive, impulsive, and hyperactive. The teacher then selects different educational practices associated with academic instruction, behavioral interventions, and classroom accommodations that are appropriate to meet that child’s needs. Finally, the teacher combines these practices into an individualized educational program (IEP) or other individualized plan and integrates this program with educational activities provided to other children in the class (Introduction, ADHD Series ).

READING AND WRITING STRATEGIES FOR STUDENTS WITH ADHD

Experts on ADHD offer a number of suggestions to help children with reading and writing. Roland Rotz and Sarah Wright suggest finding ways to provide students with secondary “fidget” activities, ones that don’t distract students from the task at hand but actually help them focus on a task. For example, allowing students to listen to music while reading a textbook, having students listen to a recorded version of a book while reading the text, or giving students an extra piece of paper to doodle on while working on a writing assignment.

Other strategies that build focus and comprehension, like reading aloud, previewing materials, asking questions, identifying the main ideas, word games and other components of successful reading programs, are helpful at an early age. In his article, ADHD at School: 10 + Tips to Improve Reading Skills , neuropsychologist Matthew Cruger writes:

Children with ADHD often have difficulty with reading comprehension because it depends on their ability to quickly sound out and recognize words- something that’s hard for students with attention deficit disorder or learning disabilities like dyslexia.

Even if ADHD students master the mechanics of reading, many have trouble understanding the text, making connections within the story, and relating what they’re reading to what they already know. Fortunately, reading comprehension skills and strategies can be taught. Children who learn multiple reading strategies, and are guided in their use, eventually choose some to use on their own.

Here are some resources that may be helpful in supporting students with ADHD:

Beyond Penguins and Polar Bears Resources Stories for Students

This series of electronic books allows students to both read and listen to stories, a feature especially useful for helping children with ADHD track and focus on text closely. The audio portion also helps students sound out words. These electronic books can be used as companions to illustrated versions of the stories, which are printed as individual books.

Determining Importance This Beyond Penguins and Polar Bears article provides a number of templates to help students distinguish the most important ideas when reading text. There are templates for identifying the essential points of text while reading or after reading. For example, students make lists to separate what things in a given text are interesting versus important. In another template, students highlight text, marking whether it is something to stop and pay attention to as a key idea, to slow down for ideas that might be important, or to note as additional information that isn’t essential.

ADHD Resources

National Association of Special Education Teachers (NASET) NASET offers a list of resources dealing with ADHD. While some materials are limited to members, there are some general materials that provide support for teachers in understanding ADHD and meeting student needs. A separate series of articles on ADHD is available to members.

NPR Interview: Diagnosis Can Miss ADHD Symptoms in Girls This “Talk of the Nation” interview focuses on Stephen Hinshaw’s longitudinal study of girls with ADHD into adolescence. As a part of the interview, listeners call in to share their stories, providing a sobering picture of stigma, neglect and misunderstanding when it comes to treating girls – and women – with this disorder.

ADDitude Magazine and Online Community As both a magazine and online community, this resource provides a host of information about ADHD. Membership to the online community is free while the magazine has a subscription fee.

Fidget to Focus: Outwit Your Boredom: Sensory Strategies for Living with ADD This book by Roland Rotz and Sarah Wright looks at what neuroscience can tell us about ADD and ways to enhance focus and attention through fidgeting or “simultaneous sensory-motor stimulation.” Rotz and Wright provide strategies and suggestions that can be helpful in classrooms and other learning situations.

This article was written by Robert Payo. For more information, see the Contributors page. Email Kimberly Lightle , Principal Investigator, with any questions about the content of this site.

Copyright December 2009 – The Ohio State University. This material is based upon work supported by the National Science Foundation under Grant No. 0733024. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation. This work is licensed under an  Attribution-ShareAlike 3.0 Unported Creative Commons license .

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Home > ETD > Doctoral > 4962

Doctoral Dissertations and Projects

K-8 teachers' experiences instructing students diagnosed with adhd: a phenomenological study.

Van C. Kirchhoff , Liberty University Follow

School of Education

Doctor of Philosophy in Education (PhD)

Katelynn Wheeler

medicated, Attention-deficit/hyperactivity disorder, Ritalin, Adderall, behavior modification

Disciplines

Curriculum and Instruction | Education

Recommended Citation

Kirchhoff, Van C., "K-8 Teachers' Experiences Instructing Students Diagnosed with ADHD: A Phenomenological Study" (2023). Doctoral Dissertations and Projects . 4962. https://digitalcommons.liberty.edu/doctoral/4962

The purpose of this phenomenological study was to describe the lived experiences of teachers who have experience working with students diagnosed with ADHD in the K-8 public school system in the Mid-Atlantic United States. The problem is that the number of students diagnosed with ADHD is rapidly increasing, and yet, educators are not being provided with the knowledge or the skills to support these students in the classroom (Dort et al., 2020). Due to the large percentage of students diagnosed with ADHD, research is needed to provide insight into what methods are being used by teachers in an inclusive classroom to enhance classroom management and to help these students with their learning. The study’s central question is: What are the lived experiences of K-8 teachers who have experience educating students diagnosed with ADHD? Expectancy Value Theory (EVT) guided the study. The study used a qualitative design, and data was collected in the form of journal prompts, individual interviews, and two focus groups. All data was transcribed, examined, in vivo, open coded, and placed into themes that developed during the research. The findings of the study showed that formal training in ADHD and support techniques for students diagnosed with ADHD is severely lacking. It also revealed how crucial it is for teachers to make a connection with these students to help them to live up to their potential. Finally, medication was shown to be a strong support method that should not be arbitrarily dismissed when given under proper medical supervision.

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Promoting Implementation of Behavioral Classroom Interventions for Children with ADHD in Urban Schools

Project Number 5 R01 HD101471-02 Agency/Funding Organization NICHD Funding Year 2021 View Full Project Details for Promoting Implementation of Behavioral Classroom Interventions for Children with ADHD in Urban Schools

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What's adhd (and what's not) in the classroom.

Signs that a child might have the disorder, and other problems that may be confused with ADHD

Writer: Caroline Miller

What You'll Learn

• How does ADHD show up in the classroom?
• What else can cause symptoms that look like ADHD?

A lot of kids with ADHD (attention-deficit hyperactivity disorder) are diagnosed when they start to struggle in school. Fidgeting, interrupting, losing homework, daydreaming — these are all common signs of ADHD. However, they can also have other causes. Whenever it looks like a child might have ADHD, it’s important to rule out other issues.  

Signs of ADHD fall into two categories. The first includes inattentive symptoms, like getting distracted or forgetting things. The second includes hyperactive and impulsive symptoms, like running around the room or shouting out answers in class.   

Other mental health concerns can cause classroom issues that look a lot like ADHD. A child who can’t focus might be distracted by anxiety, something upsetting at home, or worry about getting bullied. A child with learning disorder like dyslexia might act out because they’re frustrated with schoolwork. It’s also important to note that girls with ADHD are more likely than boys to have only inattentive symptoms. Sometimes, they’re written off as ditzy or dreamy instead of getting a diagnosis.  

To be diagnosed with ADHD, a child must have symptoms in at least two settings, like home and school. It’s normal for kids to be inattentive or hyperactive sometimes, so ADHD symptoms must last for at least six months. It’s also important to consider age. Kids who are young for their grade may get misdiagnosed with ADHD because they’re just not as mature as other kids in their class.  

When a child is struggling in school, it’s important to find help and get an accurate diagnosis, whether or not ADHD is the real issue.  

Many children with ADHD show signs of the disorder before they reach school age. But it’s in school, when they are having trouble meeting expectations for kids in their grade, that most are referred for diagnosis.

ADHD is one of the first things that’s suspected when a child’s behavior in class, or performance on schoolwork, is problematic. A child who can’t seem to sit still, who blurts out answers in class without raising his hand, who doesn’t finish his homework , who seems to be daydreaming when the teacher gives instructions—these are well-known symptoms of ADHD.

But these are also behaviors that can be a result of other factors, from anxiety to trauma to just being younger than most of the kids in the class, and hence a little less mature.

That’s why it’s important for teachers and parents both to be aware of what ADHD looks like in the classroom, and how it might be confused with other things that could be influencing a child’s behavior. Observing kids carefully is especially important when kids are too young to be able to articulate what they are feeling. And referring struggling kids for diagnosis and appropriate support can help them succeed in school and other parts of their lives, too.

ADHD symptoms

There are three kinds of behavior involved in ADHD: inattention, hyperactivity and impulsivity. Of course all young children occasionally have trouble paying attention to teachers and parents, staying in their seats, and waiting their turn. Kids should only be diagnosed with ADHD if their behavior is much more extreme in these areas than other kids their age.

These symptoms of ADHD are divided into two groups—inattentive and hyperactive-impulsive. Some children exhibit mostly inattentive behaviors and others predominantly hyperactive-impulsive. But the majority of those with ADHD have a combination of both, which may make it very difficult for them to function in school.

Here are behaviors you might observe in school in those two categories.

Inattentive symptoms of ADHD

• Makes careless mistakes in school work, overlooks details  
• Is easily distracted or sidetracked
• Has difficulty following instructions
• Doesn’t seem to be listening when spoken to directly
• Has trouble organizing tasks and possessions
• Often fails to finish work in school or chores in the classroom
• Often avoids or resists tasks that require sustained mental effort, including doing homework
• Often loses homework assignments, books, jackets, backpacks, sports equipment

Hyperactive or impulsive symptoms of ADHD

• Often fidgets or squirms
• Has trouble staying in his seat
• Runs and climbs where it’s inappropriate
• Has trouble playing quietly
• Is extremely impatient, can’t wait for his turn
• Always seems to be “on the go” or “driven by a motor”
• Talks excessively
• Blurts out answers before a question is completed
• Interrupts or intrudes on others conversations, activities, possessions

Serious impairment

It’s important to keep in mind that not every high-energy or impulsive child has ADHD. Children are diagnosed with ADHD only if they demonstrate these symptoms so often that they are causing real difficulty in at least two settings—i.e. at school and at home. And the pattern that’s causing them serious impairment must persist for at least 6 months.

Age matters

It’s also important, when considering a child’s behavior, to compare it to other children the same age—not to the range of kids in his class or grade. Within any given grade, kids’ ages can differ by almost a year, and a year can make a big difference in a child’s ability to self-regulate.

Two studies in the last few years concluded that kids who are youngest in their class are disproportionately diagnosed with ADHD. A Michigan study found that kindergarteners who are the youngest in their grade are 60% more likely to be diagnosed with ADHD than the oldest in their grade.  And it doesn’t affect just kindergarteners: a North Carolina study found that in fifth and eighth grade, the youngest children were almost twice as likely as the oldest to be prescribed medication for ADHD .

Other causes

When children exhibit behaviors that we associate with ADHD, it’s important to keep in mind that they could be caused by other underlying factors. A child who is inattentive could be distracted by chronic anxiety , by a worrisome or painful situation at home, or because she’s being bullied in the playground. These are all things a child might be embarrassed by and go to some lengths to keep secret.

Another thing children often hide is undiagnosed learning disorders. If a child is fidgeting when she’s supposed to be reading, it may be that dyslexia is causing her great frustration. And if she bolts from her chair, it could be because she is ashamed that she doesn’t seem to be able to do what the other kids can do, and intent on covering that fact up.

Girls are different

The stereotype of ADHD is boys disrupting the classroom by jumping up from their seats, getting in other kids’ business, or blurting out answers without raising their hands. But girls get ADHD too, and they tend to be diagnosed much later because their symptoms are more subtle . More of them have the only inattentive symptoms of ADHD, and they get written off as dreamy or ditzy. If they have the hyperactive-impulsive symptoms they are more likely to be seen as pushy, hyper-talkative, or overemotional. Impulsive girls may have trouble being socially appropriate and struggle to make and keep friends.

But a big reason that many girls aren’t diagnosed is that they knock themselves out to compensate for their weaknesses and hide their embarrassment about falling behind, losing things, feeling clueless. The growing awareness, as they get older, that they have to work much harder than their peers without ADHD to accomplish the same thing is very damaging to their self-esteem. Girls who are chronically hard on themselves about their lapses may be struggling with thoughts that they’re stupid or broken.

Keeping a keen eye on kids’ behavior in the classroom is important not just because it affects their learning—and potentially the ability of other kids in the class to learn—but also because it’s a window into their social and emotional development. When kids are failing or struggling in school for an extended period of time, or acting out in frustration, without getting help, it can lead to a pattern of dysfunctional behavior that gets harder and harder to break.

That’s why it’s important for parents to get a good diagnosis from a mental health professional who takes the time to carefully consider the pattern of a child’s behavior and what it might (and might not) indicate. Being not only caring but precise about defining and treating a child’s problems when he is young pays off many times over in the long run.

Frequently Asked Questions

ADHD affects learning by causing kids to have difficulty paying attention in the classroom, overlook details, have difficulty following directions, and struggle to finish schoolwork on time.

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The Impact of ADHD on Academic Performance

The importance of advocating for your child with their educators..

Posted February 17, 2023 | Reviewed by Tyler Woods

• What Is ADHD?
• Find a therapist to help with ADHD
• ADHD symptoms contribute to poor academic performance.
• The symptoms of inattentive-type ADHD make it difficult diagnose in school-age children.
• Advocating for your child with educators can improve their academic performance.
• Working with your child’s ADHD is key to their academic success.

A major concern for parents of ADHD children is their performance in school, and parents often worry over criticizing their children for behaviors like difficulty finishing homework . Poor academic performance can result in failing grades, skipping school, dropping out of high school, or not attending college.

Inattentive-type ADHD is difficult to identify

Children with the inattentive subtype of ADHD can fly under the radar at school and at home with symptoms of inattention, forgetfulness, and disorganization. Michael Jellineck, professor of psychiatry and pediatrics at Harvard Medical School, has estimated children with ADHD could receive as many as 20,000 corrections for their behavior in school by the time they are 10 years old. The symptom of inattentive-type ADHD, including behaviors like disappearing to the bathroom or nurse’s office during class to avoid a disliked task, are difficult to identify correctly as the inattentive subtype and can often be confused with other behavioral problems.

According to the Centers for Disease Control 2017 report, nine out of ten children with ADHD received classroom accommodations in school. However, most children with ADHD are not in special education programs and their teachers may know little about ADHD behaviors. Knowledge of ADHD, including symptoms, behaviors, prognosis, and treatment, varies among teachers (Mohr-Jennsen et al., 2019), and educators are most knowledgeable about the “hallmark” symptoms of ADHD, like students fidgeting or squirming in their seat and being easily distracted by extraneous stimuli (Scuitto et al., 2016).

Advocating for your child

Since my son’s inattentive ADHD is not outwardly apparent (i.e., he isn’t hyperactive or disruptive in the classroom), advocating for him, and teaching him to advocate for himself, is one of my most important jobs as a parent. I was inspired by the story of a father who would send letters to his son’s teachers explaining the boy’s learning disability. Knowing my son’s performance did not always reflect his capabilities, I emailed my son’s middle and high school teachers at the beginning of each semester detailing his ADHD, his weaknesses, and, most importantly, his strengths. I was pleasantly surprised that the reaction from many of my son’s teachers over the years was positive; they were grateful for parental communication and support. Teachers with a greater understanding of ADHD recognize the benefit of behavioral and educational treatments and are more likely to help their students (Ohan et al., 2008). In my son’s case, educators who either had ADHD themselves, or sought to learn about it, had the biggest impact in terms of my son’s academic success.

Practical strategies for common academic struggles

Due to the executive function deficits that accompany ADHD, our kids cannot just “try harder” to get good grades. They are already working harder than their peers to stay afloat in school. According to Mayes and Calhoun (2000) more than half of ADHD children struggle with written expression, my son included. Executive function deficits in ADHD make organizing ideas, planning, and editing difficult. I helped my son by having him talk it out when he had to write an essay for school (this was also an accommodation in his 504 plan to help him answer essay questions on tests and other assignments). I would start by asking him to tell me one fact about his essay’s topic. I found that he knew what he wanted to say, but organizing his thoughts on the page was an overwhelming and difficult task for him. I would furiously type while he talked, then gave him the notes, making it much easier for him to compose his essay. Another strategy was to have him incorporate something about a topic he was interested in, if possible. Anytime my son could write something about outer space or rockets he struggled less, even being selected as a national finalist in a NASA-sponsored essay contest about traveling to Mars.

Approximately 25-40% of patients with ADHD have major reading and writing difficulties, and ADHD frequently co-occurs with other learning disabilities like dyslexia, which makes reading difficult. In addition, the inattention symptoms of ADHD likely interfere with reading ability, resulting in reading the same paragraph over and over without retaining the information. As parents, we have to accept that our ADHD kids learn differently and not be concerned with the traditional, or 'right' way of doing something. My son retained information from required reading in school much better when he listened to an audiobook, rather than trying to painstakingly read the book. What did it matter if my son read the book or listened to it being read? Let’s take a cue from our ADHD kids and think outside the box.

Learning to work with my son’s ADHD gave me a better understanding of his strengths and weaknesses when it came to his academic performance. As a result, I was a better advocate for him and was able to work with his teachers to ensure his academic success.

Albert, M., Rui, P., & Ashman, J.J. (2017). Physician office visits for attention-deficit/hyperactivity disorder in children and adolescents Aged 4–17 Years: United States, 2012–2013 . National Center for Health Statistics. https://www.cdc.gov/nchs/products/ databriefs/db269.htm.

Mayes, S.D. & Calhoun, S. (2000, April). Prevalence and degree of attention and learning problems in ADHD and LD. ADHD Reports , 8 (2).

Mohr-Jensen, C., Steen-Jensen, T., Bang Schnack, M., &Thingvad, H. (2019). What do primary and secondary school teachers kno about ADHD in children? Findings from a systematic review and a representative, nationwide sample of Danish teachers. Journal of Attention Disorders 23(3): 206-219.

Ohan, J. L., Cormier, N., Hepp, S. L., Visser, T. A. W., & Strain, M. C. (2008). Does knowledge about attention-deficit/hyperactivity disorder impact teachers' reported behaviors and perceptions? School Psychology Quarterly, 23 (3), 436–449.

Sciutto, M.J., Terjesen, M.D., Kučerová, A., Michalová, Z., Schmiedeler, S., Antonopoulou, K., Shaker, N.Z., Lee, J., Lee, K., Drake, B., & Rossouw, J. (2016). Cross-national comparisons of teachers’ knowledge and misconceptions of ADHD. International Perspectives in Psychology 5(1): 34-50.

Kristin Wilcox, Ph.D. , has spent over 20 years in academia as a behavioral pharmacologist studying drug abuse behavior and ADHD medications at Emory University and Johns Hopkins University School of Medicine.

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ADHD in the Classroom: How to Support Students with Attention-Deficit/Hyperactivity Disorder

• September 2, 2021

A survey of educators found that most feel they don’t have enough information and classroom management strategies for students with attention-deficit/hyperactivity disorder (ADHD).[2] Because children with ADHD need the right resources to thrive in the classroom, this can seriously inhibit their ability to reach their academic potential.

As a teacher, you know how important it is to provide support and guidance to these students. The more familiar you are with recognizing and helping students with ADHD, the more likely they are to reach their academic potential and exhibit positive classroom behavior.

In this article, we will define ADHD and list a few symptoms to watch for in your students. Then we’ll discuss helpful classroom management strategies.

What is ADHD and How Does It Affect Students?

Of course, definitions can only go so far. Talking to someone with ADHD is the best way to learn what it is and how it feels to live with it. If you don’t have anyone to ask in real life, this video from the How to ADHD channel is a great primer for educators on what ADHD is and how it affects academics.

Is ADHD a Disability? What Educators Need to Know

As a teacher, you may not feel qualified to help children with ADHD in the classroom—especially if you don’t have much experience with it. But classroom interventions can be as simple as slight modifications your instruction or providing small accommodations for your ADHD students.[2] You could, for example, give them extra time to complete homework or give them a folder to organize all of their assignments.[13]

For issues that are beyond your expertise, you can always refer the student to your school counselor or an in-school ADHD specialist, depending on the resources available. Get to know your school counselors or psychologists so if you have a student with ADHD, you know who can help them.[5] If you don’t have an ADHD specialist at your school, you could also discuss your concerns with a school administrator. They may be able to get in touch with a specialist within your district or provide accommodations in another form.

If school accommodations are sparse, and the family has not yet looked into professional treatment (such as therapy) for their child, it can be helpful to refer parents to ADHD specialists outside of your school.[8] Additionally, try to involve parents in the process of helping or disciplining a child with ADHD in school.[10] Parents will be more familiar with their child’s symptoms and may be able to suggest tactics to help their child focus in class.

Signs of ADHD: What Teachers Should Look For

Remember that as a teacher, you are not qualified to officially diagnose a student, but you can advise a specialist as needed. If you suspect that a child might have ADHD, it is best to discuss this concern with their family and with your school administrators. After speaking to the child’s family, and if the child has not been diagnosed with ADHD, you may want to encourage that family to visit a pediatrician or other specialist.

Symptoms of ADHD may vary depending on the child’s age and how much support they’ve received. For elementary school teachers, here are a few early signs of ADHD to look for:[14]

• Low self-control
• Difficulty staying focused on lessons
• Hyperactivity that interferes with a child’s ability to pay attention
• Trouble organizing assignments and belongings
• Excessive talking with peers and difficulty staying quiet while working

To learn more about ADHD signs and how these might present in the classroom—along with common misconceptions—use this video from ADDitude Magazine as a guide.

7 Teaching Tips and Classroom Accommodations for Students with ADHD

While students who have ADHD may have additional needs, these students are just as capable of succeeding in school as are their peers. Classroom strategies designed to help students with ADHD are the best way to reduce disruptive behavior and help students reach their academic potential.[7]

These seven tips for teaching students with ADHD can help them stay focused and feel comfortable in class:

• Try to follow a regular classroom routine every day; this helps students with a range of learning disorders by limiting confusion or distraction.[12]
• Provide students with organization tools, such as a three-pocket notebook or binder, to help them keep their assignments together.[11]
• Because children with ADHD often have trouble staying focused, schedule in short breaks for students to recharge throughout the day.[19]
• Offer positive feedback regularly so they trust you and know that you have their best interests in mind.[12]
• Check out this list of children’s books about ADHD from Verywell Mind, and add a few to your classroom library to normalize discussions about ADHD.
• Students with ADHD often struggle in test-taking environments. Give these students extra time and help them find a space that is distraction free (like the school library) to take tests.[18]
• Remember, a student’s needs may exceed what you’re able to provide. In this case, refer the child to a counselor or ADHD specialist.
• Scahill, L., and Schwab-Stone, M. Epidemiology of Adhd in School-Age Children . Child & Adolescent Psychiatric Clinics of North America, July 2000, 9(3), pp. 541-555.
• Pfiffner, L., DuPall, G.J., and Barkley. R. Treatment of ADHD in School Settings . retrieved from semanticscholar.org: https://pdfs.semanticscholar.org/63ea/daa464079cdb6ffc661f1d8e3f3c6f35a7b1.pdf.
• Evans, W.N., Morrill, M.S., and Parente, S.T. Measuring inappropriate medical diagnosis and treatment in survey data: The case of ADHD among school-age children . Journal of Health Economics, September 2010, 29(5), pp. 657-673.
• Kent, K.M., Pelham, W.E., Molina, B.S., Sibley, M.H., Waschbusch, D.A., Yu, J., Gnagy, E.M., Biswas, A., Babinski, D.E., and Karch, K.M. The Academic Experience of Male High School Students with ADHD . Journal of Abnormal Child Psychology, 2011, 39(3), pp. 451-462.
• DuPaul, G.J., Weyandt, L.L., and Janusis, G.M. ADHD in the Classroom: Effective Intervention Strategies . Theory Into Practice, 2011, 50(1), pp. 35-42.
• Greene, R.W., Beszterczey, S.K., Katzenstein, T., Park. K., and Goring, J. Are Students with ADHD More Stressful to Teach?: Patterns of Teacher Stress in an Elementary School Sample . Journal of Emotional and Behavioral Disorders, 2002, 10(2), pp. 79-89.
• Miranda, A., Jarque, S., and Tarraga, R. Interventions in School Settings for Students With ADHD . Exceptionality: A Special Education Journal, 2006, 14(1), pp. 35-52.
• Loe, I.M., and Feldman, H.M. Academic and Educational Outcomes of Children With ADHD . Journal of Pediatric Psychology, July 2007, 32(6), pp. 643-654.
• Sciutto, M.J., Nolfi, C.J., and Bluhm, C. Effects of Child Gender and Symptom Type on Referrals for ADHD by Elementary School Teachers . Journal of Emotional and Behavioral Disorders, October 2004, 12(4), 247-253.
• Power, T.J., Mautone, J.A., Soffer, S.L., Clarke, A.T., Marshall, S.A., Sharman, J., Blum, N.J., Glanzman, M., Elia, J., and Jawad, A.F. A family–school intervention for children with ADHD: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, August 2012, 80(4), pp. 611-623.
• Segal, J., and Smith, M. Teaching Students with ADHD. Retrieved from helpguide.org: https://www.helpguide.org/articles/add-adhd/teaching-students-with-adhd-attention-deficit-disorder.htm.
• Dendy, C.Z. Teaching Students with ADHD: Strategies That Help Every Child Shine . Retrieved from additudemag.com: https://www.additudemag.com/teaching-strategies-for-students-with-adhd/.
• Seay, B. 20 Classroom Accommodations That Target Common ADHD Challenges . Retrieved from additudemag.com: https://www.additudemag.com/20-adhd-accommodations-that-work/.
• HealthyChildren Staff. Early Warning Signs of ADHD . Retrieved from healthychildren.org: https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Early-Warning-Signs-of-ADHD.aspx.
• Perlstein, D., and Shiel, W.C. Attention Deficit Hyperactivity Disorder (ADHD) in Teens . Retrieved from emedicinehealth.com: https://www.emedicinehealth.com/adhd_in_teens/article_em.htm#attention_deficit_hyperactivity_disorder_adhd_in_teens.
• HealthyChildren Staff. Causes of ADHD: What We Know Today . Retrieved from healthychildren.org: https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Causes-of-ADHD.aspx.
• Mayo Clinic Staff. Attention-deficit/hyperactivity disorder (ADHD) in children. Retrieved from mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/adhd/symptoms-causes/syc-20350889.
• Morin, A., and Oswalt, G. Classroom accommodations for ADHD. Understood. https://www.understood.org/articles/en/classroom-accommodations-for-adhd.
• Ditzell, J. What School Accommodations Can You Get for a Child with ADHD? Psych Central. August 10, 2021. https://psychcentral.com/adhd/adhd-accommodations.

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ADHD and classroom challenges

What teachers can do to help children with adhd, classroom accommodations for students with adhd, teaching techniques for students with adhd, teaching students with adhd.

Dealing with attention deficit hyperactivity disorder in the classroom? These tips for teachers can help you overcome common challenges and help kids with ADHD succeed at school.

If you’re a teacher, you know these kids: The one who stares out the window, substituting the arc of a bird in flight for her math lesson. The one who wouldn’t be able to keep his rear end in the chair if you used Krazy Glue. The one who answers the question, “What body of water played a major role in the development of the Ancient Egyptian civilization?” with “Mrs. M, do you dye your hair?”

Students who exhibit ADHD’s hallmark symptoms of inattention, hyperactivity, and impulsivity can be frustrating. You know the brainpower is there, but they just can’t seem to focus on the material you’re working hard to deliver. Plus, their behaviors take time away from instruction and disrupt the whole class.

Students with ADHD may:

• Demand attention by talking out of turn or moving around the room.
• Have trouble following instructions, especially when they're presented in a list, and with operations that require ordered steps, such as long division or solving equations.
• Often forget to write down homework assignments, do them, or bring completed work to school.
• Often lack fine motor control, which makes note-taking difficult and handwriting a trial to read.
• Have problems with long-term projects where there is no direct supervision.
• Not pull their weight during group work and may even keep a group from accomplishing its task.

Think of what the school setting requires children to do: Sit still. Listen quietly. Pay attention. Follow instructions. Concentrate. These are the very things kids with attention deficit hyperactivity disorder (ADHD or ADD) have a hard time doing—not because they aren’t willing, but because their brains won’t let them. That doesn’t make teaching them any easier, of course.

Children and teens with ADHD often pay the price for their problems in low grades, scolding and punishment, teasing from their peers, and low self-esteem. Meanwhile, you, the teacher, feel guilty because you can’t reach the child with ADHD and wind up taking complaints from parents who feel their kids are being neglected in the classroom. But it doesn’t have to be this way. There are strategies you can employ to help students with ADHD overcome learning challenges, stay focused without disrupting others, and succeed in the classroom .

So how do you teach a kid who won't settle down and listen? The answer: with a lot of patience, creativity, and consistency. As a teacher, your role is to evaluate each child's individual needs and strengths. Then you can develop strategies that will help students with ADHD focus, stay on task, and learn to their full capabilities.

Successful programs for children with ADHD integrate the following three components:

• Accommodations: what you can do to make learning easier for students with ADHD.
• Instruction: the methods you use in teaching.
• Intervention: How you head off behaviors that disrupt concentration or distract other students.

Your most effective tool, however, in helping a student with ADHD is a positive attitude. Make the student your partner by saying, “Let's figure out ways together to help you get your work done.” Assure the student that you'll be looking for good behavior and quality work and when you see it, reinforce it with immediate and sincere praise. Finally, look for ways to motivate a student with ADHD by offering rewards on a point or token system.

Dealing with disruptive classroom behavior

To head off behavior that takes time from other students, work out a couple of warning signals with the student who has ADHD. This can be a hand signal, an unobtrusive shoulder squeeze, or a sticky note on the student's desk. If you have to discuss the student's behavior, do so in private. And try to ignore mildly inappropriate behavior if it's unintentional and isn't distracting other students or disrupting the lesson.

Speak to a Licensed Therapist

As a teacher, you can make changes in the classroom to help minimize the distractions and disruptions of ADHD.

• Seat the student with ADHD away from windows and away from the door.
• Put the student with ADHD right in front of your desk unless that would be a distraction for the student.
• Seats in rows, with focus on the teacher, usually work better than having students seated around tables or facing one another in other arrangements.
• Create a quiet area free of distractions for test-taking and quiet study.

Information delivery

• Give instructions one at a time and repeat as necessary.
• If possible, work on the most difficult material early in the day.
• Use visuals: charts, pictures, color coding.
• Create outlines for note-taking that organize the information as you deliver it.

Student work

• Create worksheets and tests with fewer items, give frequent short quizzes rather than long tests, and reduce the number of timed tests.
• Test students with ADHD in the way they do best, such as orally or filling in blanks.
• Divide long-term projects into segments and assign a completion goal for each segment.
• Accept late work and give partial credit for partial work.

Organization

• Have the student keep a master binder with a separate section for each subject, and make sure everything that goes into the notebook is put in the correct section. Color-code materials for each subject.
• Provide a three-pocket notebook insert for homework assignments, completed homework, and “mail” to parents (permission slips, PTA flyers).
• Make sure the student has a system for writing down assignments and important dates and uses it.
• Allow time for the student to organize materials and assignments for home. Post steps for getting ready to go home.

Teaching techniques that help students with ADHD focus and maintain their concentration on your lesson and their work can be beneficial to the entire class.

Starting a lesson

• Signal the start of a lesson with an aural cue, such as an egg timer, a cowbell or a horn. (You can use subsequent cues to show how much time remains in a lesson.)
• Establish eye contact with any student who has ADHD.
• List the activities of the lesson on the board.
• In opening the lesson, tell students what they're going to learn and what your expectations are. Tell students exactly what materials they'll need.

Conducting the lesson

• Keep instructions simple and structured. Use props, charts, and other visual aids.
• Vary the pace and include different kinds of activities. Many students with ADHD do well with competitive games or other activities that are rapid and intense.
• Have an unobtrusive cue set up with the student who has ADHD, such as a touch on the shoulder or placing a sticky note on the student's desk, to remind the student to stay on task.
• Allow a student with ADHD frequent breaks and let him or her squeeze a rubber ball or tap something that doesn't make noise as a physical outlet.
• Try not to ask a student with ADHD perform a task or answer a question publicly that might be too difficult.

Ending the lesson

• Summarize key points.
• If you give an assignment, have three different students repeat it, then have the class say it in unison, and put it on the board.
• Be specific about what to take home.

More Information

• Attention-Deficit/Hyperactivity Disorder (AD/HD) - Tips and resources for teachers. (Center for Parent Information and Resources)
• In the Classroom: Ideas and Strategies for Kids with ADD and Learning Disabilities - Suggestions for teaching children with ADHD. (Child Development Institute)
• Motivating the Child with Attention Deficit Disorder - How ADHD symptoms interfere with classroom expectations and how to realistically motivate a child. (LD Online)
• Step-by-Step Guide for Securing ADHD Accommodations at School - Meeting your child’s educational needs with ADHD accommodations at school. (ADDitude)
• Contents of the IEP - Guide to developing an Individualized Education Program (IEP) with school staff to address your child’s educational needs. (Center for Parent Information and Resources)
• Neurodevelopmental Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link
• Teaching Children with Attention Deficit Hyperactivity Disorder: Instructional Strategies and Practices– Pg 1. (2008). [Reference Materials; Instructional Materials]. US Department of Education. Link
• Gaastra, G. F., Groen, Y., Tucha, L., & Tucha, O. (2016). The Effects of Classroom Interventions on Off-Task and Disruptive Classroom Behavior in Children with Symptoms of Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review. PLOS ONE, 11(2), e0148841. Link
• CDC. (2019, November 7). ADHD in the Classroom . Centers for Disease Control and Prevention. Link

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Where Should Students Be Allowed to Use Cellphones? Here’s What Educators Say

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To ban or not to ban? This question has been front and center for many schools recently as they strategize how to address students’ ubiquitous use of cellphones.

With nearly 9 in 10 teens 13 and older possessing a smartphone , these devices have become a major source of distraction and disruption in schools, especially when students’ online arguments spill over into in-school arguments and physical fights.

And many educators and school support staff feel that students’ constant access to social media on their smartphones is harming their mental wellbeing and hurting their ability to learn. Some educators go so far to say that students are addicted to their devices.

Nearly a quarter of teachers, principals, and district leaders think that cellphones should be banned from school grounds, according to a recent nationwide survey conducted in September and October by the EdWeek Research Center.

But, overall, educators are divided on the issue.

“We should be learning to manage cellphones in the classroom. They are here to stay,” one educator said in the survey. “BUT they are the biggest distraction.”

Said another survey respondent: “We recently banned cellphones. Previously, they were allowed during passing time and at lunch. However, they had taken over instructional time. Students would get out their phones without thinking and teachers would have to spend as much time redirecting as they were teaching. That, or have a power struggle over confiscation.”

But schools face headwinds from students and parents—many of whom want to be able to reach their children throughout the day—when they try to restrict students’ access to cellphones during the school day.

And as the charts below show, in many cases there’s a yawning gap between what students are allowed to do and what educators think would be best for schools.

For example, nearly three-quarters of teachers, principals, and district leaders say that high school students in their schools and districts are allowed to use their phones during lunch, but only half believe that should be permitted.

The survey also found that a significantly larger share of teachers are in favor of banning cellphones on campus than district leaders. Principals were more in line with teachers than district leaders on that decision.

The following charts show where students are allowed to use cellphones on campus, where educators think phones should be permitted, and how teachers, principals, and district leaders differ on the issue of an all-out cellphone ban.

Data analysis for this article was provided by the EdWeek Research Center. Learn more about the center’s work.

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