Supporting Students with Attention-Deficit/Hyperactivity Disorder (ADHD) in Schools

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder of childhood highly prevalent among young children and adolescents. Children and adolescents with ADHD may experience diminished attention span, daydreaming, difficulty following directions and distractibility. “These children or adolescents may be excessively active, impulsive, fidgety, or talkative, with symptoms that are present for at least 6 months and with impairment noted in more than 1 domain of the child or adolescent’s life.” Children or adolescents with ADHD may also exhibit the following signs:

• Displaying poor sense of physical and social boundaries
• Having impaired academic performance
• Difficulty with organization of physical spaces (backpacks, bedrooms, folders, etc.)
• Having negative self-esteem from internalizing the response of peers and adults related to ADHD-related behaviors
• Developing secondary anxiety, depression, and/or substance use
• Showing inconsistency in use of learned skills

Care Coordination Between Schools and Pediatricians for Students with ADHD

Schools and pediatricians working together is an effective strategy to support students with ADHD. Pediatricians play a significant role in helping to identify symptoms and diagnose ADHD as well as advocate for services and early intervention strategies to prevent poor academic outcomes and misunderstood behaviors. This includes collaborating with schools, behavioral health clinicians and specialists to establish clear, realistic and attainable goals for a child. This also involves clarifying the benefits and limitations of medication while promoting a skills-building approach to support the child with ADHD.

Administration of validated screening tools can be helpful adjuncts for making a diagnosis. Information that is shared with pediatricians, such as rating scales completed by teachers or parents, can be helpful in making a differential diagnosis between ADHD and anxiety. Pediatricians can also consider the appropriateness of using psychopharmacological interventions as well as referrals for counseling and can coordinate with the school health services team to support these treatment options.

Pediatricians should continue to work with schools and seek input regarding a child’s performance when using psychopharmacological interventions to assist with optimal titration of medication dosing. Pediatricians can continue to use tools, such as the NICHQ Vanderbilt Assessment Follow-up forms, to monitor medication efficacy and side effects.

The key action statements in the Clinical Practice Guidelines for Diagnosis, Evaluation and Treatment of ADHD in Children and Adolescents provide additional guidance for the role of the pediatrician in primary care.

Pediatricians can utilize strategies to promote relational health in families and mitigate toxic stress; this along with screening practices to identify children with increased risk factors of ADHD can lead to earlier identification, and treatment. In addition, it can potentially prevent emotional dysregulation symptoms in children before they manifest as full secondary/comorbid disorders such as anxiety, depression, and/or substance abuse.

Pediatricians as Advocates for Students with ADHD

Pediatricians can play an important role in working with the family and school to identify and implement accommodations and services that support the needs of students with ADHD.

As behaviors related to ADHD are often misunderstood, this may put a student at risk for disciplinary action including out of school suspension or expulsion. Since academic achievement is highly associated with physical, emotional and mental health, it is important for school health nurses/clinics and pediatricians to find more effective and appropriate alternatives to exclusionary discipline policies for the developing child based on behavior. One strategy emphasized in the AAP’s policy statement, Out-of-School Suspension and Expulsion is:

"As the primary care physician to a school-aged student who is exhibiting problem behavior, the pediatrician should establish communication with the school nurse and/or counselor to verify how the child’s behaviors compare with peer behaviors in the school setting. The pediatrician should work with the school, the child and family, and most effectively, mental health care professionals to facilitate and coordinate care of the student. This should occur as early as possible in the onset of behaviors that fail to respond to standard interventions.”

Pediatricians can advocate for use of evidence-based accommodations and services in schools. When doing so, they should consider issues of equity, school resources and staffing. This requires conversation with schools about realistic implementation of accommodations and services. Examples include:

• Use of a daily behavior report card and/or communication log between parents and teachers for younger children.
• Training of organizational skills, executive functions skills and emotional self-regulation skills as part of a 504-disability accommodation plan or IEP where appropriate; especially for children with comorbid developmental disabilities including autism spectrum disorder, language disorders and learning and intellectual disabilities.
• Use of a rewards-based and non-punitive approach that reinforces use of positive skills such as a token economy system.
• Advocating for a classroom functional behavior assessment (FBA) when a child shows a pattern of disruptive behaviors (i.e., aggression, property destruction, elopement) in the school environment to better understand the purpose of a child’s maladaptive behavior. Invite the development of a behavior intervention plan (BIP) to change the behavior.
• Working with schools to identify evidence-based behavioral services in the community that deliver behavioral parent training (i.e., PCIT, Triple P, MATCH-ADTC, etc.)

Pediatricians may have many local and state opportunities to serve as knowledgeable, thoughtful advocates for improved community and educational services for children with ADHD. Pediatricians who select this role need to be aware of the structure of services in the community and the key persons who implement them.

Examples of advocacy roles for pediatricians include:

• Participation in the local or state early intervention interagency council.
• Consulting with the local school system or state department of education.
• Becoming a school board member.
• Supporting school health services staff, such as a school nurse, who are working to bring awareness and education about ADHD to staff and parents and families.
• Advocating at the state level for development and funding of evidence-based behavioral health treatments at schools and in the community.

Helpful Resources:

AAP Caring for Children with ADHD: A Practical Resource Toolkit for Clinicians, 3 rd Edition
These tools are intended to assist clinicians prepare for a patient with ADHD: readying staff, screening, diagnosis, treatment, ongoing follow-up and negotiating insurance payments.

AAP School-aged Children Who Are Not Progressing Academically: Considerations for Pediatricians
This clinical report reviews commonly available options for psychological evaluation and/or treatment, medical referrals, and/or recommendations for referral for eligibility determinations at school and reviews strategies for collaborating with families, schools, and specialists to best serve children and families.

AAP Clinical Report: The Individuals with Disabilities Education Act (IDEA) for Children with Special Educational Needs
This clinical report reviews key components of the Individuals with Disabilities Education Act for the pediatric primary health care provider.

Resources for Schools:

CDC ADHD in the Classroom: Helping Children Succeed in School
This article reviews classroom strategies for students with ADHD and the role of Special Education Services and accommodations.

XQ Effective Teacher Resources and Strategies for ADHD
This webpage details a variety of strategies teachers can take into the classroom when they have students with ADHD in the classroom.

Resources for Parents & Families:

HealthyChildren.org Diagnosing ADHD in Children: Guidelines & Information for Parents
This page provides information on guidelines pediatricians use to diagnose ADHD.

CDC ADHD and School Challenges
This article is for parents who want to help their child adjust with school changes. It provides tips and resources on how to work with schools to set up the best environment.

Child Mind Institute: School Success Kit for Kids With ADHD
This article provides suggestions for tools and strategies to help kids with ADHD get set for success.

Understood.org
Organization that strives to help those who learn and think differently discover their potential through a variety of resources including a content library, podcasts, and how to spot signs in kids.