Psychosocial Academic Interventions for Children With ADHD

Academic Outcomes of Children With ADHD

ADHD Literature Review

Improving the Academic Outcomes of Children with Attention Deficit Hyperactivity Disorder

Improving the Academic Outcomes of Children with Attention Deficit Hyperactivity Disorder

According to the U.S. Centers for Disease Control and Prevention (CDC) (2014) Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition recognizable by attention deficits, hyperactivity, and impulsivity that manifest across multiple settings. The most recent version of the Diagnostic and Statistical Manual (DSM-V) describes ADHD as consisting of inattention, and/or hyperactivity/impulsivity, severe enough to interfere with day-to-day functioning and development. Common symptoms of inattention include poor listening skills, frequent mistakes, disorganized, avoidance of mentally challenging tasks, distracted, and forgetful. Hyperactivity/impulsivity symptoms include fidgeting, inappropriate physical activity, excessive talking, interrupting others, and an inability to play quietly. Children suffering from ADHD would therefore have a difficult time succeeding academically.

If ADHD were rare this would not be a significant problem, but the most recent statistics reveal that close to 11% of children between the ages of 4 and 17 were diagnosed with ADHD in 2011 (CDC, 2013). This is up from almost 8% in 2003. Among this age group, the number of children taking medications to treat ADHD increased from 4.8 to 6.1% between 2007 and 2011; however, nearly 18% of children suffering from ADHD are not receiving any form of treatment. These figures suggest that over 10% of children populating a classroom suffer from clinical ADHD and nearly 20% of these remain untreated. It naturally follows that ensuring ADHD is adequately treated, using evidence-based interventions, would optimize classroom outcomes for all children.

To better understand the impact ADHD has on academic achievement and how researchers, clinicians, and educators are addressing this issue, a review of the research literature will be conducted. Particular attention will be paid to family-school interventions designed to bring the expertise of multiple professions to bear on academic performance issues. This focus implies that psychosocial interventions may produce the best academic outcomes when compared to standard or no treatment.

ADHD in the Classroom

ADHD Diagnosis and Treatment

Parents and primary care physicians are advised to evaluate any child between the ages of 4 and 18 for ADHD if academic, attention, or hyperactivity/impulsivity problems persist across settings (Hauk, 2013). A total of six symptoms must be present for any child under the age of 17, but only five for any individual 17-years of age and older (CDC, 2014). Past recommendations were for symptoms to be apparent by the age of 6, but this cutoff has been moved to age 12. The symptoms have to be apparent in at least two different settings, persist for at least six months, and be unrelated to other psychiatric or medical conditions. Ideally, a diagnosis should be based on discussions with at least two teachers and at least one other person, preferably a mental health professional. Evidence-based guidelines have been published to help teachers, school nurses, and school psychologists make appropriate decisions when confronted with a child struggling with behavioral or academic problems (Dang, Warrington, Tung, Baker, & Pan, 2007). These guidelines are intended to improve early identification and treatment of children with ADHD.

The Chronic Care and Medical Home models are the recommended healthcare approaches for treating ADHD (Hauk, 2013). Behavioral therapy is the preferred treatment choice for all children and is the only first-line treatment administered to pre-school children. Should behavioral therapy fail to produce significant improvements then medications can be considered; however, as of 2012 the use of medications in young children has not been studied extensively. Stimulants are the preferred class of drugs to treat ADHD. Other drugs have been used to treat ADHD in children, but the scientific evidence supporting their use is not as strong. When treating adolescents, there is some concern of drug diversion; however, if diversion is suspected then drugs with little or no risk of abuse should be prescribed.

Family Factors

An investigation into the association between family dysfunction and children with ADHD found strong and consistent evidence to support this link (Kaplan, Crawford, Fisher, & Dewey, 1998). The control conditions were children with reading difficulties, reading difficulties plus ADHD, and healthy controls, but the only diagnosis linked to family dysfunction was a diagnosis of ADHD. The authors of this study hypothesized that family dysfunction would be a good predictor of a childhood ADHD diagnosis and the strength of prediction would be increased for a child suffering from ADHD and other neurodevelopmental disorders. The data did not support this hypothesis; therefore, the direction of causality could not be deduced. The family dysfunction problems associated with child ADHD were difficulty making decisions, lack of intimacy, and ill will toward family members.

The study by Kaplan and colleagues (1998) was designed to discriminate between family dysfunction contributions to ADHD vs. ADHD contributions to family dysfunction, but ongoing research into the genetics of ADHD has rendered this research question partially moot. What was important about their findings, given recent evidence that ADHD has a heritable component (Thapar, Cooper, Eyre, & Langley, 2013), is that ADHD comorbidity has little impact on the magnitude of family dysfunction. The strong correlation between ADHD and family dysfunction, independent of comorbid conditions, is consistent with the possibility that the same genetic factors help determine both outcomes. Current evidence suggests that the genetic determinants of ADHD prevalence impact the dopaminergic and serotonergic neurotransmitter systems.

As Thayer and colleagues (2013) note, however, the effect size of the genetic contribution is small and insufficiently robust to be used as a diagnostic tool. This lack of diagnostic utility is due in part to overlap with other psychiatric disorders, primarily autism spectrum disorders. Despite this limitation, the genetic findings, together with the findings of Kaplan and colleagues (1998), imply that family factors may play a significant role in determining the academic outcomes of children with ADHD; therefore, any intervention designed to improve the academic performance of these children would benefit significantly by including family members in the treatment plan.

Family-School Interventions

Children with ADHD are therefore confronted not only with their own behavioral and attention problems, but also by family problems that make it difficult to have frank and honest discussions about improving academic performance. To address the family factors contributing to poor academic achievement an intervention program was developed: the Homework Success Program (HSP) (Habboushe et al., 2001). The main focus of this seven-session, 10-week group intervention, is the training of parents to help them work effectively with teachers and to manage ADHD behavioral problems. Parents and teachers therefore enter into a collaborative arrangement designed to improve academic performance through completion of homework assignments. Children with ADHD also participate in a group of their own, where they learn the behavioral strategies introduced to the parents.

Habboushe and colleagues (2001) evaluated a case series of children with ADHD and their parents before and after exposure to the HSP intervention. Homework problems, parent-child conflict behaviors, and parental stress were all noticeably reduced in some cases. Homework completion rates stayed the same or improved, but homework accuracy increased by more than 50% in one case. While these results are encouraging, DuPaul and Power (2008) caution that teacher and parent adherence to a collaborative intervention can be highly variable. One solution to poor teacher buy-in is to engage parents first in the intervention (Raggi, Chronis-Tuscano, Fishbein, & Groomes, 2009). Accordingly, the first sessions of a family-school ADHD intervention included only the counselor and parents. The goal of these first sessions was to teach parents how to use behavioral strategies to address homework issues and develop homework management, goal-setting, contingency contracting, and parent-teacher consultation skills. By the third session teachers were included, for the purpose of educating teachers about the intervention and their respective roles. Of the 17 participants in the study the majority experienced reductions in homework and behavioral problems; however, the findings were undermined by the lack of statistical analysis.

The shortcomings associated with earlier studies investigating the efficacy of family-school interventions for children with ADHD was addressed in a recent randomized, controlled trial (Power et al., 2012). Two interventions were compared, the Family-School Success (FSS) and Coping with ADHD through Relationships and Education (CARE) programs. The FFS program focuses on improving academic performance and behavioral problems at home and school. Parent and teacher partnerships are fostered during the 12-sessions, by helping participants engage in problem identification and analysis, academic studies planning, and implementation and evaluation of the study plan. Parents and teachers developed a plan for daily report cards and how they would address specific homework problems. Children attended half of the family and parent-teacher sessions, in addition to child-only sessions at other times. Parents enrolled in the CARE program attended group sessions separately from child group sessions, but teachers were not involved in collaborative efforts with the parents. The focus of the CARE program was parent and child education, coping skills, and support.

A total of 199 children and families were enrolled in the trial and randomization distributed participants equally between the FSS and CARE programs (Power et al., 2012). Comparison of the demographic data, including socioeconomic status and race, revealed no significant difference between groups on any measure. At the end of the study period a total of 77 and 87 families in the FSS and CARE programs, respectively, had completed the study. A similar number of teachers were also enrolled in the trial. The outcome variables evaluated included intervention acceptability, homework performance, family investment, quality of parent-child interactions, ADHD symptomology, and academic performance. FSS was rated more acceptable than CARE by parents, but children and teachers rated both programs highly acceptable. Immediately post-intervention, parent as educator and parent-teacher interactions were significantly better for the FSS group, but after a three-month follow-up period only the parent-teacher interaction remained significantly different between groups. The FSS intervention was also associated with significantly better homework productivity and adherence, and lower inattention/avoidance at post-intervention, but any advantage FSS conferred to productivity and adherence was lost by the end of the follow-up period; however, inattention and avoidance remained significantly different between the groups by the end of the follow-up period, but the magnitude of the difference was diminished. The only other outcome measure that benefited from the FSS intervention was parent ratings of negative/ineffective discipline, a benefit that persisted into the follow-up period. Although academic performance was not significantly different between the two groups, it appeared to be trending towards significance (post-intervention, p = .0625; follow-up period, p = .0981).

The findings of Power and colleagues (2012) support the acceptance, feasibility, and academic advantages of the FSS program, when compared to the CARE program. What stands out about this study is the size of the sample, which allowed a research strategy that incorporated randomization to the two intervention groups. The main difference between the two interventions is the teacher-parent collaboration component of the FSS program, which improved parent as educator, homework productivity/compliance, and discipline outcomes; however, ADHD and oppositional-defiant disorder symptomology were equivalent between the two groups.

Teacher Investment

Teacher buy-in for ADHD interventions was formally investigated by Power and colleagues (2009). Approximately half the study participants were enrolled in the FSS intervention and the other half of the study participants were enrolled in the CARE program, with the latter acting as the control condition. Contrary to expectations, the primary predictor of teacher investment into ADHD academic interventions was collaboration prior to the intervention. In addition, family and school adversity, or the severity of attention and behavior problems exhibited by the child, did not have s significant impact on teacher investment. This finding suggests that teacher and school-organizational factors help determine the success of parent-teacher collaborations within an ADHD academic intervention.

Primary Care Investment

In inner-city neighborhoods, access to mental health services can be problematic, especially for minority, low-income families (reviewed by Power et al., 2010). For many families caring for a child with ADHD the primary care provider is often the only medical service utilized. Since effective treatment of ADHD depends on a multimodal approach, including primary care providers, Power and colleagues (2010) investigated the role that these medical professionals play in facilitating treatment initiation and adherence. The intervention of interest was the Partnering to Achieve School Success (PASS) program, which is primarily based in the primary care setting. Sessions are held in the clinic and schools, where family members are exposed to strategies designed to promote engagement in treatment and collaborative efforts between the school and primary care provider. The goals are to improve academic performance, educate families about ADHD, engage in behavioral therapy, manage medications effectively, and provide a resource for crisis management.

A total of 66 children diagnosed with ADHD and their families were enrolled in the PASS program (Power et al., 2010). The majority of children enrolled were African-Americans (89%) and most were on Medicaid (68%). During initial contact efforts by primary care clinicians, about 82% of families could be contacted by phone. Of these, nearly 90% agreed to schedule the first intake session and 90% attended. Overall, only 65% ever attended an initial intake session. The authors of this study further analyzed the data and found successful family contact by clinicians predicted an increased chance of family attendance at the first intake session (odds ratio [OR] = 49.0). By comparison, the chances of attending the first PASS session was increased to a lesser extend (OR = 4.3) when family members initiated contact with primary care clinicians. The amount of time spent on the phone discussing and scheduling the PASS program also predicted attendance, with 82% of families spending at least 10 minutes on the phone talking to clinicians attended the first session. By comparison, only 18% of families attended if the phone conversations with clinicians lasted less than 10 minutes.

The findings of this study (Power et al., 2010) revealed that in addition to teacher investment, primary care clinician investment is also important for successful initiation of a multimodal treatment strategy addressing the needs of families caring for a child with ADHD. The feasibility and effectiveness of implementing the PASS program in an inner-city primary care clinic was recently investigated (Power et al., 2014). Preliminary findings suggest that collaborations between schools, primary care clinicians, and families are important and feasible for effective ADHD treatment, although some barriers persist.