This literature review examines the academic challenges faced by children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and evaluates evidence-based interventions designed to improve their school performance. Beginning with prevalence data and DSM-V diagnostic criteria, the paper explores family dysfunction as a contributing factor to poor academic achievement, drawing on genetic and behavioral research. It then reviews several psychosocial intervention programs—including the Homework Success Program, the Family-School Success program, and the Partnering to Achieve School Success program—analyzing the roles of parents, teachers, and primary care providers. The review concludes that multimodal, collaborative interventions involving families, schools, and healthcare providers yield the best academic outcomes for children with ADHD.
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, disorganization, avoidance of mentally challenging tasks, distractibility, and forgetfulness. Hyperactivity/impulsivity symptoms include fidgeting, inappropriate physical activity, excessive talking, interrupting others, and an inability to play quietly. Children suffering from ADHD therefore have a difficult time succeeding academically.
If ADHD were rare, this would not be a significant problem; however, 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 in 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 is presented here. Particular attention is 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.
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 called for symptoms to be apparent by the age of 6, but this cutoff has been moved to age 12. The symptoms must 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 preschool children. Should behavioral therapy fail to produce significant improvements, medications can be considered; however, as of 2012 the use of medications in young children had 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 about drug diversion; if diversion is suspected, drugs with little or no risk of abuse should be prescribed.
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, children with reading difficulties plus ADHD, and healthy controls; however, the only diagnosis linked to family dysfunction was a diagnosis of ADHD. The authors hypothesized that family dysfunction would be a good predictor of a childhood ADHD diagnosis and that the strength of prediction would be increased for a child suffering from ADHD alongside 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 versus 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 Thapar 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.
"HSP, FSS, and CARE program outcomes and comparisons"
"Teacher buy-in and primary care provider roles in treatment"
"Synthesis of psychosocial interventions and remaining challenges"
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