TREATMENT OF ADHD IN SCHOOL SETTINGS
Linda Pfiffner, George J. DuPaul, and Russell Barkley
Over the past decade, the quantity of information about ADHD and schoolbased interventions has proliferated. A number of efforts sponsored by the US Department of Education have resulted in readily available written documents about recommended school-based interventions for meeting the needs of students with ADHD (see OSEP 2004). Major education journals and professional education associations have focused on ADHD and numerous texts have been written on the subject. A greater number of students with ADHD are being served by special education programs or through 504 accommodations in general education classrooms (Forness and Kavale 2001). Because the 1991 memorandum from the US Department of Education stipulating that ADHD/ADD may be a qualifying condition under Part B of the Other Health Impaired category, the number of students with ADHD receiving services through this mechanism increased dramatically (Forness and Kavale 2001). Clearly, awareness and identification of ADHD is ever-increasing in school districts across the country.
There remains, however, a pressing need to further develop school-based interventions and provide adequate training and resources to teachers. Several large scale studies over the past decade, however, have made clear some of the limitations of behavioral interventions. The largest single study of medication and psychosocial treatment effects for ADHD youth, referred to as the MTA study is described more fully in a later chapter, along with other combined treatment programs. Pertinent to this discussion on school-based intervention, the psychosocial treatment in that study included a package of school-based interventions received by all children in the psychosocial treatment arms along with intensive parent management training for the parents. The school interventions included an 8-week summer treatment program (described under model interventions below), 3 months of behavioral intervention in the classroom by a paraprofessional (described under model interventions below), followed by teacher –administered behavioral interventions in the classroom for the remaining 5 months of the school year. Some improvement in ADHD/ODD symptom severity occurred for those receiving this package of interventions without medication, but it was not different from the treatment-as-usual control group and was significantly less than that achieved with medication only, with the caveat that those with a comorbid anxiety disorder responded equally well to medication and psychosocial treatment (Jensen 2002). The behavioral intervention added benefit to medication in specific areas of impairment (e.g., teacher-rated social skills, academics, parent-child relationships) (Jensen, Hinshaw et al. 2001) and the best outcomes overall were achieved among the children receiving both behavioral interventions and medication (Conners, Epstein et al. 2001; Swanson, Kraemer et al. 2001). Still, the lack of greater impact of the intensive behavioral intervention in the absence of medication and on ADHD/ODD symptoms generally was unexpected and could be due to a number of factors with two of these being the well-known lack of generalization and maintenance of gains when behavioral treatments are withdrawn. Pertinent to this point, posttreatment measures were gathered at two points after the behavioral intervention had been faded and was no longer being used at its highest intensity while medication was still being used at its most effective dose. A recent study examining school-based intervention and parent training for young children at-risk for disruptive behavior disorders, also found that initial treatment effects were not maintained and did not generalize to new classrooms two years after the treatment was terminated (Shelton, Barkley et al. 2000).
These results and those from other combined treatment studies have led some to...