Reconceptualizing the approach to supporting students with Attention-Deficit/Hyperactivity Disorder in school settings

Abstract

The long-term academic outcomes for many students with attention-deficit/hyperactivity disorder (ADHD) are strikingly poor. It has been decades since students with ADHD were specifically recognized as eligible for special education through the Other Health Impaired category under the Education for all Handicapped Children Act of 1975, and similarly, eligible for academic accommodations through Section 504 of the 1973 Rehabilitation Act. It is time to acknowledge that these school-policies have been insufficient for supporting the academic, social, and behavioral outcomes for students with ADHD. Numerous reasons for the unsuccessful outcomes include a lack of evidence-based interventions embedded into school approaches, minimizing the importance of the general education setting for promoting effective behavioral supports, and an over-reliance on assessment and classification at the expense of intervention. Contemporary behavioral support approaches in schools are situated in multi-tiered systems of support (MTSS); within this article we argue that forward-looking school policies should situate ADHD screening, intervention, and maintenance of interventions within MTSS in general education settings and reserve special education eligibility solely for students who require more intensive intervention. An initial model of intervention is presented for addressing ADHD within schools in a manner that should provide stronger interventions, more quickly, and therefore more effectively.

Children with attention-deficit/hyperactivity disorder (ADHD) often experience serious difficulties in the areas of school functioning and academic achievement (Kent et al., 2011; Raggi & Chronis, 2006). For instance, children with ADHD identified in early childhood exhibit long-standing and consistent deficits in academic achievement relative to children without ADHD (Massetti et al., 2008; Rapport et al., 1999). Additionally, children with ADHD are likely to exhibit behavioral difficulties in the classroom that inhibit learning (Daley & Birchwood, 2010; DuPaul & Stoner, 2014; Fabiano et al., 2006; Friedman & Pfiffner, 2020; Loe & Feldman, 2007; Raggi & Chronis, 2006; Rapport et al., 2001). Due to these difficulties in learning and behavior, the long-term school outcomes for children with ADHD are often, although not universally, poor compared to classmates without ADHD (Altszuler et al., 2016; Arnold et al., 2020; DuPaul et al., 2019; Kent et al., 2011; Kuriyan et al., 2013; Molina et al., 2009; Pelham et al., 2020; Van Meter et al., 2023). High school students with ADHD have significantly lower grades, higher rates of failing classes, and are more likely to drop out of school than students without ADHD (Fried et al., 2018; Gordon & Fabiano, 2019; Kent et al., 2011). Thus, children with ADHD typically need sizable investments in school accommodations and interventions to offset these potential negative outcomes (Chhibber et al., 2021; Pelham et al., 2007).

Relative to other groups with school challenges, children and adolescents with ADHD make up one of the largest groups of students in need of school-based support and remediation. Current prevalence estimates of ADHD indicate that approximately 1–2 students per classroom meet ADHD diagnostic criteria (American Psychiatric Association [APA], 2022; Danielson et al., 2018; Fabiano et al., 2013). The prevalence rates of ADHD are approximately three times that of autism spectrum disorders (Kogan et al., 2018). Notably, ADHD is a chronic disorder (DuPaul et al., 2020) that is present from early in development and persists through adolescence into young adulthood. The annual societal cost of ADHD was beyond $40 billion annually in 2007 dollars (Pelham et al., 2007; adjusting for inflation it is close to $60 billion in 2024) making this a consequential condition of which many of the costs are related to the educational setting (Schein et al., 2022). Individuals with ADHD have greater financial dependence in adulthood and lower lifetime earnings (Altszuler et al., 2016; Pelham et al., 2020), both of which are directly impacted by school failure and challenges. At the typical age of retirement, individuals with ADHD are estimated to have 75% lower net worth than comparable individuals without ADHD, posing a potential burden for extended family (e.g., siblings) and governmental supports (Pelham et al., 2020). Likely due to a collection of risk factors, ADHD results in a significantly shorter life expectancy, rivaling the reductions in life expectancy due to smoking, excessive alcohol use, or heart disease (Barkley & Fischer, 2019). These issues make addressing ADHD an area in need of continuous and contemporary support, particularly during development within school settings (Bitsko et al., 2022), to prevent the worsening and life-long issues that individuals with ADHD may confront throughout the lifespan. The present article focuses on supports and interventions for students in elementary school as that is where initial identification and intervention typically occurs in educational settings (Visser et al., 2014), although many identification and intervention points may be appropriate for older grade levels as well.

History of Formal School Supports for ADHD

Before looking ahead, it is useful to look back at the development of formal approaches used within public schools in the United States to help support the learning and social behavior of children with ADHD. This helps to elucidate some of the sources of friction and inadequacy within the current approaches to helping individuals with ADHD in educational settings. It is first important to note that ADHD is not a condition limited to contemporary students; symptoms of inattention and hyperactivity/impulsivity consistent with ADHD were observed and reported in educational settings as early as the 1800s (Thome & Jacobs, 2004). Throughout the 1900s, clinical observations of children with excessive motor behavior and impulse control problems persisted (see Lange et al., 2010). With the advent of the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 1952), a label was affixed to this constellation of overactive, impulsive, and inattentive behaviors that caused consistent impairment within educational settings. Labels ranged from “hyperkinetic reaction of childhood” initially in the 1960s (APA, 1968) to attention-deficit disorder, with or without hyperactivity (APA, 1980). Over time, there was a greater recognition and inclusion of inattention symptoms in subsequent DSM iterations. Starting with the DSM-III-R (APA, 1987), the disorder was labeled attention-deficit/hyperactivity disorder with variations in the ability to denote subtypes across the major symptom domains of inattention, hyperactivity, and impulsivity. Contemporary diagnostic criteria for ADHD emphasize the presence of inattentive and/or hyperactive/impulsive symptom presentations that result in social, academic, and/or occupational impairment (APA, 2022). Thus, behavioral challenges in schools related to inattention/overactivity/impulsivity were around prior the advent of the DSM and they are likely to continue to be present as long as children are educated within typical classroom settings.

Although ADHD is largely defined by impairment in school settings and teacher report is a recommended component of a DSM-5-TR ADHD diagnosis (APA, 2022; Pelham, Fabiano, & Massetti, 2005; Wolraich et al., 2019), school classifications and mental health diagnoses are not always harmonized. Special education supports were formally introduced within schools for students ages 3–21 years in 1975 with the enactment of Public Law 94–142, termed the Education for all Handicapped Children Act of 1975 (EHA). The disability categories initially provided in the EHA were broadly defined and inclusive of students with cognitive impairment, students with physical disabilities, students with deaf or hearing impairments, students with impaired speech or vision, and students with severe emotion dysregulation. An additional category of “other health impaired” allowed for special education supports for students with impairment that did not fit into one of the other specified categories (Public Law 91–230). Within the contemporary iteration of the EHA (i.e., Individuals with Disabilities Education Act [IDEA]), there are 13 special education classifications in educational settings. However, none of the category labels include “ADHD.” Indeed, ADHD was initially only accounted for within special education based on a joint policy memorandum (Davila et al., 1991) written to help school districts interpret special education law; this memorandum stated that the Department of Education explicitly avoided creating a category for ADHD. The memorandum stated:

Last year during the reauthorization of the Education of the Handicapped Act [now the Individuals with Disabilities Education Act], Congress gave serious consideration to including ADD in the definition of “children with disabilities” in the statute. The Department took the position that ADD does not need to be added as a separate disability category in the statutory definition since children with ADD who require special education and related services can meet the eligibility criteria for services under Part B.

Furthermore, this memorandum noted that over 2000 written comments had been received indicating confusion regarding the appropriateness of special education supports and interventions for ADHD given there is no specific category for this condition, which led Davila et al. (1991) to write the policy memorandum to clarify which categories may be appropriate for students with ADHD. Note that in contrast to ADHD, autism was explicitly added as a special education category at this time.

Davila et al.’s (1991) policy memorandum posited that the Other Health Impairment (OHI) category was “not exhaustive” and could include “chronic and acute impairments that result in limited alertness” and therefore ADHD could be included within this classification. The inclusion of ADHD within the OHI category was especially confusing given that all other OHI examples were wholly medical conditions that would interfere with education (e.g., diabetes). It further noted that if a student with ADHD had a comorbid condition, it was possible that the student could be classified as having a Specific Learning Disability or an Emotional Disturbance. The policy document also noted that if a student was not eligible for special education, it was possible that the student would be eligible for accommodations under Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 701). Thus, although the policy memorandum clearly stated that ADHD has a considerable impact on school settings, ADHD remained without a distinct category within special education. Instead, a series of exceptions and explanations are used to shoehorn ADHD into alternative categories or a separate federal law not solely focused on school impairments (i.e., the Rehabilitation Act of 1973). The multiple avenues for classification, including non-classification, also make it extremely difficult for researchers and policymakers to identify and evaluate the impacts of ADHD on school progress. The policy memorandum appears to have had the express aim of avoiding the distinct classification of ADHD as an impairing condition within educational settings; furthermore, it has not been updated or modified in the more than 30 years since it was written.

Students with ADHD are also eligible for school-based accommodations under Section 504 of the Rehabilitation Act of 1973, which supports children with disabilities in general education settings. Section 504 requires that any school district receiving federal funding provide a free appropriate public education (FAPE) to any student in their jurisdiction who has a physical or mental disability that substantially limits a major life activity. Because Section 504 accommodation plans are managed at the level of the school building, the rate at which students with ADHD receive Section 504 accommodation plans is unknown, although estimates suggest that between one-tenth to up to half of all students with ADHD receive supports in the form of a Section 504 Accommodation Plan (Bussing et al., 2012; DuPaul et al., 2019; Murray et al., 2014; Spiel et al., 2014). Holler and Zirkel (2008) surveyed 89,201 public schools to observe the degree to which 504 Plans were used for students in schools and reported that ADHD was by far the most common reason for a Section 504 accommodation plan. Although commonly deployed, Holler and Zirkel’s (2008) study, and other studies (e.g., DuPaul et al., 2019; Safer & Malever, 2000), have not provided information on the content or quality of the Section 504 accommodation plans typically used for children with ADHD. Spiel et al. (2014) reported on contents of Section 504 accommodation plans relative to IEPs for students with ADHD and surprisingly, Section 504 accommodation plans were significantly less likely than IEPs to include behavior support components. To be clear, this suggests that children with ADHD receiving supports through Section 504 accommodation plans (i.e., one of the more common options for students with ADHD) often do not receive behavioral supports (see also Hustus et al., 2020), which are recommended as the first-line intervention for children with ADHD (Barbaresi et al., 2020). The lack of effective supports within IEPs and Section 504 accommodation plans likely leads to frustrations for parents and teachers, who fail to see improvements within the general education setting after the establishment of the plan.

Role of the Primary Care Physician and Mental Health Providers

Current educational policy has several consequences for children and adolescents with ADHD in schools, with a major consequence being a lack of overall cohesion in the efforts to address ADHD in schools. For instance, although typically a child with ADHD exhibits symptoms and impairment in a school setting (Evans et al., 2013; Fabiano et al., 2006), when evaluated separately by multidisciplinary special education eligibility teams, many children with ADHD do not qualify for special education services because they do not fit within one of the special education classification categories or do not evidence sufficient academic underachievement. Moreover, even when they are determined to be eligible for services, the associated accommodations and interventions for students with ADHD in formal Individual Education Programs (IEPs) often under-address social and behavioral impairments that are central to ADHD (Fabiano et al., 2009, 2022). As should already be clear, navigating the complex process of obtaining interventions and supports for a student with ADHD in the classroom can be overwhelming for parents. Thus, when searching for information on how to appropriately advocate for their child, parents of children with ADHD typically seek advisement from their child’s primary care physician (DuPaul et al., 2019).

Although it makes sense to seek guidance from the child’s pediatrician about the child’s behavior, this may not be helpful for specific advice regarding school-based treatment for a child with ADHD. For instance, the American Academy of Pediatrics (AAP) has long recommended a multi-modal approach to treatment, but it was only in the latest iteration of their treatment guidelines (Wolraich, et al., 2019) where they recommended that behavioral interventions at home and at school should be provided as a first-line approach, in combination with medication. However, no information is provided in the AAP about specific interventions or accommodations that should be used. In contrast, the Society for Developmental and Behavioral Pediatrics (Barbaresi et al., 2020) provided physicians and psychologists explicit guidance for classroom interventions to recommend for teachers’ use in classroom settings. These interventions involve establishing foundational classroom supports (e.g., a daily report card) before starting medication for a child. This allows for a 3–4 week trial period in which a classroom behavioral intervention is attempted. Because classroom behavior management approaches often work very quickly – not unlike medication – the parent, teacher, and physician can evaluate how much additional need remains for a medication treatment. Typically, a considerably lower dose of medication can be used if a foundation of effective behavioral support intervention is established (Fabiano et al., 2007; Pelham et al., 2016). Because lower doses of stimulant medication have fewer side effects than higher doses, a multi-modal, behavior therapy first, approach to treatment is both more effective and safer than a medication-first approach (Pelham et al., 2016). Despite the emphasis on behavioral support treatments in these professional guidelines, surveys have indicated that physicians do not consistently recommend effective interventions or possess adequate knowledge about school-based supports provided through special education plans (Bar et al., 2018; Tatlow-Golden et al., 2016). In other words, one of the primary contacts for families (i.e., their child’s physician) may be ill-equipped to effectively support families whose children with ADHD are struggling in school.

These challenges in outside support for children with ADHD in schools extend to outside mental health providers such as psychologists and social workers. Due to insurance billing rules, it is difficult for providers to receive reimbursement for consulting with teachers and establishing school-based positive behavior supports, and even when they are reimbursed for these services, it often is not at the rate that would be obtained for using that professional time on office-based counseling. Relying on an indirect approach where the mental health provider is consulting with the parent to interface with the school and advocate or establish interventions or accommodations may also result in inefficiencies or inaccuracies.

Current Limitations of Contemporary Approaches for Supporting ADHD in Schools

There are multiple ways that the current school-based approaches for supporting children and adolescents with ADHD, both formal and informal, are ill-suited for making a meaningful difference in the school experience and outcomes for affected students. Although concerns about special education are not new or unique to ADHD (see Heward, 2003), and given the sheer number of students with ADHD is estimated to be 1–2 students per classroom on average (APA, 2022; Fabiano et al., 2013), it is an area worthy of additional consideration. Below, we describe some of the limitations of current practice followed by a discussion of forward-looking solutions.

Inconsistencies in Support of ADHD within School Policy and Settings

Federal law on special education allows latitude among states to provide additional guidance for local educational agencies. This results in some states providing specific guidance on procedures for identifying and managing ADHD, whereas others do not provide additional guidance, thus yielding inconsistencies across states in both identification rates and procedures (Briesch et al., 2023). The lack of effective supports within IEPs and Section 504 plans also may be due to a general lack of guidance on appropriate accommodations within the classroom or testing setting. Although accommodation, intervention, and modification are often used interchangeably, efforts have been made to differentiate accommodations by defining them as “changes to practices within schools that hold students to the same standard (e.g., grade level performance), but provide a differential boost” (e.g., additional reading practice; Harrison et al., 2013, p. 556). Accommodations are typically provided through a Section 504 accommodation plan or an IEP, but there is little in the way of guidance on the appropriate accommodation for specific contexts.

Because the most common placement for a child with ADHD is within a general education classroom regardless of the presence of a formal support plan or special education eligibility (Schnoes et al., 2006), it is important to underscore that accommodations and behavioral supports typically fall under the oversight of the general education teacher (Spiel et al., 2014). Recent emphases on multi-tiered systems of support (MTSS) may attempt to remediate ADHD impairments prior to referrals to the school’s special education multidisciplinary eligibility team (Fabiano & Pyle, 2019); yet, the MTSS process is often separate from formal referral processes, resulting in misalignment in the necessary interventions that work for ADHD and the expectations that general education teachers can implement them. There is evidence that general education teachers have insufficient training for using the multiple tiers and interpreting the progress monitoring assessments (Vujnovic et al., 2014).

Furthermore, evidence-based treatments for ADHD include behavioral supports (e.g., contingency management; Evans et al., 2014, 2018; Pelham & Fabiano, 2008; Pelham et al., 1998; Pfiffner & DuPaul, 2015), stimulant medication (Connors, 2002), and combined treatment (Pelham & Altszuler, 2020). However, general education teachers have consistently noted that they are provided insufficient training specifically in supportive management of a student with ADHD using these approaches (Fabiano et al., 2013; Schatz et al., 2021), which may explain why up to two-thirds of students with ADHD receive no behavioral classroom management intervention (DuPaul et al., 2019). Possibly due to this lack of precision/fidelity/consistency within the implementation of policy, more than 10% of complaints to the Office of Civil Rights consist of “allegations of discrimination against a student with ADHD” (pp. 2; U.S. Department of Education, Office of Civil Rights, 2016). Indeed, as schools struggle with a lack of guidance for the effective support of children with ADHD, they may turn to informal school interventions that are not evidence-based or supportive, such as being sent home for the day or assigned a longer suspension due to disruptive behavior (Kolodner & Ma, 2022), exacerbating the student’s disenfranchisement from the classroom.

As outlined above, ADHD has never been addressed as a distinct special education category that is under the purview of the school. Rather, it has been relegated by the educational system as an outside of the school system diagnosis that may result in accommodations or eligibility for special education services under OHI, even though (a) the school setting is one of the primary locations where ADHD impairments are evident and need to be addressed (DuPaul et al., 2019; Fabiano et al., 2006), (b) teachers play a central role in the identification and diagnosis of ADHD (DuPaul et al., 2019), and (c) treatments need to occur in the classroom setting and targeting academic outcomes to address ADHD impairments in schools (Fabiano et al., 2021). Perhaps due to the disjointed approach to addressing ADHD in school settings, there are multiple ways that school policies and procedures are misaligned with the needs of students with ADHD, and this may result in delays in treatment implementation as well as diffusion of responsibilities.

False Dichotomy of General vs. Special Education

ADHD is predominantly addressed within general education settings in schools as even students with an IEP spend most of their day in general education classrooms (Schnoes et al., 2006). Indeed, there is a consistent finding that children with ADHD in general education settings and children with ADHD in special education settings are not reliably distinguishable other than on measures of academic achievement (Fabiano et al., 2022; Mattison, 2015). Thus, classifying a student with ADHD as needing special education may not appreciably change the everyday experience of that child in the classroom setting or the main educators responsible for teaching the child throughout the school day. Furthermore, eligibility for special education services may only increase the probability that the student receives ineffective, related services, many of them used for children with ADHD but without validity as an ADHD-specific intervention (Macphee et al., 2019; Tzang et al., 2019). Indeed, related services such as speech therapy, occupational therapy, physical therapy, and counseling may all be helpful for supporting any child’s needs in speech and language, gross and fine motor skills, or emotional functioning, respectively, but none directly address the core deficits and areas in need of growth for children and adolescents with ADHD.

Highlighting this issue is that in clinical practice it is often the case that parents are unaware of the specific special education category for the child’s classification in special education. Instead, they often say that the child is in special education for “ADHD.” Again, there is a disconnect between the typical precipitants for special education classification and the labeling of the school impairments and the supports provided. Researchers are also confronted with this problem as children with ADHD are distributed across multiple special education categories (Fabiano et al., 2010; Schnoes et al., 2006) or they are forced to collapse varied school supports and interventions into a combined category that may reduce precision of reporting and study of effective school intervention (e.g., Danielson, et al., 2018; DuPaul et al., 2019). The false dichotomy of special versus general education creates a situation where the parent and educators are aware of the school concerns related to ADHD, spend considerable time and resources conducting initial evaluations, and yet, regardless of the conclusion of the evaluation, the student will most likely continue to spend most time in the classroom where the referral originated (Schnoes et al., 2006). Thus, after all the effort, the parent and teacher are left with the same question at the end of the process with which they started at the beginning: This child is experiencing classroom impairment and what can be done to reduce it?

Over-emphasis on Symptoms on ADHD and Insufficient Emphasis on Functional Impairment

Various academic accommodations in school settings focus on addressing and reducing ADHD symptoms related to inattention or hyperactivity, whereas fewer focus on the areas of impairment that are the primary concern of parents and teachers. These include peer and adult relationships, academic progress and achievement, and social functioning within the whole class setting. Controlled evaluations of symptom-based accommodations have yielded results that question the validity of these approaches. For instance, fidget spinners, which are provided as a tool to replace unspecified, excessive fidgeting with a specified, narrow fidgeting behavior, have shown no positive impact on classroom functioning (Graziano et al., 2020). Macphee et al. (2019) reported no positive results on overall student functioning in a study that investigated the efficacy of weighted vests or yoga balls as an accommodation to help students manage restless and fidgety behavior.

Putting aside the available evidence that these various approaches are ineffective, educators must reflect on what they are really trying to accomplish with these approaches. Most parents and teachers would readily offer several goals for the student in school, and “sitting still, in a chair, facing forward” is unlikely to be high on the list of these goals. Rather, learning new class material and applying it in daily life, developing positive relationships with adults and peers, and learning how to be a positive contributor to a larger community are the main goals for successful progression in school. Focusing on behaviors peripheral to these larger goals, such as fidgeting, dedicates time and resources to interventions unlikely to result in meaningful long-term outcomes that are important for the child. Another example of misaligned interventions to address a target behavior in school would be the provision of extra time on tests or assignments for a student with ADHD; if a student is already having difficulty attending during the standard time provided it is difficult to understand how providing even more time would promote positive outcomes. It is concerning that provision of extra time is one of the most common accommodations provided (Fabiano et al., 2022; Hustus et al., 2020; Murray et al., 2014; Spiel et al., 2014) given its misalignment with underlying ADHD impairment related to persisting with tasks and sustaining mental effort as well as lack of empirical support (Pariseau et al., 2010).

These issues are consistent with the considerable efforts that have been directed toward identifying ADHD using symptom-based checklists (e.g., Pelham, Fabiano, & Massetti, 2005; Wolraich et al., 2019). Relatively less attention has been focused on the other aspects of ADHD diagnosis – namely whether these symptoms cause impairment in daily life functioning. Although accommodations have a long-standing history of implementation, research has yet to provide information regarding the efficacy of specific accommodations for students with ADHD (Graziano et al., 2020; Macphee et al., 2019) or the efficacy when used in combination with other approaches; additionally, these approaches also do not appear to remediate future psychiatric concerns (Tzang et al., 2019). Reviews of accommodation effectiveness suggest there are only a few that are efficacious for children with ADHD (Harrison et al., 2013, 2019; Lovett & Nelson, 2021), perhaps because of the disconnect between the hypothesized mechanism of action for academic accommodations (i.e., reduction in symptoms of ADHD) instead of a focus on reducing the areas of impaired functioning and building of needed skills.

Out-Sourcing of Responsibility

There are multiple ways responsibility for supporting children with ADHD are delegated to those outside of the school system. Take, for example, the consideration of formal school supports through a Section 504 accommodation plan or through an IEP based on special education eligibility within the OHI category. In both cases, the precipitating reason for identification of the student to receive these supports is a diagnosis of ADHD, something that is not universally assigned by a school psychologist using current evidence-based diagnostic procedures (e.g., Handler & DuPaul, 2005). Although an ADHD diagnosis is not required to receive special education supports or accommodations through a Section 504 accommodation plan (U.S. Department of Education, Office of Special Education and Rehabilitative Services, 2016), many districts have implicitly provided formal supports only with the presence of an outside provider’s diagnosis of ADHD (e.g., Briesch et al., 2023). In these cases, the family would need access to a medical or mental health professional to obtain a diagnosis, and the school would need to provide access to this outside professional and justify why an outside evaluation is necessary. This is different from other special education categories present in school where a school psychologist and the multi-disciplinary team could conduct comprehensive assessments to assign a particular category immediately, such as a specific learning disability or autism. Although ADHD is a prominent issue in schools and teachers are a key informant in diagnostic decision-making (Wolraich et al., 2019), evaluations to identify ADHD frequently are delegated to individuals outside the school setting (e.g., physicians, psychologists; APA, 2022; Children and Adults with ADHD, 2023). As mentioned above, physicians may be ill-prepared to provide recommendations for school-based behavioral interventions or accommodations, and instead, often provide narrow information on treatment options to the families related to pharmacological approaches (Epstein et al., 2014; Wolraich et al., 2019).

Stimulant medication is the most common ADHD treatment (Caye et al., 2019; Danielson et al., 2018). Decades of primary research, multiple systematic reviews, and meta-analyses have indicated that there are positive, acute effects of ADHD stimulant medication treatment on classroom rule-following behavior and academic productivity and that these medications are generally well-tolerated in children (Connors, 2002; Wolraich et al., 2019). However, whereas the evidence for the benefits of medication on improving classroom behavior and academic productivity are clear, there is strikingly little evidence that medication improves learning and subsequent academic achievement (Froelich et al., 2018; MTA Cooperative Group, 1999; Pelham & Altszuler, 2020; Pelham et al., 2020, 2022). This confusion spills over into educational guidelines.

As a relevant, historical example, the U.S. Department of Education (2008) released a publication for teachers entitled Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home that substantively emphasized the use of medication as a treatment for ADHD. The publication stated in a call-out box that “Behavioral strategies are used most commonly when parents do not want to give their child medication”, “Behavioral strategies can be used in conjunction with medicine”, and “Behavioral strategies may be the only options if the child has an adverse reaction to medication” (pp. 9–10). Although subsequent publications (e.g., U.S. Department of Education, 2016) softened these recommendations by including a specific note that the ameliorative impact of medication should not influence whether a student with ADHD has an impairing disability in school, the prior publication (i.e., U.S. Department of Education, 2008) belies a historical outsourcing of responsibility to medical professionals to treat impairment related to ADHD within the school setting. Indeed, there is even a potential for a conflict of interest in educational settings related to ADHD identification and special education placements as states with financial special education incentives that promote identification of ADHD have more children diagnosed with ADHD and on medication for ADHD relative to states without these incentives (Morrill, 2018).

Promotes Disenfranchisement from School

Many of the approaches to formal support of children and adolescents with ADHD in educational settings may promulgate power differentials within schools. It is challenging for a lay person unaccustomed to terms such as IEP, OHI, or Section 504 plan to negotiate within jargon-filled conversations (Rossetti et al., 2021). Lost within timelines for initial evaluations or diagnostic requirements are discussions about practical ways to support the student’s success. Furthermore, although they are invited to meetings and can participate in intervention planning, parents may be under-utilized or have their concerns left unaddressed in the IEP development process (Kurth et al., 2019, 2020). Moreover, schools may struggle to mitigate this lack of engagement as there is not a collection of evidence-based strategies to guide parents on how to best support and advocate for their child during these meetings (Goldman & Burke, 2017). When surveyed, three out of 10 parents wanted more involvement in their child’s IEP decision-making process; individuals from minoritized groups had an even greater likelihood of dissatisfaction and disenfranchisement with the process (Wagner et al., 2012). These difficulties all occur within the context of increased barriers, stressors, and strains that families of a child with ADHD are forced to manage (Bussing et al., 1998; Piscitello, Kim, et al., 2022).

To compound barriers to parent engagement, students with ADHD are also at risk for being subjected to the commonly used exclusionary and punishment-focused discipline strategies present in schools (e.g., suspension, detention) because of negative behaviors. Overall, a reliance on consequence-based approaches emphasizing punishment for disruptive or rule-breaking behaviors in schools is unlikely to be effective for students with ADHD, either immediately or over time (DuPaul & Stoner, 2014; DuPaul et al., 2022; Fabiano, 2016). Indeed, for a disorder partially defined by an avoidance of tasks that require sustained mental effort (APA, 2022), suspensions from school may serve as a negatively reinforcing consequence as the child/adolescent is afforded an opportunity to stay away from the classroom setting, which the child may experience as aversive. Moreover, these strategies may be negatively reinforcing for the teacher because removing a student who requires more effort to instruct and support is a relief for the teacher as well. It is not hard to speculate that if both the educator and student are experiencing negative reinforcement, the rates of the exclusionary punishment approaches will increase over time. This is contrary to expected decreases in behavior that would be the case if the punishments were effective.

Need for Increased Progress Monitoring

Data-based decision-making is a key aspect of effective intervention for all students, including students with disabilities. However, the typical evaluation periods in schools (quarterly for report card grades; annually for reviews of the IEP) are woefully long for children with ADHD, whose moment-to-moment variability in behavior is one of the hallmark features of the disorder (e.g., Fabiano et al., 2009). Children with ADHD may exhibit a variety of behaviors within a single school day in varied settings and situations (e.g., bus, cafeteria, classroom, hallway, academic class lesson, special area class lesson, small group activity). Based on individual areas of strength and weakness, coupled with preferences for particular activities, children may excel or require remediation across varied settings. Thus, it is inadequate to try to capture the behavior of children with ADHD through traditional goals that may be listed on an IEP and evaluated infrequently or through academic/deportment grades on a quarterly report card. A parent or adolescent receiving feedback following a lengthy time period such as this would likely feel frustration and regret without a clear idea of how to remediate the summative report of behavior. Thus, objective indicators of functioning that are evaluated frequently and that have high levels of feasibility are typically needed for children with ADHD (see Brann et al., 2022).

Inequity in Implementation for Minoritized Youth

Also of critical importance is consideration of the myriad ways in which implementation of the current systems and processes has contributed to the disenfranchisement of minoritized youth in schools (Fallon et al., 2023). Students from low socioeconomic backgrounds appear to be most at risk for the untoward consequences of being placed in more restrictive classroom settings (Kim et al., 2019). Regardless of income, Black and Hispanic students with disabilities are more likely than their White peers to be excluded from general education settings (Grindahl, et al., 2019). Racially minoritized students have also been disproportionately issued the most punitive and coercive discipline in schools for decades (Anfinson et al., 2010; Fallon et al., 2023; Fadus et al., 2021; Krezmien et al., 2006; Losen & Martinez, 2020). This inequality in schools has various negative consequences, including the student missing out on instructional time and positive school interactions (Gregory et al., 2011). If a student from a racially minoritized group has a disability such as ADHD, which is another group at risk for inequality, the rates of suspension are even more disproportionate (Brobbey, 2018). Not only do these punishment-focused strategies typically fail to improve school functioning, but they may also reduce future motivation to succeed in school for minoritized students as they progress through the education system (Del Toro & Wang, 2022; Piscitello, Kim, et al., 2022). It is imperative that efforts to improve school supports for students with ADHD seek to do so in a way that results in improved processes that will be implemented equitably for all students.

A Way Forward: Recommendations for Supporting Students with ADHD

As outlined above, ADHD has a significant impact on children and the school systems in which they function. As also outlined, there are considerable disconnects between the current approaches to supporting students with ADHD and the needs and goals for effectively supporting them. Figure 1 outlines a typical process by which students with ADHD receive formal supports in schools; it is clear there are protracted processes, potential bottlenecks, and infrequent opportunities for progress monitoring within the current system. Within this article, it is proposed that substantive changes in the conceptualization of support and intervention for ADHD within school settings are needed. First, the delegation and establishment of formal supports should be (a) situated much earlier in the process, (b) implemented in the general education setting, and (c) maintained to effectively remediate the often-serious impairments experienced by students with ADHD. Second, these supports should be implemented prior to the decision making surrounding whether an IEP or Section 504 accommodation plan is warranted. As we outline in Figure 2, immediate problem-solving and intervention at the universal and targeted tiers of intervention should commence for any child with identified attention and/or behavioral challenges; combined with ongoing monitoring and supports modified as needed, children with ADHD will receive intervention more quickly and effectively. Each of these major changes, and how they might be instituted within educational settings, are addressed more below.

Figure 1.

Prototypical Process for Obtaining Formal School-Based Supports for a Child with Attention-Deficit/Hyperactivity Disorder

Note. Gen Ed = General Education; IEP = Individualized Education Program; OT = Occupational Therapy; PT = Physical Therapy. This is a general overview and there are variations across school districts and states.

Figure 2.

Recommended Process within Multi-Tiered System of Support for Addressing Attention-Deficit/Hyperactivity Disorder within a Multi-Tiered System of Support

A reconceptualization of ADHD support in elementary school settings is necessary as there is currently little in the way of specific guidance for educators, school psychologists, other providers, and caregivers to direct ADHD intervention in school settings. Recommendations range from referrals to outside providers such as the child’s physician, which is likely result in medication initiation as the first-line intervention (Gesser-Edelsburg & Hamade Boukai, 2019; Sax & Kautz, 2003; U.S. Department of Education, 2008), to general recommendations related to securing a Section 504 accommodation plan or a special education IEP. A review of recent treatment guidelines for ADHD from prominent organizations representing psychiatrists, pediatricians, clinical psychologists, and developmental pediatricians have all noted the importance of school-based interventions for ADHD to varying degrees (see Table 1), but the details of how these interventions might be realized in a school system are largely aspirational and general. This state of the field’s recommendations ignores the obvious point that children with ADHD need dynamic intervention to address dynamic behavior. They are attending classrooms with multiple demands each day, exhibiting highly variable behavior, frequently have areas of strength that can be built upon and enhanced, and the general education teacher is likely to be working with the child each day despite recommendations for outside help. The child cannot wait for lengthy evaluation processes to commence and resolve, only to typically have the child maintained in the same classroom, with the same educator. Furthermore, situating ADHD interventions and supports formally within a MTSS framework is a novel approach that schools will have to work to adopt (Briesch et al., 2020; Fabiano & Pyle, 2018) as current guidelines do not provide actionable guidance for implementation (see Table 1). The purpose of the discussion that follows is to begin to describe how school-based interventions for ADHD, generally endorsed by professional guidelines, can be appropriately implemented within an MTSS framework.

Table 1.

Review of Practice Parameters and Treatment Guidelines Inclusion of Specific Recommendations for ADHD Interventions in Schools

Organization	School Intervention Recommendations	Educational Setting Comments/Points of Emphasis
American Academy of Child and Adolescent Psychiatry (2007)	▪ None	▪ “If a patient with ADHD has a robust response to psychopharmacological treatment … Then psychopharmacological treatment of the ADHD alone is satisfactory” (pp. 912). “If a patient with ADHD has a less than optimal response to medication, has a comorbid disorder, or experiences stressors in family life, then psychosocial treatment in conjunction with medication treatment is often beneficial” (pp. 912). ▪ Guidelines emphasize use of medications as treatment; guidelines advise obtaining teacher report on ADHD symptom rating scales but cast this as “advisable” (pp. 899) rather than necessary.
American Academy of Pediatrics (Wolraich et al., 2019)	▪ Preschool: “Evidence-based behavior Parent Training Behavior Management (PTBM) and/or behavioral classroom interventions as the first line” (pp. 10) ▪ Elementary and middle school: “Prescribe US FDAapproved medications for ADHD, along with PTBM and/or behavioral classroom intervention … Educational Interventions and individualized instructional supports, including school environment, class placement, instructional placement, and behavioral supports, are a necessary part of any treatment plan and often include an Individualized Education Program (IEP) or a rehabilitation plan (504 Plan)” (pp. 11)	▪ “Some psychosocial treatments for children and adolescents with ADHD have been demonstrated to be effective for the treatment of ADHD, including behavioral therapy and training interventions” (pp. 11). ▪Guidelines distinguish between “Interventions that are intended to help the student independently meet age-appropriate academic and behavioral expectations” (pp. 16) and “changes in the student’s program so his or her ADHD-related problems no longer result in failure … referred to as ‘accommodations’” (pp. 16). Specific examples of each approach are provided.
	▪ Adolescents: “prescribe FDA-approved medications for ADHD with the adolescent’s assent … encouraged to prescribe evidence-based training interventions and/or behavioral interventions” (pp. 11); plus the same educational interventions recommended for elementary school (pp. 11).
Society for Clinical Child and Adolescent Psychology (Evans et al., 2014, 2018; Pelham et al., 1998; Pelham & Fabiano, 2008)	▪ Across, the four literature reviews, behavioral parent training, contingency management in classroom settings, behavioral peer interventions, and training interventions in organizational skills meet criteria for well-established treatments.	▪ Note earlier reviews (Pelham et al., 1998; Pelham & Fabiano, 2008) included single case and cross-over design studies in the analysis of the evidence base whereas Evans et al. (2014) and Evans et al. (2018) focused solely on between-group design studies. Single-case design studies are most analogous to the approach teachers will need to employ for students with ADHD in school settings. ▪ Focus of the reviews was on identifying well-established treatments using standard criteria; did not discuss how to integrate into a school intervention plan.
Society for Developmental and Behavioral Pediatrics (Barbaresi et al., 2020)	▪ Evidence-based behavioral and educational interventions (e.g., behavioral parent training, behavioral classroom management, behavioral peer interventions, and, for older children, organizational skills training) are foundational for the treatment of complex and ADHD and should be implemented at the outset of treatment” (pp. S35)	▪ Guidelines emphasize that focus of treatment should be on functional outcomes, rather than ADHD symptoms. ▪ Only guideline that notes school-based behavioral and educational interventions should be implemented first (contrast with AACAP guidelines that prioritize medication treatment).
	▪ It is often necessary to combine these approaches with pharmacological treatments” (pp. S36)

Note. ADHD = Attention deficit/hyperactivity disorder; PTBM = Parent training behavior management.

Reconceptualization of ADHD Identification within Schools

It is time for schools to explicitly identify ADHD as a condition that warrants supports, interventions, and the distribution of supports across all educational settings where a student with ADHD may benefit. This includes moving beyond a primary reliance on the use of IEPs, 504 accommodation plans, and punitive school discipline procedures as mechanisms emphasized for improving school outcomes, and that new and more effective approaches are needed. This will require a hard look at the current approaches to identifying students with ADHD and it may include policy decisions that will reduce bottlenecks that inhibit the provision of evidence-based interventions. A specific recommendation is that ADHD should be addressed within multi-tiered systems of support with tailored positive behavior support approaches (DuPaul et al., 2020; Fabiano & Pyle, 2019). A corollary to this position is that ADHD should be disentangled from special education IEPs and Section 504 accommodation plans as sole mechanisms for providing accommodations, supports, and interventions as currently these are only used as consequential efforts after sustained failure. IEPs and Section 504 accommodation plans assign a label to the student in the educational system, but often not much more in terms of substantive changes. In mental health, there is currently a movement away from diagnostic categories as labels used to lead to specific treatments (Pacheco et al., 2022) given the overlap between categories and that treatments work independent of a specific diagnostic category for externalizing behaviors. The same consideration should be utilized in schools as ADHD is highly comorbid with other learning and behavioral challenges (DuPaul et al., 2019).

Rather than continuing with current practice, schools should treat the academic, behavioral, and social impairments characteristic of ADHD in a similar manner to the way reading problems are addressed within multi-tiered systems of support (MTSS; Burns et al., 2016; Stoiber & Gettinger, 2016; U.S. Department of Education, Office of Special Education and Rehabilitative Services, 2021). For example, most children within schools do not require an outside-of-school neurocognitive evaluation or physician-provided diagnosis to receive reading intervention in school. Schools currently conceptualize academic achievement as a construct along a continuum that can be modified through intervention efforts, including regular screening and progress monitoring and the provision of more intensive intervention when indicated for as long as is needed to promote all children meeting academic benchmarks through MTSS.

There is less guidance, support, and clarity to promote effective implementation of MTSS for behavior (Briesch, et al., 2020), but the framework holds considerable promise for identifying and supporting individuals with ADHD. In fact, the MTSS model of screening and intervention is consistent with the large literature on effective interventions for children and adolescents with ADHD that has utilized a single-case design approach (Pelham & Fabiano, 2008; Pelham et al., 1998; Pyle & Fabiano, 2017) wherein individual areas of impairment along with areas in need of competency development are identified and then systematically addressed using effective intervention approaches.

Even though ADHD diagnoses are typically made by psychologists or physicians outside of the school setting, these professionals often rely on the report from school professionals to inform the diagnosis; for instance, best practice currently includes the ascertainment of teacher report of the presence of ADHD symptoms and impairments within the school setting (Pelham, Fabiano, & Massetti, 2005; Wolraich et al., 2019). In fact, referral for an ADHD diagnosis may often be from a school-based problem reported by the teacher (e.g., DuPaul et al., 2019; Hawkins et al., 1991); this collateral report of symptoms and associated impairment is a necessary component of a DSM-5-TR diagnosis (APA, 2022). Arguably, the identification of a student in need of school-based behavioral support is the most straightforward step where the teacher, through the ratings, identifies the student as impaired in some aspect of academic, behavioral, or social functioning.

If these ratings are viewed outside the lens of a mental health or medical model, and high stakes decisions regarding whether medication is warranted or not are set aside, then any child who is rated by the teacher as impaired on these behavioral screenings is worthy of the initiation of a behavior support plan. There is no reason, at least at the initial identification and screening stage, to make the assessment approach more complicated or protracted by outsourcing it to other professionals outside the school (similar to academic supports for reading or math, as described above). As further support for this approach, should the evaluation suggest the child does not meet full criteria for ADHD, but there is still a signal that there are classroom-based impairments, a positive behavior support plan should still be implemented; a diagnosis does not determine whether the child should be helped in the classroom but rather the teacher report of an area in need of remediation is what should drive intervention implementation. This is completely aligned with the current approach to academic supports within schools wherein students are not required to meet criteria for a specific learning disability prior to the initiation of academic supports as intervention is provided as soon as risk for academic problems is identified.

This is not to say that an ADHD diagnosis should be disregarded. It is simply to state that for many of the approaches that can be used to help students succeed in school, an ADHD diagnosis is peripheral, or unnecessary, particularly at the outset in tiered intervention models. If school personnel were to focus more on target behaviors (e.g., “Arrives on time and prepared for class”, “Raises hand before speaking”, “Keeps hands and feet to self”, “Completes assigned work within time provided with at least 80% accuracy”) rather than attempting to identify whether sufficient ADHD symptoms were present (e.g., “Is often easily distracted by extraneous stimuli”, “Often fidgety and restless”), positive behavioral supports, at all levels of a MTSS, could be implemented to reduce impairment and promote skill development. This approach would help all students; empirical research clearly demonstrates that universally applied, positive behavior supports reduce problematic ADHD behaviors (e.g., rule-breaking, incomplete assignments) to a level that may no longer be clinically significant or impairing, which attenuates the need for an outside professional-provided diagnosis (see Fabiano et al., 2007; Fabiano & Pelham, 2003; Reid et al., 1993). When outside supports are accessed, there is evidence that a collaborative care model that unifies educators, physicians, and mental health professionals holds promise (Lyon et al., 2016; Power et al., 2013; Talbott et al., 2021). Should all providers and caregivers be united in their approach to the student with ADHD’s care, the strong sequential models of care such as those advocated by the Society for Developmental and Behavioral Pediatrics (Barbaresi et al., 2020) could be routinely realized.

Such an approach has the potential to reduce or remove several common barriers to evidence-based classroom supports for children with ADHD. In states where a medical diagnosis is necessary, parents would no longer need to seek outside ADHD evaluations as a precursor to their child receiving classroom supports. Many families experience significant barriers to accessing such evaluations as there may be a lack of accessible providers within their community. An over-emphasis on diagnosis and classification at the expense of providing immediate positive behavioral support has likely contributed to the current mental health crisis in which half of children with mental health needs in the United States do not receive mental health services (Whitney & Peterson, 2019) and the majority of services provided for children with ADHD are inconsistent with recommended best practices (Barbaresi et al., 2020; Danielson et al., 2018).

Another major barrier that would be addressed by the proposed change is that it would codify and clarify the ability of schools to provide services for students with ADHD without first going through the lengthy process of qualifying for an IEP, which can take months. As described above, this process is unnecessary to begin to address classroom impairment associated with ADHD. Once established, classroom behavioral interventions such as daily report cards are easily implemented by general education teachers, are cost-effective, and can lead to noticeable improvement within a matter of weeks (Girio & Owens, 2009; Holdaway et al., 2020; Page et al., 2016). Furthermore, daily report cards also serve as ongoing assessment of student response to intervention and inform intervention decisions within MTSS frameworks (Volpe & Fabiano, 2013). This ongoing progress monitoring can also improve objectivity in decisions related to special education placements, which may enhance equity in decision-making. There is evidence that the utilization of MTSS frameworks can improve equity of school-based social, emotional, and behavioral supports (Fallon et al., 2023; Malone et al., 2022; McIntosh et al., 2021). Overall, this proposed movement toward addressing ADHD primarily and initially through an MTSS framework rather than through existing IEP and Section 504 accommodation plans has the potential to substantially increase access to evidence-based classroom supports for youth with ADHD and to do so more quickly. There is likely merit to establishing 504 accommodation plans and IEPs for many children with ADHD, but currently this may be done prematurely before other interventions are attempted within the general education setting. By moving immediately to evaluations for accommodation plans or special education, it is possible that school districts are skipping a potential step that would result in effective and sufficient intervention for some students with ADHD.

Establishment of Formal Support Structures for ADHD in Schools

One way to achieve the goals of better support for children and adolescents with ADHD in schools is to re-examine the roles, effort, and resources currently expended. ADHD is one of the costliest conditions addressed in educational settings (Page et al., 2016; Robb et al., 2011). A large portion of the cost can be attributed to aspects of ADHD management that are not child-centered or helpful in promoting successful outcomes. Included in this category are discipline referrals to the principal’s office, costly assessments conducted as part of special education decision-making for initial referral or annual review, and interventions and treatments that are not evidence-based for ADHD behaviors (e.g., individual counseling, occupational therapy). Rather than suggest an influx of new funds are needed to appropriately support students with ADHD, it appears that the resources are already present in school systems but need to be re-delegated to promote better outcomes. For example, rather than ask school psychologists to complete comprehensive, initial referral assessments (e.g., a full battery of IQ and achievement tests) for children with ADHD, school psychologists could spend time meeting with the general education teacher and caregiver to institute effective positive behavior supports in the classroom through a MTSS framework (e.g., a school-home daily report card). De-implementation studies (Raudasoja et al., 2022; Walsh-Bailey et al., 2021) that evaluate whether component parts are ineffective, or potentially harmful, or multiphase optimization strategies to evaluate effective component parts (Collins, 2018) would be useful for evaluating school practices and could potentially reduce costs should ineffective approaches be removed and effective components be retained.

Similar to how schools utilize evidence-based approaches to teaching academic skills (Foorman & Torgesen, 2001; National Institute of Child Health and Human Development, 2000), there is now sufficient information on effective positive behavior management approaches that should also be standardized in classroom settings. Positive behavior supports could include Tier 1 strategies within the MTSS, such as classwide group contingencies (Barrish et al., 1969; Bowman-Perrott et al., 2016; Embry, 2002), and increased use of positive behavior support strategies in the classroom such as labelled praise, effective behavior requests, and effective corrective feedback (Hart et al., 2017; Owens et al., 2018; Reddy et al., 2013; see Fabiano & Pyle, 2019, for an expanded discussion). Although clearly part of an effective classroom management approach, rates of use of these strategies are extremely low, especially as children progress from primary grades and the academic demands on attention and self-control skills begin increasing (Reddy et al., 2013). A dedicated approach to training and supporting general education teachers in effective classroom management in Tier 1 has the potential to considerably improve the academic environment for children with ADHD (e.g., Fabiano & Pyle, 2019; Owens et al., 2018; Pelham, Massetti, et al., 2005; Pfiffner et al., 2013; Power et al., 2012) and to improve equity in implementation (McIntosh et al., 2021).

Following a well-implemented Tier 1 classwide approach (e.g., positive behavior support), the major change in ADHD treatment in schools would occur at Tier 2, which is the level of intervention offered to students who need more intervention beyond the standard (i.e., classwide) approach. It would be expected that most children with ADHD will require additional intervention (Pelham et al., 2016). This could include a daily report card (O’Leary et al., 1976; Volpe & Fabiano, 2013) or another evidence-based approach, such as skills training in organization for older students (Evans et al., 2013, 2018).

It is important to note that there is already the expertise and procedural infrastructure within schools to establish effective Tier 2 (or Tier 3) behavioral interventions. In a Dear Colleague letter sent by the U.S. Department of Education, Office of Special Education and Rehabilitative Services (2016), school districts were reminded that students with IEPs whose behavior was impeding their own learning, or the learning of others, should have positive behavioral supports in place. Furthermore, if the child was receiving multiple out-of-school disciplinary removals, there is evidence that the current behavioral supports are insufficient and more intensive behavioral supports are needed. Behavioral intervention plans are used in schools in these cases and include a functional behavioral assessment followed by the collection of baseline data to document the extent of the behavioral concern. Then, a plan that addresses antecedents and consequences of the targeted behavior(s) is established to reduce the occurrence of problematic behaviors and increase appropriate and adaptive behaviors. There is no reason that this approach should be delegated only to students with ADHD in special education; in fact, all the time spent evaluating students with ADHD for initial special education referrals is arguably better spent “cutting to the chase” and developing the interventions that will potentially help the child in the classroom. Institutionalizing this approach into a MTSS at Tier 2 and Tier 3 would increase the speed with which children with ADHD receive evidence-supported intervention. Because these positive behavior supports have been shown to be effective (Pelham et al., 2016), there would be fewer requests for special education evaluations and more time to support teachers in general education settings with functional behavioral assessments and subsequent intervention plan implementation. In parallel with this process, educators and caregivers may decide to develop a Section 504 accommodation plan that is inclusive of the supports and interventions that have been successfully implemented, which will serve as a framework for intervention as the student progresses.

Maintenance Plans for Supporting Students with ADHD

ADHD is a life-course persistent condition (DuPaul et al., 2020) with characteristics that make impairment likely across the developmental continuum of school settings from preschool to higher education. For this reason, treatment effects need to be planned to span years rather than weeks. Unfortunately, there is evidence in the field that fidelity of implementation of behavioral interventions is not always high (Vujnovic et al., 2013) and that the sustainability of behavioral interventions can be low (Martens & Ardoin, 2002; Yeung et al., 2016). There is also the risk that as children with ADHD move to subsequent grade levels or different schools during transitions to middle or high school, that the knowledge related to effective intervention approaches will be lost or will need to be revised given new expectations or academic demands. Schools that are underfunded and serving vulnerable students (e.g., those in rural communities, students with unstable housing; e.g., U.S. Department of Health and Human Services, 2012) and where resources to implement such a system may be lacking may also require additional supports on an ongoing basis, and this needs to be considered when policymakers are determining how to prioritize and allocate resources. Additionally, broader public health stressors (e.g., COVID-19 pandemic) and rapidly changing political and economic climates have produced a shortage of teachers. Implementing a MTSS may initially seem like a difficult task; however, investing in this set up of organized strategies will help with early identification and treatment. In the long term, this is likely to alleviate the burden experienced by schools when there are many untreated students with ADHD and related concerns.

Like the argument above, utilizing a MTSS approach that includes regular screenings and then functional behavioral assessments that are followed by behavioral intervention plans would reduce implementation drift or lack of fidelity in school-based support plans. School psychologists, school counselors, and behavioral support specialists could be trained to implement and follow-up with the behavior plans. For academic concerns in MTSS, intervention often includes assignment to a small group for reading remediation. For behavioral concerns, intervention would likely need to be individualized, but there are numerous templates for establishing daily report cards or check-in check-out procedures. The basic procedures include clear establishment of behavioral goals, creating clear criteria for goal attainment, providing frequent feedback on the student’s standing toward meeting goals, and providing contingent rewards following goal attainment (Maggin et al., 2015; O’Leary et al., 1976; Owens et al., 2020; Pyle & Fabiano, 2017; Vannest et al., 2010; Volpe & Fabiano, 2013; Wolfe et al., 2016). For instance, the addition of a daily report card for students with ADHD in special education significantly reduced observations of disruptive behavior (Fabiano et al., 2010), with these results being replicated in general education samples as well (Holdaway et al., 2020; Owens et al., 2020; Pelham et al., 2016). The daily report card intervention also can be utilized over long periods of time as it is easily modifiable as new target behaviors need to be added, goals that are achieved may be removed, and rewards can be adapted to the child’s current interests.

An additional consideration regarding maintenance of gains pertains to developmental transitions embedded within schools. As children move through grade levels, transition from preschool to kindergarten, from elementary to middle school, from middle school to high school, and from high school to college and/or career, it is critical that the appropriate interventions are in place to promote a successful transition and build upon gains at the prior educational level (e.g., Sibley et al., 2018). The characteristic symptoms of ADHD often become more pronounced and impairing upon these transitions as novel demands are presented (e.g., sitting in one place on a rug during circle time in preschool or kindergarten; managing time appropriately for long-term assignments in middle school). MTSS that include regular screening and aligned interventions should assist with reducing impairments that can be predicted at these transition points. Furthermore, as ADHD is a chronic condition, it is likely that formal written transition plans that document successful approaches will promote continuity of interventions across grades.

Summary

Many individuals with ADHD consistently evidence negative school outcomes (Arnold et al., 2020; Kent et al., 2011; Molina et al., 2009). The current disjointed and confusing collection of school policies and supports (e.g., Section 504 accommodation plans; IEPs) has been insufficient to attenuate these impairments despite considerable costs and efforts across multiple decades. Furthermore, there is clear evidence of inequities in the implementation of current policies and supports for minoritized youth (Fallon et al., 2023). The advent of MTSS provides a potential pathway for providing intervention and progress monitoring for children with ADHD as it will reduce the latency to the provision of services and supports and it will also embed these interventions within the general education setting where children and adolescents with ADHD are most likely to be educated (Schnoes et al., 2006).

At the same time, we call upon policymakers and school leaders to consider revising the formal ways that ADHD is currently addressed in schools. Whereas there is no intent to take away students’ rights to a free and appropriate education, and there remain many reasons for a child with ADHD to be referred for an IEP or Section 504 accommodation plan, we strongly suggest that these mechanisms be moved to the background and that the interventions within the MTSS be moved to the foreground. Concurrently, we also strongly suggest that the outsourcing of ADHD assessment and treatment to providers outside the school setting be minimized and that there be a concerted effort among school professionals to provide excellent, universal Tier 1 supports, routinely screen for attention and behavioral challenges in schools, implement Tier 2 and Tier 3 behavioral interventions as warranted, and refer to outside professionals only after the child or adolescent has been offered the entire suite of tiered interventions. Maintaining assessment and treatment plans within the school as a first step in intervention should also reduce the number of children prescribed medication as there are children who will respond positively to the school-based positive behavior supports and thus require no additional treatment, including pharmacological treatment (see Pelham et al., 2016, for an empirical example). Overall, the goal should be to help students with ADHD ultimately develop into successful and contributing citizens and the current outcomes for these students indicate that this is not the typical case (e.g., Gordon & Fabiano, 2019). Therefore, there is a pressing need to emphasize and develop alternative approaches in schools so that this goal can be realized.