ADHD: A Primer for Parents and Educators
By George J. DuPaul, PhD
Attention Deficit Hyperactivity Disorder (ADHD) is a disruptive behavior
disorder characterized by
inattention (difficulty concentrating on schoolwork), impulsivity (frequently
or activities), and overactivity (difficulty remaining seated when required
to do so) that are well beyond
what is expected and appropriate for a child’s gender and age.
Approximately 3–7% of school-aged children in the United States have
ADHD. Children with ADHD
typically first exhibit symptoms during the preschool or early elementary school
years, and these
symptoms are highly likely to continue throughout the child’s life. Boys
are more likely to be diagnosed
with ADHD than are girls.
There are three subtypes of ADHD: children who exhibit problems only with
concentration (ADHD Predominantly Inattentive Type), children who exhibit problems
hyperactivity and impulsivity (ADHD Predominantly Hyperactive-Impulsive Type),
and children who
exhibit problems in both areas (ADHD Combined Type).
Causes of ADHD
It is likely that children differ with respect to the specific underlying
cause of their ADHD symptoms.
There is growing evidence that ADHD is at least partially caused by genetic
factors. Specifically, the
brains of children with and without ADHD may be different. The balance of certain
chemicals, referred to
as neurotransmitters, is different, as well as the size and operation of specific
brain components such as
the prefrontal cortex. Other biological factors may come into play, such as
pregnancy and birth
complications and environmental toxins (early lead exposure or prenatal exposure
to alcohol and
tobacco smoke). Although genetic and biological factors account for ADHD symptoms
to a large degree,
environmental factors, such as the nature of classroom tasks and behavior management
style at home
and school, may make symptoms either better or worse.
In general, it is best to view ADHD as having both biological and environmental
influences, and thus
both medical and psychosocial treatments could be helpful.
Characteristics of Children With ADHD
Learning problems. The inattentive, impulsive, and hyperactive behaviors
that comprise ADHD
often lead to significant academic and social difficulties that affect children’s
functioning at home and
school. Children with ADHD frequently get school grades that are below their
potential. They may also
be at higher than average risk for grade retention and school drop-out and
are less likely to pursue postsecondary
education. Their academic underachievement probably represents a performance
rather than a lack of ability, because achievement problems are highly related
to rates of inattention and
disruptive behavior. Also, about 25% of children with ADHD also have learning
Social and behavior problems. Children with ADHD typically have difficulties
making and keeping
friends because of their higher levels of verbal and physical aggression. Family
become difficult because the child may be less likely to follow through on
parental directives and more
likely to argue with adults.
Approximately 50–60% of the children exhibit significant symptoms of
other disruptive behavior
disorders including Oppositional Defiant Disorder and Conduct Disorder. Therefore,
not only address ADHD-related behaviors but must also focus on improving academic
Best practice. No single test, questionnaire, or
source of information (parent or teacher) is sufficient to
accurately diagnose ADHD. Current best practice
requires the use of multiple assessment methods and
sources of information, including diagnostic interviews
with parents and teachers, behavior rating scales
completed by parents and teachers, and direct
observations of behavior in school or clinical settings.
Psychologists or physicians conducting these
assessments must ensure that diagnostic decisions are
made on the basis of criteria set in the Diagnostic and
Statistical Manual (4th ed.)(American Psychiatric Association,
2000; see “Resources”). They must also consider
alternative hypotheses for children’s inattentive,
impulsive, and hyperactive behavior (e.g., symptoms
caused by other learning or behavioral disorders).
Linking assessment to intervention. The evaluation
of ADHD-related behaviors does not end with the
diagnosis. Rather, it should lead to the design of
effective interventions. For example, school
professionals should use Functional Behavior
Assessment to evaluate the environmental factors
(peers laughing and paying attention to a child’s
misbehavior) that might be reinforcing or triggering a
child’s disruptive behavior to plan effective
interventions. Then, once an intervention plan is in
place, assessment information should be collected
periodically to determine whether treatment is working
and whether changes in intervention procedures are
Effective Interventions for ADHD
The two most effective interventions for reducing
the symptomatic behaviors of ADHD are central nervous
system (CNS) stimulant medications and behavior
modification procedures. Although most children
respond positively to medication, combined use of
medication and behavioral interventions tends to yield
the greatest improvement in their social skills.
Medication. CNS stimulants include methylphenidate
(Ritalin, Concerta, Metadate), dextroamphetamine
(Dexedrine), and mixed amphetamine compound
(Adderall). Numerous studies have found stimulants to
enhance attention, reduce impulsive behavior, and
increase academic productivity among the majority of
children treated. For the most part, side effects are
relatively benign and include appetite reduction,
insomnia, headaches, and stomachaches. In very rare
cases, motor or vocal tics may develop.
Several other psychotropic medications are
available for those children who do not respond to
stimulants or who experience significant side effects,
including atomoxetine (Strattera), bupropion
(Wellbutrin), and clonidine (Catapres).
Children’s response to medication varies and
requires ongoing monitoring to determine the optimal
medication and dosage. Further, medication should
always be used in combination with academic and
behavioral interventions. Regardless of the type of
medication prescribed, some children may have no or a
negative response to medication or severe side effects
that preclude medication.
Behavioral interventions. Behavioral interventions
involve systematic changes to antecedent events
(activities occurring prior to a target behavior) and/or
consequent events (activities that follow a target
behavior). The most effective treatment plans are those
that include a balance between antecedent-based and
consequent-based procedures. Interventions such as
token reinforcement (earning points for later rewards)
and daily report card systems are particularly effective
when they are used consistently in both home and
Academic interventions (peer tutoring, computerassisted
instruction) and social skills training
implemented in classroom and/or playground also may
be of benefit.
Special education and accommodations. The
diagnosis of ADHD does not by itself qualify a child for
special education services. However, many children with
ADHD will meet criteria for an educational disability
(such as Other Health Impaired, Learning Disability, or
Emotional Disturbance) and may benefit from the
services of special education to address learning and
behavior factors that interfere with school performance.
If academic progress or behavioral difficulties are
present, parents or school personnel can request an
evaluation by the special education team to determine
eligibility and need for these services.
Section 504 plans is another system of supports.
These plans are mandated by federal law for individuals
with a disability that interferes with a life activity, such
as school performance. A 504 plan for a student with
ADHD might provide extra time (or no time limits)
during testing or testing in a quiet space to compensate
for distractibility. Again, if learning or behavior
problems interfere with the school progress of a child
with ADHD, parents or school personnel can request
that the school provide a Section 504 evaluation.
Resources for Parents
Barkley, R. A. (2000). Taking charge of ADHD: The
complete, authoritative guide for parents (rev. ed.).
New York: Guilford. ISBN: 1572305606.
Ingersoll, B. D. (1997). Daredevils and daydreamers: New
perspectives on Attention-Deficit/Hyperactivity
Disorder. New York: Doubleday. ISBN: 0385487576.
Resources for Educators
American Psychiatric Association. (2000). Diagnostic
and Statistical Manual (4th ed.). Washington, DC:
Barkley, R. A. (1998). Attention Deficit Hyperactivity
Disorder: A handbook for diagnosis and treatment
(2nd ed.). New York: Guilford. ISBN: 1572302755.
DuPaul, G. J., & Stoner, G. (1999). Classroom
interventions for ADHD [videotape]. New York:
DuPaul, G. J., & Stoner, G. (2003). ADHD in the schools:
Assessment and intervention strategies (2nd ed.). New
York: Guilford. ISBN 1-57230-862-1.
Power, T. J., Karustis, J. L., & Habboushe, D. F. (2001).
Homework success for children with ADHD: A familyschool
intervention program. New York: Guilford.
Rief, S.F. (2003). The ADHD book of lists: A practical
guide for helping children and teens with Attention
Deficit Disorders. San Francisco: Jossey-Bass. ISBN
Weyandt, L. (2001). An ADHD primer. Boston: Allyn &
Bacon. ISBN: 0205309003.
Resources for Children With ADHD
Carpenter, P., & Ford, M. (2000). Sparky’s excellent
misadventures: My ADD journal. Washington, DC:
Magination Press. ISBN: 1557986061.
Gordon, M. (1992). My brother’s a world-class pain: A
sibling’s guide to ADHD Hyperactivity. DeWitt, NY:
GSI Publications. ISBN: 0962770124.
Children and Adults With Attention Deficit Hyperactivity
George J. DuPaul, PhD, is a Professor and researcher in
the College of Education, School Psychology Program,
Lehigh University, Bethlehem, PA.
© 2004 National Association of School Psychologists, 4340 East West Highway,
Suite 402, Bethesda, MD 20814—(301) 657-0270.