Here in the United States, there is a tendency to over-prescribe in some instances. But it pales in comparison to the under-prescription or under-recognition of these problems in children, â€¦We know from a variety of epidemiologic and other related studies, that as many as half of the children with conditions such as ADHD are not being treated at all.
There are many questions that pertain to the diagnosis and implementation of proper treatment to maximize resources, to best meet the needs of student with Attention Deficit/Hyperactivity Disorder (ADHD). A review of current research is presented in the following categories: 1) the identification and diagnostic process, 2) behavior management strategies in the classroom, 3) medication, and 4) collaborative effort of the use of medication and behavior modification techniques in the school and the student's home environment.
Review of the Literature
Identification and the Diagnostic Process
Attention Deficit Hyperactivity Disorder (ADHD) is defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), as persistent inattentive and/or hyperactive behaviors that are not age appropriate (Cyr & Brown, 1998). These behaviors are pervasive as demonstrated by their presence in at least two environments, and are sufficiently severe so as to interfere with social or academic functioning (DSM-IV, 2000, p. 79).
Currently there are three subtype classifications (see Appendix A for specific diagnostic criteria):
Attention Deficit/Hyperactivity Disorder Combined Type. This classification is used when six or more symptoms of hyperactivity and inattention are present for at least six months
Attention Deficit/Hyperactivity Disorder, Inattentive Type. This classification is used when at least six symptoms of inattention have been present for six months
Attention Deficit/Hyperactivity Disorder, Hyperactive-Impulsive Type. This classification is used if there is at least six symptoms of hyperactivity-impulsivity are present for six months
At the present time, there is no test for diagnosing ADHD, rather, the disorder is
usually contingent on a clinical diagnosis. This diagnosis is dependent on direct observation, parent and teacher interviews, behavior rating scales, situation questionnaires, psycho-educational testing, and medical evaluations (Pudie, Hattie, & Carroll, 2002). A team of professionals including pediatricians, psychiatrists, psychologists, teachers, parents, therapists, paraprofessionals, and students are involved in this complex diagnostic procedure. Once a diagnosis is made, the school team needs to meet with the parents again, and develop a plan to address the obstacles, such as whether medication been prescribed, and if so, when does the student need to take it. The teacher(s) again need to begin an observation process, and communicate with the parents to report the impact of the plan (Pudie, Hattie, & Carroll, 2002).
Characteristics of ADHD
Most children diagnosed with ADHD are educated in the regular classroom (Gargiulo, 2012). These students are likely to face social isolation, and higher rejection rates by their peers due to behaviors that are often exhibited (Redmond, 2011). Some behaviors exhibited in school include not being able to sit still, frequent outbursts, inattentiveness, fighting, and staring out the windows (Redmond). Teachers will also see the following behaviors; low frustration tolerance, temper outbursts, resentment toward family members, stubbornness, mood liability (instability), rejection of peers, poor self-esteem, oppositional behavior lack of effort, laziness, antagonism and aggression, perceived lack of self-responsibility, bossiness, social isolation, psychological dysfunction, and excessive insistent demands that requests must be met (Raymond, 2012). In addition to these behaviors, students have a higher failure rate in math, and language arts as these subjects require students to be able to focus and retain what they have been taught (DuPaul & Stoner, 1994). Another problem for many students with ADHD is that they often lose homework assignments or forget their books at school (DuPaul & Stoner). Teachers need to be made aware of students in the classroom that have ADHD so they can make the necessary accommodations to support students' success. There are many strategies teachers can incorporate into their daily routine to help these students.
Behavior Management Strategies for the Classroom
Of all strategies reviewed in the literature, the one reported as being used most often was a whole classroom behavior management system (DuPaul & Stoner, 1994). Some of these strategies include token reinforcement, verbal praise, time-out, and the use of appropriate movement. In addition to these few strategies, teachers will develop methods that work best for them and their students and incorporate them into daily routines.
Token reinforcement. Token reinforcement, a positive reinforcement method, is considered by some to be the best behavior management strategy teachers can use since it builds self-esteem and respect (Rief, 1993). According to DuPaul and Stoner (1994) developing a token system involves the following seven steps:
1) One or more classroom situations are identified as problematic for the child and targeted for intervention, 2) target behaviors are selected and typically include academic products (number of math problems completed in a given time) or specific actions such as, appropriate interactions with peers, 3) types of secondary reinforcers used are identified, and may include poker chips, checkmarks, stickers, or points on a card stand. Younger children generally prefer tangible rewards (stickers), whereas older children and adolescents respond to more positively to points or checkmarks, 4) values of target or goal behaviors must be pre-determined, 5) teacher and student should jointly develop a list of privileges or activities for which the tokens may be exchanged ranging from inexpensive to costly rewards, the number of tokens or points necessary to purchase each privilege can be determined between the teacher and the student, 6) tokens are exchanged for classroom privileges on at least a daily basis. Rule: shorter delays between receiving tokens and exchanging them for backup reinforcers result in a more effective program, and 7) the effectiveness of the program should be evaluated on a regular basis. (p.104)
The use of token reinforcement has produced positive results, students have increased their time on task, and the amount of work completed the accuracy of academic responses, increased academic performance, and compliance to directions (Harlacher, Roberts, & Merrell, 2006). The use of this technique has decreased hyperactivity, inattentive behavior, and decreased disruptive behavior (Harlacher, Roberts, & Merrell). According to Harlacher, Roberts and Merrell (2006) the advantage to the use of token reinforcement is its effectiveness with all students and the ability for teachers to manage large groups of students at once. It also provides classroom structure and is easily implemented.
A study conducted with four children and diagnosed with ADHD ages 11 to 12, was examined in a ABABA design in which a comprehensive behavioral program was utilized and withdrawn across an 8-week period (Coles, Pelham, Gnagy, Burrows-MacLean, Fabiano, Chacko, & ... Robb, 2005). The effects were examined in multiple setting and domains, and showed positive effects using the behavioral treatment package. "The beneficial effects of the behavioral program were seen across the four children despite heterogeneity in concurrent medication, gender, and comorbid externalizing and internalizing behaviors" (Coles et al.,
p.105). This study shows that behavioral interventions can be used successfully with children diagnosed with ADHD.
Verbal praise. In addition to implementing a whole-class token system, making use of verbal praise is another highly effective technique used by teachers. Children with ADHD usually are told what they are doing wrong, but very seldom do they hear what they are doing right. When teachers observe students exhibiting appropriate behaviors they need to immediately praise students by complimenting them on the prosocial or academic behavior they have demonstrated which will encourage the student to continue the behavior in the future (DuPaul, & Stoner, 1994). Praise can build up students' self-esteem and therefore; needs to be used four times as often as a negative comment. Teachers should try to start out using a positive statement, then the negative statement, followed up by a positive statement. This allows students to know what they did right and what they did wrong, but it does not focus only on the negative.
A study conducted by researchers in three Australian schools: in Beaudesert, Queensland; Darwin, Northern Territory; and Adelaide, South Australia found that verbal communication is a very effective strategy (Geng, 2011). The study used six male students, four of them currently taking medication. Each researcher used observation and documented their findings on a form with the following sections: (A) the student's ADHD behaviors; (B) the teacher's verbal and non-verbal strategies; and (C) the student's response to the teacher's strategies (Geng). The researchers discovered that teachers' use of positive verbal strategies included voice control (low to loud volume, firmness, tone and pace), short phrases, repeated instructions, use of the students' names and a combination of visual cues and verbal instructions. Calm verbal strategies resulted in students' calming down or complying with the teachers instructions. Another result was that when teachers stay calm, they were able to de-escalate altercations, but if the teachers became stressed out, the students' continued displaying the behavior (Geng).
Time out. A popular behavior modification strategy is "1-2-3 Magic". When the student is off-task, the teacher says, "that is one," which continues until the student reaches three. Once the student reaches three, he/she is told to take five minutes in a designated time-out area (Armstrong, 1999). If a teacher chooses this method he/she must provide the student with an activity to provide stimulation instead of allowing the student to continue with the behavior that he/she received the time out for.
A more effective use of a time-out area is to let students decide when they need to go to the area to regroup, and give them activities to stimulate them. The teacher should set rules regarding the amount of time students can stay in the area and give them a timer so they know how much time they have been in the area. Teachers should provide students with activities while in the area such as books to read, word search puzzles relating to class material, or allow students to take their journal to the time-out area (Armstrong, 1999). This allows students to be productive while letting them regroup so they can return to the classroom and be ready to stay on task.
Appropriate movement. Another strategy is to allow students with ADHD to sit in the back of the class with the understanding that they can get up and move around when needed as long as they do not disturb the class (Armstrong, 1999). This allows the student to stand up or walk around in the back of the room and still listen to what the teacher is covering in the class. Other movement strategies include giving the student a ball to squeeze or play dough to keep his/her hands busy during a lecture. When possible, the teacher should tie activities into the lesson plan which involves all the students moving (Armstrong).
Kercood and Banda (2012) conducted a study using children in 4th grade language arts class, comparing therapy balls for seating versus chairs. Four students participated, two girls and two boys, who were assessed using the Conner's Teacher Rating - Revised: Short Scales (CTRS-R-S). Two of the students met the criterion for having significant attention problems, one student was in the borderline category, and one was determined to be an average/typically developing student (Kercood & Banda, 2012). The students listened to short stories and after the story was completed, they were given a multiple-choice question sheet on a clipboard, a pencil with an eraser, and were asked to complete the questions based on the story. During the intervention phase, the students listened to short stories while either (A) sitting on a chair and doodling on a clipboard using paper and a pencil or (B) sitting on exercise ball instead of the chair (Kercood & Banda). This study was based on research that indicates exercise can be used in behavioral contingency programs to increase attention in children with ADHD and may serve as reinforcers (Kercood & Banda,). It also provides evidence that movement throughout the day can help all students with their concentration and attention (Murline, Prater & Jenkins, 2008). Engaging students in planned frequent movement activities (while providing the appropriate accommodations) increases the likelihood that students will experience success (Murline, Prater & Jenkins).
Hands-on. When students with ADHD are allowed to learn through hands-on experiences they usually display positive and appropriate behavior (Armstrong, 1999). Some hands-on activities include the use of manipulatives to learn math concepts, create battlefields to show major conflicts during wars, hands on lab materials in science to teach concepts, and form letters out of clay to learn the alphabet (Armstrong).
A study conducted by Cameron University focused on using manipulatives to solve mathematical problems. The problems focused on solving area and perimeter problems, word problems and fractions. An analysis of the data revealed that the students rapidly acquired the problem-solving skills, maintained these skills over a two-month period, and transferred these skills to a paper and pencil problem-solving format (Cass, Cates, Smith, & Jackson, 2003).
Although there are many classroom-based interventions, home-based contingencies are also needed. If teachers and parents use the same techniques, the student has consistency across environments. On a daily basis, the child needs to receive direct feedback from his or her teachers about performance in several areas of classroom functioning (DuPaul & Stoner, 1994). Collaborating with parents and creating a system for them to receive daily information about the child's classroom performance helps to maintain the consistency needed by the student. According to DuPaul and Stoner (1994) the 10 steps to incorporating this technique include:
1) Daily and/or weekly goals are stated in a positive manner, 2) both academic and behavioral goals are included, 3) a small number of goals are targeted at a time, 4) the teacher provides quantitative feedback about student performance, 5) feedback is provided by subject or class periods, 6) communication is made on a regular basis (either daily or weekly), 7) home-based contingencies are tied to school performance. Both short and long-term consequences are employed, 8) parental cooperation and involvement are solicited prior to implementation, 9) student input into goals and contingencies is solicited, particularly with older children and adolescents, and 10) goals and procedures are modified, as necessary. (p. 116)
Under Section 504 of the Rehabilitation Act of 1973, students with ADHD qualify for accommodations and modifications which could include: 1) minimizing distractions by sitting students away from windows, and doors, or near the teacher, 2) providing predictability, structure and a consistent routine, 3) giving parents a set of books to keep at home, 4) writing down the assignment in an assignment book and have the students' parents sign it daily to ensure that the student has shared the information with them, 5) motor breaks - allowing the student to run errands for the teacher, 6) using a stress ball, play dough, or another appropriate object to redirect overflow motor activity, 7) working in an alternative position/setting for example standing or kneeling at a desk or other writing surface instead of being required to sit, 8) giving visual reminders to return to a task, 9) extending time for written assignments, including classroom tests and standardized tests, 10) providing modifications of assignments, 11) demonstrating mastery of a subject by doing fewer items, 12) breaking down projects into smaller components with due dates for each, 13) providing organizational support in regular classrooms by paraprofessionals, or study buddies, 14) using color-coded folders and sticky notes to ensure correct materials are taken home for the current assignment, 15) checking of homework assignments by teacher or fellow student, and 16) allowing students to use tablets, laptops, and auditory trainers (Ryan-Krause, 2011). Although this is not a complete list of accommodations and modifications, teachers are always trying new methods to serve their students.
New teachers can ask mentors what successful strategies they have used. With all of these strategies, once implemented, the teacher is going to have to observe the student and keep a detailed log to see if the intervention is working or if new behaviors are appearing due to the chosen intervention.
Parent training. Parent management training involves teaching strategies to parents that will help reinforce appropriate behaviors. Parent training is a valuable strategy, as it focuses on finding the students' strengths, weaknesses, and helps parents understand that their child can learn, it may just be by using different methods. The ultimate goal of parent management training is to help parents become effective with behavior management. Some suggestions for parents to incorporate are: making consequences immediate and consistent, use of incentive programs, the use of time-out techniques, use of positive and negative reinforcements and hold family meetings to set goals and determine reinforcements (Ryan-Krause, 2010). The long term goal is to reduce disruptive behavior, decrease stress levels, and instill self-confidence in the child and in parenting abilities (Ryan-Krause).
A study was conducted on 10 adolescents, aged 11-15 and their parents to determine the effectiveness of behavior modification (Weijer-Bergsma, Formsma, Bruin, & Bögels, 2012). The authors used Mindful Parenting Training (MPD) for the parents, and mindfulness training for the adolescents. Both trainings were conducted in a group format, and were evaluated using questionnaires as well as computerized attention tests. Self-reporting occurred immediately after the completion of the training, and again eight weeks after and 16 weeks after the training. Following training, adolescents' attention and behavior problems reduced, while their executive functioning improved, as indicated by self-report measures as well as by father and teacher reports (Weijer-Bergsma et al.). Fathers, but not mothers, reported reduced parenting stress. Additionally, mothers reported reduced overreactive parenting, whereas fathers reported an increase (Weijer-Bergsma et al.).
Teachers are always learning and adapting their practice based on the needs of their students. There are times however for the sake of the child; a doctor might recommend medication to coincide with the behavior modifications being used at home and in the classroom.
Medications can help people with ADHD focus their attention and control their behavior, but medications do not teach people how to learn which is the job of parents and intervention specialists. According to DuPaul and Stoner (1994) more than 750,000 children are being treated annually, with psychostimulant medication being the most frequently prescribed medication for ADHD.
Stimulants work by stimulating the central nervous system (CNS), which heightens an individual's energy and alertness (Ryan & Hughes, 2011). The primary benefit of using a stimulant medication is the quickness in which it takes effect. The most commonly used stimulants include the medications described in the following sections.
Methylphenidate. Ritalin and Ritalin-SR (sustained release) are also sold in a generic form (Methylphenidate). The reported pros of this medication are that it works quickly (within 30 to 60 minutes), is effective in 70% of patients, and has a good safety record. Ritalin-SR is particularly useful for adolescents with ADHD to avoid taking a noontime dose (Flick, 1988). Precautions for this medication include that it is not recommended for patients with marked anxiety, motor tics, or with a family history of Tourette's syndrome (Flick). See dosage recommendations in Appendix B.
Dextroamphetamine. Dexedrine is also sold as Dextroamphetamine. As with Ritalin, this medication works quickly (within 30 to 60 minutes), allows individuals to avoid the noontime dose in dissolvable form and has an excellent safety record (Flick, 1998). This medication is not recommended for patients with marked anxiety, motor tics, or with a family history of Tourette's syndrome (Flick).
Premoline. Another commonly prescribed stimulant is Cylert, which goes by the generic name of Premoline. The benefit of this stimulant is that the dosage is given once daily. Precautions of Cylert include it has a slow onset of 2-4 weeks for a clinical response, and regular blood tests are needed to check liver function (Flick, 1998). Adderall is a relatively new stimulant used to treat ADHD and is not available in a generic form. Adderall was previously used in adults for weight loss (Flick).
In addition to psychostimulants, some students are prescribed antidepressants. Two antidepressants have been approved by the Food and Drug Administration (FDA) for the treatment of ADHD are Tofanil and Norpramin. Tofanil is also known as Desipramine Hydrochloride and is helpful for patients with co-morbid depression or anxiety and lasts throughout the day (Flick, 1998). Some noted precautions are that it may take up to two to four weeks for a clinical response; it can affect children with pre-existing cardiac conduction deficits, and requires a doctor's care to gradually stop taking it (Flick).
The second is Norpramin which is sold in generic form as Desipramine Hydrochloride. This medication has been effective for patients with ADHD with co-morbid depression or anxiety; and lasts throughout the day (Flick, 1998). The same precautions exist for Norpramin as with Tofanil.
The final medication consistently prescribed is Catapres also known as Clonidine Hydrochloride. This medication is an antihypertensive, which has demonstrated benefits for patients with co-morbid tic disorders or severe hyperactivity and aggression (Flick, 1998). Known precautions indicate that sudden discontinuation could result in rebound hypertension, and to avoid daytime tiredness, starting dosage should be given at bedtime and increased slowly (Flick).
Other medications currently being explored for the treatment of ADHD include: 1) Serotonin Re-Uptake Inhibitors which include Zoloft, Praxil and Effexor, 2) Tegretol, a mood stabilizer, 3) Mellaril which is a neuroleptic, 4) Inderal, a beta blocker, 5) atypical anxiolytics including BuSpar and, Lithium carbonate, and 6) other medications such as Auroix Maclobemide, Depakote, Haldol, Klonapin, and Resperidol (Flick, 1998).
According to DuPaul (1998) some factors that need to be considered when deciding to medicate are:
The apparent severity of the ADHD symptoms and the presence of disruptive behavior,
Prior treatments (e.g. behavioral) that may have failed,
The presence of anxiety (which lessens the probability of stimulants being successful),
The parents' attitude and knowledge towards medications,
The adequacy and competency of adult supervision, and
The child's attitude toward medication. (p. 153)
A study conducted in the United Kingdom on adverse drug reactions associated with ADHD medications in children received a response rate of 35.9% (Tobaiqy et al., 2011). The study determined that the most frequent side effects were loss of appetite, headaches, mood and emotional problems, stomach upset, sleep disturbance, rashes, and other skin problems (Tobaiqy et al.). Parents also reported drug-related symptoms using the tick-list approach. Using a tick-list, parents reported the most frequent symptoms as emotional problems, stomach and abdominal problems, insomnia, lack of appetite, hearing problems, coughing, blurred vision and suicidal ideation (Tobaiqy et al.). Symptoms such as these can inhibit a person's quality of life and need to be reported to medical personnel as soon as they appear. Professionals may need to change the current medication or adjust the dosage, but left untreated it may hinder rather than help the individual.
Since more children are being prescribed medications, DuPaul and Stoner (1994) recommend that school personnel become familiar with several aspects related to medical interventions. First, they must be familiar with the different medications used to treat ADHD and possible behavioral and side effects associated with medication. Next, they should understand the factors to consider in recommending medication trials for individual children, and the methods to assess treatment within school settings. Finally, they should know how to communicate assessment data to physicians and other medical professionals, and be aware of the limitations of pharmacotherapy.
Once medications are prescribed, teachers need to keep accurate records as to what they are observing about the child, such as being overly tired, cannot sit still, no change, or other behavioral manifestations. This information allows the parent to provide the prescribing physician with useful information to determine if the medication needs to be adjusted.
Effectiveness of the Strategies
Behavior modification. There are many benefits to the use of behavior modification, including that it is inexpensive for parents to incorporate compared to the cost of medication. The common goal of parents and teachers is to prepare children to become self-directed learners whose classroom achievement is similar to that of their peers (DuPaul & Stoner, 1994). For behavior modification to be fully effective, teachers and parents need to work together for the benefit of the student. This collaboration includes sharing current behaviors seen at school and at home, regular communication of how the student performed in school which should be done on a daily basis, and the strategies that are currently being incorporated.
Other benefits include giving students ownership of their behavior including the consequences, promoting social interaction through modeling by the students' peers, whole class implementation, providing immediate praise and corrective feedback, and can be personalized to fit the individual students needs without making students stand out unnecessarily (Gargiulo, 2012). Effective interventions produce or lead to increased rates of appropriate behavior and/or improved rates of learning, not solely decreases in undesirable or disturbing behavior (DuPaul & Stoner, 1994).
Kaff, Zabel and Milham (2007) asked 211 special education teachers about the use, effectiveness, and labor intensity of 24 communication and 33 behavior management strategies. Questionnaires were originally mailed to 400 teachers with a return of 211 or 53% of the surveys. The study showed special educators most often use behavior management approaches that are positive and intended to set the stage for appropriate behaviors (Kaff, Zabel, & Milham). The study found that special educators are most likely to establish classroom rules and routines, clarify expectations for student behavior, model appropriate behavior, monitor and provide feedback to students, and accommodate for individual differences (Kaff, Zabel, & Milham). As evidenced by the results of this study, the most effective strategies can be implemented at no cost to the school district.
Medication. Researchers attribute the effectiveness of medication to the drugs' ability to activate or enhance particular aspects of neurological functioning, by increasing the arousal level of the central nervous system (CNS). These drugs enable students with ADHD to concentrate better, control their impulsivity and distractibility, and to increase their attention span (Gargiulo, 2012). When medications are taken according to the physicians' directions they are safe with few side effects. These medications start to work in about half an hour, however, the peak effect on behavioral learning starts to drop after three to five hours (Green & Chee, 1998).
Research has shown that medication allows the child to self-monitor, plan his/her response and be reached by reason, reduce restlessness, keep the child focused on a task, improve classroom productivity, decrease impulsivity and disruptiveness, and improve interactions between students, parents, teachers, and peers (Green & Chee,1998). Teachers have reported the following benefits of medication in the classroom: less calling out in class, ability to get work finished without the need to be stood over, less rushed, ability to check for errors, more consistent written work, better organization, and improvements in playground behavior, grades, and confidence (Green & Chee). As with any decision affecting students, parents and guardians have the final say in the treatment.
Combination of behavioral modification and medication. The results of a large scale study conducted by Forness and Kavale (2001), suggested medication alone was more effective in changing behavior than behavioral treatment alone; however using both together produced the greatest effectiveness. The researchers observed that contrary to public perceptions, medication is prescribed less often than would be useful and that based on the neurobiological basis of such conditions, medication may be a valuable part of a scientifically-based intervention plan (Forness & Kavale). Clearly, neither approach is right for all children but a combination approach helps many, but not all students (Raymond, 2012).
There are many advantages to a combined approach. First, the behavioral component of treatment may be reduced in scope and complexity if combined with low dosages of medication (Pelham Jr., 1998). Second, the dose for most children can be reduced by 50 to 75% when medication is combined with a behavioral intervention. Third, these treatments often have complementary effects. The combined intervention appears to be more comprehensive in coverage than either treatment alone. Finally, there are several reasons to speculate that long-term maintenance of treatment effects might be improved with a combined intervention (Pelham Jr.).
There are several different views on what works best for students with ADHD. What works best for one student, might not work for another. This paper has reviewed the literature on several behavior modification techniques that teachers and parents have tried over the years and found to be successful. This review has also covered several types of medication that are currently being prescribed to students, and again, some parents and educators prefer this method. The question still remains whether teachers perceive a combination of medication and behavior modification techniques are better than either of them alone.
The purpose of this study was to evaluate teachers' perceptions of the use of behavior modification versus the use of medication. The following issues were addressed including: (1) what behavior modifications teachers have found to be effective in the classroom, (2) How teachers feel about the use of medication, (3) Teachers' perceptions of the effectiveness of the use of a combination of behavior modification and medication, (4) How often teachers communicate with the students' parents about the techniques being used in the class room and at home, and (5) What strategies teachers use to communicate with the students' parents about the techniques being used in the class room and at home.
An online survey was created using Qualtrics (an online survey tool) and a link to the survey was sent via email to superintendents of the two largest school districts in a rural Appalachian county in a Midwestern state. Each superintendent's office distributed the surveys to the teachers via email. Four weeks after the initial survey was sent, a follow-up to non-respondents was sent requesting completion of the questionnaire. Participants ranged in experience from 1 to 36 years. See Figure 1.
Figure 1. Number of participants by number of years taught.
A total of seventeen surveys were completed and returned. The respondents varied in the area of subjects being taught, ranging from general education to special education teachers. (See Figure 2).
Figure 2. Subject areas taught by participants.
The Midwestern Appalachian county where this study took place has an estimated population of 147,066 residents, covering 504.41 square miles. The closest cities are approximately a 40 minute drive to the north or to the south. The local Educational Service Center (ESC) that serves the region currently provides services for eight school districts. Many of these school districts are located in rural areas. The ESC currently has eight units (classrooms) serving children identified with multiple disabilities, which include: two K-2, two 3-6, one 7-9, two high school classrooms, and one intensive school. The county also provides preschool classes along with home schooling.
The survey was researcher-developed and contained a total of seven questions. It contained three forced-choice and four open-ended questions. Forced-choice questions asked the respondents to rate the use of medication only and the use of behavior modification only. Participants were asked to rank items on a 7-point scale ranging from very ineffective to very effective. The open-ended questions encouraged the respondents to elaborate on their responses to the forced-choice questions.
For each survey question, means, variances, and standard deviations were calculated when applicable. Based on aggregate responses, individual strategies were then ranked from very ineffective to very effective, to determine which strategy was perceived to be most successful for the participants in this study. Additionally the educators were asked to reflect on their rating of each question. Reflective comments were analyzed for common themes.
Effectiveness of behavior modification only. Participants were asked to rate the use of behavior modification only. Of the respondents, 24% (n = 4) reported that behavior modification only was effective, whereas; 12% (n = 2) stated that it was ineffective (see Figure 3). Most of the educators surveyed 88% (n = 15) reported that behavior modification was effective to various extents.
Figure 3. Effectiveness of behavior modification only for students with ADHD.
Most participants stated that behavior modification was somewhat effective, and stated the following: that students with moderate ADHD do well with organization skills and help staying on task, or being seated somewhere that limits distractions. Secondly; that behavior modification when done correctly and given appropriate time can help many people learn to handle their ADHD in ways that allow them to be successful in education and career goals. Of the four teachers who found behavior modification to be effective, they agreed that it just takes time and patience to find the correct strategy. Answers that fell in the ineffective category included students did not experience success for any length of time and that behavior modification strategies do not always work.
Effectiveness of medication only. The same educators were asked to rate the use of medication only. The results showed that 59% (n = 10) believed the use of medication only was somewhat effective, 23% (n = 4) thought the strategy was effective, and less than 1% (n = 1) believed that medication only was very effective (see Figure 4). Interestingly, teachers' ratings of medication only were the same as behavior modification only.
Figure 4. Effectiveness of medication only for students with ADHD.
The educators believed that if given in the right dose, it helps their students concentrate. It was concluded from the survey that educators think medication is necessary for some students but not for others. One teacher stated; "There are times when medication can have a negative effect. It can take a long time to find the correct dose and there are times when medication does not work at all. This year we have a student whose behavior became worse because of being put on medication." Others believe that medication is effective until it wears off, if another dose is not given during the school day.
Effectiveness of behavior modification and medication. This question asked teachers to rate the effectiveness of a combination of behavior modification and medication. The average mean = 6.06, standard deviation = .66, with a variance of .43. The results showed that 18% (n = 3) found this to be somewhat effective, 59% (n = 10) of educators found this to be effective, and 24% (n = 4) felt it was very effective (see figure 5).
Figure 5. Effectiveness of a combination of behavior modification and medication for students with ADHD.
All of the respondents stated they felt medication might increase concentration, but a behavior modification plan must be put into place to address the learned behavior of the student. Participants agreed that the more tools that are in place, the higher the chance the student has at achieving success. Teacher support through a consistent positive environment can make a huge difference in the student's ability to perform well in the classroom. One teacher states; "In my experience, a good balance between the two gives the student with ADHD and increased chance for success. Teacher support through a consistent, positive environment along with the right medication can make a huge difference in the student's ability to perform well in the classroom."
Strategies used. Educators were asked what types of behavior modification strategies they currently use in the classroom for students with ADHD. The most frequent behavior modifications used included: verbal/nonverbal cues, positive praise, rewards, and seating arrangements. Other techniques included: self-correction, redirecting, chunking assignments, peer work, breaks, graphic organizers, and fidgets.
As evidenced by the responses, what works for one student may not work for another. Educator must keep trying to find a strategy that will work for the individual student. Most teachers reported using one or more of the above strategies to help their students' achieve success in the classroom.
Notification of medication use. The respondents were asked if they were informed if their students are taking a prescribed medication, and if so, how are they informed. The responses to this question were that half were informed while the other half were not. The educators that were informed found out through the students' IEPs, the students' parents, guidance counselor, or notified by the school nurse. Of the respondents who said they were not informed, only one reported finding out from the student.
Frequency of communication with parent/guardian. Educators were asked how often they communicated with students' parents about the techniques being used in the classroom and at home. The responses were evenly divided among the choices with 24% reporting they communicate with parents less than once a month, and 18% saying they never communicate with parents. The results are reported in Figure 6. The average mean = 3.18, standard deviation = 1.67, and a variance of 2.78.
Figure 6. Frequency of communication between teacher and parents about strategies for students with ADHD.
These results leave several questions unanswered. For example: the educators that communicate with parents once a week, or 2 - 3 times a month do they see better results than those educators who never communicate with parents? Also do the educators share what they are doing in the classroom with the parents, and are they using the same techniques to get better results? Further research needs to be conducted to address the questions that have surfaced from the above responses.
Communication strategies. The final question addressed what strategies educators used to communicate with students' parents about the techniques being used in the classroom and at home. Of the responses received, 50% said they communicate through e-mails and phone calls. Other forms of communication included: (1) agenda book, (2) IEP reviews, (3) progress reports, (4) face to face, and (5) report cards. Only one respondent stated he/she did not communicate with parents since their students are considered adults.
This study was designed to determine if teachers believed medication alone was better than classroom management techniques, or if there was a need for a combination of both for students with ADHD. The results of this study are consistent with other findings stating that a combination of medication and behavior management techniques showed the greatest amount of improvement.
The respondents who all taught from 10 to 100 students diagnosed with ADHD agreed that medication alone is effective. Additionally, they felt behavior modification alone was equally effective as medication alone. Finally, participants also agreed that when behavior management techniques were used in combination with medication, they felt it had the greatest effect on their students.
These findings are consistent with literature that is beginning to accumulate to support this concept. Clearly, neither approach is right for all children but a combination approach helps many, but not all students (Raymond, 2012). Forness and Kavale (2001) also have conducted studies which have supported a combination of medication and behavior modification.
This study has left many unanswered question such as: if educators would communicate more closely with parents, would the student's behavior continue to improve and possibly stay consistent. Consistency would be ideal for the student even over the summer, but is this even realistic if teachers and parents are currently not in consistent communication with one another. Other questions include do parents and teachers rely too heavily on medications to control students they believe have a problem such as ADHD? Further research needs to be conducted to answer questions such as the ones that have been left unanswered by this research.
Implications for Practice
The findings of this study can be very beneficial for educators who are looking for behavior management techniques, or would like to know more about a medication that is prescribed to one of their students. Most teachers do not know the side effects of medications used to treat the symptoms of ADHD, and may think the student's behavior is normal. The more information the educator have the better off the students will be.
One simple strategy that can be implemented to improve services to students with ADHD would be to simply communicate with parents. If parents and teachers are using the same behavior management techniques and study habits with these students, the more consistency it provides for the students. Students with ADHD need consistency to help keep them organized and to help keep their behavior under control.
These interventions can improve educational practices and help students achieve the success they are capable of. There is a need for routine, student's with ADHD are no different, they just need help achieving a consistent routine they can adjust too. Consistency is a major factor in the lives of these children and parents and educators need to do whatever it takes to help them achieve consistency so they can be successful in and outside of the classroom.
In this review of the current research on ADHD, a few techniques for use in the classroom and at home were presented. Research continues to evaluate new interventions, as well as test new, and monitor current medications that may be taken alone or in combination to have the maximum benefit for patients with ADHD. A single cause of Attention Deficit/Hyperactivity is still unknown and for the most part, finding the true cause of this disorder may never be possible, however, with the advances in brain imagery, only time will tell. As was noted, assessment procedures are far from precise and often do not accurately diagnose this disorder. Research has come a long way in helping to develop an understanding of this disorder, but is far from finding a cure to help those who are currently dealing with symptoms of ADHD and the effects on their quality of life. The question remains, would classroom management techniques along with medications be more beneficial to students than either of these interventions alone. The current research has tried to answer some of the questions educators may have when they are teaching students diagnosed with ADHD.