Strategies for Implementing

Evidence-Based Psychosocial
Interventions for Children with
Attention-Deficit/Hyperactivity
Disorder
Ricardo B. Eiraldi, PhDa,b,*, Jennifer A. Mautone, PhDb,
Thomas J. Power, PhDa,b

KEYWORDS
• Attention deficit hyperactivity disorder
• Evidence-based psychosocial interventions
• School intervention

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent, chronic disorder

affecting millions of children. Current prevalence estimates range between 5% and
10% of the child and adolescent population in the United States.1–3 The Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV,
TR)1 defines 3 subtypes of ADHD: ADHD, combined type (ie, elevated symptoms of
inattention and hyperactivity/impulsivity); ADHD, predominantly inattentive type (ie,
symptoms of inattention in the absence of clinically significant symptoms of hyper-
activity/impulsivity), and ADHD, predominantly hyperactive/impulsive type (ie, symp-
toms of hyperactivity/impulsivity in the absence of symptoms of inattention).
Children with ADHD frequently experience impairment related to academic perfor-
mance (eg, lower achievement test scores, higher rates of grade retention)4,5 and
social interactions, including strained relationships with parents, siblings, teachers,
and peers.6,7 Because of challenging classroom behavior (eg, significant time off task,
frequent rule violations, failure to comply with teacher instructions),8 teachers often

This project was supported by grant R01MH068290 funded by the National Institute of Mental
Health and the Department of Education, K23064080 and R34MH080782 funded by the National
Institute of Mental Health, and R40MC08964 funded by the Maternal and Child Health Bureau.
The authors have nothing to disclose.
a
Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine,
Philadelphia, PA, USA
b
Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children’s
Hospital of Philadelphia, 3440 Market Street, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: eiraldi@mail.med.upenn.edu

Child Adolesc Psychiatric Clin N Am 21 (2012) 145–159

doi:10.1016/j.chc.2011.08.012 childpsych.theclinics.com
1056-4993/12/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
146 Eiraldi et al

spend a significant amount of time providing support to children with ADHD, which
may result in conflict in the student-teacher relationship.6 Also, because of behavioral
difficulty at home, children with ADHD frequently have stressful and conflicting
interactions with their parents, which negatively impact parent-child relationships and
parents’ ability to support their children’s education.2 In addition, conflict between
families and schools is common among children with ADHD, which further contributes
to school problems. This conflict may result from parental dissatisfaction with the
teacher’s attempts to meet the educational needs of the child as well as teacher
concerns about the child’s disruptive behavior in the classroom and strained
communications with parents.6 Additionally, parents of children with ADHD often feel
less effective in their efforts to support their children’s education and feel less
welcome in schools compared with the parents of children without ADHD.9 Thus,
because students with ADHD experience considerable educational impairment and
challenges relating to parents and teachers, there is a need for a comprehensive
intervention plan that targets the child’s behavior at home and school, academic
performance, and parent-child and family-school relationships.
Treatments to support children with ADHD include pharmacotherapy, most com-
monly stimulant medication, and psychosocial interventions that are implemented at
home and school, including strategies to support family-school collaboration. Psy-
chosocial interventions include strategies to address performance deficits (ie, situa-
tions in which the child knows how to perform a particular skill but does not do so
consistently) and skills deficits (ie, situations in which the child does not yet posses a
skill or performs the skill suboptimally). Interventions aimed at performance deficits
include environmental adaptations and accommodations to intervene at the point of
performance, such as techniques to modify the antecedents and consequences in the
environment to change child behavior.10 Interventions aimed at skills deficits include
direct instruction and increasing opportunities for repeated practice of new skills. The
purpose of this report is to describe evidence-based psychosocial interventions
(EBIs) targeting both performance and skills deficits that can be applied to address
the educational needs of children and adolescents with ADHD. (Readers are directed
to key references 2, 10, 13, 16, 17, 23, 41, 47, 55, 66, and 69, for more in-depth
information. Resources are provided in Box 1.)

SCHOOL INTERVENTION STRATEGIES

In many ways, schools are the ideal setting for the implementation of interventions for
ADHD. School-based services are easy to access by children and are provided in a
normalized setting in which the stigma often associated with receiving behavioral
health services in traditional clinic settings is minimized.11,12 Schools are the setting
of choice for the implementation of EBIs aimed at preventing or minimizing academic,
peer-social, and behavior problems, which are common areas of impairment in
children with ADHD.
Children with ADHD often do poorly in unstructured and unpredictable environ-
ments. A basic recommendation for teachers is to make the classroom environment
more structured and more predictable for children with ADHD. As a group, children
with symptoms of ADHD are more likely to exhibit disruptive and rule-breaking
behavior. These children are less likely to require disciplinary intervention and are
more likely to work up to their academic potential when school professionals establish
clear behavior rules and a system of consequences that are applied consistently in all
areas of the school.
 Children with Attention-Deficit/Hyperactivity Disorder 147

Box 1
Key resources

Schoolwide interventions: OSEP Center on Positive Behavioral Interventions and Supports:

Effective School-wide Interventions: www.PBIS.org
Special Accommodations: National Resource Center on AD/HD, Children and Adults with ADHD
(CHADD): http://www.chadd.org/
Token Economy/Point Systems: Center for Children and Families: http://ccf.buffalo.edu/pdf/
school_daily_report_card.pdf
National Initiative for Healthcare Quality (NIHCQ) – ADHD Toolkit: http://www.nichq.org/resources/
adhd_toolkit.html
Social Skills: Children and Adults with ADHD (CHADD): http://www.chadd.org/Content/CHADD/
EFParents/SocialSkillsforChildren/default.htm
Behavioral Parent Training: Parent-child interaction therapy (Bell & Eyberg 2002); http://pcit.phhp.
ufl.edu
The Incredible Years (Webster-Stratton, 2005); www.incredibleyears.com
Family School Partnerships: Conjoint Behavioral Consultation: Promoting Family-School Connec-
tions and Interventions23

Schoolwide Strategies
A growing number of schools around the country have been experimenting with
school-wide approaches to improving school climate. Some of these programs have
been found to be effective in reducing the need for school disciplinary actions,
decreasing the incidence of behavior problems, and making schools safer. Two of
these approaches are response to intervention13–15 and effective behavioral sup-
ports, or schoolwide positive behavior support,16 –21 referred to as positive behavior
support (PBS) hereafter. Given its emphasis on targeting school climate, PBS is
highlighted.

Positive behavior support

PBS is a service delivery system for prevention and intervention for all children. PBS
has been defined as “a systems approach to enhancing the capacity of schools to
adopt and sustain the use of effective practices for all students.”19 The practices and
systems of PBS are organized along a 3-tiered continuum of prevention with a
behavioral theoretical orientation and the empirical foundation of applied behavior
analysis. Primary prevention strategies focus on preventing new cases of problem
behaviors by using schoolwide (universal) strategies such as schoolwide discipline,
classroomwide behavior management, and effective instructional practices. Empha-
sis is placed on teaching all students key behavioral expectations and routines and
creating a proactive means of communication for students and school staff. This is
the most common application of PBS. Some PBS programs also offer targeted
group-based support for at-risk children (secondary prevention) and individualized
support for more severe cases (tertiary prevention).

Use of expert consultants

With some training and support, EBIs for ADHD can be implemented by teachers and
behavioral health staff.22 Expert consultants, such as child and adolescent psychia-
trists, school and clinical psychologists, and other behavioral health professionals can
148 Eiraldi et al

play an important role in the deployment of EBIs for ADHD in the school setting. They
can assist school districts with the development of systems and mechanisms for the
use of EBIs and provide training and support to behavioral health staff. The same
approach can be used for ensuring that interventions are implemented in a culturally
sensitive manner.
An efficient and cost-effective method that has the potential to affect many schools
within a district is the “train the trainer” approach. In this approach, the consultant
trains and supervises senior clinicians in the district with the responsibility for
providing support to individual behavioral health staff. Some school districts around
the country already use similar systems, particularly those that have adapted PBS. In
the typical deployment of PBS to a new school, a leadership team is created, and its
members are trained and supported throughout the process of developing and
implementing universal and targeted interventions in the school. A key member of the
PBS leadership team is the PBS coach. The PBS coach, usually a professional who
has received training in applied behavior analysis, is responsible for supporting school
personnel in the actual implementation of interventions by helping troubleshoot
barriers and providing technical assistance. With some modifications to address the
needs of children with specific disorders such as ADHD, PBS coaches can be trained
to provide support to behavioral health staff and teachers in the implementation of
universal and individualized behavioral interventions for the classroom and other
areas of the school. For example, the PBS coach could be trained in the use of
interventions that address performance and skills deficits that can be imple-
mented in a multitier program to improve school climate and to serve the unique
needs of children with ADHD. Similarly, the PBS coach can be trained in the
formation of school-home partnerships and the use of conjoint behavioral
consultation (CBC). CBC is a structured problem-solving process in which parents
and teachers work as partners through the 4 stages of behavioral consultation: (1)
problem identification, (2) problem analysis, (3) plan implementation, and (4) plan
evaluation.23 CBC has been found to be effective for externalizing behavior
problems at home,24,25 behavioral control at school,26 and social skills develop-
ment with peers as rated by parents and teachers.27 In this manner, the expert
school consultant could have a great impact on the way children with ADHD are
supported throughout an entire school district. This type of service could be
reimbursed using various federal and state funding mechanisms as well as by
research or training grants from federal agencies.28

Strategies to Support Individual Students

In addition to PBS strategies, which are designed to address the behavioral
performance of all students in the school, teachers of students with ADHD are often
charged with the task of adapting classroom routines and expectations to minimize
the effects of the individual student’s deficits on performance. This is often done via
an individualized education plan provided in the context of special education or an
individualized service plan under Section 504 of the Rehabilitation Act of 1973,29 and
it involves modifications to routine classroom work, tests and quizzes, and homework
assignments for the child with ADHD. Common special accommodations for the
classroom include using a modified seating arrangement whereby the child sits closer
to the teacher and away from sources of potential environmental distractions, such as
doors, windows, or other children with attention problems, and using a private
attention cue by the teacher to prompt the student to stay on task.30 Also, students
with ADHD can be given extended time for completing tests or allowed to take tests
 Children with Attention-Deficit/Hyperactivity Disorder 149

in a quiet room.31 Checking assignment books for accuracy and reducing homework
load or individualizing homework assignments can also be used.
As a group, children with ADHD lag behind their peers without ADHD in perfor-
mance and on the acquisition of important skills that affect academic productivity,
classroom behavior, and peer relations. Compared with children without ADHD,
children with ADHD are more likely to have impaired planning ability, poor sense of
time and inaccurate time estimation, lack of effort and motivation, poor self-regulation
of emotion, greater problems with frustration tolerance (which results in academic
performance problems), disruptive classroom behavior, and peer difficulties.32 These
deficits are generally chronic. Many interventions have proven to be effective, but
gains are sustained only if interventions remain in place in the settings and during
times when the child experiences difficulties.32,33 Given that most difficulties experi-
enced by children with ADHD occur because of performance deficits, most interven-
tions are geared toward enhancing performance, such as improving impulse control
or time on task.10 For children who lack skills in the first place, interventions are
focused on teaching new skills, such as social and organizational skills.34 Most
effective school-based interventions for ADHD are designed to affect the antecedents
or consequences of behavior. An example of an antecedent of a behavior would be
the way in which a teacher gives a command to a student.35 Consequences can be
defined as responses that follow a behavior that has the effect of either increasing or
decreasing the probability that the behavior will occur again.35

Positive reinforcement
There are many interventions that involve a modification of antecedents and conse-
quences. Although many of the interventions based on the modification of anteced-
ents and consequences have traditionally been included in parent training programs,
they are also used in schools and can be taught to teachers. These strategies are
based in social learning theory and are used to teach teachers how to alter the
antecedents and contingencies in the environment to shape child behavior. Many
empirically supported programs include components such as (1) setting consistent
limits and reasonable expectations, (2) giving instructions in a clear and consistent
manner, (3) providing positive reinforcement contingent on appropriate behavior, and
(4) using effective and strategic consequences for specifically identified inappropriate
behavior.36 Teachers learn how to set limits and give instructions that are specific,
clear, and brief; focus on behaviors that are within the child’s control; and develop
expectations that are developmentally appropriate for the child.37,38 Also, a primary
goal of behavioral intervention programs is to increase teachers’ use of positive
reinforcement contingent upon appropriate behavior. Specifically, teachers can
provide attention and verbal praise as positive reinforcement when students demon-
strate expected behavior and systematically ignore inappropriate behavior (ie, differ-
ential attention). Teachers learn that attention, especially when delivered immediately
after appropriate behavior (ie, at the “point of performance”), can increase the
likelihood of a desired behavior and that the goal of ignoring behavior is to decrease
the frequency with which it occurs.
Positive attending (ie, making positive statements in response to appropriate child
behavior) is highly useful in strengthening the teacher-child relationship. Because
children with ADHD frequently receive negative feedback from teachers because of
inappropriate behavior, teacher-child relationships are frequently strained. As teach-
ers learn how to utilize positive attending more regularly, interactions between
teachers and children become more positive.
150 Eiraldi et al

Token economy
Token or point systems require teachers to dispense tokens (eg, poker chips, stickers)
or points to any student in the class (as a classwide intervention) or to individual
students with ADHD (as an individualized intervention) for exhibiting previously
determined behavior. This intervention can be used for increasing on-task behavior or
appropriate classroom behavior. The reinforcement can be delivered immediately
after the student exhibits the behavior or at another specified time (eg, at the end of
a class period). It is very important that the teacher target a very specific skill or
behavior as opposed to more general or global behaviors (eg, “raising hand before
speaking” as opposed to “behaving well in class”). This intervention is more effective
when it is paired with a reinforcement system in which the student can exchange
tokens or points for preferred activities or small prizes. Also, the token/point system
intervention is more effective when the child is given the opportunity to choose from
a menu of reinforcements and when the system is consistently implemented by
teachers.10,39 Some children with ADHD respond to the token/point system only
when the intervention combines positive reinforcement and response cost.40 In this
variation of the token/point system, the child can earn points or other reinforcers for
exhibiting a specified desirable behavior but loses them when he exhibits a specified
undesirable behavior. This combination is effective because it offers the child the
opportunity to earn back lost tokens/points by exhibiting the desirable behavior.

Daily report card

The daily report card (DRC) is a behavioral intervention with strong research
support41,42 that can be developed using the CBC model. This intervention requires
planning that involves the school and the family with input from the child, implemen-
tation with elements involving the teacher and parents, and evaluation of implemen-
tation quality and outcomes. (See Box 2 for guidelines related to developing a DRC.)
As indicated in step 5, monitoring quality of implementation and child progress
toward behavioral goals are important components of the intervention process. When
the DRC intervention is not implemented properly, its effectiveness can be compro-
mised.41,42 Implementation quality can be monitored by reviewing completed DRCs
on a periodic basis to determine (1) whether it has been completed by teachers each
day, (2) whether the child has delivered the DRC to the parents each day, (3) whether
the parents evaluated child performance in relationship to an established goal, and (4)
whether reinforcers have been administered as planned. With regard to monitoring
outcomes, a strategy that is easy to use is to keep track of the number of points
earned by the child on the DRC each day or calculate the percentage of days for
which the child attains his or her goal. For cases in which implementation quality of
the DRC in the home setting is inconsistent, it may be possible to conduct the
evaluation and reinforcement phases of the intervention at school.
Considerable evidence supports the effectiveness of the DRC intervention with
children who have ADHD and related behavioral problems. In addition, the DRC has
been found to be an intervention approach that is highly acceptable and feasible for
teachers.

Self-management
Self-management, which includes self-monitoring and self-reinforcement, can be an
effective intervention for maintaining and generalizing behavioral gains made through
the use of the token/point system, especially for older children.43– 45 In this interven-
tion, children are taught to recognize and record instances of on-task behavior after
an auditory or visual stimulus at time intervals (eg, a beep from a recording device or
 Children with Attention-Deficit/Hyperactivity Disorder 151

Box 2
Constructing a daily report card

Step 1: Identify 2 or 3 target behaviors

• These should be adaptive behaviors for the classroom (eg, “complete work in time allotted”)
rather than nonadaptive responses (eg, “fails to complete work”)
• Consider including the child in the process to increase child investment
Step 2: Identify a method for recording child behavior
• Option 1: Tally the occurrence of target behavior (this option is more challenging for teachers—
consider feasibility issues)
• Option 2: Rate the child’s behavior on a 3- or 4-point scale at designated times (eg, 0 ⫽ met
goals 0%–25% of the time to 3 ⫽ met goals 75%–100% of the time). Ratings should be given
at several times throughout the day (eg, at the end of each class period)
Step 3: Educate parents about the use of the DRC
• Set reasonable goals for child behavior each day. Goals should be about 10% higher than
baseline performance
• Reinforce the child for goal attainment. The child might earn privileges at home each time he or
she reaches a goal at school
Step 4: Educate the child about the DRC goals; parent, teacher,and child roles; and opportunities
for rewards contingent on appropriate behavior
Step 5: Monitor implementation and outcomes
• Review completed DRCs to ensure proper daily use by parents and teachers
• Adjust goals according to child progress

a hand signal from the teacher).39 Initially, the teacher keeps a parallel count of the
student’s on-task behavior to assess the accuracy of the student’s own recording. As
the student becomes more accurate in recording the presence of the target behavior,
the involvement of the teacher is gradually phased out until the student is in complete
control of the intervention. Self-management can be used in conjunction with an
incentive system through which the student can reward himself for reaching certain
target goals.39 This intervention can be used to increase on-task behavior but also to
improve academic accuracy and organizational skills.46,47

Social skills training

There has been a considerable amount of research on the effects of social skills
training for children with ADHD.48,49 For the most part, studies have found that social
skills training can be effective but only when it is part of intense, multimodal
behavioral interventions focusing on multiple areas of impairment and conducted
within the child’s social milieu.50 Traditional social skills training conducted in clinical
settings, away from the environments in which these children have relationship
problems, lack social validity and, for the most part, result in little to no improvement
in social functioning.10 In contrast, a growing body of evidence shows that partici-
pation in the intense programming offered in summer treatment programs (STPs) for
children with ADHD, such as the one used in the Multimodal Treatment Study for
ADHD,50 results in long-lasting improvement in behavioral functioning, social skills,
and peer relations. These interventions are typically conducted for 6 to 8 hours a day,
5 days a week, for a period of many weeks. The STP interventions involve social skills
training followed by coached recreational activities and the use of contigency
behavior management systems, such as token/point systems and concurrent home
rewards given to the child by the parents for meeting goals related to peer
152 Eiraldi et al

relations. The behavioral effects of STPs on children’s externalizing behavior and

peer relations are comparable with those obtained through psychostimulant
medication treatment.45

Organizational skills training

Children with ADHD frequently have difficulty in organizing materials, which can
impact performance at school and at home (eg, failure to bring home materials
necessary for homework, failure to return completed assignments to school).51,52 If
children with ADHD do not learn effective organizational skills, they are likely to
continue to have difficulties into adulthood, which can impact postsecondary educa-
tion or employment function.53 Although medication treatment results in improved
organizational skills for some children with ADHD, many children with ADHD who are
treated with medication continue to display deficits in this area.54
Strategy training involves teaching students academic strategies or skills that can
be used to improve academic performance.55 Most of these interventions target
students’ ability to take accurate notes, organize their school materials, and organize
their study time more efficiently.55,56 Organizational skills training aims at giving the
student more responsibility and a sense of ownership of academic performance and
lessening the involvement of teachers and parents. These interventions have been
developed in recognition of the increased demands placed on middle school and high
school students to understand and synthesize materials from classroom lectures in
multiple subjects.57 For example, studies have been conducted with adolescents with
ADHD in which they were taught how to take notes during classroom lectures, how to
write down homework assignments with accuracy, how to organize their school
binders and other school materials, and how to memorize information to help them
study for tests and exams.58 As with other interventions for students with ADHD, the
effectiveness of organizational skills training is enhanced through the use of contin-
gency reinforcement.

Behavioral homework interventions

These interventions are designed to address problems with homework completion,
which are highly prevalent among children with ADHD.52,59 Homework is a fruitful
target for intervention because improving homework performance has the potential to
improve the family-school relationship and contribute to academic success.
Homework interventions have 2 primary elements: antecedent strategies that
create the context for homework performance and consequences, which refer to the
contingencies of homework behavior. Antecedent strategies include teacher assign-
ment of a reasonable amount of homework given the child’s age, developmental
ability, and attention skills, as well as teacher assignment of work that can be
completed by the child with minimal parental instruction and supervision (ie, rein-
forcement learning, not new skill acquisition). Antecedent strategies also involve
establishing a place for homework that is relatively free from distraction and
delineating a time for homework that is responsive to times of the day during which
children are most attentive and parents are able to monitor homework carefully.60
Homework strategies that address both the antecedents and consequences of
homework are goal setting and contingency contracting.61,62 These strategies have
multiple steps. First, when it is time for homework, the parent and child review
together the assignments and break up the work into manageable subunits that can
be completed before taking a brief break. The length of the subunits might vary from
5 minutes for a first grader to 20 minutes for a fifth grader, although this assumes a
relatively good attention span. Second, the parent and child select the first subunit to
 Children with Attention-Deficit/Hyperactivity Disorder 153

work on, which is typically an assignment that is relatively easy for the child, which
helps to build momentum for completing other assignments. Before working on the
subunit, the parent and child look over the assignment and mutually identify
reasonable goals for number of problems to be completed, number of correct
responses, and amount of time.
Third, before beginning each assignment, the parent checks to make sure the child
understands the directions and knows how to complete the task. Then, the parent
sets a timer and the child begins work. While the child is working, it is important for
the parent to monitor child performance carefully, reinforce attention and effort
periodically, and refrain from reinforcing avoidant or inattention behavior. Fourth,
when the time has expired, the parent and child evaluate work completion and
accuracy and compare performance to goals. If the child reaches the goals, he or she
earns points that can be exchanged later for privileges. If the child fails to achieve the
goal, or achieves accuracy but does not complete all the work, the child is requested
to move to the next assignment and not go back over the work. In this way, all the
homework assignments can be completed in a reasonable amount of time. In these
cases, it is important for the parent to communicate with the teacher so that the child
is rewarded for effort and does not get penalized for incomplete work.

Computer-assisted instruction
Children with ADHD frequently exhibit academic skills deficits, including problems
with comprehension and retrieval of basic facts. If tasks are novel and stimulating,
structured to match the child’s individual instructional level, and children receive
regular feedback about their performance29,63 then children with ADHD tend to
exhibit increased academic success. Computer-assisted instruction is one strategy
that may provide the necessary conditions for supporting the academic skills
development of children with ADHD.64,65 Computer-assisted instruction allows for
lessons and specific goals to be tailored to each child’s instructional level, the learning
environment tends to be more stimulating than typical paper and pencil classroom
tasks, and children receive immediate feedback from the computer about the
accuracy of their responses.64

SPECIAL CONSIDERATIONS

Most of the intervention strategies described in this article are appropriate for
elementary-age children with ADHD, reflecting the preponderance of research
conducted with this age group. Less research has been conducted with preschool-
age children and even less with adolescents who have ADHD. Several factors are
important to consider when developing or adapting interventions for preschool and
adolescent youth.
For preschoolers, a useful strategy to strengthen the parent-child relationship or
the teacher-student relationship is for parents or teachers to engage children in
nondirective play, which involves carefully observing the child’s play, refraining from
making directive statements, and affirming creative elements of the play.66 When
using reinforcement strategies with this age group, it is especially important to
administer reinforcers as soon as possible after the desired behavior occurs and to do
so using salient, concrete reinforcers. If response cost is used as a method of
punishment (eg, taking away a desired toy), the duration of withdrawal required is
typically very brief to be effective.67
For adolescents, strengthening the parent-child or teacher-student relationship
might involve giving the youth a chance to “show-and-tell” about an exciting event
and listening carefully. When designing goal setting strategies and contingency
154 Eiraldi et al

contracts, it is essential to collaborate closely with the youth and negotiate the terms
of the arrangement. Points can be administered as reinforcers, and these can be
exchanged for privileges administered at a later time (eg, on the weekend). When
identifying suitable consequences, it is often helpful to negotiate with the youth up
front so they know what to expect when expectations are not met.68 Organizational
interventions have been developed for middle school and high school students with
ADHD, and these can be highly effective in completing homework, organizing the
school binder, and keeping track of the school schedule.69 School support in the form
of a check-in teacher or guidance counselor can be very helpful in implementing and
sustaining organizational interventions.
Schools in the United States have become increasingly diverse during the last 20
years. By the year 2019, it is estimated that ethnic minority students will comprise
50% of the total public school student population.70 Research has consistently
shown that low-income and ethnic minority families are less likely than nonminority
families to seek and utilize services for ADHD.71,72 If these families do initiate
treatment, they often are at risk for early termination.73 Although research assessing
the unique effects of culture and socioeconomic status on service utilization is
lacking, most investigators agree that assessing families’ opinions and attitudes
about the causes and the treatment of ADHD is necessary to develop a treatment plan
that these families are likely to follow.74 Also, low-income and ethnic minority families
may be more likely to stay in treatment if they are involved in the development and
implementation of the interventions. A strategy that is appropriate for use by school
behavioral health staff and that involves families is the formation of school-home
partnerships.75 A partnership approach, such as CBC (described above), greatly
facilitates the adoption of culturally sensitive interventions, because the parent, who
is given equal standing in the relationship with school personnel, can contribute to the
development of interventions that are congruent with their expectations about
treatment and school goals.23,75,76 The use of school-home partnerships is not
common outside demonstration projects, and few behavioral health staff members
have been trained in the use of CBC. However, this and other promising models of
service delivery could be deployed more widely in school settings to great positive
effect with the aid of expert consultants.
Pharmacologic interventions, including stimulants and some nonstimulant options,
such as atomoxetine, are effective in the treatment of ADHD. Although medication
alone can be effective in treating the symptoms and impairments associated with
ADHD, there often is an advantage to combining medication with behavioral inter-
vention, especially with regard to improving areas of impaired executive functioning.77
Further, families typically view medication as an acceptable form of intervention when
it is used in combination with behavior therapy.78 The selection of an initial approach
to treatment (ie, medication alone, behavior therapy alone, combined treatment) is
based on shared decision making involving the family, school professionals, and the
health care team, taking into consideration the child’s likelihood of responding
favorably, potential for adverse effects, treatment history, and family beliefs and
preferences for intervention. Subsequent decisions (eg, decision to combine medi-
cation with behavior therapy) is based on response to previous attempts at treatment
and family beliefs, which can vary during the course of intervention.79
SUMMARY

An extensive amount of research has demonstrated the effectiveness of psychosocial

interventions for children with ADHD. Historically, the research has focused on
interventions targeting problems in the home or school setting, but more recent
 Children with Attention-Deficit/Hyperactivity Disorder 155

research has highlighted the importance of family-school partnerships and conjoint

approaches to intervention involving family and school. Effective approaches to
psychosocial intervention consist of strategies to address performance deficits,
promote adaptive behavior, and improve children’s self-control and academic and
social skills. Although most of the research has focused on interventions for
elementary-age children, there is an increasing emphasis on developing and validat-
ing approaches for younger and older children. With preschoolers there is greater
emphasis on addressing performance deficits, and with adolescents there is in-
creased emphasis on skill building and generalization of skills across settings. In
addition, there is a strong need to adapt psychosocial interventions so that they are
meaningful and acceptable to families of diverse ethnic backgrounds; fostering strong
family-school partnerships is a key strategy for developing culturally effective
psychosocial interventions for ADHD. Finally, given the abundance of evidence
supporting the effectiveness of medication as well as psychosocial treatments for
ADHD, integrating both approaches to interventions is often the optimal approach.
There is considerable evidence to indicate that combined approaches are more
effective in reducing ADHD symptoms and related academic and social impairments
than separate treatments.

REFERENCES

1. American Psychiatric Association. Diagnostic and statistical manual of mental disor-

ders, 4th edition. Washington, DC, 2000.
2. *Barkley RA. Attention deficit hyperactivity disorder: a handbook for diagnosis and
treatment, 3rd edition. New York: Guilford Press; 2006.
3. Polanczyk G, Silva de Lima M, Horta BL, et al. The worldwide prevalence of ADHD:
a systematic review and metaregression analysis. Am J Psychiatry 2007;164:
942– 48.
4. Barkley RA, DuPaul GJ, McMurray MB. Comprehensive evaluation of attention-deficit
disorder with and without hyperactivity as defined by research criteria. J Consult Clin
Psychol 1990;58:775– 89.
5. Marshall RM, Hynd GW, Handwerk MJ, et al. Academic underachievement in ADHD
subtypes. J Learn Disabil 1997;30:635– 42.
6. Greene RW, Beszterczey SK, Katzenstein T, et al. Are students with ADHD more
stressful to teach? Patterns of teacher stress in an elementary school sample. J Emot
Behav Disord 2002;10:79 – 89.
7. Johnston C, Mash EJ: Families of children with attention-deficit/hyperactivity disorder:
Review and recommendations for future research. Clin Child Family Psychol Rev
2001;4:183–207.
8. Atkins MS, Pelham WE, Licht MH. The Differential validity of teacher ratings of
inattention, overactivity, and aggression. J Abnorm Child Psychol 1989;17:
423–35.
9. Rogers MA, Wiener J, Marton I, et al. Parental involvement in children’s learning:
comparing parents of children with and without attention-deficit/hyperactivity disorder
(ADHD). J School Psychol 2009;47:167– 85.
10. *Pelham WE, Fabiano GA. Evidence-based psychosocial treatments for attention-
deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 2008;37:184 –214.
11. Owens PL, Hoagwood K, Horwitz SM, et al. Barriers to children’s mental health
services. J Am Acad Child Adolesc Psychiatry 2002;41:731– 8.
12. Stephan SH, Weist M, Kataoka S, et al. Transformation of children’s mental health
services: the role of school mental health. Psychiatric Services 2007;58:1330 – 8.
156 Eiraldi et al

13. *DuPaul GJ, Stoner G. Interventions for attention deficit hyperactivity disorder. In:
Shinn MR, Walker HM, Stoner G, editors. Interventions for achievement and behavior
problems in a three-tiered model including RTI. Bethesda, MD: National Association
of School Psychologists; 2010. p. 825– 48.
14. Jimerson SR, Burns MK, Van Der Heyden AM. Handbook of response to intervention:
the science and practice of assessment and intervention. New York, NY: Springer
Science⫹Business Media, LLC; 2007.
15. Sugai G, Horner RH, Gresham F. Behaviorally effective school environments. In: Shinn
MR, Walker HM, Stoner G, editors. Interventions for academic and behavior problems
2: preventative and remedial approaches. Bethesda, MD: National Association of
School Psychologists; 2002. p. 315–50.
16. *Bradshaw CP, Mitchell MM, Leaf PJ. Examining the effects of schoolwide positive
behavioral interventions and supports on student outcomes. Journal of Positive
Behavior Interventions 2010;12:133– 48.
17. *Horner RH, Sugai G, Smolkowski K, et al. A randomized, wait-list controlled effec-
tiveness trial assessing school-wide positive behavior support in elementary schools.
ournal of Positive Behavior Interventions 2009;11:133– 44.
18. Kartub DT, Taylor-Greene S, March RE, et al. Reducing hallway noise: a systems
approach. Journal of Positive Behavior Interventions 2000;2:179 – 82.
19. Lewis TJ, Sugai G. Effective behavior support: a systems approach to proactive
schoolwide management. Focus on Exceptional Children 1999;31:1–24.
20. Sugai G, Horner R. The evolution of discipline practices: school-wide positive behav-
ior supports. Child Fam Behav Ther 2002;24:23–50.
21. Sugai G, Horner RH, Todd A, et al. School-wide positive behavior support. In:
Bambara L, Kern L, editors. Individualized supports for students with problem
behaviors: designing positive behavior plans. New York, NY: Guilford Press; 2005. p.
359 –70.
22. Rappaport N, Osher D, Greenberg-Garrison E, et al. Enhancing collaboration within
and across disciplines to advance mental health programs in schools. In: West MD,
Evans SW, Lever NA, editors. Handbook of school mental health: advancing practice
and research. New York: Kluwer Academic/Plenum Publishers; 2003. p. 107.
23. *Sheridan SM, Kratochwill TR. Conjoint behavioral consultation: promoting family-
school connections and interventions, 2nd edition. New York, NY: Springer Science ⫹
Business Media; 2008.
24. Illsley SD, Sladeczek IE. Conjoint behavioral consultation: outcome measures beyond
the client level. J Educ Psychol Consult 2001;12:397.
25. Kratochwill T, Elliot S, Loitz P, et al: Conjoint consultation using self-administered
manual and video-tape parent-teacher training: effects on children challenging be-
haviors. School Psychology Quarterly 2003;18:269.
26. Wilkinson LA. Supporting the inclusion of a student with Asperger’s Syndrome: a case
study using conjoint behavioural consultation and self management. Educational
Psychology in Practice 2005;21:307–26.
27. Colton DL, Sheridan SM. Conjoint behavioral consultation and social skills training:
enhancing the play behaviors of boys with attention deficit hyperactivity disorder.
Journal of Educational and Psychological Consultation 1998;9:3–28.
28. Evans SW, Glass-Siegel M, Frank A, et al. Overcoming the challenges of funding
school mental health programs. In: Weist MD, Evans SW, Lever NA, editors. Hand-
book of school mental health: advancing practice and research. New York: Kluwer
Academic/Plenum Publishers; 2003. p. 73– 86.
29. DuPaul GJ, Stoner G. ADHD in the schools: assessment and intervention strategies.
2nd edition. New York: Guilford; 2003.
 Children with Attention-Deficit/Hyperactivity Disorder 157

30. Parker HC: The ADHD handbook for schools: effective strategies for identifying and
teaching students with attention-deficit/hyperactivity disorder. North Branch, MN:
Specialty Press, Inc; 2005.
31. Lewandowski L, Lovett B, Parolin R, et al. The effects of extended time on mathe-
matics performance of students with and without attention deficit hyperactivity
disorder. Journal of Psychoeducational Assessment 2007;17–28.
32. Barkley RA. Attention deficit hyperactivity disorder: a handbook for diagnosis and
treatment, 2nd edition. New York: Guilford Press; 1998.
33. Ingersoll B, Goldstein S. Attention deficit disorder and learning disabilities: realities,
myths, and controversial treatments. New York: Double Play; 1993.
34. Langberg JM, Epstein JN, Urbanowicz CM, et al. Efficacy of an organization skills
intervention to improve the academic functioning of students with attention-deficit/
hyperactivity disorder. School Psychology Quarterly 2008;23:407–17.
35. Tresco KE, Lefler EK, Power TJ. Psychosocial Interventions to improve the school
performance of students with attention-deficit/hyperactivity disorder. Mind & Brain,
the Journal of Psychiatry 2010;1:69 –74.
36. Forehand R, Long N. Parenting the strong-willed child. Chicago, IL: Contemporary
Books; 2002.
37. Barkley RA, Edwards GH, Robin AL. Defiant teens: a clinician’s manual for assess-
ment and family intervention. New York, NY: Guildford Press; 1999.
38. McMahon RJ, Forehand RL. Helping the noncompliant child: family-based treatment
for oppositional behavior, 2nd edition. New York, NY: Guilford; 2003.
39. DuPaul GJ, Helwig JR, Slay PM. Classroom interventions for attention and hyperac-
tivity. In: Bray MA, Kehle TJ, editors. The Oxford handbook of school psychology.
New York, NY: Oxford University Press; 2011. p. 428 – 41.
40. Bilici M, Yildirim F, Kandil S, et al. Double-blind, placebo-controlled study of zinc
sulfate in the treatment of attention deficit hyperactivity disorder. Prog Neuropsycho-
pharmacol Biol Psychiatry 2004;28:181–90.
41. *Fabiano GA, Vujnovic RK, Pelham WE, et al. Enhancing the effectiveness of special
education programming for children with attention deficit hyperactivity disorder using
a daily report card. School Psychology Review 2010;39:219 –39.
42. Owens JS, Murphy CE, Richerson L, et al. Science to practice in underserved
communities: the effectiveness of school mental health programming. J Clin Child
Adolesc Psychol 2008;37:434 – 47.
43. Drabman RS, Spitalnik R, O’Leary KD. Teaching self-control to disruptive children. J
Abnorm Psychol 1973;82:10 – 6.
44. Dunlap LK, Dunlap G: A self-monitoring package for teaching subtraction with
regrouping to students with learning disabilities. J Appl Behav Anal 1989;22:309 –14.
45. Rhode G, Morgan DP, Young KR. Generalization and maintenance of treatment gains
of behaviorally handicapped students from resource rooms to regular classrooms
using self-evaluation procedures. J Appl Behav Anal 1983;16:171– 88.
46. Gureasko-Moore S, DuPaul GJ, White GP. Self-management of classroom prepar-
adness and homework: effects on schools functioning of adolescents with attention-
deficit/hyperactivity disorder. School Psychol Rev 2007;36:647– 64.
47. *Gureasko-Moore S, Dupaul GJ, White GP. The effects of self-management in general
education classrooms on the organizational skills of adolescents with ADHD. Behav
Modif 2006;30:159 – 83.
48. Frederick BP, Olmi DJ. Children with attention-deficit/hyperactivity disorder: a review
of the literature on social skills deficits. Psychology in the Schools 1994;31:288 –96.
158 Eiraldi et al

49. Pfiffner LJ, McBurnett K. Social skills training with parent generalization: treatment
effects for children with attention deficit disorder. J Consult Clin Psychol 1997;65:
749 –57.
50. Pelham WE, Fabiano GA, Gnagy EM, et al. The role of summer treatment programs in
the context of comprehensive treatment for ADHD. In: Hibbs E, Jensen P, editors.
Psychoocial treatments for child and adolescent disorders: empirically based strate-
gies for clinical practice. Washington, DC: APA Press; 2005. p. 377– 410.
51. Langberg JM, Arnold LE, Flowers AM, et al. Parent-Reported homework problems in
the mta study: evidence for sustained improvement with behavioral treatment. J Clin
Child Adolescent Psychol 2010;39:220 –33.
52. Power TJ, Werba BE, Watkins MW, et al. Patterns of parent-reported homework
problems among ADHD-referred and non-referred children. School Psychology
Quarterly 2006;21:13–33.
53. Barkley RA, Murphy KR, Fischer M. ADHD in adults: what the science says. New York:
The Guildford Press; 2008.
54. Abikoff H, Nissley-Tsiopinis J, Gallagher R, et al. Effects of MPH-OROS on the
organizational, time management, and planning behaviors of children with ADHD. J
Am Acad Child Adolesc Psychiatry 2009;48:166 –75.
55. *Evans S, Pelham E, Grudberg M. The efficacy of note taking to improve behavior and
comprehension of students with attention-deficit hyperactivity disorder. Exceptional-
ity 1995;5:1–17.
56. Langberg JM, Epstein JN, Graham AJ. Organizational-skills interventions in the
treatment of ADHD. Expert Rev Neurother 2008;8:1549 – 61.
57. Spires H, Stone D. The directed notetaking activity: a self-questioning approach.
Journal of Reading 1989;33:36 –9.
58. Raggi VL, Chronis AM. Interventions to address the academic impairment of children
and adolescents with ADHD. Clin Child Fam Psychol Rev 2006;9:85–111.
59. Mautone JA, Lefler EK, Power TJ. Promoting Family and school success for children
with ADHD: strengthening relationships while building skills. Theory into Practice
2011;50:43–51.
60. Power TJ, Costigan TE, Leff SS, et al. Assessing ADHD across settings: contributions
of behavioral assessment to categorical decision making. J Clin Child Psychol
2001;30:399 – 412.
61. Kahle AL, Kelley ML. Children’s homework problems - a comparison of goal-setting
and parent training. Behav Ther 1994;25:275–90.
62. Miller DL, Kelley ML. The use of goal-setting and contingency contracting for
improving children’s homework performance. Journal of Applied Behavior Analy-
sis 1994;27:73– 84.
63. Zentall SS. Research on the educational implications of attention deficit hyperactivity
disorder. Exceptional Children 1993;60:143–53.
64. Mautone JA, DuPaul GJ, Jitendra AK. The effects of computer-assisted instruction on
the mathematics performance and classroom behavior of children with ADHD. J Atten
Disord 2005;9:301–12.
65. Ota KR, DuPaul GJ. Task engagement and mathematics performance in children with
attention deficit hyperactivity disorder: effects of supplemental computer instruction.
School Psychology Quarterly 2002;17:242–57.
66. *Webster-Stratton C: The incredible years: a training series for the prevention and
treatment of conduct problems in young children. In: Hibbs E, Jensen P, editors.
Psychosocial treatments for child and adolescent disorders: empirically based strat-
egies for clinical practice, 2nd edition. Washington, DC: American Psychological
Association, 2005; p. 507–55.
 Children with Attention-Deficit/Hyperactivity Disorder 159

67. DuPaul GJ, Kern L. Young children with ADHD: early identification and intervention.
Washington, DC: American Psychological Association; 2011.
68. Robin AL. Training families with adolescents with ADHD. In: Barkley RA, editor.
Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment, 3rd
edition. New York, NY: Guilford Press; 2006. p. 499 –546.
69. *Langberg JM. Homework, organization, and planning skills (HOPS) interventions.
Bethesda: National Association of School Psychologists; 2011.
70. Hussar WJ, Bailey TM. Actual and projected numbers for enrollment in public
elementary and secondary schools, by race/ethnicity: fall 1994 through fall 2019. In:
Projections of education statistics to 2019, 38th edition. Washington, DC: U.S.
Department of Education, National Center for Education Statistics, Institute of Edu-
cation Sciences; 2011. p. 34.
71. Burns BJ, Costello EJ, Angold A, et al. Children’s mental health service use across
service sectors. Health Aff (Millwood) 1995;14:147–59.
72. Kataoka SH, Zhang L, Wells KB. Unmet need for mental health care among U.S.
children: variation by ethnicity and insurance status. Am J Psychiatry 2002;159:
1548 –55.
73. Kazdin AE, Mazurick JL.Dropping out of child-psychotherapy— distinguishing early
and late dropouts over the course of treatment. J Consult Clin Psychol 1994;62:
1069 –74.
74. Eiraldi RB, Mazzuca LB, Clarke AT, et al. Service utilization among ethnic minority
children with ADHD: a model of help-seeking behavior. Administration and Policy in
Mental Health and Mental Health Services Research 2006;33:607–22.
75. Vazquez-Nuttall E, Li C, Kaplan JP. Home-school partnerships with culturally-diverse
families: challenges and solutions to school personnel. J Appl School Psychol
2006;22:81–102.
76. Sheridan SM, Kratochwill TR, Bergan JR. Conjoint behavioral consultation: a proce-
dural manual. New York, NY: Plenum Press; 1996.
77. Jensen PS, Hinshaw SP, Swanson JM, et al. Findings from the NIMH multimodal
treatment study of ADHD (MPA): implications and applications for primary care
providers. J Dev Behav Pediatr 2001;22:60 –73.
78. Krain AL, Kendall PC, Power TJ. The role of treatment acceptability in the initiation of
treatment for ADHD. J Attention Disord 2005;9:425–34.
79. Power TJ, Soffer SL, Cassano MC, et al. Integrating pharmacological and psychos-
ocial interventions for ADHD: an evidence-based, participatory approach. In: Evans S,
Hoza B, editors. Treating attention-deficit/hyperactivity disorder. Kingston, NJ: Civic
Research Institute, p. 2–15.