Diagnosis and Treatment of Attention Disorders: Roles for School Personnel
The National Association of School Psychologists
One of the most controversial and frequently occurring problems confronting parents and school personnel is the diagnosis and treatment of attention disorders, often labeled Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). Within the medical and educational communities, there is little agreement as to the nature of the condition: Is it a medical or behavioral disorder? Is it truly a 'disorder' or only a collection of symptoms reflecting many possible causes? Nor is there consistent evidence as to how it is best treated-- with behavioral interventions, medication, or both?
The complicated nature of these questions can lead to serious disagreement between parents, teachers, and other professionals about the best course of action to help a child with attention problems. Much of the controversy revolves around the prescription of medication and the appropriate role of school personnel in making recommendations to parents. In reaction, some states have gone so far as to enact legislation attempting to limit the role of school personnel in helping to identify and treat attention problems, particularly when medication is considered.
Unfortunately, restrictive legislation and debates about research findings can be counterproductive to improving both behavioral and academic outcomes for a child with ADD/ADHD. Symptoms and appropriate treatment differ from child to child but almost always impact school performance. Effective identification and treatment of attention problems in children requires a collaborative effort among family, school personnel and medical professionals to insure the best possible outcome. The importance of joint planning was emphasized recently by the American Academy of Pediatrics, in their Clinical Practice Guidelines: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder (October 2001).
The appropriate diagnosis of ADD/ADHD requires a collaborative effort using multiple sources of information, regardless of the training or credential of the professional(s) involved. It is essential to obtain multiple perspectives regarding symptoms in order to assess their pervasiveness and severity. Input from family, teachers and other school personnel who have the opportunity to observe and interact with the student over time in many different situations is therefore critical. Educational, mental health, and medical personnel with appropriate training can effectively use systematic methods of assessing inattention, activity level, and factors that may contribute to attention difficulties. Such methods might include:
Most of these measures are not medical procedures. However, it is important that a physician knowledgeable about attention problems participate in a comprehensive evaluation to rule out other medical problems that can interfere with attention and activity level and to further determine if a medical condition exists.
Eligibility for Special Education
In many states, a diagnosis of ADD or ADHD may contribute to an educational diagnosis or classification used to determine a student's eligibility for special education. The diagnosis must be related to one of the handicapping conditions included in the Individuals with Disabilities Education Act (IDEA), such as Specific Learning Disability, Severe Emotional Disturbance, or the more frequently used classification of 'Other Health Impaired.' Some states require a medical doctor's diagnosis, while other states have regulations to insure that such diagnoses are not limited to a physician's evaluation alone. Further, the Individuals with Disabilities Education Act (IDEA) requires that the determination of special education eligibility be made by the IEP Team.
It is always best practice to obtain evaluation information from multiple sources, including both home and school. Parents usually know best the age at which the child initially exhibited symptoms. This is important information that helps professionals determine if the symptoms meet the criteria outlined in the Diagnostic and Statistical Manual or 'DSM-4,' a standard diagnostic classification system. Some states may specify types of personnel to be involved in evaluating ADD for the purpose of educational intervention. It is always best practice to include the parents, classroom teacher, and support personnel who are trained to understand and identify attention problems, such as the school psychologist, school nurse, behavior support teachers, etc.
Section 504 Eligibility
Sometimes students with a true disability such as ADD/ADHD require modifications in their instructional program but do not require, or are not eligible for, special education supports. Such students may be eligible for modifications such as untimed tests, quiet work spaces, etc. under Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112). Each school system is required to have procedures for evaluating students for Section 504 accommodations and modifications. As in the case of determining special education needs, a team approach involving parents, teachers and support personnel should be followed in developing plans for students with ADD/ADHD.
Interventions for attention problems should always include the development of Positive Behavior Supports in the school and/or home setting, as appropriate to the child's needs. For some children, behavioral supports can be sufficient and effective in reducing attention problems. Medication is a common treatment for attention problems, but also the most controversial due to conflicting results from research regarding side effects of both short-term and long-term use of stimulant drugs. Many children respond quickly and positively to medication, while others may show no response or negative effects. Because identifying the most appropriate, safe medication and dosage for a given child can be quite difficult and time consuming, it is essential that parents and school personnel maintain ongoing collaboration with a physician whenever medication is prescribed.
Role of School Personnel in Intervention
Only physicians and, in some states, other specifically trained personnel, can prescribe medication. In some states and school districts, school personnel may be specifically prohibited from suggesting medication to parents. However, when a medically-based condition is suspected, it is the responsibility of all trained school personnel to provide parents with information to help them determine the need for a medical evaluation, and to provide the family and physician with relevant information to assist in any diagnosis or treatment plan.
Occasionally, schools inappropriately direct parents to seek evaluation and medication for their children as a pre-requisite for readmitting the child to school following suspension. Some states have specifically and rightly outlawed this practice. It is never appropriate to make educational placements and programming contingent upon specific treatment such as medication.
Regardless of the outcome of a medical evaluation, however, children with attention problems require support in the school and home environments. Planning and implementing effective behavior management strategies and modifications in instruction and the physical environment, as well as conducting ongoing monitoring of the student's performance, are appropriate roles for school personnel. School psychologists are particularly trained to help design and implement plans to support students with attention problems in the schools, and can also help parents develop effective strategies to support their child at home. Additionally, school personnel can provide critical information about the student's performance to physicians monitoring the effects of medication.
The identification and treatment of students with attention problems is both controversial and complex, involving many different theories, bodies of research, legal mandates and different systems that impact the student. However, regardless of professional viewpoints and legal constraints, it is essential that families, relevant school personnel and the medical community work together to insure that symptoms are evaluated and that appropriate interventions across settings are provided. With or without medication, children with attention problems benefit from a positive, supportive school and home environment and the collaboration of significant adults.
© 2002, National Association of School Psychologists, 4340 East West Hwy #402, Bethesda, MD 20814