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School Psychology Program

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1 School Psychology Program
School-based Support for Students with ADHD: Is There Life After Ritalin? George J. DuPaul, Ph.D. School Psychology Program Lehigh University Bethlehem PA 18015

2 Conclusions ADHD has enormous impact on school functioning
Medication is effective for changing behavior, but not necessarily for academic performance Individually tailored school-based interventions have potential for building upon medication effects Must go beyond “one size fits all”

3 DSM-IV CRITERIA FOR ADHD
Significant problems with inattention Significant problems with hyperactivity-impulsivity Symptoms present for at least 6 months Symptoms that caused impairment before age 7 Some impairment in two or more settings Impairment in social, academic, or occupational functioning Not due to another disorder Subtypes: Combined, Predominantly Inattentive, Predominantly Hyperactive-Impulsive

4 PREVALENCE AND SEX RATIOS
Occurs in 3 to 5 % of children Ratio of males:females is 3:1 in community and 6:1 in clinic referrals Makes up high percentage of referrals for academic and behavior difficulties Found in all countries and ethnic groups with varying prevalence - highest in US

5 PROBLEMS ASSOCIATED WITH ADHD
Conduct problems (e.g., oppositional behavior, lying, stealing, and fighting) Academic underachievement Specific learning disabilities Peer relationship problems

6 Model for School-based Assessment of ADHD (DuPaul & Stoner, 2003)
Screening Multi-method Assessment Interpretation of Results Intervention Planning & Design Intervention Evaluation

7 SCREENING: QUESTIONS TO BE ADDRESSED
Does this student have a problem related to possible ADHD? Is further assessment of ADHD required?

8 SCREENING METHODS Parent and/or teacher ratings of ADHD-related behaviors Brief interview with teacher and/or parent

9 MULTIMETHOD ASSESSMENT: QUESTIONS TO BE ADDRESSED
What is the extent and nature of the ADHD-related problems? What factors (e.g., organismic and environmental) maintain these problems? What is the frequency, duration, and/or intensity of the problem behaviors? In what settings do the ADHD-related behaviors occur?

10 MULTIMETHOD ASSESSMENT STRATEGIES
Parent and teacher interviews Reviews of school records Behavior rating scales Observations of school behavior Academic performance data Functional behavioral assessment

11 INTERPRETATION: QUESTIONS TO BE ADDRESSED
Does the child exhibit a significant number of behavioral symptoms of ADHD ? Are behaviors occurring significantly more frequently than children of the same gender and age? At what age did these begin and are these behaviors chronic and evident across many situations? Is the child’s functioning significantly impaired? Are there other possible problems or factors that could account for symptoms?

12 INTERPRETATION OF RESULTS
Number of ADHD symptoms Deviance from age and gender norms Age of onset and chronicity Pervasiveness across situations Degree of functional impairment Rule out alternative hypotheses

13 Developmental Trends for ADHD Symptoms: Boys

14 Developmental Trend for ADHD Symptoms: Girls

15 Teacher-rated Inattention as a Function of Age & Ethnicity

16 Teacher-rated HypImp as a Function of Age & Ethnicity

17 ALTERNATIVE HYPOTHESES FOR ADHD BEHAVIOR
Environmental factors Antecedent/consequent events Placement in curriculum Psychosocial stressors Within-child factors Academic skills deficits Other forms of emotional or behavioral disturbance

18 DIFFERENTIAL DIAGNOSIS
Disorders to be “ruled out”: Separation Anxiety Disorder Other Anxiety Disorders Depression/affective disorders Tourette’s Disorder Disorders which frequently co-occur with ADHD: Oppositional Defiant Disorder Conduct Disorder Learning Disabilities

19 LD VS. ADHD Lacks early childhood history of hyperactivity
“ADHD” behaviors arise in middle childhood “ADHD” behaviors appear to be task- or subject-specific Not socially aggressive or disruptive Not impulsive or disinhibited

20 INTERVENTION PLANNING: QUESTIONS TO BE ADDRESSED
What are the behavioral objectives? What are the student’s strengths and weaknesses? What are the optimum intervention strategies? What additional resources are available to address the child’s ADHD-related problems?

21 INTERVENTION PLANNING
Severity of ADHD-related behaviors Functional assessment of behavior Presence of associated disorders Response to prior interventions Availability of community resources

22 Possible Functions of ADHD Behavior
Avoid/escape effortful tasks Obtain peer attention Obtain teacher attention Obtain tangible object Sensory stimulation

23 Design Interventions Based on Functional Assessment
Descriptive analysis Identify antecedents, consequences, sequential conditions Direct observation, teacher interview, parent interview, student interview Experimental Analysis Develop hypotheses related to function of behavior Test hypotheses using direct observation Develop intervention plan based on results of experimental analyses

24 INTERVENTION EVALUATION: QUESTIONS TO BE ADDRESSED
Are changes occurring in the target and collateral behaviors? Are the treatment changes socially valid and clinically significant? Are target behaviors normalized? Are “side-effects” present?

25 INTERVENTION EVALUATION
Periodic collection of assessment data (e.g., teacher ratings, observations, academic performance measures) Consumer satisfaction ratings Comparison with normal peers Revision of treatment plan based on assessment data

26 What are the most common school difficulties associated with ADHD?
High rates of disruptive behavior Low rates of engagement with academic instruction and materials Inconsistent completion and accuracy on schoolwork Poor performance on homework, tests, & long-term assignments Difficulties getting along with peers & teachers

27 Project PASS: Initial Group Differences
1st through 4th grade students in public elementary schools in eastern PA N = 87 children with ADHD N = 38 normal controls 20 min observations in math and reading using the BOSS (Shapiro, 1996) Woodcock-Johnson Reading & Math subtests (WJ-III) Teacher ratings on the Academic Competency Evaluation Scale (ACES; DiPerna & Elliott)

28 Project PASS: Classroom Behavior in Reading

29 Project PASS: Classroom Behavior in Math

30 Project PASS: WJ-III Achievement Test Scores

31 Project PASS: ACES Teacher Ratings

32 Kindergarten Subjects Compared to District Norms on DIBELS OnRF
5

33 Letter Naming Fluency: Kindergarten Benchmark Scores
6

34 Comparison of Kindergarten Subjects and Peers on Benchmarks
7

35 Comparison of First Grade Subjects and Peers on Benchmarks
8

36 Most Common Interventions for Children with ADHD
Psychotropic Medication (e.g., CNS stimulants such as methylphenidate) Home-based contingency management (behavioral parent training) School-based contingency management interventions (e.g., token reinforcement) Academic tutoring Daily report card or school-home notes

37 MEDICATIONS FOR ADHD Stimulant Medications Tricyclic Antidepressants
Methylphenidate (Ritalin, Concerta, Metadate) Dextroamphetamine (Dexedrine) Adderall Tricyclic Antidepressants Desipramine (Norpramine);Imipramine (Tofranil) Other Antidepressants Bupropion (Wellbutrin); Fluoxetine (Prozac) Other Medications Clonidine (Catapres) Atomoxetine (Strattera)

38 BEHAVIORAL EFFECTS OF STIMULANTS
Increased Attention and Concentration Decreased Impulsivity Decreased Task-Irrelevant Activity Level Decreased Aggressiveness Increased Compliance Improved Handwriting and Fine Motor Skill Improved Peer Relations and Social Status Possible enhancement of academic productivity

39 SIDE EFFECTS OF STIMULANT DRUGS
Insomnia & Decreased Appetite (50-60%) Headaches and Stomachaches (20-40%) Prone to Crying (10%) Nervous Mannerisms (10%) Tics (<5%) and Tourette’s (Very Rare) Overfocused behavior; Cognitive toxicity Mild Weight Loss (A Few Pounds First 1-2 Years); No effect on Skeletal Growth Mild Increases in Heart Rate and Blood Pressure Cylert Affects Liver Functioning; Needs Monitor

40 Problems with Currently Available Research Literature
Limited data on school-based interventions in gen. ed. settings “One size fits all” approach is typical Emphasis on reduction of disruptive behavior rather than improvement in social behavior or academic skills Few studies of adolescents Focus on short-term outcomes & limited data on generalization of effects

41 Multimodal Treatment Study (MTA)
N = 579 children from Gr. 1-5 (M age = 8.5) randomly assigned to tx groups Medication management (n = 144), Behavioral tx (n = 144), Combined tx (n = 145), and Community Care Control Group (n = 146) 14 mos of tx (manualized) at mult. sites Multiple assessment measures collected on three occasions

42 MTA Psychosocial Interventions
Parent Training 27 group sessions over 14 mos School Intervention Child-Based Treatment: Summer Treatment Program Comprehensive behavior mod. Program Peer interventions Sports skills training Daily report cards Individualized programs, as necessary

43 MTA School Intervention Component
Teacher consultation Biweekly meetings with teachers over 14 mos Daily Report Card implemented Basic behavioral principles and classroom interventions as necessary (e.g., token economy); Stage II tx (response cost) as necessary Paraprofessional Program (UCI model) Para spent half day in classroom for 12 weeks in fall of 2nd school year Implemented behavior modification procedures including daily report card & merit badge system for social skills

44 MTA Study (cont.) Reductions in symptoms in all groups
Combined tx & medication greater symptom reduction than BT & control Combined tx > BT & control in reduction of agg./ODD symptoms & improved social skills, parent-child relations, and reading achievement Medication > BT in most cases; however meds still active while BT had been faded Predictors of individual response? Effects of school intervention component?

45 School-based Intervention for ADHD: A Meta-analysis (DuPaul & Eckert, 1997)

46 School-based Intervention for ADHD: Effects on Behavior

47 School-based Intervention for ADHD: Effects on Academics

48 Balanced “Game” Plan Too often rely solely on defense (reactive) strategies Need a strong “offense” (proactive) and a strong “defense” (reactive) Intervention plan should always include both proactive & reactive procedures (emphasis on positive)

49 School-Based Interventions for ADHD
Manipulating Antecedents (Proactive) Post Rules Instructional Modifications Workload Adjustment Providing Choices Peer Tutoring

50 School-Based Interventions for ADHD (cont.)
Manipulating Consequences (Reactive) Token Reinforcement Verbal Reprimands Response Cost Time Out from Positive Reinforcement Self-Management

51 SCHOOL-BASED INTERVENTIONS FOR ADOLESCENTS WITH ADHD
Manipulating Antecedents (Proactive) Note-taking/Study Skills Instruction Workload Adjustment Providing Choices School-based Case Manager Manipulating Consequences (Reactive) Behavioral Contract Discipline Hierarchy Self-Management Program

52 Possible Mediators for School-Based Interventions (DuPaul & Power, 2000)
Teacher-mediated Instructional strategies; Token reinforcement Parent-mediated Parent tutoring; Home-based reinforcement Peer-mediated Classwide peer tutoring Computer-assisted Drill-and-practice Self-mediated Self-monitoring; Self-management

53 Link Interventions to Behavioral Function
Avoid/escape effortful tasks Increase stimulation value of task and/or provide brief “attention breaks” Obtain peer attention Provide peer attention following appropriate behavior (e.g., peer tutoring) Obtain teacher attention Provide attention following appropriate behavior while ignoring inappropriate behavior (or time out from positive reinforcement)

54 TEACHING TECHNIQUES TO PREVENT BEHAVIOR PROBLEMS
Remind students of rules Maintain eye contact with students Remind students about expected behaviors Circulate thru classroom to monitor/provide feedback Use nonverbal cues to redirect Maintain brisk pace of instruction Insure understanding of activities Manage transitions in well-organized manner Communicate expectations about use of class time

55 TOKEN REINFORCEMENT Establish behavioral or academic goals
Choose several target situations Break situation (task) into smaller units Tokens (points, stickers) provided immediately Tokens turned in for privileges Factors to consider: Practicality for teachers What to use for rewards “Satitation” effect Expansion to additional situations Gradual “weaning” process Reactions of other students

56 “DEAD PERSON’S RULE” If a dead person can do it, it’s not a good target behavior for intervention Examples: sit still, stay on-task, don’t call out, don’t fight Appropriate target behaviors involve active responding Examples: completion of tasks, accuracy on work, participating in class discussions, getting along with others

57 STUDENT CONTRACT Specify several short-term objectives
Identify possible contingencies Positive for reaching goal Aversive for rule violations Determine time period for meeting goals Include both short and long-term payoffs Agreement by both student and teacher (counselor) to follow through Periodic revisions of contract as necessary

58 RESPONSE COST Apparatus or materials needed Description of system
Review rules with student Positive reinforcement following “on-task” behavior “Fines” following “off-task” behavior Unpredictability of contingencies Turn in points for privileges Classroom situations where system is useful Factors to consider Explanation of system to student Reactions of other students Practicality for teachers “Weaning”

59 Parent Tutoring Strong evidence that parental support of learning enhances academic ach. Several tutoring models (e.g., Reading to Read) CWPT Model : Individually-paced Frequent, imm. feedback w/error corr. Emphasis on positive reinforcement Time-efficient

60 Parent Tutoring: Controlled Case Study (Hook & DuPaul, 1999)
4 students (3 boys, 1 girl) with ADHD from 2nd & 3rd grade (w/ reading diff.) Teachers provided parents with reading passages for tutoring sessions Student read aloud for 5 min w/imm. error correction & praise for accuracy At 5-min mark, student instructed to start over & read same section x 10-min 1-min “reading check” w/same passage

61 Parent Tutoring Case Study (cont.)
2-3 parent tutoring sessions per week for 4 to 8 weeks All 4 children showed gains in reading at home based on CBM probes Variable changes in school-based reading performance Children cooperative with procedures & parents involved in their education Promising tx for some child. w/ ADHD

62 COMPONENTS OF EFFECTIVE HOME-SCHOOL COMMUNICATION PROGRAM
Daily/weekly goals specified in a positive manner Both academic and behavioral goals included Small number of goals at a time Quantitative feedback about performance Feedback provided by subject or class period Communication is made on a regular basis (either daily or weekly) Home-based contingencies tied to performance (both short-term and long-term)

63 HOME-SCHOOL PROGRAM (cont.)
Parental cooperation solicited prior to implementation Student input into goals and contingencies Goals/procedures modified as necessary

64 Peer Mediated Interventions
Playground monitors (Cunningham et al.) Peer monitoring plus self-evaluation Peer tutoring Classwide Peer Tutoring Reciprocal Peer Tutoring Cooperative Learning

65 CLASSWIDE PEER TUTORING
Divide classroom into pairs Provide academic scripts Take turns tutoring Immediate feedback & error correction Teacher monitors progress & provides bonus points Points tallied & progress charted Pairs change weekly

66 CWPT Effects on ADHD (DuPaul et al., 1998)
18 ch. w/ADHD & 10 comparison students (1st to 5th grade gen. ed.) CWPT increased active engagement w/ reduction of off-task behavior 50% of ADHD improved academically Positive effects for comparison peers High rates of student and teacher satisfaction

67 Coaching Teens with ADHD (Guare & Dawson, 1995)
Phase I Identify long-term goals Determine goal criteria Delineate barriers to reaching goals Phase II (Coaching sessions) Review Evaluate Anticipate Plan Adult vs. peer coaching? Outcomes systematically evaluated

68 Computer-Assisted Instruction
1. Delivery of instruction (e.g., aid to acquisition of new material) 2. Drill-and-practice (e.g., fluency and retention of already-instructed material) May be effective for both purposes with more evidence for drill-and-practice ?Effects due to higher stimulation value of material, self-paced, & provision of frequent, immediate feedback?

69 CAI: Controlled Case Study (Ota & DuPaul, 2002)
3 students with ADHD in 4th-6th grade at a private school for children with LD All with math skill acquisition difficulty All three students receiving medication Math Blaster software introduced sequentially across students while assessing on-task and math skills (CBA) Gains in on-task behavior and slope of math skill acquisition (for 2 out of 3)

70 CAI: Replication in Public School Setting (Mautone, DuPaul, & Jitendra, in submission)
3 2nd through 4th grade children in general education or special education classrooms All met research criteria for ADHD & none being treated with psychostimulants Baseline= typical math instruction & work CAI = Math Blaster software 15 min X 3 days per week Multiple baseline across participants design Math fluency, direct observations of behavior, & consumer satisfaction ratings were measures

71 Math Fluency Baseline Computer-assisted Instruction Brian Greg Chris
Brian Mean during baseline = 1.75 correct to 6.5 during intervention Greg M during baseline = to during intervention Chris M during baseline = 8.25 to during intervention PND = 27.3% (Brian), 21.7% (Greg), 18.2% (Chris) Chris --- DCPM - - DIPM

72 Observation Data Baseline Computer-assisted Instruction Brian Greg
Brian M baseline = 44.3 to 85.4 on-task Off-task M 67.7 to 42.6 Greg M 18.2 to 88.3 on-task 55.1 to 12.3 off-task Chris 45.8 to 92.9 on-task 56.8 to 38.1 off-task Discuss celebration of correct answers PND = 100% nonoverlap in active engaged time 54.5, 100, and 45.5 nonoverlap for off-task -- AET - -  - - Off-task Chris

73 Results - CBM Linear Regression Coefficients for Digits Correct and Digits Incorrect DCPM DIPM Baseline CAI Brian -.1 .27 1.35 .22 Greg .23 1.15 -.15 -.34 Chris -.2 .38 -.02

74 Results - Behavior Linear Regression Coefficients for Active Engaged and Off-task Behavior AET Off-task Baseline CAI Brian -.19 -.32 4.15 -.49 Greg -2.98 .0007 -1.19 3.02 Chris -.51 1.48 -8.97 4.69

75 Results – Acceptability

76 Self-monitoring of organizational skills
Adolescents with ADHD typically have difficulties in class prep. and HW For some students, problems related to poor attention to detail and low motivation to complete mundane tasks Possible students can be trained to monitor own behaviors (e.g., being ready for class)

77 Self-monitoring of org
Self-monitoring of org. skills: Controlled case study (Gureasko,DuPaul, & White in press) Three 7th grade students with ADHD All had significant problems being prepared for class Checklist of preparatory behaviors developed with teachers (% steps) Training in self-monitoring (4 days) Self-monitoring followed by fading Gains in organizational skills maintained without treatment

78 SELF-MANAGEMENT PROGRAM
Initially incorporates external and internal evaluation but works toward complete self-monitoring and evaluation Teacher and student independently “grade” student performance regarding behavior and academics for specified work period Established performance criteria Points earned for performance Bonus points for “matching” ratings Penalities for “inflated” ratings Points turned in for school based or home based privileges

79 Sample Self-Management Criteria
5 = Excellent Followed all rules for entire interval; Work 100% correct 4 = Very Good Minor infraction of rules; Work at least 90% correct 3 = Average No serious rule offenses; Work at least 80% correct 2 = Below Average Broke rules to some degree: Work 60 to 80% correct 1 = Poor Broke rules almost entire period; Work 0 to 60% correct 0 = Unacceptable Broke rules entire period; No work completed

80 SELF-MANAGEMENT (cont.)
Gradual weaning from external ratings Longer work periods to be rated Periodic, random “matching” challenges Eventual reliance on self-ratings only Factors to consider: Practical constraints “Drift” of student ratings Prepare student using external system

81 School Services for Students with ADHD
Qualifies for special education on basis of having another disability (e.g., LD) Qualifies for special education on basis of “other health impairment” Qualifies for accommodations on basis of Section 504

82 PSYCHOSOCIAL INTERVENTION STUDIES AT LEHIGH UNIVERSITY
PROJECT PASS (1st through 4th grade students) Project Coordinator: Rosemary Gruber, M.Ed. (610) PROJECT ACHIEVE (3 & 4 year olds) Project Coordinator: Suzanne Irvine, M.S.W. (610)

83 Project PASS ( ) Goal: Empirically examine effects on academic and behavior outcomes of two consultation-based approaches to designing academic interventions for students with ADHD 1st through 4th graders with ADHD (N=160) randomly assigned to individualized academic intervention (IAI) or generic academic intervention (GAI) Sample of similar aged normal controls (N=80) to examine ADHD vs. normal trajectories on dependent variables

84 Project PASS (cont.) Consultation provided for 1.5 school years
Outcomes assessed at 5 time points (including 1 year follow-up) Dependent measures include achievement tests, teacher reports of goal attainment, curriculum-based measurement, teacher ratings of behavior and academic performance, parent ratings of behavior, consumer satisfaction ratings from teachers

85 IAI Consultation -- Problem Identification (Kratochwill & Bergan, 1990; Witt, Daly, & Noell, 2000)
Teacher Education on ADHD Academic area(s) of concern Setting with most and least difficulties Intensity/Severity of problems Antecedent conditions Teacher asks question Teacher presents item Teacher shows or models how to do an item Teacher prompts the student

86 IAI Consultation - Problem Identification
Child’s typical response to antecedents Consequent conditions Patterns to academic behavior problems? Goal-setting and prioritizing Specifics of lesson to be observed for Functional Academic Assessment Agree on additional observational procedures based on data-driven hypotheses

87 IAI Consultation --Functional Academic Assessment
Classroom observation Information about teacher routine that occurs Student, teacher, and peer behaviors Review student work products in comparison to peers Basic Skills Assessment (CBA data)

88 Linking Assessment to Intervention: Hypotheses for Academic Deficits Daly, Witt, Martens, & Dool, 1997; Witt et al., 2000 MOTIVATION (e.g., There are no incentives to do the work) PRACTICE (e.g., The opportunities to do the work are too infrequent ) INSTRUCTION (e.g., Nobody has shown the student how to do the task, or not enough practice is provided. )

89 IAI Consultation: Problem Analysis
Review all data and determine adequacy of baseline data collection Based on desired performance versus actual performance, which areas are of most concern? Goals from PII still appropriate? Discussion of possible interventions, tightly linked to assessment results

90 IAI Consultation: Problem Analysis
If conflicting hypotheses --> Hypothesis testing Determine specifics of intervention plan Consultant may train the teacher and/or the student(s) on intervention implementation Progress monitoring every week Treatment integrity and feedback biweekly

91 Interventions for Students with ADHD: Guiding Principles
Intervention design linked directly to assessment data (e.g., FBA, CBA) Consultative problem-solving process integral to intervention design Intervene at “point of performance” Go beyond “train and hope” Intervention evolves based on ongoing assessment

92 Guiding Principles for Intervention (cont.)
Don’t place entire onus on classroom teacher; look to other possible treatment mediators All behavior serves a purpose; intervention should lead to functionally equivalent behavior Aim for balance between proactive and reactive strategies Typically no single intervention is sufficient; multi-component and multi-setting intervention is presumed more effective

93 Conclusions ADHD has enormous impact on school functioning
Medication is effective for changing behavior, but not necessarily for academic performance Individually tailored school-based interventions have potential for building upon medication effects Must go beyond “one size fits all”

94

95 Classroom Interventions for ADHD (DuPaul & Stoner, 1999)
Response Cost CWPT

96 ADHD INATTENTIVE TYPE VS. COMBINED TYPE
Lethargy, staring, and daydreaming less likely in combined type Lacks impulsive, disinhibited, or aggressive behavior Greater risk for anxiety symptoms Greater family history of anxiety disorders and LD

97 ADHD VS. ANXIETY DISORDERS
Not overly concerned with competence Not anxious or nervous Exhibit little or no fear Have no difficulty separating from parents Infrequently experience nightmares Inconsistent performance Not concerned with future Are not socially withdrawn May be aggressive May be able to pay attention if work is stimulating

98 DEPRESSION VS. ADHD Not usually as motorically active
Marked changes in affect/mood Concentration problems have acute onset possibly following stress event Changes in eating and sleeping habits Loss of interest or pleasure in most activities

99 ODD/CD VS. ADHD Lacks impulsive, disinhibited behavior
Able to complete tasks requested by others Resists initiating response to demands Lacks poor sustained attention and marked restlessness Often associated with parental child management deficits or family dysfunction

100 ADHD INATTENTIVE TYPE VS. COMBINED TYPE
Lethargy, staring, and daydreaming less likely in combined type Lacks impulsive, disinhibited, or aggressive behavior Greater risk for anxiety symptoms Greater family history of anxiety disorders and LD

101 ADHD VS. ANXIETY DISORDERS
Not overly concerned with competence Not anxious or nervous Exhibit little or no fear Have no difficulty separating from parents Infrequently experience nightmares Inconsistent performance Not concerned with future Are not socially withdrawn May be aggressive May be able to pay attention if work is stimulating

102 DEPRESSION VS. ADHD Not usually as motorically active
Marked changes in affect/mood Concentration problems have acute onset possibly following stress event Changes in eating and sleeping habits Loss of interest or pleasure in most activities

103 ODD/CD VS. ADHD Lacks impulsive, disinhibited behavior
Able to complete tasks requested by others Resists initiating response to demands Lacks poor sustained attention and marked restlessness Often associated with parental child management deficits or family dysfunction

104 Discussion How does your school district presently identify students with ADHD? How could present identification procedures be improved? What factors limit the assessment of students with ADHD in school settings? What could be done to address these limiting factors?


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