This resource was developed in collaboration with health care professionals and educators to provide critical information and resources for school personnel working with children who have or are suspected of having attention-deficit/hyperactivity disorder (ADHD).

Attention-deficit/hyperactivity disorder (ADHD) is classified by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as a neurodevelopmental disorder and chronic condition, which can be mild to severe, and affects the brain and central nervous system. ADHD is characterized by “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.” [American: 2013] Impairments presents in 2 or more settings, such as home, school, work, peer relationships, or other activities (including extracurricular) and are present before the age of 12 years. The symptoms of ADHD interfere with or reduce the quality of an individual’s social, academic, or occupational living.

There are 3 separate subtypes, or presentations, of ADHD. A child can be diagnosed with ADHD

• combined presentation when criteria of both inattention and hyperactivity-impulsivity are met;
• predominantly Inattentive presentation if criteria of inattention are met, but criteria of hyperactivity-impulsivity are not met;
• predominantly hyperactive/impulsive presentation if criteria of inattention are not met, but criteria of hyperactivity-impulsivity are met.

Of note, “ADD” is an outdated term formally changed to “ADHD” in 1994. What many people call attention-deficit disorder (ADD) is now known as attention-deficit/hyperactivity disorder with a predominantly inattentive presentation.

Prevalence
ADHD is one of the most common neurodevelopmental disorders of childhood that can continue into adolescence and adulthood. In a classroom of 30 children, it would not be unreasonable to expect 3 kids to have ADHD. [U.S.: 2014] Boys are more than twice as likely as girls to receive this diagnosis. [Visser: 2014] Prevalence of ADHD is rising in the United States; it is unclear if a greater number of children have the condition, or if there is better recognition of it - or both.

• Problems waiting for a turn, interrupts other kids, acts without thinking
• Cannot hold still or stay in the seat, fidgety, runs around, may show aggression, cannot play quietly, talks excessively
• Distracted easily, daydreams, does not finish tasks, forgetful, makes careless mistakes, does not seem to listen when spoken to directly
• Difficulty following instructions
• Has trouble organizing
• Fails to complete and/or hand in assignments

In addition to the challenging behavior, teachers may see positive traits:

• Creativity, brings new ideas to the classroom, artistic talent
• Ability to identify what others do not see, has a fresh perspective
• Enthusiasm and spontaneity
• Mental flexibility, intelligence

The colorful 2-page printable resource, Recognizing ADHD in the Classroom (CHADD) ( 232 KB), provides a quick summary of red flags and strategies for the classroom.

Working with Parents and Physicians: Before a Diagnosis
It is not appropriate for school personnel to tell a caregiver, “I think your child has ADHD,” or that you think their child should see a pediatrician or obtain medication. Instead, if a student is suspected of having ADHD, it is better to have regular discussions with the family about the child’s observed strengths and challenging behaviors in the school setting:

• Ask parents if there are similar challenges at home or in other settings, but do not assume that the child acts the same way outside of school.
• Gather information to understand if parents would welcome school testing and interventions to support the child. If so, perform and discuss the child’s response to those interventions. Additionally, encourage families to share your documentation with the child’s primary healthcare provider.
• It can be helpful to explain that you are concerned that an underlying medical condition may be keeping the child from achieving his or her full potential. Again, it is not appropriate for a teacher to tell a parent that their child has ADHD. (This is inferring a diagnosis.)

I’ve noticed that Johnny sometimes demonstrates __________[concerning behaviors] in class. These behaviors appear to impair his _______[learning, friendships, etc.]. Have you had similar concerns at home? Have you ever talked about these behaviors/concerns with your pediatrician?

It can take time for a family to agree that their child should get a medical evaluation, and it is the parents' choice to follow-up with medical help or not. In the meantime, school staff should work as a team to support the child, other students, and teachers who interact with the child.

The child’s primary care clinician often is the person who makes the diagnosis of ADHD; however, supporting information from the parents and educators plays an integral role. School staff should provide the family with relevant behavioral observations, test results, and supporting documentation. Specific screening forms, such as the Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( 1.1 MB), can be shared with the family, who then may discuss the ratings with their child’s clinician. Talking directly with the clinician can be helpful, too. If a mental health specialist is familiar with the child, this person should also be consulted. A psychologist may also diagnose ADHD and help in more complex cases. They can offer more comprehensive testing to examine if other conditions are affecting the child’s school performance (e.g., psychiatric, cognitive). Discussing a student with subspecialists external to the educational system requires written consent from the parent on school forms. See Communicating with the Medical Provider, below.

Barriers to Diagnosis and Treatment

• It can take time to make a diagnosis of ADHD because the diagnosis requires impaired function in 2 or more of the child’s regular settings (home and school being the most common) for a minimum of 6 months.
• Teachers may have multiple students with ADHD or other behavioral, developmental, medical, or learning problems.
• Recognition of students with the inattentive subtype can be relatively slow because these students may present with quiet school failure or not achieving their potential; however, they are not necessarily disruptive to others.
• Parents may lack the perspective to know that their child has a medical problem, and they could feel embarrassed or angry that their child struggles in school.
• Parents may perceive a poor fit with the teacher and wait to see if the issues resolve with next year’s teacher.
• Children with ADHD and high cognitive function may not struggle with academics until the material becomes increasingly complex.
• The school may have limited access to a psychologist who can help in this process.
• The child may not have a primary care provider (a medical home) or may lack insurance to cover medical visits or medications.
• Parents also may have symptoms of ADHD, which makes it difficult for them to follow through on medical and school appointments.
• Many people worry about using medications to treat ADHD in children and may not understand that medication is not always necessary.
• Minorities and uninsured children are less likely to get a diagnosis (and therefore treatment) of ADHD.

Working with Parents and Clinicians: After a Diagnosis

• A child may need behavioral accommodations for the classroom, and it is important to understand that all children have different learning styles. Supporting the child in the school environment for optimal success should be everyone’s goal.
• When children are trialing medications, frequent feedback helps ensure appropriate therapy; let the family know about improvements or side effects that you may observe.
• When a child divides time between different households, taking medication regularly can be challenging; families can arrange for medication to be given at school if needed.
• It will be essential to continue working on behavioral and academic supports in the school setting. Medication can be very helpful in managing symptoms, but it does not cure ADHD. Teach children how to structure and organize their learning environment so they can learn to manage ADHD on their own, with or without medications.

Educators can use various interventions and approaches, described below, to assist children with ADHD or other learning or behavioral challenges. Links to additional high-yield resources for educators to develop and track behavioral interventions in the school setting are compiled in Resources, below.

Visual schedules. Post them and stick to them. If children have difficulty following the class schedule, they can have their own visual schedule at their desks.
Consistent behavioral plan. All school staff (teachers, librarians, therapists, coaches, etc.) should stick with the plan. When kids know what to expect, they are more successful. See Supporting and Responding to Behavior: Evidence-Based Classroom Strategies for Teachers (PBIS).
ABC’s of behavior (antecedents, behaviors, and consequences). Understand what the child is getting out of the maladaptive behavior. Is there a better way to meet this need? Documenting can help with recognizing behavior patterns and developing individualized interventions. The ABCs of Behavior provides more details.
Response to Intervention (RTI). Use RTI, a tiered behavioral intervention model, to develop meaningful interventions and determine if additional behavioral supports are needed. See RTI Action Network: Behavior Supports (NCLD).
Brain breaks. Short breaks throughout the day for children to move around and have fun improves attention spans. See Brain Breaks (Go Noodle).
Exercise. Encourage kids with ADHD to get exercise before school (e.g., walk or ride a bike to school) and be active during recess. Exercise increases blood flow to the brain and helps kids improve their academic performance. It is counter-productive to penalize children with ADHD by taking away recess time.
Nutrition. Ensure that the child with ADHD is getting a nutritious breakfast and lunch. Stimulant medications may suppress appetite, and a noisy lunchroom can also be very distracting. Consider recess before lunch, instead of after lunch, so that children are not skipping lunch to play.
Support. Be supportive and patient. Many children with ADHD feel badly about being considered disruptive, lazy, or stupid. Verbal and non-verbal (i.e., body language) messages children get from educators and school staff can help them understand that they are not “bad kids." Be sure to reinforce positive behaviors and notice small steps in the right direction. You can do this by specifically labeling behaviors the child is getting better at and praising them. For example, “I liked the way you turned in your own assignment at the end of the work hour; excellent job.”
Be an ally. Kids with ADHD may appreciate secret passwords or signals unique to them to indicate that they can get up and move around. Consider asking a child with ADHD to pass out papers, sharpen pencils, take things to the office, etc. Most children enjoy helping a teacher, and these activities facilitate and maintain the student-teacher bond, enhance student self-worth, and allow the child with ADHD to get their physical break. Children who take medications at school may feel embarrassed if other students know that they are leaving class to take their medicine, so develop a strategy to help protect the student’s privacy (e.g., take a “note to the office”).
Team approach. Document responses to interventions and share successful (and unsuccessful) strategies with other school staff who work with the same child. The following is a list of providers in a school system and how they may be able to help children with ADHD:

• Psychologists can perform an evaluation to determine if a child has common co-occurring neurodevelopmental conditions that can affect their participation and success in the educational setting, such as a learning disability. Additionally, a child may have a more significant co-occurring medical condition such as an autism spectrum disorder. Psychologists help evaluate the child and offer treatment accommodations, such as classroom accommodations, IEP goals, and school resources, including anger management or social skills groups.
• Occupational therapists often have equipment to help children with ADHD, such as wiggly seats or balls to sit on, time-on-task buzzers/reminders, headphones, etc.
• Special educators can assist with behavioral observation and creating interventions. They can also assist in any special education planning that may need to occur.
• Nurses can provide additional information about the child’s medical condition and the possible side effects of medications. They can also assist in medication distribution.
• Physical therapists are good resources for children with both coordination disorder and ADHD.
• Speech pathologists are helpful when there is a concurrent language disorder.
• Administrators can help coordinate a school-wide (or district-wide) behavioral plan to ensure consistency in all the child’s school settings.
• Other teachers and aides may have insights and experiences to share and can be an excellent source of support. In addition, they often are the ones who help carry out any special education goals and/or accommodations set up for a child with ADHD.
• Parents are likely the best resource to learn from about their child and what to do when things are not going well. If you have useful strategies that work at school for a child, share these with parents to promote consistency across settings. Children with ADHD will have more success with consistent environments.

Behavioral supports and medication are the main evidence-based treatments for ADHD. If behavioral interventions do not appear effective, then supplementing behavior interventions with medication can be beneficial. As a guideline, medication alone should not be used as a sole form of treatment for ADHD.

Medication as Intervention

Behavioral Interventions

Natural Treatments

Many people worry that typical childhood “disruptive” behaviors are misdiagnosed as ADHD, particularly among active boys. While making an ADHD diagnosis can facilitate helpful interventions, labeling and medicating active children without ADHD can be harmful. This is why the diagnosis should be made cautiously and with input from those familiar with the child in different settings.

“Look-Alike” Conditions

Related Conditions

Contacting the prescribing clinician can be helpful if you have specific questions or concerns about the child’s medical treatment. The family’s permission is necessary for you to have direct communication with the medical provider. Obtain written consent from the parent or guardian to authorize the transfer of records, verbal and/or e-mail communications, etc., as appropriate. Sample forms to enhance communication between medical clinicians and schools can be found at Forms for Education, including a Medical Home - School Information Release Form ( 49 KB) For more information about privacy rights, see the Portal's section about Forms for Education.

Faxes, phone calls, e-mails, and (less frequently) in-person or online meetings are all methods to communicate with the medical provider; however, like educators, clinicians are often difficult to reach directly while they are working. If direct communication is challenging, see if the physician has a care manager who can help facilitate the process. This is typically a person such as a nurse, medical assistant, or social worker in the clinic who is familiar with more complex patients in the practice but not a prescriber.