PARENTAL PERCEPTIONS OF ADVERSE EDUCATIONAL OUTCOMES AMONG CHILDREN DIAGNOSED AND TREATED FOR ADHD: A CALL FOR IMPROVED SCHOOL/PROVIDER COLLABORATION

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1 Psychology in the Schools, Vol. 39(1), John Wiley & Sons, Inc. PARENTAL PERCEPTIONS OF ADVERSE EDUCATIONAL OUTCOMES AMONG CHILDREN DIAGNOSED AND TREATED FOR ADHD: A CALL FOR IMPROVED SCHOOL/PROVIDER COLLABORATION GRETCHEN B. LeFEVER, MARGARET S. VILLERS, AND ARDYTHE L. MORROW Center for Pediatric Research, Children s Hospital of The King s Daughters, Eastern Virginia Medical School E. SIDNEY VAUGHN, III Virginia Beach City Public Schools This research utilized parent report to examine the prevalence of attention deficit hyperactivity disorder (ADHD), related treatment, and associated educational outcomes among elementary school children in southeastern Virginia. In a representative sample of elementary school children, 17% had been diagnosed with ADHD. The majority of diagnosed children had been medicated for ADHD (84%). More than one third of students taking medication had received no other interventions for ADHD. Over half of the diagnosed students received behavioral therapy and almost half received a combination of medical and behavioral interventions. Children diagnosed with ADHD were 3 to 7 times ( p values 0.001) more likely than other children to receive special education, be expelled or suspended, and repeat a grade. Based on parental opinion, children diagnosed with ADHD are at high risk for school failure. Results are discussed in terms of distinctions between clinical efficacy/effectiveness and schoolwide and public health interventions implemented in the study region John Wiley & Sons, Inc. Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed mental health condition among children in the United States (American Psychiatric Association, 1994; Whalen et al., 1989). Over the years, the increasing number of young children diagnosed with ADHD has had a substantial impact on the educational system. In 1995 alone, additional expenditures by public schools on behalf of students with ADHD exceeded $3.2 billion (Forness, 1998). Given the substantial costs of these students to the educational system, schools must carefully consider their role in the diagnosis and treatment children with ADHD. ADHD treatment in the schools is likely to be influenced by the National Institute of Mental Health Collaborative Multisite Multimodal Treatment Study of Children with ADHD (i.e., the MTA study; see (Richters et al., 1995) for study background). The MTA is the largest mental health treatment study of children and was designed to evaluate outcomes associated with four ADHD treatment conditions: behavioral treatment (BT), medical management (MM), combined BT and MM (Combined), and routine community care control group (CG) (Greenhill et al., 1996). Although complete analysis of study results is still underway and results do not lend themselves to straightforward interpretations, media and other reports have portrayed results as supportive of the use of medication over behavioral interventions (Pelham, 1999). When one considers design strengths and limitations of the MTA study, several other interpretations of the data must be considered (Cunningham, 1999). Effective and efficient use of school services will require educators and other school-based professionals to understand key findings of the MTA study that have not been highlighted in media reports. First, although the majority of children in the CG received medication, outcomes were significantly better for children enrolled in the MM treatment arm than the CG (Pelham, 1999). The relative superiority of MM raises questions about the adequacy of routine management of pharmacologic interventions and indicates that children undergoing treatment for ADHD Correspondence to: Gretchen B. LeFever, PhD, Center for Pediatric Research, 855 West Brambleton Avenue, Norfolk, VA glefever@chkd.com 63

2 64 LeFever, Villers, Morrow, and Vaughn could benefit from greater collaboration between schools and providers. Second, BT was highly effective. Seventy-five percent of children who received BT only were maintained effectively over the 14-month study period without the use of any stimulant medication (Pelham, 1999). This is an impressive finding given that BT was discontinued several months prior to the collection of final outcome measures while MM was provided continuously until study completion. Understanding the benefit of BT is important because up to 30% of treated children respond negatively to medication (Elia, Borcherding, Rapoport, & Keysor, 1991; Pelham et al., 1999; Pelham, Greenslade, & Vodde-Hamilton, 1990) and some parents seek alternative interventions. Parents also preferred treatment approaches that include behavioral interventions to medication alone. Third, MM was superior to BT on parent and teacher ratings of inattention and teacher-only ratings of hyperactivity, but not on the other 16 of 19 outcome measures such as social skills and aggressive behavior (Pelham, 1999). Research has demonstrated that stimulant medications improve the core symptoms of ADHD (e.g., hyperactivity) and consequently improve short-term functioning on a limited number of dimensions (e.g., increased written output) without curing the disorder or fully alleviating symptoms and associated problems such as poor academic performance (Forness, Swanson, Cantwell, Youpa, & Hanna, 1992; Consensus Development Panel, 2000). That the MM arm was not associated with improvement on most outcome measures is not surprising; it underscores that pharmacologic intervention is not a panacea for complex behavioral problems such as ADHD. In short, the MTA study results do not call for a radical reorganization of clinical practice guidelines. They support the American Academy of Pediatrics guidelines, which continue to emphasize the benefits of behavioral interventions to address functional outcomes of children in conjunction with pharmacologic interventions for core ADHD symptoms (American Academy of Pediatrics, 2000). However, achieving maximal benefit of recommended treatment strategies may be hampered by what appears to be a lack of systematic collaboration between schools and providers (Angold, Erkanli, Egger, & Costell, 2000; Hoagwood, Kelleher, Feil, & Comer, 2000; Jensen et al., 1999; LeFever, Parker, & SHINE, 1999b). Ineffectively treated ADHD has long-term and far-reaching consequences including poor educational adjustment and a host of related social problems ranging from school dropout to substance abuse and teenage pregnancy (Consensus Development Panel, 2000). Children diagnosed with ADHD often suffer from low self-esteem and poor academic self-image, especially those children who are diagnosed during elementary school. If their problems are not addressed appropriately at a young age, these children are more likely to experience school failure (Hechtman, 1999). Randomized control trials such as the MTA study can assist practitioners with decisions regarding evidence-based treatment strategies, while community-based studies can shed light on the effectiveness of various treatment strategies as they are deployed in real-world settings. A recent community-based study of ADHD treatment indicates substantial misuse of stimulant medications (Angold et al., 2000). Angold et al. found that over half the children treated with stimulant medication did not meet ADHD diagnostic or screening criteria. Further research is needed to determine whether practice patterns involving over- and underuse of ADHD interventions are associated with adverse outcomes. An epidemiologic study of ADHD in southeastern Virginia documented a disproportionately high rate of stimulant use among elementary students: 8% to 10% of students received a dose of medication for ADHD from a school nurse during regular school hours. (LeFever, Dawson, & Morrow, 1999). The purpose of the present study was to explore associations between routine community treatment for ADHD and adverse educational outcomes of students in this region. It was also designed to further examine regional rates of ADHD treatment including medication administered outside school settings and nonpharmacologic interventions.

3 Participants Methods The study was conducted in a southeastern Virginia public school district with 34,701 students in 1997 to This school district is urban and racially and economically diverse. Three elementary schools selected to participate in this study, and, during the school year, 1,946 children were eligible to attend the selected elementary schools. These schools are referred to as the district s PRIME schools and are considered to be representative of all elementary schools in the district in terms of economic and demographic characteristics. Of the 1,946 children eligible to enroll in the selected schools, 302 (16%) chose not to attend the elementary school or moved out of the area prior to the survey. Surveys were distributed to parents of the remaining 1,644 children, resulting in a 63% return rate (N 1,032). Analyses included only students who attended school for the entire day (grades 1 5, n 808). Students in nongraded special education placements, which were designed for individuals who have severe intellectual impairments and therefore have very specific school health needs, were excluded from the study. The majority of our sample was comprised of black (50%) and white (38%) students; the remaining 12% of the sample was distributed evenly among children of Asian, Hispanic, biracial, and other backgrounds. The latter racial groups were comprised of small numbers; therefore, analyses involving comparisons by race were limited to black and white students. Procedures Survey. The survey focused on two significant child health issues in the schools: ADHD and asthma. The survey consisted of nine demographic questions, six questions on ADHD (Appendix A), four questions on asthma, and eight questions regarding the child s school and health needs. The surveys were mailed twice to the child s home and delivered once to the child at school. The survey was anonymous and no personally identifying information was released to the principal investigator (GBL). The Institutional Review Board at Eastern Virginia Medical School approved this study. Definitions. ADHD refers to children whose parents indicated that their child had been diagnosed with attention deficit hyperactivity disorder (ADD or ADHD). Behavioral interventions were defined as counseling and therapy, tutoring, or classroom accommodations (i.e., 504 Plans) for ADHD. Combined therapy was defined as a combination of behavioral and pharmacologic interventions. Statistical analysis. Descriptive statistics, chi-square analyses, and logistic regression analyses were performed using SPSS for Windows Version 7.5 (SPSS, 1997). Significance was set at p Crude and adjusted odds ratios and 95% confidence intervals (CI) were calculated for all comparisons. All two- and three-way interactions were entered into initial logistic regression models and subsequently removed due to nonsignificance. Sample Characteristics School Outcomes, ADHD Diagnosis, and Treatment 65 Results Characteristics of the study sample, the three selected schools, and all elementary schools in the corresponding district are described in Table 1. Sample characteristics were similar to those of the targeted school with minor exceptions. The sample contained fewer boys, fewer black stu-

4 66 LeFever, Villers, Morrow, and Vaughn Table 1 Characteristics of Sample, Targeted Schools, and All Elementary Schools in District A Child s Status Sample Targeted Schools All Elementary Schools n % n % n % Gender Boys , Girls , Race Black , , White , Other Suspensions ( ) NA NA ,223 7 Grade retentions ( ) NA NA , Students receiving free or reduced lunch NA NA 1, , Students receiving aid to families with dependent children NA NA , Note. NA refers to information that was not available/not collected as part of the anonymous parent survey. dents, and more students of other racial backgrounds. As anticipated, the target schools were similar to the district s total elementary school population in terms of social and economic characteristics. In our sample, 17% (95% CI, 16% 18%) of students were diagnosed with ADHD. Boys were more likely than girls (28% vs. 11%, , p 0.001) and white students were more likely than black students (22% vs. 16%, 2 3.9, p 0.05) to be diagnosed with ADHD. Compared to other students, students with health care insurance also were more likely to be diagnosed with ADHD (8% vs. 20%, 2 5.8, p 0.01). Medical, Behavioral, and Combined Interventions Children diagnosed with ADHD received a range of services to treat their condition. Most children diagnosed with ADHD received medication to treat the disorder (84%). Only 56% of the diagnosed children took ADHD medication in school, although the majority of children (74%) were taking medication at the time of the survey. More than half (57%) of children with ADHD received behavioral interventions while 47% received combined treatment. Among those students diagnosed with ADHD, 27% received medication alone, 10% received behavioral interventions alone, and 16% received no intervention. Of the medicated students, 37% received no other intervention. The rate of overall medication use was not significantly different between black and white students. Differences were observed with regard to other interventions. Compared to black students, white students were significantly more likely to receive behavioral interventions (69% vs. 43%, , p.01) and combined treatment (61% vs. 31%, , p.01). Health insurance status was not associated with overall medication use or school-based administration of medication, but it was associated with use of behavioral interventions and combined treatment. Compared to children without health insurance, children with health insurance were more likely to receive behavioral interventions (0% vs. 59%, 2 7.5, p.01) and combined treatment (0% vs. 48%, 2 5.3, p.05). Health insurance status and race were not significantly associated.

5 School Outcomes, ADHD Diagnosis, and Treatment 67 Educational Outcomes Associated with ADHD Eighty-four percent of parents with an ADHD-diagnosed child reported that ADHD affected their child s academic performance or behavior in school, and 40% believed that the school was not providing adequate services to meet their child s school health needs. Adverse educational outcomes were more prevalent among children diagnosed with ADHD. As shown in Table 2, logistic regression analyses were performed to determine risk factors associated with adverse educational outcomes. Male gender and black racial status were positively associated with several educational outcome variables. After controlling for race and gender, students with ADHD maintained a similar magnitude of risk for adverse educational outcomes (i.e., minimal change was observed between odds ratios and adjusted odds ratios) and p values remained at or below the level. In other words, after taking gender and race into account, children diagnosed with ADHD remained 3.4 to 6.7 times more likely to experience adverse outcomes. Among children who were diagnosed with ADHD, children receiving medication were more likely to be enrolled in special education than children not receiving medication (46% vs. 22%, 2 5.8, p 0.05). However, children receiving medication were not significantly different from unmedicated ADHD children in regard to being suspended or expelled from school or repeating a grade. Regarding their likelihood of being enrolled in special education, being suspended or expelled from school, or repeating a grade, ADHD children who received behavioral interventions or combined treatment were no different from ADHD children who did not receive such treatments. Discussion In a representative sample of elementary students from a school district in southeastern Virginia, parent report indicated that 17% of children had been diagnosed with ADHD. The vast majority of these children received medication to treat the disorder and many also received behavioral and combined (medication and behavioral) treatment interventions. Despite extensive treatment for ADHD in the study region, students diagnosed with ADHD continued to experience adverse educational outcomes that place them at risk for school dropout. Even after controlling for race, gender, and health care insurance status, students diagnosed with ADHD were nearly three and one half to seven times more likely to qualify for special education services, to be expelled or Table 2 Risk Factors Associated with Adverse Educational Outcomes among Students Diagnosed with ADHD (Grades 1 5) Outcome Risk Factors OR (95% CI) AOR (95% CI) Special education services Expelled or suspended Repeated a grade Male 2.9 ( )** 2.5 ( )** ADHD 4.9 ( )** 4.1 ( )** Male 4.8 ( )** 4.9 ( )** Black 2.8 ( )** 3.5 ( )** ADHD 7.1 ( )** 6.7 ( )** Black 1.6 ( )* 1.8 ( )* ADHD 3.2 ( )** 3.4 ( )** *p **p Note. OR refers to odds ratios, AOR refers to adjusted odds ratios, and CI refers to the 95% confidence interval.

6 68 LeFever, Villers, Morrow, and Vaughn suspended from school, and to have repeated a grade. Educational research has neglected to consider ADHD as a significant risk for school dropout (Alexander, Entwisle, & Horsey, 1997). Our data suggest that even in a population of students in which ADHD-related services are prevalent, ADHD is strongly associated with adverse educational outcomes and should be considered in future research on school dropout. These findings also support the view that in addition to representing an important educational issue, ADHD has become a major public health issue (LeFever, Butterfoss, & Vislocky, 1999). The fact that remarkably poor educational outcomes were observed in a population in which a high percentage of the population received ADHD treatment suggests that the provision of routine community care for ADHD does not adequately address the educational needs of affected students. School systems can ill afford to see so many children continue to receive few benefits from treatment they receive for ADHD and related behavioral problems. Research is needed to identify how treatment that has been shown to be effective in clinical research settings can be delivered successfully in community settings. As suggested by the MTA study, regular and intense collaboration between providers of treatment and the children s teachers is an important tool for optimizing ADHD treatment intervention (Swanson, Lerner, March, & Gresham, 1999). While our conclusions about educational outcomes are limited by the fact that our survey received a return rate of 63% and relied on parent report, the return rate is consistent with or better than that which is usually obtained from parent surveys administered through schools on related topics (Brener, Thomas, Krug, & Lowry, 2000). We observed no differences in the demographics of participants and the total elementary school population. Whether assessed by objective school record data or more subjective parental report, the identified rate of school-based administration of ADHD medications (8 10%) was consistent across three school districts in the study region. Regarding parent report, parents might have been reluctant to disclose their child s diagnosis, but there is little reason for them to falsely report an ADHD diagnosis or exaggerate the use of ADHD services or school-related problems. The lifetime and current use rates of medication among children diagnosed with ADHD (74% 84%) was consistent with findings from other investigation of ADHD treatment (Wilens & Biederman, 1992; Wolraich, Hannah, Pinnock, Baumgaertel, & Brown, 1996) and further establishes our parents as credible reporters. Unfortunately no information was collected regarding the timing, intensity, or quality of ADHD services delivered; such information might have shed light on the generally poor outcomes associated with the community-based ADHD care received by children in our study. The present examination of routine community ADHD care and associated educational outcomes raises issues regarding treatment effectiveness as opposed to clinical efficacy. Clinical efficacy examines the benefits of a treatment in a controlled setting, while treatment effectiveness explores therapeutic benefits in a naturalistic setting (Wolraich, 1999). The short-term clinical efficacy of psychostimulants such as Ritalin has been well documented among children with ADHD. Research has also demonstrated the efficacy of behavioral and combined interventions. Little is known about the effectiveness of such treatments as routinely delivered in schools and community settings (Hoagwood et al., 2000) or about their impact on major educational outcomes of children. Our findings highlight the need for further research on the effectiveness of communitybased ADHD treatment. One of the most important ways to increase the effectiveness of treatment for ADHD and related disorders is to improve collaboration between physicians and school professionals. Taking proactive steps toward meaningful school/community collaboration is essential if we are to reduce the public health and educational crisis surrounding ADHD identification, treatment, and outcomes. Rates of ADHD treatment are known to vary across communities, and the study region has been identified as having one of the highest per capita rates of Ritalin consumption in the country

7 School Outcomes, ADHD Diagnosis, and Treatment 69 (G. Feussner, Drug Enforcement Agency, 1999, personal communication; Morrow, Morrow, & Haislip, 1998). In this region, school and health professionals responded to high rates of ADHD prevalence by forming a community coalition 1 (LeFever, Butterfoss, & Vislocky, 1999a). The coalition s position statement regarding ADHD in the community includes a mandate to improve communication among parents, schools, and health care providers on behalf of children with ADHD. SHINE is fulfilling this goal by instituting mechanisms for systematic exchange of information between physicians, psychologists, and teachers regarding the diagnosis and treatment of children with ADHD, and its project director (GBL) has received private and state grants to facilitate such processes. Through a grant from the U.S. Department of Education, a schoolwide positive discipline program is being implemented that is aimed at reducing the educational and social functioning of students diagnosed with ADHD and to prevent the emergence of disruptive behavior disorders among at-risk students. The intention of these intervention projects, along with community support and action organized through the SHINE coalition, is to improve the lives children with ADHD and their classmates by optimizing the standard of community-based care for the treatment of ADHD and by creating educational interventions to remove social and barriers to learning. Acknowledgments This study was supported by grants from Norfolk City Public Schools, Children s Hospital of The King s Daughters, Eastern Virginia Medical School, and Merck Pharmaceuticals. The authors would like to thank Dr. Cynthia Kelly, Dr. Nermina Nakas, Cynthia Collins-Odoms, Cheryl Taylor, Kristin Warner, Dr. Thomas Lockamy, and Dr. Dwight Allen for their assistance on this project. References Alexander, K.L., Entwisle, D.R., & Horsey, C.S. (1997). From first grade forward: Early foundations of high school dropout. Sociology of Education, 70, American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attentiondeficit/hyperactivity disorder. Pediatrics, 105, American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Angold, A., Erkanli, A., Egger, H., & Costell, E. (2000). Stimulant treatment for children: A community perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 39, Brener, N.D., Thomas, R.S., Krug, E.G., & Lowry, R. (2000). Recent trends in violence-related behaviors among high school students in the United States. JAMA, 282, Consensus Development Panel. (2000). National Institutes of Health Consensus Development Conference Statement: Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD). Journal of the American Academy of Child and Adolescent Psychiatry, 39, Cunningham, C. (1999). In the wake of the MTA: Charting a new course for the study and treatment of children with attention-deficit/hyperactivity disorder. Canadian Journal of Psychiatry, 44, Elia, J., Borcherding, B., Rapoport, J., & Keysor, D. (1991). Methylphenidate and dextroamphetamine treatments of hyperactivity: Are there true nonresponders? Psychiatry Research, 36, Forness, S., Swanson, J., Cantwell, D., Youpa, D., & Hanna, G. (1992). Stimulant medication and reading performance: Follow-up on sustained dose in ADHD boys with and without conduct disorder. Journal of Learning Disabilities, 25, Forness, S.R. (1998). The impact of attention deficit hyperactivity disorder on school systems. Paper presented at the Consensus Development Conference, National Institutes of Health: Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, Washington, DC. 1 The School Health Initiative for Education (SHINE) is a community coalition funded by Children s Hospital of the King s Daughters Health System, Norfolk, VA.

8 70 LeFever, Villers, Morrow, and Vaughn Greenhill, L., Abikoff, H., Arnold, L., Cantwell, D., Conners, C., Elliott, G., Hechtman, L., Hinshaw, S., Hoza, B., Jensen, P., March, J., Nwecorn, J., Pelham, W., Severe, J., Swanson, J., Vitiello, B., & Wells, K. (1996). Medication treatment strategies in the MTA study: Relevance to clinicians and researchers. Journal of the Academy of Child and Adolescent Psychiatry, 34, Hechtman, L. (1999). Predictors of long-term outcome in children with attention-deficit/hyperactivity disorder. Pediatric Clinics of North America, 46, Hoagwood, K., Kelleher, K., Feil, M., & Comer, D. (2000). Treatment services for children with ADHD: A national perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 39, Jensen, P.S., Kettle, L., Roper, M.T., Sloan, M., Dulcan, M., Hoven, C., Bird, H., Bauermeister, J., & Payne, J. (1999). Are stimulants overprescribed? Treatment of ADHD in four U.S. communities. Journal of the American Academy of Child and Adolescent Psychiatry, 38, LeFever, G.B., Butterfoss, F.D., & Vislocky, N.F. (1999a). High prevalence of attention deficit hyperactivity disorder: Catalyst for development of a school health coalition. Family and Community Health, 22, LeFever, G.B., Dawson, K.V., & Morrow, A.L. (1999). The extent of drug therapy for attention deficit-hyperactivity disorder among children in public schools. American Journal of Public Health, 89, LeFever, G.B., Parker, J.L., & SHINE. (1999b). Providers speak out about ADHD practices in Hampton Roads. SHINE School Health Bulletin, 2 (Fall, 1999), 1. Morrow, R.C., Morrow, A.L., & Haislip, G. (1998). Methylphenidate in the United States, 1990 through American Journal of Public Health, 88, Pelham, W. (1999). The NIMH multimodal treatment study for attention-deficit hyperactivity disorder: Just say yes to drugs alone. Canadian Journal of Psychiatry, 44, Pelham, W., Arnoff, H., Midlam, J., Shapiro, C., Gnagy, E., Chronis, A., Onyango, A., Forehand, G., Nguyen, A., & Waxmonsky, J. (1999). A comparison of Ritalin and Adderall: Efficacy and time-course in children with attentiondeficit/hyperactivity disorder. Pediatrics, 103, Pelham, W., Greenslade, K., & Vodde-Hamilton, M. (1990). Relative efficacy of long-acting CNS stimulants on children with attention deficit-hyperactivity disorder: A comparison of standard methylphenidate, sustained released methylphenidate, and pemoline. Pediatrics, 86, Richters, J., Arnold, L., Jensen, P., Abikoff, H., Conners, C., Greenhill, L., Hechtman, L., Hinshaw, S., Pelham, W., & Swanson, J. (1995). NIMH collaborative multisite multimodal treatment study of children with ADHD: Background and rationale. Journal of the American Academy of Child and Adolescent Psychiatry, 34, SPSS. (1997). SPSS for Windows (Version 7.5). Chicago, IL: SPSS Corporation. Swanson, J., Lerner, M., March, J., & Gresham, F. (1999). Assessment and intervention for attention-deficit/hyperactivity disorder in the schools. Pediatric Clinics of North America, 46, Whalen, C.K., Henker, B., Buhrmester, D., Hinshaw, S.P., Huber, A., & Laski, K. (1989). Does stimulant medication improve the peer status of hyperactive children? Journal of Consulting and Clinical Psychology, 57, Wilens, T., & Biederman, J. (1992). The stimulants. Psychiatric Clinics of North America, 15, Wolraich, M. (1999). The difference between efficacy and effectiveness research in studying attention-deficit/ hyperactivity disorder. Archives of Pediatric and Adolescent Medicine, 153, Wolraich, M.L., Hannah, J.N., Pinnock, T.Y., Baumgaertel, A., & Brown, J. (1996). Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. Journal of the American Academy of Child and Adolescent Psychiatry, 35, Appendix ADHD Questions 1. Has your child been diagnosed with attention or hyperactivity problems known as ADD or ADHD? Yes No Not Sure 2. Is your child currently taking medication for ADD/ADHD? Yes No Not Sure 3. Does your child take ADD/ADHD medication at school? Yes No Not Sure 4. Do you think ADD/ADHD affects your child s grades or behavior in school? Yes No Not Sure

9 School Outcomes, ADHD Diagnosis, and Treatment Which of the following services has your child received for ADD/ADHD? Child Study Evaluation (CST) Medication 504 Plan Special Diet Counseling or Therapy Tutoring Biofeedback None 6. Which of the following have you attended because your child has ADD/ADHD? Counseling or therapy Parenting class Parent support group None

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