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Efficacy of an Organization Skills Intervention to Improve theAcademic Functioning of Students WithAttention-Deficit/Hyperactivity Disorder

Joshua M. Langberg and Jeffery N. EpsteinUniversity of Cincinnati College of Medicine and Cincinnati Childrens Hospital Medical Center

Christina M. Urbanowicz, John O. Simon, and Amanda J. GrahamCincinnati Childrens Hospital Medical Center

Children with attention-deficit/hyperactivity disorder (ADHD) exhibit significant aca-demic impairments, as evidenced by poor academic achievement, grade retention, andschool dropout. Deficits in organization skills may contribute to these academic

impairments, as children with ADHD frequently lose assignments, misplace theircompleted work, and have difficulty planning for tests. The present study examined thepilot efficacy of an 8-week organization skills intervention for children with ADHD.Thirty-seven children were randomly assigned to receive the intervention immediatelyor to a wait-list control. Participants made significant improvements in organization andhomework management skills during the intervention and these gains were maintainedat 8-week follow-up. Parents of children in the intervention group reported decreasedhomework problems. Children in the intervention group also demonstrated prepostgains on teacher ratings of academic impairment and GPA. This study suggests thattargeted academic skills interventions have the potential to improve overall academicperformance among children with ADHD.

Keywords: ADHD, organization, intervention, school-based, academic

Attention-deficit/hyperactivity disorder(ADHD) is one of the most commonly diag-nosed childhood disorders, with prevalencerates among grade-schoolers estimated at37% (American Psychiatric Association[APA], 2000). ADHD is characterized by de-velopmentally inappropriate symptoms of inat-tention, hyperactivity, and impulsivity and sig-

nificant impairment in multiple domains offunctioning (Barkley, 2006). Academic impair-ment is one of the most prevalent and problem-atic of these impairments (DuPaul & Stoner,2003). Children with ADHD consistently un-derachieve academically and are more likelythan their peers to be retained, placed in specialeducation, and to drop out of school (Barkley,Fischer, Edelbrock, & Smallish, 1990; Faraone

et al., 1993; Hinshaw, 1992).Children with ADHD exhibit specific deficitsthat are likely associated with these negativeeducational outcomes. Specifically, childrenwith ADHD often forget to complete assign-ments, complete assignments but forget to turnthem in, and make careless mistakes in theirwork (DuPaul & Stoner, 2003; Raggi & Chro-nis, 2006). Children with ADHD also have sig-nificant difficulties with time management, suchas planning for the completion of long-termprojects and studying for tests (Mash & Bark-ley, 2003). Finally, students with ADHD oftenexhibit off-task, impulsive, and disruptive be-haviors in the classroom (Hoza, Pelham, Was-

Joshua M. Langberg and Jeffery N. Epstein, Departmentof Pediatrics, College of Medicine, University of Cincin-nati; Christina M. Urbanowicz, John O. Simon, andAmanda J. Graham, Cincinnati Childrens Hospital MedicalCenter.

This project was supported in part by funding from thePrinceton City School District of Cincinnati, OH. The au-thors extend their gratitude to the Associate Superintendent,Dr. Mari E. Phillips, and to the school principals, SusanWells and Mario Basora. The authors particularly wish tothank the children, parents, teachers, and after-school pro-gram staff who participated in and supported this project.

Correspondence concerning this article should be ad-dressed to Joshua M. Langberg, Cincinnati Childrens Hos-pital Medical Center, ML #10006, Cincinnati, OH 45229-3039. E-mail: [email protected]

School Psychology Quarterly Copyright 2008 by the American Psychological Association2008, Vol. 23, No. 3, 407 417 1045-3830/08/$12.00 DOI: 10.1037/1045-3830.23.3.407

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chbusch, Kipp, & Owens, 2001). These behav-iors cause them to miss portions of class mate-rial and to have increased conflict with theirteachers.

A number of school-based psychosocial in-terventions have been developed to specificallyaddress the academic impairments associatedwith ADHD (DuPaul & Weyandt, 2006; Raggi& Chronis, 2006). Many ADHD school inter-ventions attempt to enhance academic function-ing by improving specific areas of academicachievement, for example, reading and mathe-matics abilities. These interventions have takenseveral forms, including peer tutoring (DuPaul,Ervin, Hook, & McGoey, 1998; Greenwood,Maheady, & Delquadri, 2002), computer-aidedinstruction (Mautone, DuPaul, & Jitendra,2005; Ota & DuPaul, 2002), and academic con-sultation (Jitendra et al., 2007). Although theseinterventions have been shown to be efficaciousat improving academic achievement in specificsubjects, the generalization of these academicgains to other academic subjects or to futureyears in schooling is questionable.

An alternative intervention strategy is toteach children with ADHD academic skills.Skill training interventions teach students with

ADHD skills to help them navigate and succeedin the school environment. For example, note-taking training is a skills-training academic in-tervention where students are taught to takecomprehensive and organized notes fromteacher lecture. Note-taking interventions havebeen evaluated in two small analog classroompilot studies (Evans, Pelham, & Grudberg,1995; Langberg, Bogle, Smith, & Schmidt,2004). Results of these studies suggest that stu-dents with ADHD demonstrate improved on-task performance, comprehension of material,and test scores.

Another skill training intervention that hasshown promise for students with ADHD is self-management. In self-management interven-tions, students learn to self-evaluate, monitor,and reinforce academic skills. Gureasko-Moore,DuPaul, and White (2006) examined the effi-cacy of a self-management intervention for im-proving the organizational skills of three ado-lescents with ADHD. With the use of a multiplebaseline design, the authors demonstrated that

all three participants improved their classroompreparatory skills, including coming to class ontime, with pencils, paper, and homework.

Skills training interventions have also beenevaluated as part of a multimodal package ofpsychosocial interventions. The ChallengingHorizons Program (CHP) consists of multiple

skills-focused interventions, including organi-zation, note-taking, and study-skills interven-tions. The CHP interventions have been evalu-ated as delivered through an after-school pro-gram (Evans, Langberg, Raggi, Allen, &Buvinger, 2005; Langberg et al., 2006) as wellas through teacher consultation (Evans, Serpell,Schultz, & Pastor, 2007). Participation in theCHP is associated with improved academic per-formance as measured by parent and teacherratings of academic functioning and improve-ments in school grades (Evans et al., 2007;Langberg et al., 2006).

Overall, skill training interventions seem par-ticularly appropriate for children with ADHD,because these children have significant impair-ments in organization and homework manage-ment that may contribute to the observed diffi-culties in academic achievement. Unfortu-nately, there is limited research on interventionsdesigned to improve the organization andhomework management skills of children withADHD. The only study examining the efficacy

of an individual organization skills training in-tervention was limited by a small sample size,n 3 (Gureasko-Moore et al., 2006). The re-mainder of the research conducted on organiza-tion interventions has evaluated efficacy as partof a comprehensive multimodal package of in-terventions. Although the multimodal CHP in-tervention appears to be effective, it is a labor-intensive intervention that may not be feasibleto implement in some school settings. Accord-ingly, additional research is needed on the effi-

cacy of individual skills interventions.The present study is an examination of an8-week organization and homework manage-ment intervention for children with ADHD. Themanualized intervention curriculum includesthree specific components: (a) physical organi-zation of materials (book bag, binder, andlocker), (b) accurate recording of homeworkand tests in a planner, and (c) long-term plan-ning for tests and projects. This study is de-signed to test three specific hypotheses:

1. Intervention participants who receive or-ganization and homework managementtraining will demonstrate improved use of

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these skills during intervention implemen-tation.

2. Participants will maintain skills use over

time, as indicated by an 8-week follow-upassessment.

3. Improved organization skills use willtranslate into improved overall academicperformance as measured by parent andteacher ratings and class grades.

Method

Participants and Setting

Participants attended Grades 47 in a subur-ban public school district in southwest Ohio. Atotal of 37 students (31 boys and 6 girls) whomet criteria for a research screening diagnosisof ADHD were included in the study (age range9 14). The sample was 70% Caucasian and30% African American. Students were referredto the study by teachers and school counselorswho identified students with elevated levels ofinattention or hyperactivity/impulsivity com-bined with difficulties with homework comple-

tion or organization. Students were included inthe study if they exhibited clinically significantsymptoms of ADHD (six or more symptoms ofany subtype endorsed) on either the parent orteacher Vanderbilt ADHD Rating Scale. TheVanderbilt ADHD Rating Scales are Diagnosticand Statistical Manual of Mental Disorders (4thed.)based scales (APA, 2000) with teacher-report (VADTRS) and parent-report forms(VADPRS; Wolraich, Feurer, Hannah, Baum-gaertel, & Pinnock, 1998). The 18 ADHDsymptom items on the Vanderbilt have excel-lent internal consistency reliability, Cronbachsalpha .90, and high concurrent validity withother instruments of established validity andreliability, r .79 with the Computerized Di-agnostic Interview Schedule for ChildrenIV(C-DISC-IV) (Wolraich et al., 2003). A symp-tom count score can be derived for DSMIVitems with symptoms rated as occurring oftenor very often counted as present. Participantswho met the six or more symptom criteria fromone rater (parent or teacher) were included as

long as they had no less than four symptomsendorsed by the other rater. Participants werealso required to meet an impairment criterion,

defined as a score of four or higher in one ormore areas of impairment on both the parentand teacher Vanderbilt ratings. The study wasapproved by the Institutional Review Board,

and written parental consent and verbal childassent were collected from all participants.

Families who met inclusion criteria andsigned consent were randomly assigned to treat-ment or wait-list control. To make the randomassignment procedure more palatable to theschool district, an assignment ratio of two treat-ment students to every one wait-list controlstudent was utilized, resulting in a sample of 24treatment and 13 wait-list control participants.At baseline and again at completion of the in-

tervention, families were queried about chil-drens medication use. At baseline, 11 of thetreatment participants and five of the waitlistcontrol participants were taking medication forADHD. Eight of the 11 treatment participants(73%) and three of the five control participants(60%) were taking stimulant medications. Theremaining medicated participants were usingnonstimulant medications, that is, Strattera. Al-though families were not asked to hold medica-tion constant, none of the participants mademedication changes during the intervention, as

confirmed by postintervention interviews withfamilies.

Procedures

The organization and homework manage-ment interventions were delivered as part of a2-day-per-week (Tuesdays and Thursdays) af-ter-school program. The after-school programwas held on-site at the school for 8 weeks andstudents received 1 hr, 15 min of interventioneach program day. The after-school programwas staffed by university undergraduate psy-chology students with a ratio of 3:1, students tocounselors. All students received 20 min ofindividual intervention time (1:1 student tocounselor) and 55 min of group interventioneach program day. Students returned to the af-ter-school program on one additional occasionfor follow-up evaluation, 8 weeks after the com-pletion of the intervention (i.e., 16 weeks afterbaseline evaluation). Wait-list control students

received the same 8-week intervention afterchildren in the intervention group completed theintervention.

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Treatment manual. The treatment manualoutlined all intervention procedures (Langberg,2006). The manual explained in detail how tocomplete the Organization and Homework

Management Checklists and to apply the appro-priate rewards, specified the duration of time tobe spent implementing each intervention com-ponent, and provided operationalized defini-tions for the behavior management system.Counselors reviewed the manual, receivedtraining, and were tested on procedures prior toimplementing the intervention. In addition,counselors received weekly supervision from alicensed psychologist.

Organization intervention. The Organiza-tion Checklist, developed as part of the multi-modal CHP intervention, was utilized to createa system of organization for all participants.During the first week of the after-school pro-gram, participants worked with their counselorto establish a system of book bag, binder, andlocker organization. All students were providedwith new three-ring binders, dividers, folders,and paper to develop their system. The Organi-zation Checklist includes seven operationalizedcriteria for binders, four criteria for book bag,and three for locker. For example, binder crite-

ria include: (a) there is a section for each classthe student is taking in the students binder; (b)there is a homework folder in the front of thebinder with homework to be completed on theleft side and homework to be turned in on theright side; and (c) all folders and papers aresecured by three-rings and there are no loosepapers or folders. Baseline organization wasrecorded on the first program day and systemsof organization based on the checklist wereestablished for all participants on the secondprogram day. The Organization Checklist wasthen completed by the counselor every programday for the duration of the after-school programand at the 8-week follow-up.

Homework management intervention. Dur-ing individual intervention time, counselorschecked all participants assignment notebooks/planners for homework and test recording accu-racy. After-school program participants wererequired to record their homework assignmentsin a planner and to have their teacher initial theplanner. Participants were expected to have

their four core class teachers, math, languagearts, science, and history, initial the plannerdaily. Each day the program counselors utilized

a homework tracking sheet to record the numberof teacher initials received over the numberexpected. Once a week, after-school counselorsmet with teachers to ensure that students were

not forging the teacher initials in their planners.Group intervention. During the 55 min of

daily group intervention time, students partici-pated in one of four activities: (a) homeworkcompletion, (b) math worksheets, (c) outliningchapters in school textbooks, or (d) recreationtime. All students who had homework wereexpected to complete their homework beforemoving on to any of the other activities. Recre-ation time was only an option if students hadearned free time minutes (see behavior manage-ment/reward system).

Behavior management/reward system. Stu-dents had the opportunity to earn free-time min-utes for use during the after-school program byaccurately recording their homework assign-ments and tests in their planners and gettingteacher initials. Students were not required touse their minutes daily and could choose to savefree time minutes. Free time included playinggroup board and card games.

The after-school program also included apoint system. Participants received one point for

each of the Organization Checklist criteria thatthey met. Students also received behavior pointsduring the after-school program for workingquietly, ignoring negative behavior, raisingtheir hand to ask a question, and completingextra work. Each of these behaviors was oper-ationally defined in the manual and the coun-selors memorized and were tested on the behav-ioral definitions during training. Participantscould turn in their points for gift cards as soonas they reached a predefined number of points.Both the point system and the free-time systemwere not introduced until the second week ofthe after-school program, in order to collectbaseline data on the Organization and Home-work Management Checklists.

Parent involvement. Two, 1-hr parent ses-sions were offered in the evening at the schoolduring the 8-week intervention. During the firstparent session the group leader reviewed theafter-school program components and rewardsystem and answered parents questions aboutthe program. During the second session, the

group leader presented parents with the inter-vention forms, the Organization Checklist, andthe Homework Tracking Checklist, and facili-

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tated a group discussion about how to imple-ment, monitor, and reward continued use of theorganization and homework management inter-ventions at home.

Treatment Fidelity

To assess procedural integrity, counselor ac-curacy in completing the Organization Check-list was evaluated by an outside observer for15% of all intervention sessions. The Organiza-tion Checklist contains 14 operationalized cri-teria. Integrity was calculated as the percentageof organization criteria accurately checked andrecorded (e.g., 13 out of 14 93%). Analysesrevealed that counselors completed the Organi-zation Checklists accurately (checked and ap-plied the correct operationalized criteria) M90% of the time (range 80100%). The mostcommon error was related to counselors beinglenient when applying criteria.

Treatment fidelity for the reward system wasalso evaluated. At the end of each interventionsession, counselors summed the behavior andorganization points that each participant earnedand recorded the total points earned on a re-

ward-system checklist. A research assistant in-dependently reviewed all participants foldersto verify that the correct point total was re-corded (100% of sessions were checked). Fidel-ity was recorded as yes/no based on whether thecounselor recorded the appropriate total pointvalue on the reward-system checklist. Fidelitychecks revealed that counselors recorded theappropriate total point value on 85% of all oc-casions. The most common errors were mis-takes with addition (e.g., the behavior orga-

nization point total was incorrect) or with trans-ferring numbers (e.g., the participant met sevenorganization criteria but the counselor recordedsix on the reward-system checklist). When mis-takes were found, errors were corrected to en-sure that the appropriate reward was applied.

Attendance at the after-school program andparent sessions was also recorded as a measureof treatment fidelity. Attendance at the after-school program was high, over 90%, with nochild missing more than 10% of available inter-

vention days. Attendance at the parent meetingwas moderate, 75%, with three parents who didnot attend either of the two parent sessions.

Measures

Ho me wo rk Pr ob le m Ch ec kl is t. (HPC;Anesko, Schoiock, Ramirez, & Levine, 1987):

The HPC is a parent report instrument consist-ing of 20 items. It is commonly used as ascreening tool and outcome measure to assesshomework problems. The HPC has been used inlarge field trials of ADHD Diagnostic Criteria(Lahey et al., 1994) and in the MultimodalTreatment Study of Children with ADHD(MTA Cooperative Group, 1999). Factor anal-yses conducted by Power, Werba, Watkins, An-gelucci, and Eiraldi (2006) indicate that theHPC has two distinct factors, Inattention/Avoidance of Homework (IA) and Poor Produc-tivity/Nonadherence to Homework Rules (NA).Both factors have moderate to high correlationswith the Inattention factor on the Behavior As-sessment Scale for Children (BASC), parentversion. The IA and NA factors can be com-bined to produce an HPC Total Score. The HPCwas completed by participants parents at base-line and post intervention.

Ac ad em ic pe rf or ma nc e ra ti ng sc al e.(APRS; DuPaul, Rapport, & Perriello, 1991):The primary purpose of this scale is to measure

how well the child is performing academically.The APRS is a 19-item scale that is completedby the teacher. Factor analyses of the APRShave documented a three-factor structure in-cluding Academic Success (AS), Impulse Con-trol (IC), and Academic Productivity (AP) fac-tors. The subscales can also be combined toproduce an APRS Total Score. The APRS totaland subscale scores possess acceptable internalconsistency (coefficient alphas of .72 to .95), arestable across a 2-week interval (t-test comparisonsranged fromr .88 to .95), and evidence signif-icant levels of criterion-related validity. TheAPRS was completed by participants teachers atbaseline and postintervention.

Class grades. Core class grades (math, sci-ence, language arts, and history) were collectedfor all participants involved in the study. Gradesprovide ecologically valid, objective accountsof important, school-related functioning.Grades were quantified according to a 4.0 grad-ing system to provide an overall grade-pointaverage.

Organization Checklist. The OrganizationChecklist has been utilized as an outcome mea-sure in previous studies (Evans, Langberg et al.,


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tion group with participants in the wait-list con-trol on the two rating scales to establish pre-treatment equivalence. Pretreatment equiva-lence was achieved for the HPC (p .35) andAPRS (p .41) (see means and standard de-viations in Table 1). Homogeneity of varianceat baseline for the HPC and APRS was exam-ined to ensure that statistical assumptions werenot violated due to the unequal sample sizesacross groups. At baseline, group varianceswere equivalent for the HPC (p .52) andAPRS (p .24).

Homework Problems Checklist. On the par-ent HPC ratings, there was a significant maineffect of time, F(1, 35) 15.30, p .001,indicating an overall trend toward improvementduring the 8 weeks. A significant Group Time interaction, F(1, 35) 12.42, p .01,n2 .26, was also found. Parents indicated thatparticipants in the organization intervention im-proved during the 8-week intervention, whereasthe waitlist control group made no significantchange pre to post. Specifically, intervention

participants were rated as significantly im-proved on both the HPC IA factor,t(23) 4.40,

p .001, and on the HPC NA factor,

t(23) 6.39, p .001, whereas the controlgroup made no significant changes from base-line to post, p .05. Between-groups contrastsusing standardized mean difference scores re-vealed that according to parent ratings, the in-tervention had a large effect; d .71 for HPCTS (see Table 1).

Academic Performance Rating Sale. Nosignificant effects of group, time, or group xtime interactions were found for the APRS,MANOVA (ps .05). Effect-size analyses re-

vealed a small between-group effect accordingto teacher ratings (d .28 for APRS TS) (seeTable 1).

Class grades. The repeated-measuresANOVA examining change over time for theintervention group revealed a significant trendtoward improvement in GPA combined acrossthe four core subjects (Q2; M 2.37, SD .91), (Q3;M 2.47,SD .87), (Q4;M 2.63,SD .95), p .01. Tests of within-subjectscontrasts revealed that GPA at Quarters 2 and 3

were not significantly different, p .25, butGPA was significantly higher post intervention,Quarter 4, than at Quarter 3 (p .05).

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Days in program

Percentageofcriteriamet

Binder

Bookbag

Locker

Baselineaseline Follow-upollow up

Figure 1. Graphical depiction of book bag, binder, and locker organization criteria astracked during the 8-week intervention and as recorded at the follow-up assessment.


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Discussion

This investigation evaluated the efficacy ofa multicomponent organization interventionto improve the academic performance of chil-dren with ADHD. The intervention was de-livered through a 2-day-per-week after-schoolprogram that lasted 8 weeks. Measures ofphysical organization (book bag, binder, and

locker) and homework recording demon-strated that children in the intervention groupimproved their organization skills during the8-week intervention and that these gains werelargely maintained at 8-week follow-up.These organizational skills gains translatedinto significantly improved parent ratings ofacademic functioning. Although teacher rat-ings of academic performance did not differ

0.00%

10.00%

20.00%

30.00%

40.00%

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60.00%

70.00%

80.00%

90.00%

100.00%

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

Days

Percentagerecorded

Intervention GroupWaitlist Group

Baselineaseline Interventionntervention 8-weeks post interventionweeks post intervention

Figure 2. Graphical depiction of homework and test-recording accuracy in an assignmentnotebook/planner for the intervention and wait-list control groups.

Table 1Means, Standard Deviations, and Cohens d effect sizes for Parent and Teacher Ratings

Variable

O.I. pre W.L. pre O.I. post W.L. post

dM SD M SD M SD M SD

HPCIA 25.50 6.5 23.38 7.7 19.96 5.4 22.92 7.1 .49

HPCNA 19.08 5.0 18.61 6.2 14.29 4.1 18.54 6.1 .87

HPCTS 44.58 10.3 42.00 12.8 34.25 8.8 41.46 12.2 .71

APRSAP 38.79 8.9 41.31 7.3 42.38 10.3 39.62 9.7 .27

APRSAS 21.04 5.6 20.46 4.2 21.49 7.6 22.23 4.7 -.11

APRSTS 59.00 12.7 61.62 10.1 63.83 10.4 60.92 10.8 .28

Note. Group differences at baseline were tested with two-tailed, independent-sample t tests. O.I. organization

intervention group; W.L.

wait-list control group; HPC

Homework Problems Checklist; IA

inattention/avoidance;NA noncompliance; TS total score; APRS academic performance rating scale; AP academic productivity; AS academic success; TS total score; d magnitude of between-group contrasts calculated with the use of standardizedmean difference scores; n 24 for intervention group; and n 13 for control group for parent and teacher ratings.

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significantly across groups, children in theintervention group made small gains.

In addition to improvement in parent ratingsof homework problems, the intervention re-

sulted in gains in class grades. Class grades areoften difficult to interpret as an outcome mea-sure because grade reports do not correspondtemporally with baseline and postinterventiondata collections. Nevertheless, grades are a cru-cial outcome measure when targeting academicperformance and of particular importance toparents. Participants in this study showed asmall but significant increase in overall GPAfrom the beginning of the intervention Quarter 3to postintervention, Quarter 4. Although im-provements in grades were relatively small, it isencouraging that participants demonstrated im-proved GPA at Quarter 4, because the interven-tion ended approximately 10 weeks prior to thecompletion of Quarter 4.

This study found that prior to interventionparticipants were displaying significant difficul-ties with homework recording and with organi-zation. At baseline, all participants were havingsignificant difficulties with organization acrossbinder, book bag, and locker (see Figure 1).Likewise, at baseline, participants infrequently

recorded homework and tests in their planners(see Figure 2). These findings shed some lighton the academic impairments consistently citedfor children with ADHD. Specifically, thesefindings suggest that failure to perform two coreacademic skills, accurate homework assignmentrecording and organization of school materials,may contribute to the comprehensive academicdifficulties that many children with ADHD ex-hibit.

This study also suggests that relatively minorand targeted interventions, homework manage-ment and organization skills, have the potentialto improve overall academic performance.Large improvements in academic performancewere reported by parents. Teacher initials in theplanner, an Organization Checklist, and a be-havioral point system are three relatively simpleand easy-to-implement interventions comparedto the multisystemic psychosocial interventionsthat have been evaluated for children withADHD (MTA Cooperative Group, 1999). Thishas significant clinical implications in that

counselors and teachers may be able to assistparents with implementing this system in a cost-effective manner.

The intervention included two parent trainingsessions designed to promote skill generaliza-tion over time. Follow-up analyses revealed thatmany of the organization and homework man-

agement gains made during the 8-week inter-vention were being maintained. During the twoparent training sessions, parents were providedwith the checklists and intervention materialsand a summary of the behavioral points system.Parents then worked with a group leader todevelop rewards that could be used at home tocontinue the system after the after-school pro-gram ended. Across the 8-week follow-up pe-riod intervention participants continued to ob-tain teacher initials the majority of the time. Theteacher-initial system allows parents to knowthat the homework recorded in the planner isaccurate. Because none of the intervention par-ticipants were obtaining teacher initials at base-line, the follow-up data suggest that many of theparents found this intervention worthwhile andfeasible to maintain.

Limitations

Although the results of this study are encour-aging, there are a number of limitations. The

most obvious limitation is the small sampleexamined this study. In particular, the smallcontrol group, n 13, significantly limits anyconclusions about homework management andorganizational skills of children with ADHDover time. In addition, the small sample likelylimited power to find statistically significanteffects on some outcomes with smaller effectsizes. This may partially explain the lack ofsignificant effects on teacher ratings, becauseintervention effects as rated by teachers weresmaller than those reported by parents. Thesmall sample also hindered our ability to eval-uate potential moderators of treatment efficacy,such as the age of participants and medicationuse. Specifically, the sample contained bothchildren and adolescents and participants onand off medication. The intervention may havedifferential effectiveness depending on partici-pant age and medication status, and these issuesshould be examined in future studies of organi-zation interventions. Given that children andadolescents often have markedly different aca-

demic responsibilities (Evans, Serpell, & White,2005) the wide age range is a noteworthy lim-itation.


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Because of resource limitations, the sample isnot particularly well defined. ADHD diagnoseswere made with the use of rating-scale data, notdiagnostic interviews. Also, measures of intel-

ligence and achievement were not completed.As a result, limited information is available todetermine if subjects met criteria for learningdisabilities or other comorbid diagnoses. Thesample is probably best defined as childrenidentified by school personnel as havingADHD-related problems and in need of aca-demic intervention. So although the internal va-lidity of the sample may be compromised by thelack of comprehensive assessment, the externalvalidity of this sample is quite appropriate for

such an intervention.An additional limitation is the lack of fol-low-up ratings from parents and teachers at the8-week follow-up time point. The initial studydesign included collection of 8-week follow-upratings. Unfortunately, the 8-week follow-uprating collection corresponded with the end ofthe school year. Despite persistent efforts, manyratings were not returned by parents, and asignificant percentage of teachers failed to com-plete the ratings. Although measures of physicalorganization and homework recording werecompleted at the 8-week follow-up and fourth-quarter grades are presented as a follow-up out-come, the addition of follow-up ratings wouldhave strengthened the findings.

A final limitation is that parents and teacherswere not blind to group assignment and thiscould potentially influence or bias their ratings.It is particularly difficult to keep parents andteachers blind to group assignment when usingrandomization to a wait-list control and whenparents and teachers are both involved in the

intervention. Similarly, intervention counselorswere not blind to group assignment and thismay have influenced how they interacted withthe participants. A stronger study design wouldinvolve random assignment to an attention orsham control, thereby reducing the potential forbiased ratings. In addition, the study designlimits our ability to draw conclusions about theefficacy of the organization training alone, thatis, without the use of external rewards. Specif-ically, we were not able to evaluate the differ-

ential effect of the organization training as com-pared to the training plus the use of an externalreward system.

Future Directions

Consistent with previous work (Gureasko-Moore et al., 2006), we have demonstrated that

interventions focusing on organization skillshave potential for improving the academic func-tioning of children with ADHD. Additional re-search is needed to focus on issues of general-ization of these interventions. The long-termeffects or temporal generalization of these in-terventions needs to be examined. Further, thegeneralization of these findings to specificADHD populations such as ADHD, Predomi-nantly Inattentive Type or older adolescentswith ADHD appears warranted. Finally, issuesof implementation and dissemination of such

interventions into public- and private-schoolsettings need to be explored.

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