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Interventions to Address the Academic Impairment of Childrenand Adolescents with ADHD

Veronica L. Raggi,1,2 and Andrea M. Chronis1

There exists a strong link between ADHD and academic underachievement. Both the corebehavioral symptoms of ADHD and associated executive functioning deficits likely contribute

to academic impairment. Current evidence-based approaches to the treatment of ADHD (i.e.,stimulant medication, clinical behavior therapy and classroom behavioral interventions) havedemonstrated a robust impact on behavioral variables such as attention and disruptivebehavior within classroom analogue settings; however, their efficacy in improving academic

outcomes is much less clear. Although surprisingly few treatment outcome studies of ADHDhave attempted to incorporate interventions that specifically target academic outcomes, thestudies that are available suggest that these interventions may be beneficial. The state of the

treatment literature for addressing academic impairment in children and adolescents withADHD will be reviewed herein, as well as limitations of current research, and directions forfuture research.

KEY WORDS: academic; ADHD; adolescents; behavioral; children; interventions.

INTRODUCTION

The relationship between Attention-Deficit/Hyperactivity Disorder (ADHD) and academicimpairment has long been documented (Hinshaw,1992b, 1994; Mash and Barkley, 2003; Zentall, 1993).There exists a strong link between ADHD and aca-demic underachievement (Barkley, 1998; Hinshaw,1992b) and a high rate of co-occurring learningproblems in this group (Silver, 1992). Compared withnormal controls, children with ADHD are morelikely to have a history of learning disabilities,repeated grades, placement in special education, andacademic tutoring (Faraone et al., 1993). Further-more, prospective follow-up studies of children withADHD into adolescence and adulthood indicatesignificantly higher rates of grade retention, place-

ment in special education classrooms, and schooldropout and expulsion relative to their peers (Barkleyet al., 1990). The academic difficulties of children andadolescents with ADHD are significant, and typicallyinclude failure to complete homework, poor com-prehension of material, poor study skills, low test andquiz grades, poor preparation for class, disruptivebehavior, peer conflict, and conflict with teachers(Evans et al., 2004; Hinshaw, 1992b; Robin, 1998;Zentall, 1993).

CORE SYMPTOMS OF ADHD AND ACADEMIC

IMPAIRMENT

The core symptoms of ADHD according to thecurrent version of the Diagnostic and StatisticalManual of Mental Disorders (DSM-IV) (AmericanPsychiatric Association, 2000), inattention, hyperac-tivity and impulsivity, appear to play a considerablerole in the development of academic impairment inchildren and adolescents with the disorder. Indepen-dent of the level of executive functioning deficits, the

1Department of Psychology, University of Maryland, College Park,

MD 20742, USA.2To whom correspondence should be addressed; e-mail: vraggi@

psyc.umd.edu

Clinical Child and Family Psychology Review, Vol. 9, No. 2, June 2006 (� 2006)

DOI: 10.1007/s10567-006-0006-0

851096-4037/06/0600-0085/0 � 2006 Springer ScienceþBusiness Media, Inc.

severity of ADHD symptoms has been found topredict academic underachievement in reading, writ-ing and mathematics (Barry et al., 2002). Symptomsof inattention typically result in off-task behavior inthe classroom; failure to listen to classroom or taskinstructions; forgetting to complete and turn in, los-ing, or failing to finish assignments; and shiftingactivities often (Mash and Barkley, 2003). Observa-tional measures of children with ADHD have dem-onstrated increased off-task behavior; decreasedwork productivity; more activity and more errors ontasks over time; frequent distractions from assignedtasks; slower and less likelihood of returning to anactivity once interrupted; less attention to the rulesgoverning a task; and decreased ability to shiftattention across tasks flexibly; than control children(Hoza et al., 2001; Lorch et al., 2000; Shelton et al.,1998; Zentall, 1993).

Symptoms of hyperactivity or excessive verbaland motor activity in children with ADHD also haveimplications for academic functioning, including dif-ficulty staying seated in the classroom; excessivefidgeting; greater touching of objects; and playingnoisily (Mash and Barkley, 2003). All of thesesymptoms may lead to increased discipline and neg-ative teacher attributions in the classroom and lowerlevels of task completion. Activity patterns mayappear disorganized and students with ADHD mayfail to repeat specific activity patterns long enough toestablish routines (Zentall, 1993).

Finally, symptoms of impulsivity, the child’sdifficulty in withholding active responses, typicallyresult in academic errors because the child fails towait long enough to consider alternative information,consequences, or responses (Zentall, 1993). Failure toinhibit salient or immediate responses results in poormultiple choice test performance, which requirescarefully considering multiple alternatives beforeresponding; poor planning, studying for tests, andcompletion of long-term projects, which requireholding back overt responses while making covertones; and failure to read directions or ask for help,because this requires waiting (Mash and Barkley,2003; Robin, 1998; Zentall, 1993).

EXECUTIVE FUNCTIONING DEFICITS

AND ACADEMIC IMPAIRMENT IN ADHD

The academic impairment observed in childrenand adolescents with ADHD is also consistent withresearch suggesting a core deficit in behavioral inhi-bition, the ability to delay prepotent responses to an

event, and to filter out competing stimuli (Barkley,1997). According to Barkley’s model, this primarydeficit is hypothesized to affect numerous executivefunctioning processes including nonverbal workingmemory, delayed internalization of speech (i.e., ver-bal working memory), immature self-regulation ofaffect/motivation/arousal, impaired reconstitution,and reduced motor control/fluency/syntax (Barkley,1997).

Specific deficits in each of these areas may havedirect implications for the development of academicproblems in children with ADHD. For example,deficits in nonverbal working memory have beendocumented in children with ADHD (Barkley et al.,1992) and appear to result in forgetfulness, animpaired ability to organize and execute actions rel-ative to time (i.e., time management), and reducedhindsight and forethought, leading to a reduction inthe anticipation of future events (Mash and Barkley,2003). These problems may manifest in ADHD asdifficulty remembering to complete and turn inhomework assignments, difficulty planning ahead forcompletion of long-term projects, and difficulty pri-oritizing or organizing homework tasks. Immatureself-regulation of affect, motivation and arousal inchildren and adolescents with ADHD may lead togreater emotional expression in reactions to eventsand a diminished ability to induce motivational statesin the service of goal-directed behavior. Consistentwith these hypotheses, studies have shown that chil-dren with ADHD demonstrate lower work produc-tivity, lower self-expectations, less persistence andmore discouragement at academic tasks, less enjoy-ment of learning, and a preference for easy overchallenging work (Carlson et al., 2002; Hoza et al.,2001). In addition, immature self-regulation of affectand motivation may result in the emotional andbehavioral problems observed within the classroom,student-teacher conflict, and suspensions and otherpunishments, all of which serve to reduce studentproductivity and opportunities for learning. Fur-thermore, children with ADHD have been found todisplay greater difficulties in the development ofmotor coordination, especially in the planning andexecution of complex, lengthy, and novel chains ofgoal-directed behavior (Mash and Barkley, 2003).They also demonstrate slower motor-response andperceptual speed (Barkley et al., 1992; Plomin andFoch, 1981). These deficits may affect numerousabilities, including competence in sports-related ormechanically inclined activities and classes (e.g.,music, carpentry, football, art, etc.), and result in

86 Raggi and Chronis

difficulties within the classroom which may includepoor penmanship, typing errors, and sloppy work.

Therefore, both the core behavioral symptoms ofADHD and disrupted executive functioning pro-cesses have direct implications for the development ofacademic problems within this population. Theseproblems extend beyond off-task and disruptivebehavior in the classroom to include academicproblems such as failure to complete homework,poor comprehension of material, poor study skills,sloppy work and poor penmanship, low test and quizgrades, failure to read directions carefully, rushingthrough assignments, decreased motivation and per-sistence, inability to plan ahead to complete long-term projects, grade retention, and placement inspecial education. Current empirically supportedapproaches for ADHD appear to offer some benefitin addressing these academic problems; however, theyalso have significant limitations, which will bedescribed below. A more comprehensive approachincorporating other interventions that specificallytarget academic problems in children and adolescentswith ADHD may be necessary to more effectivelyameliorate the academic difficulties of this group.

CURRENT EVIDENCE-BASED APPROACHES

IN THE TREATMENT OF CHILD

AND ADOLESCENT ADHD

Current evidence-based treatments for child andadolescent ADHD consist of stimulant medicationand behavioral interventions, which include bothparent training and school-based interventions(Pelham et al., 1998). Stimulant medication has beenfound to produce large, robust effects on a number ofoutcome measures including symptoms of ADHD,on-task behavior, disruptive behavior, and compli-ance (see Swanson et al., 1995 for a review). There isalso strong evidence to suggest that stimulantsimprove academic productivity (i.e., task completion)and academic accuracy in the short-term withinclassroom analogue settings (Evans et al., 2001;Pelham et al., 1999; Swanson et al., 1995).

In contrast, no evidence is currently available tosuggest that stimulant medication has an effect onlong-term academic achievement (Swanson et al.,1995). In addition, limited studies have examined theefficacy of stimulant medication for a broad range ofacademic outcome measures (e.g., achievementscores, grades, comprehension of material, task per-sistence, organization, correct use of directions).Those that have utilized these measures have gener-

ally found considerably smaller effect sizes than forbehavioral variables (Kavale, 1982; Rapport et al.,1994). Further, it is unclear whether stimulant med-ication, when used regularly, translates into long-term improvements in academic performance withina naturalistic classroom setting, as opposed to ananalogue classroom. In addition, a number of limi-tations exist to an exclusive pharmacologicalapproach in the treatment of ADHD, all of whichmay apply to the treatment of academic impairmentin this population. Despite large effects on manybehavioral outcome measures, stimulant medicationdoes not normalize behavior. Furthermore, a signif-icant minority of children (about 20–30%) is con-sidered non-responders, and may show decrements inbehavioral and academic performance on medicationrelative to placebo conditions (Barkley, 1990; Pelhamand Murphy, 1986; Rapport et al., 1994). Althoughthese drugs offer considerable short-term benefits onattention and behavior, they fall short in their abilityto teach long-term skills or habits, which may beparticularly important for improving academicfunctioning (e.g., organizational and study skills),and they require compliance with daily dosingrequirements (Spencer et al., 1995). Finally, manyparents and children may be opposed to medicationuse (Smith et al., 2000; Swanson et al., 1995).Therefore, while stimulant medication offers mean-ingful improvements in ADHD symptoms, classroombehavior, and work productivity in the short term,significant limitations are present. These limitationshighlight the need to develop efficacious psychosocialinterventions which involve parents and the schoolsystem and which demonstrate long-term benefit onthe academic functioning of children and adolescentswith ADHD.

In addition to the evidence for the effectivenessof stimulant medication, a large and convincing evi-dence base exists for behavioral parent training andbehavioral school interventions, which has resulted intheir classification as ‘‘empirically-validated treat-ments’’ for ADHD, according to the American Psy-chological Association (APA) Division 53 criteria(Lonigan et al., 1998; Pelham et al., 1998). Behavioralparent training and behavioral school interventionsfocus on the manipulation of environmental variablesincluding antecedents (i.e., location, setting, struc-ture), positive consequences (i.e., parent and teacherattention or praise, tangible rewards, point systems,daily report cards, and token economies), and nega-tive consequences (i.e., time out, loss of privileges,reprimands, and response-cost procedures) to

87Academic Interventions

improve behavioral outcomes (Chronis et al. 2005;Pfiffner and Barkley, 1998). These behavioral tech-niques are a necessary component of effective treat-ment for the behavioral and academic impairment ofchildren with ADHD. However, the large majoritiesof studies that have tested behavioral interventionsfocus on classroom behavior (i.e., on-task anddisruptive behavior) and have not included academicoutcome measures. Behavioral techniques may bemore limited in their ability to address academicperformance unless the academic behavior (e.g.,accuracy of assigned work) is directly targeted(DuPaul et al., 1998). Further, studies conducted sofar have generally employed the use of analogueclassroom settings in which paraprofessionals directlyimplement the treatment program. Therefore, resultsmay not generalize to real-world clinical behaviortherapy, in which teachers and parents are the agentsof change. These interventions typically require con-siderable time and effort to implement, and, as aresult, have variable levels of acceptability andpracticality for use by parents and teachers. Anothersignificant caveat is the limited evidence to suggestthat behavior management programs promotegeneralization and maintenance of behavioral gainsbeyond the duration for which the token economy orother system is implemented (Pelham et al., 1998).Therefore, while these programs offer considerablebenefit for improving classroom behavior, theireffectiveness when directly targeting academic per-formance within a naturalistic classroom setting isless clear. Classroom behavioral interventions, whichspecifically target academic impairment and measureacademic outcomes in real-world settings, should betested in order to more fully address the academicproblems of children and adolescents with ADHD.

RATIONALE FOR DEVELOPING

AND TESTING ACADEMIC-FOCUSED

INTERVENTIONS

Due to some of the significant limitations ofstimulant medication and behavior managementapproaches, as well as evidence for smaller effect sizesfor academic outcomes than for behavioral outcomeswhen testing these approaches, researchers havesought to develop and test alternative behavioralstrategies to address the academic problems of chil-dren with ADHD. While behaviorally based class-room interventions typically target on-task anddisruptive behavior, academic interventions forADHD focus primarily on manipulating antecedent

conditions such as academic instruction or materialsin order to improve both behavioral and academicoutcomes (DuPaul and Eckert, 1998). Although sur-prisingly few treatment outcome studies have at-tempted to incorporate academically focusedinterventions (DuPaul and Eckert, 1998), the studiesthat are available suggest that these interventionshave beneficial effects on academic performance (e.g.,Ervin et al., 1998; Evans et al., 1995; Ford et al.,1993). A recent meta-analysis of school-based inter-ventions for children with ADHD found that bothbehavior management and academic interventionshad similar positive effects on ADHD-relatedbehaviors. It was however, difficult to discern theeffectiveness of these approaches on academicperformance due to the relatively few studiesemploying academic outcome measures (DuPaul andEckert, 1997).

Teachers may prefer academic interventions overstrict behavior management approaches given theirtime efficiency and more direct targeting of academicdeficits (DuPaul and Eckert, 1998). Further, they mayoffer increased generalizability and maintenance ofgains, as they often teach skills or use techniques thatmay be applied to a wide variety of situations.Finally, direct targeting of academic impairment mayreduce the risk for negative long-term outcomesassociated with increased academic problems in olderchildren and adolescents with ADHD.

Academic approaches that have been developedand show some preliminary support for use withchildren with ADHD include: peer and parenttutoring, task and instructional modifications, strat-egy training, self-monitoring, use of functionalassessment, and homework management programs(DuPaul and Eckert, 1998). The duration of thispaper will focus on a review of the research investi-gating the impact of academic interventions on theon-task behavior and academic performance of chil-dren and adolescents with ADHD. Interventionswhich were considered and included in this paper arethose which manipulate academic antecedents ratherthan focus on traditional behavior managementapproaches, those which examine academic outcomes(e.g., attention to a task or on-task behavior, taskcompletion, task accuracy, grades, and achievementscores), and those which test these approaches in aclinical group of children with either ADHD,hyperactivity, or disruptive behavior problems. Wechose to include those studies which focused strictlyon on-task behavior if these studies also met ourother two criteria, since a child’s attention to a task is


a critical component of academic productivity.Potential advantages and limitations of each ap-proach, the current state of the research literature,limitations of current study designs, and futuredirections will be discussed for each particular inter-vention.

PEER TUTORING

Children with ADHD show significant amountsof off-task and disruptive behavior during instructionand independent seatwork in the classroom (Abikoffet al., 1977). Large class size, lack of individualizedinstruction and prompts, and passive attentionrequirements may be a few of the key factors thatexacerbate existing difficulties of children withADHD. As a result, they may be less likely to inte-grate and learn class material, and may demonstratelower levels of work productivity (Pfiffner andBarkley, 1998). Peer tutoring is a method of instruc-tion in which children with ADHD are paired with apeer tutor that aids them in learning academicmaterial. This method allows for one-to-oneinstruction that is individually tailored to the child’sacademic ability and is delivered at the student’s ownpace (DuPaul and Stoner, 1994). It requires activeresponding on the part of the student, and frequent,immediate feedback in the form of prompts andpraise is provided by the tutor. Peer tutoring has beenfound to be effective in a variety of academic areasfor students with a wide range of cognitive and aca-demic abilities (Greenwood et al., 1991).

Unfortunately, despite the convincing rationalefor the potential benefits of peer tutoring on theclassroom behavior and academic productivity ofstudents with ADHD, only a few studies haveexamined the efficacy of this method for use with thispopulation (DuPaul et al., 1998; DuPaul andHenningson, 1993; Robinson et al., 1981). In a pre-liminary study, 18 hyperactive boys in 3rd grade wereexposed to a peer tutoring procedure in which onestudent coached another on reading and learning touse new vocabulary words in sentences (Robinsonet al., 1981). This procedure also involved tokenreinforcement for successful completion of peertutoring tasks. Using a single subject, BAB reversaldesign, the mean number of tasks completed duringthe intervention condition rose to over 9 times thenumber completed during the reversal conditions. Inaddition, both children and teachers were able toeffectively implement the intervention independentlyfrom the investigators. Although these results are

promising, the relative effects of peer tutoring versuscontingency management approaches provided bythe token system within this study are unclear due tothe study design and small sample size.

Two additional studies examining peer tutoringin children with ADHD have been conducted. Thesestudies have employed a specific model of peertutoring, Classwide Peer Tutoring (CWPT), devel-oped by Greenwood, Delquadri, and Carta (1988). Inthis model, students with ADHD and their class-mates are trained in tutoring procedures, and thenrandomly paired with one another for an academicsubject. The tutor is provided with a script of aca-demic material (e.g., 30 math problems) related to thecurrent content of instruction in the classroom(DuPaul and Henningson, 1993). Items are dictatedorally to the tutee one at a time from the script. Thetutee then responds orally to the problem, but mayuse paper to work out difficult problems. Points areawarded to the tutee for each correct response, andfeedback from the tutor is given for each incorrectresponse. The item list is repeated multiple times, andthen the students switch roles. During the tutoringsessions, the teacher monitors the behavior of tutor-ing pairs and provides assistance, if necessary. Typi-cally, privileges and other reinforcers are notnecessary with this procedure but may be used whenadditional incentives are needed (DuPaul and Hen-ningson, 1993; Greenwood et al., 1988).

A preliminary study attempted to investigate theeffects of CWPT on the academic behavior and per-formance of a 7-year-old boy with ADHD using anABAB reversal design (DuPaul and Henningson,1993). During baseline and reversal conditions,mathematics instruction was provided according tothe typical classroom routine, which involved10–20 min of didactic skills instruction to the entireclass with periodic requests for certain students tocomplete problems on the board or at their own desk.In contrast, the peer tutoring condition was imple-mented according to the CWPT approach describedabove (Greenwood et al., 1988). Results demon-strated large increases in on-task behavior, decreasesin fidgeting behavior, and increases in math problemaccuracy during intervention conditions compared tobaseline and reversal conditions. Unfortunately, thesefindings are limited due to the examination of a singlecase, and the lack of academic performance measures(DuPaul and Henningson, 1993).

The encouraging results from this preliminarystudy were followed with an investigation of CWPTin a group of 18 children with ADHD and 10 peer


comparison students in grades 1 through 5, againemploying an ABAB reversal design (DuPaul et al.,1998). Each experimental condition lasted 1 to2 weeks and the specific subject area targeted wasbased on the child’s weakest academic area accordingto his or her teacher. During baseline conditions, theteacher conducted class activities according to typicalroutine, which included independent seatwork andlarge and small group instruction. During interven-tion conditions, the CWPT approach was imple-mented. Mean active on-task behavior of studentswith ADHD was increased from a mean of 29%during baseline conditions to a mean of 80% duringintervention. Similarly, off-task behavior droppedfrom a mean of 24–27% during baseline conditions to6–8% during CWPT conditions. Similar improve-ments were observed for peer comparison students.Changes in academic performance were more vari-able for students with ADHD, relative to behavioraleffects, as a result of the intervention. An averageincrease of 22% in weekly test scores was observedwith the implementation of four 20-minute CWPTsessions, as opposed to an average gain of 13% in testscores during baseline. Seven of the 14 students withADHD (50%) for which test data were available wereclassified as treatment successes, defined as showingan incremental improvement of at least 10% on post-test scores during intervention conditions comparedto baseline conditions. In contrast, three of 10 peercomparison students without ADHD (30%) wereconsidered treatment successes. Children who werepresented with material that was more challengingwere more likely to experience treatment success.Finally, a high level of consumer satisfaction wasreported by both teachers and students (DuPaulet al., 1998).

These two preliminary studies offer evidence thatCWPT is an effective intervention for students withADHD which can improve both classroom behaviorand academic performance. Advantages of thisapproach include one-to-one individualized instruc-tion, frequent and immediate feedback, active par-ticipation of students, and high levels of practicalityand acceptability. Peer tutoring can be implementedby teachers in a general education setting with a highlevel of fidelity using a resource (i.e., peer tutors) thatis readily available in the classroom (DuPaul andHenningson, 1993). Another advantage highlightedin the DuPaul et al. (1998) study is the potentialbenefits of CWPT for all students, regardless ofdiagnosis. This allows teachers to implement theintervention with the entire class, without having to

single out students with ADHD which may createsocial stigma, especially among adolescents (DuPauland Henningson, 1993). Peer tutoring may also pro-vide opportunities for the development of prosocialbehavior in children with ADHD, as they areencouraged to interact with peers who may nototherwise choose to interact with them socially.Furthermore, it appears from current data thatCWPT increases both on-task behavior and academicaccuracy, with a greater effect on the former. How-ever, it is likely that the amount of improvement inacademic performance may increase through a long-term intervention, since an increasing differentialresponse over time to CWPT versus baseline wasobserved in the DuPaul et al. (1998) study.

One more study attempted to extend peertutoring findings by examining their use in the homesetting as implemented by parents. This study byHook and DuPaul (1999) examined whether parenttutoring procedures are also effective for improvingthe academic performance of children with ADHD.Four children with a diagnosis of ADHD, in grades 2and 3, participated in a multiple baseline design inwhich a parent tutoring procedure based on the workof Greenwood et al. (1988) was tested. This proce-dure involved 10-min tutoring sessions on oral read-ing tasks, held weekly twice for a period of1–2 months. Similar to CWPT, the procedureinvolved one-to-one instruction, immediate feedback(i.e., error correction and praise), and required activeresponding. Words correct per minute (wcpm)increased for all participants from baseline to tutor-ing conditions for reading performance at home, andfor three of four participants at school, althoughreading performance was not normalized comparedto control children. In addition, these gains werepartially maintained at one-month follow-up.Students’ attitudes towards reading improved slightlyfrom baseline to follow-up for three of four students,and parents and teachers reported high levels ofconsumer satisfaction with the intervention (Hookand DuPaul, 1999).

These results are encouraging and parallel resultsfound for the CWPT intervention. Future studies ofboth parent and peer tutoring procedures are there-fore recommended and would benefit from the use oflarger sample sizes; employing between-groups sub-ject designs; increasing the breadth of academic per-formance measures; varying the duration, frequencyand length of tutoring sessions; examining the gen-eralizability of improvements due to CWPT to otheracademic domains or classrooms; and determination


of the moderators in family, school and child char-acteristics that influence the effectiveness of thisapproach are warranted. Parent tutoring proceduresmay be useful in combination with peer tutoring inthe classroom, and future studies may also examinethe impact of these approaches together in theremediation of academic difficulties.

COMPUTER-ASSISTED INSTRUCTION

Computer-assisted instruction (CAI) entails thepresentation of specific instructional objectives,highlighting of essential material, use of multiplesensory modalities, division of content into smallerchunks of information, use of repeated trials, andprovision of immediate feedback about responseaccuracy (Ford et al., 1993; Kleiman et al., 1981;Mautone et al., 2005; Ota and DuPaul, 2002). Thismethod has been suggested as a way to improve thesustained attention and work performance of chil-dren with ADHD. Aspects of CAI may help teachersplan individualized activities for students with shorterattention spans, allowing these students to be moreactively involved in learning, and increasing confi-dence and motivation (Fitzgerald, 1994).

Although preliminary research has found thatchildren may improve on-task behavior and increasework productivity during CAI, very few studies haveexplored the effects of CAI on children with ADHDspecifically. An initial study by Ford et al. (1993)examined aspects of CAI on the attention of twenty-one, 3rd and 4th grade students with ADHD throughcomparison of various reading and math computersoftware packages. Using a within-participantsdesign, participants were instructed with four soft-ware programs in a random order: math drill andpractice; math instructional game; reading drill andpractice; and reading tutorial, drill and practice. Eachpackage compared two different formats: gameversus non-game format, playing against the com-puter or against a partner, animated or non-animatedgraphics, and unlimited time to respond or limitedtime to respond. Results indicated that the attentionof participants increased on software with a gameformat, without animation, and with unlimited timeto respond. Straight tutorial animation did not ap-pear to hold the attention of children with ADHD aswell as games did. Further, more inattentive behav-iors occurred on the reading versus math softwarepackages. Unfortunately, numerous methodologicalproblems limit the conclusions that can be drawnfrom this study. This study did not control for

carryover effects or assess inter-observer agreementon behavioral observations, was implemented in alaboratory and not a naturalistic classroom setting,and the procedures used to diagnose ADHD were notconsistent with recommended practice (Ford et al.,1993). Furthermore, due to the many differences incontent, task and format, it is impossible to parseapart whether the differences were due to packageformat or other factors. Finally, while this studychose to focus on behavioral (rather than academic)improvement, it is quite likely that CAI may haveeffects on academic performance as well. It thereforewould be beneficial for future studies to focusresearch attention on academic, in addition tobehavioral outcomes.

More recent studies have attempted to extendprevious findings through examining changes inacademic performance in addition to on-taskbehavior, conducting studies in classroom settings asopposed to the laboratory, and using more carefullycontrolled study designs that assess inter-observeragreement and treatment integrity. For example, arecent study by Ota and DuPaul (2002) examinedthe effects of CAI on the mathematics performanceand on-task behavior of three, 4th through 6thgrade students with ADHD. This study was con-ducted in a private, special education setting. Usinga multiple baseline design, modest improvements inmathematics performance (i.e., digits correct perminute) and significant improvements in on-taskbehavior were observed for all participants duringtreatment (i.e., 20 min of CAI 3 to 4 times per week)compared to baseline conditions (i.e., regular teacherinstruction and independent seatwork). Treatmentintegrity was assessed by having teachers complete achecklist of the number of steps they followed dur-ing the CAI intervention. Inter-observer agreementwas also assessed on 33% of the observations foreach of the three participants. This study built uponprevious literature by examining the effects of CAIspecifically on mathematics performance, and byassessing for inter-observer agreement and treatmentintegrity. The modest increases in academic perfor-mance found in the CAI condition may be due tothe short duration over which this intervention wasimplemented. In addition, all three students werealso receiving stimulant medication; different resultsmay have been found for children who are not usingmedication. Finally, this study has limited general-izability, as the intervention was conducted in aprivate school, special education setting (Ota andDuPaul, 2002).


Another study extended preliminary research tofocus on younger students with ADHD within ageneral education classroom. Mautone et al. (2005)examined the effects of CAI on the mathematicsperformance and classroom behavior of three, 2ndthrough 4th grade students with ADHD. The CAIpackage involved difficulty levels tailored to individ-ual academic needs, structured tasks presented in agame format, frequent and immediate feedback, anda short, video game reward for a certain number ofpoints earned. A controlled case study was used inwhich the intervention was introduced sequentiallyamong the three students. Baseline conditions in-volved typical instruction consisting of independentseatwork and group work. Results found increases inmath digits correct per minute and on on-taskbehavior for all participants. Attention changes wereimmediate upon implementation of the intervention,whereas academic skills appeared to change moregradually. This is expected considering the severeskills deficits of these students which would likelytake more time to change (Mautone et al., 2005).Effect sizes for this intervention were all greater than1.0, which is notably larger than the average effectsize of 0.47 for CAI on academic achievement foundin a meta-analysis examining 28 studies of CAI(Kulik et al., 1985). This suggests that CAI may beespecially beneficial for improving the academic per-formance of students with ADHD. This study alsoextends previous findings through matching students’academic needs to features of CAI, implementationwithin a general education classroom as opposed to alaboratory or private school, special education set-ting, use of students who were not medicated withstimulants, and assessment of treatment integrity andinter-observer agreement.

Not all research on CAI in an ADHD popula-tion has demonstrated positive effects greater thantypical or traditional instruction. Fitzgerald et al.(1986) compared the efficacy of CAI with traditionalpaper-and-pencil instruction (TI) and with ano-practice condition, in the mastery of spellingwords. Nine students were selected for the studybased on scores in the clinical range on the Conner’sTeacher Rating Scale. Students received five newspelling words for each condition each week, for aperiod of five weeks. In contrast to other studies ofCAI, results from this study found that CAI and TIwere equally effective and superior to the no practicecondition. This study controlled for the amount oftime the children spent on each practice condition,and each child participated in all three conditions

(Fitzgerald et al., 1986). As the previous studies thathave found positive benefits of CAI in children withADHD examined mathematics performance, it maybe the case that CAI confers no greater benefit onspelling task performance in children with ADHDthan traditional methods. Future studies should at-tempt to replicate these results and continue toexamine whether CAI is superior or equivalent totraditional approaches for other academic tasks, aswell as whether certain aspects of CAI (i.e., format,animation, novelty, reinforcement schedule) canbe identified that are beneficial for the learning ofchildren with ADHD (Fitzgerald et al., 1986).

Despite limitations of the current research, CAIoffers a novel approach that may increase activeresponding and attention, motivation, and learning inchildren with attention problems. Advantages of CAIparallel those of peer and parent tutoring which alsoprovide immediate feedback and require activeresponding on the part of the student. The CAI ap-proach may be highly desirable for use in classroomsbecause it allows teachers more flexibility and timefor individualized instruction, and provides a novelalternative to traditional instruction that may suc-cessfully capture the attention of children withADHD. Unfortunately, too few studies have beenconducted, those that have contain methodologicalflaws, and some findings have been contradictory.This prevents any definitive conclusions from beingdrawn regarding the efficacy of CAI for childrenwith ADHD, although preliminary data appearpromising.

TASK/INSTRUCTIONAL MODIFICATIONS

Task or instructional modifications involveimplementing procedures such as reducing tasklength, dividing tasks into subunits and setting goalsfor the child to achieve in shorter time intervals, usingincreased stimulation of the task (e.g., color or tex-ture), giving explicit instructions, and modifying thedelivery or modality of instruction depending on thestudent’s individual learning style (e.g., fast-pacedversus slow-paced, visual versus auditory) (Dubeyand O’Leary 1975; Dunlap et al., 1994; Ervin et al.,1998; Zentall and Leib, 1985). These methods focuson increasing the structure and organization of thechild’s environment, making goals and tasksappear more manageable to reduce frustration andincrease persistence, and increasing relevant stimula-tion to help sustain attention. Unfortunately,although often included in Individualized Education


Plans (IEPs) and widely used in classrooms forimproving the performance of students with emo-tional and behavioral problems, developmental dis-abilities and ADHD, instructional and taskmodifications remain largely untested for their effec-tiveness in improving the performance of childrenwith ADHD. The majority of studies that have beenconducted used single case experimental designs andhave other methodological limitations which make itdifficult to generalize their effectiveness to popula-tions of students with ADHD.

Visual versus Auditory Presentation of Material

A couple of single case design studies havecompared instruction in auditory versus visualmodalities on the learning rate and acquisition ofreading skills in children with ADHD. As childrenwith ADHD have been theorized to have difficultiesin the internalization of speech (i.e., working memorydeficits), having them respond orally may allow for agreater integration and retention of material thanwhen they must learn information silently. Dubeyand O’Leary (1975) examined the effects of oral ver-sus silent reading on the comprehension of twohyperactive children. Each child read four stories persession, two silently and two orally. Each reading wastimed and followed by five comprehension questionswhich the children answered orally. Results foundthat oral reading consistently produced more effectivecomprehension than did silent reading, reducing bynearly one-half the number of comprehension errorsproduced by silent reading. Although oral readingresulted in slower reading speed, which may have ledto more efficient processing of information, speedappeared to account for a minimal proportion of thevariability in comprehension across conditions(Dubey and O’Leary, 1975). Oral reading may allowincreased processing through presentation in bothvisual and auditory modalities, more efficient pro-cessing of information, or may facilitate appropriateattentional behavior. However, these results are lim-ited to two children taking part in one individualtutoring session. Clearly, replication of this study andother studies involving the comparison of materialpresented visually versus in auditory formats areneeded. Furthermore, the potential long-term impactof oral reading, and the generalizability of its benefitsfor children with ADHD, should be examined.

Another study investigated the effects of taskmodifications on the reading performance of threechildren, two with ADHD and developmental delays,

and one with ADHD alone (Skinner and Johnson,1995). This study employed an alternating treatmentdesign which involved the use of taped words pre-sented at two different speeds, fast-taped words(FTW) and slow-taped words (STW). During FTW,students were instructed to read aloud with anaudiotape that delivered 15 words at the speed of oneword per second and follow along on a worksheet.During STW, 15 words were delivered in 75 s (oneword every 5 s). During assessment-only conditions,students had to read word lists aloud from work-sheets. It was hypothesized that this audiotapemodeling would increase oral reading accuracy.Consistent with this hypothesis, the accuracy andrates of accurate reading increased relative to baselinefor the child with ADHD using both FTW and STW.In contrast, for the two children with ADHD anddevelopmental problems, greater improvements wereobtained using the FTW procedure. This study sug-gests that the opportunity to model accurateresponding may improve reading performance, whe-ther presented at a slow or fast speed. Contrary toexpectations, slower pacing did not increase students’reading accuracy. This study has several limitationsincluding being conducted in a laboratory setting,having a very small sample size, lack of teacheracceptability data, and the lack of generalized learn-ing across untreated words (Skinner and Johnson,1995). In addition, there may be a differential treat-ment response in children with and withoutco-occurring developmental disorders, which shouldbe examined further in future studies.

Adding Structure to a Task

In addition to the modality of presentation, ithas been hypothesized that adding structure to a taskmay increase the saliency of appropriate responses inchildren with ADHD, thereby lessening the need forself-produced stimulation (Zentall, 1975). Consistentwith this, Pfiffner and Barkley (1998) recommendincreased structure and predictability in classroomactivities (i.e., posting a daily schedule and classroomrules, conveying explicit instructions, giving oneinstruction at a time) as beneficial for children withADHD. In a study by Zentall and Leib (1985), 15hyperactive and 16 non-hyperactive children partici-pated in a repeated measures crossover design con-trasting two conditions: a high-structure task inwhich participants had to replicate two designs fromtwo models of black and white paper square designs;and a low-structure task which involved creating


original designs from the same number of black andwhite squares. Results found reduced activity levelsfor both hyperactive and control children in the high-structure task. Unfortunately, no accuracy ofperformance comparisons from high to low taskstructure were conducted because no correct positionor number of squares was indicated in the lowstructure task (Zentall and Leib, 1985). Therefore,while this study suggests that added task structuremay promote sustained attention and reduced activ-ity levels, it is unclear whether this translates intoimproved academic performance. Furthermore, thisstudy should be considered of a preliminary naturebecause a number of limitations were presentincluding a lack of control for participants’ abilitylevel, and a lack of inclusion of measures of inter-observer agreement, treatment integrity and fidelity,and consumer acceptability and satisfaction.

Choice Making

An important task modification that has beenexplored and found effective for students withdevelopmental disabilities is that of choice making(Newton et al., 1993). Choice making allows the childa certain level of individual decision-making andpersonal control over the nature of the task. Thisconsists of allowing the child to select academic tasksor materials from a number of pertinent and struc-tured alternatives. This technique may be beneficialnot only in increasing task performance and pro-ductivity, but also in improving social relatedness(Koegel et al., 1987).

Although not specifically tested with childrenwith ADHD, two single case design studies haveexamined and found some preliminary support for theefficacy of choice making in a naturalistic setting forstudents with emotional and behavioral disorders(Dunlap et al., 1994). Two participants in 5th grade,one with ADHD and one with severe emotional dis-turbance (SED), participated in the first study. AnABAB reversal design was used to examine differencesbetween a choice condition and a no-choice condition.The no-choice condition consisted of English andSpelling assignments being routinely presented on theblackboard and completed by students independently.These assignments were selected by teachers. In thechoice condition, students were given an individual-ized menu of academic activities containing 6–10 rel-evant options. Choice making resulted in significantlyhigher levels of task engagement and less disruptivebehavior than no choice conditions.

In the second study, an ABAB reversal designwas used with a 5-year-old boy with SED (Dunlap etal. 1994). Choice conditions involved the childselecting a book to be read during the session. In thetwo no choice conditions, the teacher selected a bookto be read. This study also attempted to determine ifthe effects of choice were due to obtaining one’spreferred activity, or to the act of having a choice.Therefore, in the second no choice condition, thechild was given a book that he preferred; this wasbased on his previous choices. This study replicatedthe positive effects of the choice condition. In addi-tion, the no choice, preference condition was notassociated with increased rates of task engagement orreductions in disruptive behavior. Therefore, it ap-pears that the perception of having a choice improvesbehavior, whereas being given preferred materialdoes not. These results are promising, and have thepotential for easy application in classroom settings.However, the sample size of three limits any gener-alizations that could be made from this data. Also,these studies chose to specifically focus on behavioraloutcomes, and therefore, it is unclear how improve-ments in on-task behavior translate into changes inacademic performance using this technique.

Only one study has examined the use of choicemaking specifically in children with ADHD. Powelland Nelson (1997) tested the efficacy of choice mak-ing with a 7-year-old boy with ADHD. Baselineconsisted of a no-choice phase in which the child wasdirected to work on the same assignment as the restof the class. During the choice phases, the teacherpresented three different assignments taken from theclass curriculum, and the child chose one to complete.Disruptive and off-task behavior was found todecrease during the choice compared to the no-choiceconditions. This study suggests that choice proce-dures may be helpful for managing the behaviors ofchildren with ADHD in the general classroom. Aswith the other studies of choice making, academicachievement and work productivity were not mea-sured in this study. More research in this area wouldbenefit from including academic outcome measuresand examining moderators, which influence the effec-tiveness of this intervention under various environ-mental conditions for children with ADHD.

Within-task Stimulation

A significant body of research has been devotedto examining the effects of high stimulation contextson improving the performance of hyperactive


children on various tasks. This research is based onoptimal stimulation theory, which suggests that allindividuals have a biological need to optimize thelevel of incoming stimulation. Within this theory,hyperactive children have been hypothesized to havea greater need for stimulation and to be less tolerantof situations involving minimal stimulation, whichresults in increased errors, and excessive motor andverbal activity (Zentall, 1975). Therefore, accordingto this theory, high-levels of intra-task stimulationmay serve to decrease activity levels and improve theperformance of these children.

One of the main lines of research inquiry intowithin-task stimulation has examined the effects ofadding color to various tasks on the performance andactivity level of children and adolescents withADHD. Sustained attention has been found toimprove and activity level reduced in children withADHD when color is added to simple vigilance orcopying tasks (Zentall et al., 1985; Zentall andKruczek, 1988). For example, in a study of 16 boyswith attention and behavior problems and 16controls, ages 14–18, those boys with attention andbehavior problems performed better on a repetitivecopying task when presented with high-stimulationcolored letters than with low-stimulation black andwhite letters, whereas the opposite was true of con-trols (Zentall et al., 1985). These benefits of colorstimulation resulted in fewer errors for hyperactivechildren during the early and middle stages of thetask. This suggests that over time, adaptation mayoccur, and that the novelty of color wears off and nolonger serves to increase stimulation. Extending theseresults to a search-attention task involving visualscanning, a study by Zentall (1985) found equivalentresults to those found for sustained attention tasks.That is, the performance of hyperactive children wasnormalized during color conditions, especially duringthe first two-thirds of task performance.

In addition to improving performance on simplesearch and sustained attention tasks, the effect ofcolor stimulation on more complex tasks has beenexamined, as well as the temporal placement of colorstimulation as a moderating influence. Zentall (1986)analyzed the effects of color stimulation placed earlyversus late on two types of tasks, a repetitive vigilancetask (the continuous performance task or CPT), anda complex learning task that required children toidentify a relevant dimension (e.g., a number) fromirrelevant dimensions (e.g., shape and position).Consistent with previous studies, between-groupsanalyses for the CPT sustained attention task found

that stimulation added early or late normalized theperformance and reduced the activity of hyperactivechildren compared to controls. However, in thecomplex learning task, color stimulation added latereduced the activity (e.g., talking, motor movements)of hyperactive children greater than color stimulationadded early to the task. No treatment effects of per-formance were found. This may be due to a flooreffect, since the hyperactive children infrequentlysolved the complex task (Zentall, 1986).

Similarly, when color was added initially to rel-evant cues in a spelling task requiring visual memory,slower task responses were observed in hyperactivechildren compared to controls; however, when thetask was initially practiced without color, hyperactivechildren actually outperformed normal comparisonswhen color was later added to relevant cues (Zentall,1989). Therefore, from these studies, it appears thatcolor may help children with ADHD to sustainattention when added late to learning tasks; however,when added early it appears to disrupt learning andperformance on complex tasks in which the child hasnot yet identified relevant cues from among themultiple task stimuli (Zentall, 1986).

Additionally, color added late may be morebeneficial to children with ADHD when performinglengthier tasks that require extended responding.Belfiore et al. (1996) examined this hypothesis byexamining nonspecific color added late to both a sightlearning task and a reading comprehension task.Consistent with hypotheses, all three students withADHD learned sight words equally well in the nocolor and color added late conditions for the sightword-learning task. However, for the longer readingcomprehension task, all three students increasedaccuracy under the color added late condition, com-pared to the no color condition. After adapting torelevant cues of the reading task, color added latermay help students read more thoroughly and sustainattention to lengthy tasks (Belfiore et al., 1996).While these findings are promising, they should bereplicated with a larger sample size and shouldcompare differences between an ADHD and controlgroup of children to determine whether these effectsare specific to children with ADHD. Furthermore, inaddition to the temporal placement of color, othermoderators of the effects of intra-task stimulationshould be investigated. For example, some evidencesuggests that color used to highlight important lettersor parts of a sentence will aid in remembering thespelling or comprehending the sentence and lead togreater performance than color added to irrelevant


parts of letters or sentences (Zentall and Kruczek,1988).

Finally, a study by Zentall and Meyer (1987)expanded upon previous evidence of the positive ef-fects of intra-task stimulation for children withADHD by examining whether adding active motorresponses into rote tasks (i.e., a word decoding andauditory vigilance task) would modulate the sensa-tion-seeking activity and impulsive errors of childrenwith ADHD. The active motor response involvedgiving children the option of repeatedly pressing abutton in order to view various color slides of people,nature scenes, and inanimate objects. This optionalinstrumental motor response was given during thecompletion of a rote task. Consistent with optimalstimulation theory, it was found that under activeresponse conditions, the impulsive errors, talking,noise making, and hyperactivity of children withADHD was normalized for repetitive tasks. There-fore, it appears from this study that increasing stim-ulation through the requirement of instrumentalmotor responses may effectively preempt more dis-ruptive types of stimulation-seeking activity andimpulsive error performance for children withADHD (Zentall and Meyer, 1987).

Overall, these studies offer considerable evidencethat intra-task stimulation involving color signifi-cantly improves the performance and reduces thehyperactivity of children with ADHD. More specifi-cally, current data suggest that for simple tasks (e.g.,vigilance, copying, visual search, continuous perfor-mance) color added early or midway through the tasknormalizes the behavior and performance of childrenwith ADHD in comparison to control children. Colormay provide needed stimulation and promote closerattention to detail for these children. For morecomplex tasks involving learning acquisition (e.g.,spelling requiring visual memory, concept formationtasks, and reading comprehension), color added earlyappears to inhibit the performance of children withADHD relative to controls. This may be a result ofthe disrupted ability to focus on relevant cues amongmultiple stimuli initially and grasp the task at hand.However, when color is added later in the task, itagain confers benefits to children with ADHD andappears to help sustain attention over a longer timeperiod, enhancing performance on complex tasks.

Therefore, with a population of children withADHD it appears that color stimulation is an effec-tive tool for reducing hyperactivity and improvingsustained attention. This approach may be easilyimplemented by teachers in the classroom, however,

requires cognizance of the conditions and temporalplacement under which color is likely to be beneficialversus harmful. Future research should focus on amore thorough examination of potential moderatorsto the relationship between color stimulation andimproved performance in these children (i.e., rele-vance of stimuli, presence of other competing stimuli,etc.). Finally, other forms of stimulation (e.g.,incorporating motor responses into the task) mayalso offer benefit to students with ADHD and shouldbe examined more carefully in future studies.

Although promising, much work remains to bedone in the examination of task or instructionalmodifications likely to be of benefit for children withADHD. Pfiffner and Barkley (1998) have recom-mended a number of additional instructional modi-fications that appear beneficial and should be tested.For example, they suggest that academic assignmentsbe brief to accommodate the child’s attention spanand presented one at a time rather than all at once ina packet or group, and that shorter time limits beimplemented with use of a timer. Delivering a lessonin an enthusiastic, yet task-focused style and allowingfrequent and active child participation may also behelpful. Furthermore, they recommend varying pre-sentation formats to maintain interest and motiva-tion. These intervention approaches remain to betested for children with ADHD. In practice, inte-grating these intervention approaches and individu-alizing task and instructional modifications throughthe use of a functional analysis, described in detaillater in this paper, is more likely to result in robusteffects than any individual modification alone, and isconsistent with the recommendation to providemultimodal treatment approaches for children withADHD (Pelham et al., 1998).

SELF-MONITORING

Self-monitoring and self-reinforcement proce-dures are widely used and are emerging as effectivetools in improving social and academic behavior inthe classroom setting in general (Dunlap and Dunlap,1989; Hertz and McLaughlin, 1987; Mace andKratochwill, 1988). There also exists a small litera-ture that suggests these gains may apply to childrenwith ADHD as well. These techniques typically in-volve children setting goals for on-task behavior orclasswork completion and accuracy, self-monitoringthose goals, and self-administering rewards uponsuccessful completion. Self-management proceduresappear to have a number of potential advantages


over other approaches (Kern et al., 1994), includingincreased maintenance of behavior change whencombined with other behavior management systems(Drabman et al., 1973); improved generalizationrelative to parent or teacher-implemented interven-tions (Rhode et al., 1983); less teacher and parenttime required; and the opportunity to teach studentsindependence, responsibility, and adaptive socialbehavior (Kern et al., 1994).

For example, in a study of six boys, ages 11 to13-years-old, with a variety of diagnoses includingsevere emotional disturbance (SED), learning dis-abilities (LD), developmental delays, depression, andADHD, Kern et al. (1994) found evidence for theefficacy of self-management procedures in improvingon-task behavior and reducing disruptive behavior.In this study, participants were taught to self-monitortheir on-task behavior and one individualized targetbehavior on a five-minute variable interval schedule,and to record this behavior at the sound of a bell on atape recorder. Training and feedback were provideduntil student-observer agreement reached 80%.Points were awarded according to the accuracy of thestudent’s self-monitoring record of his behaviorduring the session. These points could be cashed infor a tangible reward. A multiple baseline design wasutilized, and all students showed significant increasesin the percentage of intervals engaged in on-taskbehavior following implementation of the self-man-agement procedures. This study therefore offers pre-liminary support for the utility of self-managementprocedures in improving on-task behavior in theclassroom (Kern et al., 1994). However, significantlimitations were present. The study was broad in itsinclusion of a variety of diagnoses and not specific toADHD and the procedures were largely implementedby paraprofessionals and not by classroom teachers,limiting generalizability to real world settings. Thatis, it is possible that parents or teachers may havemore difficulty implementing this approach on aconsistent basis. Finally, while this particular studychose to specifically focus on improving behavioraloutcomes, it would be beneficial for future studies ofthis technique to examine the effects of this techniqueon academic outcomes as well.

A similar study examining self-reinforcementwas conducted by Drabman et al. (1973) in whicheight disruptive boys (ages 9–10) in a remedial read-ing class made self-ratings of their behavior and wererewarded for matching within one point of theirteacher’s ratings of their behavior. During thismatching phase, items correct averaged 138 per hour,

compared to 83 items correct per hour during base-line. Disruptive behavior was also significantlyreduced. Performance during the matching phase wascomparable to performance during token reinforce-ment by the teacher for good behavior (average of130 items correct per hour) which did not involvematching ratings. In a subsequent self-evaluationphase, children received reinforcement based on theirself-ratings which was not contingent upon matchingwith teacher ratings of their behavior. Number ofitems correct per hour averaged 158, disruptivebehavior showed an 88% decrease from baseline, andthere was a 0.70 correlation between student andteacher ratings during this condition. Therefore,students were relatively honest and accurate in theirself-ratings, even after removal of the matching pro-cedure. The authors suggest that this maintenance ofappropriate behavior and honest self-ratings mayhave been a result of a number of factors, includingsocial reinforcement by teachers and peers forappropriate behaviors and honesty, observations ofacademic progress, and bonus points awarded formatching during the earlier phases. This study dem-onstrated robust effects on academic accuracy andproductivity using a shaping procedure whichresulted in accurate self-monitoring in the absence ofteacher checking. However, similar to the previousstudy by Kern et al. (1994), subjects were studentswith academic and emotional problems rather than adiagnosis of ADHD. It is therefore critically impor-tant to determine if these encouraging results will bemaintained with a group of students with a diagnosisof ADHD.

A series of single subject studies was utilized tocompare the effects of methylphenidate (MPH), self-reinforcement, and their combination on the aca-demic performance of six male students with ADHD,ages 9–12 (Chase and Clement, 1985). Following2 weeks of a baseline condition, each subject partic-ipated in seven treatment phases consisting of: MPH(plus non-contingent reinforcers), self-reinforcement(plus a drug placebo), and MPH plus self-reinforce-ment. Self-reinforcement involved each subject set-ting a goal for the number of reading questions hewould answer by the end of the day, self-recording hiscompletion and performance, meeting with the con-sultant to determine if he reached his goal, andrecording points earned to be exchanged for rein-forcers. Results suggest that the MPH-alone condi-tion did not improve academic performance, mostlikely due to the fact that the children were alsoreceiving non-contingent reinforcers in this condition.


These reinforcers may have counteracted the positiveeffect of MPH on short-term task productivity whichhas been well documented in other studies of theeffects of this drug (Pelham, 1993; Swanson et al.,1995). In contrast, self-reinforcement alone generatedlarge and highly reliable positive effects for five out ofsix children on the amount of reading questionscompleted. The accuracy of each child’s performanceon the reading questions was not targeted with con-tingent reinforcers; however, this accuracy alsoshowed substantial improvement, and therefore sug-gests that this procedure may generalize to otheracademic behaviors as well as task completion. Forall six children, the combination of MPH and self-reinforcement was found to be the most effective forimproving the academic performance, both in termsof the amount and accuracy of work completed.External validity of this study may have been some-what compromised given the use of a small samplesize and an ‘‘experimental classroom’’. In addition,the medication dosage was not experimentally con-trolled, rather optimal dosage was determined on anindividual basis by the child’s prescribing physicianprior to the start of the study (Chase and Clement,1985). Nevertheless, these results suggest that utiliz-ing a multimodal approach combining medicationand an academic intervention such as self-manage-ment may be most effective in improving academicperformance.

Abijola and Clement (1995) replicated this studywith some improvements upon the study design bycomparing: drug placebo; noncontingent reinforcers;0.3 mg/kg MPH; 0.7 mg/kg MPH; and self-rein-forcement in various combinations. Participants were6 boys with ADHD participating in a daily morningreading tutorial. Results found that MPH demon-strated differential effects on various academic mea-sures, that self-reinforcement consistently improvedacademic performance with a mean effect size of 2.66,and as in the previous study, the MPH and self-reinforcement combination conferred the greatestbenefit.

Overall, preliminary research on the use of self-reinforcement strategies suggests that these proce-dures are beneficial for improving the attention andacademic performance of children and adolescentswith ADHD, especially when combined with otherevidence-based approaches (i.e., stimulant treatment,reward systems). Furthermore, the success of thisapproach may vary depending upon the cognitive-developmental level of the child or adolescent,and may be particularly helpful for increasing

independence and responsibility in older children,although this remains to be tested. Future studieswould benefit from the use of larger sample sizes, theemployment of academic outcome measures in addi-tion to behavioral targets, evaluation within real-world classroom settings as opposed to analogueclassrooms, and the implementation of these inter-ventions over a longer time frame in order to fullyestablish the self-reinforcement skills and habitswithin the child or adolescent with ADHD.

STRATEGY TRAINING

Strategy training involves teaching and trans-ferring a specific skill to children that they canimplement in an academic situation to improve theirperformance (Evans et al., 1995). Similar to self-reinforcement, strategy training takes some of theburden off parents and teachers, giving addedresponsibility and ownership to the student. Simi-larly, there may also be increased opportunities forgeneralization if the strategy taught is applicable to avariety of academic situations.

Douglas et al. (1976) employed a cognitivetraining program to teach 18 hyperactive children inmore effective and less impulsive strategies forapproaching cognitive tasks, academic problems, andsocial situations. The intervention involved a com-bination of modeling, self-verbalization and problemsolving strategy training techniques. The trainerwould work on a task with the child while verbalizingaloud a clear statement about the nature of theproblem and the strategies he was using to solvethe problem. The child was then instructed to do thesame. Emphasis was also placed on planning aheadand thinking sequentially and on learning strategiesfor organizing ideas and work materials. Over thecourse of the 3-month treatment and at 3-monthfollow-up, the treatment group showed significantimprovement on several criterion cognitive measurescompared to a no-treatment control group. Althoughan attempt was made to use different materials in theassessment battery and training sessions, the authorsacknowledged that these materials likely resembledeach other in essential ways (Douglas et al., 1976).This makes it less clear the extent to which thetreatment group improved as a result of the inter-ventions or rather familiarity with the testing mate-rials. Furthermore, some measures, such as mathachievement, memory testing, and the Connors Tea-cher Rating Scale, showed no significant time bygroup interactions. Therefore, it remains uncertain


whether self-verbalization and problem solvingtraining effectively improve the cognitive perfor-mance of hyperactive children. Nevertheless, this isan important initial study into the use of self-ver-balization and problem solving training across a widerange of academic and social tasks. It seems plausiblethat techniques designed to encourage the child withADHD to stop and examine different alternativeswould be effective in reducing the impulsive decisionmaking which results in numerous academic errorsand omissions (Douglas et al., 1976). However, thishypothesis awaits further research.

Another particular strategy has been tested foradolescents with ADHD. In recognition of thedemands placed upon middle and high school studentsto understand and synthesize material from lectureformat classes, Evans et al. (1995) attempted to test adirected note-taking activity (DNA) over an 8-weekperiod in a lecture format classroom embeddedwithin an intensive summer treatment program, inorder to decrease off-task behavior and improvestudy habits of adolescents with ADHD. In thisDNA, originally designed as a model of explicitinstruction by Spires and Stone (1989), students weretaught to divide notes into main ideas and supportingdetails through the use of lectures and models ofnotes to compare with their own. Gradually, lessinstruction is given in the note-taking process untilstudents are able to produce accurate notes inde-pendent of any prompting. Results found significantincreases in on-task behavior and improvement inscores on daily assignments as a result of takingnotes. In addition, high quality notes were associatedwith better comprehension and higher on-taskbehavior and assignment scores. Although offeringsignificant improvements in academic performance,this study was conducted in an experimental class-room setting, and therefore, it is unclear whether thisintervention would be as successfully implemented bya teacher with a larger class size and more demandingclassroom setting. Furthermore, quiz scores wereunaffected by the intervention and suggest that long-term comprehension requires not only taking notesbut also utilizing them to study (Evans et al., 1995).Therefore, this note-taking intervention may be mosteffective when combined with a larger set of educa-tional interventions to address the behavior andacademic achievement of adolescents with ADHD.

Utilizing the positive effects of the note-takingintervention combined with knowledge of thepotential efficacy of a multimodal approach to thetreatment of adolescents with ADHD, a multi-com-

ponent academic intervention was implementedwithin the context of an after-school treatment pro-gram for seven adolescents with ADHD, at a publicmiddle school (Evans et al., 2004). The challenginghorizons program (CHP) combined psychosocial andeducational interventions that included note-takinginstruction using the DNA approach, and individu-alized study skills and organizational skills training.Organizational skills training involved bi-weeklyreview of the adolescent’s assignment notebook torecord whether assignments were written downclearly and accurately, review of the binder to recordwhether classwork was filed in folders according toeach subject area, and review of the assignmentnotebook and book bag to record whether loosepapers were present. Points were earned for meetingcriteria which could be exchanged for individualizedrewards. Study skills training involved training stu-dents in the use of memorization techniques to studyfor upcoming tests and exams. Dependent measuresused to assess improvement included students’ gradesand symptom and impairment rating scales. Pre-liminary findings from the first year of the programreported large effect sizes on measures of inattentionand school functioning and small to moderate effectsizes for grades (Evans et al., 2004). Results from thesecond year of the program found moderate to largeeffect sizes on academic functioning and classroomdisturbance as rated by parents and teachers, whereasthe community care group showed either no changeor a decline on these measures (Evans et al., 2005).Furthermore, examination of grade point average(GPA) across semester found that while no differ-ences were present between groups during the firstsemester, the CHP group had a significantly higherGPA than the community care group during thesecond semester.

These findings suggest that the multi-componentCHP may be an effective intervention for addressingacademic impairment in adolescents with ADHD.While the data reported in these two studies areencouraging, they should be interpreted with cautionsince a quasi-experimental design was utilized, andsample sizes were small. Additionally, the CHPintervention was a comprehensive program whichincluded parent training and social skills interven-tions in addition to educational interventions, andtherefore, which intervention or combination ofinterventions resulted in the improvement observedon academic measures cannot be determined. There-fore, future studies should employ study designs thatisolate study skills, organization, and note-taking


approaches to determine their relative effectivenessfor improving task performance and classroombehavior in children and adolescents with ADHD.

Overall, the limited research on strategy training,prevents any conclusions from being drawn at thistime. However, the rationale for why some of thesetechniques may be useful based on the specific deficitsof children with ADHD (e.g., problem solving andself-verbalization strategies to address impulsivedecision making), appears noteworthy and warrantsfurther research. Strategy training may teach olderchildren and adolescents important habits and skillsto improve academic performance, while takingresponsibility and burden off parents and teachers.Alternatively, instruction by clinicians, parents andteachers in the use and practice of these strategiesmay itself be time consuming and require activeinvolvement over the long term. It remains unclearthe length of time it takes before adult involvementcan be tapered and the child or adolescent becomesan expert in the self-application of these strategies. Italso remains unclear whether these strategies, oncelearned, may generalize to other settings or class-rooms beyond that in which they were taught. Fi-nally, as each strategy may target a different aspect ofthe problem, it becomes important to assess the needsof each individual child, and may be beneficial toincorporate a number of strategies into the treatmentof a child or adolescent with ADHD with significantacademic problems.

HOMEWORK-FOCUSED INTERVENTIONS

A particularly important academic target for thetreatment of children and adolescents with ADHD ishomework completion and accuracy. Large-sampleeducational research has shown that, aside fromability, time spent on homework is the best predictorof student grades and achievement (Cooper et al.,1998; Keith, 1982). Also, parental involvement insupporting homework activities results in academicgains (Epstein, 1986). Unfortunately, research hasbeen inconsistent and methodologically weak indocumenting the effectiveness and best proceduresfor homework interventions (Rhoades and Kratoch-will, 1998). Furthermore, very few of these studies arespecific to children with ADHD, and no study in thisarea has been conducted on adolescents or middleschool students with ADHD, who present withunique developmental and environmental challenges.

Research on homework interventions for stu-dents with general academic problems have suggested

that the use of goal setting and contingency con-tracting, parent training in structuring the home set-ting, and parent–teacher consultation are beneficial inthe remediation of homework difficulties (Aneskoand O’Leary, 1982; Bergan and Kratochwill, 1990;Kahle and Kelley, 1994; Miller and Kelley, 1994;Weiner et al., 1998). In homework-specific parenttraining programs, parents are taught to identify andtarget specific behaviors and establish a consistenthomework routine (i.e., determining a quiet settingwith minimal distractions, starting the process early,providing aid when needed, breaking down assign-ments, and prioritizing tasks) (Anesko and O’Leary,1982). Given the frequent difficulties children andadolescents with ADHD experience in the areas ofplanning ahead, prioritizing, filtering out distractions,and focusing on one task at a time, it makes sensethat a homework intervention specifically targetingthese areas would be particularly beneficial for thisgroup.

Another parent-implemented interventiondesigned to target homework difficulties is the use ofgoal setting procedures. Goal setting consists of thecomparison of performance goals against presentperformance level, and may be viewed as a form ofself-monitoring in which children evaluate their ownperformance (Bandura, 1977). Goal setting is typi-cally combined with contingency contracting, inwhich the addition of performance-contingentrewards are used to increase the efficacy of goalsetting. These procedures are used to directly targetthe homework process and provide a frameworkaround which children can complete homework(Miller and Kelley, 1994). As both self-monitoringof goal performance and contingency managementin the classroom have proven successful forincreasing the on-task behavior and task completionof children and adolescents with ADHD, theseinterventions are also likely to prove effective whenimplemented by parents and focused on improvinghomework performance.

Other studies have attempted to involve theschool system in treatment for homework difficultiesthrough parent–teacher consultation. Coordinationacross home and school is vitally important in iden-tifying and resolving points of breakdown in thehomework process, as each setting may influence theother. For example, a child may not be collecting hishomework materials at school and bringing themhome, making it difficult for parents at home to helpthe child complete homework. Conjoint behavioralconsultation has proven effective for children with


academic problems as a method in which parents andteachers work together to address the academic, so-cial and behavioral needs of an individual child(Weiner et al., 1998). This approach may be partic-ularly salient for children and adolescents withADHD, who due to forgetfulness, lack of organiza-tion, and impulsivity in conveying information, mayoften not bring homework materials home or writedown homework assignments and may convey inac-curate information about projects and assignments toparents.

Teaching parents to structure the homeworkprocess, use goal setting, and consult with school staffare intervention approaches that have been tested andfound effective for use with general populations ofstudents with academic problems, but have beenlargely untested for efficacy in a population of chil-dren with ADHD. In recognition of the importanceof homework in predicting academic success and thesalient homework problems of children with ADHD,Habboushe et al. (2001) developed a comprehensive,family-school intervention program for children withADHD that incorporated homework managementprocedures, goal setting, and parent–teacher consul-tation in a 10-week, 7 session group treatment forparents. Preliminary case studies illustrate positiveoutcomes on parent and teacher reports of home-work problems, and increases in homework accu-racy and completion rates. No group treatmentoutcome study based on this program has currentlybeen reported.

Future studies should use multiple baseline andABAB reversal designs to examine academic com-ponents such as goal setting, parent–teacher consul-tation, and parent structuring of the homeworksetting, as well as multiple baseline and between-groups designs that test the impact of comprehensiveprograms that integrate these approaches, such as theone developed by Habboushe et al. (2001) onimproving the homework and academic performanceof children with ADHD. Furthermore, these studieswould benefit from expanding the range of outcomemeasures used to include measures of parent–childconflict, parenting stress, impairment and the inclu-sion of teacher ratings. Homework accuracy ratesneed to be isolated and examined as a separatedependent variable, because increasing homeworkcompletion rates without homework accuracy doesnot indicate learning. Finally, most of these studieswere conducted with children, and developmentalmodifications to these interventions may be necessarywhen working with adolescents.

CLASSROOM-BASED FUNCTIONAL

ASSESSMENT PROCEDURES

Considering the plethora of academic strategiesreadily available to teachers and other school per-sonnel, it often becomes difficult to make an appro-priate intervention choice for an individual child.Furthermore, as children with ADHD who do receivespecial education services spend the majority of theirday in general education classrooms (Reid et al., 1994),the burden of meeting their educational needs falls onthe shoulders of general education teachers (Reid andMaag, 1998), who often express difficulty managingthe needs of these children (Reid et al., 1994). Teachersand other school personnel may collaborativelydevelop and implement academic accommodationsbased on policy guidelines (i.e., Individuals with Dis-abilities Education Act Amendments, 1997 (IDEA)),whichmay notmatchwith our current knowledge baseof what works (Nelson et al., 1999), and may or maynot be appropriate for an individual child.

An important and increasingly utilized tool inthe behavioral assessment and intervention planningfor children is that of functional assessment (FA).This procedure allows the clinician, teacher or otherprofessional to individualize academic interventionsfor the target child, based on the identification andmanipulation of environmental variables that serve toinitiate, maintain and/or increase the child’s prob-lematic behavior in a particular setting (DuPaul andStoner, 1994; Ervin et al., 1998). These variables mayinclude antecedent causes such as seat location in theclassroom; activity grouping (i.e., independent versusgroup work); time of day; active or passive responserequirements; task structure; sequence or organiza-tional structure of the curriculum; lesson length, dif-ficulty or format; instructional strategies used (e.g.,mneumonics, peer tutoring); and presence of certainpeers or friends (Reid and Maag, 1998). Specificconsequences (e.g., lack of teacher response, peerattention, immediate or delayed feedback, avoidanceof a particular subject) that influence the particularproblematic behavior are also identified and system-atically manipulated. The information derived fromthese analyses is used to collaboratively develop aneffective and socially acceptable intervention for anindividual child.

The majority of studies on functional assessmenthave been conducted in highly controlled settingswith children and adolescents with severe develop-mental disabilities who exhibit high intensity behav-iors such as aggression, disruption or self-injury (Carr


and Durand, 1985; Carr et al., 1980; Iwata et al.,1982) and with children with emotional and behav-ioral disorders who exhibit off-task and disruptivebehaviors (Blair et al., 1999; Clarke et al., 1995; Kernet al., 1994). More recently, this approach has beenexamined for its efficacy in increasing on-taskbehavior and reducing disruptive behavior in childrenand adolescents diagnosed with ADHD (Broussarand Northup, 1995; Ervin et al., 1998; Hoff et al.,2005; Lewis and Sugai, 1996; Northup et al., 1995;Umbreit, 1995). Since the strategies utilized as aresult of a functional analysis include changes toacademic format, structure, and instructions, it islikely that the benefits of this approach extendbeyond that of on-task behavior to other academicoutcomes. However, no study to date has examinedthe effects of this approach on increasing academicproductivity and accuracy in children or adolescentswith ADHD. This is despite the mandated use of FAby IDEA in school settings to improve the classroombehavior and performance of children with a varietyof special needs including ADHD (Hoff et al., 2005).Therefore, it is critical that more studies be conductedto examine the benefits of FA for use in general andspecial education settings as employed by schoolpersonnel to address the academic problems of chil-dren and adolescents with ADHD. This approachmay prove the most effective means of interventionselection for an individual child with ADHD andmay aid in the development of 504 plan and Indi-vidualized Education Plan (IEPs) goals and inter-vention plans which are more effective andappropriate for a given child.

There also may be some significant limitations tothe school-based application of FA principles,including the considerable effort and time on the partof school personnel to generate and subsequently testhypotheses in order to design an appropriate inter-vention for an individual child. Some have suggestedthe use of interviews and brief functional assessmentmethods to address some of these practical concerns(Harding et al., 1994; Kern et al., 1994); more costand time efficient methods of FA should be exploredthrough future research. Furthermore, results of FAmay not generalize to other classroom settings inwhich the child is currently involved without sys-tematic intervention testing in those settings as well.

MULTIMODAL TREATMENT APPROACHES

While the focus of this literature review largelyhas been the examination of each individual academic

technique, there have also been a number of multi-modal treatment packages, which successfully incor-porate many of these academic interventions. Forexample, the aforementioned CHP Program incor-porates note-taking, organizational, and study skillstraining within the context of a comprehensive psy-chosocial treatment targeting multiple domains.

Another well-researched, multi-component pro-gram is the Children’s Summer Treatment Program(STP), which combines an intensive summer treat-ment program with a school-year, outpatient follow-up program (Pelham et al., 2005). During the summerprogram, children spend 2 h daily in classrooms inwhich individualized seatwork, peer tutoring andcomputer-assisted instruction is provided. The rest ofthe day is spent in recreationally based group activi-ties. Evidence-based contingency management tech-niques are utilized throughout the program andinclude the use of a point system, daily report card,time out, public recognition, and home-basedrewards (Pelham et al., 2005).

Analyses of 258 boys with ADHD who attendedthe STP found large effect sizes on direct observationsof on-task and disruptive behaviors (Pelham andHoza, 1996). In addition, the classroom-basedbehavioral components of the STP (i.e., token econ-omy, DRC and time out) have been specificallyexamined in two studies (Carlson et al., 1992; Pelhamet al., 1993), which found improvements in on-taskand disruptive classroom behavior but limitedimprovements in academic productivity as a result ofthese interventions. The academic interventionsincorporated into the classroom component of theSTP (e.g., peer tutoring, CAI) do not appear to havebeen isolated to examine their effect on academicproductivity. A modified treatment design in whichsome students receive these academic interventionsand others do not, as has been conducted with othercomponent interventions within the STP (e.g., timeout), may be necessary in order to tease apart theeffect of the academic versus behavioral classroominterventions used within the STP. While aspects ofthe STP such as CAI and peer tutoring may likelyhold benefit in improving academic performance, itis currently unclear the extent to which these indi-vidual academic components contribute to anyimprovements observed in academic productivity oron-task behavior in the STP classroom. Further,other academic measures such as achievement testscores and academic accuracy may be importantoutcomes to examine when isolating these STPcomponents.


In another large, well-controlled study, Hecht-man et al. (2004) compared the following threetreatments in a sample of 103 children with ADHD:(1) stimulant medication alone; (2) stimulant medi-cation plus psychosocial treatment that includedacademic remediation, organizational skills training,individual psychotherapy, parent training, and socialskills training; and (3) stimulant medication plusattention control treatment. Results found noadvantage on standardized achievement test scores orparent-report on the Homework Problems Checklistfor the combined treatment compared to stimulantmedication alone and stimulant medication plusattention control. Therefore, this particular studysuggests that there may be little support for theincremental benefit of academic assistance in specifi-cally enhancing the long-term achievement scores andreducing the parent-reported homework problems ofstimulant-responsive children with ADHD (Hecht-man et al., 2004).

Similarly, early findings from the largest andmost well-controlled study in child mental health todate, the Multimodal Treatment Study of Childrenwith ADHD (MTA; MTA Cooperative Group,1999), found that the combined treatment (i.e.,medication plus intensive parent training, biweeklyteacher consultation, a paraprofessional aide workingdirectly with the child in the classroom, and partici-pation in the STP program) did not prove superior tomedication management alone on multiple domainsof functioning, including ADHD core symptoms andachievement test scores (MTA, 1999). However,numerous authors highlight limitations presentwithin the MTA study design that may have favoreda positive outcome for the pharmacological approach(see Cunningham, 1999; Pelham, 1999). Furthermore,in later analyses of a composite variable obtained bycombining parent and teacher report, the combinedtreatment was found to be statistically and clinicallysuperior (demonstrating 12% greater treatment suc-cess) than the medication management alone condi-tion (Conners et al., 2001). In addition, significantlylower medication doses were required in the com-bined treatment versus the medication managementalone condition (MTA Cooperative Group, 1999).Therefore, findings from the MTA study suggest thata comprehensive behavioral intervention may offerthe greatest advantage and contribute significantadditional benefit beyond the effects of medicationalone on multiple domains of functioning.

Both the MTA study and Hechtman’s multi-modal approach compare medication to a compre-

hensive psychosocial treatment, and therefore cannotanswer questions such as the extent to which specificacademic interventions improve the achievement andacademic behavior of children with ADHD, theeffects of these interventions on non-stimulantresponsive children, and their efficacy compared toother active behavioral approaches. Furthermore,while the MTA incorporated a wide variety of out-come measures, no measures of academic productiv-ity or quality, test and quiz scores, or grades wereutilized; only achievement scores were used to assessacademic changes. Achievement scores may be lesslikely to detect small, daily changes in academicperformance and therefore may not adequatelyhighlight any differences that may exist in academicperformance across conditions. Future studies of theseparate and combined effects of these treatmentswould benefit from incorporating a wider range ofacademic outcome measures, some of which are moredirectly targeted by the interventions (e.g., dailyclasswork and test performance).

CONCLUSION

Children and adolescents with ADHD experi-ence significant and debilitating impairments in aca-demic performance and school-related behaviorrelative to their peers. This appears to be largely aconsequence of the manifestation of executive func-tioning deficits in children with ADHD and resultingsymptoms of inattention, hyperactivity and impul-sivity. Academic problems of children and adoles-cents with ADHD commonly lead to significantnegative outcomes including grade retention, specialeducation placement, suspension or expulsion, andeventually, job failure. While stimulant medicationand behavior modification typically target and haveproven effective for improving the on-task and dis-ruptive behavior of children with ADHD within theclassroom, the effects of these evidence-basedapproaches on academic performance are muchsmaller and less often studied, and limitations to theutilization of these interventions in general do exist.

Academic interventions focus primarily onmanipulating antecedent conditions such as academicinstruction or materials in order to improve bothbehavioral and academic outcomes. Interventionswhich have received some research attention andhave demonstrated at least some preliminary benefitin the treatment of children and adolescents withADHD include: (1) classwide peer tutoring and par-ent tutoring which employ one-to-one instruction,


immediate and frequent feedback, and requireactive responding; (2) instructional and task modi-fications, which may include allowing students tochoose assignments from among several pertinentalternatives, presenting material orally and requir-ing oral responses in addition to presenting mate-rial visually, adding structure or using explicitinstructions, employing computer-assisted instruc-tion, and using color or texture to increase stimu-lation within tasks; (3) classroom functionalassessment procedures; (4) self-monitoring andreinforcement, particularly for older children andadolescents; (5) strategy training, including note-taking, study skills and organizational skills inter-ventions; and (6) homework-focused interventionswhich incorporate goal setting, parent structuringof the homework process, and parent–teacherconsultation approaches.

Of these interventions, there are a fewapproaches that currently appear most promising. Inparticular, peer tutoring has resulted in large effectson on-task behavior and smaller but still significanteffects on academic productivity in two group-designstudies. Self-monitoring techniques have resulted inlarge effects on on-task behavior, disruptive behavior,academic output and academic accuracy in a fewstudies (i.e., two between-group studies and onewithin-subjects design). These benefits were found tobe larger than the effects of MPH on academics inone study; in another study, academic performanceand the accuracy of self-ratings were maintained evenafter the matching process was withdrawn, in whichstudents received points for matching ratings withinone point of their teachers. Task modifications suchas the addition of color stimulation to certain tasksresulted in fewer errors and greater productivity in acouple of studies employing a between-groups design.However, the benefits of color appeared to varydepending upon the complexity of the task, and thetime in which stimulation was added to the task (i.e.,early, middle or late). Finally, it also appears thatsome multimodal programs which incorporate orga-nizational and note-taking skills training, and/oremploy techniques such as peer tutoring and com-puter assisted instruction (e.g., the ChallengingHorizons Program and the Summer Treatment Pro-gram) have experienced reliable success in improvingthe academic productivity and grades of children withADHD. Therefore, it would be beneficial to isolatesome of the component interventions used withinthese programs and test them in well-controlledgroup design studies.

Salient Characteristics of Academic-Focused

Interventions

Although relatively little attention has beenfocused on the development of academic-focusedinterventions in the treatment of academic impair-ment in children and adolescents with ADHD, andthe research that has been conducted is mainly of apreliminary nature, some tentative recommendationscan also be derived from this review as to which as-pects of academic-focused interventions may be mostbeneficial to the child or adolescent with ADHD.

First, it appears that academic interventionswhich require active engagement on the part of thestudent with ADHD typically result in better per-formance than those with passive attentionalrequirements (e.g., oral versus silent reading; peertutoring versus traditional instruction, note-takingversus passive listening to lecture format classes).Active engagement may improve the length ofattention span and allow for a deeper level of infor-mation processing. Active processing of informationmay be particularly important for increasing taskaccuracy. For example, in the Evans et al. (1995)study, the process of note-taking improved dailyassignment scores and attention, but did not improveweekly quiz scores, which may require active studyingof the notes taken in addition to the process ofwriting notes.

Another important goal of academic-focusedinterventions may be to decrease distractions and/orreduce the amount of competing, non-relevant stim-uli, while providing an optimal level of relevantstimulation to hold attention on the current task.CAI research found some evidence that computeranimation may be more of a detriment than a benefitto the task performance of children with ADHD,possibly due to providing too great a level of taskstimulation, whereas providing computer activities ina game format was found to be beneficial to attentionand performance. Similarly, adding color to a writtenor computer task appears to confer benefits for thechild with ADHD in increased attention on simplertasks, but for more complex operations, adding colormay function as a distraction that actually inhibitslearning. In addition, providing a choice of task fromamong several structured alternatives may serve toincrease interest level, relevant stimulation, and thusthe attention of the child with ADHD. Therefore, aconsistent theme throughout the research on manyacademic-focused interventions is an attempt to in-crease relevant stimulation while removing potential


sources of distracting stimuli. This is consistent withoptimal stimulation theory, which hypothesizes thatchildren with ADHD have a greater need for stimu-lation and are less tolerant of situations involvingminimal stimulation, which result in increased errorsand excessive motor and verbal activity in this groupduring repetitive or mundane tasks or activities(Zentall, 1975).

Consistent with behavioral management prac-tices which stress the effectiveness of positive rein-forcement in the treatment of children with ADHD,the academic-focused interventions reviewed hereintypically provided immediate feedback in the form ofteacher and parent praise, computer rewards, tangi-ble rewards or privileges. The use of positive feedbackmay be an important component to the implemen-tation of these academic interventions, as they serveto reinforce targeted behaviors and increase motiva-tion and persistence at tasks.

Consistent with academic accommodations forstudents with ADHD that are typically included onIEP plans, the academic-focused approaches tested inthese studies often attempt to divide academicmaterial into smaller chunks of information, ordivide homework into smaller subunits through theuse of goal setting. By making the workload appearmore manageable, and focusing a child’s attention ononly one aspect of a task, increases in productivityhave been observed. This may be a particularlyimportant skill for children with ADHD to learngiven their difficulties with organization and thecompletion of multi-step tasks. These techniques area main component included in CAI, peer and parenttutoring, note-taking, self-monitoring and goalsetting interventions.

Another characteristic of some of these inter-ventions is the transferring of decision making andresponsibility to the older child, which may be pre-ferred by teachers and parents over the use ofbehavioral control, because of their time and costefficiency. For example, having children set their owngoals for productivity and monitor their task com-pletion and accuracy frees up teacher time for moreindividualized instruction. Methods which placeadded responsibility on the child may also increasethe maintenance of behavior change and generaliza-tion across settings, as children develop habits andskills that are further reinforced over time. The abilityof these approaches to be effective is most likelyhighly dependent on the cognitive and developmentallevel of the child. As children with ADHD transitioninto adolescence, developmental changes such as

increases in independence seeking, and cognitivechanges such as increases in abstract thinking andproblem solving capabilities (Smith et al., 2000), maymake it more likely for the older child or adolescentwith ADHD to become actively engaged in andresponsible for aspects of his or her own intervention.

Another common theme observed was the focuson providing one-to-one instruction or tailoring theintervention to the specific needs of the child. Forexample, CAI instruction was designed to be self-paced, and to provide a choice among various levelsof difficulty. Peer and parent tutoring also focuses onone-to-one instruction, allowing the child to progressat his or her own pace, and to receive individualizedfeedback. These approaches may be particularlysalient for the child with ADHD, who may need amore intensive level of instruction at his or her ownability level in order to be successful. Finally, func-tional assessment procedures result in the develop-ment of an intervention which effectively modifies theantecedents and consequences maintaining theproblematic behavior in the given environment for aspecific child. Use of FA procedures may be the mosteffective method for practically choosing among avariety of efficacious alternatives.

The recurring themes presented here suggest thatthere are likely certain aspects of academic-focusedinterventions for children and adolescents withADHD that are commonly incorporated into avariety of approaches due to their acceptability, effi-cacy, and practicality. It is recommended that futureresearch attempt to uncover potential mediators andmoderators of intervention success through a carefulexamination of components or aspects common tomany academic-focused interventions. For example,active components of CAI may include aspects of theformat, animation, novelty, reinforcement schedule,and duration of the intervention. Furthermore, dis-mantling studies which examine only one componentof a given intervention are also of paramountimportance in developing a more comprehensiveunderstanding of what it is about these interventionsthat are beneficial for children and adolescents withADHD.

Limitations of Current Research and Future Directions

Perhaps the most realistic conclusion that can bederived from this review is that while certain aca-demic-focused interventions show considerablepromise for children and adolescents with ADHD,surprisingly little research attention has been devoted


to testing their efficacy in the treatment of academicimpairment in ADHD, and the majority of studiesthat have been conducted are severely limited bymethodological flaws. As academic impairment is oneof the major concerns for children and adolescentswith ADHD, the field of clinical research and prac-tice may benefit from increasing their focus on thisfunctional domain. Future studies would benefit fromemploying larger sample sizes within randomized,controlled trials utilizing between-groups designs.This will serve to bolster preliminary evidence derivedfrom single case and multiple baseline studies. Inaddition, the duration of most interventions was onlyone to two weeks, and more robust effects mayrequire longer-term studies to be implemented withlonger interventions and longer follow-up periods.Finally, many previous studies did not control forcarryover effects, did not assess inter-observeragreement, and did not employ adequate measures oftreatment fidelity and integrity. Therefore, it becomesdifficult to make any real conclusions regarding theseresults given the myriad of confounding factors whichmay account for positive findings.

Furthermore, while many studies employedmeasures of on-task and disruptive behavior, manyfewer employed academic outcome measures (e.g.,task completion and accuracy, grades, quiz andassignment scores, achievement test scores, readingcomprehension). This is critically important given theneed to directly target and improve the academicbehavior of these children. Some of the studieshighlighted above observed large increases in on-taskbehavior and work productivity, with more variablechanges in the accuracy of work. Accuracy rates maybe more indicative of learning than on-task behavioror completion of work, and may be more difficult tochange. Therefore, future studies may benefit from amore careful focus on objective measures of academicsuccess such as improving task accuracy, test andquiz scores, and comprehension of material.

Another significant methodological caveat thatarose repeatedly throughout these studies is the use ofresearchers to implement treatment in laboratory-based classroom settings, rather than implementationby teachers in an ecologically valid setting (i.e.,regular or special education classrooms). Further-more, as most studies failed to include measures oftreatment acceptability, fidelity, and satisfaction, itremains unclear whether teachers, parents and otherschool professionals can effectively and consistentlyemploy these interventions and will consider thempractical, feasible and desirable for incorporation

into their daily activities. Effectiveness studies in real-world settings are direly needed to explore thesequestions. Although some academic interventions areeasy to apply (e.g., incorporating choice in tasks,adding color or other stimulation), other interven-tions require considerable time and effort on the partof teachers and parents in order to teach children anew habit or skill (e.g., note-taking training, studyskills training, self-monitoring), implement a newtechnique (i.e., parent tutoring, homework program),or develop an individualized intervention (i.e., func-tional assessment). This may decrease the accept-ability of the intervention by teachers and parentsand the feasibility of implementation in home andschool settings. Alternatively, it is possible that manyshort-term academic interventions may have morerobust effects if administered over the long-term.O’Leary (1980) argued that changes in standardizedachievement test scores have been demonstrated as aresult of some short-term behavioral interventions,and therefore, replication and extensions of thesetreatments for at least 6–12 months are criticallyneeded in order to determine if long range academicchanges can be made. This is consistent with theconcept of teaching ‘‘skills’’. Therefore, practicalityand feasibility for implementation within the schoolsetting must be balanced with the need for methodswhich offer the most long-term benefit to the aca-demic skills of children with ADHD.

In developing more time- and cost-efficientmethods, it would be essential to explore whetherteachers and parents may be able to taper theirinvolvement over time as older children and adoles-cents master academic habits and skills. Unfortu-nately, due in part to the short duration of mostacademic-focused treatment studies and the lack offollow-up assessments, this question remains largelyunexplored, with the exception of some preliminaryevidence that older children are capable of accuratelyself-monitoring their behavior and task performance.The ability to taper involvement over time will likelybe partially dependent on the cognitive-developmen-tal level of the child or adolescent. Therefore, studiesneed to be expanded beyond the examination of ele-mentary school age children to include a wider rangeof ages and a greater number of adolescents, in orderto understand critical developmental and individualdifferences which may influence treatment.

Another constraint of some of these studies in-volves the inconsistency with which a diagnosis ofADHD was established. Some studies required onlythat participants surpass a cut-off score on the


Conner’s Behavior Rating Scale teacher version (e.g.,Ajibola and Clement, 1995; Belfiore et al., 1996;Fitzgerald et al., 1986; Zentall, 1985) or anotherteacher report measure (e.g., Robinson et al., 1981;Zentall, 1986). This is not consistent with best prac-tices for diagnosing ADHD, which include the inte-gration of reports from multiple individuals in morethan one setting (Barkley, 1998). In addition, somestudies did not restrict their sample to individualswith ADHD, and therefore it cannot be determinedfrom this data how much these findings apply tochildren with ADHD versus children with emotionaland behavioral disorders in general.

For example, LDs are highly comorbid withADHD and result in unique and typically moresevere educational problems for the child withADHD (Silver, 1992; Hinshaw, 1992a, 1992b). Theexacerbation of academic difficulties found inchildren and adolescents with ADHD whom have aco-occurring learning disability suggests that thebenefits of interventions may be dampened in thisgroup (Hinshaw, 1992b), especially when adminis-tering short-term approaches that target only onedomain. Most of the studies highlighted in this reviewdid not examine the differential impact of treatmenton those children with ADHD who also have an LD.Future studies should examine this variable as amoderator of treatment outcome.

There are other important areas of methodologicalconcern. As mentioned previously, academic-focusedinterventions often utilize immediate feedback andconsequences (i.e., praise and rewards) as part of theintervention. While this addition likely bolsters treat-ment effects, it also makes it difficult to disentangle theeffects of contingency systems implemented concur-rently with academic interventions from the effects ofthe academic interventions alone. Study designs needto be aware of this potential pitfall and correct for itthrough comparison of academic-focused treatmentwith and without contingencies, and/or throughcontrolling for this variable in the study design oranalyses.

Furthermore, studies of academic interventionsimplemented within the context of a multi-compo-nent treatment program (e.g., goal setting inhomework programs, study skills in an after-schooltreatment program, CAI in the STP program)would benefit from dismantling studies designed toexamine each individual component to determinethe relative benefits of each. As individual compo-nents are found effective, a constructive treatmentstrategy may be used to develop a comprehensive

treatment package to enhance outcome. Given thesignificant and wide-ranging academic deficits chil-dren and adolescents with ADHD manifest, it islikely that a multi-focused intervention will be mosteffective in the amelioration of these difficulties. Assome academic-focused interventions prove effec-tive, examination of the relative efficacy of thesetechniques or treatment packages through compar-ison to other active treatments (i.e., behaviormodification programs and stimulant medicationalone, and in combination) will become an impor-tant next step.

As research evidence accumulates, our knowl-edge base of effective academic-focused interventionsshould be used to inform parents, teachers and policymakers. Policy recommendations of ‘‘best practices’’for educational accommodations should be consis-tent with research knowledge of ‘‘empirically sup-ported’’ treatments in order to accurately direct theefforts of school professionals and practitioners.Increasing the communication between researchers,teachers and parents and the federal dollars allottedto education will most effectively result in currentknowledge being put to use effectively. Furthermore,collaboration between home and school settings canresult in more robust effects as teachers can com-municate daily success and goal achievement to par-ents, and parents can support teacher-implementedinterventions through reward systems at home, andvice versa. Through active efforts at disseminatingresearch findings and through communication acrossdisciplines and settings, strides can be made in the useof effective academic approaches for children andadolescents with ADHD in both home and schoolsettings. These approaches may serve not only toimprove grades and academic productivity in theshort term, but also to disrupt negative long-termtrajectories involving grade retention, school drop-out, suspensions and expulsions, and substanceabuse.

ACKNOWLEDGMENTS

During the preparation of this review, V. Raggiwas supported by an APA Society for ClinicalChild and Adolescent Psychology DissertationResearch Grant. Dr. A. Chronis was supported bygrants from the National Institute of Mental Health(R03MH070666-1; R34 MH073567-01) and McNeilConsumer & Specialty Pharmaceuticals, manufac-turer of ConcertaTM.


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