Running Head: ATTENTION DEFICIT HYPERACTIVITY DISORDER

Attention Deficit Hyperactivity Disorder/ Attention Deficit Disorder

Jenna Saska

Brandman University
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Abstract

The DSM-V defines Attention Deficit Hyperactivity Disorder / Attention Deficit

Disorder as having three categories: inattention, hyperactive-impulsive, and inattention and

hyperactive-impulsive. In the prior publication (DSM-IV-TR date 2000), ADHD and ADD were

listed separately. Since Attention Deficit Disorder has been absorbed into one of Attention

Deficit Hyperactivity Disorder’s three sub categories in the DSM-V, this paper will focus on

ADHD and the laws that apply to accommodating students, the role of the School Psychologist,

and the ethical responsibilities of diagnosis and accommodation. The sources used in this paper

discuss in great detail Section 504 of the Rehabilitation Act of 1973, IDEA, ethical dilemmas

and considerations for researchers and School Psychologists, and the obligations of educational

institutions that serve students with ADHD. With the greater use of mitigation methods in place,

particularly non-pharmaceutical measures, students with ADHD can perform similarly to their

peers and the ethical considerations of diagnosis and accommodations will become more clear.
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Introduction

Section 504 of the Rehabilitation Act of 1973 provides a basis for a Free Appropriate

Public Education for all students, regardless of ability. Section 504 is more broad than other laws

put in place for students with disabilities, including IDEA and ADA (now ADAAA), as it

requires that students receive accommodations if needed, but does not require an Individualized

Education Plan be put in place for each student. Some examples of students that qualify for

accommodations under Section 504 are children with diabetes, a child with a broken leg, or a

student with ADHD. The purpose of Section 504 accommodation is to give students the ability to

receive an accommodation for a specific issue that could be temporary (like a broken leg) or

more permanent, like diabetes or ADHD. A student with diabetes may need extra bathroom

breaks, so with a 504 accommodation in place they are not restricted by general classroom rules

regarding bathroom breaks. The same can be applied to students with ADHD, who may need

additional testing time, or may exhibit distracting behaviors that for a student without ADHD

could be penalized by their teacher (like getting out of their seat without permission). Section

504 dictates that a “substantially limiting” disability lasting for at least six months can qualify for

accommodations. Mitigation methods like medication and behavior supports can be put in place

for students with ADHD, but not all diagnosed students require accommodations even though

they qualify under Section 504. Section 504 enables students to receive accommodations while

in a general education setting, and some students diagnosed with ADHD do just as well as their

peers without the need for accommodations.

Section 504, IDEA Part B, and ADAAA

There are three elements to Section 504 of the Rehabilitation Act of 1973 to qualify for

special education. They are: 1) a mental or physical impairment which 2) limits one or more
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major life activities 3) substantially. (DuPaul, G. J., & Zirkel, P. A., 2019). IDEA Part B requires

that these criteria be related to education, whereas Section 504 is more broad and instead only

requires that there be a “substantially limiting” impairment. In the 2008 amendments of the

Americans with Disabilities Act, Congress broadened the scope of eligibility under Section 504

by expanding the explicit examples for major life activities and the instructions for determining

substantial, while leaving the impairment element open-ended (DuPaul et al, 2019). As students

with ADHD often cannot prove that their disability substantially limits their ability to function in

a classroom setting with or without mitigating measures in place, they can have a difficult time

qualifying for an Individualized Education Plan (IEP) because they need to prove that their

impairment “substantially limits” them in the classroom. ADHD diagnosis rates continue to rise,

and currently about 10% of children in school have an ADHD diagnosis (Smith, 2019). The

reason for this steady uptick in diagnoses is multi-faceted.

The responsibility of each school is to provide a Free Appropriate Public Education

(FAPE) to all students, regardless of ability. With advancements in research, evaluation, and

laws that support students, ADHD has become easier to diagnose despite its similar presentation

to other disorders (anxiety, depression, etc.) in an educational environment. While diagnosis rate

continues to rise, an argument could be made that this is in part due to overdiagnosis of ADHD.

Although false positives are generally favored over false-negatives (since that could be proven to

be discriminatory), if a student is incorrectly diagnosed with ADHD they can be given

accommodations in school without legitimately needing an accommodation (DuPaul et al,

2019). The effect of false-positives can ripple through the education system, as argued by both

Lindstrom, W., & Lindstrom, J. H. (2017) and Ainsworth, R. (2015). Both sources make a case

that the large number of students with ADHD diagnoses have the potential to corrupt college
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admission data, testing data, and other areas of the education system due to accommodations

which both articles argue may be unnecessary. However, with a combination of intervention

strategies in a supportive environment both in school and at home, students with ADHD can

make enough progress to not need additional testing time as part of their accommodations

(DuPaul, G. J., Power, T. J., Evans, S. W., Mautone, J. A., & Owens, J. S., 2016). DuPaul et al

2016 argues that psychosocial and educational interventions should be used for students with

ADHD before accommodations like additional time for test taking is implemented. This strategy

allows for students to make progress on their time-management skills prior to giving additional

test taking time, which may not be a necessary accommodation if improvements in other areas

are first made. This intervention approach, if widely used, could allow fewer students to need

accommodations for test taking, thus eventually eliminating the idea that students with ADHD

are skewing data because they receive unfair accommodations.

Prior to the ADA Amendments Act, court cases in the 1990s and into the 2000s argued

that ADHD symptoms, which primarily affect concentration and thought processes, did not

warrant disability protection under Section 504 (Muller, 2015). Changes made to ADA with the

ADA Amendments Act of 2008 overruled court cases which had previously narrowed the

definition of “substantially limits” in order to side against the party with ADHD. In overruling

cases that had narrowed the definition of “substantially limits”, the ADAAA sought to re-

emphasize the original intention of the ADA to keep qualifications for disabilities more open

ended. The ADAAA also declared that the use of mitigating measures when determining the

parameters of “substantially limits” is irrelevant (for example, if a student’s performance was

improved by a medication this would not be taken into consideration), and also further defined

“major life events” (Muller, 2015). One court case in particular, Toyota Motors v. Williams, was
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overruled because it had narrowed the definition of “substantially limiting” to something which

would debilitate most people in their daily lives, which William’s diagnosis of myotendinitis did

not. (Muller, 2015). With the ADA Amendments Act of 2008, individuals with disabilities both

in school and the workforce were given protections that originally were intended for the ADA of

1990, which through court rulings had been substantially limited. The return of the original intent

of the ADA now allows for protection for individuals with disabilities that “substantially limit”

certain aspects of their life which the general population is able to perform.

ADHD Diagnosis and Treatment In Non-white Populations

The biopsychosocial-cultural model can be used to get a more accurate picture of

students with ADHD as well as provide a framework for intervention strategies from an inclusive

perspective. Minority students are two times less likely to be diagnosed with ADHD as their

white peers (Pham, 2015). Cultural norms with relation to neurological disorders like ADHD are

partly to blame for the discrepency in diagnosis between white and non-white students. Parental

observation and reporting is dependent on recognizing symptoms, and as a result some cultures

may not emphasize reporting of ADHD symptoms to medical and educational professionals.

Behavior problems exhibited by non-white students can sometimes be perceived as an issue

unrelated to a disability, and thus is left untreated. Medication for ADHD symptom mitigation is

also less often used by non-white parents for their children once diagnosed. Behavior

modification is more widely used than in white children with ADHD (Pham, 2015).

Behavior modification is also the most popular choice for ADHD treatment among the

African American community. Medication is generally less popular among non-white parents

due to a variety of factors, including perception of mental health issues, socioeconomic status,

access to healthcare, and perhaps most importantly, the implicit and explicit bias that existed in
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Special Education in the United States well into the twentieth century. Special Education was

used after the Civil Rights era to cloister African-American students in classrooms away from

their white peers in a post-segregation school system. Because of this history, not only are there

rules regarding testing of African American students for Special Education, but also parents of

African American students today are well aware of the racist past of Special Education. This

amalgamation of factors has resulted in only two thirds of African American students receiving

the diagnoses and accommodations necessary to ensure that they receive a Free Appropriate

Public Education. (Mattox G. A., & Vinson, S. Y., 2018).

Ethical Dilemmas

There has been a consistent rise in the number of students diagnosed with ADHD, which

is expected to continue. This steady increase in diagnoses has led to some backlash regarding

accommodations of students with ADHD. The perception that students with ADHD perform

similarly to their peers and thus should not be given accommodations like additional time for

testing can be correlated to false-positive diagnoses, but research suggests that students with

additional testing time do in fact demonstrate a legitimate need. It has also been argued that

students who qualify for accommodations under Section 504 of the Rehabilitation Act generally

have limited issues in their education that would require any accommodations (Ainsworth,

2015). Although mitigating measures like medication have allowed students with ADHD to

perform similarly to their peers, some researchers believe that if students with ADHD are given

accommodations, it puts their peers at a disadvantage. This argument also suggests that students

are overdiagnosed with ADHD, which puts students without a disability at a disadvantage by

having to work within the confines of how the education system is currently set up for them,

including blindly comparing test scores to students with extra time allotted due to their
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accommodation (Ainsworth, 2015). While the author cites court cases to establish a precedent

that ADHD is indeed overprescribed and students with a diagnosis are often not disadvantaged in

their education when mitigation methods are in place, further research shows that some of the

court cases cited by Ainsworth were overturned with the ADA Amendments Act of 2008. Since

ADHD symptoms are not always obvious to a passive observer, it is more easy to understand

why existing bias towards students that require accommodations persists. Also, since medication

is often very successful at mitigating symptoms, many students with otherwise noticeable

symptoms in a classroom setting appear to act similarly to their peers.

The topic of college admissions testing and available data extended to another source,

which studied the guidelines given by DOJ technical assistance, testing guidelines across testing

agencies, and gave recommendations for Learning Disability and ADHD guidelines. The authors

mention the possibility for students to have a “false positive” diagnosis for ADHD, who are then

granted accommodations when these students do not necessarily need them. Also discussed is the

importance of standardized testing practices for secondary and post secondary admissions, as

well as the importance of a truly fair testing environment. The need to accommodate students is

protected by the ADA and ensures that test metrics aren’t skewed by treating every student,

regardless of ability, by the same standard. In order to have a true representation of a student’s

ability, each student needs to be treated fairly, including students that require more time for their

testing. Without giving an accommodation to a disabled student, the student would test below

where their true ability level is. This argument forms the basis of why a Free Appropriate Public

Education extends to the value of accommodations for students that have less obvious

disabilities, like ADHD (Lindstrom, W., & Lindstrom, J. H., 2017).

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A similar argument is touched upon and refuted in Expanding Protection for Attention

Deficit Hyperactivity Disorder Individuals under the Americans with Disabilities Act by

Christine Muller, published in the Loyola Journal of Public Interest Law in 2015. This article

looked extensively at the history and legal precedent of the ADA and subsequently the ADAAA

and its effect on individuals diagnosed with ADHD both while in school and as a working

professional. Citing cases both prior to and after the ADAAA, Muller asserts that ADHD can by

definition be a “substantially limiting” neurological disorder and students should have an

opportunity to be accommodated if necessary. The author argues that in cases where students

were found to not qualify for accommodations, their educational institutions were potentially

discriminating against them, and that the cases highlighted never determined whether a school

was following ADA guidelines in the first place. The author argues that ADHD can substantially

limit a student’s ability to learn, and that the ADA states that students should be evaluated based

on their performance when no mitigating measures (including medication) are in place.

In order to provide a Free Appropriate Public Education to all students, documented

disabilities must continue to be treated appropriately and while bias persists in the public sphere

regarding ADHD, there are mitigation methods which could quelch some of the concerns

brought forth by the above mentioned research. With a wider use of behavior therapy both at

school and home, students with ADHD have been documented to perform more closely to their

peers and when medicated, required smaller doses of medication to achieve the same results

(Cole et al, 2019).

The Role of School Psychologists

Behavior rating scales are used by School Psychologists to determine whether the student

they are assessing falls within the normal range or deviates from the norm. Factors such as false
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positives and negatives (looking on-task but actually being off-task, and vice versa), age and

gender, and parent and teacher reporting, as well as in-class observation by the School

Psychologist all must be taken into consideration when evaluating a student (DuPaul et al, 2019).

School Psychologists also have a large number of tests they can administer to students to test

their concentration. There are a multitude of tests available to School Psychologists to determine

inattention and concentration issues with students suspected of having ADHD. These tests have

been widely used, and are structured so that the tester can accurately measure the student being

tested against a large data set in order to make an accurate determination. It is the responsibility

of the School Psychologist to clearly communicate with parents/guardians to ensure that support

in the school setting is carried over into the home environment (DuPaul et al, 2016). Using data

from many different areas helps a School Psychologist more accurately determine if a student

meets the criteria for accommodation. Many students with ADHD are given medication to

mitigate their concentration issues, and School Psychologists are tasked with doing their best to

assess the student either when not medicated or when it is suspected that they are not medicated,

as an accurate determination of their abilities can only be made when mitigating factors are taken

out of the equation. School Psychologists are able to, through the support of school staff and the

parents/guardians of the student, implement intervention strategies to help children with ADHD

under Section 504 implementation procedures. Along with intervention strategies and behavior

therapy, students are oftentimes using medication to mitigate symptoms.

The most widely used mitigation option for ADHD is medication. While medication can

be a benefit to many students and their families, it also has the potential for side effects in both

the short and long term. Although medication is often used to mitigate symptoms of ADHD,

there are other mitigation options that have been proven to be similarly effective. In a recent
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study by Cole et al published in August 2019, 127 unmedicated students were studied over the

course of the school year both at home and in school. In the randomized study, half of the

students received behavior consultation and the other half did not. Of those given behavior

consultation (BC), 50% of students did not require medication and those that did used smaller

doses than the students not given BC. In this study, students were given a total of 40% less

medication over the course of the year than they otherwise would have received (Cole et al,

2019). This study, while small, is a great example of how the use of behavior interventions can

have a lasting impact on ADHD student success as well as the ability to limit the use of

medication when behavior supports are consistent.

Limitations

In order to reduce and eventually eliminate existing bias in the education system around

accommodations as an unfair advantage, the ways in which professional educators work with

students could use some alteration and improvement. At the onset of symptoms and diagnosis,

School Psychologists should implement behavior supports for students with ADHD that can

reduce the incidence of needing medication, or can work in conjunction with medication to

mitigate symptoms and help students function in the classroom similarly to their peers. The

American Academy of Pediatrics (AAP) guidelines have recommended that children 6 and older

diagnosed with ADHD should use both medication and behavior therapy to mitigate symptoms,

and that children 5 and under should start out with behavior therapy alone (Smith, 2019).

Although the use of medication is common, it does not need to be the most widely used option to

mitigate symptoms of ADHD. The AAP guidelines were established in 2011, and since then no

changes have been made even though there is continued research on the effectiveness of

behavior therapy without the need to also use medication.

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While it is the responsibility of the School Psychologist to determine what methods of

intervention could be most effective for students at their school site, it is the responsibility of the

educational team to ensure that standards are met so that the students being served receive the

services they are entitled to. In order to consistently provide quality services, the educational

team must work well together and be competent in their individual roles and responsibilities

within this system. If the team can effectively provide services for students within the school

setting, the parents/guardians of students will have an easier time continuing intervention

strategies in the home setting. Each student is supported both in school and at home, and the

need for everyone to work together is vital in achieving the intervention goals set out for

students. Behavior therapy can be done both in school by professional educators and at home by

the child’s parents. Evidence suggests that when behavior therapy is applied both in school and

at home it is more effective (Moreno-García, I., Meneres-Sancho, S., de Rey, C. C.-V., &

Servera, M., 2019).

Conclusion

While not all students will be able to see improvement via behavior therapy in

coordination with medication, a larger percentage of students with ADHD could succeed in

school and may not need to use the accommodations they are granted using this multidisciplinary

approach. Non-white communities are already applying behavior therapy more widely than

medication for symptom mitigation, and with a larger number of schools implementing behavior

therapy for students, data will continue to show that medication is only one option to achieve

success. ADHD is one of the most common disabilities among school-aged children, and as the

population of children with ADHD not only increases but also ages, non-pharmaceutical options

should continue to be studied. Additional testing time for students is necessary under Section 504
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and IDEA Part B, and despite some existing bias regarding college admissions data, the vast

majority of students requiring accommodations have a legitimate need which cannot be

undervalued. Research and law has made great strides in the last three decades with respect to

understanding, evaluating, and treating ADHD, and should continue on this trajectory with the

guidance of ethical principles and a thirst for scientific advancement.

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