Donovan PSY89999 21

ADHD Interventions
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Successful Intervention Strategies for Children with ADHD
A Doctoral Project
Presented to the Faculty
School of Behavioral Sciences
California Southern University
In partial fulfillment of
the requirement for the
Degree of
DOCTOR
OF
PSYCHOLOGY
BY
Michael Donovan
July, 2018
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© 2018
Michael Donovan
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APPROVAL
We, the undersigned, certify that we have read this doctoral project and approve it as adequate in
scope and quality for the degree of Doctor of Psychology.
Doctoral Candidate: Michael Donovan
Title of Doctoral Project: Successful intervention strategies for children with ADHD
9/7/2018
Signed: ___________________________________________
Brandon Eggleston, Ph. D. Doctoral Project Committee Chair Date
9/4/2018
Signed: _________________________________________
Patrick McKiernan, Ph. D. Doctoral Project Committee Member Date
9/4/2018
Signed: _______________________________________
Melanie Shaw, Ph. D. Doctoral Project Committee Member Date
9/4/2018
Signed: _______________________________________
Gia Hamilton, PsyD, Dean, School of Behavioral Sciences Date

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ACKNOWLEDGEMENTS
From the time I was little, my parents were strong proponents for education. They helped
lay the foundation for completing this dissertation and degree. My wife and children were
understanding of the moments where I was distracted by the work and not as available as I will
be with the completion of this project. I hope my children will feel proud their father is a doctor
and will use this accomplishment as an inspiration for their many future successes.
Along the way, I have received wonderful support from family and friends. Whether
checking in or providing plenty of material for papers and assessments, I have been appreciative
to have them on my side.
This paper is the culmination of years of work learning about clinical psychology and a
solid year of focusing on the field of ADHD. Without the guidance and patience of Dr. Brandon
Eggleston, I couldn’t have started or finished this project. And to Dr. Shaw and Dr. McKiernan
for their revisions and suggestions along the way- thank you.
I have spent close to twenty years in education and during that time have worked with
many children with ADHD, teachers who have supported them, therapists who have cared for
them and parents who have sought advice and have been able to share some of their own
successes. The children I have worked with who have the diagnosis of ADHD have inspired this
project. The teachers who will sometimes literally do back flips to support them and their
parents who advocate for their children have been a driving force behind the work you are about
to read.
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ABSTRACT
Title: Successful interventions for children with ADHD

Author: Michael Donovan
Degree: Doctor of Psychology
Institution: California Southern University
Scope of Study: Attention Deficit Hyperactivity Disorder [ADHD] is the most common,
neurodevelopmental diagnosis for children, affecting approximately 5% of children in the United
States. While stimulant medication is often a popular intervention, there are a number of other
possibilities. Through an extensive and diversified literature review several successful
interventions emerged. The primary theoretical perspectives included cognitive behavioral
therapy, executive functioning training and mindfulness.
Findings and Conclusions: CBT was an important intervention explored and a variety of sub
categories to CBT became a focus such as play therapy and the need to support children’s
executive functioning skills. The LeJa CBT plan, Plan My Life Program to help with Executive
Functioning skills and the concepts in the Daily Report Card are just a few of the successful
interventions explored. There were ideas and programs shared for successful interventions both
in the classroom and school-wide. There were valuable interventions in the category of
mindfulness. Breathing and relaxation techniques, guided meditations, and yoga could all be
used both in school and out. A number of smart applications were highlighted along with
specific mindfulness programs with an established curriculum and plan of action, including one
called MindUp.
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This document can be used as an organized and meaningful resource for any parent, teacher or
psychotherapist interested in exploring various, successful interventions for children with
ADHD. The literature review was extensive and the results were definitive in highlighting for
adults that there are many options for interventions that do not include the use of medication.
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TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS………………………………………………………………………4
ABSTRACT………………………………………………………………………………………5
CHAPTER ONE: OVERVIEW OF THE STUDY……………………………………………….8
Background of the Problem……………………………………………………………….8
Statement of the Problem………………………………………………………………...10
Purpose of the Study……………………………………………………………………..11
Theoretical Framework…………………………………………………………………..13
Significance of the Study………………………………………………………………...14
Definitions and Key Terms………………………………………………………………15
CHAPTER TWO: LITERATURE REVIEW……………………………………………………17
Cognitive Behavioral Therapy…………………………………………………………...18
Executive Functioning Skills…………………………………………………………….18
Classroom Climate……………………………………………………………………….22
Teacher Knowledge……………………………………………………………………...26
Classroom and School Interventions…………………………………………………….28
Use of “smart applications”……………………………………………………………...34
Parent Training…………………………………………………………………………..36
Play Therapy……………………………………………………………………………..45
Positive Psychology……………………………………………………………………...49
Mindfulness………………………………………………………………………………52
Mindfulness Training and Cognitive Behavioral Therapy………………………………53
Breathing Techniques……………………………………………………………………55
Yoga……………………………………………………………………………………...55
Mindfulness Curriculums for Schools…………………………………………………...58
Coloring………………………………………………………………………………….61
Biofeedback……………………………………………………………………………...61
Meditation………………………………………………………………………………..64
Mindful Parent Training…………………………………………………………………65
CHAPTER THREE: METHODOLOGY………………………………………………………..66
Research Method………………………………………………………………………...67
Validity and Reliability…………………………………………………………………..68
Participants……………………………………………………………………………….71
Researcher Bias…………………………………………………………………………..72
Instrumentation…………………………………………………………………………..73
Data Analysis…………………………………………………………………………….74
CHAPTER FOUR: RESULTS…………………………………………………………………..76
Context for Research Questions………………………………………………………….76
Describe Participants and Location……………………………………………………...79
Presentation of Results-Research Question One…………………………………………80
Presentation of Results-Research Question Two………………………………………...83
Presentation of Results-Research Question Three……………………………………….89
CHAPTER FIVE: DISCUSSON OF FINDINGS……………………………………………….94
Description of Study……………………………………………………………………..94
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Discussion of Findings…………………………………………………………………...98
Implications……………………………………………………………………………..104
Considerations for Future Research…………………………………………………….109
REFERENCES…………………………………………………………………………………114
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Chapter One
Overview of the Study
ADHD (attention-deficit hyperactivity disorder) can have a negative impact on a child’s
school experiences resulting in low student achievement, impacted self-esteem and contentious
peer relationships and interactions. Attention-Deficit Hyperactivity Disorder (ADHD) is the
most commonly diagnosed psychiatric disorder, occurring in 5-7% of children worldwide.
Diagnosis is typically made in the school-aged children. (Safavi, Ganji, & Bidad, 2016) Parents,
educators, doctors, therapists and many others involved in the diagnosis and treatment of ADHD
have varying opinions on significant treatment options, including school-based interventions and
pharmacological intervention. There is extensive literature to review regarding successful ADHD
treatments for children.
Background of the Problem
(ADHD) is a neurocognitive behavioral developmental disorder most commonly seen in
childhood. There has been extensive research into understanding the factors underlying ADHD,
leading to far more treatment options available for both adolescents and adults with this disorder.
(Antshel- et al., 2011) Presentation of ADHD symptoms frequently begins in childhood (before
12 years of age) and must be differentiated from normative development levels, resulting in
added challenges of accurate diagnosis before the age of 5 years (Sonuga-Barke, Koerting,
Smith, McCann, & Thompson, 2011). ADHD is now recognized as a lifelong condition, with up
to 80% of those diagnosed as children continuing to meet diagnostic criteria as adolescents and
adults and at least 90% of individuals having some form of lifelong impairment in one or more
domains (Biederman et al., 2000). Outward signs of hyperactivity-impulsivity tend to decrease
with age, but symptoms of inattention generally remain ([Dopfner, Hautmann, Gortz-Dorten,
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Klasen, & Ravens-Sieberer, 2015) throughout the lifespan. There are three major areas to explore
for successful treatment options for children with ADHD. The incorporation of psychotherapy,
which would focus on cognitive behavioral therapy and behavioral therapy, is a primary option
that would support the parents and the school as they support the child. In addition, a therapeutic
environment will help the child learn and develop necessary skills related to executive
functioning, school skills and peer relationships. Parent and teacher training are also important
aspects of psychotherapy treatment plans. Stimulant medication has proven effects in helping to
treat children with ADHD. Approximately 15 million children in the United States are in need
of mental health services, with studies documenting that only 21% of those in need receive those
services (Merikangas et al., 2010). Teachers, counselors and school psychologists are in
positions where they should be current in the research surrounding interventions for ADHD.
Teachers should make necessary accommodations and modifications for the children to succeed
in their classroom, while psychologists and counselors should be involved in individual and
group therapy sessions and monitoring behavioral intervention plans based on reward principles.
Cognitive behavioral therapy is just one psychotherapeutic approach to be incorporated into
supporting children in a school setting. Brief therapy is another orientation worth exploring as
short “bursts” can prove beneficial for children experiencing impulsive and hyperactive issues.
Mental health service delivery in schools has the added advantage of providing a continuum of
prevention to intervention services at the setting and individual levels (Barrett et al., 2013).
Cognitive training has received increasing attention. It has been suggested that these programs
are effective as ADHD treatment or as a tool to improve cognitive ability and academic
performance in all age groups. Training involves repetition of specific or multiple cognitive
processes over several weeks after which period performance enhancement is expected on the
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trained tasks. Working memory is often the target of cognitive training because of its assumed
capacity to influence a range of other cognitive processes. Working memory deficits have also
been associated with failure in academic performance. Therefore, the training of executive
functions can be a potential strategy for ADHD treatment (de Oliveira Rosa, et al., 2017)
Executive functioning skill deficits present children with ADHD major obstacles in the school
setting and at home when needing to complete longer-term projects and spend time studying.
Cognitive training has strong potential for children with ADHD and with the appropriate
background, it can be conducted as a part of school-based counseling.
Stimulant medications are considered an effective treatment for attention deficit
hyperactivity disorder (ADHD), and their prescription is consistently on the rise. (Avisar &
Lavie-Ajavi, 2014)
Martin Seligman is a leading theorist in Positive Psychology. Studies have shown that
providing mindfulness training to parents, without a focus on reducing problem behaviors, can
enhance positive interactions with their children and increase their satisfaction with parenting.
(Singh et al., 2010) In addition to exploring mindfulness training for parents, training will be
explored for children. There are various programs that can be incorporated into classrooms and
school settings; a review of possible options that would make sense for integration into school
programming to help students with ADHD will be infused into the research.
Statement of the Problem
The initial diagnosis can often be overwhelming and confusing for families. Parents of
children with ADHD have poor communication and clashes over the treatment of child as
compared to parents of children without ADHD (Wymbs & Pelham, 2012). Disagreements over
rewards and consequences and parenting styles, in general, are intensified for parents as they try
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to better understand the diagnosis, its impact on family and the steps to take in their child’s best
interest. In classrooms, finding strategies that work for children with ADHD can be a tireless and
daunting task for teachers. It would appear there is no shortage in society of those with opinions,
whether valid or not, each one believes their idea to be the best. There are advocates against
stimulant medication. There are education professionals who don’t believe children with ADHD
should learn in a mainstreamed classroom environment. There are parents who believe it is a
phase and doctors who maintain the only option is to medicate.
If ADHD is the most commonly diagnosed disorder, where is the most common
treatment plan? There is no shortage of opinions, but the good news is that there is no shortage of
research. For each opinion, research can be found to both substantiate and discredit. A review of
research that combines the various treatment plans for elementary aged children with ADHD
could serve as a meaningful document that would help both parents and teachers as they navigate
the diagnosis of ADHD and determine the most effective and most successful interventions to
support children.
Purpose of the Study
The purpose of this study will be to focus on elementary aged children with ADHD and
explore effective, successful strategies to help them be successful in school. The primary focus
will be on intervention plans in place in schools, successful strategies used in the classroom and
school-based counseling options that assist student achievement; inclusive of academic, social
and emotional. There will be a focus on topics such as mindfulness training, school-based
intervention plans, and psychotherapy. The project will be designed to highlight available
research for teachers and parents to help support children.

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In addition to a theoretical review of research focused on successful intervention
strategies, parent and educator training with regards to strategies to help students with ADHD
will be explored. When therapeutic, behavioral and mindfulness interventions are unsuccessful,
medication is also an option to support students with ADHD. Medications will be reviewed as a
piece of the puzzle in gaining expertise in the area of supporting children with ADHD. A review
of dosage, side effects and transmittal will be incorporated into the research.
Research Questions
Mindfulness-based interventions, classroom strategies, school-based counseling, and
psychotherapy focused on behavioral training are all valid treatment options for children (and
adults). In most cases, many of these treatment plans are used hand in hand and often, elements
of each one is incorporated into a holistic approach or at the very least, explored as parents and
teachers work to figure out what works best for each individual child. Each child is unique and
what works for one, won’t necessarily work for the next. In order to decide which treatment
plans to explore and implement, parents and teachers need valid research in order to make an
informed decision.
Through a theoretical analysis of research conducted about treatment plans for children
with ADHD, parents and teachers will be better equipped to decide on the treatment plans they
feel will be of greatest value and benefit for their children and their students. The research will
be organized to allow for adults to read, review and reflect on ADHD treatments. The driving
questions will focus on elementary aged children and will encompass their lives, both in school
and out of school.

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1. Which classroom strategies, interventions and ideas are particularly useful in
offering parents and teachers a “toolbox” to help children with ADHD find
success in the classroom?
2. What are proven mindfulness activities and programs that can be beneficial in
training parents, teachers and children with ADHD to incorporate into
everyday living?
3. Which therapeutic approaches are most successful in working with children
with ADHD?
Theoretical Framework
Appropriate and successful interventions can have a major impact on children with
ADHD. For parents and teachers, the information and research can be overwhelming and
controversial. There are valid reasons for attempting all types of interventions; understanding
their validity and potential obstacles is critical for adults making decisions for children.
Similarly, children themselves need to understand ADHD and ways they can be involved in their
own treatment. Psychotherapy and mindfulness are two leading interventions for children with
ADHD.
The theoretical orientation of this paper will support adults in gathering relevant literature
reviews and data already available. A review of behavioral therapy will be incorporated into the
research.
There has been an explosion of interest in mindfulness-based programs (MBPs) such as
Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy
(Crane, et al., 2017). Martin Seligman’s work and specifically, research from the domain of
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Positive Psychology will be a part of the theoretical framework for the purpose of identifying
mindfulness-based programs that have produced evidence that they benefit children.
Positive Psychology is seen as another “wave” in the field of psychology and Seligman was a
leader, particularly during his time as the President of the American Psychological Association.
His focus on positive psychology was rooted in the revelation of developing what was right,
rather than fixating on what was wrong, sparked during his career as APA president. The
message that we should be teaching our children and ourselves to look at our strengths rather
than our weaknesses (Seligman & Csikszentmihalyi, 2000). Another leader in this framework,
with work to be infused into the focus on mindfulness is Carol Dweck and her focus on the
growth mindset. Many mindfulness skills programs have been launched in schools. Studies to
date, reviewed by Tan and Martin (2015), have yielded promising results. Some of these
programs will be incorporated into this research in an effort to provide valuable resources to
schools and parents. The concepts of mindfulness have been in action for centuries and so the
notion of “not reinventing the wheel” applies when considering ways to embrace this approach
and use it as a successful intervention for children.
Significance of the Study
ADHD is the most common neurodevelopmental disorder to impact children. The
significance of this study will focus on the most influential adults in a child’s life- their parents
and their teachers. In addition, literature review and findings will uncover ways for children
themselves to better understand the diagnosis and to have access to successful interventions.
Parents will gain an understanding of the various interventions for children with a focus on
psychotherapy, including behavior management, and ways positive psychology and mindfulness
training for parents and children can have a major impact. Empirically supported treatments for
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children and adolescents with ADHD include behavior management and some training
interventions (Evans, Sarno, Owens, & Bunford, 2014). Parents will gain further insight into the
school setting and have access to classroom and school based programs and interventions they
can consider when advocating for their children. Similarly, a review of successful programs,
interventions and strategies used in school will offer professionals insight into various
possibilities when working with students with ADHD.
Lastly, the significant material reviewed and gathered will provide both parents and
students with resources they can use and in turn, can share with children in developing plans for
ADHD. Because of doubts about the benefits of stimulant medication on academic functioning
in natural settings (Langberg & Becker, 2012) and reluctance on the part of teenagers to take
medication, there has been a focus on the development of psychosocial treatments. This study is
conducted in the hopes of serving as a resourceful guide in considering multiple options and
multiple interventions for children with ADHD.
Key Terms and Definitions
ADHD- Attention-deficit/hyperactivity disorder (ADHD) is a developmental
disorder with two major components: (a) attention deficit and (b) impulsivity and hyperactivity.
They demonstrate a variety of cognitive, emotional, social, and behavioral disorders: lower
learning skills, motivation, and academic achievements; emotional difficulties, including
frustration, guilt, anger, anxiety, and depression; social difficulties, including antisocial and
aggressive behavior; delinquency; and substance abuse. Overall, they experience difficulties in
executive functioning, planning, problem solving, and controlling their behavior, which are more
visible in such children compared not only with normative peers, but also with children with
similar problems but without ADHD. (Ziperfal & Shechtman, 2017)

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Mindfulness- Mindfulness-based stress reduction (MBSR) programs consist of
approaches that aim to facilitate patients' acceptance, and are focused on reducing distress by
changing negative thoughts, emotions and attitudes towards the illness. (Chien, Bressington,
Yip, & Karatzias, 2017)
Stimulants- such as methylphenidate (MPH; Ritalin and Concerta) and
dextroamphetamine-AMP (d-AMP; Adderall) are the most common pharmacologic treatments
(The MTA Cooperative Group 1999) and abundant data support the potentially positive effects
of prescription stimulants for the majority of children, adolescents, and adults with ADHD.
Stimulants are classified as Schedule II drugs (i.e., providing positive medicinal effects but also
considerable abuse potential). The nonmedical use of prescription stimulants represents the
second common most form of illicit drug use in college, second only to marijuana use. (Lakhan
& Kirchgessner, 2012)
Cognitive Behavioral Therapy (CBT) - CBT joins together cognitive and behavioral
therapies, and gained popularity in the late 1960s as a treatment approach. Cognitive therapists
believe that how a person interprets an event is more important than the actual event itself.
Therefore, treatment focuses more on cognitions than on overt behaviors; reducing dysfunctional
thoughts helps to improve adjustment. (Antshel et al., 2011)

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Chapter Two
Literature Review
Although this disorder is prevalent and has pervasive adverse impact on children and
their families, no clear effective treatment for ADHD has been identified. Rather, multiple
pathways to understanding and treating ADHD exist (Conway, 2012). There is extensive
research on the neurological causes of ADHD and the various possibilities on how stimulant
medication can help with brain functioning. Similarly, there is research about behavior
interventions, psychotherapy and many strategies, interventions and techniques.
The most popular study to date examining the long-term effects of ADHD treatment, the
Multimodal Treatment study on ADHD (MTA) funded by the National Institute on Mental
Health, published their most recent findings in 2009 (Molina et al., 2009), most of which are
inconclusive. After a 6- and 8-year follow-up of 579 children diagnosed with ADHD who
received different treatment combinations (medication and behavior therapy): (1) ADHD
children continued to show a reduction of symptoms, but were still more symptomatic than their
non-ADHD peers; (2) there were no differences between ADHD children remaining on
medication after the 14-month trial and those who discontinued the medication at the 14-month
period; and (3) the initial advantages noted among ADHD children taking a combination of
medication and therapy compared with those receiving therapy alone soon dissipated. For some,
this study's findings suggest the mandated course of treatment include medication and for others,
the avoidance of medication. Also, although gains were made using BT, they were not
sustainable. The inconclusiveness of the research to date has led other researchers and clinicians
to consider alternative approaches to treating ADHD (Conway, 2012). Understanding ADHD is
key to understanding how to design successful intervention plans.

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Attention Deficit Hyperactivity disorder likely arises from multiple changes in biological,
psychological, and social domains from which many etiologies of small effect, both
environmental and genetic, interact and result in symptoms (Atkinson & Hollis, 2010).
Biologically, the dysregulation of dopamine in the frontal part of the brain has been identified as
a major issue for children with ADHD. This part of the brain helps control concentration,
impulse control, inhibition and motor activity. The frontal lobe of the brain relies heavily on the
reward principle which becomes compromised for those with ADHD. This leads professionals
and researchers to dig deeper beyond biological factors and also explore behavior. Beyond that,
environmental factors such as food additives and nicotine have been explored. While the
research is extensive and moves in many different directions, there continues to be no concrete
evidence as to the cause or clear understanding of diagnosis. There is need for more research in
child psychiatry at the basic biological level, focusing on early human brain development, to help
better understand the pathophysiology of ADHD and child psychiatric illnesses in general
(Stevens & Vaccarino, 2015).
Cognitive behavioral therapy can be a successful psychotherapeutic approach for children
with ADHD. Before reviewing literature focused on successful therapy plans, it is necessary to
have a clear understanding of CBT. The therapy is based on three components and can look very
different depending on the training a therapist has had and the needs of the client. The principles
embedded in CBT, however, will remain consistent.
CBT is based on three hypotheses. According to Dobson and Dobson (2017), the access
hypothesis states that the content and process of our thinking are knowable, or can be accessed.
Thoughts are not “unconscious” or “preconscious,” or somehow unavailable to awareness.
Rather, cognitive-behavioral approaches endorse the idea that, with appropriate training and
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attention, people can become aware of their own thinking. The mediation hypothesis states that
our thoughts mediate our emotional and behavioral responses to the various situations in which
we find ourselves. The cognitive-behavioral model does not endorse the idea that people simply
have an emotional response to an event or situation, or simply act without any cognitive
processes, but rather, the model holds that the way that we construe or think about the event is
pivotal to the way we feel. Similarly, it is our cognitions or thoughts that strongly influence our
behavioral patterns in various life situations. For example, we feel anxious only when we view a
situation as threatening. When we have a “threat cognition,” we are also likely to attempt to
escape the situation or to avoid it in the future, if possible. These thoughts, as well as the
corresponding emotional responses and behavioral reactions, may all become routine and
“automatic” over time. Even in cases where emotional and behavioral responses seem to be
reflexive, though, cognitive behavioral theorists argue that there is cognitive mediation between
the event and the person’s typical responses in that situation. The change hypothesis, which is a
corollary of the two previous ideas, states that because cognitions are knowable and mediate our
responses to different situations, we can intentionally modify the way we respond to events
around us. Individuals can become more functional and more adaptive as we come to understand
our emotional and behavioral reactions and learn to deploy cognitive strategies systematically in
service of our life goals.
Cognitive behavioral therapy is often used as a successful strategy in helping children
with ADHD begin to understand how it impacts their brain and how their impulses, inattention
and/or hyperactivity can affect their decision-making and interpersonal relationships. CBT plans
are created to not only have a therapist listen to the child’s experiences and frustrations, but to
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design treatment plans that involve confronting cognitive beliefs and “assigning homework” so
the child is practicing implementing behavioral interventions into daily life in between sessions.
There are many different types of CBT interventions and treatment plans. LeJA is a
combination of a training intervention aiming to improve learning skills and a coaching part
aiming to enable the children to cope with actual developmental tasks such as preparing for their
working life (Linderkamp et al., 2011). Therapeutic techniques of behavioral and metacognitive
therapy were used because there is evidence for their efficacy as described earlier. Moreover,
LeJA includes organization training for which there is recent evidence of efficacy (Evans,
Owens, & Bunford, 2014). Over the course of 16-20 sessions, CBT therapists will use the LeJa
system to ensure the children understand ADHD. Together, they will set achievable goals,
which will focus on life skills, organization and relationships. One of the best parts of the LeJa
CBT approach is that the therapist maintains regular communication with the child’s teacher.
They will discuss conflicts with parents, teachers and peers and work together to resolve issues
and problem solve. All too often, therapists and the school do not engage in a collaborative
partnership. A treatment plan like LeJA is worth exploring because of the connection between
home and school- schools will often gladly work to implement strategies the therapist is
recommending and when the child understands that their teachers, parents and therapist are a
partnership, with the child as the focus, it can be a powerful approach.
In a one-to-one setting, 16-20 sessions per participant of 60 minutes were carried out. The
training intervention starts with psychoeducation on ADHD and learning problems and the
identification of individual goals and personal resources. In subsequent units of explicit practice,
participants are trained how to solve problems in a structured way, using problem-solving
strategies and techniques such as cue cards (Camp & Bash, 1981) and self-instruction training
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(Meichenbaum & Goodman, 1971). The therapists guide the adolescent's behavior by scaffolding
(Wood, Bruner, & Ross, 1976), for example, giving prompts as operant reinforcement in cases of
successful behavior and provide direct- and self-instructional methods. In addition,
organizational skills such as time management, use of an appointment calendar, and setup of a
beneficial learning environment at home are discussed and implemented.
In up to four coaching sessions, therapists help the adolescents to cope with recent
personal problems such as conflicts with parents or peers or lacking career opportunities, using a
self-management approach supporting self-regulation (Karoly & Kanfer, 1982). Moreover,
general factors of efficacy such as problem actuation and resource activation (Grawe, 1997) are
implemented. Up to two optional follow-up sessions can be conducted 1 and 3 months after the
last regular appointment.
During treatment, the teachers of the participants are involved through regular telephone
contacts. The therapists offer to send information material about ADHD and the treatment and
ask about current problems and improvements, which later are reported to the adolescents.
Parents are invited to take part in three two-hour meetings with other parents and therapists for
psychoeducation and to initiate self-help processes.
CBT treatment plans are often designed by the therapist and with collaboration from the
child with ADHD. The plans are shared with parents and should be shared with teachers. Each
goal will contain a number of sessions, session goals and homework assignments. Some of the
topics focused on during CBT sessions can include magnification and minimization, “should”
statements, emotional reasoning and all-or-nothing thinking. Once the sessions are complete,
therapists, children and parents discuss the possibility of “booster” sessions which happen less
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frequently but allow for check-ins and any “fine tuning” of emotional, behavioral or functioning
skills the child might require.
Often, the therapist will focus on helping the child to strengthen their executive
functioning skills as a part of cognitive behavioral therapy training. In addition to their need to
focus on cognitive restructuring, a focus on executive functioning skills offers children tangible
ideas and concrete strategies to practice implementing in their daily lives, including in the school
setting. Many of these skills focus on time management, the value of checklists and task
management and an overall sense of the importance of staying organized when the child’s brain
feels disorganized.
Executive function skills are mental processes that focus on working memory, cognitive
flexibility and inhibition control. These skills are used to help prioritize, strategize, plan and
organize. Many children with ADHD will experience deficits in executive function skills. Often,
this will first be noticed in the school setting. Homework assignments may be missing, student
desks and lockers extremely unorganized and overall the child will exhibit signs of not being
prepared and seeming to always be “on the wrong page.” These are just some of the signs that
ADHD is impacting the child. Understanding executive functioning and how it impacts children
with ADHD is important for the child, the school and the parents. By employing strategies, such
as using a penda flex folder to keep all necessary papers in one place, or checklists on the inside
of lockers or notebooks, simple techniques can serve as great support.
While CBT is an effective therapeutic approach, it can also incorporate areas of executive
functioning training. A research study was completed comparing a CBT program called “Plan
My Life” and a Solution-Focused Therapy program without a specific goal. Each session was 8
weeks and relied on initial information from the children, parents, therapists and school and also
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relied on information from the same people during the post-assessment category of the study.
Diagnosis, the completion of inventories and a variety of other criteria and rules were
established. The research question would try to answer the effectiveness of each type of therapy
and whether or not one was better than the other.
Plan my life was a CBT in which at every session a fixed, planning skill focused, subject
was discussed. Planning and organization strategies (such as a to-do list) were presented (Kuin,
Boyer, & Van der Oord, 2013). Plan my life (PML) offered therapists a clear goal and focus for
each of the eight sessions. This would include how the first ten minutes of the session were
spent and how homework was assigned as an “experiment” and with choice built into the
possibilities. Sessions would focus on topics such as the use of a daily planner, concentration in
the classroom and during homework, and getting help from friends and family. PML is a
structured therapy plan. The solution-focused therapy sessions each focused on solving self-
formulated problems.
When the research was complete, there was a marginal difference between the two
therapies, but the PML program stood out over SFT. Also, the follow-up from clients in the
PML trial was greater, indicating a possible improvement in overall life planning and time
management skills. As PML is evaluated more positive and has marginal additional beneficial
effects to SFT, especially PML seems like a promising asset to fill the gap in mental health care
for children with ADHD (Boyer, Geurts, Prins, & Van, 2015).
There were some potential controversies and limitations established in this research, most
notably that it was conducted in Dutch mental health care and so the differences between
protocols in the United States system, including ADHD in the school setting, could be a major
variable. Worth mentioning though, is the fact that the research did reinforce that clients
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25
continued to show progress following their involvement. Even more interesting was the fact that
of those clients who were able to establish their own focuses through SFT, many selected a focus
on executive functioning skills.
Activity schedules, commonly used with individuals with developmental disabilities such
as autism, may be a promising alternative for students with ADHD who display low on-task
behavior during independent class work time. An activity schedule is "a set of pictures or words
that cue a person to engage in a sequence of activities" (McClannahan & Krantz, 1999, p. 3),
thereby allowing a student to complete an activity without the direct prompting or guidance of an
adult. Research with individuals with developmental disabilities has shown the effectiveness of
activity schedules in teaching independence with a variety of skills, including on-task behavior
(MacDuff, Krantz, & McClannahan, 1993), social interactions (e.g., Krantz, MacDuff, &
McClannahan, 1993; MacDuff, Krantz & McClannahan, 1993), vocational and daily living skills
(e.g., Pierce & Schreibman, 1994; Wacker et al., 1985), as well as decreases in disruptive
behavior (Krantz, MacDuff, & McClannahan., 1993; Pierce & Schreibman, 1994). Activity
schedules may be a promising intervention for increasing on-task behavior with children with
ADHD in the classroom. Many children with ADHD also experience issues with reading
struggles and comprehension; reinforcing the possibility these picture activity schedules could be
a helpful strategy in the classroom. Another reason they could be successful is because they set
up the child to practice independent tasks and lessens the times in the classroom where that child
is seeking out the support of the teacher. That support, while incredibly important and necessary,
can become an issue with peers.
For children with ADHD, anger and social skills concerns can often interfere with
success in the classroom and with friends and peers. To address anger and social skills concerns,
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26
two cognitive-behavioral programs to explore are: Strong Kids- Grades 6-8: A Social and
Emotional Learning Curriculum (Merrell et al. 2007) and Transforming Anger to Personal
Power: An Anger Management Curriculum for Grades 612, 2nd Edition (Fitzell, 2007). In
addition, resources from Waterman & Walker's (2009) Helping At-Risk Students, Second
Edition: A Group Counseling Approach for Grades 6-9 could also be helpful. These programs
demonstrate alignment with the best practices in anger management by focusing on emotional
and social-cognitive factors in relevant contexts. Moreover, they offer essential skills such as
social skills training, behavioral and emotional self-regulation, and perspective-taking (Lochman
et al., 2010).
Programs that target EF deficits, such as the Homework, Organization, and Planning
Skills (HOPS) for middle school students, facilitate homework management and organization of
materials (Langberg et al., 2012). This program can be delivered during the school-day and is
based on a 16-week intervention plan that will focus on a variety of organization skills for
children. The HOPS intervention appears to have considerable promise as an effective school-
based intervention for improving the organizational skills of children with ADHD (Langberg, et
al., 2012). The training also involves the parents. The HOPS intervention was designed to be
implemented in school settings without ongoing coaching or supervision. The intervention was
also designed to be brief. It consists of 16 meetings with each meeting lasting 20 min or less, and
the full intervention is completed in less than one school semester. Based upon feedback from
school staff regarding feasibility (Langberg, Vaughn, et al., 2011), the HOPS intervention is
implemented during the school day (students are pulled from elective periods) and includes only
two meetings with parents (Langberg, et al. 2018).

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A child’s classroom is often an environment where they spend the majority of their day.
It’s important that environment is conducive to academic learning and is designed as a
comfortable learning space. Children with ADHD can be easily distracted and will benefit from
a classroom set up that allows for flexibility in seating and movement.
Classroom climate is characterized as the emotional support and instructional
management in a learning environment (Buyse et al., 2008; Lee & Bierman, 2015). Overall,
classrooms with more positive climates tend to be associated with positive academic outcomes
among students (Dotterer & Lowe, 2011; Lee & Bierman, 2015). However, conceptual
mechanisms that underlie these links remain underexplored. Accordingly, in the present study,
we tested a complex theoretical model exploring both mediating (i.e., engagement) and
moderating (i.e., child gender and anxious solitude; AS) factors in the association between
classroom climate and achievement.
A positive classroom climate is typically evidenced by a high degree of teacher sensitivity,
encouragement, and support, along with clear expectations and effective behavioral management
(Downer, Sabol, & Hamre, 2010). In comparison, a negative classroom climate may be
characterized by teacher aloofness, criticism, disorganization, and disruption (Dotterer & Lowe,
2011; Gazelle, 2006).
Classroom climate can impact student achievement, motivation, well-being (Buyse et al.,
2008; Lee & Bierman, 2015), and in particular, engagement (Dotterer & Lowe, 2011). Emotionally
supportive environments may foster a sense of acceptance, belonging, and relatedness, which may
in turn lead children to become more engaged (Wang & Holcombe, 2010). In addition, quality of
instruction and clarity of teacher expectations predict student participation and on-task behavior
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(Dotterer & Lowe, 2011; Pianta et al., 2002).
Physical activity is positively associated with youth emotional well-being as was shown in
a large-scale study conducted by Reid and colleagues (2015). Further, Ahn, and Fedewa (2011) in
a meta-analysis of 73 studies found that physical activity had a small but significant effect on
children's mental health. More specifically, physical exercise can reduce stress, depression, and
anxiety, and increase children's self-esteem. A combination of aerobic and resistance training
activities was especially beneficial. Importantly, children with cognitive impairment and
emotional disturbance showed the greatest mental health gains from physical activity compared to
children from the general population. A more recent study also indicated that youth who reported
higher levels of engagement in physical activity and less leisure screen-time also reported lower
levels of depressive symptoms (Kremer et al., 2014).
One possible reason why physical activity integrated in learning of academic content
produces positive outcomes in children's academic skills is the increased levels of arousal and
attention, which are critical for learning (Grieco et al., 2009; Howie et al., 2014; Janssen et al.,
2014). Another explanation may come from research on the embodied cognition built on Piaget's
(1952) proposition that knowledge originates from action.
Furthermore, performing just a single exercise bout can have a positive effect on academic
performance. Hillman et al. (2009) demonstrated that after 20 min of moderate intensity walking,
elementary school children improved their reading comprehension evaluated by the WRAT-III
relative to their performance during resting period, though no significant improvement was
observed in spelling and math. In another study, children with ADHD had reading comprehension
and math performance after a single bout of 20 min of aerobic exercise relative to their
performance in a seated condition (Pontifex et al., 2013). A correlational study by Eveland-Sayers

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et al. (2009) found an association between physical fitness and academic performance in third,
fourth, and fifth graders. Physical fitness defined as "the ability to carry out daily tasks with vigor
and alertness, without undue fatigue" (U.S. Department of Health and Human Services 2008, p.
53).
Learning is greatly affected by children's behavior in the classroom, specifically by their
ability to stay on task and follow directions. Movement in the classroom helps to refocus attention
and gives the brain a break necessary to consolidate information (Howie et al. 2014; Janssen et al.
2014; Kuczala & Lengel, 2010). Integration of physical activity into teaching academic content,
in addition to a positive effect on academic performance discussed earlier, is also beneficial for
maintaining on-task behavior. For example, Grieco et al. (2009) designed a program Texas I-CAN
where 10-15 min of moderate-to-vigorous physical activity were integrated in teaching
mathematics, language arts, science, social studies, and health. The program was implemented
throughout a school year with third grade students. The results indicated that children in the Texas
I-CAN program were able to maintain their on-task behavior, while children's attention in the
inactive classroom declined over time with a greater reduction seen in the overweight children.
Therefore, incorporating physical activity in the classroom may help maintain on-task behavior,
especially for overweight children. Furthermore, Mahar and colleagues (2006) discovered
significant increases in on-task behavior after short classroom-based physical activities when
compared to the control classrooms; a stronger effect found for children who had been the least
on-task at baseline. Even such a simple intervention as a 10-15-min exercise break can
significantly improve on-task behavior (Howie et al. 2014; Janssen et al. 2014). Finally, allowing
children to sit on a stability ball (which allows movement) as compared to regular chairs may help
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children to stay on task (Fedewa and Erwin 2011).
The Challenging Horizons Program (CHP) is a school-based intervention for young
adolescents with ADHD that has demonstrated promise in multiple pilot studies that are described
in the following paragraphs. Intervention development for the CHP began in 1999 and focused on
academic and social impairment. Organization interventions were first tested with students with
ADHD in this setting to address the disorganization of materials and assignments (Storer, Evans,
& Langberg, 2014). Study skills including note-taking (Evans, Pelham, & Grudberg, 1995) and
flash cards were incorporated to help students improve their comprehension of written and spoken
information. An interpersonal skills group (ISG) was developed to help adolescents improve their
relations with peers and adults and took a novel approach, incorporating common developmental
challenges facing adolescents. These interventions were provided within the context of an
afterschool program offered for 2 hr. 15 min per day two to three times per week at a public middle
school. Given concerns about the feasibility of offering after school programs, a modified version
of the CHP was developed that involved providing a subset of the interventions to middle school
students in the context of a mentoring relationship (CHP-M). Students met with a school staff
member approximately once per week and received the organization interventions noted earlier
(Evans, et al., 2016).
Keeping homework tasks organized, managing time, ensuring materials are in their proper
spots and returned to school can all be challenges for children with ADHD. Beyond those
challenges, there is the consideration of either too much energy or not enough energy left after a
full school-day and often a day that involves extracurricular activities, sports and activities for
children. Homework time can be frustrating for both parents and children. Behavior parent
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31
training can be an incredible support for parents and there are various programs worth considering
when the homework routines and nightly battles reach the point of no return.
The programs explored serve as potential resources at school and at home. Teachers are
professionals who spend the majority of the child’s day with them, so their understanding,
awareness and willingness to intervene on behalf of children with ADHD is especially important.
Teachers should be trained regarding warning signs, assessment and intervention strategies in the
classroom and beyond. As a part of embracing concepts inherent in becoming 21st century
teachers, many are open to various strategies, including creating alternative seating classroom
environments. Standing desks, stability balls, exercise bikes, bouncy bands and many other pieces
of furniture and equipment are incorporated into the classrooms to serve as effective intervention
strategies. But not all teachers are well-trained or understand what they could or should be doing
for children in their classes with ADHD.
Teachers play a major role in the identification and referral of children with ADHD, as
they are in a privileged position to inform both parents and clinicians about the child’s behavior
and how it compares to others in the class, in various situations, from social interactions to task
focused activities, over long periods of time. Moreover, as current diagnostic criteria for ADHD
(APA, 2000) require documentation of impairment in more than one setting, and evidence suggests
that parents are not good informants for symptoms at school (Sayal & Goodman, 2009), the
diagnosis of ADHD in children must rely on the information obtained from the school staff too.
Evidence suggests, however, that most teachers have little or no training on childhood behavioral
disorders, including ADHD (Kos, Richdale, & Jackson, 2004; White et al., 2011).
It can be helpful for teachers to determine what they know and what they don’t know about
ADHD; knowledge is power and the more they are aware, the better they can impact their students.
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There are an abundance of professional development opportunities available to teachers in the area
of recognizing and intervening for students with ADHD. One approach could be teachers
completing a “survey” that provides them individual results about their understanding, or lack
thereof, of ADHD.
The KADDS (knowledge about attention deficit disorders) is a 36-item survey designed to
measure teachers’ knowledge and misconceptions of ADHD in three content areas: associated
features (i.e., general information about the nature, causes, and prognosis of ADHD; 15 items),
symptoms/diagnosis of ADHD(9 items), and treatment of ADHD (12 items). The KADDS uses a
true, false, or do not know (T−F−DK) format. This format allows for potential differentiation of
what teachers do not know from what they believe incorrectly (i.e., misconceptions). For example,
if a teacher answers 20 items correctly, 11 incorrectly, and chooses DK for 5 items, her knowledge
score would be 20 and her misconceptions score would be 11. DK responses are not counted
toward the knowledge or misconceptions scores (Sciutto et al., 2016).
Teachers' knowledge about ADHD clearly has the potential to impact students with ADHD
in numerous ways, such as through an increased likelihood that a teacher will seek professional
consultation, as well as the likelihood that they teacher will be supportive of behavioral treatments
in the classroom. However, research both on teachers' knowledge and its impact on students is
relatively scarce, and sample sizes have often been modest, thus making generalizations about
these issues difficult (Ohan et al., 2008).
Within the extensive array of BPT programs for children with ADHD, two programs have
been developed that target homework functioning: a) Family School Success Program (FSS;
Power, Karustis, & Habboushe, 2001) and b) Parents and Teachers Helping Kids Organize
(PATHKO; Abikoff et al., 2013). Both programs include many efficacious components of BPT
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33
(i.e., consistent responding, timeout, goal setting, rewards, and positive attention; Kaminski, Valle,
Filene, & Boyle, 2008) and have demonstrated efficacy in improving parent-reported problem
behaviors during homework time (Abikoff et al., 2013; Power et al., 2012). Further, these
academic-focused BPTs improved self-reported parenting strategies, teacher reported homework
problems, and parent- and teacher-reported organizational skills.
The daily report card (DRC) is an operationalized list of a child's target behaviors (e.g.,
interrupting, noncompliance, academic productivity), and it includes specific criteria for meeting
each behavioral goal (e.g., "interrupts three or fewer times during math instruction"). Teachers
provide immediate feedback to the child regarding target behaviors on the DRC, and typically
some reward is provided contingent on the child's performance. DRCs are commonly employed
and acceptable interventions for school settings (Chafouleas, Riley-Tillman, & Sassu, 2006).
The daily report card is a strong tool to be used in cognitive behavioral therapy approaches,
impacting a connection between the child’s behavior in school and communication between the
school and home. The DRC is data driven and can be analyzed by a school psychologist or
behaviorist as they look for strengths and weaknesses, consider successes they are experiencing as
they work toward extinguishing certain behaviors and they can also become tuned into
antecedents. The DRC relies on a partnership between the home and school and in successful
cases, the therapist will also become involved so it can be reviewed and discussed as a part of the
cognitive behavioral therapy approach. Overall, the results of the present study support the DRC
as an effective stand-alone intervention for students with ADHD based on the results of single-
case studies. The implementation of the DRC significantly changes behavior, increasing desirable
behavior by almost 30 percentage points from baseline to intervention (Pyle & Fabiano, 2017).
Activity schedules, commonly used with individuals with developmental disabilities such as
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34
autism, may be a promising alternative for students with ADHD who display low on-task behavior
during independent class work time. An activity schedule is "a set of pictures or words that cue a
person to engage in a sequence of activities" (McClannahan & Krantz, 1999, p. 3), thereby
allowing a student to complete an activity without the direct prompting or guidance of an adult.
Activity schedules may be a promising intervention for increasing on-task behavior with children
with ADHD in the classroom (Cirelli et al., 2016).A system like the Daily Report Card has high
chances of success because it connects the home, the school and the student. When intervention
programs are implemented and include all the important adults working together for a child, the
chances of success are great. While the DRC is a successful intervention, there are children with
ADHD who become very self-aware and self-conscious about individualized support put in place
to help them. They worry about standing out, being made fun of and not being treated like the rest
of their classmates. There are many classroom management and behavior interventions teachers
can put into place for all students in their classroom.
The Mystery Motivator intervention is one example of a classroom behavior management
intervention that can be easily implemented by teachers (Rhode, Jensen, & Reavis, 1992).
Essentially, the Mystery Motivator is a contingency contract in that it is framed around a written
description of dependent relationships involving student performance, teacher performance, and
reinforcing consequences (Schloss & Smith, 1998).
When implemented in the classroom, teachers first develop a Mystery Motivator chart
showing the days of the week or month. Then, using a variable ratio reinforcement schedule, they
randomly select the days or class periods during which students may earn an unknown reward for
exhibiting previously agreed-upon behaviors (e.g., randomly selected math lessons). On these days
or class periods, the teacher either marks an “M” in invisible ink or covers each square on the chart
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35
with a slip of paper that can later be removed (e.g., a positive note) and marks an “M” in permanent
ink. The chart is then placed in a visible location. At the end of each designated period (e.g., at the
end of each day’s math lesson) for which the students meet the behavioral goals, a student is asked
to fill in that day’s square (if invisible ink was used) or lift the slip of paper to reveal whether or
not an “M” is present that day. If an “M” is present, the students are then awarded a reward selected
by the teacher but unknown to the students. If an “M” is not present, the students are praised for
meeting the behavioral goals and reminded they will have another opportunity to earn a reward
the following school day (Kowalewicz & Coffee, 2014).The initial C&C (check and connect)
intervention program was designed to increase school engagement for middle and high school
students with learning or emotional disabilities who were at risk for dropping out of school
(Sinclair et al., 1998). The therapeutic mechanism for the C&C program is derived from Comer's
(1984) postulate: "It is the attachment and identification with a meaningful adult that motivates or
reinforces a child's desire to learn" (p. 327). In C&C, each student has a monitor who checks the
student's attendance, tardiness, office referrals, and school suspensions and checks for failing class
grades. The connection with the student is implemented at two different levels. At the basic level,
the mentor meets with the student and provides feedback about the student's school engagement
as well as the importance of staying in school. They engage in problem solving (Braswell &
Bloomquist, 1991) for any at-risk behaviors needing attention. The C&C student receives the
intensive intervention if the mentor finds that the student's risk has increased based on the
behavioral data described above. The intensive intervention includes more detailed problem
solving for negotiating alternatives to suspensions, the use of behavioral and/or academic contracts
and family mediation for truancy, social skills instruction, and teacher-student consultation.
Results showed that the treatment group had better attendance, academic assignment completion,
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36
number of school credits earned, and enrollment but mixed results regarding general educators'
and special educators' evaluation of the students' problem behavior and academic competence
(Sinclair et al., 1998).CICO (check in check out) is an intervention for students at risk for
emotional and behavior difficulties that uses adult mentor feedback with a morning check-in and
an afternoon checkout; it also includes a formalized daily progress report (DPR) card completed
by the teacher with verbal feedback that is sent home every day and includes the student's
performance on school-wide behavior expectations (e.g., be respectful, be responsible, and be
safe). The DPR includes a description of daily behavior expectations and goals and whether or not
those expectations are met. When students meet their daily goal, they receive a reward to reinforce
their appropriate behavior (Fairbanks, Sugai, Guardino, & Lathrop, 2007).Filter et al. (2007)
studied the effectiveness of the CICO program in reducing problem behaviors with 19 students in
three different elementary schools who were unresponsive to Tier 1 class-wide interventions. The
results showed a significant decrease in office discipline referrals for 13 of the 19 students. In
another CICO study, with 36 elementary school students, that evaluated the functional relationship
of the students' problem behavior (McIntosh, Campbell, Carter, & Dickey, 2009), the results
showed that students whose problem behavior was motivated by escape-based consequences
showed an increase in problem behavior and no improvement in prosocial behavior or decreased
rate of office discipline referrals. However, students whose problem behavior was maintained by
teacher attention showed a decrease in problem behavior, an improvement in social behavior, and
a decrease in the rate of office discipline referrals. Studies show the effectiveness of CICO but also
indicate that students who are motivated by teacher social approval were the most likely to respond,
whereas students motivated to escape academic tasks were not likely to make improvements in
problem behavior using this intervention. However, it is difficult to separate the active treatment
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37
ingredients in CICO because both reinforcement using the DPR and adult-student coaching are
involved. The CCE (check connect expect) program (Cheney et al., 2009) integrated components
from the C&C and CICO programs. Similar to C&C, the students enrolled in CCE began at a basic
level where the students checked in and checked out with a coach every day. Similar to CICO, the
students received teacher feedback about their DPR performance, which was taken home to parents
to review. The DPR points earned by the students over 2-week periods dictated the level of
intervention received and when the students graduated from the program. Cognitive and behavioral
therapy approaches can be extremely beneficial for children with ADHD. Often, the children
engage in these therapies alone and enjoy the one to one attention and the therapeutic support they
receive. For many parent and child relationships, ADHD can have a strained impact on the parents
and the child and in many cases, the entire family. Parents are encouraged to explore ways the
cognitive and behavioral therapy approaches may become valuable resources, not just for the child
with ADHD, but for all involved.
Multi-tiered frameworks like Positive Behavior Interventions and Supports (PBIS) have
been recommended for preventing and remediating behavior problems. One multi-tiered
framework for creating this type of positive school climate is Positive Behavior Interventions and
Supports (PBIS). In Tier 1, all students in the building are taught a set of three to five universal
behavioral expectations and publicly acknowledged for meeting those expectations. Tier 2 is
targeted at small groups of students exhibiting comparable problems, whereas Tier 3 is highly
individualized and reserved for students with chronic and intense behavioral issues. Tiers 2 and 3
require ongoing monitoring of student progress so that decisions can be made about whether to
continue, discontinue, or adapt intervention. In most schools, 10% to 15% of the school's
population is expected to require a Tier 2 intervention. Because of this, Tier 2 interventions must
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38
be practical and feasible. Specifically, Tier 2 interventions share several key features (Mitchell,
Bruhn, & Lewis, 2015); they should:
* Be readily available so that students can be enrolled in an intervention as soon as the need
arises;
* Fit well within existing classroom routines and procedures so that only minimal time
commitment and changes in practices are required;
* Not require extensive training or skills, but, rather, be easy to implement;
* Align with Tier 1 expectations and procedures;
* Be able to be implemented by all staff, who are aware of their roles and responsibilities
associated with relevant components; and
* Be implemented with fidelity across groups of students.
Tier 2 interventions include, but are not limited to, variations of check-in/check-out
(CICO), self-regulation strategies (e.g., goal-setting, self-monitoring), social skills instruction,
problem-solving activities, and cognitive-behavioral treatments (McDaniel, Bruhn, & Mitchell,
2015). Despite this range of Tier 2 interventions, generally, most schools implement only one or
two interventions, and they are unlikely to be matched to students' area of risk (Anderson &
Borgmeier, 2010). Instead, schools often adopt a "one size fits all approach" in which all students
who are recognized as needing Tier 2 support receive the same Tier 2 intervention rather than
one that is targeted at a specific skill deficit or behavior problem (Stormont & Reinke, 2013).
This is problematic because students' needs vary and, thus, certain interventions may or may not
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39
be appropriate given the nature of the behavior. For example, some research suggests the Tier 2
intervention CICO may be more effective for students with attention-maintained behavior
(McIntosh, Campbell, Carter, & Dickey, 2009). Similarly, students who struggle interacting
positively with peers may benefit from explicit social skills instruction (McDaniel, Bruhn, &
Troughton, 2016). An alternative to the blanket approach is to have a variety of interventions
available and use student data and teacher input to place students into an intervention that
research has shown is effective in addressing students' specific behavioral needs (McDaniel,
Bruhn, & Mitchell, 2015).
For instance, Tier 2 strategies targeting self-regulation skills have been recommended for
students who struggle with attention-related issues such as being off task (Briesch & Chafouleas,
2009). One reason is because self-regulation skills like setting, observing, and monitoring
behavioral goals can help students with problematic behavior become more aware of their
behavior and then engage in academic tasks (Arslan, 2014). The self-regulation strategy of self-
monitoring has been successful in improving behaviors such as work accuracy and productivity,
latency, disruptive behavior (DB), social interactions, and academic engagement (AE) for
nondisabled students and learners with a wide range of disabilities (e.g., attention-deficit
hyperactivity disorder [ADHD], emotional/behavioral disorders, autism; (Joseph & Eveleigh,
2011; Sheffield & Waller, 2010). Self-monitoring involves students thinking about their
behavior, being aware of its occurrence, and then recording the degree of occurrence. This
process is often accompanied by setting a goal, teacher feedback, and reinforcement (Joseph &
Eveleigh, 2011; Sheffield & Waller, 2010).
Recently, electronic self-monitoring, which uses mobile technology to deliver prompts
and track self-recorded behavior, has been touted as an efficient and socially valid alternative to
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40
paper-based self-monitoring methods (Crutchfield, Mason, Chambers, Wills, & Mason, 2015).
Furthermore, mobile technology-based self-monitoring exemplifies key features of Tier 2
interventions such as being readily available and easy to implement, especially given the
ubiquity of technology in schools and the familiarity with technology of school-age children. As
such, extensive training using mobile technology is not required, making implementation more
feasible. In the past, self-monitoring technology was limited to prompting devices such as a
kitchen timer or Motivador™, which is a small paging device. With the advent of mobile apps,
both prompting and recording behavior are now possible.
Wills and Mason (2014) found that I-Connect, a noncommercial (i.e., unavailable for
public purchase) self-monitoring app, improved the on-task behavior of two high school
students, one with a learning disability and the other with ADHD.
The effects on behavior of another noncommercial app, SCORE IT, have been evaluated
in at least three different studies. In the first two studies (Bruhn et al., 2016; Bruhn et al., 2015),
SCORE IT was used to decrease talk outs and problem behavior and increase AE of students
receiving special education services for a host of academic and behavioral issues. Both studies
were in middle schools that were either not implementing a Tier 1 PBIS plan or doing so with
low fidelity. Although students demonstrated positive changes in behavior, the studies were
limited by taking place in very structured and consistent classrooms that followed the same
model and sequence each day (e.g., 20 min whole group instruction, 20 min small group
instruction, 20 min independent reading, 20 min computer adaptive instruction).
To extend the research on SCORE IT to less structured classrooms, Vogelgesang et al.
(2016) examined its effects on the AE of three elementary students with hyperactivity and
inattention in a general education math classroom. Different from previous studies, students
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41
received little feedback on their self-monitoring and no extra reinforcement for meeting goals or
following procedures. All students demonstrated a strong, functionally related improvement in
AE. Despite these positive outcomes as well as positive teacher perceptions of the app,
limitations of the studies merit further research. Specifically, there were a limited number of data
points in each phase, no evidence of a Tier 1 PBIS plan in place, and no distal measures of
effects due to a lack of continuous implementation.
One of the key components of CBT is the assigning of homework between sessions. This
approach gives the client tasks to focus on while away from therapy and then each session begins
with a review of the successes or obstacles found in completing the homework assignments.
Broad externalizing behavior problems (BEBPs), including aggression, hyperactivity,
inattention, and impulsivity, are among the most common mental health referrals among young
children (Upshur, Wenz-Gross, & Reed, 2009). Behavioral parent training (BPT) programs are
among the most well-established evidence-based interventions to improve BEBPs in young
children as they are associated with significant improvements in child behavioral functioning and
parenting practices (Evans, Owens, & Bunford, 2014; Eyberg, Nelson, Duke, & Boggs, 2004).
BPT programs have traditionally focused on employing parents as agents of child behavior
change by training parents in behavioral principles (Briesmeister & Schaefer, 2007). Often BPT
programs not only focus on didactically teaching parents positive parenting practices, but also,
more often, use modeling and within-session skill practice to foster skill acquisition. One
component common across many BPT models involves the use of parental homework
assignments. Parental homework assignments typically involve asking parents to practice skills
learned in treatment within the home context (Kazantzis, Deane, Ronan, & L'Abate, 2005).
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42
One particular BPT program that relies heavily on coaching and in-session practice,
while making extensive use of parental homework assignments, is Parent-Child Interaction
Therapy (PCIT; [Zisser & Eyberg, 2010]). Examining the effects of homework completion
within the context of BPT programs that incorporate in-session practice, such as PCIT, may be
especially important to determine the clinical utility of assigning homework during BPT beyond
session practice.
When a child is diagnosed with ADHD, a parent with little understanding of the disorder
can be left with too many questions and not enough answers. The internet can provide
information and give parents access to other parents through blogs and other forms of social
media. There are nationally-recognized programs, such as CHADD (children and adults with
ADD), where the resources are plentiful. But some parents need more attention and more
training. The behaviors associated with a child with ADHD can become overwhelming and
frustrating and parents need to accept early on that in order to provide all the love, understanding
and support their children will need, they too may need to receive that support.
Another parent training program for parents to consider is PMTO, which stands for
parent management training- the Oregon model. PMTO is a therapy consisting of weekly
sessions in which the therapist works with the parent(s) of one family. The children are not
present during these sessions. The PMTO therapy aims to replace parents’ coercive parenting
practices by the five effective parenting practices as defined by the SIL model. Role play is an
important mechanism in the PMTO sessions to teach and extensively practice these effective
parenting skills. The therapist uses the role play to demonstrate good and bad examples and to
determine which parenting skills need extra attention (Forgatch, Bullock, & Patterson, 2004). As
soon as the parent has sufficiently practiced the parenting skill, the therapist and parent choose a
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specific situation for the next week during which the parent will try to apply the newly acquired
skill at home. In between sessions, the therapist calls the parent for support and to answer
questions. Usually, the therapy takes place at the agency, but occasionally sessions are given at
the parents’ home as well. Treatment duration depends on the family’s needs and progress
throughout the therapy, but typically takes between 15 and 25 weekly sessions (Thijssen et al.,
2017).
Parents are often provided little information about ADHD. Schools may design
Individualized Education Programs to support the children or sometimes a 504 Plan is put into
place. Other times, the child doesn’t require supports in school, or what they require is so
minimal, interventions can be put in place through good teaching. Schools may suggest
resources such as websites or books for parents to learn more about ADHD and often have a list
of local therapists if the parent is seeking that support either for themselves, their family or their
child. Parents need to know they are not alone and there are many ways to get support.
Parent training programs are designed to increase positive parenting and decrease
externalizing child behaviors. They are based on social learning principles and the goal is to
modify the behavioral contingencies within the child’s environment. Changes in the
environmental antecedents (e.g., commands) and consequences (e.g., time out) are intended to
lead to modifications in the child’s behaviors (Fabiano et al. 2015). Parents are taught behavior
management strategies aimed at increasing the occurrence of adaptive behaviors (e.g.,
compliance) through positive interactions, praise and rewards, and reducing the frequency of
non-compliant behaviors (Tarver et al. 2014). They are generally offered in a group format by
trained professionals and meet on a weekly or bi-weekly basis for 8–12 sessions (Chronis et al.
2004). Training parents to use behavior modification techniques, positive parenting practices,
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and reduce the use of harsh parenting practices contributes to minimize children’s ADHD
symptoms and prevent the development of other behavioral problems.
Parent training is a treatment designed to decrease child behavior problems by teaching
parents to interact more effectively with their children. Specifically, parents are taught how to
reinforce their child for desired behaviors and to decrease the occurrence of undesired behaviors
through consistent use of techniques such as differential attention and timeout. In a review
article, parent training was classified as a “best practice recommendation” for young children
with disruptive behavior problems (Eyberg et al., 2008). Parent training is a unique intervention
for children in that the parents’ behavior, rather than the child’s behavior is targeted in treatment.
Thus, parents’ beliefs about the extent to which they have influence over their child’s behavior is
particularly salient and parental locus of control may influence acceptability of parent training
interventions. Locus of control is a belief about the extent to which one can control his or her
environment (Rotter 1966). Parental locus of control is defined as parents’ sense of control over
and responsibility for their child’s behavior (Campis et al., 1986).
Parent training programs commonly provide rationales to parents at the outset of
treatment, which are intended to help increase parent “buy-in” (or acceptability) of the
intervention. For example, in Parent–Child Interaction Therapy, parents are told that they are not
responsible for their child’s problems, but they have the power to resolve the problems. They are
then given an explanation of “specialized parenting,” which includes the idea that very difficult
children require a special kind of parenting to effectively manage their challenging behaviors
(McNeil & Hembree-Kigin, 2010).
The Family-School Success program (FSS) was developed to address the limitations of
previous multimodal treatments through its focus on improving family involvement in education
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and family-school partnerships. Specifically, FSS is a 12-session family-school intervention
designed to improve parenting practices, family involvement in education, family-school
collaboration, and student homework and academic performance. In addition to behavioral
parent training (e.g., frequent opportunities for child-directed play, use of token economy
systems, and strategic use of punishment), which has demonstrated strong evidence of
effectiveness in treating children with ADHD (Evans, Owens, & Bunford, 2014), FSS includes
three educationally focused intervention components: conjoint behavioral consultation (CBC),
daily report cards, and systematic homework interventions (Power et al., 2012). Results of a
randomized clinical trial of this intervention revealed that FSS had a significant effect on
educational performance, specifically homework performance, as well as parenting practices and
the quality of the family-school relationship (Power et al., 2012). Children in the FSS group (as
compared with a support and education group) showed a significantly greater decrease in parent-
reported homework inattention or task avoidance and a significant increase in teacher-reported
student homework responsibility. Furthermore, participants in FSS demonstrated a decrease in
parent ratings of negative or ineffective discipline and an increase in parent- and teacher-reported
quality of the parent-teacher relationship in relation to the control condition (Power et al., 2012).
Therapists and parent training intervention programs continue to get creative and find
ways to reach parents, being mindful of time restraints involved in working and raising a family.
Parenting a child with ADHD also affects parenting behaviors and contributes to parenting-
related stress, which arises when parents’ perceptions of the demands of parenting outweigh
their resources for dealing with them (Theule et al., 2013). Scholars have differentiated child
characteristics that contribute to parenting-related stress (i.e., child ADHD) from parent
characteristics (i.e., personality factors, psychopathology), although a meta-analysis concluded

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that parents of children with ADHD experience significantly more parenting-related stress across
both domains compared to parents of non-ADHD children (see Theule et al., 2013). Collectively,
these studies point to the crucial role that stress generated by contextual factors (e.g., family and
life circumstances) and child factors (e.g., parenting a difficult child with ADHD) may play on
parental behavior.
Among the recent treatment literature, Evans et al. (2014) found that many studies have
used modified delivery models of well-established practices to remove barriers to treatment
attendance that can be found in multisession clinic-based group parent training programs. One of
those parent training formats consist of individual telephone support provided to parents. This
type of distance learning offers more flexibility for therapists and parents, provides
individualized attention to parent–child problems and specific behaviors based on each child’s
impaired area of functioning, and improves access to an intervention by limiting treatment
barriers to attendance such as cost of traveling and childcare arrangements (Chronis et al. 2004;
Evans et al. 2014). McGrath et al. (2011) assessed the effectiveness of a telephone-based BPT
for families of children with either ODD, ADHD, or anxiety disorders who were not using
medication. The treatment group received handbooks and videos to use at home as well as a
weekly telephone session from a coach. Compared to a control group, the intervention group
reported significant diagnosis decreases among children with ODD, ADHD, and anxiety.
Another telephone-based BPT study was conducted for families of preschool children with
externalizing problem behavior (Kierfeld et al., 2013). Children in this study were not taking
medication. The treatment group received reading material and 11 weekly telephone
consultations aimed at increasing motivation and reviewing key concepts. The treatment group
also reported improvements in dysfunctional parenting strategies and parents’ ability to solve
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difficult parenting situations, although the intervention had only a small effect on improvement
of positive parenting. Parents learned about behavior management techniques through the
reading material since the telephone consultations did not aim to teach the techniques, use role-
playing, verbal examples or focus on skill implementation and yet significant changes were
obtained. Based on parent-reported data, the authors concluded that this treatment is effective for
well-educated parents that are motivated (Kierfeld et al. 2013). Finally, Dose and Dopfner (2015)
evaluated a telephone self-help program in families of children with ADHD age 6–12 years and
taking medication. Although there were no changes in children’s ADHD symptoms, the
telephone assisted self-help for parents of children with ADHD was effective with regards to
children’s psychosocial functioning and oppositional symptoms.
The Triple P - Positive Parenting Program is a behavioral intervention, which was
developed as a multilevel system of parenting support designed to prevent and treat behavioral,
emotional and social problems in children by enhancing parents' knowledge, skills, and
confidence (Sanders, 2012). Triple P includes five levels of interventions on a continuum of
increasing severity of children's behavioral and emotional problems. Level 1 represents a form of
universal prevention that offers psycho-educational information on parenting skills to interested
parents. Level 2 represents a brief form of intervention offering one or two sessions for parents
of children with mild behavioral problems. Level 3 includes a 4-session intervention designed for
parents of children with mild to moderate behavioral difficulties, and it includes active parenting
skills training. Level 4 is considered the core Triple P intervention and targets parents of children
at risk. Parents are trained in strategies intended to strengthen the parent-child relationship, to
promote desirable behavior, to teach a variety of child behavior management skills such as using
clear and calm instructions, and implementing logical consequences, planned ignoring, quiet
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time, or time-out. Level 4 Triple P can be delivered to parents in different formats: individual,
group, telephone-assisted, self-directed, or online. Level 5 is an enhanced program for families in
which additional sources of distress are present (Sanders, 2003).
Over 25,000 specialists from fields such as healthcare, psychological counseling,
education, social services in 27 countries worldwide (Romania being, according to our
knowledge, the first country from Eastern Europe) deliver this intervention, and many of them
have conducted effectiveness studies. The Triple P program has been extensively employed for
preventive and intervention purposes with children at risk or already exhibiting high levels of
behavioral problems, and its effectiveness has been addressed by an impressive number of
scientific research papers over a 30 year period (Sanders, Kirby, Tellegen, & Day, 2014)
Comer and colleagues (2015) have suggested that PCIT (parent child interaction therapy)
may be particularly amenable to a video teleconferencing (VTC) format, given that, by design,
the PCIT therapist is not in the same room as the family for most of the treatment, but rather is
remotely monitoring from another room and providing real-time feedback to parent(s) via a
parent-worn bug-in-the-ear device. With VTC, therapists can remotely provide in-the-moment
feedback during parent–child interactions in the home, regardless of a family’s geographic
proximity to a mental health clinic. Such Internet-delivered PCIT (I-PCIT) can afford a
comparable quantity of therapist contact relative to standard, clinic-based PCIT. Moreover,
treating families in homes may enhance the ecological validity of treatment by providing parent
coaching in the very settings in which child behaviors are most problematic. VTC platforms are
being increasingly used to remotely provide full courses of real-time treatment in the home for a
number of clinical populations (Comer et al., 2017),
PCIT (Eyberg & Funderburg, 2011) is a well-established, clinic-based, behavioral parent-

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training program for young children that places central emphasis on improving parent–child
interaction patterns and the quality of parent–child relationships. PCIT draws on attachment and
social learning theories to emphasize positive attention, consistency, problem-solving, and
communication. Parents first learn to build a positive and rewarding parent–child relationship via
positive attending skills and differential reinforcement, and then learn effective discipline
strategies and time-out procedures. The precise length of PCIT for a given family is titrated to
the quickness with which the family achieves mastery criteria. A distinguishing feature of PCIT
is the use of in-session parent coaching. The therapist monitors the family from behind a one-
way mirror and provides live and individualized coaching through a parent-worn bug-in-the-ear
device.
I-PCIT (Comer et al., 2015) follows traditional clinic-based PCIT, but uses a VTC
platform to enable therapists to remotely deliver treatment to families in their homes. Instead of
interacting in front of a one-way mirror at a clinic, families use a webcam to broadcast home-
based interactions to their therapists, who remotely provide live coaching through a parent-worn
Bluetooth earpiece (Chou et al., 2016; Comer et al., 2015).
Children with ADHD benefit from parent-training models that elicit greater consistency
in rules, advocate the use of rewards, and foster less harsh parenting, relate to less oppositional
and defiant behavior, as well as parental reports of their child's problems with attention (Bor,
Sanders, & Markie-Dadds, 2002; Jones, Daley, Hutchings, Bywater, & Eames, 2008; Strayhorn
& Weidman, 1989). Interventions that promote positive family functioning, such as the
Incredible Years, improve outcomes when implemented with children diagnosed with ADHD
(Hartman, Stage, & Webster-Stratton, 2003; Webster-Stratton, Reid, & Beauchaine, 2013).
While CBT can be an extremely successful strategy, there are various options for different types
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of therapies to support children with ADHD. Play therapy is a developmentally appropriate and
effective way to work with children experiencing a myriad of mental health problems. In play
therapy, toys are carefully selected to be used in the playroom, which allows a child to speak
through their natural language of play (Landreth, Ray, & Bratton, 2009). There are many play
therapy approaches that can be used when working with children with ADHD.
CCPT (child centered play therapy) is an empirically validated, evidence-based
intervention for children experiencing emotional and behavioral problems (Lin & Bratton, 2015;
Ray, et al., 2015). In CCPT, the relationship between therapist and child is the foundation for
therapeutic change. The therapist provides attitudinal conditions and developmentally
appropriate materials to facilitate free expression and self-directed play of the child. In a safe
environment, the child moves toward self-enhancing behaviors and ways of being. Over the last
70 years, researchers have explored the process and outcomes of CCPT through quantitative and
qualitative methods. However, procedural clarification of CCPT only evolved over the last 20 to
30 years. In 2004, Ray introduced the Play Therapy Skills Checklist (PTSC), a form that had
been used in training of therapists to measure specific skills in CCPT, into publication. Ray
(2011) further released a treatment manual for CCPT research in order to establish a protocol
fitting standards necessary for consideration as an evidence-based treatment (Southam-Gerow &
Prinstein, 2014). To date, CCPT has an established protocol and evidence of positive outcomes.
As the evidence-based movement has progressed, rigorous standards were enacted to
ensure the credibility of results related to outcome-based experimental research. One such
standard is the requirement of treatment fidelity. Treatment fidelity is the degree to which a
clinician follows the procedures of a treatment as it was intended (Beidas et al., 2013). In order
to explore the effectiveness of an intervention, the intervention must be delivered in a consistent

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manner across therapists and according to identified procedures. The ability to measure fidelity
of implementation has become critical to the evidence-based process (McLeod, et al., 2015) and
researchers have called for measurable checks on the independent variable of treatment when
investigated through experimental procedures (Comer & Kendall, 2013).
In the initial publication of the PTSC (Ray, 2004), Ray noted that the instrument was
developed over a period of years at the University of North Texas Center for Play Therapy. At
the time, the PTSC had only been used in the training and supervision of new play therapists.
The PTSC was divided into two categories of Non-Verbal Communication and Therapist
Responses. Nonverbal communication included whether the therapist leaned toward the child,
appeared comfortable, seemed interested in the child, matched the child’s tone, and genuinely
matched personal tone to verbalizations. Therapist responses included verbalized responses made
by the therapist to the child that included tracking behavior, reflecting content, reflecting feeling,
facilitating decision-making, facilitating creativity, esteem-building, facilitating relationship, and
enlarging the meaning (Landreth, 2012; Ray, 2011) for more information in these categories).
Limit-setting also appeared on the PTSC but was not categorized under the main two headings.
Following its 2004 publication, the PTSC began to be used in CCPT outcome research as
a measure to check treatment fidelity. The initial use of the PTSC in research studies appeared
related to informal checks on whether therapists were enacting the verbal and nonverbal skills of
CCPT within the context of supervision. More recently, studies used the PTSC to specifically
measure the verbal skills of play therapists in CCPT to ensure they were using responses aligned
with CCPT procedures, especially when using the CCPT manual (Ray, 2011). In manualized
procedures, Ray (2011) suggested that adherence to the PTSC should fall between 90% to 100%
to be considered CCPT consistent. However, because reliability procedures had not been
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conducted on the use of the PTSC, the instrument did not meet the most stringent standards for a
treatment fidelity measure in research, thus providing some limitations to the extent to which
researchers could claim treatment fidelity.
Reality play therapy helps a client to explore the effectiveness of choices they are making
using WDEP (wants, doing, evaluation and planning). Davis and Pereira (2013) proposed that
with child clients a creative way to explore WDEP would be through therapeutic drawing.
Beyond drawing, other techniques could include using sand or using paint. The therapist will
ask questions to help guide the child’s drawings and then use that to drive discussions. “I
wonder” statements are often used. A counselor working from a reality therapy lens views that
the client’s total behavior is driven by the desire to meet one of their five basic needs: survival or
self-preservation, love or belonging, power or inner control, freedom or independence, and fun
or enjoyment (Glasser, 1998).
The five basic needs activity is a way to help students better understand their needs,
where they feel they are lacking and begin to explore how to have those needs met. Play in this
area can focus on arts and crafts as children work with a therapist to create circles that are
divided into 5 sections representing the different needs. When infusing cutting, gluing and other
types of art, the child is engaged in an activity that may distract them from inhibition and help
them feel more comfortable to open up.
The Quality World Activity lets children imagine what their perfect world would look
like, who would be in it and what would happen. They can draw their world or often times,
particularly with younger children, they can use blocks and other play items to build their world.
As they design the world the therapist has great opportunities for questioning. Often, this
activity will be a great example to focus in on issues connected to the family and to the school,
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based on what the child includes or omits. Sori, Hecker, and Bachenberg (2016) suggested that a
therapist working with a child building their quality world will guide them to choose new ways
to get needs met through their relationships with others.
Wubbolding (2011) described total behavior in reality therapy as consisting of four
dimensions: thinking, acting, feeling, and physiology. This total behavior activity allows the
child to focus in on a behavior that is being impacted by their ADHD. Whether through acting
out, role-playing or the use of puppets, the child and therapist dedicate significant time to the
behavior, the problems, the conflicts and the solutions.
Adlerian play therapy has four phases: building the relationship, investigating the
lifestyle, gaining insight, and providing reorientation/reeducation. During the first phase of
Adlerian play therapy, the counselor and child work together to build a safe and trusting
relationship. The child and counselor share leadership of the session. As the relationship
strengthens, in the second phase, the counselor investigates the child’s lifestyle by exploring his
or her fictional goals, goals of misbehavior (Meany-Walen et al. 2015). The Adlerian play
therapy approach has a manual that therapists can refer to for selecting activities, designing
treatment plans and timelines and evaluating goals and effectiveness. The Adlerian approach,
based on the work of Alfred Adler and on the principles of individual psychology, will
incorporate activities such as puppets, sand and developing stories centered on child behaviors.
Another unique approach to play therapy is incorporating nature-therapy. Many children
with ADHD thrive when given the flexibility of movement and fresh air is always an
encouragement for any child. By taking the play therapy approach into the great outdoors, the
ADHD child may feel more endeared to the therapist, and benefit from being in an environment
that doesn’t contain the boundaries of walls or the suffocation of an office. Within nature-based,
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child centered play therapy (NBCCPT; Swank & Shin, 2015), we integrate the principles of
CCPT (Landreth, 2012) within the natural, outdoor environment, such as (a) striving to foster a
caring relationship, in a safe, supportive environment, where the child can explore and express
him/herself; (b) allowing the child to take the lead during sessions, with the counselor reflecting
the child’s feelings and experiences; and (c) setting limits as the need arises to facilitate a safe
environment for the child. According to Jensen, Biesen and Graham, the present meta-analytic
findings confirm that play therapy interventions demonstrate a significant, small effect on a
variety of outcomes. These effects are comparable to previous studies of non-behavioral
interventions, but notably lower than comparative studies of behavioral interventions (2017).
Schools and parents must come together in support of children with ADHD. By working
hand in hand, the support for the child and actually, the support for all the adults involved, has a
better chance at being successful. While there are proven interventions such as cognitive,
behavioral and cognitive behavioral therapy, these aren’t the only options. Play therapy and
rational-emotive based therapies have also been used, as has mindfulness. The key is
maintaining an open mind and an open heart in exploring successful interventions for children
with ADHD. Both parents and schools must take on responsibilities in putting strategies into
place and designing daily living plans. It is critical to remain positive, even when the feelings of
hopelessness and frustration are at their worst. Remembering that children will model the
behaviors feelings and moods of the adults they are closest to is necessary. Positive psychology
is another option to consider.
Given the predominantly negative views and understanding of ADHD both in research
and practice, children with ADHD may particularly benefit from a greater emphasis on the
strengths-based perspective that is encouraged through positive psychology (Climie et al., 2013).
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Importantly, this perspective does not deny or minimize the challenges faced by those with
ADHD but rather underscores the need to pay equal and explicit attention to their strengths,
resources, and successes (Rhee, Furlong, Turner, & Harari, 2001). Specifically, this involves
understanding both common strengths across the population of children with ADHD and those
unique to individual children, recognizing that ADHD is a heterogeneous disorder. Informed by
resilience perspectives, a strengths-based approach also involves looking for and learning from
success trajectories to identify critical protective factors within children and their environments
most important for this population (Masten, 2014). Finally, this approach expands the definition
and scope of positive outcomes in ADHD to broader goals of positive well-being and
developmentally appropriate achievements rather than symptom reduction, creating a more
meaningful and optimistic focus for intervention (Climie et al., 2013).
Ultimately, the insights and emphasis of positive psychology offer a more balanced,
holistic, and hopeful approach to a disorder that is so often viewed within a negative light.
Strengths-based perspectives fit well within modern school philosophies, and indeed, schools
have been recognized as a unique and influential venue through which to promote resilience
among at-risk children (Masten, Herbers, Cutuli, & Lafavor, 2008). The positive emphasis of a
strengths-based approach to ADHD may help educators see beyond the behaviors that can lead to
frustration to instead focus on nurturing strengths, celebrating successes, and fostering resilience.
Within this context, children are supported in developing unique capabilities as a means to
support and compensate for areas of deficit (Climie et al., 2013). Given the increased risk of
comorbidities within the ADHD population (Barkley, 2014), an early focus on building assets
may also help to mitigate the risk of further complications (e.g., a child with ADHD who has
positive school experiences may be at a lower risk of developing comorbid depression).

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Moreover, the application of positive psychology perspectives, in combination with current
approaches that aim to reduce symptomology and impact, holds promise to encourage
individuals with the disorder to recognize their own strengths, develop a sense of optimism, and
learn to manage their disorder effectively, allowing them to focus on their own happiness,
relationships, and occupational success.
First, it is important to understand common areas of strength in children with ADHD. In
what areas are these children successful, and how are parents and educators able to support their
growth and development in both areas of strength and need? Identifying areas of potential
strength across children with ADHD will serve to provide a broad understanding of the unique
capabilities of this population. Recent research examining strengths in children with ADHD has
begun to identify a number of areas in which these children are no different from those without
ADHD. There is a need to continue this avenue of research so as to better understand areas of
ability and how they can be used to support success.
Second, it is important to understand what protective factors may be most influential for
children with ADHD. Protective factors are those that serve to shield children with ADHD
against further negative outcomes (Burt et al., 2008), such as the development of comorbid
conditions (e.g., depression, oppositional defiant disorder). These protective factors, both internal
and environmental, function by providing children with the resources to overcome life’s
challenges. Recent research in this area has identified a number of key protective factors for
children in general, as well as those with ADHD. Not surprisingly, maternal mental health,
socioeconomic status, and individual intelligence are well-known protective factors (Masten,
2014). Other possible areas warranting further attention for this population include self-efficacy
beliefs, achievement motivation, and positive friends (Masten et al., 2008).

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Third, research can play an important role in investigating the most effective approaches
through which to implement strengths-based and positive psychology-grounded interventions for
children with ADHD. With a growing emphasis on evidence-based intervention, further research
is required to understand how to translate strengths-based perspectives to the classroom for these
children. In addition, there is a growing number of strengths-based and resilience-boosting
programs (Alvord, Zucker, & Grados, 2011; Waters, 2011).
Mindfulness meditation originates from eastern contemplative practices and Buddhism.
One of the well-recognized Western definitions of mindfulness comes from Jon Kabat-Zinn, one
of the central founders of the field of mindfulness science (Black, Milam, & Sussman, 2009). He
defined mindfulness as, 'paying attention in a particular way: on purpose, in the present moment,
and nonjudgmentally (Kabat-Zinn, 1994). All of these attributes can be developed by the practice
of intentionally directing and maintaining attention on targets such as the breath or sensory input
as in meditation or mindful awareness practice.
Mindfulness focuses on self-regulation of attention, the ability to regain focus, and in
general, awareness of thoughts, feelings, and sensations (Hayes et al., 2004). It basically helps
improve gaps between action and impulse. Incorporating mindfulness in clinical practice may
prove effective in reducing dissociation and promoting adaptive functioning (Sharma, Sinha, &
Saeed, 2016).
Mindfulness training is an intervention based on eastern meditation techniques, that help
increasing awareness of the present moment, enhances non-judgmental observation, and reduces
automatic responding (Kabat-Zinn, 2003). Individuals with ADHD face significant
neurodevelopmental hurdles with inattention and/or hyperactive/impulsive behavior through
their life-span. Mindfulness training may be one self-regulatory method for strengthening
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attentional processes (orienting, alerting, and executive attention). (Cassone, 2013) Mindfulness
training has been shown to be an effective tool with which to enhance the self-regulation of
attention in individuals with ADHD, in conjunction with other evidence-based treatments.
(Dumas, 2005; Zylowska, Smalley, & Schwartz, 2005) Mindfulness training is expected to
improve attention in three aspects: orienting attention, alerting attention, and executive attention.
(Fan et al., 2002; Raz & Buhle, 2006) Orienting attention concerns the use of all available
sensory inputs in the perceptual field to direct and select situation-appropriate information.
Alerting attention refers to sustaining attention by achieving and maintaining a vigilant state.
Executive attention involves examining, monitoring, and resolving conflicts among one’s
ongoing behavioral reactions to the immediate environment. (Josefsson & Broberg, 2011)
There has been an explosion of interest in mindfulness-based programs (MBPs) such as
(MBCT) in the last two decades. MBSR has accrued a robust evidence base in improving mental
health outcomes in those with chronic physical health problems (Bohlmeijer et al. 2010).
Learning to meditate may not be straightforward. Unlike activities such as yoga or football, no
immediate feedback to students is possible in meditation as there are no easily discernible
outward signs of performance. (Remko et al., 2017)
The premise behind adding mindfulness-based techniques to cognitive-behavioral therapy
(CBT) is that by learning a new way of paying attention to their thoughts, clients could reduce
their tendency for depressogenic thinking (Ma & Teasdale, 2004). MBCT is a manualized
treatment that was adapted from MBSR, thus combining aspects of CBT for depression with
aspects of mindfulness-based stress reduction (Ma & Teasdale, 2004; Morgan, 2005).
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The mindfulness-based component of MBCT involves guided or unguided mindfulness exercises
designed to increase nonjudgmental awareness of thoughts, feelings, and emotions as they occur,
which is also referred to as decentering (Ma & Teasdale, 2004; Morgan, 2005). MBCT has been
adapted for children, and there is now a mindfulness-based cognitive therapy for children
(MBCT-C). A 12-week developmentally appropriate version of MBCT has been designed to
improve self-management of attention, promote decentering, enhance emotional self-regulation,
and develop social-emotional resiliency (Semple & Lee, 2008; Semple et al, 2010). In adapting
MBCT for children, the seated breath and body meditations are shortened and mindful
movement exercises are added to make it more suitable and appealing to children (Semple et al.,
2010). When considering the developmental stage of children, it was necessary to adapt MBCT
related to their attentional capacity and stage of abstract reasoning (Semple & Lee, 2008).
Children with ADHD will often experience stress as a result of their disorder. Because
executive functions such as organization and time management are impacted, children may
experience stress both in school and at home. Often, teachers and parents may express feelings
of disappointment and frustration and certain behaviors may result in consequences for the child.
Impulse-control, focus and attention are all aspects of ADHD and when unable to control these
daily functions, stress can become a major issue. Accepting stressors rather than trying to escape
and avoid them reduces feelings of being under pressure. This also allows the person to re-
perceive the situation and thus, brings about a cognitive change. Mindfulness also helps people
understand that thoughts are just thoughts and not "you" or "reality." This can reduce tendency to
judge and automatic reactions to thoughts, leading to better self-regulation. It also enables people
to be in the "here and now" rather than being in the 'past' or 'future' and thus reduces rumination
and daydreaming (Anand & Sharma, 2014).

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Application of mindfulness based interventions for youth is growing exponentially within
clinical and educational settings. Proponents emphasize benefits in reduction of a wide range of
psychopathology including internalizing and externalizing disorders, as well as enhancement of
functioning and skills in attentional focus and concentration, emotion regulation, social and
academic performance, adaptive coping, frustration tolerance, self-control, and self-esteem.
Findings to date are encouraging, though research design reflects the nascent nature of the field
and continues to be insufficient to confirm treatment efficacy or mechanisms of change (Zack, et
al. 2014).
For children with ADHD, learning about mindfulness becomes just one more strategy for
them to maintain in their “tool box” of ways to function with this neurodevelopmental disorder.
Becoming mindful of their brain function, impulses, focus and attention can increase a child’s
ability to self-regulate behaviors and decisions. There are many forms of mindfulness to
consider, including but not limited to, meditation, yoga, breathing and relaxation techniques.
Many of these activities can be used in different environments, at different times and can be
subtle and unnoticeable to others. For example, understanding the impact of breathing
techniques to be used in the classroom setting will arm a child with ADHD with the option of
using learned techniques when they feel themselves losing focus or becoming more hyperactive.
For many children, being able to use this strategy without drawing attention to themselves
becomes a big draw for them. The quote “take a deep breath” takes on a whole new meaning as
children learn about mindfulness and how their breathing can change brain and body functions.
According to traditional scriptures, its ultimate goal is to achieve a unified state of
consciousness and self-realization, yoga may be used to improve overall health and well-being
(Muktibodhananda, 1998). Yoga involves different techniques such as physical postures

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(asanas), controlled breathing (pranayamas), deep relaxation (yoga nidra), and meditation
(Muktibodhananda, 1998).
Reviews of multiple studies suggest that Yoga may be effective as a complementary or
concomitant treatment in the overall management plan of dealing with Attention Deficit
Hyperactivity Disorder (ADHD) (Haffner, Roos, Goldstein, Parzer, & Resch, 2006; Jensen &
Kenny, 2004). Studies utilizing yoga in school settings have been shown to benefit children and
adolescents (Serwacki & Cook-Cottone, 2012). According to Khalsa et al., a yoga program
might help children recover their self-esteem and confidence, restore their mental health,
promote positive attitudes, improve concentration, and reduce stress and anxiety (2012). The
practice of yoga requires effort and discipline. A child’s first contact with yoga is often
demanding. When yoga is added to a child’s already existing academic and extracurricular
activities, the child may experience higher levels of stress in the short term. According to Hayes
and Feldman, this temporary increase in stress may also be part of the process of becoming
mindful as individuals begin to recognize the typical habits of the reaction to stress (2004).
Incorporating yoga into a school day can be a challenge. Some of the obstacles would include
finding teachers who are certified yoga instructors and finding the time in an already busy
schedule to fit it in. However, schools have been embracing the concept of mindfulness and
many have found ways to incorporate yoga poses and stretches into “brain breaks” in
classrooms, during Physical Education classes and even during recess. Yoga can also be found
in after school enrichment class offerings. Beyond the classroom, children with ADHD can
explore yoga as an activity that not only promotes mindfulness but also boasts great benefits
toward a healthy body, increased flexibility, balance and agility, and often encourages a sense of
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teamwork and cooperation when participating in classes with other participants eager for similar
outcomes.
Mendelson et al. (2010) utilized yoga, breathing exercises, and guided mindfulness
practices in their study of the impact of mindfulness interventions on stress in fourth- and fifth-
grade students. The goal of using these interventions was to improve the children's capacity for
sustained attention as well as increase their awareness of and ability to regulate their cognitive,
physiologic, and bodily states (Mendelson et al., 2010). Participants reported that they enjoyed
the intervention and noticed a decrease in their symptoms of stress (Mendelson et al., 2010).
Research also shows yoga has physiological benefits that increase resilience to stressful events in
practitioners (Galantino et al., 2008). When incorporated in whole classrooms and when the
recognition that most children will benefit from these interventions, it means the child with
ADHD will not feel singled out and identified.
Yoga Kids (Wenig, 2003) adapts Hatha yoga for use with children and youth by
describing the postures as animals and nature, frequently cueing children to breathe deeply, and
guiding their imagery during the meditation. The YogaKids intervention was designed to
incorporate mindful yoga into the classroom to enhance student development and self-regulation
(Bergen-cico, Razza & Timmins, 2015).
Yoga is just one of many mindful approaches to support children with ADHD. While it
is excellent many schools and many teachers are embracing yoga in the classrooms and the use
of mindful strategies, the realities of limited time in the school day and serious curricular
requirements are very prevalent. For that reason, mindfulness has the ability to become an
intervention for children with ADHD that involves parent and family training.
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There are various ways to learn about mindfulness and begin to incorporate it into
schools, families, homes and everyday living for children with ADHD. There are diverse
methods of delivery and mindfulness plans and systems designed to meet different learning
styles and living needs.
In recent years, many mindfulness programs and curriculums have been developed such
as MindUP (Schonert-Reichl et al., 2015), Soles of our Feet (Bellack et al., 1997; Singh et al.
2011), Learning to BREATHE (Broderick and Frank 2014), and Mindful Schools (Semple et al.
2016). Most of these curriculums involve mindfulness training and social-emotional
psychoeducational components taught across multiple weeks (the programs above range from 6
to 18 sessions) (Harnett & Dawe, 2012; Semple et al. 2016; Zenner et al. 2014). The most
commonly taught social-emotional components are greater awareness of emotions; ability to
identify maladaptive emotions, thoughts and behaviors; and promoting positive thoughts and
behaviors. The mindfulness skills typically taught include awareness of breath, senses, thoughts,
and emotions (Zenner et al. 2014).
Singh et al. (2007) utilized the meditation on the Soles of the Feet program with a group
of seventh-grade boys exhibiting aggressive behaviors. Aside from observing reductions in their
aggressive behaviors, participants reported being more relaxed, increased impulse control, better
focus, and improvements in sleeping (Singh et al., 2007).
The Mindfulness in Schools Programme (MiSP) has been developed as a universal
intervention for young people in secondary schools. It is a complex intervention that includes
elements that are applicable to young people who are stressed and experiencing mental health
difficulties, are in the normal range of mental health or who are flourishing. By teaching
mindfulness as a way of working with everyday stressors and experiences, participants across the
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full range of the normal distribution of well-being can potentially benefit (Huppert, 2009). As a
universal intervention it also minimizes inequalities in accessing the intervention and the
acceptability, stigma and social comparison that often arise when targeting interventions at
subgroups of young people within schools. Finally, the MiSP curriculum is designed to fit into
the school curriculum and, following appropriate training, be taught by school teachers
embedded in the schools, which reviews suggest is necessary for long-term sustainability (Weare
& Nind, 2011).
As the field of mindfulness continues to grow and various stakeholders such as educators
and parents embrace the possibilities, more and more resources and programs are becoming
available. For children with ADHD, executive functioning skills are compromised and often
contribute to some type of difficulties in school, whether in the completion of classwork or
homework, staying organized and managing time, or potential conflicts with teachers and peers.
The more access schools have to programs they can research and consider for implementation,
the better equipped they are to support children with ADHD.
MindUp is a classroom-based program (Hawn Foundation, 2008) that incorporates
mindfulness practices that may promote children’s cognitive control abilities and regulation of
stress, well-being, and pro sociality. The MindUP curriculum is derived from psychological
theory and informed by research in the fields of developmental neuroscience (Diamond, 2009,
2012), contemplative science and mindfulness (Roeser & Zelazo, 2012), SEL (Greenberg et al.,
2003), and positive psychology (Lyubomirsky, Sheldon, & Schkade, 2005). The curriculum
includes 12 lessons, and each component of the program builds on previous skills learned,
moving children from focusing on subjective sense-based experiences (e.g., mindful smelling,
mindful tasting) to cognitive experiences (e.g., taking others’ perspectives), to actions such as the
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practice of gratitude and the doing of kind things for others in the home, classroom, and
community (Schonert-Reichl, et al, 2015).
One such mindfulness program that relies both on school and home is called Stop and
Breathe. It is a 9-week mindfulness intervention designed for teens aged 11–18 years by
experienced classroom teachers and mindfulness practitioners with researchers from the Oxford,
Cambridge and Exeter universities. The program consists of nine 45-min group sessions and
mindfulness home practices designed to improve emotional awareness, sustained attention, and
attentional and emotional regulation. The program is standardized, highly recognized; and the
preliminary research, though based on small intervention populations, suggests that it is effective
(Kuyken et al., 2013).
Mindfulness is encouraged both in school and at home for children with ADHD. It can
take on many forms, from participating in yoga classes on the weekend to subtle breathing
techniques while seated in a classroom. There are many, varied, activities to use as a part of a
mindfulness approach. Many adults and children have found coloring to be a strategy that can
calm them down and help refocus their thoughts.
The importance of executive functioning and self-regulation in the disorder has led to the
successful use of alternative, holistic approaches such as mindfulness meditation training in adults
and adolescents with ADHD (Zylowska et al., 2008) and the use of art therapy, specifically the
mandala, for self-awareness, self-expression, conflict resolution, and healing (Green, Myrick, &
Crenshaw, 2013; Slegelis, 1987). The main aspect of a meditative approach and activity, such as
the use of the mandala with ADHD clients, is that it is a cognitive and intention-based process
characterized by self-regulation and attention to the present moment with an open and accepting
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orientation toward one’s experiences. This may result in improved attention and concentration as
well as possibly offering symptom relief to adolescents coping with negative side effects
associated with ADHD (Zylowska et al., 2008).
By creating or coloring a mandala, the brain shifts more easily into a meditative state, an
alpha wave frequency, which often results in an inner calmness and relaxed state (Beaucaire,
2012). This meditative state occurs as the mandala is being created, colored, or is observed.
Consequently, the sense of inner peace, a potential correlation associated with the mandala’s
properties, may neutralize causes of stress and might help to reorder one’s thoughts (Green &
Drewes, 2013). A mandala is any piece of artwork that is created within a bound shape, customarily
a circle (Henderson, Rosen, & Mascaro, 2007).
Biofeedback can be used in conjunction with mindfulness to further target these behaviors
by bringing greater awareness to the physiological changes that occur with changes in our
emotional state (Lloyd et al. 2010).
Biofeedback teaches individuals how to monitor and modify their physiological responses
(Schoenberg and David 2014). Heart rate is a common physiological response that is targeted in
biofeedback (Wheat and Larkin 2010). Through observing heart rate variability (HRV), an
individual may monitor and regulate their physiological responses. HRV is the naturally occurring
beat-to-beat variation in the heart rate and can be influenced by breathing patterns, thoughts, and
emotions (Childre 2013; Lehrer & Gevirtz, 2014; Lloyd et al., 2010; McCraty and Childre 2010).
The HeartSmarts program with emWave technology is a multi-session mindfulness and
biofeedback program that is divided into five modules. Each module has four or five core learning
experiences paired with activities designed to teach students mindfulness techniques and social-
emotional awareness. The curriculum begins with psychoeducational activities that foster a greater
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awareness of emotions and how emotions affect the student's body, school work, and other people.
Students are then taught mindfulness techniques such as mindful breathing as well as focused
awareness on current emotional states and how to shift from a focus on undesired emotions to
beneficial emotions using techniques such as positive self-talk. To help provide concrete feedback
for students on their breathing, a biofeedback component is introduced during the third module of
HeartSmarts (the emWave technology). The emWave is a biofeedback monitor that provides
students with real-time physiological information about their breathing, heart rate, and heart rate
variability (with the use of a finger or ear sensor). This program allows for students to observe on
a computer screen changes in their heart rate and heart rate variability as they change their rate of
breathing. The program includes activities to help the student better control their breathing. First,
students are taught how they can alter their HRV through changing their breathing pattern. In one
activity, students are instructed to breathe at the same rate as a ball that moves up ("breathe in")
and down ("breathe out") on the screen to further reinforce this concept. Once students' have
mastered the focused breathing technique, computerized games are introduced to allow for further
practice (Rush, et al. 2017).
The emWave technology can be used in both the school and home setting and can be used
for a broad range of age groups. Children with ADHD who use this technology gain extra practice
understanding the importance of breathing techniques and the screens that change as a result of
their successful breathing and shifting heart rate, offer children a visual and immediate feedback.
Often, mindfulness is a difficult intervention to monitor, but the emWave relies on success and
achievement; the children with ADHD are given immediate rewards, which an important
component of their brain are functioning.

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Several questions need to be addressed regarding school-based mindfulness interventions,
including how to successfully integrate mindfulness with academics, and the amount of time
required for these practices to show an effect (Garrison Institute 2005). Several studies of multi-
week, multi-component mindfulness interventions have shown positive effects on academic
outcomes (Benson et al. 2000; Greenberg et al. 2003; Schonert-Reichl et al. 2015) and on measures
of executive functions including self-regulation, working memory, and attention (Flook et al.,
2010; Napoli et al. 2005; Schonert-Reichl et al. 2015; Zeidan et al. 2010; Zelazo and Lyons 2012).
Because mindfulness interventions have largely been evaluated as complete, packaged programs
without component analyses, it can be difficult to ascertain the most effective components or
practices in multi-component mindfulness interventions that may lead to behavioral changes such
as improvements in academic achievement.
Most school-based mindfulness programs are multi-week, multi-component interventions,
and we know little about the required intensity and frequency of mindfulness exercises for positive
outcomes to be obtained. Although studies of necessary dosage are limited in children, some
studies conducted with adult populations suggest that it is possible to see immediate effects in
cognitive variables such as memory after short mindfulness practice sessions (Albert & Thewissen,
2011). Additionally, shorter sessions of mindfulness practice may be more developmentally
appropriate for children, who typically have a harder time sitting comfortably and focusing on
their breath for more than 3 min (Burke 2010).
Training, educating and explaining to children the concepts of mindfulness can prove
beneficial as they integrate these skills to help with symptoms of ADHD. In classrooms and
schools, one particular helpful technique could be the introduction of a daily mindful moment.
This concept can be simple, yet powerful in serving as a reminder to children the benefits of taking
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a quick moment to breathe and rest. A meditation chime can ring over the school’s PA system
during random moments each day. Children and adults will quickly learn that hearing that chime
is their daily meditation reminder to take a deep breath. This moment can be just that, lasting less
than ten seconds but serving as a reinforcement for the power of relaxation, breathing and
meditation.
Meditation is an important focus in mindfulness interventions, and there are currently so
many resources available to children through the internet, apps and social media for guided
meditation mindfulness. The Triple R Program is a mindfulness-based program that consists of
six, once a week session each 1 hour in duration, followed by two booster sessions. A pilot study
into the Triple R Program found moderate increases in mindfulness skills after six weeks, with
increased mindfulness skills significantly associated with decreased negative emotional symptoms
(Dove & Costello, 2017). With the exception of the first session which started with introduction
and relationship building activities, the sessions started and finished with a brief guided
mindfulness meditation. These meditations involved visualizations, scanning the different parts of
the body, paying attention to sensory stimuli, focusing on the breath, observing thoughts, and
noticing feelings. Each session also included activities, discussions, and story books related to
weekly topics. These topics included awareness of feelings, mindfulness, noticing feelings in the
body, noticing thoughts, and healthy friendships (Bannirchelvam, Bell, & Costello, 2017). All of
these topics typically become issues for children with ADHD.
When thinking about children, understanding what is important to them and ways to
educate and inspire them using their interests is key. In a time in their lives with great access to
smartphones and advanced technology, the consideration of applications [apps] that can be used
to help them better understand and engage in mindfulness practice is worth considering. There is
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no shortage of multimedia exposure to mindfulness applications for children and adults. For
children with ADHD, being able to access an app on their phone or device during times when they
begin to recognize they need to refocus can be an amazing success in the encouragement of self-
advocacy and self-understanding.
Headspace On-The-Go is a smartphone application delivering simple daily activities based
on mindfulness practice. It teaches beginners the basic concepts of mindfulness through simple
guided meditations and content is supported by science. Participants were instructed Putting the
‘app’ in Happiness 169 123 to follow the daily mindfulness exercises feature of the ‘‘Take 10’’
program for 10 min a day over 10 days. The application was brief and easy to use, free to download
and accessible to smartphones globally (Howells, Ivtzan, & Eiroa-Orosa, 2016).
Including parents in mindfulness treatment may be beneficial, because parents (of children)
with ADHD (Harvey et al. 2001; Murray and Johnston, 2006) may show less consistent parenting,
and inconsistent parenting increases the susceptibility to ADHD in children who are genetically at
risk for ADHD (Martel et al., 2010). That is, parents of children with ADHD are likely to
experience more stress (Deault, 2010), which may lead to becoming less patient, paying more
attention to disruptive behavior and acting more reactive (Bögels et al., 2010; Dumas 2005).
In Mindful Parenting (MP) training, parents learn to pay attention to their children and
their parenting in a non-judgmental way, to increase their awareness of the present moment with
their child, and to reduce automatic (negative) reactions to their child (Bögels et al., 2010; Kabat-
Zinn & Kabat-Zinn, 1997). Also, participants learn to take care of themselves and bring calm into
their family. A few studies have investigated the effects of mindfulness or meditation training for
children and adolescents with ADHD and mindfulness or meditation training for parents and show
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promising results (Bögels et al., 2008; Harrison et al., 2004; Singh et al., 2010; van der Oord et al.,
2011).
The mindfulness treatment is conducted in groups of four to six adolescents, and consists
of 8-weekly 1.5 hour sessions. Eight weeks after the last session, adolescents and parents follow a
joined booster session. The treatment is based on a mindfulness program developed for children
with ADHD and their parents (Bögels et al. 2008; van der Oord et al. 2011) and was also inspired
by the Mindfulness in Schools Project (Huppert and Johnson 2010). To enhance compliance,
adolescents and their parents met with the trainers before the start of the intervention, to discuss
the problems they face, difficulties in parenting, the potential benefits of meditation, expectations
of the training, motivation, and the necessity of doing homework. To increase the adolescents’
commitment to training and home practice, a reward system was used (see Bögels et al. 2008; van
der Oord et al. 2011).
Chapter Three
Methodology
Attention-Deficit Hyperactivity Disorder (ADHD) is the most common behavioral health
concern among children and adolescents, affecting 5–10% of the population (National Institutes
of Health [NIH], 1998; Centers for Disease Control and Prevention [CDC], 2005). Its core
symptoms include inattention, hyperactivity, and impulsivity, and related features often include
poor interpersonal relationships, conduct problems, and academic failure (American Psychiatric
Association [APA], 2000). It was once believed that children with ADHD “grew out” of the
disorder as they approached adulthood; however, emerging data suggest that those with the
diagnosis continue to struggle across a variety of areas including work, school, and social
relationships as adolescents and adults (Mannuzza & Klein, 1999; Molina & Pelham, 2003;
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Weiss & Murray, 2003). Stimulant medication is often the primary recommendation for children
with ADHD, however, many parents are hesitant to begin that treatment and often seek out
alternate options. Both psychotherapy and mindfulness training are two interventions for
children with ADHD.
Research offers support for amelioration of ADHD symptoms utilizing a range of
individualized cognitive training components (Cortese et al. 2015). Several studies have
investigated the effectiveness of CBT methods specifically with adolescents and found positive
effects (Antshel et al., 2012; Evans et al., 2005; Wolraich et al., 2005). Research on college
students with ADHD provided combined group CBT with individualized mentoring followed by
a booster session also found an overall reduction in ADHD symptoms (Anastopoulos & King,
2015). Additional studies indicate strong effect sizes for behavioral modification techniques in
addressing ADHD attention and organization skills (Fabiano et al., 2015). Some researchers
propose that a multi-modal approach to intervention for ADHD, especially when comorbid with
other symptomatology that includes both cognitive training and behavioral modification
approaches, may be most effective (Chronis et al., 2006).
Behavioral therapy is just one of many successful interventions for children with ADHD.
Other psychotherapies include cognitive behavioral therapy and play therapy. A student can
realize great benefits when engaged in psychotherapy. Counseling in school and classroom
interventions also play a key role in a child’s success.
Mindfulness training has also proven to be a successful intervention for children with
ADHD. There are many types, including yoga, breathing and relaxation techniques and even
coloring. The premise for all mindfulness interventions is the same. On a behavioral level,
mindfulness meditation focuses on increasing the ability to control attention, and on reducing
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automatic responses (Teasdale et al., 1995). On a neuropsychological level, research shows that
mindfulness meditation enhances performance on tasks measuring EF, such as attention, working
memory and cognitive control (Heeren & Philippot, 2011; Semple, 2010). And at brain level,
evidence is found for changes in activity in the fronto-striatal circuits after mindfulness or
meditation training (Chiesa & Serretti, 2010; Kilpatrick et al., 2011; Tang et al., 2010).
The aim of this theoretical study was to review the literature available regarding
interventions for elementary aged children with ADHD. There is extensive research and credible
articles written about the use of psychotherapy as an intervention for ADHD and in the past
decade more articles have been written about incorporating mindfulness as a strategy. A review
of the available literature focused on non-pharmacological interventions offered a vast and
diverse look into many evidence-based programs that have been successfully incorporated into
treatment plans. Three research questions addressed were:
(1) Which classroom strategies, interventions and ideas are particularly useful in offering
parents and teachers a “toolbox” to help children with ADHD find success in the
classroom?
(2) What are proven mindfulness activities and programs that can be beneficial in training
parents, teachers and children with ADHD to incorporate into everyday living?
(3) Which therapeutic approaches are most successful in working with children with
ADHD?
Developing a solid foundation for a research study is enabled by a methodological
analysis and synthesis of quality literature (Barnes, 2005; Webster & Watson, 2002). One of the
main reasons for conducting the literature review is to enable researchers to find out what is
already known. However, it is important to remember that not everything reported in the
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literature is of equal rigor (Ngai & Wat, 2002). Quality literature stimulates additional research
studies, thus providing validation of the original theory proposed (Barnes, 2005). Conducting an
effective literature review that will yield a solid theoretical foundation should also provide a firm
foundation to the selection of the methodology for the study (Ngai & Wat, 2002). An effective
and quality literature review is one that is based upon a concept-centric approach rather than
chronological or author-centric approach (Webster & Watson, 2002). Bem (1995) noted that
“authors of literature reviews are at risk for producing mind-numbing lists of citations and
findings that resemble a phone book – impressive case, lots of numbers, but not much plot” (p.
172). Thus, researchers must continuously ask themselves when reviewing literature and when
writing the literature review: ‘how is the work presented in the article I read related to my
study?’ Answering this question will allow researchers to tie the literature into their own study.
Moreover, during the review of the literature researchers should utilize sources that substantiate
the presence of the problem under investigation (Barnes, 2005).
A theoretical review yields many advantages when considering various methods for
research. First, a theoretical review determines whether other researchers have addressed the
topic of interest (Leedy & Ormrod, 2013). Second, it provides an in-depth review and analysis of
the topic, thereby allowing for a range of explanations, which is particularly useful when
investigating complex topics (Creswell, 2013). Third, it shows how others have conducted work
in this area, reveals sources of data, methodological approaches and measurement tools of
interest that may exist, offers new perspectives for consideration, and potentially provides an
understanding and interpretation of research findings (Leedy & Ormrod, 2013). Fourth, it
outlines the key theories and traces the development of those theories, as well as analyzing the
existing theories highlighting flaws or advantages of one theory over another (American
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Psychological Association, 2010b; Creswell, 2013). Fifth, a theoretical review provides an
avenue to objectively review the literature in a given field without being biased (Costa et al.,
2013) or constrained by a particular theoretical perspective (Creswell, 2013).
One of the most challenging aspects of a literature review is knowing when you are
finished. Often, the resources are boundless and the articles seem to be endless. Leedy and
Ormrod (2005) noted that one common rule of thumb is that the search is near completion when
one discovers that new articles only introduce familiar arguments, methodologies, findings,
authors, and studies. Thus, when reading a new literature piece, if one “will get the feeling that
‘I’ve seen this (or something similar to it) before’” (Leedy & Ormrod, 2005, p. 82), it may
suggest that the literature search is near completion. The end of the search can also be indicated
when no new citations are discovered and articles cited in newly discovered literature have
already been reviewed. In sum, as Webster and Watson (2002) observed: “You can gauge that
your review is nearing completion when you are not finding new concepts in your article set” (p.
16).
Describing various interventions that have proven successful for students with ADHD
means finding too many valuable resources, tools and strategies. By compiling research and
selecting the interventions that not only boast great results but also seems likely to be
implemented, each reader is provided great details and descriptions of these interventions.
Descriptive research is research used to “describe” a situation, subject, behavior, or phenomenon.
It is used to answer questions of who, what, when, where, and how associated with a particular
research question or problem. Description research is used to observe and describe a research
subject or problem without influencing or manipulating the variables in any way. Hence, these
studies are really correlational or observational, and not truly experimental. Therefore,
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descriptive research does not attempt to answer “why” and is not used to discover inferences,
make predictions or establish causal relationships.
Descriptive research is used extensively in social science, psychology and educational
research. In some types of descriptive research, the researcher does not interact with the subjects.
In other types, the researcher does interact with the subjects and collects information directly
from them. Some descriptive studies may be cross-sectional, whereby the researcher has a one-
time interaction with the test subjects. Other studies may be longitudinal, where the same test
subjects are followed over time (“Overview of Descriptive Research” (2018).
This project relies on a theoretical orientation study. Therefore, there is not a specific
population of participants to describe. In reviewing successful intervention strategies for
elementary-aged children with ADHD, the primary focus during the literature review was on
children between the ages of 8 and 12. In many instances, there were valuable strategies
discovered that highlighted adolescents, but could certainly be incorporated with elementary
school children. The focus was on literature reviewed from the United States, however, there
were also instances where excellent information was uncovered from other areas of the world,
such as England, Finland, and Hong Kong.
In each of the articles reviewed, the research relied on participants, and the majority of
experimental designs focused on medication and included trial groups receiving medication,
those not receiving medication and in many instances, a placebo was a part of the trial. Criteria
for participation in many of the studies was established and included diagnostic criteria for
ADHD and participation criteria with a review of school records, family history and overall
background of the child. Many of the children were given pre and post assessments as a part of
the clinical work represented in the articles reviewed.

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When completing a theoretical review, it is important to understand and gain a
background in the concept of researcher bias. In this type of approach, the author isn’t able to
depend on their own data collection and analysis regarding their findings, but rather must place
trust in the literature reviews they are completing that have been conducted by other researchers.
The reality is significant in that there are many articles written by researchers and authors with a
specific viewpoint and they work diligently to find or provide the research to support their
theories.
Seasoned research experts know that bias can find its way into any research program –
it’s naïve to think that any research could be completely from it. But when does bias become a
problem? And how do we identify and control the sources of bias to deliver the highest-quality
research possible? The goal of reducing bias isn’t to make everyone the same but to make sure
that questions are thoughtfully posed and delivered in a way that allows respondents to reveal
their true feelings without distortions. The risk of bias exists in all components of qualitative
research and can come from the questions, the respondents and the moderator (Sarniak, 2015).
Understanding the different types of research bias and what to look for when conducting research
can provide a strong lens into when research bias may be prominent.
Publication bias refers to the selective publication of studies with a particular outcome,
usually those which are statistically significant, at the expense of null studies. A related issue,
selection bias, or the tendency of meta-analytic authors to select certain types of studies and not
select others for inclusion in meta-analysis, whether intentionally or not, will also be discussed.
Selection bias and publication bias do not necessarily co-occur, and it should not be assumed that
selection bias implies the presence of publication bias. It is important to note upfront that not all
unpublished studies are unpublished due to obtainment of null results or theory-contradictory

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findings. Some studies are not published due to major methodological or measurement flaws in
the data. Including such deeply flawed studies in meta-analysis is inadvisable as their inclusion
would bias the results. Meta-analytic scholars may address this issue by developing and
including in the publication clear quality-control criteria for inclusion of unpublished (and
published) studies, so long as these criteria are not developed with the intention of giving an
advantage to certain outcomes over others. Yet relatively little information is available regarding
the extent and impact of publication bias on psychological science, and considerable debate
remains about the appropriate methods for psychological science to reduce the impact of
publication bias. This article attempts to address some of these gaps in current knowledge by
examining publication bias in a sample of 91 recently published meta-analyses. We will consider
common approaches to controlling publication bias, namely including unpublished studies and
using statistical tests to examine and control for publication bias (Fergusson & Brannick, 2012).
The literature review search was conducted using the California Southern library
databases and the Google Scholar internet search engines. The two databases utilized through the
library services at California Southern University fell under the category of Behavioral Health
Sciences. The first database accessed was ProQuest and the second database accessed was
PsycARTICLES. The initial search using these databases used the key terms ADHD, ADD,
attention deficit hyperactivity disorder in the ‘all text’ category with a date range of 2012 to
2018. When typing ADHD into ProQuest, over 24,000 articles were available and when doing
the same search in PsycARTICLES, a little under 3,000 articles were available. PsycARTICLES
is a function of EBSCOHost. The same search in Google Scholar would provide 629,000
articles but entering the established date range would change that to over 83,000 articles. The
date ranges helped to immediately refine searches, as did several key words including:
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interventions, strategies, classroom, psychotherapy and mindfulness. These keywords were used
interchangeably with ADHD, add and by spelling them out. As certain authors became
prominent during searches, a search focused on those names began to yield different articles and
different topics. A search of leading theorists in the field of ADHD would also result in new
article options.
By focusing on a particular age group, the ability to sift through articles became an easier
task in narrowing down the search. Another key to the success was not including medication as
one of the potential interventions for children with ADHD. When disregarding those articles, the
selection was even further narrowed. The following criteria was used to determine the eligibility
of the study:
● peer reviewed articles
● qualitative and quantitative empirical studies
● were written in English
● publication dates were between 2012 and 2018
● includes any participants that fell within the age range; gender and community were not
criteria based factors
● article predominantly discusses ADHD and interventions
Data analysis is a process that is very important in every research as it is the foundation
on which the researcher lays the pillars of the theories, frameworks, and concepts of the study. In
fact, data analysis provides the researcher the basis for proving the research hypothesis and for
establishing the validity of the entire study. To put it succinctly, data analysis is the process by
which a researcher applies one or a combination of two or more statistical techniques such as
ANOVA, sampling methods, correlation analysis, regression analysis, and multivariate analysis
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to describe, evaluate or illustrate a given data and subsequently make inductive inferences in the
conclusion which is the most important part of a research. The choice of the best method of data
analysis for your research depends on the research model you’ve adopted; that is, whether your
study is qualitative or quantitative (Lopes, 2018).
This doctoral project focuses on successful intervention strategies for elementary aged
children with ADHD. The research questions for the project focus on psychotherapy, with a
focus on CBT and play therapy, along with a focus on behavior intervention. A major focus for
the project is on the incorporation of mindfulness based interventions to help support children
with ADHD. And there is an important focus on strategies to be used in school and at home,
which include classroom based approaches and parent training. Pharmacology is not
incorporated into this project as one of the possible interventions. The goal is to provide parents
and teachers with resources they can explore and implement if they are seeking out those
resources prior to beginning the use of medication.
The literature review was abundant with articles focused on these interventions. The
articles were organized using the annotated bibliography format, ensuring descriptions of each
article and what sections of the project they would be appropriate for were clear and concise.
This project is a theoretical study.
The data analysis focus will be varied. First, a review of researcher bias and reliability
and validity will be explored. Like most research, there is a lot of information to support the use
of the interventions studied, while at the same time, there is plenty of information supporting
pharmacology as the most significant, primary intervention for children with ADHD. Like
Natasha, I am also exploring the Grounded Theory analysis. From the beginning of my work, I
believed that the adults who work with children with ADHD- parents, teachers and therapists-
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would appreciate a document they could refer to with plenty of intervention resource, strategies
and ideas. The work also lends itself toward thematic analysis. An organization of the different
types of interventions and the data supporting them will prove helpful as the project moves
toward completion.
Chapter Four
Results
ADHD is the most common childhood disorder in the United States. Attention - deficit/
hyperactivity disorder (ADHD) is a behavioral condition that makes focusing on everyday
requests or routines challenging (American Psychiatric Association [APA], 2013). This includes,
but is not limited to problems getting organized, staying focused, and making realistic plans.
Further, ADHD is associated with difficulties in emotional and behavioral control, including
poor social relationships and higher rates of accidental injury or death (Barkley, 2014). ADHD is
typically diagnosed in school-aged children and has only recently been considered as a disorder
that can persist into adulthood (Biederman et al., 2010). While medication is often prescribed
and deemed to be an important intervention in supporting children with ADHD, there are many
other interventions to be considered, explored and could also be used in conjunction with a
prescribed medication regimen. There are books, articles, and plenty of associations and
websites where valuable information can be found for adults seeking alternate interventions
beyond medication. Parents may often hope to put together a plan that doesn’t involve
medication. Schools are tasked with creating intervention plans that don’t include a focus on
medication and psychotherapists must design and implement treatment plans separate of a
prescription for a stimulant medication or other possibility.

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Once the elementary aged child is diagnosed with ADHD, having access to literature that
includes varied treatment options and intervention plans is important for the adults working with
the child. This project focuses on a review of literature that has been conducted and organized to
offer insights into various intervention opportunities.
There is a focus on the importance of talk therapy and developing a relationship with a
therapist who is trained in working with children with ADHD. As a part of that therapeutic
intervention, both cognitive behavioral therapy and play therapy have been explored and many
different types of plans have been researched. Parent training is also an important focus for
families, so there is research highlighting interventions in this area. The child will spend the
majority of each day in a school setting and so research has been conducted to help organize
ideas, strategies and interventions that have proven successful both in individual classrooms and
school settings. Children’s struggles with executive functioning skills became an important
component of research when consider successes and failures both in and out of school. Many
evidence-based treatments for young children with ADHD involve working with parents and
caregivers (Fabiano et al., 2009). Broadly speaking, these treatments focus on teaching parents
how to structure the environment and to provide contingencies to encourage and reinforce
desirable behaviors (e.g., compliance). However, when working in school settings, it can be
challenging to engage parents in treatments (Hornby & Lafaele, 2011), and a high level of
parental involvement is often not feasible (Stormshak et al., 2016). As such, some school-based
treatments for students with ADHD involve working directly with students and training them to
use skills that are critical for homework completion, such as setting short- and long-term goals,
accurate homework recording, and organizational skills. In these skills-based treatments, parents
are typically involved in a secondary role, to assist with generalization to the home setting and
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across time (e.g., Evans et al., 2016; Langberg et al., 2012), for example by helping parents to
structure the homework completion environment and to provide rewards/ consequences to
reinforce positive homework behaviors.
Along with the interventions in school, the concept of mindfulness has emerged as a
worthy intervention for children with ADHD. Understanding the background of mindfulness
and how it can affect the child’s brain and body is critical and then equally important is
understanding the varied options for mindfulness. This practice can be incorporated both in the
school setting and at home.
Through a theoretical analysis of research conducted about treatment plans for children
with ADHD, the approach is for parents and teachers to be better equipped to decide on the
treatment plans they feel will be of greatest value and benefit for their children and their
students. A review of literature that highlights successful interventions and strategies provides
meaningful information when considering options to support children. The research is organized
to allow for adults to read, review and reflect on ADHD treatments. The research questions focus
on elementary aged children and will encompass their lives, both in school and out of school: (1)
which classroom strategies, interventions and ideas are particularly useful in offering parents and
teachers a “toolbox” to help children with ADHD find success in the classroom? (2) What are
proven mindfulness activities and programs that can be beneficial in training parents, teachers
and children with ADHD to incorporate into everyday living? And (3) which therapeutic
approaches are most successful in working with children with ADHD?
The results will be organized by research question. The results will be organized as a
summary of strategies researched.

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Participants
The participants embedded in the research conducted through the literature review were
mostly elementary aged children. Participants were typically organized in one of two categories-
childhood (birth-12 yrs) or school age (6-12 yrs). In some instances, research was used that
relied on data collected from adolescents because the information proved valuable resources for
elementary aged children, as well. There was an emphasis on participants and research
conducted in the United States, particularly when focused on educationally based intervention
strategies, in an effort to align education systems and standards. However, there was research
conducted from around the world that could be integrated into US schools and would prove to be
successful classroom and school based strategies and interventions.
The majority of participants in the review of literature were boys. While some of the
research included both genders, the prevalence for diagnosis and treatment of ADHD is with
boys. The most commonly cited gender differences in children with ADHD are related to
prevalence rates, impulsivity-hyperactivity levels, and patterns of co-occurring disorders (Gaub
& Carlson, 1997). For example, boys outnumber girls 3-to-1 in community samples and 9-to-1 in
clinical samples (APA, 2000). Specifically, boys are likely to be more hyperactive and impulsive
and to have more comorbid externalizing disorders (e.g., conduct disorder, oppositional defiant
disorder), whereas girls are more likely to be inattentive and to have comorbid internalizing
disorders (e.g., anxiety, depression; APA, 2000; Gaub & Carlson, 1997). A study conducted
more than 25 years ago highlighted how contextual bias can result in the under identification of
girls with ADHD because girls are not as externalizing (Berry, Shaywitz, & Shaywitz, 1985).
However, others have maintained that boys and girls with ADHD are more alike than different
(Rucklidge, 2008). Researchers have suggested that although females experience core symptoms
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similar to males and continue to experience symptoms throughout the lifespan, only females with
severe symptoms are identified (Rucklidge, 2008). Although boys with ADHD are identified to
be more hyperactive and impulsive, many girls with ADHD also experience dysfunctional levels
of hyperactivity and impulsivity. It continues to be the case that further studies are needed to
examine how gender influences the assessment and treatment of ADHD.
Results for Research Question One
The first research question is, which classroom strategies, interventions and ideas are
particularly useful in offering parents and teachers a “toolbox” to help children with ADHD find
success in the classroom? The research reviewed yielded a number of resources to answer the
question. The field of research was narrowed down to include classroom strategies,
interventions and ideas that appeared to be best practices occurring in individual classrooms and
school-wide. Both teachers and parents would benefit from learning about particular programs
and strategies and were, perhaps, ones they hadn’t tried or been familiar with.
The interventions included in this project needed to be considered successful for
elementary aged children. Through an intense review of available literature there were many
strategies available for inclusion. However, some of the research did not share results that
overwhelmingly supported the program or intervention as highly successful and therefore, it was
not included in the literature review.
Several programs were reviewed to be used as interventions including a program called
The Challenging Horizons Program and another that focused on the importance of teacher
understanding of ADHD called The KADDS (knowledge about attention deficit disorders).
There were ample resources to be used in classroom settings for children with ADHD. Two
other programs that emerged during research included strong home and school connections. The
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first was the Family School Success Program (FSS) and the second was Parents and Teachers
Helping Kids Organize (PATHKO). The Mystery Motivator intervention was an example of a
successful classroom behavior management intervention. One program stood out above the rest
and the data collected and results analyzed supported it to be a highly effective intervention
worthy of being a part of a parent and teacher “toolbox” to help children with ADHD find
success in the classroom.
One study reviewed focused on two different interventions that would help with
homework and organizational skills and would be a school-based intervention program.
Ultimately the HOPS Program (homework, organization and planning skills) was included in this
research over the CHIEF Program (completing homework by improving efficiency and focus).
The study evaluated the impact of two relatively brief interventions, HOPS and CHIEF,
implemented during the school day by SMH (school mental health) providers on the homework
problems and organizational skills of young children with ADHD. The HOPS intervention
targets organization and planning aspects of homework, whereas the CHIEF intervention targets
focus and efficiency during homework completion. Participants in both HOPS and CHIEF made
large, significant, and pre- to post-improvements on parent ratings of homework problems and
organization and planning skills as compared with a waitlist control (HOPS ds range from .79–
1.27; CHIEF ds range from .57–1.08) and these gains were maintained at a 6-month follow-up.
Only HOPS participants made significant improvements in comparison with waitlist according to
teacher ratings, with moderate effect size differences for teacher-rated COSS Organized Actions
and Materials Management (Langberg et al., 2018).
The HOPS intervention was developed using the Deployment Focused Model of
treatment development and testing (Weisz, Jensen, & McLeod, 2005), which starts with the
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collection of expert opinion through focus groups with key stakeholders (Lyon, et. al., 2014).
The HOPS intervention was designed to be implemented in school settings by SMH providers
without ongoing coaching or supervision. The intervention was also designed to be brief. It
consists of 16 meetings between the student and SMH provider, with each meeting lasting 20
minutes or less, and the full intervention is completed in less than one school semester. Based
upon feedback from school staff regarding feasibility (Langberg, et. al., 2011), the HOPS
intervention is implemented during the school day and includes only two meetings with parents.
To date, this model of the HOPS intervention has been evaluated in a small randomized trial
(total N = 47) as compared with a waitlist control (Langberg et al., 2012). Participants in the
intervention demonstrated significantly greater improvements in comparison with waitlist on
parent ratings of homework problems, organization, and planning (Cohen’s ds = .7–.8) but did
not on teacher ratings. The data from this study contributes to a fairly extensive body of literature
documenting that interventions targeting the homework and organization problems of students
with ADHD are effective (Bikic et al., 2016; Evans, Owens, & Bunford, 2014).
Another important intervention based on classroom implementation was also deemed to
be a prominent intervention because of its connection between the home and the school. The
daily report card (DRC) is a commonly employed behavioral intervention for treating attention
deficit hyperactivity disorder (ADHD) in schools. Much of the support for the DRC comes from
single-case studies, which have traditionally received less attention than group studies. This lack
of attention to single-case studies results in an incomplete review of the literature for this
intervention. One study utilized meta-analytic techniques to examine the DRC as used in single-
case studies, with moderating variables explored through hierarchical linear modeling. Fourteen
articles, including data on 40 single-subject cases, were included in the analyses.

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Overall, the results of the study support the DRC as an effective stand-alone intervention for
students with ADHD based on the results of single-case studies. The implementation of the DRC
significantly changes behavior, increasing desirable behavior by almost 30 percentage points
from baseline to intervention. The effects of the DRC are consistent and large. CICO (check in
check out) was another program reviewed that incorporated research focused on the daily
progress report.
Although the benefits of the DRC were considerable, significant variability remained not
only among students but also among studies in terms of the treatment effect, suggesting that
there were student- and study-level moderators. In the present study, age, gender, class type,
home-school communication, and study quality were examined as potential moderators of the
DRC. Neither age nor gender moderated the treatment effect. These results are positive,
suggesting that students from different genders and age groups will equally benefit from the
DRC intervention (Pyle & Fabiano, 2017).
Results for Research Question Two

The second research question is, what are proven mindfulness activities and programs
that can be beneficial in training parents, teachers and children with ADHD to incorporate into
everyday living? Mindfulness is described as the act of being present consciously, paying
attention intentionally to what happens here and now, with an open-minded, curious, friendly and
compassionate attitude, without rejecting, judging or criticizing, simply accepting what is
happening in the present moment (Kabat-Zinn, 2003). Clinical mindfulness training is intended
to increase awareness helping us act consciously without being drawn into our thoughts,
emotions and sensations thus reducing automatic responses. It allows us to develop skills and
increase our repertoire of resources to respond with greater choice, choosing our behaviors and
solving situations and daily difficulties with greater skill. In turn, it improves the ability to
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maintain attention and concentration, decrease impulsivity, help calm down and relax, increase
frustration tolerance, reduce stress and therefore improve our quality of life (Huguet, 2017).
In the last few years, mindfulness research has grown rapidly. In general, mindfulness-based
interventions have been shown to be effective in treating internal focused disorders but it is still
unclear if they are useful in treating externalizing disorders. However a meta-analytic review
suggests that mindfulness-based therapies are useful in ADHD (Cairncross & Miller, 2016).
Mindfulness has received increasing attention in the most recent years, yet it has been
around for centuries. There were many programs and interventions worth exploring through the
literature review and in doing so, a number of options for implementation emerged. Mindfulness
can take on many shapes and forms and go in several different directions. For classroom
interventions, breathing and relaxation techniques were reviewed, along with classroom yoga,
stretching and movement exercises. There are schools who incorporate yoga into classroom
routines and school-wide “breaks” for children. Brain breaks were discussed throughout
literature and seemed appropriate interventions.
Yoga programs for schools and home were reviewed, as were meditation programs.
YogaKids and MiYoga are just two programs that have specific curriculums designed to meet
the needs of children.
The importance of breathing techniques, relaxation strategies and physical movement
were incorporated into the writing. One idea for a school was the “mindful moment” that would
occur each day at a different time. When the meditation chime would come over the school’s PA
system it was a signal to all adults and children in the school to stop what they were doing for a
mindful moment. They would take a deep breath, stretch and/or use imagery, and visualization
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and relaxation techniques. It would last for just moments so as to be enough to make an impact,
but not too much to cause a disruption to plans and routines.
were two aspects of mindfulness that were explored. This approach proved extremely beneficial
because of its ability to connect to the children in the classroom or at home, to be implemented
by parents and discussed as a part of a cognitive behavioral therapy treatment plan.
There are mindfulness programs that can be incorporated in the school setting. Three
programs that were included in the review were MindUP, Soles of our Feet and Learning to
BREATHE.
Another was the Mindfulness in Schools Programme (MiSP).
Another interesting mindfulness strategy worth exploring, both for school and home
interventions, focused on breathing techniques and biofeedback. The HeartSmarts program with
emWave technology is a multi-session mindfulness and biofeedback program that is divided into
five modules.
One idea that capitalized on the youth of today’s society zeroed in on the idea that many
children either have their own smartphone or have access to one. There are many applications to
explore that can be used for mindfulness sessions. One such “app” included in the literature
review was Headspace On-The-Go. And yet another important aspect of mindfulness training
focused on parents and the idea that it is something they can get involved with as they look for
ways to support their child with ADHD.
The Triple R Program was a successful mindfulness program found during the research.
The six week intervention program (TRIPLE R: Robust, Resilient, Ready to Go) was developed
by a non-government organization and the delivery was supported by provisionally registered

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psychologists enrolled in Master of Psychology (Counselling) and Master of Psychology
(Educational and Developmental) courses. At least one school teacher was present at each
session.
The program was developed based on a range of mindfulness principles and
developmentally appropriate exercises for children as outlined by Snel (2013). Each one hour
weekly session provided a combination of psycho-education, activities and mindfulness practice
centered on a particular theme, such as the body, feelings, mind, and relationships. Each session
consisted of whole-group activities and also included activities for groups of three to five
children, which were then discussed in plenary. Allocation to smaller groups was random.
Session one provided an outline of the program, an understanding of mindfulness, and the
opportunity for children and facilitators to get to know each other. Session two focused on
naming and understanding feelings, and practicing observing different feelings in the body.
Session three focused on understanding how and where different sensations and feelings
manifest in the body. Session four focused on the mind, observing thoughts, and discussing how
they relate to feelings and sensations. Session five focused on mindful relationships,
understanding elements of healthy and unhealthy friendships and how behavior impacts others.
Session six focused on reviewing learning over the six-week program and engages children in a
feedback process. Each session started with a brief mindfulness practice and ended with an audio
guided mindfulness exercise written by Snel (2013). The program was delivered at the same time
each week during term time (Dove & Costello, 2017).
Mindfulness was measured using the CAMM. The CAMM was developed to be used
with children from nine years old (Greco et al., 2011), and was adapted from the Kentucky
Inventory of Mindfulness Skills (Baer, Smith, & Allen, 2004). The CAMM is a 10 item scale
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that assesses present-moment awareness and non-judgmental, non-avoidant responses to
thoughts and feelings. Symptoms were measured using the Revised Children's Anxiety and
Depression Scale (RCADS; Chorpita et al., 2000). The RCADS was designed to measure
symptoms specific to the DSM-IV (American Psychiatric Association [APA], 1994) anxious and
depressive disorders for children aged 8-18 years (Chorpita et al., 2000; de Ross, Gullone, &
Chorpita, 2002). The RCADS is a 47 item self-report questionnaire (Dove & Costello, 2017).
The relationship between the change in mindfulness skills (as measured by the CAMM)
and the change in emotional symptoms (as measured by the RCADS scales) across time were
investigated using Pearson correlations. The derived scores used in the correlations were
calculated by taking the difference between post intervention and pre intervention, which
preserved the intra individual change across time. The correlation represents the relationship
between the change in mindfulness and the change in emotional symptoms across time, with a
negative relationship indicating that increased mindfulness skills was associated with reduced
negative emotional symptoms (Dove & Costello, 2017).
The result of the current study provided some support for the first hypothesis that
children's self-reported mindfulness skills would be higher post intervention than pre-
intervention. There was a significant increase in self-reported mindfulness skills post
intervention. Given the links in the literature between increased mindfulness and improved well-
being (Huppert & Johnson, 2010), the comparatively small investment in time and resources
needed to conduct a six week program in a school setting shows much promise (Dove &
Costello, 2017).
There is meaningful research about mindfulness, its impact on children with ADHD and
the successes of this intervention in supporting them. One study of a mindfulness program
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includes formal and informal practices. A study was completed regarding the success of a
mindfulness program. The program lasted for 8 weeks, included 6 children per group and each
session lasted 75 minutes. Each week, participants had mindfulness exercises to practice at home
(homework completion forms were delivered). The sessions were highly structured and followed
the same outline: at the beginning of each session homework was checked out and discussed, and
at the end personal reflection and feedback of the session were promoted. On the first session
group rules were established and mindfulness psychoeducation was provided. Also, the training
room was as free as possible from distractors. In addition, on the last session a satisfaction
questionnaire ad hoc was administered to the children to evaluate their satisfaction with the
mindfulness treatment.
Mindfulness meditation training has received preliminary support as an effectiveness
treatment for ADHD in teens and adult (Cairncross & Miller, 2016). Few studies nowadays have
evaluated the impact of this novel intervention in ADHD-diagnosed children under twelve in
clinical settings. The few studies include a parallel mindful parenting training (Van der Oord,
Bögels, & Peijnenburg, 2012). However the findings do suggest that mindfulness may be a
useful intervention for children with ADHD. The study's main goal is to know the effect on the
core symptoms of ADHD and the executive functions and comorbidity symptoms of an
intervention program based on mindfulness in untreated children newly diagnosed with ADHD.
Results from the Satisfaction with Treatment Questionnaire suggest that children who completed
the program report satisfaction with the training. 90% of the participants liked very much
participating in the mindfulness program. Furthermore, 80% of children indicated that they
would recommend the program to their friends, and many families asked for further mindfulness
training after the follow-up meeting. Feasibility of treatment research has shown that once
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children are enrolled in mental health services, there is generally a high potential for dropping
out (Wierzbicki & Pekarik, 1993). One patient dropped out the study, which represents a 16.7%,
similar dropout rates are found in the literature. In addition, the attendance rate of 87.5% among
all participants provided further support for treatment feasibility. Acceptability of Treatment
Program evaluations were highly positive, as both parents and their children endorsed the
benefits of mindfulness training in terms of affective and behavioral outcomes.
Regarding clinical symptoms, pre-to posttest reductions in scores were observed in all
core symptoms of ADHD (inattention, hyperactivity and impulsivity) and in oppositional
behavior. There was a significant reduction of total ADHD symptoms evaluated on the ADHD
Rating Scale-IV (p= .042) and Conners Rating Scale parents version (p= .042). Regarding
hyperactivity/impulsivity symptoms, statistically significant differences were shown on the
parent-rated Conners Rating Scale (p= .043). This study suggests that mindfulness could be
effective in treating children with ADHD. Furthermore, it adds an alternative therapy for those
parents who reject stimulant treatment, for patients who have side effects or who do not show a
response with stimulant treatment. Therefore, these findings suggest possible new non-
pharmacological intervention strategies, contributing to the advance of the treatment of these
patients and improving the quality of life of these children and in turn reducing the potential
effects and costs associated with drug treatment, and ultimately we will be increasing the quality
of care of these patients (Huguet, 2017).
Results for Research Question Three
The third research question is, which therapeutic approaches are most successful in
working with children with ADHD? Many of the interventions found regarding elementary aged
children with ADHD worked hand in hand. For example, when prescribing stimulant
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medication, psychotherapy is often a recommended intervention. When incorporating
mindfulness, there are time where elements of play therapy, such as coloring were part of the
intervention. The most successful psychotherapeutic intervention identified for children with
ADHD was cognitive behavioral therapy.
CBT is an established technique that trained therapists will use, either in out of school
sessions or there are even programs that were explored and can be implemented in school. This
type of therapy helps affect the child’s cognitive thinking and reasoning while also focusing on
behavioral modifications.
Plan My Life was one CBT program reviewed through the literature review. A CBT
Program can also focus on executive functioning skills, which are often a major source of
contention for children with ADHD. Other programs that emerged during the literature review
were Strong Kids: A Social and Emotional Learning Curriculum and Transforming Anger to
Personal Power: An Anger Management Curriculum. In addition, Helping At-Risk Students: A
Group Counseling Approach was also a possible program worth exploring,
In CBT sessions, goals are set at the onset of each meeting and the sessions will often end
with a homework assignment, a task, to be worked on in between sessions. One CBT
intervention that emerged as a successful intervention was called LeJa.
The aim of a study focused on LeJa was to investigate how the improvements in ADHD
symptoms were facilitated and whether there were moderators of treatment outcome. The results
can be used to advance the intervention and discover for whom and under which conditions it is
promising (Hennig et al., 2016)
LeJA is a combination of a training intervention aiming to improve learning skills and a
coaching part aiming to enable the adolescents to cope with actual developmental tasks such as
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preparing for their working life (Linderkamp, Hennig, & Schramm, 2011). Therapeutic
techniques of behavioral and metacognitive therapy were used because there is evidence for their
efficacy as described earlier. Moreover, LeJA includes organization training for which there is
recent evidence of efficacy (Evans, Owens, & Bunford, 2014). The intervention was
implemented by advanced students of Special Needs Education and two doctoral students of
Psychology. Treatment fidelity was assured through the use of a standardized treatment manual
and weekly supervision. In a one-to-one setting, 16-20 sessions per participant at 60 minutes
were carried out. The training intervention started with psychoeducation on ADHD and learning
problems and the identification of individual goals and personal resources. In subsequent units of
explicit practice, participants were trained how to solve problems in a structured way, using
problem-solving strategies and techniques such as cue cards (Camp & Bash, 1981) and self-
instruction training (Meichenbaum & Goodman, 1971). The therapists guided the adolescent's
behavior by scaffolding (Wood, Bruner, & Ross, 1976), for example, gave prompts as operant
reinforcement in cases of successful behavior and provided direct- and self-instructional
methods. In addition, organizational skills such as time management, use of an appointment
calendar, and setup of a beneficial learning environment at home were discussed and
implemented. In up to four coaching sessions, the therapists helped the adolescents to cope with
recent personal problems such as conflicts with parents or peers or lacking career opportunities,
using a self-management approach supporting self-regulation (Karoly & Kanfer, 1982).
Moreover, general factors of efficacy such as problem actuation and resource activation (Grawe,
1997) were implemented. Up to two optional follow-up sessions were conducted 1 and 3 months
after the last regular appointment. During treatment, the teachers of the participants were
involved through regular telephone contacts. The therapists offered to send information material
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about ADHD and the treatment and asked about current problems and improvements, which later
were reported to the adolescents. Parents were invited to take part in three two-hour meetings
with other parents and three therapists for psychoeducation and to initiate self-help processes
(Hennig, et.al, 2016).
The combination of including both parents and teachers in this system was very
meaningful and was one of the main reasons it stood out as a successful intervention. Whenever
a therapist, the child’s teacher and the child’s parent can work together and form a partnership,
the child is at a definite advantage.
ADHD symptom severity significantly declined from 1.19 to 0.92 (d = -0.44). Academic
enablers measured by the percentage of successful behavior in the teacher-rated questionnaire
increased from 63% to 71% (d = 0.42). Reading strategy knowledge (WLST) increased in raw
scores from 56.57 to 59.45, resulting in a small effect size of d = 0.25. An effect of d = 0.30
could be seen for the decrease of errors made in the flexibility task from 8.69 to 6.55 on average.
The aim of this study was to investigate potential mediation and moderation effects in a
cognitive behavioral training intervention for children with ADHD. The symptom reductions
were mediated by an improvement in academic enablers and strategy knowledge in line with an
initial assumption. There was a large mediating effect through enhanced academic enablers and a
small effect through the improvements in reading strategy knowledge.
Another therapeutic intervention researched was play therapy. During research, there
were great resources outlining various types of play therapy, the skills associated and the needs
they could help address for the children. For someone unfamiliar with the tenets of play therapy,
it is a much more detailed, comprehensive and successful intervention than originally thought
and much more intense than simply playing.

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The play therapy that emerged as a successful intervention that could be used in multiple
settings, but could be applied in a school setting was Adlerian Play Therapy. Adlerian play
therapy is both humanistic and goal-oriented. One study included two participants who received
biweekly Adlerian play therapy sessions each week for 6 weeks. They received an individual
session at the beginning of the week and a group session (both participants together) near the end
of the week. Per Sweeney et al. (2014), two participants is sufficient for group play therapy.
Participants received more individual sessions than group sessions because of the staggered start
times. Individual sessions were 30-minute sessions following the Adlerian Play Therapy
Treatment Manual (Kottman, 2009). The group sessions lasted 45 minutes and incorporated
principles of Adlerian play therapy with group play therapy. To date, a treatment protocol for
group Adlerian play therapy does not exist.
All sessions were conducted at an elementary school. Because the school did not have a
designated playroom, the counselors used a spare room for a playroom and used a mobile play
kit. Throughout the sessions, toys were supplied from each of Kottman and Meany-Walen's
(2016) categories: aggressive, expressive, family/nurturing, pretend/fantasy, and scary toys.
Review of the two participants suggests that Adlerian play therapy was clearly effective
in reducing the one boy’s targeted behaviors as evidenced by very effective treatment results for
the intervention and follow-up phases on the various scales. This is particularly important in
counseling-related outcomes because it is advantageous for changes to be maintained or
improved after the intervention is removed. The other boy also showed very effective treatment
results for Adlerian play therapy during the intervention phase on the scales.
The ASCA National Model (2012) offers several recommendations regarding responsive
services that we followed in this intervention. For example, ASCA directs school counselors to
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use goal-focused and brief interventions. In this intervention, a theoretically framed intervention
that targeted goals specific to each child was used. Counseling was brief in nature and the
ultimate goal was to increase positive classroom behavior, thereby supporting the mission of the
school. The ASCA National Model (2012) also recommends collaboration with stakeholders; in
this intervention, there was collaboration with parents, teachers, and mental health providers to
support student achievement. Using Adlerian play therapy is one way to support various aspects
of the ASCA National Model (2012) when providing responsive services (Meany-Walen, et.al.
2016).
Chapter Five
Description of Study
If attention-deficit hyperactivity-disorder [ADHD] affects approximately 5-10% of
children and has been determined to be the most common neurodevelopmental diagnosis in
children, why isn’t there a clear formula to follow when deciding on and implementing
interventions to help these children find success in school, at home and throughout their lives?
In order to gain a deep understanding and ability to contemplate successful interventions
regarding a disorder such as ADHD, it is important to first understand the history of this disorder
and how it impacts children, in learning settings, socially and biologically.
Symptoms now attributed to ADHD were first described in 1775 by Melchior Adam
Weikard, a German physician, in Der Philosophische Arzt (Barkley, Peters, & Weikard, 2012).
By the end of the 19th century, Dr. Alexander Crichton noted the disabling features of ADHD,
including restlessness, attentional difficulties, problems in school, and early onset (Palmer &
Finger, 2001). By the turn of the 20th century, Sir George Still (1902) conducted the first study
of 43 children who demonstrated problems with self-regulation and sustained attention

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contributing to the inability to learn. Still (1902) further discussed these symptoms as "an
abnormal defect of moral control in children" (p. 1008). By the 1960s, a task force was
developed to better understand this constellation of symptoms-then referred to as minimal brain
dysfunction -which established the three core symptoms now associated with modern day
ADHD: inattention, impulsivity, and hyperactivity (Clements, 1966).
With the advent of the Diagnostic and Statistical Manual of Mental Disorders (DSM;
American Psychiatric Association [APA], 1952), minimal brain dysfunction was noted with a
constellation of symptoms similar to those used today, although the disorder was thought to have
its etiology in damage to the brain from illness or traumatic injury. The working diagnosis in the
second edition of the DSM became hyperkinetic reaction of childhood/adolescence; the key
factor was that the behaviors diminished by adolescence (APA, 1968). When the third edition
(DSM-III) was published in February 1980, the world was first introduced to the diagnosis of
attention-deficit disorder with or without hyperactivity, with onset before age 7 and symptom
duration >6 months (APA, 1980). The next revision, the DSM-III-R (APA, 1987), changed the
diagnosis to ADHD and noted that "the disorder is frequently not recognized until the child
enters school" (p. 57). The DSM III- R (APA, 1987) also noted that this disorder may persist into
adulthood and that abnormalities of the central nervous system may be predisposing factors;
prevalence at the time was indicated to be approximately 3% of children in the United States.
The fourth edition (DSM-IV; APA, 1994) changed the diagnosis to ADHD with three subtypes:
predominantly hyperactive, predominantly inattentive, and combined. The DSM-IV noted that
most individuals experience symptoms into late adolescence and adulthood, the disorder was
common among first-degree relatives, and the prevalence was up to 5% in school-age children
(APA, 1994). The text revision of the DSM-IV (APA, 2000), which remained in use until the
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current fifth edition (DSM -5; APA, 2013), offered no change to the diagnostic criteria. Today,
clinicians must use diagnostic criteria set forth by the DSM -5 (APA, 2013). This latest edition
moved ADHD from "Disorders Usually First Evident in Infancy, Childhood or Adolescence" to
"Neurodevelopmental Disorders," with an updated symptom onset of before age 12, allowing
clinicians to more easily diagnose adults as it requires fewer symptoms to achieve diagnosis
(APA, 2013). This change also allowed ADHD to be diagnosed as a comorbid condition with
autism spectrum disorders for those who meet both sets of diagnostic criteria (APA, 2013).
ADHD is now considered a neurobehavioral disorder, affecting approximately 11% of
school-age children (Visser et al., 2014), with approximately 75% persisting into adulthood
(Brown, 2013). ADHD is characterized by symptoms of inattention, impulsivity, and
hyperactivity, which are developmentally inappropriate and interfere with the individual's ability
to function in home, academic, occupational, and social settings. Although family conflicts do
not directly cause ADHD, they can change the way in which ADHD manifests and may result in
additional psychiatric issues, such as antisocial and criminal behaviors (Langley et al., 2010).
In addition to the external (i.e., social) and environmental (i.e., clinical) symptom presentations
leading to a diagnosis of ADHD, there are also internal or biological bases, which are often more
difficult to detect. Such biological factors were compiled in a 2013 meta-analysis of the
evidence-based genes associated with ADHD (Thapar, Cooper, Eyre, & Langley, 2013).
Although genetics is only one component of the diagnostic conundrum, a meta-analysis of 1,800
genetic studies determined heritability of ADHD to be between 75% and 91%, and that multiple
genes, as opposed to a single gene, were a likely factor (Zhang et al., 2012).
Medication was not included as one of the interventions explored during this study,
instead, the programs, strategies and ideas were researched, included and analyzed for adults
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who would like to consider options other than medication. Interventions have been organized for
adults who care for children with ADHD to use as a reference and resource. Teachers would be
able to find ideas to use in classrooms and school settings, therapists would review successful
therapeutic techniques used in psychotherapy and parents would have access to information that
would help them become more knowledgeable about possibilities for their child, while also
becoming exposed to parent and family training and intervention techniques.
Elementary aged children were the focus, but not just those in the United States. The
research was strong for interventions occurring around the world and so the literature review was
far reaching and inclusive of children from different countries. In different countries and
different parts of the world, there are interventions and programs for ADHD that aren’t as widely
known or used in the United States. Both girls and boys were the focus, but the research
indicated a higher prevalence for ADHD in boys than in girls.
The initial problem identified was the possibility for confusion for parents beginning to
understand their child’s ADHD diagnosis. While many believe medication is the only answer,
respect should be given to parents seeking alternate interventions. Whether through google or
the reading of various books, a parent’s research can quickly become too overwhelming and very
frustrating.
Through the development of three important research questions, this study highlights
some of the most successful interventions that don’t include medication, or that are used in
conjunction with medication. The first research question was, which classroom strategies,
interventions and ideas are particularly useful in offering parents and teachers a “toolbox” to help
children with ADHD find success in the classroom? The second research question was, what are
proven mindfulness activities and programs that can be beneficial in training parents, teachers
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and children with ADHD to incorporate into everyday living? The third research question was,
which therapeutic approaches are most successful in working with children with ADHD?
A theoretical orientation was used in an effort to thoroughly review available literature
regarding successful interventions for children with ADHD. This type of approach allowed for
all three research questions to be explored and organized into a summary of interventions. The
most prevalent interventions were even further reviewed through the interpretation and analysis
of results.
Discussion of Findings
Teachers are familiar with working with children with ADHD. There are students in
many grades in many schools who have been diagnosed. In some instances, these students have
documented plans such as a 504 Plan or an Individualized Education Plan that outlines necessary
interventions and supports for children with ADHD. Sometimes, students with ADHD take
medication during the day. And there are often times when these children do not have specific
plans and do not take medication, but require interventions in the classroom. They may also
require the attention of other school personnel such as counselors, behaviorist and administrators.
Teacher awareness of ADHD is critical and often the diagnosis occurs in part because of a
teacher’s answers on a questionnaire, such as the Conners’ Scale. Successful teachers will
implement behavior plans, reward systems and will maintain regular communication with
parents. The reward center of the child’s brain is compromised when they have ADHD and so
the more positive praise and the more rewards they can be offered- the better!
During the research for this study, one intervention emerged as an important and
successful strategy that can be implemented in any school setting. The daily report card is one
program that should be highlighted because of its focus on behavior and academic success, as
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well as being reliant on communication between the home and school. Often, for children with
ADHD, homework issues emerge as an ongoing battle. The HOPS Program is a successful
strategy worth considering. The Homework, Organization, and Planning Skills (HOPS)
treatment is a skills-based treatment that focuses on teaching organization and planning skills
that are important for homework completion. Although primarily a skills training intervention,
HOPS also utilizes principles of contingency management. Specifically, SMH professionals use
a points system to reinforce skills implementation at school and encourage parents to implement
a similar points system at home (Breaux, et.al, 2018).
Findings from the present study should be interpreted within the context of several
limitations. First, we did not have a measure of the parent-SMH professional working alliance,
which has been found to be important in prior clinic-based research (Kazdin & McWhinney,
2017; Hawley & Weisz, 2005). It will be important for future research to discern whether the
parent-clinician working alliance is important in school-based treatments. The engagement
variables included in the present study may provide some insight into this question, as parents
with a strong working alliance with the clinician are typically more engaged (Karver et al.,
2008). Second, several of the measures used in the present study were single item. It will be
important for future research to look at involvement in a more in-depth manner and to tease apart
aspects of involvement that might be particularly influential. Additionally, we did not observe
student or parent behavior during sessions or retain physical copies of the parent monitoring and
rewarding plans. As such, there are no objective or observational data to compare to SMH
professional report. Third, the working alliance was assessed only once near the middle of
treatment. There is some evidence that including multiple alliance measurements starting early in
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treatment may produce a more accurate estimate (Crits-Christoph, Gibbons, Hamilton, Ring-
Kurtz, & Gallop, 2011).
Findings from the study should be interpreted within the context of several limitations.
First, there was not a measure of the parent-SMH professional working alliance, which has been
found to be important in prior clinic-based research (Kazdin & McWhinney, 2017; Hawley &
Weisz, 2005). It will be important for future research to discern whether the parent-clinician
working alliance is important in school-based treatments. The engagement variables included in
the study may provide some insight into this question, as parents with a strong working alliance
with the clinician are typically more engaged (Karver et al., 2008). Second, several of the
measures used in the study were single item. It will be important for future research to look at
involvement in a more in-depth manner and to tease apart aspects of involvement that might be
particularly influential. Additionally, student or parent behavior during sessions was not
observed or did they retain physical copies of the parent monitoring and rewarding plans. As
such, there are no objective or observational data to compare to SMH professional report. Third,
the working alliance was assessed only once near the middle of treatment. There is some
evidence that including multiple alliance measurements starting early in treatment may produce a
more accurate estimate (Crits-Christoph, Gibbons, Hamilton, Ring-Kurtz, & Gallop, 2011).
In summary, this study highlights the importance of therapeutic process variables in
school-based treatments delivered by SMH professionals. This study also documents the
importance of simultaneously measuring several process variables and outcomes in treatment
outcome research. Important next steps will be to develop SMH professional trainings focused
on these core therapeutic skills, pulling on existing clinical psychology literature with some
adaptation for treatment in school setting (e.g., there may be differences in appropriateness of
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self-disclosure). Future research would then explore whether providing these types of trainings
can enhance the outcomes of existing school-based treatments for youth with ADHD (Breaux,
et.al, 2018)
Mindfulness has been a practice that has been around for centuries but has just recently
received more attention with children and in schools. When researching the answer to the
second research question, the resources available surrounding the concept of mindfulness were
beyond fruitful. While this study includes successful interventions deemed worthy of inclusion
in this project, the list is far from exhaustive.
The Triple R Mindfulness Program emerged as a successful intervention to be
implemented when seeking mindful strategies for children with ADHD. This intervention is
based on a six week program that can be implemented in the school setting. The study of the
Triple R Program aimed to investigate the effectiveness of a school mindfulness-based
intervention program. The program was found to increase mindfulness skills, and there was a
general decrease in negative emotional symptoms.
The result of the study provided some support for the hypothesis that children's self-
reported mindfulness skills would be higher post intervention than pre intervention. There was a
significant increase in self-reported mindfulness skills post intervention. Given the links in the
literature between increased mindfulness and improved well-being (Huppert & Johnson, 2010),
the comparatively small investment in time and resources needed to conduct a six week program
in a school setting shows much promise.
The intervention was uniquely designed, and its efficacy has not previously been tested.
The TRIPLE R intervention program successfully improved children's awareness and
understanding of mindfulness, and taught mindfulness skills that can be employed in everyday
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situations. This intervention was designed using developmentally appropriate tools based on the
work of Snel (2013) and employed a variety of different delivery methods to cater for different
learning styles. Critically, the intervention focused on experiential learning, linking learnt
concepts to practical experience to improve mindfulness skills.
This study has some limitations. Firstly, it must be noted that the results do not guarantee
that the significant increase in mindfulness skills can be wholly subscribed to the mindfulness
intervention. It could be argued that a range of additional factors caused the increase in
mindfulness skills, such as independent learning and practice. It is also possible that children
answered positively in the post intervention questionnaire due to response bias, a desire to
present themselves as 'performing', or simply because they were more familiar with the terms.
While some individual responses indicated little change in mindfulness skills, overall
observation throughout the program, and children's reflections and feedback in Session 6 indicate
there was indeed an increase in understanding and practice of skills at the end of the program.
These observations and data corroborate the finding that mindfulness skills increased
considerably at the end of the program (Dove & Costello, 2017).
The answer to the third research question became clear early in the research. Cognitive
behavioral therapy [CBT] is a therapeutic technique that yields great success with children with
ADHD. The therapy focuses on individual therapy sessions where goal setting and “homework
assignments” are a key part of the process. Different programs are designed based on weekly
sessions and often involve exit strategies regarding therapy. Mindset and specific behavior
interventions are discussed and addressed in this type of therapy.
LeJa is just one of many types of CBT intervention program options for children with
ADHD. In this study, the efficacy of a specific intervention for children with ADHD combining
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an adolescent-directed problem-solving and organizational skills training including (cognitive-)
behavioral, coaching, and self-management elements with a behavioral parent and teacher
training was evaluated on primary, secondary, and self-rated outcome constructs in a twofold
analysis.
The first analysis compared the intervention to waiting list controls, thus controlling for
effects of maturation and other developmental trends. Large effects were found for a reduction of
ADHD core symptoms rated by parents and teachers. These results are in line with recent meta-
analytically derived effects for pre- and post-designs (Van der Oord, Prins, Oosterlaan, &
Emmelkamp, 2008), although these effects were based on studies evaluating psychosocial
interventions for ADHD in childhood. Pelham and Fabiano (2008) state in their review that pre-
and post-designs of behavioral interventions result in larger effect sizes than control group
designs. They calculated a medium effect size of d = 0.44 for ADHD symptoms in waiting list
comparisons, which is lower than the effects found in this study. Regarding academic enablers,
teachers noted their increased use in school resulting in a medium significant effect.
In addition to the encouraging results in primary outcome measures, one secondary outcome,
namely internalizing problem behavior, rated by parents decreased. Last, self-rated effective
learning behavior increased, indicating that adolescents themselves consciously applied learning
and problem-solving strategies which were trained during the intervention.
These findings are similar to a pre- and post-efficacy study of CBT in adolescents with
ADHD (n = 68) by Antshel et al. (2012). Apart from a reduction of ADHD symptoms the
authors found that internalizing behavioral symptoms rated by parents (d = 0.65) and teacher-
rated learning problems (d = 0.81) decreased and classroom functioning increased (d = 0.79)
(Schramm, Hennig, & Linderkamp, 2016).

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One limitation regarding research focused on CBT was in regard to gender. This
discrepancy can be found as a theme in research regarding ADHD. Because only eight girls
were in the sample, they were underrepresented. This is a typical finding reflecting lower
prevalence rates of ADHD in girls (Polanczyk et al., 2007) and lower rates of referrals of girls
compared to boys even when showing similar levels of impairment (Novik et al., 2006).
Play therapy was another popular technique for therapists to use when working with
children with ADHD. There were several great programs researched and they were able to be
implemented both in the school setting and in out-of-school therapy.
Implications
The implications regarding this theoretical study and ideas for further and continued
research are strong. As evidenced, the research regarding interventions for ADHD are bountiful.
The work was organized in a way to support the adults as they seek out, implement and assess
various successful interventions for children with ADHD.
Cognitive behavioral therapy emerged as a leading therapeutic technique for trained
therapists to use when providing “talk therapy” to children with ADHD. CBT relies on goal
setting, homework assignments and a focus on cognition and behavior. There are many options
to explore when seeking specific CBT treatment plans to use with children with ADHD and the
constant theme was that one size does not fit all. There is extensive literature focused on the
merits of CBT, with some of the more successful programs included in this literature review.
When seeking out a therapist for a child with ADHD, understanding their background and
training connected to CBT should often be a first step. Also, parents should familiarize
themselves with the aspects of this type of therapy and should, in turn, find a therapist they trust
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and work to build that rapport and establish a strong relationship. A successful outside therapist
will be open to ongoing communication with the parent and the child’s school.
There are important skills to consider when supporting children with ADHD in the school
setting. Executive functioning skills are often impacted by this disorder. Social skills and peer
relations are also skills that can be affected. The literature outlined several key programs and
interventions to be incorporated into school setting and which would ultimately support parents
as they help their children better develop executive functioning skills. Organization, time
management and an overall difficulty with planning skills are key aspects of the ADHD
diagnosis. There are programs to be implemented in the school setting and hopefully carryover
would occur at home. One of these programs reviewed was called the HOPS Program. There
are “apps” that can also be used to help children with these skills and it was determined that
whenever they have access to technology, children seem more interested.
Mindfulness was an important focus in this study. The history and biological factors
involved in mindfulness were reviewed before even beginning to discuss potential interventions.
Ultimately, the review was rich with possibilities for implementing mindfulness as a successful
intervention. Whether yoga, coloring or physical exercise, there are many components of
mindfulness. Breathing techniques and relaxation strategies were a major focus and the research
supported their success in helping children with ADHD to reset, recharge and be able to use
mindful strategies to react differently to hyperactivity, inattention and impulsivity. Self-
regulation is the regulation of affect, cognitions, or behaviors in accord with goal-directed
behavior (Karoly, 1993). Self-regulation has been considered to encompass three main
components. The first is the endorsement of particular standards of thought, feeling, or behavior
that are mentally represented and monitored. The second component is the motivation to reduce
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discrepancies between standards and real states. The third component is sufficient capacity to
reduce the discrepancy, despite encountering barriers and temptations (Baumeister & Heatherton,
1996; Carver & Scheier, 2012). Failures in self-regulation can occur in any of these three areas
and all are considered to be necessary to enable successful self-regulation. Difficulties with self-
regulation are symptomatic of many clinical conditions, such as impulsivity in attention-
deficit/hyperactivity disorder (Barkley, 2010). . Self-regulation is a complex function relying on
multiple cognitive and affective systems, and effective symbiosis between these systems, most
pertinently, executive functions (EFs) and emotion regulation.
Mindfulness was another intervention that boasted a number of “apps” to be accessed and
one online program to help train children with ADHD was the HeartSmart Program using
emWave technology. This type of bio-feedback approach could be implemented in various
settings, including in the school, at home or with a therapist. The emWave technology teaches
children how to use their breathing and brain functioning to make specific changes. In one
example, children are hooked up to this device and view a forest scene that is in black and white.
As they breathe and relax their heart rate, the scenes begin to change color so ultimately the
forest is filled with bright colors and is a visually appealing scene for them to look at and also
immediately understand how their brain and their changes were responsible for the changes they
view on the screen. Eventually, this understanding can lead to children implementing similar
strategies when not being monitored by the emWave device. In moments of hyperactivity or
impulsivity, they can hopefully recall techniques learned during these exercises. If changes in
breathing will make a difference, children need to be taught to understand why those changes are
important and how it works for their body.

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Themes throughout the research continuously connected. Mindfulness programs could
be used to not only help with self-regulation, but also to impact executive functioning skills.
When thinking about mindfulness, aspects of positive psychology were connected. Similarly,
CBT could be used to help with those skills, while also affecting a child’s behavioral strategies.
During CBT therapy, psychotherapists will focus on a child’s cognitive thinking and behavioral
decisions. When mindfulness is incorporated into this type of therapy there are great benefits for
the child. In addition to learning CBT based skills such as cognitive restructuring, meditation
practices can be incorporated as a support for these challenging thought provocations.
Parent and teacher training were key in supporting children with ADHD. There are
specific plans and programs for parents, along with support groups and training interventions for
them to engage in. Teachers receive professional development, but an understanding of
assessment, diagnosis, symptoms and treatment continues to be an area requiring further
attention for teachers.
A review of the literature and organization of this paper also allows parents to recognize
there are many programs and supports available to them as they begin to better understand their
child with ADHD. Often, prior to diagnosis, there can be extreme discord in the family. This
can impact the relationship between the parents and also have a negative effect on the child’s
self-esteem. If they are constantly disciplined and receive messages they are a disappointment,
the lifelong impacts can be devastating. This is why parent understanding is so important.
Whether exploring support groups, family and parent therapy or even reading books and visiting
advocacy sites such as CHADD, parents need to understand this disorder the same way they
would take steps to better understand any illness their child might experience. Different, though,
is that ADHD is not a life threatening illness and when understood and when the successful
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interventions are put in place, the child can realize great successes and achievements. First, they
need their parents understanding and support.
The premise of this project focused on the value in gathering successful interventions,
programs and resources that could be available for adults seeking support as they support
children with ADHD. The research questions helped drive the research and ultimately helped in
organizing and summarizing the interventions based on themes. With so many children affected
by ADHD, the driving question remained true from beginning to end. If you are a parent with a
child with ADHD and prefer alternate interventions beside medication, what are those choices
for you to consider? If you are a teacher without the right to suggest medication, what can you
do in your classroom or school setting that would change or enhance the learning environment
for a child with ADHD? And if you are a therapist meeting with the parents of an ADHD child
who aren’t ready or willing to discuss medication, what will your recommendations be? The
assumption is that therapists have the answers, but providing them with organized literature,
highlights from successful interventions and a varied approach of programs and strategies, can
only help.
The field of clinical psychology can benefit from this type of document because of its
varied nature. Instead of focusing on just one question or just one aspect of one disorder, the
literature review has been conducted, evaluated, analyzed, organized and summarized in a way
that will allow any parent, teacher or therapist easy access to the information. The implications
for research have been strong. ADHD continues to be the most prevalent disorder among
children and as noted, there is wonderful research that has already been conducted regarding
successful interventions. Organizing those interventions into one document has been the success
of this study. The literature was extensive and could sometimes be overwhelming. Organizing
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what appears to be some of the more successful interventions into one document, provides all the
adults a starting point for understanding. As the diagnosis for ADHD has evolved, the
compilation of interventions should have also evolved. The research has been conducted and the
literature has been published, but organizing it into one document can only benefit the parents,
teachers and therapists seeking ideas and strategies.
Considerations for Future Research
When considering ideas for future research regarding interventions for elementary aged
children with ADHD, the first concept focuses on medication. Stimulant medication is often
prescribed to help children with ADHD but often, parents can be hesitant or have serious
concerns about medication. One recommendation for future research would be studies that rely
heavily on the combination of medication and other interventions. When parents, teachers and
therapists are able to read about the successes of medication, in conjunction with specific
interventions, it may help change negative perceptions about medication. One document that
does contain a list of the medications that are prescribed to children along with the research
regarding their success and failure rates could be a benefit. Included in this research could be
side effects, health concerns and risks and all medication information compiled in one, easy to
read and access, location.
Another consideration would be to focus on interventions used for girls with ADHD.
The research showed more boys are diagnosed with ADHD than girls. This underdiagnoses
could be related to misinformation among parents and teachers. Further research studies focused
just on girls would be a recommendation. Having the ability to read about how specific
interventions impact just the girls could become a helpful resource for parents, teachers and for
therapists. The rates for girls being diagnosed with ADHD are higher than would appear given
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the focus of literature on boys. Future research that further explores why girls are not recognized
with this disorder as much as boys would be valuable.
Further research is also needed regarding teacher understanding and teacher training in
respect to ADHD. More studies should be conducted regarding teachers’ full understanding of
the ADHD diagnosis and how it impacts children. A child’s temperament can often be affected
by this disorder and teachers need to understand and have strategies they can use. One
consideration for future research that would have a meaningful impact on teacher’s
understanding of ADHD, would be an audit conducted regarding coursework in this area at the
college level and during teacher preparation programs. Because this disorder is the most
commonly diagnosed for children, the likelihood of all teachers encountering students with
ADHD is extremely high. Preparing them better at the college level to understand all aspects of
this disorder could improve teacher understanding. Studies connected to teacher preparation and
students’ with ADHD success in classrooms would be beneficial future research.
Although children’s temperament has been consistently linked to social behavior, more
detailed theory and evidence regarding specific temperament links to later peer relations have
only emerged in relatively recent literature. Previous research with attention-deficit-hyperactivity
disorder (ADHD) populations, for example, suggested that aspects of children’s self-regulation
of attention and emotion (i.e., effortful control) are linked to social problems and peer
relationship difficulties (Barkley, 1996; Hinshaw & Melnick, 1995).
More difficult temperament and associated social withdrawal also tend to predict poorer
teacher–child relationships (Justice, Cottone, Mashburn, & Rimm-Kaufman, 2008; Rydell,
Bohlin, & Thorell, 2005). In turn, the quality of teacher–child relationships has been consistently
linked to positive educational outcomes from preschool through middle childhood (O’Connor &
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McCartney, 2007), including children’s academic success, social skills, and behavioral
adjustment. Teacher–child relationships are theorized to be important because early patterns of
teacher–child interaction, established in elementary classrooms where teachers spend large
amounts time with individual students, may be carried forward into adolescence (Rimm-
Kaufman & Pianta, 2000).
Along the same category of teacher understanding of ADHD, more research is needed
regarding the diagnosis of ADHD. Often, teachers are included in this process due to the nature
of the diagnosis including symptoms persisting in more than one environment. But filling out a
survey or questionnaire can often be subjective and so if the diagnosis is made without a teacher
having proper training, strong understanding and an even stronger background and foundation
regarding ADHD, than their answers and eventual diagnosis could be invalid.
ADHD is not a new diagnosis and as the research has evidenced, its recognition dates
back to the 18th century. As the decades moved on and the field of science and psychology
continued to evolve, so did understanding of this brain disorder. The ADHD diagnosis has been
a part of the various iterations of the DSM, until the most recent when the diagnosis appears
clearer and focus on hyperactivity, impulsivity and inattention. One concern that emerged
during the research focuses on adults’ understanding of ADHD. There is important information
included in this project to help adults better understand the diagnosis of ADHD means that the
child’s brain does not function the way other children’s might. All too often, adults may believe
children with ADHD are the product of poor parenting, perhaps spend their days in classrooms
with unqualified teachers or simply haven’t received the therapy they so desperately require for
their bad behavior. Helping the adults involved understand the concepts of neurotransmitters,
dopamine and how their malfunctioning not only impacts the child’s brain, but simply isn’t their
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fault, is an imperative step to take prior to considering successful interventions. You can’t
effectively solve a problem without first understanding it.
Once there is understanding of the disorder, the interventions should start to make more
sense. There is extensive research to support the use of medication as an intervention for
children with ADHD. The research can be found to highlight anecdotal stories of success and
also to provide scientific data regarding the change for children on medication in all settings,
particularly school, home and improved peer relationships. This project excluded the use of
medication, not because it isn’t a successful intervention, but because adults and children
experiencing this diagnosis for the first time should have access to various interventions if
medication is not their first choice.
The research regarding ADHD and successful interventions for elementary-aged children
was abundant. Many of the valuable resources provided were beyond a five year range. It is
recommended members of the field of psychology continue exploring and updating research
regarding ADHD.
The beginning of this project focused on narrowing down three research questions which
would drive the research and literature reviews. All three questions have been successfully
explored and organized in this document. The theme throughout focused on successful
intervention strategies and as evidenced throughout this entire body of work, there are many
programs, ideas, trainings and resources available as parents, teachers and therapists seek out the
successful intervention strategies to implement with the children they raise, teach or work with to
support as they grow and live a successful life with ADHD.
The research included a background of the diagnosis and a more scientific understanding
of how ADHD impacts a child’s brain. At the conclusion of reading this project, an adult would
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118
be offered a diverse sampling of interventions to use with children with ADHD. First, they focus
on ways to support parents and then move into the possibilities in school settings. For school
settings, the focus can be on classroom strategies, school-wide programs and school-based
counseling and specific curriculums. Executive functioning skills emerged as an important focus
in helping children find greater success in the school setting. The concepts of mindfulness could
be interventions used by the parents, in the school setting or by therapists.
Many of the interventions relied on connections between these three important groups of
adults. If medication isn’t an option or other interventions will be exhausted before considering
medication, then the parent, teacher and therapist triangle is an important relationship that
becomes the first most successful intervention strategy for children with ADHD.
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119
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ADHD Interventions

DocuSign Envelope ID: A51056B1-7FD8-4118-B80A-172BA7A09288

Successful Intervention Strategies for Children with ADHD

Presented to the Faculty

School of Behavioral Sciences

California Southern University

scope and quality for the degree of Doctor of Psychology.

Doctoral Candidate: Michael Donovan

Brandon Eggleston, Ph. D. Doctoral Project Committee Chair Date

Patrick McKiernan, Ph. D. Doctoral Project Committee Member Date

Melanie Shaw, Ph. D. Doctoral Project Committee Member Date

Gia Hamilton, PsyD, Dean, School of Behavioral Sciences Date

to have them on my side.

Title: Successful interventions for children with ADHD

neurodevelopmental diagnosis for children, affecting approximately 5% of children in the United

possibilities. Through an extensive and diversified literature review several successful

interventions emerged. The primary theoretical perspectives included cognitive behavioral

therapy, executive functioning training and mindfulness.

psychotherapist interested in exploring various, successful interventions for children with

Overview of the Study

ADHD (attention-deficit hyperactivity disorder) can have a negative impact on a child’s

peer relationships and interactions. Attention-Deficit Hyperactivity Disorder (ADHD) is the

most commonly diagnosed psychiatric disorder, occurring in 5-7% of children worldwide.

pharmacological intervention. There is extensive literature to review regarding successful ADHD

treatments for children.

Background of the Problem

(ADHD) is a neurocognitive behavioral developmental disorder most commonly seen in

domains (Biederman et al., 2000). Outward signs of hyperactivity-impulsivity tend to decrease

Cognitive behavioral therapy is just one psychotherapeutic approach to be incorporated into

background, it can be conducted as a part of school-based counseling.

Stimulant medications are considered an effective treatment for attention deficit

Statement of the Problem

phase and doctors who maintain the only option is to medicate.

Purpose of the Study

research for teachers and parents to help support children.

In addition to a theoretical review of research focused on successful intervention

Mindfulness-based interventions, classroom strategies, school-based counseling, and

and out of school.

1. Which classroom strategies, interventions and ideas are particularly useful in

success in the classroom?

training parents, teachers and children with ADHD to incorporate into

3. Which therapeutic approaches are most successful in working with children

There has been an explosion of interest in mindfulness-based programs (MBPs) such as

Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy

and use it as a successful intervention for children.

Significance of the Study

ADHD is the most common neurodevelopmental disorder to impact children. The

possibilities when working with students with ADHD.

multiple interventions for children with ADHD.

Key Terms and Definitions

ADHD- Attention-deficit/hyperactivity disorder (ADHD) is a developmental

learning skills, motivation, and academic achievements; emotional difficulties, including

similar problems but without ADHD. (Ziperfal & Shechtman, 2017)

Mindfulness- Mindfulness-based stress reduction (MBSR) programs consist of

Yip, & Karatzias, 2017)

Stimulants- such as methylphenidate (MPH; Ritalin and Concerta) and

dextroamphetamine-AMP (d-AMP; Adderall) are the most common pharmacologic treatments

& Kirchgessner, 2012)

thoughts helps to improve adjustment. (Antshel et al., 2011)

interventions, psychotherapy and many strategies, interventions and techniques.

to consider alternative approaches to treating ADHD (Conway, 2012). Understanding ADHD is

key to understanding how to design successful intervention plans.

(Stevens & Vaccarino, 2015).