Chapter 6: Attention Deficit Hyperactivity Disorder and Other Health Impairments

Dr. Edward Hallowell describes attention deficit hyperactivity disorder (ADHD) like having a racecar brain with the brakes of a bicycle.

Introduction

Children come to school with a wide variety of health conditions that can influence their learning, behavior, attendance, and participation in school activities. Some of these conditions primarily affect a student's physical health, while others influence attention, energy level, or alertness. Although these learners often have average or above-average intelligence, their health condition may create barriers that make it more difficult to fully participate in the educational program without appropriate supports.

The IDEA category of Other Health Impairment (OHI) includes a broad range of chronic and acute medical conditions that adversely affect a student's educational performance. Among these conditions, attention-deficit/hyperactivity disorder (ADHD) is by far the most common and is one of the disabilities teachers are most likely to encounter in today's classrooms. Because many students with ADHD spend the majority of their school day in general education classrooms, it is essential that all educators understand its characteristics and know how to create learning environments that promote attention, engagement, organization, and self-regulation. This chapter explores the characteristics of ADHD and other health impairments, including how these conditions are defined under IDEA, how ADHD is identified and treated, and the educational supports that help students succeed in school. It also examines classroom strategies, accommodations, school health services, and the collaborative roles of educators, families, and healthcare professionals in supporting students with health-related needs.

Other Health Impairment

There are many health conditions that can affect a child's ability to learn and participate successfully in school. Some primarily affect physical strength or stamina, while others influence attention, alertness, or energy level. Many of these conditions are chronic, meaning they are ongoing or recur over time. Others are acute, developing suddenly and temporarily affecting a student's strength, vitality, or alertness. When these health conditions interfere with educational performance, students may require accommodations, specialized instruction, school health services, or other supports to fully participate in school.

IDEA defines Other Health Impairment as:

Although IDEA includes many different medical conditions within the Other Health Impairment category, attention-deficit/hyperactivity disorder (ADHD) is by far the most common and is the primary focus of this chapter.

Attention Deficit Hyperactivity Disorder

Many are surprised to learn that attention deficit hyperactivity disorder (ADHD) is not a specific category of disability under IDEA, but rather fits into the category of Other Health Impairment. ADHD is a chronic neurodevelopmental disorder that is usually first identified during childhood, although its characteristics often persist into adulthood. It results from differences in the way the brain develops and functions, affecting attention, activity level, and impulse control. Affecting approximately 5–7% of school-age children, ADHD is the most common neurodevelopmental disorder of childhood (Boston Children's Hospital, 2023). The primary characteristics of ADHD are inattention, hyperactivity, and impulsivity, although children will experience these characteristics in different combinations and levels of severity.

In the past, professionals distinguished between attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD). However, this distinction is no longer relevant. Since 1994, physicians have combined both groups under one umbrella category of ADHD, which is then divided into three subcategories.

As the names of the subcategories imply, children with ADHD may experience difficulties with attention, hyperactivity, impulsivity, or a combination of these characteristics. The Merriam-Webster Dictionary defines impulsivity as, “Doing things or tending to do things suddenly and without careful thought.” Children who are impulsive display behaviors that range from blurting out answers and interrupting others to engaging in risk-taking behavior that can lead to dangerous situations. Children with ADHD have varying combinations of these characteristics of hyperactivity, inattention, and impulsivity and the specific combination and severity of these characteristics varies from one child to another.

ADHD Diagnosis

ADHD is a medical condition, which is why it falls under the IDEA category of Other Health Impairment. A diagnosis of ADHD must be made by a qualified medical professional, such as a family physician, pediatrician, or psychiatrist. Although neuroimaging studies have demonstrated a neurological basis for ADHD, brain imaging is currently used only in research settings and is not part of the routine diagnostic process. Instead, diagnosis relies primarily on information gathered through interviews with the child and parents, behavioral observations, and standardized rating scales completed by parents and teachers. Because teachers have the opportunity to observe students in structured learning environments and can compare their behavior with that of same-age peers, their observations and rating scales provide an important part of the diagnostic process.

According to the U.S. Centers for Disease Control (CDC)(2024b), people with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development:

Inattention

Based on the DSM-5, a diagnosis of inattention for children up to 16 years of age requires six or more symptoms from the list below. Those 17 years and older must have five or more symptoms. Symptoms of inattention must have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level.

Hyperactivity and Impulsivity

Based on the DSM-5, a diagnosis of hyper-activity-impulsivity for children up to 16 years of age requires six or more symptoms of inattention from the list below. Those 17 years and older must have five or more symptoms. Symptoms of hyperactivity-impulsivity must have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level.

In addition, the following conditions must be met:

Because symptoms can change over time, the presentation may change over time as well. It is important to remember that all children display some of these behaviors from time to time. For children with ADHD, however, these characteristics are persistent rather than temporary. They occur more frequently and to a greater degree than would be expected for the child's developmental level, resulting in difficulties across major life settings such as home, school, and the community (CDC, 2024b). It is equally important to recognize that there is no evidence that ADHD is caused by poor parenting, food allergies, watching television, or playing video games (CHADD, 2015; NASET, 2024)

A diagnosis requires evidence of significant impact of the ADHD symptoms in two or more settings. While this is typically home and school, other community settings can be considered as well. The symptoms must have been present before age 12 and have persisted for at least six months. The behavior must also be developmentally inappropriate, meaning they occur more frequently or are more severe than would be expected for a child of the same age and developmental level (NASET, 2024).

In addition to the characteristics of inattention, hyperactivity, and impulsivity included in the DSM-5 criteria, there are several other characteristics of ADHD that teachers should recognize. Children with ADHD may have a poor sense of time and struggle with delayed gratification. They may also have difficulty sustaining motivation, working toward long-term goals, and tolerating frustration. Executive functioning skills, including working memory and cognitive flexibility, are often affected, contributing to inconsistent academic performance. Unfortunately, the combined characteristics of ADHD often have a negative impact on social relationships and many of these students struggle with friendships and social interactions throughout their school years (NASET, 2024).

Prevalence

According to a CDC survey conducted in 2016, 9.4% of U.S. children between the ages of 2 and 17 had been diagnosed with ADHD. The diagnosis was more than twice as common in boys (12.9%) as in girls (5.6%). ADHD is also highly comorbid with other conditions. Approximately 60% of children with ADHD had at least one additional diagnosis. About half also had a behavior or conduct disorder, 45% had a learning disability, and 30% had anxiety. Other commonly occurring comorbid conditions included depression, autism spectrum disorder, and Tourette syndrome (ADDitude, 2022).

Researchers have reported somewhat different findings regarding the prevalence of the three ADHD presentations. Some studies suggest that the combined presentation is the most common, whereas others report that the predominantly inattentive presentation is most common and the combined presentation is least common (Kinman & Raypole, 2021). One possible explanation is that the characteristics of the combined presentation are often more noticeable to parents and teachers, making these students more likely to be identified and referred for evaluation. Similarly, because the mental image many people have of ADHD is based on the characteristics of the combined type, they are less likely to recognize the other types and, therefore, might think combined type ADHD is more common than other types. These findings serve to remind educators that ADHD does not look the same in every student and that those with predominantly inattentive characteristics may be especially likely to go unrecognized.

Treatment

Although there is no cure for ADHD, the condition can be effectively managed. Treatment is typically multimodal and may include education about the disorder, behavior therapy, medication, and appropriate school-based supports. The American Academy of Pediatrics (AAP) recommends behavior therapy as the primary treatment for young children with ADHD. For children six years of age and older, the AAP recommends a combination of behavior therapy and medication. Because ADHD is a medical condition, decisions regarding medication are outside the scope of practice for educators. However, teachers can encourage families to seek a medical evaluation when ADHD is suspected. Any medication used to treat ADHD must be prescribed and monitored by a qualified medical professional.

Because ADHD is associated with differences in the brain's neurochemical functioning (Curatolo et al., 2010), it is not surprising that medication, particularly stimulant medication, can be an effective treatment for many individuals with ADHD. Commonly prescribed stimulant medications include brand names such as Ritalin, Adderall, and Concerta. These medications increase the activity of certain neurotransmitters in the brain, improving attention, working memory, and impulse control. As a result, many individuals experience improvements in behavior, academic performance, and social relationships.

However, stimulant medications must be carefully monitored. Although they are effective for many individuals with ADHD, they do not work equally well for everyone, and finding the most effective medication and dosage often requires adjustment as the child grows. Research indicates that ADHD medication reduces symptoms for approximately 70–75% of the children for whom it is prescribed. The most common side effects include decreased appetite, difficulty sleeping, headaches, stomachaches, irritability, and, for some children, increased symptoms of anxiety. Approximately 80% of children with ADHD who take medication use a stimulant medication, while about 17% take an antidepressant. Some parents have expressed concern that taking stimulant medication during childhood may increase the risk of substance abuse later in life. However, research has found no evidence to support this concern (NASET, 2024).

According to a 2016 CDC survey, among children 2–17 years of age with an ADHD diagnosis:

These findings illustrate that ADHD is typically managed using a combination of behavioral and medical interventions, although the specific treatment plan varies depending on the child's age, symptom severity, individual characteristics, and family preferences (CDC, 2024a).

Behavioral therapy is an important component of a multimodal approach to treating ADHD. Based on the principles of applied behavior analysis (ABA), behavioral therapy helps children increase appropriate behaviors and decrease behaviors that interfere with learning and social interactions. This approach emphasizes skill development by providing positive reinforcement for desired behaviors and explicitly teaching appropriate replacement behaviors for undesired behaviors. While many people are tempted to use punishment to help the child with ADHD learn more appropriate behaviors, research shows that this is generally much less effective than using positive reinforcement and motivation. Obviously, there will be times when correction for inappropriate behavior will be necessary. However, these occasions should be treated in the same way as other types of error correction and be conducted calmly and with sensitivity (NASET, 2024).

Education

ADHD often affects a student's performance in school. Approximately 90% of school-age children with ADHD receive some type of school support, such as classroom accommodations or specialized instruction (CDC, 2024a). Many students with ADHD perform below their potential, not because they lack the ability to learn, but because their difficulties with attention, organization, impulse control, and executive functioning interfere with their ability to acquire knowledge and skills and demonstrate their learning. Learners with ADHD in U.S. schools who require only classroom accommodations may receive those under Section 504 of the Rehabilitation Act. Those who also require specialized instruction may be eligible for services under the Other Health Impairments category of IDEA. Some students with ADHD also have a co-occurring disability, such as a specific learning disability or an emotional or behavioral disorder. In these cases, these students may be found eligible for special education under that disability category.

Students with ADHD benefit from classrooms that are structured, predictable, and well organized. Helpful strategies include maintaining a consistent daily schedule, explicitly teaching classroom rules and expectations, and establishing clear routines. As discussed earlier in this chapter, students with ADHD also respond well to positive reinforcement, making schoolwide positive behavior support systems especially beneficial. Because organization and executive functioning are common areas of difficulty, these students often benefit from additional organizational support, including instruction in the use of planners, checklists, and self-management strategies. Graphic organizers and guided notes can also help students organize information, stay engaged during instruction, and successfully complete academic tasks.

When giving directions, be clear, concise, and specific. Avoid giving instructions while students are talking or moving about the room. If students will need to leave their seats, first gain their attention, next give the directions, and then allow them to leave their seats to begin the task. Some students with ADHD have difficulty with multi-step directions, so you may have to give instructions in smaller steps to ensure that these students can successfully follow through.

The same principle applies to larger assignments. Task analysis can be used to break complex projects into smaller, manageable steps, with timelines or checkpoints established for completing each one. For shorter activities, visual timers or even simple kitchen timers can help students become more aware of the passage of time and stay focused on the task. Finally, learning activities that are meaningful, engaging, and relevant to students' interests can help sustain attention and improve performance (NASET, 2024).

Providing immediate feedback whenever possible is especially important for students with ADHD. Many of these students struggle with motivation, so frequent encouragement and positive reinforcement can help sustain effort and engagement. Some students may also require more powerful or immediate reinforcers than are typically needed by their peers. Relying solely on the intrinsic satisfaction of "a job well done" may not be enough. Instead, a well-designed reinforcement system that allows students to earn meaningful incentives can increase motivation, promote appropriate behavior, and support academic success (NASET, 2024).

Students with ADHD also benefit from instructional approaches that actively engage them in the learning process. Direct instruction is particularly effective because it provides frequent opportunities for teacher guidance, active responding, and immediate feedback. Students with ADHD generally maintain attention more successfully during engaging, teacher-directed instruction than during extended periods of independent seatwork. Incorporating novel materials, varied activities, and hands-on learning experiences can further increase engagement and help sustain attention. These strategies reduce the demands placed on students' executive functioning while increasing opportunities for successful engagement and learning (NASET, 2024).

Together, these instructional strategies reduce the demands placed on students' executive functioning while increasing opportunities for successful engagement and learning. Teachers can further support executive functioning by thoughtfully structuring the student's daily schedule. Many students with ADHD demonstrate better attention and on-task behavior earlier in the school day. When possible, it is helpful to schedule subjects requiring sustained attention and concentration, such as reading and mathematics, during the morning while reserving more active or elective classes, such as physical education and music, for later in the day. Elementary school schedules often follow this pattern naturally. However, middle and high school schedules are typically less flexible, so creating a schedule that aligns with a student's attentional strengths may require collaboration and advocacy among teachers, parents, school counselors, and administrators (NASET, 2024).

Because many students with ADHD have difficulty remaining seated for extended periods, incorporating regular opportunities for movement throughout the school day can improve attention and self-regulation. Some movement breaks can involve the entire class, such as brief stretch breaks or teacher-led movement activities. Other opportunities can be built into everyday classroom routines, such as allowing students to stand while working or providing standing desks that any student may use during independent work. Movement can also be incorporated through purposeful classroom responsibilities. Active classroom jobs, such as feeding the class pet, watering plants, or delivering the attendance or lunch count to the office, provide natural opportunities for physical activity. For students who need additional movement beyond these regularly scheduled activities, teachers can create more informal opportunities for a movement break, such as delivering a note to the office, taking materials to another classroom, or distributing supplies to classmates (NASET, 2024).

Other Health Impairments

In addition to ADHD, there are more than 200 other health conditions, many of them rare, that are grouped under the label of Other Health Impairment (OHI). These conditions may be the result of genetic factors or be due to environmental conditions and experiences. Some conditions are present at birth and others are acquired as a result of an illness or an accident. In some cases, the cause is unknown (NASET, 2024). Given the large number of health conditions included under the OHI label, it is difficult to provide more than broad generalizations about these students. To learn more, visit a site, such as the Mayo Clinic, which maintains comprehensive guides to hundreds of conditions.

The child’s parents are often an invaluable source of information as they generally have a great deal of experience managing the child’s health challenges. When teachers are made aware that a new student with a health impairment will be joining their class, they should ask about how the condition may affect school related factors such as the child’s stamina, mobility, physical strength, ability to pay attention, and attendance (NASET, 2024).

The school environment may also need to be adapted to ensure that it is safe, accessible, and supportive for students with health impairments. For example, specialized equipment, such as a wheelchair-accessible desk, adaptive seating, or other assistive devices, may be needed. Schools should also establish procedures for responding to medical needs and emergencies, including ensuring that appropriate staff are trained and prepared to respond if a medical situation arises.

The definition of Other Health Impairment specifically mentions several health conditions in addition to ADHD. These include asthma, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, and Tourette syndrome. It is important to note that the IDEA definition uses the phrase “such as” to introduce this list. This is important because it means that this is not an exhaustive list. A child with a health condition not on this list may still be eligible for services under the category of OHI if the condition negatively impacts strength, vitality and alertness and adversely affects learning (CPIR, 2024).

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School Health Services

School health services may be provided by a school nurse or by another qualified person. These services can include dispensing medications, repositioning to prevent pressure sores, specialized feeding such as tube feeding, clean intermittent catheterization, suctioning, management of a tracheostomy, and planning for the safety and care of the child at school. Services can also include training the child to meet their own hygiene and health care needs while at school (NASET, 2024).

It is not unusual for a student with a health condition to miss school. This may mean missing one day each month for a regularly scheduled medical treatment or it may mean missing school for longer periods of time due to a health crisis. Even if the student misses a large amount of school due to being homebound or hospitalized, the school is still responsible to provide specialized instruction and related services as stipulated in the IEP. Educators need to remember that special education is a service and not a place, and provision of special education services is not limited to the school building. Children can receive special education services in a variety of settings, including in the home and in the hospital (NASET, 2024).

Students whose medical condition requires hospitalization or extended time at home may be eligible for homebound instruction. In these situations, a homebound teacher may provide instruction in the student's home or hospital to help ensure continuity of learning and implementation of the student's IEP or educational plan. However, homebound instruction is not intended to replace classroom instruction on an hour-for-hour basis. Instead, it typically consists of a limited number of instructional hours each week, four to five hours is common, with the expectation that students will complete additional work independently as their health permits. Many hospitals also provide educational services for students who are hospitalized for extended periods. In these cases, hospital educators collaborate with the student's school to coordinate instruction and support continued academic progress (Children's Health, 2024).

As schools have become more accustomed to online and hybrid learning, the need for traditional homebound instruction has decreased for many students with health conditions. Virtual learning often allows students to continue receiving instruction from their usual teachers while also maintaining connections with classmates. Another advantage is that students are often able to participate in more instructional time than would typically be possible through traditional homebound services. Online instruction can also ease transitions between school and home by allowing students to remain connected to their classes as they move from the classroom to home-based learning or return to school following an illness or hospitalization (NASET, 2024).

Conclusion

ADHD and other health impairments present unique challenges, but they do not define a student's potential. When educators understand the educational implications of these conditions, collaborate with families and healthcare professionals, maintain high expectations, and provide individualized supports, students with ADHD and other health impairments can thrive academically, socially, and emotionally.

Notice and Reflect Challenge

Observe a classroom, school, or community setting during the coming week. Notice situations in which an adult helps a learner remain engaged, organized, focused, or self-controlled. If any incidents of challenging behavior occur, pay attention to the strategies that are used before, during, or after the incident.

Reflect

Glossary

References

About the Author

Dr. Kathleen VanTol has over 35 years of experience working in the field of education. She holds a doctorate in special education from Western Michigan University and is a professor of special education at Dordt University. She is also a Board Certified Behavior Analyst and a Board Certified Advocate in Special Education.