Background
Previous research (especially the national MTA study) and expert opinion regarding ADHD makes it clear that ADHD cannot be treated optimally or even diagnosed without reliable data regarding ongoing classroom behavior and academic progress. No successful attempts to create a school community network have previously been reported. This project has explored the potential, obstacles and related costs. In this project we have explored the potential for identifying children with ADHD and communicating with parents and community professionals when parents consent to the screening and request professional (especially community pediatricians) sharing of standardized teacher ratings and results of school-based interventions.

School Screening
In fall 2009, teachers for grades 1-5 in 5 Mississippi school districts completed Vanderbilt teacher ratings for ADHD online for all children whose parents consented (47%; N = 5727) in a separate study yielding 1091 children exceeding the cut score for ADHD symptoms in 20.4%. In spring 2009, the ADHD ratings were repeated for children screening positive for ADHD in the fall plus 103 other children randomly selected from those with initial negative screens. Teachers also completed a school intervention questionnaire reflecting disciplinary actions and some other school resources utilized for the children. We contacted parents of children screening positive for ADHD and used a structured interview (N = 471 reached) to attempt to enroll them and to understand any resistance to a physician referral. One theme we heard from parents during the phone calls was that they felt the problem was in the management or perception of the teacher rather than in their child. In the fall of '09 917 children were rescreened, those who were positive for ADHD the previous spring plus the 103 randomly selected controls. 365 were positive for ADHD and individualized letters were sent to those positive both times to motivate enrollment in addition to recruiting phone calls. The letters described the child's profile of performance/behavior such ADHD subgroup characteristics, co-morbid risks, disciplinary actions taken the previous year and any school supports in place. Although some parents noted that the first year was a "wake-up call", the rate of enrolling was still disappointing. In the spring of '10 we obtained teacher ADHD ratings again and collected data on school interventions (SIQ) being provided for these children and individualized letters reporting on difficulties over the span of two years were mailed to parents to encourage professional referral. The SIQ costs questionnaire and Vanderbilt ratings were completed by 328 teachers for 761 children. Special education coordinators compared their list of children identified as in special education with those identified by the teachers as a reliability check and a sample of 29 special education teachers also completed the SIQ for some of the children.

Results and Comments re school screening: Prior to this project there were no school/community screening programs for ADHD in Mississippi and only one failed attempt in the professional literature (Wolraich, et. al, 2005). Such programs could be of great public health value since a registry of positive cases could be identified and provided with early intervention services. One likely reason that programs like this do not exist is that standard screens identify such a large proportion of all children that providing services on that scale seems unfeasible. This appears especially true in programs such as this one, where consent was required, which may have created a selection bias toward a larger proportion (20.4%) of positive children overall and a larger proportion with inattentive ADHD (11.4%) than expected – a subgroup less likely to come to attention at school as they do not have disruptive behavior. Most of these parents (77.4%) reported that they were already aware of development and behavior problems but only 25% were under care (Sturner, 2009-2). We therefore identified a large group of children with unmet needs. However, we also discovered that parents generally do not pursue a referral to their child's doctor from a single positive ADHD screening test result. Our interviews with these parents revealed that they tended to believe the problem was a teacher issue. Also, schools are reluctant to identify new cases of ADHD fearing they will be responsible for expensive interventions. We therefore created models for screening that address issues of feasibility, school cost and parent acceptance. We have illustrated how subgroups of children with ADHD can be identified with characteristics that put them at even higher risk for requiring supplementary, expensive educational interventions and more severe disciplinary actions. This approach of identifying higher risk subgroups may motivate more parents to seek help and schools to provide targeted intervention that may thus be less intensive and expensive, resulting in reduced costs rather than additional ones. We have identified a number of ways subgroups could be identified for intervention. For example, children who had persistent difficulties through the year might be a better target group than children only showing difficulties initially on a single screen. By end 59.7% of the first screening year children initially screening positive for ADHD still met criteria (Sturner, R. et. al. 2009-1).

We also found significant differences in disciplinary outcomes when comparing all standard clinical ADHD groupings (Sturner, et al., 2010) and when comparing approaches for selecting the highest risk ADHD subgroups using either standard clinical, statistical modeling, or a Recursive Partitioning Algorithm (CART). Derived groupings were found to predict office referral better than standard groups and CART better than factor analysis with 6 distinct syndromes of behavior predicting disciplinary outcomes between 80.0 and 89.3% almost all including the "angry" item in combination with ADHD symptoms and performance variation. Recognizing and tracking specific syndromes of behavior, especially those including anger, in children with ADHD symptoms may help point educators to interventions other than just escalating discipline.

It is our impression from this project that screening in the schools for ADHD could be a very important clinical endeavor but such screening and follow through is likely to be most productive when it is done universally and results are shared with parents on an ongoing manner. High-risk children should be tracked by educational and disciplinary outcomes, so escalating problems can be highlighted and more aggressively addressed.

Funding Sources

• Cisco Foundation
• NIMH ARRA Grant
• Asbury Foundation