Child and Adolescent Mental Health 21, No. 4, 2016, pp. 183–191 doi:10.1111/camh.

12159

A school consultation intervention for adolescents

with ADHD: barriers and implementation strategies
Margaret H. Sibley1, Sandra Olson2, Candance Morley3, Mileini Campez4 &
William E. Pelham Jr3
1
Department of Psychiatry and Behavioral Health, Herbert Wertheim College of Medicine, Florida International
University, Miami, FL, USA. E-mail: msibley@fiu.edu
2
Hillsborough County Public Schools, Tampa, FL, USA
3
Center for Children and Families, Florida International University, Miami, FL, USA
4
Department of Psychology, Florida International University, Miami, FL, USA

Background: Academic impairment is among the most troubling domains of impairment for adolescents with
Attention Deficit/Hyperactivity Disorder (ADHD). Method: This investigation presents results of a yearlong aca-
demic intervention delivered to adolescents with ADHD (N = 218) by engaging school staff as interventionists
through behavioral consultation with an outside mental health professional. Results: The intervention was
coordinated successfully in some cases, but not in others. The principal challenge to intervention coordination
was sustaining monthly contact between consultants and interventionists (38.5% success rate) and scheduling
in-person consultation meetings with interventionists (40.0% success rate). Implementation of the interven-
tion was enhanced when the student (a) attended a public (vs. private) school, (b) had an IEP or Section 504
plan in place, (c) was in middle school (vs. high school), (d) had a parent who communicated regularly with the
school, and (e) had a special education support staff member or counselor (vs. teacher or administrator) as a
school interventionist. Conclusions: Considering these data, recommendations are provided for effective
coordination of academic interventions for adolescents with ADHD.

Key Practitioner Message

• Many practitioners who work with adolescents with ADHD wish to coordinate academic interventions with
secondary school staff.
• Key barriers to doing so include difficulties monitoring student progress and scheduling in-person consulta-
tion meetings with school staff; however, these barriers are reduced when a school counselor or special
education staff member (rather than a teacher) is engaged as a partner in intervention delivery.
• Outside professionals receive better collaboration from schools when the student has a recognized
diagnosis through an individualized education plan or Section 504 plan.
• Promoting parent-secondary school collaboration is a key to enhancing academic intervention delivery.
• Schools may be reticent to provide additional interventions in certain educational settings including gifted
classes, private schools, and high schools.

Keywords: ADHD; adolescence; intervention

substance abuse (Molina & Pelham, 2003). Among these

Introduction
Attention Deficit/Hyperactivity Disorder (ADHD; Ameri-
can Psychiatric Association-APA, 2013) is a neurodevel-
opmental disorder characterized by impairing levels of
inattention, overactivity, and impulsivity that affects 5–
10% of adolescents (Centers for Disease Control and
Prevention, 2013). Adolescents with ADHD experience a
range of symptom-related impairments that include
trouble with friendships (Bagwell, Molina, Pelham, &
Hoza, 2001), frequent and intense arguments with par-
ents (Edwards, Barkley, Laneri, Fletcher, & Metevia,
2001), school failure (Kent et al., 2011), disciplinary and
legal problems (Sibley et al., 2011), motor vehicle acci-
dents (Barkley, Murphy, & Kwasnik, 1996), elevated
rates of teen pregnancy (Mick et al., 2011), and
concerns, secondary school academic impairment is
particularly troubling because it often catalyzes addi-
tional risks (Kuriyan et al., 2013; Molina et al., 2012),
making it a key target for treatment.
Empirically developed and tested academic interven-
tions for adolescents with ADHD are historically
resource-intensive models designed for afterschool
(Evans, Schultz, DeMars, & Davis, 2011; Langberg
et al., 2007) or summer delivery (Smith, Pelham, Gnagy,
& Yudell, 1998). The common element of these treat-
ments is remediation of adolescent organization, time
management, and planning (OTP) deficits, which are the
most commonly recognized mechanism of academic
impairment in these youth (Barkley, Edwards, Laneri,
Fletcher, & Metevia, 2001; Langberg, Dvorsky, & Evans,

© 2016 Association for Child and Adolescent Mental Health.

Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
184 Margaret H. Sibley et al.
2013; Sibley, Altszuler, Morrow, & Merrill, 2014). A key
component of OTP interventions for teens with ADHD is
adult supervision and reinforcement of skill practice
(Evans et al., 2011; Sibley et al., 2016). Without adoles-
cent–adult partnership in intervention delivery, teens
with ADHD are prone to desist new skill use over time
(Sibley et al., 2016). Although OTP treatment modules
produce large effects, empirically tested delivery models
tend to be highly intensive (120–400 hr of treatment;
Evans et al., 2011; Smith et al., 1998) and rely on non-
stakeholder adults (i.e., hired camp counselors, college
students) to oversee and reinforce OTP skill use. As a
result, school districts may not possess the resources to
implement these treatments, and reinforcement of OTP
skill use may not occur during the adolescent’s daily
activities.
One solution to these criticisms may be a behavioral
consultation intervention delivered to secondary school
staff. For elementary school students with ADHD,
behavioral school consultation is an effective and com-
monly implemented low-resource model (DuPaul &
Weyandt, 2006; Fabiano et al., 2009; Pfiffner, Barkley,
& DuPaul, 1998). Behavioral school consultation is an
indirect model of service delivery that has a long history
of effective implementation for a range of classroom-
based concerns (Reddy, Barboza-Whitehead, Files, &
Reddy, 2000). Under this model, inside or outside
mental health professionals consult with school staff to
collaboratively devise school-based interventions
(Erchul & Sheridan, 2014). These efforts typically
include collaborative conceptualization of the child’s dif-
ficulties at an initial meeting, collection of observational
and rating scale data about the child’s classroom behav-
ior, joint teacher–consultant intervention planning
meetings, and regular follow-up with the teacher to mon-
itor student progress (DuPaul & Weyandt, 2006). These
interventions produce large effects on child ADHD symp-
toms, problem behaviors, and academic performance in
the elementary school classroom setting (Fabiano et al.,
2009).
Given the success of low-intensity behavioral consul-
tation models in treating elementary school children
with ADHD, it is surprising that this approach rarely has
been applied to treating OTP deficits in adolescents with
ADHD. Such an intervention would locate treatment in
the setting of impairment, engage adults with which the
adolescent has daily contact as interventionists, and
might overcome resource barriers that have prevented
widespread implementation of higher intensity treat-
ment models for adolescents with ADHD. In a small
controlled study (N = 47), Langberg, Epstein, Becker,
Girio-Herrera, and Vaughn (2012) recruited middle
school counselors who were compensated for their par-
ticipation, provided them with an OTP intervention man-
ual, and offered brief training on its implementation.
Although formal behavioral consultation was not pro-
vided after the initial training, this study demonstrated
that highly engaged secondary school staff can effec-
tively deliver low-resource OTP interventions during the
school day. The only evaluation of a secondary school
behavioral consultation intervention for ADHD was a
quasiexperimental study by Evans, Serpell, Schultz, and
Pastor (2007). In this study, about half of the participat-
ing staff declined to implement more than one interven-
tion, failed to make adjustments when given consultant
Child Adolesc Ment Health 2016; 21(4): 183–91
feedback, and displayed inadequate fidelity when imple-
menting the interventions (Evans et al., 2007). Despite
implementation difficulties, this study demonstrated
promising differences in academic failure rates between
students at treatment and comparison schools (Schultz,
Evans, & Serpell, 2009). Thus, secondary school staff
appear capable of delivering brief OTP interventions to
students (Langberg et al., 2012); however, they appear
to do so with variable consistency when engaged in natu-
ralistic settings (Evans et al., 2007).
There may be several contributors to variable sec-
ondary school staff participation in behavioral consulta-
tion interventions for ADHD. Traditionally, these models
require approximately 5 hr of teacher meetings per stu-
dent over the course of a semester in addition to the time
spent in implementing the daily intervention protocols
(DuPaul & Weyandt, 2006; Pfiffner et al., 2007). Middle-
and high-school regular education teachers typically
teach over 100 students daily and counselors often carry
caseloads of over 1,000 students (Benner & Graham,
2009; Eccles, 2004). As such, some school staff
members may possess insufficient time to deliver the
interventions. Secondary school teachers typically iden-
tify as teachers of ‘content’ (e.g., Algebra), and may not
be trained to provide intervention support to students
(NCRI, 2013). For example, national survey data indicate
that secondary school teachers commonly believe that
providing intervention to a student with ADHD is outside
of their job scope (Fabiano et al., 2002). In addition,
secondary school promotes a culture of self-reliance, so
some staff may feel that supportive interventions for
ADHD are unwarranted (DuPaul & Weyandt, 2006;
Rubie-Davies, Flint, & McDonald, 2012). Even when
teachers wish to provide interventions, the structure of
secondary schools can be prohibitive – teachers may not
see the students daily, breaks in between classes may
provide insufficient time to deliver interventions, and the
students and teachers may not share free periods
(Eineder & Bishop, 1997).
Despite these barriers, behavioral consultation for
secondary school students with ADHD may be success-
ful under certain circumstances. For example, increased
staff time and resources may be available to secondary
students with ADHD when they receive accommodations
through an Individualized Education Plan (IEP) or
Section 504 Plan. When students are placed in high-
resource educational settings, their teachers may teach
fewer students and have designated time for intervention
delivery (NCRI, 2013). Furthermore, if noninstructional
staff (i.e., counselors, administrators, lead special edu-
cators) are engaged in behavioral consultation, they may
also have more time and flexibility to coordinate care.
Finally, a parent who is highly involved in schooling may
collaborate with school staff during intervention delivery
by assisting with monitoring, skill reinforcement, or con-
tingency management. When parents are highly engaged
in consultation, they relieve some of the burden of inter-
vention delivery from school staff (Hill & Tyson, 2009).
The purpose of this study was to identify specific
implementation challenges to and environmental factors
that enhance delivery of a secondary school-based
behavioral consultation model for adolescents with
ADHD. Outside school consultants offered a full-year
OTP consultation intervention to the school staff of 218
culturally diverse adolescents with ADHD attending 114
© 2016 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12159 Secondary school consultation for ADHD 185

different local schools. For our first aim, we monitored Table 1. Characteristics of the sample
the consultant and school interventionist interactions to Age at start of school year M (SD) 13.28 (1.62)
detect the aspects of intervention delivery (i.e., identify- Male (%) 73.9
ing a school interventionist, monitoring student pro- Race/Ethnicity (%)
gress, holding consultation meetings, and obtaining White Non-Hispanic 6.5
school interventionist commitment to deliver interven- Black/African American 16.7
tions) that provided the greatest challenges to initial Hispanic any race 73.1
implementation. We hypothesized that holding consul- Other 3.7
tation meetings and obtaining interventionist commit- Parent education level (%)
High school or less 21.7
ment would be the most challenging aspects of
Some college 34.4
delivering behavioral consultation in secondary schools
Bachelor’s degree 28.8
(Evans et al., 2007). For our second aim, we examined Master’s degree or higher 15.1
predictors of successful implementation (i.e., possessing Estimated Full Scale IQ M (SD) 95.38 (11.73)
an IEP or 504 plan, educational setting, parent–school Math achievement 92.34 (16.28)
communication, school level, and type of professional Reading achievement 95.06 (14.41)
that served as the interventionist) to identify circum- ADHD diagnosis (%)
stances that may enhance future attempts to deliver ADHD-PI 39.0
consultation models to adolescents with ADHD. We ADHD-C 60.1
hypothesized that possessing an IEP or 504 plan, ADHD-H/I 0.9
ODD/CD (%) 36.7
placement in special education (NCRI, 2013), high par-
Class placement (%)
ent–school communication (Hill & Tyson, 2009), and
Regular 72.9
receiving the intervention from a counselor (rather than Gifted 7.9
teacher; Langberg et al., 2012) would be associated with Special education 19.2
successful implementation. School accommodations for ADHD (%)
Individualized education plan 47.1
Section 504 plan 16.2
Method None 36.7
Participants
Participants were 218 adolescents with ADHD in the 6th
tered a brief phone screen to parents containing DSM-IV-TR
(n = 112) or 9th grade (n = 106) in a large ethnically diverse
ADHD symptoms and questions about impairment. Families
US urban area. These students participated in a controlled
were invited to an intake assessment if the parent phone
trial designed to evaluate the effects of behavioral interven-
screen and teacher nomination indicated: (a) four or more
tion for ADHD at the transition to middle- and high school
symptoms of either Inattention or Hyperactivity/Impulsivity
(Sibley, Morley, Olson, Coxe, & Pelham, 2015). Participants
(APA, 2000) and (b) clinically significant academic problems
attended 114 different schools (94.5% public) in the fourth
(at least a ‘3’ on a 0–6 IRS; Fabiano et al., 2006). At intake,
largest school district in the United States, which comprises
informed parental consent and youth assent were obtained.
392 schools, over 350,000 students, and over 40,000
ADHD diagnosis was confirmed through a combination of
employees. The school district covers over 2,000 square
parent structured interview (Computerized-Diagnostic Inter-
miles including rural, suburban, and urban neighborhoods.
view Schedule for Children; Shaffer, Fisher, Lucas, Dulcan,
The school district is the second most ethnically diverse in
& Schwab-Stone, 2000) and parent and teacher symptom
the United States, with students speaking 56 different
and impairment ratings. Dual Ph.D. level clinical review was
languages at home and representing 160 countries of origin.
used to determine diagnosis and study eligibility. As part of
The district reports that 70.2% of students receive free or
this process, clinicians used all available information to con-
reduced-priced lunch (Miami-Dade County Public Schools,
sider age of onset, chronicity, comorbid symptoms, and set-
2015). Annual per-pupil expenditure in the local school dis-
tings of impairment when making ADHD diagnoses. When
trict ($12,298; Miami-Dade County Public Schools, 2015) is
disagreement occurred, a third clinician was consulted. Fam-
very similar to the national average for the same year
ilies enrolled and received treatment in three cohorts of
($12,608; U.S. Department of Education, 2014), suggesting
equivalent size (n = 72, 73, 73) that were recruited in the
that school resources were reflective of typical United States
spring of three consecutive school years and were provided
schools. Sample demographic characteristics are reflective of
treatment through the summer and upcoming school year.
the district’s diversity (see Table 1).
No incentives were given to parents, adolescents, or school
At study intake (end of 5th or 8th grade), the participants staff for participation in treatment activities.
were referred by their schools and were required to: (a) meet
Following summer intervention, participants in both study
DSM-IV-TR (APA, 2000) criteria for ADHD, (b) be matriculating
conditions received identical school year follow-up services
to 6th or 9th grade, (c) display significant academic impairment
using a manualized treatment based on existing consultation
(at least a ‘3’ on a 0–6 the teacher version of the Impairment
interventions for adolescents with ADHD (Evans et al., 2007;
Rating Scale; IRS, Fabiano et al., 2006), (d) have an estimated
Langberg et al., 2012). Two master’s level clinicians served as
IQ > 75, and (e) have no history of an autism spectrum disor-
consultants (one school social worker, one school psychologist),
der. Participants were randomly assigned to receive high-
each carrying an annual caseload of approximately 36 students
intensity (320 hr adolescent + 12 hr parent services) or low-
at a time, each of whom required a maximum of 2 hr of monthly
intensity (12 hr adolescent + 12 hr parent services) summer
clinical contact. Based on past empirical findings, the interven-
intervention (for description of these interventions and full
tion herein promoted successful delivery in secondary school
study design, see Sibley et al., 2015). Following summer inter-
settings by: (a) flexibility in who could serve as the school inter-
vention, all participants received school year follow-up services
ventionist, (b) conducting monthly discussions about student
using the consultation model described herein.
performance via in-person meeting, phone, or email according
to the school interventionist’s preferences, and (c) utilizing prac-
Procedures tical OTP intervention components that can be implemented
All procedures were approved by the university’s Institutional through brief interventionist-student interactions (Evans et al.,
Review Board and the local school district’s research com- 2007; Langberg et al., 2012). The OTP components included
mittee. Trained bachelor’s level research assistants adminis- domain-specific skill-based interventions designed to promote:

© 2016 Association for Child and Adolescent Mental Health.

186 Margaret H. Sibley et al.
(a) recording homework in a planner, (b) planning the use of
time prior to initiating homework (c) monitoring missing work
through the online grade book, (d) regularly organizing and
monitoring the cleanliness of the student’s book bag, (e) a
home–school progress report, (f) behavioral problem-solving
with specific teachers, (g) note taking instruction and monitor-
ing, and (h) practicing appropriate study skills. When the target
of academic impairment was beyond the scope of manualized
interventions, the consultant and interventionist conjointly
devised specialized interventions. When practical, contingency
management was integrated in all interventions using school-
based privileges.
During the first week of the school year, consultants con-
tacted each student’s school to request an initial meeting.
Earlier, the consultant contacted all parents by preferred
method of communication to extend parents the opportunity
to schedule the school meeting on their own if they so pre-
ferred. When parents declined to schedule the meeting, the
consultant relayed the meeting time and date to parents as
soon as it was scheduled and encouraged their attendance.
As a result, parents attended 47.4% of initial school meet-
ings. At the initial school meeting, consultants worked with
school to identify a staff member who would be well posi-
tioned to deliver brief OTP interventions to the student.
School staff members who volunteered to serve as interven-
tionists were 27.4% teachers, 57.2% counselors, 3.4%
administrators, and 12.0% special education staff.
At this meeting, the consultant and interventionist devised
a plan for holding monthly discussions about the student’s
school functioning. These semistructured interviews included
systematic querying of the student’s functioning across the
seven OTP domains noted above. At the end of each query, the
consultant used a five-point impairment rating scale (1 = defi-
nitely does not need additional intervention to 5 = definitely
needs additional intervention) to rate each domain. Integrating
information gathered during these monthly interviews with
teachers, identically formatted monthly interviews with par-
ents, and review of student grades, the consultant provided a
final rating of the student’s monthly need for intervention
across the seven target domains listed above. Consultants
contacted the school interventionists to request a 30-min in-
person consultation meeting when a student scored a ‘4’ or ‘5’
on the impairment rating for any domain. The domain of
greatest impairment became the target of intervention. Con-
sultants concomitantly informed the parents that the student
qualified for monthly intervention. When attempts to schedule
consultation meetings were not immediately successful, the
parents were invited to facilitate contact with the school inter-
ventionists. Once a consultation meeting was scheduled, the
parent was informed of the date and time of the meeting and
was encouraged to attend. A parent attended 37.6% of consul-
tation meetings. During the consultation meetings, the con-
sultant discussed intervention options with the school
interventionist using a collaborative approach that empha-
sized the autonomy of the interventionist in designing the
details of the intervention with consultant input.
Measures
Implementation. In a secure database, consultants system-
atically logged whether and when an initial school meeting
occurred, all attempts to contact school staff for monthly pro-
gress monitoring or to schedule meetings, whether students
qualified for monthly intervention, whether the school consulta-
tion meetings were held, which interventions were selected, and
the proceedings and outcomes of all the consultation meetings
(i.e., meeting attendance, whether the consultant agreed to
implement an intervention). These logs were coded to produce
the following variables for each participant: (a) occurrence of the
initial school meeting (0 = no/1 = yes), (b) a count of the num-
ber of months in which the consultant attempted to coordinate
a consultation meeting because a need for intervention was
indicated by monthly progress ratings, (c) a count of the number
of monthly requests for consultation that resulted in a meeting
with the school, and (d) a count of the number of consultation
Child Adolesc Ment Health 2016; 21(4): 183–91
meetings at which the interventionist agreed to implement an
intervention for the student.
Predictors of implementation success. Class placement
(gifted vs. regular vs. special education), whether the student
possessed an IEP or Section 504 plan (IEP, 504, none), school
type [private vs. regular public vs. special resource allocated
(SRA) public], and school level (middle vs. high) were obtained
through direct access to student records. SRA public schools
were historically struggling schools to which the school district
allocated additional resources for instruction, intervention, and
enrichment to accelerate student achievement scores. Parent–
school communication was measured by consultant report pro-
vided at the end of the year to the question: ‘How well do you
believe the parent communicated with the school?’ using a
seven point scale (1 = not at all effectively, 7 = very effectively).
School interventionist position (teacher vs. administrator vs.
school counselor vs. special education staff) was obtained
through school interventionist report.
Results
Implementation
Descriptive statistics were obtained to provide informa-
tion about implementation of the intervention at each
step in the behavioral consultation model. Figure 1 pro-
vides a consort diagram for intervention implementa-
tion. In 92.7% of cases (n = 202/218), the parent agreed
to school-based services. In 87.6% of cases, (n = 191/
218), the school agreed to collaborate with the consul-
tant. With the approval of the parent and the school, an
initial school meeting was held and an interventionist
volunteered for 80.3% of participants (n = 175/218). In
cases where an initial school meeting did not occur, the
reasons were: school did not respond to consultant
attempts to contact (46.5%; n = 20), parent was not
interested in receiving services (18.6%; n = 8), school
was not interested in receiving consultation (16.3%;
n = 7), school required parent to attend meeting and
parent did not respond to the attempts to contact
(11.6%; n = 5), student was not interested in participat-
ing in intervention (2.3%; n = 1), student was placed into
state custody (2.3%; n = 1), and student was placed in a
residential care facility (2.3%; n = 1).
For participants with a school interventionist
(n = 175), the consultant sought an average of 4.75
(SD = 1.41) monthly discussions with the school inter-
ventionists to assess the need for additional interven-
tion. On average, 38.5% of these attempts were
answered. In all, 96.6% of school interventionists
engaged in at least one progress-monitoring discussion
during the year (n = 169/175). For participants
(n = 169) whose school interventionists engaged in at
least one progress-monitoring discussion, decision to
intervene was made at least once for 75.7% of these par-
ticipants (n = 128/169). When the verdict of monthly
contact was a need for intervention, on average, 40.0% of
indicated in-person consultation meetings occurred.
Such a meeting occurred at least once for 62.5% of par-
ticipants (n = 80/128) for whom the interventions were
deemed indicated. The mean number of in-person con-
sultation meetings per participant was .67 (range = 0 to
3). When consultation meetings were held, the school
interventionist agreed to implement an intervention at
an average of 77.4% these meetings. In all, at least one
intervention was successfully coordinated for 51.6% of
participants with indicated impairment (n = 66/128).
© 2016 Association for Child and Adolescent Mental Health.
doi:10.1111/camh.12159
Table 2 displays the frequency with which each inter-
vention module was discussed with and agreed to by the
school interventionist at the in-person consultation
meeting.
Predictors of implementation success
To examine the predictors of successful intervention
coordination at each step of implementation, four sepa-
rate Generalized Linear Model analyses were conducted
for the following outcomes: (model 1) securing a school
interventionist (yes/no; n = 202; participants whose
parents declined intervention services excluded), (model
2) number of monthly progress discussion held
(n = 175; participants without a school interventionist
excluded), (model 3) rate of school interventionist partic-
ipation in indicated consultations (n = 128; participants
for whom no consultation meetings were indicated
excluded), and (model 4) school interventionist always
agreed to implement an intervention when indicated
(yes/no; n = 80; participants for whom consultation
meetings were not held were excluded).
Generalized Linear Modeling has been shown to be a
powerful method of detecting relationships involving
normally and non-normally distributed variables
(McCullagh & Nelder, 1989). All assumptions (including
appropriateness of variable distributions) were tested
prior to analyses. Model 1 assumed a binomially dis-
tributed outcome and employed a logit link function and
Consultant attempted to
schedule initial school
meeting (N = 218)
Initial school meeting
held (n = 175)
At least one monthly
discussion held with
interventionist (n =169)
Impairment noted for at
least one month (n= 128)
Consultation meeting
agreed to at least once by
interventionist (n = 80)
Interventionist agreed to
implement at least one
intervention (n = 60)
Figure 1. Intervention coordination success rates
© 2016 Association for Child and Adolescent Mental Health.
Secondary school consultation for ADHD 187
five simultaneously modeled predictors: school services
eligibility (IEP vs. 504 vs. none; reference category =
none), class placement (gifted vs. special education vs.
regular; reference category = regular), parent–school
communication, school type (private vs. SRA public vs.
regular public; reference category = regular public), and
school level (high vs. middle; reference category = mid-
dle). Models 2 and 3 assumed normally distributed
outcomes with an identity link function and model 4
assumed a binomially distributed outcome and
employed a logit link functioning. For models 2–4, six
simultaneously modeled predictors: school services eli-
gibility (IEP vs. 504 vs. none; reference category = none),
class placement (gifted vs. special education vs. regular;
reference category = regular), parent–school communi-
cation (continuous normally distributed variable),
school type (private vs. SRA public vs. regular public; ref-
erence category = regular public), school level (high vs.
middle; reference category = middle), and intervention-
ist position (administrator vs. counselor vs. special edu-
cation staff member vs. teacher; reference category =
teacher) were employed .
Full results for models 1–4 are found in Tables 3 and
4. Results indicated that schools were most likely to
agree to an initial school meeting and identify an inter-
ventionist if parent involvement was high and a school
interventionist was least likely to be identified if the
school was private. Monthly progress discussions
Parent declined services
(n = 16)
No initial school meeting
held (n = 43)
School declined meeting
(n = 27)
188 Margaret H. Sibley et al. Child Adolesc Ment Health 2016; 21(4): 183–91

Table 2. Implementation of intervention modules barriers may be to position permanent consultants in

schools, so that they are readily accessible to school staff
Discussed at Agreed to
(Sadler, Evans, Schultz, & Zoromski, 2011). However, it
meeting n implement n (%)
seems that this solution may not be financially viable for
Recording homework in a 66 47 (71.2) many school districts (American Association of School
planner Administrators, 2012). Another solution may be to
General problem-solving 10 6 (60.0) employ an intervention model with fewer points of con-
Daily/weekly progress report 21 15 (71.4) tact between the consultant and interventionist – such a
Specific teacher consultation 4 4 (100.0) model was successfully implemented by Langberg et al.
School materials organization 7 6 (85.7) (2012). It may be the case that providing school staff with
Active study skills 3 2 (66.7)
a user-friendly intervention manual and small incen-
Homework to do list 7 6 (85.7)
Missing assignment tracking 2 2 (100.0)
tives for delivery (Langberg et al., 2012) may be a more
Note-taking 0 – affordable and practical option for schools than offering
ongoing consultation. One implication of the interven-
‘Discussed at Meeting’ indicates the number of participants for tionist’s difficulties scheduling meetings with and receiv-
whom the consultant suggested the intervention at the in-person ing feedback from the consultant is that outside mental
consultation meeting. ‘Agreed to Implement’ indicates the rate health professionals sometimes secured by parents to
at which the school interventionist agreed to implement the sug- coordinate secondary school-based interventions may
gested intervention.
face difficulties collaborating with school staff. As such,
these clinicians should seek effective nonschool-based
models for academic intervention delivery (e.g., Meyer &
occurred most frequently when the student possessed a Kelley, 2007; Sibley et al., 2016) when unable to over-
504 plan, the student was placed in gifted classes, or the come these challenges.
interventionist was a special education support staff Despite noted communication problems between con-
member. When intervention was indicated, school inter- sultants and interventionists, for some participants, inter-
ventionists were most likely to invite consultation if par- vention was coordinated successfully and repeatedly. A
ent involvement was high and were least likely to do so if
the student was in high school or gifted classes. Finally,
when consultation meetings were held, school interven- Table 3. Predictors of initial identification of Interventionist and
tionists were most likely to consistently agree to inter- Interventionist response to progress ratings
vention delivery if the student was in middle school and
they were special education support staff member or Χ2 df p b SE p
counselor. Securing an Interventionist 23.43 8 <.01
(n = 202)
School services (ref: none)
Discussion
IEP .17 .42 .70
This investigation sought to identify implementation chal- 504 Plan 1.84 1.10 .09
lenges to and environmental factors that enhance delivery Class placement (ref: regular)
of a secondary school-based consultation model for ado- Gifted .36 .72 .61
lescents with ADHD. Findings mirrored past evidence Special education .12 .53 .83
Parent–school communication .26 .13 .04
(Evans et al., 2007) that secondary school consultation
School type (ref: regular public)
interventions for adolescents with ADHD are coordinated Private 1.58 .67 .02
successfully in some cases, but not in others. The princi- SRA public .10 .70 .89
pal challenge to intervention coordination was sustaining School level (ref: middle)
monthly contact between the consultants and interven- High school .57 .42 .18
tionists (38.5% success rate) and scheduling in-person Interventionist response 49.46 11 <.01
consultation meetings with the interventionists (40.0% to progress ratings (n = 175)
success rate). Implementation of the intervention was School services (ref: none)
enhanced when the student (a) attended a public (vs. pri- IEP .07 .06 .23
vate) school, (b) had an IEP or Section 504 plan in place, 504 Plan .13 .07 .04
Class placement (ref: regular)
(c) was in middle school (vs. high school), (d) had a parent
Gifted .27 .09 <.01
who communicated regularly with the school, and (e) had Special education .10 .06 .10
a special education support staff member or counselor (vs. Parent–school communication .00 .01 .71
teacher or administrator) as a school interventionist. Each School type (ref: regular public)
finding is discussed below. Private .00 .14 .99
Results indicated relative success in obtaining parent SRA Public .02 .08 .77
(92.7%) and school (87.6%) approval to conduct the School level (ref: middle)
consultation intervention. In addition, when in-person High school .06 .05 .22
consultation meetings were held, the interventionist Interventionist Position
agreed to deliver an indicated OTP intervention in a (ref: teacher)
Administrator .16 .14 .25
majority of cases (77.4%). The greatest challenges to
SPED Staff .21 .08 <.01
implementation of the secondary school consultation Counselor .07 .07 .33
model was coordinating the monthly progress discus-
sions with the interventionists and scheduling in-person b, unstandardized beta; SE, standard error; p, significance.
consultation meetings. One solution to these communication Bold indicates significant values (p < 0.05).

© 2016 Association for Child and Adolescent Mental Health.

doi:10.1111/camh.12159 Secondary school consultation for ADHD 189

Table 4. Predictors of Interventionist agreement to a consulta- Other factors (see Tables 3 and 4) that influenced
tion meeting and to implement interventions delivery included school level (middle vs. high school)
and parent–school communication. High schools may be
Χ2 df p b SE p
more likely to emphasize student autonomy than middle
Interventionist consultation 19.95 11 .04 schools – creating philosophical barriers to intervention-
Agreement (n = 128) ist engagement (Rubie-Davies et al., 2012). There is
School services (ref: none) almost no research evaluating the school-based inter-
IEP .02 .09 .86 ventions for high-school adolescents with ADHD (for
504 Plan .03 .10 .73 exception, see Sadler et al., 2011), indicating a need to
Class placement (ref: regular) develop realistic and effective strategies that match typi-
Gifted .24 .12 .05
cal school contexts. In addition, efforts to engage parents
Special education .12 .09 .18
Parent–school communication .03 .02 .03
of adolescents with ADHD in appropriate collaboration
School type (ref: regular public) with schools may enhance school staff willingness to
Private .14 .19 .47 devote intervention time to a student (Hill & Tyson,
SRA Public .12 .13 .37 2009). Parent–school collaborative interventions are
School level (ref: middle) successful for elementary school-aged students with
High school .23 .07 <.01 ADHD (Power et al., 2012) and these findings suggest
Interventionist Position (ref: teacher) that parent involvement remains an important mecha-
Administrator .29 .20 .15 nism of treatment in adolescence.
Counselor .07 .12 .54 One limitation to this study is its local sample, which
SPED Staff .09 .11 .44
was highly Hispanic and African American, and its
Interventionist Intervention 19.92 11 .05
agreement (n = 80)
large centralized school district, which may not be
School services (ref: none) representative of all US schools. Despite, our sample’s
IEP .54 .84 .52 ethnic diversity, it should be noted that the socioeco-
504 Plan .48 .93 .60 nomic distribution (see Table 1) in our sample included
Class placement (ref: regular) equal representation of highly, moderately, and
Gifteda – – – modestly educated parents. However, the findings in
Special education .22 .84 .79 this study may not generalize to school districts with
Parent–school communication .03 .15 .83 above-average financial resources. In addition, we did
School type (ref: regular public) not collect personal information (e.g., race, salary, age)
Privatea – – –
from the interventionists, as they were not considered
SRA Public 1.02 1.31 .44
School level (ref: middle)
participants in the study. Finally, we were unable to
High school 2.07 .74 <.01 measure the extent to which the interventionists appro-
Interventionist Position (ref: teacher) priately implemented agreed upon interventions. Thus,
Administratora – – – a limitation to this study is its lack of fidelity and integ-
SPED Staff 3.30 1.32 .01 rity observations during school staff attempts to imple-
Counselor 2.34 1.22 .05 ment interventions. Developing methods to accurately
measure intervention fidelity in similar contexts is an
b, unstandardized beta; SE, standard error; p, significance.
a important area for future research.
Indicates that the parameter could not be estimated due to too
In conclusion, it appears that under certain circum-
few cases with values in this cell.
Bold values indicate p < 0.05. stances, consultation models for ADHD can be success-
fully coordinated in secondary schools. However,
successful implementation of this treatment model was
lower than reported in elementary schools (DuPaul &
clear implication of this study (see Tables 3 and 4) is that Weyandt, 2006; Pfiffner et al., 2007; Power et al., 2012).
obtaining an IEP or 504 plan for a secondary school stu- As such, continued development of practical school-
dent with ADHD is an important key to enhancing school- based interventions that match secondary school
based services – including increasing school staff openness environmental constraints are needed. For example,
to collaborating with outside therapists. Thus, clinical pro- engaging model peer interventionists (instead of over-
fessionals should encourage families of secondary school burdened school staff) may be a novel approach to deliv-
students with ADHD to initiate this process. Placement in ering treatment within the framework of available school
certain educational settings also facilitated successful resources. The findings herein also suggest a need to
intervention coordination. In particular, although gifted make available OTP interventions for teens with ADHD
teachers were most likely to hold monthly discussions with that are delivered outside of the school setting. Commu-
the consultant (perhaps because they teach fewer impaired nity clinic-based interventions that target academic
students, leaving more time to devote to those who are), impairment in adolescents with ADHD may be important
they were least likely to agree to provide intervention. Fur- alternatives when families are unable to coordinate
ther, private schools were less likely to collaborate with consistent intervention in schools.
consultants than public schools. Students in special edu- Overall, these results indicate that at the outset of
cation, on the other hand, were more likely to experience intervention, professionals who serve adolescents with
successful intervention coordination. These results beg ADHD should make efforts to maximize staff time and
careful consideration of appropriate educational placement resources available to the teen. This may include work-
for students who may require school-based intervention ing with parents and school administrators to secure an
for ADHD – some gifted and private school settings may be IEP or 504 plan, assess the appropriateness of the stu-
prohibitive of certain educational supports. dent’s educational placement, or making specific efforts

© 2016 Association for Child and Adolescent Mental Health.

190 Margaret H. Sibley et al.
to engage the parent in intervention provision. Interven-
tion collaborators should be stakeholders with adequate
time and motivation to monitor the student skill use on a
consistent basis. When a consultation model is imple-
mented, stakeholder engagement should be consistently
monitored and targeted if it starts to wane. For example,
established engagement building approaches, such as
Motivational Interviewing (Miller & Rollnick, 2013),
briefly can be delivered to parents and school staff and
may maximize implementation consistency over time.
Future work is needed to empirically test how engage-
ment efforts might mitigate implementation difficulties
detected herein.
Acknowledgements
This project was funded by the Institute of Education Sciences
(R324A120169). The authors declare that they have no compet-
ing or potential conflicts of interest. The manuscript was pre-
pared by M.S. with assistance from all coauthors. S.M. oversaw
all aspects of the research project. C.M. and S.O. assisted with
data collection. M.C. assisted with data preparation. W.P.
provided valuable expertise and advice on study design, inter-
vention delivery, and data collection.
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Accepted for publication: 18 February 2016
Published online: 8 April 2016