Attention-Deficit/Hyperactivity Disorder (ADHD), characterized by developmentally inappropriate levels of inattention, hyperactivity, and impulsivity (Martin & Zirkel, 2011), is among the most prevalent disorders in childhood and adolescence. Prevalence rates vary considerably across studies, but data find that the disorder occurs in approximately 5–10% of children in the United States, which translates to an average of one child in every classroom (Danielson et al., 2018; Faraone et al., 2003). Furthermore, actual prevalence may be even higher than these estimates suggest, given the finding that teachers reported an equal number of students that they believed had ADHD but were not diagnosed to those that were formally diagnosed and identified (Fabiano et al., 2013).

The prevalence rates of ADHD in youth are especially concerning given the negative outcomes both in school and beyond. Research has consistently documented that youth with ADHD demonstrate substantial impairments in reading and math performance as compared to peers (e.g., Bussing et al., 2012; Efron et al., 2014). It has been documented that students with ADHD are 40% more likely to drop out of school than their peers (International Consensus Statement on ADHD, 2002), and only 8% of young adults with the most persistent ADHD symptoms go on to complete a college-level education (Hechtman et al., 2016). These outcomes extend beyond academic impairments and can persist into adulthood. Research shows that students with ADHD face socialization challenges such as peer rejection and adjustment difficulties (Marshal et al., 2003), while adults with ADHD have higher prevalence of anxiety, depression, bipolar and personality disorders and schizophrenia than the general population (Solberg et al., 2017).

School-Based Supports for Students with ADHD

One way to mitigate the potential for negative outcomes is through the provision of school-based supports for students with ADHD (e.g., DuPaul et al., 2012). Although a small percentage of students with ADHD receive school-based accommodations under Section 504 of the Rehabilitation Act (1973) (13.6% reported in DuPaul et al., 2019), a much larger percentage receive special education services under the Individuals with Disabilities Education Act (IDEA, 2004) (42.9%; DuPaul et al., 2019). Potential advantages of a special education diagnosis include additional legal protections for students and their families as well as access to specialized instruction provided by trained personnel in addition to the accommodations and modifications that typically characterize 504 plans (Rhinehart et al., 2022). This latter point may be particularly important given research documenting the significant benefit of intervention over accommodation supports in reducing the impairments experienced by students with ADHD (Harrison et al., 2020). Spiel et al. (2014) found that students with ADHD were more likely to receive several services (e.g., study skill instruction, behavior modification) and accommodations (e.g., use of aids during tests, reduced length of assignments) when they had individualized education plans (IEPs) than 504 plans.

Although there are noted potential benefits of receiving special education supports, there is also evidence to suggest that many students with ADHD are not being appropriately identified and served through the U.S. public school system. Between the years of 2011 and 2015, 1 in 9 of the complaints received by the Department of Education’s Office for Civil Rights (OCR) regarding disability-related discrimination in school systems was related to students with ADHD not receiving a free and appropriate public education (OCR, 2016). Among the problems noted by the OCR were the fact that many students with ADHD were never identified or referred for evaluation, and when evaluations were conducted, they were deemed inadequate (OCR, 2016). Compounding these issues is the disproportionality that has been identified in special education identification. Studies have shown that Black children with ADHD were more likely to be identified under the category of emotional disturbance (ED) than other health impairment (OHI) than their white peers (Mandell et al., 2008), and that the chances of being identified for ADHD are reduced for Latinx students and those from homes where the primary language is not English (Rhinehart et al., 2022).

Many factors likely help to explain the misidentification of students with ADHD within school settings; however, one notable issue worth considering is the lack of specificity within the federal definitions. Although definitions of each educational disability are published within IDEA, these definitions are rather vague and terms undefined. This is problematic, given prior research suggesting that undefined portions of federal definitions can be interpreted differently from state to state and lead to different eligibility criteria (Maki et al., 2015). Although states must adhere to the federal eligibility guidelines, they are also permitted to adopt more specific eligibility criteria than what IDEA rather broadly outlines. In analyzing state criteria for special education services under the autism category, MacFarlane and Kanaya (2009) found that the majority (65%) of states used eligibility criteria that were more specific than the federal criteria; however, notable differences were identified. For example, whereas some states required students to meet DSM criteria, others required either a clinical or medical diagnosis. MacFarlane and Kanaya (2009) suggested that these differences with regard to eligibility criteria may help to explain the observed variability in prevalence rates across states. More recently, Maki et al. (2015) reviewed the state-level criteria for specific learning disability (SLD) and found that although 90% of states used the federal definition of SLD, substantial variability was identified across states with regard to the level of guidance provided around use of specific methods of identification (i.e., ability-achievement discrepancy, pattern of strengths and weaknesses, response to intervention).

Inter-state variability in eligibility criteria has been identified across multiple educational disabilities; however, is likely to be even more pronounced for the identification of students with ADHD. Although students with ADHD may qualify for special education under several different IDEA categories (e.g., ED, SLD), federal guidelines added specific reference to ADD/ADHD under the category of OHI in 1999 (U.S. Department of Education, 1999). Of the 14 categories of disability specified under IDEA (2004), OHI serves as one of the broadest umbrellas under which students with a range of health concerns may be found eligible for special education services. According to the current federal definition,

Other health impairment means having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that—

  1. (i)

    Is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, and Tourette syndrome; and

  2. (ii)

    Adversely affects a child’s educational performance. [§300.8(c)(9)]

Although ADHD is one of a dozen eligible conditions listed under the federal IDEA definition of OHI, no additional specificity is provided at the federal level surrounding impairment-specific determinations of eligibility. This is despite the fact that researchers have estimated that up to 40% of those students receiving special education services under OHI may have ADHD (Forness & Kavale, 2001). Furthermore, phrases used within the IDEA definition such as “limited alertness” and “adversely affects a child’s educational performance” are not operationally defined, and therefore may be interpreted differently. Taken together, these factors suggest that there are likely to be substantial discrepancies in OHI eligibility criteria for students with ADHD across states; however, to date research has not been conducted to confirm this. As noted by Maddox et al. (2019), marked differences in evaluation practices across states likely helps to explain why prevalence rates fluctuate dramatically across states. As such, the purpose of the current study was to review state-level special education eligibility criteria for OHI, with particular interest in identifying the degree to which eligibility guidance exists specific to students with ADHD and the extent to which this guidance varies across state departments of education (SDEs). Specifically, we broke down the federal definition into three parts and sought to answer the questions of:

  1. 1.

    To what extent do SDEs specify what is needed to establish that the student has a health impairment (i.e., “due to a chronic or acute health problem”)? When provided, how variable is this guidance across states?

  2. 2.

    To what extent do SDEs provide further clarification/elaboration as to what is meant by "…heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment"? When provided, how variable is this guidance across states?

  3. 3.

    To what extent do SDEs specify what is needed to establish that the student’s disability “adversely affects [their] educational performance"? When provided, how variable is this guidance across states?

Method

Search Procedure

Members of the research team conducted a web search between January and August 2022 to identify any guidance provided at the state level regarding eligibility decision making for students with ADHD under OHI. Potential documents were identified for inclusion by reviewing the state department of education (SDE) website for each of the 50 states and the District of Columbia. First, a member of the research team reviewed the special education section of the website to identify the state eligibility criteria for OHI. In addition, a Google search was conducted within each website to identify any additional guidance or resources that may be related to serving students with ADHD using the key words: “ADHD,” “attention deficit hyperactivity disorder,” and “other health impair*.” Any documents that referenced eligibility decision making for either OHI in general, or ADHD in specific, were downloaded and saved for further review.

Once all possible documents were obtained, members of the research team reviewed the documents for each state to determine whether guidance was provided specific to the eligibility of students with ADHD under the category of OHI. In all cases, ADHD-specific documents were prioritized over general guidance for determining eligibility under OHI. That is, if both ADHD-specific and OHI-general documents were available, the guidance most specifically targeted toward identification of students with ADHD was retained for coding. To ensure that the correct documents had been accurately identified, a contact person from each SDE was then emailed to confirm the appropriateness and recency of the documents. If the contact person provided a new document, the new document was coded. State contacts that did not respond initially were sent follow-up emails. Confirmation was ultimately obtained from all but one SDE.

Coding Procedure and Analysis

Once documents were confirmed, two members of the research team independently reviewed each document to answer three main questions related to components of the federal definition. First, we sought to determine whether the state specified what was needed to establish that the student has a health impairment (i.e., “due to a chronic or acute health problem”). If the SDE provided some specification of what an evaluation should entail (e.g., type of measures or diagnostic criteria that to utilize), this information was recorded and descriptively summarized.

Additionally, if the SDE provided some specification of who can determine whether a health impairment exists, this information was also recorded. For the purpose of this analysis, these individuals were categorized into one of four groups. Those individuals licensed by a state to provide health care services (e.g., physician, nurse practitioner, physician’s assistant) were assigned to the category “licensed medical providers.” Those individuals licensed by the state to provide mental health treatment (e.g., licensed mental health counselor, licensed psychologist, licensed social worker) were assigned to the category “licensed mental health professionals.” Those individuals certified by state departments of education to provide services to students in schools (e.g., psychoeducational specialist, school counselor, school psychologist) were assigned to the category “certified school personnel.” Finally, if the SDE made general reference to the need for individuals to have appropriate training or credentials without specifying what these were, this was categorized under “qualified personnel.”

Second, we sought to determine whether the state provided further clarification/ elaboration as to what was meant by "…heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment." If the SDE included either definitions of alertness or specific examples of what this might look like in a school setting, this language was captured and descriptively summarized.

Third, we sought to determine whether the state specified what was needed to establish that the student’s disability “adversely affects [their] educational performance." Specifically, we searched for any reference to the need to assess particular domains (e.g., academic achievement, behavioral functioning) or to utilize particular assessment tools (e.g., norm-referenced testing, classroom observations) to inform eligibility decision making. Any relevant language was again captured and descriptively summarized.

When coding across all three eligibility questions, we also sought to determine whether any of the outlined criteria were mandated by the SDE as opposed to being recommended practice. Specifically, we coded specific pieces of information as “mandated” if the SDE used verbiage such as must, required to, shall, and/or will when referring to a particular guideline. If the language used by the SDE seemed to denote suggested practices (e.g., it is recommended that, should, ought to) or to simply provide possible examples (e.g., could, may, might), this was not considered mandated.

Subsequent to the first round of coding, interrater reliability estimates were calculated for each of the coding questions by dividing the number of agreements by the numbers of agreements plus disagreements. Interrater reliability was found to be consistently high across questions 1 (92%), 2 (96%) and 3 (88%); however, any identified discrepancies were discussed amongst members of the research team to ensure consensus.

Results

Documentation related to the IDEA eligibility category of OHI was found for all SDEs excepting Iowa, which utilizes a non-categorical eligibility system. As such, results are based on a total of 50 SDEs. Approximately 1 in 5 SDEs (22%; n = 11; i.e., CA, CT, DC, IL, MA, MD, NV, NY, OH, PA, WA) utilized the federal eligibility criteria without further elaborating upon them. Of the remaining 39 SDEs, 40% (n = 20) provided elaboration on one criterion (i.e., AK, AL, AZ, DE, FL, ID, IN, KY, ME, MI, MT, NJ, OK, SC, SD, TX, VA, VT, WV, WY), 24% (n = 12) provided elaboration on two criteria (i.e., AR, KS, LA, MO, MS, NC, NE, NH, NM, OR, RI, UT), and 14% (n = 7) provided elaboration regarding all three criteria (i.e., CO, GA, HI, MN, ND, TN, WI). Each criterion is discussed next.

Criterion 1: Due to Chronic or Acute Health Problem

First, we sought to understand the extent to which SDEs specified what is needed to establish that the student has a health impairment (i.e., “due to a chronic or acute health problem”), including who can make this determination. The majority of SDEs (70%; n = 35) noted the need for an evaluation or formal diagnosis of the health problem by an appropriate individual(s) (see Table 1). Eleven SDEs (22%; i.e., AK, FL, HI, KS, MI, MT, NC, NJ, OR, TN, TX) mandated that only a licensed medical provider (e.g., physician, nurse practitioner, physician’s assistant) could diagnose or verify the presence of a chronic or acute health problem. An additional six SDEs (12%; i.e., AZ, DE, MN, SC, WV, WY) noted that diagnosis by a licensed medical provider was necessary for all categories of OHI except for ADHD. These SDEs noted that an ADHD determination could also be made by a licensed mental health professional (in all cases) or certified school personnel (in all cases except MN). An additional 12 SDEs (24%) made specific mention of the fact that diagnosis by a medical professional was not required for either OHI (i.e., CO, ND, NE, UT, VA, WI) or ADHD (i.e., AR, KY, LA, MS, NM, RI) but did not specify who could make this determination (LA only noted “qualified personnel”). Oklahoma and Georgia did not provide mandates; however, Oklahoma recommended that the determination of OHI be made by either a licensed medical provider, licensed mental health professional, or certified school personnel and Georgia recommended that the determination of ADHD be made by either a licensed medical professional or mental health professional. Finally, only five SDEs (10%) did not make any specific mention of licensed medical providers. Two of these SDEs (i.e., ID, MO) mandated determination of ADHD be made by a licensed mental health professional or certified school personnel. The final two SDEs (i.e., NH, VT) mandated that determination of OHI be made by “qualified personnel,” without specifying who would fall under this category.

Table 1 States providing guidance regarding who can make determination of health impairment/ADHD
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Beyond noting who can make a determination that a student has a health impairment, 8 of the 50 SDEs (16%) provided some specification as to what an evaluation should entail. Two SDEs (4%; i.e., DE, MN) specifically referenced the need to ensure that students meet diagnostic criteria for ADHD. The use of rating scale data was noted by an additional three SDEs (6%; i.e., AL, KY, SC). Alabama State Board of Education’s (2013) regulations were the most specific, requiring that:

Standard scores (total or composite) on two out of three of the same norm-referenced scale designed specifically to determine the presence of ADD or ADHD must be at least two standard deviations above or below the mean….ratings from three or more scales must be obtained from at least three independent raters, one of whom may be the parent (p. 513).

Both Kentucky and South Carolina recommended the use of rating scales plus student observations, with South Carolina’s SDE (2011) specifically noting the need to document “that the student’s observable school and/or classroom problem behaviors related to ADHD are occurring at a significantly different rate, intensity, or duration than the substantial majority of typical school peers” (p. 29). Mississippi’s Department of Education (2015) required “a statement as to whether the behaviors are typical for the child’s age, setting, circumstances, and peer group, and if not, how the behaviors are different AND a description of the correlation between documented behavior and results of ADHD assessments” (p. 121). Less specific guidance was provided by Arkansas and South Dakota, with Arkansas’s Department of Education (n.d.) noting that “typically, assessments for ADD are comprehensive, involving input from both home and school, and include an evaluation of the child’s medical, psychological, educational, and behavioral functioning” (p. 3) and South Dakota’s Department of Education (2016) noting that “if ADHD is the impairment, behavioral evaluations must be administered” (p. 8).

Criterion 2: Having a Heightened Alertness to Environmental Stimuli That Results in Limited Alertness with Respect to the Educational Environment

In addition to needing to document the presence of a health problem, the federal eligibility criteria for OHI also specify that the health impairment must result in limited strength, vitality and/or alertness. The latter criterion of “heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment” is most applicable to those students with ADHD. Very few SDEs (18%; n = 9), however, provided additional elaboration or examples beyond the federal definition (see Table 2 for specific wording). In describing how this might manifest, all nine states (i.e., AR, CO, GA, HI, MN, MO, ND, TN, WI) referenced difficulties paying attention, focusing, or remaining on-task. Additionally, multiple SDEs referenced difficulties with (a) organization (i.e., CO, GA, HI, MN, WI), (b) following directions (i.e., AR, GA, HI, MN), and (c) completing assignments (i.e., GA, HI, MN). Less common descriptors included (a) limited awareness of surroundings (i.e., ND), (b) difficulty transitioning between tasks (i.e., GA), (c) impaired social interactions (i.e., CO, GA), (d) impulsivity (i.e., AR, CO), and (e) overactivity (i.e., AR).

Table 2 States providing elaboration on alertness criterion
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Criterion 3: Adversely Affects a Child’s Educational Performance

The final criterion used in the determination of eligibility for OHI is a demonstration that the student’s educational performance is adversely impacted by their potential health impairment. Of the 50 states examined, 17 SDEs (34%) elaborated upon what domains should be assessed to measure adverse impact (see Table 3). All SDEs that specified domains to assess (34%; n = 17) made reference to the assessment of academic achievement. For example, Nebraska’s Department of Education (2008) noted that an educational evaluation “should include a combination of…individual achievement testing, classroom assessment data, norm-referenced testing data, criterion-referenced assessments, district-wide assessments, and curriculum-based assessments” (pp. 138–139). Additionally, most of these SDEs (22%; n = 11) also made explicit that educational performance extends beyond academics to encompass domains of functioning such as adaptive, behavioral, cognitive, communication, and physical. Assessment of particular domains was nearly always recommended (as opposed to being mandated), with the exception of Minnesota and Tennessee, which both required an evaluation of student academic performance when conducting an evaluation for OHI.

Table 3 States providing elaboration regarding what domains to assess to measure adverse impact
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In addition to noting the assessment of particular domains of functioning, 15 SDEs (30%) also provided some guidance around the types of data sources that were recommended or required (see Table 4). It was most common for SDEs to reference observations (i.e., AL, CO, IN, KS, ME, MN, NC, ND, NE, NM, TN) or interviews (i.e., CO, IN, KS, LA, ME, MN, NC, ND, NE, NM, TN), with 11 states (22%) noting each. Although the use of observations was often noted, five SDEs either mandated (8%; i.e., IN, KS, NC, TN) or highly recommended (2%; i.e., NM) that observations should take place across settings and Minnesota’s Department of Education (2018) specifically required “one or more documented systematic observations in the classroom or other learning environment by a licensed special education teacher.” Similarly, although general mention was sometimes made of conducting interviews, seven SDEs (14%; i.e., CO, IN, MN, ND, NE, NC, TN) specifically highlighted the importance of conducting interviews with parents or caregivers, whereas Louisiana mandated that families be interviewed to clarify any concerns and help to identify relevant health providers.

Table 4 States providing elaboration regarding what data sources to use to measure adverse impact
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Also common among the SDEs reported in Table 4 was mention of documentation of progress monitoring in response to attempted interventions (18%; n = 9) and conducting record reviews (16%; n = 8). Documentation of prior intervention attempts was required by six SDEs (12%; i.e., AL, HI, KS, LA, MS, NC) and suggested by two (4%; i.e., CO, NE). For example, North Carolina’s Department of Public Instruction (2021) noted the requirement of “two scientific research-based interventions to address academic and/or behavioral skill deficiencies and documentation of the results of the interventions, including progress monitoring documentation” (p. 67) when conducting an evaluation for OHI. Within those SDEs that mentioned reviewing existing records, specific mention was given to attendance, discipline, and state assessment data.

Finally, four SDEs (8%) referenced the need to conduct a functional behavior assessment (FBA), with two of these SDEs requiring it (i.e., LA, MS) and the other two recommending them (i.e., CO, NM). For example, documentation from the Mississippi Department of Education noted “when considering eligibility under OHI due to ADD/ADHD, the supporting evidence must contain a description of the child’s behaviors, settings in which the behaviors occur, antecedents leading to the behaviors, and consequences immediately following the behaviors” (p. 121).

Discussion

Given prior research documenting substantial inter-state variability with regard to eligibility criteria for less diffuse categories of educational disability (e.g., ED, MacFarlane & Kanaya, 2009; SLD, Maki et al., 2015), it was hypothesized that eligibility guidance specific to students with ADHD would also vary substantially across states. The current review confirmed this hypothesis, highlighting notable variability concerning the extent to which SDEs have tried to help clarify elements of the fairly vague federal IDEA definition. Specifically, we found that a total of 11 SDEs utilized the federal eligibility criteria without further elaborating upon them, 20 provided elaboration on one criterion, 12 provided elaboration on two criteria, and only 7 provided elaboration regarding all three criteria. Such findings are fairly consistent with what was found previously for the category of autism. That is, Macfarlane and Kanaya (2009) noted that although two-thirds of states expanded upon the federal eligibility criteria, there was a great deal of variability in terms of what this expansion entailed.

With regard to the assessment of ADHD, there is a general consensus that evaluations should be multi-method and multi-source in nature and that practitioners should gather information about which symptoms are present, how pervasive and chronic they are, and the degree to which the symptoms impair student functioning (Handler & DuPaul, 2005). Recommendations for multi-method, multi-source ADHD assessment typically include record review, multi-informant interviews (i.e., parents, teachers, student), multi-informant behavior rating scales (i.e., parents, teachers), and behavioral observations (DuPaul & Stoner, 2015). Although reference was occasionally made in the documents reviewed to the importance of comprehensive assessments in confirming a health impairment, fewer than 1 in 5 SDEs provided specific information regarding what this should entail. The data source most frequently referenced was the use of standardized behavior rating scales. This is perhaps not surprising given that rating scales have been called the “sine qua non of methods for diagnosing ADHD” in light of the ease with which information can be collected and summarized across multiple informants; however, notable limitations include a limited focus on symptoms (in isolation of impairment and context) and the subjective nature of the ratings (Pelham et al., 2005, pp. 462–3). Although research demonstrating modest correlations between teacher ratings and observational data suggests the unique and potentially important information gained through classroom observations (e.g., Minder et al., 2017; Staff et al., 2021), SDEs infrequently referenced use of direct observation within guidelines for ADHD assessment.

The fact that relatively few SDEs provided guidance regarding how to determine the presence of a health impairment is likely explained, in part, by the fact that a number of SDEs require an outside determination of whether a health impairment exists. For example, 11 of the SDEs that broadly specified guidelines for OHI required confirmation of a health impairment by a licensed medical provider such as a physician or nurse practitioner. It is not surprising that a medical diagnosis was required in these states given the nature of most health problems cited in IDEA (e.g., asthma, diabetes, heart conditions). What is noteworthy, however, in contrast, is that none of the SDEs that specifically referenced the assessment of ADHD required a medical diagnosis. Rather, in these cases, greater latitude was offered, such as (a) noting that the presence of ADHD may be determined by other qualified personnel such as licensed mental health professionals (including licensed psychologists or licensed social workers, who may already work in the schools) and/or certified school personnel (e.g., school psychologists, school counselors) or (b) explicitly noting that a medical diagnosis was not required. The continued requirement of an outside diagnosis is problematic for multiple reasons. Most notably, it raises significant concerns related to equity, as outside providers may be more difficult for some students to access, such as those living in particular geographic areas (e.g., rural, frontier) or from low-income and economically marginalized families. Additionally, research has shown that less than half of physicians use any formal criteria when making ADHD diagnoses (Chan et al., 2005), therefore calling the validity of some medical diagnoses into question. Taken together, these results speak to the need for all SDEs to consider how eligibility guidance may need to look different for ADHD within this broader category.

In contrast to clinical diagnosis of ADHD, what is unique to the determination of an educational disability under IDEA is the requirement that the student’s disability “adversely affects a child’s educational performance.” It has been noted that although (a) use of the term “educational performance” seems to imply more than academic performance alone (e.g., social-emotional development) and (b) the Office of Special Education Programs (OSEP) has advised states to consider both academic and non-academic areas, decision makers are still not in universal agreement regarding interpretation of this phrase (Thomas, 2016). The data collected herein reflect this disagreement, with 5 SDEs only noting the need to assess academic achievement, 12 SDEs noting that educational performance more broadly encompasses functioning across other domains (e.g., adaptive; social, emotional, and behavioral functioning), and the remaining 33 making no specific reference to domains of impairment at all. Although not binding, OSEP (2010) noted in an opinion letter that “a child with high cognition and ADHD could be considered to have an ‘other health impairment’ and could need special education and related services to address the lack of organizational skills, homework completion and classroom behavior, if appropriate” (pp. 1–2). In the absence of state-level guidance surrounding this criterion, courts—left to decide how to interpret the federal definition—have frequently arrived at a narrow interpretation that excludes areas of non-academic performance (Thomas, 2016). Unfortunately, this may mean that although impairment in social and/or behavioral domains could put some students with ADHD at risk for long-term negative outcomes, these students would be precluded from receiving special education supports in the absence of academic impairment. Concerns related to the variable interpretation of this criterion apply not only to the category of OHI but to other IDEA disability categories as well.

Finally, SDEs were least likely to elaborate upon the federal criterion that students have “a heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment.” Although inattention was consistently referenced as one way in which limited alertness may manifest, the provision of additional examples by some SDEs (e.g., organization, following directions, work completion) may help school-based teams to consider how this may look different depending on the student.

Implications for Practice

Two of the primary takeaways of the current review are that (a) many states are silent with regard to interpretation of IDEA specific to OHI and (b) when guidance is provided, it is inconsistent across states. There are a few important implications of these findings. First, the fact that very limited—or in some cases no—guidance was found for many of the states reviewed raises concerns regarding the reliability of diagnosis within states, schools, and even practitioners as well. When SDEs are silent on the law, this leaves local education agencies (LEAs) to interpret IDEA independently. Unfortunately, inadequately defined constructs and a lack of agreed upon criteria have been identified as primary drivers of bias in psychoeducational decision making (Davidow & Levinson, 1993). As with many disability categories, disparities in the identification of youth with ADHD have been highlighted in national data, with Black and Latinx youth less likely to receive an ADHD diagnosis than their white peers (Morgan et al., 2013; Schneider & Eisenberg, 2006). Such statistics could imply that some groups of students are being under identified and consequently not receiving needed services. Additionally, however, there exists the possibility that some students are instead being misidentified. For example, Ballentine (2019) highlighted that externalizing behaviors and impaired social relationships may be more likely to be interpreted as oppositional defiant disorder (i.e., a behavioral disorder) in Black children while interpreted as ADHD (i.e., a neurodevelopmental disorder) in white children. Further, Grice (2002) cited court cases in which factors such as parental support, social emotional development, and behavioral skills impacted whether students with ADHD qualified for special education, and under which special education category (i.e., ED, OHI, SLD). These diagnostic distinctions impact student educational outcomes, as students with ED experience worse academic outcomes and higher social stigma than other children in special education (Anderson et al., 2001; Greenbaum et al., 1996). Although there does not exist a universally agreed upon “litmus test” for the identification of ADHD (International Consensus Statement on ADHD, 2002), states can, at minimum, provide guidance to promote LEAs’ use of multi-method, multi-source assessments consistent with recommended best practices to reduce bias in decision making (DuPaul & Stoner, 2015).

The fact that guidance—when provided—varied notably across SDEs raises a different set of concerns. The current review highlighted the fact that some states have adopted much stricter interpretations of IDEA than others, which may serve to limit access to school-based services. As noted previously, the requirement of needing an outside medical evaluation raises equity concerns for those students and families for whom provider access may be more challenging. On the other hand, stringent school-based evaluation requirements may force some families to seek out alternative strategies (e.g., medication) to address unmet student needs. As one example, Alabama’s requirement of “administration of the same behavior rating scale or ADD/ADHD scale by at least three persons, one of whom may be the parent” (p. 503) is more stringent than the DSM’s requirement of “present in two or more settings.” Interestingly, Alabama also reports one of the highest medication rates for students with ADHD in the country (i.e., 77%; Centers for Disease Control and Prevention, 2023). A study by the United States Government Accountability Office (2019) highlighted the lack of consistency in state eligibility criteria as one of the primary reasons why discrepancies in special education identification exist across states. With regard to OHI, the percentage of school-age students found eligible in 2020–21 varied from 0.94% in Arizona to 2.99% in Maine (OSEP, 2023). One of the consequences of having eligibility criteria that vary substantially across states is that different decisions regarding the need for special education may be made for the same student. Practically speaking, this means that a student could move from one state to another and lose their eligibility—as well as those services associated with it.

Limitations and Directions for Future Research

Great effort and intention were taken in compiling relevant information regarding state-level special education eligibility criteria for OHI. Nevertheless, limitations of this review exist and should be noted. First, despite extensive outreach and research, we were unable to contact the department of education for the state of Connecticut, which meant that the information for this state could not be verified. Additionally, a few SDEs indicated that new guidance documents were in preparation and therefore some of the information collected may already be out of date. Second, the language utilized by the authors of each document was used to categorize the information as being a mandate (e.g., shall, must) as opposed to a recommendation (e.g., might, should). It is therefore possible that the way in which some pieces of state guidance were interpreted may deviate from the SDE’s intended meaning.

Third, the current study was descriptive in nature and therefore we did not conduct an evaluation of the guidance offered by each SDE. As SDE guidance was not directly compared with recommended best practices in the assessment of ADHD, references to specific recommendations or mandates made by SDEs should not be interpreted as endorsement. Finally, it is important to note that although the focus of the current study was to understand what guidance SDEs provide surrounding eligibility decision making, actual school-based diagnostic practices may not mirror these guidelines. Guidance documents, in particular, are not binding and it is therefore possible that diagnostic practices may vary more substantially within states than across them. Kanaya and Ceci (2007), for example, found notable discrepancies between cut-off scores used by practitioners to identify students with intellectual disabilities and those endorsed federally. Related, although students with ADHD may have either an IEP or a 504 plan, the focus of this study precluded gathering information regarding what guidance is provided to schools around 504 eligibility and plan development. Additional research is therefore needed to better understand both the actual diagnostic decision-making practices of school-based multidisciplinary teams, and how districts are using both supportive approaches to address ADHD impairment.

Conclusions

Although there is a small likelihood that the federal definition of OHI will change to become more explicit, states do have the latitude to provide expanded guidance to school districts surrounding special education eligibility decision making. A small number of SDEs, including Colorado (2020), North Dakota (2020), and Wisconsin (2016) have produced comprehensive, stand-alone manuals designed to support school-based teams in identifying and supporting students with OHI. Among the information provided in these documents were concrete examples to aid in interpreting the federal definition language, examples of data sources and decision-making rules, and descriptions of evidence-based practices for supporting students with specific needs. These manuals may serve as a model for other states looking to improve the reliability of decision making, as well as for practitioners in search of guidance to inform their own practice.