School-Based Interventions for Attention-Deficit/Hyperactivity Disorder (ADHD) in Middle Schools: A Review of the Literature

Abstract

Attention-deficit/hyperactivity disorder (ADHD) presents unique challenges for middle school students, a population navigating heightened academic, social, and emotional demands. This review examines empirical literature on school-based interventions targeting ADHD in middle school populations, a group often under-represented in intervention research. This review synthesizes findings from studies on academic accommodations, organizational training (e.g., HOPS), self-management strategies, mental health supports (e.g., CBT), and integrated programs like STAND and the Challenging Horizons Program. Evidence suggests that targeted school-based interventions can improve executive functioning, task engagement, academic performance, and social–emotional outcomes. However, interventions vary in efficacy depending on implementations’ fidelity, individual differences, and contextual supports (such as family involvement and school resources). Although promising, many interventions are limited by scalability, sustainability, and a lack of rigorous longitudinal data. This paper identifies critical gaps in middle school-specific research and highlights the need for future studies on long-term outcomes, student self-advocacy, and the reduction of stigma. Overall, this review underscores the potential of multi-component, school-based approaches to mitigate academic and behavioral challenges in middle school students with ADHD. We also call for expanded efforts to tailor and sustain these interventions in real-world educational settings.

1. Introduction

This review examines existing literature regarding how school-based interventions can help students with ADHD who may be struggling with the increased demands of middle school. Unfortunately, there is limited research on school-based interventions for ADHD in middle school populations (students aged 11 to 14). We aim to present the extent of the literature that does exist, while offering future directions for much-needed research in this age group. We use this research to explore the role of interventions like organizational skills training, self-regulation strategies, individualized academic support, and counseling. When implemented effectively, these interventions can allow students with ADHD to succeed in middle school by teaching them strategies that can aid them socially, academically, emotionally, and professionally (DuPaul et al., 2021; Evans et al., 2016). By doing so, they can break repeating cycles of academic disengagement and social difficulties, facilitating better future outcomes for students in need.

Structure and Methodology

The aim of this review is primarily informational, offering an applied perspective. We have surveyed a wide breadth of research to distill and present educational information for parties who may benefit, such as school systems, treatment providers, and researchers. To do so, we searched for and gathered all accessible published studies from Google Scholar and EBSCO ProQuest that were (1) peer-reviewed, (2) published in scientific journals, (3) published after the year 1990, (4) addressed students between the ages of 11 and 14 or who were otherwise identified as “middle school” or “junior high” students, who also (5) were identified as having attention-deficit/hyperactivity disorder (ADHD). Only peer-reviewed research was included, with the exception being brief information from the American School Counselor Association. Our sections denote separate interventions and types of interventions. The determination of our section themes was guided by the grounded theory of Glaser and Strauss (1967). A priori, we set intentions to create sections on (1) effects of ADHD relevant to middle school and (2) each separate kind of intervention we encountered that had more than two published studies from different research groups. We then formed inductive major and minor themes from reviewed studies germane to our intentions, with minor themes comprising specific interventions. While reviewing the literature, an additional section on treatment team roles appeared beneficial and was added. We used the constant comparative method throughout analyses: Studies were organized, distilled into notes, and analyzed into conceptual section domains simultaneously. The two authors compared notes and analyses continuously.

2. Attention-Deficit/Hyperactivity Disorder (ADHD) and Its Effects

ADHD is a neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity (American Psychiatric Association, 2022). For diagnosis, symptoms must last longer than six months, first appear before age 12, cause distress and/or impairment, and not be solely a manifestation of oppositional behavior. ADHD’s symptoms frequently disrupt daily functioning and negatively impact academic performance, social relationships, quality of life, and life outcomes (e.g., Hinshaw, 2002; Wehmeier et al., 2010). The disorder’s behavioral symptoms are often accompanied by cognitive and executive functioning deficits, such as impaired working memory, difficulty with inhibition, and poor cognitive flexibility (Langberg et al., 2012). Additionally, most children with ADHD struggle with the disorder from early life throughout childhood and adolescence, highlighting the need for early intervention to mitigate its future effects (Biederman et al., 1996). In Biederman et al.’s (1996) study, 85% of 128 children with ADHD (ages 6–17) continued to experience the disorder at 4-year follow up. Only 15% experienced remission, with half doing so in childhood and the other half in adolescence.

The effects of ADHD develop over time, going beyond behavioral symptoms to include emotional and psychological issues (Stern et al., 2020). ADHD symptoms predict emotional psychopathology, such as anxiety and depression symptoms, as evidenced by a longitudinal study conducted on a sample of British twins (Stern et al., 2020). In this study, ADHD in childhood significantly predicted anxiety and depression symptoms from childhood into young adulthood. Additionally, the study notes the presence of shared genetic relationships between ADHD and emotional psychopathology, suggesting that there is a genetic basis for the overlap between ADHD and these difficulties.

ADHD symptoms are often heightened by the demands of the middle school environment (Langberg et al., 2008a). Even when symptoms were manageable in earlier years, middle school presents greater challenges. Students must adapt to a new education module, such as having multiple classes a day and interacting with multiple teachers. They must do so while being expected to self-regulate in an unfamiliar environment that presents many social and cognitive challenges. While managing these new expectations is difficult for any adolescent, those with ADHD tend to have a harder time adjusting to the change of environment (Langberg et al., 2008a). As a result, students with ADHD are at higher risk for social difficulties, academic disengagement, and poor long-term educational outcomes, including higher school dropout rates (Zendarski et al., 2016).

Academic challenges can contribute to feelings of inadequacy and the development of counterproductive coping strategies that hinder social and emotional functioning (Wise et al., 2019). Without appropriate support, students with ADHD are at risk of academic disengagement, greater strain, failures, and lower overall achievement (Zendarski et al., 2017). Longitudinal research also suggests that students with ADHD have lower rates of high school graduation and postsecondary enrollment, highlighting the long-term impact of academic difficulties if interventions are not implemented early (Barkley et al., 2008).

Maladaptive Achievement Strategies

Students with ADHD struggle to stay engaged with tasks that require sustained attention, time management, and the ability to navigate the social complexities of their peer groups (Langberg et al., 2008a). These challenges cause students with ADHD to depend on the use of maladaptive achievement strategies (MASs). MASs are cognitive and behavioral means that students use to meet personal needs in academic contexts but that disadvantage or harm them (Iines et al., 2023). One common example of a MAS is task avoidance, where students avoid a task they find difficult or uncomfortable. Despite their short-term functionality, long-term, MASs harm students academically and emotionally. Students using MASs display a fear of failure, feelings of low competence, and avoidant behavior when met with a challenging task (Iines et al., 2023). MAS-like task avoidance can slow academic and social growth and create a learning gap between students with ADHD and their peers. Task-avoidant behavior is also a predictor of declining peer acceptance and increased academic struggles (Laursen et al., 2021). Task avoidance behavior can create a negative feedback loop, promoting greater feelings of inadequacy and making non-preferred tasks feel increasingly uncomfortable (Orhan et al., 2023).

Interventions to combat MASs and the social, emotional, and academic challenges of ADHD can help mitigate the gap between students with ADHD and their peers (Iines et al., 2023). It is important to teach these skills early on with consistency, as behavioral patterns that develop around 11 or 12 years of age are likely to persist into adulthood (Eccles & Roeser, 2009). Implementing these approaches in schools can continuously integrate academic and social skills into the school day using a structured format. Interventions designed to address ADHD-specific cognitive deficits, such as working memory training and support for executive functioning, can help students adapt to the academic and social demands that come with the middle school environment (Fabiano & Pyle, 2019). Structured strategies to promote better executive functioning, such as those focusing on self-regulation, time management, and organizational skills, can help weaken the cycle of avoidance and disengagement related to MASs. If these interventions are employed effectively, they can alter the developmental and academic trajectory of students with ADHD (DuPaul & Stoner, 2014).

3. Academic and Classroom-Based Interventions

Academic challenges can contribute to feelings of inadequacy and the development of MASs that hinder social and emotional functioning (Wise et al., 2019). Without appropriate support, students with ADHD are at risk of academic disengagement, greater strain, failures, and lower overall achievement (Zendarski et al., 2017). Longitudinal research also suggests that students with ADHD have lower rates of high school graduation and postsecondary enrollment, highlighting the long-term impact of academic difficulties if interventions are not implemented early (Barkley et al., 2008).

3.1. Accommodations

Accommodations are supportive academic changes designed to minimize the barriers of ADHD symptoms, including difficulty with attention, impulse control, and executive functioning (American Psychiatric Association, 2022). These changes may involve adjustments to the learning environment, applying different instructional methods, or changing assessment procedures. Common accommodations for students with ADHD include extended time on assessments, organization support (i.e., binder organization, file management, etc.), and access to teacher notes or a note taker (Harrison et al., 2020). Executive functioning deficits are evidenced in people with ADHD through poor response speed and accuracy, as well as high distractibility (Randall et al., 2009). Accommodations can address the increased complexity of academic tasks and the heightened expectations that come with the transition from elementary to middle school (Langberg et al., 2012). In the U.S., students with ADHD can access accommodations through an Individualized Education Plan (IEP) or a 504 plan—legal documents that provide students with accommodations and/or modifications to the curriculum (similar supports exist in other countries). IEPs and 504 plans aim to ensure that students receive support to overcome challenges related to disabilities that affect academic performance and functioning.

Specifically, prompting, sensory accommodations, and structured breaks have been examined for their efficacy in improving task engagement and reducing disruptive behaviors. Harrison et al. (2022) examined the comparative efficacy of these strategies against one another in 15 middle school students with ADHD in the United States. They evaluated their impact on task engagement, disruptive behavior, and latency (i.e., delay time to initiate task performance). The study found that prompting was the most effective in increasing task engagement and reducing disruptive behavior as measured by direct observation. Prompting is a strategy in which students are verbally or gesturally reminded to remain on task. Although Harrison and colleagues found it effective, they also found that prompting relied heavily on adult intervention, which could encourage dependency rather than independence.

On the other hand, sensory accommodations (including fidget tools such as stress balls and putty) were found to have limited effectiveness (Harrison et al., 2022). Although students reported enjoying the sensory items, these accommodations did not significantly improve task engagement or reduce disruptive behavior compared to groups receiving different accommodations. Sensory items appeared to increase distractibility, a finding that is consistent with previous research (Graziano et al., 2020). The popularity of sensory items among students may stem from their novelty or the immediate enjoyment they provide. Yet evidence suggests they do not functionally address ADHD-related academic difficulties.

Another commonly used accommodation is breaks. Breaks involve allowing students to take some time to rest after a set period of work (e.g., a few minutes). While breaks may provide temporary relief from academic demands, they do not significantly improve task engagement or reduce disruptive behaviors compared to prompting or self-management (Harrison et al., 2022). These findings suggest that while breaks can be beneficial in certain contexts, they should not be relied upon as the primary strategy for addressing ADHD-related academic difficulties. Instead, integrating breaks into a broader framework of task-specific accommodations, such as chunking (dividing work into manageable parts), may yield more meaningful improvements in academic outcomes (Lim & Kwok, 2016).

These studies commonly come with notable limitations, including small sample sizes that are skewed heavily male and white, with only one female and five non-white participants in Harrison et al. (2022). Overall, however, the findings tentatively suggest that accommodations can be effective in supporting middle school students with ADHD, particularly when they target challenges such as self-regulation and task engagement (Harrison et al., 2022). While sensory tools and breaks provide relief and are enjoyable to students, more structured accommodations appear to be the most beneficial in cultivating long-term academic success. Targeted support through accommodations can help students navigate the complex academic environment of middle school and reduce the risk of academic failure and social disengagement. However, accommodations can be supported by other interventions that allow students to develop independence and longer-term skills.

3.2. Self-Management

Compared to accommodations, self-management allows students to take greater ownership over their behavior and development. Self-management primarily emphasizes academic behaviors and classroom readiness, although it can also improve social and emotional functioning. It focuses on classroom preparation skills and task-related behaviors. In this context, self-management teaches students how to monitor their own behaviors, set goals for improvement, and adjust their actions based on self-generated feedback (Gureasko-Moore et al., 2006; Harrison et al., 2022; Shapiro et al., 1998). Self-management interventions aim to promote independence in students by gradually reducing the need for teacher involvement, allowing students to take on more responsibility for their academic behavior (Shapiro et al., 1998). The translation of skills from school to other settings allows students to practice their skills independently across contexts, reinforcing them (Evans et al., 2014; Stan, 2021). This may be particularly useful in secondary education, where students transition between multiple classrooms, teachers, and social settings.

In one study, middle school students who met DSM-IV criteria for combined-type ADHD (n = 3) tracked behaviors, such as homework completion and punctuality, and received reinforcement based on their performance (Gureasko-Moore et al., 2006). Results were measured by students’ own critique forms and the experimenters’ and teachers’ observation of conformity to preparation skills. Results indicated significant improvements in their ability to prepare for class, remain on task, and engage appropriately with peers compared to baseline, with gains maintained at 3-week follow-up. Future research with a larger sample size and randomized control is needed to investigate potential long-term benefits.

More recently, Harrison et al. (2022) compared the effectiveness of self-management and other accommodations with a slightly larger sample size of 15 American middle school students, 14 of whom were male. The intervention took place in the 60 min following the end of the school day. RAs instructed students to use a self-management form consisting of four statements (“I was on-task”) with yes/no check boxes. Efficacy was measured through observer ratings of disruptive behavior and task engagement and by recording task latency in seconds. Interestingly, students in this study reported being dissatisfied with self-management, perceiving it as distracting, even though outcomes showed it was effective in aiding task engagement. In fact, it produced the most significant improvements in task engagement when compared to accommodations. Importantly, self-management was found to be just as effective as prompting. Prompting is an accommodation often included in IEPs, but it relies heavily on adult involvement, rather than adolescents’ own agentic behavior.

Self-management and its ability to be performed somewhat independently were backed by Shapiro et al. (1998), whose self-management intervention began with teacher involvement in monitoring. Students in this case study (n = 2) then gradually transitioned to greater student autonomy, with students showing similar improvements as Harrison et al. (2020) as measured by teacher ratings, observations, and rating scales. These findings support similar evidence from elementary schoolers with ADHD, illustrating that similar interventions can reduce avoidance and off-task behavior (Sluiter et al., 2020).

Despite the supposed efficacy of self-management as outlined in the above studies, small sample sizes reduce confidence in the generalization of these findings. A much larger study (n = 148) reported barriers to implementation (Bussing et al., 2016). This study taught six forms of self-management, including activity outlets (such as sports), sleep regulation, dietary restrictions, homework help, family rules, and prayer. Parents reported liking the intervention, but students were likely to resist. Compared to their parents, high-risk adolescents reported much less willingness to engage in all self-management interventions, except increased activity outlets. These findings suggest that while self-management holds promise, its effectiveness may be limited by differences in adolescents’ willingness to participate and the type of self-management intervention used.

3.3. Organization Skill Interventions

Organization skill deficits often contribute to broader academic struggles for students with ADHD (Bikic et al., 2017; Cole et al., 2024). Deficits in planning and organization are strong predictors of poor academic performance, including lower grades and inconsistent homework completion (Langberg et al., 2012; Meltzer & Krishnan, 2007). Many students with ADHD experience persistent difficulties in areas such as time management, organization of materials (i.e., keeping track of school supplies and assignments), and task planning (i.e., breaking down and sequencing steps for long-term projects; Langberg et al., 2012). Such challenges may help explain the well-established gap in academic achievement between students with ADHD and their typically developing peers. Without effective strategies or support, students with ADHD are more likely to fall behind academically (Lawrence et al., 2021). Studies suggest this effect is not due to a lack of intelligence or general cognitive ability (DuPaul & Stoner, 2014; Langberg et al., 2008b). Rather, the symptoms of ADHD are often deficits specifically in the executive functioning skills that are required for success at school. Targeting organizational skills can lead to academic improvements, such as increased assignment completion and a higher GPA (Breaux et al., 2019; Langberg et al., 2012).

3.4. Homework, Organization, and Planning Skills (The HOPS Program)

The Homework, Organization, and Planning Skills (HOPS) intervention is a structured program that targets specific executive function skills (Langberg et al., 2012). HOPS focuses on enhancing academic performance while reducing classroom and homework-related difficulties that stem from ADHD. The program is manualized in structured sessions. It includes 16 brief (up to 20 min) one-on-one sessions with school mental health providers, targeting three main skill areas: organization of school materials, recording and management of homework, and planning/time management (Langberg et al., 2011). American middle school students with ADHD (n = 47) were assigned to receive the intervention or waitlist control (Langberg et al., 2012). Students receiving the HOPS intervention demonstrated significantly higher grade point averages than those who did not, with gains maintained at follow-up. Many parents continued to monitor and reinforce the HOPS skills beyond the intervention period, which may have contributed to the maintenance of academic improvement. HOPS focuses on enhancing academic performance while reducing classroom and homework-related difficulties that stem from ADHD. The program includes strategies for organizing materials, managing time effectively, and accurately recording assignments. In another study, American middle schoolers with ADHD (n = 111) participating in HOPS had significantly higher GPAs than a comparison group, with gains maintained post-intervention (Breaux et al., 2019). The large sample size, as well as the relatively high gender (66% male) and ethnic diversity (55% white) in this study a strong snapshot of HOPS’ efficacy. The middle school students with ADHD who participated in HOPS also demonstrated significant improvements in organizational skills compared to baseline, as measured by GPA, assignment completion, and by parent and school staff ratings of homework and organizational skills (Breaux et al., 2019).

Even so, there were gaps in response to the intervention study, particularly where homework recording was concerned (Breaux et al., 2019). Approximately 25% of students were identified as non-responders, although 68% of students demonstrated a high acquisition of organizational and homework recording skills. Furthermore, students started to show differences in how quickly they were improving their skills early on. In other words, some students began progressing faster than others from the beginning. This suggests that school mental health providers could identify responders by the third or fourth week of intervention and implement additional support for students who showed slower progress. Understanding these early response patterns may allow for more targeted interventions that maximize student outcomes. These results also suggest that attending to individual differences in intervention efficacy may be warranted. There is likely a need for individualized approaches in ADHD interventions. The efficacy of specific skills can differ based on the individual student’s learning and behavioral patterns. Additionally, recording of homework—a skill closely tied to time and task management—exhibited meaningful variability. Some participants responded to the intervention, while others did not. This variability may suggest that interventions should aim to improve a broad range of skills, accommodating the heterogeneity of ADHD symptoms and individual differences in student strengths and weaknesses.

Breaux et al. (2019) also contributed to understanding the role of teachers and parents in the success of academically based ADHD interventions. While students’ improvements in organizational skills were consistently linked to better academic outcomes, teacher-reported outcomes did not always reveal these improvements. Teachers may lack sufficient time or exposure to observe subtle changes in executive function behaviors (Sibley et al., 2014). Similarly, other evidence suggests teacher ratings may not capture significant improvements in organizational skills from pre- to post-trial (Langberg et al., 2012). This discrepancy may be due to middle school teachers’ limited opportunities to observe students’ organizational skills in detail, as well as limited interaction time due to the structure of the school day.

In this study, homework recording and time management skills were more predictive of parent-reported outcomes. While parents may see the most benefits from improvements in organization, teachers may prioritize skills that directly affect in-class performance, such as time management and task completion (Bikic et al., 2017). Despite these findings, parent-reported use of monitoring and reinforcement was not significantly associated with outcomes, suggesting that student-led skill acquisition may be more critical for success (Breaux et al., 2019). The distinction between parents’ and teachers’ reported outcomes should be considered when designing interventions to ensure they address the specific needs and expectations of both home and school environments. Furthermore, the influence of parental involvement in monitoring and reinforcing skills may also be limited. This may particularly be the case when students are encouraged to self-monitor their behaviors as part of the intervention (Abikoff et al., 2013). Despite its weaknesses, studies on HOPS with large sample sizes provide encouraging evidence for its effectiveness with middle school students with ADHD.

3.5. The STAND Program

STAND (Supporting Teens’ Academic Needs Daily) aims to help middle school students with ADHD and their unique academic and behavioral challenges in both home and school settings (Sibley et al., 2013). STAND targets the increasing academic demands and reduced parental oversight that often lead to declines in organizational skills, homework completion, and overall academic performance. STAND integrates structured family-based and school-based interventions tailored to the needs of middle school students. A randomized controlled trial of STAND in middle school participants with ADHD and their families provided evidence to support the program’s efficacy (Sibley et al., 2013), showing significantly greater improvements for STAND compared to treatment as usual (TAU).

The comparison TAU group continued with the standard course of treatment they had been receiving prior to the study. Yet in STAND, American students (n = 36) and their families engaged in eight weekly family sessions. These sessions focused on parental involvement in schoolwork, utilizing web-based grade monitoring systems, and establishing structured routines for homework and studying (Sibley et al., 2013). Clinicians worked with families to implement individualized academic interventions, emphasizing organization, time management, and effective communication between the home and school environments. STAND also included monthly group parent-training sessions, equipping parents with additional tools to sustain intervention effects beyond the structured sessions. Parents were trained to monitor and support their child’s academic behaviors through a daily privilege contract. In this contract, students could earn privileges at home based on in-school behavior. Parents were encouraged to coordinate a teacher meeting, bringing together the student, core academic teachers, and clinicians when necessary. After treatment, approximately two-thirds of parents consistently implemented a daily privilege contract (Sibley et al., 2013). Additionally, over half maintained regular home–school communication. This data suggests preliminary treatment maintenance effects, with benefits sustained after the conclusion of the treatment period. Further research is needed to determine whether parents continue these academic interventions into the following school year, though.

In this trial, acute treatment effects were observed across several symptom and academic variables, with significant effect sizes. Compared to the treatment-as-usual (TAU) group, students receiving STAND demonstrated significant improvements in grades, even if these gains were small in size. Beyond academic improvements, STAND also significantly reduced parent-reported oppositional defiant disorder (ODD) symptoms and adolescent-reported home conflict (Sibley et al., 2013). These results highlight its benefits in improving parent–adolescent relationships. Unlike TAU, where parent–adolescent conflict increased, STAND reportedly created a more collaborative dynamic. This may have enhanced treatment engagement. Even so, challenges remained, as one-third of families struggled to maintain home interventions post-treatment, often citing time constraints and student resistance. Despite positive changes with STAND, the program did not significantly impact teacher-rated outcomes, and improvements in GPA were modest (Sibley et al., 2013). It is possible that teachers required a longer period to notice behavioral improvements. GPA fluctuations may have been influenced by contextual trial factors, such as noticeable last-minute grade recovery efforts in the TAU group relative to the course of improvement among those in STAND. Despite these limitations, the application of STAND with middle school students demonstrated potential for enhancing academic behaviors and mitigating ADHD-related academic difficulties.

4. Mental Health Interventions

Adolescents with ADHD often struggle with the regulation and processing of emotion, leading to a need for mental health support (Christiansen et al., 2019). Mental health interventions for ADHD have shown to have success when administered in outpatient clinical settings, such as mental health clinics (e.g., Safren et al., 2005; Sprich et al., 2016). Unfortunately, families can experience notable challenges accessing outpatient services, such as financial constraints, long waitlists, and logistical difficulties like transportation and scheduling conflicts (P. L. Owens et al., 2002; Sprich et al., 2015). Bringing mental health intervention into schools can mitigate these difficulties with accessibility, benefitting students with ADHD.

School mental health services are delivered before or during school through several formats (Prout & Prout, 1998). Individual counseling sessions are commonly offered to students identified as needing targeted support. These sessions are often brief in both time and number of sessions. They tend to focus on areas such as emotional regulation, problem-solving, motivation, and academic planning. Despite their benefits, the success of school-based mental health interventions relies on adequate training and implementation (Langley et al., 2010). Teachers and school mental health professionals must be equipped with the skills and time to deliver interventions. Yet they are often faced with challenges such as competing responsibilities, logistical issues, and a lack of parent engagement (Langley et al., 2010). Additionally, maintaining long-term benefits relies on several difficult-to-provide factors, such as ensuring consistency in intervention delivery and providing continuing support after the intervention (DuPaul et al., 2019).

4.1. General Therapy/Counseling for Mental Health

Although studies on students with executive functioning issues outside of school consistently yield promising results (Sprich et al., 2016), there is limited research on school counseling provided in middle schools themselves. When provided, school-based mental health counseling tends to be free to students and places less responsibility on families. However, collaboration between schools and families is important to reinforce strategies outside the counseling session and to ensure a holistic, coordinated approach to each student’s needs. Many schools follow the American School Counselor Association’s (ASCA) recommendation of one school counselor serving 250 students (American School Counselor Association (ASCA), n.d.). This guideline emphasizes the importance of school counselors. However, this standard is a recommendation and not a rule. Since many schools do not have the resources they need, the national average is below this standard, with one counselor serving 376 students (American School Counselor Association (ASCA), n.d.). Despite these challenges, treatment in schools may carry less stigma due to the many developmentally and socially appropriate reasons students may seek counseling, such as peer and family conflict (Weist & Evans, 2005). Given the barriers, integrating mental health therapy into school settings provides a more accessible and sustainable way to support middle school students with ADHD.

4.2. Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is an intervention for improving ADHD-targeted emotion regulation, attention, planning, and organization skills while countering executive functioning deficits (Safren et al., 2005; Young & Bramham, 2012). CBT uses a wide array of techniques that can be individually fitted to clients’ needs, both cognitive and behavioral. CBT targets behavioral issues through rewards and environmental adjustments, providing positive reinforcement for beneficial behaviors and preventing reinforcement for counterproductive ones. CBT also employs behavioral activation, a strategy that focuses on increasing engagement with positively reinforcing activities and reducing avoidance behaviors (Kanter et al., 2010). Organization skills training is also often included in CBT as a behavioral strategy. CBT targets cognitive issues through the practice of identifying and reframing automatic thoughts of inadequacy and failure, which may lead to the use of MASs (Iines et al., 2023; Safren, 2006). Furthermore, CBT aims to enhance self-regulation strategies such as thought monitoring and problem-solving techniques (Young & Bramham, 2012).

Thought monitoring helps individuals identify and challenge negative or distorted automatic thoughts. Problem-solving techniques provide structured methods for addressing challenges, aiming to enhance confidence and reduce helplessness. Together, these strategies promote emotional regulation, resilience, and more effective coping. Preliminary studies have found that implementing CBT interventions in middle school settings leads to significant pre- to post-treatment reductions in hyperactive behaviors in students with ADHD (Rofiah et al., 2021). The study specifically focused on creating more adaptive beliefs about the self. Three middle school students with ADHD were prompted to identify core beliefs that trigger hyperactivity, including low self-esteem and low self-efficacy. Students were then asked to identify the conditions arising from these negative core beliefs, such as self-inflicted punishment and aggression toward others. Students were then guided through the deconstruction of this belief and were encouraged to view themselves more positively. This intervention led to a significant reduction in hyperactive and inattentive behaviors as measured by the Vanderbilt ADHD rating scale—preliminary evidence for use of CBT for this population (Ogg & Fefer, 2011; Rofiah et al., 2021).

Studies on the efficacy of CBT for medication-treated adolescents with ADHD in outpatient settings (n = 46; ages 14–18) have yielded promising results (Sprich et al., 2016). Twelve sessions of CBT showed significant improvements on the ADHD rating scale (AR-IV) compared to the waitlist control group (DuPaul et al., 1998; Sprich et al., 2016). This symptom scale measured executive functioning, emotional regulation, and impulse control. A 30% or greater reduction on the ADHD rating scale was used to calculate responder status (Sprich et al., 2016). Participants in the study who completed the CBT program showed a 50% beneficial response rate, compared to 18% for those in the waitlist condition. This may suggest that it was CBT that contributed to beneficial changes in these adolescents, rather than solely medication. Like many ADHD studies though, the sample was primarily boys (36 of 46), with more research needed on CBT for adolescent girls with ADHD.

Emerging evidence also supports the feasibility and efficacy of CBT for late elementary and early middle school-aged students with comorbid ADHD and anxiety. A pilot randomized controlled trial examined the outcomes of an adapted version of the Cool Kids CBT program for children aged 8 to 12 with both ADHD and anxiety (Sciberras et al., 2015). The CBT intervention taught children and parents core anxiety-management skills—such as psychoeducation, cognitive restructuring, gradual exposure, problem-solving, and supportive parenting—while adapting delivery with breaks, visual aids, and repetition to meet the needs of children with ADHD. The intervention, delivered over 10 sessions, was well tolerated: There were no participant dropouts and high session attendance. Parents and teachers reported significant improvements from pre- to post-treatment in ADHD-related behavior reductions, quality of life, and family functioning. Gains were observed across home and school environments, indicating the potential for generalized improvements. The findings suggest that brief CBT interventions, when tailored to the needs of youth with ADHD, can promote meaningful emotional and behavioral change.

4.3. Mindfulness

Mindfulness is the practice of directing focused, non-judgmental attention to the present moment while openly accepting inner experiences (Kabat-Zinn, 2003). This practice helps individuals become more aware of their thoughts, emotions, and physical sensations without reacting impulsively (Niazi & Niazi, 2011). Mindfulness interventions may be particularly effective for middle schoolers as they transition through adolescence and cope with increased emotional and cognitive demands (Schonert-Reichl & Lawlor, 2010). Structured mindfulness allows for self-awareness and emotional regulation strategies. These abilities may aid in navigating academic, emotional, and social challenges more effectively (Baer, 2003). Techniques such as breathing exercises, body scans, and mindful observation teach students to manage their emotions and thoughts, aiming to create better focus and emotional resilience in the classroom.

Mindfulness-based therapies (MBTs) have shown promising results in reducing core ADHD symptoms, particularly inattention and hyperactivity/impulsivity (Virone, 2023). Meta-analytic data found significant improvements in ADHD symptoms following MBTs (Cairncross & Miller, 2016). One neurological study found that mindfulness was associated with significant sustained attention improvements and reduced mind-wandering among middle school students (Caballero et al., 2019). These results aligned with prior research that suggests that mindfulness interventions improve executive functioning skills, including self-regulation and attention (Tang et al., 2012). The study also found that students who engaged in mindfulness practices demonstrated increased activation in brain regions linked to executive function, indicating potential neurological benefits of mindfulness for adolescents with ADHD (Caballero et al., 2019). Additionally, a systematic review reported strong support for MBTs improving attention in individuals with ADHD at various developmental stages (Lee et al., 2017). These findings expand on prior research that indicates that mindfulness interventions may also be able to help adolescents become more aware of their emotions and behaviors and prevent maladaptive thinking (Deplus et al., 2016; Siebelink et al., 2021). Once learned, mindfulness can be practiced independently and can reduce reliance on teachers for self-regulation and prompting. Developmental stage may matter, though. Some research suggests that older students may be more receptive to mindfulness strategies, as they are better able to reflect on their behaviors and apply learned techniques to manage symptoms (Virone, 2023). The potential for mindfulness to foster long-term self-regulation skills highlights its value as a school-based intervention, particularly when integrated into broader social–emotional learning (van de Weijer-Bergsma et al., 2012; Zylowska et al., 2008).

5. Social Interventions

Given that social skills are essential for children’s development, deficits in these skills can have lasting effects on mental health, social adjustment, and behavioral outcomes (Nijmeijer et al., 2008; Sancassiani et al., 2015). Children with poor social skills are at higher risk for social isolation, which can lead to mental health conditions like depression (Segrin & Flora, 2000). When children struggle with social cues or conflict resolution it can lead to behavioral problems, such as aggression (Hukkelberg et al., 2019). Early interventions targeting social skills can improve outcomes by helping children engage more effectively with peers. Interventions can mitigate social challenges for middle school students with ADHD and increase the chance for positive long-term outcomes.

Children with ADHD are often particularly vulnerable to social skills deficits, which contribute to interpersonal conflict, peer rejection, and consequent negative long-term social, academic, and emotional outcomes (Mrug et al., 2012; Sancassiani et al., 2015). There is evidence that children with ADHD may often lack specific knowledge of appropriate social behaviors (de Boo & Prins, 2007). Additionally, children with ADHD may struggle to recognize emotion in others (Staff et al., 2022). There is also evidence that suggests that children with ADHD may overestimate their social abilities and how much they are liked by others (Diener & Milich, 1997; Hoza et al., 2004). Additionally, children with ADHD often have difficulties with conversational language and nonverbal social cues (Sancassiani et al., 2015). These difficulties can lead to problems in conversation, such as failing to stay on topic, missing nonverbal cues, or interrupting others (Bruce et al., 2006; Camarata & Gibson, 1999).

Social difficulties for students with ADHD may also contribute to task avoidance, a maladaptive achievement strategy. A longitudinal study in Finland examined the relationship between avoidance of academic tasks, school achievement, and peer acceptance among first grade students (n = 545; Laursen et al., 2021). Teachers assessed task avoidance using the Behavioral Strategy Rating Scale (Zhang et al., 2011). Peer acceptance was measured through sociometric nominations (asking students to nominate peers they like or dislike). Academic achievement was evaluated using standardized tests in math and reading. Early task avoidance significantly predicted declines in academic performance on standardized tests, leading to diminished peer acceptance over time. These results highlight the interconnected nature of academic and social challenges. Students with ADHD often lack motivation in terms of achievement. This may lead to greater risk of developing MASs and the challenges that come with it (Iines et al., 2023). Despite early evidence, future research is needed to determine the relationship between task-avoidant behaviors and social challenges in middle school students.

5.1. Social Skills Training

In response to these challenges, social skills training (SST) programs have been developed to help children with ADHD improve their social functioning. SST teaches students social receiving, interpreting, and behavioral skills through discussion and activities, including games and role-play (Tenhula & Bellack, 2008). Empirical evidence regarding the effectiveness of SST has been mixed (DuPaul & Weyandt, 2006). There are concerns about the generalization of skills to natural settings and the maintenance of improvements over time. Even so, SST may be effective if implemented correctly, particularly when parents are involved in reinforcing skills across various contexts (de Boo & Prins, 2007). A critical challenge in traditional SST is that it is often delivered in artificial, clinic-based settings. This fails to mimic real-world interactions, as children in these groups often do not know their peers outside of the group setting. This can reduce the opportunities for children to practice and apply new skills in real-life contexts. To address this limitation, implementing SST in more natural environments, such as schools, may increase the likelihood of skill generalization. When children learn skills within their daily social contexts, such as interacting with classmates, they are more likely to practice the skills in authentic situations, making them more effective (DuPaul & Weyandt, 2006).

While there is limited research on the use of social skills training for ADHD in middle school settings, there is evidence of its effectiveness in elementary-aged populations. SST’s implementation in schools makes interventions more accessible to students and families. Researchers in Korea implemented a brief (eight sessions) school social skills intervention with 10 elementary-aged children with ADHD (Paek et al., 2009). After the intervention, the children showed a significant improvement compared to baseline in self-reported social skills on the Matson Evaluation of Social Skills with youngsters (MESSY; Matson et al., 2010). There was also a positive correlation between the increase in student’s self-reported scores and teacher scores for the students on both the ADHD rating scale (AR-IV) and the MESSY (DuPaul et al., 1998; Paek et al., 2009). Participants also showed a significant improvement in self-reported self-esteem on the Rosenberg Self Esteem Scale (RSES), compared to baseline (Rosenberg, 1965; Paek et al., 2009).

Corkum et al. (2010) further explored the potential of social skills programs by examining the Working Together: Building Children’s Social Skills Through Folk Literature program for Canadian elementary school students (n = 16). This school-based program incorporates a series of structured social skills lessons. Each lesson focuses on a specific skill framed within folk stories to make the content engaging and relatable for children. It was delivered over 16 weeks in public schools. The program was found to be both feasible and effective in improving the social skills of children with ADHD: There were significant post-treatment improvements in both parent and teacher ratings of social skills on the Social Skills Rating System (SSRS; Corkum et al., 2010; Gresham & Elliott, 1990). The children’s reports of their own social skills on the SSRS also indicated a significant improvement from pretreatment to post-treatment scores.

The Working Together program specifically addressed pragmatic language skills, such as making conversation, introducing oneself, and negotiating conflicts—skills that are particularly relevant for peers’ interaction (Corkum et al., 2010). This approach embeds social skills within folk stories and involves both parents and teachers in reinforcing the skills outside the group sessions. This approach aims to increase the likelihood that the children apply the learned skills in a variety of settings, such as home and school. Along with improvements in social skills, this study found that children with better-developed pragmatic language skills also exhibited more significant improvements in their social skills. This may suggest that pragmatic skills are a notable predictor of success in social skills interventions.

5.2. Integrated Approaches

Integrated approaches allow students to receive comprehensive support, targeting academic, social, and emotional challenges (DuPaul et al., 2012). By combining support across domains, such approaches aim to ensure that students receive well-rounded assistance. This is particularly important as social, academic, emotional, and behavioral challenges are often interconnected, with struggles in one area influencing performance and well-being in others. Programs that integrate these various aspects can provide students with the tools and strategies they need to succeed both at school and in their personal lives.

6. The Challenging Horizons Program

The Challenging Horizons Program (CHP) serves as a useful example of an integrated model. The CHP combines behavioral interventions, academic support, and mental health resources to improve the functioning of middle school students with ADHD. The CHP is a school-based intervention designed to improve the academic, social, and mental health outcomes of middle school students with ADHD (Evans et al., 2004). It combines behavioral interventions with recreational and educational activities to improve both academic and social functioning. The after-school program includes primary counselor time, a social impairment group (ISG), recreation time, a study skills group, and individual education time for homework completion. This structure is designed to address students’ social, emotional, and academic needs. The Challenging Horizons Program also has two major components—a more general academic support (AS) component and a one-on-one mentoring (M) component with role models. By targeting multiple areas of challenge for students with ADHD, the program aims to create improvements in school and at home.

6.1. CHP Academic Support

A core component of the CHP is its focus on academic success. Students are provided with structured interventions aimed at improving homework completion, class participation, and assignment submission rates (Evans et al., 2004). This component is designed to address common academic challenges such as incomplete assignments, forgetfulness, and difficulty managing multiple tasks simultaneously (DuPaul et al., 2021). These strategies are reinforced by regular communication between counselors and parents to create consistency between school and home environments. Academic improvements measured through the students’ grade point averages (GPAs) before and during the intervention have demonstrated significant improvements in language, arts, math, science, and social studies (DuPaul et al., 2021). Stated improvements also included an increased proficiency in organization and time management skills, with participants in the CHP condition exhibiting significantly greater gains compared to those receiving community care. Another study on the CHP-AS found that students who received one-on-one coaching to break tasks into smaller, more manageable steps reported feeling more in control of their academic responsibilities and even significantly improved their homework completion and task initiation skills (Evans et al., 2016).

6.2. CHP Social and Mental Health Support

In addition to academic support, the CHP places significant emphasis on enhancing social skills and addressing mental health challenges. Social functioning improvements measure peer relationships, family dynamics, and self-esteem. Although positive trends were observed in peer relationships and family interactions as measured by the Social Skills Improvement System (SSIS) (Elliott & Gresham, 2008), further intensive interventions may be necessary to achieve more substantial improvements (Evans et al., 2004). Mental health support within the CHP is individualized, with counselors providing ongoing support and supervision to address the mental health needs of students while promoting adherence to the program. Reductions in ADHD symptoms during treatment—including reductions in attention and hyperactivity—were documented by various ADHD-related survey measures. including the ADHD rating scale (DuPaul et al., 1998). Despite modest effect sizes on some outcomes, the intervention yielded medium effects on peer and sibling relationships and small effects on ADHD symptoms, adult–child relations, and self-esteem, alongside small-to-moderate improvements in GPA marked by a shift from declining to slightly improving grades.

When the CHP also included one-on-one mentoring for middle school students with ADHD, the CHP-M demonstrated improvements in social functioning and emotional regulation, as well as abilities to engage more positively with peers and teachers (Evans et al., 2016). Students were paired with trained mentors—such as college students or older peers—who served as role models. These mentors offered emotional support and helped students navigate both academic and personal challenges. Mentors engaged with students in regular sessions, discussing topics like emotional regulation, social skills, and stress management. This mentor–mentee relationship aims to help students practice social interactions in a low-stakes environment, fostering a sense of belonging and reducing feelings of isolation. The supportive relationship with their mentors allows students to develop coping strategies for managing emotional distress and social difficulties. Although this can be valuable, Evans et al. (2016) found that American students with ADHD (n = 326) who participated in the CHP-AS showed significant improvements in academic performance over the CHP-M alone and community care conditions in terms of homework completion and task initiation. Both components together may contribute to the best outcomes.

7. Teacher Knowledge and Training

Meta-analytic data suggest that ADHD affects 5.6% of teenagers, ages 12–18 (Salari et al., 2023). Due to this relatively high prevalence, equipping educators with accurate knowledge and effective intervention strategies is important in creating positive outcomes for students. In one study, middle school students with ADHD claimed they felt misunderstood by their teachers (Maya Beristain & Wiener, 2020). Accordingly, research has highlighted significant deficiencies in teachers’ knowledge about ADHD. In one study, teachers were assessed on their perceived and actual knowledge of ADHD (Weyandt et al., 2009). Weyandt et al. (2009) surveyed 132 school staff in the U.S. with a 24-item questionnaire to compare practicing teachers with recent education graduates. Findings indicated that teachers with experience in working with students with ADHD demonstrated greater factual knowledge about the disorder, though significant misconceptions existed. For instance, many teachers held inaccurate beliefs about ADHD treatment, including believing in pseudoscientific treatments like special diets and vitamin therapy. Additionally, general education teachers had a lower level of ADHD knowledge compared to school psychologists, who are often more informed about diagnostic criteria and intervention strategies. Special education teachers displayed slightly greater knowledge than their general education counterparts. However, this difference was not statistically significant. Both general education and special education teachers exhibited uncertainty about some ADHD-related concepts, particularly regarding treatments’ effectiveness. It is important to note, however, that this research may be somewhat out of date. Training and broader ADHD awareness has arguably improved since publication of Weyandt et al.’s (2009) study. A more recent 2023 study from Spain used a validated measure—the ADHD-Specific Knowledge and Attitudes of Teachers questionnaire (n = 206; Cueli et al., 2023). Cueli et al. (2023) found that special education teachers did, in fact, have significantly more knowledge of ADHD than general education teachers. However, these findings should be contextualized within possible differences in school structure and teacher education between the U.S. and Spain.

Another study examined similar research questions with a different scope. Guerra and Brown (2012) assessed the ADHD knowledge levels of middle school teachers in South Texas (n = 107). Using the Knowledge of Attention Deficit Disorders Scale (KADDS), they assessed three specific areas: general ADHD knowledge, knowledge of symptoms/diagnosis, and knowledge of treatments (Sciutto et al., 2000). Results indicated that teachers were most knowledgeable about identifying symptoms and diagnosis (Guerra & Brown, 2012). Teachers’ understanding of general ADHD knowledge and treatment strategies was comparatively weaker. Adamis et al. (2024) expanded on these findings, surveying Irish teachers’ (n = 288) knowledge and attitudes toward ADHD. Findings indicated that ADHD knowledge was low, with a mean score of 9.5 out of 18 (measured as correctly identifying DSM ADHD symptoms). Additionally, 58% of teachers held negative attitudes toward ADHD, compared to the 42% holding positive attitudes. Negative attitudes were significantly more prevalent among teachers working in boys’ schools. Teachers with positive attitudes were more likely to be male and have fewer discussions with colleagues about ADHD. This study highlights the relationship between knowledge, attitudes, and behavior, suggesting that optimal ADHD training may best consider pre-existing contexts and perceptions, such as gender-related beliefs and attitudes.

When training does exist, it may often be insufficient. Regardless of their diagnostic knowledge, many teachers report a lack of preparation in actually dealing with ADHD-related challenges in the classroom. In-service education—professional development provided to teachers—can play a key role in building teachers’ confidence and ability to support students with ADHD. Various forms of in-service training have increased teachers’ preparedness and willingness to include students with ADHD in their classrooms (Zentall & Javorsky, 2007). The specific content and approach of the training influences the kinds of strategies teachers use when working with students. According to Zentall and Javorsky’s (2007) research, those who participated in university-based programs were more likely to implement positive, evidence-based practices. These teachers learned to minimize transition times and create stimulating learning environments to the benefit of students. In contrast, teachers who received training through Local Education Agency (LEA) programs reported having more accessible resources. However, teachers were more inclined to use traditional discipline strategies like time-outs and classroom removals. The study also highlighted the value of training in functional assessment, which helped teachers better understand the reasons behind student behavior and led to a decrease in punishments and led to improvements in student behavior.

Other evidence suggests teacher training is effective to a degree (Latouche & Gascoigne, 2019). A brief in-service training workshop on primary school teachers’ (n = 274) ADHD knowledge and self-efficacy showed promising results. Teachers who participated in the workshop demonstrated a significant increase in ADHD knowledge and a modest improvement in self-efficacy measured by both the KADDS and the Teachers’ Sense of Self-Efficacy Scale (TSES; Sciutto et al., 2000; Tschannen-Moran & Hoy, 2001). While both knowledge and self-efficacy declined slightly at a one-month follow-up, they remained higher than baseline levels (Latouche & Gascoigne, 2019). These findings suggest that even brief training sessions can enhance teachers’ understanding of ADHD, providing a cost-effective and practical approach to addressing gaps in knowledge and confidence. Given the evolving nature of ADHD research, continuous professional development is essential to ensure that teachers remain informed about evidence-based practices to support students with ADHD (Dwarika & Braude, 2020).

8. Treatment Teams

It is important to note that there are a variety of persons that affect the successful implementation of any one of the interventions covered above. Effective school-based interventions for students with ADHD demand the collaborative efforts of teachers, school psychologists, counselors, and administrators in creating an environment that accommodates the needs of students with ADHD. Team-based approaches aim to meet each student’s unique needs with an array of different resources. A coordinated effort among educators and support staff is important to develop tailored strategies that address students’ academic, emotional, and behavioral needs. Teachers can implement specific instructional modifications. School psychologists can assess and address underlying cognitive and emotional factors. Counselors can support social–emotional development. By working together, these professionals can create a supportive and structured environment that can maximize the success of school-based treatment and interventions. We would like to comment further on the unique work of a few of these roles.

School psychologists are at the center of ADHD interventions. They oversee evaluations to establish ADHD and other learning-affected conditions, and they direct eligibility for IEPs, 504 plans, or similar resources. Their responsibilities include neuropsychological testing, behavior ratings, classroom observations, and family and staff consultation. Besides evaluation, they collaborate with school counselors. Together, they facilitate group or individual sessions, handle short-term crises, and deliver social–emotional learning programs in classrooms. These services build skills, increase awareness, and give students explicit strategies for coping (Spiel et al., 2014; Wiener, 2020; Weist et al., 2012). Teachers can help mitigate ADHD-related difficulties by dividing tasks into manageable steps, giving unambiguous instructions and regular feedback (J. S. Owens et al., 2017; Gathercole et al., 2008). Students with ADHD receive more corrective feedback from teachers than their typically developing peers (Staff et al., 2023). Teachers are also directly responsible for some interventions, such as the Daily Report Card. The frequent use of this particular teacher-driven aid has been shown to improve organization, reduce problem behavior, and aid engagement (Meza et al., 2020). Administrators are also important for school-based intervention, as they monitor how supports are put into practice. They also organize teachers, psychologists, and counselors to make sure practices are consistent within the school (Wexler, 2018). Lastly, parents facilitate their child’s skill practice at home, staff observe and adjust interventions, and students themselves are encouraged to join in planning and self-advocacy. Together, this varied team constructs the scaffolding students with ADHD need to succeed both academically and socially (Pfiffner et al., 2013; Lyon et al., 2016; Sibley et al., 2013; Pounds & Cuevas, 2019).

9. Future Directions

In this review, we argue that school-based interventions can be effective supports for middle school students with ADHD. While school-based interventions for ADHD in middle schools have demonstrated promise, several critical areas warrant further exploration to enhance their effectiveness, sustainability, and accessibility. Future research should focus on interventions’ sustainability, stigma reduction, financial feasibility, and strategies to encourage student self-advocacy.

We can take some of the specific evidence-based programs we have covered as examples, such as the CHP and STAND. Sustainability of the Challenging Horizons Program is key to ensuring its long-term success and widespread implementation (Evans et al., 2004). Maintaining the program’s effectiveness over time requires careful consideration of several key factors. Programs like the CHP rely on adequate funding. To ensure sustainability, schools must secure consistent financial support for essential resources such as personnel, training, and program materials. This could involve exploring alternative funding sources, such as grants, partnerships with community organizations, or re-allocation of school resources. Additionally, like most programs, the CHP’s effectiveness depends on the availability of skilled staff, including school psychologists, teachers, and administrators. To sustain such programs, schools should invest in ongoing professional development and ensure that personnel are trained to meet the evolving needs of students with ADHD.

STAND offers another case for how future studies could be best directed. While feasibility and acceptability for STAND have been demonstrated (Sibley et al., 2013), the long-term maintenance of its effects remains unclear. Follow-up studies should assess academic performance and family engagement improvements beyond middle school and into high school. Additionally, examining treatment moderators—such as families’ socioeconomic status, parental involvement, and comorbid conditions—could help tailor interventions to different subgroups of students with ADHD.

The use of school-based CBT interventions for middle schoolers with ADHD also shows evidence of promise. However, more information is needed here as well. One key area for future research is the scalability and feasibility of implementing CBT in school settings. Many existing studies focus on small sample sizes or single-case studies, limiting their generalizability (Rofiah et al., 2021). Large-scale, randomized controlled trials are necessary to determine the long-term efficacy of school-based CBT and to assess its impact across different student populations, such as those from under-represented and low-income communities. Additionally, research should explore how school-based CBT can be integrated within existing support systems—like IEPs and existing interventions—to enhance treatment’s effectiveness.

Combining CBT with peer mentoring or teacher-led reinforcement strategies may improve engagement and outcomes, especially for students with severe symptoms. Future studies should also investigate whether certain components of CBT are more effective for specific ADHD symptom profiles (Sprich et al., 2016). Comparing cognitive restructuring versus behavioral reinforcement may be fruitful here. Finally, as technology-based interventions are more widely used, future research should examine the potential benefits of digital CBT tools, such as mobile applications or virtual coaching, to supplement school-based interventions. Given the success of outpatient CBT for adolescents with ADHD, exploring hybrid models that combine in-person school-based CBT with digital interventions may offer a means for expanding access to effective treatments (Sprich et al., 2016). By addressing these gaps, future research can help optimize school-based CBT programs, ensuring that they are both evidence-based and accessible for middle school students with ADHD.

Unfortunately, financial feasibility remains a major barrier to implementing effective school-based interventions. Although school-based interventions eliminate some barriers like direct costs to students and their families, many interventions depend on high levels of parental involvement. Parental involvement with intervention can be challenging for low-income families with limited time and resources. Research should explore cost-effective models of intervention delivery. These may include peer mentoring, school-based behavioral coaching, or digital interventions that reduce the burden on caregivers. Investigating funding structures and policy changes that could support ADHD interventions in public schools can aid in increasing accessibility for all students.

It is also important to address the stigma associated with ADHD in middle school settings—a barrier that can undercut interventions a priori. Middle school students with ADHD often feel misunderstood by both parents and teachers, furthering the potential for feelings of “otherness” and fears of failure (Maya Beristain & Wiener, 2020). Public stigma is when populations use stereotypes to emotionally distance themselves from out-group members (e.g., those with ADHD), effectively creating an empathy gap (Corrigan & Calabrese, 2001). Public stigma can certainly be detrimental to students. Self-stigma may be even more harmful. Self-stigma occurs when an ostracized individual internalizes the negative way in which others view them. It can impact the stigmatized individual’s self-esteem and ability to smoothly integrate into social situations (Fabrega, 1990). In a school setting, teacher attitudes toward ADHD vary significantly, with many educators holding negative perceptions of the disorder (Adamis et al., 2024). Covert and overt stigma from teachers may impact students with ADHD. Future studies should examine the efficacy of teacher training programs in reducing ADHD stigma and promoting inclusive classroom environments.

Interventions targeting peer perceptions of ADHD may be a fruitful avenue for future study as well. Such interventions might improve social integration for students with the disorder, improving life outcomes. Research has found that there is a high peer stigma surrounding ADHD (Martin et al., 2007). Peers are less likely to empathize with peers with ADHD than they are with neurotypical peers, or even peers with physical illness or disabilities. Participants in Martin et al.’s (2007) study were also less likely to stigmatize ADHD in child-age students, with a higher likelihood to stigmatize adolescents. In a study by Walker et al. (2008), peers were more likely to associate ADHD with violent and antisocial behaviors compared with asthma and other physical ailments (Walker et al., 2008). Thus, there may be a useful role for positive perception interventions for ADHD in middle school populations.

Lastly, future research should focus on enhancing student self-advocacy. As adolescents transition into middle school, they become more aware of their ADHD and the accommodations that help them succeed (Maya Beristain & Wiener, 2020). The Individuals with Disabilities Education Improvement Act (IDEA) states that students aged 14 and older must participate in IEP meetings. Yet many students lack the necessary self-advocacy skills to meaningfully engage in these discussions (Pounds & Cuevas, 2019). Self-advocacy skills in students with disabilities have been associated with higher school retention rates and positive outcomes in adulthood (Roberts et al., 2014). Future studies should examine interventions aimed at teaching self-advocacy skills and student participation in treatment planning. Developing structured programs to train students in self-determination and communication strategies may lead to better long-term outcomes for adolescents with ADHD.

Overall, more research is needed to assess the efficacy of interventions in a school environment, especially where middle school is concerned. There is significantly less research on school-based interventions for middle school students with ADHD than for other age groups or settings. Previous research has primarily investigated either the efficacy of interventions that are school-based or interventions aimed at middle school populations. Yet very few studies have examined both of these factors together. Although the literature that exists seems to offer promising results, it must be tested on this population and setting. Further exploration of this area of research could be highly beneficial for the future of clinical school psychology and the treatment and understanding of middle schoolers with ADHD.