Secondary Logo

Journal Logo

School Problems with Learning and Behavior

Attention-Deficit/Hyperactivity Disorder, Behavior Regulation and Virtual School Support

Wallace, Claire MA*; Ievers-Landis, Carolyn E. PhD†,‡; Scherer, Catherine DO†,‡; Roizen, Nancy MD†,‡; Augustyn, Marilyn MD§

Author Information
Journal of Developmental & Behavioral Pediatrics: February/March 2017 - Volume 38 - Issue - p S41-S43
doi: 10.1097/DBP.0000000000000292
  • Free


Claire Wallace, MA, Carolyn E. Ievers-Landis, PhD

Given the variety of options for home-based learning available to families who wish to pursue nontraditional schooling, clinicians should be informed about different types, including virtual schools. Most states offer online curricula for individual courses, which students can use for credit recovery or for advanced course options.1 Some states also offer online schooling providing a full range of curriculum for an academic year.

As of 2014, more than 315,000 students participated in fully online virtual schools nationwide.1 There are benefits and potential deficits participating in these virtual schools. Children with impairing emotional and/or behavioral health concerns may benefit from a more flexible school environment with fewer distractions. In Tony's case, he might require fewer behavioral supports at home compared with the traditional school setting while he and his mother continue in therapy to improve his emotion regulation. In addition, there are hybrid options available; for example, children may be able to attend school for a portion of a day until they workup to a regular school day. However, it may be challenging to evaluate the success of a student's performance in a virtual school. There is some indication that test scores and yearly progress reports of virtual schools show significantly lower performance of these students compared with those attending traditional schools for various reasons (including student mobility). However, the availability of virtual schools in a state has been related to higher graduation rates.2 Parents should be encouraged to compare the many options available to choose the program/school that fits best with their child's unique needs. For example, there are a number of recently established private, college preparatory virtual schools affiliated with universities.

As with traditional school, active parental involvement is typically a crucial component to students' success. The clinician in Tony's case could assist his mother to create a plan for monitoring Tony's daily activities and staying engaged with him. A recent study highlighted the potential benefit of moderate to vigorous physical activity on attention.3 The clinician could also encourage Tony's mother to identify and request specific tools within the virtual system available for children with attentional and behavioral challenges. Many virtual school programs offer individual or small-group tutoring sessions, targeted assessments, and parent-teacher communication tools for at-risk students.4 Whether full-time or part-time virtual school is a temporary or longer-term option should be considered on enrollment and be reexamined at regular intervals along with monitoring of the child's symptoms and child/family preferences.

    Catherine Scherer, DO, Nancy Roizen, MD

    To effectively develop an intervention plan, a comprehensive evaluation of Tony's emotional dysregulation and dysfunction at school and home is needed to identify additional factors that may be contributing to his ongoing problems. If attention-deficit/hyperactivity disorder (ADHD) is the correct diagnosis, he could also have an anxiety disorder, an oppositional-defiant disorder, or an unrecognized learning disorder.1,2 A family history can identify risk for other disorders. His clinician should screen for medical issues including vision, hearing, sleep disorders, and iron deficiency anemia. A detailed school history may help identify strengths and weaknesses in his learning and social skills. A home survey of environmental factors such as screen time, exercise, and social activities is essential.

    Tony's mother has chosen an online schooling option. Most states offer a public school K-12 online curriculum that is teacher led in a virtual classroom with the parent participating as a learning coach. His parents can request that their local school district perform psychoeducational testing and a functional behavioral analysis.3 He may qualify for additional school supports such as an individualized education program or 504 plan through Individuals With Disabilities Education Act under “other health impairments.” His mother should create a school environment that includes a regular school routine with breaks as needed. The school environment should also include at least 2 hours of physical activity over the course of the day4 and social involvement outside the home (such as sports, clubs, or religious activities).

    The comprehensive intervention plan for this year should be developed with an ultimate goal for a successful transition into second grade. Establishing a working relationship with a behavioral therapist can provide both the parents and child skills to improve behavior and family functioning.3 Medication management should continue to focus on minimizing the core ADHD symptoms. Evaluation of the dose and type of medication is essential to maximize effectiveness and minimize side effects. Over time, behavioral therapies may result in a decreased need for medication.3

      Marilyn Augustyn, MD

      The first public school in the United States was founded by Puritan settlers in 1635 in the home of Schoolmaster Philemon Pormont and later moved to School Street in Boston where its students included Benjamin Franklin, Samuel Adams, and John Hancock. Thus from the inception of public education in the United States, the home was at the base. The recent rise in virtual schooling, which started in the late 1990s, has been viewed as an innovation to our home-based origins. It is important that pediatric clinicians be aware of the impact of educational changes on the patients they care for.

      Virtual schooling is defined as schools that deliver all curriculum or instruction through the Internet and electronic communication, usually with students at home and teachers at a remote location and often with everyone participating at different times.1 There are over 300 full-time virtual schools across the United States. In 2011, these schools enrolled nearly 200,000 students,2 with 64% of these being charter schools and 36% operated by districts. It is important to recognize that public virtual schools are not homeschools, nor are the students who attend virtual schools considered “homeschooled.”

      For this young man and his family, it is important to consider the “whole child” when making educational recommendations to the family. Maximizing the attention-deficit/hyperactivity disorder management and any potential comorbidity is critical as is continuing to support the family as this decision unrolls through the academic year. Perhaps in these situations, we all need to be more like Albert Einstein who wrote, “I never teach my pupils, I only provide the conditions in which they can learn.”


      1. Facts About K12 Public Virtual Schools. Available from: Accessed January 27, 2016.
      2. Miron G, Horvitz B, Gulisono C. Virtual Schools in the US 2013: Politics, Performance, Policy and Research Evidence. Available from: Accessed January 27, 2016.

      ADHD; behavior regulation; virtual school

      Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.