Attention-Deficit/Hyperactivity Disorder Accommodations, Behavior Therapy, and Stimulant Medication: A Randomized Clinical Trial

Importance: Although widely deployed, little is known about the efficacy of academic accommodations for attention-deficit/hyperactivity disorder (ADHD), alone or in combination of behavior therapy and stimulant medication. Objective: To evaluate the efficacy of academic accommodations alone and in combination with behavioral interventions and stimulant medication. Design, Setting, and Participants: This was a crossover randomized clinical trial with participants introduced to all conditions. Children with ADHD were enrolled in kindergarten through sixth grade. Academic accommodations were changed daily in a randomized order. Stimulant medication and placebo alternated weekly. The general classroom and enhanced behavior classroom intervention alternated every 2 weeks. The study was conducted in summer treatment program classrooms. For the present study, behavior was evaluated in (1) a classroom period where participants completed independent assignments and (2) a classroom period where participants were taught a lesson, completed small group cooperative tasks related to the lesson, and then took a quiz. Study data were analyzed from March to July 2026. Interventions: The single and combined effects of academic accommodations, behavior therapy, and stimulant medication (methylphenidate, 0.3 mg/kg) were evaluated. Academic accommodations were extended time on tasks, frequent breaks during tasks, a low-distraction workspace, and the ability to stand at the desk, compared with a condition without an accommodation. A general classroom setting was compared with a classroom setting with enhanced behavior intervention. Main Outcomes and Measures: Main outcomes were classroom rule violations during each of the two, 1-hour class periods, the number of seatwork items completed correctly (ie, academic productivity), and the quiz score. Results: Of 306 children screened, 280 were enrolled in the study. A total of 255 children (mean [SD] age, 8.8 [1.6] months; 201 male [79%]) started the intervention, and 235 (84%) completed the study. Compared with placebo, stimulant medication increased effects related to seatwork productivity by 22% (ie, the rate ratio [RR] for this condition indicated that receiving medication compared with placebo multiplied the expected count of problems completed per minute by 1.22; 95% CI, 1.19-1.25), and quiz scores were significantly improved by 3.9 points (95% CI, 3.10-4.70 points). Medication and behavioral therapy significantly reduced classroom rule-breaking behavior by 37% (RR, 0.63; 95% CI, 0.60-0.67) and 61% (RR, 0.39; 95% CI, 0.37-0.42), respectively. There was no evidence that any of the academic accommodations significantly improved behavior or academic outcomes. No interactions were significant. Conclusions and Relevance: Results of this crossover randomized clinical trial question whether school-based academic accommodations for children with ADHD should continue to be emphasized as accommodations were ineffective when used alone or in combination with other ADHD treatments. Results support the continued use of behavioral and pharmacological treatment for ADHD. Trial Registration: ClinicalTrials.gov Identifier: NCT05469386.