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Identifying and Treating Attention Deficit Hyperactivity Disorder - Page 2
ADHD Article

Services Public Schools Required to Provide

Two important federal mandates protect the rights of eligible children with ADHD—the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 (Section 504). The regulations implementing these laws are 34 CFR sections 300 and 104, respectively, which require school districts to provide a “free appropriate public education” to students who meet their eligibility criteria. Although a child with ADHD may not be eligible for services under IDEA, he or she may meet the requirements of Section 504.

The requirements and qualifications for IDEA are more stringent than those of Section 504. IDEA provides funds to state education agencies for the purpose of providing special education and related services to children evaluated in accordance with IDEA and found to have at least one of the 13 specific categories of disabilities, and who thus need special education and related services. Attention Deficit Hyperactivity Disorder may be considered under the specific category of “Other Health Impairment” (OHI), if the disability results in limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment and that is due to chronic or acute health problems.

Under IDEA, each public agency—that is, each school district—shall ensure that a full and individual evaluation is conducted for each child being considered for special education and related services. The child’s individualized education program (IEP) team uses the results of the evaluation to determine the educational needs of the child. The results of a medical doctor’s, psychologist’s, or other qualified professional’s assessment indicating a diagnosis of ADHD may be an important evaluation result, but the diagnosis does not automatically mean that a child is eligible for special education and related services. A group of qualified professionals and the parent of the child determine whether the child is an eligible child with a disability according to IDEA. Children with ADHD also may be eligible for services under the “Specific Learning Disability,” “Emotional Disturbance,” or other relevant disability categories of IDEA if they have those disabilities in addition to ADHD.

After it has been determined that a child is eligible for special education and related services under IDEA, an IEP is developed that includes a statement of measurable annual goals, including benchmarks or short-term objectives that reflect the student’s needs. The IEP goals are determined with input from the parents and cannot be changed without the parents’ knowledge. Although children who are eligible under IDEA must have an IEP, students eligible under Section 504 are not required to have an IEP but must be provided regular or special education and related aids or services that are designed to meet their individual educational needs as adequately as the needs of nondisabled students are met.

Section 504 was established to ensure a free appropriate education for all children who have an impairment—physical or mental—that substantially limits one or more major life activities. If it can be demonstrated that a child’s ADHD adversely affects his or her learning—a major life activity in the life of a child—the student may qualify for services under Section 504. To be considered eligible for Section 504, a student must be evaluated to ensure that the disability requires special education or related services or supplementary aids and services. Therefore, a child whose ADHD does not interfere with his or her learning process may not be eligible for special education and related services under IDEA or supplementary aids and services under Section 504.

IDEA and Section 504 require schools to provide special education or to make modifications or adaptations for students whose ADHD adversely affects their educational performance. Such adaptations may include curriculum adjustments, alternative classroom organization and management, specialized teaching techniques and study skills, use of behavior management, and increased parent/ teacher collaboration. Eligible children with ADHD must be placed in regular education classrooms, to the maximum extent appropriate to their educational needs, with the use of supplementary aids and services if necessary. Of course, the needs of some children with ADHD cannot be met solely within the confines of a regular education classroom, and they may need special education or related aids or services provided in other settings.

How ADHD is Evaluated

A diagnosis of ADHD is multifaceted and includes behavioral, medical, and educational data gathering. One component of the diagnosis includes an examination of the child’s history through comprehensive interviews with parents, teachers, and health care professionals. Interviewing these individuals determines the child’s specific behavior characteristics, when the behavior began, duration of symptoms, whether the child displays the behavior in various settings, and coexisting conditions. The American Academy of Pediatrics (AAP) stresses that since a variety of psychological and developmental disorders frequently coexist in children who are being evaluated for ADHD, a thorough examination for any such coexisting condition should be an integral part of any evaluation (AAP, 2000).

Behavioral Evaluation

Specific questionnaires and rating scales are used to review and quantify the behavioral characteristics of ADHD. The AAP has developed clinical practice guidelines for the diagnosis and evaluation of children with ADHD, and finds that such behavioral rating scales accurately distinguish between children with and without ADHD (AAP, 2000). Conversely, AAP recommends not using broadband rating scales or teacher global questionnaires in the diagnosis of children with ADHD. They suggest using ADHD-Specific rating scales including:
CPRS-R:L-ADHD Index
(Conners Parent Rating Scale—1997
Revised Version: Long Form, ADHD Index Scale)

CTRS-R:L-ADHD Index
(Conners Teacher Rating Scale—1997
Revised Version: Long Form, ADHD Index Scale)

CPRS-R:L-DSM-IV Symptoms
(Conners Parent Rating Scale—1997
Revised Version: Long Form, DSM-IV Symptoms Scale)

CTRS-R:L-DSM-IV Symptoms
(Conners Teacher Rating Scale—1997
Revised Version: Long Form, DSM-IV Symptoms Scale)

SSQ-O-1
(Barkley’s School Situations Questionnaire—Original Version, Number of Problem Settings Scale)

SSQ-O-II
(Barkley’s School Situations Questionnaire—Original Version, Mean Severity Scale)
(Taken from Green, Wong, Atkins, et al. (1999). Diagnosis of Attention Deficit/Hyperactivity Disorder. Technical Review 3. Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, as cited in AAP, 2000).

As with all psychological tests, child-rating scales have a range of measurement error. Appropriate scales have satisfactory norms for the child's chronological age and ability levels.

Collecting information about the child’s ADHD symptoms from several different sources helps ensure that the information is accurate. Appropriate sources of information include the child’s parents, teachers, other diagnosticians such as psychologists, occupational therapists, speech therapists, social workers, and physicians. It is also important to review both the child’s previous medical history as well as his or her school records.

Educational Evaluation

An educational evaluation assesses the extent to which a child’s symptoms of ADHD impair his or her academic performance at school. The evaluation involves direct observations of the child in the classroom as well as a review of his or her academic productivity.

Behaviors targeted for classroom observation may include:

  • Problems of inattention, such as becoming easily distracted, making careless mistakes, or failing to finish assignments on time;
  • Problems of hyperactivity, such as fidgeting, getting out of an assigned seat, running around the classroom excessively or striking out at a peer;
  • Problems of impulsivity, such as blurting out answers to the teacher’s questions or interrupt-ing the teacher or other students in the class; and
  • More challenging behaviors, such as severe aggressive or disruptive behavior.

Classroom observations are used to record how often the child exhibits various ADHD symptoms in the classroom. The frequency with which the child with ADHD exhibits these and other target behaviors are compared to norms for other children of the same age and gender. It is also important to compare the behavior of the child with ADHD to the behaviors of other children in his or her classroom.

It is best to collect this information during two or three different observations across several days. Each observation typically lasts about 20 to 30 minutes.

In order to receive special education and related services under Part B of IDEA, a child must be evaluated to determine (1) whether he or she has a disability and (2) whether he or she, because of the disability, needs special education and related services. The initial evaluation must be a full and individual evaluation that assesses the child in all areas related to the suspected disability and uses a variety of assessment tools and strategies. As discussed in the section on Legal Requirements (above), a child who has ADHD may be eligible for special education and related services because he or she also meets the criteria for at least one of the disability categories, such as specific learning disability or emotional disturbance. It is important to note that the assessment instruments and procedures used by educational personnel to evaluate other disabilities—such as learning disabilities—may not be appropriate for the evaluation of ADHD. A variety of assessment tools and strategies must be used to gather relevant functional and developmental information about the child.

An educational evaluation also includes an assessment of the child’s productivity in completing classwork and other academic assignments. It is important to collect information about both the percentage of work completed as well as the accuracy of the work. The productivity of the child with ADHD can be compared to the productivity of other children in the class.

Once the observations and testing are complete, a group of qualified professionals and the parents of the child will review the results and determine if the child has a disability and whether the child needs special education and related services. Using this information, the child’s IEP team, which includes the child’s parents, will develop an individualized educational program that directly addresses the child’s learning and behavior. If the child is recommended for evaluation and determined by the child’s IEP team not to meet the eligibility requirements under IDEA, the child may be appropriate for evaluation under Section 504.

Medical Evaluation

A medical evaluation assesses whether the child is manifesting symptoms of ADHD, based on the following three objectives:

  • To assess problems of inatten-tion, impulsivity, and hyperactiv-ity that the child is currently experiencing;
  • To assess the severity of these problems; and
  • To gather information about other disabilities that may be contributing to the child’s ADHD symptoms.

Part B of IDEA does not necessarily require a school district to conduct a medical evaluation for the purpose of determining whether a child has ADHD. If a public agency believes that a medical evaluation by a licensed physician is needed as part of the evaluation to determine whether a child suspected of having ADHD meets the eligibility criteria of the OHI category, or any other disability category under Part B, the school district must ensure that this evaluation is conducted at no cost to the parents (OSEP Letter to Michel Williams, March 14, 1994, 21 IDELR 73).

In May 2000, the American Academy of Pediatrics (AAP) published a clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with ADHD. The guideline, developed by a committee comprised of pediatricians and experts in the fields of neurology, psychology, child psychiatry, child development, and education, as well as experts in epidemiology and pediatrics, is intended for use by primary care clinicians who are involved in the identification and evaluation process. The recommendations are designed to provide a framework for diagnostic decisionmaking and include the following:

  • Medical evaluation for ADHD should be initiated by the primary care clinician. Questioning parents regarding school and behavioral issues, either directly or through a pre-visit questionnaire, may help alert physicians to possible ADHD.
  • In diagnosing ADHD, physicians should use DSM-IV criteria.
  • The assessment of ADHD should include information obtained directly from parents or caregivers, as well as a classroom teacher or other school professional, regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment.
  • Evaluation of a child with ADHD should also include assessment of co-existing conditions such as learning and language problems, aggression, disruptive behavior, depression, or anxiety.

What Are the Treatment Options?

Although at present no cure for ADHD exists, there are a number of treatment options that have proven to be effective for some children. Effective strategies include behavioral, pharmacological, and multimodal methods.

Behavioral Approaches

Behavioral approaches represent a broad set of specific interventions that have the common goal of modifying the physical and social environment to alter or change behavior (AAP, 2001). They are used in the treatment of ADHD to provide structure for the child and to reinforce appropriate behavior. Those who typically implement behavioral approaches include parents as well as a wide range of professionals, such as psychologists, school personnel, community mental health therapists, and primary care physicians. Types of behavioral approaches include behavioral training for parents and teachers (in which the parent and/or teacher is taught child management skills), a systematic program of contingency management (e.g. positive reinforcement, “time outs,” response cost, and token economy), clinical behavioral therapy (training in problem-solving and social skills), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, development of problem-solving strategies, self-reinforcement) (AAP, 2001; Barkley, 1998b; Pelham, Wheeler, & Chronis, 1998). In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behavior. Of these options, systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained individuals have been found to be highly effective (Abramowitz, et al., 1992; Carlson, et al., 1992; Pelham & Hoza, 1996). A later study conducted by Pelham, Wheeler, and Chronis (1998) indicates that two approaches—parent training in behavior therapy and classroom behavior interventions—also are successful in changing the behavior of children with ADHD. In addition, home-school interactions that support a consistent approach are important to the success of behavioral approaches.

The use of behavioral strategies holds promise but also presents some limitations. Behavioral strate-gies may be appealing to parents and professionals for the following reasons:

  • Behavioral strategies are used most commonly when parents do not want to give their child medication;
  • Behavioral strategies also can be used in conjunction with medicine (see multimodal methods);
  • Behavioral techniques can be applied in a variety of settings including school, home, and the community; and
  • Behavioral strategies may be the only options if the child has an adverse reaction to medication.

The research results on the effectiveness of behavioral techniques are mixed. While studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy (Pelham & Fabiano, 2001), it is difficult to isolate its effectiveness. The multiplicity of interventions and outcome measures makes careful analysis of the effects of behavior therapy alone, or in association with medications, very difficult (AAP, 2001). A review conducted by McInerney, Reeve, and Kane (1995) confirms that the effective education of children with ADHD requires modifications to academic instruction, behavior management, and classroom environment. Although some research suggests that behavioral methods offer the opportunity for children to work on their strengths and learn self-management, other research indicates that behavioral interventions are effective but to a lower degree than treatment with psychostimulants (Jadad, Boyle, & Cunningham, 1999; Pelham, et al., 1998).

Behavior therapy has been found to be effective only when it is implemented and maintained (AAP, 2001). Indeed, behavioral strategies can be difficult to implement consistently across all of the settings necessary for it to be maximally effective. Although behavioral management programs have been shown to enhance the academic performance and behavior of children with ADHD, followup and maintenance of the treatment is often lacking (Rapport, Stoner, & Jones, 1986).

In fact, some research has shown that behavioral techniques may fail to reduce ADHD’s core characteristics of hyperactivity, impulsivity, and inattention (AAP, 2001; U.S. Department of Health and Human Services [DHHS], 1999). Conversely, one must consider that the problems of children with ADHD are seldom limited to the core symptoms themselves (Barkley, 1990a). Children frequently demonstrate other types of psychosocial difficulties, such as aggression, oppositional defiant behavior, academic underachievement, and depression (Barkley, 1990a). Because many of these other difficulties cannot be managed through psychostimulants, behavioral interventions may be useful in addressing ADHD and other problems a child may be exhibiting.

Pharmacological Approaches

Pharmacological treatment remains one of the most common, yet most controversial, forms of ADHD treatment. It is important to note that the decision to prescribe any medicine is the responsibility of medical—not educational—professionals, after consultation with the family and agreement on the most appropriate treatment plan. Pharmacological treatment includes the use of psychostimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers (NIMH, 2000). Stimulants predominate in clinical use and have been found to be effective with 75 to 90 percent of children with ADHD (DHHS, 1999). Stimulants include Methylphenidate (Ritalin), Dextroamphetamine (Dexedrine), and Pemoline (Cylert). Other types of medication (antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers) are used primarily for those who do not respond to stimulants, or those who have coexisting disorders. The results of the Multimodal Treatment Study (MTA), which are discussed in further detail in the next section, confirm research findings on the use of pharmacological treatment for patients with ADHD. Specifically, the study found that the use of medication was almost as effective as the multimodal treatment of medication and behavioral interventions (Edwards, 2002).

Administering Medication at School

  • Develop a plan to ensure that medication is administered in accordance with doctor’s recommendation
  • Include this plan in the child’s IEP
  • Maintain child and parent rights to medical confidentiality

Researchers believe that psychostimulants affect the portion of the brain that is responsible for producing neurotransmitters. Neurotransmitters are chemical agents at nerve endings that help electrical impulses travel among nerve cells. Neurotransmitters are responsible for helping people attend to important aspects of their environment. The appropriate medication stimulates these underfunctioning chemicals to produce extra neurotransmitters, thus increasing the child’s capacity to pay attention, control impulses, and reduce hyperactivity. Medication necessary to achieve this typically requires multiple doses throughout the day, as an individual dose of the medication lasts for a short time (1 to 4 hours). However, slow- or timed-release forms of the medication (for example, Concerta) may allow a child with ADHD to continue to benefit from medication over a longer period of time. Doctors, teachers, and parents should communicate openly about the child’s behavior and disposition in order to get the dosage and schedule to a point where the child can perform optimally in both academic and social settings, while keeping side effects to a minimum. If it is determined that the child should receive medication during the school day, it is important to develop a plan to ensure that medication is administered in accordance with the plan. Such a plan would be an appropriate component of the child’s IEP. In addition, schools must ensure that the child’s and parent’s rights to medical confidentiality are maintained.

Although the positive effects of the stimulant medication are immediate, all medications have side effects. Adjusting the dosage of the medicine can diminish some of these side effects. Some of the more common side effects include insomnia, nervousness, headaches, and weight loss. In fewer cases, subjects have reported slowed growth, tic disorders, and problems with thinking or with social interaction (Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995). Medication also can be expensive, depending upon the medicine prescribed, the frequency of administration, and the subsequent frequency of refills. Stimulant medicines do not “normalize” the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers (DHHS, 1999). Nonetheless, the American Academy of Pediatrics (AAP) finds that at least 80 percent of children will respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who do not respond to one medication may have a positive response to an alternative medication, and concludes that stimulants may be a safe and effective way to treat ADHD in children (AAP, 2001).

In January 2003, a new type of nonstimulant medication for the treatment of children and adults with ADHD was approved by the FDA. Atomoxetine, also known as Straterra, may be prescribed by physicians in some cases.

Multimodal Approaches

Research indicates that for many children the best way to mitigate symptoms of ADHD is the use of a combined approach. A recent study by the NIMH—the Multimodal Treatment Study of Children with ADHD (MTA)—is the longest and most thorough study of the effects of ADHD interventions (MTA Cooperative Group, 1999a, 1999b). The study followed 579 children between the ages of 7 and 10 at six sites nationwide and in Canada. The researchers compared the effects of four interventions: medication provided by the researchers, behavioral intervention, a combination of medication and behavioral intervention, and no-intervention community care (i.e., typical medical care provided in the community).

Multimodal intervention improves . . .

  • Academic performance
  • Parent-child interaction
  • School-related behavior

and reduces . . .

  • Child anxiety
  • Oppositional behavior

Of the four interventions investigated, the researchers found that the combined medication/behavior treatment and the medication treatment work significantly better than behavioral therapy alone or community care alone at reducing the symptoms of ADHD. Multimodal treatments were especially effective in improving social skills for students coming from high-stress environments and children with ADHD in combination with symptoms of anxiety or depression. The study revealed that a lower medication dosage is effective in multimodal treatments, whereas higher doses were needed to achieve similar results in the medication-only treatment.

Researchers found improvement in the following areas after using a multimodal intervention: child anxiety, academic performance, oppositional behavior, and parent-child interaction. Positive results also were found in school-related behavior when multimodal treatment is coupled with improved parenting skills, including more effective disciplinary responses, and appropriate reinforcements (Hinshaw, et al., 2000). These findings were replicated across all six research sites, despite substantial differences among sites in their samples’ sociodemographic characteristics. The study’s overall results appear to apply to a wide range of children and families identified as in need of treatment services for ADHD (NIMH, 2000). Other studies demonstrate that multimodal treatments hold value for those children for whom treatment with medication alone is not sufficient (Klein, Abikoff, Klass, Ganeles, Seese, & Pollack, 1997).

In October 2001, the AAP released evidence-based recommendations for the treatment of children diagnosed with ADHD. Their guidelines state that:

  • Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition; \
  • The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target out-comes to guide management;
  • The clinician should recommend stimulant mediation and/or behavioral therapy as appropriate to improve target outcomes in children with ADHD;
  • When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and the presence of coexisting conditions; and
  • The clinician should periodically provide a systematic followup for the child with ADHD. Monitoring should be directed to tar-get outcomes and adverse effects, with information gathered from parents, teachers, and the child.

The AAP report stressed that the treatment of ADHD (whether behavioral, pharmacological, or multimodal) requires the development of child-specific treatment plans that describe not only the methods and goals of treatment, but also include means of monitoring over time and specific plans for followup. The process of developing target outcomes requires careful input from parents, children, and teachers as well as other school personnel where available and appropriate. The AAP concluded that parents, children, and educators should agree on at least three to six key targets and desired changes as requisites for constructing the treatment plan. The goals should be realistic, attainable, and measurable. The AAP report found that, for most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances (AAP, 2001).

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