Classroom Interventions for ADHD

As almost any parent of a child with ADHD can tell you, teachers play a critical role in determining their child’s success at school. One important reason for this is that teachers are responsible for implementing the classroom accommodations and behavioral interventions that have been recommended to help a child succeed. Teachers also play an important role in the development of these strategies. Without a teacher’s consistent cooperation and support for such plans, there is little chance that even the best-developed strategies will succeed.

For these reasons, it is important to learn more about how teachers regard different interventions for ADHD children. This was the focus of an interesting study published recently in the Journal of Clinical Child Psychology (Pisecco, S. et al., (2001). The Effect of Child Characteristics on Teachers’ Acceptability of Classroom-based Behavioral Strategies and Medication for the Treatment of ADHD. 30, 413-421.)

Participants were 159 experienced elementary school teachers from urban and suburban school districts in a large southwestern city. Each teacher was given a short vignette describing the classroom behavior and academic performance of a “typical” child with ADHD. For half the teachers, the child described was a boy and for the other half, the child described was a girl. After reading the vignette, the teachers were given a brief description of four different interventions that could be used with the child. These interventions were as follows:

Daily Report Card (drc)

The DRC is an intervention that requires parents and teachers to identify 3-5 problem behaviors to work on. These behaviors are translated into daily goals for the child. For example, the daily goals for a child with ADHD might be: 1) Follow class rules, 2) Complete assigned work, and 3) Get along well with peers. At the end of each day, the teacher gives the child a grade to indicate how well each goal was met and the child takes the report card home and either earns or loses privileges depending on the grades received for that day. This intervention thus provides parents with a daily report of how their child is doing in key academic and behavioral areas and enables parents to provide their child with appropriate consequences.

Response Cost Technique (rct)

In this the child earns points in the classroom for exhibiting specific positive behaviors (e.g. completing tasks) and loses points for exhibiting negative behaviors (e.g. blurting out answers). The teacher keeps a running tally of the child’s point total and at predetermined times during the day, the child is allowed to redeem points for a list of pre-determined rewards (e.g. access to the class computer). The different reward options are worked out in advance and each reward costs a specified number of points.

Classroom Lottery (cl)

This is an intervention in which all children in the classroom earn points based on their behavior. The teacher establishes a brief list of class rules and posts them. Students are told they will earn class jobs (e.g. line monitor, office messenger) according to how well they follow the rules. At unannounced times during the day, the teacher checks to see who is following the rules and the names of these children are written down. At the end of the day, the names of children who were following the rules at a predetermined level (e.g. 4 out of 5 times checked) are written down and placed in a “hat”. The teacher then draws names from the hat to match the number of class jobs available and each child selects a job when their name is drawn. A nice feature of this system is that it is used to manage an entire classroom and does not require special treatment for students with ADHD.

Stimulant Medication

Because medication is the most frequently used treatment for ADHD, it was also included as one of the possible interventions. The specific medication described was Ritalin, because it is the one with which teachers are likely to be most familiar.

After reading the intervention descriptions, teachers rated each one on 3 different dimensions:

how acceptable it was to them
how effective they believed it would be
how quickly they believed it would have an effect

These ratings thus provided researchers with information on how teachers felt about 3 types of behavioral interventions as well as medication.

Results

Which Interventions Were Most Acceptable To Teachers?

Overall, teachers rated the Daily Report Card intervention most acceptable. This was strongly preferred to the other behavioral interventions for boys and girls while the Classroom Lottery intervention received the lowest acceptability ratings from teachers.

Interestingly, the DRC received significantly higher acceptability ratings than medication, and this was true for boys and girls. In addition, for girls, the Response Cost Intervention received significantly higher acceptability ratings than medication. Overall, teachers rated medication as a less acceptable treatment option for girls with ADHD than for boys with ADHD.

What Expectations Of Effectiveness And Timeliness Do Teachers Have For Different Interventions?

Overall, teachers believed the Daily Report Card intervention would be as effective and as quick to produce change as medication. They also indicated that the DRC intervention would be more effective for girls than for boys, and that medication would yield more rapid improvement in boys than in girls. The Response Cost Intervention was rated to be as effective and timely as medication treatment for girls, but this was not true for boys.

Summary And Implications

Results from this study indicate that teachers do not necessarily favor the use of medication treatment for all students with ADHD. The Daily Report Card was more acceptable to teachers than medication treatment for boys and girls with ADHD, and teachers believed this intervention would be as effective as medication. For girls, a second behavioral technique -- the Response Cost Procedure -- was also more acceptable than medication treatment. Overall, teachers regarded medication treatment as a less acceptable option for girls than for boys.

The interpretation of these results is not clear-cut. On one hand, the finding that teachers regard medication as less acceptable than certain behavioral approaches and that they have positive expectations for behavioral interventions like the DRC can be seen as encouraging. On the other hand, data from the MTA study suggest that teachers’ belief that behavioral interventions will be as helpful and as quick to produce change as well-conducted medication treatment is unlikely to be correct. One wonders, therefore, why medication treatment should be a less acceptable option to teachers than interventions that are not likely to be as helpful. Perhaps it is more common for teachers to have a bias against medication than is generally believed.

The finding that teachers regard medication as less acceptable for girls than for boys is intriguing. Existing data indicate that medication treatment has comparable effects for boys and girls. Therefore, it is not clear why teachers feel medication is more acceptable for boys. Disruptive behavior problems are more likely to be evident in boys with ADHD than in girls with ADHD, and perhaps teachers are less inclined to believe that medication is as necessary for the former because ADHD girls are typically less disruptive in the classroom.

Regardless of the reason for this finding -- and this would be interesting to explore in subsequent research -- the authors suggest that teachers’ belief that medication is more acceptable and works more quickly for boys than girls may possibly influence the likelihood of boys and girls receiving medication. This is because a teacher who believes medication is less acceptable than other strategies may advocate interventions other than medication. Unfortunately, it is possible that this could have the effect of depriving a child of a treatment that would provide important benefits. These findings suggest this would be more likely to occur for girls than for boys.

There are several limitations in this study that should be recognized. First, the sample of teachers was from a relatively narrow geographic region, and one cannot assume that similar results would be found in other communities. Ideally, this study should be extended to include a nationally representative sample of teachers. It would also be important to gather teachers’ ratings of combined treatments, in addition to their ratings of medication and behavioral interventions in isolation. This is because results from the MTA study indicate that the combination of medication and behavioral intervention is likely to be more effective than either approach alone.

How teachers feel about “multi-modal” treatment, and what their expectations are for the success of such treatment, would thus be important to investigate. Finally, it would be very helpful to learn why teachers find some treatments more acceptable than others, and, in particular, why they regard medication treatment more favorably for boys than for girls. Learning more about the reasons for teachers’ ratings would be especially important for developing more effective collaborative relationships between teachers, parents, and health-care providers.

Despite these limitations, the results of this study are both interesting and provocative. One hopes that it will lead to additional work in this important area.

Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.

Reproduced with permission of David Rabiner, Ph.D. - HelpforADD.com