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Attention-deficit/hyperactivity disorder general education elementary school teachers' knowledge, training, and ratings of acceptability of interventions
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English
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Small, Stacey
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Attention-deficit-disordered children -- Education   ( lcsh )
Hyperactive children -- Education (Elementary)   ( lcsh )
Teacher-student relationships   ( lcsh )
Operant conditioning   ( lcsh )
barriers
adhd
behavior
children
instructional management
Dissertations, Academic -- School Psychology -- Specialist -- USF   ( lcsh )
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government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

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ABSTRACT: Given that researchers estimate approximately one child in every classroom has Attention-Deficit/Hyperactivity Disorder (ADHD), and that most of these students are served in the general education classroom, it is imperative that general education teachers know how to effectively teach these students. Seventy-two general education elementary school teachers completed a survey containing demographic information, a knowledge of ADHD questionnaire, and a survey on interventions for students with ADHD. Results indicated that teachers scored an average of 57% correct on the Knowledge of Attention Deficit Disorders Scale (KADDS), scoring statistically significantly higher on the Symptoms/Diagnosis subscale compared to the General and Treatment subscales. In terms of the interventions, teachers felt more knowledgeable, perceived their skill to be greater, rated as more acceptable, and rated lower barriers to the implementation of classroom management interventions such as the use of cues, prompts, and attention checks; physical arrangement; structure; and varied presentation and format of materials. Teachers felt they knew least about, had less skill, rated as less acceptable, and had more barriers to the implementation of behavior management interventions such as token economy, response cost, and time-out from positive reinforcement, as well as self-management techniques. Most demographic variables were unrelated to teachers' knowledge of ADHD, their perceived knowledge of interventions, and their ratings of acceptability of interventions. Based on the information presented, teachers need more training and knowledge in the area of ADHD and interventions for students with ADHD in order to effectively help children with the disorder. Importantly, school psychologists and other service providers who suggest interventions for teachers to use for students with ADHD need to consider the factors that contribute to teachers' acceptability of interventions.
Thesis:
Thesis (Ed.S.)--University of South Florida, 2003.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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by Stacey Small.
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Title from PDF of title page.
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Document formatted into pages; contains 142 pages.

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University of South Florida
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aleph - 001430566
oclc - 52420261
notis - AJL4027
usfldc doi - E14-SFE0000084
usfldc handle - e14.84
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ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: GENERAL EDUCATION ELEMENTARY SCHOOL TEACHERS' KNOWLEDGE, TRAINING, AND RATINGS OF ACCEPTABILTY OF INTERVENTIONS by STACEY SMALL, M.A. A thesis submitted in partial fulfillment of the requirements for the degree of Education Specialist Department of Psychological and Social Foundations College of Education University of South Florida Major Professor: Linda Raffaele Mendez, P h D Kathy Bradley-Klug, Ph.D. Robert Dedrick, Ph.D. Date of Approval: March 20, 2003 Keywords: adhd, barriers, behavior, children, instructional management Copyright 2003, Stacey Small, M.A.

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Teachers’ Knowledge i Table of Contents List of Tablesiv Abstract v Chapter I: Introduction1 Research Questions5 Importance of the Study6 Definition of Research Variables6 ADHD6 General Education Elementary School Teachers6 Knowledge of ADHD6 Educational Interventions7 Treatment Acceptability7 Barriers to Implementation7 Chapter II: Review of the Literature 8 Diagnosing ADHD8 Theories to Explain ADHD9 Neurological factors9 Genetic factors11 Environmental toxins11 Side effects of medications12 Psychosocial factors13 Behavioral disinhibition13 Treatment Strategies14 Educational Interventions16 Structure17 Physical arrangement18 Varied presentation of format and materials18 Use of cues, prompts, and attention checks19 Brief academic tasks interspersed with passive tasks19 Peer tutoring20 Teacher attention23 Token economy23 Response cost24 Time-out from positive reinforcement24 Home-based contingencies24

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Teachers’ Knowledge ii Self-management32 Teacher Knowledge and Training in ADHD35 Teacher Acceptability of Interventions and Barriers to Implementation41 Conclusion51 Purposes of the Study52 Chapter III: Method53 Participants53 Measures57 Demographics57 Knowledge of Attention Deficit Disorders Scale (KADDS)58 Teacher Intervention Survey61 Procedures63 Research Questions65 Chapter IV: Results66 Teachers’ Experiences with ADHD66 What is the Knowledge of GE Elementary School Teachers with Regard to the Following?69 What is the Perceived Knowledge of GE Elementary School Teachers with Regard to Educational Interventions for Children with ADHD?73 How Well Trained do GE Elementary School Teachers Perceive Themselves to be Regarding Interventions for Children with ADHD?75 How Acceptable do GE Elementary School Teachers Perceive Various Educational Interventions to be for Children with ADHD?76 What are Some of the Perceived Barriers that GE Elementary School Teachers Face in Implementing Empirically Supported Interventions for Children with ADHD?78 What Teacher Variables are Related to GE Elementary School Teachers’ Knowledge of ADHD?81 What Teacher Variables are Related to GE Elementary School Teachers’ Acceptability of Educational Interventions?87 Chapter V: Discussion91 Introduction91 Teachers’ Knowledge of ADHD93 Teachers’ Perceived Knowledge of Interventions95 Training in Interventions96 Acceptability of Interventions97 Types of Barriers98 Teacher Variables Related to Knowledge of ADHD99 Teacher Variables Related to Acceptability of Interventions101 Limitations of Study102 Future Directions103 Summary104

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Teachers Knowledge iii References105 Appendices116 Appendix A: Items on the Knowledge of Attention Deficit Disorders Scale (KADDS) by Subscale117 Appendix B: Items on Teacher Intervention Survey121 Appendix C: Barrier Items on Teacher Intervention Survey122 Appendix D: Letter to Principals to Request Teacher Participation123 Appendix E: Letter to Teachers125 Appendix F: Part I: Demographics Questionnaire127 Appendix G: Part II: Knowledge of Attention Deficit Disorders Scale (KADDS)128 Appendix H: Part III: Teacher Intervention Survey130

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Teachers’ Knowledge i v List of Tables Table 1Characteristics of Participating Schools55 Table 2Participating Teacher Characteristics56 Table 3Cronbach’s Alpha and Descriptive Statistics for Knowledge of Attention Deficit Disorders Scale (KADDS)59 Table 4Cronbach’s Alpha for the Teacher Intervention Survey62 Table 5Participants’ Experiences with ADHD 67 Table 6Teachers’ Scores on KADDS70 Table 7Most Common Correct Responses on KADDS71 Table 8Most Common Incorrect Responses on KADDS72 Table 9Most Common “Don’t Know” Responses on KADDS72 Table 10Teachers’ Ratings of Perceived Knowledge of Interventions74 Table 11Teachers’ Ratings of Perceived Skills of Interventions75 Table 12Teachers’ Ratings of Acceptability of Interventions77 Table 13Barrier Scores per Intervention79 Table 14Rank Order of Teachers’ Knowledge, Skill, Acceptability of Interventions, and Barriers to Implementation80 Table 15Teacher Variables Related to Knowledge83 Table 16Summary Table of Predictors for Perceived Knowledge of Interventions84 Table 17Summary Table of Predictors for Acceptability of Interventions88

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Teachers’ Knowledge v Attention-Deficit/Hyperactivity Disorder: General Education Elementary School Teachers’ Knowledge, Training, and Ratings of Acceptability of Interventions Stacey Small, M.A. ABSTRACT Given that researchers estimate approximately one child in every classroom has Attention-Deficit/Hyperactivity Disorder (ADHD), and that most of these students are served in the general education classroom, it is imperative that general education teachers know how to effectively teach these students. Seventy-two general education elementary school teachers completed a survey containing demographic information, a knowledge of ADHD questionnaire, and a survey on interventions for students with ADHD. Results indicated that teachers scored an average of 57% correct on the Knowledge of Attention Deficit Disorders Scale (KADDS), scoring statistically significantly higher on the Symptoms/Diagnosis subscale compared to the General and Treatment subscales. In terms of the interventions, teachers felt more knowledgeable, perceived their skill to be greater, rated as more acceptable, and rated lower barriers to the implementation of classroom management interventions such as the use of cues, prompts, and attention checks; physical arrangement; structure; and varied presentation and format of materials. Teachers felt they knew least about, had less skill, rated as less acceptable, and had more barriers to the implementation of behavior management interventions such as token

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Teachers Knowledge vi economy, response cost, and time-out from positive reinforcement, as well as selfmanagement techniques. Most demographic variables were unrelated to teachers knowledge of ADHD, their perceived knowledge of interventions, and their ratings of acceptability of interventions. Based on the information presented, teachers need more training and knowledge in the area of ADHD and interventions for students with ADHD in order to effectively help children with the disorder. Importantly, school psychologists and other service providers who suggest interventions for teachers to use for students with ADHD need to consider the factors that contribute to teachers acceptability of interventions.

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Teachers’ Knowledge 1 Chapter I Introduction Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most commonly diagnosed childhood disorders. It is estimated that it is found in three to five percent of the school-age population, affecting three times as many males as females (Barkley, 1998; DuPaul & Stoner, 1994). This translates into about one student in every classroom (Barkley, 1998; DuPaul & Stoner, 1994). Children with ADHD are usually inattentive, impulsive, and hyperactive, and they may have a variety of school-related problems, including difficulty paying attention, following directions, staying seated, listening, and completing assignments (Barkley, 1998; DuPaul & Stoner, 1994). Children with ADHD often exhibit social problems including poor peer relations (Barkley, 1998; DuPaul & Stoner, 1994). Additionally, these problems are often accompanied by other associated problems (e.g., low self-esteem) that may further affect the academic performance of these students (Barkley, 1998; DuPaul & Stoner, 1994; Gardill, DuPaul, & Kyle, 1996). Children with ADHD also have a high comorbidity rate with other disorders, which may exacerbate the academic performance of these students. Chances of children with ADHD also having an anxiety disorder, major depression, oppositional defiant disorder, or conduct disorder are 25%, 25%, 35%, and 20-56%, respectively (Barkley, 1998). Therefore, teachers may have a more difficult time teaching these students.

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Teachers’ Knowledge 2 Currently, under the Individuals with Disabilities Education Act (IDEA), students with ADHD are eligible for special education services under the category of Other Health Impaired if the following criteria are met: (a) the student must be diagnosed with ADHD by the school district or the school must accept the diagnosis made by another qualified professional; (b) the ADHD must result in limited access to academic tasks due to heightened alertness to environmental stimuli; (c) the effects of the ADHD must be chronic (long-lasting) or acute (have a substantial impact); (d) the ADHD must result in an adverse effect on educational performance; and (e) the student must require special education services in order to address the ADHD and its impact (Children and Adults with Attention-Deficit/Hyperactivity Disorder, 2001; Cohen, 1999). In order to qualify for special education services, a student must be identified as disabled according to state criteria, which are based on IDEA. Most state criteria consider students eligible for special services if there is at least a 1 to 1.5 standard deviation difference between an IQ test and an achievement test. However, it is estimated that about 50% of students with ADHD do not qualify for special education services (i.e., don’t meet the 1 to 1.5 standard deviation difference between IQ and achievement) and are accommodated full-time in the general education classroom (Reid, Vasa, Maag, & Wright, 1994; Yasutake, Lerner, & Ward, 1994). It also is estimated that of the other 50% of students with ADHD who qualify for special education services, approximately 85% of these students receive at least part of their instruction in the general education setting (Yasutake et al., 1994). Additionally, ADHD is recognized as a handicapping condition under Section 504, which is an anti-discrimination law and obliges public schools to provide accommodations to students with ADHD even if they do not qualify for special services under the Individuals

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Teachers’ Knowledge 3 with Disabilities Education Act (IDEA), and students with ADHD are therefore entitled to due process and related services (Cohen, 1999). Thus, general education (GE) classroom teachers are required to know how to work effectively with these students. In working effectively with students diagnosed with ADHD, many factors have to be considered. Teachers need to be knowledgeable not only about the etiology, diagnosis, and prognosis of the disorder, they also need to know how to implement educational interventions that have been shown to have positive outcomes for students with ADHD. Although students spend approximately 30 hours per week in school, and school presents many challenges for students with ADHD, not much information is available regarding the role that teachers play in the lives of students with ADHD. Therefore, investigating ways of helping teachers teach students with ADHD is extremely important. Additionally, knowledge of a disorder and its treatment course have been found to increase acceptability of interventions (Power, 2000). Thus, it is crucial to examine what general education (GE) teachers know about ADHD. The first goal of this study was therefore to determine how knowledgeable GE elementary school teachers are on the topic of ADHD. Identifying teachers’ knowledge about ADHD can provide data regarding what kinds of information teachers are lacking in this area so that pre-service or in-service programs can be re-evaluated given that the probability of a GE teacher having a child with ADHD in his/her class is extremely high. A second goal of this study was to investigate how skilled teachers believe they are in implementing various educational interventions (e.g., token economy, teacher attention). This is important because there are many interventions which can be implemented by teachers that have been empirically demonstrated to work effectively

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Teachers’ Knowledge 4 with students with ADHD. Understanding how well trained teachers believe themselves to be regarding the implementation of interventions can affect teacher preparation programs. The third and fourth goals of this study were to investigate teacher acceptance of interventions to determine what barriers exist that play a role in teachers’ decisions to not implement various empirically supported interventions. Although it is important to be knowledgeable about interventions, knowledge does not equate to actual use; therefore, it also is important to understand why certain interventions are practiced while others are not. Just because an intervention is effective does not necessarily mean that a teacher is going to implement it in his/her classroom. The fifth and sixth goals of this study were to determine which demographic factors, such as how many years a teacher has been teaching, the teacher’s level of education (e.g., bachelor’s degree, master’s degree, etc.), the amount of pre-service training on the topic of ADHD, etc., relate to teachers’ knowledge of ADHD and their acceptability of interventions. This is important to know for the purposes of planning teacher training programs in order to determine what information should be taught in the curriculum (e.g., more training in ADHD or training at the advanced level) or if experience makes a difference.

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Teachers’ Knowledge 5 Research Questions 1) What is the knowledge of general education elementary school teachers with regard to the following: A) Symptoms/diagnosis of ADHD? B) Treatment of ADHD? C) General information about the nature, causes, and outcomes of ADHD? 2) What is the perceived knowledge of general education elementary school teachers with regard to educational interventions for children with ADHD? 3)How well trained do general education elementary school teachers perceive themselves to be regarding interventions for children with ADHD? 4) How acceptable do general education elementary school teachers perceive various educational interventions to be for children with ADHD? 5) What are some of the perceived barriers that general education elementary school teachers face in implementing empirically supported interventions for children with ADHD? 6)What teacher variables (e.g., number of years teaching, number of in-services attended on ADHD, etc.) are related to general education elementary school teachers’ knowledge of ADHD? 7) What teacher variables (e.g., number of years teaching, number of in-services attended on ADHD, etc.) are related to general education elementary school teachers’ ratings of acceptability of educational interventions?

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Teachers Knowledge 6 Importance of the Study As previously stated, many educational interventions have been shown to work effectively for students with ADHD; however, many teachers do not use these interventions. Researchers have found that the kind of intervention (e.g., use of positive vs. negative consequences) and the amount of time and effort required by teachers to apply educational interventions contribute to teachers willingness to implement interventions (Power, Hess, & Bennett, 1995). Hence, identifying why teachers do not use certain effective interventions can help suggest changes to pre-service or in-service programs. Additionally, if by identifying what teachers know about the disorder as well as what kinds of interventions they are likely to use and the reasons why some interventions are acceptable, school psychologists can design and help teachers implement interventions for students with ADHD. Definition of Research Variables ADHD. A disorder defined in the Diagnostic and Statistical Manual-Text Revision (DSM-TR) that is characterized by inattention, hyperactivity, and impulsivity (American Psychiatric Association, 2000). General Education Elementary School Teachers. Teachers who teach in a general education classroom (Pre-K-5). Knowledge of ADHD. Understanding the behaviors exhibited by a student with ADHD, understanding the treatment for ADHD generally and specifically, and other general information regarding ADHD, as well as understanding educational interventions for children with ADHD. Knowledge was measured by the total score and subscale scores on the Knowledge of Attention Deficit Disorders Scale (Sciutto, Terjesen, &

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Teachers’ Knowledge 7 Bender Frank, 2000) and scores on the question on the Teacher Intervention Survey that asks how knowledgeable teachers’ feel in regard to this intervention. Educational Interventions. Interventions that can be carried out in the classroom by a teacher that research has shown to work effectively for students with ADHD, such as giving a reward for positive behavior, removing a privilege for negative behavior, or using different modalities when teaching (e.g., large group, small group, independent seat work, videos, overheads, projects, etc.). Treatment Acceptability. The degree to which an educational intervention is deemed suitable, fair, and reasonable for the problem(s) experienced by the student by GE teachers (Kazdin, 1980). This variable was measured by the question on the Teacher Intervention Survey that asks to what degree do you think this intervention is suitable, fair, and reasonable for most kids with ADHD. Barriers to Implementation. Obstacles that GE teachers perceive to hinder their ability to provide appropriate educational interventions (i.e., lack of time to implement, lack of teacher training, or lack of knowledge). This variable was measured by the following questions on the Teacher Intervention Survey: how knowledgeable do you feel in regard to this intervention, how well trained (skilled) do you feel in regard to this intervention, and how likely are you to have the time/resources to implement this intervention.

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Teachers’ Knowledge 8 Chapter II Literature Review This literature review presents background information pertaining to ADHD, including its prevalence and possible etiologies. Then, educational interventions that have been proven effective for children with ADHD are discussed. Next, information regarding teachers’ knowledge and training in ADHD in general, as well as their knowledge and training in effective educational interventions is presented. Finally, information concerning teacher acceptability of interventions and barriers to implementation is summarized. Diagnosing ADHD In order to diagnose ADHD, a multimodal approach is recommended. Information should be obtained from parents, teacher(s), and clinician(s) (Barkley, 1998; DuPaul & Stoner, 1994). The current Diagnostic and Statistic Manual of Mental Disorders (DSMTR) divides ADHD into three categories: Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive, which consists of core symptoms in inattention; AttentionDeficit/Hyperactivity Disorder, Predominately Hyperactive-Impulsive, which consists of core symptoms in hyperactivity and impulsivity; and Attention-Deficit/Hyperactivity Disorder, Combined, which consists of core symptoms in inattention, hyperactivity, and impulsivity (American Psychiatric Association, 2000). In order to warrant a diagnosis of

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Teachers Knowledge 9 ADHD, the child must display a certain number of the following symptoms (depending on the type of ADHD) for at least six months and before seven years of age: (a) doesnt pay close attention to tasks or makes careless mistakes; (b) has difficulty sustaining attention; (c) does not seem to listen; (d) shifts from one uncompleted task to another; (e) difficulty with organizational skills; (f) reluctant to engage in tasks that require sustained mental effort; (g) often loses things necessary for tasks; (h) is easily distracted; (i) is often forgetful; (j) fidgets, squirms, or seems restless; (k) has difficulty remaining seated; (l) has difficulty playing quietly; (m) often on the goŽ; (n) talks excessively; (o) blurts out answers; (p) has difficulty awaiting turn; (q) interrupts or intrudes on others (American Psychiatric Association, 2000). Theories to Explain ADHD There are many theories regarding the cause of ADHD, and in the last decade much research has been conducted on the etiology of this disorder. The current view is that ADHD has many causes, including neurological factors, genetic factors, environmental toxins, side effects from medications taken by children, psychosocial factors, and behavioral disinhibition. Neurological factors. Initially, ADHD was thought to be caused by brain damage (Barkley, 1998; Stubbe, 2000). The disorder was thought to occur as a result of known brain infections, trauma, or other injuries or complications that occurred during pregnancy or delivery (Barkley, 1998). Some studies have demonstrated that brain damage, especially hypoxia (a condition in which there is a decrease of oxygen to the tissue in spite of adequate blood flow to the tissue) or anoxia (a condition in which there is an absence of oxygen supply to an organ's tissues although there is adequate blood

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Teachers’ Knowledge 10 flow), is associated with attention deficits and hyperactivity (Cruikshank, Eliason, & Merrifield, 1988; O’Doughterty, Nuechterlein, & Drew, 1984). Additionally, Holdsworth and Whitmore (1974) found that children with seizure disorders have a higher incidence of developing ADHD; however, Rutter (1977) has found that most children with ADHD do not have a history of significant brain injuries and, therefore, it seems improbable that such injuries are the main cause ADHD. Many investigators have found decreased cerebral blood flow to the right striatum and orbital prefrontal regions in children with ADHD (Lou, Henriksen, & Bruhn, 1984; Lou, Henriksen, Bruhn, Borner, & Nielson, 1989). Additionally, some researchers have found that those diagnosed with ADHD have smaller prefrontal cortexes compared to those without ADHD (Casey, Castellanos, Giedd, & Marsh, 1997). Dysfunctions or imbalances in some neurotransmitters such as norepinephrine and dopamine also have been proposed as possible causes of ADHD (Arnsten, 2000; Barkley, 1998, Biederman & Spencer, 2000). Many researchers have investigated the effects of preand perinatal factors as a possible explanation for ADHD. Hartsough and Lambert (1985) and Sprich-Buckminster, Biederman, Milberger, Faraone, and Lehman (1993) have found a slightly higher occurrence of unusually short or long labor, fetal distress, low forceps delivery, and toxemia or eclampsia in children with ADHD than in a control group. However, other investigators have not found a greater incidence of pregnancy or birth complications in children with ADHD compared to children without ADHD (Goodman & Stevenson, 1989; Schmidt et al., 1987). Other investigators, (e.g., Breslau et al., 1996; Sykes et al., 1997) found that low birth weight is associated with an increased risk of hyperactivity.

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Teachers’ Knowledge 11 Genetic factors. Genetic factors also have been suggested as a probable cause of ADHD (Barkley, 1998; Jenson, 2000). Many studies have demonstrated higher rates of psychopathology (particularly depression, substance abuse, conduct problems, and hyperactivity) among the parents of children with ADHD versus those without ADHD and among the biological parents of adopted children with ADHD than in adoptive parents of children with ADHD (Biederman et al., 1995). Twin studies have shown greater concordance for inattention and overactivity between identical twins than between fraternal twins. For example, Edelbrock, Rende, Plomin, and Thompson (1995) found correlations of .68 for monozygotic twins and .29 for dizygotic twins for parent ratings on the attention subscale of the Child Behavior Checklist. Similarly, results of a Sherman, Iacono, and McGue (1997) study showed a greater concordance for monozygotic twins than for dizygotic twins based on data from a Teacher Rating Form (which is an adaptation and a combination of the behavioral items from the Conners Teacher Rating Scale, the Rutter Child Scale B, as well as additional items to include DSM-III and DSMIII-R criteria for ADHD) and maternal reports obtained from a modified version of the Diagnostic Interview for Children and Adolescents-Revised, Parent Version. Several investigators, (Goodman & Stevenson,1989; Thapar, Holmes, Poulton, & Harrington, 1999) have found heritability estimates to be approximately .75. These studies all suggest that genetics plays a strong role in contributing to the development of ADHD. Environmental toxins. Another suggested cause of ADHD is environmental toxins, such as lead. A small statistically significant relationship has been found between elevated blood lead levels in children and a higher risk for hyperactivity and inattention (Needleman et al., 1979). Specifically, Needleman et al. (1979) found that teachers

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Teachers’ Knowledge 12 reported increased distractibility, increased frequency of daydreaming, lack of persistence, inability to follow directions, and lack of organizational skills in participants with high lead levels. Currently, there is some evidence to show that body lead levels are minimally associated with hyperactivity and inattention in children; however, children with ADHD often show negligible, if any, increase in their body lead (Jensen, 2000). Evidence also exists showing that cigarette smoking and/or alcohol consumption during pregnancy is greater in mothers (and parents depending on the study) of children with ADHD than in control children (Denson, Nanson, & McWatters, 1975; Earls, Reich, Jung, & Cloninger, 1988; Kupperman, Schlosser, Lindral, & Reich, 1999; Milberger, Biederman, Faraone, & Jones, 1998; Streissguth et al., 1984). However, it is important to remember that these results are correlational and therefore it cannot be proven that it is the maternal cigarette smoking or drinking that contributes to the development of ADHD. Additionally, since ADHD has been shown to have a genetic basis, the parents of these children also are more likely to be diagnosed with ADHD. However, the genetic relationship between mothers with ADHD and the child with ADHD, rather than the mothers’ greater smoking, has been thought to better describe this link (Barkley, 1998). Side effects of medications. Another proposed cause of ADHD involves the side effects of some medications. Some studies have found that medications which are used to treat seizure disorders, particularly Phenobarbital and Dilantin, may cause problems with inattention and hyperactivity (Committee on Drugs, 1985; Wolf & Forsythe, 1978). Wolf and Forsythe (1978) found that 42% of children in their study who were given barbiturates, such as Phenobarbital, developed behavior disorders, especially hyperactivity. These data were based on parental perception and observation of their

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Teachers’ Knowledge 13 child’s behavior. However, since few children diagnosed with ADHD take these medications, such drugs cannot be considered to be a major cause of ADHD. While some researchers have suggested that Theophylline, a medication used to treat asthma and certain allergies, has been found to cause hyperactive symptoms, results of a metaanalysis on the behavioral and cognitive effects of methylxanthines revealed no significant detrimental effects of Theophylline (Stein, Krasowski, Leventhal, Phillips, & Bender, 1996). Psychosocial factors. Psychosocial factors also have been proposed as a possible cause of ADHD. Some researchers claim that hyperactive behavior is the result of poor parenting. Several studies involving the interactions between parents and their hyperactive child show that these parents are more likely to give commands to their children and to be more negative toward them than are parents of children without ADHD (Barkley, Fischer, Edelbrock, & Smallish, 1991; Cunningham & Barkley, 1979, Danforth, Barkley, & Stokes, 1991; Woodward, Taylor, & Dowdney, 1998). However, these studies also show that the hyperactive children are more negative and less compliant to parental commands than are children without the disorder. Thus, it is impossible to determine which behavior precedes the other (i.e., whether the parent causes the child's problems or the child's problems cause the parent’s negative reactions) (Barkley et al., 1991; Cunningham & Barkley, 1979, Danforth, Barkley, & Stokes, 1991; Tarver-Behring, Barkley, & Karlsson, 1985; Woodward et al., 1998). Behavioral disinhibition. One of the latest theories regarding the causes of ADHD has been postulated by Barkley (1997). He proposes that those diagnosed with ADHD exhibit a deficit not in attention, but rather with behavioral inhibition. According to this

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Teachers’ Knowledge 14 theory, while most people are able to delay responses to events (e.g., talking to ourselves to control our behavior) in order to develop self-regulation or self-control, those with ADHD are not able to develop these skills. Barkley believes that self-control is initiated by behavioral inhibition, which allows the brain’s executive functions to be engaged in order to decide the most suitable response to a situation. These functions direct and guide behavior through the motor control system and are protected from distracting information by behavioral inhibition (Barkley, 2000). In short, those with ADHD are inclined to be driven by the moment and are less capable of organizing and controlling their behavior with regard to the future (Barkley, 1998). Treatment Strategies When it comes to treating children with ADHD, the literature supports the use of medication, behavioral interventions, and instructional management interventions (Barkley, 1998; DuPaul & Stoner, 1994). The most prescribed medication for ADHD is stimulants. The use of medication has many benefits including: temporarily improving the ability to control motor behavior, enhancing concentration or effort on tasks, improving self-regulation, increasing effort and compliance, decreasing verbal and physical hostility, decreasing negative social interactions, and increasing the amount and accuracy of work when performing previously learned skills (Shelton & Barkley, 1995). Despite the positive gains made by stimulants, they also have many limitations. First, while there are many studies on the short-term efficacy of stimulants, to date there is not any empirical research that documents the long-term efficacy in improving any area of impairment or outcome (e.g., academic achievement, antisocial behavior, or higher-order cognitive processes) (Pelham & Fabiano, 2000). Second, because many children only

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Teachers’ Knowledge 15 receive medication during the school day, it is likely that many parents never directly benefit from improved behavior exhibited by children while medicated, leaving the parent-child relationship untreated (Pelham & Fabiano, 2000). Third, while the majority of children respond positively to medication, about 20% to 30% do not respond positively to medication (Pelham & Fabiano, 2000). In some cases, the side effects of the medication cause worse problems than the symptoms of ADHD itself (e.g., stimulants may cause tics in those predisposed to a tic disorder) or sometimes the medications do not improve behavior. Fourth, children may intentionally or unintentionally forget to take their medication, especially in adolescence (Pelham & Fabiano, 2000). Fifth, medication does not teach alternative behaviors for coping with problematic situations (Shelton & Barkley, 1995). Behavioral interventions, including parent training, have been found to reduce the increased stress experienced by the parents of children with ADHD (Barkley, 1998). Additionally, in contrast to medication, behavioral treatments (e.g., contingency management) are flexible and powerful enough to treat any impaired area of functioning. Various instructional management techniques (e.g., using various modalities, placing the child with ADHD near the teacher) have no side effects, can be used with all kids (e.g., those with Tourette’s syndrome), and most parents are comfortable with them. In summary, the research shows that a multimodal treatment approach which includes a combination of medication, behavior modification, and instructional interventions results in the most positive outcomes for students with ADHD. Various professional organizations, including the National Association of School Psychologists (NASP), state that medication should be considered only after attempting or ruling out

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Teachers’ Knowledge 16 alternative, less invasive treatments (e.g., instructional modification, behavior management) (NASP, 1998). Educational Interventions Children with ADHD have difficulty in the classroom since it is a structured environment (DuPaul & Stoner, 1994). They have difficulty sitting still (DuPaul & Stoner, 1994). They have trouble finishing work or difficulty starting work (DuPaul & Stoner, 1994). They are fidgety and they often blurt out the answer to a question without raising their hand and waiting to be called on (DuPaul & Stoner, 1994). All of these behaviors make it harder for a teacher to teach a child. The literature has consistently found that children with ADHD exhibit more failure and receive more negative feedback from others than their peers who do not have ADHD (Hinshaw & Melnick, 1995; Whalen & Henker, 1985). Additionally, it is well established in the literature that those with ADHD are at risk for serious long-term consequences such as depression, substance abuse, school failure, loneliness, and trouble with the law (Barkley, 1998; DuPaul & Stoner, 1994). As mentioned previously, the prevalence of about one child per classroom with ADHD emphasizes the need for empirically supported school-based interventions. Thus, this part of the literature review describes the instructional and behavioral management aspects of treatment that GE teachers can implement in their classrooms that have been empirically supported. The instructional management techniques include structure, physical arrangement of the classroom, varied presentation of formats, use of cues, prompts, brief academic tasks interspersed with passive tasks, and peer tutoring. The behavioral components of treatment fall under the category of contingency management. Included under contingency management are teacher attention, token

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Teachers’ Knowledge 17 economy, response cost, time-out from positive reinforcement, and home-based contingencies. Additionally, since children with ADHD usually act before they think, it has been postulated that self-management skills such as self-monitoring, selfreinforcement, and/or self-instruction can increase academic success and behavior in these children. Therefore, the research in this area also will be presented. Much of the research on interventions for students with ADHD has been with students with the disorder, but other studies have been done on students with behavior disorders and/or low achieving students and the results have been generalized to students with ADHD. Additionally, in many instances, combinations of strategies are used to improve the behavior of a child with ADHD (e.g., a combination of token economy and response cost). Therefore, the following describes some of the studies that have used the above-mentioned interventions, either alone or in combination with students with behavior or learning disorders in general, and with those specifically with ADHD. Structure. Many researchers have found that students with ADHD perform better when there is structure in the classroom (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul & Stoner, 1994; Gardill et al., 1996). They suggest posting rules as well as providing students with a daily schedule so that students know what to expect for the day as well as any transitions that will take place (Barkley, 1998; DuPaul & Stoner, 1994; Gardill et al., 1996). Zentall and Lieb (1985) observed decreased levels of activity in both hyperactive and non-hyperactive children in a structured environment (defined as carrying out specific responses for successful performance), which suggests that structure is beneficial in decreasing activity levels in students.

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Teachers’ Knowledge 18 Physical arrangement. Some researchers suggest that the physical arrangement of the classroom can influence the behavior and academic performance of students, though research to date has focused on students without behavior problems and not specifically on those with ADHD (Rosenfield, Lambert, & Black, 1985; Weinstein, 1979). For example, Rosenfield et al. (1985) investigated the effects of classroom seating arrangements on the incidence of off-task behavior. Their results indicated that fifthand sixth-grade students were engaged in significantly more on-task behavior when they were seated in circles as opposed to rows or clusters. Additionally, for students with ADHD, being seated in close proximity to the teacher has been found to promote and maintain student attention (Barkley, 1998). Varied presentation of formats and materials. Research shows that varying the format of presentations and task materials through the use of different modalities increases and maintains student interest, motivation, and on-task behavior (Barkley, 1998). Investigators recommend the use of videos, overheads, posters, and models, as well as the addition of color, shape, and texture to assist in focusing and maintaining a student’s attention (Barkley, 1998; Gardill et al., 1996; Zentall, 1993). For example, when color was added to pages requiring students to copy words, the amount of errors decreased for students with attention problems although no difference was observed for matched controls (Zentall, Falkenberg, & Smith, 1985). Similarly, in a sustained attention task which required participants to match a sample picture (e.g., a giraffe) with one of six variants of the picture, hyperactive children were more active than controls in the black and white condition, but when color was added to the pictures, hyperactive children were not different from controls (Zentall & Dwyer, 1989).

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Teachers’ Knowledge 19 Use of cues, prompts, and attention checks. Researchers have documented that using short verbal cues, subtle nonverbal prompts, attention checks, and a timer helps students with ADHD to focus their attention on assigned tasks (Gardill et al., 1996). Additionally, Gardill et al. (1996) have suggested that when directions are given, it is beneficial to have someone (e.g., the child with ADHD, another member of the class, or the whole class) repeat the directions for the class. Research also has suggested that when teachers provide cues (e.g., “Listen” or “All eyes on me”), prompts, or signals of when to do or not to do something, problem behaviors are decreased, and student achievement and attention are increased (DuPaul & Stoner, 1994; Gardill et al., 1996). Brief academic tasks interspersed with passive tasks. Researchers have documented that for children with ADHD, academic tasks should be brief and instructions should be presented in a stepwise fashion rather than all at once (Barkley, 1998; DuPaul & Stoner, 1994). It is recommended that teachers give immediate feedback regarding the accuracy of the assignments (Barkley, 1998; Gardill et al., 1996). Zentall and Meyer (1987) found that when engaging in an auditory sustained attention task, hyperactive children made more impulsive errors compared to non-hyperactive children in a low-stimulation passive-response condition. However, in a high-stimulation activeresponse condition, hyperactive children did not perform differently than controls. Therefore, it is suggested that interspersing active tasks (e.g., doing a project on the American Indians) with passive tasks (e.g., completing a worksheet on the American Indians) may enable students with ADHD to release energy in desirable ways (Gardill et al., 1996).

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Teachers’ Knowledge 20 Peer tutoring. Peer tutoring has been found to be beneficial to children with ADHD by increasing students’ on-task behavior and academic performance (DuPaul & Henningson, 1993; DuPaul & Stoner, 1994; Gardill et al., 1996). Peer tutoring contains many of the procedures that have been found to help children with ADHD: active responding; an increased opportunity to practice skills; individual attention; the instructional pace is set by the learner; constant prompting of responses; and frequent and immediate feedback about the quality of their performance (DuPaul & Eckert, 1998). To demonstrate the effects of peer tutoring on the classroom performance of children with ADHD, DuPaul and Henningson (1993) employed an ABAB reversal experimental design during mathematics instruction. The participant was a 7-year-old male student diagnosed with ADHD who received instruction in a GE classroom. During baseline, whole group instruction was provided by the teacher, followed by independent seat work. A research assistant recorded the number of off-task and fidgety behaviors during 10-minute observations at least three days per week. Following each observation, the student with ADHD, as well as several peers (chosen at random), completed 2-minute curriculum-based measurement (CBM) math probes. During the first intervention phase, a classwide peer tutoring (CWPT) approach was implemented. Prior to the start of the study, the participant’s entire class was taught the classwide peer tutoring procedures which consisted of a “script” (e.g., 30 math problems) of academic material for the tutor. In this method, the tutor dictates to the tutee one problem at a time and the tutee is required to orally respond to the problem. Scrap paper is provided if needed. If the tutee responds correctly, s/he is rewarded two points. If the tutee answers the problem incorrectly, the tutor provides the correct answer and the tutee practices the problem. The

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Teachers’ Knowledge 21 tutee can earn one point after practicing the correct response three times. After 10 minutes, the students switch roles. At the end of each week, points are added up and the team with the most points from peer tutoring participates in a “lottery” system in which reinforcers (e.g., small toys) are awarded on a random basis. The second baseline followed the same procedures as for the initial baseline phase and the second peertutoring phase contained the same procedures as the first peer tutoring phase. Results indicated that the participant’s on-task behavior went from 39% of the intervals during the first baseline condition to 89% of the intervals during the first peer tutoring phase. Fidgety behavior decreased from 31% during the first baseline phase to 4% during the first peer tutoring intervention. When baseline conditions were reinstituted, on-task behavior decreased to 70% and fidgety behaviors increased to 23%. Finally, when classwide peer tutoring procedures were reimplemented, on-task behavior increased to 90% and fidgety behaviors decreased to 4%. Additionally, the peer tutoring increased the number of digits correct as indicated from CBM probes. During the initial baseline, the mean number of digits correct obtained was 5. During the first peer tutoring phase, the mean number of digits correct increased to 8.6 and decreased to 7 digits correct when baseline procedures were reinstituted. Implementation of the second peer tutoring phase increased the participant’s number of digits correct to 13.3. These results indicate that peer tutoring can increase the appropriate behavior and academic performance of a child with ADHD. DuPaul, Ervin, Hook, and McGoey (1998) conducted a similar study on CWPT in a general education classroom. In their study, 18 first-fifth graders diagnosed with ADHD, as well as 10 peers, were assigned peer tutors by the students’ respective

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Teachers’ Knowledge 22 teachers. The same CWPT procedures as in the DuPaul and Henningson (1993) study were applied. Outcome measures were determined by the frequency of off-task behaviors, on-task behaviors, fidgety behavior, as well as academic behavior. An ABAB reversal design was implemented and each experimental condition lasted from 1-2 weeks. During the peer-tutoring session, participants worked on either math or spelling (depending on the child’s weakest academic area according to the teacher). Pretests were administered on Mondays prior to instruction and posttests were given on Fridays after the lesson occurred. Preand posttests consisted of 10-20 items in which students had to either write the answer to mathematical computation problems or write the correct spelling of dictated words. Their results indicated that CWPT increased active on-task behavior and decreased passive on-task behavior. Students with ADHD were actively on-task 29% of the intervals during the initial baseline phase. When the CWPT intervention was initially implemented, on-task behavior increased to a mean of 80%. During the second baseline condition, the students’ on-task behavior decreased to a mean of 21% but returned to a mean of 83% when CWPT was reinstated. Classwide peer tutoring also reduced off-task behavior from a mean initial baseline of 27% to a mean of 6% after implementation of the second CWPT condition. As for fidgety behavior, during the initial baseline condition, the mean percentage of fidgets exhibited by students with ADHD was 6%. Thirteen of the 18 students with ADHD decreased fidgety behavior during the first CWPT. Eight of the participants with ADHD increased the amount of fidgets during the return to baseline phase. Ten of the students with ADHD decreased the amount of fidgeting during the second CWPT procedure.

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Teachers’ Knowledge 23 Academically, five of the participants with ADHD performed higher on the posttest when the CWPT was first implemented. When baseline conditions were returned, six of the participants had lower posttest scores. Upon return the CWPT conditions, nine of the students with ADHD improved academically. Teachers who implemented the CWPT responded to a consumer satisfaction questionnaire. Sixteen out of 17 of the participating teachers reported satisfaction with the CWPT and all 17 teachers indicated that they would use CWPT after the study ended. Teacher attention. Teacher attention is the most popular technique used by teachers to increase appropriate behavior (Abramowitz & O’Leary, 1991). Teachers usually give frequent verbal feedback, both positive and negative, to their students, as well as nonverbal feedback such as nods, frowns, smiles, and pats of approval (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul & Stoner, 1994; Gardill et al., 1996). Withdrawal of positive teacher attention contingent upon undesirable behavior has been found to decrease inappropriate behavior (Barkley, 1998). Researchers recommend that praise should be delivered immediately after the desired behavior, and it should be given in a sincere manner with a warm tone of voice (DuPaul & Stoner, 1994). Researchers also suggest that reprimands should be calm, firm, consistent, short, immediate, and in close proximity, rather than emotional and/or delayed, in order to be most effective (Abramowitz & O’Leary, 1990, 1991; Abramowitz, O’Leary, & Futtersak, 1988; Rosen, O’Leary, Joyce, Conway, & Pfiffner, 1984; Van Houten, Nau, MacKenzieKeating, Sameoto, & Colavecchia, 1982). Token economy. Token economies involve awarding children tokens or points which are dependent upon specified appropriate behaviors (Abramowitz & O’Leary,

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Teachers’ Knowledge 24 1991). These tokens or points can be exchanged for activities, objects, or privileges (Abramowitz & O’Leary, 1991). Response cost. Response cost involves the removal of privileges, tokens, or points for inappropriate behavior (DuPaul & Stoner, 1994). Time-out from positive reinforcement. Time-out from positive reinforcement, which restricts the child’s access to positive reinforcement, has been found to be an effective technique in improving the behavior of children with ADHD (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul & Stoner, 1994; Gardill et al., 1996). The conditions of time-out usually involve either placing the child on the periphery of the classroom, having the child put his or her head down on the desk, or putting the child in another room (Abramowitz & O’Leary, 1991; Barkley, 1998; Gardill et al., 1996). Home-based contingencies. Home-based contingency management procedures consist of programs that combine school and home efforts to improve children’s classroom behavior (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul & Stoner, 1994; Fiore et al., 1993). This approach usually involves teachers filling out a daily report card or checklist which indicates whether the child fulfilled the specified goals for that day (e.g., paying attention to class activities, completion of assigned work, accuracy of work, and following the rules) (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul & Stoner, 1994; Fiore et al., 1993). The report is usually sent home with the child for the parents to sign and return to the teacher (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul & Stoner, 1994; Fiore et al., 1993). The parents provide suitable rewards at home for appropriate behavior at school (e.g., household privileges, television time, spending the night at a friend’s house) (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul &

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Teachers’ Knowledge 25 Stoner, 1994; Fiore et al., 1993). This procedure is advantageous to teachers because it is economical, efficient, and permits the classroom teacher to establish daily communication between the home and school, without the need for the teacher to alter his or her teaching style (Abramowitz & O’Leary, 1991; Barkley, 1998; DuPaul & Stoner, 1994; Fiore et al., 1993). Some research indicates that while contingent positive reinforcement should be the main component of behaviorally based interventions for students with ADHD, solely relying on positive reinforcement may divert the child from the task at hand (DuPaul & Stoner, 1994). Therefore, researchers have investigated the effects of using positive, as well as negative reinforcement, to increase the on-task behavior and academic accuracy of students with ADHD (Abramowitz, O’Leary, & Rosen, 1987; Acker & O’Leary, 1987). Abramowitz et al. (1987) examined the effects of positive and negative teacher attention on students’ off-task behavior and academic accuracy by conducting a two-part study. The first part of their study involved a reversal design in which students with behavioral and/or academic difficulties who were involved in a remedial summer program participated in an experiment that compared either reprimands or encouragement with no-feedback conditions. Findings suggested that reprimands were more effective in reducing off-task behavior than the no-feedback condition, with encouragement yielding inconsistent results. Additionally, there were no significant differences among the three conditions on the amount of work completed correctly. The second part of their study, which involved the same participants, compared reprimands and encouragement directly to each other. Reprimands reduced off-task behavior compared to encouragement.

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Teachers’ Knowledge 26 Additionally, academic productivity was superior in the reprimand condition compared to the encouragement condition. Many researchers have found that token economies increase desirable behavior, as well as improve academic performance, in children with ADHD by reducing activity level and increasing time on task (Pfiffner & O’Leary, 1987; Pfiffner, Rosen, & O’Leary, 1985; Robinson, Newby, & Ganzell, 1981). Barkley (1998) has suggested that the following can be used as effective reinforcers: homework passes, removing lowest grade or making up missing grade, grab bag with small toys or school supplies, free time, computer time, stickers/stamps, running errands, helping the teacher, earning extra recess, playing special games, and art projects. Robinson et al. (1981) found that third graders with ADHD completed more daily teacher-made vocabulary assignments and passed more standardized weekly reading tests when a token economy system was in place. Pfiffner et al. (1985) also found that second and third graders with behavior problems increased their academic productivity and on-task behavior when a token economy system was implemented. While the above studies on token economies emphasize individual rewards, Rosenbaum, O’Leary, and Jacob (1975) investigated the effects of group reward and individual reward for 10 male hyperactive elementary school students. The participants were divided into two groups (individual reward program and group reward program) to allow maximum balancing with regard to age, grade in school, and score on the Conner’s abbreviated scale. The student’s teacher rated the participant four times daily on individually determined target behaviors. At the end of the day, the student could exchange his tokens (in this experiment cards were used) for candy, either for himself

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Teachers’ Knowledge 27 (individual reward) or for himself and the entire class (group reward). Teachers completed the Conner’s Teacher Rating Scale four times during the course of the study, and they completed the Problem Behavior Report at the end of each week. Results indicated a significant treatment effect, but no difference was found between groups. Maintenance effects continued four weeks post intervention. Teachers also completed a questionnaire to assess teacher satisfaction with the interventions. Results suggested that the teachers preferred the group intervention procedure (2(1)=9.60, p <.005). Rapport, Murphy, and Bailey (1982) compared the effects of medication to the behavior modification technique of response cost in order to reduce the off-task behavior and increase the academic performance of two second grade males diagnosed with an attention deficit disorder according to DSM-III criteria. An ABACBC within-subjects design was carried out in the participants’ general education classroom. The first medication condition involved several dosages of Ritalin (starting at 5-mg and increasing each week by 5-mg increments until improvements in behavior were stable). The second medication condition consisted of the dosage of Ritalin that was determined to be the most effective during the first medication phase (15mg was considered optimal for both children). For one student, the response-cost intervention consisted of two wooden stands with numbered cards (20 to 0 in descending order) attached to each stand. When the student was off-task, the teacher would flip a card down thereby decreasing the number shown. For the other student, the response-cost intervention consisted of a batteryoperated electronic counter with a digital display. The digital display was automatically set at zero at the beginning of each experimental session and it automatically increased by one number each minute. The teacher held a hand-held device that would decrease the

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Teachers’ Knowledge 28 digital display by one number when the student was off-task. The students could earn up to 20 minutes of free time for on-task behavior. The amount of time earned was equal to the number on the card or the digital display. Results indicated that both response cost and psychostimulants were effective in increasing the on-task behavior and the academic performance of the participants, with the response cost procedure having an even greater effect. Many researchers have found that combining token economies with response cost has been proven to be beneficial in increasing on-task behavior, productivity, academic accuracy, and improving attention of children with ADHD (DuPaul, Guevremont, & Barkley, 1992; DuPaul & Stoner, 1994). As with other punishment procedures, response cost has been proven to be most effective when it is applied right away, unemotionally, and consistently (Barkley, 1998). It is suggested that when combining token economies with response cost, the chance to earn tokens or points should be greater than the possibility of losing them to avoid negative earnings (Barkley, 1998). McGoey and DuPaul (2000) examined the effects of a token reinforcement intervention and a response cost intervention on the disruptive behavior of preschool children. Four preschoolers (two males and two females) participated in this single subject withdrawal design counterbalanced between participants. The token reinforcement intervention consisted of earning buttons to be displayed on a chart for following classroom rules (stay in the area, keep hands and feet to yourself, quiet listening when the teacher is talking, finish your work [stay on-task], or raise your hand to talk). At the beginning of the day, teachers reminded students of the class rules and the opportunity to earn buttons. At the end of each activity, if a participant met the criteria of

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Teachers’ Knowledge 29 three small buttons, they were given a large button in its place. At the end of the preschool day, if they earned three big buttons, they were rewarded (e.g., stickers, hand stamps). The response-cost intervention consisted of the same button chart that was used with the token economy. However, in this case, the children started off with five small buttons and one big button per activity and they lost buttons for not following the rules. Again, at the beginning of the day, the teacher reminded the children of the rules and about losing buttons. At the end of each activity, if the child kept at least three small buttons, they retained the large button. At the end of the day, if the child retained three large buttons, s/he was rewarded (e.g., stickers, hand stamps). Both the response cost and token reinforcement interventions decreased student’s aggressive behavior. However, while the teachers rated both interventions as acceptable, they preferred the response cost procedure. Time-out from positive reinforcement is an effective procedure to decrease disruptive behavior in students (Barkley, 1998). White and Bailey (1990) used a multiple baseline design to investigate the effects of a time out procedure called “Sit and Watch” to reduce the number of disruptive behaviors (noncompliance, aggression, and throwing objects) in two elementary school physical education classes. One class consisted of 30 general education fourth grade students and the other class contained 14 fourth and fifth grade boys with severe behavior problems. The physical education teacher was trained in the “Sit and Watch” intervention for 30-minutes, which included a handout of the procedure and examples of behaviors for which the procedure was to be used. During baseline, the number of disruptive behaviors was recorded. During the “Sit and Watch” intervention, the teacher removed the student from the activity and explained to him/her

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Teachers’ Knowledge 30 the reason. The student then picked up a 3-minute timer and walked to an area away from other students and sat down on the ground. When the timer was done, the student was allowed to rejoin the class. Additionally, the teacher requested back-up procedures in the form of lost privileges for some students, especially for the students with behavior problems. Results indicated that the “Sit and Watch” procedure was effective for reducing the disruptive behaviors for both general education and behavior disordered students. Specifically, for the students with severe behavior problems, disruptive behaviors decreased by 98% and for those in the general education class, disruptive behaviors decreased by 93%. The physical education teacher completed a questionnaire on “Sit and Watch” and described the procedure as effective in reducing the number of disruptive behaviors in the classes, noted that time to learn or implement the procedure was minimal, and stated there were no observed negative side effects for the students. Some researchers have used a creative approach to time-out. Spitalnik and Drabman (1976) placed orange cards on the desks of children with mental retardation when they misbehaved. The presence of the cards made them ineligible for any tangible reinforcer. Foxx and Shapiro (1978) used ribbons to denote children’s eligibility for various reinforcers and a removal of the ribbon when children were misbehaving. DuPaul and Stoner (1994) have suggested that in order for time-out to be effective, participation in the ongoing classroom activities has to be intrinsically reinforcing to the child. They also recommend that time-out should be implemented right after disobeying the rules and applied consistently. Additionally, in order for the time-out to be effective, the following criteria are recommended: (a) the time-out period should last approximately 1 minute for every two years of age of the child; (b) there should be a short period of calm,

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Teachers’ Knowledge 31 nondisruptive, quiet behavior required prior to its termination; (c) and the child should express eagerness to fix, alter, or compensate for the misbehavior that led to the time-out in the first place. The most important variable for determining the effectiveness of timeout is the removal of the child from the reinforcing environment, not the amount of time the child spends in time-out (DuPaul & Stoner, 1994). Research regarding home-based contingencies has demonstrated great improvements in student behavior. Ayllon, Garber, and Pisor (1975) implemented a token economy and response-cost system in a third grade classroom with students with severe disruptive behaviors. While these procedures were beneficial in immediately decreasing inappropriate behaviors, appropriate behavior was not maintained. Therefore, a schoolhome motivational system was added in which a “Good Behavior” letter was sent home if the child met the criteria for appropriate conduct. Parents provided their child with consequences if a letter was sent home or not. Results suggest that the average level of disruptive behavior decreased from 90% at baseline to 10% during the 12 day implementation of the intervention; however, long term effects were not reported. Budd, Leibowitz, Riner, Mindell, and Goldfarb (1981) also examined the effects of a home-school contingency to decrease the disruptive and aggressive behaviors of preschool and kindergarten-aged students. In this procedure, students were given a token card in which they were given stickers at the end of each period for behaving appropriately. If the child earned a predetermined number of stickers, the child earned the opportunity to exchange the token card at home for a preestablished privilege. Similar to the Ayllon et al. (1975) study, the results of this study also found that for most of the students, inappropriate behavior decreased.

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Teachers’ Knowledge 32 Kelley and McCain (1995) also examined the effects of a school-home note procedure. However, due to the fact that many researchers have found that the addition of aversive consequences is important for effective classroom management (Abramowitz & O’Leary, 1990; Acker & O’Leary, 1987), this study investigated the school-home notes intervention with and without the addition of a response cost condition in order to improve academic productivity and classroom behavior of five elementary school students, two of whom were specifically diagnosed with ADHD. School-home notes containing the target behaviors of “Completed Classwork Satisfactorily” and “Uses Classtime Well” were placed on the desks of participants during morning work. At the end of each morning session, the teacher rated the students’ performance on each of the target behaviors as “Yes,” No”, or “So-So.” The notes were taken home at the end of the day, and parents delivered consequences contingent on that day’s performance. Contracts were made between children and parents that defined the contingencies for reinforcement. In the response cost condition, the notes also contained five smiley faces in addition to the other target behaviors. If students were off-task or behaved inappropriately, they were told to cross off a smiley face. As with the other experiments on home-based contingencies, this study also found that on-task behavior and academic productivity improved for all subjects, with the addition of the response cost showing even greater improvements in on-task behavior. Self-management. Children with ADHD have trouble with self-control (Barkley, 1998). Therefore, researchers have examined the effects of various self-management techniques in order to increase a child’s self-management skills (Barkley, Copeland, & Sivage, 1980; Davies & Witte, 2000; Edwards, Salant, Howard, Brougher, &

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Teachers’ Knowledge 33 McLaughlin, 1995; Hinshaw, Henker, & Whalen, 1984; Hoff & DuPaul, 1998; Shapiro, DuPaul, & Bradley-Klug, 1998). In self-management, students are taught to monitor, record, analyze, and reinforce their own behavior. Strategies that encompass selfmanagement methods include self-monitoring, self-reinforcement, and self-instruction (Barkley, 1998; DuPaul & Stoner, 1994). While the research regarding instructional management techniques and contingency management have found positive results for children with ADHD, the research regarding self-management has been controversial. However, many studies have achieved success in increasing the appropriate behavior and/or academic success of students with ADHD. Therefore, a few studies regarding this area will be presented. Most self-management procedures require a child to rate his/her behavior at set intervals. Initially, student and teacher need to match the rating of the student’s behavior on a regular basis, with the eventual goal to fade out the teacher, and the student to be able to record his/her own behavior (DuPaul & Stoner, 1994). Many of these procedures also use a reinforcement system such as a token economy and/or a response-cost system, in addition to the self-management procedure. Specifically, Hoff and DuPaul (1998) examined a self-management strategy for three elementary school boys with either ADHD or Oppositional Defiant Disorder (ODD) in order to decrease their disruptive behavior. A multiple probe across settings (two general education settings and the playground) design was used. After a baseline condition, students were told that the teacher was going to rate their behavior on a scale from 1 to 5 (1=poor, 5=excellent) for following each of the classroom rules. The teacher ratings corresponded to points, which students could redeem for a backup reinforcer.

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Teachers’ Knowledge 34 During the next phase, students were taught to evaluate their own behavior at set intervals and if their rating matched the teachers, they were given a certain amount of points which could be redeemed for a reward at a later time. The amount of time students had to match their behavior ratings to the teacher’s was gradually faded to zero. The data revealed that the self-management technique was effective in decreasing the students’ disruptive behavior in both structured and unstructured settings. Additionally, teachers and students both filled out a treatment acceptability questionnaire in which they responded that they liked the intervention. However, this study was only conducted with three students from the same school so caution needs to be exercised when generalizing the results. Additionally the separate effects of only using the self-management strategy in the absence of the token economy system was not evaluated. Another study exploring the use of self-management to improve the classroom behavior of students with ADHD was conducted by Shapiro et al. (1998). Two adolescents with ADHD participated in this study. The self-management procedure was similar to the previous study; however, instead of ratings being compared to classroom rules, specific target behaviors for each student were identified (e.g., having all materials needed for the lesson, not talking to peers, following instructions the first time they were given). Results of this study also suggest that the self-management program improved the targeted behaviors for each student. However, this experiment was a case study and thus experimental controls, and reliability data were not collected. Despite these limitations, it appears that self-management programs are effective for some children with ADHD, though more research needs to be done in this area.

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Teachers’ Knowledge 35 Teacher Knowledge and Training in ADHD Teaching children with ADHD can be difficult because of their inattentiveness, hyperactivity, and/or impulsivity. Therefore, to effectively teach a child with ADHD, teachers need a large repertoire of interventions. The interventions with the most empirical support have been noted above. It has been found that knowledge about a disorder is related to the acceptability of interventions. Therefore, it is important to decipher how knowledgeable teachers are regarding ADHD (Liu, Robin, Brenner, & Eastman, 1991). To date, there is not much research regarding what general education teachers know about ADHD and what kinds of training they have had. The few studies that have been conducted do not show promising results. For example, in their study of 115 teachers and psychological service providers, Hawkins, Martin, Blanchard, and Brady (1991) found that while 85% of respondents reported teaching a child with ADHD, only 39% had received training in ADHD, and only 16% of the trained respondents had actually been taught to use a variety of intervention techniques. Additionally, the majority of trained personnel reported a maximum of three clock hours of training in ADHD (including hours of in-service training, coursework, and workshops). In a study by Whitworth, Fossler, and Harbin (1997), 33% of the participants (N=100) wanted more training in ADHD, though the authors did not specify what kinds of training (if any) the participants had regarding ADHD. Additionally, the participants of this study were teachers in rural schools, but the results seem consistent with teachers in urban areas, as well (e.g., Hawkins et al., 1991; Reid et al., 1994). Reid et al. (1994) surveyed 554 general education elementary school teachers to determine their perceptions of their ability to deal with children diagnosed as having

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Teachers’ Knowledge 36 ADHD. Their results indicated that many teachers do not believe they have received sufficient training to adequately address the problems displayed by these students. Teachers also expressed a need for training in interventions that are useful with students experiencing attentional problems. Jerome, Gordon, and Hustler (1994) conducted a survey comparing 439 American and 850 Canadian teachers’ knowledge and attitudes towards ADHD. Their results showed that there was a lack of opportunity for teachers from both countries to learn about ADHD both during college and after graduation. Most of the Canadian and American samples (99% and 89%, respectively) reported either receiving little or no instruction regarding ADHD during their college years, and 89% of the Canadians and 92% of the Americans reported receiving little training after graduation. Teachers’ scores on the knowledge section of the questionnaire indicated that their understanding of basic concepts about ADHD was good (on a 20 item true/false questionnaire, the Canadian sample got 78% correct and the American sample got 77% correct). However, teachers seemed to be least knowledgeable about dietary management (approximately 66% of all teachers thought that ADHD can be caused by sugar and food additives, and 77% of the Canadian sample and 81% of the American sample indicated that diets are helpful in treating children with ADHD) and long-term prognosis (41% of the Canadian teachers and 50% of the American teachers thought that most children with ADHD outgrow the disorder when they reach adulthood). Demographic variables of participants also were analyzed with regard to item responses. For both the Canadian and American groups, those with specific training in ADHD scored higher on the knowledge questionnaire. Additionally, those who had

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Teachers’ Knowledge 37 higher educational qualifications, particularly in special education, tended to score higher on the knowledge questionnaire. Demographic variables such as place of employment (rural/urban) or gender of respondent had no effect on responses. Interestingly, for the Canadian sample, those who were either more recently trained or more experienced tended to perform better on knowledge of ADHD. A limitation of this study was that the survey used had unknown validity. Additionally, the survey mostly contained questions on basic concepts of ADHD and did not contain any specific questions regarding educational interventions (other than the question “if medication is prescribed, educational interventions are often unnecessary”). Piccolo-Torsky and Waishwell (1998) surveyed 154 elementary school teachers using the same survey as in the Jerome et al. (1994) study. Their results were very consistent with the Jerome et al. (1994) study. They found that 83% of the respondents had received no formal training in ADHD in their undergraduate work. They also found similar results to the Jerome et al. (1994) study in which teachers had a good basic knowledge of ADHD (mean score was 81% out of 100%) but were less knowledgeable about diet (54% thought that ADHD could be caused by sugar or food additives and approximately 74% thought that diets were effective in treating children with ADHD) and long term prognosis (72% thought that most children with ADHD outgrow the disorder when they reach adulthood). With regard to demographic variables, they found no significant differences between score on the knowledge questionnaire and age of the respondent, grade taught, years of teaching experience, marital status, or amount of contact with children with

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Teachers’ Knowledge 38 ADHD. However, those who were qualified to teach special education and/or who had read more than 10 books/articles on ADHD tended to score higher. In 1999, Jerome, Washington, Laine, and Segal did a follow-up study to their 1994 study comparing the results of the Canadian teachers in 1994 to a sample of recent Canadian graduates who had just completed their training prior to working in the field. Though their sample was limited in that it only included 42 participants, the results were disappointing. They were hoping that as a consequence of improvements in the curriculum regarding teacher training in ADHD in teacher training courses, more recent graduates of these programs would be more knowledgeable in ADHD than the practicing teachers surveyed in the original study. They found that the current and previous sample scored similarly on the factual knowledge test regarding etiology, natural history, and management of ADHD (77% and 78%, respectively). Myths and misconceptions still existed regarding the value of dietary treatments and its persistence into adolescence (although the article did not give exact percentages regarding these). Unfortunately, the authors did not describe what changes occurred in the curriculum that caused the authors to hypothesize that more recent graduates would perform better on the survey than less recent graduates. A study by Yasutake et al. (1994) also found that teachers have limited training regarding ADHD. Their results indicated that 78% of the respondents had received no instruction related to ADHD in their undergraduate education classes, and 50% of the sample reported that they had not had any training in ADHD since they graduated. All of the respondents reported that they would benefit from learning more about ADHD. Though this study had a sample size of only 42 teachers from a large city, these results

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Teachers’ Knowledge 39 are consistent with other studies which have found a lack of training and knowledge among teachers regarding ADHD. Power et al. (1995) also asked the participants of their study (147 general education elementary and middle school teachers) to respond to an ADHD knowledge questionnaire, called the ADHD Knowledge Scale, which is a 17-item true/false instrument designed to measure diagnosis and treatment knowledge of ADHD. Scores on the knowledge questionnaire did not differ with respect to elementary or middle school teachers. Both scored an average of 10.9 (SD=1.9) out of a possible 17. Most of the teachers (90%) reported teaching at least one student diagnosed with ADHD. Additionally, 85% of the teachers reported attending at least one workshop on ADHD. In a more recent study, Sciutto et al. (2000) examined teachers’ knowledge and misperceptions regarding ADHD. One hundred and forty-nine general and special education elementary school teachers from an eastern state completed three surveys: The Knowledge of Attention Deficit Disorders Scale (KADDS), a Demographics Questionnaire, and a Self-Efficacy Questionnaire. The KADDS is a 36-item survey in which respondents answer “True,” “False,” or “I don’t Know” to questions regarding the symptoms/diagnosis of ADHD; the treatment of ADHD; and general information about the nature, causes, and outcome of ADHD (e.g., Most estimates suggest that ADHD occurs in approximately 15% of school-age population). Demographic information included questions such as age, gender, years of teaching experience, grades taught, type of class (GE or Special Education), etc. Lastly, participants rated their self-efficacy (on a scale from 1-7) regarding the extent to which they felt they could effectively teach a student with ADHD.

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Teachers’ Knowledge 40 A repeated measures ANOVA was conducted to determine if there was a difference between teachers’ rating on one area of knowledge compared to the other areas. Results indicated that there was a significant difference between the knowledge domains, F (2,147)=108.74, p <.001. A post hoc analysis using the Bonferroni correction ( pc=.0167) revealed that teachers’ scores on the symptoms/diagnosis subscale of the KADDS were significantly higher than scores on both the treatment, F (1,148)=158.61, p <.001 and general information subscales, F (1,148)=194.73, p <.001. Teachers’ scores on the treatment and general information subscales did not differ significantly from one another, F (1,148)=.006, p =.939. It was also found that teachers answered “Don’t Know” significantly less on the symptoms subscale compared to the treatment and general subscales, F (1,148)=81.37, p <.001, F (1,148)=83.12, p <.001, respectively. The mean percentage of teachers responding “Don’t Know” to the treatment and general subscales did not differ significantly from each other, F (1,148)=2.64, p =.106. With regard to teachers’ misperceptions, it was reported that teachers had fewer misperceptions on questions related to symptoms than to questions related to treatment and general information, F (1,148)=27.19, p <.001, F (1,148)=59.18, p <.001, respectively, but their scores did not differ significantly between the treatment and general subscales, F (1,148)=5.50, p =.020. It is interesting to note that some of the most common misperceptions had to do with questions regarding behavioral/psychological interventions for children focusing primarily on the child’s problem with inattention, children with ADHD generally experiencing more problems in novel situations than in familiar situations, and children with ADHD can be treated by reducing the dietary intake of sugar or food additives.

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Teachers’ Knowledge 41 Analyses also suggested that teacher variables (age, gender, educational level, number of special education classes taken, etc.) were unrelated to overall knowledge of ADHD (all p’ s>.05). However, overall knowledge of ADHD was found to be positively related to teacher’s confidence in their ability to effectively teach a child with ADHD, r (145)=.29, p <.001. A small but significant relation was found between KADDS total scores and the number of children with ADHD taught, r (128)=.22, p <.011 and years of teaching experience, r (142)=.18, p =.029. Lastly, this study also found that teachers’ overall knowledge of ADHD was related to their past experience with children with ADHD. Teachers who reported having taught one or more children with ADHD scored significantly higher on the KADDS total, t (129.93)=3.24, p <.002, general information, t (144)=3.85, p <.001, and symptoms/diagnosis, t (128.93)=3.11, p =.002. No significant relation was found on the treatment subscale, t (144)=1.66, p =.099). It is interesting to note that teachers were not as knowledgeable about the treatment of ADHD even after having taught students with the disorder. Results of this study are consistent with previous literature regarding teachers’ knowledge of ADHD. However, this study did not tap into what teachers’ knowledge is regarding specific interventions that they can apply in their classroom. Additionally, the subject pool was rather homogeneous. Teacher Acceptability of Interventions and Barriers to Implementation While many interventions have been recommended for students with ADHD and other behavioral problems, it is important to consider whether or not a teacher finds the intervention(s) acceptable or not. Treatment acceptability refers to perceptions of whether treatment is fair, reasonable, or intrusive, appropriate for a given problem, and consistent

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Teachers’ Knowledge 42 with notions of what treatment should be (Kazdin, 1980). Additionally, it is important to consider the level of knowledge that teachers have regarding ADHD and interventions for the disorder because knowledge may not always directly transfer to implementing the intervention. For example, a teacher who is very knowledgeable about ADHD may have other factors that impede him/her to carry out interventions (e.g., an intervention might be too time consuming). Additionally, teachers may be knowledgeable in some areas of ADHD, such as etiology and symptoms, but they may not know how to carry out specific interventions in the classroom. Therefore, it is important to determine what factors influence a teacher’s likeliness to use an intervention and what factors contribute to him/her not using an intervention. When it comes to the acceptability literature regarding teachers implementing educational interventions for children with ADHD and the reasons for barriers to implementation, empirical investigations are very limited. A search of the literature identified only three studies. In the first study, 147 general education middle and elementary school teachers from a suburban middle-class community read four vignettes (Power et al., 1995). The first vignette described a child with ADHD based on DSM-IIIR criteria. The other three vignettes described three interventions for ADHD: a daily report, a response cost technique, and the use of stimulant medication. After reading each vignette, teachers responded to a 10-item acceptability scale which was a shortened version of the Intervention Rating Profile (IRP). Results indicated that teachers preferred behavioral interventions using positive (daily report) as opposed to negative consequences (response cost). They also found that teachers viewed a combination of behavioral interventions and medications as more acceptable for children with ADHD

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Teachers’ Knowledge 43 than medication used alone. Teachers also responded to a 17-item true/false questionnaire to measure their knowledge of ADHD. The average score was 10.9 (SD=1.9). Unfortunately, the study did not include which questions were most frequently answered incorrectly, nor did it include any information regarding why teachers viewed interventions as acceptable or not. In addition, they found that knowledge of ADHD and years of teaching were generally unrelated to ratings of acceptability. Matlock (1999) investigated the differences between controlling and autonomous teachers’ use of interventions for students with ADHD. Her sample consisted of 85 public elementary school teachers in 30 elementary schools comprised of small towns and rural areas in Oklahoma. Using the “Problems in Schools Questionnaire,” 81 of the respondents were classified as autonomous and 4 of the participants were classified as controlling. The importance and presence of components in the instructional environment were measured using the Instructional Environment Form of The Instructional Environment System-II (TIES-II). There were no significant differences between the two groups of teachers on the importance of the components to ensure student success in the classroom. However, significant differences were found on six of the questions regarding the presence of the instructional components in the classroom, with controlling teachers reporting more of the components present in their classrooms. Significant differences were not found on any of the measures between novice and experienced teachers. However, results indicated that teachers with specific training in working with students with ADHD were more likely to try various alternative educational interventions such as peer tutoring.

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Teachers’ Knowledge 44 The third study investigated what factors teachers perceive as impeding their ability to implement educational interventions for students with ADHD (Reid et al., 1994). Participants responded on a Likert scale from 1 (Not Important) to 5 (Extremely Important) to a 13-item survey that described various barriers to effective programming for students with ADHD. Their sample consisted of only third grade teachers (general education and resource room teachers). Respondents chose time to administer specialized interventions, lack of training, class size, and severity of problems as the most important barriers that caused them not to implement interventions. These results are important because they give insight into what needs to be changed administratively (e.g., smaller teacher/student ratio and more training). Their study did not investigate teachers’ general knowledge of ADHD nor did it investigate teacher’s knowledge of interventions. Since there is not a lot of literature addressing teachers’ acceptability of educational interventions and barriers to implementation with regard to ADHD, more information needs to be gathered in these areas. There is some information that exists on teacher acceptability of interventions for children with behavior disorders. The results of these studies can be used for children with ADHD since many of the behaviors exhibited by students with ADHD are similar to those with behavior disorders. The following studies on treatment acceptability explored issues such as problem severity, time to implement the intervention, type of treatment approach (positive or reductive), treatment effectiveness, and understanding of the treatment (Calvert & Johnston, 1990; Elliot, 1988; Elliot, Witt, Galvin, & Peterson, 1984; Gresham, 1989; Hall & Didier, 1987; Johnson & Pugach, 1990; Kazdin, 1980; Kutsick, Gutkin, & Witt, 1991; Martens & Meller, 1989; Martens, Peterson, Witt, & Cirone, 1986; Martens, Witt, Elliott, &

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Teachers’ Knowledge 45 Darveaux, 1985; Reimers, Wacker, & Koeppl, 1987; Von Brock & Elliott, 1987; Witt, 1986; Witt, Elliott, & Martens, 1984; Witt & Martens, 1983; Witt, Martens, Elliott, 1984). One of the initial studies concerning acceptability of interventions was by Kazdin (1980). Participants in his study were 94 undergraduate college students. They were presented with audiotaped case descriptions concerning a child’s behavior problem (which varied according to gender, age, intelligence, and setting) as well as four proposed interventions (reinforcement for incompatible behavior, medication, shock, and time-out from reinforcement) that were applied to the behavior problem. After listening to the case descriptions, the participants were asked to rate the intervention strategies on two separate measures, the Treatment Evaluation Inventory (TEI) and the Semantic Differential. The TEI is a 15-item Likert scale which assesses information pertaining to the treatment such as whether the treatment is acceptable for the child’s behavior; willingness to carry out the procedure; suitability of the procedure for the child; and the likeability, fairness, and humanity of the procedure. The Semantic Differential is a list of bipolar adjectives that describes the qualities of a treatment and covers items such as Evaluative, Potency, and Activity. This study revealed that reinforcement for incompatible behavior was the most acceptable treatment, followed by time-out from reinforcement, medication, and electric shock. Additionally, all interventions were rated as more appropriate for more severe problematic behavior. Limitations of the above study include the participant sample. Being undergraduate students, most probably have never actually had the opportunity to use any of the interventions described in the study. The study also did not note what the

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Teachers Knowledge 46 participants knowledge was regarding the various interventions. If the students have never heard of the techniques or if they dont understand the specific procedures involved, then these could both influence their acceptability of interventions. Additionally, the study only investigated four treatments. There are many other treatments that have been found to be effective for students with problematic behaviors (e.g., response cost). Inclusion of these other procedures may have revealed different results. The acceptability of behavioral interventions used in classrooms was investigated by Witt and Martens (1983). In their study, 180 preservice and student teachers from a university in the western part of the United States read one of 18 different case studies and responded on a 6-point Likert Scale (Strongly Disagree to Strongly Agree) to a 20item survey, the Intervention Rating Profile (IRP), which asks questions such as whether an intervention is appropriate for a given problem, whether it requires too much time to implement, whether it adversely affects other children, and whether it poses undue risk to the child. Each case study contained a description of a behavioral intervention implemented to correct a specific problem. The 18 case studies contained three types of behavior problems: mild (daydreaming), moderate (using obscene language), and severe (destroying other childrens property); six different behavioral interventions: praise, ignoring, home-based reinforcement, response cost lottery, token economy, and time-out; and two different amounts of time to implement the interventions: low amount of teacher time required to implement the intervention and large amounts of time required to implement the intervention. Each of the 18 case studies was evaluated by 10 individuals.

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Teachers’ Knowledge 47 They found that, for the most part, the interventions were perceived as moderately acceptable; however, intervention acceptability appeared to be dependent upon the type of behavior problem exhibited. For example, a positive intervention that requires low amounts of teacher time and was applied to a mild behavior problem was considered the most acceptable overall, while a reductive intervention that requires a great amount of teacher time and was applied to a mild behavior problem was considered least acceptable. Although the behaviors described in this study do not necessarily refer to children with ADHD, the results may be generalized to the population. One limitation of this study is its homogeneous sample. Additionally, since they were undergraduates, the participants might not have had experience in actually implementing these interventions, which might have affected their responses. The factors which affected teachers’ judgments in implementing behavioral interventions were explored by Witt et al. (1984). One hundred eighty teachers (grades K-12) from two states read a vignette that described a child with a behavior problem as well as a description describing an intervention that was applied to the behavior problem and then filled out the Intervention Rating Profile (IRP). Descriptions varied concerning the severity of the behavior problem of the hypothetical student and the amount of time involved to implement the intervention as well as the type of intervention applied. Severity of the behavior problem was described as daydreaming (lowest level of severity), using obscene language (medium level of severity), and destruction of others’ property (greatest level of severity). The amount of teacher time required to implement the intervention was divided into low (less than 30 minutes to maintain the intervention on an ongoing basis), medium (1-2 hours of preparation to initiate the program and 30

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Teachers’ Knowledge 48 minutes to 1 hour per day to maintain the intervention), and high (1-2 hours of preparation time to initiate the program and more than 1 hour per day to maintain the intervention). The interventions were categorized into positive and reductive interventions. Positive interventions included praise (requiring low amounts of teacher time), home-based reinforcement (requiring medium amounts of teacher time), and token economy (requiring high amounts of teacher time). Reductive interventions included ignoring, response cost, and seclusion time out. The results were analyzed using a three-way factorial analysis of variance (ANOVA) to determine the effects of type of intervention, amount of teacher time, and severity of behavior problem on teacher’s judgments of acceptability of interventions. Importantly, results indicated that interventions which require low amounts of teacher time were not considered acceptable for severe forms of behavior problems. Additionally, it was reported that interventions that required low levels of teacher time were considered acceptable if the intervention was positive. If the intervention required medium amounts of time, reductive interventions were considered most acceptable. Interventions that required the most amount of teacher time did not differ in acceptance if they were positive or reductive. These results are significant because many of the interventions described can be used for students with ADHD and in this study, the acceptability of interventions was greatly affected by the amount of time involved to prepare and implement such interventions. The limitations of the study by Witt et al. (1984) involve the case descriptions. While they are not included in the article, the authors mention that the descriptions contained a relatively limited amount of information such as a particular gender and age

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Teachers’ Knowledge 49 of a student and a small number of interventions that participants could choose from. When answering information based on case studies, participants tend to base their judgments on only the information presented, when in reality other information would be used when determining what intervention to try with a particular child which could influence the participants’ decisions regarding the acceptability of interventions. Additionally, information regarding the demographics of the sample is not included except for the range and mean years of experience; however, this information was not analyzed with regard to the acceptability of interventions. Additionally, it is not known if the teachers were general education or special education teachers, or if they had any training in the design and implementation of behavioral interventions. In order to determine if education was related to acceptability of interventions, Tingstrom (1989) conducted a study using a pre-post test experimental design. In his experiment, 34 undergraduates enrolled in an educational psychology course served as the experimental group, while 39 undergraduates enrolled in a statistics or child/adolescent psychology class made up the control group. All participants read a case description and an intervention option, then filled out the Treatment Evaluation Inventory (TEI). The vignette described a 4th grade male who exhibited inappropriate behaviors in class, such as disturbing others, frequently getting out of his seat, using obscene language, and occasionally destroying others’ property. The interventions consisted of differential reinforcement of incompatible behavior (DRI), a home-based reinforcement program, ignoring, and time-out. Those in the experimental condition received approximately 5 hours of lecture on general learning principles and interventions approximately two weeks after pre-testing. Prior to the lectures, there were no statistically

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Teachers’ Knowledge 50 significant differences between the two groups on acceptability measures, F (1,71)=.16, p =.69. After the intervention, there were statistically significant increases in the acceptability ratings of all the interventions accept DRI, while there were no statistically significant changes in acceptability ratings from preto posttesting for control group participants. These results are important in that they suggest that educating teachers about interventions will increase their acceptability. However, this research was analogue in nature in that participants read case studies. Information regarding participants’ actual use of the interventions either before the intervention or as a result of the intervention was not measured. While many of the above mentioned articles investigated teacher acceptability of interventions, there are not many studies that actually assess the frequency of use of the various interventions. This is important because acceptability of interventions is likely to be related to how often interventions are used. Therefore, Martens et al. (1986) had 2,279 general and special education teachers from two states complete the Classroom Intervention Profile in order to investigate teachers’ perceptions of school-based interventions regarding effectiveness, ease of use, and frequency of use. Those interventions which were found to be most effective, easiest to use, and most frequently used included verbal redirection and manipulation of previously contracted rewards. Important results of this study with regard to ADHD concern the intervention of time-out. While this intervention has proven effective for students with ADHD, in this study, timeout was considered the third effective intervention and the third easiest to use (after those mentioned above); however, it ranked fifth in its frequency of use. This could be related to the fact that teachers prefer positive interventions as opposed to those involving

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Teachers’ Knowledge 51 punishment. However, this study utilized a questionnaire format which may not have accurately reflected a teacher’s actual use of the various interventions. Additionally, this study did not assess teachers’ knowledge of and/or training in the interventions, which could impact teachers’ perceptions of the interventions. Also, reasons as to why respondents perceived certain interventions as effective or not was not ascertained. Conclusion Children with ADHD are at serious risk for underachievement in school, dropping out of school, engaging in criminal activity, and becoming substance abusers (Reeve, 1994). Teachers can play a major role in preventing these students from suffering from these types of problems throughout their lives. Though various educational interventions have been proven to be effective in teaching children with ADHD, this review of the literature has shown that teachers are seriously lacking in training and knowledge in ADHD. Most of the research that does exist on this topic focuses on general knowledge of ADHD and does not contain specific information on what interventions teachers can apply in their classroom to help improve the behavior and academic performance of children with ADHD. Additionally, acceptability of interventions for ADHD is important because it is often necessary to use time-consuming interventions over long periods of time for children with ADHD, which is a practice some teachers may view as unreasonable. Also, one might assume that the more knowledge a teacher has about ADHD, including symptoms, diagnosis, and interventions for students with the disorder, the more likely the needs of these students would be met effectively. However, as demonstrated by the above information, knowledge may not always impact practice, as there can be other variables that influence a teacher’s decision to use a certain

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Teachers’ Knowledge 52 intervention, such as amount of time involved to implement the intervention. A reexamination of undergraduate teacher training programs as well as in-service training programs is needed so that teachers can be more effective in teaching children with ADHD. Purposes of the Study The purposes of the present study were to (a) add to the literature about GE elementary school teachers’ knowledge of ADHD in terms of symptoms/diagnosis, treatment, and general information about the nature, causes, and outcomes; (b) explore GE elementary school teachers’ knowledge regarding specific educational interventions for ADHD; (c) investigate GE elementary school teachers’ training regarding educational interventions for ADHD; (d) identify which educational interventions GE elementary school teachers feel are acceptable to implement and why some interventions are not accepted; and (e) clarify the research in the area of how teacher variables (e.g., number of years of teaching) relate to GE elementary school teachers’ knowledge of ADHD or their acceptability of interventions. Although there have been some studies that have measured teachers’ knowledge regarding ADHD, there is no study that has measured what teachers know about all of the specific educational interventions that have been empirically supported for ADHD. Also, a number of educational interventions for ADHD have been studied in the literature; however, few studies have considered whether teachers perceive these interventions to be acceptable. In addition, there have been some mixed findings regarding whether demographic variables are systematically related to teachers’ knowledge and/or training in ADHD.

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Teachers’ Knowledge 53 Chapter III Method Participants The current study used a non-experimental design to describe teachers’ knowledge of ADHD and interventions for children with this disorder. Correlational analyses were conducted to examine the relation between teachers’ demographic characteristics and teachers’ knowledge of ADHD, their knowledge of interventions, and their ratings of acceptability of interventions. The study was conducted in one large school district in Southwest Florida (approximately 164,000 students). The district is divided into seven areas based upon geographical location. The original sampling procedures for this study involved recruiting 14 elementary schools (two from each of the seven areas). A total of 26 schools were contacted; 10 principals said “no” and nine never replied even after two phone calls, and an email message if the email address of the principal was obtained. Various reasons were given for not participating (i.e., too many new teachers, the school was focusing on academics and standardized assessment, or no reason was given at all). No mention was made regarding the study being about ADHD. Therefore, seven elementary schools participated, representing six of the seven areas. Table 1 contains the demographics of the participating schools and the county.

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Teachers’ Knowledge 54 The total number of participants (all of whom were general education teachers) from the seven schools was 72. Seventy-eight people originally completed the survey, but two participants indicated that they were special education teachers, and four did not indicate if they were general or special education teachers. Therefore, 6 of the 78 participants were eliminated. General education teachers were chosen because most of the children with ADHD spend the majority of their school time in the general education classroom (Reid et al., 1994; Yasutake et al., 1994). The demographics of the participants are shown in Table 2. Completion of the first round of surveys resulted in a 31% response rate. The second round resulted in a 35% total response rate. Most of the teachers were female (97%), and had a bachelor’s degree (64%). The average age of the participants was 39.92 years (SD=10.63 years), and the average number of years of teaching experience for the participants was 11.77 years (SD=9.32).

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Teachers’ Knowledge 55 Table 1 Characteristics of Participating Schools SchoolNo. of students/ schoolaNo. of GE teachers/ schoolb% of students who receive free/ reduced priced luncha% of student s with disabilitiesc% of minority studentsdNo.of respondents/ school % of respondents/ school 1 924382612291642 2 795407712711230 3 415227218531045 4 7833032Data not available 471343 5 75027311638622 6 9414064185638 7 529247824741250 County (Mean) 731.50Data not available 531555 Source: ahttp://www.sdhc.k12.fl.us (12-7-02), bdata provided by contact person from each participating school, chttp://info.doe.state.fl.us/fsir2001 (12-7-02), ddata obtained from county school district’s MIS department.

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Teachers’ Knowledge 56 Table 2 Participating Teacher Characteristics N% Gender Males Females 2 70 3 97 Age range (M=39.92, SD=10.63) 21-30 years 31-40 years 41+ years 17 22 32 24 31 44 Educational level BA/BS MA/MS 46 26 64 36 Grade taught Pre-Kindergarten Grade 1 Grade 2 – Grade 3 Grade 4 – Grade 5 25 23 24 35 32 33 Years total teaching experience (M=11.77, SD=9.32) 0-2 3-8 9-15 16-25 26+ 7 26 20 11 9 10 36 28 13 13 Note. Not all N’s add up to 72 due to missing data and therefore not all percents add up to 100%.

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Teachers’ Knowledge 57 Measures Demographics. Part I of the survey was a modified version of a demographics questionnaire from Anastopoulos (1992). It included 13 demographic questions including seven identifying information questions (i.e., age, gender, highest degree earned, specialization/certification, number of total years teaching) and six questions regarding respondents’ experiences with ADHD (i.e., whether or not teacher learned about ADHD during teacher training, how many students with ADHD has the teacher taught, and how else the teacher has learned about ADHD, such as in-service presentations, reading books or articles, or watching TV programs on ADHD), as well as what educational placement the teacher thinks is most appropriate for a student with ADHD (e.g., full-time GE, fulltime special education, or part-time special education). This instrument was initially reviewed by an expert panel consisting of a Special Education professor, a Measurement professor, and a practicing school psychologist, as well as the researcher’s thesis committee and five student colleagues. The instrument also was piloted in three graduate research methods courses at a major public university. Information was provided by writing comments on the survey or by email. Based upon feedback from these various sources, some of the items and directions were reworded to increase clarity, and additional room was left to provide respondents more available space for their answers. Specifically, the set up of questions on “attended in-services” and “engaged in self-study” (i.e., read any books, articles, pamphlets) were changed for easier readability. Also, the question pertaining to “what do you think is the most appropriate educational placement for a student with ADHD” was changed from “where do you think students with ADHD should be taught” and the choices for answers were changed from “General education,”

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Teachers’ Knowledge 58 Special education,” and “Resource room,” to “Full-time general education,” “Full-time special education,” “Part-time special education,” and “Other.” Additionally, a listing of ADHD characteristics eliminated in the questionnaire, but described in the Letter to Teachers. Knowledge of Attention Deficit Disorders Scale (KADDS). The Knowledge of Attention Deficit Disorders Scale (Sciutto et al., 2000) contains 36 items designed to assess teachers’ knowledge and misperceptions regarding symptoms/diagnosis of ADHD, the treatment of ADHD, and general information about the nature, causes, and outcome of ADHD. Appendix A contains a listing of the subscales and their respective items. Each item is answered as “True,” “False,” or “Don’t Know.” Correct answers are scored as one point; incorrect, don’t know, and missing answers are scored as zero points. Scores are found by calculating the total number of points and then converting them to a percent for each subscale and for the total scale. Using a sample of 149 elementary school teachers from New York, coefficient alpha for the Total KADDS was .86. The subscales of General Information, Symptoms/Diagnosis, and Treatment all showed coefficient alphas of .71. Information regarding this measure’s validity is unavailable. Based upon information from the expert panel, the researcher’s thesis committee and colleagues, and the students who completed the survey, the items were rewritten in first person language and the directions were rewritten to provide clearer information. For the pilot study, the KADDS was completed by 46 participants; however, one respondent only completed some of the demographics information, therefore this person was eliminated. Average time to complete the survey was 15-20 minutes. The coefficient alpha for the Total KADDS was .90, while the coefficient alpha for the subscales ranged

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Teachers’ Knowledge 59 from .70 (General) to .81 (Treatment). For the main study (n=72), the coefficient alpha based on the Total KADDS was .82. Subscale reliabilities ranged from .54 (Symptoms/Diagnosis) to .68 (General), which is lower than the literature and pilot study. Reasons for this could be that the variability of the scores in the main study was less than that of the literature and pilot study. Descriptive statistics for the KADDS based upon the literature, the pilot study, and the main study are presented in Table 3. Table 3 Cronbach’s Alpha and Descriptive Statistics for the Knowledge of Attention Deficit Disorders Scale (KADDS) Literature (N=149 elementary school teachers) Pilot study (N=45 students from graduate measurement classes) Main study (N=72 general education elementary school teachers) Total Mean SD # of items Alpha 17.21 6.70 36 .86 19.69 7.23 36 .90 20.68 5.48 36 .82 Continued on the next page

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Teachers’ Knowledge 60 Table 3 (continued) Literature (N=149 elementary school teachers) Pilot study (N=45 students from graduate measurement classes) Main study (N=72 general education elementary school teachers) General M ean SD # of items Alpha 6.43 2.88 15 .71 7.07 2.90 15 .70 7.61 2.70 15 .68 Symptoms/Diagnosis Mean SD # of items Alpha 5.65 2.13 9 .71 6.31 2.01 9 .75 6.44 1.48 9 .54 Treatment Mean SD # of items Alpha 5.14 2.56 12 .71 6.31 3.18 12 .81 6.62 2.23 12 .60 Note. Total=Total KADDS, General=General Subscale, Symptoms/Diagnosis =Symptoms/Diagnosis Subscale, Treatment=Treatment Subscale. Scores represent number correct.

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Teachers’ Knowledge 61 Teacher Intervention Survey. A modified version of a teacher questionnaire developed by Matlock (1999) was used to ascertain teachers’ self-reported knowledge regarding interventions that a teacher can use with students with ADHD. Matlock’s questionnaire is intended to assess teachers’ perceived familiarity with interventions commonly recommended for use with students with ADHD. Teachers indicate on a Likert scale from one (low response) to five (high response) “how knowledgeable they are regarding,” “how effective they perceive,” and “how willing they would be” to implement various interventions in their classrooms for students with ADHD. According to the literature, there are several reasons why various interventions are not implemented in the classroom with not having the time and resources being the reasons cited most (Elliot, 1988; Reid et al., 1994; Reimers et al., 1987). Therefore, this question was added to the survey to ascertain if this was one of the reasons why the teachers in this study implemented or failed to implement certain interventions. As with the other instruments, this survey was reviewed by an expert panel, the researcher’s thesis committee, colleagues, and piloted in graduate research methods classes. Based upon feedback from these sources, many changes were made, including more specific directions, and the rewriting of most of the items to enhance clarity (e.g., describing the subtypes of ADHD and indicating if a student is taking medication for their ADHD). Reliabilities for the sixitems for each intervention on the Teacher Intervention Survey are presented in Table 4. Coefficient alpha ranged from .79 (Teacher attention) to .96 (Use of cues, prompts, and attention checks) for the main study, with nine of the 12 interventions having reliabilities greater than .90. The six items for each intervention consisted of a single item for

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Teachers’ Knowledge 62 knowledge, skill, effectiveness, acceptability, time/resources, and use (see Appendix B for the exact wording of the questions). Additionally, three of the items (knowledge, skill, and time/resources) were combined to form a barriers construct (see Appendix C for exact wording). The reliabilities for the three-item barriers variable ranged from .72 (Token economy) to .94 (Use of cues, prompts, and attention checks) for the main study. This information is presented in Table 4. Table 4 Cronbach’s Alpha for the Teacher Intervention Survey ConstructTotal scale reliabilityBarrier scale reliability Pilot study (N=45) Main study (N=72) Pilot study (N=45) Main study (N=72) Teacher attention.87.79.82.76 Token economy.92.85.89.72 Response cost.90.87.86.78 Time-out from positive reinforcement .91.92.84.84 Home-based contingencies .83.91.79.81 Structure.93.93.90.88 Physical arrangement.95.93.92.87 Continued on the next page

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Teachers’ Knowledge 63 Table 4 (continued) ConstructTotal scale reliabilityBarrier scale reliability Pilot study (N=45) Main study (N=72) Pilot study (N=45) Main study (N=72) Varied presentation and format of materials .95.92.91.83 Use of cues, prompts, and attention checks .95.96.95.94 Brief academic tasks interspersed with passive tasks .93.96.91.90 Peer tutoring.95.91.93.85 Self-management.92.90.88.84 Note. Response scale for all constructs is a Likert Scale (1=Very Low to 5=Very High), and the number of items for each construct is six for Total scale and three for Barriers scale.Procedures A local school district was contacted to request permission to collect data from its schools. Additionally, permission from the Institutional Review Board at the University of South Florida was sought. Once permission was granted, the original procedures indicated that the researcher would randomly select two elementary schools from each area (the county where the study was conducted is divided into seven areas based on geographical location) for a total of 14 schools. The principals of the selected schools were contacted via letter (see Appendix D), follow-up phone call, email (and personal

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Teachers’ Knowledge 64 visit if necessary) to request their teachers’ participation in the survey. Principals were requested to sign a form and return it to the investigator. If a principal from an area did not allow his/her teachers to participate in the study, then another school in that area was randomly selected. This procedure was continued until 26 schools were contacted. Seven principals agreed to let their teachers participate in the study (six out of the seven areas were represented). For all participating schools, the researcher spoke to the contact person (principal, assistant principal, guidance counselor, ESE specialist, teacher) and explained the study (i.e., the researcher was interested in finding out what kinds of knowledge teachers have in general about ADHD, what they know about educational interventions, how they feel about implementing various educational interventions, and reasons why some educational interventions are used while others are not). Additionally, the duties of the contact person were explained (e.g., to explain to the participants that a survey that would describe the purpose of the study would be placed in their mailbox, how long it would take to complete the survey, any directions to complete it, where to put the completed questionnaire, and the deadline to complete it). Appendices E-H contain this information. Ten days following the distribution of the survey, the investigator went to the participating schools to pick up the completed surveys and place a token of appreciation (candy) in a central location (that was approved by the contact person) as well as a letter to thank those who completed the survey and to remind those who had not. Additionally, extra surveys were left for respondents to fill out if they lost their original. One week later, the investigator returned to the participating schools to pick up the completed

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Teachers’ Knowledge 65 surveys as well as leave another thank you letter. Each time the researcher went to the participating schools, the contact person was informed either by phone or email. Research Questions 1) What is the knowledge of general education elementary school teachers with regard to the following: A)Symptoms/diagnosis of ADHD? B)Treatment of ADHD? C)General information about the nature, causes, and outcomes of ADHD? 2) What is the perceived knowledge of general education elementary school teachers with regard to educational interventions for children with ADHD? 3)How well trained do general education elementary school teachers perceive themselves to be regarding interventions for children with ADHD? 4) How acceptable do general education elementary school teachers perceive various educational interventions to be for children with ADHD? 5)What are some of the perceived barriers that general education elementary school teachers face in implementing empirically supported interventions for children with ADHD? 6)What teacher variables (e.g., number of years teaching, number of in-services attended on ADHD, etc.) are related to general education elementary school teachers’ knowledge of ADHD? 7) What teacher variables (e.g., number of years teaching, number of in-services attended on ADHD, etc.) are related to general education elementary school teachers’ ratings of acceptability of educational interventions?

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Teachers’ Knowledge 66 Chapter IV Results The following section begins with a description of the participants’ experiences with ADHD. Then, each research question will be listed along with the types of analyses conducted and the results found. Teachers’ Experiences with ADHD The survey included a number of questions addressing teachers’ experiences with ADHD (e.g., whether or not they had ever taught a student with ADHD, if they knew anyone outside of the classroom who had ADHD, their preparation regarding their learning experiences in this area, and where they thought was the appropriate educational setting for a student with ADHD). All of this information is shown in Table 5. Importantly, 96% of the participants had taught at least one student with ADHD, and 56% had taught six or more pupils with ADHD. A majority of the teachers noted that they learned about ADHD during their teacher training (64%); however, most of this information consisted of only brief information such as learning about ADHD as part of a class. Results also indicated that about half of the teachers had some in-service training on ADHD, with 85% of those participants receiving 1-5 hours of in-service training. The data also showed that most of the teachers engaged in some form of self-study involving looking up information on ADHD in books (53%), articles (93%), handouts/pamphlets

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Teachers’ Knowledge 67 (89%), on television (65%), and on the Internet (31%). About half of the teachers spoke to a professional (e.g., physician, psychologist, or other professional) about a student’s ADHD. Seventy-nine percent of the participants knew someone outside of school who has ADHD. Other demographic information revealed that 43% of the participants believe that students with ADHD should be taught in the general education classroom the entire class day, while 21% believe that these students should spend at least part of their time in a special education setting. A good percentage (33%) of teachers indicated that the placement of the student should depend on his/her needs and not on the ADHD label. Table 5 Participants’ experiences with ADHD N% No. of students taught who had ADHD 0 1-2 3-5 6+ 3 10 19 40 4 14 26 56 Continued on the next page

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Teachers’ Knowledge 68 Table 5 (continued) N% ADHD TrainingaTeacher training In-service Self-study books Self-study articles Self-study pamphlets/handouts Self-study television programs Self-study internet 46 34 38 67 64 47 22 64 47 53 93 89 65 31 Spoken with professionals regarding student’s ADHD Yes No 35 35 49 49 Know anyone outside of classroom with ADHD Yes No 57 15 79 21 Most appropriate educational placement for a student with ADHD Full-time general education Full-time special education Part-time special education Otherb31 2 15 24 43 3 21 33 Note. aNumbers do not add to 100% because teachers could check more than one category. bThose that listed other indicated placement should meet the needs of the student, and not the ADHD label.

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Teachers’ Knowledge 69 What is the Knowledge of GE Elementary School Teachers with Regard to the Following: A)Symptoms/diagnosis of ADHD? B)Treatment of ADHD? C)General information about the nature, causes, and outcomes of ADHD? To address the first research question, which asked about the amount of knowledge that teachers have regarding ADHD in terms of etiology, diagnosis, prognosis, and educational interventions, descriptive statistics, including the mean, standard deviation, range, skewness, and kurtosis on the Total KADDS as well as for each subscale were calculated. Scores were found by dividing the number of correct items by the total number of items and converting to a percent. On the Total KADDS, teachers’ average score was 57% (Range=17% to 86%). The distribution was approximately normally distributed (skewness=-0.77, kurtosis=0.67). On the subscales, teachers scored the highest on the Symptoms/Diagnosis subscale (M=72%, Range=22% to 100%) and scored the lowest on the General subscale (M=51%, Range=13% to 100%). The skewness of the subscales ranged from -0.76 to -0.30 (General=-0.30, Symptoms/Diagnosis=-0.76, and Treatment=-0.52). The kurtosis of the subscales ranged from –0.40 to 0.38 (General=-0.40, Symptoms/Diagnosis=0.37, and Treatment=0.38). It should be noted that each of the subscales was moderately correlated with the other subscales (Range=.52 to .63). These results are shown in Table 6. A one way within-subjects ANOVA indicated a statistically significant difference between teachers’ scores on the subscales of the KADDS, F (2,142)=64.77, p <.0001. Post hoc analysis indicated that participants scored significantly higher on the

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Teachers’ Knowledge 70 Symptoms/Diagnosis subscale compared to the General and Treatment subscales, but there was no difference on participants’ scores on the General and Treatment subscales. Table 6 Teachers’ Scores on the Knowledge of Attention Deficit Disorders Scale (KADDS) ScaleNo. of itemsM (% correct)SD KADDS Total General Information Symptoms/Diagnosis Treatment 36 15 9 12 57 51 72 55 15.23 17.99 16.46 18.63 Note. N=72.The five most common correct answers, incorrect answers, and don’t know responses are listed in Tables 7, 8, and 9, respectively. Respondents answered “don’t know” less often to symptoms/diagnosis questions than to general information and treatment questions, but there was not a statistically significant difference between “don’t know” responses on the General subscale compared to the Treatment subscale.

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Teachers’ Knowledge 71 Table 7 Most Common Correct Responses on the KADDS Question no.QuestionSubscale% 9 Children with ADHD often fidget or squirm in their seats. (True) S99 3 Children with ADHD are frequently distracted by extraneous stimuli. (True) S97 13It is possible for an adult to be diagnosed with ADHD. (True) G94 26Children with ADHD often have difficulty organizing tasks and activities. (True) S93 10Parent and teacher training in managing a child with ADHD are generally effective when combined with medication treatment. (True) T89 16Current wisdom about ADHD suggests two clusters of symptoms: One of inattention and another consisting of hyperactivity/impulsivity. (True) S89 Note. G=General Information, S=Symptoms/diagnosis, T=Treatment.

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Teachers’ Knowledge 72 Table 8 Most Common Incorrect Responses on the KADDS Question no.QuestionSubscale% 1M ost estimates suggest that ADHD occurs in approximately 15% of school age children. (False) G10 5I n order to be diagnosed with ADHD, the child’s symptoms must have been present before age seven. (True) S10 4 Children with ADHD are typically more compliant with their fathers than with their mothers. (True) G15 27Children with ADHD generally experience more problems in novel situations than in familiar situations. (False) G15 34Behavioral/Psychological interventions for children with ADHD focus primarily on the child’s problems with inattention. (False) T17 Note. G=General Information, S=Symptoms/diagnosis, T=Treatment.Table 9 Most Common “Don’t Know” Responses on the KADDS Question no.QuestionSubscale% 35Electroconvulsive Therapy (i.e., shock treatment) has been found to be an effective treatment for severe cases of ADHD. (False) T72 Continued on the next page

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Teachers’ Knowledge 73 Table 9 (continued) Question no.QuestionSubscale% 6 ADHD is more common in 1st degree biological relatives (i.e., mother, father) of children with ADHD than in the general population. (True) G65 4 Children with ADHD are typically more compliant with their fathers than with their mothers. (True) G57 17Symptoms of depression are found more frequently in children with ADHD than in children without ADHD. (True) G56 1M ost estimates suggest that ADHD occurs in approximately 15% of school age children. (False) G54 Note. G=General Information, S=Symptoms/diagnosis, T=Treatment.What is the Perceived Knowledge of GE Elementary School Teachers with Regard to Educational Interventions for Children with ADHD? Teachers’ perceived knowledge of interventions was measured by the question that asks about teachers’ knowledge on the Teacher Intervention Survey (Question #1). Participants responded on a Likert scale from 1 (Very Low) to 5 (Very High). Descriptive statistics are presented in Table 10. Results ranged from 4.27 to 3.10 and indicated that teachers felt more knowledgeable about instructional management techniques than behavioral management interventions. A one way within-subjects ANOVA indicated a statistically significant difference among teachers’ perceived knowledge of the various interventions, F (11,759)=26.80, p <.0001. Pairwise comparisons found 10 of the pairs to

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Teachers’ Knowledge 74 be statistically significant at the p <.05 level, one pair to be statistically significant at the p <.01 level, 40 pairs to be statistically significant at the p <.001 level, and 15 pairs to not be statistically significant. Table 10 Teachers’ Ratings of Perceived Knowledge of Interventions (N=70) Type of interventionMeanSD Use of cues, prompts, and attention checks4.270.74 Physical arrangement4.240.71 Structure4.210.74 Varied presentation and format of materials4.010.75 Home-based contingencies3.890.89 Peer tutoring3.890.77 Brief academic tasks interspersed with passive tasks3.840.83 Attention3.570.84 Token economy3.540.85 Response cost3.540.83 Time-out from positive reinforcement3.310.98 Self-management3.100.84 All interventions combined3.780.91 Note. Scores were on a Likert Scale (1=Very Low to 5=Very High).

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Teachers’ Knowledge 75 How Well Trained do GE Elementary School Teachers Perceive Themselves to be Regarding Interventions for Children with ADHD? The perception of GE elementary school teachers’ training in interventions was measured by the question that asked about teacher preparedness (Question #2) on the Teacher Intervention Survey. This question tapped into the ability to apply the skill. Teachers responded on a Likert scale from 1 (Very Low) to 5 (Very High). Table 11 lists the descriptive statistics for teacher’s perceived skill in interventions. The information is presented in order of the intervention teachers feel most trained in (Use of cues, prompts, and attention checks) to least trained (Self-management). A one way within-subjects ANOVA revealed a statistically significant difference among teacher’s perceptions of their training in various interventions, F (11,737)=30.29, p <.0001. Follow-up tests indicated eight comparisons were statistically significant at the p <.05 level, 43 pairs were statistically significant at the p <.001 level, and 15 pairs were not statistically significant. Table 11 Teachers Ratings of Perceived Skill of Interventions (N=68) Type of interventionMeanSD Use of cues, prompts, and attention checks4.290.69 Physical arrangement4.210.72 Structure4.140.77 Varied presentation and format of materials3.820.80 Home-based contingencies3.780.86 Continued on the next page

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Teachers’ Knowledge 76 Table 11 (continued) Type of interventionMeanSD Brief academic tasks interspersed with passive tasks3.720.83 Peer tutoring3.670.83 Attention3.530.87 Response cost3.350.81 Token economy3.220.91 Time-out from positive reinforcement3.091.02 Type of interventionMeanSD Self-management3.030.81 All interventions combined3.650.89 Note. Scores were on a Likert Scale (1=Very Low to 5=Very High).How Acceptable do GE Elementary School Teachers Perceive Various Educational Interventions to be for Children with ADHD? GE elementary school teachers’ perceptions of how acceptable various educational interventions are for children with ADHD were measured by the question that asked about acceptability of interventions (Question #4) on the Teacher Intervention Survey. Teachers responded on a Likert scale from 1 (Very Low) to 5 (Very High). Table 12 displays the results of this analysis. The information is ordered with the intervention that teachers felt was the most acceptable (Use of cues, prompts, and attention checks) at the top and the least acceptable (Time-out from positive reinforcement) at the bottom. Results of a one way within-subjects ANOVA revealed a statistically significant difference among teachers’ ratings of acceptability of interventions, F (11,748)=39.39,

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Teachers’ Knowledge 77 p <.0001. Follow-up pairwise comparisons revealed nine pairs statistically significant at the p <.05 level, 46 pairs statistically significant at the p <.001 level, and 11 pairs not statistically significant. Table 12 Teachers’ Ratings of Acceptability of Interventions (N=69) Type of interventionMeanSD Use of cues, prompts, and attention checks4.060.84 Structure4.010.81 Physical arrangement4.000.71 Varied presentation and format of materials3.860.83 Brief academic tasks interspersed with passive tasks3.650.85 Home-based contingencies3.590.88 Peer tutoring3.420.88 Attention3.130.86 Token economy3.040.76 Self-management2.990.90 Response cost2.650.87 Time-out from positive reinforcement2.390.96 All interventions combined3.390.79 Note. Scores were on a Likert Scale (1=Very Low to 5=Very High).

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Teachers’ Knowledge 78 What are Some of the Perceived Barriers that GE Elementary School Teachers face in Implementing Empirically Supported Interventions for Children with ADHD? The kinds of barriers that exist in implementing interventions were measured by averaging the scores on the questions that ask about knowledge, training, and time/resources (Question #’s 1, 2, and 5) on the Teacher Intervention Survey to form a “Barriers” score since the research has shown that knowledge, training, and time/resources have been main factors in determining the use of certain interventions (Reid et al., 1994). Teachers responded on a Likert scale from 1 (Very Low) to 5 (Very High). The numbers represent to what extent the items are barriers to the interventions with high numbers indicating lower barriers to implement the intervention. The results of the “Barriers” score for each intervention are listed in Table 13. The information is presented with the intervention that teachers found had the least barriers (Use of cues, prompts, and attention checks) to those that had the most barriers (Self-management). Additionally, a one way within-subjects ANOVA revealed a statistically significant difference between barriers and the different intervention, F (11,748)=37.62, p <.0001. Follow-up pairwise tests found six pairs statistically significant at the p <.05 level, 45 statistically significant at the p <.001 level, and 15 pairs not statistically significant.

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Teachers’ Knowledge 79 Table 13 Barrier Scores per Intervention (N=69) Type of interventionMeanSD Use of cues, prompts, and attention checks4.260.70 Physical arrangement4.180.65 Structure4.150.70 Varied presentation and format of materials3.850.73 Brief academic tasks interspersed with passive tasks3.720.78 Peer tutoring3.710.71 Home-based contingencies3.640.82 Attention3.510.73 Response cost3.320.73 Token economy3.200.74 Time-out from positive reinforcement3.090.90 Self-management3.030.71 All interventions combined3.630.89 Note. Scores were on a Likert Scale (1=Very Low to 5=Very High).To better understand the relationship between teachers’ knowledge of interventions, their perceived skill, the acceptability of interventions, and which interventions have the least barriers, each of these areas was rank ordered by score according to intervention (see Table 14). As demonstrated by this table, teachers felt more knowledgeable, perceived their skill to be greater, rated as more acceptable, and rated fewer barriers to the implementation of interventions that fell under the instructional

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Teachers’ Knowledge 80 management category, notably use of cues, prompts, and attention checks; physical arrangement; structure; and varied presentation and format of materials. Teachers felt they knew least about, had less skill, rated as less acceptable, and perceived more barriers to the implementation of the interventions that fell under the behavior management category, notably, token economy, response cost, time-out from positive reinforcement, and self-management. Table 14 Rank Order of Teachers’ Knowledge, Skill, Acceptability of Interventions, and Barriers to Implementation InterventionKnowledgeSkillAcceptabilityBarriersa Use of cues, prompts, and attention checks 1111 Physical arrangement2232 Structure3323 Varied presentation and format of materials 4444 Home-based contingencies5567 Peer tutoring6776 Brief academic tasks interspersed with passive tasks 7655 Attention8888 Continued on the next page

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Teachers’ Knowledge 81 Table 14 (continued) InterventionKnowledgeSkillAcceptabilityBarriersa Token economy910910 Response cost109119 Time-out from positive reinforcement 11111211 Self-management12121012 Note. aThe lower the rank order the lower amount of barriers.What Teacher Variables (e.g., number of years teaching, number of in-services attended on ADHD, etc.) are Related to GE Elementary School Teachers’ Knowledge of ADHD? The next research question focused on the relationship between teacher demographic variables and their knowledge of ADHD. Variables used were highest degree attained, grade level currently teaching, total number of years teaching experience, number of students with ADHD taught, learned about ADHD during teacher training (yes, no), number of in-services attended, and amount of self-study. These demographic questions were from the Demographics section of the questionnaire. The knowledge questions were from the KADDS and the knowledge question on the Teacher Intervention Survey. The information found from this part of the analysis is presented in Tables 15-16. Since all of the correlations in Table 15 are positive except for the correlation between grade and symptoms/diagnosis knowledge, the higher the participants’ degree, the higher grade they taught, the more experience, the more students with ADHD taught, and the more teacher training, in-services attended, and self-study, the better the participant performed on the Total KADDS and the subscales. As shown in

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Teachers’ Knowledge 82 Table 15, the amount of variance in knowledge of ADHD explained by all the predictors ranged from 7% (Symptoms/Diagnosis subscale) to 29% (General subscale). While most of the predictors for total knowledge of ADHD were not significant when controlling for the effects of the other variables, two relationships were statistically significant: (1) Total score on the KADDS and the amount of teacher training (beta=.31, p <.05) and (2) Total score on the KADDS and the amount of self-study (beta=.29, p <.05). With regard to treatment knowledge, when controlling for the effects of the other predictors, the same variables as general knowledge were statistically significant: Teacher training (beta=.34, p <.05) and self-study (beta=.41, p <.001). Regarding perceived knowledge of interventions, the total variance explained by the set of predictor variables ranged from 7% (token economy) to 20% (use of cues, prompts, and attention checks). Only seven of the relationships were statistically significant when controlling for the effects of the other variables: Participants who taught lower grades perceived their knowledge of home-based interventions to be better (beta=-.28, p <.05), participants who had less years of teaching experience had greater perceived knowledge of providing structure (beta=-.38, p <.05), participants who had taught more students with ADHD and who engaged in more self study perceived their knowledge of varying the presentation and format of materials to be better (beta=.38, p <.01, beta=.25, p <.05, respectively), participants who taught more students with ADHD perceived their knowledge of providing cues, prompts, and attention checks to be higher (beta=.38, p <.01), and participants who had a bachelor’s degree perceived themselves to be more knowledgeable about self-management than those who had a master’s degree (beta=-.30, p <.05). When it comes to all the interventions combined, participants who taught more students with ADHD perceived

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Teachers Knowledge 83 themselves to be more knowledgeable about interventions in general (beta=.34, p <.05) (see Table 16). Table 15 Teacher Variables Related to Knowledge (N=69) PredictorsTotalGeneralSymptoms/ Diagnosis Treatment rB etarBetarBetarBeta Degree.12.04.17.05.02-.00.07.03 Grade.05-.02.09.01-.08-.10.06.00 Experience.24.18.30.13.14.14.11.20 # of students with ADHD taught .23.08.37.19.06-.02.06-.02 Teacher training.10.31*.02.24.04.16.19.34* In-service.30.17.44.29.15.10.10-.02 Self-study.36.29*.28.17.15.12.41.41** R2.25.29.07.26 Note Degree was coded as BA/BS, MA/MS; Grade was coded as prek -1st, 2nd-3rd, 4th-5th; Experience was coded as 0-2, 3-8, 9-15, 16, 25, 26+, # of students with ADHD taught was coded as 0, 1-2, 3-5, 6+, Teacher training was coded as yes/no; In-service was coded as yes/no and number: 1-2, 3-5, or 6 or more; Selfstudy (read any books, articles, pamphlets/handouts, watched any television programs, searched the Internet for information on ADHD) was coded as yes/no. p<.05, **p<.001.

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Teachers’ Knowledge 84 Table 16 Summary Table of Predictors for Perceived Knowledge of Interventions OutcomePredictors DegreeGradeExperience# of students with ADHD taught Teacher training In-serviceSelf-study R2Beta Coefficients Attention.10-.17.02.04.22-.05.05.04 Token Economy.07-.05.15-.11.02-.21-.05.13 Response Cost.13-.09.11.07.19-.22-.33.10 Time-out from positive reinforcement .09-.06-.06-.15.13-.09-.24.00 Home-based contingencies.18.03-.28*-.20.26-.10.11.18 Continued on the next page

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Teachers’ Knowledge 85 Table 16 (continued) OutcomePredictors DegreeGradeExperience# of students with ADHD taught Teacher training In-serviceSelf-study R2Beta Coefficients Structure.18-.11-.12-.38*.27-.04.15.21 Physical arrangement.12-.17-.14-.15.22-.04.11.12 Varied presentation and format of materials .19-.11-.16-.20.38**-.02-.10.25* Use of cues, prompts, and attention checks .20.09-.17-.16.38**.06.00.20 Continued on the next page

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Teachers’ Knowledge 86 Table 16 (continued) OutcomePredictors DegreeGradeExperience# of students with ADHD taught Teacher training In-serviceSelf-study R2Beta Coefficients Brief academic tasks interspersed with passive tasks .10-.14.00.05.27-.06-.13.13 Peer tutoring.10-.17-.05.15.24.05-.07.11 Self-management.13-.30*.05.13.25.09-.06.05 All interventions combined.14-.15-.08-.12.34*-.08-.07.18 Note. N’s varied from 67 to 68; Degree was coded as BA/BS, MA/MS; Grade was coded as pre-k -1st, 2nd-3rd, 4th-5th; Experience was coded as 0-2, 3-8, 9-15, 16, 25, 26+, # of students with ADHD taught was coded as 0, 1-2, 3-5, 6+, Teacher training was coded as yes/no; In-service was code d as yes/no and number: 1-2, 35, or 6 or more; Self-study (read any books, articles, pamphlets/handouts, watched any television programs, searched the Intern et for information on ADHD) was coded as yes/no. *p<.05, **p<.01.

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Teachers’ Knowledge 87 What Teacher Variables (e.g., number of years teaching, number of in-services attended on ADHD, etc.) are Related to GE Elementary School Teachers Acceptability of Educational Interventions? The last research question focused on the relationship between teacher demographic variables and their acceptability of interventions. Variables used were highest degree attained, grade level currently teaching, total number of years teaching experience, number of students with ADHD taught, learned about ADHD during teacher training, number of in-services attended, and amount of self-study. These demographic questions were from the Demographics section of the questionnaire. The acceptability of interventions question is found on the Teacher Intervention Survey. The information found from this part of the analysis is presented in Table 17. The amount of explained variability in acceptability of interventions ranged from 7% (Response Cost) to 23% (Teacher Attention). While many of the relationships were not significant when controlling for the effects of the other variables, three items had a significant relationship: (1) participants felt that providing teacher attention was more acceptable the more inservice hours attended (beta=.40, p <.05), (2) participants who taught more students with ADHD were more accepting of home-based contingencies (beta=.30, p <.05), and (3) participants who attended more in-services were more accepting of providing structure (beta=.35, p <.05).

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Teachers’ Knowledge 88 Table 17 Summary Table of Predictors for Acceptability of Interventions OutcomePredictors DegreeGradeExperience# of students with ADHD taught Teacher training In-serviceSelf-study R2Beta Coefficients Attention.23.11.04-.30.26.02.40*.09 Token Economy.11-.02.16-.03.13.23.11.10 Response Cost.07.00.18.06.10.00-.23-.02 Time-out from positive reinforcement .09.03.17.24.09.07-.19-.17 Home-based contingencies.19.10-.13-.14.30*.18.14.16 Continued on the next page

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Teachers’ Knowledge 89 Table 17 (continued) OutcomePredictors DegreeGradeExperience# of students with ADHD taught Teacher training In-serviceSelf-study R2Beta Coefficients Structure.19.14-.07-.26.12.14.35*.17 Physical arrangement.10-.02-.16.00.27.18.04-.02 Varied presentation and format of materials .08-.08.01-.04.15.04-.02.23 Use of cues, prompts, and attention checks .11.05-.07-.05.13.16.19.14 Continued on the next page

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Teachers’ Knowledge 90 Table 17 (continued) OutcomePredictors DegreeGradeExperience# of students with ADHD taught Teacher training In-serviceSelf-study R2Beta Coefficients Brief academic tasks interspersed with passive tasks .09-.22-.11.02.16.01.02.07 Peer tutoring.12-.13.04.14-.02.12.30-.09 Self-management.12.07.04-.21.05.12.25.20 All interventions combined.17.01.01-.08.26.19.21.12 Note. N’s varied from 67 to 68; Degree was coded as BA/BS, MA/MS; Grade was coded as pre-k -1st, 2nd-3rd, 4th-5th; Experience was coded as 0-2, 3-8, 9-15, 16, 25, 26+, # of students with ADHD taught was coded as 0, 1-2, 3-5, 6+, Teacher training was coded as yes/no; In-service was code d as yes/no and number: 1-2, 35, or 6 or more; Self-study (read any books, articles, pamphlets/handouts, watched any television programs, searched the Intern et for information on ADHD) was coded as yes/no. *p<.05.

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Teachers’ Knowledge 91 Chapter V Discussion Introduction The purpose of this study was to examine GE elementary school teachers’ knowledge and training of ADHD, as well as their ratings of acceptability of interventions. Seven elementary schools participated with a total of 72 GE teachers completing the survey. The total response rate was 35%. There were seven research questions. The first research question asked about GE elementary school teachers’ knowledge of ADHD, including the symptoms/diagnosis of the disorder, treatment, and general information about the nature, causes, and outcomes of ADHD. The second question investigated the perceived knowledge of GE elementary school teachers with regard to educational interventions for children with ADHD. The third question examined how well trained GE elementary school teachers perceive themselves to be regarding interventions for children with ADHD. The fourth question asked how acceptable GE elementary school teachers perceive various educational interventions to be for children with ADHD. The fifth research question examined some of the perceived barriers that GE elementary school teachers face in implementing empirically supported interventions for children with ADHD. The last two research questions investigated the relationship between teacher variables (e.g., number of years teaching, number of in-services attended

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Teachers’ Knowledge 92 on ADHD, etc.) and their knowledge of ADHD and acceptability of educational interventions. The participants in this study were similar in many aspects to participants in other studies that investigated teachers’ knowledge of ADHD (Bussing, Gary, Leon, Garvan, & Reid, 2002; Hawkins et al., 1991; Jerome et al., 1994; Piccolo-Torsky & Waishwell, 1998; Power et al. 1995; Reid et al., 1994; Sciutto et al., 2000; Whitworth et al., 1997; & Yasutake et al., 1994). Most of the studies in the literature, including the current study, consisted of a majority of female respondents who had a bachelor’s degree. The only exception was the research by Sciutto et al. (2000), in which most of the participants had a master’s degree. Most of the respondents in the current study were less than 41 years old (55%). In the Bussing et al. (2002) study, 54% of the teachers were greater than 41 years old and in the Piccolo-Torsky and Waishwell (1998) study 81% of the respondents were older than 40. In the current study the average number of years of teaching experience was 11.77 years, which is similar to the Bussing et al. (2002) study and the Sciutto et al. (2000) study in which the average number of years of teaching experience was 13.6. and 12.57, respectively. In the literature, a majority of the participants have not received any training as undergraduates or as current teachers on the topic of ADHD (Hawkins et al., 1991; Piccolo-Torsky & Waishwell, 1998; Yasutake et al., 1994). Some of the studies reported 27% to 50% of their respondents had not received any information regarding ADHD during their teacher training (Bussing et al., 2002; Sciutto et al., 2000), compared to the current study, where many of the respondents had received some training in ADHD during their undergraduate years (64%). Less than half of the respondents (47%) in the current study received some in-service training, compared to 76% in the

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Teachers’ Knowledge 93 Sciutto et al. (2000) study and 33% in the Bussing et al. (2002) study. A majority of participants in the current study as well as other investigations have read a book and/or an article on ADHD (Bussing et al., 2002; Sciutto et al., 2000). About half of the respondents in this study have spoken to a professional regarding a student’s ADHD, compared to 14% in the Jerome et al. (1994) study. Regarding the educational opportunities of students with ADHD, 43% of the participants in this study believed that students with ADHD should spend their educational time in a full-time general education placement, which is slightly less than the 60% of respondents in the Whitworth et al. (1997) study who “agreed” to “strongly agreed” that students with ADHD should remain in general education classrooms. However, 33% of the respondents in the current study indicated that placement should meet the needs of the student and not the ADHD label. With regard to the response rate, the usable response rate of this study (35%) was similar to the Sciutto et al. (2000) response rate (37%). However, other studies on teachers’ knowledge of ADHD, their acceptability of interventions, and teachers’ experiences with ADHD reported response rates of 55%-86% (Bussing et al., 2002; Piccolo-Torsky & Waishwell, 1998; Power et al., 1995; Reid et al., 1994). Reasons for the higher response rates in other studies could be that the participants were from middle class suburban communities, upper middle class districts, or gifts were included with the survey (i.e., gift certificate). Teachers’ Knowledge of ADHD Children with ADHD can be challenging to teach because of their inattentiveness, hyperactivity, and/or impulsivity. Therefore, teachers need to know how to use a variety of interventions in order to meet the individual needs of students with ADHD. It has been

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Teachers’ Knowledge 94 found that knowledge about a disorder is related to how acceptable teachers view interventions. Therefore, it is important to consider the knowledge teachers have regarding ADHD. The little research that exists in this area indicates that teachers perform in the low to average range on ADHD knowledge tests (either true/false, or true/false/I don’t know), with scores ranging from 47%-81% correct (Jerome et al., 1994; Jerome et al., 1999; Piccolo-Torsky & Waishwell, 1998; Power et al., 1995; Sciutto et al., 2000). However, teachers tend to perform better on questions regarding symptoms/diagnosis, and less well on the nature, course, and treatment of ADHD. The present study is consistent with the literature. Overall, teachers scored 57% correct and performed best on questions regarding the symptoms/diagnosis of ADHD. Although most studies have found misperceptions regarding dietary management as an effective treatment for ADHD, this study also found misperceptions in this area. Other areas showed even greater misperceptions among teachers in this sample (e.g., the percent of the school age population who have ADHD, and the age at which symptoms must have been present in order to be given the diagnosis of ADHD). Specifically, with regard to the Sciutto et al. (2000) study, since their research utilized the same knowledge questionnaire, results of the current study are relatively similar. Pertaining to the most common correct, incorrect, and don’t know responses, four of the five responses in each category were the same in both studies. Therefore it appears that teachers tend to be better at answering symptoms/diagnosis questions because many times these questions relate to what a teacher directly observes a student in his/her class demonstrating (i.e., Children with ADHD often fidget or squirm on their seats). These results also suggest that teachers still have many misperceptions regarding ADHD. Scores on the KADDS

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Teachers’ Knowledge 95 also were similar to the Sciutto et al. (2000) study, however, those in the present study tended to perform slightly better than those in that study (57% and 48%, respectively). Teachers’ Perceived Knowledge of Interventions Since each student has unique needs, it is important for teachers to be able to have a repertoire of interventions in order to best meet the needs of students, especially those that are exhibiting difficulties such as ADHD. While there are some studies that have tapped into teachers’ knowledge of ADHD, none of these studies specifically asked questions regarding the various empirically supported interventions to be used for students with ADHD. In the present study, teachers’ perceived knowledge for the various interventions ranged from a mean of 3.10 to 4.74, measured on a scale of 1 (low) to 5 (high). In general, teachers believed they knew more about instructional management techniques such as the use of cues, prompts, and attention checks; physical arrangement of the classroom; structure; and varied presentation and format of materials. Teachers felt they knew less about behavioral management methods such as token economy, response cost, and time-out from positive reinforcement. Interestingly, teachers also indicated that they felt least knowledgeable about self-management techniques, which is the most controversial intervention mentioned in this study. Using cues, arranging the classroom, or using different techniques do not usually require additional amounts of teacher time, resources, or advanced training. In contrast, the other techniques mentioned above require additional training, require more steps and take more time to implement, which may be why teachers feel less knowledgeable about these interventions.

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Teachers’ Knowledge 96 Training in Interventions While it is not only important for teachers to have knowledge regarding interventions in ADHD, it also is beneficial for them to actually know how to implement the intervention. The research in this area is limited, but what exists demonstrates that teachers do not have much training in interventions (Hawkins et al., 1991; Matlock, 1999; Reid et al., 1994; Yasutake et al., 1994). However, none of these studies specifically asked respondents about their knowledge of research-based interventions for students with ADHD. Rather, they asked respondents questions regarding interventions such as “What is the first step in your intervention procedure?” “What has been the primary objective of your classroom interventions?” “Which intervention has worked best for you?” or “if respondents feel they need more training in ADHD,” without specific reference to interventions. In the Hawkins et al. (1991) study only 16% of respondents who had some training in ADHD had been taught to use a variety of techniques. Forty percent indicated that their intervention consisted of adapting instruction, and 37% indicated changing student behavior. The Reid et al. (1994) study showed that teachers who had prior training in ADHD were more confident in their ability to set up effective behavior contracts and adjust lessons or materials for students with ADHD. Matlock (1999) also found that those who had specific training in working with students with ADHD were more likely to try various alternative educational interventions such as peer tutoring. Teachers in this study felt their skill in implementing interventions was moderate to high (range 3.03 to 4.29, with 1 indicating very low training and 5 indicating greater training). Interestingly, teachers perceived their knowledge and skill in interventions

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Teachers’ Knowledge 97 similarly, indicating both greater knowledge and greater skill in instructional management techniques such as using cues, prompts, physical arrangement, and structure, and lesser knowledge and skill in behavioral interventions such as token economy, response cost, and time-out from positive reinforcement. As with their knowledge of interventions, teachers felt the least proficient in their skill in selfmanagement techniques. Acceptability of Interventions While knowledge and training of interventions are extremely important for teachers, it also is imperative that support personnel who suggest interventions for students with ADHD take into consideration which interventions teachers find acceptable and which they do not. The one study of acceptability of interventions in the area of ADHD has shown that teachers prefer positive interventions (daily report) as opposed to negative consequences (response cost) (Power et al., 1995). Other studies involving children with behavior disorders have demonstrated that severity of behavior and amount of time required to implement the intervention are extremely important (e.g., Witt et al., 1984; Witt & Martens, 1983). For example, teachers tend to prefer positive interventions applied to mild behavior problems, and reductive interventions that require considerable amounts of teacher time applied to a mild behavior problem are considered least acceptable. However, in all of these studies, participants were provided a written or oral case study and were only given a limited amount of interventions to choose from. None of the studies asked teachers how acceptable they felt about all of the empirically supported interventions for students with ADHD.

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Teachers’ Knowledge 98 The current study demonstrated, consistent with participants’ perceptions of their knowledge of and training in ADHD, that token economy, response cost, and time-out from positive reinforcement were considered the least acceptable interventions while use of cues, prompts, and attention checks, structure, and physical arrangement were considered the most acceptable (range 2.39-4.06, with 1 indicating not very acceptable and 5 indicated very high acceptability). It appears as if the greater the knowledge and training of the teacher, the greater the acceptability of an intervention. This is important because frequently school psychologists suggest interventions such as token economy and response cost for teachers to use for students with ADHD. However, if teachers do not feel that they know about the intervention, or how to use it appropriately, then they may not implement it correctly or at all. This could greatly affect the learning environment of the student and cause additional stress on the teacher. Therefore, it is important for support staff to work very closely with teachers in order to recommend interventions the teacher feels comfortable implementing and give guidance and support for those that s/he does not feel confident implementing. With help and increased knowledge and feedback in implementing the various interventions, teachers may become more acceptable of those interventions that tend to be more difficult to implement (i.e., token economy, time-out from positive reinforcement). Types of Barriers There are many reasons why teachers do not implement various interventions. The research has demonstrated that time to administer interventions, lack of training, class size, and severity of problems are the greatest barriers to instruction (Reid et al., 1994). In this study, teachers felt that response cost, token economy, and time-out from

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Teachers’ Knowledge 99 positive reinforcement had the most barriers to implementation. These interventions also take more time and resources to administer than using cues, prompts, and attention checks; physical arrangement; and structure. Additionally, as with the other areas, teachers felt that self-management had the most barriers to implement. Therefore it is important to understand why teachers feel these barriers hinder their ability to implement various interventions. If teachers become more knowledgeable and have more training where they get a chance to practice implementing various interventions and receive feedback, teachers may learn that in fact, the interventions do not really take more time/resources. Teacher Variables Related to Knowledge of ADHD The present study found that teachers with more training and those that engaged in self-study scored higher on the Total knowledge part of the KADDS as well as on the Treatment subscale. This information is similar to that found in the Jerome et al. (1994) study, which found that the amount of teachers’ specific training in ADHD strongly predicted test scores. Sciutto et al. (2000) found that knowledge of ADHD was unrelated to various teacher characteristics including age, education level, and number of special education classes taken, but that the more students with ADHD that a teacher taught, the higher the score on the Total KADDS (as well as the General and Symptoms/Diagnosis subscale) a finding not found in the present study. Piccolo-Torsky and Waishwell (1998) found no significant differences in knowledge with regard to the age of the teacher, grade taught, years of teaching experience, marital status, or amount of reported contact with a student with ADHD, which was corroborated in this study. It appears the research in this area is conflicting, and therefore more research needs to be done in this area. With regard

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Teachers’ Knowledge 100 to perceived knowledge of interventions, the present study found that when combining all the interventions, teachers who taught more students with ADHD felt more knowledgeable about the subject. With regard to specific interventions, the relationship between the predictors and the interventions varied. For home-based contingencies, teachers who taught lower grades felt more knowledgeable in this area. Reasons for this result could be that at the lower grades, teachers tend to establish a greater relationship with parents. With regard to structure, teachers with less experience perceived their knowledge in this intervention to be greater. Those with less experience teaching tend to be younger and more recently completed undergraduate training. Therefore, it could be hypothesized that recent graduates learn more about using structure in the classroom compared to less recent graduates. With varied presentation and format of materials, teachers who taught more students with ADHD and engaged in more self-study perceived their knowledge in this area to be greater. Since teaching a child with ADHD can be very demanding, the more students with ADHD a teacher has taught, the various modalities a teacher may have tried and therefore feel more knowledgeable about. Additionally, reading various books/articles/pamphlets or searching the Internet for information regarding ADHD may provide some instruction on this intervention. Also, those who taught more students with ADHD felt more knowledgeable about their ability to use cues, prompts, and attention checks. As with varied presentation and format of materials, by experiencing teaching more students with ADHD, using cues and prompts may be an intervention that teachers have used repeatedly and therefore feel more knowledgeable about. Additionally, those with a bachelor’s degree felt more knowledgeable in the area of self-management. Reasons for this could be that there were many more participants in

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Teachers’ Knowledge 101 the study with a bachelor’s degree compared to a mater’s degree, therefore the results could be biased. There is not any other study that has measured teachers’ perceived knowledge of interventions. More research needs to be done in this area. Teacher Variables Related to Acceptability of Interventions Since there are many interventions that have been found to be successful for students with ADHD, it is important to see if there are any specific teacher variables that are related to teachers’ acceptability of interventions. The present study found that while controlling for the other predictors, the more students with ADHD teachers taught, the more acceptable they found home-based contingencies, and the more in-services attended, the more accepting they were of providing teacher attention and structure. Teachers tend to talk a lot to the parents of children who exhibit inappropriate behavior in school. Therefore, the more experience a teacher has teaching students with ADHD and the more they find themselves discussing issues with parents of children with ADHD, the more accepting they may be of home-based contingencies. When teachers in this study attended in-services on ADHD, teacher attention and structure could have been emphasized or a teacher could believe that implementing these interventions are in their repertoire of skills. They may therefore like these interventions and find success with them, finding them more acceptable. However, when combining all the interventions together, there was not any predictor that was related to acceptability of interventions. Though there is not much literature in this area, Power et al. (1995) found that the number of years of teaching experience was not related to teachers’ ratings of acceptability of interventions, which they noted was an unexpected result of their study but was also found in the present study.

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Teachers’ Knowledge 102 Limitations of Study There were several limitations to the study. First, the information obtained was by self-report. As such, there was no way to determine if the respondents were answering truthfully or not. This is particularly important for items that ask about teachers’ use of various interventions, because by using a self-report survey, information pertaining to the accuracy of the interventions or to treatment integrity was not obtained. Another limitation was that the severity of the ADHD symptoms of the students in the participating teachers’ classrooms was not known. If a teacher had only had experience with students with milder symptoms, he or she might not think that some educational interventions are necessary or appropriate. A third limitation concerned the various subtypes of ADHD. Teachers may not know what subtype of ADHD a student has or not even realize that various subtypes exist. This also could impact the types of interventions that a teacher will use. A fourth limitation involves the reliability of the Teacher Intervention Survey. Using a single item to measure a variable can be a weakness. The fifth limitation has to do with the generalizability of the results. Since the sample is from teachers in one school district in one state, the results can only be generalized to teachers at similar types of schools with similar backgrounds. The sixth limitation involves the terms and definitions on the Teacher Intervention Survey. Teachers may not be familiar with the terminology or the descriptions. Additionally, the low response rate may mean that a true cross section of the teachers was not obtained, which may have resulted in bias in the sample.

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Teachers’ Knowledge 103 Future Directions Based on the results of this study, GE elementary school teachers need more training in behavioral management techniques if they are to work effectively with students with ADHD. This could be done at both the in-service and pre-service level. School psychologists could help provide the in-services to teachers. Also, more research needs to be done in the areas of teacher variables related to knowledge of ADHD and acceptability of interventions. Finding ways to help students succeed in school is a priority of most teachers. This includes having the knowledge and skill to apply various interventions for students with challenging behaviors, and the research in this area is limited. It is interesting to note that in rating their perceived knowledge of and training in interventions and their ratings of acceptability of interventions, none of the average scores of the participants fell below 3, indicating a moderate score. It would therefore be advantageous to have school psychologists work as consultants to teachers where they can observe teachers working with a child with ADHD, help them implement interventions and interview them about their techniques and barriers. It also may be helpful to investigate undergraduate teacher education programs and in-services about ADHD to determine what information teachers actually receive about this disorder. Asking teachers what steps they take when a child is exhibiting specific inappropriate behavior may also provide information regarding teachers’ knowledge, training, and ratings of acceptability of interventions. Other directions include a larger sample size representative of teachers all over the United States.

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Teachers’ Knowledge 104 Summary The purpose of the study was to investigate GE teachers’ knowledge of ADHD, their perceived knowledge of and training in interventions, as well as their ratings of acceptability of interventions and which barriers hinder the implementation of interventions. The study also investigated which teacher demographic variables were related to teachers’ knowledge of ADHD and their ratings of acceptability of interventions. Results indicated that teachers have a limited knowledge of ADHD, scoring an average of 57% on the knowledge questionnaire. Teachers scored statistically significantly higher on the Symptoms/Diagnosis subscale compared to the General and Treatment subscales. Teachers also felt more knowledgeable, perceived their skill to be greater, rated as more acceptable, and rated lower barriers to implementation instructional management interventions such as use of cues, prompts, and attention checks; physical arrangement; structure; and varied presentation and format of materials. Teachers felt they knew least about, had less skill, rated as less acceptable, and had more barriers to the implementation of behavior management interventions such as token economy, response cost, and time-out from positive reinforcement, as well as self-management techniques. Most demographic variables were unrelated to teachers’ knowledge of ADHD, their perceived knowledge of interventions, and their ratings of acceptability of interventions.

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Teachers’ Knowledge 105 References Abramowitz, A. J., & O’Leary, S. G. (1990). Effectiveness of delayed punishment in applied setting. Behavior Therapy, 21 231-239. Abramowitz, A. J., & O’Leary, S. G. (1991). Behavioral interventions for the classroom: Implications for students with ADHD. School Psychology Review, 20 (2), 220-234. Abramowitz, A. J., O’Leary, S. G., & Futtersak, M. W. (1988). The relative impact of long and short reprimands on children’s off-task behavior in the classroom. Behavior Therapy, 19 243-247. Abramowitz, A. J., O’Leary, S. G., & Rosen, L. A. (1987). Reducing off-task behavior in the classroom: A comparison of encouragement and reprimands. Journal of Abnormal Child Psychology, 15 (2), 153-163. Acker, M. M., & O’Leary, S. G. (1987). Effects of reprimands and praise on appropriate behavior in the classroom. Journal of Abnormal Child Psychology, 15 (4), 549-557. American Psychiatric Association (2000). Diagnostic and statistic manual of mental disordersText Revision (DSM-TR). Washington, DC: American Psychiatric Association. Anastopoulos, A. D. (1992). Test of ADHD Knowledge. ADHD Clinic, University of Massachusetts Medical Center, Worcester, MA. Arnsten, A. F. T. (2000). Genetics of childhood disorders: XVIII. ADHD, part 2: Norepinephrine has a critical modulatory influence on prefrontal cortical function. Journal of the American Academy of Child and Adolescent Psychiatry, 39 (9), 12011203. Ayllon, T., Garber, S., & Pisor, K. (1975). The elimination of discipline problems through a combined school-home motivational system. Behavior Therapy, 6 616-626. Barkley, R. A. (1997). Behavioral Inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121 (1), 65-94. Barkley, R. A. (1998). Attention-Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment (2nd ed.). New York: The Guilford Press.

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Teachers’ Knowledge 106 Barkley, R. A. (2000). A New Look at ADHD: Inhibition, Time, and Self-Control Video Manual. New York: The Guilford Press. Barkley, R. A., Copeland, A. P., & Sivage, S. (1980). A self-control classroom for hyperactive children. Journal of Autism and Developmental Disorders, 10 (1), 75-89. Barkley, R. A., Fischer, M., Edelbrock, C., & Smallish, L. (1991). The adolescent outcome of hyperactive children diagnosed by research criteria-III. Mother-child interactions, family conflicts and maternal psychopathology. Journal of Child Psychology and Psychiatry, 32 (2), 233-255. Biederman, J., Faraone, S. V., Mick, E., Spencer, T., Wilens, T., Kiely, K., Guite, J., Ablon, J. S., Reed, E., & Warburton, R. (1995). High risk for attentiondeficit/hyperactivity disorder among children of parents with childhood onset of the disorder: A pilot study. American Journal of Psychiatry, 152 (3), 431-435. Biederman, J., & Spencer, T. J. (2000). Genetics of childhood disorders XIX. ADHD, part 3: Is ADHS a noradrenergic disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 39 (10) 1330-1333. Breslau, N., Brown, G. G., DelDotto, J. E., Kumar, S., Ezhuthachan, S., Andreski, P., & Hufnagle, K. G. (1996). Psychiatric sequelae of low birth weight at 6 years of age. Journal of Abnormal Child Psychology, 24 (3), 385-400. Budd, K. S., Leibowitz, J. M., Riner, L. S., Mindell, C., & Goldfarb, A. L. (1981). A reinforcement package for preschool and kindergarten children. Behavior Modification, 5 (2), 273-298. Bussing, R., Gary, F. A., Leon, C. E., Garvan, C. W., & Reid, R. (2002). General classroom teachers’ information and perceptions of attention deficit hyperactivity disorder. Behavioral Disorders, 27 (4), 327-339. Calvert, S. C., & Johnston, C. (1990). Acceptability of treatments for child behavior problems: Issues and implications for future research. Journal of Clinical Child Psychology, 19 (1), 61-74. Casey, B. J., Castellanos, F. X., Giedd, J. N., & Marsh, W. L. (1997). Implications of right frontostriatal circuitry in response inhibition and attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36 374-383. Children and Adults with Attention-Deficit/Hyperactivity Disorder (2001). The CHADD Information and Resource Guide to AD/HD. Maryland: CHADD.

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Teachers’ Knowledge 107 Cohen, M. (1999). What you need to know about AD/HD under the Individuals with Disabilities Education Act [Pamphlet]. C.H.A.D.D. Committee on Drugs, American Academy of Pediatrics (1985). Behavioral and cognitive effects of anticonvulsant therapy. Pediatrics, 76 644-647. Cruikshank, B. M., Eliason, M., & Merrifield, B. (1988). Long-term sequelae of water near-drowning. Journal of Pediatric Psychology, 13 379-388. Cunningham, C. E., & Barkley, R. A. (1979). The interactions of normal and hyperactive children with their mothers in free play and structured tasks. Child Development, 50 217-224. Danforth, J. S., Barkley, R. A., & Stokes, T. F. (1991). Observations of parent-child interactions with hyperactive children: Research and implications. Clinical Psychology Review, 11 703-727. Davies, S., & Witte, R. (2000). Self-management and peer-monitoring within a group contingency to decrease uncontrolled verbalizations of children with attentiondeficit/hyperactivity disorder. Psychology in the Schools, 37 (2), 135-147. Denson, R., Nanson, J. L., & McWatters, M. A. (1975). Hyperkinesis and maternal smoking. Canadian Psychiatric Association Journal, 20 183-187. DuPaul, G. J. & Eckert, T. L. (1998). Academic interventions for students with AttentionDeficit/Hyperactivity Disorder: A review of the literature. Reading and Writing Quarterly: Overcoming Learning Difficulties, 14 (1), 59-82. DuPaul, G. J., Ervin, R. A., Hook, C. L., & McGoey, K. E. (1998). Peer tutoring for children with attention deficit hyperactivity disorder: Effects on classroom behavior and academic performance. Journal of Applied Behavior Analysis, 31 (4), 579-592. DuPaul, G. J., Guevremont, D. C., & Barkley, R. A. (1992). Behavioral treatment of Attention-Deficit Hyperactivity Disorder in the classroom: The use of the attention training system. Behavior Modification, 16 (2), 204-225. DuPaul, G. J., & Henningson, P. N. (1993). Peer tutoring effects on the classroom performance of children with attention deficit hyperactivity disorder. School Psychology Review, 22 (1), 134-143. DuPaul, G. J. & Stoner, G. (1994). ADHD in the schools: Assessment and intervention strategies. New York: The Guilford Press.

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Teachers’ Knowledge 108 Earls, F., Reich, W., Jung, K. G., & Cloninger, C. R. (1988). Psychopathology in children of alcoholic and antisocial parents. Alcohol Clinical Experimental Research, 12 481487. Edelbrock, C., Rende, R., Plomin, R., & Thompson, L. A. (1995). A twin study of competence and problem behavior in childhood and early adolescence. Journal of Child Psychology and Psychiatry, 36 (5), 775-785. Edwards, L., Salant, V., Howard, V. F., Brougher, J., & McLaughlin, T. F. (1995). Effectiveness of self-management on attentional behavior and reading comprehension for children with attention deficit disorder. Child and Family Behavior Therapy, 17 (2), 1-17. Elliott, S. N. (1988). Acceptability of behavioral treatments: Review of variables that influence treatment selection. Professional Psychology: Research and Practice, 19 (1), 668-680. Elliott, S. N., Witt, J. C., Galvin, G. A., & Peterson, R. (1984). Acceptability of positive and reductive behavioral interventions: Factors that influence teachers’ decisions. Journal of School Psychology, 22 353-360. Fiore, T. A., Becker, E. A., & Nero, R. C. (1993). Educational interventions for students with Attention Deficit Disorder. Exceptional Children, 60 (2), 163-173. Foxx, R. M., & Shapiro, S. T. (1978). The time-out ribbon: A non-exclusionary timeout procedure. Journal of Applied Behavior Analysis, 11 125-143. Gardill, M. C., DuPaul, G. J., & Kyle, K. E. (1996). Classroom strategies for managing students with Attention-Deficit/Hyperactivity Disorder. Intervention in School and Clinic, 32 (2), 89-94. Goodman, R., & Stevenson, J. (1989). A twin study of hyperactivity: II. The aetiological role of genes, family relationships, and perinatal adversity. Journal of Child Psychology and Psychiatry, 30 691-709. Gresham, F. M. (1989). Assessment of treatment integrity in school consultation and preferral intervention. School Psychology Review, 18 (1), 37-50. Hall, C. W., & Didier, E. (1987). Acceptability and utilization of frequently-cited intervention strategies. Psychology in the Schools, 24 153-161. Hawkins, J., Martin, S., Blanchard, K. M., & Brady, M. P. (1991). Teacher perceptions, beliefs, and interventions regarding children with Attention Deficit Disorders. Action in Teacher Education, 13 (2), 52-59.

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Teachers’ Knowledge 109 Hartsough, C. S., & Lambert, N. M. (1985). Medical factors in hyperactive and normal children: Prenatal, developmental, and health history findings. American Journal of Orthopsychiatry, 55 (2), 190-201. Hinshaw, S. P., Henker, B., & Whalen, C. K. (1984). Cognitive-behavioral and pharmacologic interventions for hyperactive boys: Comparative and combined effects. Journal of Consulting and Clinical Psychology, 52 (5), 739-749. Hinshaw, S. P., & Melnick, S. M. (1995). Peer relationships in boys with attention deficit hyperactivity disorder with and without comorbid aggression. Developmental Psychopathology, 7 627-647. Hoff, K. E., & DuPaul, G. J. (1998). Reducing disruptive behavior in general education classrooms: The use of self-management strategies. School Psychology Review, 27 (2), 290-303. Holdsworth, L., & Whitmore, K. (1974). A study of children with epilepsy attending ordinary schools: I. Their seizure patterns, progress, and behavior in school. Developmental Medicine and Child Neurology, 16 (6), 746-758. Jensen, P. S. (2000). ADHD: Current concepts on etiology, pathophysiology, and neurobiology. Child and Adolescent Psychiatric Clinics of North America, 9 (3), 557572. Jerome, L., Gordon, M., & Hustler, P. (1994). A comparison of American and Canadian teachers’ knowledge and attitudes towards Attention Deficit Hyperactivity Disorder (ADHD). Canadian Journal of Psychiatry, 39 (9), 563-567. Jerome, L., Washington, P., Laine, C., & Segal, A. (1999). Graduating teachers’ knowledge and attitudes about Attention Deficit Hyperactivity Disorder: A comparison with practicing teachers. Canadian Journal of Psychiatry, 44 (2), 192. Johnson, L. J., & Pugach, M. C. (1990). Classroom teachers’ views of intervention strategies for learning and behavior problems: Which are reasonable and how frequently are they used? The Journal of Special Education, 24 (1), 69-84. Kazdin, A. E. (1980). Acceptability of alternative treatments for deviant child behavior. Journal of Applied Behavior Analysis, 13 (2), 259-273. Kelley, M. L., & McCain, A. P. (1995). Promoting academic performance in inattentive children: The relative efficacy of school-home notes with and without response cost. Behavior Modification, 19 (3), 357-375.

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Teachers’ Knowledge 110 Kuperman, S., Schlosser, S. S., Lindral, J., & Reich, W. (1999). Relationship of child psychopathology to parental alcoholism and antisocial personality disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (6), 686-692. Kutsick, K. A., Gutkin, T. B., & Witt, J. C. (1991). The impact of treatment development process, intervention type, and problem severity on treatment acceptability as judged by classroom teachers. Psychology in the Schools, 28 325-331. Liu, C, Robin, A. L., Brenner, S., & Eastman, J. (1991). Social acceptability of methylphenidate and behavior modification for treatment of attention deficit hyperactivity disorder. Pediatrics, 88 560-565. Lou, H. C., Henriksen, L., & Bruhn, P. (1984). Focal cerebral hypoperfusion in children with dysphasia and/or attention deficit disorder. Archives of Neurology, 41 825-829. Lou, H. C., Henriksen, L., Bruhn, P., Borner, L., & Nielson, J. B. (1989). Striatal dysfunction in attention deficit and hyperkinetic disorders. Archives of Neurology, 46 48-52. Martens, B. K., & Meller, P. J. (1989). Influence of child and classroom characteristics on acceptability of interventions. Journal of School Psychology, 27 237-245. Martens, B. K., Peterson, R. L., Witt, J. C., & Cirone, S. (1986). Teacher perceptions of school-based interventions. Exceptional Children, 53 (3), 213-223. Martens, B. K., Witt, J. C., Elliott, S. N., & Darveaux, D. X. (1985). Teacher judgments concerning the acceptability of school-based interventions. Professional Psychology: Research and Practice, 16 (2), 191-198. Matlock, E. A. (1999). Differences in elementary school teachers’ instructional environment and perceived competence toward children with Attention Deficit Hyperactivity Disorder as a function of attitudes toward control versus autonomy, training, and experience. Unpublished doctoral dissertation, Oklahoma State University, OK. McGoey, K. E., & DuPaul, G. J. (2000). Token reinforcement and response cost procedures: Reducing the disruptive behavior of preschool children with attentiondeficit/hyperactivity disorder. School Psychology Quarterly, 15 (3), 330-343. Milberger, S., Biederman, J., Faraone, S. V., & Jones, J. (1998). Further evidence of an association between maternal smoking during pregnancy and attention deficit hyperactivity disorder: Findings from a high-risk sample of siblings. Journal of Clinical Child Psychology, 27 (3), 352-358.

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Teachers’ Knowledge 111 National Association of School Psychologists (NASP) (1998). Students with attention problems [on-line], http://www.nasponline.org/information/pospaper_add.html. Needleman, H. L., Gunnoe, C., Leviton, A., Reed, R., Peresie, H., Maher, C., & Barrett, P. (1979). Deficits in psychologic and classroom performance of children with elevated dentine lead levels. The New England Journal of Medicine, 13 (300), 689695. O’Doughterty, M., Nuechterlein, K. H., & Drew, B. (1984). Hyperactive and hypoxic children: Signal detection, sustained attention, and behavior. Journal of Abnormal Psychology, 93 178-191. Pelham, W. E., & Fabiano, G. (2000). Behavior modification. Child and Adolescent Psychiatric Clinics of North America, 9 (3), 671-688. Pfiffner, L. J., & O’Leary, S. G. (1987). The efficacy of all-positive management as a function of the prior use of negative consequences. Journal of Applied Behavior Analysis, 20 265-271. Pfiffner, L. J., Rosen, L. A., & O’Leary, S. G. (1985). The efficacy of an all-positive approach to classroom management. Journal of Applied Behavior Analysis, 18 (3), 257-261. Piccolo-Torsky, J. & Waishwell, L. (1998). Teachers’ knowledge and attitudes regarding Attention Deficit Disorder. ERS Spectrum, 16 (1), 36-40. Power, T. J. (2000, March). Understanding and improving adherence with pharmacological and behavioral interventions. Paper presented at the meeting of The National Association of School Psychologists, New Orleans, LA. Power, T. J., Hess, L. E., & Bennett, D. S. (1995). The acceptability of interventions for Attention-Deficit Hyperactivity Disorder among elementary and middle school teachers. Developmental and Behavioral Pediatrics, 16 (4), 238-243. Rapport, M. D., Murphy, H. A., & Bailey, J. S. (1982). Ritalin vs. response cost in the control of hyperactive children: A within-subject comparison. Journal of Applied Behavior Analysis, 15 205-216. Reeve, R. E. (1994). The academic impact of ADD. Attention, 5 (2), 8-12. Reid, R., Vasa, S., Maag, J., & Wright, G. (1994). An analysis of teachers’ perceptions of Attention Deficit-Hyperactivity Disorder. The Journal of Research and Development in Education, 27 (3), 195-202.

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Teachers’ Knowledge 112 Reimers, T. M., Wacker, D. P., & Koeppl, G. (1987). Acceptability of behavioral interventions: A review of the literature. School Psychology Review, 16 (2), 212-227. Robinson, P. W., Newby, T. J., & Ganzell, S. L. (1981). A token system for a class of underachieving hyperactive children. Journal of Applied Behavioral Analysis, 14 (3), 307-315. Rosen, L. A., O’Leary, S. G., Joyce, S. A., Conway, G., & Pfiffner, L. J. (1984). The importance of prudent negative consequences for maintaining the appropriate behavior of hyperactive students. Journal of Abnormal Child Psychology, 12 (4), 581-604. Rosenbaum, A., O’Leary, K. D., & Jacob, R. G. (1975). Behavioral intervention with hyperactive children: Group consequences as a supplement to individual contingencies. Behavior Therapy, 6 315-323. Rosenfield, P., Lambert, N. M., & Black, A. (1985). Desk arrangement effects on pupil classroom behavior. Journal of Educational Psychology, 77 (1), 101-108. Rutter, M. (1977). Brain damage syndromes in childhood: Concepts and findings. Journal of Child Psychology and Psychiatry, 18 1-21. Schmidt, M. H., Esser, G., Allenoff, W., Geisel, B., Laucht, M. & Woerner, W. (1987). Evaluating the significance of minimal brain dysfunction: Results of an epidemiological study. Journal of Child Psychology and Psychiatry, 28 (6), 803-821. Sciutto, M. J., Terjesen, M. D., & Bender Frank, A. S. (2000). Teachers’ knowledge and misperceptions of attention-deficit/hyperactivity disorder. Psychology in the Schools, 37 (2), 115-122. Shapiro, E. S., DuPaul, G. J., & Bradley-Klug, K. L. (1998). Self-management as a strategy to improve the classroom behavior of adolescents with ADHD. Journal of Learning Disabilities, 31 (6), 545-555. Sherman, D. K., Iacono, W. G., & McGue, M. K. (1997). Attention-deficit hyperactivity disorder: A twin study of inattention and impulsivity-hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 36 (6), 745-753. Shelton, T. L., & Barkley, R. A. (1995). The assessment and treatment of attentiondeficit/hyperactivity disorder. In. M. C. Roberts (Ed.), Handbook of Pediatric Psychology (633-654). NY: The Guildford Press. Spitalnik, R., & Drabman, R. (1976). A classroom time out procedure for retarded children. Journal of Behavior Therapy and Experimental Psychiatry, 7 17-21.

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Teachers’ Knowledge 113 Sprich-Buckminster, S., Biederman, J., Milberger, S., Faraone, S. V., & Lehman, B. K. (1993). Are perinatal complications relevant to the manifestation of ADD? Issues of comorbidity and familiality. Journal of the American Academy of Child and Adolescent Psychiatry, 32 (5), 1032-1037. Stein, M. A., Krasowski, M., Leventhal, B. L., Phillips, W., & Bender, B. G. (1996). Behavioral and cognitive effects of methylxanthines. Archives of Pediatric and Adolescent Medicine, 150 284-288. Streissguth, A. P., Martin, D. C., Barr, H. M., Sandman, B. M., Kirchner, G. L., & Darby, B. L. (1984). Intrauterine alcohol and nicotine exposure: Attention and reaction time in 4-year-old children. Developmental Psychology, 20 (4), 533-541. Stubbe, D. E. (2000). Attention-deficit/hyperactivity disorder overview. Child and Adolescent Psychiatric Clinics of North America, 9 (3), 469-479. Sykes, D. H., Hoy, E. A., Bill, J. M., McClure, B. G., Halliday, H. L., & Reid, M. M. (1997). Behavioural adjustment in school of very low birthweight children. Journal of Child Psychology and Psychiatry, 38 (3), 315-325. Tarver-Behring, S., Barkley, R. A., & Karlsson, J. (1985). The mother-child interactions of hyperactive boys and their normal siblings. American Journal of Orthopsychiatry, 55 (2), 202-209. Thapar, A., Holmes, J., Poulton, K., & Harrington, R. (1999). Genetic basis of attention deficit and hyperactivity. British Journal of Psychiatry, 174 105-111. Tingstrom, D. H. (1989). Increasing acceptability of alternative behavioral interventions through education. Psychology in the Schools, 26 188-194. U. S. Department of Education (2001). http://info.doe.state.fl.us/fsir2001. Von Brock, M. B., & Elliott, S. N. (1987). Influence of treatment effectiveness information on the acceptability of classroom interventions. Journal of School Psychology, 25 131-144. Van Houten, R., Nau, P. A., MacKenzie-Keating, S. E., Sameoto, D., & Colavecchia, B. (1982). Analysis of some variables influencing the effectiveness of reprimands. Journal of Applied Behavior Analysis, 15 65-83. Weinstein, C. (1979). The physical environment of the school: A review of the research. Review of Educational Research, 49 577-610. Whalen, C. K., & Henker, B. (1985). The social worlds of hyperactive (ADDH) children. Clinical Psychology Review, 5 447-478.

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Teachers’ Knowledge 114 White, A. G., & Bailey, J. S. (1990). Reducing disruptive behaviors of elementary physical education students with sit and watch. Journal of Applied Behavior Analysis, 23 (3), 353-359. Whitworth, J. E., Fossler, T., & Harbin, G. (1997). Teachers’ perceptions regarding educational services to students with Attention Deficit Disorder. Rural Educator, 19 (2), 1-5. Witt, J. C. (1986). Teachers’ resistance to the use of school-based interventions. Journal of School Psychology, 24 37-44. Witt, J. C., Elliott, S. N., & Martens, B. K. (1984). Acceptability of behavioral interventions used in classrooms: The influence of amount of teacher time, severity of behavior problem, and type of intervention. Behavioral Disorders, 9 95-104. Witt, J. C., & Martens, B. K. (1983). Assessing the acceptability of behavioral interventions used in classrooms. Psychology in the Schools, 20 510-517. Witt, J. C., Martens, B. K., & Elliott, S. N. (1984). Factors affecting teachers’ judgments of the acceptability of behavioral interventions: Time involvement, behavior problem severity, and type of intervention. Behavior Therapy, 15 204-209. Wolf, S. M., & Forsythe, A. (1978). Behavior disturbance, phenobarbital, and febrile seizures. Pediatrics, 61 (5), 728-731. Woodward, L., Taylor, E., & Dowdney, L. (1998). The parenting and family functioning of children with hyperactivity. Journal of Child Psychology and Psychiatry, 39 (2), 161-169. Yasutake, D., Lerner, J., & Ward, M. (1994). The need for teachers to receive training for working with students with attention deficit disorder. B. C. Journal of Special Education, 18 (1), 81-84. Zentall, S. S. (1993). Research on the educational implications of Attention Deficit Hyperactivity Disorder. Exceptional Children, 60 (2), 143-153. Zentall, S. S., & Dwyer, A. M. (1989). Color effects on the impulsivity and activity of hyperactive children. Journal of School Psychology, 27 165-173. Zentall, S. S., Falkenberg, S. D., & Smith, L. B. (1985). Effects of color stimulation and information on the copying performance of attention-problem adolescents. Journal of Abnormal Child Psychology, 13 (4), 501-511.

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Teachers’ Knowledge 115 Zentall, S. S., & Leib, S. L. (1985). Structured tasks: Effects of activity and performance of hyperactive and comparison children. Journal of Educational Research, 79 (2), 9195. Zentall, S. S., & Meyer, M. J. (1987). Self-regulation of stimulation for ADD-H children during reading and vigilance task performance. Journal of Abnormal Child Psychology, 15 (4), 519-536.

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Teachers’ Knowledge 116 Appendices

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Teachers’ Knowledge 117 Appendix A: Items on the Knowledge of Attention Deficit Disorders Scale (KADDS) by Subscale Subscale Items I. General Information 1. Most estimates suggest that ADHD occurs in approximately 15% of school age children. 2. Children with ADHD are typically more compliant with their fathers than with their mothers. 3. ADHD is more common in the 1st degree biological relatives (i.e. mother, father) of children with ADHD than in the general population. 4. It is possible for an adult to be diagnosed with ADHD. 5. Symptoms of depression are found more frequently in children with ADHD than in children without ADHD. 6. Most children with ADHD "outgrow" their symptoms by the onset of puberty and subsequently function normally in adulthood. 7. If a child with ADHD is able to demonstrate sustained attention to video games or TV for over an hour, that child is also able to sustain attention for at least an hour of class or homework. 8. A diagnosis of ADHD by itself makes a child eligible for placement in special education. Continued on the next page

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Teachers Knowledge 118 Appendix A (continued) Subscale Items 9. Children with ADHD generally experience more problems in novel situations than in familiar situations. 10. There are specific physical features which can be identified by medical doctors (e.g., pediatrician) in making a definitive diagnosis of ADHD. 11. In school age children, the prevalence of ADHD in males and females is equivalent. 12. In very young children (less than 4 years old), the problem behaviors of ADHD children (e.g. hyperactivity, inattention) are distinctly different from age-appropriate behaviors of children without ADHD. 13. Children with ADHD are more distinguishable from children without ADHD in a classroom setting than in a free play situation. 14. The majority of children with ADHD evidence some degree of poor school performance in the elementary school years. 15. Symptoms of ADHD are often seen in children without ADHD who come from inadequate and chaotic home environments. II. Symptoms/Diagnosis 1. Children with ADHD are frequently distracted by extraneous stimuli. 2. In order to be diagnosed with ADHD, the child's symptoms must have been present before age seven. Continued on the next page

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Teachers’ Knowledge 119 Appendix A (continued) Subscale Items 3. One symptom of children with ADHD is that they have been physically cruel to other people. 4. Children with ADHD often fidget or squirm in their seats. 5. It is common for children with ADHD to have an inflated sense of self-esteem or grandiosity. 6. Children with ADHD often have a history of stealing or destroying other people's things. 7. Current wisdom about ADHD suggests two clusters of symptoms: One of inattention and another consisting of hyperactivity/impulsivity. 8. In order to be diagnosed as ADHD, a child must exhibit relevant symptoms in two or more settings (e.g., home, school). 9. Children with ADHD often have difficulties organizing tasks and activities. III. Treatment 1. Current research suggests that ADHD is largely the result of ineffective parenting skills. 2. Antidepressant drugs have been effective in reducing symptoms for many children with ADHD. 3. Parent and teacher training in managing a child with ADHD are generally effective when combined with medication treatment. Continued on the next page

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Teachers’ Knowledge 120 Appendix A (continued) Subscale Items 4. When treatment of a child with ADHD is terminated, it is rare for the child's symptoms to return. 5. Side effects of stimulant drugs used for treatment of ADHD may include mild insomnia and appetite reduction. 6. Individual psychotherapy is usually sufficient for the treatment of most children with ADHD. 7. In severe cases of ADHD, medication is often used before other behavior modification techniques are attempted. 8. Reducing dietary intake of sugar or food additives is generally effective in reducing the symptoms of ADHD. 9. Stimulant drugs are the most common type of drug used to treat children with ADHD 10. Behavioral/Psychological interventions for children with ADHD focus primarily on the child's problems with inattention. 11. Electroconvulsive Therapy (i.e. shock treatment) has been found to be an effective treatment for severe cases of ADHD. 12. Treatments for ADHD which focus primarily on punishment have been found to be the most effective in reducing the symptoms of ADHD.

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Teachers’ Knowledge 121 Appendix B: Items on Teacher Intervention Survey Teacher Attention: give student positive and negative verbal feedback, as well as nonverbal feedback such as nods, frowns, smiles, and pats of approval 1H ow much knowledge/understanding do you have regarding this intervention? 2H ow skilled do you perceive yourself to be in implementing this intervention? 3H ow effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4T o what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5H ow likely are you to have the time/resources to implement this intervention? 6H ow likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? Note. Questions for all twelve interventions were set up the same way with the name of the intervention and a description as well as the same six questions.

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Teachers’ Knowledge 122 Appendix C: Barrier Items on Teacher Intervention Survey Teacher Attention: give student positive and negative verbal feedback, as well as nonverbal feedback such as nods, frowns, smiles, and pats of approval 1H ow much knowledge/understanding do you have regarding this intervention? 2H ow skilled do you perceive yourself to be in implementing this intervention? 5H ow likely are you to have the time/resources to implement this intervention? Note. Questions for all twelve interventions were set up the same way with the name of the intervention and a description as well as the same three questions.

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Teachers’ Knowledge 123 Appendix D: Letter to Principals to Request Teacher ParticipationMonth XX, 2002 PRINCIPAL PRINCIPALS_FIRST_NAME PRINCIPALS_FIRST_NAME OR CURRENT PRINCIPAL SCHOOL_NAME ADDRESS CITY, STATE ZIP_CODE Dear Principal PRINCIPALS_LAST_NAME (OR Current Principal): I am a graduate student in the School Psychology Program at the University of South Florida. I would like to request your cooperation for all of the general education teachers at your school to participate in a research study that I am conducting on Attention-Deficit/Hyperactivity Disorder (ADHD). Specifically, I am interested in general education elementary school teachers’ knowledge, training, and ratings of acceptability of interventions for students with ADHD. This study is important because the research indicates that there is at least one student in every classroom with ADHD. If we can identify what teachers’ know about the disorder as well as what kinds of interventions they are likely to use and the reasons why some interventions are acceptable, school psychologists can design and help teachers implement interventions for students with ADHD. The study consists of a survey (True/False, Scale of 1 to 5, and a few fill in the blank), which would require about 15-20 minutes of the teachers’ time. A copy of the survey is enclosed. If you agree to participate I would like to discuss with you the options of administering the survey. Some ways I have considered are the following, but I am willing to do whatever is easiest for you I could go to a faculty meeting and explain, distribute, and collect the survey. I could go to a faculty meeting and explain and distribute the survey and have a contact person or convenient location for respondents to place the surveys, which I will come and pick up. I also could come and place the surveys in the teachers’ mailboxes and have a contact person or convenient location for respondents to place the surveys, which I will pick up. All information obtained in connection with the study will be kept confidential. Additionally, when the study is complete, a copy of my study will be sent to you. If you decide to participate, please return the following page to me in the self addressed stamped envelope by DATE. I will call you in a week to discuss more of the details and set up a meeting with you, but in the meantime, please feel free to contact me with any questions. I realize that you and your teachers are very busy and I greatly appreciate the time you have taken to assist me in my research. Thank you very much. Sincerely, Stacey Small 813-765-4063 shsmall@helios.acomp.usf.eduContinued on the next page

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Teachers’ Knowledge 124 Appendix D (continued)Participation in ADHD Study PRINCIPALS_FIRST_NAME PRINCIPALS_LAST_NAME Principal SCHOOL_NAME ADDRESS CITY, STATE ZIP_CODE I, ____________________________________ agree to allow my teachers to (please print) participate in a research study conducted by Stacey Small. If you are not the person I should get in touch with, please list the name of a contact person at the school: _________________________________________________ NamePosition _________________________________ _______________________ Principal’s Signature Date

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Teachers Knowledge 125 Appendix E: Letter to TeachersMonth XX, 2002 Dear Teacher: I am interested in studying teachers knowledge of Attention-Deficit/Hyperactivity Disorder (ADHD) and their acceptability of interventions. I am extremely grateful to you for taking time out of your busy schedule to assist me in my research. The following pages contain a survey regarding teachers knowledge and training in ADHD. Part I asks about demographic information. Part II is a knowledge survey regarding ADHD. Part III inquires about specific interventions for ADHD. Directions for completing each part of the survey are listed at the beginning of each section. It should take you about 15-20 minutes to complete the entire survey. You will not be paid for your participation in this study. By taking part in this study, you will be helping to provide information to determine if teachers need more training on the subject of ADHD and to help school psychologists recommend interventions that teachers find useful. There are no risks to participating in this study. Please place your completed survey in ________________ by DATE. Your privacy and research records will be kept confidential to the extent of the law. Authorized research personnel, employees of the Department of Health and Human Services and the USF Institutional Review Board may inspect the records from this research project. The results of this study may be published. However, the data obtained from you will be combined with data from other people in the publication. The published results will not include your name or any other information that would in any way personally identify you. Surveys will not contain any code names or numbers. The researcher will be the only ones to have access to the data. The data will be kept in a locked file cabinet and only the principal investigator will have access to it. If you would like a copy of the results, please feel free to contact me (information provided below). When completing these questions, please think of a student of yours who has ADHD who exhibits inattention, hyperactivity, and/or impulsivity (even if he or she is taking medication for these symptoms). This may be a student whom you currently teach or one that you have taught previously (but please focus on a student you taught in general education). If you have neverContinued on the next page

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Teachers’ Knowledge 126 Appendix E (continued)taught a student with ADHD, please complete the survey anyways. Please answer the survey independently. Also, please keep in mind that there are a variety of ways to work with children with ADHD. I am trying to learn more about your own experiences, attitudes, and opinions. Your decision to participate in this research study is completely voluntary. You are free to participate in this research study or to withdraw at any time. If you choose not to participate, or if you withdraw, there will be no penalty or loss of benefits that you are entitled to receive. Additionally, your teaching or job status will in no way be affected by your decision to participate or not participate. If you have any questions about this research study, please contact the principal investigator at 813-765-4063 or shsmall@helios.acomp.usf.edu. If you have questions about your rights as a person who is taking part in a research study, you may contact a member of the Division of Research Compliance of the University of South Florida at 813-974-5638. This research project/study and informed consent form were reviewed and approved by the University of South Florida Institutional Review Board for the protection of human subjects. This approval is valid until the date provided below. The board may be contacted at (813) 9745638. Approval Consent Form Expiration Date: _______ Thank you very much for your cooperation! I certify that participants have been provided with an informed consent form that has been approved by the University of South Florida’s Institutional Review Board that contains the nature, demands, risks and benefits involved in participating in this study. I further certify that a phone number has been provided in the event of additional questions. Sincerely, Stacey Small shsmall@helios.acomp.usf.edu School Psychology Graduate StudentUniversity of South Florida

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Teachers’ Knowledge 127 Appendix F: Part I – Demographics (format for original survey modified to conform to thesis format requirements) Please answer the following questions by either writing your answer on the blank or circling your response. A. Identifying Data 1. Your age ______ 2. Gender a. Male b. Female 3. Highest degree attained ______4. Specialization/ Certification ______ 5. Grade level(s) you currently teach? ______ 6. Classes you currently teach? a. General Ed b. Special Ed 7. Total number of years of teaching experience? ______ B. Experience with ADHD 1. Did you learn about ADHD during your teacher training? a. No b. Yes, briefly during course work/field placements (i.e., was taught in part of a class) c. Yes, extensively during course work/field placements (i.e., had an entire semester course on ADHD) 2. How many students with documented ADHD have you taught? a. 0b. 1 or 2c. 3-5d. 6 or more 3. If you’ve had students with ADHD in your classroom, have you ever spoken with their physicians, psychologists, or other professionals about their ADHD? a. Not applicable b. No c. Yes, once or twice d. Yes, many times 4. Have you ever: If Yes, What are the Total Hours (for question a) or the Total Number (for questions b-e)? a. attended an in-service presentation on ADHD?a. No. b. Yesa. 1-2b. 3-5c. 6 or more b. read any books on ADHD?a. No. b. Yesa. 1-2b. 3-5c. 6 or more c. read any articles on ADHD?a. No. b. Yesa. 1-2b. 3-5c. 6 or more d. read any pamphlets/handouts on ADHD?a. No. b. Yesa. 1-2b. 3-5c. 6 or more e. watched any television programs on ADHD?a. No. b. Yesa. 1-2b. 3-5c. 6 or more f. searched the internet for information on ADHD?a. No. b. Yes 5. Do you know anyone outside of school who has ADHD (either child or adult)? a. No b. Yes 6. What do you think is the most appropriate educational placement for a student with ADHD? a. Full-time general education b. Full-time special education c. Part-time special education d. Other _______________________________

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Teachers’ Knowledge 128 Appendix G: Part IIKnowledge of Attention Deficit Disorders Scale (KADDS) (format for original survey modified to conform to thesis format requirements)Please answer the following questions regarding Attention-Deficit/Hyperactivity Disorders (ADHD) by circling your response. If you are unsure of an answer, respond Don't Know (DK), DO NOT GUESS. Please DO NOT leave any items BLANK. True (T), False (F), or Don't Know (DK) (circle one): 1. Most estimates suggest that ADHD occurs in approximately 15% of school age children. T F DK 2. Current research suggests that ADHD is largely the result of ineffective parenting skills. T FDK 3. Children with ADHD are frequently distracted by extraneous stimuli. T F DK 4. Children with ADHD are typically more compliant with their fathers than with their mothers. T FDK 5. In order to be diagnosed with ADHD, the child's symptoms must have been present before age seven. T F DK 6. ADHD is more common in the 1st degree biological relatives (i.e. mother, father) of children with ADHD than in the general population. T FDK 7. One symptom of children with ADHD is that they have been physically cruel to other people. T F DK 8. Antidepressant drugs have been effective in reducing symptoms for many children with ADHD. T FDK 9. Children with ADHD often fidget or squirm in their seats. T F DK 10. Parent and teacher training in managing a child with ADHD are generally effective when combined with medication treatment. T FDK 11. It is common for children with ADHD to have an inflated sense of self-esteem or grandiosity. T F DK 12. When treatment of a child with ADHD is terminated, it is rare for the child's symptoms to return. T FDK 13. It is possible for an adult to be diagnosed with ADHD. T F DK 14. Children with ADHD often have a history of stealing or destroying other people's things. T FDK 15. Side effects of stimulant drugs used for treatment of ADHD may include mild insomnia and appetite reduction. T F DK 16. Current wisdom about ADHD suggests two clusters of symptoms: One of inattention and another consisting of hyperactivity/impulsivity. T FDK 17. Symptoms of depression are found more frequently in children with ADHD than in children without ADHD. T F DK 18. Individual psychotherapy is usually sufficient for the treatment of most children with ADHD. T FDK Continued on the next page

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Teachers’ Knowledge 129 Appendix G (continued) 19. Most children with ADHD "outgrow" their symptoms by the onset of puberty and subsequently function normally in adulthood. T F DK 20. In severe cases of ADHD, medication is often used before other behavior modification techniques are attempted. T FDK 21. In order to be diagnosed as ADHD, a child must exhibit relevant symptoms in two or more settings (e.g., home, school). T F DK 22. If a child with ADHD is able to demonstrate sustained attention to video games or TV for over an hour, that child is also able to sustain attention for at least an hour of class or homework. T FDK 23. Reducing dietary intake of sugar or food additives is generally effective in reducing the symptoms of ADHD. T F DK 24. A diagnosis of ADHD by itself makes a child eligible for placement in special education. T FDK 25. Stimulant drugs are the most common type of drug used to treat children with ADHD T F DK 26. Children with ADHD often have difficulties organizing tasks and activities.T FDK 27. Children with ADHD generally experience more problems in novel situations than in familiar situations. T F DK 28. There are specific physical features which can be identified by medical doctors (e.g., pediatrician) in making a definitive diagnosis of ADHD. T FDK 29. In school age children, the prevalence of ADHD in males and females is equivalent. T F DK 30. In very young children (less than 4 years old), the problem behaviors of ADHD children (e.g. hyperactivity, inattention) are distinctly different from ageappropriate behaviors of children without ADHD. T FDK 31. Children with ADHD are more distinguishable from children without ADHD in a classroom setting than in a free play situation. T F DK 32. The majority of children with ADHD evidence some degree of poor school performance in the elementary school years. T FDK 33. Symptoms of ADHD are often seen in children without ADHD who come from inadequate and chaotic home environments. T F DK 34. Behavioral/Psychological interventions for children with ADHD focus primarily on the child's problems with inattention. T FDK 35. Electroconvulsive Therapy (i.e. shock treatment) has been found to be an effective treatment for severe cases of ADHD. T F DK 36. Treatments for ADHD which focus primarily on punishment have been found to be the most effective in reducing the symptoms of ADHD. T FDK

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Teachers’ Knowledge 130 Appendix H: Part IIITeacher Intervention Survey (format for original survey modified to conform to thesis format requirements)There have been many different interventions suggested for students with ADHD, several of which are listed below. Please answer each question by placing a check in the appropriate box with 1 indicating very low and 5 indicating very high. Please only check one box. If you are undecided, please check the box you feel is most appropriate. A. TEACHER ATTENTION: give student positive and negative verbal feedback, as well as nonverbal feedback such as nods, frowns, smiles, and pats of approvalVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? B. TOKEN ECONOMY: awarding tokens or points which are dependent upon specified appropriate behaviorsVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? Continued on the next page

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Teachers’ Knowledge 131 Appendix H (continued)C. RESPONSE COST: taking away privileges, tokens, or points, for inappropriate behaviorVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? D. TIME-OUT FROM POSITIVE REINFORCEMENT: restricting the child’s access to positive reinforcement such as placing the child in the corner of the room on a chairVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? Continued on the next page

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Teachers’ Knowledge 132 Appendix H (continued)E. HOME-BASED CONTINGENCIES: combining school and home efforts to improve child’s classroom behavior, such as teacher fills out a daily report card or check list which indicates whether the child fulfilled the specified goals for that day and sends the report home for the parent to sign and the parent provides suitable rewards at home for appropriate behavior at schoolVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? F. STRUCTURE: providing organization in the classroom such as posting rules, providing students with daily scheduleVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? Continued on the next page

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Teachers’ Knowledge 133 Appendix H (continued)G. PHYSICAL ARRANGEMENT: arranging seats in classroom, such as having student with ADHD in close proximity to teacherVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? H. VARIED PRESENTATION AND FORMAT OF MATERIALS: using different modalities such as videos, overheads, posters, models, as well as adding color, shape, or textureVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? Continued on the next page

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Teachers’ Knowledge 134 Appendix H (continued)I. USE OF CUES, PROMPTS AND ATTENTION CHECKS: using short verbal cues, such as “All eyes on me” or “Listen,” subtle nonverbal prompts, a timer, when giving directions, someone repeats them back to the classVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? J. BRIEF ACADEMIC TASKS INTERSPERSED WITH PASSIVE TASKS: presenting tasks briefly, providing instructions in a stepwise fashion rather than all at once, mixing active tasks (doing a project on something) with passive tasks (completing a worksheet independently)Very Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? Continued on the next page

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Teachers’ Knowledge 135 Appendix H (continued)K. PEER TUTORING: have student help or be helped by another studentVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)? L. SELF-MANAGEMENT have student monitor and evaluate his/her own academic and social behaviorVery Low1Low2Moderate3High 4Very High5 1. How much knowledge/understanding do you have regarding this intervention? 2. How skilled do you perceive yourself to be in implementing this intervention? 3. How effective do you consider this intervention to be for students with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 4. To what degree do you think this intervention is suitable, fair, and reasonable for most kids with documented ADHD who exhibit inattention, hyperactivity, and/or impulsivity (even if they are taking medication for these symptoms)? 5. How likely are you to have the time/resources to implement this intervention? 6. How likely would you be to implement this intervention if you had a student in your class who had documented ADHD and who exhibited inattention, hyperactivity, and/or impulsivity (even if he or she was taking medication for these symptoms)?


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general education elementary school teachers' knowledge, training, and ratings of acceptability of interventions /
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2003.
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ABSTRACT: Given that researchers estimate approximately one child in every classroom has Attention-Deficit/Hyperactivity Disorder (ADHD), and that most of these students are served in the general education classroom, it is imperative that general education teachers know how to effectively teach these students. Seventy-two general education elementary school teachers completed a survey containing demographic information, a knowledge of ADHD questionnaire, and a survey on interventions for students with ADHD. Results indicated that teachers scored an average of 57% correct on the Knowledge of Attention Deficit Disorders Scale (KADDS), scoring statistically significantly higher on the Symptoms/Diagnosis subscale compared to the General and Treatment subscales. In terms of the interventions, teachers felt more knowledgeable, perceived their skill to be greater, rated as more acceptable, and rated lower barriers to the implementation of classroom management interventions such as the use of cues, prompts, and attention checks; physical arrangement; structure; and varied presentation and format of materials. Teachers felt they knew least about, had less skill, rated as less acceptable, and had more barriers to the implementation of behavior management interventions such as token economy, response cost, and time-out from positive reinforcement, as well as self-management techniques. Most demographic variables were unrelated to teachers' knowledge of ADHD, their perceived knowledge of interventions, and their ratings of acceptability of interventions. Based on the information presented, teachers need more training and knowledge in the area of ADHD and interventions for students with ADHD in order to effectively help children with the disorder. Importantly, school psychologists and other service providers who suggest interventions for teachers to use for students with ADHD need to consider the factors that contribute to teachers' acceptability of interventions.
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