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improvement in the quality of life for teachers of children with ADHD (Barbaresi &
Olson, 1998).
8.2 DATABASES SEARCHED AND INCLUSION CRITERIA
Information about the databases searched and the inclusion/exclusion criteria used for
this section of the guideline can be found in Table 19.
8.3 STUDIES CONSIDERED
18
The review team conducted a new systematic search for RCTs that assessed the effi-
cacy and/or safety of interventions delivered by teachers in educational settings for
children and young people with ADHD.
Six trials met the eligibility criteria set by the GDG, providing data on 26,117 chil-
dren. Three of the trials were cluster RCTs. All trials were published in peer-reviewed
journals between 1989 and 2006. In addition, four studies were excluded from the
analysis. The most common reason for exclusion was that they were not RCTs (further
information about both included and excluded studies can be found in Appendix 17).
Electronic databases CENTRAL, MEDLINE, EMBASE, CINAHL,
PsycINFO, ERIC
Date searched Database inception to April 2006; table of content
October 2007 March 2006
Study design RCT (efficacy)
Patient population Participants (children) diagnosed with ADHD
Interventions Screening; teacher advice; teacher advice screening;
teacher-led interventions; teacher training; multicom-
ponent teacher training
Outcomes Improvement on ADHD symptoms (teacher-rated and
parent-rated); improvement on conduct problems
(teacher-rated and parent-rated); improvement on
reading; improvement on mathematics
Table 19: Databases searched and inclusion/exclusion
criteria for clinical evidence
18
Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capi-
tal letters (primary author and date of study publication, except where a study is in press or only submitted
for publication, then a date is not used).
Interventions for children with ADHD in educational settings
209
Interventions for children with ADHD in educational settings
210
8.4 CLINICAL EVIDENCE FOR SCREENING FOR
ADHD IN EDUCATIONAL SETTINGS
8.4.1 Introduction
Key behaviours related to ADHD are readily observable in children at school and it
might be advantageous for teachers to be able to recognise those pupils who may have
ADHD. In the US, clinical practice guidelines recommend that teachers should be
involved in the process of diagnosing ADHD by completing rating scales and provid-
ing information about possible symptoms and impairment in the school setting
(American Academy of Child and Adolescent Psychiatry, 2007). Teachers thus have
a crucial role in assisting with accurate clinical case identification.
A screening programme for ADHD has attractions: the early identification of
problems; early intervention; and, if repeated regularly throughout primary and
secondary school, recognising cases that ‘slipped through the net’ or have a late onset.
The potential downsides of screening are the identification of false positive or false
negative cases, as well as the economic costs involved.
Current practice
To the best of the knowledge of the GDG and the review team, no screening interven-
tions for children with ADHD are carried out in schools in the UK.
Definitions
Two types of screening have been defined. One, a ‘case identification’ approach, may
be seen as screening, but it is distinct from a universal programme of screening which
collects data across all children in schools and selects possible cases of ADHD for
further assessment or referral. This section considers the latter possibility.
8.4.2 Clinical evidence for screening versus no intervention
There was only one study from the six included trials that involved a comparison of
screening of children with ADHD as an intervention compared with no intervention
in a school setting (TYMMS2006) (see Table 20 for further details). This study also
involved advice to teachers in a factorial design and that is dealt with in the next section
(TYMMS2006). The class teachers of 2,040 participating English primary schools
completed a rating scale at the end of the children’s first year at school. The rating scale
was based on the DSM-IV diagnostic criteria. The intervention involved identifying chil-
dren who, at the end of the first year of school, exhibited severe ADHD symptoms, based
on the cut-off points for the number of criteria deemed to represent severe ADHD symp-
toms as suggested in DSM-IV. The names of these pupils in half of the schools in the
sample were forwarded to the new class teachers. The schools were randomly selected.
Outcome measures were collected 18 months later, half-way through school year 2 when
pupils were aged 6 to 7 years. The identification of children with severe ADHD symp-
toms had no detectable impact on ADHD symptoms, reading or mathematics.
8.4.3 Clinical evidence summary
From the original search only one study (TYMMS2006) was identified that assessed
the efficacy of screening in educational settings. The quality of the evidence was
moderate given that only one study was included. Evidence suggests that there is little
to no effect in introducing a screening programme on children’s ADHD symptoms or
academic achievement.
Screening versus no intervention
Total no. of trials (total 1 (25,482)
no. of participants)
Study ID TYMMS2006
Diagnosis Pupils in school
Baseline severity PIPS On-entry: 2.23 (3.53)
Treatment length 2 years
Age of subjects 4 years at initial visit
Benefits
ADHD core symptoms Y2 Behaviour scale: SMD 0.04 (0.16 to 0.24)
(teacher-rated) Quality: Moderate K 1, N 25482
Mathematics KS1: SMD 0.05 (0.18 to 0.09)
Quality: Moderate K 1, N 25482
PIPS: SMD 0.09 (0.07 to 0.26)
Quality: Moderate K 1, N 25482
Reading KS1: SMD 0.10 (0.24 to 0.05)
Quality: Moderate K 1, N 25482
PIPS: SMD 0.11 (0.28 to 0.05)
Quality: Moderate K 1, N 25482
Table 20: Study information and evidence summary table
for trials of screening
Interventions for children with ADHD in educational settings
211
Study information and evidence from the important outcomes and overall quality
of evidence are presented in Table 20. The full evidence profiles and associated forest
plots can be found in Appendix 19 and Appendix 18, respectively.
Interventions for children with ADHD in educational settings
212
8.5 CLINICAL EVIDENCE FOR ADVICE TO TEACHERS ABOUT
ADHD, EFFECTIVE CLASSROOM INTERVENTIONS AND
TEACHER TRAINING
8.5.1 Introduction
This section reviews the effect of advising teachers about ADHD in general and of
providing classroom management techniques for children with ADHD. It then consid-
ers the issue of teacher training.
8.5.2 Advice to teachers about classroom strategies for children
with ADHD
Introduction
Some parents conceptualise ADHD as more of an educational than a health problem
and request educational input and services (Poduska, 2000). In the UK two-thirds of
parents of children with ADHD have consulted and discussed their concerns with
teachers (Sayal et al., 2006a). Therefore, improving teachers’ knowledge of ADHD
alongside providing advice on how to work with children who might have ADHD
may improve outcomes. To achieve this, teachers need to be equipped with informa-
tion about the behavioural problems that children with ADHD are likely to exhibit in
the classroom, possible reasons for that behaviour, suggestions for its management
and information about seeking further help with particular children.
Current practice
The review team was unable to find any recent UK-based surveys of teachers’ knowl-
edge of ADHD. At the present time, it is highly likely that teachers’ knowledge of the
disorder varies according to the training that they have received and whether they
have direct experience of children with ADHD. A recent study set in one Local
Education Authority (LEA) found that over half the teachers had experience of teach-
ing a child with a clinical diagnosis of ADHD (Sayal et al., 2006b), and the provision
of a brief educational intervention for teachers has been found to raise awareness and
improve recognition of children with possible ADHD (Barbaresi & Olson, 1998;
Sayal et al., 2006b). Beyond the recognition of children with ADHD, providing
advice to teachers about ADHD and how to help children with the disorder within
mainstream classrooms has, in some studies, also been combined with other related
approaches such as screening and parent training.
Definition and aim of intervention
In the context of this section, the advice for teachers is not part of their pre- or
in-service training, delivered in person. The kind of advice that is considered is
communicated in the form of written information about the underlying causes of
ADHD, and strategies for helping children with the disorder in the classroom setting.
The strategies generally involve making adjustments to the classroom environment,
groupings with other pupils and interactions with the teacher. Advice can also be
more specific; for example, updating a teacher on the treatment of a particular child
given by other professionals with suggestions about how the teacher might build upon
that work.
8.5.3 Clinical evidence for advice given to teachers as
an education intervention
Of the six included trials, three involved advice given to teachers as an intervention
(see Table 21 for further details).
Teacher advice Teacher advice Teacher advice
versus no screening versus (TA) parent
intervention no intervention training (PT)
versus parent
training
Total no. of trials 1 (25,482) 1 (25,482) 1 (30)
(total no. of
participants)
Study ID TYMMS2006 TYMMS2006 CORKUM2005
Diagnosis Pupils in school Pupils in school ADHD
Baseline severity PIPS On-entry: PIPS On-entry: CPRS-R (short):
2.23 (3.53) 2.23 (3.53) PT: 71.94(9.42)
PT TA :
73.07(8.38)
CTRS-R (short):
PT: 71.40(17.57)
PT TA :
64.75(12.18)
Treatment length 2 years 2 years 10 weeks
Age of subjects 4 years at initial 4 years at initial 9 years
visit visit
Table 21: Study information and evidence summary table
for trials of teacher advice
Continued
Interventions for children with ADHD in educational settings
213
Interventions for children with ADHD in educational settings
214
Teacher advice Teacher advice Teacher advice
versus no screening versus (TA) parent
intervention no intervention training (PT)
versus parent
training
Benefits
ADHD core – – ADHD Index:
symptoms SMD 1.15
(combined (2.03 to 0.28)
teacher/ Quality: Moderate
parent-rated) K 1, N 30
ADHD core Y2 Behaviour: Y2 Behaviour: –
symptoms SMD 0.19 SMD 0.13
(teacher-rated) (0.39 to 0.01) (0.32 to 0.07)
Quality: Moderate Quality: Moderate
K 1, N 25,482 K 1, N 25,482
Conduct problems – – CPRS/CTRS
(combined (oppositional):
teacher/ SMD 0.08
parent-rated) (0.88 to 0.72)
Quality: Moderate
K 1, N 30
Mathematics KS1: KS1: –
SMD 0.05 SMD 0.15
(0.18 to 0.09) (0.01 to 0.28)
Quality: Moderate Quality: Moderate
K 1, N 25,482 K 1, N 25,482
PIPS: SMD 0.05 PIPS: SMD 0.01
(0.12 to 0.21) (0.17 to 0.15)
Quality: Moderate Quality: Moderate
K 1, N 25,482 K 1, N 25,482
Reading KS1: KS1: –
SMD 0.02 SMD 0.19
(0.17 to 0.12) (0.04 to 0.34)
Quality: Moderate Quality: Moderate
K 1, N 25,482 K 1, N 25,482
PIPS: SMD 0.09 PIPS: SMD 0.17
(0.26 to 0.08) (0.01 to 0.33)
K 1, N 25,482 K 1, N 25,482
Table 21: (Continued)
In one study (TYMMS2006), the intervention consisted of sending an advice booklet
to half of the schools (randomly selected). This booklet contained general information
about ADHD as well as teaching and classroom management strategies that had been
previously shown to help children with ADHD, such as those evaluated in the meta-analy-
ses published by DuPaul and Eckert (1997) and Purdie and colleagues (2002). In this same
study (TYMMS2006) the effectiveness of this advice booklet was assessed in conjunction
with screening (mentioned previously in Section 8.4). The third teacher advice interven-
tion (CORKUM2005) consisted of providing teachers with a general information pack-
age about ADHD including the CHADD Educators’ Manual (Fowler & the National
Education Committee, 1992) at the start of the intervention period and then sending them
weekly brief updates about what the parents had learned that week in a concurrent parent-
training programme, and suggestions on how to use similar strategies in the classroom.
Study information and evidence from critical outcomes and overall quality of
evidence are presented in Table 21. Full evidence profiles and associated forest plots
can be found in Appendix 19 and Appendix 18, respectively.
Clinical evidence summary
Advice given to teachers versus no intervention The quality of the evidence was moder-
ate given that only one study (TYMMS2006) addressed the comparison of advice given
to teachers and no intervention. The evidence suggests that there is little to no effect in
providing advice to teachers in relation to children’s ADHD symptoms or academic
achievement. The authors of the study, however, state that the advice booklet was read
by a small percentage of the teachers, which could account for the lack of positive results.
Advice given to teachers screening versus no intervention There is limited
evidence from one study (TYMMS2006) of the combined effect of advice given to
teachers and screening. The results indicate little to no effect in children’s ADHD
symptoms or academic achievement. The intervention had a negative effect on some
of the academic outcome measures.
Advice given to teachers as an added intervention to parent training A further study
(CORKUM2005) examined the efficacy of giving advice to teachers in addition to a
parent-training programme in improving the behaviour of children with ADHD. The
general quality of the evidence was moderate reflecting the paucity of the data in this area.
The effectiveness of giving advice to teachers in addition a parent-training pro-
gramme was large (SMD 1.15) in reducing children’s ADHD core symptoms as rated
by both parents and teachers. However, there was little to no effect (SMD 0.08) of this
intervention when added to parent training in improving children’s conduct problems.
In summary, there is some evidence that advice to teachers as an added intervention to
a parent-training programme is effective in reducing children’s ADHD core symptoms.
8.5.4 Clinical evidence for teacher-led educational interventions
for children with ADHD
Introduction
As discussed in the introduction to the guideline and to this chapter, children with
ADHD are at risk academically and socially, and they can be difficult to manage in
Interventions for children with ADHD in educational settings
215
Interventions for children with ADHD in educational settings
216
the classroom. Interventions to improve those difficulties are desirable and since
teachers work with these children for several hours each day, they are in a position
to be able to implement strategies in the context of the school environment.
Additionally, all children and young people, including those with ADHD, have the
right to a school experience that provides a broad, balanced and relevant curriculum,
including the National Curriculum, which is appropriately differentiated according to
their needs (DfES, 2001). The Special Educational Needs Code of Practice (DfES,
2001) further describes the kind of assistance which may be required by particular
children, including those who demonstrate the symptoms of ADHD.
Teacher-led educational interventions mainly consist of managing academic
activities or adapting the physical environment. A description of a wide range of
strategies for use with children with ADHD is given by Cooper and Ideus (1996).
They suggest techniques such as:
● seating the child in a place that is relatively free from distraction (for example,
doors and windows) in a position where the teacher can easily intervene if the
child is not attending
● having a designated quiet area for a child to work in
● providing stimulating activities
● giving concise, clear instructions
● following a defined, regular timetable
● avoiding repetitive tasks
● breaking down tasks into a series of small steps
● giving frequent positive feedback
● working in a pair rather than a group
● isolating the child from the class for a short time when they are misbehaving
● giving points or tokens as rewards to be exchanged at a later time for a favourite
activity or treat
● taking away points or tokens if the child misbehaves.
Current practice
According to the Special Needs Code of Practice, the LEA will need to consider, on
an individual basis, whether these interventions can be provided through School
Action Plus or whether the LEA needs to undertake a statutory assessment. Although
there is a statutory requirement to provide appropriate education to all children,
including those with ADHD, local practice varies.
Definition and aims of interventions
Teacher-led interventions are defined as programmes and/or techniques delivered by
teachers within the classroom such as those described in the introduction above.
Teacher-led interventions versus no intervention
From the six included trials, there was one comparison involving a teacher-led inter-
vention named ‘giving effective commands’ (Barkley, 1997), which consists of the
teacher giving the child a command once and, if necessary, proceeding to a warning
where the child is informed of the consequences of not carrying out the command;
in cases where the child does not comply, the threat is carried out (KAPALKA2005)
(see Table 22 for further details). Children’s behaviour was assessed using the School
Situation Questionnaire as rated by their teachers.
Study information and evidence from critical outcomes and overall quality of
evidence are presented in Table 22. Full evidence profiles and associated forest plots
can be found in Appendix 19 and Appendix 18, respectively.
Clinical evidence summary
The only reported relevant outcome was conduct problems (teacher-rated) and the
quality of the evidence was moderate, reflecting the paucity of the data.
There is evidence from KAPALKA2005 indicating a large effect (SMD 1.47) of
teacher-led behaviour interventions compared with a control group in reducing conduct
problems as rated by teachers.
Teacher-led intervention versus no intervention
Total no. of trials (total 1 (86)
no. of participants)
Study ID KAPALKA2005
Diagnosis ADHD
Baseline severity School Situations Questionnaire:
Treatment: 5.6 (1)
Control: 5.5 (1.05)
Treatment length 2 weeks
Age of subjects 7.4 years
Benefits
Conduct problems School Situations Questionnaire:
(teacher-rated) SMD 1.47 (1.94 to 0.99)
Quality: Moderate K 1, N 86
Table 22: Study information and evidence summary table for
trials of teacher-led interventions
Interventions for children with ADHD in educational settings
217
8.5.5 Clinical evidence for teacher training on the identification
of ADHD and school-based interventions
Introduction
The Special Educational Needs Code of Practice published by the DfES (2001) states
that for mainstream schools:
Provision for pupils with special educational needs is a matter for the school as
a whole. In addition to the governing body, the school’s head teacher, the SENCO
Interventions for children with ADHD in educational settings
218
or SEN team and all other members of staff have important responsibilities. In
practice the division of day-to-day responsibilities is a matter for individual
schools, to be decided in the light of a school’s circumstances and size, priorities
and ethos.
The NSF for Children (2004) highlights the need for support and training of front-
line professionals who have daily contact with children. Despite this, teachers receive
limited training about child mental health problems (Gowers et al., 2004) or special
needs in general (Aubrey et al., 2007).
As discussed earlier, in England teachers’ knowledge about ADHD and experi-
ence of teaching a child with a diagnosis of ADHD is variable. In the US, where over
90% of teachers have reported experience of teaching a child with ADHD (Bussing
et al., 2002; Power et al., 1995), the following topics have been highlighted as impor-
tant for in-service education: ADHD; adapting lessons for pupils with ADHD;
managing stress caused by children with ADHD in the classroom; behavioural
management; and implementation of behaviour plans (Barbaresi & Olson, 1998;
Bussing et al., 2002; Walter et al., 2006).
The provision of in-service training, peer observation and coaching by profes-
sionals can be effective (Adey et al., 2004; Dreyfus & Dreyfus, 1986; Dall’Alba &
Sandberg, 2006; Joyce & Showers, 1980; Sparks, 1986), but the process takes time,
and Adey and colleagues (2004) suggested that 30 hours of in-service provision are
required for sustained changes to teachers’ classroom practice.
Since, first, teachers have to deal with children with ADHD on a daily basis,
second, schools and their staff have responsibilities for such children and third, the
knowledge basis is variable, it makes sense to consider enhancing the training of
teachers in the area at the pre-service and in-service stages.
Current practice
Anecdotally, parents report that they need to be proactive in terms of educating teach-
ers about ADHD and that consistent teacher education approaches (for example,
in-service education or training for SENCOs) are desirable.
Teacher-training versus no intervention From the six included trials only two
involved a comparison of teacher training with control. One study (BLOOMQUIST
1991) consisted of one 2-hour in-service and six 45- to 60-minute consultation
sessions over a 10-week period. Teachers were given educative and restructuring
exercises to help modify potential dysfunctional opinions they might have held
toward pupils with ADHD in mainstream classes. Teachers were trained in behav-
ioural child management methods and encouraged to actively participate with their
students in ‘collaborative problem-solving’. A second study (BARKLEY2000)
consisted of a teacher-training programme where teachers were trained by a master
teacher and child psychologist in behavioural treatments. During the training, teach-
ers were given information about defiant behaviour and behavioural interventions
such as rewarding children for nondisruptive behaviour, setting up a home token
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