Hyperactivity and inattentive behaviour in the classroom.

Attention-deficit/ hyperactivity disorder (ADHD) is one of the most common
developmental disorders. The three key symptoms of ADHD are attention deficits,
hyperactivity and impulsive behavior. Children with ADHD are easily distracted,
are very active, and have difficulty waiting for their turn. These behaviors
are known to hamper classroom functioning and hyperactive and/or inattentive
children will benefit from support in the classroom.

With a prevalence of 3 to 6%, ADHD is the most common pediatric psychiatric
disorder (Landelijke Stuurgroep Multidisciplinaire Richtlijnontwikkeling,
2005). Of the 2 million children in Dutch primary schools, about 60 to 120
thousand children meet the criteria for ADHD. This translates into one child in
every two classrooms. The National Health Organization (2000, p. 53) states
that 2% of the children with ADHD require immediate intervention. About 4%
(about 80.000 children in the Netherlands) show less severe symptoms, but still
need intervention (National Health Organization, 2000). A proportion of this
subgroup of 80.000 children meets the criteria for ADHD; another proportion
meets criteria associated with subthreshold ADHD (see below; National Health
Organization, 2000). We consider this group of 80.000 children with
(subthreshold) ADHD the target population of our study.

This study focuses on the treatment of children with (subclinical) ADHD
symptoms who are currently being sent to their school care system, often
followed by application for pediatric mental health care for diagnosis and
treatment. In 2010, we developed the teacher training 'Hyperactivity and
inattentive behavior in the Classroom' at the department of Neuropsychology of
the VU University. This training is based on international evidence-based
teacher programs for ADHD, including the American Summer Treatment Program
(Prof. Pelham and Prof. Swanson). These programs have proven to be effective in
reducing ADHD symptoms and improving social skills. This study aims to
determine the effectiveness of our teacher training, and to implement this
training in Dutch regular primary schools, and by this avoiding referral of
these children to pediatric mental health care.

This project aims (I) to examine the effectiveness of the teacher training
'Hyperactivity and inattentive behaviour in the Classroom', and (II) to
implement this training into Dutch regular primary schools.

Randomized controlled trial with two treatment conditions (between subjects):
'Hyperactivity and inattentive behaviour in the Classroom' and regular care.
Children in both conditions are followed for 18 weeks. Data on behavioural,
social emotional and academic functioning will be gathered at three time points
(within subjects): (T1) at baseline, directly prior to trial; (T2) after 6
weeks; (T3) after 18 weeks.

The teacher training 'Hyperactivity and inattentive behavior in the classroom'
consists of two phases.

Phase I is an universal program, which applies to the classroom in general.
Phase II is an optional, individual program that is added to the universal
program when the intervention needs to be intensified.

Elements in the Phase I include: setting up classroom rules (for example: "when
the teacher is talking, we are listening"), structuring the daily and weekly
programs, arranging the classroom, and methods for mildly punishing
unfavourable behavior. Emphasis however is on consequent rewarding of good
behavior. After 6 weeks, the teacher uses a specific evaluation tool to
evaluate the effectiveness of the Phase I program on the hyperactive (and/or
inattentive) child. Research shows that this program has a positive effect on
all the children in the classroom (Waschbusch, Pelham, & Massetti, 2005).
Depending on the effect that Phase I had on this child, the level of
intervention may be intensified for this child, i.e. Phase II may be added for
this child.

Phase II is an individual program in which the teacher and child work with a
Good Behavior Card. The teacher formulates three behavioral goals for the
child, such as "I am sitting still on my chair during math class". The teacher
provides the child with feedback on his or her goals at least once a day, and
the teacher rewards the child for reached goals. Only direct and immaterial
rewards are used. It is very important that the teacher and child set the
rewards and the rewarding criterion. This criterion has to be set so that the
child will meet the criterion in 70-80% of the times. Phase II itself consists
of three levels that increase in intensity. The higher the intensity, the more
often the teacher provides feedback on the child's goals. As from week 7, the
teacher evaluates the individual program every three weeks with the evaluation
tool.

Duration of Phase II is 12 weeks. In case the highest level of intervention
does not result into satisfying behavioral change, the teacher is advised to
contact a health care professional.

To facilitate implementation and usage of the training, the manual contains
many examples and worksheets, with examples of classroom rules, rewards and a
model Good Behavior Card.

Participation is free of risks. The burden can be described as following.

Prior to the trial, teachers and parents complete two questionnaires, which
takes 25 minutes in total. Will will also conduct a 20 minute telephone
interview with the teacher.

Implementation and use of the program: 6 hours on average to read the manual,
and 10 to 15 minutes in the classroom per day in the first three weeks, and 5
to 15 minutes in the following weeks (depending on the intensity level).

Teachers and parents fill out two questionnaires on T1, T2 and T3 (Strengths
and Weakness of ADHD-symptoms and Normal Behavior and Strengths and
Difficulties Questionnaire), which takes 10 minutes in total. The child
completes a test battery on T1, T2 and T3. The battery consists of
questionnaires and academic tasks. The battery takes 75 minutes including a
break. In the weeks in which T1, T2 and T3 take place, the child wears a
actometer for 5 consecutive days and nights. Wearing an actometer is similar to
wearing a watch.

Finally, we conduct a 16 minute classroom observation on T1, T2 and T3, which
is no burden for child and teacher.