teachers' comfort and importance ratings for interventions for preschoolers with ad/hd

TEACHERS’ COMFORT AND IMPORTANCE RATINGS FORINTERVENTIONS FOR PRESCHOOLERS WITH AD/HD

MELISSA STORMONT AND MOLLY S. STEBBINS

University of Missouri-Columbia

The main purpose of this study was to explore preschool teachers’ ratings of both the perceivedimportance of and their comfort levels implementing interventions for children with AD/HD.Participants included 138 teachers from licensed child care facilities. Teachers completed aquestionnaire that required them to rate, on a 7-point Likert-type scale, the importance of 43interventions and how comfortable they would be executing the strategy if asked to do so in theclassroom. Overall, teachers concluded that the majority of the interventions were mostly impor-tant and believed they would be comfortable using the strategies. In addition, findings indicatedthat preschool teachers’ importance and comfort ratings were highly correlated. Teacher vari-ables (i.e., years of teaching experience, educational level, and having a student with AD/HD)were not correlated with, or discriminative of, comfort and importance ratings. The implicationsof these findings are discussed. © 2001 John Wiley & Sons, Inc.

Over the past two decades, research has documented important findings related to teachervariables and intervention preferences for school-aged children with Attention Deficit/HyperactivityDisorder (AD/HD; e.g., Reid, Vasa, Maag, & Wright, 1994). One area that has received littleattention is teachers’ intervention preferences for preschool children with AD/HD. Even thoughmost children are not diagnosed with AD/HD in the preschool years, the onset of symptoms mustbe prior to age 7 (Barkley, 1998). The characteristics of AD/HD in preschoolers include problemsrelated to attention and/or hyperactivity and impulsivity that occur at significantly higher levelsthan in same-aged peers (American Psychiatric Association, 1994; Lerner, Lowenthal, & Lerner,1995). These behavioral and attentional problems must occur across settings and be corroboratedby multiple informants (American Psychiatric Association, 1994). It is important to assess teach-ers’ intervention preferences for preschoolers with AD/HD as these children typically manifestproblematic behavior that requires understanding and appropriate early intervention to avoid thedevelopment of secondary problems (e.g., aggression; Stormont, 1998).

Research has assessed teacher preferences for intervention practices with school-aged stu-dents with AD/HD. One study investigated teachers’ intervention goals and preferences for work-ing with children with AD/HD. The intervention goals teachers cited most often included adaptinginstruction (40%) and changing the students’ behavior (37%) as opposed to changing the environ-ment (8%), restricting diet (4%), or using a combination of the above (11%; Hawkins, Martin,Blanchard, & Brady, 1991). Teachers believed that the three most effective interventions wereadapting instruction (33%), behavior management (29%), and structuring the environment (22%).Other research has found that teachers prefer interventions that are positive and individualized innature (i.e., daily progress reports of a child’s behavior with positive contingencies upon goalcompletion) rather than a response-cost approach, medication, or a classroom lottery (Pisecco,Huzinec, Curtis, & Mathews, 1999; Power, Hess, & Bennett, 1995).

In addition to what teachers select as preferred intervention options, it is also important toconsider factors that may be influential in their decision making. Years of teaching experience hasnot been found to be related to the acceptability of different intervention options (Power et al.,1995). Similarly, years of experienceand teaching level (e.g., elementary, middle) have not beenfound to be associated with beliefs regarding intervention effectiveness (Hawkins et al., 1991) or

Correspondence to: Dr. Melissa Stormont, Dept. of Special Ed., 380 McReynolds Hall, University of Missouri-Columbia, Columbia, MO 65211–2010; e-mail: [email protected].

Psychology in the Schools, Vol. 38(3), 2001© 2001 John Wiley & Sons, Inc.

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with intervention preferences (Zentall & Stormont-Spurgin, 1995). However, teachers with moretraining and experience in the area of AD/HD expressed more confidence in modifying the behav-ior of children with the disorder (Reid et al., 1994). That is, teachers with more training were morecomfortable constructing behavioral contracts and adapting materials and lessons when comparedto educators with less training.

In an investigation of accommodation preferences, Zentall and Stormont-Spurgin (1995) foundthat general educators and special educators were willing to use and had success with a variety ofaccommodations for children with AD/HD. However, special educators reported a greater will-ingness to try new instructional techniques and had more success changing input and outputresponses than general educators. General educators were also more likely than special educatorsto report that they had not and would not try items within the input/output accommodation cat-egory. Accommodations in this category included encouraging routines to improve organizationalabilities, helping the student organize their locker, and using written and verbal cues to highlighttask requirements. Thus, there were some interventions and accommodations that fell outside ofthe realm of what teachers were comfortable with or were willing to implement in their classroom.General educators may need to have a greater understanding of children with AD/HD in order tounderstand the utility of some accommodations (e.g., organizational strategies).

Preschool teachers in child care centers may have some of the same perceptions and/orconcerns as general educators related to interventions for children with AD/HD since both groupsreceive little, if any, training in special education. Therefore, the main purpose of this study was todocument accommodation/ intervention strategies that preschool teachers believed were impor-tant to use with young children with AD/HD and to also assess how comfortable teachers were, orwould be, using these interventions. The second purpose was to determine if certain teacher vari-ables were associated with intervention preferences. The preschool teacher variables selected forthis investigation included level of education (i.e., high school, undergraduate, graduate), cur-rently having a child with AD/HD in their classroom, and years of teaching experience. Years ofexperience was included as a teacher variable as preschool teachers are less likely to have collegedegrees and therefore may obtain most of their knowledge through experience on the job.

Method

Participants

Participants in this study included 138 preschool teachers. Participants were predominantlyfemale (95%) and working full-time (75%). Eighty-two percent were Caucasian and 18% wereAfrican American. The majority of teachers had some college-level education or degree (67%),with smaller percentages having a high school or vocational-level education (17%) or a graduatelevel education or degree (16%). The number of years of experience ranged from less than 1 to 4years (60%), 5 to 9 years (20%), or more than 10 years (20%). The teachers in this study taughtchildren who were between the ages of 3 and 6 years.

Measures

Intervention Preferences Questionnaire.The first part of the informal questionnaire includeddemographic questions related to gender, job status, educational level, and number of years teach-ing. The remainder of the questionnaire listed 43 interventions and instructions to rate each inter-vention on two 7-point Likert-type scales, one for rated importance and one for rated comfortusing the intervention (see Tables 1 and 2). A rating of 7 for importance represented interventionsteachers believed were “extremely important” and comfort ratings of 7 represented interventionsthat teachers were “totally comfortable” using or would be comfortable using if they had not

260 Stormont and Stebbins

Table 1Means and Standard Deviations of Each Intervention by Category and Importance Rating

Intervention by Rating Category M SD

Extremely ImportantGive verbal compliments for improved work. IM 6.70 0.66Identify the student’s interests. IM 6.70 0.72Point out cause and effect of behavior. BM 6.70 0.72Give verbal compliments for improved behavior. BM 6.64 0.75Obtain specific readings for professional development. OS 6.62 0.85State small goals for improved social behavior to student. BM 6.58 0.81

Mostly ImportantAsk student to explain back understanding of directions. IM 6.46 0.74Call name/touch student/use private signals/move closer. BM 6.46 0.76Determine student’s preference for playing. IM 6.41 0.89Use games to encourage attention and learn material. IM 6.38 0.82Encourage verbal participation in small/ large groups. IM 6.32 0.94Praise any effort in waiting turns. BM 6.30 1.04Send home notes to parents about improved behavior. OS 6.29 1.03Conduct conferences with other professionals. OS 6.22 1.07Send home notes with activities parents can do with child. OS 6.21 0.91Allow nondisruptive, directed movement in classroom. IM 6.19 0.99Use teaching activities that encourage active responding. IM 6.18 1.17Use fewer words in explaining tasks. IM 6.16 1.10Cue student about upcoming difficult times. BM 6.16 1.23Give individual activity rewards for improvements. BM 6.15 1.23Instruct and reinforce social routines. IM 6.15 1.07Practice planning specific activities. IM 6.15 1.02Use picture prompts (e.g., helpers chart). IM 6.12 1.06Conduct more frequent conferences. OS 6.11 0.98Organize locker/cubby with labels and places for items. IM 6.09 1.17Encourage parents to establish places for things at home. OS 6.08 1.06Walk around classroom frequently during free play. BM 6.05 1.32Teach routine of “Do I have everything I need?” IM 6.04 1.11Allow student to sit closer to teacher during group time. BM 5.96 1.19Send notes/behavioral ratings to family doctor. OS 5.81 1.45Allow student-paced activities rather than teacher-paced. IM 5.77 1.22Display particularly good work samples for students. BM 5.74 1.49Use time-out (remove child from activity for a brief time). BM 5.74 1.42Alternate low and high interest tasks. IM 5.73 1.11

Somewhat ImportantGive tallies for good conduct or tasks completed. BM 5.48 1.33Assess the student’s organizational skills. IM 5.33 1.33Allow limited choice of tasks, topics, and activities. IM 5.31 1.69Give social time as a reward for low-level noise. BM 5.19 1.46Give two tasks with less preferred task completed first. IM 5.11 1.44Encourage doodling or play while waiting/sitting/ listening. IM 5.10 1.75Ignore minor behavioral disruptions. BM 5.00 1.69Give two seats so the student can change placement. IM 4.95 1.66

NeutralAllow reduced standards for acceptable work. IM 4.06 1.87

Note. Interventions were rated on a 1 to 7scale, where 15 not at all important, 25 mostly unimportant, 35somewhat unimportant, 45 neutral or not sure, 55 somewhat important, 65 mostly important, 75 extremely important.Intervention categories are: IM5 Instructional Management; BM5 Behavioral Management; OS5 Outside Support.Wording of items has been condensed from the original questionnaire.

Teachers’ Intervention Ratings 261

Table 2Means and Standard Deviations of Each Intervention by Category and Comfort Rating

Intervention by Rating Category M SD

Totally ComfortableGive verbal compliments for improved work. IM 6.70 0.66Give verbal compliments for improved behavior. BM 6.63 0.78Identify the student’s interests. IM 6.61 0.89Obtain specific readings for professional development. OS 6.60 0.89Point out cause and effect of behavior. BM 6.59 0.87

Mostly ComfortableAsk student to explain back understanding of directions. IM 6.44 0.83Encourage verbal participation in small/ large groups. IM 6.41 0.88Use games to encourage attention and learn material. IM 6.41 0.91Praise any effort in waiting turns. BM 6.39 1.02State small goals for improved social behavior to student. BM 6.39 0.99Call name/touch student/use private signals/move closer. BM 6.38 0.92Determine student’s preference for playing. IM 6.37 0.90Instruct and reinforce social routines. IM 6.33 1.08Organize locker/cubby with labels and places for items. IM 6.24 1.20Give individual activity rewards for improvements. BM 6.20 1.30Use picture prompts (e.g., helpers chart). IM 6.18 1.10Use teaching activities that encourage active responding. IM 6.17 1.15Allow nondisruptive, directed movement in classroom. IM 6.14 1.07Use fewer words in explaining tasks. IM 6.12 1.11Cue student about upcoming difficult times. BM 6.12 1.24Teach routine of “Do I have everything I need?” IM 6.10 1.15Walk around classroom frequently during free play. BM 6.08 1.28Send home notes to parents about improved behavior. OS 6.08 1.24Practice planning specific activities. IM 6.06 1.07Allow student to sit closer to teacher during group time. BM 6.04 1.27Encourage parents to establish places for things at home. OS 5.98 1.21Use time-out (remove child from activity for a brief time). BM 5.96 1.46Conduct more frequent conferences. OS 5.96 1.13Send home notes with activities parents can do with child. OS 5.95 1.24Conduct conferences with other professionals. OS 5.92 1.31Alternate low and high interest tasks. IM 5.90 1.22Display particularly good work samples for students. BM 5.87 1.39Allow student-paced activities rather than teacher-paced. IM 5.61 1.35Give tallies for good conduct or tasks completed. BM 5.61 1.43Allow limited choice of tasks, topics, and activities. IM 5.55 1.71Assess the student’s organizational skills. IM 5.52 1.33Send notes/behavioral ratings to family doctor. OS 5.52 1.58

Somewhat ComfortableGive two tasks with less preferred task completed first. IM 5.38 1.58Give social time as a reward for low-level noise. BM 5.27 1.62Give two seats so the student can change placement. IM 5.17 1.75Ignore minor behavioral disruptions. BM 5.15 1.68Encourage doodling or play while waiting/sitting/ listening. IM 5.04 1.79Allow reduced standards for acceptable work. IM 4.08 2.02

Note.Interventions were rated on a 1 to 7scale, where 15 not at all comfortable, 25 generally uncomfortable, 35somewhat uncomfortable, 45 neutral or not sure, 55 somewhat comfortable, 65 generally comfortable, 75 totallycomfortable. Intervention categories are: IM5 Instructional Management; BM5 Behavioral Management; OS5 OutsideSupport. Wording of items has been condensed from the original questionnaire.


actually used the strategy in the past. All of the items were taken from the School ModificationsAssessment Checklist (SMAC), which has been used in past research with school-aged children(Zentall & Stormont-Spurgin, 1995). This scale was used to assess subjective perceptions ofimportance and comfort levels of preschool teachers when presented with interventions for stu-dents with AD/HD. There was no assessment of implementation or success using interventions.

Interventions were included in the questionnaire if they met two criteria. First, they needed tobe age-appropriate for preschoolers. Of the 98 interventions from the SMAC, only 43 were deter-mined to be appropriate for the preschool population. Second, interventions had to be strategiesrecommended by experts for children in general, for children with special needs, and/or specifi-cally for children with AD/HD (Jones & Jones, 1999; Lerner et al., 1995; Turnbull, Turnbull,Shank, & Leal, 1999; Zentall, 1993). Each of the 43 interventions met this second criteria andwere grouped according to three categories: instructional management, behavioral management,and outside support. Outside support was added due to the importance of collaboration with otherprofessionals and parents when working with children with challenging behavior and due to teach-ers’ reported willingness to participate in such collaboration (Davino, Lehr, Leighton, Miskar, &Chambliss, 1995).

The instructional management category included 23 instructional techniques to assist indi-viduals in learning information such as motivational techniques for groups to engage children inlearning, strategies for teaching organizational skills, and other individualized accommodations(e.g., modifying classroom seating and standards, and providing visual and verbal feedback toconvey progress). The behavior management category included 13 behavior management tech-niques such as proactive and reactive management strategies to improve and reward on-task behav-ior, interventions to prevent behavior problems through the use of proximity and cueing, andtechniques to modify behavior. The outside support category included seven techniques for col-laboration among professionals and parents including techniques designed to facilitate communi-cation with parents and physicians, encourage parent involvement, and support professionaldevelopment.

Procedure

All licensed preschools (N 5 41) in a mid-sized Midwestern city were mailed a letter ofinvitation to participate in the study. The letter was addressed to the director of the preschool andincluded a brief explanation of the study. Directors were promised, in return for their participation,a professional development assessment and workshop with the first author. After follow-up mail-ings and other attempts to reach the preschool directors, a total of 30 (73%) preschool directorsagreed to participate in the study. Individual teachers in each of these preschools were then askedto participate in this project and a response rate of 72% was achieved, which is a good responserate for survey research (Babbie, 1990).

Each participating director was contacted by phone and given the choice of having a graduateresearch assistant deliver and wait for teachers to complete questionnaires or having the directorsdeliver and collect the questionnaires. Steps were taken to ensure the confidentiality of teacherresponses by providing written instructions that asked teachers to place completed questionnairesinto a sealed envelope. Teachers were also instructed to complete the questionnaire to the best oftheir ability and to not discuss their answers with other teachers or consult any resource materials.

Results

A descriptive analysis of preschool teachers’ importance and comfort ratings related to inter-ventions for children with AD/HD was conducted. Items were placed into descriptive categories(e.g., mostly important) by rounding mean scores. Tables 1 and 2 present item ratings within each


of the intervention strategy categories of instructional management, behavior management, andoutside support.

Instructional Management

The preschool teachers studied believed it was extremely important and were totally com-fortable giving compliments for improved work and identifying students’ interests. Teachers rated14 (64%) of the interventions within the instructional management category as mostly importantand reported that they were mostly comfortable implementing 16 (73%) of the interventions inthis category. Interventions that teachers rated as somewhat important and were somewhat com-fortable implementing included giving two tasks with the less preferred task to be completed first,encouraging doodling or play while waiting, sitting, and listening, and giving two seats so thatstudents can change placement. Teachers also rated assessing students’ organizational skills andallowing limited choice of tasks, topics, and activities as somewhat important strategies and ratedallowing reduced standards for acceptable work as a strategy they were somewhat comfortableimplementing. Teachers were neutral on the importance of allowing reduced standards for accept-able work.

Behavioral Management

Tables 1 and 2 also show that teachers reported that they believed it was extremely importantto point out the cause and effect of behavior, give verbal compliments for improved behavior, andstate small goals for improved social behavior to the student. Teachers also rated pointing out thecause and effect of behavior and giving verbal compliments for improved behavior as interven-tions they were totally comfortable using. Teachers rated 8 (57%) of the interventions as mostlyimportant and reported that they were mostly comfortable implementing 10 (71%) of the inter-ventions. Interventions that teachers rated as somewhat important and were somewhat comfort-able implementing included giving social time as a reward for low-level noise and ignoring minorbehavioral disruptions. Teachers also rated giving tallies for good conduct or tasks completed as astrategy that was somewhat important.

Outside Support

Teachers reported that they believed it was extremely important to obtain specific readingsfor professional development and that they were totally comfortable obtaining these readings. Theother outside support items were in the mostly important and mostly comfortable descriptivecategory according to mean ratings.

Correlational Analysis

As many of the same items were reported by teachers to be extremely important and totallycomfortable, the overall relationships among comfort and importance within categories were exam-ined. To determine the relationships among the three comfort ratings and a total comfort rating aswell as the three importance ratings and a total importance rating, correlational analyses wereconducted (see Table 3). A very high correlation was found between the overall importance of allof the accommodations and the overall comfort that teachers reported in using accommodations(r 5 .80). Specific intercorrelations within categories (e.g., instructional management-importanceand instructional management-comfort) also yielded significant relationships with high correlations.

Teacher Variables

To investigate the second purpose of this study, teachers’ educational levels, and whetherteachers currently had a child with AD/HD in their classroom were entered as independent vari-


ables in Analyses of Variance with intervention ratings serving as dependent variables; a total ofsix dependent variables resulted (i.e., behavior management-comfort, behavior management-importance, instructional management-comfort, instructional management-importance, outsidesupport-comfort, and outside support-importance). In order to control for Type I error, a Bonfer-roni correction was employed using an alpha of .05. The corrected alpha required for statisticalsignificance was .004 (.05 divided by 12). The results indicated that the groups did not differ intheir importance or comfort ratings according to their educational level or their experience with achild with AD/HD. Correlational analyses were run for the continuous variable years of teachingexperience. A Bonferroni correction using an alpha of .05 resulting in an alpha of .008 (.05 dividedby 6) required for statistical significance. Years of experience teaching was not significantly asso-ciated with comfort or importance ratings.

Discussion

Overall, findings from the descriptive analyses indicated that teachers had high ratings ofimportance and comfort for the same items; correlational analyses supported these strong rela-tionships. Overall, the preschool teachers in this study believed that most of the interventions forpreschoolers with AD/HD were important and they reported that they would be comfortableimplementing the interventions if given the opportunity. The results also indicated that years ofteaching experience, educational level, and the presence of a child with AD/HD in the classroomwere not significantly related to intervention ratings. Our findings support previous research witholder children that has found that years of teaching experience was not related to the acceptabilityof different intervention options (Power et al., 1995), beliefs regarding intervention effectiveness(Hawkins et al., 1991), or with intervention preferences (Zentall & Stormont-Spurgin, 1995).

Findings from this study have several implications for preschool teachers and professionalsinvolved in providing professional development opportunities for early childhood educators. Wedid not find that preschool teachers were even somewhat uncomfortable implementing interven-tions or believed certain interventions were somewhat unimportant. Thus, findings from this studyclearly indicate that preschool teachers have positive perceptions regarding the importance ofeffective interventions for children with hyperactivity and there does not appear to be a discrep-ancy between importance and comfort levels. At a minimum, these findings illustrate that thepreschool teachers in our sample showed a willingness to try innovative strategies when workingwith preschoolers with AD/HD. Preschool teachers may have positive intervention ratings due totheir knowledge of children’s developmental variations.

Table 3Intercorrelations Among Comfort and Importance Ratings Overall andfor the Three Intervention Categories

Category 1 2 3 4 5 6 7 8

1. Overall Importance Rating — .80 .79 .95 .72 .85 .55 .712. Overall Comfort Rating — .95 .75 .90 .69 .75 .603. Instructional Management-Comfort — .81 .78 .59 .60 .524. Instructional Management-Importance — .60 .70 .45 .595. Behavior Management-Comfort — .82 .58 .436. Behavior Management-Importance — .39 .467. Outside Support-Comfort — .758. Outside Support-Importance —

Note.All correlations are significant at the .01 level.


Even though we did not have any negative ratings for interventions, there was some variabil-ity. Professionals need to determine the interventions that teachers believe are very important andare totally comfortable using as well as the interventions teachers rate at the somewhat level. If anintervention is being proposed to teachers and they have rated the intervention at the somewhatlevel in importance and/or comfort, then teachers need to be provided some support. This supportcan be in the form of providing information to justify why the intervention is important. Forexample, teachers may not understand how the systematic use of planned ignoring can extinguishcertain behavior (Jones & Jones, 1999). In addition, whenever possible, teachers must be sup-ported in selecting interventions that match their beliefs. If teachers are not totally comfortableusing an intervention then it may not be consistently implemented (or used at all).

Results from this study also have implications for future research in this area. One thing thatis not clear from this study is whether teacher ratings were based on actual experience. Futureresearch should investigate whether teachers perceive certain interventions are important and areactually using them in their classroom with students with and without AD/HD. It would also beinteresting for future research to have teachers rank interventions that they believe are most impor-tant for all children and then rank interventions specifically for children with AD/HD. This wouldallow more of a comparison across groups of children with and without AD/HD. It is also impor-tant to consider that teachers in this study were responding to interventions that are positive andappropriate for children with AD/HD. Future research should assess whether preschool teachersalso provide positive ratings for inappropriate techniques. For example, research has found thatsome teachers still believe sugar and food additives are major contributors to AD/HD and maysubsequently employ inappropriate interventions (Jerome, Gordon, & Hustler, 1994; Stormont &Stebbins, in press).

Overall, it is important that teachers’ intervention preferences be considered and that profes-sional development be designed based on such findings. Findings from this study indicated thatpreschool teachers have high comfort and importance ratings for most interventions and thatseveral teacher variables were not significantly associated with, or discriminative of, ratings. Lastly,the generalizability of the results of this study are limited for several reasons. Only one geographicregion of the country was represented and 95% of the teachers in this sample were female. Thus,findings may not be generalized to other regions, to urban and rural areas, or to male teachers.Also, the only ethnic backgrounds that were represented in this sample were Euro-Americans andAfrican Americans. This study needs to be replicated with teachers of different ethnic back-grounds. Finally, 83% of the teachers in this study had at least some college background. Thus,findings may not be representative of preschool teachers who do not have the same educationalbackground as the teachers in this study.

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teachers' comfort and importance ratings for interventions for preschoolers with ad/hd

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