Award Title: Development and initial evaluation of a school-based intervention for ADHD
Funder: Department of Health and Social Care

Abstract: Background: Attention deficit/hyperactivity disorder (ADHD) is a prevalent and impairing neurodevelopmental disorder affecting 2-5% of children. These children are at risk of negative health, social and educational outcomes; ADHD incurs an estimated 670 million annual cost to health, education and social care in the UK. Children with ADHD often experience severe difficulties at school despite drug treatment: effective psychosocial interventions are needed. There is mixed evidence for the effectiveness of existing school-based interventions for ADHD, which are complex and resource-intensive, contradicting the preferences of teachers for short, flexible strategies that suit a range of ADHD-related classroom-based problems. They are also poorly evaluated. Aims: To develop an acceptable and feasible intervention for ADHD in primary schools that is feasible to further evaluate in a methodologically rigorous trial. The intervention will take the form of a 'toolkit' of strategies. The main aims are to:	Develop a prototype toolkit 	Refine the toolkit so that it is feasible and acceptable to implement in the school setting 	Establish whether a future definitive trial of efficacy is feasibleAdditional aims:	Update, identify and synthesise existing evidence to select strategies for inclusion in the toolkit 	Identify suitable outcome measures to assess core ADHD symptoms, child and teacher wellbeing and identify an appropriate primary outcome for a future definitive trial 	Develop and test a framework for costing the toolkit, and for assessing cost-effectiveness in a future definitive trial 	Assess whether observational measures of behaviour, classroom functioning and teacher-reported ADHD symptoms indicate improvement following use of the toolkitMethods. I will apply Intervention Mapping, a framework for developing theory- and evidence-informed behaviour change interventions, combined with extensive co-creation from a stakeholder group comprised of school staff, people with ADHD, parents and specialists in education and ADHD. The intervention will be assessed for feasibility and acceptability and further modified in an iterative optimisation study, with 16-32 children with ADHD and staff participating from eight primary schools. Timeline for delivery. The initial development of the intervention will take place over 18 months, with the iterative optimisation study running for 2  years. Anticipated impact: Following this project, the intervention will be suitable to be evaluated for efficacy and cost-effectiveness in a larger trial. An effective intervention for ADHD that can be delivered by non-specialists in school will improve the functioning of children with ADHD in a setting where they struggle most. Improved function at this crucial stage has the capacity to significantly improve the developmental trajectory of children with ADHD, their current and future health and relationships as well as educational and occupational functioning. The same strategies could be applied while children wait for assessment and might reduce the need for specialist intervention and demands on child mental health services. My intervention will offer initial support to those children who face long delays accessing specialist mental health services. It could be used to identify children who need specialist support, and to support children with milder problems who do not meet clinical thresholds.

Lay Abstract: Background. Every classroom will have on average at least one child who will struggle to sit still, pay attention and resist impulses to do things like jump out of their seat. When these problems are really severe this can be due to ADHD, or 'attention deficit hyperactivity disorder'. Children with ADHD face major difficulties at home and school. They are less likely to learn well and make good friendships than other children. Children with ADHD are also more likely to have accidents and injuries, and other mental health problems. Teaching a child with ADHD can be difficult, both one-to-one and as part of a whole class, and this can impact on the classroom experience for other children. Medicines that help to reduce symptoms of ADHD do not suit every child. Even when drugs work, children with ADHD need extra help to address struggles at school. Strategies are needed to help teachers support them. Existing advice for teachers is in the form of complicated programmes that try lots of different things at the same time. As a result, teachers struggle to learn and use the programmes, meaning children do not benefit from them. As every child and school are different, teachers tell us that they need a range of simple options that they can choose from to suit each child with ADHD. Aims and methods. I plan to design a 'toolkit' with a collection of strategies teachers can use to help children with ADHD cope better in primary school. I have worked with teachers and parents to develop this project. There are two main parts:	Designing the toolkitI will use a method called 'Intervention Mapping'. This sets out a clear framework to design treatments that are acceptable to people who use them and are based on the best available evidence. This will be informed by theories about how children learn new skills and how the symptoms of ADHD come about. I will work closely with school staff, people with ADHD, parents and professionals to design the toolkit.	Testing and improving the toolkitTo test whether the toolkit is acceptable and practical for teachers to use, I will conduct an experimental study. Eight primary schools and a total of 16-32 children with ADHD will take part, each using the toolkit for one school term. I will collect feedback about what went well and what did not, and whether I should make any changes before the next school tries the toolkit. I plan to use several different ways to explore whether the toolkit is acceptable and potentially helpful for children with ADHD. Teachers and parents will complete questionnaires, and I will run focus groups with school staff and interview parents and children about their experiences. This will inform whether the toolkit is ready to be tested further in future research. Future benefits. If the testing of the toolkit shows that it may be helpful, I will go on to do a larger scale study to investigate how much children benefit and if it is value for money. If the toolkit does help children with ADHD cope in school, these children will learn better and find school less stressful. This might prevent them from developing other mental health problems and help them avoid getting into accidents, trouble with teachers, and fights. They could go on to have a better chance of getting good qualifications, better jobs and have positive relationships with other people. In other words, it might lead to improved health and better life chances. Teachers might also find it easier to teach the whole classroom and be less stressed.

Research Activity Codes: 7.1 INDIVIDUAL CARE NEEDS
Health Categories: MENTAL HEALTH