Appendix A: ADHD Teacher Interview

Student Name: …………………………………. Student Grade ………………………..

Interview Date: …………………………………………………….

Teacher …………………………… Length of time teacher has known student ……………

Describe the student’s academic performance and present placement in the curriculum (using relevant district criteria) in:

Reading: …………………………………………………….…………………………………………………….……………………………………………………………………………………………….

Math: …………………………………………….…………………………………………………………………………………………………….………………………………………………

Written language: …………………………………………………….…………………………………………………………………………………………………….………………………………………………

Content area subjects: …………………………………………………….…………………………………………………………………………………………………….………………………………………………

Describe any behavioral difficulties that the child may have in the classroom or any other school setting. [Note to interviewer: This question is repeated until no further problem behaviors are given].

When did this behavior first appear? ___________________________________________

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How frequently does the problem behavior occur? __________________________________

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In what settings does the behavior typically appear? When is it most severe? _____________

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What do you think motivates the student to show this behavior? ______________________

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Are there any observable events that allow you to predict that the behavior will occur? _____

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What are the typical outcomes or consequences of this behavior? _______________________

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What are some factors that seem to make the behavior worse? _________________________

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What are some strategies that have already been tried to address the problem behavior? ____

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How successful was each strategy? ________________________________________

Please rank those behaviors listed above that concern you, ranked from greatest to least importance:

1 ___________________________   4. ___________________________

2 ___________________________   5. ___________________________

3 ___________________________   6. ___________________________

How are this student’s social interactions with other students? ____________________________________________________________________________________________________________________________________________________________

Where would you rank this student in social skills? (Please check against number)

1                                 |                       2                                  |           3

Lowest quarter of the class      | Average range of social skills            | Highest quarter of the class

Describe the general quality of the student’s interactions with you: ____________________________________________________________________________________________________________________________________________________________

Please describe any physical symptoms of concern (if any) you have observed in this student (e.g. complaints of stomach pains, excessive sleepiness, low or high attention level, etc.):

________________________________________________________________________

________________________________________________________________________

What would you consider as relative strengths for this child? ____________________________________________________________________________________________________________________________________________________________

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What are some activities, experiences, or opportunities that this child sees as rewarding or positively reinforcing in school? For each example, please indicate the frequency that the child seeks to engage in the activity/experience:

_______________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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[Note: Before the conclusion of the interview, the interviewer should have the instructor complete the Child Behavior Disorders Rating Scale]

Additional notes:

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