Effective but Not Feasible—What Support Staff in All-Day Primary Schools Think of Pedagogical Interventions with Regard to Children with ADHD

: Children with attention deﬁcit/hyperactivity disorder (ADHD) are faced with multiple challenges both in the classroom and in the homework situation. While there are many studies on pedagogical interventions by teachers in the classroom, this is hardly the case when it comes to support staff in after-school homework supervision. In this study, 196 support staff with different qualiﬁcations were asked not only about their knowledge of ADHD, their subjective level of stress, and whether they felt trained enough to work with children with ADHD, but also to assess the effectiveness and feasibility of 25 interventions in homework supervision. Overall, the respondents rated effectiveness higher than feasibility. Higher qualiﬁcations, greater knowledge, and better preparation went hand in hand with higher ratings of effectiveness. The more stressed the support staff feel themselves to be, the less feasible they rate the measures. The results underline the neces-sity of employing well-trained pedagogical staff to supervise children with ADHD. A number of interventions can be identiﬁed that the support staff deem to be both effective and feasible, and that promise a high level of implementation in practice. At the same time, more attention should be given to potential obstacles to using recommended measures in training and further education.


Attention Deficit/Hyperactivity Disorder and Its Effects on School Performance
The link between attention deficit/hyperactivity disorder (ADHD) and difficulties in school, both socially and in academic performance, has been well studied. Children with ADHD are characterised by three core symptoms: concentration problems, hyperactivity, and impulsiveness. Each of these causes problems at school as well as during homework. For example, the high level of restlessness makes it more difficult for the child to sit quietly in her chair; impulsiveness leads to more violations of group rules, with children more often interrupting in inappropriate ways, or working in an impulsive manner; and they have more difficulty listening to instructions and waiting until everything relevant has been explained. Both hyperactivity and impulsiveness can lead to more complaints from other children [1], and to the teacher using disciplinary measures more often [2]. An observational study conducted by Owens et al. [3] has found that the rate of classroom disruptions in the group of children with (or with a tendency towards) ADHD was 9 to 17 disruptions per hour, significantly higher than for the comparison group, with 1 to 2 disruptions per hour. It is thus not surprising that those teaching children with ADHD report more stress due to the behaviour of such children [4,5].
The lack of concentration results in increased off-task behaviour [6,7]; tasks are processed in an unstructured or incomplete manner; the children are more distracted and make careless mistakes more often [7]. In addition, they more often forget what to do in homework or leave the materials necessary for the homework behind [8]. The underlying causes of these main symptoms, such as executive functioning deficits (e.g., attention, working memory, and inhibition) or an aversion to the experience of delay and dysfunctional responses to reward and punishment [9], as well as problems in time management [10], may be particularly relevant to school and homework performance.
It is thus not surprising that children with ADHD fail more often at school. For example, they achieve worse grades than their peers, drop out of school more often, use school-based services more often, and may have other comorbid learning disorders [11]. As for homework, it has been shown that problems in elementary school are a very good predictor of later academic success [12]. Given these fundamental difficulties, their prevalence, and the associated burden for both the child and the social environment, it is clear that ADHD is a relevant topic in schools, and that effective interventions that also include the homework situation should be implemented.

Effective Interventions to Improve School and Homework Performance
One of the most common interventions for children with ADHD is the use of psychostimulants [13], and the fact that they are effective with regard to the cognitive and behavioural functioning of pupils with ADHD is well documented [14]. However, there are a number of limitations. For example, there is a group of non-responders as well as a group with low compliance to the intervention. Medication seems to significantly reduce the core symptoms of ADHD, although there are clear individual differences here. With regard to school performance, however, the picture is somewhat ambiguous. Several meta-analyses come to the conclusion that, if there are any improvements, then these are short-rather than long-term, and that no uniform picture can be found across the subjects [15,16]. Further, the fact that adverse side effects (such as sleep disturbances, decreased appetite, and decreased height growth) are not uncommon with the use of psycho-stimulants, as well as the lack of long-term studies [17], should lead us to consider alternative treatments and coping mechanisms.
There are a number of well-researched non-pharmacological interventions in the school setting [18]; these evidence-based classroom management strategies include academic and cognitive behavioural interventions, behaviour modification techniques, peer tutoring [19], and self-monitoring [20,21]. In some cases, the interventions directly address the possible causes of ADHD mentioned above. For example, placing the child in a seat where she is less distracted, presenting tasks in small steps, using visualisation aids such as signal cards, and so on address potential deficits in executive functions. Contingency management, positive rewards, and school-home daily report cards can help motivate children and prevent problems caused by reward delay [22,23]. Although we can assume that school-based interventions are effective, their effects seem to be heterogeneous [24]. For the homework situation, too, there are some well-researched methods that help improve homework performance. For example, interventions such as goal setting and contingency contracting [25,26], as well as self-management strategies [27], have been studied in this context. In addition, the training of specific organisational skills [28] has proven to be effective.

Potential Factors Influencing the Use of Pedagogical Interventions
Thus, although there is, at least for the classroom situation, a whole range of wellresearched interventions available, teachers seem to use significantly fewer of these interventions than would be useful [3,[29][30][31], and it is thus necessary to investigate the conditions under which they do use them. One possible relevant variable may be their knowledge of ADHD. Various studies have found that teachers' knowledge of ADHD is good, with knowledge of symptoms being better than knowledge of causes and interventions [32,33]. Several studies suggest that a higher level of teacher knowledge is correlated with the use of appropriate interventions with children with ADHD [29,32,34,35], although the study by Blotnicky-Gallant et al. [36] found no significant correlation. Strelow et al. [37] were able to show in a path model that, in addition to a direct influence on the intention of teachers to use effective classroom management strategies, knowledge of ADHD also has an indirect influence through the fact that teachers expect these classroom management strategies to be effective. Moreover, perceived behaviour control seems to be relevant for the intention to use such interventions [37]. Of particular interest, therefore, seem to be which interventions teachers perceive to be not only effective, but also feasible. Furthermore, Strelow et al. [37] investigated the stress caused by the behaviour of children with ADHD, with this stress being positively correlated with the intention to use both effective and ineffective classroom management strategies. Finally, a study by Clunies-Ross [38] showed that increased stress among teachers is associated with the increased use of reactive as opposed to proactive classroom management strategies.
Another variable could be the qualifications of the pedagogical staff. For example, there are differences in knowledge between pre-and in-service teachers [39] and between pedagogical and non-pedagogical staff [40]. Consistent with these findings, the level of qualification seems to play a role in whether there is a higher acceptance of the use of effective interventions [35,37,41]. Similarly, targeted training of teachers on the increased use of effective teaching interventions may also help reduce symptoms in children with ADHD [42].
Overall, there is still very little research on this possible correlation. Above all, support staff working in after-school supervision have not yet been surveyed. However, doing so also seems to be of particular relevance, as such staff often supervise homework; as described above, significant problems with children with ADHD can be observed in this setting, which, besides continuing the negative interaction between support staff and child, can also impact negatively on school performance [43].

Preferences Regarding Pedagogical Interventions
Teachers seem to prefer interventions that are positively oriented and require little time and effort [44,45], with teachers using lower-threshold interventions (e.g., positive attention and preferential seating) more often than higher-intensity interventions (e.g., daily report card and behavioural contract) [41]. However, teachers with more training in ADHD seem to be more willing to use measures with a greater degree of sophistication [46].
When asked in an interview study about their strategies for dealing with pupils with ADHD, teachers reported using significantly more reactive than proactive interventions [47].

Research Questions
Most studies have so far investigated the use of classroom management strategies with children with ADHD with regard to pre-or in-service teachers. Previous research has thus focused mainly on the classroom situation. However, children with ADHD show clear difficulties especially in the homework situation, too, which can lead to negative interactions between support staff and child, and to further problems for children with ADHD [8,48]. To the best of our knowledge, there is a research gap here, as support staff working in after-school homework supervision have not yet been surveyed.
This study thus aims to explore (1) which interventions support staff consider to be particularly effective in supporting children with ADHD. In addition, it is of interest (2) how feasible they deem these interventions to be. In this context, special attention will be paid to those interventions that support staff deem to be very effective, but at the same time not very feasible.
As mentioned above, studies with teachers show that knowledge of ADHD is positively correlated with the use of pedagogical interventions to support these children. Thus, it is also assumed here that (3) there is a positive correlation between knowledge of ADHD and how effective and feasible the interventions are rated.
The group of pedagogical support staff in the after-school sector is very heterogeneous in terms of qualifications. Those with a background in education seem to have more knowledge of ADHD than those without [40]. Furthermore, experienced teachers seem to have a more positive attitude towards effective methods of supporting ADHD children and also use these methods more frequently. Thus, our hypothesis is that (4) support staff with a background in education will attribute a higher effectiveness to pedagogical interventions with regard to children with ADHD than support staff without such qualifications. Similarly, (5) support staff who feel appropriately trained to work with ADHD children will rate the interventions as more effective and feasible.
As described above, teachers often experience interactions with children with ADHD as more stressful. Thus, (6) consideration will be given to the correlation between the stress that support staff experience in dealing with children with ADHD and how they rate the interventions.

Sample
The sample is identical to that already described in the article by Domsch et al. [40] in this Special Issue. A total of 196 support staff (89.3% female; 7.1% male; 3.6% missings) working in after-school homework supervision at 40 primary schools in North Rhine-Westphalia and Hesse in Germany took part in the survey.
With an average age of M = 43.01 (SD = 14.16), they had worked in after-school supervision for an average of M = 6.65 years (SD = 6.22; ranging from 6 months to 40 years). Of the 196 participants, 42 were teachers, 84 were other educational professionals (e.g., caregivers, social workers), 34 had no pedagogical qualifications, and the remaining 36 provided no information in this regard.

Instrument of Measurement
To assess knowledge of ADHD, we used a questionnaire based on the "Knowledge of Attention Deficit Disorders Scale (KADDS)" [49]. The questionnaire consists of 25 items, with the same number of items for four areas: (A) symptoms, development, and prevalence; (B) diagnostics and comorbidity; (C) causes; and (D) treatment and knowledge. The total knowledge value is formed across all items. Psychometric properties are satisfactory, with Cronbach's α = 0.85 for the total knowledge scale.
The support staff completed the Intervention List, a questionnaire developed for this study. They were asked to rate a list of 25 interventions in terms of their effectiveness (four-point Likert scale from "not effective" = 0, to "extremely effective" = 3), and their feasibility ("not feasible" to "very feasible") in supporting children with ADHD.
The measures compiled in the list are derived from effectiveness studies on improving the management of the homework situation for children with ADHD, and have proven to be very effective here both in terms of helping children complete the homework tasks themselves and improving the family climate and school performance [26,28]. They were also complemented by further measures to improve the homework situation in general. As the measures are usually aimed at parents in the home environment, they were further adapted to the homework situation at school. The 25 measures relate to different areas of intervention, including antecedent-based (e.g., modified materials and single seat), consequence-based (e.g., reward system, positive attention, and daily report cards), and self-regulation strategies (e.g., signal cards, ifthen plans, and checklists of materials). The list was presented to four experts (school psychologist, coordinator in the area of after-school supervision, and two psychologists with expertise in ADHD), who were asked to assess how appropriate these interventions are when it comes to supporting children with ADHD (they unanimously rated all the interventions as being appropriate). Good internal consistencies were achieved by the overall scale for effectiveness ratings (α = 0.87) and for feasibility ratings (α = 0.82).
Experience of stress and preparation: Besides surveying the support staff in terms of their knowledge and demographics, we used a five-point scale (0 = not at all to 4 = absolutely) to investigate how well prepared the support staff feel to work in the context of homework supervision for children with ADHD, and how they evaluated the challenge involved with dealing with such children, with the same being asked with regard to homework supervision in general.

Effectiveness and Feasibility Ratings
Effectiveness and feasibility ratings correlate with r = 0.43 (p < 0.001). Overall, the support staff gave a higher rating to the effectiveness of the interventions (M = 2.35, SD = 0.39) than to their feasibility (M = 2.0, SD = 0.40), with this difference being significant in a t-test for dependent samples (t(177) = 11.25, p < 0.001, d = 0.84). Thus, 88% of the effectiveness ratings and 48% of the feasibility ratings for the interventions were above 2 (on a scale from 0 to 3). Table 1 shows the ratings of the items, sorted in descending order of effectiveness rating, with praise for appropriate behaviour rated as the most effective intervention, and the use of negative consequences the most ineffective. Therefore, it is clear that positive interventions such as praise (item 1) are rated as being much more effective than negative interventions such as general negative consequences (item 25) and time-out (19). Furthermore, items that promote the exchange of information between teaching staff, support staff in homework supervision, and parents are considered to be particularly effective (items 2, 3, 5, and 10). There is a high correlation between effectiveness and feasibility ratings with regard to verbal praise (item 1, Table 1), which is rated as both the most effective and the most feasible measure, as well as with regard to returning the child's attention to the task by means of a short signal (touch or name; item 7) and visualising the time remaining (item 14). The largest differences between effectiveness and feasibility ratings arise with regard to the following items: supporting the child in a small group is rated as being both very effective and difficult to implement (difference = 1.41, item 4); there is also a clear difference in the items concerned with discussing the tasks in advance (difference = 0.85, item 6) and retrospectively (difference = 0.79, item 20), as well as continuously liaising with teachers and parents (difference = 0.8, item 3), with the high differences being due mainly to low feasibility rates.

Amount of Expertise and Effectivness/Feasibility Ratings
In order to investigate the correlation between the level of expertise on the one hand, and effectiveness and feasibility ratings concerning pedagogical interventions for children with ADHD (research questions 3 and 4) on the other, we conducted a Pearson's correlation as well as a MANOVA. The results confirm a small but significant positive correlation between knowledge of ADHD and effectiveness (r = 0.22, p < 0.01) and feasibility (r = 0.17, p < 0.01) ratings.
It was further assumed that support staff with a pedagogical qualification would rate the predefined interventions as being more effective and feasible. We conducted a MANOVA with effectiveness and feasibility ratings as dependent variables, and the three different categories of vocational-training background (teachers, other educational professionals, and no pedagogical qualifications) as the independent variable. The significant multivariate effect (F(2282) = 3.14, p < 0.05, η 2 p = 0.04) is based on a significant main effect regarding effectiveness ratings (F(2142) = 4.03, p < 0.05, η 2 p = 0.05). On the other hand, no significant main effect was found for feasibility ratings as a dependent variable

Experience of Stress and Preparation
We also asked (scale from 0 to 4) the support staff how well prepared they felt to work in the context of homework supervision for children with ADHD (M = 1.96, SD = 0.86), and how stressed they felt when dealing with such children (M = 1.83, SD = 0.88). Even though the levels of stress are in the middle range of the scale, they are significantly higher than the general experience of stress in homework supervision (M = 1.29, SD = 0.87, (t(189) = 7.32, p < 0.01, d = 0.53).
As expected, support staff who feel better prepared report lower levels of stress (r = −0.24, p < 0.01). The feeling of being better prepared is also correlated to a small but significant extent with a higher effectiveness rating (r = 0.17, p < 0.05), and to a medium extent with a higher feasibility rating (r = 0.31, p < 0.01) (research question 5). The average experience of stress (research question 6) is not correlated with the effectiveness ratings (r = 0.05, p = 0.54), but it is correlated with the feasibility ratings (r = −0.19, p < 0.05).

General Discussion
There are a number of well-researched pedagogical interventions available to support children with ADHD, but teachers often under-use them [29,30,49], with moderating variables thus being sought to close this scientist-practitioner gap [49]. This study extended the field of research to the homework situation by asking support staff working in after-school homework supervision to rate the effectiveness and feasibility of methods in the supervision of children with ADHD. This is particularly relevant because such children exhibit less on-task behaviour in school situations that place high demands on self-regulation, information processing, and motivation [50]. This is the case not only in individual work, but also in homework situations.
The first two research questions are about assessing the effectiveness and feasibility of support staff interventions for children with ADHD. We find that there is a correlation between effectiveness and feasibility ratings, with a similar correlation being found in different studies: the higher the effectiveness of interventions is rated, the greater the willingness is to use them [51]. Here, teachers seem to prefer interventions that require little effort and are positively oriented [36,44,52], with the willingness to use more elaborate interventions increasing with the challenges of the pupil. In our study, too, simple praise for appropriate behaviour was attributed the highest effectiveness as well as feasibility. However, it is noticeable that even those interventions that are more difficult to implement are rated as particularly effective, and thus have a higher discrepancy between effectiveness and feasibility. One group of such interventions concerns communication between teachers, support staff working in homework supervision, and parents. On the one hand, there are approaches to structured school-parent communication such as daily report cards, which have a good empirical foundation in terms of their effectiveness [53]. On the other, this also relates to internal school communication channels, which, in addition to regular exchanges, also include communication structures about the specific homework. In fact, a frequently reported problem when it comes to children with ADHD doing their homework is that they do not know what they have to do [8], so that they cannot do the task at all. At the same time, a not inconsiderable percentage of support staff consider these interventions to be impossible or barely feasible. What is needed here are school-internal routines that take into account the possible obstacles so that information can be passed on and shared.
There are high ratings of effectiveness, but low ratings of feasibility with regard to small group sizes, too. Class size is often seen by teachers as a major barrier to implementing interventions [30,49]. A smaller group size may thus allow both more time for individual support for children with ADHD and fewer opportunities for them to be distracted. Hart et al. [54] investigated the effect of group size (individual, small, and large group) on on-task behaviour during an instructional phase and a performance phase (with standardised tasks). While in the instructional phase, children with ADHD in a small group showed more ontask behaviour than children in a large group, this difference could not be observed in the performance phase. The authors conclude that a smaller group size is particularly beneficial in the instructional phase. In fact, our study also found high ratings of the effectiveness of pre-and post-discussion of homework, which, however, a large number of support staff considered to be hardly or not at all feasible. Based on their study results, Langberg et al. [12] claim that parental involvement in the homework situation (e.g., supportive structuring, motivation) is an important predictor of school grades. Transferred to the situation in homework supervision, such interventions would be easier in smaller groups with more intensive engagement with the individual children. Further studies would have to investigate the effects of smaller groups on on-task behaviour, the actions of the support staff, and how they interact.
The other research questions relate to the correlation between the level of qualification (knowledge of ADHD or pedagogical training) and how the interventions were rated. It was found that better knowledge of ADHD is linked to higher ratings of effectiveness and feasibility. This is in line with the findings of previous studies that showed that knowledge of ADHD is related to the ability to teach children with ADHD effectively as well as to approach them more positively [32,37,49,55]. Strelow et al. [37] describe this correlation in a path-model. Knowledge of ADHD seems to be important, but not sufficient for the intention to use effective interventions. In their path model, there was a positive correlation between knowledge and effectiveness ratings, which in turn was a main factor for the intention to implement pedagogical interventions. In line with our assumption, there were also group differences in terms of effectiveness ratings between support staff with pedagogical qualifications and those without, with the former not only having more knowledge of ADHD [40], but also rating the effectiveness of the interventions higher. A similar result has been found by Zemp et al. [56] in a comparison between pre-and in-service teachers. Here, too, in-service teachers showed higher knowledge values as well as higher effectiveness ratings. Thus, the feeling of being prepared to support children with ADHD in the homework situation is also associated with higher effectiveness and feasibility ratings. The results suggest that teachers should be trained to deal with children with ADHD. In a recent review, Ward et al. [57] investigated the influence that in-service teacher training on ADHD has on the implementation of pedagogical interventions. They showed that, after a teacher-training session, it is mainly short-term knowledge gains that are achieved, while behavioural changes on the part of the teachers can be observed above all in repeated session appointments.
Finally, we investigated the correlation between the stress of working with children with ADHD in the homework situation and the effectiveness and feasibility ratings. In line with studies with teachers [5], our study also showed that a higher level of stress was reported when supporting children with ADHD. As for the effectiveness ratings, there was no significant correlation with the perceived stress. While Strelow et al. [37] also found no significant correlation between individual stress caused by children with ADHD and effectiveness ratings of classroom management strategies, another study showed a positive correlation [56]. Here, however, more stressed teachers tended to report a lower feasibility of the proposed measures. On the one hand, it is possible that the feeling of an overall low ability to act is associated with a higher experience of stress in dealing with children with ADHD. On the other, it is also conceivable that the higher stress experienced leads to greater helplessness.

Limitations
Our study has some limitations. Besides the use of a new questionnaire, we should also mention the fact that the study is limited to only two regions in Germany. The recruitment of a larger sample as well as the collection of further possible variables (e.g., the actual intention to carry out measures, personal attitudes towards children with ADHD, and perceived behaviour control) would allow more differentiated results. In addition, the focus of the study is on support staff in homework supervision in primary schools. In the future, it would be interesting to study support staff in homework supervision in secondary schools, too. The results of Szép et al. [51] indicate that, in secondary schools, at least in the morning lessons, teachers implement fewer interventions in supporting children with ADHD.
Overall, no statements can be made about causal relationships, as the results are based on correlations. Furthermore, the data are based exclusively on self-assessments. It would certainly be interesting to integrate direct observation as well as the experience of the children affected.

Conclusions
Our results support the claim that knowledge of ADHD, but also a general basic teaching qualification, is relevant for supporting children with ADHD. We should take into account here what support staff themselves consider to be effective and, above all, feasible, or how measures could be implemented together with them. The most appropriate way to organise teacher-training programmes may be to allow the trainee teacher to meet several times with her/his mentor, so that interventions can be tried out in between, reflected on afterwards, and perceived obstacles can be discussed. This more problem-solving focused approach would allow interventions to be more closely tailored to the individual pupil's starting-point, but also to the needs and experience of stress of support staff. Closing the scientist-practitioner gap is also relevant because of potential secondary stress among pupils. School and homework tasks are among the (burdensome) duties that children (with ADHD) face. Adults should try to support them in such a way that they can face these duties with confidence and a sense of success. Institutional Review Board Statement: Ethical review and approval were waived for this study since no vulnerable samples are examined, and the study does not violate the physical or psychological integrity, the right to privacy or other subjective rights or the interests of study participant.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The datasets are stored at Muenster University of Applied Studies and can be accessed there.

Conflicts of Interest:
The authors declare no conflict of interest.