ADHD Attachment B3 Parent Communication and Knowledge

OMB No: ??? Exp. Date ???

ADHD Communication and Knowledge

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he following questions are about communication between parents, physicians and schools. Please circle the number associated with your response or write your answer on the blank line. For these questions, “contact” or “communication” is defined as a phone call, e-mail, personal visit, transfer of written materials/reports by fax, mail, etc. The reasons for contact may include: to clarify the diagnosis, to address ongoing/unresolved AD/HD related problems, or for AD/HD medication management.

1. Has your child been diagnosed with ADD/ADHD? O Yes – if yes, skip to CK 3 O No 2. Are you concerned that your child may have ADD or ADHD? O Yes O No – if no, STOP 3. Is the school aware of your child’s (diagnosis/your concern)? O Yes O No 4. Have you had contact with your child’s teacher or other school professionals (concerning your child’s ADHD/about your concerns) in the past year? O Yes O No – if no, skip to CK10 5. How many times? _________

6. Who did you speak with? (check all that apply) O Principal O Teacher (General Education) O Special Education Teacher O School Psychologist O School Counselor O Nurse Practitioner O Receptionist/Secretary O Don’t Know/Remember O Other: Specify ________________ 7. What was the nature of the contact? (check all that apply) O Clarify diagnosis O Medication management O Don’t Know/Remember O To address ongoing/unresolved problems O Other: Specify __________________ 8. What is the length of time you spent attempting contact/communicating with the school about your (child’s ADHD/concerns)? Hours _______ Minutes _______

9. What steps has the school taken to address your concerns? O Nothing O 504 plan O Behavioral intervention O Counseling O IEP O Classroom modifications/accommodations O Social skills training O Tutoring 10. Have you had contact with the physician’s office (concerning your child’s ADHD/about your concerns) in the past year? O Yes O No – if no, skip to TC 15 11. How many times? _________ 12. Who did you speak with? (check all that apply) O Physician O Nurse O Nurse Practitioner O Receptionist/Secretary O Don’t Know/Remember O Other: Specify _______________ 13. What was the nature of the contact? (check all that apply) O Clarify diagnosis O Medication management O Don’t Know/Remember O To address ongoing/unresolved problems O Other: Specify _________________ 14. What is the length of time you spent attempting contact/communicating with the doctor’s office about your (child’s ADHD/concerns)? Hours _______ Minutes _______ 20. Who from your child’s doctor’s office has communicated with your child’s school? (check all that apply) O Physician O Nurse O Nurse Practitioner O Receptionist/Secretary O Don’t Know/Remember O Other: Specify __________________ ________________________________________ The next set of questions concern your feelings about your child’s diagnosis. Please rate how much you agree or disagree with each statement on a scale from 1-5, with 1 being disagree and 5 being agree. Circle the number that best fits your response. 1. I feel we can overcome our child’s emotional/behavioral problems with good parenting and good teachers. Disagree Agree 1 2 3 4 5 2. Our child will always have problems. Disagree Agree 1 2 3 4 5 3. As few people as possible should know about our child’s diagnosis. Disagree Agree 1 2 3 4 5 ________________________________________ The following questions are about ADHD. Please answer to the best of your knowledge. We are just trying to get a general idea of people’s knowledge of Attention-Deficit Disorder. 1. How knowledgeable do you feel about ADHD? Unknowledgeable Knowledgeable 1 2 3 4 5 Inattention: O Yes O No O Don’t Know Impulsiveness: O Yes O No O Don’t Know Dyslexia: O Yes O No O Don’t Know 5. Which treatment you think works best for ADHD: (check one) O Diet restrictions such as the Feingold diet O Stimulant medications such as Ritalin O Behavior modification O Psychotherapy O Play Therapy O Don’t Know 6. Which classroom placement is best for children with ADHD? (check one) O Regular classroom with no changes O Regular classroom with changes like behavior modification O Resource room with changes like behavior modification O Special class for children with ADHD O Special school for children with ADHD and Learning Disabilities O Don’t Know 9. Which statements are true about the long-term use of stimulant medication? (check one response for each statement) They can be stopped by puberty: O Yes O No O Don’t Know They have definite long term benefits: O Yes O No O Don’t Know They can stunt growth: O Yes O No O Don’t Know They have a permanent effect on the brain: O Yes O No O Don’t Know They are frequently stopped because the patient develops tolerance: O Yes O No O Don’t Know

15. How many times in the last year have you asked your child’s school and doctor to communicate? _________ 16. How many times have you helped with delivering information (verbally or papers) between your child’s school and physician? _________ 17. How many times in the past year has someone from your child’s school communicated with someone from your child’s doctor’s office about your (child’s ADHD/concerns)? 1 time in the last year 2 times in the last year 3 times in the last year 4times in the last year 5 or more times in the last year Don’t Know/Remember None – if none, skip to next section 18. What was the nature of the contact? (check all that apply) Clarify diagnosis Medication management Don’t Know/Remember To address ongoing/unresolved problems Other: Specify ________________ 19. Who from your child’s school has communicated with your child’s doctor’s office? (check all that apply) O Principal O Teacher (General Education) O Special Education Teacher O School Psychologist O School Counselor O Nurse Practitioner O Receptionist/Secretary O Don’t Know/Remember O Other: Specify ________________ 2. What have been your main sources of information about ADHD? (check all that apply) O My primary care physician O Other physician: Specify ______________ O Mental Health Provider O School O Parent Support Group O Library O Bookstore O Internet O Friends/Peers O Not applicable/Don’t Know O Other: Specify ______________________ 3. Which among the following items is the major cause of ADHD? O A neurological or nerve disorder O A mental disorder with a biological basis O An emotional disorder O A learning disorder O None of the above O Don’t Know 4. What do you think are the main characteristics of ADHD? (Check one response for each characteristic) Hyperactivity: O Yes O No O Don’t Know Aggression: O Yes O No O Don’t Know 7. Which is the most common cause of ADHD (check a response for each statement) O Exposure to toxins before birth O Inherited O Poor schooling and parenting O Prematurity O None of the above O Don’t Know 8. Which statements are true about stimulant medication such as Ritalin? (check one response for each statement) Have a high safety margin: O Yes O No O Don’t Know Need to be given daily/continuously: O Yes O No O Don’t Know Should only be given if psychosocial interventions don’t work: O Yes O No O Don’t Know Are effective only in a minority of children: O Yes O No O Don’t Know Have lasting effects: O Yes O No O Don’t Know

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by