Psychology in the Schools, Vol.

52(2), 2015 
C 2014 Wiley Periodicals, Inc.
View this article online at wileyonlinelibrary.com/journal/pits DOI: 10.1002/pits.21803

TEACHER-TO-TEACHER CONSULTATION: FACILITATING CONSISTENT AND

EFFECTIVE INTERVENTION ACROSS GRADE LEVELS FOR STUDENTS WITH ADHD
MATTHEW J. GORMLEY AND GEORGE J. DUPAUL
Lehigh University

Teacher-to-teacher consultation (TTC) is an extension of standard behavioral consultation that seeks

to transfer an established and effective intervention across a grade-level transition by including
teachers from both grade levels as conjoint consultees at the beginning of the second school year.
The purpose of the current study was to determine if TTC could facilitate the maintenance of
previous intervention-level behavioral functioning across a grade-level transition for three students
with attention-deficit/hyperactivity disorder (ADHD). A multiple baseline, multiple probe design
was employed. Results indicated that the TTC procedure was able to maintain the behavioral
gains made during Year 1, across a grade-level transition into Year 2. Additionally, acceptability
data demonstrated that both teachers and students found the procedure and resultant interventions
acceptable. C 2014 Wiley Periodicals, Inc.

Attention-deficit/hyperactivity disorder (ADHD) is among the most common reasons for

mental health referrals among school-aged children, affecting 5% to 7% of U.S. school-aged
children (American Psychiatric Association [APA], 2013; Barkley 2006). This disorder is defined
by developmentally inappropriate, chronic levels of inattention and/or hyperactivity-impulsivity
(Barkley 2006). Currently, research supports three forms of treatment: psychostimulant medication
(e.g., methylphenidate), behavioral interventions (e.g., daily behavior report card), and the
combination of both (MTA Cooperative Group, 1999; Pelham & Fabiano, 2008). Given that only
parents can make the decision to medicate their child and evidence suggesting that parents prefer
behavioral treatments (Corkum, Rimer, & Schachar, 1999), school professionals should be prepared
to implement behavioral interventions with and without medication.
With regard to these treatments, it has been suggested that individualized strategies are more
effective relative to prepackaged treatment (DuPaul, Eckert, & McGoey, 1997). Further, factors
such as the ease of implementation, the match between the intervention and teaching style, the
teacher’s understanding of the treatment plan, motivation to implement the intervention, and the
availability of feedback regarding performance all impact the quality and integrity of service delivery
by teachers (Klinger, Ahwee, Pilonieta, & Menendez, 2003; Witt, Noell, LaFleur, & Mortenson,
1997). Behavioral consultation facilitates both the individualized tailoring of interventions to a
particular child and the preferences of the teacher.
Behavioral consultation involves a collaborative partnership between the consultee and con-
sultant to identify and intervene on child-centered academic, behavioral, or social needs using
a four-stage process: (a) problem identification, (b) problem analysis, (c) plan implementation,
and (d) problem evaluation (Kratochwill & Bergan, 1990). This method has been used to effec-
tively address a variety of difficulties, including ADHD (Colton & Sheridan, 1998; Murray, Rabiner,
Schulte, & Newitt, 2008; Sheridan, Eagle, Cowan, & Mickelson, 2001; Sheridan & Kratochwill,
2008).
For example, Murray et al. (2008) utilized behavioral consultation to develop goals for use
with a daily behavior report card intervention for 15 elementary students (grades kindergarten to
fifth) diagnosed with ADHD. Results demonstrated that the intervention was effective in increasing
academic productivity relative to a control group (Cohen’s d = .72). The intervention was rated as

Correspondence to: Matthew J. Gormley, Department of Education and Human Services, Lehigh University, 111
Research Drive, Bethlehem, PA 18015. E-mail: mjg510@lehigh.edu

124
 Teacher-to-Teacher Consultation 125

highly acceptable by parents, teachers, and students, and most teachers indicated that the intervention
should be continued in the next year, given the students’ improvement.
The continuation of treatment across a grade-level transition (e.g., from second to third grade)
is of particular importance, given that the effects of pharmacologic and psychosocial interventions
are temporary and individuals regress toward baseline levels when treatment is withdrawn (MTA
Cooperative Group, 2004; Shelton et al., 2000). Such an approach would provide continuous
treatment for a chronic disorder and provide support to the new teacher in the form of a previously
established intervention package. Conceptually, consistency through the grade-level transition
should effectively maintain previous gains because the student is familiar with the behavioral
expectations. Unfortunately, no previous study has demonstrated the transfer of an intervention
from one school year to the next for students with ADHD. One potentially effective mechanism
to facilitate the grade-level transition of students with ADHD is through a modified version of
behavioral consultation: teacher-to-teacher consultation (TTC).
The TTC procedure follows the same four stages of behavioral consultation during the initial
intervention year; however, after the grade-level transition, both the current and previous teacher meet
with the consultant. The goal of this meeting is twofold. First, the previous teacher is able to provide
insights from experience working with the student, and the current teacher is able to ask questions
regarding the feasibility of implementation and voice concerns regarding any possible modifications.
Second, it allows the current teacher and the consultant to begin a collaborative relationship at the
onset of the school year. Following the TTC meeting and reimplementation of a previously effective
intervention, follow-up meetings between the consultant and new teacher continue, consistent with
the problem evaluation stage of the behavioral consultation model, as described in Kratochwill
and Bergan (1990).
In summary, despite ample evidence demonstrating that ADHD is a chronic disorder (APA,
2013; Barkley, 2006) and that, while effective, treatments for this disorder do not have lasting effects
beyond their implementation (MTA Cooperative Group, 2004; Shelton et al., 2000), there are no
studies demonstrating the maintenance of an intervention across a grade-level transition. Given the
nature and course of ADHD, this creates a significant gap in the treatment of students with ADHD.
Specifically, a lack of evidence-based, grade-level transition services delays these students’ access
to treatments that have established efficacy.
Therefore, the purpose of the current study was to (a) replicate previous studies demonstrating
effective use of behavioral consultation to identify and address the behavioral deficits of students
with ADHD and (b) determine whether TTC can maintain the behavioral gains of students with
ADHD across a grade-level transition. Additionally, the current project sought to determine: (a)
whether the TTC process was acceptable to teachers and (b) whether the interventions implemented
in the course of TTC were acceptable to teachers and students. Based on previous findings, it was
hypothesized that the initial behavioral consultation would lead to improvements in child-centered
behavioral difficulties and that the interventions implemented would be acceptable to both teachers
and students. Further, based on conceptual assumptions, it was hypothesized that TTC would be
effective at maintaining behavioral gains across the grade-level transition, that the consultation
process would be acceptable to teachers, and that the interventions implemented would be acceptable
to teachers and students.
METHOD
Participants and Setting
Six students (Grades 1–4) identified by parents and/or teachers as meeting criteria for ADHD
attending general education classrooms were recruited from a public elementary school in eastern

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126 Gormley and Dupaul

Pennsylvania. Through the course of the study, three students were dropped. One student left the
district, a second student’s previous teacher left the school and could not be reached to complete the
TTC procedure, and, finally, one student was removed because two study participants were enrolled
in the same classroom. The decision to remove this student was made to simplify implementation
for the teacher and limit cross contamination of intervention procedures between participants. The
decision between the two students was made in an effort to balance the remaining participants
between the two consultants. Therefore, the final sample consisted of 3 students: Emily, Josh,
and James. Emily was an 8-year-old Hispanic female enrolled in the third grade, meeting criteria for
ADHD, combined type and oppositional defiant disorder (ODD). Josh was a 6-year-old Hispanic
male enrolled in first grade who met criteria for ADHD, combined type and conduct disorder (CD).
James was a 9-year-old Hispanic male enrolled in third grade meeting criteria for ADHD combined
type and ODD.
All consultation meetings and interventions were conducted within the school building. To be
included in the study, participants had to (a) enter the study while enrolled in Grades 1 to 4 in general
education classrooms; (b) be referred by the classroom teacher for having at least one significant aca-
demic, behavioral, or social deficit that requires intervention; (c) receive a score at or above the 90th
percentile on either the inattentive or hyperactive-impulsive subscale of the ADHD Rating Scale-IV
(DuPaul, Power, Anastopoulos, & Reid, 1998) based on both parent and teacher ratings; (d) meet
Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000)
diagnostic criteria for ADHD (predominantly inattentive type, predominately hyperactive-impulsive
type or combined type) utilizing the Clinical Interview–Parent Report Form (Barkley, 1997);
(e) display no significant symptoms of autism, developmental disabilities, intellectual disability,
sensory impairment, or brain damage; and (f) provide informed consent from a parent to participate.

Screening Measures
The ADHD Rating Scale-IV (Home and School Versions; DuPaul et al., 1998) is a behavior
rating scale that includes 18 items directly linked to the DSM-IV-TR (APA, 2000) criteria for ADHD.
This measure consists of two nine-item factors (i.e., hyperactivity-impulsivity and inattentive). Items
are rated on a 4-point Likert scale, ranging from 0 (Never or Rarely) to 3 (Very Often) and yield two
subscale scores (inattention and hyperactivity, which were used in the proposed study for screening
purposes) and a total score (derived from the sum of both subscales). Scores range from 0 to 54
(0–27 on each subscale) and can be compared to a nationally representative sample of 2000 four- to
20-year-olds. The ADHD Rating Scale-IV was found to have strong internal consistency (α = .95)
and test–retest reliability (α = .90; DuPaul et al., 1998).
The disruptive behaviors section of the Clinical Interview–Parent Report Form (Barkley, 1997)
is a structured interview conducted with the student’s parents to assess current symptoms and
symptoms experienced within the last year. The Clinical Interview–Parent Report Form covers the
DSM-IV-TR (APA, 2000) criteria for ADHD, ODD, and CD via structured questions aimed at
identifying relevant symptoms, symptom frequency, and severity.

Dependent Measures
The primary dependent measure was the Behavioral Observation of Students in Schools (BOSS;
Shapiro, 2011). Specifically, the BOSS was used as a weekly probe through all phases of the current
study. The BOSS captures active (e.g., reading aloud) and passive (e.g., listening to the teacher)
engagement, as assessed during 15-second momentary time sampling. During the remainder of
each interval, the student’s off-task behavior is assessed using a partial interval recording method.

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Table 1
Inter-Observer Agreement Average Percentage and Range

Total Occurrence Non-Occurrence Kappa

On-Task Behavior Average 99.13 96.64 98.59 .98

Range 97–100 89–100 96–100 .93–1
Off-Task Behavior Average 98.61 93.62 98.18 .95
Range 96–100 80–100 95–100 .85–1
Combined Behavior Average 98.92 95.72 98.40 .97
Range 97–100 86.5–100 96.1–100 .90–1

Three types of off-task behavior are assessed: motor (e.g., walking around the room), verbal (e.g.,
humming), and passive (e.g., looking out the window). For the current study, categories were
collapsed to form a single “Off-task” code and a single “On-task” code. The BOSS has been used
with students with ADHD (DuPaul et al., 2004; Ota & DuPaul, 2002) and has been found to have
adequate interobserver agreement (kappa = .93–.98; DuPaul et al., 2004).
Inter-observer agreement (IOA) data were collected by graduate students in school psychology
during 21% of observations across all phases and participants (see Table 1). Four calculations of
IOA are reported to provide an accurate estimate of agreement: (a) total agreement (M = 98.92%),
(b) occurrence agreement (M = 95.72%), (c) non-occurrence agreement (M = 98.40%), and (d)
kappa, calculated as described in Cohen (1960; M = .97).
The Behavioral Intervention Rating Scale (BIRS; von Brock & Elliott, 1987) was used to assess
the acceptability of the intervention and TTC procedure for teachers. The BIRS is a 24-item measure
in which items are scored on a 6-point Likert scale (1 = Strongly Disagree to 6 = Strongly Agree).
Total score served as the primary measure of acceptability. Previous research has demonstrated that
the BIRS has high reliability (α = .97; Elliott & Treuting, 1991). In the current study, the BIRS was
modified such that "consultation" replaced the word "intervention" to allow for ratings of procedural
acceptability. This modification was made in Sheridan et al. (2001), with a negligible impact on
reliability coefficients (α = .95).
The Functional Assessment Observation (FAO; O’Neill et al., 1997) was used to generate
hypotheses regarding the function of the student’s classroom behavior. The FAO is a structured
observation form that consists of four main sections: Behaviors, Predictors, Perceived Function,
and Actual Consequences. The Behaviors section allows for listing of specific behaviors the teacher
identified as problematic. The Predictors section consists of important stimuli or events identified by
the teacher that are related to problem behaviors. The Perceived Function section asks the observer
to indicate the apparent function of a behavior. Finally, the Actual Consequences section asks the
observer to record the true consequence of the student’s behavior.
The Children’s Intervention Rating Profile (CIRP; Witt & Elliot, 1985) is a seven-item scale
scored on a 5-point Likert scale to assess the student’s perception of fairness and acceptability of
the intervention. The CIRP has been previously used in consultation research to assess intervention
acceptability (Colton & Sheridan, 1998; Murray et al., 2008) and provides a total score that served
as the primary measure of child acceptability.
The Consultant Evaluation Form (CEF; Erchul, 1987) is a 12-item scale administered to
consultees to evaluate the effectiveness of the consultant. Items are scored on a 7-point Likert scale,
ranging from 1 = Strongly Disagree to 7 = Strongly Agree. The CEF has been used in previous
consultation research with teachers and was found to have strong internal consistency (r = .83

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128 Gormley and Dupaul

for teachers and r = .89 for parents; Sheridan et al., 2001). The CEF total score was used as the
dependent measure regarding consultant effectiveness.
Consultation integrity checklists were developed for each of the three types of behavioral
consultation meetings (i.e., problem identification, problem analysis, and problem evaluation) to
ensure that the consultant followed a standard procedure with each teacher for each type of con-
sultation meeting. Consultation sessions were audiotaped, and 20% of the sessions were randomly
selected and coded for integrity by graduate students in school psychology. On average, consultants
completed 96.6% of the consultation goals appropriately.

Design
An AB, multiple-baseline, across-participants, multiple-probe design was used to answer the
research questions. All students began the first year in a baseline phase. The first student in each
group began the intervention phase following the stabilization of their baseline data. Subsequent
students began intervention following the completion of the prior student’s predetermined goal.
During Year 2, all students continued in the intervention phase. Probes using the BOSS recording
system (Shapiro, 2011) were conducted approximately once per week during all phases. This resulted
in 16 probes for Emily and 20 probes for Josh and James.

Procedure
Following informed consent, teachers and parents completed the ADHD Rating Scale–IV and
parents completed the Clinical Interview–Parent Report Form (Barkley, 1997) with the first author
by telephone to establish a diagnosis of ADHD. After the diagnosis had been confirmed, teachers
were contacted by the consultant (one of two graduate students in school psychology, including the
first author) to determine a mutually agreeable time to schedule a problem identification meeting.
During this meeting, teachers identified a specific target behavior that they wanted to change, and
a data collection system was created for teachers to track the target behavior. It should be noted
that although teachers collected data, this information was used for consultation procedures only
and is not reported as outcome data. This decision was made to ensure standard data collection
methodology across years, given the possibility of changes in the measurement system across years
based on teacher preferences.
During the baseline phase, teachers were instructed to continue their typical teaching practices.
For one student, Josh, the teacher had already begun an individualized intervention. Given that Josh
was still experiencing difficulties, his teacher was instructed to continue the intervention as designed
during the baseline phase. Teachers were instructed to not begin a new behavioral intervention during
this phase. BOSS observations were conducted by graduate students in school psychology blind to
the purposes and experimental conditions of the study. After achieving stable baseline data, the FAO
(O’Neill et al., 1997) was conducted to generate a hypothesis regarding the function of the target
behavior.
Next, during the problem analysis stage, the teacher and consultant jointly reviewed the collected
data, determined the sufficiency and adequacy of the data, and discussed the function of the problem
behaviors. The teacher then chose an intervention plan linked to the function of the problem behavior,
and the consultant provided training in the intervention, as necessary.
BOSS observations continued through the plan implementation phase. Similar to baseline,
IOA observations were conducted for 20% of the observations to ensure reliable data collection
procedures. Additionally, the consultant held brief (e.g., 15-minute) meetings as needed with the
teacher to problem-solve implementation difficulties. Plan evaluation meetings were conducted
approximately every other week to review student progress. During these meetings, the teacher and

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consultant determined whether the student’s goal had been met and decided to continue or modify
the intervention.
Given the ethical dilemma of withholding treatment from students in need of intervention, the
initial 6 participants were split into two cohorts. Participants 1 to 3 were in the first group and
participants 4 to 6 were in the second group, and the multiple baseline procedure for each group was
run concurrently The consultation and intervention phases for the second participant in each cohort
occurred following the attainment of the predetermined goal by the first participant in that cohort.
Cohorts were not retained for the second year of the study due to attrition (see the Participants and
Setting section).
Intervention was suspended after the conclusion of the first school year for the summer break.
After first-year data collection ended, the teacher completed the BIRS and CEF to assess intervention
acceptability. At the start of the following school year, the consultants contacted each student’s
previous teacher and their current teacher to schedule a TTC meeting. As previously described,
the goal of the TTC meeting was to facilitate the transfer of the intervention between teachers by
considering the previous teacher as an expert on the classroom implementation of the intervention.
A major goal of this initial meeting was to cultivate current teacher motivation to implement
intervention and make any necessary adaptations to allow the intervention to fit with the current
teacher’s style.
To achieve these goals, the Conjoint Needs Identification Interview (CNII) and Conjoint Needs
Analysis Interview (CNIA; Sheridan & Kratochwill, 2008) were combined and modified to facilitate
the transfer of the intervention between teachers. One modification made across the interview was
a focus on “Last Year” and the “Current Year” in place of “Home” and “School,” as found in the
CNII and CNAI. In general, the TTC meeting followed the outline of the CNII (i.e., Social Opening,
Open Up Dialogue, Discuss Child and Teacher Strengths, Discuss Goals and Desires, Select Needs,
Select/Define the Priority, and Select a Focus/Setting). Next, two sections from the CNAI were
completed (i.e., What is Happening; Why is it Happening?), followed by a combined section: What
Works/What Doesn’t/What to do Now? The final three sections (Collect Information, Meet Again,
and Closing) of the TTC interview were taken from the CNII (see Sheridan & Kratochwill, 2008,
for more detail regarding these interviews).
The stated goals of the TTC meeting included (a) identification and definition of the child’s
previous and current priorities, (b) identification of strengths of the child and teachers, (c)
highlighting the role of the new teacher in goal setting and decision making, (d) establishment of
a working relationship between the consultant and the new teacher, (e) validation of shared goals
of supporting the child by transferring knowledge and experience from teacher to teacher, and (f)
increase the communication and knowledge regarding the child between teachers.
Following the TTC meeting, the Year-1 teachers completed the BIRS to assess the process
acceptability of TTC. Additionally, interventions were re-implemented, including any modifications
indicated by the student’s new teacher for all students simultaneously. Problem evaluation meetings
again occurred on a bi-weekly basis with the same goals listed previously until all students achieved
behavioral functioning similar to the previous year. After all participants attained previous interven-
tion levels of functioning for three consecutive sessions, teachers were administered the BIRS and
CEF. Similarly, students were administered the CIRP to assess treatment and process acceptability.

Interventions
Emily. Emily’s teacher identified talking with peers during math lessons as her target behavior
because this interfered with instruction and Emily’s math achievement. Results of the FAO indicated
that this behavior was maintained by both peer and teacher attention. Based on this function teacher

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130 Gormley and Dupaul

request, a sticker chart was created such that if Emily called out two or fewer times during math
class, she received teacher praise and a sticker for that period. Her teacher declined a secondary
reinforcer and stated that the sticker and praise would be sufficient. During Emily’s second year,
her teacher utilized a classwide system that included working quietly as a target behavior. Emily
earned tokens for appropriate behavior that were redeemed for prizes. Given that Emily’s previous
intervention was included within this larger classroom system, no individualized intervention was
implemented during Year 2.

Josh. Josh was referred by his teacher because he would play with his chair (i.e., rock back
and forth, tip back in the chair) and play with items in his desk. However, baseline data collection
indicated that this was not a significant problem. The teacher then indicated that although behavior
during math had gotten significantly better due to a more enjoyable unit, Josh’s behavior during
independent reading continued to be problematic. Baseline data collection corroborated this report,
and the remaining data and intervention were conducted within the independent reading setting. This
change in setting is described in the Results section and can be seen in Figure 1. Results of Josh’s
FAO indicated that his off-task behavior was maintained by escape from the academic task in favor
of a preferred activity. To help maintain task engagement, a response-cost system was created such
that each time that his teacher needed to redirect Josh, he received a tally mark. At the end of the
period, if Josh had five or fewer tallies, he earned a sticker for that period. If Josh earned 75% of
available stickers, he earned a home-based reward (e.g., video game time). Specific targets included
remaining in his work area (sitting or standing within 2 feet of his desk) and appropriately (silently
or quietly) reading books. During the second year, this intervention was continued as originally
designed.

James. James was initially referred for property destruction during reading; however, this
behavior was not seen during baseline. During a follow-up meeting, his teacher reported that James
often would stop working and just sit at his desk, and this was sometimes accompanied by negative
statements (e.g., “This is stupid”). She further indicated that this was most problematic during the
morning writing period (see Figure 1). Results of the FOA indicated that his behavior was maintained
by teacher attention. A reinforcement system was created such that when the teacher observed James
working appropriately for approximately 3 minutes, she would provide a nonverbal signal to provide
immediate reinforcement (i.e., recognition that she noticed him working appropriately). Following
three occurrences during the period, James was provided with 2 minutes of one-on-one reading
with the teacher. During the second year, James’ teacher instituted a classwide system that included
on-task behavior and student recognition for appropriate behavior. Students received tickets for
appropriate behavior that could be used in a class raffle for prizes (e.g., lunch with the teacher).
Given that this system included the components of James’ previous intervention, no individual
intervention was implemented.

Data Analysis Plan

Direct observation data were visually analyzed for changes in level, trend, and the immediacy
of change across conditions. Further, the percentage of nonoverlapping data across phases was
calculated, and the improvement rate difference (IRD; Parker, Vannest, & Brown, 2009) was used
as an estimate of the effect size for each participant. Briefly, IRD is the improvement rate of the
intervention phase minus the improvement rate of the baseline phase. Each improvement rate is
calculated by dividing the number of improved data points by the total number of data points within
each phase. Within the baseline phase, a data point was considered improved if it was equal to
or greater than any point in the intervention phase. Within the treatment phase, a data point was

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FIGURE 1. Percent of intervals spent engaged (denoted by diamonds) and off-task (denoted by squares) across participants
and phases. Dotted lines represent setting and target changes. Solid lines represent changes in study phases. Outlier data are
labeled with specific circumstance on the given day of observation.

considered improved if it was greater than all data points in the baseline condition. The IRD results
in a percentage score and a confidence interval to provide an estimate of the treatment effect size
for each participant. To address the final research aims, mean treatment and process acceptability
scores are reported descriptively for each participant.
Based on visual analysis and data collector report regarding atypical classroom conditions,
certain data points were identified as outliers (see Figure 1). There were two atypical conditions that
coincided with the outlier data points identified with visual analysis: change in teacher and change
in typical structure. Emily and James both had one outlier data point in which the typical teacher
was not present. In both cases, data points were disparate from the greater trend observed without

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132 Gormley and Dupaul

that data point. Three data points were inconsistent with the greater pattern observed with Josh. Two
instances consisted of the teacher conducting one-on-one testing with a student in the classroom,
and therefore the behavioral contingencies were not in place during these observation periods (see
Figure 1, labeled "Reading free period"). The third data point identified as an outlier was collected
during a session in which the class was engaged in a craft activity loosely related to the book they
were reading and therefore represented a fundamentally different context relative to the typical data
collection period. Given these differences, IRD values are reported both with and without the outlier
data included.

RESULTS
The multiple probe results are presented for each participant in Figure 1. Specific intervention
results are presented separately by student. Next, improvement rate differences are reported. Finally,
BIRS, CEF, CIRP scores are presented.
Emily. During baseline, Emily’s level of engagement remained constant (M = 58.33%), with
some variability in her off-task behavior (M = 53.25%). On initiation of the intervention, there was
a clear improvement in Emily’s on-task behavior level (M = 79.29%, percentage of non-overlapping
data [PND] = 100%). Off-task behavior did not immediately decrease; however, following an initial
spike, these behaviors showed a negative trajectory until the final 2 weeks of data collection at the
end of the first school year. Overall, Emily’s off-task behavior during intervention (M = 33.17%)
was lower relative to baseline (PND = 71.43%).
During the second year of intervention, Emily’s on-task behavior was consistently high, with
the exception of a single outlier when a substitute teacher was present. Emily’s average engaged
time during the second year was 82.74% of intervals (PND = 85.71%). If the outlying data point is
excluded (see Figure 1, "Substitute Teacher"), average engaged time was 86.81% (PND = 100%).
With regard to off-task behavior, Emily’s second-year average was 16.37% of intervals (PND =
100%). If the outlier is removed, off-task behavior was exhibited in 13.19% of intervals.
Josh. Josh’s total baseline average of on-task behavior was 49.44% of intervals. Following
the setting change, engaged time steadily declined (M = 43.30%). Similarly, total off-task behavior
average (M = 56.25%) increased following the setting change (M = 59.37%). The initiation of
intervention was followed by an immediate increase in the percentage of engaged time (M =
80.42%, PND = 100%) and an immediate decrease in the percentage of off-task time (M = 34.72%,
PND = 83.3; off-task behavior following the setting change only, PND = 100%).
Following the summer break, Josh’s engaged time showed significant variability (M = 58.10%,
PND = 42.86%); however, the majority of this variability was explained by atypical classroom
situations (e.g., "Reading free periods" and a language arts "Craft," see Figure 1). If outliers are
removed, Year 2 behavior observations are similar to those from the first year (M = 73.56%,
PND = 75%). Estimates of PND are further improved if the data following the setting change is
removed (PND = 100%). Similarly, off-task behavior during the second year of intervention was
highly variable (M = 36.31%, PND = 71.43%). With outliers removed, the off-task percentages
approximate the first intervention phase (M = 22.92%, PND = 100%).
James. James’s baseline average of intervals, including engaged (M = 52.38%) and off-task
(M = 47.31%) behavior, were initially unstable. Following a setting and target change, both
engagement (M = 47.92%) and off-task (M = 56.23) behaviors stabilized. After intervention was
implemented, there was an immediate change in both engaged (M = 73.45%, PND = 100%) and
off-task (M = 37.50%, PND = 0%) behavior levels. If only the data following the target and setting
change is considered, PND for off-task behavior increases substantially (PND = 75%). During the

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Table 2
Combined Improvement Rate Difference Values and Confidence Intervals (.95) Across Behaviors, Participants,
and Data Type)

Engaged Off-Task Total

Emily
All 0.50 0.60 0.55
(0.0–1.0) (0.1–1.0) (0.2–0.9)
Outlier 1.00 0.60 0.80
(1.0–1.0) (0.1–1.0) (0.5–1.0)
Josh
All 0.19 0.34 0.27
(–0.2 to 0.6) (0.0–0.6) (0.0–0.5)
Setting 0.27 0.39 0.33
(–0.1 to 0.7) (0.0–0.7) (0.0–0.6)
Set/Out 1.00 1.00 1.00
(1.0–1.0) (1.0–1.0) (1.0–1.0)
James
All .42 –0.2 0.13
(0.1–0.7) (–0.6 to 0.2) (–0.1 to 0.4)
Setting 0.50 0.51 0.50
(0.1–0.9) (0.1–0.9) (0.2–0.8)
Set/Out 1.00 0.75 0.88
(1.0–1.0) (0.4–1.0) (0.7–1.0)

Note. All = all data points included; Outlier = outlier removed; Setting = data before setting change removed; Set/Out =
data before setting change removed and outlier removed.

second year, James’s engaged (M = 74.47%, PND = 88.89%) and off-task (M = 22.60%, PND =
66.67%) behaviors were very similar to the first year intervention phase levels. If the outlying data
point is removed, both engaged (M = 79.10%, PND = 100%) and off-task (M = 17.15%, PND =
75%; PND = 100% with only data after setting change) behavior improved.
Improvement Rate Difference. In additional to traditional visual analysis and PND calcula-
tions, IRDs were calculated (Parker et al., 2009). Given the variability of the data in the current
study, IRDs were calculated for various combinations of the data. Specifically, IRDs were calculated
using all the data for a given participant, with outliers removed, and with outliers removed and using
baseline data only following a setting change. Using all data points for all students, overall IRDs
ranged from 0.13 (James) to 0.55 (Emily). Conversely, if outliers are removed and baseline data only
after a setting change are used, IRDs range from 0.80 (Emily) to 1.0 (Josh). Further, IRD values
across years were very consistent for engaged behavior (i.e., 1.0 using final data for all participants).
Off-task IRDs showed more variability between years for Emily (0.21, Year 1; 1.0, Year 2) and
James (0.42, Year 1; 1.0, Year 2). IRDs for all participants are presented in Table 2.
Acceptability. Following the end of the first and second year, the classroom teacher completed
the CEF to evaluate the consultant. Scores ranged from 5.58 to 7.00 (M = 6.29), suggesting that
interactions with the consultants were highly acceptable. Teachers also completed the BIRS, modified
to rate satisfaction with the consultation procedure. Scores on this measure ranged from 4.08 to 5.88
(M = 4.96), suggesting that teachers found the TTC procedure helpful and acceptable. Additionally,
each teacher completed a BIRS with regard to the specific intervention implemented during the

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Table 3
Consultant, Process, and Intervention Acceptability

Emily Josh James Totals

Teacher 1 2 1 2 1 2 1 2 Overall

CEF 6.75 7.00 6.17 6.00 6.25 5.58 6.39 6.19 6.29
BIRS Cons. 5.33 5.88 4.96 4.08 4.71 4.83 5.00 4.93 4.96
BIRS Inter. 5.13 5.88 4.96 4.38 5.00 5.25 5.03 5.17 5.10
CIRP 6.29 4.43 6.14 5.62

Note. CEF = Consultant Evaluation Form (scores range from 1–7); BIRS Cons. = Behavioral Intervention Rating Scale:
Consultation Version (scores range from 1–6); BIRS Inter. = Behavioral Intervention Rating Scale: Intervention Version
(scores range from 1–6). CIRP = Children’s Intervention Rating Profile (scores range from 1–7).

school year. Scores on this measure ranged from 4.38 to 5.88 (M = 5.10), demonstrating moderate
to high levels of satisfaction with individual interventions. Finally, at the close of the study, students
completed the CIRP to provide their perspective regarding the intervention. Scores ranged from 4.43
to 6.29 (M = 5.62), demonstrating moderate to high levels of student acceptability for the strategies
employed to assist them in the classroom. Acceptability rating data are presented in Table 3.

DISCUSSION
The purpose of the current study was to (a) demonstrate the utility of behavioral consultation
to identify and address the behavioral difficulties of students with ADHD and (b) determine whether
TTC can maintain the obtained gains across a grade-level transition. Further, this study investigated
the acceptability of the TTC process and the resultant interventions from the perspective of teachers
and students. The current study found that interventions designed in the context of behavioral
consultation were effective in improving all three students’ on-task behavior and reducing their
off-task behavior. Further, the TTC procedure was able to maintain these gains across a grade-level
transition, and all interventions and procedures were rated as acceptable by teachers and students.
These findings replicate previous research demonstrating the effectiveness of consultation
procedures for students with ADHD (Colton & Sheridan, 1998; Murray et al., 2008; Sheridan et al.,
2001). The current study extends this literature by demonstrating the utility of a new variant of
consultation (i.e., TTC) at maintaining student gains. Additionally, the process of TTC and the
resultant interventions were rated highly by participants, commensurate with previous research
(Sheridan et al., 2001; Sheridan & Kratochwill, 2008).
Relative to Sheridan et al. (2001), the results of the current study indicate higher teacher inter-
vention satisfaction, lower process satisfaction, and equivalent consultant satisfaction. The higher
intervention satisfaction can be explained by Emily and James’s second-year teacher’s ratings. These
higher scores were expected, as these teachers were essentially rating their previously existing class-
wide system. The lower process satisfaction scores are difficult to interpret relative to previous
research. Specifically, to the authors’ knowledge, the TTC procedure has not been previously stud-
ied. It is possible that this procedure is less acceptable relative to more traditional behavioral
consultation or conjoint behavioral consultation because it is outside of teachers’ typical expecta-
tions for consultation. Additionally, first-year teachers may feel some level of discomfort telling a
subsequent year teacher how to effectively manage a student. Similarly, second-year teachers may
find the process of another teacher providing unsolicited input on their own classroom practices less
acceptable relative to strategies provided by a school psychologist following a specific request for
assistance.

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 Teacher-to-Teacher Consultation 135

Broadly, these results are the first to demonstrate the utility of a consultation procedure specif-
ically intended to maintain behavioral gains from one school year to the next. This type of service
delivery is necessary, given that the behavior of students with ADHD has been shown to return to
baseline levels following the removal of an intervention. For example, Shelton and colleagues (2000)
conducted a 2-year follow-up study comparing kindergarten students who received classroom-based
interventions and those who did not. Despite initial differences between groups at the end of the
intervention, data from the 2-year follow-up indicated no significant differences between groups.
Similarly, longitudinal follow-up of the MTA cohort has found that initial group differences have
become nonsignificant, with ratings of symptom severity for all groups slightly increasing over time
(Jensen et al., 2007; Molina et al., 2009).

Implications for Practice

Although we are unaware of any research to demonstrate this, anecdotal reports suggest that
there is little, if any, transition planning for students who experience behavioral difficulties due to
ADHD but do not have an Individualized Education Plan or Section 504 Plan. Often, a general
warning about a student may be provided (e.g., "They’re a handful!"), but specific strategies are
rarely outlined. Given the chronic nature of ADHD, the TTC procedure will provide a structure in
which the student’s new teacher will be able to gain specific insights into the behavioral difficulties
of a student. Similarly, teachers will be provided with firsthand experience regarding interventions
that were successful for the student during the previous year. Additionally, the TTC procedure
provides a context in which a consultant can begin a collaborative relationship with the new teacher
regarding the target student. Collectively, and most important, the procedure provides a mechanism
for continuous and effective service delivery to students who are likely to struggle without supports.

Limitations
Despite the promising initial outcomes of this study, there are several limitations that should
be taken into account. First, the number of outlying data points makes interpretation more difficult.
The presence of substitute or student teachers resulted in lower engaged time and higher off-task
levels (Emily and James). Additionally, two second-year data points for Josh were collected during a
reading-free period in which there was minimal teacher supervision and rule enforcement. Given the
lack of rule enforcement, it is not surprising that his behavior returned to baseline levels. Although
unplanned, these data points can be interpreted as analogous to a reversal condition. Regardless,
Josh’s response to the second-year intervention phase would have been better demonstrated with
additional data points of typical instruction. Although not ideal, data collection was ended prior
to gaining these additional data points due to the proximity to winter break and the atypicality of
classroom instruction after the final point.
Further, although all teachers were asked to collect their own data and decision-making was
conducted in part using these data, reliance on graduate student data collection limits external validity.
It is unclear whether the procedure would have been as effective using only teacher-collected
data. Additionally, integrity data were not systematically collected for teachers’ implementation
of interventions. Available data suggest that teachers implemented the interventions consistently,
and the positive impact of the interventions indicates that teachers delivered the intervention with
sufficient integrity; however, this conclusion is speculative.
Another limitation is the short duration of certain phases. Specifically, Emily’s baseline con-
dition was relatively short (i.e., 2 weeks), represented by only two researcher-collected data points.
Although not reported, teacher-collected data were used to inform the transition between Emily’s

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136 Gormley and Dupaul

baseline and treatment conditions, and these data indicated a stable pattern of behavioral perfor-
mance. However, the lack of availability of these data for this report limits the findings.
Additionally, all three participants in the current study were Hispanic elementary students
attending the same school. It is unclear whether the interventions and procedures would be as effective
for children of different ages and ethnicities. With regard to students’ ratings of acceptability, the
CIRP was not completed following the first year of intervention. These ratings would have provided
useful information regarding the specific interventions used each year. Further, the data could be
informative in practice to determine the impact of program modifications over time and different
intervention types (e.g., individual vs. classwide).
Finally, the interpretation of TTC’s effectiveness is made more difficult given that two students
transitioned into rooms with effective behavior management systems. However, this type of transition
is likely to naturally occur within school settings, given that nearly 70% of general education teachers
indicate they usually or always use a classroom-level behavior support or management plan, with
94% indicating that such practices are important or very important (Gable, Tonelson, Sheth, Wilson,
& Park, 2012). Further, although the classroom-level intervention hinders interpretation, in both
cases, the classroom systems in place encompassed the specific needs of the target student. For
example, Emily’s initial behavior management plan centered on reinforcement for working quietly;
in her second classroom, the classwide system included reinforcement for working quietly. Given
that the framework of TTC encourages the modification of interventions between years to fit with
the new classroom culture and context, the assumption of a previous target within the classwide
system is expected and encouraged.

Directions for Future Research

Given the limitations of this study, several directions for future research are indicated. First,
to better demonstrate the external validity of the TTC procedure, the present results should be
replicated with a larger and more diverse sample. Similarly, future studies should rely more heavily
on teacher-collected data to enhance external validity and demonstrate the utility of this procedure
within the school setting. Finally, additional studies should document student acceptability after
each school year to gain additional insight into the effect of modifications.
To further demonstrate the efficacy of the TTC procedure, future studies should more care-
fully select the contexts in which data collection occurs. Specifically, data collection should focus
on typical classroom situations and avoid atypical activities (e.g., reading-free periods). Further,
teacher implementation data should be systematically collected to more fully demonstrate that the
intervention procedures are responsible for the student’s behavior.
The lower process acceptability scores relative to previous consultation research should be
further explored. Future research could utilize qualitative methods to explore teacher perspectives
regarding the positive and negative aspects of the TTC procedure, specifically addressing the extent
to which the TTC procedure differed from their initial expectations of consultation. Additionally,
teachers should provide feedback regarding how to make the procedure more acceptable and efficient.
Larger scale studies could also document existing teacher relationships, as this may impact the
acceptability of the TTC procedure. Specifically, teachers who have a positive relationship with a
high level of mutual respect may rate the process more highly relative to teachers with a negative or
neutral relationship.

CONCLUSION
Overall, the results of the present study are encouraging but indicate a need for additional
research. Specifically, the current results demonstrate that a consultation procedure (TTC) designed

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 Teacher-to-Teacher Consultation 137

to maintain the behavioral gains of students with ADHD across a grade-level transition is an effective
and acceptable service delivery model. These results have direct applications for school psychologists
working with teachers to improve outcomes for children with ADHD. Future research should seek
to address the methodological limitations of this study and extend the application of TTC to broader
populations.

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