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Date: 12 Aug 2008

Parent Consent for Son or Daughter to Participate

Dear Parent or Guardian

We would like to ask your permission for your son or daughter to help us assess the efficacy of
this Multi-modal Intervention Program for Children with ADHD. The program will enable us to
see if these (below mentioned) kind of interventions will help the children to improve their
reading, writing, math skills and over all classroom performance.

Process

Initial Screening: You will receive some forms to describe the behaviors of your son/daughter in
school setting, that you have observed or are aware of. The teachers will also receive similar
forms and will report about the behaviors of your son/daughter they observe in the school setting.
I will also go and observe your son/daughter and will fill-out the similar forms.

Initial Evaluation: If your son/daughter will be found eligible to be a part of the main
intervention program, he/she will be tested on some basic intelligence test. Based on overall
results, he/she will be enrolled in one of the three groups. All the students, in group 1, 2 and 3
will be tested on some psycho-educational evaluations to assess their current level of academic
performance and behavior in school setting. You and the teachers will also fill-out the
questionnaire again related with behaviours, before the intervention period.

Main Interventions: Based on the results of the screening and evaluation, students assigned to
the group 1 will receive the interventions for 6 months to improve their behaviors and class room
learning and performance. Teachers and you will also receive some training to deal with the
behaviour problems. Students in group 2 and 3 will not receive direct interventions.

Post Study Evaluation: All the students will be tested again on the same psycho-educational
assessment to assess the change in their performance and behavior in school setting, after six
months. You and the teachers will also fill-out the questionnaire again related with behaviours.

Proposed Intervention Program: It will consist of a total of 72 sessions of approximately, 1 hour

each, across the span of 6 months, which will provide training to the students in the areas of
reading writing and math. You as a parent/ guardian will also be a part of the training program.
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You will have to attend a total of 6/8 sessions of one hour each, across the 6 months. Your
training will comprise of home based strategies to manage the attention deficit hyperactive
behaviors.

School teachers will be contacted and will be provided some training on the strategies to deal
with attention deficit hyperactive behaviors in the classroom setting for a total of 5 sessions.

For the interventions, the child and you will have to come to the City Library on the assigned
days.

Potential Benefits and Concerns: You may or may not benefit by the program. One possible
benefit will be the better classroom performance of your son or daughter, as well as less
problematic behaviors at school and home. The possible concern may be mild tiredness or fatigue
similar to the fatigue experienced after one hour of home work assignments.

Participation is completely voluntary and you may decide not to join or to leave the program in
the middle if you chose to. There will not be any kind of penalty on you in that case. The study is
a part of doctoral research and is approved by the school of your child.

Not a Special Education Assessment: Please note that this is not a school based assessment and
the results will not be shared with the school professionals to determine special education
eligibility.

Liability: There is no fee or any financial liability on you, if you chose to participate in the
program. The transport arrangement to and from your house to the library will have to be
arranged and paid for by you. The project will not arrange or pay for any kind of transportation.
Although there is no possible danger due to the project, if any accident or injury occurs to you or
your child at the venue during the intervention schedule, no medical and related expenses will not
be paid by the project; and you or your insurance company will have to pay for the bills and
expenses.

Information is Confidential: All information will be held confidential as is legally possible. All
the intervention documents and the forms will carry the number assigned to you child and not the
name, city or the name of the school. Only the researcher will see the final documents where the
names are mentioned. After the completion of the project, all names will be removed from all the
documents, so that the number can not be connected to any name or personal situation.
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Questions: We would appreciate if you would return the form on the back of the page whether or
not you would like your on or daughter to participate, so that we know that information has
reached you. You may keep the attached copy of the letter for your records. For all the questions
or concerns, please feel free to contact principal researcher, Parul Saxena at 843-441-4084 or
parulsaxena2006@gmail.com.

Thank You for your consideration.

Sincerely

Parul Saxena
Ph.D. Student
ALUW, Coimbatore India.
Current Address: 609, S Lafayette Street
Hemingway, SC 29554.
Ph: 843-441-4084

For the PhD Research Work- study about children with ADHD
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Please check the appropriate statements and send it back to the school in the attached
envelop. Please do not write your name on the envelop to maintain confidentially and you
may simply drop at the front office of the school.

____ I have read and I understand the permission letter.

____ I give consent for my son/ daughter (name) _____________________ to participate

in the study.

____ I have received a copy of Ms Saxena’s letter for my records.

____ I would like to have more information before giving my consent.

____ I have explained this letter to my child.

____ My child gives consent to participate in the study.

____ I do not want my son/ daughter to participate in the study.

____ My child doesn’t want to participate in the study.

Parent’s Name: (print) ___________________________________ Date: ____________

Signature : ______________________________________

Student’s Name: (print) __________________________________ Date: ____________

Signature : ______________________________________