children
Article
Universal Design for Learning for Children with ADHD
Alessandro Frolli 1, * , Francesco Cerciello 1 , Clara Esposito 1 , Maria Carla Ricci 2 , Rossana Pia Laccone 1
and Fabio Bisogni 1
Citation: Frolli, A.; Cerciello, F.;
Esposito, C.; Ricci, M.C.; Laccone,
R.P.; Bisogni, F. Universal Design for
Learning for Children with ADHD.
Children 2023, 10, 1350. https://
doi.org/10.3390/children10081350
Academic Editor: Jun Kohyama
Received: 11 July 2023
Revised: 24 July 2023
Accepted: 2 August 2023
Published: 4 August 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Children 2023, 10, 1350. https://doi.org/10.3390/children10081350
1 Disability Research Centre of Rome University of International Studies, 00147 Rome, Italy;
francesco.cerciello@unint.eu (F.C.); clara.esposito@unint.eu (C.E.); rossana.laccone@gmail.com (R.P.L.);
fabio.bisogni@unint.eu (F.B.)
2 FINDS—Italian Neuroscience and Developmental Disorders Foundation, 81040 Caserta, Italy;
m.ricci@unint.eu
* Correspondence: alessandro.frolli@unint.eu; Tel.: +39-347-4910178
Abstract: Attention Deficit–Hyperactivity Disorder (ADHD) is a psychiatric condition that shows
developmentally inappropriate levels of inattention, hyperactivity, or impulsivity. Symptoms begin
at a young age and usually include a lack of attention, poor concentration, disorganization, difficulty
completing tasks, forgetfulness, and losing things. It is important to diagnose and treat the disorder
at a young age so that the symptoms do not persist into adulthood and cause other comorbid
conditions. Learning difficulties, motor impairment, anxiety, or depressive disorders may occur
with this condition. To improve the academic careers of children with ADHD, we focused on a
specific innovative educational approach (Universal Design for Learning) that could improve basic
learning skills (reading, writing, and arithmetic skills) to prevent or manage any learning difficulty
that could occur with ADHD. The Universal Design for Learning is an individualized approach that
combines current neuroscientific knowledge, creating personalized teaching based on the strengths
and weaknesses of the student. The goal of this study is to analyze the impact that this approach has
on basic learning abilities. We found that both interventions led to improvements in test performance,
indicating that interventions were necessary to enhance reading, writing, and arithmetic skills.
Furthermore, the group that received an educational intervention based on Universal Design for
Learning demonstrated a more significant improvement in these areas. Additionally, we propose that
the set of techniques implemented by teachers in the classroom helped children to read, write, and
perform math tasks correctly and more fluently.
Keywords: Universal Design for Learning: learning; ADHD; hyperactivity; impulsivity; teaching
1. Introduction
Attention Deficit–Hyperactivity Disorder (ADHD) is a psychiatric condition that has
long been acknowledged as having an impact on children’s functioning. Individuals af-
fected by this disorder exhibit levels of inattention, hyperactivity, or impulsivity that are not
developmentally appropriate. Symptoms typically manifest at an early age and commonly
include a lack of attention, poor concentration, disorganization, difficulty completing tasks,
forgetfulness, and misplacing items. Diagnosing and treating the disorder early in life
is crucial to prevent the persistence of symptoms into adulthood, which can lead to the
development of other comorbid conditions [1]. ADHD is a prevalent psychiatric disorder
that primarily affects children and adolescents. Due to its diverse nature as a developmental
disorder, its exact causes remain unclear, leading to biased and extensive diagnostic assess-
ments involving traditional clinical interviews and behavior evaluations [2,3]. In children,
ADHD is characterized by hyperactivity, which results in an inability to control impulses
and attention deficits that minimally impact their social engagement and daily activities.
As individuals with ADHD transition into adulthood, they may encounter challenges
related to time management, organization, goal-setting, and maintaining employment.
https://www.mdpi.com/journal/children
Children 2023, 10, 1350 2 of 15

These difficulties can further complicate relationships, lower self-esteem, and potentially
lead to addiction. ADHD is the most common neurodevelopmental disorder in childhood,
affecting approximately 4–8% of children worldwide [2]. The prognosis of ADHD is often
complicated by the presence of comorbidities, and impairments may worsen during ado-
lescence or adulthood [4,5]. The treatment for ADHD is typically multimodal, involving
a combination of approaches, such as medication, psychoeducation, and psychological
interventions [6]. However, the current multimodal approach has certain limitations [7].
One significant challenge is motivating individuals with ADHD to engage consistently in
their treatment [8]. Additionally, psychotherapies can be costly [9], and there is often a
high risk of dropout [10,11]. ADHD is associated with psychosocial functional impairment
and significantly reduced subjective health-related quality of life [12,13]. Children with
ADHD are about four times less likely to graduate from university compared to their peers
and tend to have a lower socioeconomic status on average [14]. They often experience
conflictual relationships with parents, siblings, peers, and partners [12,14]. Their risk of
delinquency is increased by a factor of two–three [14,15]. Approximately 75% of indi-
viduals with ADHD have an additional mental disorder, and about 60% have multiple
comorbid mental disorders, which can impact prognosis and require specific therapeutic
interventions [16]. Specifically, learning difficulties (e.g., in reading, writing, and arith-
metic), motor impairments, anxiety disorders, and oppositional defiant behavior may occur
early in childhood development in comorbidity with ADHD [17,18]. It is important to
differentiate the difficulties that may arise regarding academic skills from the presence
of a specific disorder (Specific Learning Disorder) or simply general difficulties. Specific
Learning Disorder (SLD) is a neurodevelopmental condition with biological origins that
mainly impacts academic skills, such as writing, reading, and mathematical abilities. It
typically emerges during the school years, even when individuals possess adequate in-
tellectual capabilities [19,20]. Several studies focusing on school-aged children with both
ADHD and SLD have revealed neuropsychological challenges across various domains,
particularly executive functions [21,22]. Specifically, children with ADHD demonstrate
significant difficulties in response inhibition and working memory [23–27] while those
with SLD exhibit deficits in central executive functioning [28,29], especially concerning
working memory [30]. In recent years, the role of inhibition and shifting has garnered
increased attention [31]. Nevertheless, only a limited number of studies have thoroughly
examined the distinct neuropsychological profiles of children with ADHD and SLD. For in-
stance, some authors [32] demonstrated that individuals with reading difficulties displayed
more pronounced impairments in rapid automated naming, phonemic awareness, working
memory, and verbal reasoning when compared to those with ADHD. Another study [33]
identified specific impairments in impulse control and inhibition among children with
ADHD while those with SLD exhibited deficits in phonological level, verbal short-term
memory span, and verbal IQ. Studies focusing on graphomotor functioning in children with
ADHD have consistently reported that their handwriting tends to be illegible, error-prone,
and less organized compared to children without ADHD. These handwriting difficulties,
in turn, have a negative impact on their academic performance [34,35]. Researchers have
employed digitizing technology, such as computer tablets, along with kinematic analysis of
handwriting movements. The kinematic analysis involves examining various variables,
such as time, acceleration, speed, and their derivatives, to provide objective and quantifi-
able markers for investigating handwriting in individuals with ADHD [36]. This form
of analysis is particularly relevant in graphomotor research concerning individuals with
ADHD, as their poor handwriting is not solely attributed to visual–perceptual or linguistic
challenges. Instead, it is believed to be linked to fundamental aspects, such as the regulation
of force, speed, and size of movements; motor control; and timing of movements [37,38].
By using digitizing technology and kinematic analysis, researchers can gain deeper insights
into the underlying motor control issues contributing to the handwriting difficulties ex-
perienced by children with ADHD. Aligned with this interpretation, certain researchers
propose that individuals, both children and adults, with ADHD might encounter delays
Children 2023, 10, 1350 3 of 15

in procedural learning and the automatization of skills, such as handwriting and reading.
These skills require sustained attentional control and dedicated practice over an extended
period [39]. There is evidence to support this perspective. In a particular study, researchers
utilized a serial motor sequence learning task to explore implicit learning in children with
ADHD [40]. The results indicated that children with ADHD exhibited a distinct rate of
learning compared to the control group while performing motor sequences. Specifically,
they demonstrated reduced priming effects, and these differences could not be attributed
to poor perceptual-motor abilities. To address the symptoms and impairments experienced
by elementary school students with ADHD, three distinct intervention types have been
implemented: behavioral strategies, self-regulatory strategies, and academic strategies [41].
Behavioral interventions aim to replace socially undesirable behaviors (e.g., shouting) with
socially appropriate behaviors (e.g., working quietly). From a behavioral perspective, each
behavior must be understood within the context of its antecedents and consequences [42].
Self-regulation interventions aim to enhance student’s ability to exercise self-control in
environments where they experience functional impairments. These interventions typically
involve teaching students to identify and record a target response, potentially reinforcing
improved performance or accurate recording [43]. In contrast to behavioral and self-
regulatory interventions that target ADHD symptoms, academic intervention strategies
focus on addressing the functional impairments associated with symptoms. Specifically,
these interventions aim to enhance the development of literacy and numeracy skills and im-
prove academic task performance [41]. More precisely, an innovative pedagogical measure
that could be beneficial in this context is Universal Design for Learning (UDL). UDL is an
instructional design framework developed by the Centre for Applied Special Technology
(CAST) that aims to create an educational environment that is accessible and beneficial to
every student, regardless of their individual learning needs or disabilities. By incorporating
UDL principles, educators can tailor their teaching methods and materials to accommodate
a wide range of learners, promoting equal access to knowledge and fostering student
engagement and success [44]. UDL is an educational approach that focuses on adapting
and flexibly accommodating education and communication to cater to a wide range of
cognitive profiles, cultural backgrounds, and sensory functioning. It is a theoretical frame-
work that strives to design curricula that meet the needs of students from the outset of their
learning journey and make the education system more inclusive and individualized [45].
Universal Design for Learning (UDL) originated from the concept of Universal Design
in architecture (UD), which focuses on designing buildings and infrastructure to ensure
access for all individuals, including those with disabilities [46]. In the context of education,
UDL represents an approach that aims to enhance access, participation, and progress for
all students, including those with disabilities, within the general curriculum [47]. The
UDL framework is grounded in contemporary neuroscience research and current learn-
ing theories, utilizing digital technology to create a flexible education environment that
removes barriers for learners [45]. Neuroscience reveals that each human mind is unique,
with distinct differences in anatomy, chemistry, and physiology. Learning occurs through
intricate communication within and between three primary networks in the brain: affective
networks related to motivation and engagement, recognition networks contributing to
information perception and knowledge transformation, and strategic networks involved
in planning and organizing procedures and skills [48]. This aligns with educational theo-
rists such as Vygotsky and Bloom, who identified three domains of learning: emotional,
cognitive, and skills. The UDL framework provides a customizable structure to design
educational programs that cater to the diverse needs of individual learners [49]. It is guided
by three core principles: engagement, representation, and action and expression. The
engagement principle focuses on strategies to increase student motivation by providing
meaningful choices, promoting self-regulation, and offering diverse forms of feedback,
including self-assessment and mastery-oriented feedback. Representation involves pre-
senting information in various ways, making it accessible to all students through multiple
media, languages, and pedagogical approaches that prioritize checking understanding
Children 2023, 10, 1350 4 of 15

and message clarity. The action and expression principle emphasizes alternative methods
for students to acquire and practice knowledge and skills, utilizing assistive technologies,
varied control schemes, and flexible teaching approaches to accommodate individual stu-
dent needs, such as adjusting text speed or implementing alternative strategies for task
completion. Globally, UNICEF [50] has identified the need for better training of educators
to include students with disabilities in classrooms, highlighting the necessity of training
educators in effective frameworks and practices proven to be effective in teaching students
with disabilities in inclusive settings, including UDL. Therefore, it is crucial to translate
and disseminate UDL principles on a global scale to support inclusive practices. Already,
countries such as Canada, Australia, South Korea, and Portugal have embraced the UDL
principles and guidelines, demonstrating its growing acceptance and implementation
worldwide. The CAST Institute has translated these principles and guidelines into various
languages, including Arabic, Chinese, and others, making them accessible on their website.
Given the heterogeneity of studies and the multimodal nature of interventions that can be
conducted for individuals with ADHD, exploring the potential effects of an educational
model based on general principles that can be adapted to the skills and characteristics of
each student is of great interest. Can an innovative educational approach such as Universal
Design for Learning be more efficient than traditional didactics concerning the automation
of reading, writing, and calculation skills in children with ADHD? Ultimately, this study
aims to compare two teaching strategies (traditional inclusive educational strategies and
Universal Design for Learning) among a sample of 3rd-grade elementary school children
with ADHD and examine the effects of these approaches on their academic and learning
abilities.

2. Materials and Methods

2.1. Participants
In this study, we examined a group of 60 individuals diagnosed with Attention Deficit–
Hyperactivity Disorder (ADHD) starting from the third year of primary school. These
subjects were divided into two groups, each consisting of 30 individuals. All participants
were selected from five primary schools in Caserta, Italy, and came from similar socio-
cultural backgrounds in terms of their parents. The family and environmental context did
not influence educational attainment in either group. The inclusion criteria for the study
were as follows: (a) belonging to the same class level (third grade), (b) having a diagnosis
of ADHD without any additional comorbidities as determined by the Kiddie Schedule for
Affective Disorders and Schizophrenia (K-SADS) [51], (c) possessing an IQ ranging from 95
to 105 as assessed by the Wechsler Intelligence Scale for Children (WISC-IV) [52,53], and
(d) belonging to a medium–high socio-cultural class, as evaluated by the SES scale [54].
After confirming the inclusion criteria for the sample, the subjects were randomly assigned
to two experimental groups, each consisting of 30 individuals. Both groups shared the
same inclusion criteria and did not differ significantly in terms of socio-cultural factors.
The first experimental group (GR2) comprised 30 subjects with an average age of 8.32 (SD
0.43) and an average SES index of 7.10 (SD 0.62), including 14 males and 16 females. The
control group (GR1) consisted of 30 subjects with an average age of 8.29 (SD 0.39) and an
average SES index of 7.21 (SD 0.68), including 17 males and 13 females. More detailed
information can be found in Table 1. To assess academic skills, we employed the following
tests: Test MT, Battery for the Evaluation of Writing and Spelling Skills (BVSCO-2), and Test
AC-MT 6-11. These tests were administered twice: the first assessment (T0) took place four
months after the start of the school year, and the second assessment (T1) was conducted
at the end of the school year. Additionally, we used the Wechsler Intelligence Scale for
Children (WISC-IV) to assess the participants’ IQ levels [52]. Teachers also completed the
Child Behavior Checklist to evaluate the emotional–behavioral profile of the participants.
After the initial assessment, both groups received two different types of interventions,
lasting for five months. The data were collected and analyzed at the FINDS Neuropsychiatry
Children 2023, 10, 1350 5 of 15

Outpatient Clinic by licensed psychologists in collaboration with the Rome University of

International Studies (UNINT).

Table 1. Description of the sample.

All Gr1 Gr2

N 60 30 30
Male (number) 31 17 14
Age (years) 8.30 (0.39) 8.29 (0.39) 8.32 (0.43)
Sociocultural background (SES) 7.15 (0.60) 7.21 (0.68) 7.10 (0.62)
Comorbidities (K-SADS) Absence Absence Absence
Intelligence (WISC-IV) 97.46 (1.08) 96.48 (1.09) 98.44 (1.12)

As shown in Table 1, the two groups are comparable in terms of gender, age, socioeco-
nomic background, absence of psychopathologies, and IQ.

2.2. Instruments
The protocol used consists of the following tests:
SES: a self-administered questionnaire was utilized to gather information regarding
the educational level and profession of the parents. This questionnaire also indicated the
individual or family’s position within the social system [54].
WISC-IV: The participants’ IQ levels were assessed using the Wechsler Intelligence
Scales [52,53]. These scales are comprehensive intelligence assessment tools that provide a
synthesized measure of intellectual ability. They generate various indices to assess different
aspects of cognitive functioning:
1. Global IQ Index: This index represents an overall measure of general intellectual ability,
taking into account various cognitive skills and abilities;
2. Verbal Comprehension Index (ICV): This index assesses verbal reasoning ability, includ-
ing comprehension and verbal expression based on previously acquired information;
3. Visuo-Perceptive Reasoning Index (IRP): This index evaluates perceptive reasoning
abilities, such as the ability to analyze visual information and solve visual puzzles;
4. Index of Working Memory (IML): This index measures the capacity to retain and uti-
lize information within short periods. It involves tasks that require holding and
manipulating information in memory;
5. Processing Speed Index (IVE): This index assesses the speed at which individuals can
process information efficiently, particularly in timed tasks.
These indices provide a comprehensive and detailed profile of the participants’ cog-
nitive abilities, allowing for a better understanding of their intellectual strengths and
weaknesses. The Wechsler Intelligence Scales are widely used in clinical and educational
settings to assess cognitive functioning and help tailor interventions and support based on
individual needs.
CBCL: to evaluate the emotional-behavioral profile, the Child Behavior Checklist was
administered, and completed by the teachers. This checklist assesses the profile of children
and adolescents, specifically those aged between 1 12 –5 and 6–18, based on the diagnostic
criteria outlined in the DSM-IV [55].
Test MT-3 Clinic: to measure reading and comprehension skills from primary school to
the second year of secondary school [56], the Test MT-3 Clinic was administered.
BVSCO-2: to evaluate all aspects involved in the learning path of writing: graphism,
spelling competence and the production of written text [57], the BVSCO-2 was adminis-
tered.
AC-MT 6-11: for the assessment of numerical and computational skills including
tests of calculation and writing and recovery of arithmetic facts [58], the AC-MT 6-11 was
administered.
Children 2023, 10, 1350 6 of 15

2.3. Procedures
After a period of 4 months from the commencement of the school year, we conducted
assessments of the student’s academic skills and emotional profiles using the MT-3 Clinic,
BVSCO-2, AC-MT 6-11 tests, and the CBCL. Following this initial assessment, interven-
tions were provided to the two groups as follows: the control group (GR1) received a
specialized inclusive teaching approach of the traditional type. This approach involved
implementing strategies commonly used for managing children with ADHD. These strate-
gies included structured programming of activities in the classroom, combining various
behavioral techniques, such as positive reinforcement, extinction, time out, and token econ-
omy. Additionally, time and school environment were organized, changes were monitored,
and specific objectives were set. The management of classroom spaces and sources of
distraction included providing clear and concise instructions. The experimental group
(GR2) underwent the Universal Design for Learning, an innovative educational approach
that allows for a high level of customization in the teaching proposal. Specifically, it refers
to three brain networks that, by integrating with each other, enhance the learning process:
the affective network (motivation), the receptive network (retrieval and processing of ex-
ternal information), and the executive network (planning and re-elaboration of outgoing
responses). In particular, students in the group managed through UDL were initially
assessed through: (a) an analysis of their motivation to study and any affective obstacles
in the learning process; (b) an analysis of their learning style and the main channels used
for information reception; (c) an analysis of their executive functioning style, including an
exploration of inhibitory systems, working memory, and problem-solving abilities. The
first two networks were evaluated through structured and targeted interviews while the
third network was assessed through the administration of the Raven’s Matrices [58], Corsi
Test [59], and Tower of London tasks [60].
Based on the evaluations conducted, personalized educational plans were created,
focusing on the three networks, and the same compensatory measures were chosen accord-
ing to the assessment results. The study objectives remained the same as those of the class;
the only interventions made were based on the evaluation of the affective network. Finally,
study materials were selected in line with the analysis of the receptive network.
These interventions were implemented over a period of 5 months. After the school
year, we conducted a reassessment of the sample’s academic skills and emotional profiles,
utilizing the same methods employed in the initial assessment.

3. Results
The data analysis was conducted using the SPSS 26.0 statistical software (2019). A
significance level of 1% (α < 0.001) was considered significant.
To assess the effectiveness of the intervention, we compared Groups 1 and 2 at two
different time points, T0 and T1, to determine if there were improvements within each
group over time. Additionally, we compared both groups at T1 to ascertain which educa-
tional intervention was more effective. To perform these comparisons, a two-way mixed
MANOVA (Multivariate Analysis of Variance) with a 2*2 design was conducted. The
factors analyzed were within-group factor, time (T0 and T1), and between-group factor,
group (Group 1 and Group 2).
The two independent variables analyzed were time and group while the dependent
variables were the MT and AC-MT tests. The results are presented as follows.
For the MT test, the findings are as follows:
The analysis reveals a significant interaction between the three subscales
(scale*time*group) [F (1, 58) = 97.907, p < 0.001]. This indicates that there are notable
interactions among the subscales, time, and type of treatment. Specifically, at T1, both inter-
ventions led to significant improvements in the three subscales of the MT tests. However,
in Group 2 (G2), there was a more significant improvement in the correctness parameter
compared to Group 1 (G1) (Table 2 and Figure 1).
 Children 2023, 10, x FOR PEER REVIEW 7 of 15

Children 2023, 10, 1350 7 of 15

interactions among the subscales, time, and type of treatment. Specifically, at T1, both in-
terventions led to significant improvements in the three subscales of the MT tests. How-
Table 2. Interaction between scale*time*group in the MT tests.
ever, in Group 2 (G2), there was a more significant improvement in the correctness pa-
rameter
Groupcompared to MTGroup 1 (G1) (Table 2 and
Time Figure 1). SD
Means F p
1 Accuracy T0 9.63
Table 2. Interaction between scale*time*group in the MT tests.
1.15
T1 6.86 1.33
Group MT Time Means SD F p
Fluency T0 1.98 0.11
1 Accuracy T0 9.63 1.15
T1
T1 6.86
3.27 1.33
0.36
Fluency
Comprehension T0
T0 1.98
5.56 0.11
0.67
T1
T1 3.27
7.40 0.36
0.67
Comprehension T0 5.56 0.67
2 Accuracy T0 9.60 1.32
T1 7.40 0.67
T1 3.33 0.95 97.907 <0.001 *
2 Accuracy T0 9.60 1.32
Fluency T1
T0 3.33
1.99 0.95
0.10 97.907 <0.001 *
Fluency T0
T1 1.99
3.89 0.10
0.21
Comprehension T1
T0 3.89
5.70 0.21
0.74
Comprehension T0 5.70 0.74
T1 9.26 0.90
T1 9.26 0.90
* Statistical significance.
* Statistical significance.

12

10

0
Gr 1 Gr 2

T0 COR T1 COR T0 RAP T1 RAP T0 COMP T1 COMP

Figure 1. Interaction between scale*time*group in the MT tests.

Figure 1. Interaction between scale*time*group in the MT tests.

For the
For the AC-MT
AC-MTtest,
test,we
wefound:
found:
The analysis reveals a significant interaction between the two subscales
The analysis reveals a significant interaction between the two subscales (scale*time*group)
(scale*time*group) [F (1, 58) = 63.140, p < 0.001]. This indicates that there are notable inter-
[F (1, 58) = 63.140, p < 0.001]. This indicates that there are notable interactions among
actions among the subscales, time, and type of treatment. Specifically, at T1, both inter-
the subscales, time, and type of treatment. Specifically, at T1, both interventions led to
ventions led to significant improvements in the two subscales of the AC-MT tests. How-
significant improvements in the two subscales of the AC-MT tests. However, in Group 2
ever, in Group 2 (G2), there was a more significant improvement in the correctness pa-
(G2), there was a more significant improvement in the correctness parameter compared to
rameter compared to Group 1 (G1) (Table 3 and Figure 2).
Group 1 (G1) (Table 3 and Figure 2).
Then, we conducted a comparison between Groups 1 and 2 at two different time
points, T0 and T1, by individually analyzing the BVSCO and CBCL tests. The aim was to
determine which of the two educational interventions was most effective (within-variable
time). Additionally, we compared both groups at T1 to assess the differences between
them (between-variable group). For this analysis, we performed a two-way mixed-design
univariate ANOVA with a 2*2 design. The factors analyzed were the within-group factor,
time (T0 and T1), and between-group factor, group (Group 1 and Group 2).
Children 2023, 10, 1350 8 of 15

Children 2023, 10, x FOR PEER REVIEW 8 of 15

Table 3. Interaction between scale*time*group in the AC-MT tests.

Group AC-MT Time Means SD F p

Table 3. Interaction between scale*time*group in the AC-MT tests.
1 Accuracy T0 11.00 1.20
Group AC-MT Time
T1 Means
7.96 SD0.76 F p
1 Accuracy T0 11.00 1.20
Fluency T0 198.40 14.33
T1 7.96 0.76
T1 181.63 7.59
Fluency T0 198.40 14.33
2 Accuracy T1
T0 181.63
10.76 7.59
1.33
2 Accuracy T0
T1 10.76
4.26 1.33
0.69 63.140 <0.001 *
Fluency T1
T0 4.26
198.20 0.69
12.57 63.140 <0.001 *
Fluency T0 198.20 12.57
T1 149.13 4.64
T1 149.13 4.64
* Statistical significance.
* Statistical significance.

210

160

110

60

10

Gr 1 Gr 2

-40

T0 COR T1 COR T0 RAP T1 RAP

Figure 2.
Figure 2. Interaction
Interaction between
betweenscale*time*group
scale*time*groupin in
thethe
AC-MT tests.
AC-MT tests.

Then,
For thewe conducted
BVSCO a comparison
test, we found: between Groups 1 and 2 at two different time
points, T0 and T1, by individually analyzing the BVSCO
The analysis reveals a significant interaction and CBCL
between time tests. The aim
and group was to
(time*group)
determine which of the two educational interventions was most effective (within-variable
[F (1, 58) = 53.578, p < 0.001]. This indicates that there are notable interactions between the
time).
two Additionally,
variables, time, we
andcompared
the type ofboth groups at T1
intervention. to assess the
Specifically, differences
both between
treatments resulted in
them (between-variable group). For this analysis, we performed a two-way mixed-design
an improvement in the BVSCO scale. However, this improvement is more significant in
univariate ANOVA with a 2*2 design. The factors analyzed were the within-group factor,
Group 2 compared to Group 1 (Table 4 and Figure 3).
time (T0 and T1), and between-group factor, group (Group 1 and Group 2).
For the BVSCO test, we found:
Table 4. Interaction between time*group in the BVSCO scale.
The analysis reveals a significant interaction between time and group (time*group)
[F (1,Group
58) = 53.578, p <Time
0.001]. This indicates
Means that there are
SD notable interactions
F between pthe
two variables, time, and the type of intervention. Specifically, both treatments resulted in
1 T0 11.63 1.42
an improvement in the BVSCO scale. However, this improvement is more significant in
Group 2 compared to T1 Group 1 (Table6.33
4 and Figure 3).0.84
2 T0 11.20 1.18
T1 2.20 1.42 53.578 <0.001 *
* Statistical significance.
 Group Time Means SD F p
1 T0 11.63 1.42
T1 6.33 0.84
2 T0 11.20 1.18
Children 2023, 10, 1350 9 of 15
T1 2.20 1.42 53.578 <0.001 *
* Statistical significance.

20
18
16
14
12
10
8
6
4
2
0
Gr 1 Gr 2

T0 T1

Figure 3. Interaction between time*group in the BVSCO scale.

Figure 3. Interaction between time*group in the BVSCO scale.
For the CBCL test, we found:
For the CBCL test, we found:
The analysis reveals a significant interaction between time and group (time*group)
The analysis reveals a significant interaction between time and group (time*group)
[F (1, 58) = 178.112, p < 0.001]. This indicates that there are notable interactions between
[F (1, 58) = 178.112, p < 0.001]. This indicates that there are notable interactions between the
the two variables, time, and the type of intervention. Specifically, both treatments resulted
two variables, time, and the type of intervention. Specifically, both treatments resulted in a
in a reduction of externalizing symptomatology in the CBCL scale. However, this reduc-
reduction of externalizing symptomatology in the CBCL scale. However, this reduction is
tion is more significant in Group 2 compared to Group 1 (Table 5 and Figure 4).
more significant in Group 2 compared to Group 1 (Table 5 and Figure 4).
Table 5. Interaction between time*group in the CBCL scale.
Table 5. Interaction between time*group in the CBCL scale.
Group Time Means SD F p
Group 1 Time T0 Means 27.46 2.54
SD F p
1 T0 T1 27.4626.30 3.32
2.54
2 T1 T0 26.3027.93 2.09
3.32
T1 17.26 2.54 178.112 <0.001 *
2 T0 27.93 2.09
* Statistical significance.
Children 2023, 10, x FOR PEER REVIEW T1 17.26 2.54 178.112 10 of *15
<0.001
* Statistical significance.

30

25

20

15

10

0
Gr 1 Gr 2

T0 T1

Figure4.
Figure 4. Interaction
Interaction between
between time*group
time*groupin
inthe
theCBCL
CBCLscale.
scale.

4. Discussion
The significance of a multimodal approach in the treatment of ADHD cannot be over-
stated. While psychostimulant medications are often the first-line treatment for ADHD
and can lead to substantial symptom reduction, it is essential to acknowledge that medi-
Children 2023, 10, 1350 10 of 15

4. Discussion
The significance of a multimodal approach in the treatment of ADHD cannot be over-
stated. While psychostimulant medications are often the first-line treatment for ADHD and
can lead to substantial symptom reduction, it is essential to acknowledge that medication
alone is not a comprehensive intervention [61–63]. Some parents may have reservations
about medicating their children due to concerns about stigma, side effects, or potential
long-term effects [64]. Recent studies have indicated that there are no long-term cognitive
benefits of medication, such as improved reaction time or verbal working memory, after six
years when participants are unmedicated during testing [65]. Therefore, it is widely recog-
nized that a multimodal approach is necessary for effective ADHD treatment. Psychiatric
guidelines recommend the incorporation of social skill training, behavioral interventions,
and educational approaches alongside medication [66–68]. By integrating various strate-
gies, treatment becomes multi-contextual, enhancing benefits and improving the prognosis
for individuals with ADHD. The implementation of Universal Design for Learning (UDL)
in children with ADHD holds significant potential for addressing the unique challenges
they face in the learning environment. UDL is an inclusive educational framework that
aims to cater to the diverse needs of all learners, including those with disabilities or learning
differences. Children with ADHD often struggle with sustaining attention, managing im-
pulsivity, and organizing tasks, which can impact their academic performance and overall
learning experience. UDL’s core principles of providing multiple means of representation,
engagement, and expression can be particularly beneficial for these students. In terms of
representation, UDL encourages educators to present information in diverse ways, utilizing
various media, visual aids, and technology to accommodate different learning styles. For
children with ADHD, this means accessing information through visual cues, videos, or
interactive materials, which can enhance their comprehension and engagement with the
content. The principle of engagement emphasizes providing meaningful choices and pro-
moting self-regulation to increase student motivation. For children with ADHD, this could
involve offering them options in how they demonstrate their understanding of a topic or
allowing them to choose topics of personal interest for projects. In terms of expression,
UDL advocates for flexible methods for students to acquire and demonstrate knowledge
and skills. For children with ADHD, this means allowing them to use alternative means of
expression, such as oral presentations, graphic organizers, or digital tools, which can better
align with their strengths and abilities.
By adopting UDL principles, educators can create a more inclusive learning environ-
ment that addresses the specific needs of students with ADHD, promoting their academic
success and overall well-being. A multimodal approach that incorporates UDL alongside
other interventions can optimize the outcomes for children with ADHD and help them
reach their full potential. In our study, we focused on the educational intervention and
investigated the impact of Universal Design for Learning as an individualized approach
that can address the specific needs of children with ADHD in comparison to traditional
educational strategies commonly employed in schools.
We found that both interventions led to improvements in test performance, indicating
that interventions were necessary to enhance reading, writing, and arithmetic skills. Fur-
thermore, the group that received an educational intervention based on Universal Design
for Learning demonstrated a more significant improvement in these areas. Additionally,
we propose that the set of techniques implemented by teachers in the classroom helped
children to read, write, and perform math tasks correctly and more fluently. Regarding
engagement, UDL promotes creating a positive and inclusive learning environment where
students with ADHD feel motivated and supported. Offering choices and opportunities for
self-regulation can empower these learners to actively participate in the learning process
and foster a sense of autonomy.
We attribute our results to the improved self-regulation stimulated by the individu-
alized approach as supported by previous studies [69]. Over the past decade, numerous
studies have provided evidence for the hypothesis that children with ADHD exhibit a
Children 2023, 10, 1350 11 of 15

generalized deficit in self-regulation, impacting abilities such as information processing,

response inhibition, arousal, alertness, planning, executive functioning, metacognition, and
self-monitoring [70–74]. As the results suggest, teachers’ knowledge about ADHD and
its management techniques is crucial, and a deeper understanding of the cognitive and
affective functioning of students may enhance improvements in academic foundational
skills within the educational system. Furthermore, it is important to highlight the positive
effects reported by teachers. Following the implementation of the intervention, teachers ob-
served improvements in primary symptoms and behavioral difficulties typically associated
with ADHD, such as externalizing symptoms. They identified a reduction in hyperac-
tive/impulsive behaviors and a significant increase in self-control among the experimental
group. Similarly, in the group that received the traditional intervention, typical problems
associated with the disorder were also reduced according to the teachers’ observations.
Finally, the collaboration between teachers, parents, and specialists is essential in imple-
menting UDL effectively for children with ADHD. By working together, they can identify
the most appropriate accommodations and support strategies, ensuring that the learning
environment is conducive to their success.

5. Conclusions
In conclusion, this study aimed to compare two commonly used educational inter-
ventions for managing ADHD in school settings. The intervention employing traditional
personalized teaching strategies demonstrated a positive effect on children’s basic learning
skills, underscoring the importance of early intervention. However, Universal Design for
Learning proved to be more effective in fostering these abilities. This highlights the value
of personalized teaching interventions that consider individual differences beyond mere
symptomatology.

Limitations
Finally, we acknowledge the limitation of our study and emphasize the importance
of conducting follow-up assessments to verify the stability of the observed improvements
over time. While UDL offers a flexible and inclusive approach to teaching and learning, it
does present certain limitations and challenges that warrant consideration:
1. Complex Implementation: Fully integrating UDL principles into curriculum design and
instruction requires significant changes in educational practice. This may necessitate
time, resources, and adequate training for educators;
2. Access to Technological Resources: UDL encourages the use of digital technologies
to provide multiple modes of content presentation. However, not all schools or
districts have the resources to offer a wide range of technologies or reliable internet
connections;
3. Measurement and Assessment: Assessing student performance within the UDL model
can be more complex compared to traditional assessment methods. Measuring student
progress through flexible and personalized assessments can pose challenges;
4. Lack of Experimental Evidence: Despite UDL’s strong theoretical foundations and re-
search basis, there may still be a lack of long-term experimental evidence to demon-
strate its effectiveness in every educational context;
5. Financial Resources: Full implementation of UDL may require significant financial
investments for acquiring resources, technologies, and educator training.
Despite these limitations, UDL remains a valuable approach to creating an inclusive
and flexible learning environment that can benefit many students with diverse needs.
However, it is important to continue scientific research using the UDL to provide additional
data and develop a more solid scientific foundation for this educational methodology,
especially considering the scarcity of studies.
Children 2023, 10, 1350 12 of 15

Author Contributions: Conceptualization, A.F. and F.C.; methodology, M.C.R.; software, M.C.R.;
validation, R.P.L., C.E., and F.C.; formal analysis, M.C.R.; investigation, F.B.; resources, F.C. and C.E.;
data curation, M.C.R.; writing—original draft preparation, A.F., R.P.L., C.E. and F.C.; writing—review
and editing, A.F. and M.C.R.; visualization, M.C.R.; supervision, A.F. and F.B.; project administration,
A.F. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki. The study was approved by the Ethics Committee and the Academic Senate of the
University of International Studies of Rome.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

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