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Attention Deficit/Hyperactivity Disorder (ADHD) is a common childhood neurodevelopmental disorder (Ford, Goodman, & Meltzer, 2003; Froehlich et al., 2007; Swanson et al., 1998). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) (American Psychiatric Association, 2000) specifies three subtypes of ADHD according to the most prominent group of symptoms: predominantly inattentive, predominantly hyperactive/impulsive, and combined (having symptoms of inattention and hyperactivity/impulsivity). In all subtypes, the maladaptive behaviour is present before the age of seven, is evident in two or more settings, is inconsistent with the child's developmental level and has a negative impact on social and academic domains. Research shows that ADHD symptoms persist into adolescence and adulthood (Fayyad et al., 2007; Langley et al., 2010; Ramtekkar, Reiersen, Todorov, & Todd, 2010; Taylor, Fauset, & Harpin, 2010) increasing the risk of low quality of life, impairment in academic and occupational functioning, other psychiatric problems and antisocial behaviour (Cumyn, French, & Hechtman, 2009; Danckaerts et al., 2010; Langley et al., 2010).
Epidemiological data suggest that ADHD remains underdiagnosed (Bussing, Zima, Gary, & Garvan, 2003; Sayal, Goodman, & Ford, 2006a), although an increase in recognition over the last decade has been reported in the United Kingdom (Sayal, Ford, & Goodman, 2010). In particular, girls are underrepresented in clinical samples compared with community samples (Biederman et al., 2002, 2005; Ramtekkar et al., 2010), suggesting that their ADHD symptoms are less frequently recognised. Gender differences in service use have been reported in most studies (Bussing et al., 2003; Froehlich et al., 2007; Gaub & Carlson, 1997; Graetz, Sawyer, Baghurst, & Hirte, 2006). Possible explanations for this include different symptom expression in boys and girls (Biederman et al., 2002; Levy, Hay, Bennett, & McStephen, 2005), for example, involving a higher prevalence of inattentive subtype in girls and more oppositional behaviour in boys; actual gender differences in neural activation (Valera et al., 2010); and differences in adults’ perception of the same behaviour in boys and girls (Biederman et al., 2005). Research and clinical experience suggest that children with inattentive subtype of ADHD are at risk of remaining undiagnosed and therefore untreated (National Institute for Health & Clinical Excellence, 2008; Ramtekkar et al., 2010).
Teachers are important in the recognition and referral of children with ADHD (Ford et al., 2003; Sayal & Goodman, 2009; Sayal, Hornsey, Warren, MacDiarmid, & Taylor, 2006b) because they have many opportunities to observe the child's behaviour in comparison with that of normative peers, while the observation of a child in a clinical setting may not reveal the core symptoms of the disorder. Teachers may initiate the process by raising concerns about a child's inattention or hyperactivity, and they are frequently the first person parents consult when they notice these problems (Sayal et al., 2006a). Specialist child health services routinely request information from schools as part of the diagnostic process to confirm the pervasive nature of the impairment (Committee on Quality Improvement, American Academy of Pediatrics, 2000; National Institute for Health & Clinical Excellence, 2008).
Vignette methodology has been widely used to assess factors that influence teacher recognition and perceptions about interventions; for example, the child's behavioural difficulties, ADHD subtype, and gender have been proposed as having an influence on the likelihood of teachers conceptualising the problem as ADHD and initiating a referral to specialist services (Groenewald, Emond, & Sayal, 2009; Pisecco, Huzinec, & Curtis, 2001; Sciutto, Nolfi, & Bluhm, 2004). Previous research suggests that child gender might influence adults’ social judgment and socio-cultural expectations of appropriate behaviours; for example, using vignette methodology, Maniadaki, Sonuga-Barke and Kakouros (2003) found that child gender influenced teacher judgments of whether disruptive behaviours were perceived as being typical. More specifically with ADHD, adults (parents and educators) described a greater sense of self-efficacy in relation to girls than boys (Maniadaki, Sonuga-Barke, & Kakouros, 2006). However, other factors are also important. Adults’ judgments about the severity of ADHD or behavioural problems also influence their views about appropriateness of referral for further assessment (Abidin & Robinson, 2002; Maniadaki et al., 2006).
Some studies suggest that symptom type and the gender of the child generate a bias in teachers’ perception of the difficulties and management decisions (Pisecco et al., 2001; Sciutto et al., 2004). In an attempt to clarify teachers’ recognition of ADHD in girls, a recent study found that teachers’ recognition of ADHD was greater in a vignette describing a girl with combined ADHD than with inattentive ADHD (Groenewald et al., 2009).
In this study, we investigate the relative effect of gender and subtype on teacher recognition practice. This study expands on the previous study by including both genders as well as inattentive and combined ADHD subtypes (Groenewald et al., 2009). We focus on these subtypes as, amongst children who met criteria for ADHD in a large UK prevalence study involving a nationally representative community sample (Ford et al., 2003), the predominantly hyperactive/impulsive subtype of ADHD was very uncommon (4% of 8-10-year-old children with ADHD) compared with the inattentive (36%) and combined (60%) subtypes. Furthermore, longitudinal data demonstrate that the predominantly hyperactive/impulsive subtype of ADHD tends not to be stable over time with many young children in this group meeting criteria for the combined subtype as they reach school-age (Lahey, Pelham, Loney, Lee, & Willcutt, 2005). In keeping with developing evidence about a gender bias in referral, we anticipated that teachers would more readily identify ADHD in boys. We also expected that combined subtype of ADHD would be easier to recognise than inattentive subtype (Graetz et al., 2006; Groenewald et al., 2009; Sciutto et al., 2004). We hypothesized that gender and subtype would have an interactive effect (i.e. inattentive ADHD in a girl would have the lowest rate of recognition as ADHD, whereas combined ADHD in a boy would have the highest).
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This study highlights the influence of ADHD subtype on teachers’ recognition of ADHD. Teachers who read a vignette describing a child with combined subtype of ADHD were more likely to conceptualise the problems as ADHD and to think that medication might be helpful. The child's gender did not influence teachers’ views and other parameters (need for specialist referral or non-pharmacological interventions) were not influenced by ADHD subtype or child gender. Therefore, our hypothesis about the interactive effect of ADHD subtype and the gender of the child on teachers’ recognition of ADHD was only partially confirmed.
These findings are in agreement with a previous study (Groenewald et al., 2009), which found higher rates of recognition for combined subtype of ADHD. Our findings support the possibility that the higher male-to-female ratio in referred samples compared with community samples reflects a different symptom expression across genders, i.e. girls having more inattentive subtype, which is less frequently recognised as ADHD and referred to specialist services (Biederman et al., 2002).
The lack of gender influence on teachers’ recognition and proposed management of ADHD contrasts with existing literature. In our study, ADHD subtype seemed more important than child gender. Using a similar methodology, other studies found that child gender influenced teachers’ views on interventions for ADHD (Pisecco et al., 2001) and the likelihood of a referral to a school psychologist (Sciutto et al., 2004). Our findings might reflect an improvement in teachers’ awareness of the existence of ADHD in girls and of the need for the same strategies to be implemented irrespective of the child's gender.
Teachers’ reluctance to endorse the use of medication may be partially explained by teachers’ opinion that medication should be ‘a last resort’. Many of them also expressed this as a written comment. This explanation is supported by teachers’ high endorsement of all nonpharmacological interventions. Studies show that teachers prefer behavioural and educational interventions over medication (Curtis, Pisecco, Hamilton, & Moore, 2006; Ohan, Cormier, Hepp, Visser, & Strain, 2008). This is consistent with NICE recommendations that medication should be prescribed only for ADHD with moderate/severe impairment (National Institute for Health & Clinical Excellence, 2008). A further factor that may explain the reluctance to endorse medication is that teachers most frequently (89%) chose the option ‘attention difficulties’ as a conceptualisation of the vignette; the option ‘ADHD’ was chosen by 43% of teachers only. This suggests that teachers recognised the presence of an attention problem, but did not consider appropriate to attach a diagnosis to it, hence, they did not think that medication would be beneficial. Teachers’ significantly higher endorsement of medication for combined subtype may reflect their better ability to recognise it as ADHD.
The scores for perceived need for referral to specialist services (paediatricians, child and adolescent psychiatrists) were low considering that the vignettes included a sufficient number of symptoms of ADHD required to meet diagnostic criteria, as well as comments on the pervasiveness of the symptoms and their negative impact on the child's functioning. Teachers’ views, as expressed in their written comments, highlighted their willingness to deal with the difficulties within the school but also a perception that the difficulties were not sufficiently severe to meet the threshold to be seen by specialist health services.
Our results are based on a much larger sample than previous similar research and simultaneously examined gender and ADHD subtype (Groenewald et al., 2009; Pisecco et al., 2001; Sciutto et al., 2004). The questionnaire distribution meant that similar numbers of teachers with comparable demographic characteristics read each vignette. Although the vignettes only described ADHD cases, teachers were not aware of the study hypothesis as they were asked to participate in a survey about children's needs.
Several methodological limitations should be highlighted. We do not know precisely how the questionnaires were distributed within the schools and whether schools had full staff numbers or vacancies. Although the overall teacher response rate was lower than expected, amongst participating schools more teachers than expected took part in the study. The participating schools also appeared to be nationally representative. The use of vignettes is an accepted methodology to elicit teacher's views; however, it can be argued that the reported findings may not reflect teachers’ decisions and their actual behaviour in everyday practice. Finally, we focused on the two most common subtypes of ADHD and future research could investigate the role of all 3 subtypes.
Clinical and training implications
When collaborating with or making enquiries of teachers during the diagnostic process for ADHD, clinicians should stress the importance of assessing the child's concentration and attention span even in the absence of symptoms of hyperactivity or impulsivity. This becomes more relevant as the child moves into adolescence, when hyperactivity is less prominent. Teachers need to be informed when medication is initiated for ADHD and their views should be sought when monitoring progress, both to optimise children's treatment and to add to teachers’ experience of the potential benefits of pharmacological treatment. NICE guidelines (National Institute for Health & Clinical Excellence, 2008) highlight the need to provide training for teachers; our results suggest that one of the aims should be an increase in teachers’ awareness of inattentive subtype of ADHD as a possible cause of difficulties at school.
To better clarify the role of gender and subtype on teachers’ recognition of ADHD, research is necessary to study teachers’ perceptions and management of children with ADHD in the classroom situation. Qualitative research exploring teachers’ views would inform our understanding of their conceptualisation of the problems and the use of medication.