What Do Primary and Secondary School Teachers Know About ADHD in Children? Findings From a Systematic Review and a Representative,Nationwide Sample of Danish Teachers

Abstract

Objective: To identify what primary and secondary school teachers know about ADHD in children and, furthermore, to identify which factors predict their knowledge. Method: A 29-item questionnaire about ADHD was distributed to a random, nationwide, and representative sample of Danish primary and secondary school teachers. Data were analyzed descriptively and by hierarchical regression analysis. Results: A total of 528 teachers were included. Most teachers identified the symptoms of ADHD (79%-96%) and effective classroom intervention strategies (75%-98%). However, knowledge about other characteristics, etiology, prognosis, and treatment was inconsistent, for example, only 56% and 17% correctly rejected diet as a cause and effective treatment for ADHD. Among the strongest predictors for correct knowledge was having been provided postgraduate education about ADHD. Conclusion: Teachers require knowledge about ADHD to successfully include and manage children with ADHD and, additionally, to ensure positive working environments for teachers and support constructive school–home working collaborations.

Keywords

ADD/ADHD survey research teachers knowledge

Introduction

The ongoing inclusion of children with special needs to regular education classes takes place across a number of countries and requires a certain amount of special educational knowledge; knowledge that does not necessarily lie within the border of competency of the regular teacher. Children and adolescents with ADHD are often among this group of students, as ADHD has an estimated prevalence of 5.29% (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). A student affected by ADHD can be particularly difficult to manage within a classroom setting that is not tailored to the child’s difficulties and needs, as the student can be restless, fidgety, noisy, and disruptive compared with non-affected classmates (Abikoff et al., 2002). Longitudinal studies document that children and adolescents with ADHD are at increased risk for expulsion, repeating grades, and getting detentions. Consequently, these children are at risk of academic underachievement and lower academic attainment as adults (Loe & Feldman, 2007).

In Denmark, the majority of schools are public and Danish children attend mandatory education for 10 years from approximately the age of 6 to 15. Children with psychiatric problems and intellectual disabilities have, since the signing of the Salamanca declaration in 1994 (UNESCO, 1994), been obliged to include children with special needs and disabilities into the regular education system. In 2012, a political strategy in Denmark, aimed at increasing the inclusion of children with special needs to the regular education classes, was initiated, and it is expected that 96% of all school-age children in 2015 will be integrated (The Danish Ministry for Children and Education, 2013). Thus, there is a strong demand for teachers to possess the skills and knowledge about children with special needs as well as about normative development.

Danish school teachers have a 4-year formal education equivalent to a professional bachelor’s degree, including theoretical and practical experience with teaching and pedagogy. The training is mostly focused upon normative development, and only recently specific education about children with special needs has become a compulsory part of the curriculum. There are no formal programs in Denmark that are aimed at managing and developing children with ADHD or other disabilities. It is often up to the individual teacher to identify and implement classroom management strategies. Thus, despite a political obligation to ensure the integration of children with disabilities such as ADHD into regular education classrooms, no formal training or specific guidance has been provided to Danish teachers. This makes the study of Danish teachers’ knowledge about ADHD and what they may consider effective treatments important, especially as a recent systematic review concluded that teachers’ knowledge about ADHD was important in predicting the academic outcomes (Sherman, Rasmussen, & Baydala, 2008). Ratings of work-related stress have risen among teachers since the process of inclusion was initiated. This increase in stress could be related to teachers’ lack of knowledge about disorders such as ADHD. Identifying and targeting gaps in knowledge could be beneficial for both students and teachers.

A Systematic Review of the Literature

Before describing the present study, we briefly review the literature regarding teachers’ knowledge of ADHD. We used this review to develop our study and identify important gaps in the existing literature. This review was based on a systematic search of the Pubmed, PsycINFO, and Embase, July 2014, using the keywords ADHD; hyperkinetic disorder*; hyperkinetic syndrome*; attention deficit*; deficit-hyperactivity; minimal brain dysfunction AND teacher*; educator* AND knowledge; attitude*; perception*; stigma*; awareness*. Our search returned 1,383 studies. A total of 33 studies met our inclusion criteria and were included in the final review.

Knowledge About Symptoms and Behaviors Associated With ADHD

Among teachers in the included studies, 70% to 100% reported knowing that children with ADHD can have difficulties sustaining attention in settings with low arousal (Aguiar et al., 2014; Bekle, 2004; Jones & ChronisTuscano, 2008; Kos, Richdale, & Jackson, 2004; Krowski, 2009; Ohan, Cormier, Hepp, Visser, & Strain, 2008; Piccolo-Torsky & Waishwell, 1998), 90% to 100% of teachers reported knowing that ADHD is associated with difficulties planning and organizing activities (Aguiar et al., 2014; Krowski, 2009; Macey, 2007), and 88% to 98.6% recognized that children with ADHD can be distracted by extraneous stimuli (Alkahtani, 2013; Krowski, 2009; Liesveld, 2007; Macey, 2007; Sciutto, Terjesen, & Bender, 2000). The symptoms of hyperactivity and impulsivity were also frequently recognized among teachers, with 85% to 95% identifying that children with ADHD can be fidgety, have difficulties sitting still, or be hyperactive (Aguiar et al., 2014; Krowski, 2009; Liesveld, 2007; Macey, 2007; Sciutto et al., 2000), and 79% to 87% recognized that children with ADHD can generally act impulsively (Macey, 2007; West, Taylor, Houghton, & Hudyma, 2005).

Between 55% and 100% of surveyed teachers recognized that inattentive behaviors are not a result of misbehavior or desires to be oppositional (Aguiar et al., 2014; Bekle, 2004; Jerome, Gordon, & Hustler, 1994; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998), 13.8% to 75% knew that children with ADHD are not aggressive, mean, or cruel toward others (Aguiar et al., 2014; Alkahtani, 2013; Krowski, 2009; Macey, 2007; Rodrigo, Perera, Eranga, Williams, & Kuruppuarachchi, 2011), and 85% to 93% rejected the statement that children with ADHD can do better if only they tried harder (Aguiar et al., 2014; Bekle, 2004; Jerome et al., 1994; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998). Thus, there is support within the literature to suggest that teachers in general have adequate knowledge regarding the symptoms of ADHD.

The Prognosis of Children and Adolescents With ADHD

Our review identified that few studies have investigated what teachers know about the prognosis of ADHD. In those few studies, 7% to 82% reported knowing that ADHD continues into adulthood for a significant proportion of individuals (Alkahtani, 2013; Hawkins, Martin, Blanchard, & Brady, 1991; Jerome et al., 1994; Krowski, 2009; Nur & Kavakci, 2010; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998). Across six studies, we found that 41% to 73% recognized the risk associated with ADHD for long-term antisocial involvement (Bekle, 2004; Ghanizadeh, Bahredar, & Moeini, 2006; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998), and in only one study 71.3% of teachers recognized the association between ADHD and the risk of lower educational attainment (Rodrigo et al., 2011). A total of 51% of teachers in a Turkish sample recognized the long-term risk for substance use problems (Nur & Kavakci, 2010), and in two studies, 62% to 65% recognized that ADHD was a risk factor for the development of other psychiatric disorders (Rodrigo et al., 2011). Teachers seemed to have less knowledge regarding the prognosis of ADHD but, in general, this domain was underinvestigated.

Causes of ADHD

In the scientific literature, there is a general consensus that the causes of ADHD have strong genetic and biological underpinnings (Thapar, Cooper, Eyre, & Langley, 2013). While social adversity is more frequently found in families with ADHD, this association has often been linked to gene–environment correlations rather than being causal to the development of ADHD (Thapar et al., 2013). In our review, 43% to 86% of U.S. samples recognized the genetic basis of ADHD or acknowledged the heritability of ADHD (Kos et al., 2004; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998). Findings from Europe and Australia ranged between 26% and 74% (Kos et al., 2004; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998), and findings from non-Western countries such as Iran and Saudi Arabia were in the 13% to 46% range (Alkahtani, 2013; Ghanizadeh et al., 2006; Taghi Badeleh, 2013). The variations in findings did not seem to be due to time effects, as there were no systematic improvements in the knowledge of this topic across the years the studies were conducted. When teachers were asked whether they believed ADHD to be a disorder with biological causes (e.g., abnormal brain development, caused by birth complications, etc.), 32% to 90% responded “yes” (Aguiar et al., 2014; Bekle, 2004; Coronado, 2013; Ghanizadeh et al., 2006; Glass & Wegar, 2000; Jerome et al., 1994; Kos et al., 2004; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998). In contrast, 20% to 97% of samples correctly rejected that ADHD is caused by poor parenting or parental spoiling (Aguiar et al., 2014; Alkahtani, 2013; Barbaresi & Olsen, 1998; Bekle, 2004; Coronado, 2013; Ghanizadeh et al., 2006; Jerome et al., 1994; Jones, 2007; Kos et al., 2004; Krowski, 2009; Liesveld, 2007; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998; Rodrigo et al., 2011), that ADHD is caused by stress and chaos in the home (35% to 86%; Bekle, 2004; Coronado, 2013; Jerome et al., 1994; Kos et al., 2004; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998), or that ADHD is caused by the consumption of sugar/food additives (15% to 100%; Barbaresi & Olsen, 1998; Bekle, 2004; Coronado, 2013; DiBattista & Shepherd, 1993; Jerome et al., 1994; Jones, 2007; Kos et al., 2004; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998). These findings suggest that, in some teacher populations, beliefs that ADHD is caused by psychosocial factors are relatively common.

Treatment of ADHD

The international guidelines support that a combination of social and pharmacological intervention is the most effective treatment for school-age children with ADHD (National Institute for Health and Care Excellence, 2008). In our review, 9% to 86% of surveyed teachers believed medicine to be an effective treatment for ADHD (Adeosun, Ogun, Fatiregun, & Adeyemo, 2013; Kasten, Coury, & Heron, 1992; PalaciosCruz et al., 2013; Snider, Busch, & Arrowood, 2003) and 8% to 40% knew that stimulants were the most common type of drug used to treat children with ADHD (Akram, Thomson, Boyter, & McLarty, 2009; Alkahtani, 2013; Krowski, 2009; Nur & Kavakci, 2010). Adequate knowledge in these studies was generally low; however, the majority of studies were conducted in non-Western countries, where our review suggests that knowledge about ADHD seems to be underdeveloped in general. Studies demonstrated that 58% to 96% of samples from both Western and non-Western countries knew that medication is not the sole treatment for ADHD (Akram et al., 2009; Bekle, 2004; Jerome et al., 1994; Jones & ChronisTuscano, 2008; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998); 63% to 95% knew that even when medications have been prescribed, there is still a need for psychosocial and classroom interventions (Aguiar et al., 2014; Akram et al., 2009; Bekle, 2004; Coronado, 2013; Jerome et al., 1994; Kos et al., 2004; Liesveld, 2007; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998); and 14% to 90% knew that medication does not cure ADHD (Akram et al., 2009; Alkahtani, 2013; Coronado, 2013; Kos et al., 2004; Krowski, 2009). Despite variations, there seemed to be a widespread understanding that medication is not the only treatment option for ADHD. However, a number of studies suggested that teachers were uncertain about whether pharmacological treatment could increase the risk of later substance use disorders (2% to 92%; Akram et al., 2009; Coronado, 2013; Jones & ChronisTuscano, 2008; Kasten et al., 1992; Kos et al., 2004; Krowski, 2009; PalaciosCruz et al., 2013).

In the included studies, 80% to 97% knew that quiet surroundings and 1:1 interactions with teachers could benefit the concentration of children with ADHD (Aguiar et al., 2014; Bekle, 2004; Coronado, 2013; Jerome et al., 1994; Jones & ChronisTuscano, 2008; Kos et al., 2004; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998). Thus, knowledge and expectations about the efficacy of medications and effective classroom strategies were fair across samples despite great variations in findings. However, in only 13% to 47% of included studies, teachers supported that diets are usually not helpful in treating ADHD (Alkahtani, 2013; Bekle, 2004; Coronado, 2013; Jerome et al., 1994; Klein, 2002; Kos et al., 2004; Krowski, 2009; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998).

Are There Any Predictors of Correct Knowledge About ADHD in Children?

Looking at the 24 studies that attempted to identify factors associated with adequate knowledge about ADHD, we found that most studies supported that educating teachers about ADHD (Aguiar et al., 2014; Alkahtani, 2013; Coronado, 2013; Ghanizadeh et al., 2006; Jerome et al., 1994; Kos et al., 2004; Liesveld, 2007; Piccolo-Torsky & Waishwell, 1998; Snider et al., 2003; Taghi Badeleh, 2013; West et al., 2005) and experience with teaching children with ADHD (Alkahtani, 2013; Kos et al., 2004; Liesveld, 2007) were correlated with higher knowledge scores. On the contrary, in most studies, factors such as years of experience (Aguiar et al., 2014; Akram et al., 2009; Jerome et al., 1994; Kos et al., 2004; Krowski, 2009; Nur & Kavakci, 2010; Ohan et al., 2008; Piccolo-Torsky & Waishwell, 1998; Rodrigo et al., 2011; West et al., 2005) and age (Ghanizadeh et al., 2006; Jerome et al., 1994; Kos et al., 2004; Krowski, 2009; Nur & Kavakci, 2010; Piccolo-Torsky & Waishwell, 1998; Sciutto et al., 2000) of the teachers were not correlated with higher knowlegde scores.

Research Needs Identified in the Existing Literature

Many of the studies reviewed here have contributed to our understanding of teachers’ knowledge of ADHD and the factors that may be associated with better knowledge scores. However, this review has highlighted the need for further studies to continue improving our understanding of the topic. The external validity of the included studies was often hampered by small sample sizes and limited representation of different populations of teachers (only one study included in the review was conducted in Europe; Akram et al., 2009). These limitations highlight the need for large, representative studies, as well as studies conducted in European contexts. Only one study in the review (Liesveld, 2007) had extended the search for predictors of knowledge about ADHD in teachers beyond tests for differences or correlations. This study used hierarchical regression analyses to control for confounding and partial out variance for different components relevant in predicting knowledge about ADHD in teachers. More studies need to use this or similar approaches as these factors may be important in improving the knowledge of ADHD in teachers.

Aims

Based on the research needs identified, we carried the first large, nationwide, and representative survey of primary and secondary school teachers in Denmark. The aims of this study were to answer the following research questions:

Research Question 1: What do Danish teachers know about ADHD? (a) Which symptoms and behaviors do teachers associate with ADHD? (b) What do they think causes ADHD? (c) What prognosis do teachers associate with ADHD? and (d) What do teachers believe are effective treatments and interventions for children with ADHD?

We hypothesized that knowledge about symptoms of ADHD would be superior to the teachers’ knowledge about, for example, the causes of ADHD, the prognosis, and the treatment. We believed that teachers would lack knowledge about the long-term outcomes of ADHD and that teachers would tend to support psychosocial theories of etiology and treatment of ADHD to a greater extent than we have evidence to support. Our secondary aim was to answer the following research question:

Research Question 2: Which factors are related to adequate knowledge about ADHD?

We hypothesized that postgraduate education about ADHD would predict a higher percentage of correct answers. We wished to examine this research question in our study and to test if these predictors would still predict correct knowledge scores after controlling for other predictors such as years of experience, as there is currently a lack of studies investigating this in the existing research literature.

Materials and Method

Sample

For the purpose of carrying out the present study, we established contact with the Danish Union of Teachers (DUT), the only trade-specific union for teachers in Denmark. The DUT had records of 46,333 active teachers with email addresses teaching in Danish primary and secondary schools. In the Danish school system, primary and secondary schools are not separated institutions or levels, but children attend 10 years of mandatory education in the so-called “Folkeskole.” Due to this organization of the school system, we were not able to identify primary and secondary school teachers separately, as all educated teachers can teach at all levels. The DUT drew a random and representative sample of 3,000 of their members and distributed the questionnaire by providing an electronic link in an email. The email included a letter of invitation along with a consent form. The decision to only send out the questionnaire to N = 3,000 members was made by the DUT who wished to limit the burden on its members, as the union carry out multiple surveys on various topics each year. This sampling procedure is used by the DUT in all surveys they carry out. It took about 30 minutes to fill out the questionnaire and no incentives were provided for participation. In total, 575 teachers (19.2%) completed the questionnaire during the two weeks of data collection. Unfortunately, it was not possible to send out reminders to non-responders or to check the number of invalid email addresses.

As the present study focused on school teachers only, n = 35 (6.1%) nursery school teachers were excluded from the 575 responses, as they do not have the same educational background as primary and secondary teachers in Denmark. Furthermore, n = 12 (2.1%) of the 575 responders were excluded because they categorized themselves as neither teachers nor nursery school teachers. Thus, a total of 528 teachers fulfilled the inclusion criteria, filled out the entire questionnaire, and were included in the study. Validation options in the survey software used for the present survey meant that there were no missing data. The characteristics of the included respondents were comparable with the total population from which the sample was drawn on parameters such as sex, region, and age (Table 1).

Table 1.

Total Members of DUT and Included Sample Characteristics.

	Members of DUT		Random DUT sample		Included sample		Sample vs. respondents
	n	%	N	%	n	%	χ²	df	p
Sex
Male	12,760	27.5	803	26.8	126	23.9	2	1	.163
Female	33,573	72.5	2,197	73.2	402	76.1
Age
≤29	2,556	5.5	159	5.3	22	4.2	8.2	4	.086
30-39	14,056	30.3	893	29.8	131	24.8
40-49	13,041	28.1	912	30.4	167	31.6
50-59	11,667	25.2	748	24.9	151	28.6
60+	5,013	10.8	288	9.6	57	10.8
Region
Capital region	12,782	28.1	856	28.5	120	22.7	8.6	4	.071
Zealand region	6,639	14.6	464	15.5	89	16.9
Southern region	10,071	22.1	578	19.3	119	22.5
Central region	10,727	23.6	823	27.4	150	28.4
Northern region	5,281	11.6	277	9.2	50	9.5

Note. DUT = Danish Union of Teachers.

The Survey

It became clear from the literature review that there was no consensus regarding the most appropriate way to assess knowledge and beliefs about ADHD in teachers. The most frequently used scale across all of the 33 studies we reviewed was the Knowledge of Attention Deficit Disorders Scale (KADDS; Sciutto et al., 2000), which was used in only 4 studies. As this questionnaire had not been translated to Danish, and because the DUT wished to be able to edit, impact, and approve all items included in the questionnaire, we decided to create a new questionnaire for the purpose of the study. The final questionnaire consisted of three sections. The first section collected background information. The second section asked questions regarding the teachers’ perceptions of their access to knowledge, help, and assistance relating to students with ADHD; about the teachers’ own perception of their knowledge; and their wishes to acquire more knowledge. The third and final section consisted of 29 statements about ADHD. The 29 statements were organized in four sub-sections concerning (a) symptoms of ADHD/other characteristics of patients with ADHD, (b) etiology, (c) prognosis, and (d) treatment/strategies used in the work with children with ADHD, following the basic structure found in the reviewed studies.

To support the content validity of the questionnaire, individual items were developed with guidance from the items in studies identified in the systematic review by the diagnostic criteria for ADHD in International Classification of Diseases, 10th Revision (ICD-10)/Diagnostic and Statistical Manual of Mental Disorders (5th ed; DSM-5; American Psychiatric Association, 2013; World Health Organization, 1992) and published research studies and handbooks. Furthermore, the statements were inspired by ongoing discussions about ADHD in the popular media, for example, that ADHD is caused by and can be effectively treated with diets. A member of the research group with extensive experience of working with ADHD and the associated research literature approved the final structure and content of the questions included. As a part of the working collaboration with DUT, minor changes were made to the original questionnaire. Statements placing too much emphasis on parental involvement in the development of ADHD and personal attitude, such as “ADHD is not a valid diagnosis,” were removed. Although the questionnaire used in this study was not validated in terms of measuring test–retest reliability, factor-structure, and so forth, we did ensure the face validity by testing the questionnaire in a small pilot study among acquaintances working as school teachers. In the pilot study, the questionnaire was filled out and we received oral feedback about the perceptions and misunderstandings of the individual items. This feedback was used to correct individual items.

Teachers rated their agreement with the statement on a 4-point Likert-type scale 1 = strongly agree, 2 = agree, 3 = disagree, and 4 = strongly disagree. In addition, a fifth response category was available in all statements (5 = don’t know), as earlier studies have documented the importance of this response category to fully distinguish between misconceptions and a lack of knowledge (Sciutto et al., 2000). The answers were coded as correct, incorrect, or don’t know. For example, if a respondent expressed “strongly agree/agree” to the statement “ADHD is a hereditary condition,” the response was coded as correct. However, if a respondent expressed “strongly agree/agree” to the statement “ADHD is solely determined by social factors,” the response was coded as incorrect (see Table 3). In the questionnaire, the items had an almost equal distribution of true and false statements to ensure the participants’ engagement and to be able to differentiate whether respondents could distinguish true from false statements within sections.

Internal Consistency

Cronbach’s alpha was calculated to evaluate the internal consistency of the questionnaire on the 29 knowledge items and on the four subscales of the questionnaire. The internal consistency across all 29 items was high (α = .880). The internal consistency on the four subscales of the questionnaire was lower (Symptoms/Characteristics, α = .738; Etiology, α = .668; Prognosis, α = .684; and Treatment, α = .605) but within the good to acceptable range. The internal consistency of the combined questionnaire was similar to the findings from other studies using, for example, the KADDS where internal consistency has been found in the range .331 to .881 (Jones & ChronisTuscano, 2008; Krowski, 2009; Sciutto et al., 2000).

Data Analytic Plan and Statistical Analyses

As one of our aims was to assess the knowledge of Danish teachers regarding various aspects of ADHD, data were primarily analyzed descriptively presenting the number of correct, incorrect, and don’t know responses. As a secondary aim was to identify which factors predicted adequate knowledge about ADHD after controlling for the effect of covarying factors, we analyzed our data using multiple linear regression analysis. We used this approach to identify statistically significant and meaningful predictors of adequate knowledge. In addition, we ran hierarchical regression analysis to partial out the variance and to arrive at coefficients (β) for each of the entered covariates. To make the responses on the 5-point Likert-type scale eligible for these analyses, we created a variable summing up the percent correct answers out of the total of 29 items answered for each teacher. The alpha level was set at .05. Statistical analyses were performed using the SPSS, 22nd ed. (IBM Corporation, 2013), and figures were created using STATA, 12th ed. (StataCorp, 2011).

Sample Characteristics

Of the 528 teachers included in the study, n = 126 (23.9%) were males and n = 402 (76.1%) were females. The mean age of the sample was (46.2, SD = 10.2). The distributions of age, gender, and region of Denmark in the included sample were similar to the distributions of all the members of the DUT association (Table 1).

The mean years of experience with teaching was 17 (SD = 10.7), and the majority were teaching nonspecial education classes (Table 2). However, most teachers had experience with children with ADHD from their classrooms (90.9%), and many had experience with ADHD from their private life (66.1%). A total of 42.0% reported that they had not received any specific education about ADHD either during or after their formal education. In the sample, 37.7% had received 1 to 10 hr and 20.3% had received 11 or more hours of education about ADHD. Although the majority had some education about ADHD, 62.5% stated that they did not know sufficiently enough about ADHD. A large part of the teachers also expressed a lack of knowledge at their schools and lack of access to special education support, further education, and school psychologists. The majority (80.5%) expressed a wish to acquire more knowledge about ADHD (Table 2).

Table 2.

Characteristics of Sample and Teachers’ Experience About Needs and Knowledge About ADHD.

		M	SD
Age		46.2	10.2
Years of experience		17.0	10.7
		n	%
Years of experience
0-5		69	13.1
6-10		115	21.8
11-15		94	17.8
16-20		68	12.9
20-25		40	7.6
26 or more		142	26.9
Teaching classes
Nonspecial needs		425	85.6
Special needs		76	14.4
Children with ADHD in classroom
At least one		480	90.9
None		30	5.7
Received education about ADHD
No education		222	42.0
1-10 hr		199	37.7
11 hr or more		107	20.3
	Yes		No
	n	%	n	%
Private experience with children with ADHD	349	66.1	151	38.6
I have adequate knowledge about ADHD	180	34.1	330	62.5
There is adequate knowledge about ADHD at my school	120	22.7	353	66.9
I have access to the knowledge about ADHD at my school	300	56.8	151	28.6
I have access to support for specific problems/issues about students with ADHD at my school	248	47.0	241	45.6
I need for support from special education teachers during some periods	414	78.4	75	14.2
I have access to special education teachers at my school	140	26.5	327	61.9
I would like to acquire more knowledge about ADHD/teaching children with ADHD	425	80.5	67	12.7
The inclusion of children with ADHD have given me access to further education	87	16.5	318	60.2
There is adequate access to school psychologist at my school	193	36.6	335	63.5

Knowledge About ADHD

Symptoms/other characteristics

The teachers showed adequate recognition of symptoms of ADHD but were less able to identify the correct answers of associated characteristics (Figure 1, Table 3). For example, only 46.4% identified that children with ADHD tend to have more symptoms of depression. Their responses were often correct, but mostly the teachers had answered that they did not know. The teachers tended to know that, as children, more boys than girls are affected by ADHD (73.5% correct); however, less knew that girls with ADHD can, in fact, be hyperactive (56.1%).

Figure 1.

Percent correct/incorrect/don’t know on 29 items about ADHD.

Table 3.

Knowledge About ADHD (Correct/Incorrect/Don’t Know).

	Correct	Incorrect	Don’t know
	%	%	%
Symptoms/other characteristics
A student with ADHD can concentrate equally well as a student without ADHD (F)	78.8	17.8	3.4
Students with ADHD are easily distracted by stimuli (T)	96.2	2.3	1.5
Students with ADHD are often hyperactive (e.g., cannot sit still) (T)	92.6	5.3	2.1
Students with ADHD have difficulties planning and organizing tasks and assignments (T)	94.3	1.7	4.0
To be diagnosed with ADHD, the symptoms (of ADHD) must be present in multiple settings (T)	79.0	2.3	18.8
Children with ADHD are mean to other people (F)	92.8	3.4	3.8
Children with ADHD have a higher frequency of symptoms of depression (T)	46.4	6.8	46.8
ADHD affects 3-4 as many boys as girls (T)	73.5	3.6	22.9
Children with ADHD are not as intelligent as children without ADHD (F)	88.1	4.4	7.6
During school years, ADHD is equally present among boys and girls (F)	66.3	5.7	28.0
Girls with ADHD are not hyperactive (F)	56.1	17.0	26.9
Etiology
Sugar and additives are a cause of ADHD (F)	56.4	18.2	25.4
Abnormal brain development is a cause of ADHD (T)	60.8	18.0	21.2
ADHD is a hereditary condition (T)	59.3	20.3	20.5
ADHD is solely determined by social factors (F)	83.1	8.0	8.9
Child rearing is an important factor in the development of ADHD (F)	66.5	22.9	10.6
Prognosis
Children with ADHD are at an increased risk for involvement in criminal activities later in life (T)	58.9	22.7	18.4
Children with ADHD are at an increased risk for psychiatric problems later in life (T)	48.9	15.5	35.6
Children with ADHD have equal academic attainments as adults as children without ADHD (F)	38.3	34.1	27.7
Children with ADHD can as adults have difficulty getting and maintaining jobs (T)	61.9	16.1	22.0
The majority of children with ADHD outgrow ADHD during puberty or adulthood (F)	57.8	14.0	28.2
Treatment
Structure and a high degree of predictability are beneficial when teaching children with ADHD (T)	98.3	0.4	1.3
A calm environment is beneficial for children with ADHD (T)	97.3	0.9	1.7
The right parental attitude can remove a child’s problems in the classroom (F)	56.1	33.0	11
Praise is an effective method for reducing behavioral problems in students with ADHD (T)	75.4	12.1	12.5
A diet without sugar and food coloring is an effective treatment for ADHD (F)	17.2	36.7	46.0
Psychotropic drugs can cure ADHD (F)	62.1	12.1	25.8
CBT is a sufficient treatment for ADHD (F)	42.0	16.9	41.1
Medicine acting as a brain stimulant is used to treat ADHD (T)	54.5	4.7	40.7

Note. (F) = false; (T) = true; CBT = cognitive-behavioral therapy.

Etiology

Less certainty and correct responses were identified in the teachers’ knowledge about the causes of ADHD (Figure 1, Table 3). Most could identify that ADHD is not solely determined by social factors (83.1%) and more than half correctly identified ADHD as a disorder associated with abnormal brain development (60.8%). However, results suggest that only half of the teachers identified the correct answer for the statement about sugar and other diet-related factors (56.4%). Results indicated that there was less knowledge regarding the etiology of ADHD compared with their knowledge about symptoms and that the teachers tended to either incorrectly identify social/environmental factors as the drivers behind the development of ADHD or simply not know the answers to some of our statements.

Prognosis

As for the section about etiology, confusion about the prognosis was prevalent among the teachers. For the statement regarding the increased risk for lower academic attainment of children with ADHD during adulthood, 38.3% identified the correct answer, 34.1% answered incorrectly, and 27.7% did not know. Confusion about whether or not the majority of children with ADHD outgrow ADHD during adulthood also appeared to exist, with 57.8% correctly identifying that ADHD for many is a persisting disorder (Figure 1, Table 3).

Treatment/intervention

The teachers generally demonstrated adequate recognition of important pedagogical factors known to be helpful for children with ADHD, such as the importance of a structured, predictable (98.3%) and calm environment (97.3%) and the effectiveness of praise as a method to reduce problematic behaviors (75.4%; Figure 1, Table 3). About half correctly identified that stimulant medicine is used to treat ADHD (54.5%) and that medicine as such does not cure ADHD (62.1%). However, confusion seemed to exist for the effectiveness of diet interventions (17.2% correct).

Predictors of adequate knowledge

To identify which factors predicted more adequate knowledge about ADHD in children, regression analyses were used to estimate the effect of, for example, years of experience and having received specific postgraduate education about ADHD (Table 4). The final model entering all covariates was statistically significant (F = 13.3, p > .001) and explained 16% of the observed variance. In the final model, sex, years of experience, and receiving training about ADHD during education were not statistically significant after controlling for the other co-variates. The strongest predictors for correct answers were as follows: having private experiences with ADHD increased the percent correct answers by 3.1%, teaching special education classes increased the percent correct answers by 6.6%, and for each increase in the categories specifying the number of hours of postgraduate education (1 = no postgraduate education, 2 = 1-10 hr, 3 = 11-20 hr, 4 = 21-30 hr, 5 = 31-40 hr, and 6 = 41 hr plus), the percent correct answers increased by 2.6%.

Table 4.

Predictors of the Total Percent Correct Responses in Teachers on Knowledge Items.

	Model 1		Model 2		Model 3		Model 4		Model 5
Variable	B	β	B	β	B	β	B	β	B	β
Constant	70.6**		58.8**		57.9**		57.1**		63.4**
Sex	3.3*	.1*	2.9	.1	2.8	.1	2.9	.1	2.6	.1
Years of experience	0	0	0	0	0	0	0.1	0	−0.1	0
Private experience with ADHD	−3.8*	−.1*	−3.5*	−.1*	−3.4*	−.1	−3.0*	−.1*	−3.1*	−.1*
Teaching regular/special education classes			10.7**	.2**	9.6**	.2**	6.7*	.1*	6.6*	.1*
Courses about ADHD during education					1.5*	.1*	0.6	0	0.3	0
Postgraduate courses about ADHD							3.0**	.3**	2.6**	.2**
Having access to knowledge about ADHD at workplace									1.8*	.2*
R	.02		.076		.085		.136		.155
F	3.4*		10.5**		9.5**		13.4**		13.32*
ΔR²	.02		.056		.009		.051		.019
ΔF	3.4*		31.1**		5.0*		30.3**		11.3*

p < .05. **p < .001.

Discussion

This study is the first nationwide and representative study to be conducted among teachers to our knowledge. In line with our first hypothesis and the findings from the review, teachers demonstrated a high degree of recognition of symptoms of ADHD (78.8%-96.2%). The findings are reassuring as teachers are important gatekeepers when it comes to referring children with difficulties for psychiatric assessment. Not only were they often able to correctly recognize the symptoms of ADHD, but 92.8% also correctly identified that being mean to others is not characteristic for children with ADHD. Thus, teachers seemed to be able to distinguish symptoms of ADHD and conduct disorder (CD)/oppositional defiant disorder (ODD) in this one item in our survey. However, as with any other survey, our findings in this domain may lack ecological validity. It is unclear whether the teachers’ ability to correctly identify symptoms of ADHD in a questionnaire correlates with their ability to identify and differentiate among symptoms and behaviors in everyday life. This needs to be investigated in future studies.

In this study, 73.5% of the teachers knew that there is a male predominance of ADHD; however, only 56.1% correctly identified that girls can be hyperactive, while a large proportion stated that they did not know. Previous studies have detected that identifying ADHD in females seems to be more challenging, for teachers, than detecting ADHD in males. In one study, 4 out of 10 teachers reported more difficulties in recognizing ADHD in females, 85% of the teachers believed that females are more likely to remain undiagnosed, and teachers believed females to have less behavioral problems compared with males (Quinn & Wigal, 2004). In another study, elementary school teachers were more likely to be willing to refer males compared with females for psychiatric assessment when presented with vignettes where the sex of the child was experimentally altered—especially if the child in the vignette showed symptoms of hyperactivity (Sciutto, Nolfi, & Bluhm, 2004). Our finding, in combination with those from other studies, indicates that teachers’ uncertainty about what ADHD looks like in females may maintain a potential problem of underdiagnosis of females or cause a delay in referral. A recent study showed that the age of first diagnosis of ADHD tends to be older for females than males (Mohr-Jensen & Steinhausen, 2015). However, this same study also documented that the diagnosis of females with ADHD is on the rise, suggesting that knowledge about ADHD in females may be improving. Future studies should further investigate gaps in teachers’ knowledge about females with ADHD to ensure adequate referral and treatment of this at-risk group. In addition, any program aimed at improving knowledge about ADHD in school teachers may wish to pay special attention to this topic.

Another topic that may deserve special attention in future intervention programs is related to improving knowledge about comorbidity and the long-term prognosis of ADHD in children. Despite teachers being able to distinguish symptoms of ADHD and ODD/CD in our study, fewer teachers (46.4%) were aware that children with ADHD are at an increased risk of developing depressive symptoms. It seems important to increase the teachers’ awareness about the increased risk of depressive symptoms and disorders in children with ADHD to aid teachers in the early detection of comorbid disorders while they are still subthreshold. In line with findings from the studies of our review, our study identified some uncertainties among teachers related to the long-term consequences of ADHD. Only about half the teachers surveyed (57.8%) correctly identified that ADHD is not outgrown during adolescence/adulthood, 58.9% recognized the increased risk of becoming involved in criminal activities, 38.3% knew about the risk of lower educational attainment, and 48.9% knew about the increased risk for experiencing psychiatric problems. No previous studies had investigated whether teachers knew that ADHD is associated with difficulties getting and maintaining jobs in adulthood, but our findings suggest that knowledge about the prognosis of ADHD is also insecure in these domains. One could argue that knowledge about the prognosis of any disability is not relevant to professionals working with children and adolescents with ADHD. Making teachers experts in all aspects of ADHD is naturally not the aim or goal; however, we believe that it is important that they learn about the long-term risk experienced by their students, as it might increase attention to potentially emerging difficulties.

We found evidence both for and against our hypothesis that Danish teachers would support psychosocial factors and interventions as being important in relation to ADHD. Among the surveyed teachers, 66.5% and 83.1% knew that ADHD is not solely determined by social factors and that poor child rearing is not the cause of ADHD. However, 22.9% of the teachers believed child rearing practices to be essential for the development of ADHD and only 56.4% of the teachers rejected that diet is a cause of ADHD. We find it problematic that 33% of teachers believed parental attitude to be important with respect to removing the child’s behavioral problems at school and that only 18.2% knew that dietary interventions are not effective for treating ADHD. Naturally, parents of children with ADHD can lack knowledge about effective techniques to manage their children’s difficulties, however, clinical experience often supports that parents of children with ADHD do in fact make an effort and try their very best. We need to gain more insight into the origin, extent, and motivation behind these relatively frequent misbeliefs. A qualitative study has documented that the consequences of such beliefs can be that parents experience conflicts with professionals and sometimes feel blamed for their child’s difficulties, which can result in major emotional distress (Harborne, Wolpert, & Clare, 2004). Such conflicts might in turn negatively affect the integration and development of the child with ADHD in the schools.

We also identified that teachers may need more knowledge about the nature and efficacy of medications often prescribed to children with ADHD. A total of 62.1% correctly identified that stimulants cannot cure ADHD—findings that are only slightly below those from other studies (Akram et al., 2009; Kos et al., 2004; Krowski, 2009). Educational programs about ADHD for teachers should include modules regarding the efficacy and limitations of medical treatment to ensure that teachers have appropriate expectations about medication, as this may be critical to ensure treatment adherence over time.

Consistent with previous studies, teachers demonstrated correct knowledge of the effectiveness of classroom interventions. In our study, 75.4% to 97.3% of the teachers correctly identified that children with ADHD benefit from praise, structure, predictability, and a calm learning environment. These findings are positive because, after all, it is of utmost importance that the teachers are aware of behavioral techniques that may be beneficial in creating a positive learning environment for the affected children. However, future studies need to identify to what extent these techniques are practiced in everyday life within the schools.

It should be noted that many of the listed classroom management strategies were not specific interventions aimed at children with ADHD but could rather be described as good guidelines for managing a classroom. We refrained from asking teachers about their knowledge of more specific techniques such daily report cards, token economy systems, or specific programs such as Class-Peer Tutoring (Dupaul & Stoner, 2014). The rationale for this was that we wished to measure their knowledge about the behavioral practices (e.g., praise is an effective method for reducing behavioral problems in students with ADHD) that approach the more specific techniques (token economy systems) instead of their recognition of the names of specific programs. Second, we decided to interrogate the knowledge of the teachers in a more general sense, as many teachers have little specific training in such methods, as our results support. Future surveys of this population may benefit from investigating teachers’ knowledge of the existence of specific programs to supplement the findings from this study.

Finally, our second hypothesis, that having postgraduate education about ADHD significantly predicted a higher percentage of correct answers was supported. There seemed to be a dose response effect between knowledge scores and the number of hours of postgraduate education. Contrary to our hypothesis, courses about ADHD received during the teachers formal education, was not a significant factor in the final model. The reasons may be many, and the finding need further exploration.It could be a result of only 26.2% having received such education during the years of their formal education or be related to the quality or extent of the teaching received at the teachers academy. In addition, after control of other factors, private and professional experience with children with ADHD were related to higher scores. We could also establish that the age and sex of the teacher did not predict higher scores. This suggests that all teachers, regardless of their age or years of experience, should potentially be targeted when running courses aimed at improving knowledge about ADHD. This is the first study using a representative sample to document that postgraduate education about ADHD matters, at least with respect to improved scores on factual knowledge. Intervention studies aimed at improving the knowledge about ADHD in teacher populations should identify if this knowledge also impacts on practical ability and if such effects can be documented in randomized controlled trials.

Limitations

Despite the strengths of the present study, limitations apply. First, the rather low response rate (19.2%) might be a threat to the external validity of the study, as the teachers responding to the questionnaire might have self-selected. However, as the population was comparable on sex, age, and regional distributions to the population from which the sample was obtained, the bias might be minimal. The low response rate might simply be a result of the lack of opportunity for sending out reminders, the short time span for data collection, and so forth. In addition, the fact that teachers filled out the questionnaires online opened the possibility for teachers to look up the correct answers to the statements online. However, due to the relatively frequent presence of insecurities about the correct answers to our statements, we believe this bias to have been minimal. In addition, it should be noted that our questionnaire did not undergo rigorous psychometric development or test–retest reliability testing which may impact the validity of our findings in some areas. Due to the study being conducted in collaboration with DUT, we were not able to ask important questions, such as whether or not the teachers regarded ADHD as a valid diagnosis; thus, we do not know to which extent the teachers genuinely accept the construct of ADHD. However, only minor changes and omission of questions were necessary, and the collaboration with DUT was vital to ensure the large and representative study population.

As our review identified great variations in findings both between and within countries, our results might not generalize to settings outside of Denmark. Factors associated with more adequate knowledge about ADHD may, however, generalize to a greater extent and be important for interventions outside of Denmark.

Conclusion

Results of the present study identified both strengths and weaknesses in regards to the knowledge about ADHD of Danish teachers. Although many years have passed since the first surveys of teachers’ knowledge about ADHD surfaced, there are several indications that the teachers’ knowledge regarding ADHD may not have substantially improved. Teachers need more knowledge about the characteristics, etiology, prognosis, and treatment of ADHD, and we document that the most potent mechanisms for change might be through postgraduate education. Our results identified that the vast majority of teachers wish to improve their knowledge about ADHD. Politicians and policy makers must ensure that resources are made available for educating teachers about ADHD, especially now as it is becoming more common for children with ADHD to be included in regular education classrooms. These initiatives seem vital if the aims of inclusion are to be achieved, namely, to create positive and developing learning environments for children with ADHD, which ultimately should lead to more equal opportunities for those with developmental disorders and improve the work environment for teachers.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Christina Mohr-Jensen, MSc Psychology, is a PhD student at Aalborg University Hospital at the Research Unit for Child and Adolescent Psychology. She is an External Lecturer at the Institute of Communcation and Psychology at Aalborg University. Her main research interests are developmental aspects of ADHD and epidemiology

Tom Steen-Jensen, BSc Psychology, is studying in the master programme of Psychology at the Institute of Communication and Psychology at Aalborg University.

Maria Bang-Schnack, BSc Psychology, is studying in the master programme of Psychology at the Institute of Communication and Psychology at Aalborg University.

Helena Thingvad, BSc Psychology, is studying in the master programme of Psychology at the Institute of Communication and Psychology at Aalborg University.

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