Use of School-Based Interventions for ADHD,Professional Support,and Burnout Symptoms among Teachers in Iceland

Abstract

Objective:

Effective school-based interventions for youth with ADHD are critical to their success. We examined whether teacher application of such interventions and perceptions of professional support related to greater well-being, including fewer burnout symptoms.

Method:

Teachers in primary schools in Iceland were invited to participate in an online survey, including questions about professional support and the Maslach Burnout Inventory (MBI). The sample comprised N = 592 (88.5% female) participants.

Results:

Regression analyses indicated that use of recommended ADHD interventions was positively associated with MBI-Personal Achievement (PA). Greater satisfaction with professional support related to lower MBI-Emotional Exhaustion and MBI-Depersonalization, and higher MBI-PA. Level of professional support was positively associated with use of recommended interventions.

Conclusion:

Effective interventions and support for students with ADHD may enhance teacher well-being. Icelandic teachers require further training and professional support in best practices for ADHD, to help promote teacher and student success.

Keywords

ADHD behavioral interventions school-age children teachers teacher burnout

Attention-Deficit/Hyperactivity Disorder and the School Environment

Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed disorders in childhood (Costello et al., 2003; Smith et al., 2006), with estimated worldwide prevalence among children and adolescents from 5 to 10% (Faraone et al., 2003; Polanczyk et al., 2007; Thomas et al., 2015). Based on a reported prevalence of 5% or higher, at least one child in each group of 20 students, on average, meets diagnostic criteria for ADHD (Faraone et al., 2003). A large body of literature has documented the association between the disorder and a host of academic challenges, including lower academic achievement, grade retention, learning disabilities, and school drop-out (Arnold et al., 2020; DuPaul & Langberg, 2015). Hence, classroom teachers are often the first to suggest that students undergo psychoeducational assessment for various reasons, including ADHD. Indeed, such evaluations should incorporate teacher observations of a student’s behavior and academic functioning (Pliszka & AACAP Work Group on Quality Issues, 2007; Wolraich et al., 2019). Furthermore, teachers are often responsible for providing this group of students appropriate interventions and accommodations in the classroom to support their academic, behavioral, social, and emotional functioning (DuPaul et al., 2020; Mikami et al., 2022; Staff et al., 2022).

Because children with ADHD spend a majority of their day in the school environment it is imperative that they receive adequate support and their needs are met (e.g., Fabiano & Pyle, 2019). Specifically, it is important that teachers have knowledge and skills in implementing current best practices when teaching children with ADHD. Behavior management procedures (BMPs) are based on basic behavioral principles specifying how setting events, antecedents, and consequences influence behavior, and can be divided into behavioral classroom management, parent training, and peer interventions (Evans et al., 2018). An example of behavior classroom management procedures is establishing rules in the classroom where appropriate, ideally with student input (Johansson et al., 2020), reinforcing positive behavior (e.g., delivering attention contingent on appropriate behavior), and actively monitoring students (DuPaul & Stoner, 2015; Fabiano et al., 2015; Pelham & Fabiano, 2008; Pelham et al., 1998). Recently, Evans et al. (2018) evaluated evidence-based treatments for children and adolescents with ADHD and found that BMPs are well-established, evidence-based treatments for preschool and elementary school age children.

Given their empirical support, methods based on BMPs are described in the Icelandic Clinical Guidelines for Diagnosis and Treatment of ADHD, published by The Directorate of Health, a government agency in Iceland (Baldursson et al., 2012), and based on the Clinical Practice Guidelines of the American Academy of Pediatrics (AAP) (2011) and the Clinical Guidelines of the National Institute for Health and Care Excellence (NICE, 2018) in the United Kingdom. In addition to BMPs, the guidelines also include several frequently recommended school-based accommodations for students with ADHD.

According to the Icelandic clinical guidelines, in line with evidence-based BMPs noted previously, and classroom interventions and accommodations recommended for ADHD (e.g., Pfiffner & DuPaul, 2015), attention to task, work completion, and other appropriate behaviors should be reinforced systematically (DuPaul et al., 2012; Fabiano et al., 2015). In addition, students with ADHD may need frequent check-ins and follow-up support by school staff to help them sustain their attention, on-task behavior, and motivation. To that end, they might benefit from maintaining proximity to their teacher, for example via a specific seating arrangement that facilitates close monitoring and check-ins. Youth with ADHD also may require frequent breaks between periods during which they need to stay focused. It also may be especially important for students with ADHD to have a clear daily schedule as well, often accompanied by visual aids. The Icelandic clinical guidelines also state that many students with the disorder need an individual education program, for example with academic material and classroom tasks being divided into smaller segments, and students with ADHD may need extended time to complete assignments and exams. Finally, school staff is expected to have a thorough understanding of ADHD and how its symptoms may affect students (Baldursson et al., 2012). This is consistent with NICE guidelines suggesting that a child’s environment be modified to target the symptoms of ADHD (NICE, 2018). Thus, teachers have numerous responsibilities in accommodating students with ADHD in their classroom.

Classroom Behavior Management, Teacher Burnout, and Professional Support

Frequently, teachers are required to handle various stressors at work, including a heavy workload, role ambiguity, limited workplace social support, and/or classroom management challenges. As a result, teachers tend to report high levels of work-related stress and burnout (Johnson et al., 2012; Maslach et al., 2001). According to Maslach and Jackson (1986), professional burnout is a multifaceted construct, consisting of three underlying phenomena; a) emotional exhaustion; feeling physically and emotionally overextended, b) depersonalization; a distant attitude towards others (e.g., students), and c) a loss of self-confidence and lacking feelings of personal accomplishment. Differentiating between these separate, but related, dimensions of burnout, therefore, is important. These dimensions and symptoms have mainly been assessed via self-report measures, such as the Maslach Burnout Inventory (MBI; Maslach et al., 1996).

Student misbehavior has been conceptualized as behavior that disrupts the process between teaching and learning or that interferes with orderly function in the classroom (Aloe et al., 2014), a definition associated with a common description of ADHD-related behavior in academic settings (DuPaul & Stoner, 2015; Kofler et al., 2008). Notably, managing student behavioral challenges has been shown to be one of the most salient contributors to stress, and eventually burnout, among teachers (Aloe et al., 2014; Kokkinos, 2007; McCormick & Barnett, 2011). On the other hand, teachers reporting higher classroom management self-efficacy appear to be less likely to experience burnout (Aloe et al., 2014). Furthermore, Ross et al. (2012) found that teacher application of evidence-based behavioral interventions (e.g., setting clear expectations, reinforcement of positive behavior) with fidelity was associated with lower burnout and greater self-efficacy.

In addition to self-efficacy and classroom management, researchers have also investigated the role of perceived support in burnout among teachers, with administrative support (Slišković et al., 2016), a supportive organizational climate at school (Lavian, 2012), and workplace social support (Ju et al., 2015) all relating to reduced reports of teacher burnout. Interestingly, Fiorilli et al. (2019) revealed that internal resources and support (i.e., within the workplace) were more strongly associated with burnout than support external to the workplace (i.e., family, friends). Relatedly, Shackleton et al. (2019) reported that teacher perceptions of safety and administrative support with respect to behavior management significantly predicted all dimensions of burnout as measured by the MBI. Hence, both individual (e.g., self-efficacy, classroom management skills) and environmental (e.g., workplace social support, administrative support) factors appear to play a role in burnout symptoms among teachers. Accordingly, professional support merits attention within this area of research.

Preventing or mitigating teacher burnout may not only benefit teachers themselves, but also students, based on results of a study suggesting a negative relationship between teacher levels of stress and burnout and positive student behavior and academic outcomes (Herman et al., 2018). With respect to teachers of students with ADHD specifically, Sherman et al. (2008) concluded, based on a literature review, that teacher knowledge of interventions for students with ADHD may enhance student outcomes. In addition to fostering positive student functioning (Korpershoek et al., 2016), it is likely that successful application of behavioral interventions in the classroom for all students, including those with ADHD, significantly relates to teacher well-being.

To date, there are few studies examining factors contributing to stress and burnout among teachers in Iceland. Recent research by Einarsdóttir et al. (2019) revealed that 65% of participating primary school teachers rated their job as highly or extremely stressful, which authors speculated could, in part, be due to student behavioral difficulties. Of teachers participating in the study, a sobering 42% reported clinically significant levels of emotional exhaustion, which is higher than that among other college-educated professionals (Einarsdóttir et al., 2019). Similarly, in a previous study by Björgvinsdóttir and Pétursdóttir (2014), 90% of participating teachers reported that student misbehavior consumed much of their time and approximately 80% indicated that behavioral difficulties increased their stress. Perhaps most concerning was that among this group of teachers, 56% had considered leaving the profession as a result of student behavior challenges (Björgvinsdóttir & Pétursdóttir, 2014). Neither the study by Einarsdóttir et al. (2019) nor the one by Björgvinsdóttir and Pétursdóttir (2014) focused specifically on ADHD symptom management in the classroom; however, it is likely that at least some of the behavior problems affecting participants in these studies occurred among students with ADHD, particularly given the prevalence of ADHD pharmacotherapy in Iceland. Specifically, although epidemiological data regarding ADHD prevalence in Iceland currently are lacking, prescription rates for psychostimulant ADHD medications among children and adolescents ages 3 to 18 in Iceland are among some of the highest worldwide (Raman et al., 2018). Based on these data, Icelandic youths presumably receive diagnoses of ADHD at a rate higher than many of their counterparts across the world, including in other Nordic countries, which may suggest ADHD is prevalent in Icelandic classrooms.

Regarding students with ADHD specifically, Sæmundsdóttir (2009) surveyed N = 122 elementary school teachers in Iceland about their knowledge and perceived skills in teaching children with ADHD. Only a small percentage of respondents reported that the university programs they attended prepared them “well” or “very well” for teaching students with ADHD and large class sizes frequently prevented participating teachers from adequately meeting the needs of students with the disorder (Sæmundsdóttir, 2009). As a result, Sæmundsdóttir (2009) concluded that pre-service teacher education programs should provide more training concerning ADHD in the classroom. These findings mirror those of international studies, in which pre-service and in-service teachers appear to lack ADHD-related knowledge and skills (e.g., Giannopoulou et al., 2017; Mohr-Jensen et al., 2019; Poznanski et al., 2018; Rodrigo et al., 2011). Similarly, a systematic review and meta-analysis by Ward et al. (2022) revealed that studies of sufficient quality documenting the impact of teacher training on the functioning of students with ADHD are lacking. Thus, further research is needed to examine the relationship between teacher training and preparation and their capacity to accommodate student needs, including those with ADHD. Given the studies suggesting that teachers may need additional training to effectively support students with ADHD, as well as studies indicating high levels of exhaustion and stress among them, partly due to student misbehavior, which commonly co-occurs with ADHD (Azeredo et al., 2018), examinations of the association between ADHD in the classroom and teacher stress and burnout are warranted. Interestingly, however, Ozdemir (2006) examined this very hypothesis and found limited differences in burnout symptoms among teachers of students with and without an ADHD diagnosis. Specifically, teachers of students without the disorder reported higher personal accomplishment, relative to the other teacher group. The sample was small and, as a result, the generalizability of the findings was limited (Ozdemir, 2006), highlighting the need for studies with sufficient statistical power and larger samples representative of the teacher population.

Although studies on this specific topic are scant, it is plausible that teacher employment of evidence-based practices to meet the needs of students with ADHD, along with sufficient professional support, reduces their likelihood of experiencing professional burnout. Importantly, if knowledge and application of effective practices for ADHD symptom management in the classroom relate to diminished stress and exhaustion among teachers, this may provide promising avenues for prevention and intervention, both pertaining to increased teacher job satisfaction, as well as enhanced support for students with the disorder. There is a great need for more detailed information about the application of behavioral interventions in the classroom for students with ADHD, what promotes or impedes successful implementation of these practices, and whether and how ADHD symptom management in the classroom influences teacher’s perceived stress, including symptoms of burnout.

Purpose of Study

To date, no studies concerning the relationship between teacher use of evidence-based interventions for students with ADHD, level of support, and burnout symptoms have been conducted in Iceland. Based on recent international data suggesting Iceland has some of the highest ADHD medication prescription rates among children under the age of 18 worldwide (e.g., Raman et al., 2018), investigations of other interventions for ADHD and related factors clearly are warranted. Accordingly, the present study investigated the relationship between self-reported use of clinical guidelines for treatment of ADHD in the classroom (i.e., evidence-based practices), perceived support for managing ADHD in the classroom, and symptoms of burnout among primary school teachers in Iceland. The study hypotheses were as follows: 1) self-reported use of clinical guidelines for treatment of ADHD in the classroom would negatively predict self-reported symptoms of burnout, while accounting for covariates. That is, as teachers reported using a greater number of methods according to clinical guidelines for treatment of ADHD in the classroom, they would endorse fewer symptoms of Depersonalization and Emotional Exhaustion, and more symptoms of Personal Achievement; 2) teachers who reported higher level of and satisfaction with the support they received for managing ADHD in the classroom (i.e., predictor variables) would experience lower Depersonalization and Emotional Exhaustion, and greater Personal Achievement, while accounting for covariates; 3) teachers who reported greater levels of and satisfaction with the support they receive for managing ADHD in the classroom (i.e., predictor variables) would endorse use of a higher number of clinical guidelines for treatment of ADHD in the classroom, while accounting for covariates. All hypotheses were tested using hierarchical regression analysis.

Method

Participants

Participants were recruited electronically via online questionnaires emailed to all members of the Association of Teachers in Primary Schools (ATPS). Members include certified teachers, instructors, specialized teachers, school counselors, and program managers. The ATPS comprises approximately 5,000 members, resulting in an overall response rate of approximately 12%. The present sample was limited to participants who endorsed teaching at least one student with a preliminary or formal diagnosis of ADHD that school year (N = 592), of whom 88.5% identified as female (9.6% male, 1.9% other/missing). The gender distribution was similar to that of the overall population of primary school teachers in Iceland in 2019 ([82.5% female, 17.5% male], Statistics Iceland, 2020), although female teachers were slightly overrepresented in this sample. Participant mean age was 48.4 years (SD = 9.8), ranging from 22 to 70 years and their mean length of teaching experience was 16.7 years (SD = 10.1). A majority of participants (52%) had completed a bachelor’s degree in education, nearly 25% had completed a master’s degree in the same field, and approximately 20% had acquired a teaching certificate and/or possessed an undergraduate or graduate degree in fields other than education. The ATPS includes everyone who teaches at the primary school level in Iceland, encompassing grades one to ten (i.e., students ages 6–16). Approximately one third of participants reported teaching primarily at each school level (i.e., grades 1–4 = 33.3%, grades 5–7 = 32.3%, grades 8–10 = 32.1%). Participants from the capital city region comprised 55% of the sample while approximately 44% reported their geographic location to be outside the capital region.

Measures

An online survey was designed (in Icelandic) to answer the research hypotheses, via Google Forms. The survey included questions about teacher application of interventions for ADHD, level of and satisfaction with support for managing ADHD in the classroom, burnout symptoms, as well as background questions concerning participant demographics.

Demographics

Background questions asked participants about their gender, chronological age, highest educational level completed, years working as a teacher, educational level taught (grades 1–4, 5–7, or 8–10), and geographical area in Iceland.

Teacher perceived level of support and application of classroom interventions for ADHD

Questions about level of support from other school staff in managing ADHD in the classroom and their satisfaction with the support they received were based partially on questions by Sæmundsdóttir (2009). Regarding level of support, participants were asked: “Have you received support/consultation regarding students with ADHD from other school staff members this school year?” For this question, participants were presented with a list of various school staff members (e.g., school administrator, special education teacher, school psychologist, etc.) and asked to check all those, if any, from whom they had received support regarding students with ADHD. Level of support was conceptualized as a total count of school staff members from whom participants endorsed having received support, with possible scores ranging from 0 to 8. For participant satisfaction (i.e., “How satisfied/dissatisfied are you with the support you received in working with students with ADHD?”) respondents were presented with five response options(i.e., “very dissatisfied,” “dissatisfied,” “neutral,” “satisfied,” and “very satisfied”), along with “do not know” and “prefer not to answer,” both of which were treated as missing. Regarding participant application of classroom interventions for students with ADHD, a question based on the Clinical Guidelines of the Directorate of Health in Iceland (Baldursson et al., 2012) was designed specifically for the purposes of the current study. For this item, participants were presented with a list of seven strategies, described within the Clinical Guidelines, and asked to indicate which, if any, they used for supporting students with ADHD in the classroom, along with response options of “other,” “do not know,” and “prefer not to answer” that were treated as missing. Possible scores represented the total count of specific methods endorsed and ranged from 0 to 7.

Maslach Burnout Inventory

The Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981) consists of 22 items that form three subscales all pertaining to the broader construct of burnout, including: Emotional Exhaustion (EE) with nine items, Depersonalization (DP) with five items, and Personal Accomplishment (PA) with eight items. Items are presented as statements of personal feelings or attitudes, answered on a seven-point scale of frequency, ranging from “never” = 0 to “daily” = 6. The highest possible score for EE is 54 points, for DP 30 points, and for PA 48 points. For both EE and DP, higher scores correspond with more symptoms of experienced burnout; conversely, a lower PA score corresponds with a higher degree of experienced burnout. Internal consistency has been shown to be high for EE (α = 0.89), and somewhat lower, albeit acceptable, for DP (α = 0.77) and PA (α = 0.74) (Maslach & Jackson, 1981). An Icelandic version of the MBI was used in the current study (Andrason & Levy, 1992). Analyses of MBI subscale internal consistency coefficients in the current sample ranged from suboptimal for DP (α = 0.67) to acceptable for EE (α = 0.90) and PA (α = 0.82).

Procedure

The study was approved by the National Bioethics Committee in Iceland (VSNb2019020017/03.01). A recruitment email was sent from the office of the ATPS twice; in April and May 2019, with the aim of reaching all employed teachers in primary schools in Iceland. The email included a short introduction of the nature and purpose of the study. Recipients were informed that results would provide important information regarding teachers’ working environment, their knowledge and opportunities for managing symptoms of ADHD among students in the classroom, and how these factors potentially relate to symptoms of burnout. Additionally, potential participants were informed that participation was completely voluntary, anonymous, and could be discontinued at any time, without consequences. Information in the email directed participants to Google Forms, where an online survey was accessible. Participation was equal to providing informed consent. Finally, should participation have resulted in any discomfort or distress, participants were provided contact information for a licensed psychologist, who was unaffiliated with the study, and encouraged to reach out to the psychologist, free of charge.

Data Analysis

The present study employed a cross-sectional, correlational design. Data were analyzed using Microsoft Excel and IBM SPSS Statistics. Responses including “Not sure,” “Prefer not to answer,” and “Not applicable” were treated as missing. Mean scores, intercorrelations, and internal consistency coefficients for all MBI subscales were computed.

All study hypotheses were tested using hierarchical multiple regression. Covariates for all regression models were chosen based on previous research on professional burnout and included participant gender ([e.g., Purvanova & Muros, 2010]; male = 0; female = 1), teaching experience (e.g., Brewer & Shapard, 2004) in years, and participant level of education ([e.g., Friedman, 1991]; undergraduate = 0; graduate = 1). For hypothesis 1, the independent variable (IV) was the total number of endorsed methods according to clinical guidelines for treatment of ADHD in the classroom, ranging from 0 to 7, and the dependent variable (DV) was symptoms of burnout, as measured by the three MBI subscales. For hypothesis 2, the IVs were level of support from others in teaching students with ADHD, as endorsed by participants from a list (i.e., total count), and satisfaction with support for managing ADHD in the classroom (as measured on a five-point scale ranging from “very dissatisfied” = 1 to “very satisfied” = 5). The DVs were symptoms of burnout, as measured by the three MBI subscales. For hypothesis 3, levels of and satisfaction with professional support for managing ADHD in the classroom served as the IVs. The DV was the total count of self-reported use of clinical guideline strategies for treatment of ADHD in the classroom. No major violations to assumptions for hierarchical multiple regression analysis (i.e., multicollinearity, homoscedasticity, linear function assumptions, homogeneity of covariance) were identified.

Results

Descriptive Results

The mean number of methods for supporting students with ADHD in the classroom endorsed by participants was 4.37 (SD = 1.84), with a total number of reported methods ranging between 0 and 7. The most commonly endorsed method (78%) was “dividing academic material and classroom tasks into smaller segments” whereas the least commonly endorsed method (44%) was “reinforcing concentration and work completion systematically” (see Table 1 for details). For perceived level of support, the mean number of school staff providing support to participants was 1.12 (SD = 1.40), ranging between 0 and 6 staff members total (see Table 2 for more information). As for participant satisfaction with received support, approximately 37% reported being either “very dissatisfied” or “dissatisfied”; 36% indicated they were “neutral”; and 27% disclosed being either “satisfied” or “very satisfied.” MBI subscale scores ranged between 0 and 54 for EE (M = 16.03, SD = 11.62), between 0 and 26 for DP (M = 3.30, SD = 4.18), and between 3 and 48 for PA (M = 35.39, SD = 7.86). Exploratory descriptive analyses revealed that 9.6% of participants scored 1.5 SDs above the sample mean or higher on EE, 9.3% scored 1.5 SDs above the sample mean or higher on DP, and 7.9% scored 1.5 SDs below the sample mean or lower on PA.

Table 1.

Total Endorsement of Each of Seven Methods for Managing ADHD in the Classroom, Based on Clinical Guidelines.

Method applied according to clinical guidelines	Count (n)	%
I arrange seating so a student with ADHD maintains close proximity to the teacher.	368	62.5
I provide frequent breaks between periods during which the student needs to stay focused.	439	74.5
I design an individual education plan for students with ADHD.	317	53.8
I divide academic material and classroom tasks into smaller segments.	461	78.3
I design a clear and visual daily schedule.	313	53.1
I reinforce concentration and work completion systematically.	259	44.0
I provide the student with extended time to complete assignments and exams.	417	70.8

Table 2.

Participant Endorsements of Professionals Providing Support Regarding Supporting Students with ADHD in the Classroom.

Professional/staff member	Count (n)	%
Guidance counselor	92	15.5
Occupational therapist	37	6.3
School nurse	25	4.2
School psychologist	109	18.4
Special educator	185	31.3
Social educator	108	18.2
School support service professional (i.e., behavior management consultant, instruction consultant, social worker)	103	17.4
Other (e.g., “colleagues,” “administrators,” “support services administrator,” “healthcare professionals,” “applied behavior analysis specialists”)	25	4.2

Hypothesis 1

A hierarchical multiple regression was run three times, once for each subscale of the MBI (DV), to determine whether the addition of number of clinical guidelines methods endorsed (IV), improved the prediction of burnout above and beyond gender, years of teaching experience, and level of education. See Table 3 for details on each regression model. The full model of gender, teaching experience, participant education, and number of methods according to clinical guidelines endorsed, predicting symptoms of MBI-EE (step 3) was not statistically significant, R² = .02, F(4, 561) = 2.09, p = .081; adjusted R² = .01. The addition of the number of endorsed clinical guidelines methods to the prediction of MBI-EE (step 3) did not lead to a statistically significant increase in R², F(1, 561) = 1.767, p = .197. Teaching experience, however, retained its significant, negative association with EE at all steps of the model, β = -.10, p = .016 (step 3).

Table 3.

Hierarchical Multiple Regression Analyses With MBI-EE, MBI-DP, and MBI-PA as DVs, and Number of Endorsed Methods According to Clinical Guidelines as IV.

Predictor	MBI subscales
	MBI-EE		MBI-DP		MBI- PA
	∆ R²	β	∆ R²	β	∆ R²	β
Step 1 (control)	0.01*		0.01*		0.00
Gender		.04		.02		−.01
Years of teaching		−.10*		−.11*		.03
Step 2	0.00		0.01		0.00
Level of education		−.02		.07		−.02
Step 3	0.00		0.01		0.01*
Number of methods endorsed		.06		.08		.10*

Note. ns vary because of missing data; n = 565. DV = dependent variable; IV = independent variable; MBI-DP = Maslach Burnout Inventory – Depersonalization subscale; MBI-EE = Maslach Burnout Inventory – Emotional Exhaustion subscale; MBI-PA = Maslach Burnout Inventory – Personal Achievement subscale.

p < .05.

The full model of gender, teaching experience, participant education, and number of methods according to clinical guidelines endorsed to predict symptoms of MBI-DP (step 3) was statistically significant, R² = .02, F(4, 561) = 3.25, p = .012; adjusted R² = .02. The addition of the number of endorsed clinical guidelines methods to the prediction of MBI-DP (step 3) did not lead to a statistically significant increase in R², F(1, 561) = 3.59, p = .059. Teaching experience, however, retained its significant, negative association with DP at all steps of the model (step 3), β = −.10, p = .022.

The full model of gender, teaching experience, education, and number of clinical guidelines methods endorsed to predict symptoms of MBI-PA (step 3) was not statistically significant, R² = .01, F(4, 561) = 1.58, p = .178; adjusted R² = .004. The addition of endorsed number of clinical guidelines methods to the prediction of MBI-PA (step 3), however, led to a statistically significant increase in R² of .01, F(1, 561) = 5.46, p = .020, and the number of endorsed methods was significantly associated with MBI-PA, β = .10, p = .020. Teaching experience, however, was not significantly associated with PA at any step of this model: β = .03, p = .481 (step 3).

Hypothesis 2

A hierarchical multiple regression was run three times, once for each subscale of the MBI to determine whether the addition of level of support in assisting students with ADHD in the classroom, and satisfaction with such support, improved the prediction of burnout. See Table 4 for details on each regression model. The full model tested to predict symptoms of MBI-EE (step 3) was statistically significant, R² = .15, F(5, 548) = 18.77, p < .001; adjusted R² = .14. The addition of level of support and participant satisfaction with such support (step 3) led to a statistically significant increase in R² of .13, F(2, 548) = 42.56, p < .001, and participant support satisfaction was significantly and negatively associated with EE, β = -.37, p < .001. Teaching experience was significantly and negatively associated with EE at steps 1 and 2, but not at step 3, β = −.08, p = .06.

Table 4.

Hierarchical Multiple Regression Analyses With Perceived Levels of Support in Assisting Students With ADHD in the Classroom and Satisfaction With Received Support in General as IVs and MBI-EE, MBI-DP, and MBI-PA as DVs.

Predictor	MBI subscales
	MBI-EE		MBI-DP		MBI-PA
	∆ R²	β	∆ R²	β	∆ R²	β
Step 1 (control)	0.01*		0.01		0.00
Gender		.04		.02		−.02
Years of teaching		−.11*		−.11*		.03
Step 2	0.00		0.00		0.00
Level of education		−.02		.07		−.03
Step 3	0.13**		0.05**		0.02*
Satisfaction w/support		−.37**		−.23**		.11*
Level of support		.02		.05		−.04

Note. ns vary because of missing data; n = 553. DV = dependent variable; IV = independent variable; MBI-D = Maslach Burnout Inventory – Depersonalization subscale; MBI-EE = Maslach Burnout Inventory – Emotional Exhaustion subscale; MBI-PA = Maslach Burnout Inventory – Personal Achievement subscale.

p < .05. **p < .01.

The full model tested to predict symptoms of MBI-DP (step 3) was statistically significant, R² = .07, F(5, 548) = 7.87, p < .001; adjusted R² = .06. The addition of level of support and satisfaction with such support (step 3) led to a statistically significant increase in R² of .05, F(2, 548) = 14.71, p < .001, and support satisfaction was significantly and negatively associated with DP, β = −.23, p < .001. Teaching experience was significantly and negatively associated with DP at all model steps, β = −.08, p = .05 (step 3). The full model tested to predict symptoms of MBI-PA (step 3) was not statistically significant, R² = .02, F(5, 548) = 1.90, p = .093; adjusted R² = .01. The addition of levels of support and satisfaction with such support (step 3) led to a statistically significant increase in R² of .02, F(2, 548) = 4.17, p = .016, and support satisfaction was significantly and positively associated with PA, β = .11, p = .018. Teaching experience was not significantly associated with PA at any step of this model, β = .01, p = .808 (step 3).

Hypothesis 3

A hierarchical multiple regression was run to determine whether the addition of level of support and satisfaction with such support, improved the prediction of the number of endorsed clinical guidelines methods (see Table 5 for details). The full model (step 3) was statistically significant, R² = .08, F(5, 548) = 9.71, p < .001; adjusted R² = .07. The addition of level of and satisfaction with professional support (step 3) led to a statistically significant increase in R² of .07, F(2, 548) = 20.29, p < .001. In this model, female gender significantly predicted the total number of endorsed methods across all steps of the model, β = .12, p = .004 (step 3), and level of support also significantly predicted the DV, β = .27, p < .001 (step 3).

Table 5.

Hierarchical Multiple Regression Analysis With Level of and Satisfaction With Support in Teaching Students With ADHD as IVs, and Number of Endorsed Methods According to Clinical Guidelines as DV.

Number of clinical guidelines endorsed
Predictor	∆ R²	β
Step 1 (control)	0.01*
Gender (female)		.12**
Years of teaching		−.01
Step 2	0.00
Level of education		−.00
Step 3	0.07**
Satisfaction with support		−.06
Level of support		.27**

Note. ns vary because of missing data; n = 553. DV = dependent variable; IV = independent variable.

p < .05. **p < .01.

Discussion

To our knowledge, the current study was the first to examine teacher use of clinical guidelines for treatment of ADHD in the classroom in Iceland. The purpose of the study was to investigate the relationship between self-reported teacher use of clinical guidelines for management of ADHD symptoms in the classroom, burnout symptoms, and level of and satisfaction with support for managing ADHD in the classroom.

Burnout Symptoms, Use of Evidence-Based Methods, and Professional Support

The hypothesis that as teachers reported using a greater number of methods per clinical guidelines for treatment of ADHD in the classroom, they would report fewer symptoms of burnout was supported for the PA, but not the DP and EE, dimensions of the MBI. In other words, while accounting for participant gender, years of teaching experience, and their level of education, their self-reported adherence to clinical guidelines significantly and positively predicted greater PA. Interestingly, however, greater teaching experience was associated with lower scores of both EE as well as DP, but no such associations were found between teaching experience and PA. Taken together, these results indicate that self-reported adherence to clinical guidelines may play a helpful role in teacher self-confidence and sense of achievement, while greater teaching experience may serve as a buffer against feeling emotionally exhausted and distant towards others. To some extent, these findings are consistent with prior research, suggesting that perceived knowledge and use of methods for managing behavior influences teacher symptoms of burnout (Aloe et al., 2014; Ross et al., 2012), and that years of teaching experience may relate negatively to burnout (Brewer & Shapard, 2004). The present study adds to this body of literature by illustrating the potential role of effective management of ADHD symptoms in the classroom in elevating teachers’ sense of accomplishment, thereby diminishing burnout symptoms. Given the negative association between teaching experience and EE and DP symptoms, paying close attention to early career teachers and their job-related well-being may be especially important.

The hypothesis that teachers reporting greater professional support for managing ADHD in the classroom would experience fewer symptoms of burnout was partially supported. Participant satisfaction with the support they received in teaching students with ADHD was significantly predictive of lower MBI-EE and MBI-DP, and higher MBI-PA scores, suggesting fewer symptoms of burnout. In contrast, the number of professionals/colleagues providing such support was not significantly associated with any MBI dimension. These results indicate that as teachers report feeling more satisfied with the support they receive, the less likely they are to experience symptoms of burnout. These findings are consistent with prior research on organizational support and perceived workload as factors associated with symptoms of burnout among teachers (Johnson et al., 2012; Maslach et al., 2001; Shackleton et al., 2019). Additionally, in a recent systematic review, Kangas-Dick and O’Shaughnessy (2020) concluded that to inform teacher well-being intervention efforts, consideration of individual factors is perhaps necessary, but insufficient. Instead, an ecological approach that involves an examination of the systems, climate, and culture that either promote or impede teacher well-being, is crucial (Kangas-Dick & O’Shaughnessy, 2020). Based on descriptive findings, teachers participating in the present study, on average, received support from approximately one professional. Unfortunately, only 27% of participants reported being “satisfied” or “very satisfied” with the support they received, while 37% were either “dissatisfied” or “very dissatisfied.” Ensuring teachers experience adequate support within their professional environment that meets their needs, therefore, may help reduce the risk of burnout within this population.

Finally, the hypothesis that teachers who reported greater satisfaction with and higher level of support for managing ADHD in the classroom would adhere to a higher number of clinical guidelines methods was partially supported. Specifically, participants reporting a larger group of professionals or colleagues from whom they could seek support were more likely to endorse using a higher number of clinical guidelines for managing ADHD symptoms in the classroom, whereas satisfaction with such support was not significantly associated with the number of strategies endorsed by participants. Based on these findings, teacher use of effective support strategies for students with the disorder may rest upon having a number of individuals to whom to turn for supervision and guidance. Indeed, multidisciplinary collaboration that includes contributions of several professionals has been recommended as part of an effective intervention program for individuals with ADHD (e.g., Talbott et al., 2021).

Additional findings

Interestingly, a closer examination of the specific methods endorsed revealed that most participants reported using the strategy of “dividing academic material and classroom tasks into smaller segments” (78%). Conversely, “systematically reinforcing concentration and work completion” (44%) was the least commonly endorsed. Positive reinforcement is a principle that underlies these methods and, ideally, should therefore be one of the most commonly used. In fact, a meta-analysis examining the effects of school-based interventions for students with ADHD revealed that strategies relying on systematic reinforcement of appropriate behavior (i.e., contingency management) were associated with improvements in student behavior as well as academic functioning (DuPaul et al., 2012). Furthermore, DuPaul et al. (2012) noted that “. . .even when used in isolation, contingency management interventions are effective, especially for enhancing classroom behavior and engagement with instructional activities” (p. 406). A more recent meta-analysis by Gaastra et al. (2016) extended these findings by demonstrating that interventions aimed at the consequences of behavior (e.g., systematic reinforcement of behavior), as well as self-regulation strategies, had the most impact on behaviors of students exhibiting symptoms of ADHD. Combined with the fact that participants in the present study, on average, only reported using approximately four out of seven strategies for supporting students with the disorder, these findings have important implications for teacher-delivered interventions in the classroom and suggest several underused opportunities among teachers in using effective interventions to support this student population. Presumably, teachers in Iceland would benefit from additional training and professional support in using evidence-based interventions, especially systematic reinforcement of appropriate behaviors, when working with students with ADHD.

Descriptive analyses of MBI subscale scores in the current sample indicated substantial variation in their experiences with symptoms of burnout, with some participants experiencing minimal levels of burnout, and others disclosing high levels of burnout symptoms, as reflected, for example, in participant Emotional Exhaustion scores ranging from the lowest (i.e., 0) to the highest possible (i.e., 54) total score for that subscale. Because nationally representative cutoff scores for clinical levels of burnout as measured by MBI subscales are non-existent in Iceland, no calculations of the prevalence of burnout in this sample were conducted. Nevertheless, to some degree, the present findings echo results of previous studies that depict alarming levels of exhaustion among teachers in Iceland (Björgvinsdóttir & Pétursdóttir, 2014; Einarsdóttir et al., 2019), in that between 8 and nearly 10% of participants had at least one MBI subscale score deviating 1.5 SDs or more from the sample mean, indicating elevated experiences of burnout. It is important to note, however, that these numbers are merely exploratory, have not been validated psychometrically, and, therefore, do not serve as estimates of teacher burnout prevalence. As such, the true prevalence of clinical burnout in this sample is unknown. Instead, these findings illustrate the need for more detailed data regarding teacher burnout and its risk and protective factors, which would help inform prevention and treatment efforts to support teacher well-being, hopefully fueling continued research in this area.

Collectively, the present results suggest that teacher self-reported use of clinical guidelines for management of ADHD symptoms in the classroom relates to a stronger sense of achievement and self-confidence. Teachers with more years of teaching experience appear less likely to experience feeling distant from others or emotionally exhausted. Importantly, teachers who are satisfied with the support they receive in working with students with ADHD also are not as drained emotionally, less likely to experience depersonalization, and more likely to possess feelings of personal achievement. This has implications for practice in the schools, and underscores the importance of ensuring teacher job satisfaction, particularly as it pertains to professional support.

Study Limitations

A few limitations of the study should be noted. According to the MBI manual (Maslach & Jackson, 1986), respondents should not be informed they are answering questions regarding burnout. In the introduction to the online questionnaire, however, participants were informed that burnout was one of the research topics, although the name of the MBI was not mentioned. This may have affected the present findings to some degree. Further, the internal consistency of the MBI-DP subscale was less than optimal in this sample; hence, findings should be interpreted cautiously. Moreover, it could be argued that the number of different staff members providing support and a global satisfaction score are insufficient to measure participants’ perceptions of the amount and quality of professional support they receive. The current study was cross-sectional, rendering any causal inferences inappropriate. Lastly, the study also relied on a self-report measure of teacher use of evidence-based methods for classroom management of ADHD, which is subject to bias. Thus, the accuracy, intensity, or frequency with which participants truly use these strategies is unclear. Additionally, it is unclear to what extent endorsement of a higher number of strategies translates to successful support of students with ADHD in the classroom. Despite these limitations, the findings speak to members of the school community in general, are consistent with previous research findings, and help inform future studies within this area.

Future Directions

Future research might involve replicating this study using a large, nationally representative sample of participants employed as primary school teachers. Ideally, such studies should use objective measures of teacher employment of these strategies (e.g., direct observations) that might paint a more valid picture of the support students with ADHD receive in the school environment, and the effects these practices have on school community members’ health and well-being. Clearly, investigations of effective prevention and intervention to promote teacher well-being are needed. Based on the present findings, adequate teacher training in use of successful strategies for managing student behavior and ADHD symptoms in the classroom might be beneficial, particularly if implemented within a caring school climate in which effective collaboration and readily available professional support are the norm.

Conclusion

This study offers practical suggestions concerning ways to improve teachers’ and students’ working environment, including providing sufficient pre- and in-service training in using evidence-based behavior management methods in the classroom and ensuring educators receive adequate professional support that meets their own and their students’ needs. Presumably, if teachers are skilled in using effective classroom management strategies, they are likely to have fewer symptoms of burnout and to feel more personally accomplished in their work. In turn, using these skills in the classroom might increase positive student behavior, particularly for those who struggle because of ADHD symptoms, and support their academic achievement.

It is important that students with ADHD receive appropriate interventions, based on the best available knowledge (e.g., DuPaul & Stoner, 2015; Pfiffner & DuPaul, 2015). Evidence-based classroom practices should be the first choice for every student with ADHD (DuPaul et al., 2012), given that it is in both the teachers’ and students’ best interest.

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.

ORCID iD

Bergljot Gyda Gudmundsdottir

Author Biographies

Erla Karlsdóttir, MSc, Reykjavik University, Iceland, is a licensed psychologist and serves as a school psychologist at South Center, City of Reykjavík, Iceland. The current study is based on her master’s thesis in clinical psychology at Reykjavik University.

Bergljot Gyda Gudmundsdottir, MA, PhD, University of Rhode Island, US, is a licensed psychologist, certified school psychology specialist, and associate professor at the University of Iceland, School of Education, Iceland.

Berglind Sveinbjörnsdóttir, MSc, Northeastern University, US; PhD, Western New England University, US, is a board certified behavior analyst (BCBA) and assistant professor at Reykjavik University, Iceland, Department of Psychology.

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