An Examination of Teacher Trainees' Knowledge of ... - Springer Link

School Mental Health (2012) 4:105–114 DOI 10.1007/s12310-012-9071-3

ORIGINAL PAPER

An Examination of Teacher Trainees’ Knowledge of Attention-Deficit/Hyperactivity Disorder Will H. Canu • Emily B. Mancil

Published online: 14 February 2012 Springer Science + Business Media, LLC 2012

Abstract Research has suggested that in-service teachers learn relatively little about attention-deficit/hyperactivity disorder (ADHD) during their education, but that on-thejob learning helps mitigate this deficiency. Current teacher trainees may receive more ADHD education than past cohorts, though it is unclear whether their ADHD knowledge is superior to that of peers and, more broadly, whether it is adequate for referral and other service provision in the classroom. This study compares the ADHD-related knowledge of teacher trainees to that of undergraduate peers of diverse majors. Trainees’ knowledge was more accurate than the peer comparison group, yet findings suggest that substantial room for improvement remains. Keywords Attention-deficit/hyperactivity disorder ADHD Teacher education Special education

Introduction Attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder that, according to the Diagnostic and Statistical Manual of Mental Disorders (4th edition text revision, DSM-IV-TR; American Psychiatric Association, APA, 2000), at least partially presents before the age of 7 years and is distinguished by impairing levels of inattention (IA) and/or hyperactivity-impulsivity (HI). ADHD W. H. Canu (&) E. B. Mancil Department of Psychology, Appalachian State University, 222 Joyce Lawrence Lane, Boone, NC 28608, USA e-mail: [email protected] E. B. Mancil Department of Psychology, University of South Carolina, Columbia, SC, USA

has a prevalence of 8.6% in school-age children in the United States (Centers for Disease Control and Prevention, CDC, 2009), with worldwide estimates in a similar range (Skounti, Philalithis, & Galanakis, 2007) and substantively consistent across North America, Europe, Asia, and Oceania (Polanczyk, de Lima, Horta, Biederman and Rohde 2007). Many parents of children with ADHD first notice excessive motor activity (e.g., an inability to stay still) and impulsivity related to deficits in executive functioning (e.g., planning and judgment) in the preschool years. However, the disorder is most often diagnosed during early elementary school, when children encounter difficulties with school adjustment (APA, 2000) due to rule-breaking behaviors related to HI as well as those more characteristic of IA (e.g., failing to follow through on age-appropriate instructions; Lavin, 2008). Impairment in academic pursuits is common for children with ADHD and can be pervasive, often negatively affecting interpersonal adjustment, classroom productivity, and academic achievement (Barkley, Fischer, Smallish, & Fletcher, 2006; Frazier, Demaree, & Youngstrom, 2004). Such children underperform in schoolwork productivity and mastery of age-appropriate material and skills (Ek, Westerlund, Holmberg, & Fernell, 2011; Powers, Marks, Miller, Newcorn, & Halperin, 2008). Overall, maladjustment in school may stem from a combination of several factors above and beyond the simple presence of IA and HI, including (a) comorbid learning disabilities (46% prevalence in children with ADHD; Larson, Russ, Kahn, & Halfon 2011), (b) lower intrinsic motivation (Carlson, Booth, Shin, & Canu, 2002), (c) discounting of long-term rewards in the rationing of effort (Marco et al., 2009), (d) limited perception of immediate penalties for academic underperformance (Luman, Oosterlaan, Knol, & Sergeant, 2008), (e) negative peer relations (Hoza et al., 2005), and

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(f) impaired executive functions (e.g., working memory; Rapport, Scanlan, & Denney, 1999). Given this extensive range of deficits, it is understandable that many children with ADHD fail to adapt to and progress in school. Indicators of such maladjustment include more frequent use of special education and other in-school services, grade retention (42% rate in those with ADHD; Barkley et al., 2006), disciplinary problems leading to suspension or expulsion, and failure to complete high school (32% drop out of school; Barkley, DuPaul, & McMurray, 1990; Biederman, Petty, Evans, Small, & Faraone, 2010; Gale´ra, Melchior, Chastang, Bouvard, & Fombonne, 2009). ADHD and Teachers in the Schools Trends regarding school maladjustment and prevalence estimates (e.g., CDC, 2009) and other data suggesting teachers will likely encounter at least one student with ADHD during each year of service (Jerome, Gordon, & Hustler, 1994; Ohan, Cormier, Hepp, Visser, & Strain 2008) indicate that it is important to convey adequate understanding of ADHD and related interventions to teacher trainees (i.e., teacher candidates in their final undergraduate semester and in-school student teaching placement; Vereb & DiPerna, 2004). As new in-service teachers, these budding professionals will be expected to notice warning signs (i.e., bona fide ADHD symptoms) and to avoid inaccurate interpretations of ‘‘misbehavior’’ leading to unwarranted ADHD evaluations. They will also be called upon to implement, evaluate, and support treatments for children with ADHD (Hawkins, Martin, Blanchard, & Brandy, 1991; National Council for Accreditation of Teacher Education, NCATE, 2008), requiring savvy regarding the nature of ADHD. In sum, even novice teachers should have specific knowledge regarding ADHD-related phenomena that is sufficient to enable accurate recognition of ADHD in their students, understanding of its common etiological factors (e.g., for psychoeducational purposes, at least), and empathic and effective management of associated disruptive behavior, academic difficulties, and peer rejection. However, unfortunately, very little empirical research sheds light on how well teacher trainees understand ADHD phenomena, and specifically so in relation to their peers. Beyond Education: Does Teaching Experience Beget ADHD Knowledge? Several studies have compared the relative extent of ADHD-related knowledge of in-service teachers (i.e., active and certified) versus pre-service teachers (i.e., student teachers and teacher candidates), and, in general, this literature suggests the former to be better informed than the

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latter. These findings hold true in Australia (Kos, Richdale, & Hay, 2006; Kos, Richdale, & Jackson, 2004), the United States (Sciutto, Terjesen, & Frank, 2000), and Canada (Jerome et al., 1994; see Scottish exception, Akram et al., 2009). Positive associations have been demonstrated between extent of direct teaching experience with students with ADHD and (a) degree of ADHD-related knowledge (Jerome et al., 1994; Kos et al., 2004, 2006; Sciutto et al., 2000; for exception see Hepperlen, Clay, Henly, & Barke´, 2002), (b) confidence to effectively instruct a child with ADHD (Kos et al., 2006), and (c) greater endorsement of in-class behavioral interventions (Ohan, Visser, Strain, & Allen, 2011). The degree of informational advantage that in-service teachers possess, however, may be limited. For instance, in-service teachers tend to overestimate the extent of their ADHD knowledge (48 out of 100 on a visual scale, versus 29 for trainees) in comparison to actual accuracy on a questionnaire measure (61 and 53% correct, respectively; Kos et al., 2004). Kos et al. (2004) suggest that this overconfidence in experienced teachers may actually hinder motivation to seek additional formal education about ADHD. Altogether, the literature unfortunately suggests that the incremental benefit of experience has a ceiling (i.e., observation of children with ADHD can augment accurate knowledge only so much). Further, extant findings suggest that the potential benefits of specific, advanced training regarding ADHD (e.g., a continuing education workshop), such as improved understanding and decreased negative bias (Ohan et al., 2011; Ru¨sch, Angermeyer, & Corrigan, 2005), seem unlikely to be realized in teaching practice (Hepperlen et al., 2002). That duration of teaching experience does not appear to be linearly associated with accurate understanding of ADHD reinforces the importance of examining the extent of teacher’s pre-service knowledge. Teachers’ Knowledge: Misperceptions About ADHD While experienced teachers may hold somewhat more accurate beliefs about ADHD than novices, knowledge for both groups in certain areas may still be limited, resulting in potentially problematic consequences. Largely, teachers do seem aware that the cardinal symptoms of ADHD are hyperactivity and inattention (*90% accurate endorsement; Sciutto et al., 2000), but other basic information appears to be commonly misunderstood. For instance, regarding prevalence, 23% of a sample of Virginia schoolteachers believed the rate of ADHD to be between 16 and 25%, and 13% believed it to be greater than 26%, substantially higher than current estimates (Glass & Wegar, 2000). As a whole, teachers also appear to be inaccurate in their understanding of etiological (e.g., significant familial


transmission, true), intervention (e.g., electroconvulsive therapy as an alternative therapy, false), and situational (e.g., behavior being better in familiar situations, false) facets of the disorder (\50% accuracy; Sciutto et al., 2000). Other studies have revealed inaccuracies in teachers’ knowledge related to similar topics, such as response to stimulant treatment sufficing for diagnosis (false), likelihood that the disorder will remit before adulthood (false), and a direct linkage between ADHD and delinquency (false) (Akram et al., 2009; Glass & Wegar, 2000; Jerome et al., 1994). Although the findings from such studies are evidently mixed, one conclusion seems clear: Teachers’ knowledge regarding ADHD is often is incomplete or inaccurate, and certain common gaps (e.g., unrealistically high prevalence, likelihood of remission by late high school) have negative implications for service provision (e.g., over- or under-referral for assessment). In this light, it is unfortunate that in-service teachers, despite the desire to receive more disorder-specific training (Jerome et al., 1994), report having had very few opportunities to learn about ADHD over the course of their formal education (Akram, Thomson, Boyter, & McLarty 2009). Why ADHD Knowledge Matters: Association with Intervention-Related Behavior One could argue that only certain deficits in ADHD knowledge could be problematic for teachers. For instance, misunderstanding of gender distribution (e.g., incorrect belief that it is a disorder that only affects males) might be quite problematic for the identification of affected female students, whereas knowledge that lead exposure is associated with ADHD may have less bearing on accurate detection of at-risk students or other critical intervention behaviors. However, even general measures of ADHD knowledge (i.e., including items related to symptom presentation, prevalence, etiology, course, and intervention) have been shown to predict important teacher attitudes and behavioral intentions regarding intervention for ADHD. For instance, in a group of experienced Australian teachers (M = 20 years in service), those in the top quartile of general ADHD knowledge (C80% accuracy, as measured by the ADHD Knowledge Scale, Jerome et al., 1994) were more likely to perceive home-based behavioral therapy, classroom accommodations, and other educational support services as potentially beneficial for diagnosed students, as compared to those in the bottom quartile of knowledge (B70% accuracy; Ohan et al., 2008). Importantly, teachers in this ‘‘high’’ ADHD knowledge group were also more likely to endorse willingness and intent to seek assessment and intervention services on behalf of students with ADHD symptoms. Others have corroborated that the way that teachers react to and view ADHD-related symptoms and

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various treatments can impact the types and efficacy of interventions used within the classroom (Sherman, Rasmussen, & Baydala, 2008). The extent to which teachers exhibit patience with and a positive attitude toward affected students, as well as their knowledge of appropriate instructional techniques and relative ability to collaborate with other professionals regarding ADHD-related intervention, can also affect the classroom performance and behavior of those diagnosed with ADHD (Sherman et al., 2008).

Current Study It has been suggested that more comprehensive ADHD knowledge in teachers plays a role in referrals for assessment and other in-school services that are effective and in the best interest of students (Ohan et al., 2008). However, a recent examination of course syllabi from a randomly selected sample of teacher training programs in the United States (N = 28) found that about 16% of programs provided instruction related to identification and characteristics of children with emotional and behavioral problems (e.g., ADHD, depression, at-risk for mental health problems), and that the average, programmatic in-class exposure to such material was a mere 11 min (range 0–100; State, Kern, Starosta, & Mukherjee, 2011). Prior reports by teachers in the United States, Canada, Australia, and Scotland similarly suggest that this reflects a historical trend, but also that ADHD-specific teaching experience may address this deficit to some degree (Akram et al., 2009; Jerome et al., 1994; Kos et al., 2004). While current pre-service teachers are implicitly limited in their teaching experience with affected students, this gap might be counterbalanced by initial training in this area surpassing that of past trainees (Kos et al., 2006). Unfortunately, published research examining pre-service (i.e., trainee) teachers’ ADHD-related knowledge is scant (Kos et al., 2006), suggesting that evaluation of whether these emerging professionals are well equipped for the challenge of teaching affected children is imperative. The current study evaluates the relative preparedness of teacher trainees along these lines by comparing their understanding of ADHD to that of an undergraduate peer group. It was hypothesized that teacher trainees would have more accurate ADHD knowledge, considering the likelihood that individuals in this group might be expected to have relatively more formal training in this area, on average, and also greater intrinsic interest in child development. Confirmation of this hypothesis was considered a necessary step toward establishing that the preparation of current novice teachers to serve students with ADHD is adequate. Examination of the actual (versus relative) accuracy of the

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teacher trainee’s ADHD knowledge was also considered an important focus of the study.


Measures Demographics

Method Participants Participants included 534 pre-service teachers (i.e., students completing a 15-week teaching internship as the final requirement for their education degrees) and 377 undergraduate students from a public university in the southeastern United States. Both groups received course credit for participation. The latter group was comprised of students enrolled in introductory and intermediate level psychology courses. Overall, there was mixed concordance between the groups demographically. The mean age of the teacher trainee (TT) group was 24.8 years (SD = 6.0 years), with those in the comparison peer (CP) group tending to be younger, t (903) = 16.07, p \ .001, M = 19.7, SD = 3.7, and not in their final year of undergraduate work (8.6%, n = 34, in 4th year or higher). Therefore, it was not surprising that those in the TT group had higher educational attainment (M years post-secondary schooling completed = 3.6, SD = .5) than those in their comparison peers, M = .8, SD = 1.0, t (921) = 54.30, p \ .001. No sex differences were detected, v2 (1, N = 927) = 1.1, p = .30 (75.6 and 78.5% female in the teacher trainee and peer groups, respectively), and personal experience with ADHD was equivalent across groups as well, v2 (1, N = 921) = .271, p = .603, with 21.6% of TT and 20.1% of CP participants indicating having personal or within-family experience with the disorder. A difference did emerge for ethnicity, v2 (6, N = 916) = 24.79, p \ .001 (see Table 1). Post hoc comparisons indicated greater diversity in the CP versus the TT samples, with the CP pool containing a larger percentage of Hispanics than the TT group (2.8 and 0.6%, respectively) and the TT group containing a greater percentage of Caucasians than the CP group (95.3 and 89.1%, respectively). To enable statistical control for these differences in ethnicity, two dichotomous dummy variables were created for Caucasian and Hispanic status for use in subsequent analyses. Age and educational level were also utilized as control variables. Major designations among the CP group were diverse, with thirty-nine disciplines reported across participants; the three most common were psychology (12.5%), biology (10%), and exercise science (8.5%; undeclared/unknown = 17.4%). Data were collected in the first month of a fall and spring academic semester; given this limited window, those in the CP group had not yet covered psychology course material that was directly related to ADHD.

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General demographic information was collected (e.g., gender, age, ethnicity), as well as mental health history for the participant and their family. This included ADHD diagnosis, specifically, in order to determine the amount of personal ADHD-specific exposure participants might have had. In addition, participants completed an item that tapped the degree of prior experience with children diagnosed with ADHD, using a ten-point Likert-type scale (0 = no experience, 9 = a great amount of experience). Knowledge and Beliefs The Knowledge and Beliefs Questionnaire (Kos et al., 2004) includes 27 items measuring perceived (i.e., the amount of ADHD knowledge participants believed they had) and actual knowledge (i.e., the amount of knowledge they actually had about ADHD). Some of these items had been employed in previous studies (Jerome et al., 1994; Sciutto et al., 2000) and others are based on extant ADHD literature (see Kos et al., 2004, for further detail regarding measure development). Perceived knowledge in this study was measured on a Likert scale that ranged from one (no knowledge) to nine (very knowledgeable), which represents a format change from the 10 cm visual analog scale used in the paper and pencil version. Actual knowledge was measured by a scale comprised of 27 statements related to ADHD, with answer choices of True, False, and Don’t Know (see Table 2). Item responses were later coded as Correct (i.e., accurate response; item score = 1) and Incorrect or Don’t Know (i.e., inaccurate knowledge; item score = 0, inaccurate knowledge). Items scores were then summed, resulting in a scale score range from 0 to 27, with high scores indicating more accurate knowledge. Internal consistency of item scores was satisfactory in our sample (a = .77). Procedure Those in the TT group were directed to the survey during an internship seminar at the beginning of each full-length semester in the 2009–2010 academic year by their supervising professor. CP undergraduates were informed of the opportunity to complete the study via electronic mail. Two hundred fifty TT and 243 CP participants completed the survey in fall of 2009, whereas 284 and 134 from each group, respectively, completed it in spring 2010. Participants answered online survey questions via SurveyMonkey.com. Informed consent forms were completed at the beginning of each survey. Online questionnaires followed, and participants were allowed to skip any questions they

School Mental Health (2012) 4:105–114 Table 1 Mean (standard deviations) or distribution of demographic and dependent data

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Teacher trainees (n = 534)

Comparison peers (n = 377)

Male

21.5% (n = 115)

24.4% (n = 96)

Female

78.5% (n = 419)

75.6% (n = 297)

Age

24.83 (5.96)

19.70 (3.65)

College education (years)

3.6 (.52)

.76 (1.04)

Caucasian

95.3% (n = 511)b

89.1% (n = 351)a

African American

2.1% (n = 11)

2.8% (n = 11)

Hispanic

0.6% (n = 3)a

2.8% (n = 11)b

Asian

1.3% (n = 7)

1.8% (n = 7)

American Indian

0.2% (n = 1)

0% (n = 0)

Other

0.4% (n = 2)

0.3% (n = 1)

Gender

Ethnicity

Superscripts indicate statistically significant differences, with increasing means indicated by alphabetic order; ADHD Experience = exposure via family or friends

Perceived knowledge

5.11 (1.48)

4.31 (1.83)

Actual knowledge

16.55 (3.82)

14.50 (4.31)

ADHD experience

20.1%

21.6%

deemed unduly stressful. All study procedures were reviewed and approved by the university’s Institutional Review Board.

Results Comparison of Teacher Trainees to Undergraduate Peers Given the detected group differences on demographic variables, hypotheses regarding group differences on perceived ADHD knowledge and accuracy of true ADHD knowledge were tested with Analyses of Covariance (ANCOVAs). Age, education, and the two ethnicity variables (Caucasian = 1, non-Caucasian = 0; Hispanic = 1, non-Hispanic = 0) were entered as covariates in both analyses. Results indicated statistically significant differences for both actual knowledge, F (5, 892) = 12.66, p \ 0.001, corrected model partial eta squared (g2) = .07,1 and perceived knowledge, F (5, 906) = 14.53, p \ 0.001, g2 = .07, with teacher trainees having a higher percentage of actual ADHD knowledge, answering a mean of 16.38 items (SD = 3.82) accurately (60.6%, counting don’t know and incorrect answers as inaccurate knowledge), and a higher degree of perceived ADHD knowledge (M = 4.83, SD = 1.47, on the 9-point scale). Comparatively, the CP group answered 14.75 (4.31) of the questions accurately (54.6%) and had a mean perceived ADHD knowledge rating of 4.28 (1.83).2 Few of the covariates in these ANCOVAs emerged with a statistically significant relationship to the dependent variable in question. Hispanic

status, F (1, 906) = 5.50, p = .02, g2 = .006, and education level, F (1, 906) = 9.35, p = .002, g2 = .01, were independently associated with perceived understanding of ADHD, the former negatively and the latter positively so. Only Caucasian status, F (1, 892) = 5.48, p = .02, g2 = .006, was positively related to actual ADHD knowledge. Examination of Item-Level Responses Table 2 shows the percentage of teacher trainees and undergraduate peers who correctly answered each of the knowledge items. Inspection of this table shows items 17 (‘‘ADHD affects male children only,’’ correct answer: false, TT = 96% correct; CP = 87%) and 24 (‘‘Children from any walk of life have ADHD,’’ true, TT = 95%; CP = 86%) were most often correctly answered by both groups. Items 12 (‘‘Diets are usually not helpful in treating most children with ADHD,’’ true; TT = 13%, CP = 18%) and 26 (‘‘Research has shown that prolonged use of stimulant medications leads to increased addiction; i.e., drug, alcohol; in adulthood,’’ false; TT = 15% and CP = 13%) were the items least commonly answered correctly by the groups.

Discussion The aims of the present study were to compare the accuracy of ADHD knowledge across TT and CP groups. TT knowledge scores were significantly higher than CP. 2

1

Partial eta squared (g2) effect sizes are as follows: small = .001, medium = .06, large = .14 (Cohen, 1988).

Estimated marginal means for perceived and actual ADHD knowledge are reported here; for unadjusted mean scores, see Table 1.

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Table 2 Percentage of correct responses on ADHD knowledge items Item 1. There are a greater number of boys than girls with ADHDT T

Teacher trainees (n = 534) (%)

Comp peers (n = 377) (%)

70

57.4

2. There is approximately 1 child in every classroom with a diagnosis of ADHD

68.7

65.5

3. If medication is prescribed, educational interventions are often unnecessaryF

79

54.3

4. ADHD children are born with biological vulnerabilities toward inattention and poor self-controlT

48.3

46.7

5. If a child responds to a stimulant medication (e.g., Ritalin), then they probably have ADHDF

83.8

72.8

6. A child who is not overactive, but fails to pay attention, may have ADHDT

40.5

42.1

7. ADHD is often caused by food additives 8. ADHD can be diagnosed in the doctor’s office most of the timeF

46.3 46.1

43.9 29.2

9. Children with ADHD always need a quiet environment to concentrateF

64.6

43.1

10. Approximately 5% of American school-aged children have ADHDT

48.1

48.7

11. ADHD children are usually from single-parent familiesF

66.2

59.6

F

12. Diets are usually not helpful in treating most children with ADHD

T

12.5

17.5

13. ADHD can be inheritedT

49.3

48

14. Medication is a cure for ADHDF

85.3

65

15. All children with ADHD are overactiveF

76.7

67

16. There are subtypes of ADHDT

83.2

76.4

17. ADHD affects male children onlyF

95.9

86.5

18. The cause of ADHD is unknown

T

44.4

32

19. ADHD is the result of poor parenting practicesF

93.7

82.5

20. If a child can play Nintendo for hours, then he/she probably doesn’t have ADHDF

86.4

72.6

21. Children with ADHD cannot sit still long enough to pay attentionF

60.4

28.2

22. ADHD is caused by too much sugar in the dietF 23. Family dysfunction may increase the likelihood that a child will be diagnosed with ADHDT

77.2 28.9

63.2 24.9

24. Children from any walk of life have ADHDT

95

85.8

25. Children with ADHD usually have good peer relations because of their outgoing natureF

50

39.6

26. Research has shown that prolonged use of stimulant medications leads to increased addiction (i.e., drug, alcohol) in adulthoodF

15.1

12.7

27. Children with ADHD generally display an inflexible adherence to specific routines and ritualsF

31.2

18.5

‘‘Comp peers’’ are those in the non-teacher comparison group of Psychology Department research participants (mostly general psychology students). Superscript ‘‘T’’ and ‘‘F’’ denote the True and False responses coded as correct for each item.

Results supported the hypothesis that teacher trainees would score higher than their undergraduate peers on actual knowledge, and this finding carried over to ratings of self-perceived accuracy of knowledge, as well. These differences were statistically robust even when controlling for age, education level, and ethnicity, and equated to mediumsized effects. Given that teacher trainees have a required curriculum that includes content on intellectual and other psychological difficulties that many CP participants may not have been exposed to, it makes sense that teacher trainees have relatively robust ADHD-related knowledge. At this university, Educational Psychology, one of the building-block courses that all teacher trainees must complete, includes one class period (i.e., 50–75 min) dedicated to discussing ADHD and related behaviors, assessment, and different types of intervention. Additional ADHD instruction is sometimes provided at the discretion of

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individual instructors, such as showing a video and asking students to complete a worksheet in response, or requiring students to complete a short written assignment on the disorder. Students seeking particular specialized degrees (Elementary Education, Middle Grades Education, and Special Education) also complete two semesters of parttime, in-class experience prior to a one-semester teaching internship, which provides additional opportunities to learn about ADHD via direct contact with affected children or in-school service providers. By extension, as compared to non-teaching peers, the TT group likely includes a much higher proportion of individuals with substantial experienced-based ADHD education. It is encouraging that our sample of teacher trainees, who are described as receiving a degree of formal (i.e., classroom) ADHD instruction that falls within but on the high end of expectations (State et al., 2011), seem to know


more about ADHD than their undergraduate psychology peers. The effect is a substantial one that holds up even when controlling for demographic differences. However, results suggest that there is room for improvement. In most academic grading rubrics, a score of 62%, the mean unadjusted accuracy score in the TT group on the ADHD knowledge measure, is passing, but still unsatisfactory, usually graded as a ‘‘D.’’ Taking a more empirical view, previous studies also suggest that this score is below a cutoff for general teacher ADHD knowledge that should cause concern (i.e., 70% accuracy; Jerome et al., 1994), due to association with low endorsement of the utility of empirically supported interventions and similarly low willingness to refer perceived-at-risk students for services. As noted earlier (Jerome et al. 1994; Ohan et al., 2008), teachers with class sizes that exceed 20 students are likely to encounter at least one student with ADHD in their classroom each year, and it is critically important that teachers are able to identify ADHD symptoms, empathize with and understand the difficulties associated with that disorder, and know when and how to appropriately refer a child that may have ADHD for assessment and other services. Unfortunately, many newly licensed teachers may not have an adequate base of knowledge regarding ADHD to undertake these important tasks effectively. Teacher Trainee ADHD Knowledge: Strengths A close examination of the data (see Table 2) indicates, however, certain areas in which these teacher trainees seem to be quite knowledgeable relative to their non-education peers. A notable example is in the area of pharmacological intervention for ADHD, as demonstrated by items such as: ‘‘If medication is prescribed, educational interventions are often unnecessary’’ (false; TT = 79%, CP = 54.3% correct), ‘‘If a child responds to stimulant medication, e.g., Ritalin, then they probably have ADHD’’ (false; 83.8, 72.8%), and ‘‘Medication is a cure for ADHD’’ (false; 85.3, 65%). TT participants also appeared to have an advantage regarding several common misconceptions about the disorder, even for items that yielded high accuracy across both groups, such as: ‘‘ADHD affects male children only’’ (false; 95.9, 86.5%), ‘‘Children from any walk of life have ADHD,’’ (true; 95, 85.8%), and ‘‘ADHD is the result of poor parenting practices’’ (false; 93.7, 82.5%). It is heartening that these budding professionals have relatively accurate knowledge regarding pharmacological intervention, particularly given its high utilization in children with ADHD. The pattern of responses seems to indicate that while teacher trainees recognize that stimulants are often effective at addressing ADHD symptoms, they also understand it is not a cure per se, and that a combination of medication and educational interventions is

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likely to be most effective. This may signal that current teacher trainees are willing to implement educational interventions for affected children, and may do so regardless of their medication status. In addition, these teacher trainees appear to understand that ADHD is a chronic disorder, and that monitoring throughout schooling is necessary in order to ensure these children are receiving adequate intervention—pharmacological, psychosocial, and educational—to address their learning challenges. Further, it is positive that teacher trainees less frequently endorse common misconceptions (i.e., myths) about ADHD, as compared to the CP group. This may have substantial implications related to the likelihood of referral for ADHD assessment or related services. For instance, because teacher trainees were more likely to believe that ADHD affects both sexes, they may be unlikely to overlook their female students who are exhibiting ADHD symptoms and related problems. In addition, because these trainees tend to understand that ADHD can affect children regardless of the quality of parental support, they may be less likely to discount the expression of ADHD in a child with seemingly disinterested (or, alternatively, intrusive) parents. In essence, the relatively high accuracy of TT knowledge regarding such issues suggests that they will be open to identifying and referring the full range of children, who may warrant diagnosis, ultimately facilitating appropriate treatment and accommodation. Teacher Trainee ADHD Knowledge: Weaknesses Though the TT group performed well in many areas when compared to CP, there were certain areas in which the former’s knowledge was unsatisfactory (operationalized as \50% accuracy). This was particularly evident in items related to the origin and cause of ADHD, such as. ‘‘The cause of ADHD is unknown’’ (true; TT = 44.4% correct, CP = 32%), ‘‘ADHD children are born with biological vulnerabilities toward inattention and poor self-control’’ (true; 48.3, 46.7%), ‘‘ADHD is often caused by food additives’’ (false; 46.1, 23.9%), and ‘‘ADHD can be inherited’’ (true; 49.3, 48%). The TT group also had an inadequate grasp, overall, of two queries related to diagnosis and adherence to routine: ‘‘ADHD can be diagnosed in the doctor’s office most of the time’’ (false, 46.1, 29.2%) and ‘‘Children with ADHD generally display an inflexible adherence to specific routines and rituals’’ (false, 31.2, 18.5%). Both groups commonly had misconceptions about dietary influence on ADHD (‘‘Diets are usually not helpful in treating most children with ADHD,’’ true; 12.5, 17.5%) and, as an exception to the previously described trend of accuracy regarding psychostimulants, both TT and CP participants were quite inaccurate regarding addiction risk related to medication use (Research has shown that

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prolonged use of stimulant medications leads to increased addiction, i.e., drug, alcohol, in adulthood, false, 15.1, 12.7%). While one might wish teacher trainees, and their inservice counterparts, to demonstrate accuracy in their overall ADHD knowledge, perhaps the TT group’s common misconceptions regarding ADHD etiology may be of relatively little importance. In terms of recognition, referral, and classroom interventions, for instance, believing that food additives may have caused a girl’s ADHD symptoms is certain less crucial than knowing that ADHD affects both sexes. On the other hand, the knowledge that ADHD has biological and genetic roots may be particularly important. This specific knowledge may help mitigate common frustrations (e.g., poor parent–teacher communication, failure to schedule and show up for conferences) experienced by teachers when working with parents of children who have ADHD. If teachers recognize that parents are naturally more likely to demonstrate similar symptoms as their children, they may in turn be better able to empathize and persist in the kinds of collaborative efforts necessary to effectively address childrens’ needs. Other common TT mistakes seem to reflect a misconstrual of symptoms that are typical to ADHD and of bestpractice assessment procedures. For instance, a large majority in the TT group (68.8%) incorrectly identified ‘‘inflexible adherence to… routines and rituals’’ as characteristic of ADHD, whereas it is a central feature only in other childhood disorders (e.g., autism). Fortunately, such confusion seems unlikely to pose added threat to affected students as long as appropriate referral for assessment occurs. Other incorrect knowledge in this vein (i.e., ADHD can be diagnosed in a single doctor’s visit, altering diet treats ADHD, use of stimulants leads to addiction) runs counter to current empirically based guidelines (e.g., American Academy of Pediatrics Subcommittee on Attention-Deficit/Hyperactivity Disorder, 2011) and thus may result in counterproductive recommendations (e.g., limit sugar intake in order to address child ADHD symptoms, dissuading parents from trying efficacious stimulant therapy). Future research could determine whether these deficiencies in specific types of ADHD-related information hold true in independent samples, in order to determine potential foci for modifying future teacher education.

Limitations and Future Directions Probably, the most telling limitation of the current study is that the sample was drawn from a single public university in the southeastern United States, and as such, is geographically and experientially homogenous. Anything short of a systematic comparison of the course and practical

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requirements of this TT cohort to peers drawn from a nationally representative sample of teacher education programs cannot fully gauge the representativeness of the current data. However, recent findings suggest that the experience of the pre-service teachers surveyed herein is not out of the expected range (State et al., 2011). Further, states (e.g., North Carolina Professional Teaching Standards Commission, 2007) and national accrediting bodies (e.g., NCATE, 2008) establish standards for teacher education that, by extension, create at least some agreement across undergraduate curricula. While admitting that generalization of the current findings should be done with caution, it seems reasonable to suggest that trainees from other institutions in the United States with similar accreditations (i.e., NCATE, State of North Carolina) who have likely had comparable training experiences related to learners with special needs would perform similarly in terms of acquired ADHD-specific knowledge. In addition, although consistent with the demographics in the university’s general student body, this sample was overwhelmingly Caucasian. This, along with the singleprogram limitation noted above, suggests that the current study should be replicated in other settings and with better representation of ethnic minorities before the findings are broadly generalized. Further, comparisons between the TT group and an in-service teacher sample were not conducted in this study. While informal comparison between the extent of TT ADHD knowledge and that of previous inservice cohorts (e.g., Kos et al., 2004) suggests more similarity than disparity, the current data do not shed light on whether currently employed teachers possess greater accuracy of ADHD knowledge as compared to trainees, something that future studies might usefully clarify. Finally, the ADHD knowledge and beliefs measure utilized in this study is one that lacks detailed, published psychometric description. Scores are therefore somewhat difficult to interpret in terms of standing relative to the general population. As such, future research might productively establish the psychometric qualities of this instrument or seek to replicate and extend our findings using another, better-established instrument (e.g., Knowledge about Attention Deficit Disorder Questionnaire, KADD-Q; West, Taylor, Houghton, & Hudyma, 2005). As indicated earlier, not all teacher trainees in the current study were earning a specialized degree that required classroom experience prior to student teaching. Overall, previous research (Jerome et al., 1994; Kos, et al., 2004; Sciutto et al., 2000) demonstrated that direct experience teaching children with ADHD was positively associated with accuracy of ADHD knowledge, indicating that experience-based learning may be an effective way to educate teacher trainees. If all of the trainees had received experience within the classroom prior to this study, it is possible


that the mean score would have been higher. Therefore, another possible direction for future research would be to include systematic experimentation with practical and internship requirements in a teacher education curriculum in order to directly examine their effects on ADHD knowledge. In a similar vein, it may be informative to compare the knowledge of teacher trainees across different specializations (e.g., Elementary Education, Middle Grades Education, High School Education, or Special Education) to determine if those in certain areas fare better than others. Specific examination of Elementary Education and Special Education trainees might be especially warranted, given the common presentation of ADHD in the early school years and in special education classrooms. To the authors’ knowledge, this study is the first to show that teacher trainees have greater ADHD knowledge than their undergraduate peers. Although it is encouraging that teacher trainees seem to be learning more about ADHD in school than comparison student peers, results suggest that there is room for improvement in the accuracy of their knowledge (i.e., 80% accuracy associated with positive beliefs and intentions regarding ADHD intervention; Jerome et al., 1994). Future research should examine what materials and methods are most effective for their learning and whether additional emphasis on special education for all teacher trainees may help them to be better prepared when they step into the classroom. In addition, subsequent studies might productively employ a longitudinal design to examine which specific areas of teacher ADHD knowledge (e.g., KADD-Q Causes, Characteristics, and Treatment subscales; West et al., 2005) are most critical to effective classroom intervention and positive student outcomes. Finally, the issue of determining specific methods of how accurate ADHD knowledge can be conveyed to teacher trainees and in-service teachers alike has yet to be solved. However, given the ambiguous benefit of on-the-job experience for acquiring such knowledge (e.g., Hepperlen et al., 2002; Koss et al., 2004), perhaps the most productive target for change is degree of pre-service instruction, increasing time and diversity of experiences within the classroom. This seems especially true given the recent data suggesting nearnegligible ADHD content coverage in a large set of teacher trainee programs in the United States (State et al., 2011). Teacher educators might productively commence the change process by (a) systematically measuring the knowledge of their graduating, novice teachers regarding ADHD (and other disorders that impair learning and adjustment in school), (b) setting a benchmark for desired accuracy (e.g., 80%, that suggested by the findings of Jerome et al., 1994), and (c) observing whether the controlled modification(s) of ADHD-related instruction (e.g., extent, timing, focus, setting) lead to knowledge improvements (or decrements) in subsequent graduating cohorts.

113 Acknowledgments The authors would like to thank Roma Angel for her collaborative effort in recruiting the teacher trainee participants. This paper is partly based on the senior honors thesis completed by Ms. Mancil in the Department of Psychology at Appalachian State University, and the authors would like to acknowledge Lisa Curtin for her valuable input at that stage. We would also like to thank Pam Kidder Ashley for her suggestions regarding a more recent draft.

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