Journal ofhttp://jad.sagepub.com/ Attention Disorders
Increasing Teachers' Knowledge About ADHD and Learning Disorders: An Investigation on the Role of a Psychoeducational Intervention Ana P. Aguiar, Renata R. Kieling, Adriana C. Costa, Neusa Chardosim, Beatriz V. Dorneles, Mariana R. Almeida, Ana C. Mazzuca, Christian Kieling and Luis A. Rohde Journal of Attention Disorders published online 30 July 2012 DOI: 10.1177/1087054712453171 The online version of this article can be found at: http://jad.sagepub.com/content/early/2012/07/26/1087054712453171
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453171 1Aguiar et al.Journal of Attention Disorders © 2012 SAGE Publications
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Increasing Teachers’ Knowledge About ADHD and Learning Disorders: An Investigation on the Role of a Psychoeducational Intervention
Journal of Attention Disorders XX(X) 1–8 © 2012 SAGE Publications Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054712453171 http://jad.sagepub.com
Ana P. Aguiar1, Renata R. Kieling1, Adriana C. Costa1, Neusa Chardosim1,
Beatriz V. Dorneles1, Mariana R. Almeida1, Ana C. Mazzuca1, Christian Kieling1, and Luis A. Rohde1
Abstract Objective: To investigate elementary school teachers’ baseline knowledge about ADHD and learning disorders (LD) and the impact of a strategy to increase awareness of these disorders. Method: A total of 37 teachers were selected from four elementary schools in the catchment area of the University Hospital, in Porto Alegre, Brazil.To evaluate teachers’ knowledge, two self-report questionnaires about ADHD and LD were applied before and after an awareness program on these disorders. Results: The intervention significantly increased teachers’ knowledge of both disorders, even after adjustment for confounding factors (p < .001). In the repeated measures ANCOVA, only teachers’ previous knowledge of ADHD/LD (p < .001) was significant in predicting score change in knowledge before and after the intervention. Conclusion: Results suggest the efficacy of a brief psychoeducational intervention program for increasing teacher awareness and knowledge about ADHD and LD. Future studies are warranted to confirm the efficacy and evaluate the long-term impact of this intervention. (J. of Att. Dis. 2012; XX(X) 1-XX) Keywords ADHD, learning disorders, teacher knowledge, awareness
Introduction ADHD is the most common childhood externalizing disorder, characterized by symptoms of inattention, hyperactivity, and impulsivity. ADHD affects around 4% to 6% of children and adolescents in Brazil (Anselmi, Fleitlich-Bylik, Menezes, Araújo, & Rohde, 2010; Rohde et al., 1999), a rate compatible with international data showing a worldwide prevalence of 5.29% (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). ADHD causes significant impairment in affected participants. During school years, the disorder is often associated with poor academic performance, grade retention, suspension, expulsion, and difficulties in relationships (Lahey et al., 2004), resulting in a poor quality of life (Klassen, Miller, & Fine, 2004). Based on the amount of impairment associated with the disorder, it is considered a public health problem (Lesesne, Abramowitz, Perou, & Brann, 2000). Learning disorders (LD) affect about 5% to 10% of school-age children and include several different disorders
such as reading, mathematics, written expression, expressive language, and mixed receptive–expressive language disorders. The most frequent diagnosis associated with LD is ADHD (Maughan & Carroll, 2006). It is estimated that 15% to 20% of children with LD present criteria for the diagnosis of ADHD and that 25% to 40% of children with ADHD present comorbid reading disorder (Maughan & Carroll, 2006), while 11% to 26% have mathematics disorder (Capano, Minden, Chen, Schacher, & Ickowicz, 2008; Faraone et al., 1993; Gross-Tsur, Manor, & Shalev, 1996). The comorbidity between ADHD and LD increases the level of distress caused by each disorder individually for the 1
Federal University of Rio Grande do Sul, Porto Alegre, Brazil
Corresponding Author: Luis A. Rohde, ADHD Outpatient Program (ProDAH) at the Child and Adolescent Psychiatric Division, Hospital de Clínicas de Porto Alegre, Ramiro Barcellos Street, 2350, 90035-003 Porto Alegre, RS, Brazil Email:
[email protected]
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Journal of Attention Disorders XX(X)
child, the family, and the community. In addition, it determines several lifelong impairments with broad social and economic impacts. Despite the high prevalence and impact of these disorders, little attention has been directed toward strategies for awareness and promotion of mental health in affected subjects, especially in developing countries (Sherer, 2002). According to the clinical parameters of the American Academy of Child and Adolescent Psychiatry, ADHD requires a multi-informant assessment approach (Pliszka et al., 2007). Some guidelines for LD assessment suggest that direct or phone interviews with school professionals can help in establishing the onset of problems, clarifying their nature, identifying emotional and behavioral difficulties at school, and determining the appropriateness of previous assessments and response to prior interventions (Beitchman, Cantwell, Forness, Kavale, & Kauffman, 1998). In this context, teachers play a fundamental role in early detection and should be able to recognize the typical clinical characteristics of the disorders. A higher level of knowledge can also help reduce misconceptions and prejudices about LD and ADHD. Nevertheless, there are few studies that investigate teacher knowledge about ADHD and LD, and even fewer that evaluate the impact of awareness strategies. In a search in different databases (PubMed, PsycINFO, and Web of Science), 29 articles were found dealing specifically with teacher knowledge about ADHD and LD, or with the impact of awareness strategies. It is important to stress that almost all previous studies in this subject were conducted in the United States and European countries, reinforcing the relevance of studies in developing countries. Among the few conducted outside the United States, an Israeli study showed that 13% of teachers believe that LDs are the result of parental attitudes, particularly the habit of “spoiling” the child (Brook, Watemberg, & Geva, 2000). In Brazil, a survey with 432 teachers found that 59% of them believed that ADHD was caused by absent parents who cannot set limits, and 52% believed that sports could replace pharmacotherapy (Gomes, Palmini, Barbirato, Rohde, & Mattos, 2007). Syed and Hussein (2009) assessed the knowledge of 49 Pakistani teachers on ADHD signs and symptoms through questionnaires applied before and after a weeklong workshop on the subject. Although the intervention was effective in improving teachers’ knowledge about ADHD, the external validity (replicability) of the study is arguable, because long interventions are often not palatable for teachers in school settings from low- and middle-income countries (Graeff-Martins et al., 2006). Thus, baseline teacher awareness of ADHD and LD, and how to improve this knowledge are both important areas of research, especially considering the few studies available on the subject. The main objective of this study was to investigate the baseline knowledge of a sample of elementary school teachers
about ADHD and LD, and the impact of a psychoeducational awareness intervention focusing on these disorders. Our hypothesis was that the intervention would be feasible and significantly improve teacher knowledge about ADHD and LD.
Method An open naturalistic study was carried out to evaluate the feasibility and efficacy of implementing an intervention to promote teacher awareness on ADHD and LD. The study was done in Porto Alegre, the capital of the southernmost state of Brazil. The project was approved by both the State Department of Education and the Ethical Committee of our University Hospital (approved as an institutional review board [IRB] by the Office for Human Research Protections, United States of America—IRB 00000921). Written informed consent was obtained from the teachers.
Sample First, we mapped all schools localized in the catchment area of the primary care unit of our University Hospital. After discussing the project with school principals, we selected four schools to participate. This was a convenience sample (not a random sample) based on logistics and requirements by the State Department of Education. All the teachers of the first to fourth elementary grade classes of these four schools (N = 44) were invited, and 37 accepted to take part of the intervention program.
Measures To evaluate teachers’ pre- (T1) and postintervention (T2) knowledge, we adapted two self-report questionnaires used in previous investigations, one focusing on ADHD and the other on LD. The questionnaires consisted of two parts. The first part asked for demographic background including age, educational level, years of teaching experience, and whether the teacher had already had a student diagnosed with ADHD and/or LD in his or her class. The second part contained 20 affirmatives about etiology, symptoms, and treatment of each disorder, with three possible answers: “true,” “false,” and “don’t know.” ADHD. After extensive discussions with experts on ADHD, we selected the 20 most appropriate affirmatives to measure teachers’ knowledge on ADHD extracted from the three instruments previously used in the available literature (Jerome, Gordon, & Hustler, 1994; Kos, Richdale, & Jackson, 2004; Sciutto, Terjesen, & Frank, 2000). These affirmatives included concepts about etiology, symptom presentation at school, management, and treatment of the disorder. Extra care was taken to keep the original format of these instruments, and we conducted a
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Aguiar et al. careful translation and adaptation of the final instrument into Brazilian Portuguese. Learning Disorders. After consultation with LD specialists, we selected three previous sources to compose a final instrument with also 20 affirmatives: (a) learning disability study’s questionnaire—this scale was used in a North American research with 1,200 adults (Roper Starch Worldwide, 1995); (b) the report on LD from the National Association of Special Education Teachers (NASET, 2007); and (c) a chapter about LD written by an experienced psychologist published in a classic textbook of psychiatry (Tannock, 2007). A LD specialist from our group (A.C.C.) selected some statements from these three sources out of which our group again chose the 20 more appropriate affirmatives to assess teachers knowledge on LD. The affirmatives included statements about etiology, symptoms presentation at school, management, and treatment of the disorder. After that, again our own group conducted a careful translation and adaptation to Brazilian Portuguese. The scales are available online at www.ufrgs.br/prodah.
Intervention The intervention program was conceptualized to be a consistent but quick and easy method to implement package of units of learning on ADHD and LD. The total length of the intervention was about 6 hr to make it deliverable on a 1-day basis. Our previous experience with school-based interventions to reduce school dropout in developing countries (Graeff-Martins et al., 2006; Hoven et al., 2008) clearly suggests that long interventions lasting several days are not palatable for teachers in these cultures. The format includes a well-balanced mixture of lectures on ADHD and LD, presentations of clinical vignettes specially constructed for challenging potential misconceptions (Syed & Hussein, 2009), followed by a vivid group discussion about ADHD/ LD issues. The distribution of the contents was done according to the following schedule: a. Application of the pretest scales on ADHD and LD—20 min b. Introduction to the program and presentation of clinical vignettes dealing with frequent misconceptions about ADHD and LD—15 min c. Discussion of the vignettes—30 min d. Lecture on ADHD symptoms presentation at school and etiology—40 min e. Lecture on LD symptoms presentation at school and etiology—40 min f. Coffee break—20 min g. Presentation and discussion of clinical vignettes dealing with ADHD/LD symptoms presentations— 30 min
h. Lecture on strategies for managing ADHD at school—50 min i. Lecture on strategies for managing LD at school—50 min j. Final discussion on doubts—45 min k. Application of the posttest scales on ADHD and LD—20 min The content of this intervention program was based on previous material developed by our own group on the recognition and management of ADHD/LD for parents and teachers (Knapp, Rohde, Johanpeter, & Lyzkowski, 2002; Rohde & Benczik, 1999), as well as on the standard classroom management programs extensively discussed in the literature (Barkley, 2006; Pelham, 2002). Before the intervention program, each teacher received a written manual summarizing the content discussed during the 6-hr program. This material is available online at www.ufrgs.br/prodah. Because teachers from four different schools were enrolled simultaneously, the research team conducted the intervention program in our University Hospital (Hospital de Clínicas de Porto Alegre). A senior professor of child psychiatry, a resident of psychiatry and one of pediatrics, a professor of education and a doctoral level student of education (both LD clinicians), a neuropsychologist, and three research assistants comprised the research team. To assure that the program might be deliverable by investigators without extensive experience in the field (increasing its external validity), the residents of psychiatry (C.K.) and pediatrics (R.R.K.) and the doctoral student of education (A.C.C.) conducted the intervention program with the presence of the senior child psychiatrist to guarantee that the integrity of the intervention was kept. The two residents received a 10-hr training on the ADHD content of the program by the senior professor of child psychiatry (L.A.P.R.) and the doctoral student of education, and the same 10-hr training in the LD component of the program by the senior professor of education (B.V.D.). Teachers were released from their activities at school on the day of training, so that they could take part in the intervention; no financial incentive was offered. Total cost of the intervention was approximately US$400, including coffee break and photocopies of handouts. The auditorium where the intervention was held was provided free of charge by our University Hospital, and all lecturers were investigators from our research group.
Data Analyses The comparison between pre- and postintervention scores from the two questionnaires was assessed by repeated measures ANCOVA, adjusting for school, initial teacher knowledge, and years of teaching experience. An unbiased estimate of the effect size (ES) was also computed for the
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Journal of Attention Disorders XX(X)
Table 1. Teachers’ Knowledge About ADHD and Learning Disorders Pre- and Postintervention Mean score (SD) Disorder ADHD (n = 36) LD (n = 36)
Answer
Pre
Post
Mean difference (CI 95%)
p
Partial η2
Correct Don’t know Correct Don’t know
14.94 (2.52) 3.06 (2.43) 14.81 (2.02) 1.94 (2.11)
17.36 (1.93) 0.22 (0.48) 17.61 (1.46) 0.14 (0.42)
2.03 [1.37-2.68] 2.83 [2.06-3.60] 2.78 [2.21-3.34] 1.80 [1.05-2.60]
