Dr. David Rabiner - What Do Teachers See?
* * TEACHERS' RATINGS OF ADOLESCENTS WITH ADHD: DO DIFFERENT TEACHERS SEE THE SAME THING?
When children move into middle school, they generally go from having a single primary teacher to as many as 5 different teachers for core subjects. As one might expect, the relationships established with different teachers often differs, and a child may get along well in several classes but have important difficulties in others. This can be especially frustrating for parents who have a teen ager with ADHD, because the behavior and academic performance of students with ADHD tends to be more erratic and inconsistent to begin with. Knowing what to make of these sometimes very different reports can be particularly important when it comes to treatment issues and to determining whether any modification/adjustment to a child's medication may be warranted.
Just how closely do the behavior ratings that teachers provide of students with ADHD agree? This important question was examined in a recently published study (Molin, B.S., Pelham, W.E., Blumenthal, J., & Galiszewski, E. (1998). Agreement among teachers' behavior ratings of adolescents with a childhood history of ADHD. Journal of Clinical Child Psychology, 27, 330-339.
In this study, behavior ratings of 66 adolescent boys were obtained from multiple teachers using standardized behavior ratings scales. The ratings scales used were the Teacher Report Form, the Iowa/Abbreviated Conners, and the Disruptive Behavior Disorders Rating Scale. Ratings from 2 to 5 teachers were collected for each child. At the time that the teacher ratings were collected, the boys ranged in age from 13 to 18. All had received a diagnosis of ADHD several years earlier. Whether they still carried a diagnosis of ADHD at the time of the study was not indicated, and information on the treatment adolescents were receiving at the time is not noted. I would assume, however, that since these teens were part of an ongoing study, that the majority were receiving some type of treatment at the time.
The teachers completing the rating scales included both regular education teachers (78%) and special education teachers (22%). Teachers of primary academic courses (68%) and specialty courses such as art and music were included (32%).
Although the precise level of agreement between different teachers varied somewhat depending on the particular behavior rating scale examined (i.e. TRF, Iowa/Conners, or DBDRS) the general level of agreement between teachers was generally no better than moderate.
In general, agreement between teachers that a student was not displaying clinically significant problems with attention and/or hyperactivity was pretty good. Thus, the majority of students were rated as being in the "normal" range by their different teachers who provided the ratings. This probably reflects the fact that the children's symptoms were being managed well by the treatment they were receiving, as well as the possibility that the symptoms of some students had diminished over the years to the point that they were no longer creating clinically significant impairment.
What about the agreement between a child's different teachers when at least one of the teachers rated the child as showing clinically significant problems? In this case, the level of agreement was not very good, ranging from between 17 to 38% for randomly selected pairs of teachers. In other words, when one teacher reported the student to show significant problems with inattention and/or hyperactivity/impulsivity, the likelihood that another teacher also reported clinically significant problems was considerably less than 50%. The level of disagreement was higher for attention problems than for hyperactive/impulsive behaviors. Even for the latter, however, the level of agreement was not very good.
Overall, the authors conclude when teacher ratings are used to discern whether a student's behavior is sufficiently impaired to warrant a diagnosis or clinical attention, the agreement between teachers is not that much better than what would be obtained by chance. What are the implications of these results for evaluating teens for ADHD and managing the treatment of students previously diagnosed?
In regards to diagnosis, these data highlight how difficult this task can be with older students. Now, for children with hyperactive/impulsive symptoms, the diagnosis will almost always have occurred years earlier, so this is not usually an issue. This is because the difficulties these students have are generally quite obvious during elementary school and even before.
For some students with the inattentive symptoms only, however, problems are not always so obvious earlier on. This is especially true for children who are bright, who may be able to get by reasonably well in elementary school even though they have important problems with attention simply because the academic demands are not that great. Thus, even though they would not be doing as well as they could be, they are managing to get by.
With the transition to middle school, however, and the increased organizational and academic demands this generally entails, the teen may start to struggle in much more noticeable ways. It is not necessarily because their difficulties with attention are more pronounced, but may instead reflect the increased level of demands they confront. In this case, the student may not even be evaluated for possible ADHD prior to middle school.
The results of this study clearly indicate that in such instances, a diagnosis of ADHD can not be made based on symptoms observed by a single teacher, even when those problems are in a clinically elevated range. Instead, multiple sources of information, including reports provided by parents, by the adolescent him or herself, and data gleaned from psychological tests may all be required.
In my own experience, I have seen situations where a teen was started on medication based on the problems reported by a single teacher. The current study highlights what important problems there can be with such an approach to diagnosis. It is essential to remember that for a diagnosis of ADHD to apply, there needs to be some evidence of impairment in more than one setting. Thus, impairment in only a single class, with no real problems anywhere else, should not be assumed to reflect ADHD.
These data also highlight the need to obtain feedback from multiple teachers to obtain an accurate picture of how an adolescent is handling the demands of school. It is clear that different teachers will observe different levels of strengths and difficulties. As a result, relying on feedback from a single teacher - whether it is positive or negative - will often provide a limited and inaccurate understanding of the child's overall adjustment at school.
It is also important to recognize that when one teacher reports a child to be struggling, while other teachers observe the child to be doing fine, it does not mean that someone is right and someone is wrong. Children can and do behave differently with different teachers and there are a variety of reasons for this. These reasons can range from a teacher and student being a poor match to a child's having a particularly hard time with certain material and acting out in response.
So, the most productive approach, I think, to such discrepant teacher reports is to systematically examine the possible reasons why the teen is struggling in a particular class. Is is problems in how the teacher is managing the student? Is it a class that the teen is not interested in so his/her ADHD symptoms appear much more pronounced? Is it a class where the child struggles with the material and deals with frustration by acting out?
These are not necessarily easy issues to sort out, and it may not always be possible to sort things out with complete certainty. Rather than backing away from this complexity, however, the more careful the efforts that parents and clinicians make to understand the reasons for a teen's inconsistent performance with different teachers, the more likely it is that an effective approach to intervening where needed can be made.
(For an introduction to the educational rights for children with ADHD, go to http://www.helpforadd.com/rights.htm)
A note from Dr. Rabiner:
I hope the above information was of interest to you and potentially helpful. Staying informed about the latest research findings on ADD/ADHD will enable you to make better informed decisions about the best ways to promote your child's healthy development. That is my objective in publishing a monthly newsletter, ADHD RESEARCH UPDATE, and I invite you to become a regular subscriber. If you work with children who have ADHD in a professional capacity, I also think you will find that ADHD RESEARCH UPDATE is a convenient way to stay on top of important new research information.
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David Rabiner, PhD
is hearing a student say,
"Thank you for understanding me."