Chapter II

Understanding ADHD

Over the past several decades, attention and activity disorders have been described in a number of different terms, including hyperactive and hyperkinetic. Severe and chronic problems with regulating attention and activity are now commonly known as Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). Published literature refers to the terms ADD and, the term ADHD is the official term found in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (American Psychiatric Association, 2013).
The term Attention Deficit Hyperactivity Disorder ADHD has become very common within the educational community over the last decade or two. ADHD is one of the most predominant disorders that teachers will be faced with in the classroom (American Psychiatric Association, 2013; Center for Disease Control and Prevention, 2013). Behaviors associated with ADHD can be stressful and frustrating for teachers when encountered. The Individuals with Disabilities Education Act IDEA was purposefully created to ensure that students received the necessary services to be successful in the classroom, as well as in life. An appropriate diagnosis is required before any of these services can be offered and provided to the student. The Diagnostic and Statistical Manuel of Mental Disorder-Fifth Edition DSM-V explicitly outlines the observable behaviors that children with ADHD may exhibit. Clinicians use these guidelines to make a diagnosis and begin treatment of the disorder (APA, 2013).
The DSM-V (American Psychiatric Association, 2013) is published by the American Psychiatric Association and is used to classify and diagnose mental disorders in individuals. The DSM-V (American Psychiatric Association, 2013) defines ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. Some hyperactive, impulsive, and inattentive symptoms must be present before the age of seven in order for individuals to be diagnosed as having ADHD. In addition, symptoms must be present in at least two settings: school, home, work, etc. in order for a diagnosis to be valid (American Psychiatric Association, 2013).
In 2011, over one in ten children in the United States were diagnosed as having Attention- Deficit Hyperactivity Disorder (ADHD)—representing a 3.2% increase over estimates in 2003 and a 6% increase since 1978 (Centers for Disease Control and Prevention, 2011). ADHD has three presentations of symptoms: inattentive, hyperactive-impulsivity, and comorbid inattentiveness with hyperactivity-impulses (American Psychiatric Association 2013). Research findings indicate boys demonstrate a higher rate of ADD/ADHD diagnosis than girls (Baue`rmeister, Shrout, Chavez, Rubio-Stipec and Ramirez, 2007; Bruchmüller, Margraf, & Schneider, 2012).
The DSM-V classifies ADHD into two separate subtypes: Predominately Inattentive Type and Predominately Hyperactive- Impulsive Type (American Psychiatric Association, 2013). There is Combined Type as well, which is a combination of the above two subtypes. The DSM-V specifies that the frequency and intensity of the symptoms must be “maladaptive and inconsistent” with developmental level (American Psychiatric Association, 2013). Some symptoms described in the DSM-V include: failure to give close attention to details, difficulty sustaining attention in tasks or play activities, does not listen when spoken to, and is easily distracted and forgetful (American Psychiatric Association, 2013).
The ADHD Label
An ADHD diagnosis may also come with social stigma. According to the American Psychological Association (2015), the stereotype of ADHD refers to a “hyperactive little boy.” One qualitative study revealed that symptoms of an ADHD diagnosis are associated with negative attitudes of the diagnosed child (Law, Sinclair & Fraser 2007). As these examples seem to suggest, ADHD may also be functioning as a disparaging label, which negatively influences how these students are viewed. Teachers may perceive that some students are having performance deficiencies based on being labeled with an ADHD diagnosis rather than on observations. The symptoms combined with the negative stigma may pose damaging consequences for children diagnosed with ADHD in the classroom.
Ohan, Visser, Strain and Allen (2011) describes label bias as the difference between the way an individual with a label is perceived versus the way in which an individual without a label is perceived. Label bias can produce both negative and positive responses from individuals.
Peer and Parent Perception’s of ADHD students
Martin, Pescosolido, Olafsdottir, and McLeod (2007) conducted a study examining the stigma associated with ADHD and found that ADHD had the highest social rejection rate as compared to depression, normal troubles, and physical illness. Roughly one in five respondents preferred that their family or their children avoid social contact with children who have feelings and behaviors consistent with ADHD (20.47%). The same study also went on to find that more than one- fifth of respondents reported not wanting to have a child with ADHD move next door (22.19%) or not wanting to have their child make friends with a child with ADHD (23.47%). The rejection rate is only slightly lower with respect to spending an evening with these children and their family (16.9%) or having a child with ADHD in their child’s classroom (19.3%).
In a similar study, Law, Sinclair, and Fraser (2007) asked child participants to read vignettes about a same-aged peer demonstrating symptoms of ADHD and found that participants held predominantly negative attitudes toward the described peer and reported that they were unwilling to engage with the peer in social, academic, and physical activities.
ADHD Perception by Educators
Children labeled with ADHD and those without may be viewed differently by educators. Vignette studies have presented descriptions of children with ADHD symptoms, but varied the presence of an ADHD diagnostic label. When the label was present, teachers saw students as having more serious behavioral issues, being more likely to disrupt the classroom, and requiring more time and effort than they were able to provide (Ohan, Visser, Strain and Allen, 2011).
The way in which a teacher perceives a student with ADHD will dictate the expectations and treatment of that student. Teacher perceptions of these students come from experiences in the confines of the classroom and from a lack of knowledge about the disorder. Gargaro (2009) and Graeper (2010) found that teachers often reported that working with students with ADHD was very stressful and resulted in a negative interaction. Gerhman (2013) found that regardless of the teachers perception of working with students diagnosed as ADHD they believed that could achieve academic success. For teachers to better serve students with ADHD, they must be sensitive to and knowledgeable about the vast challenges and stigma that these students may experience, and be aware of their own beliefs and personal biases about this disorder (Bell, 2011).
Social challenges for ADHD children
Behavioral and academic challenges are not the only difficulties students with ADHD face. Children with ADHD are often rejected by their peers due in large part to their overtly aggressive responses to stressful situations and their intrusive nature (Webber & Plotts, 2008). These responses to social situations cause children with ADHD to have difficulties in making and keeping friends, as well as, interpreting the intentions of others when encountered (DuPaul, Weyandt and Janusis, 2011; Webber & Plotts, 2008).
Most published studies to date deal with the existence of friendships among youth with ADHD, but do not address friendship quality, real-life friendship interactions, or the characteristics of the friend (Mikami, 2010 and Normand, Schneider, & Robaey, 2007). Typically, Peers are most often asked to indicate which of their acquaintances they look at as or would consider friends. However, should the respondents not understand friendship as an intimate and mutually satisfying dyadic relationship, the responses may indicate little more than the liking of an individual.
In their recent observational study conducted with 259 school-aged children, Mrug and her colleagues (2007) found that not following activity rules, complaining, whining, teasing, and inattention to others predicted peer rejection in children with ADHD two months later, at the end of a summer camp (Mrug, Hoza, Pelham, Gnagy, & Greiner, 2007).
It is estimated that 50% to 80% of children diagnosed with ADHD can also be labeled as being rejected or socially isolated from their peers. In comparison to their peers, children with ADHD are more likely to be rated as intrusive, argumentative, and awkward in social interactions. In the classroom setting, teachers have rated students with ADHD as more interfering, noncompliant, and aggressive than other children in the classroom (McQuade & Hoza, 2008). Although most children with ADHD experience difficulties with social interactions, past research has suggested that severity of social skills deficits can vary depending on subtype.
Kats-Gold and Priel (2009) determined these youths with ADHD have greater emotional understanding social skills impairments than their typical peers. The researchers believed emotional understanding and social skills were linked. Male students with ADHD cannot verbally express feeling related words or define complex emotions, and this may lead to more acting out, inappropriate behavior, and lack of social skills.
Teacher knowledge/training on ADHD

Teacher knowledge, or lack thereof, could result in a general misunderstanding or misinformation about ADHD. Teachers with limited knowledge about ADHD may overlook or miss behaviors signifying a child in need of assistance (Ohan, Cormier, Hepp, Visser & Strain, 2008). Jones and Chronis-Tuscano (2008) found that teachers who participated in their study reported having limited prior training related to ADHD, with regular-education teachers reporting less training than special-education teachers. Anderson, Watt, Noble and Shanley (2012) reported that in-service teachers were found to have significantly higher total knowledge of ADHD and higher perceived knowledge than those of pre-service teachers. In addition, teachers were found to have reasonable knowledge of characteristics and causes of ADHD but to have limited knowledge of treatments for ADHD, thus indicating that teacher-training institutes need to provide accurate and comprehensive information about ADHD and its treatment.
Another study on teacher training conducted, Syed and Hussein (2009) looked at teacher knowledge of signs and understanding of ADHD. Their findings show a significant increase in teacher awareness by teachers after the training; teacher awareness remained after a six-month period.
Martinussen, Tannock and Chaban (2010) concluded that 76% of general education teachers had none or only limited training about ADHD, and 41% of special education teachers stated they have had little or no training in ADHD. Additionally, it was found that general education teachers who had moderate to extensive training in ADHD were more likely to use recommended strategies and approaches. Martinussen, Tannock and Chaban suggested pre-service programs include ADHD training and in-service teachers need in-depth professional development in this area.
Related to interacting with students with ADHD, lack of teacher training is well established in research findings (Syed &Hussein, 2009; Martinussen, Tannock, & Chaban 2011). However, when provided moderate training on interventions, teachers are more likely to use recommended approaches. Web-based training is also identified as effective (Jordan, Smith & Dillon 2004)
Experience working with a topic or subject can provide knowledge, or it can come from training or education received. Teacher knowledge will be recognized as that gained through post secondary education and on the job training received while working in a school. According to Gehrman (2013), Graeper (2010), and Jones and Chronis-Tuscano (2008), teachers that participated in their studies reported receiving minimal training related to ADHD during their pre-service curriculum with general education teachers receiving less than their special education counterpart. Teacher knowledge levels appear to greatly increase with their experience working with ADHD children in their classroom (Anderson, Watt, Noble, & Shanley, 2012; Kos, Richdale, & Hay, 2006; Kos, Richdale, & Jackson, 2004). Knowledge gained through experience was directly related to working in a classroom with ADHD students, not simply the years working in a classroom as a teacher. The areas of increased knowledge center on the characteristics of the disorder, however, the areas of etiology and treatments remained lower when studied by Anderson, Watt, Noble and Shanley (2012).
Kos, Richdale and Hay (2006) identified professional development and in-service training as critical components in providing increased teacher knowledge of ADHD and treatments. Unfortunately, that knowledge does not appear to translate into classroom behavioral management techniques for the general education teachers (Jones & Chronis-Tuscano, 2008). Opportunities for supervised training and practice of behavior management techniques could help bridge the gap between knowledge and use.
Jordan, Smith and Dillon (2004), through the use of web-based applications, looked at how to enhance teacher preparation to better serve students with ADD/ADHD. The study used graduate students with a majority being teachers in their first or second year. The on-line ADD/ADHD class was compared with a Learning Disabilities class in a typical college classroom setting. A survey was given to both classes regarding their knowledge and efficacy of ADD/ADHD. The data show the on-line course was effective in helping teachers feel more knowledgeable about ADD/ADHD.