Attention deficit hyperactivity (ADHD) disorder is a common childhood neurodevelopmental disorder. The symptoms of hyperactivity, impulsivity and inattention often become evident in a structured classroom setting. Teachers play a key role in identifying these features and referring these pupils for assessments.
This study investigated the understanding and perceptions of ADHD amongst Foundation Phase teachers at independent schools in Johannesburg.
This study was conducted at nine independent schools in the Johannesburg area.
A total of 95 teachers filled out a standardised questionnaire, the Knowledge of Attention Deficit Disorders Scale (KADDS), which looks at three aspects of ADHD, namely, associated features, symptoms and treatment. The teachers also answered several demographic questions such as their sex, age, level of education, knowledge of a person outside the school with ADHD and confidence to teach a child with ADHD. An informal directed discussion group was conducted, which comprised 32 teachers who had filled in the questionnaire. Open-ended questions were asked during the discussion group.
The overall results were the highest obtained compared to similar previous studies. These teachers had a very good knowledge with regard to the symptoms of ADHD, they had a fair understanding about the treatment of ADHD and their knowledge about the associated features of ADHD was limited. Exposure to children with ADHD and higher number of ADHD workshops attended and ADHD articles read were beneficial to the teachers’ overall knowledge about ADHD. Years of experience and the age of the teacher were not associated with a greater knowledge about ADHD.
Independent school Foundation Phase teachers displayed a good level of knowledge about ADHD. This knowledge was enhanced by continual ADHD education and exposure to children with ADHD.
The classroom setting is often where symptoms of attention deficit hyperactivity disorder (ADHD) are most evident; it is therefore not uncommon for a teacher to notice this behaviour initially. Demands are put on the child to sit still at a desk for long periods of time, and the child with ADHD struggles to do this (Kos, Richdale & Hay
Teachers play a major role in various aspects of the child with ADHD. The students’ success at school is largely influenced by teachers who are willing and actively involved in working with them, in the framework of a system that supports identifying those with ADHD and providing necessary interventions for them (Pfiffner, Barkley & Du Paul
Importantly, understanding and knowledge about ADHD have been shown to be related to teachers’ attitudes and behaviour towards these children, highlighting how crucial the school environment is for the children with ADHD (Canu & Mancil
To the best of the authors’ knowledge, this is the first study in South Africa that examines Foundation Phase teachers in an independent school setting. We would expect results to differ from other studies at government schools because of various factors. Having a small number of learners per class in independent schools with a low learner to teacher ratio should provide the teacher in the independent school with the opportunity to notice a child with ADHD behaviour. There may be adequate ADHD training for teachers organised through these independent schools (Kellner, Houghton & Douglas
The aim of this study was to evaluate Foundation Phase teachers’ perceptions and understanding of ADHD in independent schools in Johannesburg with regard to general information about ADHD, how ADHD presents and is diagnosed and the treatment modalities that are available. We examined whether the level of knowledge was influenced by certain demographic factors, such as the level of education, length of teaching career, knowledge of ADHD people outside the school setting, number of ADHD courses attended and having taught children with ADHD in the past.
According to Glass and Weger (
Attention deficit hyperactivity disorder is a common neurodevelopmental disorder (Efron
The expression of ADHD is a complicated sequential pathway that involves genetic, environmental and protective factors that each play their role in the disease development (Vizzini et al.
The diagnosis of ADHD is clinical, based on set criteria defined by diagnostic classification systems (American Psychiatric Association
The treatment of ADHD includes certain medication options as well as behavioural management techniques, with most clinical guidelines internationally suggesting a stepwise approach to ADHD management (Halperin, Bédard & Curchack-Lichtin
If left untreated, the long-term prognosis of this disorder is poor, with ADHD sufferers not succeeding at school, in the workplace and in relationships (Mannuzza & Klein
Teachers can play an ongoing and pivotal role in these children’s lives in the areas of recognising features (Layton et al.
Management of these children often involves medication (Bachmann et al.
Studies performed internationally and nationally on teachers’ perceptions and knowledge of ADHD have shown that definite areas are lacking on this topic, and further training is suggested amongst Foundation Phase teachers (Perold, Louw & Kleynhans
The majority of international studies about teachers’ knowledge on ADHD suggests that it is limited (Sciutto et al.
Limited knowledge about ADHD was observed in several international studies (Alkahtani
Very few studies have been conducted in South Africa examining teachers’ perceptions and understanding of ADHD. In 2010, the Knowledge of Attention Deficit Disorders Scale (KADDS) was used amongst teachers in Alexander township in Johannesburg (Lazarus
This study was a mixed-methods study. The first part of the study uses a relational and cross-sectional study design in the first two sections: (1) the demographics and (2) the questionnaire. Section A of the questionnaire considered the teachers’ personal details such as sex, age, level of education and teaching experience. Teachers also needed to circle how many ADHD articles they had read as well as how many workshops on ADHD they had attended. They were required to quantify the number of children with ADHD they had taught during their career, if they knew anyone with ADHD outside school and if they felt confident to teach a child with ADHD. The second part was Section B, which was the KADDS questionnaire. The second part of the study was an informal discussion with several participants who had participated in the KADDS questionnaire.
This study took place in nine independent primary schools in Johannesburg from January to March 2019.
The study population was teachers in the Foundation Phase of independent schools. A non-probability convenience sampling was performed with a sample size of 95 teachers. These educators were believed to have certain characteristics that would enable them to provide the relevant information required for the aim of this study. Foundation Phase educators were specifically selected for this study as this is often the schooling period when ADHD symptoms become evident (Pfiffner et al.
An informal discussion group, comprising 32 teachers, was conducted after the initial questionnaire. Open-ended questions were used in order to gain more insights into teachers’ knowledge about ADHD. These teachers had all completed the KADDS questionnaire and consented to participate in the discussion group. The venue was the staff room at one of the participating schools. The duration of the group was approximately 1 h. The chief investigator and one of the supervisors interviewed the candidates; the interview was audio-recorded and notes were taken. Open-ended questions relating to the pertinent themes of the questionnaire were explored.
The research tool used was the KADDS, a well-validated ADHD scale designed by Sciutto et al. (
Twenty-four independent primary schools in Johannesburg were approached to participate in the study. The invitation to participate was extended via email, and those who did not respond were followed up by a phone call. Three schools declined to participate, 14 schools never responded to either email or telephone communication and nine schools agreed to participate in the study. The final sample consisted of 95 Foundation Phase teachers. A pilot study was implemented using three Foundation Phase teachers to ensure that the questionnaire was clear and easy to understand, as well as to confirm that the allocated time to fill out the questionnaire was appropriate.
Descriptive and inferential statistics were used to summarise the sample respondents and to test the objectives of this research study. The demographic characteristics of the respondents were illustrated using proportions. The comparison of proportions for correct answers obtained in each section of KADDS was tested using the large sample approximation test based on the chi-square distribution. The Marascuillo procedure was then used to identify the actual pair of proportions that differs significantly.
Pearson’s correlation coefficient was used to measure the degree of linear association between demographic variables and sections of KADDS.
Ethical approval to conduct the study was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand (certificate number: 180967).
Consent forms were provided to the school principals as well as to the participants who filled out the questionnaires. The aim of the study was clearly outlined, and anonymity was ensured. The participants understood that their names, their schools and their pupils would not appear in the research or subsequent publications. The consent form also clearly explained that participation was voluntary and that they can withdraw from the study at any time if they wished so.
The researcher was present when the forms were completed, and thus teachers had the opportunity to ask any further questions or clarify certain aspects of the study.
Regarding the informal discussion group, teachers who chose to participate were given a consent form to sign, agreeing to be part of the group, as well as a consent form that they agreed to be audio-recorded. As confidentiality is difficult to ensure in this scenario, the consent form had guidelines that asked participants to respect one another’s privacy, not to share what was said during the group and allow a safe space for participants to express their views. These group rules were reiterated at the beginning of the informal discussion group.
Proportions in each demographic variable category.
Demographic variable | Proportions in each category (%) |
---|---|
< 30 | 6 |
30–39 | 30 |
40–49 | 25 |
50–59 | 25 |
> 59 | 14 |
None | 0 |
1–3 | 3 |
4–6 | 21 |
7–9 | 24 |
> 9 | 25 |
None | 0 |
1–2 | 1 |
3–4 | 9 |
> 4 | 90 |
None | 0 |
1–2 | 1 |
3–5 | 9 |
> 5 | 90 |
Bachelor | 40 |
Graduate diploma | 37 |
Postgraduate | 23 |
No | 5 |
Yes | 95 |
No | 3 |
Yes | 97 |
ADHD, attention deficit hyperactivity disorder.
The KADDS questionnaire considered three different aspects of ADHD knowledge: (1) associated features, (2) symptoms and (3) treatment.
The average score for the questionnaire amongst this group of teachers was 63%, with a standard deviation of 8.1%.
In this section on
The genetic effect of ADHD was largely unknown in the group of participants, with only 41% (39 teachers) answering correctly. A teacher in the focus group who answered this correctly said:
‘There’s a large genetic component. We teach an ADHD child, and when we meet the parents it’s obvious that one of them has ADHD too.’ (Participant 5, 46 years old, female)
The vast majority of teachers were unaware of the latest statistics on ADHD in school-age children, with only 14 teachers (14.7%) having the correct answer. The prevalence of ADHD differed between men and women, and 50 teachers were aware of this (52.6%).
In this category, 90 (94.7%) teachers knew that it was possible for an adult to be diagnosed with ADHD. Of the 95 teachers, 57 (60%) knew that ADHD symptoms are generally not outgrown, as evidenced in the following quote:
‘By high school many have stopped their medication and are doing nicely, however many do need it long term from Grade 1 until matric.’ (Participant 12, 62 years old, female)
Only 35.8% of participants (34 teachers) were aware that children with ADHD have higher rates of depression than those without ADHD.
Of the 95 teachers, 88 (92.6%) knew that an ADHD diagnosis does not make a child eligible for placement at a special school. Attention deficit hyperactivity disorder behaviour and a normal 4-year-old behaviour may appear to be the same, and 16 teachers (16.8%) in this group were aware of this fact.
Children without ADHD may exhibit ADHD symptoms if they come from home environments that are either chaotic or inadequate and 46 teachers (48.4%) in this group answered this correctly. Only nine (9.5%) teachers knew that these children were more compliant with their fathers compared to their mothers; 31 teachers marked this answer as ‘I don’t know’. Only 22 (23.2%) of these teachers were aware that children with ADHD experience less problems in a novel situation.
The results of this section showed that the majority of teachers had a very good understanding of the diagnosis and symptoms of ADHD. On average, the proportion of questions answered correctly was 77%, with a standard deviation of 13.4%.
Most of the questions in this section were answered correctly by the majority of the teachers, with 11% of teachers getting all the answers correct. Teachers were aware that certain features were required to make a diagnosis, and they understood that symptoms need to occur in different settings, as well as the possibility of an adult diagnosis being made. They also knew about the poor effect of ADHD on a child’s self-esteem.
Ninety teachers (94.7%) were aware about the classification of ADHD into two clusters. To diagnose an ADHD, symptoms need to be present in two or more settings and 77 teachers (81%) knew this. Fifty-three teachers (56%) knew that ADHD symptoms do not need to be present before the age of 7 years.
Eighty-four teachers (88%) knew that children who have ADHD are distracted by extraneous stimuli, as clear in the following quote:
‘When they’re on their own with no distractions, they can sit for hours and do puzzles or Lego. In a busy classroom they’re often unable to do the work. They’ll hear a sparrow outside the class and think “What’s that?” and forget about their class work.’ (Participant 3, 51 years old, female)
The majority of teachers (93.7%) were aware that children squirming in their seats is a feature of ADHD. An ADHD diagnosis means that children are often disorganised when it comes to tasks and activities, and 91 teachers (95.8%) knew this.
Eighty-one teachers (85%) were aware that being cruel to others is not a feature of ADHD. Children with a diagnosis of ADHD do not steal or destroy other people’s things, and 58 teachers (61%) knew this.
Sixty-four teachers (67.4%) knew that a good self-esteem is not common with children with ADHD:
‘Their self-esteem often improves with the medication. It is very undermining for the child when they can’t perform on par with their colleagues.’ (Participant 12, 62 years old, female)
In this section on treatment, on average, 63% teachers, with a standard deviation of 13.6%, answered the questions correctly. Only one teacher got all the answers correct.
The majority of this group of teachers were unaware of the role of anti-depressant medication in ADHD treatment, and that electroconvulsive therapy (ECT) has no place in ADHD treatment. Most teachers in this group felt that sugar and colourants influence ADHD behaviour negatively. They were also unaware of the primary elements of ADHD being addressed with behavioural therapy.
Behavioural interventions for ADHD do not primarily focus on inattention and 42 teachers (44.2%) in this group were aware of this fact. Only 28 teachers (28.5%) knew that reducing sugar or food additives could not reduce ADHD symptoms. When asked about whether sugar affects the behaviour, one teacher in the focus group answered:
‘Yes definitely! Our school tuckshop has limited sweets. With the younger kids we try [
Only 25 teachers (26%) knew that anti-depressant medication may help in reducing ADHD symptoms. Thirty teachers (31.6%) were correct in answering that ECT is not effective for severe cases of ADHD. Sixty-three teachers in this group were not sure about the answer and answered ‘I don’t know’.
Questions 37, 38 and 39 of the KADDS were included for training purposes, and they were added to the questionnaire and were not categorised. Fifty-one teachers (53.7%) knew that prolonged stimulant use does not lead to an increased addiction in adulthood. Thirty-seven teachers said they did not know the answer:
‘Parents often mention they’re concerned that the medication may make their child turn into a drug addict. However, the opposite is true.’ (Participant 2, 32 years old, female)
Less than half (44.2%) of the teachers knew that if a child responds to stimulant medication, the child does not necessarily have ADHD. A small percentage (33.7%) of teachers knew that inflexibility to certain routines and rituals is not a feature generally displayed by those with ADHD.
The proportions of correct answers for each section of KADDS varied from 50% to 77%, and there is a need to establish statistically whether the proportions are different for each section. The chi-squared test was carried out to compare the three sections, and the test statistic value obtained was 174.08 at two degrees of freedom, with a probability value (
To establish which proportions are different, a Marascuillo procedure was used. The
To establish whether knowledge of sections of KADDS was influenced by certain demographic factors, Pearson’s correlation coefficient was calculated for each pair (each section of KADDS with each demographic variable), and the results are presented in
Pearson’s correlation coefficient for demographic variable with Knowledge of Attention Deficit Disorders Scale section.
Demographic variable | KADDS section |
||
---|---|---|---|
Associated features | Symptoms | Treatment | |
Age | −0.05 | 0.02 | 0.13 |
Experience | −0.03 | 0.00 | 0.02 |
Articles read | 0.14 | −0.02 | 0.37 |
Workshops | 0.10 | 0.03 | 0.23 |
Children with ADHD taught | 0.20 | 0.19 | 0.27 |
Education | 0.08 | 0.07 | 0.01 |
ADHD, attention deficit hyperactivity disorder; KADDS, Knowledge of Attention Deficit Disorders Scale.
The results of the administered KADDS questionnaire amongst the independent schools Foundation Phase teachers in Gauteng revealed that this group did particularly well compared to other groups that have participated in the previous studies using the KADDS. The results of this study showed that the educators’ overall percentage score of correct responses was 63%, which means that the respondents answered 63% of all the 39 KADDS items correctly. This is one of the highest scores reported internationally where the KADDS tool was used. These results are very similar to those obtained by Kos (
When making comparisons between the different subsets used in studies that used the KADDS, the current study found that the section on
In the
In total, 41% of the independent schoolteachers were unaware that ADHD has a genetic link. Interestingly, in a sample of teachers studied by Glass and Wegner (
Children with ADHD seem to have better behaviour in novel situations, and many independent schoolteachers did not know this. This seems to be true of the other South African studies too (Lazarus
Most independent schoolteachers knew that the prevalence of ADHD differs between boys and girls, with just over half the group of independent teachers getting the correct answer. In comparison, only 33% of the teachers in Lazarus’ (
Two-thirds of the independent schoolteachers in this study answered that ADHD symptoms are more obvious in the classroom than in a free play environment. This question was answered relatively well in Lazarus’ (
The overall score for the
The current study showed that the vast majority of independent schoolteachers were well aware that being unable to sit still was an ADHD feature, and once again most of the independent teachers (more than 90% in this case) knew about the different clusters of ADHD. These behavioural symptoms are well known to teachers, with both local and international studies showing similar results (Kern et al.
The independent schoolteachers scored 63% overall in the
The vast majority of independent schoolteachers were aware that a certain parenting style did not cause ADHD. In a previous study conducted in Johannesburg including private and public schoolteachers, 42% of the teachers indicated that they felt ‘inadequate’ parenting may be the cause of ADHD (Kern et al.
Only a quarter of the independent schoolteachers answered correctly that anti-depressants may be used to treat ADHD (Otasowie et al.
The effect of sugar and preservatives in ADHD behaviour was answered correctly by only less than one-third of the independent schoolteachers. In the Alexandra study, only 7% answered this correctly (Lazarus
Electroconvulsive therapy as a form of ADHD was answered correctly by only one-third of the independent schoolteachers. The majority of teachers answered ‘I don’t know’. Electroconvulsive has rarely been used in ADHD, and this has been used to treat co-morbid conditions such as severe depression (Reichenberg & Seligman
The role of stimulant medication in later substance abuse was answered correctly by only half of the independent schoolteachers, with a large proportion answering that they did not know the answer. The concern of teachers having a misunderstanding about ADHD medication and the perception that it may lead to drug abuse behaviour may cause teachers to offer incorrect advice to families. For example, teachers may suggest to parents that a child should try an exclusionary diet to manage symptoms because ADHD medication may lead to harmful behaviour (Sciutto et al.
The question regarding inflexibility and adherence to rituals was answered correctly by only one-third of the independent schoolteachers. These are symptoms of autism spectrum disorder. If these symptoms are mistaken as ADHD, this may have ramifications when it comes to offering advice to parents and managing these children in the classroom (Efron
In this study, only four teachers felt unconfident to teach children with ADHD. Two of these teachers were over 50 years old and had taught for many years, whilst the other two teachers were far younger and had less teaching experience. All these four teachers passed the questionnaire overall. This suggests that experience may not always instil a sense of confidence; however, other studies have shown that an increased level of confidence is associated with more knowledge about ADHD (Sciutto et al.
Previous studies have found that the longer one teaches for, the more knowledge one has about ADHD, as was the case with Canadian teachers (Jerome et al.
Better knowledge of ADHD has been linked to more exposure of children with ADHD (Kos et al.
More training has been associated with better knowledge about ADH (Kos et al.
The current study showed significant differences in detecting ADHD symptoms by those teachers who had read more ADHD articles as opposed to those who had read fewer articles. Sciutto et al. (
Sciutto et al.’s (
Of the 24 schools that were approached, only nine agreed to participate. This begs to the question of why those schools refused to participate. Was it simply because the principals in these schools felt the teachers were too busy and did not have the time to participate? Or perhaps those schools did not have regular ADHD training and the results would show this? Did those schools that participated have a greater interest in the topic, and as such encourage their staff to keep up to date on the subject? Furthermore, as only nine schools participated in this study, a possible limitation may be that this sample is not representative of all independent schools in the province.
Participation in this study was voluntary. A purposive, non-probability sampling method was used. This sample does not fully represent the population of independent school Foundation Phase teachers as those who responded had chosen to do so. Also, all the participants in this study were women and only schools in a certain geographic location were selected for this research, which rendered this study as both small and narrow. Thus, generalisability of the findings was a concern, and widespread conclusions about independent school Foundation Phase teachers’ knowledge regarding ADHD may not be possible from this study.
The KADDS was designed in 2000. Some developments in ADHD research have subsequently resulted in new knowledge regarding the topic, as well as guideline changes. Whilst the Diagnostic and Statistical Manual of Mental Disorders (
The question regarding behaviour in children aged 4 years is complex. The number of pre-school children with an ADHD diagnosis has doubled over the past 10 years, proving that there is a possibility that ADHD-type behaviour can be observed in very young children and it differs from their neuro-atypical peers. This is seen with the American Academy of Paediatrics (AAP) including this very young group in their stratification system for managing young children with ADHD (Fiks et al.
Workshop attendance was a variable that was used with the purpose of showing that workshops are associated with better knowledge of ADHD. Sciutto et al.’s (
Firstly, the specific nature of the training programmes was not explored at all. Secondly, a training programme may not address certain key aspects. By doing this, it may prove to be a less effective programme, or potentially even inadvertently allow certain misconceptions to be strengthened as inaccurate beliefs held by participants are not addressed or rectified (Sciutto et al.
A follow-up study could entail using independent Foundation Phase teachers once again. However, unlike the current study, a measurement could be instituted and implemented before and after ADHD training. A programme focusing on the main areas of ADHD that are pertinent to teachers could be developed.
Overall, the independent schoolteachers in this study scored very well. This is in comparison to other bodies of research, both locally and internationally, which have used the KADDS.
The teachers in this study had very good knowledge with regard to the symptoms of ADHD, they had a fair understanding about the treatment of ADHD and their knowledge about the associated features of ADHD was limited. The proportion of knowledge of each section of KADDS was significantly different from any other KADDS section.
Exposure to children with ADHD resulted in teachers having the most knowledge in terms of recognising symptoms of ADHD, being aware about features that are associated with ADHD, and the medication and behavioural interventions that are available and effective.
Years of experience was not associated with a greater knowledge about ADHD.
Knowledge of a family member or friend outside the school with ADHD was found to be advantageous to this group of teachers. This study found that their understanding of the available treatments for ADHD was better compared to teachers who had no relationship with people with ADHD.
Workshops about ADHD and reading material related to ADHD are beneficial to teachers’ overall knowledge of the condition as compared to those who had read fewer articles and attended less workshops. An association between workshop attendance and ADHD articles read was found.
As ADHD prevalence is at its highest, and children are often being diagnosed in the Foundation Phase because of the increased demand to sit attentively for longer periods of time, regular workshops should be available for Foundation Phase teachers. This study, as with other bodies of research, has shown that ongoing training is effective in improving teachers’ understanding of the condition, recognising ADHD symptoms as well as providing tools for managing these children in the classroom.
The authors have declared that no competing interests exist.
All authors contributed equally to this work.
This research received no specific grant from any funding agency in the public, commercial or non-for-profit sectors.
The authors confirm that the data supporting the findings of this study are available within the article.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.