Patient Education and Counseling xxx (2006) xxxxxx

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Knowledge and attitudes towards attention deficit hyperactivity

disorder among elementary school teachers
Ahmad Ghanizadeh a,*, Mohammad Jafar Bahredar b, Seyed Reza Moeini c
a
Shiraz University of Medical Sciences, Iran
b
Clinical Psychologists, Shiraz University of Medical Sciences, Iran
c
Hazrat Fatemeh Heart Center, Shiraz, Iran

Received 12 April 2005; received in revised form 6 September 2005; accepted 8 September 2005

Abstract

Objective: Attention deficit/hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in child and adolescent
psychiatry. ADHD children are at risk for academic and psychological difficulties. Lack of cooperation between schools, parents and
therapeutic institutions inhibits a multimodal treatment program. This study surveys teachers knowledge and attitudes towards attention
deficit hyperactivity disorder.
Method: One hundred and ninety six elementary school teachers in Shiraz, Iran, anonymously completed a self-report questionnaire on
ADHD.
Results: Knowledge about ADHD was relatively low. 46.9% of respondents agreed that ADHD is due to biological and genetic vulnerabilities
and causation. 53.1%of all the teachers considered ADHD to be the result of parental spoiling. The attitude score towards ADHD children was
also low. 64.8% agree that the same disciplinary rules used for all students should also be applied to ADHD children. 77.6% believe that
ADHD students experience difficulties in their relations with their classmates. There was a significant correlation between teachers
knowledge of ADHD and their attitude. The main sources of knowledge about ADHD were: Television and radio; friends and relatives;
periodical, newspapers and magazines.
Conclusion: Knowledge about ADHD was sound to be very low.
Practice implications: Health and/or Educational Ministry should promote a special course on ADHD for teachers and education should be
part of the curriculum in faculty training. Providing these educational programs on television and radio may be highly effective as they were
the most common source of information.
# 2006 Published by Elsevier Ireland Ltd.

Keywords: Knowledge; Attitudes; ADHD; Teachers

1. Introduction interpersonal interactions [3] and motherchild disruption

Attention deficit hyperactivity disorder (ADHD) is one of
the most common childhood psychiatric disorders that and
has been estimated to affect 218% of school-age children
[1]. ADHD is associated with significant impairment in
multiple domains of functioning, including poor educational
attainment [2]. ADHD is also associated with maladaptive
* Corresponding author. Present address: Department of Psychiatry,
Hafez Hospital, Shiraz, Iran. Tel.: +98 711 627 93 19;
fax: +98 711 627 93 19.
E-mail address: ghanizad@sina.tums.ac.ir (A. Ghanizadeh).
[4]. Problems due to ADHD are not just transient
phenomenon and can adversely affect the developmental
pathway which results impairment of productivity of them
[5]. To decrease this impairment, effective health care
interventions are necessary.
Since psychiatric assessment of ADHD and subsequent
psychological and medical management is strongly related
to teacher information, teachers knowledge about this
disorder is very important. Probably, an improved knowl-
edge base in teachers could lead to improved collaboration
with treatment programms [6]. Also, little is known about
cultural variations in knowledge and attitude about ADHD.

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PEC-2553; No of Pages 5
2 A. Ghanizadeh et al. / Patient Education and Counseling xxx (2006) xxxxxx
Cultural variations in knowledge and attitude may also play
an important role in access to care. In addition, the manner in
which teachers conceptualize ADHD is influenced by
cultural and environmental factors. Therefore, the current
study helps us understand how to facilitate and provide
access to treatment and develop appropriate educational
material. Also, lack of teachers information on ADHD may
induce a stressful classroom for students.
In Iran there is not yet any educational program on
ADHD for teachers. Frequently, ADHD students may be
rejected from class and few of them are referred to child and
adolescent psychiatrists or psychologist.
This study surveys the knowledge and attitude of
elementary school teachers towards ADHD. This is the
first study on this subject in Iran, a non-Western country.
2. Method
One hundred and ninety six primary school teachers from
the province of Shiraz, one of the largest cities in Iran,
voluntarily participated in this study. The study involved
taking a stratified random sample of teachers in the city of
Shiraz. The entire city was divided to comprise a grid of
sectors of four educational areas. The response rate was
85%. The data was collected by self-report questionnaire
which were completed by the subjects privately. The
subjects had enough time to complete that taking about
15 min complete. The initial questionnaire was prepared by
the authors on the foundation of some prior studies and was
similar to them [7,8]. The questionnaire consisted of two
parts. The first part obtained information regarding
demographic characteristics including: age, sex, educational
level, marital status and number year of teaching. The
second part consisted of some true/false questions (false = 0;
yes = 1) regarding knowledge, attitude and source of
acquired information on ADHD. The face validity was
approved by one child and adolescent psychiatrist and a
clinical psychologist. A pilot study showed that the
questionnaire had a satisfactory testretest reliability
(r = 0.78). The knowledge score had a range of 08 (0
indicating the least amount of knowledge). The attitude
score had a range from 0 to 12 and it was normally
distributed. The final version was used in the study.
Table 1
The characteristics of the teachers (N = 196)
Variables Male
Mean of age (S.D.) 40.22 (5.66)
Marital status
Single (%) 3.8
Married (%) 96.2
Mean years of education 14.80 (1.56)
Mean years of experience 19.46 (5.71)
It was stressed that the information collected would be
confidential, and would be used for analysis in writing an
article in order to improve the life of children with ADHD
and their families by increasing the knowledge and changing
attitudes of teachers. The questionnaire was anonymous and
subjects were discussed that it would not be used for any
other purpose.
3. Results
The main demographic characteristics are shown in
Table 1. The rate of male was 44.9%. The average age of the
sample was 38.92 years. Table 2 shows teachers knowledge
and attitude towards ADHD children.
3.1. ADHD knowledge
About 46% of respondents agreed that ADHD is due to
biological and genetic vulnerabilities and causation and not
parental spoiling. However, more than half of them believed
that it is due to parental spoiling. One-third of respondents
think that ADHD may be caused by excessive sugar intake.
Most of the subjects were unaware of Ritalin. Only 61
respondents (31.1%) were aware of Ritalin and this rate was
not different between male and female.
More than 55% of respondents reported that ADHD
students are at risk of developing truancy. The rate was not
significantly different between male and female subjects.
Also, 64.8% believed that ADHD students are at risk for
depression and delinquency.
In the opinion of the educators, ADHD children show
improvement by mean age of 15.8 years (range: 1220
years). The mean age of improvement reported in female and
male educators were 16.09 and 15.66 years, respectively.
Meanwhile, 8.7% of respondents reported that ADHD
related difficulties continued for life. This rate was reported
more frequently by female educators (P < 0.01).
3.2. ADHD attitude
One hundred and fifty two from 196 respondents
agreed that ADHD students should receive a special
education setting and this would be more favourable than
mainstream education. 64.8% agree that the same discipline
Female Total P-value 95% CI
37.32 (6.62) 38.92 (6.26) 0.004 0.94 to 4.85
14.9 9
85.1 91
13.97 (1.63) 14.38 (1.64) 0.001 0.34 to 1.30
18.09 (7.75) 19.11 (6.73) 0.26 0.94 to 3.69
 A. Ghanizadeh et al. / Patient Education and Counseling xxx (2006) xxxxxx 3

Table 2
Teachers attitude and knowledge score towards ADHD
Variable Male Female Total P-value 95% CI
Score of ADHD attitude (max = 12) 7.27 (2.43) 7.65 (2.08) 7.42 (2.33) 0.26 1.06 to 0.32
Score of ADHD knowledge (max = 8) 4.04 (1.56) 3.56 (1.32) 3.79 (1.51) 0.03 0.03 to 0.92

rules used for all students should also be applied to ADHD Table 3
children. 89.3% thought that these students needed Correlations of knowledge and attitude with age and educational levels
psychological support and 49% reported that specially Variable Attitude Age Educational level
*
trained educators should teach these students. 95.9% Knowledge 0.234 0.08 0.178*
believed that educators should be aware of any ADHD Attitude 1 0.06 0.06
students in their classes. *
P < 0.01.
About 13% of respondents reported that ADHD
students IQ is lower than non-ADHD students. 44.4%
believed that their IQ is similar to other students and 38.3% Table 4
reported that ADHD students IQ was more than non- Teachers source of information about ADHD
ADHD students. Source N %
77.6% of respondents believed that ADHD student TV and radio 58 29.6
experience difficulties in their relations with their classmates Friends and relatives 28 14.3
Periodical, newspapers, magazines 27 13.8
and 51% believe that they experience difficulties in their
Specialized literature 26 13.3
relations with their family. 39.8% agreed that educational Special course 11 5.6
achievement of ADHD students will be less than that of non- Medical personnel 6 3.1
ADHD student. 39.8% agree that these students should Other 39 19.9
receive less homework and 27% agree that they should be
examined orally.
Table 2 and Fig. 1 show that the attitude score was
relatively low and was not related to gender. Knowledge of 4. Discussion and conclusion
males was reported more than females. However, again it
was relatively low. 4.1. Discussion
Table 3 and Fig. 1 show that there is a significant positive
correlation between knowledge and attitude and education The most striking finding of this study was the lack of
level. sufficient knowledge and weak tolerant attitudes. The
About 85.7% of teachers self-rated their information knowledge level did not differed between female and male
about ADHD as very low or unknown. Table 4 demonstrated teachers. This probably indicates that daily classroom
teachers source of information about ADHD. activity is stressful for ADHD students in Iran. However, the
attitude score of teachers was differed and it was higher in
males as compared to females. It is regrettable that teachers
knowledge at the age of 40 in the ADHD domain is low and
insufficient.
A prior study showed that only 15% respondents were
unaware of Ritalin [7]. Meanwhile, in the current study this
rate was 69.9%. This shows that the subjects knowledge
about Ritalin is very low and that increased awareness could
benefit on ADHD students [9] and could also decrease
teachers level of stress [10].
In the current study most of the respondents agree that
parental spoiling could cause ADHD. This is contrary to a
prior study, which showed that most of respondents believed
that ADHD was due to biological causes and agreed that
ADHD was not caused by poor parenting [6]. Regarding the
use of medication, only 37.8% of teachers marked as true the
statement ADHD can be treated with medication. This is
Fig. 1. Scatter gram of correlation of attitude with knowledge of teachers on in contrast with a prior study that showed 82% of teachers
ADHD. marked this statement as false [6].
4 A. Ghanizadeh et al. / Patient Education and Counseling xxx (2006) xxxxxx
More than half of the current studys subjects agree
that ADHD students are at a high risk of developing
truancy. A prior study showed that 21.7% of the educators
agreed that ADHD students were at high risk of developing
truancy [7]. This may show that teacher subjects in the
current study are more aware of some outcomes of
ADHD. However, the rate of the respondents who reported
ADHD related difficulties continue for life was lower
than that of a similar study. They reported a rate of 28.3%
[7].
About 13% of respondents reported that ADHD students
IQ is lower than non-ADHD students. 44.4% believed that
their IQ is similar to that of other students and 38.3%
reported that their IQ is higher than that of non-ADHD
students. These rates in a prior study were 6.5, 80.4, 2.6%,
respectively [7]. This shows that the rate of respondents who
think that ADHD students IQ is similar to non-ADHD
students is lesser than that of other studies.
The rate of respondents who reported that specially
trained educators should teach ADHD students was the same
as that of prior study [7]. About 64% of the teachers
mistakenly believe that the disciplinary frame should be the
same for ADHD pupils as well as other classmates (without
ADHD). For example, to take into consideration their
handicap and allow them leave the class for few minutes
when their concentration is reduced, as it is difficult for them
to remain in class listening to lectures. In spite that these
pupils require understanding, empathy and support, 39.1%
of the teachers are wrong while recommending the same
punishments for these pupils as the other classmates. The
rate of educators who reported that ADHD students
experience difficulties in their relation with their classmates
was more than the rate (56%) in prior study. However, the
rate for experience of difficulties in relation with their family
is similar [7].
About 39.8% of respondents agree that the educational
achievement of ADHD students would be lower than that of
non-ADHD student. Another survey showed that only
15.2% of educators belied to this to be true [7]. This may
show that our educators are more aware of educational
outcomes of ADHD students.
Less than half of respondents agree that ADHD students
should receive less homework and less than one-third agree
that they should be examined orally. This shows that the
educators are usually unaware about the quality and quantity
of ADHD students homework and also the way that these
students should be examined.
A positive relationship was found between knowledge
and attitude. This indicates that those who know more about
ADHD also have a more tolerant attitude. Probably, the key
to developing tolerant attitudes would then be increasing
teachers knowledge in this domain education level did not
strong correlate with knowledge and there was not any
correlation between attitude and education level. This shows
that special courses or lectures or formal instructions on
ADHD students should be provided.
Medical personnel are in the sixth place as source of
knowledge about ADHD for teachers. This indicates that
these personnel should take a more active role in the
education of teachers.
4.2. Conclusion
Nearly all of the subjects believed that they were unaware
of ADHD. The main source of information regarding ADHD
was television and radio [11]. Only 5.7% of respondents
passed special educational courses on ADHD and medical
personnel found to be the sixth most commonly used source
of information.
4.3. Practice implications
This shows that the Health or Educational Ministry of
Iran should promote a special course on ADHD for teachers
and that it should be part of their education in faculty
training. Providing educational programs on television and
radio may be highly effective as they were the most common
source of information. This study also showed that coverage
of television and radio on ADHD was very low and should
be increased. Television and radio programs should be
encouraged to expose the Iranian people to experts in field of
ADHD so as to decrease obstacles in the management of
these students. This not only increases the well being of
students but also the performance of all of their classmates
[7].
Acknowledgments
The authors thank Halleh Koleini for help with editing.
This study was supported in part by Research Centre n
Psychiatry and Behavioural Sciences of Shiraz University of
Medical Sciences.
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