TEACHERS. PREFERENCES FOR INTERVENTIONS FOR ...

TEACHERS. PREFERENCES FOR INTERVENTIONS FOR ETHNICALLY DIVERSE LEARNERS WITH ATTENTIONDEFICIT HYPERACTIVITY DISORDER Jamie G- Wood, Kelly D_ Heiskell, Dawn M_ Delay, Jody Ann S_ Jongeling, and Darrick Perry

ABSTRACT

One hundred sixty-eight elementary and middle school teachers participated in this investigation on the impact of student gender and ethnicity on teacher recommendations for interventions for attention-deficit hyperactivity disorder (ADHD). Participants read a scenario describing a student with ADHD accompanied by a student photo which depicted his/her ethnicity and gender. Partici-

pants were then asked how strongly they would recommend four common interventions. Findings suggest teachers are more likely to recommend interventions requiring less parental involvement for minority students than- for Caucasian students. Elementary and special education teachers were more likely to recommend interventions with greater empirical support than were middle school and regular education teachers. Ramifications for intervention selection in schools and suggestions for future investigations are reviewed.

Attention-Deficit Hyperactivity Disorder is one of the most common childhood disorders. Approximately 3 to 7% of school-age children are diagnosed with ADHD (Pastor & Reuben, 2002). About 50% of these students take psychotropic medication to treat their ADHD, while 12 to 34% receive other interventions such as special education and mental health services (Pastor & Reuben, 2002). The core symptoms of ADHD include impulsivity, inattention, and overactivity. The disorder is further divided into subtypes including" combined type (ADHD-CT), predominantly inattentive type (ADHD-lA), and predominantly hyperactive-impulsive type (ADHD-HI) (American Psychiatric Association, 1994). Due to these primary difficulties, children with ADHD often experience significant problems in school settings (see DuPaul & Stoner, 2003, pp. 72-106, for a review of associated academic concerns).

Jamie G. Wood, Kelly D. Heiskell, Dawn A. Delay, and Jody Ann S. Jongeling, Pittsburgh State University, Pittsburg, Kansas. Darrick L. Perry, Southeast Education Interlocal #637, Pittsburg, Kansas. Requests for reprints should be sent to Jamie G. Wood, Department ofPsy-

chology and Counseling, Pittsburg State University, Pittsburg, KS 66762. Email: [email protected] ADOLESCENCE, Vol. 44, No. 174, Summer 2009 Libra Publishers, Inc., 3089C Clairemont Dr., PMB 383, San Diego, CA 92117

While the core symptoms noticed by teachers and others are often consistent, other variables may help explain important differences in the rates at which the disorder is diagnosed and in preferences for certain intervention strategies over others. One important variable which interacts with the prevalence of diagnosis of ADHD is gender. Many more males than females are diagnosed with ADHD; and the ratio has varied depending on the source of the research. Referrals in clinics approximate a 6:1 ratio while referrals in community settings approximate a 3:1 ratio (Pastor & Reuben, 2002). Another somewhat understudied variable is the ethnicity of the child. Some studies have found significant differences between Caucasians and African American students (e.g., DuPaul et aI., 1997; Epstein, March, Connets, & Jackson, 1998; Reid, DuPaul, Power, Anastopoulos, & Riccio, 1998). Notsurprisingly, concern has been expressed regarding the accuracy of current a.ssessment methodology with ethnic minority students (Bauermeister, Berrios, Jimenez, Acevedos, & Gurdon, 1990). Just as a multitude of factors seem to affect the prevalence of ADHD diagnosis, intervention selection may also be influenced by ethnidgender variables. Prior to addressing these possibilities, the currentresearchers reviewed the general literature on intervention for ADHD and the impact of teacher variables on the success of intervention. Several studie,';"have provided support for both behavioral arid pharmacological interventions. It is clear that medication treatment providesat the very1eastshort,term benefits academically, behaviorally, and socially (see DuPaul, Barkley, & Connor, 1998, for a review), Longterinstudies seem to have suggested that the intervention method and success of the approach may hinge on whether the student has other comorbid conditions along with ADHD (Jensen, Martin; & Cantwell, 1997).1\s the previous report attests, students who have other behavioral and/or psychological concerns, may find that other treatments such as behavior modification or counseling are beneficial. Modification of instruction, curriculum, and the physical enviroument of the classroom may also prove efficacious. (see DuPaul & Stoner, 2003, pp. 139-189), for suggestions). The impact of teacher effort on an intervention's success would seem to be omnipotent. For example, when teachers disagree with an inter' vention, they may choose to refuse to implement it, implement it improperly, of fail to finish the treatment (Eckert & Hintze, 2000; Wilson & Jennings, 1996). Logically, it follows that the degree to which teachers "believe in" the possible success of a given intervention may phiy a major role in the intervention outcome. Undoubtedly, numerous

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factors affect teachers' perceptions about their preference for certain . interventions over others. The amount of effort involved, duration of effort, resources, and support are factors teachers are likely to ponder in considering their intervention preferences. One investigation found that plans for teacher support were crucial to the success ofinterventions (Horner, Albin, & O'Neill, 1991). Other research has indicated that teachers identify several barriers to instruction when working with students with ADHD (Reid, Vasa, Maag, & Wright, 1994). The most serious barriers included the time needed to administer specialized interventions, a lack of teacher training, classroom size, and severity of ADHD-related problems. While pragmatics are likely to guide teacher perceptions about interventions, other variables may inadvertently playa role as well. While some interventions require greater effort on the teacher's part than others, how teachers perceive the student can influence whether or not they are likely to provide the necessary effort. Nearly all students with disabilities pose unique combinations of academic and behavioral challenges for teachers. Differences in teacher perceptions about the difficulty of working with students with disabilities may be related in part to the nature of the disability involved. One investigation found that students with "hidden disabilities," i.e., without physical abnormality, were more likely to be rejected and found intolerable by their teachers (Cook, 2001). The stress perceived by the teacher in working with a student with ADHD is often related to the nature of the specific symptoms displayed. Greene, Besterczey, Katzenstein, Park, and Goring (2002) found that elementary teachers viewed students with ADHD as more stressful to teach than classmates without ADHD. However, the students with ADHD who evidenced oppositional/aggressive behavior or severe social impairment were rated as significantly more stressful to work with than students with ADHD who did not have such problems. Given the test teachers are posed when confronted with the concerns of students with ADHD, it is interesting to review their perceptions regarding the use an9. effectiveness of various interventions. Several investigations have explored the factors governing teacher perceptions regarding interventions for students with ADHD. The acceptability of an intervention may be rated differently based on the age of the student or the type and severity of behaviors displayed (Bennett, Power, Rostain, & Carr, 1996; Eckert & Hintze, 2000; Elliott, 1998; Schneider, Kerridge, & Katz, 1992). In addition, teacher acceptability for a particular type of intervention may also be related to the information presented during an evaluation (Layoe, 2002). In this

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investigation, teacher acceptability was found to be higher when functional descriptions of the problem behaviors were included in the evaluation. Power, Hess, and Bennett (1995) found that teachers tend to prefer positive interventions over negative interventions. A general sampling of teachers showed that teachers also tend to prefer interventions that take less time to implement and those that are less intrusive to the classroom (Fairbanks & Stinnett, 1997). Special education teachers were found to report using Contingency Contracting over two less intensive and time-consuming intervention approaches when working with students with ADHD than did their general education counterparts (Higgins, 2000). In addition to student factors and.those associated with classroom functioning, other studies have investigated teacher characteristics which affect perceptions of interventions. Wood, Downs, Pappas, and Wade (2004) found that elementary school teachers were more knowledgeable regarding interventions than were secondary school teachers, and special education teachers were more knowledgeable than their regular education counterparts. This is not·to imply that regular education teachers are not wanting of more education in this area. Bus~ng, Gary, Leon, and Wilson, and Reid (2002) found that of a sampling of general education teachers, 94% wanted more training in ADHD. In addition, in a survey of teachers from the United States and New Zealand, 53 to 66% ofthe respondents had not had any previous training for ·ADHD (Curtis, Pisecco, Hamilton, & Moore, 2006). Vereb and DiPerna (2004) found that along with teacher knowledge, years of teaching experience with students with ADHD and level of training were positively correlated with the acceptability oftreatments involving behavior management and medication. Results from Glass (2001) were similar but found that teacher's receipt of information (or lack thereof), on ADHD from other school personnel affected how teachers worked with students with ADHD. Glass and Wegar (2000) established that many teachers, when faced with the lack of information, will prefer an intervention of medication over other treatments, even when they believe that the disorder is mediated by environmental variables. When comparing academic and behavioral interventions, teachers' acceptability has also been influenced by the inclusion of causal statements which included a mechanism to understand ADHD, they were more likely to give favorable acceptability ratings to academic interventions. In a study of high school teachers, Rush (2005) found that teachers' overall perceptions of adolescents with ADHD were related to the teachers' access to information and their own training on educating students with ADHD. As the following sections will illustrate, disabilities such as ADHD may be

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perceived differently in various minority ethnic groups and therefore teacher perceptions of how they should help assist such students may differ. In an epidemiological study, Phillips (1968) first discovered that sociocultural subgroups displayed different types of problem behavior. Waechter, Anderson, Juarez, Langsdorf, and Madrigal (1979) revealed that African American students tended to exhibit a different combination of behaviors as shown by a significantly higher score on three of the 10 items on the Abbreviated Connors Teacher Rating Scale (Connors, 1969). These were outwardly noticeable behaviors, which included: "demands must be met immediately," "temper outbursts," and "drastic mood changes." Other reports have also suggested that evaluators see African American boys as having the most severe symptoms of ADHD· (Epstein et al.,1998). Whether such characteristics actually exist to a higher degree in students of various ethnicities remains to be seen. However, it is clear that such a perception exists. Minority students' chances at successful interVention are further encumbered by frequent differences in SES and poverty-associated comorbidity (Vargas & Rand, 1999). Regardless of cumulative factors, there is startling evidence that when it comes to· rates of identification, ethnicity by itself does matter. A study by Lambert, Sandoval, and Sassone· (1978) revealed that teachers identified Black students as hyperactive more often than Hispanic or White children. Similar findings have been discovered in a variety of special education categories as well. Numerous reports have established that African American boys are disproportionately placed in special education (Artilles & Trent, 2000; Dove, Hodge, & Serwatka, 1986; Patton, 1998). Although the above investigations were not limited to students with ADHD, it is quite obvious that decisions for interventions with minority students with exceptionalities are not always based on objective diagnostic criteria alone. There may also be a bias when the cultural background of the assessor is different from the student being assessed. A study by Stevens (1981) found that Caucasian school personnel tended to attribute ADHD to Black more often than to White or Mexican American students. In another study using the Connors Rating Scale with an ethnic cally mixed group (African Americans, Hispanics, and Caucasian), results indicated that teachers applied different criteria for the diagnosis of ADHD based on the ethnicity and gender of the child (Adams, Macy, & Kocsis, 1984). An important question to consider is whether the biases which lead to variance in diagnostic characteristics and rates further affect preferences for interventions and their use. Although information regarding the intervention process for ethnically diverse children diagnosed with ADHD is almost non-existent, it

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is reasonable to suggest that ethnicity also plays a role in the intervention process, especially after reviewing the current data on evaluation and diagnosis. According to Arnold et a!. (2003), Caucasian children are significantly less symptomatic than African American and Latino children on some ratings, but the response to treatment does not differ significantly by ethnicity after controlling for public assistance. This came from a randomized clinical trial of 579 children ages 7-9 years receiving 14 months of medication management, behavioral treatment, a combination, or community care. Given this empirical evidence suggesting similar best practice intervention guidelines regardless of ethnicity, the next question would be whether teachers in fact recommend similar interventions regardless of ethnicity. Perhaps one variable teachers consider in their choice of interventions is the view of students' parents. There is growing evidence that parents of minority children may have a diff,,",ent social construction of their idea of ADHD and be resistant to diagnosis or use of certain interventions (e.g., stimulant medication) (Davison & Ford, 2001). African American parents are often less likely to use specific medical labels for their children's ADHD, instead preferring to apply a behavioral problem label or simply refer to their child as "bad" (Bussing, Schoenberg, Rogers, Zima, & Angus, 1998). African American parents are less likely to desire school interventions as part of the treatment plan for their child with ADHD (Bussing et a!., 1998). If teachers are knowledgeable and cognizant of parents' philosophical differences, teachers may adjust their choices for intervention. Quite possibly however, other significant variables such as gender of the student interact with the aforementioned factors. Gender differences in children with ADHD have been discovered in many areas including prevalence rates and scores obtained on evaluation instruments. As previously mentioned, males are diagnosed with ADHD at a higher rate than females. However, some have proposed that the reason for this is that the behaviors used to define ADHD in the DSM-IV. were identified from a sample pool composed mostly of males (Frick et al., 1994; Lahey et a!., 1994). It has also been argued that because males are referred for testing and diagnosed with ADHD at a higher rate than females, females diagnosed with ADHD have more severe social problems than their male counterparts (Greene et al. 2001). However, Nolan, Volpe, Gadow, and Sprafkin (1999), indicated that severity of inattentive and hyperactive symptoms were similar for males and females in the ADHD-I and ADHD-HI categories. The above-mentioned study also indicated that in the ADHD-C group, females had significantly higher total ADHD and hyperactivity/impul-

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sive symptom severity scores and somewhat higher inattentive symptom severity scores than did males. This suggests that the main differences for ADHDsyniptm;ns among males and females may lie within the ADHD-C category. Even if the females referred for testing display more severe behaviors than males, the number of males diagnosed with ADHD outnum, bers females, This creates a problem when trying to conduct research on gender differences in ADHD. Bussinget al. (1998) cite lack of statistical power as a reason for finding few gender differences in their study ofexplimatory models of ADHD." Females represented less than 20% of their sample, due to underrepresentation in special education. "Gender may also impact the way teachers react to students with ADHD. Literat';'re suggest that males display more externalizing beha:viors, including ADHD symptoms, than do females (Arnold 1996; Hepinstall & Taylor, 1996). Abikoff et al. (2002) found that when comparing observable behaviors, males with ADHD had higher rates on interferenc,e ofdassroom, environment, total aggres'sion, and gross motor movements than did females withADHD.Females with the disor; der showed less severe disruptive, rule~breaking behaviors than did lllales with ADHD. If these types of behavior patterns are consistent across time; teachers may come to expect certain types of behaviors and have preconceived notions of how a child withADHD will affect their classroom on the basis of gender. "" Reid et aL (2000) conducted a study o[the effect of gender on teacher behavior""ratings scales. Their study indicated that whiie there was no qualitative' difference in symptomatology across gender and that the ADHD construct is consistent across gender, gender did have a significant effect on teacher ratings of ADHD symptomatology; Reid and his colleagues (2000)also foundthat oetween-gender ratings increased as seventy of symptoms increased. They also suggest the reason for the higher ratings have to do with the fact that male behaviors tend to be more disruptive to the classroom environment and therefore more salient to the classroom teacher. How does this information affect how teachers perceive intervention needs for ADHD? Kashani, Chapel, Ellis, and Shekim (1979) found that females with ADHD were usually referred for learning problems rather than behavior-problems, whereas boys identified as hyperactive were more frequently referred for behavior problems than learning. Breen and A1tepeter (1990) found that behavioral patterns might be more frequently identified as ADHD in boys than in girls due to the frequencY of the disruptive classroom behavior exhibited by boys. This research supports the aforementioned research by Greene and his col-

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leagues (2001), suggesting that females must exhibit more extreme symptoms to be referred by teachers for behavioral problems related toADHD. The current investigation sought to understand the role of gender and ethnicity of students withADHD in the strength ofteacherrecommendations for various interventions. We hypothesized that: (1) Based on the research of Bussing et al. (1998), teachers would more strongly recommend interventions which required less family involvement for students with ADHD who were ethnic minorities than they would for Caucasian students. (2) The strength of teacher recommendations for interventions would differ for male students versus female students. (3) Based on the research of Wood, Downs, Pappas, and Wade (2004) and others, special educations teachers would more strongly recommend interventions with more empirical support (be more knowledgeable) than regular education teachers, and elementary school teachers would perform similarly in comparison to middle-school teachers.

METHOD

Participants Participants for the study were 168 teachers who were recruited from one of two sources. Some were recruited from seven small-tomedium-size school districts whose superintendents had agreed to allow their teachers to participate during beginning-of-the-year inservice training programs. The remaining participants were current teachers in courses in a Master's degree program at a small Midwestern university. Twenty-five of the participants were special education teachers and 143'were regular education teachers. Only teachers who were currently teaching elementary (N ~ 99) or middle school/junior high (N ~ 65) were used as participants. The rationale behind this decision was that the majority intervention with students with ADHD is likely to occur in younger grades. The average years of teaching experience among the participants was approximately 12 years (M ~ 11.72).

Materials Materials consisted of a multiple-page survey. The initial page was used for informed consent and stated the purpose of the study and participant's right to participate or to decline. The second page of the survey featured brief instructions informing participants that on the subsequent page they would read a scenario about a student with

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ADHD and then respond to a series of questions about their reactions. The next page contained a picture of a male or female African Ameri· can, Hispanic or Caucasian child. Pictures of each child were accompa· nied by the brief scenario describing the child. An example scenario read as follows: Maria Benitez is a 5th-grade student at Washington Elementary. Her academic achievement is considered average and her effort level is typical of a child her age. She has been diagnosed with ADHD and primarily has problems with hyperactivity and impulsivity. Maria has been referred to the school intervention team for academic and behavioral concerns .

. Other than the gender and ethnicity of the student, the scenarios did not vary. Scenarios were followed by a series of questions in which teachers were asked to rate how strongly they would recommend vari· ous types of intervention for the child described., Interventions were rated on a scale of 0 to 4, with 4 being the most favorable and 0 being the least favorable. There were four intervention questions: counseling (COUNS), behavioral modification (BEMOD), medication (MED), and classroom modification (MODCLASS). The order of the intervention questions was randomized. Finally, each survey also included a section asking participants a series of questions concerning their type of classroom experience. These questions included years of teaching (YOT), age level of students taught (TEACHER LEVEL), and regular education teacher or special education teacher (TEACHER TYPE).

Procedures Prior to the beginning of the actual survey project, 127 students from an educational psychology class were shown the photos of children to be used in the study. The students were asked to provide the gender and ethnicity (Caucasian, Mrican American, Hispanic) of each child. The procedure for collecting data from both the teachers in schools and from those in university classes was exactly the same. Participants were informed of the study's purpose and of their right to participate or decline. The surveys were completed individually while a researcher was present to answer any questions. No questions were raised. Participants were informed to turn over their survey when finished and to remove the informed consent sheet and hand it in separately. After all materials were collected by the researcher, each group was informed ofthe study's hypotheses, and participants were thanked for their participation.

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RESULTS

Interrater reliability for the gender and for the ethnicity of the child in the scenario was extremely high (98.7% and 97.6%, respectively). The alpha value for all other analyses was set at .05. Four 2 X 3 ANCOVAS were employed to ascertain the effects of the independent variables of the gender and the ethnicity of the student on the dependent variables of the four questions on the strength of recommendations for various interventions (COUNS, BEMOD, MODCLASS, MED). The variables YOT, TEACHER TYPE, and TEACHER LEVEL were covariants in each of the ANCOVAS. The fir~t analysis revealed a significant main effect for ethnicity of the student on .the strength of teacher recommendations for the MODCLASS intervention, F(2, 158) = 3.43, p = .04. Post hoc comparisons utilizing the LSD procedure indicated that the strength ofteacher recommendations for the MODCLASS intervention was higher for Mrican American students, M = 2.91, than for Caucasian students, M = 2.40, P = .03. TEACHER TYPE had a significant effect on the strength of teacher recommendations for the COUNS intervention. The strength ofrecommendations for the COUNS intervention was higher among Regular Education Teachers, M = 2.59, than they were among Special Education Teachers, M = 2.0, F(l, 158) = 4.20, P = .04. TEACHER TYPE also had a significant effect on the strength of "teacher recommendations for the BEMOD intervention. Ratings among Regular Education Teachers were higher, M = 3.08, than they were among Special Education Teachers, M = 2.63, F(1, 158) = 3.85, P = .04. TEACHER LEVEL significantly affected the strength of teacher recommendations for the MED intervention, F(1, 158) = 21.97, P < .00l). Elementary Teachers had stnmger recommendations for MED intervention, M = 2.14, than did Middle School Teachers, M = 1.31 (t = 5.07, dt = 162, P < .001.

DISCUSSION

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As predicted, teachers more strongly recommended interventions requiring less family support for some ethnic minority students (African American) than they did for Caucasian students. Teachers may have been knowledgeable about the differences in how African American families tend to regard ADHD and felt as though an intervention based

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p.rimarily on teacher responsibility (modifying the classroom) would be advisable. One could contend however, that some of the other interventions offered, e.g., counseling and/or behavior modification do not require extensive family involvement. However, such procedures may involve parental consent and teachers may have simply preferred the intervention under which they alone had the most cGntrol when working with the African American students. Consistent with previous findings and our hypotheses, certain groups of teachers appeared to be more koowledgeable of evidencebased interventions than others. Regular education teachers' recommendations for the counseling intervention and the behavior modification intervention were significantly stronger than were the recommendations for these interventions by special education teachers. As longitudinal empirical investigations have revealed (Jensen, Martin, & Cantwell, 1997), the effect size for behavior management and counseling interventions are small in comparison to other interventions (medication) for students who have no comorbid concerns (as was the case in the scenarios of the current investigation). Special education teachers were possibly more koowledgeable of such findings than regular education teachers. In perhaps another finding related to teacher koowledge, elementary teachers more strongly recommended an evidence-based intervention (medication) than did middle school teachers. There are several possible explanations for the dearth of significant findings specifically related to the gender and ethnicity variables. The first may be related to differing perceptions regarding behaviors pertinent to referral diagnosis versus preferences for interventions for students once they are diagnosed. Despite the numerous differences in males versus females in symptoms and behaviors salient to referral and diagnosis, apparently the teachers in our current investigation did not allow that to affect their judgment about the utilization of interventions. It is also possible that similar phenomena exist in consideration of students of various ethnicities. Despite findings that African American students tend to be recognized for different and more severe ADHD symptoms, our results imply that such recognition does not lead to changes in treatment preferences, other than the tendency to select interventions which rely less on family involvement. Perhaps many of our teachers were koowledgeable of previous findings indicating that response to intervention is not mediated by ethnicity (Arnold et aI., 2003). While the above observations may seem to have positive connotations, our findings may also indicate that some minority students are

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not getting the evidence-based interventions they deserve. The finiling that teachers more strongly recommended modifying the classroom environment for African American students· than for Caucasian students may indicate that teachers do not always pursue the most beneficial treatment for such students. This finding is also somewhat perplexing however if' light of our other findings indicating no significant ethnic differences in strength of teacher recommendations for the behavior modification intervention, the counseling intervention, or the medical intervention. These phenomena remained unexplained and worthy of future investigation. Our study has several limitations, one of which could have significantly affected the results on the gender variable. In an effort to maintain internal contr:ol, we opted to characterize the students in all scenarios as primarily having problems with inattention and hyperactivity/impulsivity. While we gained greater internal validity via this decision, we may have portrayed certain students with ADHD unrealistically. As previously mentioned, the symptoms related to diagnosis and referral are often different for females versus males and the teachers in our study may have found the descriptions of the female students incongruent with what they have come to expect from them. Our findings regarding differing perceptions of special education teachers versus regular education teachers may have been affected by the sizeable difference in the two sample sizes, although such percentages seem similar to those found in contemporary public schools. Nevertheless, future investigations may wish to compare various teacher groups of equal sample size to insure greater accuracy and power in statistical analyses. In addition to the aforementioned design consideration, we offer other suggestions for future research efforts. Perhaps case study methodology would prove valuable in assessing teacher perceptions with students with ADHD of different genders and ethnicities at each step of the referral-diagnosis-treatment process. Such studies may shed light on the point at which perceptions of students differ based on important variables. Future investigations should consider investigating intervention preferences with individual groups of students, e.g., African American females, using descriptions for such students which most accurately portray information consistent with previous research. It may also prove valuable to employ a forced-choice design strategy which requires teachers to select a certain intervention over others as opposed to having them rate their recommendations for each intervention. Another interesting possibility might involve exploration of the role of teacher knowledge of family dynamics in teacher choice for

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intervention. While there may be some bias in the selection of intervention for genders and ethnicities, it may be that many teachers ba~ such decisions on the family dynamics of the given student (which were not supplied in the current investigation). Undoubtedly, a variety of student, teacher, family, and environmental factors will continue to affect the diagnosis and treatment of students with ADHD. Our primary goal should remain to explore factors which allow for equity in the diagnosis and treatment of various student groups with ADHD.

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