How Can Teachers Best Help Us Identify ADHD?
Current diagnostic criteria for ADHD involves documentation of impairment in more than one setting. Since most kids receive an ADHD diagnosis during their school years, we greatly depend on teachers to provide us with information on behavior and symptoms. However, there is no standard way for teachers to measure ADHD and many have little to no training on ADHD or behavioral problems.
A group of researchers in Brazil recently conducted a cross-sectional study to determine what might be the best way to accurately glean information on ADHD from classroom teachers. The teachers of 247 third graders were asked about ADHD in students using three methods. These included:
a. An overt question about potential cases of ADHD in their students: “Which of the following students do you think has ADHD?”
b. The 25-item Strengths and Difficulties Questionnaire (SDQ), a structured broad-band questionnaire on common child mental health problems, including ADHD.
c. The Swanson, Nolan, and Pelham IV scale (SNAP-IV), a narrow-band instrument using a subscale of hyperactivity and symptoms of oppositional defiant disorder.
Teachers identified an average of one in five students (21.1%) as having ADHD using the overt question. The broad questionnaire (SDQ) identified 5.3% of students, and the narrow questionnaire (SNAP-IV) identified 11.3%.
All of the students that were identified as having ADHD by teachers, combined with a random sample of students who were not identified as having ADHD, were assessed by a team led by a child psychiatrist for true ADHD based on diagnostic standards. Fifty-two students were positively identified as having ADHD using any of the instruments by teachers. The clinical team confirmed diagnosis in 18 students; 17 of these were among those identified by teachers.
Both the SNAP-IV and the SDQ showed moderate agreement with the final diagnosis. Upon detailed analysis, the SNAP-IV was the most accurate tool used by teachers, with the SDQ performing at close to “chance” level.
Half of each teacher’s students were evaluated prior to the teacher completing a short, one-day course designed to increase their awareness of ADHD and the other half were evaluated after. The teachers’ completion of the course on ADHD did not significantly affect their ability to accurately identify the disorder in students. In addition, the presence of comorbid externalizing disorders, which may seem like ADHD to an untrained observer, affected the correct identification of true cases (Kieling R et al, Eur Child Adolesc Psychiatry 2013;online ahead of print).
CCPR’s Take: Most of us have had the experience of getting back a subjective report by a teacher or parent that describes a different child than the one we appear to have in our office. This study suggests that ADHD-specific questionnaires may help us get better information, but that untrained eyes are just that—untrained.
The Power of a Child’s Subjective Response to Trauma
By now most of us know how PTSD looks in DSM-5. Among a number of changes is the removal of criterion A2, which required a response to an event to include “intense fear, helplessness, or horror.” Criterion A1—exposure to actual or threatened death, serious injury, or sexual violence—was slightly edited, but remains a diagnostic requirement for the disorder.
It has been well studied in adults that criterion A1 (described in DSM-IV-TR as “The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others”) is more likely to predict the development of posttraumatic stress than meeting criterion A2. In fact, this is the rationale for the removal of the subjective reaction criterion in DSM-5.
However, the predictive power of these criteria was not well-studied in children. Prior to the publication of DSM-5, a group of researchers in Denmark set out to determine the predictive value of criterion A1 and A2 to see if they performed the same for children as they did for adults.
The study involved 533 school-age children (average age 13.6) who completed classroom-based questionnaires about “the worst event they had ever experienced” that included a description of the event and their feelings following it. They were then assessed for probable PTSD using the Children’s Revised Impact of Event Scale (CRIES-13), a standard screening instrument for PTSD.
According to the scoring method used, 24% of events mentioned by the children were classified as A1 events (actual or threatened death or serious injury), while 59% met criterion A2 (the child reacted with fear, helplessness, or horror).
Surprisingly, in contrast to studies in adults, a subjective reaction of fear to an event was significantly more predictive of probable PTSD using the CRIES-13 than exposure to what is objectively defined as a “traumatic event.” When each criterion was looked at alone, children who met Criterion A2 were nine times more likely to develop PTSD than those who did not. Meeting Criterion A1 doubled the chance of developing PTSD (Verlinder E et al, European J Psychotraumatology 2013;4:20436).
CCPR’s Take: This study showed that children’s perception of threat can be incredibly meaningful in predicting PTSD—perhaps even more so than the actual risk from an event. While there was not strong enough evidence to keep criterion A2 in the new version of DSM, we should let this be a reminder to ask questions related to children’s subjective reactions to an event, even if those are no longer required for an official diagnosis.