Article Text

Original research
Knowledge and attitudes on attention deficit hyperactivity disorder (ADHD) among school teachers in Anuradhapura district, Sri Lanka: a descriptive cross-sectional study
  1. Navoda Wijerathna1,
  2. Charith Wijerathne1,
  3. Himeshika Wijeratne1,
  4. Chathuri Wijesiri1,
  5. Randika Wijerathna1,
  6. Windhya Wijerathna1,
  7. Janith Warnasekara2,
  8. Thilini Agampodi2,
  9. Shashanka Rajapakse3
  1. 1 Rajarata University of Sri Lanka Faculty of Medicine and Allied Sciences, Saliyapura, Sri Lanka
  2. 2 Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
  3. 3 Department of Physiology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
  1. Correspondence to Dr Shashanka Rajapakse; shashanka1015{at}gmail.com

Abstract

Objective This study aimed to assess the knowledge and attitude of school teachers from a rural district in a developing country towards children with attention deficit hyperactivity disorder (ADHD).

Design A population-based descriptive cross-sectional study was conducted using probability proportionate to size cluster sampling.

Setting This study was conducted in 21 government schools in Anuradhapura district, Sri Lanka.

Participants The study sample consisted of 458 teachers with a mean age of 41 completed years ranging from 24 to 59 years.

Main outcome measurements We assessed knowledge, attitudes and sources of information on ADHD using the self-administered, validated Knowledge of Attention Deficit Disorder Scale (KADDS), Teacher Attitudes Towards Inclusion Scale (TAIS) and the Perceived and Actual Sources of Information questionnaires.

Results The median KADDS score was 11 (IQR 8–14) and 45.5% (n=208) of participants lacked sufficient knowledge. Percentages of the correct answers, misconceptions and ‘don’t know’ responses were 28.2%, 24.5% and 45.5%, respectively. The majority of teachers believed that the children with ADHD generally experience more problems in novel situations than in familiar situations (63.5%), a diagnosis of ADHD by itself makes a child eligible for placement in special education (61.1%), and children with ADHD do not often have difficulties organising tasks and activities (61.1%). Some participants (12%) stated that punishment would improve the outcome of the children with ADHD. The attitudes were positive with TAIS 1 and 2 median scores of 46 (IQR 36–58) and 49 (IQR 40–59). The majority of participants relied on informal knowledge gained through their personal experience in the classroom on ADHD (n=337, 76%). The majority of teachers (n=300, 67.7%) preferred to be educated through seminars.

Conclusions School teachers possess a positive attitude. However, they have poor knowledge and significant misconceptions regarding ADHD which may affect the identification and management.

  • MENTAL HEALTH
  • PSYCHIATRY
  • Child & adolescent psychiatry
  • EDUCATION & TRAINING (see Medical Education & Training)

Data availability statement

Data are available upon reasonable request. Data relevant to the publication would be made available upon reasonable request to the corresponding author.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • School teachers from 21 government schools from a rural district in Sri Lanka were selected using cluster sampling probability proportionate to size to assess the knowledge and attitudes on attention deficit hyperactivity disorder.

  • The standard Knowledge of Attention Deficit Disorder Scale, Teacher Attitudes Towards Inclusion Scale and the Perceived and Actual Sources of Information questionnaires were translated and validated in local languages.

  • The study focused on teachers engaged in regular teaching programmes and did not include teachers engaged in special education programmes, braille teachers of special schools for children with significant visual impairments.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a childhood psychiatric disorder with a persistent pattern of inattention and/or hyperactivity-impulsivity that has a direct negative impact on academic, occupational or social functioning for at least 6 months.1 2 The global prevalence of ADHD among children aged 3–12 years is 7.6%, and 5.6% of teenagers aged 12–18 years are reported to have ADHD. The prevalence among children is higher compared with that of the adult population (2.85%).3 4 ADHD prevalence varies with age, gender, presence of other psychiatric disorders and geographical location.5 6 The mean prevalence of ADHD in childhood is reported as 3.3% in high-income countries and 0.6% in low and lower middle-income countries where deficits in identification and referral may contribute to low prevalence.7 The cultural and contextual effects on the health-seeking behaviour of parents and caregivers, methodological differences in diagnosing ADHD and the availability of research studies may contribute to the high variability in the prevalence of ADHD in different regions.8

The limited studies conducted to assess the prevalence of ADHD in the childhood population in Sri Lanka show a prevalence ranging from 5.1% to 6.5%.9 Hence, a typical Sri Lankan classroom consisting around 45–50 students possibly might have one to two children with symptoms of ADHD. The diagnosis of ADHD is mainly clinical and is based on the history of the early development of the child provided by the parents and teachers. Therefore, the awareness and knowledge of teachers regarding ADHD are crucial in suspecting and referring children with suggestive symptoms of ADHD, especially, since the symptoms should be noticed in at least two settings in order to be diagnosed. Current evidence suggests that there is limited and inadequate knowledge about ADHD among teachers leading to poor identification, referral and provision of intervention. Students with ADHD are often at greater risk of school dropout and academic failure due to a lack of appropriate support.10 Thus, the knowledge and attitudes of school teachers about childhood ADHD are crucial in providing an enabling environment for children with ADHD to achieve their potential and in implementing, supporting and evaluating the treatment of children with ADHD.11

There is limited evidence of Sri Lankan teachers’ knowledge and attitude towards children with ADHD. Evidence indicates that the teachers’ knowledge about symptoms and presentation of ADHD was below 50% in an urban environment, with only two out of 10 teachers having even heard of the disease. However, the teachers’ attitudes towards behavioural therapy were positive.12 Considering the importance of the teacher’s role in the identification, treatment, implementation and evaluation of ADHD, we aimed to describe the knowledge and the attitudes of school teachers from a rural geography in Sri Lanka.

Methodology

Study setting

A descriptive cross-sectional study was conducted in government schools of Anuradhapura district registered at the Department of Education, North Central Province, Sri Lanka. Anuradhapura is geographically the largest district in Sri Lanka. There are five educational zones, 564 schools and 11 957 teachers employed in the education system of the Anuradhapura district.

Study sample

The sample size was calculated using a 5% prevalence of ADHD, an error margin of 2% and a significant level of 95%.9 The calculated minimum sample size was 456.12 All the schools in the Anuradhapura district, registered at the Education Department of the North Central Province, and the total number of teachers were listed according to the Sinhalese alphabetical order. The cumulative population was calculated by adding the current cluster to the sum of all previous clusters on the list. A cluster was the school, within whose cumulative population the random number was placed. This procedure was carried out until the sample size was achieved. Teachers from grade 1 to grade 13 were recruited to the study and a maximum of 50 teachers from each school were enrolled using a simple random sampling. We excluded the braille teachers of special schools for children with blindness.

Administrative approval

Administrative approval was obtained from the Director of Education of North Central Province, Zonal Directors of the Anuradhapura district and the principals of the selected schools. Written informed consent was obtained from all research participants before data collection.

Translation and cultural adaptation of tools

We used a self-administered questionnaire consisting of the translated and cognitively validated Knowledge of Attention Deficit Disorder Scale (KADDS), Teacher Attitudes Towards Inclusion Scale (TAIS) and the Perceived and Actual Sources of Information (PASI) questionnaires. The KADDS measures the actual knowledge of ADHD with regard to the symptoms, diagnosis, associated features and treatment.13 TAIS 1 assesses the attitude towards a child with hyperactive behaviour and TAIS 2 the attitude towards a child with attention deficit behaviour.14 The PASI questionnaires assess the current and preferred sources of information. Authors obtained written permission from the original authors of the KADDS, TAIS and PASI questionnaires. The questionnaires were translated by a panel of experts which included both clinical and language experts.15 16 Forward and back translations were conducted in both Sinhalese and Tamil (native languages in Sri Lanka). Another panel of experts rated and selected the best translations for each language for each item of the tool. The final translated items were decided on the consensus of the panel and the investigators according to Sumathipala and Murray’s method.17 We performed a cognitive validation of the questionnaire by selecting a group of native Sinhalese-speaking and native Tamil-speaking teachers from schools of the Anuradhapura district who were not selected for the study. This included the initial administration of the questionnaire to the teachers followed by a focus group discussion to see the feasibility of understanding each item and quickly responding, whether the teachers’ cognitions simulate the intended original meaning of the items, problems in ambiguous terms and their suggestions of better terms.18 Amendments were made accordingly. The finalised culturally adopted translations were used in the study (online supplemental material 1).

Supplemental material

Data analysis

Data were analysed using a Beta version of SPSS statistical software. Depending on the distribution of awareness and the attitude scores, median and IQRs were used. Spearman’s rank test, Mann-Whitney U test and Kruskal-Wallis test were used as a measure of the strength of association of the awareness and the attitude among school teachers of Anuradhapura district about ADHD with sociodemographic factors.

Patient and public involvement

The conceptualisation of the research idea was based on the issues teachers face when managing classrooms. Discussions were held with school teachers and principals who would not be potential participants before the implementation to better understand the extent of the problem and also to minimise the discomfort and burden of questionnaire filling.

Results

The study sample included 458 teachers from 21 schools with a response rate of 96.7%. The mean age in completed years was 41 with a range of 24–59. The mean teaching experience in completed years was 14 with a range of 1–36. The mean student contact completed hours per week was 27 (±10). The sociodemographic characteristics of the study population are presented in table 1.

Table 1

Demographic details of school teachers from Anuradhapura district, Sri Lanka (n=458)

The median KADDS score is 11 (IQR 8–14) (figure 1). Percentages of the correct answers, misconceptions and ‘don’t know’ counts were 28.2%, 24.5% and 45.5%, respectively. Incorrect answers represent misconceptions, and the most common misconception (63.5%) in this study sample was that children with ADHD generally experience more problems in novel situations than in familiar situations. A majority of teachers (n=280, 61.1%) believed that a diagnosis of ADHD by itself makes a child eligible for placement in special education, and that ADHD children do not often have difficulties organising tasks and activities. Of all the participants, 12% had marked that punishment would improve the outcome of the students with ADHD (table 2). Knowledge about ADHD was associated positively with higher educational qualifications (Kruskal-Wallis test, p=0.052, H=10.9).

Figure 1

Distribution of knowledge regarding attention deficit hyperactivity disorder among school teachers of Anuradhapura district (n=458).

Table 2

Misconceptions regarding attention deficit hyperactivity disorder among teachers from Anuradhapura district, Sri Lanka (n=458)

Teachers’ attitude towards children with predominantly hyperactive behaviour (TAIS 1) and children with predominantly attention deficit behaviour (TAIS 2) was positive with a median score of 46 (IQR 36–58) and 49 (IQR 40–59), respectively (figure 2). A score of more than 42.5 for both TAIS 1 and TAIS 2 was considered positive. Teachers’ attitudes towards students with predominantly inattentive symptoms were associated positively with student contact hours (Spearman’s correlation 0.09, p=0.06) (table 3).

Figure 2

Distribution of attitude regarding attention deficit hyperactivity disorder among school teachers of Anuradhapura district (n=458). TAIS, Teacher Attitudes Towards Inclusion Scale.

Table 3

Association of KADDS score, TAIS 1 score and TAIS 2 score with sociodemographic factors among school teachers of Anuradhapura district

The source of information regarding ADHD for the majority of school teachers (n=337, 76%) of the Anuradhapura district was informal knowledge gained through their personal experience in the classroom, followed by electronic media (60%, n=266) and printed media (52.8%, n=234). Although 67.7% (n=300) of teachers prefer to be educated about ADHD through seminars, only 189 (42.6%) have received formal instruction through seminars. The second most preferred source of information was electronic media (n=249, 56.1%).

Discussion

We report the knowledge and attitude of school teachers on ADHD from 21 government schools from a rural district of a low middle-income country. The majority (61.9%) of study participants lacked sufficient knowledge regarding ADHD and one-fourth of the teachers had misconceptions. Also, a systematic programme to educate teachers on ADHD does not seem to exist in the country.

In the current study, the median knowledge score was lower (11 out of 39) compared with other countries. In a multicountry study assessing the knowledge of ADHD using the same scale, the highest mean of knowledge score was reported from the USA (22.2) and the lowest from Saudi Arabia (5.3) and Vietnam (11.8).19 Similar studies conducted in the Caribbean nation and South Africa have shown poor knowledge of teachers about childhood ADHD.10 20 In both studies, the mean total score was less than 50%. A previous study conducted in the urban Gampaha district of Sri Lanka has also shown knowledge scores to be below 50% among primary school teachers.12 Therefore, improving rural teachers’ knowledge of ADHD would be helpful in early identification and management.8

Our results show that the misconceptions (incorrect answers) regarding childhood ADHD among Sri Lankan school teachers are high. Several other studies have reported misconceptions regarding symptoms and treatment.21 22 Sciutto et al reported that the mean misconception rate was highest in Iraq (11.95) and lowest in the USA (5.7) and Saudi Arabia (5.3).19 We report a misconception rate of 24.5%. Even though Sri Lanka is a country with universal free education, a high rate of literacy and postprimary education, the misconception rate is comparatively higher than most countries. Teachers’ misconceptions on appropriate educational placement of students with ADHD are a barrier affecting the implementation of effective strategies for children with ADHD.23

Children with ADHD can be subjected to stigma and distress especially when the teachers and caregivers have poor knowledge and attitudes on the condition. A study that assessed explicit stigma towards an age and gender-matched peer with ADHD or depression and another peer with ‘normal issues’ indicated that the peers with ADHD perceived all dimensions of stigma except perceived dangerousness and fear than the peers with depression.24 There is a higher likelihood of children with ADHD being excluded or rejected by their peers which could lead to drastic unhealthy personality changes in the child. Studies on the implications of ADHD are scarce in Sri Lanka and the current study reflects the urgent need for further studies on this aspect.

Punishment does not improve the outcome of students with ADHD. However, 16.8% of teachers who participated in the study conducted in the Gampaha district, Sri Lanka, advocated punishment as a means to improve the behaviour of children with ADHD.12 In our study, 12% of the participants had marked that punishment would improve the outcome of childhood ADHD. Current evidence indicates that punishment exerted greater control over the response allocation of children with ADHD with increased time on task, and children with ADHD appear more sensitive to the cumulative effects of punishment than typically developing children.25 Hence, it is a must to take immediate measures to address these significant misconceptions that would affect children with ADHD adversely.

The attitudes of teachers towards behavioural therapy have been positive and teachers who had training in child psychology had a more favourable attitude and knowledge.12 Hence, the capacity exists to improve the well-being of children with ADHD in educational settings. Our results demonstrate that even though rural teachers have poor knowledge regarding ADHD, they possess a positive attitude in identifying and caring for childhood ADHD. Studies have shown that school teachers in coaching groups have a more secure and effective teacher–student relationship with children having emotional and behavioural difficulties and that a more detailed assessment of a child’s functional level before the intervention is important.26 ADHD could be successfully managed in schools when appropriate systems and strategies are employed by all staff.27 However, there are no programmes in Sri Lanka to enhance knowledge of ADHD among teachers.

In the current study, the period of service of the teacher positively correlated with the TAIS 2 score probably attributable to the current lack of formal training and the resulting reliance of teachers on their experience to identify students with ADHD. A study conducted in the Caribbean nation showed a difference in knowledge scores based on the teacher’s educational level from secondary school level to master level as the mean increased from 8.8 to 13.5.11 These findings indicate that teachers gain knowledge and develop favourable attitudes with their experience and exposure.

According to the PASI questionnaires, the most common source of obtaining information was their day-to-day classroom experience, which is an informal method prone to establish misconceptions. This may explain the high prevalence of misconceptions in this population. The current provision of knowledge of ADHD through seminars and electronic media is inadequate. However, most teachers preferred to obtain better knowledge through seminars incorporated into the formal training programmes. By providing proper education about ADHD to the teachers, early recognition and directing of children with ADHD to medical professionals could be improved.

The limitations of the study include the exclusion of braille teachers of special schools for children with significant visual impairments. The study did not assess the mode of punishment the teachers believed would reduce the symptoms of ADHD (physical, verbal or other). The study tools were translated and only cognitively validated. We did not perform a psychometric validation of the tools. The particular district predominantly consists of the rural sector. Hence, the findings may not represent a fully urban population.

Conclusion

Knowledge among Anuradhapura district school teachers about ADHD is poor with significant misconceptions. The majority of teachers have not received proper education or training regarding ADHD during their training period or while in service. However, teachers’ attitude towards caring for children with ADHD is positive. Considering the adverse effects of poor knowledge and misconceptions of teachers about childhood ADHD, the findings highlight the urgent need for implementing strategies to improve the knowledge of school teachers regarding childhood ADHD.

Recommendations

We recommend conducting further studies in different regions to obtain better evidence regarding the knowledge and the attitudes of teachers regarding children with ADHD. We further recommend providing adequate training for teachers to achieve sufficient competency to recognise children with ADHD and classroom management techniques to create an enabling and encouraging environment for children with ADHD to achieve their educational goals. The focus population could be newly recruited teachers and the delivery of knowledge could be integrated into the initial training in teaching. We also recommend that the National School Health programme pay more attention to mental and behavioural disorders of children during the school medical inspections so that affected children would have more opportunities to be referred to specialists.

Data availability statement

Data are available upon reasonable request. Data relevant to the publication would be made available upon reasonable request to the corresponding author.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by the ethics review committee of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka (ERC/2018/55), and written informed consent was obtained from all participants before recruiting to the study. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors acknowledge Dr Wajantha Kothalawala, Consultant, Child and Adolescent Psychiatrist; Dr Karu Prasanna, Senior Registrar, Teaching Hospital Anuradhapura; Dr Amanda Wettasinghe, Registrar, Teaching Hospital Kalubowila; Chandima de Alwis, Medical Officer, Psychiatric Unit, Teaching Hospital Anuradhapura; Dr Kaleinesan Kesavan, Registrar; Dr C Prathipan, Medical Officer, Teaching Hospital Anuradhapura; Dr Sivamynthan Srikumaran, Medical Officer, Teaching Hospital Anuradhapura; Mr D A Wehella, Lecturer, Department of English Language Teaching, Rajarata University of Sri Lanka; Mr A A M Nizam, Lecturer, Department of English Language Teaching, Rajarata University of Sri Lanka; Ms N D Jayasinghe, Lecturer, Department of English Language Teaching, Rajarata University of Sri Lanka; Mrs Jenita Paul, Instructor, National Institute of Language Education and Training, Sri Lanka; and Mrs Niluka Lakmali, Teacher, Aloysius College Rathnapura, for their support in translating and validating the questionnaires used in the study. We further acknowledge the Provincial Director of Education, Department of Education, North Central Province; Zonal Directors of Education; and the principals and teachers of selected schools.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @ShashankaIR

  • Contributors Conceptualisation: NW, CWijer, HW, CWijes, RW, WW, SR. Data curation: NW, CWijer, HW, CWijes, RW, WW, JW, SR. Formal analysis: NW, CWijer, HW, CWijes, RW, WW, JW, SR. Investigation: NW, CWijer, HW, CWijes, RW, WW. Methodology: NW, CWijer, HW, CWijes, RW, WW, SR. Project administration: SR. Supervision: JW, TA, SR. Visualisation: NW, CWijer, HW, CWijes, RW, WW, JW, TA, SR. Original draft: NW, CWijer, HW, CWijes, RW, WW. Writing—review and editing: JW, TA, SR. Guarantor: SR

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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