Attention-Deficit/Hyperactivity Disorder (ADHD), a psychiatric disorder characterized by abnormal levels of hyperactivity, impulsivity and/or inattention (American Psychiatric Association, 2013), is among the most diagnosed conditions in preschoolers and children in elementary school (Willcutt, 2012). The most common conceptualization of ADHD comes from a neurobiological perspective, which describes ADHD as caused by brain dysfunction (Wright, 2012). Nevertheless, no objective biological markers for ADHD can be detected in the brain of an individual child (Te Meerman et al., 2017) and the diagnostic process of ADHD as a whole is largely based on subjective assessments of student behavior by teachers and parents (Groenewald et al., 2009; Sayal et al., 2008).

Singh (2006) describeshow Western educational institutions are mandated to screen for potential behavioral and academic problems in students. To achieve this, schools are populated with medical and psychological staff. However, non-medical staff as well are increasingly integrated into the detection of behavioral, emotional, and learning disorders, particularly so in the case of ADHD (Conrad, 2006). Teachers have the opportunity to constantly compare a student’s behaviors to the behaviors of other students in the classroom (Elder, 2010). This unique observational position allows teachers to take on an informal role as ‘disease-spotters’ (Phillips, 2006), and, by extension, also the task of spotting disorders, such as ADHD. In practice, this means that teachers are often the first to signal a child’s hyperactivity, impulsivity and/or inattention to parents (Sax & Kautz, 2003).

Not much empirical research has been conducted on teachers’ perspectives of and experiences in their role as disorder-spotter with regard to ADHD. Prior research has discussed teachers’ willingness to take on the role of disorder-spotter, to refer students for assessment by a medical practitioner, and to suggest medical treatment to parents (Malacrida, 2004). Research on all steps of the diagnostic process of ADHD is highly relevant, since students with a medical diagnosis of ADHD encounter significantly more difficulties in their educational career than other students: They repeat a grade more often  and have a higher chance of school dropout (Fried et al., 2016).

By means of focus groups in four Flemish elementary schools, this study investigates teachers’ decisiveness in assigning a child’s hyperactivity, impulsivity and/or inattention to ADHD as the underlying cause. Concretely, we will examine to which extent teachers are decisive or indecisive in their observation that ADHD is, or is not, the underlying cause of a child’s hyperactivity, impulsivity and/or inattention. We propose it is important to investigate teachers’ decisiveness in assigning a child’s hyperactivity, impulsivity and/or inattention to ADHD, since it is likely that their decisiveness plays a role in the information and recommendations they give to parents. Furthermore, when teachers have assigned the child’s behavior to ADHD as the underlying cause and the label of ADHD is applied to the child, the effects of this label according to educational researchers are potentially far-reaching, since teachers’ academic perceptions and expectations are considerably lower for students with a label of ADHD (Batzle et al., 2010). Therefore, cautiousness by teachers when labeling children with ADHD and suggesting medical assessment and medication to parents is advised. In the result section, we will discuss teachers’ decisiveness and the nature of child-related factors that made teacher indecisive whether ADHD was indeed at the base of a specific child’s hyperactivity, impulsivity and/or inattention.

The data were collected in East-Flanders, a Dutch-speaking province in Belgium, as part of an international comparative project. The project was approved by the Ethics Committees of the faculty of Political and Social Sciences of Ghent University and the University of Québec in Chicoutimi. For this study, we conducted focus groups in four elementary schools in 2018, reaching 23 teachers in total. The Summer school had the lowest percentage of children with a low educated mother (16%), the lowest percentage of children who did not speak the official educational language, Dutch, at home (13%), and the lowest percentage of children who received a school allowance (17%) (Agency for Educational Services, 2018). The Autumn school had the highest percentages on all three accounts (respectively 44%, 44%, and 40%). The ratio preschool/elementary school differed, with the Spring School having the lowest ratio (1:4) and the Autumn School the highest (3:1). We only found female teachers prepared to participate. In all schools, the teachers presented a good mix in years of teaching experience and all teachers had experience with ADHD in the classroom. The verbatim transcriptions were analyzed in the tradition of conventional content analysis by means of the software package NVivo 12. Conventional content analysis is generally used when a study aims to describe a phenomenon and when existing theory or research literature on this phenomenon is limited (Hsieh & Shannon, 2005). We focused on teachers’ statements when they were asked to think back about a time when they had a child in their classroom that exhibited behaviors that they thought could be indicative of ADHD. To ensure systematics in the analysis process, we rigorously followed the series of steps of conventional content analysis as described by Schreier (2012). The categories and names for the categories were not preconceived, but emerged from the data. With conventional content analysis, code development, and application have to be performed separately (Schreier, 2012). In practice, this means that we generated a coding frame during a pilot phase and that the coding frame did not change during the main analysis. Each child that teachers talked about was coded under one of two main categories: Decisiveness in specific cases and Indecisiveness in specific cases. Often for one child, multiple subcategories applied. The main categories are linked to teachers’ understandings and beliefs about ADHD and their perception of their capability to detect ADHD in children.

We investigated teachers’ decisiveness in assigning a child’s hyperactivity, impulsivity and/or inattention to ADHD as the underlying cause. In three of four schools, when teachers talked about specific children, they were, more often than not, sure of their observation that ADHD was or was not the underlying cause of the child’s hyperactivity, impulsivity and/or inattention. However, several child-related factors such as a child’s young age, problematic home situation, chaotic upbringing, mutual behavioral adjustments by teacher and child, a possible other disorder, and a high IQ which results in boredom made them indecisive about the cause of hyperactivity, impulsivity and/or inattention in specific children. Multiple implications follow from our results. Firstly, teachers’ decisiveness might be more school-related than teacher-related. Amongst each other, teachers of the same school were largely in agreement on the presence or absence of ADHD in specific children and on the factors that made detection difficult. Secondly, according to these teachers, hyperactivity, impulsivity and/or inattention do not necessarily have to be caused by ADHD. Our results suggest that teachers were more likely to explain hyperactivity, impulsivity and/or inattention with ADHD when other factors that could cause these features to their knowledge were absent. Two implications arise. Firstly, whether or not a child is suspected of ADHD by his/her teacher depends on the teacher’s perceptions about what factors outside of ADHD could cause hyperactivity, impulsivity and/or inattention. Secondly, a teacher might not know of the child’s situation and miss the presence of a factor outside of ADHD that could cause a child to exhibit hyperactivity, impulsivity and/or inattention. We recommend that teachers are made aware of and reflect on the mechanisms behind their practices as disorder-spotters and their personal involvement in relation to the academic and social problems in children who exhibit hyperactivity, impulsivity and/or inattention (Rafalovich 2005).

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