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Study shows why children with ADHD should be reevaluated each year: Attention problems perceived by teachers are far less stable than we imagine

While the study below was pub­lished a few years ago, it makes an impor­tant point that I think is worth revis­it­ing.

In the study, pub­lished in the Jour­nal of Devel­op­men­tal and Behav­ioral Pedi­atrics, my col­leagues and I looked at how fre­quent­ly teacher rat­ings of inat­ten­tive symp­toms per­sist in chil­dren from one grade to the next. We felt this was an impor­tant issue to exam­ine because recog­ni­tion that ADHD is often a chron­ic con­di­tion can obscure the fact that atten­tion prob­lems do not always reflect an endur­ing child char­ac­ter­is­tic, and that impor­tant changes are pos­si­ble when chil­dren move to a new class­room.

As you will see below, clin­i­cal­ly-ele­vat­ed atten­tion prob­lems as per­ceived by teach­ers are less sta­ble than you may have imag­ined. Our find­ings high­light the impor­tance of care­ful­ly reeval­u­at­ing chil­dren each year so that chil­dren do not con­tin­ue to car­ry a diag­no­sis that may no longer apply and to be treat­ed for prob­lems at school that are no longer evi­dent.

Summary and Implications

Data from 3 diverse sam­ples indi­cates that more than 50% of ele­men­tary school chil­dren rat­ed by their teacher as hav­ing clin­i­cal­ly sig­nif­i­cant inat­ten­tive symp­toms one year do not show sim­i­lar prob­lems the fol­low­ing year. This was true even for chil­dren with a care­ful­ly con­firmed diag­no­sis of ADHD, i.e., those from the MTA Study, who had not start­ed med­ica­tion treat­ment between the 2 rat­ings.

Why might cross-grade sta­bil­i­ty of ele­vat­ed teacher rat­ings of atten­tion dif­fi­cul­ties be so mod­est? Var­i­ous expla­na­tions are pos­si­ble includ­ing pos­i­tive change in the child asso­ci­at­ed with mat­u­ra­tion, the res­o­lu­tion of a sig­nif­i­cant life stres­sor, or per­haps improved nutri­tion and/or sleep. Teach­ers may also use rat­ing scales dif­fer­ent­ly, with some teach­ers prone to assign high­er rat­ings than oth­ers.

How­ev­er, it is also pos­si­ble that for some chil­dren, a change in class­room con­text is an impor­tant fac­tor. This echoes find­ings obtained with mid­dle school stu­dents, where rat­ings of ADHD symp­toms between teach­ers often do not show strong agree­ment. This dif­fer­ence has been attrib­uted by some researchers to the unique char­ac­ter­is­tics asso­ci­at­ed with dif­fer­ent class­rooms.

Because ele­men­tary school chil­dren typ­i­cal­ly have only a sin­gle teacher, how­ev­er, it is eas­i­er than with mid­dle school stu­dents to over­look class­room con­text as a pos­si­ble fac­tor in a child’s atten­tion dif­fi­cul­ties. To the extent that this is the case, it may inad­ver­tent­ly lead some chil­dren to be diag­nosed with ADHD.

We believe these find­ings have sev­er­al use­ful clin­i­cal impli­ca­tions for the use of teacher rat­ings in the assess­ment and man­age­ment of ADHD.

First, as is already wide­ly rec­og­nized, our find­ings under­score the impor­tance of not over-rely­ing on symp­tom counts in mak­ing an ADHD diag­no­sis; doing so may iden­ti­fy many chil­dren whose dif­fi­cul­ties at school are like­ly to be tran­sient. This was evi­dent in the fact that a reduc­tion to the nor­ma­tive range of atten­tion prob­lems was some­what less fre­quent for chil­dren from the MTA Study — who had been care­ful­ly diag­nosed with ADHD — than for chil­dren from the oth­er 2 sam­ples.

The impor­tance of reeval­u­at­ing chil­dren annu­al­ly to learn whether inat­ten­tive symp­toms report­ed by one teacher are evi­dent in the child’s new class­room is also high­light­ed. For chil­dren who have been tak­ing med­ica­tion, this should be done when the child has been off med­ica­tion for a brief peri­od. In the absence of such a pro­ce­dure, some chil­dren are like­ly to be main­tained on med­ica­tion to address dif­fi­cul­ties that may no longer be present.

If rat­ings made by the child’s new teacher indi­cate that atten­tion dif­fi­cul­ties are no longer promi­nent, it must be rec­og­nized that this does not nec­es­sar­i­ly mean that a child’s prob­lems have resolved in an endur­ing way. In such instances, a more exten­sive assess­ment would be war­rant­ed to bet­ter under­stand the rea­son for the appar­ent change so that well-informed deci­sions about pos­si­ble treat­ment mod­i­fi­ca­tions can be made.

Our study has sev­er­al lim­i­ta­tions that should be acknowl­edged. First, the num­ber of chil­dren in each sam­ple is rel­a­tive­ly small. Sec­ond, because we did not have good data on med­ica­tion treat­ment for chil­dren in sam­ples 1 and 2, we do not know how many may have shown nor­mal­ized symp­toms in year 2 in response to such treat­ment. Final­ly, we have no infor­ma­tion for why symp­tom reports often declined so sub­stan­tial­ly. Although we believe that a change in class­room con­text may have played an impor­tant role, we did not exam­ine this direct­ly.

Two final points are impor­tant to make. First, cur­rent diag­nos­tic cri­te­ria for ADHD enable the diag­no­sis to be made even if a child’s symp­toms have only been evi­dent in a sin­gle grade. Our find­ings sug­gest that requir­ing symp­toms to have been evi­dent in mul­ti­ple grades might help pre­vent diag­nos­ing with ADHD chil­dren whose atten­tion prob­lems at school have a good chance of being tran­sient.

Final­ly, these data should not be con­strued as under­min­ing the valid­i­ty of ADHD as a dis­or­der or as indi­cat­ing that ADHD is sim­ply in the ‘eye of the behold­er’. In each sam­ple, a sig­nif­i­cant per­cent­age of chil­dren showed atten­tion prob­lems that per­sist­ed across grade. In addi­tion, we did not fol­low chil­dren long enough to deter­mine how often such prob­lems may reemerge in chil­dren for whom sub­stan­tial declines were evi­dent.

Thus, while our find­ings high­light the impor­tance of not treat­ing chil­dren based on the assump­tion that ADHD symp­toms will per­sist, they also indi­cate that such prob­lems cut across grades for many chil­dren. How­ev­er, the fact that this is fre­quent­ly not the case under­scores the val­ue of care­ful­ly reeval­u­at­ing chil­dren with ADHD when they have tran­si­tioned to a new class­room.

The Study in More Detail

How sta­ble are teacher reports of clin­i­cal­ly ele­vat­ed atten­tion prob­lems in chil­dren? The answer to this ques­tion has impor­tant impli­ca­tions about the neces­si­ty of reeval­u­at­ing chil­dren with ADHD on an annu­al basis.

Because ADHD is often a chron­ic con­di­tion, it can lead par­ents and pro­fes­sion­als to assume that chil­dren with sig­nif­i­cant atten­tion prob­lems at school will dis­play these dif­fi­cul­ties the fol­low­ing year. How­ev­er, atten­tion prob­lems do not always reflect an endur­ing child char­ac­ter­is­tic and may be exac­er­bat­ed by aspects of the child’s class­room con­text in a par­tic­u­lar year.

For exam­ple, when placed in a dis­or­ga­nized class­room with a teacher who strug­gles with behav­ior man­age­ment issues, some chil­dren may dis­play ele­vat­ed atten­tion prob­lems. How­ev­er, when placed in a bet­ter orga­nized class­room the fol­low­ing year with a teacher who con­sis­tent­ly rewards atten­tive, on-task behav­ior, these same chil­dren may show far few­er dif­fi­cul­ties.

In a study pub­lished in the Jour­nal of Devel­op­men­tal and Behav­ioral Pedi­atrics, my col­leagues and I exam­ined the sim­ple ques­tion of how fre­quent­ly clin­i­cal­ly ele­vat­ed teacher rat­ings of atten­tion dif­fi­cul­ties per­sist from one grade to the next. We felt this was an impor­tant ques­tion to exam­ine because if such rat­ings are fre­quent­ly not sta­ble across grade, it would high­light the need for care­ful annu­al reeval­u­a­tions for chil­dren diag­nosed with ADHD. Oth­er­wise, some chil­dren could con­tin­ue to car­ry a diag­no­sis that may no longer apply and to receive med­ical treat­ment for prob­lems at school that are no longer evi­dent.

We exam­ined this ques­tion in 3 sam­ples of ele­men­tary school chil­dren with clin­i­cal­ly ele­vat­ed teacher rat­ings of atten­tion dif­fi­cul­ties, i.e., rat­ings that fell in the top 10% of the pop­u­la­tion for chil­dren their age. Par­tic­i­pants in Sam­ple 1 were 27 first graders, those in Sam­ple 2 were 24 4th graders, and those in Sam­ple 3 were 28 7- to 9-year-old chil­dren from the Mul­ti­modal Treat­ment Study of ADHD (MTA Study).

Chil­dren in sam­ples 1 and 2 did not have a for­mal ADHD diag­no­sis but were iden­ti­fied sim­ply by hav­ing ele­vat­ed teacher rat­ings of inat­ten­tive symp­toms. Those from the MTA Study had all been care­ful­ly diag­nosed with ADHD Com­bined Type; the chil­dren we select­ed were those who had been ran­dom­ly assigned to the Com­mu­ni­ty Care con­di­tion and who did not receive any med­ica­tion treat­ment dur­ing the ini­tial study peri­od.

As not­ed above, all chil­dren had ele­vat­ed teacher rat­ings of inat­ten­tive symp­toms at base­line. These rat­ings were obtained the fol­low­ing year from children’s new teacher so that the cross-grade sta­bil­i­ty of ele­vat­ed rat­ings could be com­put­ed. On aver­age, fol­low-up rat­ings were obtained 12–14 months lat­er.

Summary Results

In all 3 sam­ples, few­er than 50% of chil­dren were rat­ed with clin­i­cal­ly-ele­vat­ed atten­tion prob­lems by their new teacher. The per­cent­ages were 37% of chil­dren in the 1st grade sam­ple, 33% of chil­dren in the 4th grade sam­ple, and 46% of chil­dren from the MTA sam­ple. The per­cent­age of chil­dren whose rat­ings of atten­tion dif­fi­cul­ties had declined to the nor­mal range was 44% for the 1st grade sam­ple, 50% for the 4th grade sam­ple, and 25% for the MTA sam­ple.

In the 1st grade sam­ple, for exam­ple, 14 chil­dren had at least 6 inat­ten­tive symp­toms rat­ed at the high­est lev­el at base­line. At fol­low-up, 10 had 2 or few­er symp­toms (70%) includ­ing 5 who were report­ed to show 0 symp­toms (36%); only 2 chil­dren (14%) were still rat­ed with 6 or more symp­toms.

These find­ings high­light the impor­tance of care­ful­ly reeval­u­at­ing chil­dren each year so that chil­dren do not con­tin­ue to car­ry a diag­no­sis that may no longer apply and to be treat­ed for prob­lems at school that are no longer evi­dent.

Rabiner_David– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and helped pre­pare the self-paced, online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

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