Teachers' evaluations for the detection of primary‐school children with attention deficit hyperactivity disorder

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This article was downloaded by: [Ams/Girona*barri Lib]On: 17 October 2014, At: 05:18Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UKEuropean Journal of Special NeedsEducationPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rejs20Teachers' evaluations for the detectionof primaryschool children withattention deficit hyperactivity disorderMaria Kypriotaki a & George Manolitsis aa Department of Preschool Education , University of Crete , GallosUniversity Campus, Rethymno, Crete, GreecePublished online: 26 Jul 2010.To cite this article: Maria Kypriotaki & George Manolitsis (2010) Teachers' evaluations for thedetection of primaryschool children with attention deficit hyperactivity disorder, European Journalof Special Needs Education, 25:3, 269-281, DOI: 10.1080/08856257.2010.492940To link to this article: http://dx.doi.org/10.1080/08856257.2010.492940PLEASE SCROLL DOWN FOR ARTICLETaylor & Francis makes every effort to ensure the accuracy of all the information (theContent) contained in the publications on our platform. 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Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditionshttp://www.tandfonline.com/loi/rejs20http://www.tandfonline.com/action/showCitFormats?doi=10.1080/08856257.2010.492940http://dx.doi.org/10.1080/08856257.2010.492940http://www.tandfonline.com/page/terms-and-conditionshttp://www.tandfonline.com/page/terms-and-conditionsEuropean Journal of Special Needs EducationVol. 25, No. 3, August 2010, 269281ISSN 0885-6257 print/ISSN 1469-591X online 2010 Taylor & FrancisDOI: 10.1080/08856257.2010.492940http://www.informaworld.comTeachers evaluations for the detection of primary-school children with attention deficit hyperactivity disorderMaria Kypriotaki* and George ManolitsisDepartment of Preschool Education, University of Crete, Gallos University Campus, Rethymno, Crete, GreeceTaylor and FrancisREJS_A_492940.sgm(Received 18 August 2009; final version received 8 February 2010)10.1080/08856257.2010.492940European Journal of Special Needs Education0885-6257 (print)/1469-591X (online)Original Article2010Taylor & Francis253000000August 2010MariaKypriotakimkypriotaki@edc.uoc.grThe early detection of children with attention deficit hyperactivity disorder(ADHD) by teachers can contribute to the prevention of secondary disorders in achild and this can have serious implications for the childs overall development.The aims of the present study were to examine: (1) the validity of the originalassessment of the teachers in detecting school-age children nominated as childrenwith ADHD by their teachers; and (2) the factors that influence teachersevaluations on a rating scale assessing ADHD, such as childs gender, the parentslevel of education, the childs social and academic behaviour in the classroom, theteacherstudent relationship, as well as the teachers cooperation with the parents.Teachers were asked to fill in a Greek standardised rating scale for the detectionof children with ADHD and a student behaviour questionnaire for 420 primary-school students nominated as children with ADHD by teachers. The studysfindings showed that teachers detect far more students with ADHD than thenumber expected from the norms based on the standardised ADHD rating scale.Teachers not only nominated more boys than girls as students with ADHD, butalso made more accurate identifications for girls than for boys, particularly in thelater primary-school grades. Childrens age or parental educational backgrounddid not influence the teachers initial nominations or their later ratings. Multipleregression analyses indicated that the teachers beliefs about a childs peerrelations and the quality of teacherchild relationships predicted teachers ratingson the ADHD scale more than other factors did.Keywords: attention deficit hyperactivity disorder; primary school; teachers;evaluationIntroductionAttention deficit hyperactivity disorder (ADHD) is central among the disorders ofchildhood (Kerns, Eso, and Thomson 1999) and constitutes the most common schoolproblem presenting serious consequences for the learning processes. The frequencythe disorder is met among school-age children varies between 3% and 7% (AmericanPsychiatric Association 2000). This percentage rises significantly when children eval-uation scales are administered to parents and teachers (Havey et al. 2005; Rinn andNelson 2009). The basic symptoms of this disorder are inattention, impulsiveness andhyperactivity (Brandau and Pretis 2004; Pisecco, Huzinec, and Curtis 2001) or acombination of the three (Nowacek and Mamlin 2007). The criteria for determining*Corresponding author. Email: mkypriotaki@edc.uoc.grDownloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 270 M. Kypriotaki and G. ManolitsisADHD require the presence of symptoms in two or more settings, such as school andhome (De Nijs et al. 2004) with a duration of at least six months (Mrug, Hoza, andGerdes 2001). The determination of the frequency of ADHD presents a considerablediscrepancy owing to the conceptual approach of the researchers, the data collectiontools, and the size and type of the population in question (Kalantzi-Azizi andKarademas 2004). This disorder is diagnosed at least three times more often in boysthan in girls (Barkley 1998).As a result of ADHD symptoms, impulsiveness and hyperactivity, a considerablenumber of children that suffer from this disorder face major difficulties at school (Kos,Richdale, and Hay 2006) and home. They are being rejected by their peers (Mrug,Hoza, and Gerdes 2001), and later when they become teenagers and adults withADHD they will often have social and communication skills deficits (Robbins 2005).Children with ADHD are in danger of school failure (LeFever et al. 2002), pooracademic achievement (Pisecco, Huzinec, and Curtis 2001), and they are more proneto accidents (Barkley 1998) and exhibiting delinquent behaviour. The increasedfrequency of the disorder, its chronic nature if it is not addressed in time and alsothe presence of multiple problems in children with ADHD, makes necessary the useof valid and reliable psychometric tools that will identify children with this disorder(Kalantzi-Azizi, Aggeli, and Efstathiou 2005).The importance of early detection of children with ADHD and children in dangerof developing ADHD is essential to ensure proper psychoeducational treatment(Sauver et al. 2004). Early diagnosis is often a difficult process, because manyproblems associated with ADHD are characteristics of other disorders as well(Sciutto, Terjesen, and Bender Frank 2000). What is more, ADHD characteristics aremanifested together with other related problems, such as learning difficulties, stressand depression (Reuner and Oberle 2000), oppositional defiant disorder (Dpfner,Schrmann, and Frhlich 1998), conduct disorder (Pelham, Fabiano, and Massetti2005), Tourette syndrome (Spencer et al. 1998) and so on. Owing to the complexityof the disorder and associated problems, an assessment from an interdisciplinarygroup is necessary (Kypriotaki 2004; Sciutto, Terjesen, and Bender Frank 2000).The role the teacher plays in this assessment is determinative (Kypriotakis 2001)because of his immediate involvement in the learning process, the consequent behav-iour of the student inside the school environment, the students performance, and therelationship of the student with other fellow students. Further, the teacher can detectearly, unidentified deficiencies and contribute to the prevention of secondarydisorders in a child through the learning requirements established in the classroom.Teachers contribute important information, because of their extensive contact withchildren in structured and unstructured activities and social situations (Atkins,Pelham, and Licht 1985; De Nijs et al. 2004) and their knowledge of abilities/behaviours that suit the childrens age (Lauth, Heubeck, and Mackowiak 2006). Often,the teacher becomes part of the referral procedure of a child with special educationalneeds (Rinn and Nelson 2009; Stevens, Quittner, and Abikoff 1998). In addition, his/her reports are used in the assessment (Biederman et al. 2004; Sciutto, Terjesen, andBender Frank 2000) and in the implementation of an individualised educationalprogramme (Vereb and DiPerna 2004).Many times the teachers are the first to acknowledge that a child cannot concen-trate or is hyperactive; nevertheless, they often make mistaken judgments concerningstudents with ADHD (Amador-Campos et al. 2006; Rinn and Nelson 2009; Sciutto,Terjesen, and Bender Frank 2000; Stevens, Quittner, and Abikoff 1998) and manyDownloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 European Journal of Special Needs Education 271teachers have limited knowledge of the nature, the symptoms, the causes, the manage-ment and the interventions that are related to ADHD (Jerome, Gordon, and Husler1994).Previous studies have indicated that teachers knowledge of ADHD primarilycomes from media or friends and relatives and not from scientific resources (Ghani-zadeh, Bahredar, and Moeini 2006; Stormont and Stebbins 2005). Furthermore,parents often complain that their children with ADHD do not get the proper guidanceand support at school owing to lack of teacher knowledge (Concannon and Tang2005). Inconsistent diagnosis can worsen a situation and contribute to the recurrentfailure of a student inside the classroom (Baum and Olenchak 2002).Research studies concerning teacher assessment of children with ADHD focus onthe teachers knowledge (for review see Kos, Richdale, and Hay [2006]) of the symp-toms of ADHD (Bacchini, Affuso, and Trotta 2008; Nowacek and Mamlin 2007;Vereb and DiPerna 2004), the causes, the frequency the disorder is manifested (Glassand Wegar 2001; Havey et al. 2005), the treatment (Glass and Wegar 2001; Haveyet al. 2005; Kerns Eso, and Thomson 1999; Snider, Busch, and Arrowood 2003;Kasten, Coury, and Heron 1992) and the potential referral of children that are consid-ered to have ADHD (Yang and Schaller 1997). Moreover, previous studies examinedfactors associated with teachers which influence their judgment of children withADHD (Kos, Richdale, and Jackson 2004; Sciutto, Terjesen, and Bender Frank 2000;Stevens, Quittner, and Abikoff 1998; Stormont and Stebbins 2005; Vereb and DiPerna2004), factors that influence students behavioural and academic outcomes (Sherman,Rasmussen, and Baydala 2008) and the traits of students that influence teacherassessment of therapy approval (Pisecco, Huzinec, and Curtis 2001) and referral ofthese children (Sciutto, Nolfi, and Bluhm 2004).For example, Kos, Richdale, and Jackson (2004) conclude that the experience ofan ADHD student in the classroom is related to teachers knowledge of the disorder.Accordingly, Sciutto, Terjesen, and Bender Frank (2000) showed that experience withan ADHD student was an important factor which allowed teachers to learn more aboutthe disorder and that their self efficacy and years of teaching experience are factorsthat are associated with their knowledge of ADHD. In contrast, Stevens, Quittner, andAbikoff (1998) found that teachers experience with a student with ADHD, teachersknowledge and their educational status were not significant predictors of theirestimations of ADHD and oppositional defiant disorder (ODD).In a recent study, Stormont and Stebbins (2005) showed that the educational statusof primary-school teachers is related to their knowledge of the disorder; however, theyears of teaching experience, the nature of occupation (full- vs. part-time) and theknowledge they think they possess were not related to the disorder. In another studyby Vereb and DiPerna (2004), who conducted research on teacher knowledge ofADHD and its treatment and teachers beliefs on the different forms of treatment,found that the teachers knowledge of the disorder, the years of educational experiencewith students with ADHD and their training were positively correlated with theirtemperate attitude towards medication. To summarise, teachers judgment of childrenwith ADHD seems to be influenced by their knowledge of ADHD characteristics.However, there are conflicting findings regarding the importance of years of teachingexperience and teachers general educational status in identifying children withADHD.The degree to which the teachers original assessment is applicable is an importantissue because the early detection of children with ADHD from teachers can contributeDownloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 272 M. Kypriotaki and G. Manolitsisto the prevention of secondary disorders in a child and this can have serious implica-tions for the childs overall development. Teacher assessments are often used to helpdetermine a diagnosis, the appropriate educational setting and therapies that wouldbenefit the student (Brown 1985, cited in Stevens, Quittner, and Abikoff 1998). Thus,teachers need to know the characteristics of ADHD so as to alleviate difficulties thatcome up (Harlacher, Roberts, and Merrell 2006). The aims of the present study wereto examine: (1) the validity of the initial teacher assessment in detecting primary-school children nominated as children with ADHD by their teachers; and (2) thefactors that influence teachers evaluations on a rating scale assessing ADHD, such aschilds gender, the parents level of education, the childs social and academic behav-iour in the classroom, the teacherstudent relationship and the teachers cooperationwith the parents.MethodSampleThe study sample comprised 420 primary-school children (712 years old) who wereinitially nominated as children with ADHD by 365 teachers. At first, 79 primaryschools (48 from urban and 31 from rural areas) from the island of Crete, Greece, wererandomly selected. Subsequently, teachers of every single class were asked to identifywhether any of the students in their classroom suffered from ADHD. All the studentsthat were initially identified by their teachers as children with ADHD participated inthe present study.MaterialsTeachers were asked to complete a standardised rating scale for the identification ofchildren with ADHD for each participant as well as a questionnaire assessingparticipants school behaviour and achievement inside the classroom.ADHD rating scale-IVThis scale was constructed by DuPaul et al. (1998) and was standardised in Greece byKalantzi-Azizi, Aggeli, and Efstathiou (2005). The instrument is an 18-item, four-point scale ranging from never/rarely to sometimes, often and very often. Each itemdescribes a behaviour that is indicative of ADHD symptoms (e.g., he/she interrupts orannoys the others). Teachers were asked to respond with how frequently each partic-ipant manifested the behaviours listed on the scale. Cronbachs alpha and SpearmanBrown split half reliability of the scale in the present sample was strong (0.87 and 0.83respectively).Student behaviour questionnaireThis questionnaire was comprised of demographic items (the parents educationalbackground, the childs age, gender, grade, number of siblings, birth order, number ofclassmates in his/her classroom) and seven other items on a five-point rating scale.Five of the seven items, ranging from excellent to very poor, assessed the studentsschool achievement, his/her relationship with classmates, his/her quality of behaviourDownloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 European Journal of Special Needs Education 273in group activities, the quality of relationship with his/her teacher, and the quality ofteachers cooperation with his/her parents. The other two items, ranging from alwaysto never, assessed the frequency of a students participation in group activities and thefrequency with which his/her classmates chose him/her as a teammate.ProcedureThe study was conducted between April and May of the 200708 school year.Questionnaires were distributed to the teachers of the randomly chosen primaryschools. Teachers were asked to fill in the questionnaires only for the students thatthey believed had ADHD. A total of 620 primary-school teachers were asked whetherthey believed that any of their students was an ADHD child; 120 responded that theydid not believe that any child of their class suffered from ADHD. Therefore, 500questionnaires were distributed and 420 were returned yielding a response rate of84%.ResultsAccuracy of teachers identifications of students with ADHDOur first aim was to examine whether or not students identified as having ADHD bytheir teachers were misidentified. Two participants had missing data regarding theirschool grade. Therefore, 418 students were included in the analyses (see Figure 1). Inthese analyses, the identification of the students with ADHD was based on two distinctcut-off points of the standardised rating scale. The first one was the score thatrepresented the 85th percentile of the scales normative scores; according to the Greekstandardisation of the teachers form rating scale, the 85th percentile is the best cut-off point for the identification of children with ADHD (Kalantzi-Azizi, Aggeli, andEfstathiou 2005). The second criterion was the score that represented the 98thpercentile of the scales normative scores; the 98th percentile is considered by theexperts (Achenbach 1991) as the strictest cut-off point for a scale that assesses childsbehaviour.Figure 1. Frequencies of students identified initially by their teachers and above the 85th and the 98th percentile of the attention deficit and hyperactivity disorder rating scale-IV according to their gender.Figure 1. Frequencies of students identified initially by their teachers and above the 85th andthe 98th percentile of the attention deficit hyperactivity disorder rating scale-IV according totheir gender.Downloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 274 M. Kypriotaki and G. ManolitsisFigure 1 shows that according to the normative criteria (above 85th or 98th percen-tile) of the ADHD rating scale-IV that teachers completed, girls were identified moreaccurately than boys as suffering from ADHD. The only case in which the frequencyof girls identified by both the teacher and the standardised scale did not differ signif-icantly (2(1) = 2.59, p = 0.11) from the respective frequency of boys was betweenfirst and third grade when the normative cut-off point of the scale was set at the 85thpercentile. For example, 69.1% of the boys and 74.3% of the girls attending Grades13 who were initially identified by their teachers as children with ADHD receivedscores in the scale above the 85th percentile according to the norms of the scale. Theremaining 30.9% of the boys and 25.7% of the girls attending Grades 13 who wereinitially identified by their teachers as children with ADHD could be characterised asmisidentifications because they did not get scores above the lowest cut-off point (85thpercentile) of the standardised scale. Among girls in Grades 48, 88.4% of thoseinitially identified by their teachers as having ADHD received scores above the 85thpercentile of the standardised scale. This was a significantly higher percentage thanthat of girls in Grades 13 (2(1) = 6.76, p < 0.01). The respective percentage of boys(62.5%) was significantly lower than that of girls (2(1) = 99.01, p < 0.001) in Grades46, but not significantly lower than the boys percentage in Grades 13 (2(1) = 3.15,p = 0.08).In terms of the children who got scores above the strictest cut-off point of the stan-dardised scale (the 98% percentile) the percentages of both boys and girls were quitelow (see Figure 1). In this case, teachers accurately identified significantly more girlsthan boys at all grade levels (Grades 13: 2(1) = 58.88, p < 0.001; Grades 46: 2(1)= 75.39, p < 0.001).These findings suggest that Greek teachers identified students as children withADHD at a higher frequency than the number of students that were identified by thestandardised rating scale. However, it seems that the frequency of false alarms basedonly on teachers initial identifications decreased largely from the initial school gradesto later ones.Factors associated with teachers identifications of students with ADHDIt was examined whether teachers initial identifications of children with ADHD wereinfluenced by gender, grade level, parental education and whether teachers rating onthe ADHD scale was influenced by student-related variables (students schoolachievement, peer relations, students frequency of participation in group activities,quality of students involvement behaviour in group activities, peers acceptance,teacherchild relationship and teacherparent cooperation).Teachers initially identified significantly more boys than girls (2(1) = 167.6 p 0.05).Parental educational background was a significant factor that influenced teach-ers initial identification of students with ADHD. Table 2 shows that the studentsthat were identified by their teachers as having ADHD differed both according totheir mothers (2(6) = 196.99, p < 0.001) and fathers (2(6) = 201.13, p < 0.001)educational background. In particular, more students identified as children withADHD had parents who only finished primary school than finished university orcollege.Downloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 European Journal of Special Needs Education 275In order to examine whether teachers ratings on the ADHD rating scale-IV wereinfluenced by factors related to students behaviour in the classroom and his/herachievement, we performed a series of hierarchical multiple regression analyses. First,we examined whether students behaviour and achievement factors were associatedwith their scores on the ADHD rating scale-IV that was completed by the teachercontrolling for the parents educational level. Mothers and fathers educational levelwas aggregated in one variable called parents educational level. The parents educa-tional level was entered in the first step of the multiple regression analyses and eachone of the student related variables was entered separately in the second step of themultiple regression analyses. These analyses findings are shown in Table 3. AsTable 3 shows, all of the student-related variables were significant predictors ofchildrens scores in the standardised scale that was completed by their teachers afterthe effects of parents education were controlled.In order to examine which one of the aforementioned student-related variablesassociated best with childrens scores on the ADHD rating scale-IV completed by theteacher, we performed a final stepwise multiple regression analysis. In this analysiswe entered all the independent variables together. These findings suggest thatTable 1. Frequency of students identified by their teachers as children with attention deficithyperactivity disorder in relation to demographic variables.Demographic variables Frequency %GenderaBoys 342 81.6Girls 77 18.4School gradeb1 73 17.52 69 16.53 81 19.44 72 17.25 67 16.06 56 13.4Notes: aone missing case; btwo missing cases.Table 2. Frequency of students identified by their teachers as children with attention deficithyperactivity disorder according to the parents education.Fathera MotherbEducational background Frequency % Frequency %Primary school 121 32.2 102 27.1Junior high school 73 19.4 63 16.7High school 89 23.7 106 28.1Technical school 20 5.3 7 1.9College 22 5.9 34 9.0University 51 13.6 65 17.2Notes: a44 missing cases; b43 missing casesDownloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 276 M. Kypriotaki and G. Manolitsisteachers judgments about students peer relations and teacherstudent relationshipwere the best student-related predictors of childrens scores on the ADHD ratingscale-IV (Table 4).According to these findings, childrens gender and parental education backgroundwere significant factors that influence teachers initial judgment regarding the childrenwho were characterised by him/her as having ADHD. Moreover, teachers tended torate higher the children who did not get along well with their peers or their teachers.DiscussionFindings from this study suggest that teachers detect far more students with ADHDthan the number expected from the results based on the ADHD rating scale. Inparticular, if we take into consideration the stricter criterion of the 98th percentile,then the frequency of false alarms on behalf of the teacher rises significantly, espe-cially in relation to boys (see Figure 1). This is probably because of limited teacherknowledge of ADHD as well as the different way the symptoms manifest themselvesin boys and girls. For example, symptoms such as aggressive behaviour or motoractivity, which usually characterise boys, obviously make them stand a greater chanceof being considered as students with ADHD, because they disturb the peace in theclassroom. The present studys findings are in line with previous studies (Glass andWegar 2001; Havey et al. 2005) and signal how important it is for teachers to learnmore about ADHD. Besides, previous studies have shown that teachers tend toexaggerate ADHD symptoms (Amador-Campos et al. 2006) and identifysymptoms that are not characteristic of the disorder (Pilling 2000).Table 3. Results of hierarchical multiple regression analyses for the prediction ofparticipants scores on attention deficit hyperactivity disorder rating scale-IV.Variables order R2 1. Parents education 0.01 0.012. School achievement 0.05 0.06**2. Peer relations 0.11 0.12**2. Frequency of students participation in group activities 0.06 0.07**2. Quality of students behaviour in group activities 0.03 0.04*2. Frequency that his/her classmates choose him/her as a teammate 0.08 0.09**2. Quality of teacherstudent relationship 0.06 0.07**2. Quality of teacherparent cooperation 0.02 0.03*Notes: *p < 0.01; **p < 0.001.Table 4. Results of the stepwise multiple regression analysis for the prediction ofparticipants scores on attention deficit hyperactivity disorder rating scale-IV when all thesignificant independent variables entered in the model. Variables order R2 1. Peer relations 0.09 0.09**2. Quality of teacherstudent relationship 0.02 0.11*Notes: *p < 0.01; **p < 0.001.Downloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 European Journal of Special Needs Education 277Another interesting finding was that teachers seem to be more accurate in identi-fying girls than boys, according to the criteria of the ADHD rating scale (over the 85thand the 98th percentile). It is possible that teachers appear more accurate in identifyinggirls because many problems related to ADHD in boys (e.g., aggressive behaviour) arealso characteristic of other disorders and, therefore, classified under other disorders,such as ODD or conduct disorder. Indeed, teachers are likely to assess only the severecases of ADHD in girls and that is the reason why they seem to be more accurate, asfar as girls are concerned. There was no significant difference between the frequencyof boys and girls in Grades 13 that were assessed by teachers as having ADHD andreached above the 85th percentile (see Figure 1).Additionally, teachers identified significantly more boys than girls as ADHDstudents. This can be because of the different way the symptoms are manifested inboys and girls respectively (Abikoff et al. 2002), as well as to the fact that ADHD ismore frequent in boys than in girls. As a result, ADHD symptoms in girls could oftenbe overlooked by teachers because girls with ADHD do not cause as many disruptionsin the classroom as boys. In other words, when an ADHD child exhibits aggressivebehaviour the teacher more easily notices the rest of his/her deviant behaviour, whilein the case of girls, who are not as disruptive in the classroom, their ADHD goesunnoticed.The findings of the present study are in line with the findings of other studieswhich have shown that teachers tend to identify more boys than girls, irrespective ofthe type of symptoms that the child manifested (Sciutto, Nolfi, and Bluhm 2004).Moreover, other findings have shown that clinicians tend to diagnose boys more oftenthan girls with ADHD (Gardner et al. 2002), or that both parents and teachers attributegreater problems with attention span, impulse control, and motor activity to boys thanto girls (DuPaul 1991).The grade of students initially identified by teachers as children with ADHD wasalso examined to determine whether it influenced teachers judgement. The presentfindings showed that the detection of students with ADHD by their teachers did notdifferentiate according to the grade that students attended. Theoretically, it could beanticipated that the frequency of students with ADHD would be diminished in thelater primary-school grades, if in earlier grades students were detected and followedan effective psychoeducational treatment. This finding might reveal that even olderchildren suffer from ADHD, because they have never been addressed so as to receiveproper support.Findings from the present study also suggest that teacher referral is influenced byparental education. This finding agrees with other research (Sauver et al. 2004) thathas shown that lower levels of parental education are associated with an increased riskfor ADHD. This may be because of the fact that teachers believe that the parents whohave a lower level of education cannot offer their children the appropriate conditions,circumstances or run the required psychoeducational interventions, so as to lessen themanifestation of the symptoms (Sauver et al. 2004).Another interesting finding is that a childs scores on the ADHD scale were influ-enced by teachers judgment of the relationship the child has with his/her classmates.In other words, it is more likely for a student to be assessed as suffering from ADHDby the teacher scale when the teacher believes that this student does not get along wellwith his/her classmates. This may be related to the fact that the majority of childrenwith ADHD do not get along well with their peers and their relationships are mainlydriven by rejection, isolation, lack of popularity, or difficulties in the apprehension ofDownloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 278 M. Kypriotaki and G. Manolitsissocial messages (Bacchini, Affuso, and Trotta 2008; Bagwell et al. 2001; Greshamet al. 1998; Hinshaw and Melnick 1995); besides, the ADHD symptoms themselvesmake relationships with peers challenging (Mrug, Hoza, and Gerdes 2001).Furthermore, findings from this study suggest that it is more likely that a studentwill be thought as suffering from ADHD (teacher rating scale) if the teacher believesthat the student does not get along well with his/her own teacher. The present findingsextend the literature examining the association of teacherstudent interactions withstudents disruptive behaviour. Hughes, Cavell and Jackson (1999) revealed that poorteacherstudent relationships predicted increased levels of aggression in a sample ofsecond and third graders nominated by teachers as aggressive children. The presentstudy extends the previous findings as it is shown that the quality of teacherstudentrelationships predicted increased levels of rating in a scale for the assessment ofADHD in a sample of primary-school children nominated by teachers as children withADHD. Maybe these disturbed teacherstudent relationships stem from a lack ofattention span or an increased motor activity or impulsive behaviour in the classroom;a repertoire that makes learning processes difficult. However, it is possible forteachers to attribute negative qualities to some students based on their own disturbedrelationships with them, a tendency that does not protect these students against beingcategorised as ADHD students.In conclusion, findings from the present study suggest that: (1) teachers assess farmore students as children with ADHD than the number based on the ratings from thestandardised Greek version of the ADHD rating scale-IV; (2) teachers identify moreboys than girls as having ADHD, but their assessment of girls seems more valid thanthat of boys; (3) teachers assess more easily as students with ADHD those childrenwho come from parents that have a low educational level; (4) teachers inferencesfrom the relationship of a student with his/her peers and the relationship of the samestudent with his/her own teacher are the strongest predictors of the total score that thestudent will get on the ADHD rating scale; and (5) school achievement is not a strongpredictor of the score that the student will get on the ADHD rating scale.The present findings contribute to the literature that underline teachers importantrole in the identification of children with special educational needs. In addition, theconceptualisation of ADHD by teachers is also influenced by social context factors.For example, proximal and distal social context attitudes towards ADHD and lack ofcourses on special education during pre-service teachers training may favour a stress-ful environment for students with ADHD and their classmates and their teachers. Thenew trend in educating children with special educational needs necessitates the appro-priate training of teachers of mainstream classrooms in order to be able to identifyaccurately and early their students difficulties.The present study also has certain limitations. One limitation is that our resultsrefer to students that have initially been assessed by teachers as suffering from ADHD.They cannot be generalised to a population that has not received the same initialassessment by the teachers. This means that the present study did not take into consid-eration the children that may have ADHD, but have not yet been diagnosed as such bytheir teachers. Additionally, these results only refer to the teacher assessment andthere are no similar results for parent assessment. It should be noted that the results ofthe present study come from the answers of teachers who work in public schools inCrete, the largest island in southern Greece with 500,000 inhabitants. A recommenda-tion for future research is to conduct a replication study on a national level. Finally,the supplementary completion of the Greek version of the ADHD rating scale-IV byDownloaded by [Ams/Girona*barri Lib] at 05:18 17 October 2014 European Journal of Special Needs Education 279parents (parent version) would contribute to cross-validation of the children identifiedas suffering from ADHD.ReferencesAbikoff, H.B., P.S. Jensen, L.E. Arnold, B. Hoza, L. Hechtman, S. Pollack, D. Martin, J. et al.2002. 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