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

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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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