ADHD knowledge, perception and misconceptions among Sudanese elementary school teachers 2022

Abstract

Background

Attention deficit hyperactivity disorder (ADHD) is impaired functioning in at least two settings: home and school due to impulsivity, hyperactivity and inattention.

Primary school teachers play an essential role in assessing children’s behaviour and are often the first ones to recognise a child with ADHD as they are exposed daily to children and play a role in evaluating treatment plans at school. This study aims to assess the knowledge, perception and misconceptions of elementary school teachers in the locality of Khartoum regarding ADHD and to examine the differences in their knowledge in terms of sociodemographic variables.

Method

The study uses a descriptive cross-sectional study design conducted at 37 randomly selected elementary schools in the locality of Khartoum in October/November 2022. We applied cluster sampling and used a structured self-administered two-part questionnaire consisting of sociodemographic data and ADHD knowledge scale.

Results

The study included 321 teachers, 270 (84.1%) females and 51 (15.9%) males. The mean age of participants was 47.9 (SD = 8.5) years, with an average teaching experience of 21.94 (SD = 10.2) years.

The overall knowledge about ADHD was 48.53% (SD = 9.71). Teachers tend to show higher knowledge about ADHD symptoms and relatively poor awareness regarding ADHD treatment. Mean knowledge was higher in teachers with previous experience with an ADHD child.

Conclusion

Elementary school teachers in Khartoum seemed to lack sufficient understanding of ADHD, especially when it came to treatment options. Raising awareness should be prioritised to help students with ADHD.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Attention deficit hyperactivity disorder (ADHD) significantly affects children’s education and social life. Teachers are key to early recognition and support, but often lack adequate knowledge, especially regarding treatment options.

WHAT THIS STUDY ADDS

• Elementary school teachers in Khartoum show insufficient ADHD knowledge, particularly in treatment awareness, and even though symptom recognition is relatively better, overall understanding remains poor, with an average knowledge score of 48.53%.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study highlights the urgent need for professional development programmes focused on ADHD for teachers.

Introduction

Attention deficit hyperactivity disorder (ADHD) is an impaired function in at least two settings: home and school due to impulsivity, hyperactivity and inattention.¹ It has three subtypes: a hyperactive type, an inattentive type and a combined hyperactive and inattentive type.²

It is one of the most commonly diagnosed childhood psychiatric disorders and is estimated to affect 5% of children globally.³ There seems to be a strong genetic predisposition for developing ADHD since children of affected parents have a higher risk.⁴ In addition, those suffering from conditions such as Klinefelter’s, Turner’s, fragile‐X and neurofibromatosis type I tend to have a higher risk.⁵ Moreover, environmental factors like low socioeconomic status and living in foster care increase the risk of developing ADHD. Prematurity and low birth weight also come with a higher risk.⁶ The diagnosis of ADHD can be a real challenge since there is no single blood test or imaging modality that can help reach an accurate diagnosis of ADHD, so even professional physicians might face difficulties. In addition, symptoms of ADHD can differ according to age, context and gender.⁷ It is usually diagnosed before the age of 7 based on the clinical picture and diagnostic criteria, and 30%–50% of children diagnosed with ADHD continue to exhibit symptoms into adulthood, contrary to the popular belief that children outgrow ADHD.⁸

ADHD can present a unique set of difficulties and challenges through each stage of development. In preschool, children with ADHD tend to find difficulty interacting with their peers and lag in their social skills compared with other children. They also tend to be non-compliant with adult requests.^{9 10} In elementary school, those children struggle with social interactions and have difficulty paying attention during classes and performing tasks impacting their academic performance.^{11 12} During adolescence, they struggle with hyperactive and impulsive behaviour, engage in high-risk activities and have poor social skills.¹³ During adulthood, they tend to have occupational and marital problems, and unstable relationships and are at increased risk for other comorbid psychiatric diseases such as depression, anxiety and substance abuse.¹⁴

Primary school teachers play an essential role in assessing children’s behaviour and are often the first to recognise a child with ADHD as they are exposed daily to children.¹⁵ They also play a role in evaluating treatment plans at school.¹⁶ Parents also genuinely tend to follow recommendations about ADHD from teachers which can be misleading as teachers with low knowledge about ADHD can give inappropriate advice.17,19 Treatment of ADHD is multimodal and consists of stimulant therapy, family education and behavioural strategies at home and school in which teachers play a key role.²⁰ Thus, lack of knowledge and negative attitude toward ADHD among teachers can result in treatment failure.^{21 22}

In a study conducted in Khartoum state, the prevalence of ADHD inattentive subtype among school children was 3.5%, the hyperactive subtype was 6.9% and the combined type was 1%. The prevalence increases dramatically with an increase in age and in rural areas.²³ About half of the children with ADHD also meet the criteria for at least another psychiatric disorder.²⁴ They also have an increased risk of suicidal attempts during adulthood.²⁵ The goal of this study is to shed some light on the level of teachers’ knowledge about ADHD. Teachers are considered the first who perform referrals of ADHD children. Therefore, they must possess a high knowledge and awareness about ADHD and its symptoms. Having sufficient knowledge enables the teacher to deal better with ADHD children and significantly increases their chances of recovery. This study aims to assess the knowledge, perception and misconceptions of elementary school teachers in the locality of Khartoum regarding ADHD and to examine the differences in teachers’ knowledge in terms of sociodemographic variables.

Methods

A descriptive cross-sectional design was used. We collected data using a structured self-reported questionnaire (online supplemental file 1) from elementary teachers working in governmental schools in the locality of Khartoum, one of the seven localities of Khartoum state, the capital of Sudan. The study was conducted in October and November 2022.

The sample population consisted of all teachers working full-time in governmental elementary schools in the locality of Khartoum. Teachers eligible to participate in this study were those who had direct contact with students.

According to the data provided by the ministry of education, there are 679 male and 2096 female teachers in 185 elementary governmental schools in the locality of Khartoum. The ministry of education divided the locality of Khartoum into four educational sectors. From each sector, a total of 8–10 schools were selected using simple random selection depending on how much each sector represents from the total number of elementary governmental schools in the locality of Khartoum. A total of 37 schools were randomly selected, and all teachers from the selected schools who fulfilled the inclusion criteria and agreed to participate in the study were included. With a population of 2775 and a CI of 95%, the calculated sample size was 321 teachers.

321 teachers answered the standard self-administered survey. The survey included two parts: sociodemographic and a specific ADHD knowledge test. Professor Mark Sciutto developed the ADHD knowledge test, which is called the Knowledge of Attention Deficit Disorders Scale (KADDS). Permission was taken from Professor Mark Sciutto for the questionnaire. The KADDS has 36 questions about ADHD. Teachers answer these questions by saying true, false or “don’t know”. The test is divided into three main subclasses: general knowledge about ADHD (15 questions), symptoms and diagnosis of ADHD (9 questions) and treatment modalities of ADHD (12 questions). For analysis, all right answers were coded as one and wrong and don’t know answers were coded as zero and then total score was computed for each participant and the mean total knowledge calculated by the average correct answers of all participants. We conducted a pilot study in an elementary school for girls to test the clarity of the questions and the time consumed to complete them. Those involved in the pilot study were not included in the main study.

We used Statistical Package of Social Science (SPSS) version 26 for data analysis. Sample characteristics were described using descriptive statistics. Pearson correlation and independent sample T-test were used to examine teachers’ knowledge of ADHD in terms of sociodemographic variables.

Patient and public involvement

This study focused on assessing the knowledge, perceptions and misconceptions of elementary school teachers regarding ADHD. The research questions and study design were developed by the research team, and the analysis and interpretation of results were conducted by the researchers. Teachers were involved in this study by providing their valuable insights through a structured self-administered questionnaire. Their responses were fundamental to understanding the current state of ADHD knowledge in this key demographic. This research was undertaken to identify knowledge gaps that, once addressed, can lead to improved support and outcomes for students with ADHD in school settings. Although individual findings were not communicated back to participants, the results are intended to inform broader educational strategies and policy recommendations benefiting both teachers and children with ADHD. No patients were involved in this study.

Results

Sample characteristics

The study included 321 teachers, 270 (84.1%) females and 51 (15.9%) males. The mean age of participants was 47.9 (SD=8.5) years with an average teaching experience of 21.94 (SD=10.2) years. Most teachers had Bachelor’s degrees (70.4%), 10.6% had Master’s degrees and only 1.2% had Doctoral degrees. From the total sample, 7.5% admitted that they had never heard about ADHD before and were excluded from the final results. 44.9% of the teachers reported previous experience with a child with ADHD, while 55.1% denied it (table 1).

Table 1. General characteristics of the study participants (n=321).

Characteristic	N (%)
Gender
Male	51 (15.9%)
Female	270 (84.1%)
Level of education
High school	20 (6.2%)
Diploma	37 (11.5%)
Bachelor degree	226 (70.4%)
Master	34 (10.6%)
Doctorate	4 (1.2%)
Years of teaching experience
10 years or less	66 (20.6%)
11–20 years	64 (19.9%)
21–30 years	135 (42.1%)
More than 30 years	56 (17.4%)
Have you ever heard about ADHD
Yes	297 (92.5%)
No	24 (7.5%)
Prior experience with child with ADHD
Yes	133 (44.9%)
No	164 (55.1%)

ADHD, attention deficit hyperactivity disorder.

General knowledge

Many teachers (71.7%) were aware that most kids with ADHD struggle in elementary school. They also recognised (88.6%) that these children’s behaviour is easier to spot in class than at playtime. Additionally, most teachers (76.4%) understood that some symptoms of ADHD can appear in children from chaotic home environments, even if they do not actually have ADHD. Over half the teachers knew that ADHD is more likely in close relatives (parents) of children with ADHD and more common in males compared with females (57.6%). 62.3% of the teachers recognised that an adult can be diagnosed with ADHD contrary to the popular beliefs that it is strictly a childhood disorder. On the other hand, few teachers were aware that ADHD children typically do not struggle more in new environments than in familiar ones.

Knowledge of attention-deficit/hyperactivity disorder symptoms/diagnosis

The majority of teachers were aware that children with ADHD frequently fidget in their seats (96.3%) and that to be diagnosed with ADHD, a child must exhibit relevant symptoms in two or more settings (eg, home, school) (90.2%). Moreover, 87.9% of the teachers recognised that ADHD children often struggle with organisation and that ADHD children are easily distracted (84.2%). However, most of the teachers were unaware that ADHD is not linked to aggressive or destructive behaviours.

Knowledge of attention-deficit/hyperactivity disorder treatment

While a significant majority of teachers (92.3%) recognise the effectiveness of combining medication with training for parents and teachers, a smaller portion (25.9%) grasp that individual therapy alone may not suffice. Most realised that ADHD treatments which focus primarily on punishment are not the most effective in reducing its symptoms (77.4%). However, there is a need to address some misconceptions. Nearly 60% of teachers mistakenly believe ADHD stems from poor parenting. Additionally, a vast majority (over 90%) are unaware that reducing sugar or additives does not significantly impact ADHD symptoms. Perhaps, most concerning, over 20% of teachers hold the false belief that electroconvulsive therapy is a viable treatment for ADHD.

The mean total knowledge about ADHD was 48.53% (SD=9.71). The mean general knowledge about ADHD was 44.67% (SD=13.05). While mean knowledge about ADHD symptoms and treatment was 69.06% (SD=14.06) and 37.96% (SD=14.45) respectively (figure 1).

Figure 1. Average percentage of ADHD knowledge among primary school teachers (n=297). This bar chart illustrates the average percentage of knowledge among primary school teachers across different aspects of ADHD. It includes “ADHD overall knowledge” (48.53%), “General knowledge” (44.67%), “Knowledge about ADHD symptoms” (69.06%) and “Knowledge about ADHD treatment” (37.96%). ADHD, attention deficit hyperactivity disorder.

Even though female teachers expressed a higher level of knowledge about ADHD, this difference was statistically insignificant (table 2). Moreover, there was no evidence to suggest any correlation between the age of the teachers, teaching experience, educational level and the teachers’ knowledge regarding ADHD. We conducted an independent sample t-test to compare ADHD general and overall knowledge and knowledge of ADHD symptoms for those who had previous experience with a child with ADHD and those who had not and it was statistically significant; however, the magnitude of difference in the means was very small.

Table 2. Differences in ADHD overall knowledge in terms of gender and prior experience with child with ADHD.

Characteristic	Mean (SD)	t	df	P value
Gender		−0.79	295	0.42
Male	47.5 (10.75)
Female	48.7 (9.5)
Previous experience with child with ADHD		3.12	295	0.002
Yes	50.35 (8.88)
No	46.88 (10.15)

ADHD, attention deficit hyperactivity disorder.

Mean knowledge regarding ADHD treatment was higher among those who had previous experience with a child with ADHD compared with those who had not but this difference was statistically insignificant.

Discussion

This research investigated the knowledge, perceptions and misconceptions of ADHD among elementary school teachers in Khartoum (n=321). While teachers play a crucial role, the study revealed a lack of adequate understanding regarding ADHD symptoms and treatment options. Teachers are instrumental in the early identification of ADHD and the implementation and evaluation of various treatment approaches within the school environment. The overall knowledge score about ADHD was 48.53% (SD=9.71), which is remarkably similar to a study conducted in Colombia that reported a mean total knowledge score of 48.52%.²⁶ Furthermore, studies in the USA and South Africa found comparable results, with teachers averaging 47.8% and 42.6% correct, respectively.^{27 28} Conversely, a study from Saudi Arabia reported a lower score of 38%.²⁹

Teachers generally show greater understanding of ADHD symptoms and diagnosis compared with treatment options.^{26 27} This aligns with their limited involvement in the treatment process. However, a study in northern Jordan reported a different trend, with teachers scoring higher on knowledge of general ADHD features followed by symptoms and diagnosis, with the lowest scores in treatment.³⁰ Their total average knowledge score was just 21.3%. Interestingly, a study conducted in Ethiopia deviated from the norm, revealing that teachers there had the highest knowledge scores in ADHD treatment compared with other categories.³¹

In line with other studies,^{32 33} research shows no significant statistical difference between males and females in their overall understanding of ADHD, including knowledge of symptoms and treatments. However, it is worth noting that a study conducted in Taiwan did report a statistically significant finding of higher ADHD knowledge among female teachers compared with their male colleagues.³⁴

Pearson correlation of the study results showed no statistically significant relationship between knowledge of ADHD and years of teaching experience. This finding is in line with other similar studies.^{28 35} A study in Saudi Arabia reported higher knowledge among teachers with 6–10 years of teaching experience.²⁹ Results also showed no statistically significant relationship between ADHD knowledge and a teacher’s educational level. A contrary finding to a similar study in Ethiopia which reported a significant positive correlation between ADHD knowledge and teachers’ educational level.³¹

We conducted an independent sample t-test to compare ADHD general and overall knowledge and knowledge of ADHD symptoms for those who had previous experience with a child with ADHD and those who had not and it was statistically significant suggesting higher knowledge among those with previous experience. This was not the case regarding the ADHD treatment subclass since the difference was not statistically significant. These findings are consistent with a similar study conducted by Sciutto et al.²⁷ Another study conducted in Saudi Arabia reported similar results.²⁹

Misconceptions were also common, 80.1% of the teachers believed that reducing dietary intake of sugar or food additives is generally effective in reducing the symptoms of ADHD, and this appeared to be a commonly shared misconception. To illustrate, a study from South Africa reported that 65.2% of the participants incorrectly believed that reducing dietary sugar is effective in reducing ADHD symptoms.²⁸ Another study from the USA also reported the same finding.²⁷ 43.4% of the teachers believed that most ADHD children “outgrow” their symptoms by the onset of puberty. In addition, 60.9% of the teachers believed that children with ADHD tend to be physically cruel to others, and 47.5% of them believed that children with ADHD have a history of stealing and destroying other people’s things which reflects a tendency to attribute anything negative to ADHD and stigmatising the disorder. These misconceptions may also affect teachers’ attitudes toward children with ADHD seeking help.

The level of teacher knowledge found in this study could be due, at least in part, to the absence of training programmes or workshops. These programmes could equip teachers with the skills to recognise, manage, refer and develop effective strategies for dealing with students with ADHD. Since the study was conducted only in the locality of Khartoum, the results of the study may not be representative of all elementary school teachers’ knowledge and misconceptions although cluster random sampling was used.

Conclusion

Elementary school teachers in Khartoum seemed to lack sufficient understanding of ADHD, especially when it came to treatment options. Teachers who had experience with ADHD students in the past were better informed. There were also some common mistakes teachers made about ADHD symptoms and treatment.

Recommendation

Elementary school teachers should receive special training and workshops in order to be able to identify ADHD symptoms and ADHD red flags. This should be done in collaboration with educational psychologists for the teachers to be more prepared to offer adequate teaching, assistance and support for children with ADHD. The parents should also be encouraged to get involved in the treatment process of their children.

Further research should be conducted on a larger scale to assess teachers’ knowledge regarding ADHD.

Data availability statement

Data are available upon reasonable request.