Journal of Pediatric Nursing 36 (2017) 141–148

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

Teachers' Experiences With and Perceptions of Students With Attention

Deficit/hyperactivity Disorder
Kay Lawrence, MSN, RN, CCRN-K a,⁎, Robin Dawson Estrada, PhD, RN, CPNP-PC b, Jessica McCormick, MEd b
a
School of Nursing, University of South Carolina, Aiken, SC, United States
b
College of Nursing, University of South Carolina, Columbia, SC, United States

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The purpose of this research was to examine teacher experiences with and perceptions of students with
Received 30 December 2016 attention deficit/hyperactivity disorder (ADHD). Teachers are integral in helping these children learn effectively
Revised 15 June 2017 and foster healthy relationships, yet little is known about their interactions with these children.
Accepted 18 June 2017 Design and Method: Semi structured interviews were conducted with a purposive sample of fourteen currently
practicing or retired elementary and middle schools teachers in North Carolina and South Carolina. All interviews
Keywords:
were audio-recorded then analyzed for common themes.
Attention deficit disorder
Attention deficit hyperactivity disorder
Results: Participants obtained ADHD information from in-services or peer interaction, rather than formal educa-
Teacher perceptions tion. Culture and gender influenced teacher perceptions, and ADHD classroom strategies were based on anecdot-
Teacher knowledge al experience. Teachers experienced guilt and worry while negotiating student needs, school system constraints,
Classroom strategies and family issues.
Gender expectations Conclusions: While teachers have developed effective coping mechanisms through informal means, formal edu-
cation and support will help teachers better serve students with ADHD.
Practice Implications: Pediatric nurses in many settings can benefit from better understanding how teachers per-
ceive and interact with students who have attentional issues.
© 2017 Elsevier Inc. All rights reserved.

Background
Attention deficit hyperactivity disorder (ADHD) is the most
commonly diagnosed childhood mental health disorder in the United
States. Typically diagnosed in childhood, ADHD is a chronic disorder
with long-term implications for educational outcome, safety, and the
ability to maintain employment as an adult (Kuriyan, Pelham, Molina,
et al., 2013). The American Psychiatric Association (2013) now defines
ADHD as a neurodevelopmental disorder (as opposed to previous cate-
gorization as a disruptive behavior disorder) with three types: 1) inat-
tentive (previously known as attention deficit disorder, or ADD); 2)
hyperactive-impulsive (without inattentive symptoms); and 3)
combined (with both hyperactive and inattentive symptoms). The
symptoms should not be explainable by another condition, such as an
anxiety disorder. Symptoms should also have an impact in two or
more settings, affecting school, social, or work functioning, and be pres-
ent before 12 years of age.
⁎ Corresponding author: Kay Lawrence, MSN, RN, CCRN-K.
E-mail addresses: marthal@usca.edu (K. Lawrence), robin.estrada@sc.edu
(R.D. Estrada), jmccorm@mailbox.sc.edu (J. McCormick).
Over 6.4 million, or 11% of children in the United States, have at
some point been diagnosed with ADHD by a healthcare provider
(USDHHS and National Institute of Mental Health, 2014). Males are
more than twice as likely to have ever received a diagnosis as females
(CDC, 2017), due in part to gender differences in ADHD symptoms. Fe-
males with attentional issues are more likely to have non-disruptive in-
attentive symptoms that may be characterized as forgetfulness or
laziness. Males are more likely to manifest more noticeable hyperactive
and impulsive behavioral symptoms that may lead to classroom, social,
or workplace disruptions. While the disruptive nature of their symp-
toms may contribute to the greater likelihood of boys being diagnosed,
girls experience the same difficulties with school including significant
impairment in academic, emotional, and behavioral areas (DuPaul,
Jitendra, Tresco, & Junod, 2006). White children are more likely to be di-
agnosed with ADHD than African American or Hispanic children
(Centers for Disease Control and Prevention, CDC, 2017).
The prevalence of parent-reported ADHD varies from state to state
with a low of b5% (Nevada) to a high of N11% (Iowa, Ohio, Louisiana,
Arkansas, Mississippi, Alabama, North & South Carolina, Indiana, & Ten-
nessee); it is higher overall in the eastern half of the US with comparable
rates reported for northern and southern states (CDC, 2017). Interna-
tionally, rates of ADHD are rising, as is the use of medication as a
treatment modality, although the etiology of this rise is unclear

http://dx.doi.org/10.1016/j.pedn.2017.06.010
0882-5963/© 2017 Elsevier Inc. All rights reserved.
142 K. Lawrence et al. / Journal of Pediatric Nursing 36 (2017) 141–148

(Conrad & Bergey, 2014). Finally, although it is unclear exactly how Design and Method
socio-economic status is related to the development of ADHD, children
attending schools where a higher percentage of students qualify for free Setting and Participants
or reduced lunches are less likely to receive a diagnosis of ADHD (Lee,
2008). This may reflect a lack of access to resources, making diagnosis We conducted this qualitative, descriptive study with currently
less likely for disadvantaged children (Fabiano et al., 2013). practicing or retired elementary and middle school teachers from four
In addition to inattentiveness, impulsivity, and hyperactivity, chil- counties in North and South Carolina. Childhood ADHD prevalence
dren with ADHD may exhibit socially troublesome behavior such as dif- rates for North and South Carolina are 11.6% and 11.7% respectively,
ficulty in maintaining eye contact, infringing on personal space, and compared to a national rate of 11% for 2011 (CDC, 2017). After obtaining
interrupting others. These behaviors not only interfere with a child's university institutional review board approval, we recruited a purposive
ability to learn, but can negatively impact a child's ability to interact sample of interview participants first through personal contacts, then
with others and can affect the child's social relationships (Hong, 2008; snowball referrals in an effort to diversify the sample. All of the teachers
Muntigl & Horvath, 2014). Children with ADHD symptoms may be we contacted agreed to be interviewed. Demographic information in-
viewed negatively by their peers who do not have attentional issues cluding age, gender, ethnicity, educational background and years of
(Law, Sinclair, & Fraser, 2007), which can contribute to an increased teaching experience was collected prior to beginning the interview. Of
risk of co-morbidities such as depression and anxiety (Bussing & the 14 participants, all had classroom experience with students diag-
Mehta, 2013). They may also be viewed negatively by adults, including nosed with ADHD by a health care professional (psychiatrist, physician,
teachers and healthcare providers. Teachers experience daily challenges nurse practitioner, or psychologist). The teachers were predominantly
when interacting with students with ADHD, including keeping children White (n = 12) and female (n = 13), with an average age of 40. They
on task, managing classroom disruptions, and optimizing learning had a range of 3 to 39 years of teaching experience (Table 1).
(Ohan, Cormier, Hepp, Visser, & Strain, 2008). Over time, these interac-
tions can affect teacher perceptions of children diagnosed with ADHD,
and in turn affect how they approach future interactions with students Data Collection
suffering from attentional issues. School nurses, pediatric nurses, and
nurse practitioners often interact with children with ADHD in school After giving informed consent, each teacher participated in a single,
and clinical settings. Their views of children with attentional issues one-hour, audio-recorded individual interview with one of the authors.
may influence diagnosis, as well as the treatment recommendations Most interviews took place in classrooms during teacher work periods
they make. or at an agreed-upon location away from the school. Some interviews
Even if negatively held biases are not overtly expressed, children (n = 3) took place during the school day on the playgrounds or during
with ADHD are often very aware of how others perceive them, and “center time” (self-directed learning stations during classroom time)
can suffer from feelings of worthlessness and despair (Mueller, when classes were actually in session, by teacher request and in order
Fuermaier, Koerts, & Tucha, 2012). This internalized stigma can to minimize participant inconvenience. Although this interview setting
have lifelong implications for these children, contributing to diffi- did result in some initial distractions for the students, they quickly accli-
culty with employment, drug use, and an increased risk for unlaw- mated to the presence of the researcher (in a back corner of the class-
ful behavior if ADHD is untreated (Cahill et al., 2012; Kuriyan et al., room or at a picnic table to the side of the playground).
2013; Lee, Humphreys, Flory, Liu, & Glass, 2011). Positive school- The first and second authors, both of whom had professional experi-
based interactions and relationships with invested adults have the ence with ADHD, developed and refined the interview guide. (Name
potential to mitigate long-term negative outcomes (Rush & redacted) is a pediatric nurse practitioner with thirty years' experience
Harrison, 2008). However, little is known about how teachers per- in managing children with behavioral disorders, including ADHD.
ceive their students with ADHD, or the effect of these perceptions
on interactions between students and teachers. The purpose of
this qualitative, descriptive study was to explore 1) teachers' un-
Table 1
derstanding of and experiences with ADHD students, both person- Participant demographics.
ally and professionally; and 2) how teachers learn and develop
Characteristic n
the educational strategies they employ in their classrooms. We con-
clude with recommendations for future research and directions for Sex
development of interventions designed to optimize classroom in- Female 12
Male 2
teractions with children with ADHD.
Age
20–29 4
30–39 3
Theoretical Framework 40–49 3
50–59 2
This work was guided by Bronfenbrenner's Process-Person-Context- 60 and older 2
Time (PPCT) model, a bioecological conceptualization of the complex Race/ethnicity
interactions and intersections of multiple multi-level factors on devel- White 12
opment (Bronfenbrenner, 2005). The concepts in this model allow for African American 1
the identification and examination of relevant variables contributing Hispanic/Latino 1
Education
to disparate outcomes for children with ADHD. Specific examples in-
Baccalaureate 7
clude interactions between children with ADHD and their parents, Master's 5
classmates, and teachers (process); age, gender, and physicality of the Pursuing doctorate 2
child (person); home and school environments (microlevel context);
Years of teaching experience
the effect of a parent's work schedule (mesosytem context); the histor- 0–5 years 3
ical and current societal understanding of ADHD (chronosystem con- 6–10 years 1
text); and changes in the behavioral manifestations of ADHD as a child 11–15 years 4
matures (time). The PPCT model guided development of the semi-struc- 16–20 years 2
N20 years 4
tured interview guide as well as data analysis.
 K. Lawrence et al. / Journal of Pediatric Nursing 36 (2017) 141–148
(Name redacted) has over thirty years' experience in pediatric nursing.
(Name redacted) has experience in educational administration working
with both k-12 and higher education administrators. Additionally, all
three authors are mothers of children diagnosed with ADHD. Each au-
thor had experienced both positive and negative interactions with
their children's teachers. Some teachers were knowledgeable about
ADHD and practiced effective individualized interventions. Others
were poorly informed and resistant to suggestions to enhance learning.
These interactions stimulated a desire to better understand the complex
perceptions of teachers related to children with ADHD. The develop-
ment of the interview questions was informed by these experiences,
as well as the PPCT constructs. Each interview began with an opening
question: “Could you tell me what you know in general about ADD/
ADHD?” (as teachers may have not been aware of the recent changes
in DSM-V categorization), and how they had acquired this knowledge.
Questions then explored each teacher's classroom and personal experi-
ences with students with ADHD. Teachers were specifically asked about
problematic behaviors such as hyperactivity, inattention, and social in-
teraction. Other questions explored their observations on gender differ-
ences as well as family/social and economic influences on children's
behaviors and peer interactions. Interaction with healthcare providers
from diagnosis to medication adjustment was explored, and finally,
teachers discussed administrative and/or system processes involved
with providing services to children with ADHD, interactions with par-
ents, and interventions utilized in the classroom. Interviewers used
probe questions (e.g., tell me more about that) and format tying (i.e., re-
peating the last few words of a participant's statement) to encourage
participants to offer more detail or description. The initial interview
guide is included in Table 2.
Data Analysis
Using a thematic analysis approach (Saldana, 2016) we began data
analysis first with the transcription of four interviews by a professional
transcription service. The principal investigator reviewed the tran-
scripts to assure they represented the participants' voices as accurately
as possible, reconciling and correcting the few and minor differences
with the digital audio-recordings. These transcripts were then used by
the first two authors for independent reading to familiarize themselves
with the content of the interviews and to begin initial coding. In order to
encourage reflexivity during the analysis phase, they then met to dis-
cuss initial thoughts, assumptions, and understandings of key concepts,
and to reconcile any differences between identified codes. The resulting
coding schema developed from this initial exercise was then used to
code the remaining interviews directly on the digital files, which were
Table 2
Interview guide.
1) What do you know about ADHD?
2) Tell me about your experiences with children with attentional disorders in your
classes.
3) What non-verbal behaviors or characteristics do you find particularly
problematic when interacting with these students?
4) What non-verbal behaviors or characteristics do you find to be problematic
when these children interact with their peers?
5) I am interested in eye contact in conversations with children with ADHD. Tell
me about your experiences related to this situation.
6) What, if any, differences do you see in non-verbal behaviors between girls and
boys?
7) Tell me about the strategies you use to facilitate interactions with students in
your class with ADHD.
8) What do you think I should know that I haven't already asked?
Additional questions were asked depending on participant's answers to initial
questions.
The interview guide was modified as saturation was achieved in relation to some
themes.
143
loaded into QSR International's NVivo 10 Software (2012). These two
team members independently conducted initial coding of each digital
audio file and began searching for themes. They then met to compare
and contrast the individually identified codes and themes, discuss the
relationships between themes, the relevance of the theoretical frame-
work constructs, and how well the themes represented experiences
with ADHD as related by the teacher participants (Table 3). This itera-
tive process culminated in a final discussion, confirmation by all three
authors, naming of themes, and write-up (Saldana, 2016).
Results
Data analysis was informed by the constructs of the PPCT model.
Raw data themes were organized into sub-categories, then into six
main themes (Table 3). Each main theme is discussed in detail with
supporting data from the participants. All names used for participants
are pseudonyms.
Teacher Knowledge about ADHD
Participants were first asked about their understanding of ADHD
and how they acquired their knowledge. Most teachers related
knowing that there were attentional problems with aspects of hy-
peractivity as well as inattentiveness, but focused mainly on the ex-
ternal manifestations. As Charlotte, a 32 year-old kindergarten
teacher described:
Very active behavior, unable to sit still unable to focus for very long
at all, a lot of movement, blurting out. Often times my students have had
to stand, they can't sit down at their desks so they're standing, which is
fine. Or a lot of times if we're sitting on the carpet they might have a ball
in their hand, something they can play with, with their fingers.
Charlotte also related the difficulties of dealing with inattentive
symptoms:
I have a little boy this year who was just diagnosed with ADD. He
was quiet and wouldn't complete his work and you don't see the prob-
lem for a while, it's harder because they're quiet and you're dealing with
all the other things. But he would daydream, tear up his erasers, and tear
his paper and look around the room and not complete his work but you
don't notice that as much as you do the ones who are blurting out.
Lawanda, a 28-year-old master's prepared teacher (and the only
doctoral student in this sample) with a background in divergent learn-
ing was unique in her explanation of ADHD as an inability to filter out
multiple stimuli:
The definition that I kind of operate from is one in which, not that the
child is not attentive, but that the child is too attentive, in that every-
thing stimulates their brain… I think that everything can kind of capture
their mind… I′ve heard other things but as a teacher and as a person
that's what I operate from.
All teachers said they learned about ADHD through informal chan-
nels from peers or through in-service training, rather than through
their formal education. Lawanda was the only teacher that received
some instruction in her coursework, but it was minimal and focused pri-
marily on autism:
In undergrad I had a course in teaching with exceptionalities and we
covered autism spectrum. As a preservice teacher it was one semester.
Even thinking about my development course, maybe reading about it
in a book. I think in my master's program in divergent learning we
talked about it [ADHD] because we were practitioners but formally,
no. That program was based on Gardner's theory of multiple intelli-
gences so when we talked about a child who moved we talked about
kinesthetic learning.
Most teachers described their education related to ADHD as inade-
quate and expressed a desire to know more about this disorder both
in general and specific aspects. Some teachers related that they had
learned about symptoms and treatment of ADHD as well as how to
144 K. Lawrence et al. / Journal of Pediatric Nursing 36 (2017) 141–148

Table 3
Overview of results.

Main themes Sub-categories Relevant framework Raw data themes

constructs

Teacher knowledge about ADD/ADHD Understanding of ADD/ADHD Process Activity

Sources of knowledge Lack of focus
Hyperactivity vs. inattention Peers' opinions and experiences
Personal experiences with ADD/ADHD
True cases of ADD/ADHD
Learning about ADD/ADHD from peers
Teacher expectations related to culture, Gender differences Person Boys being boys
race and ethnicity, gender, and age Regional differences Context Boys being more physical
Cultural differences Boys participating less
Age differences Girls starting drama
Girls being more chatty
Behavior more acceptable when younger
Teacher perceptions of home Lack of discipline Context Expectation of appropriate behavior
environment Lack of involvement Parental involvement
Over protection Parent “babying” child
Family economic status
Parental desire for testing
Lack of discipline at home
Children not being read to at home
Young parents
Lack of consequences at home
Difficult situations
Teacher negotiation of systems Balancing educational system requirements Process Institutional policies
and relationships with students Professional boundaries
Negotiating systems with sensitivity to Saving face
parents Classroom demands
Balancing interventions to help the child Code words
with ADD/ADHD without distracting other Documentation
students Careful how we talk to parents
Teachers can't diagnose
Standardized testing
Accommodations
Better to catch ADD/ADHD early
Classroom strategies Flexibility and creativity with Process Allowing activity
implementation Alternative activities
Evaluation of strategies as pragmatic Assuring positive interactions
interventions Redirecting
Communicating consequences
Decreasing distractions
Utilizing multiple methods of instructions/strategies
Flexibility
Knowing the student
Getting their attention
Teaching material in smaller bites
High maintenance
Other students as helpers
Preferential seating
Private signal
Reward system
Movement can help a child attend
Emotional toll on teachers Feelings of responsibility Process Long term consequences if student is not
Feelings of guilt Time successful in class
Worry for students' futures Hurt feelings
Frustration
Dissonance between knowing about ADHD
and dealing with it daily
Guilt related to problematic interactions
Didn't do enough to help

deal with the school system from having a child or other relative with
attentional issues. Jean, a 55 year-old middle school teacher stated:
I have a daughter who, not the H so much, it's just attention deficit
that we've had to work with triggers, and she had herself, for lack of a
better term, medicated once she hit law school.
All teachers who related family experiences with ADHD also
shared that they used these personal experiences to inform their un-
derstanding of their students' behavior. Teachers who had these per-
sonal experiences felt they had more insight, understanding, and
patience with their students, while others expressed skepticism
regarding the validity of their students' diagnosis. One teacher sug-
gested that some students and their families relied on the diagnosis
as a “crutch” to excuse what they perceived to be willful, rather
than impulsive, behaviors.
Teacher Expectations Related to Culture, Gender, Age, and Race and
Ethnicity
Participants were specifically asked about how they thought culture,
race and ethnicity, gender, and student age affected perceptions of
 K. Lawrence et al. / Journal of Pediatric Nursing 36 (2017) 141–148
children with ADHD. A unique finding was the perception that appro-
priate behavior is at times conceptualized and understood differently
in the US south. Amanda, a native southerner stated:
If families aren't teaching those appropriate things they come to
school and don't do it. At one parent teacher conference one little boy
kept saying, ‘Yeah. Yeah. Yeah.’ And I said say, “Yes ma'am”. And his fa-
ther said, ‘Well I don't make him say yes ma'am.’ And I said, ‘Well I do.’
Charlotte, who had moved to the southeast as an adult, related her
experiences with how she felt negatively perceived:
Coming from the north. I'm sure I was perceived as rude. I never
thought ‘yeah’ was rude. I've noticed that in the south there's definitely
more emphasis on eye contact.
These general expectations for appropriate behavior may impact
how children with ADHD are perceived as well. As Charlotte continued:
I've seen that with people who are older… they don't have the pa-
tience for these little people who now, it seems to me, more are being
diagnosed with ADD than what they say used to be; and I've heard a
lot of these older folks say, “All they need is a good spanking, or a
good whooping”. I guess that's [what it is] called down here. And I
know children personally who I'm very close to that it doesn't matter
how hard you spank that child or how many times you spank that
child, it's not going to change how active they are. They have a motor
in them that's just going and what bothers me the most is when you
see a child tore up about it because they are getting in trouble.
A number of participants expressed differing expectations and per-
ceptions of boys and girls with ADHD. The teachers did observe ADHD
to be more common in their male students as compared to their female
students, as would be expected based on US prevalence rates. They also
noted that the behaviors associated with a diagnosis seemed to differ
between boys and girls. Brian, a 27-year-old middle school teacher,
noted:
Boys tend to be more non-verbal, like where they're going to play
whereas girls are just louder. They draw more attention. They're more
verbally loud. The boys are more physically aggravating to their peers.
The behavior of the boys was more likely to be accepted as normal
and viewed positively than the girls. Jean, a veteran teacher with a back-
ground in middle school social studies, made the following observation
about boys with ADHD:
They start out playing, they like to build things… they're trans-
formers. Then they'll want to start fighting with them and that of course,
that becomes a problem. That's just boys.
Girls' behavior was much more likely to be problematized by the
teachers:
My boys would have a tendency to be more active. The girls would
start drama. (Angela, a middle school science teacher).
Salvador, a Latino middle school teacher, stated:
I've only had one or two official IEPs [Individual Education Plans] for
girls, whereas boys, it's in the dozens, but I feel like the boy's behavior is
just a little bit more social and girl's behavior is not as social. Their [boy's]
behaviors are trying to get their friends' attention and girls are more shut
in and defiant. I guess what I'm trying to stumble into is it seems like it's
more acceptable to be a boy with ADHD than a girl with ADHD.
Hyperactive behavior was much more likely to be accepted in youn-
ger children. Often teachers related how classmates were protective of
their friends with ADHD and went out of their way to help them to
stay on task. However, once the children reached middle school, they
were more likely to have social issues related to their behaviors.
Amanda related:
I think children are very resilient, I think they, kind of, in their own
little way, take everybody's differences, especially the younger they
are in kindergarten and first grade pretty much everybody is friends
with everybody.
But with older children, peers became much less patient with the
behaviors:
For the most part… they have kind of a different relationship with
peers in that a lot of times they are looked to as the clown, and it's all
145
fun and games until the other ones are ready to work, and then it's
like ‘SHUT UP! Can you move him? Can you move her?’ (Rachel, middle
school teacher).
The White participants explored topics of culture and gender in rela-
tion to their experiences with ADHD, but did not take up the question of
how race and ethnicity may influence perceptions. However, the only
African American participant, Lawanda, related an observation regard-
ing these variables:
I think more activity is just better tolerated in Black kids. Black peo-
ple seem to be more.
OK with kids running around being kids.
While not rising to the level of a theme, this interesting initial finding
warrants reporting and future exploration.
Teacher Perceptions of Home Environment
A number of participants spoke of the influence that they believed
the home environment had on children with ADD/ADHD. Most
expressed negative perceptions of the home environment stating that
they believed there was a lack of discipline, or either inadequate paren-
tal involvement or lack of encouragement for children to be indepen-
dent. Angela spoke of a perceived lack parental interaction:
I think there's a lot of home factors as well. We have all kinds of chil-
dren that are coming from varied background that aren't getting the
nursery rhymes in bed, and they're not getting the children's stories
and they're not getting the love and they're not getting the feedback
of worth.
Amanda expressed the perception that there should be closer coop-
eration between teachers and parents:
There seems to be a lot of indulgence at home, a lack of discipline.
You can't just give a pill and not provide some coping mechanisms.
There needs to be cooperation between school and home.
Charlotte described a situation in which a child did not receive need-
ed intervention:
He could benefit so much from something. You just got the idea that
[the parents thought] we'll just kick him in the tail. We'll discipline.
There are a lot of them that think that's what they need.
Rachel related a situation in which she felt a mother did too much for
a child and discouraged independence:
In her babying him because he's used to somebody being right there
all the time coaxing him on, “No, no, no, you need to do this. No, no, no,
don't write there.” And I said, “It's OK if he does it wrong.”
Some teachers addressed the difficulties that some families face in
balancing work and family time. Angela noted:
A lot of them do come from single family households or single per-
son households. Their mom works swing shift. It's difficult.
Jean noted the positive effect of parental involvement in the man-
agement of ADHD:
Then you've got some diagnosed that the parents stay on them. That
makes all the difference in the world. Then you have some that are not.
Some of them give them the pill and that's it.
Teacher Negotiations of System and Relationships
Many participants related experiences of negotiating multiple con-
siderations in order to reach the best situation for students. One point
where this negotiation occurred was when teachers believed a student
had attentional issues and needed further evaluation. Teachers related
experiences of balancing concern for the student with both systems is-
sues and how this was presented to parents. They related requirements
for documentation, prescribed approaches in how they framed student
issues to parents, and the perceived need to help parents understand
that the diagnosis of ADHD was a process. In speaking to systems issues
Jean stated:
We used the tested word. You know, ‘Maybe we need to get him
tested. Maybe we need to find out, try to find out what's going on.’
146 K. Lawrence et al. / Journal of Pediatric Nursing 36 (2017) 141–148
Then hopefully the psychologist or whoever is testing the child will,
we're not supposed to say.
Brian said specifically that teachers cannot express an opinion based
on their experience:
We are told not to mention ADHD and/or medication. I think the
protocol is to go to the nurse or guidance or something. And they broach
it. I mean we can't diagnose somebody like that.
Teachers also spoke of considering classroom interventions so
the needs of students with ADHD were balanced with the needs
of other students and those of the teacher. Melissa talked about
balancing the ADHD student's need to move with the needs of
other students:
The standing is something that I've just, because they're up and
down or they will be knocking down chairs because they're moving so
much and it actually causes less distraction to have them just stand
and that's what they want to do because they will be moving side to
side or they'll want to bounce up and down.
Patricia, a retired teacher recalled a situation from her student teach-
ing experience:
Of course when I started my student teaching by myself I was going
to conquer this child and that's all I did. He sat right by me at the desk
and I didn't have time for any other children, only him because he
couldn't sit in his seat… so teachers need to know how to manage this
behavior without consuming all your energy.
Classroom Strategies
In addition to an acknowledged need for medication for some stu-
dents with ADHD, teachers employed a variety of behaviorally based
classroom interventions. All participants reported learning these inter-
ventions from peers or professional workshops, not in their educational
programs. Broad categories of interventions included allowing activity,
assuring positive interactions, redirecting, communicating conse-
quences, decreasing distractions, and utilizing multiple methods of in-
struction. Teachers who allowed some adaptive activity related that
students who were allowed to move some were often able to focus bet-
ter and were less distracting to peers. Some ways that teachers allowed
activity in a controlled manner included sending these students on er-
rands, giving them objects to fidget with, allowing them to chew gum,
and using a chair that bounced. Use of these activity interventions re-
quired thoughtfulness and pre-planning on the part of the teacher so
that the use of activity was balanced with the needs of other students.
As Melissa described her strategy:
I try to keep them actively engaged and learning through things like
throwing a ball around or have them moving around. I find that with
ADHD kids… that's better practice than just having them sit in their
desks all day.
Linda, a retired teacher described several ways to allow movement:
I would have a basket of things, like a little ball. Things that are quiet
but manipulative, like squeeze the ball. I would let them stand in the
back of the room but not in the row where they're going to bother
somebody else… Short parts of work. I always try to break up what
we're doing so we change up every 15 min.
Teachers also related ways in which they assured positive interac-
tions for students. Some teachers reported breaking down assignments
so that students experienced success with completing a task. Other
ways of ensuring a positive experience included giving rewards that
were not strictly academic so that students who were struggling aca-
demically still felt rewarded. They also related correcting students in
private as much as possible. One teacher noted that telling students
how long a learning activity was going to take, noting that students
did better focusing on an activity perceived as boring when they knew
a time limit. Brian utilized a similar strategy but also added that he
liked to communicate with students so they knew what to expect:
You know if you have a presentation you give them a time frame. I'm
only going to spend twenty minutes on this. If we can get this done in
twenty minutes we will do something outside I promise. And just, you
know, tell them that.
Patricia spoke to her belief that students with ADHD should receive
positive recognition whenever possible:
Rewards. I always had a treasure box and you know, trying to make
sure, evening things out for children with ADHD, or children who were
challenging, and children who were not challenged as much, and eve-
ning the ability to get in that treasure box because a lot of these children
don't ever get any rewards.
Students who were easily distracted often benefited from re-direc-
tion. Teachers related a number of ways of redirecting students includ-
ing touching them or standing beside them when they seemed
distracted. They also related calling on a student that they believed
was becoming distracted. Patricia, a retired teacher explained her redi-
rection strategy as follows:
Realizing that proximity is very important to these children. Have
very significant cues to cue them into what you want them to do. Like
one of the things I did was the little sticky pads. If I come by and put a
sticky pad on your desk then you know that I need your attention.
You had to use proximity and you had to make eye contact with these
children and beforehand instruct them if I come by your desk and do
certain things, then that means I want you to pay attention to me.
Teachers related the belief that making consequences explicit was
helpful in motivating students to try to manage their attentional diffi-
culties. Consequences of not completing work included missing recess
or free time and not doing well academically which might require the
student to take a summer class. The teachers noted that sometimes a
consequence of missing recess or free time often made the student's be-
havior worse in the case of those who were hyperactive.
Charlotte described a stepwise way of explaining consequences:
You'd start with conferencing. Okay, ‘Here's the behaviors that I ex-
pect and here's why. It's not just about you, it's about the distraction of
the other students in the classroom; it's about getting what you need.
Patricia expressed frustration with the blanket policy of taking away
a student's recess time:
Because a lot of these children don't ever get any rewards. They're
the ones that have stay in for recess. I do not believe in, I don't like keep-
ing ADHD children in for recess. These children need to get out.
A common means of dealing with students with ADHD was
attempting to decrease distractions through preferential seating.
Teachers reported seating students with ADHD at the front of the class
to decrease their distraction by other students. They also reported plac-
ing these students in the back of the classroom where they could move
more without distracting other students. Lawanda reported having a
desk in the corner of her classroom behind a file cabinet and seating a
student there when re-directing did not work. This strategy decreased
distractions for him:
Now I do have to re-direct him a lot, not so much about his behavior
but about his work… He gets in a rhythm but it's so easy for him to get
off, so I just tell him about where he's been in terms of his work when
he's focused and when he's not focused… I′ve actually moved him,
not as punishment, but to benefit his focus, to that desk in the corner be-
hind the file cabinet.
Brian noted that although preferential seating usually is construed to
mean seating at the front of the room, this should be individualized for
the child with ADHD:
For preferential seating we usually put them in the front of the room
but sometimes it's better to put them in the back so they can move and
don't distract others.
The teachers reported that using multiple methods of instruction
benefited all students, especially those with ADHD. Some of these
methods included using hands on activities like science labs, encourag-
ing students in things that interested them, use of videos, and simply
varying types of instruction. Those who used hands on activities such
as science labs reported that although students with ADHD enjoyed
the activities, they often had trouble focusing on the instructions for
 K. Lawrence et al. / Journal of Pediatric Nursing 36 (2017) 141–148
the lab. Consequently, she did not believe they learned as much as they
might have if they were able to attend to instructions. Some teachers
saw videos as helpful supplemental instruction which students with
ADHD related to as a visual reinforcement of things they had learned
through classroom activities. Melissa noted:
I have found a lot of ADD kids do well with videos because it capti-
vates them… So maybe when I put it all together, I heard it, I saw it,
I've got examples.
None of the teachers interviewed indicated that the strategies they
tried in the classroom were learned as part of their education as teachers.
Those who noted a source for the strategies they had employed attribut-
ed informal communications with colleagues or continuing education of-
ferings. Patricia's summary was typical of what teachers said:
Educating myself. Reading on my own. Attending classes that were
available. I just did a lot of reading… And if I would have a particular sit-
uation with a child in the classroom maybe go back and reread some of
the materials that I believe helped me.
A critical aspect of using intervention strategies successfully was
knowing the individual child and being willing to be flexible in trying
different approaches. Teachers related learning strategies such as find-
ing ways to allow movement then trying different means of doing this
for a child until they found a specific way to make this strategy work.
Emotional Toll on Teachers
Participants were not asked directly about the emotional impact that
they felt as a result of working with children who had ADHD. However,
the emotional toll teachers experienced was a common theme they ex-
plored as they related the daily challenges of teaching children with
ADHD. Teachers expressed painful emotions when they felt children
were being hurt and a great deal of responsibility for their students' fu-
tures. Charlotte expressed her difficulty in dealing with one particular
situation with a child who was not in her class, yet she still felt respon-
sible for him:
What bothers me the most is when you see the child tore up about
it… and this one little boy is always in trouble and he gets unsatisfactory
and it tears him up. He gets emotional about it and he doesn't under-
stand why he has to sit and he gets in trouble at home for it.
Some teachers expressed their worry about children's future. Rachel
told of her immense feeling of responsibility for her student's futures:
What will they be able to do? There used to be a lot of jobs for people
that couldn't do anything extremely difficult, but I don't know. Part of
my job is preparing, is to teach them how to get along in life…When
it comes to, they're about to do job interviews and what you and I
may be trained to deal with, may not be overlooked by a boss looking
at hiring somebody.
Discussion
Using Bronfenbrenner's bioecological framework, we explored
teacher experiences and perceptions of their students with ADHD (see
Table 3). The framework suggests the complexity and intersection of
personal and contextual factors in the ecology of children diagnosed
with ADHD. Martin (2014), in a study of the relationship between
ADHD and student experiences of educational adversity, noted that
while ADHD explained some aspects of adversity, other contextual var-
iables also played a role. Similarly, the reported research confirms that
interactions between teachers and students with ADHD are influenced
by multilevel factors.
Educational background, years of classroom experience, and person-
al/family experiences all informed the teachers' perceptions of students
with ADHD. Participants specifically addressed a lack of information
about ADHD in their formal education and reported primarily learning
about ADHD from in-service or workshop settings, or informally from
peers. These sources may contribute to knowledge and perceptions
about ADHD that are inconsistent or inaccurate. Those who had either
147
formal or in-service education were more likely to support classroom
interventions for children with ADHD such as preferential seating or
redirecting techniques. These findings substantiate findings by other re-
searchers (Bussing, Gary, Leon, Garvan, & Reid, 2002; Mulholland,
Cumming, & Jung, 2015; Ohan et al., 2008).
Culture, gender, and age all influenced how the teachers related
their understanding of ADHD. For example, ADHD behaviors were con-
ceptualized and perceived differently based on variables such as where
the teacher was socialized or the gender of the student. While most
teachers discussed culture and gender-based differences in perception
of ADHD, only one teacher, an African American woman, discussed eth-
nicity as a perceived reason for differences in rates of diagnosis. Future
research should explicitly explore how race and ethnicity, of both the
teacher and the student, influences how ADHD is understood, experi-
enced, diagnosed, and treated.
This research reveals new ideas related to difficulties that teachers
face in negotiating school system regulations and requirements, while
fulfilling unspoken expectations as to how they should present informa-
tion on their student's behavior to parents. First, teachers consistently
spoke of feelings of responsibility to their students with ADHD while
balancing the needs of these students with the needs of other students
in their classrooms. The intersection of these multilevel constructs
added to the complexity and challenge of managing students with
ADHD in a classroom setting (Bronfenbrenner, 2005). Relatedly, a
unique finding revealed in this research is that of the emotional toll
on teachers as part of their experience with students diagnosed with
ADHD. Bussing et al. (2002) and Mulholland et al. (2015) explored
teacher stress related to teaching students with ADHD. In these reports,
teachers noted class size, extra time needed for interventions, lack of
training, and severity of the ADHD as sources of stress. Based on our
findings, the component of emotional toll related to teachers' caring
about their students, in terms of both present needs and potential fu-
ture difficulties, is likely a significant factor in a teacher's experience
of stress.
Finally, an important contextual factor revealed in this study is the
teachers' often negative perceptions of the child's home environment.
As ADHD is heritable (Thapar, Cooper, Eyre, & Langley, 2013), it is likely
that teachers of children with ADHD are interacting with parents who
also have attentional challenges. Parents with ADHD may be less
equipped to model interactional and organizational strategies for their
children, further affecting the child's school performance and social in-
teractions. Additionally, parents with ADHD were once children with
ADHD, putting them at risk for experiencing suboptimal interactions
with teachers and peers during their own school years. These experi-
ences may influence how or even if they engage in interactions with
their child's teacher. Further, just as some teachers consider the child's
ADHD behaviors to be willful and controllable (especially if female), a
teacher may conclude the parent's behaviors indicate that they do not
care about their child, potentiating and perpetuating stigma for both
the parent and child.
Teachers fulfill an important role in the life of school-aged children.
They facilitate optimal learning and the acquisition of social skills,
which are particularly important for children diagnosed with ADHD.
This research helps fill the notable gaps in the literature related to
teacher experiences with their students with ADHD. Further, it sug-
gests formal education regarding the etiology and expression of
ADHD (for both child and parent), as well as evidence-based educa-
tional strategies, would benefit not only the student but may mitigate
the emotional toll teachers experience. Additional research is needed
in areas such as how the role of the teacher intersects with that of
the health care provider in the diagnosis and ongoing management
of ADHD, how teachers cope with their own feelings related to stu-
dents with ADHD, in-depth exploration of cultural and socio-economic
influences on ADHD with teachers from diverse backgrounds, and fur-
ther exploration of effective teacher-parent-healthcare provider com-
munication processes.
148 K. Lawrence et al. / Journal of Pediatric Nursing 36 (2017) 141–148
Limitations
Limitations of this research include small sample size although satu-
ration was achieved with the themes of behavioral issues, process of di-
agnostics, ways of learning about ADHD, and classroom interventions.
Another limitation is the homogeneity of the sample. The majority of
participants were white females, with the exception of one African
American female and two white males, one of whom was Latino. Re-
view of teacher information on local school websites revealed that the
sample was a close approximation of the racial/ethnic makeup of the
teacher workforce in the districts where this research was conducted.
Finally, this research only considered teacher perspectives. As per-
ceptions are created through ongoing relationships (in this case, be-
tween teachers, their students with ADHD, family members, and
health care providers, all situated within complex contexts), examina-
tion of these issues from multiple perspectives and diverse interactants
will lead to more robust understanding of how these interactions affect
children and others.
Implications for Pediatric Nurses
This research highlights important information for pediatric nurses,
school nurses, and pediatric nurse practitioners. A clearer understand-
ing of teacher ADHD knowledge and perceptions has the potential to
foster more effective communication and collaboration amongst health
care providers, educators, and family members of children with ADHD,
and should inform evidence-based interventions designed to positively
affect the well-being of children and teachers. Pediatric nurses in both
acute and primary care settings should incorporate evidence-based
ADHD information and education in discussions with parents to facili-
tate understanding and enhance their ability to serve as effective and
knowledgeable advocates for their child. School nurses, an integral
part of the educational team, can serve as a source of knowledge and ev-
idence-based educational strategies to support teachers and optimize
student educational and mental health outcomes. Finally, better under-
standing of student behaviors in the educational environment can in-
form recommendations made by pediatric nurse practitioners for
psychosocial and pharmacological interventions.
COI Statement
The authors have no real or perceived conflicts of interest to report.
Funding Source
None.
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disor-
ders (5th ed.). Washington, DC: American Psychiatric Association.
Bronfenbrenner, U. (2005). The bioecological theory of human development. In U.
Bronfenbrenner (Ed.), Making human beings human: Bioecological perspectives on
human development. Thousand Oaks, CA: Sage.
Bussing, R., Gary, F., Leon, C., Garvan, C., & Reid, R. (2002). General classroom teachers' in-
formation and perceptions of attention deficit hyperactivity disorder. Behavioral
Disorders, 27(4), 327–337.
Bussing, R., & Mehta, A. S. (2013). Stigmatization and self-perception of youth with atten-
tion deficit/hyperactivity disorder. Patient Intelligence Journal, 5, 15–27.
Cahill, B. S., Coolidge, F. L., Segal, D. L., Klebe, K. J., Marle, P. D., & Overmann, K. A. (2012).
Prevalence of ADHD and its subtypes in male and female adult prison inmates.
Behavioral Sciences & the Law, 30(2), 154–166.
Centers for Disease Control and Prevention (CDC) (2017). Attention-deficit/hyperactivity
disorder (ADHD). Retrieved from http://www.cdc.gov/ncbddd/adhd/index.html.
Conrad, P., & Bergey, M. (2014). The impending globalization of ADHD: Notes on the ex-
pansion and growth of a medicalized disorder. Social Science and Medicine, 122,
31–43.
DuPaul, G., Jitendra, A., Tresco, K., & Junod, R. (2006). Children with attention deficit hy-
peractivity disorder: Are there gender differences in school functioning? School
Psychology Review, 35(2), 292–308.
Fabiano, G. A., Pelham, W., Majumdar, A., Evans, S., Manos, M., Caserta, D., ... Carter, R.
(2013). Elementary and middle school teacher perceptions of attention-deficit/hy-
peractivity disorder prevalence. Child & Youth Care Forum, 42, 87–99. http://dx.doi.
org/10.1007/s10566-013-9194-1.
Hong, Y. (2008). Teachers' perceptions of young children with ADD/ADHD in Korea. Early
Child Development and Care, 178(4), 399–414.
Kuriyan, A. B., Pelham, W. E., Jr., Molina, B. S. G., et al. (2013). Young adult educational and
vocational outcomes of children diagnosed with ADD/ADHD. Journal of Abnormal
Child Psychology, 41, 27–41.
Law, G. U., Sinclair, S., & Fraser, N. (2007). Children's attitudes and behavioural intentions
towards a peer with symptoms of ADD/ADHD: Does the addition of a diagnostic label
make a difference. Journal of Child Health Care, 11(2), 98–111.
Lee, K. (2008). ADD/ADHD in American early schooling: From a cultural psychological
perspective. Early Child Development and Care, 178(4), 415–439. http://dx.doi.org/
10.1080/03004430701321852.
Lee, S. S., Humphreys, K. L., Flory, K., Liu, R., & Glass, K. (2011). Prospective association of
childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and
abuse/dependence: A meta-analytic review. Clinical Psychology Review, 31, 328–341.
Martin, A. (2014). The role of ADHD in academic adversity: Disentangling ADHD effects
from other personal and contextual factors. School Psychology Quarterly, 29(4),
395–408.
Mueller, A., Fuermaier, A., Koerts, J., & Tucha, L. (2012). Stigma in attention deficit hyper-
activity disorder. ADHD Attention Deficit Hyperactivity Disorder, 4, 101–114. http://dx.
doi.org/10.1007/s12402-012-0085-3.
Mulholland, S., Cumming, T., & Jung, J. (2015). Teacher attitudes towards students who
exhibit ADHD-type behaviours. Australasian Journal of Special Education, 39(1),
15–36. http://dx.doi.org/10.1017/jse.2014.18.
Muntigl, P., & Horvath, A. O. (2014). I can see some sadness in your eyes: When experien-
tial therapists notice a client's affectual display. Research on Language and Social
Interaction, 47(2), 89–108.
NVivo (2012). Qualitative data analysis software. QSR International Pty Ltd (Version 10).
Ohan, J. L., Cormier, E., Hepp, S. L., Visser, T. A. W., & Strain, M. C. (2008). Does knowledge
about attention-deficit/hyperactivity disorder impact teachers' reported behaviors
and perceptions? School Psychology Quarterly, 23(3), 436–449. http://dx.doi.org/10.
1037/1045-3830.23.3.436.
Rush, C., & Harrison, P. (2008). Ascertaining teachers' perceptions of working with adoles-
cents diagnosed with attention-deficit/hyperactivity disorder. Educational Psychology
in Practice, 24(3), 207–223.
Saldana, J. (2016). The coding manual for qualitative researchers. Los Angeles, CA: Sage.
Thapar, A., Cooper, M., Eyre, O., & Langley, K. (2013). Practitioner review: What have we
learnt about the causes of ADHD? Journal of Child Psychology and Psychiatry, 54(1),
3–16.
U.S. Department of Health and Human Services, & National Institute of Mental Health
(2014). Attention Deficit Hyperactivity Disorder. Retrieved from http://www.nimh.
nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
(Accessed 08/19/2016).