School Psychology Review,

2004, Volume 33, No. 3, pp. 421-428

RESEARCH BRIEF
Teachers' Knowledge of ADHD, Treatments for ADHD,
and Treatment Acceptability: An Initial Investigation

Rebecca L. Vereb
Lehigh University

James C. DiPeina
The Pennsylvania State University

Abstract. The purpose of this study was to begin to explore the relationship among
teachers' knowledge of Attention Deficit Hyperactivity Disorder (ADHD), knowl-
edge of common treatments for ADHD, and acceptability of different approaches
to treatment for ADHD (medication and behavior management). Relationships
also were explored between these variables and teachers' training and experience
in working with children with ADHD. Results indicated that teachers' knowledge
of ADHD, years of teaching experience with students with ADHD, and training
demonstrated positive relationships with ratings of medication acceptability. In
addition, teachers' participation in ADHD training was positively correlated with
knowledge of ADHD and acceptability of behavior management strategies. Over-
all, fewer positive relationships were observed than predicted. In addition, ob-
served statistically significant relationships were relatively small in magnitude,
raising questions about the importance of considering these variables in interven-
tion planning for students with ADHD. Directions for future research are discussed.

When children exhibit behavior prob-
lems in school, teachers often are the first to
recognize and recommend that they receive a
comprehensive assessment. Beyond this ini-
tial recommendation, teachers play a key role
in classification decisions in that their obser-
vations and reports typically are used in diag-
nosis and treatment determination. In addition,
if a child is diagnosed with a disorder and a
treatment plan is established, it may be the re-
sponsibility of the teacher to implement an in-
tervention in the classroom. When teachers
disagree with a recommended treatment, they
may refuse to implement the intervention, may
implement it improperly, or may fail to com-
plete treatment (Eckert & Hintze, 2000; Wil-
son & Jennings, 1996). Researchers have sug-
gested that such compromised treatment integ-
rity ultimately affects the effectiveness of treat-
ment (Wickstrom, Jones, LaFleur, & Witt,
1998; Wilson & Jennings, 1996). Other vari-
ables also may affect treatment effectiveness.

Correspondence concerning this article should be addressed to James C. DiPema, The Pennsylvania State
University, 105 Cedar Building, University Park, PA 16802; E-mail: jdipema@psu.edu

Copyright 2004 by the National Association of School Psychologists, ISSN 0279-6015

421
 School Psychology Review, 2004, Volume 33, No. 3
such as a teacher's knowledge of a student's
problem, knowledge of the intervention, or the
acceptability of the intervention (how appro-
priate the intervention is perceived by the
teacher for the target problem). The purpose
of this study was to undertake an initial explo-
ration of the relationship among these variables
relative to Attention Deficit Hyperactivity Dis-
order (ADHD), a behavioral disorder that oc-
curs in 3% to 7% of school-age children
(American Psychiatric Association, 2000).
Treatment acceptability researchers have
attempted to identify factors that affect accept-
ability ratings for treatments. For example,
treatments that are less intrusive in the class-
room, take less time to implement, and use
positive rather than negative consequences
often are rated as more acceptable than treat-
ments without these characteristics (Fairbanks
& Stinnett, 1997). Also, rater and child char-
acteristics can affect acceptability ratings. Spe-
cifically, the amount of knowledge the rater
has regarding the given treatment is positively
related to the ratings of acceptability. That is,
the more individuals know about a specific
treatment, the higher they tend to rate the ac-
ceptability of that treatment (Elliott, 1988;
Miltenberger, 1990).
Treatments also may be rated as more or
less acceptable depending on a student's age
or the type and severity of the behaviors being
exhibited (Bennett, Power, Rostain, & Carr,
1996; Eckert & Hintze, 2000; Elliott, 1988;
Schneider, Kerridge, & Katz, 1992). Fairbanks
and Stinnett (1997) found that teachers are
more accepting of any potentially effective
behavioral intervention when the target student
is presenting externalizing problem behaviors
rather than other types of problems. They con-
cluded that teachers who are less tolerant of
misbehavior tend to be more accepting of any
behavior management program. Thus, teach-
ers' tolerance level for problem behaviors may
affect acceptability.
Treatment acceptability research in the
area of disruptive behavior disorders has fo-
cused primarily on acceptability of interven-
tions for students with ADHD. Power, Hess,
and Bennett (1995) examined several factors
(e.g., knowledge of ADHD, teaching experi-
422
ence, type of intervention) related to teacher
acceptability ratings of treatments for ADHD,
and their results suggested that teachers are
more accepting of positive rather than nega-
tive interventions. The results also indicated
that severity of a problem behavior is positively
correlated with treatment acceptability,
whereas the amount of time and effort involved
in implementation are inversely related to ac-
ceptability. Power et al. (1995) also hypoth-
esized that willingness to accept and use a treat-
ment is dependent on two factors: amount of
knowledge about ADHD and number of years
of teaching experience. Neither of these fac-
tors correlated strongly with acceptability rat-
ings. The researchers, however, indicated that
the range of scores on the knowledge scale was
restricted, possibly due to the participants' high
level of education, and may have affected the
statistical significance of the correlations
(Power etal., 1995).
In sum, characteristics of the treatment,
teacher, student, and presenting behaviors all
play a role in ratings of treatment acceptabil-
ity. Teacher acceptability ratings of treatments
for ADHD are related to the severity of the
child's behavior, the amount of time and effort
required to implement the intervention, and
whether the intervention uses positive or nega-
tive techniques. Research is less conclusive
regarding the relationship between treatment
acceptability, knowledge of ADHD, and years
of teaching experience (Power et al., 1995). In
addition, although researchers have explored
the relationship between parents' knowledge
of treatments for ADHD and their acceptabil-
ity of those treatments (e.g., Liu, Robin,
Brenner, & Eastman, 1991; Rostain, Power, &
Atkins, 1993), the relationship between teacher
knowledge of treatments for ADHD and treat-
ment acceptability ratings has received far less
attention in the empirical literature.
Teachers' willingness to implement an
intervention has been found to significantly
affect the effectiveness of that intervention
(Fairbanks & Stinnett, 1997; Wickstrom et al.,
1998). Developing an understanding of the
relationships between teachers' knowledge of
ADHD, its treatment, and ratings of accept-
ability may assist school psychologists in the

initial selection and prioritization of possible
classroom-based interventions for students
with ADHD. Thus, the purpose of this initial
investigation was to explore the relationship
between teachers' knowledge of ADHD,
knowledge of treatments for ADHD, and rat-
ings of acceptability for two common treat-
ments for ADHD (medication and behavior
management strategies). In addition, the study
explored relationships between key teacher
variables (e.g., training and experience) and
their knowledge of and treatments for ADHD.
The current study is an extension of the re-
search conducted by Power et al. (1995), in
that knowledge of ADHD and knowledge of
treatments for ADHD are being examined as
separate variables. Previous research has used
measures of knowledge that include items on
both general knowledge of the disorder and
knowledge of treatments, but the measure de-
veloped for the current study divides these
items into two different scales so that the in-
fluence of each type of knowledge on treat-
ment acceptability can be examined. Based on
the research of Bennett et al. (1996), Elliott
(1988), Liu et al. (1991), and Power et al.
(1995), it was predicted that:
1. Teachers' knowledge of ADHD, knowl-
edge of treatments for ADHD, and rat-
ings of acceptability for two common
treatments (medication and behavior
management strategies) would demon-
strate moderate positive relationships with
one another.
2. Teachers' experience and training in
working with students with ADHD would
exhibit moderate positive relationships
with their knowledge of ADHD, knowl-
edge of treatments for ADHD, and rat-
ings of treatment acceptability.
Method
Participants
Forty-seven elementary teachers partici-
pated in the study'. The sample was primarily
female (94%) and approximately equally dis-
tributed across Grades K-6. Participating
teachers had a mean of 13 years of teaching
experience (5D = 8.76), and 85%, 4.3%, and
Teacher Knowledge
10.6 % were certified in general education,
special education, or both domains, respec-
tively. The participants worked in five differ-
ent districts in Pennsylvania and New Jersey,
with the districts representing urban, suburban,
and rural locations.
Measures
Knowledge of ADHD Rating Evalu-
ation (KARE). The KARE is a teacher sur-
vey developed for this study consisting of items
in four domains: Knowledge of ADHD (31
questions). Knowledge of Treatments com-
monly used for ADHD (12 questions). Medi-
cation Acceptability (5 questions), and Behav-
ior Management Acceptability (5 questions).
The Knowledge of ADHD items measure
teacher knowledge of etiology, symptoms, and
prognoses for students with ADHD. These
questions utilize a True/False format, with an
option of Don't Know to differentiate guesses
from inaccurate knowledge. The Knowledge
of Treatments items include questions regard-
ing teacher knowledge of the implementation
and effectiveness of treatments commonly used
for students with ADHD, such as medications
and behavior management techniques. These
questions also employ a True-False-Don't
Know format. The Medication Acceptability
and Behavior Management Acceptability items
ask teachers to rate the acceptability of these
two different types of treatments for ADHD.
Teachers provide their ratings using a 4-point
Likert format (1 = Not at all Likely to 4 = Very
Likely). Sample items from each of the KARE
scales appear in Table 1.
To explore the content validity of the
KARE, 20 experts reviewed a preliminary ver-
sion prior to its use in the current study. Ex-
perts were members of the International Soci-
ety for Research in Child and Adolescent Psy-
chopathology who have conducted research in
the area of ADHD and/or treatment acceptabil-
ity. This pilot version included 59 items, and
experts were asked to evaluate the importance
of each item using a 4-point scale (1 = Not at
all Important, 4 - Critical). Mean scores for
the 59 items ranged from 2.34 to 3.78. Items
with mean scores less than 3.00 (i.e., less than
"Important") were examined and expert com-
423
 School Psychology Review, 2004, Volume 33, No. 3

Table 1
Sample Items From the Knowledge of ADHD Rating Evaluation (KARE)
Item

Knowledge of ADHD"

To be diagnosed with ADHD, a child must exhibit relevant symptoms in two or more settings
(e.g. home, school).

There are three types of ADHD: Predominantly Inattentive, Predominantly Hyperactive/

Impulsive, and Combined Type.

Knowledge of Treatments'

Behavior management techniques can improve a child's ability to pay attention in class.

Medication will help a child with ADHD achieve better grades in school.

Medication Acceptability''

How appropriate is medication for treating students with ADHD?

How acceptable is medication for treating students with ADHD?

Behavior Management Acceptability''

How likely would you be to recommend behavior management techniques to parents seeking help
for their child with ADHD?

How necessary are behavior management techniques for treating students with ADHD?

Note. "Items rated as True, False, Don't Know; ''Items rated on Likert scale of 1-4, with high scores reflecting greater
acceptability.

ments were considered to guide decisions re- Professional experience questionnaire. A

garding retention, revision, or elimination. Of
the initial 59 items, 12 questions were elimi-
nated and 9 were modified in response to ex-
pert recommendations.
Reliability estimates were generated for
each of the KARE scales using data from the
current sample. Estimates of internal consis-
tency (Cronbach's alpha) ranged from .58
(Knowledge of Treatments Scale) to .81 (Be-
^ • 1 », A u-i- c 1 N
havioral Management Acceptability Scale).
Test-retest stability (n - 24, 4-week interval)
ranged from .76 (Behavior Management Ac-
ceptability Scale) to .80 (Medication Accept-
ability and Knowledge of Treatment Scales).
Although both estimates of reliability were
acceptable for three of the four scales, reliabil-
ity evidence was mixed for the Knowledge of
Treatments Scale and results including this
scale should be interpreted with caution.
424
questionnaire was administered to teachers to
assess key information about professional ex-
periences (e.g., certification, years of teaching
experience, years teaching students with
ADHD). The questionnaire also asked if teach-
ers had previous training (e.g., in-services,
seminars, conferences) regarding ADHD and
its treatment in school populations.
„ ,
Procedures
A packet containing a copy of the KARE,
the professional experience questionnaire, and
a consent form were distributed to teachers
during in-service trainings or faculty meetings
at participating schools. The purpose of the
study was explained and teachers were invited
to participate. Teachers who volunteered to
participate completed a consent form, the
KARE, and the professional experience ques-
 Teacher Knowledge

Table 2
Relationships Among Knowledge of ADHD, Knowledge of Treatment,
Acceptability of Medication, and Acceptability of
Bebavior Management Strategies
Knowledge of ADHD Knowledge of Treatment

Knowledge of ADHD Treatments .14 (.34)

Medication Acceptability .37 (.01) -.32 (.03)
Behavior Management Acceptability .27 (.08) .28 (.06)

Note, p-values appear in parentheses.

tionnaire. In all, 90 packets were distributed Prediction 2

to teachers and 48 were completed, yielding a
53% return rate. In addition, 32 participants
were asked to complete the KARE a second
time for test-retest reliability, and 24 (75%)
returned the second questionnaire.
Results
Teacher scores on the Knowledge of
ADHD scale ranged from 14 to 27 items cor-
rect out of a possible 31 items (M = 21.57, SD
= 3.68). Scores on the Knowledge of Treat-
ments scale ranged from 3 to 10 correct out of
a possible 12 items (M - 6.53, SD = 1.69).
Medication acceptability scores ranged from
11 to 26 (M= 18.39, SD = 3.79), and Behavior
Management acceptabiUty scores ranged from
14 to 27 (M= 21.92, SD = 3.29).
Prediction 1
The first prediction was that teachers'
knowledge of ADHD, knowledge of treatments
for ADHD, and treatment acceptability would
be moderately positively correlated with one
another. Contrary to the first prediction, teach-
ers' knowledge of ADHD was unrelated to their
knowledge of treatments for ADHD (see Table
2). Teachers' knowledge of ADHD was posi-
tively related to their ratings of medication
acceptability but unrelated to their ratings of
acceptability for behavioral interventions.
Teachers' knowledge of treatments was nega-
tively correlated with their medication accept-
ability ratings but unrelated to their behavior
management acceptability ratings.
The second prediction was that teachers'
training and experience with students with
ADHD would be moderately related to their
knowledge of ADHD and knowledge of treat-
ments for ADHD as well as their ratings of
treatment acceptability. As displayed in Table
3, results indicated that years of teaching ex-
perience with students with ADHD was only
significantly related with ratings of medication
acceptability. Conversely, teachers' participa-
tion in training regarding ADHD was positively
correlated with their knowledge of ADHD,
acceptability ratings of medication, and accept-
ability ratings of behavior management strate-
gies. Participation in training, however, was
not related to knowledge of treatments.
Discussion
The current study had two objectives.
The primary objective was to explore the rela-
tionship between teacher knowledge of ADHD,
knowledge of treatments for ADHD, and ac-
ceptability of common treatments (medication
and behavior management) for ADHD. The
secondary objective was to explore the rela-
tionship of teacher training and experience with
their knowledge of ADHD, treatment, and ac-
ceptability of interventions.
The results of the current study supported
only a positive relationship between teacher
knowledge of ADHD and their acceptability
of medication treatments. Power et al. (1995)
failed to find a statistically significant relation-
ship between teacher knowledge of ADHD and

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 School Psychology Review, 2004, Volume 33, No. 3
Table 3
Correlations Between Teachers' ADHD Experience, Training, Knowledge,
and Acceptability Ratings
Teaching Experience with ADHD
Knowledge of ADHD
Knowledge of ADHD Treatments
Medication Acceptability
Behavior Management Acceptability
Note, p-values appear in parentheses.
treatment acceptability. However, the magtii-
tude of the current findings was comparable
to those found in studies that examined the re-
lationship between parental knowledge of
ADHD and medication acceptability (Bennett
et al., 1996; Liu et al., 1991). These findings
suggest that what teachers know about ADHD
is related to acceptability of medication for stu-
dents with ADHD. It is important to note that
the current study separated knowledge of
ADHD from knowledge of treatments, unlike
previous research, which has combined the two
areas into one knowledge score. Interestingly,
teachers' knowledge of treatments of ADHD
was negatively related with their medication
acceptability ratings, but given the mixed
reliability evidence for the Knowledge of
Treatments scale, any conclusions regard-
ing this relationship must be made with cau-
tion. These same patterns, however, did not
exist between knowledge of ADHD, knowl-
edge of treatments, and acceptability of be-
havioral interventions. The observed corre-
lations between these variables indicated no
statistically significant relationships among
them. Although the differences across these
findings are somewhat surprising, perhaps
most important is that none of the observed
relationships were large. Thus, the practical
implications of the relationships necessitate
further study to determine if they are impor-
tant for practitioners to consider when plan-
ning interventions for students with ADHD or
if other factors may have a greater impact on
treatment acceptability.
426
ADHD Training
.29 (.06) .49 (.01)
.10 (.51) .06 (.70)
.40 (.01) .31 (.04)
.06 (.68) .34 (.02)
The second prediction was that teachers'
training and experience with students with
ADHD would be positively related to their
knowledge of ADHD, knowledge of treatments
for ADHD, and ratings of treatment acceptabil-
ity. The current results suggest that no relation-
ship exists between experience with teach-
ing students with ADHD and knowledge of
ADHD, knowledge of treatments for ADHD,
or acceptability ratings of behavior manage-
ment interventions. In previous studies,
mixed results had been noted regarding the
relationship between teacher experience and
knowledge of ADHD. Studies by Jerome,
Gordon, and Hustler (1994) and Sciutto,
Terjesen, and Bender Frank (2000) indicated
positive relationships between teacher ex-
perience with students with ADHD and
knowledge of ADHD. The results of the cur-
rent study, however, are consistent with the
findings of Power et al. (1995) in that
teacher experience with students with ADHD
and knowledge of ADHD were not related.
Teaching experience with ADHD demon-
strated a moderate relationship with ratings of
medication acceptability, and this finding may
suggest that such experience provides teach-
ers with more exposure to medication inter-
ventions (and outcomes) than other types of
interventions.
Results also indicated that teachers with
training in ADHD had greater knowledge of
ADHD than teachers without training. Al-
though these relationships were statistically
significant in the predicted direction, they

were not as strong as predicted. They were con-
sistent, however, with Jerome et al.'s (1994)
findings that teachers who had received spe-
cific training regarding ADHD knew more
about the disorder than teachers who had little
to no training. No significant relationship ex-
isted between training and knowledge of treat-
ments, but small relationships were noted be-
tween training and acceptability. The combi-
nation of these findings may indicate that
teachers who participate in training primarily
retained, or perhaps only were provided, in-
formation about the presenting features of the
disorder rather than potential treatments for the
disorder.
There were several limitations to the
study, and most resulted from the sample of
participating teachers. Specifically, participat-
ing teachers were volunteers, and teachers who
were willing to participate in this study may
have different experiences and perspectives
regarding ADHD and its treatment than
those who were not willing to participate.
Similarly, although the participating teach-
ers represented several different school dis-
tricts, teachers working in urban schools
were underrepresented and may have differ-
ent ideas and experiences with regard to stu-
dents with ADHD, which again may have af-
fected the findings. In addition, teachers in
Grades 7 through 12 were not included in the
sample, so findings are limited to the elemen-
tary level.
A third potential limitation may have
been the qualifications and experiences of the
participants. For example, a large majority
(79%) of the participants had earned at least a
Master's degree, and 64% of the participants
had received training in ADHD. Thus, the par-
ticipants may have had more accurate knowl-
edge and different views of students with
ADHD than teachers who did not participate
in the study. Finally, the somewhat low inter-
nal consistency of the Knowledge of Treat-
ments scale makes it difficult to draw any firm
conclusions regarding the relationship between
this scale and the other variables included in
this study.
An important direction for research is to
further explore relationships between teachers'
Teacher Knowledge
knowledge of ADHD, knowledge of common
treatments for ADHD, and treatment accept-
ability to determine (a) if significant (and siz-
able) relationships exist, and (b) if such rela-
tionships can be manipulated to promote bet-
ter outcomes for students. Future research also
should examine other relationships, such as
how, or if, knowledge and treatment accept-
ability factors are related to the integrity with
which teachers implement interventions for
students with ADHD. By understanding what
variables infiuence treatment integrity, practi-
tioners can proactively address potential threats
to integrity, through tactics such as educating
a teacher regarding an intervention to change
the teacher's acceptability of the proposed in-
tervention. Alternatively, researchers have
shown that providing teachers with feedback
regarding their implementation of an interven-
tion improves integrity (Jones* Wickstrom, &
Friman, 1997; Noell, Witt, Gilbertson, Ranier,
& Freeland, 1997). As such, it is important that
future research compare a variety of strategies
(e.g., feedback regarding treatment implemen-
tation, information sharing prior to implemen-
tation) to determine which strategy, or combi-
nation of strategies, are most likely to yield
high integrity.
Effectively teaching students with
ADHD often requires the use of a variety of
interventions in the classroom. Researchers
(e.g., Eckert & Hintze, 2000) have suggested
that teachers' acceptability of various treat-
ments may infiuence their willingness to uti-
lize them. This study examined the relation-
ship between teacher ratings of treatment ac-
ceptability, their knowledge of ADHD and of
treatments commonly used for students with
ADHD, and results revealed fewer significant
relationships than predicted. In addition, ob-
served statistically significant relationships
were relatively small in magnitude and raise
questions about the importance of considering
these variables in intervention planning for stu-
dents with ADHD. As such, additional research
is necessary to further explore the magnitude
of these relationships as well as the importance
of taking these variables into consideration
when planning classroom-based interventions
for students with ADHD.
427
 School Psychology Revievi?, 2004, Volume 33, No. 3

Footnote Liu, C , Robin, A. L., Brenner, S., & Eastman, J. (1991).

'A power analysis was conducted to deter-
mine the number of participants needed for the pro-
posed correlation analyses. With a moderate effect
size of .35, an alpha of .05, and power set at .80, the
number of participants required was 46.
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Rebecca L. Vereb is an intern at the Louisiana School Psychology Internship Con-

sortium and a doctoral candidate in the school psychology program at Lehigh Uni-
versity. Her research interests include attention deficit hyperactivity disorder and
treatment acceptability.

James C. DiPerna, PhD, is Assistant Professor in the School Psychology Program at

the Pennsylvania State University. His research interests include academic and emo-
tional competence, school-based prevention programs, and the use of technology to
facilitate learning.

428