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How Well Do Parents and Teachers Agree on the Diagnosis of ADHD?
One of the more frustrating experiences for parents that I have encountered is the extent to which their perceptions of their child's behavior can differ from that of their child's teacher. This seems to generally take the form of teachers reporting problems at school that parents do not observe at home, but the reverse situation occurs as well. A sometimes unfortunate consequence of these different parent and teacher perceptions is that communication and trust between parents and teachers can suffer. Parents can come to believe that the teacher must be mishandling their child (which, of course, can sometimes be the case). Teachers can interpret parents' report of no problems at home as reflecting either deliberate denial of their child's difficulty or an obliviousness that results from an absence of involvement. When such impasses occur, it is unfortunately the child who frequently suffers because there is no agreement between parents and teachers/school about how to proceed.
Just how well do parents and teachers generally agree on information related to the diagnosis of ADHD? This was the question addressed in a study published recently in the Journal of the American Academy of Child and Adolescent Psychiatry (Mitsis, E.M. et al; (2000). Parent- teacher concordance for DSM-IV ADHD in a clinic referred sample. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 308-313). The answer to this question has important implications for the evaluation and management of ADHD, and I believe the data from this study are quite instructive.
Participants were 74 children (60 boys and 14 girls) from 7 to 11 years old who were referred to a clinic because of problems related to disruptive behavior. The parents and teachers of these children were interviewed separately via phone using a highly structured psychiatric interview (the interview used was the Diagnostic Interview Schedule for Children - DISC) so that the presence/absence of each specific symptom of ADHD could be obtained from both sources. These interviews enabled the researchers to determine whether the child qualified for a diagnosis of ADHD, and the specific subtype the child qualified for (i.e. Combined Type, Inattentive Type, or Hyperactive/Impulsive Type) according to each source, and when parent and teacher information was considered jointly. (Note: It is important to remember that the figures reported below refer to the percentage of children in a sample referred to a clinic for behavior problems who met diagnostic criteria for ADHD. These figures are much higher, of course, than would be found in a general population.)
Results
How well did parents and teachers agree? As it turns out, not very well. Among the 74 children, 85% met criteria for any subtype of ADHD according to parent information (this means that 85% met diagnostic criteria for either the combined, inattentive, or hyperactive/ impulsive subtypes according to parents). Using the information gathered from teachers, 76% met diagnostic criteria for one of the ADHD subtypes. Parents and teachers agreed on the presence vs. absence of any type of ADHD diagnosis (e.g. if diagnosis based on parent data was the combined type and diagnosis based on teacher data was the inattentive type it was considered an agreement) 74% of the time. This means they disagreed on the presence or absence of ADHD more than a quarter of the time. (This is not really very impressive when you consider that chance agreement alone would be 50%).
Agreement for the particular subtype of ADHD was especially poor. Among 55 children who met criteria for ADHD, Combined Type, according to parents or teacher, parents and teachers agreed on only 17 cases. Agreement between parents and teachers for the ADHD, Hyperactive/Impulsive subtype was only 2 of 24 cases and for the Inattentive subtype it was only 2 of 20 cases.
The authors also examined how diagnoses based on combined parent and teacher data compared to diagnoses based on each source alone. These comparisons are quite interesting and are shown in the chart below. (Note: ADHD-C=combined type; ADHD-H/I = hyperactive/ impulsive type; ADHD-I = inattentive type).
Percentages Of Diagnoses Based On Parent, Teacher, And Combined Parent-teacher Information
(Note: The numbers in the table above reflect the percentage of children who were diagnosed with each subtype of ADHD, or who were not diagnosed with any subtype of ADHD, based on parents alone, teachers alone, or the combination of parent and teacher information. For example, the first entry indicates that 15% of children were not diagnosed with any type of ADHD based on the parent report alone. The fact that the percentage of children diagnosed with the inattentive or hyperactive/impulsive subtypes in the combined column are so low reflects the fact that when both parent and teacher data is combined, almost every child diagnosed with ADHD received the combined type diagnosis.)
Several things are noteworthy here. First, it should be stressed that when information from parents and teachers is integrated in the diagnostic process, children are more likely to be diagnosed with ADHD of some type (i.e. only 7% had no diagnosis in the combined condition vs. 15% and 24% for parents and teachers respectively. This is probably because each reports certain symptoms that the other does not observe, and when these reports are then combined, a greater number of symptoms is reported than for either source considered separately.) It is also evident that when combined information is used, the combined subtype is by far the most common, and that relatively few children are diagnosed with either of the other two subtypes.
How do parents and teachers compare directly? First, it is interesting that using teacher data alone was less likely to result in a child being diagnosed than using parent data alone (i.e. 24% of children received no diagnosis based on teacher data compared to only 15% using parent data.). Second, even though teachers are less likely to report ADHD symptoms overall than parents, they are more likely to see children as being highly inattentive (i.e. 20% of children diagnosed with inattentive subtype according to teachers compared to only 10% according to parents). This is most likely because teachers observe children in a context where problems with attention are much more likely to be evident.
How Do Parent Reports Of Their Child Symptoms At School Compare To Teacher Reports?
The data reported above is based on parent report of symptoms they observe in their child at home. Parents were also asked, however, about symptoms they believed their child to display in school and these were compared to what teachers reported about the child. The percent agreement for each symptoms was assessed and ranged from 50-76% for hyperactive/impulsive symptoms and from 43-78% for inattentive symptoms. This is not especially good when one would expect agreement to be 50% by chance alone. In fact, after correcting for chance agreement, it was found that parent and teacher agreement on individual symptoms was rarely better than chance. When reports were treated as a composite score using the different hyperactive/impulsive and inattentive symptoms, rather than considering each symptom individually, a modest but significant correlation was obtained. Thus, there was at least some significant consistency between parent and teacher reports of how the child behaves at school when a more global rating of hyperactive and inattentive behaviors was considered.
Summary And Implications
The results of this study highlight the importance of obtaining information from both parents and teachers in the evaluation process. As is clear from the data above, parents and teachers do not necessarily agree on the presence or absence of sufficient number of symptoms to warrant any type of ADHD diagnosis in a large number of cases (i.e. 24% in this sample). This is the case even when parents have sought an evaluation because of behavior problems their child was displaying. In cases where parents are less concerned about their child's functioning - as often occurs when a child is having problems at school but not at home - one might expect that agreement between parents and teachers would be even lower.
Even in this sample, however, the level of disagreement on specific subtypes was surprising. Having parents report on their child's behavior at school in addition to their child's behavior at home is no solution to this problem, as agreement with what teachers report observing for individual symptoms is often no better than chance. Even for more global measures of ADHD symptoms, agreement remains relatively modest.
The clear message from these data is that relying on a single source for diagnostic purposes - in reality, this would generally be the parent - runs the substantial risk of misdiagnosis. These data suggest that when only one source is used, children who perhaps should have been diagnosed with some type of ADHD will not be. The concern, of course, is that this will preclude a child from receiving treatment who really needs it. Of course, the opposite is also possible - i.e. relying on a single source will result in a child being diagnosed with ADHD who should not be. The authors of this study argue that the use of data from both parents and teachers is essential to arrive at the most accurate diagnosis possible - a conclusion with which I would strongly agree. Unfortunately, we know that for a variety of reasons this often fails to happen and children are diagnosed by physicians when information has been obtained directly from teachers.
It should also be emphasized that obtaining data from both parents and teachers is also critically important for the ongoing monitoring of how a child who has been diagnosed is responding to treatment. Knowing how a child's treatment - regardless of what that treatment consists of - is affecting behaviors specifically targeted for improvement is critical for determining whether treatment is being successful or needs to be modified. As this study makes clear, a treatment provider who relies solely on parent reports for information about a child's behavior at school is likely to receive a different - and probably less accurate - account of what is going on than if the data about school behavior was obtained from the child's teacher. It is thus quite important for parents to insist that periodic feedback from the child's teacher be obtained and conveyed to their child's treatment provider so that appropriate decisions about treatment can be made. (Remember, this is what I developed the ADHD Monitoring System to do. If you have not yet received your copy, just send an email message to monitor@helpforadd.com and it will be sent to you automatically.)
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.