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Educational practitioners’ beliefs and conceptualisation about the cause of
ADHD: A qualitative study
This is an Accepted Manuscript of an article published by Taylor & Francis
in Emotional and Behavioural Difficulties on 1st February 2016, available
online: http://www.tandfonline.com/doi/10.1080/13632752.2016.1139297.
Abigail Emma Russell1*, Darren A. Moore1and Tamsin Ford1
1 University of Exeter Medical School, University of Exeter, UK
* Corresponding author:
a.e.russell@exeter.ac.uk
Acknowledgements
The authors thank Sophie Arnell and Marianne Tay for their help with data collection for this
project, and Ginny Russell for her continuing support and advice. This research was supported
by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied
Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation
Trust. The views expressed are those of the authors and not necessarily those of the NHS, the
NIHR or the Department of Health. This study was funded by a University of Exeter Medical
School PhD studentship.
Declaration of Conflicting Interests
None.
Abstract
Objectives: Educational practitioners play an important role in the referral and treatment of
children with attention-deficit/hyperactivity disorder (ADHD). This study aimed to explore how
educational practitioners’ conceptualise their beliefs about the causes of symptoms of ADHD.
Method: 41 educational practitioners from schools in the UK participated in focus groups or
individual interviews. Data were analysed using thematic analysis. Results: Practitioners’ beliefs
fell into two categories: biological and environmental. Practitioners conceptualised the causes of
ADHD in lay-theoretical models: a ‘True’ ADHD model considered that symptoms of ADHD in
many cases were due to adverse environments; and a model whereby a biological predisposition
is the root of the cause of the child’s symptoms. Conclusion: Differential beliefs about the causes
of ADHD may lead to practitioners blaming parents for a child’s behaviour and discounting
ADHD as a valid condition. This has implications for the effective support of children with
ADHD in schools.
Keywords: ADHD, teachers, schools, theory, mental health
Introduction
Scientific understanding of causes of ADHD
Current understanding of the causes and aetiology of attention deficit/hyperactivity
disorder (ADHD) considers the interaction of a network of biological, psychological and social
factors, with a strong genetic predisposition that may be differentially expressed (Faraone et al.
2015). These factors may interplay to increase or decrease risk of ADHD. ADHD is also
considered as a dimensional disorder where symptoms can be considered a trait-like measure
rather than as a distinct category (Shah and Morton 2013). The inter-relationship between genetic
and environmental risk factors has led to the suggestion that it may be unhelpful and incorrect to
dichotomise genetic/biological and environmental explanations at all (Thapar et al. 2013).
Despite this, much research has focused on disentangling these two influences (Knopik et al.
2006; Nikolas and Burt 2010), although researchers more recently have promoted the study of
gene-environment interactions (Ficks and Waldman 2009; Rutter, Moffitt, and Caspi 2006).
Evidence is mounting for environmental moderation of genetic influences on ADHD (Nikolas,
Klump, and Burt 2015) and although ADHD is still considered to be influenced by heritable
factors, environmental factors at home and school may amplify or diminish the development
and/or the impact of ADHD symptoms (Tarver, Daley, and Sayal 2014). Thus, current research
suggests that the causes of ADHD are complex, multi-dimensional and interacting.
ADHD and school
Children spend much of their lives in school. As educational practitioners often work with large
numbers of children, they are aware of developmental norms and are well-placed to recognise
when a child is struggling, either academically or socially. Therefore educational practitioners
play an important role in referral of children for potential diagnosis of ADHD. Educational
practitioners are also well placed to deliver treatment to support these children in a setting where
inattention, restlessness and impulsivity pose particular challenges. Phillips (2006) frames
teachers’ involvement as ‘sickness and treatment broker’ (p433) as well as ‘an informal role as
disease-spotters’ (p434). The UK’s National Institute for Health and Care Excellence (NICE)
clinical practice guidelines recommend that teachers who have received training about ADHD
and its management should provide behavioural interventions in the classroom to help children
and young people with ADHD (NCCMH, 2011).
Educational practitioners are key in identifying when children may have ADHD and
communicating this to parents, however their beliefs about the cause of these symptoms may
impact on whether they advocate referral of children with suspected ADHD (Hillman 2011).
When considering a diagnosis of ADHD, medical professionals investigate whether the
symptoms occur across settings, thus multiple perspectives on a child are often sought. Lee
(2008) asked early childhood teachers in the USA about their interactions with the parents of
children with ADHD symptoms, and all had experience of liaising with parents who viewed their
child’s behaviour differently to the teacher, emphasising the need for multiple perspectives to
inform understanding of the problems the child is experiencing.
Educational practitioners’ beliefs about what underpins ADHD behaviour may affect the
use of any teacher-led interventions in school (Vereb and DiPerna 2004). It has been suggested
that if the treatment recommended by healthcare professionals is in line with teachers’ beliefs,
teachers are more likely to implement and adhere to it (Eckert and Hintze 2000). This applies to
both medication and behavioural management for children with ADHD, and may impact on the
effectiveness of school-based interventions and strategies used in order to facilitate the progress
of the child (Moore et al. 2015). If practitioners are unaware of causes of ADHD or endorse
beliefs that lead them away from using school-based interventions recommended for children
with ADHD, this can have long term impacts on the child’s achievement and well-being.
Existing research
Teachers’ knowledge of the causes of ADHD has been explored in quantitative research,
which suggests that many teachers endorse biological and medical models of ADHD, and do not
typically believe that it can be caused by poor parenting (Anderson et al. 2012; Bekle 2004;
Couture et al. 2003). The majority of qualitative research exploring the causes of ADHD samples
parents rather than teachers. For instance, Harborne, Wolpert, and Clare (2004) interviewed ten
parents who had sons with ADHD. They found that parents believed the causes of ADHD to be
biological in nature; however they felt that others (including teachers) believed the cause to be
poor parenting, leading parents to feel blamed.
One study used vignettes (written descriptions of an often-hypothetical child) and open-
ended questions to explore what teachers believe is the cause of a child’s problem behaviour
(Hillman 2011). Hillman found that responses fell into two categories: medical and non-medical,
although she did not discuss whether teachers endorsed both categories or had polarised beliefs
(Hillman 2011). Vignette studies such as these leave little room for exploration of what teachers
experience in their day-to-day work with real children with ADHD, however there is limited
research of any kind in this field. Einarsdottir (2008) interviewed 16 Icelandic teachers about
their experiences around ADHD. The teachers expressed the opinion that ADHD was innate
within the child. The teachers further distinguished between a ‘badly behaved’ child and a child
with ADHD by whether, given time, the child could and would learn the rules of the school. Lee
(2008) found that three of ten teachers interviewed about ADHD suggested that in their
experience ADHD was more often found in children from socioeconomically disadvantaged
backgrounds, and the notion of a child having ‘no structure at home’ was also mentioned. This
reflects quantitative findings that ADHD is more prevalent in socioeconomically disadvantaged
groups (Russell, Ford, and Russell 2015).
A recent review of non-pharmacological interventions for ADHD notes the gap in
research conducted in the United Kingdom (UK) surrounding teachers’ beliefs about the causes
of ADHD (Richardson et al. 2015). Previous qualitative research with teachers has been
conducted in the USA, Iceland, and Korea. To our knowledge the current study is the first to
explore these issues in the UK. Existing studies are limited by a narrow age range of children
taught (often ages 4-7) and have not explicitly explored educators’ beliefs about the children with
ADHD they have worked with. Previous research is often restricted to teachers rather than other
educational practitioners who have experience working with children with ADHD in schools. In
addition, educational practitioners have a wealth of first-hand experience of children with ADHD
symptoms, and their insights, beliefs and theories about the causes of ADHD may be captured to
usefully inform current research directions about causes and nosology of ADHD.
Aims of the current study
The current study therefore aims to use qualitative research methods in order to address a
topic that we know little about: how do educational practitioners in the UK conceptualise the
causes of ADHD? The study also aims to go beyond some previous research to include views of
the wide range of educational staff who may work with children with ADHD within their job
role, for example teaching assistants (TAs), head teachers, pastoral care workers and special
educational needs and disabilities co-ordinators (SENDCo’s) in addition to teachers. This is in
order to capture the experiences of the full range of practitioners who work with children with
ADHD in the school setting. There are two specific research questions:
1. What do educational practitioners believe are the causes of symptoms of ADHD?
2. How do educational practitioners conceptualise these causes?
Methods
Participants
Participants were 41 educational practitioners that self-identified as having worked with
children or young people with ADHD, recruited from 223 schools in the South West of England.
Schools were approached either by email from the lead researcher to a named contact or through
a newsletter. If a school expressed interest in participating, a named contact, often the head
teacher or SENDCo, acted as gate-keeper and liaised with the researcher in identifying staff with
relevant experience who were interested in participating.
Practitioners were recruited from three types of school; primary (ages 4-11), secondary
(ages 11-18) and pupil referral units (PRUs; also known as alternative provision, for pupils
excluded from mainstream education, ages 5-18). Practitioners had a range of educational roles:
11 were teaching or learning support assistants (LSAs); 18 were teachers, team leaders or head of
year; six had responsibilities as SENDCo’s; three were involved in pastoral support for students;
three were deputy head teachers and two were head teachers. There was a wide range of
experience represented across practitioners: the average length of experience was 14 years (range
0-35 years). Nine practitioners were male. Practitioners could not recall precisely how many
children they had worked with that had a diagnosis of ADHD, although estimates ranged from 1-
40. Most practitioners stated that over their career they had worked with many more children
who had symptoms of ADHD but had no formal diagnosis that practitioners were aware of. Table
1 supplies a summary of participant information.
Table 1: Characteristics of participants
Characteristic N
Female 32
Primary 19
Secondary 7
PRU 15
Worked with ages 0-4 14
Worked with ages 5-11 33
Worked with ages 11 and up 25
Worked with <10 children with ADHD
diagnosis 13
Worked with ≥10 children with ADHD
diagnosis 12
Teacher 16
TA/LSA 11
Co-ordinator or team leader or head of year 11
Pastoral support 3
SENDCo 6
Head/deputy head teacher 5
Notes: Numbers may not add up as several practitioners had several roles within the school
and some had worked with a large range of age groups. TA: Teaching assistant, LSA: learning
support assistant, SENDCo: special educational needs and disabilities co-ordinator
Data collection
41 practitioners took part in either one of six focus groups or three individual interviews.
We used focus groups where there was more than one participant from a school, otherwise
individual interviews were conducted. Focus groups had on average seven practitioners.
Interviews and focus groups took place at the school where the practitioners worked; with minor
exceptions based on participant request and convenience. The use of focus groups in
combination with individual interviews in qualitative research is well established (Morgan 1996).
Focus groups allow breadth of experience and views around a topic to be elicited as well as
exploring mutual experiences and understandings. Interviews can explore individuals’
experiences and views in greater depth, thus the two techniques complement each other to allow
for a rich understanding of both individual experiences and beliefs, and how these are understood
and expressed in the wider social context of the school (Michell 1999; Bauer, Yang, and Austin
2004).
Each interview or focus group lasted between 40 minutes and one hour, the length was
determined by the amount of time practitioners had available. Both interviews and focus groups
followed the same topic guide which covered various areas of experiences working with children
with ADHD, including what practitioners believed about the causes of ADHD, and were semi-
structured. Practitioners provided informed consent before taking part and were given the
opportunity to choose a pseudonym to be used for the study analysis and write-up. The
University of Exeter Medical School research and ethics committee provided ethical approval for
this study.
Procedure
All focus groups and interviews were conducted by the lead author (AER), who has prior
experience working as a TA in a specialist school, and an academic background in psychology. In
focus groups she was assisted by one of two psychology undergraduate research students who
took field notes in order to aid later transcription and to ensure all topics were covered. To
encourage participation and discussion in focus groups all practitioners were encouraged to
express their views, and at the end of each focus group or interview practitioners were given an
explicit opportunity to add or raise any other issues they wished to discuss. Incentives were not
provided with the exception of light refreshments during the session.
Analysis
Audio recordings were transcribed verbatim by the two research students and
transcriptions were checked by AER prior to data analysis. Transcripts were then read and re-
read by AER and DM. Data were analysed using thematic analysis as outlined by Braun and
Clarke (2006). Thematic analysis is a flexible method for analysing qualitative data that assumes
no specific epistemological or theoretical approach and can be used to identify, analyse and
organise repeating patterns within data. There is a focus on identifying features of the data,
known as codes, then organising these into patterns of responses related to research questions,
known as themes (Braun and Clarke 2006). In order to generate initial codes AER and DM first
read and discussed two focus group transcripts to generate an initial overarching coding
framework. AER and one of the two research students then independently coded each transcript
within this framework, which also allowed space for new codes to be generated. Coding each
transcript twice increased the reliability of the analysis. This coding was amalgamated using
NVivo version 10 with similar codes or synonyms being merged and novel codes preserved in
order to retain the maximum level of detail at this stage.
The coded data were grouped into tentative themes and subthemes by AER and DM.
These were reviewed to ensure that collated extracts formed a pattern and we explored whether
these themes appeared credible in the context of the entire data set as well as ensuring that all
data relevant to a theme had been coded appropriately. This process continued in an iterative
manner until a thematic map was drafted. Themes were clearly defined in order to identify and
describe their core aspects. Although this process is described linearly, in actuality analysis was
cyclical and reflexive (Braun and Clarke 2006).
Results
The thematic analysis identified six themes relevant to the two research questions.
Themes and key findings are summarised below in Table 2.
Table 2: Research questions, themes and key findings
Research
Question
Theme Findings
What do
educational
practitioners
believe about the
causes of ADHD?
Biological
Practitioners put forth a variety of biological
attributions for the causes of ADHD including
those based in the brain and genetic causes.
Practitioners displayed a lack of detailed
knowledge about these biological attributions.
Environmental
Practitioners commonly attributed the cause
of ADHD behaviours to be due to the home or
parenting. Others mentioned diet as an
exacerbating factor. Practitioners infrequently
discussed the role of the school context in the
child’s symptoms.
How do
educational
practitioners
conceptualise the
causes of ADHD?
‘True’ ADHD
Practitioners in several focus groups put
forward the theory of there being a true or
pure ADHD that is biologically caused, rarely
seen in their experience, and the child is
perceived to have no volitional control over
their symptoms. This is positioned at one end
of a continuum, with the other end being
environmentally-caused ADHD.
Environmental
ADHD
This is the other end of the spectrum from
True ADHD. Environmental ADHD was
discussed by a number of practitioners as
being a misdiagnosis of ADHD, the
symptoms of which were caused entirely by
the environment and thus were not truly
ADHD. Practitioners believed this to be the
most common cause of ADHD behaviour that
was seen in their particular school.
Biology exacerbated
by environment
The majority of practitioners believed that
ADHD was caused by biological factors;
however the impacts of this predisposition
could be exacerbated or ameliorated by the
environment in which the child is raised.
Environment
becoming biology
Some practitioners discussed a critical or
sensitive period early in childhood where
negative experiences due to the environment
could become biologically entrenched and
therefore lead to ADHD as a biological
manifestation
1. What do practitioners believe about the causes of ADHD?
Most practitioners discussed ideas around both biological and environmental causes for
ADHD and factors that exacerbate or ameliorate symptoms. These were, however, differentially
endorsed and expressed, with biological factors most frequently assumed to be the main cause of
ADHD. Practitioners described these biological factors as being ‘in the brain’ or genetic.
However, compared to biological causes, practitioners discussed environmental factors for
longer, and in more detail and depth. In terms of environmental causes for symptoms,
practitioners had more elaborate views that included areas of home and parenting, diet and
school. These views mirror those reported by Hillman (2011), who categorized beliefs into
‘medical’ (in this case biological) and ‘non-medical’ (environmental) viewpoints. In this study
practitioners did not often consider these polarised views as mutually exclusive and were
accepting of colleagues with opposing views within focus groups.
Biological
Many practitioners acknowledged ADHD as a disorder with a biological cause, as Rose
summarises: ‘Well it has to be biologically caused if we’re going to give it a medical label
doesn’t it really’ (teaching role: SENDCo, school type: Secondary). When practitioners spoke
about the biological basis for ADHD they distinguished between neurological deficits, including
imbalances of neurotransmitters, and genetics. Practitioners were explicit about their lack of
detailed knowledge about the biological causes of ADHD; Tarquin finishes a discussion with
colleagues about the possibilities: ‘yeah, I dunno if genetics affects it or what… you know, some
sort of biological thing’ (deputy head teacher, PRU).
In the brain. The majority of practitioners discussed biological or neurological causes,
with attributions for symptoms being varied. Practitioners provided explanations that clearly
situated the cause of ADHD as neurological: ‘I think it’s partly just the way the brain sort of fires
off really’ (Janet, teacher and co-ordinator, Secondary). Hannah discusses this further: ‘I have
heard…that brain scans can show a difference in the brains of people with ADHD and people
without’ (LSA, Primary). Occasionally practitioners explicitly based their assumptions on the
basis that methylphenidate/Ritalin is given as a treatment for ADHD, thus assuming that ADHD
has a neurological basis:
‘I assumed it’s some sort of chemical imbalance, I’ve always assumed that because then
if you give them Ritalin which is a chemical it affects, it in some way it calms that’
(Briony, SENDCo, Secondary).
Genetic. Some practitioners mentioned that the causes of ADHD are ‘like a genetic thing’
(Tarquin, deputy head teacher, PRU). Others mentioned the heritability of ADHD, for example
Victor discusses children who are strikingly like their parents: ‘they were literally carbon copies
of each other and you think is that in the gene pool somewhere possibly’ (teacher and co-
ordinator, Primary). As ADHD known to be highly heritable (Faraone et al. 2015), it is likely
that a substantial proportion of children with ADHD have a parent with ADHD. When
practitioners describe ADHD as running in families, these influences on the child may be a
mixture of genetics compounded by the environment created by the parent, who may struggle
with maintaining routine and consistency due to their symptoms (Weiss et al. 2000).
Lack of knowledge. In discussing biological causes of ADHD, practitioners often used
vague language or stated that they were unsure, reflecting their lack of expertise on the subject.
Kitty frames this as a lack of sufficient qualification: ‘I wouldn’t be qualified to say what that
[medical/genetic element] was and where you draw the line’ (SENDCo, Primary, author edits in
square brackets). This reflects findings of studies with parents, who report that they do not know
about causes of ADHD (Bussing et al. 2003). Practitioners in the current study often discussed
ways in which they attempted to acquire this knowledge, be it asking colleagues, reading
research or from the wider media:
‘One of the teaching assistants at school has an ADHD son and I asked her what she
thought the causes were’ (Ellen, teacher and co-ordinator, Primary);
‘[I] watched a documentary on it; it’s about a woman who had a diagnosis’ (Victor,
teacher and co-ordinator, Primary).
Neurological and genetic research into ADHD suggests high heritability, genetic links to
neurotransmitters and anatomical differences in structural and functional brain imaging (Cortese
et al. 2012; Faraone et al. 2005). However, these are not sufficiently elucidated to inform
assessment and intervention so perhaps this lack of detailed knowledge is unsurprising.
Environmental
The majority of discussion around the subject of what causes ADHD symptoms was
environmentally focussed, with elaborate and specific references to environment being common.
Perhaps this was because practitioners felt they had sufficient experience and knowledge to
elaborate on environmental causes. The environment was sometimes talked about in the context
of ameliorating symptoms:
‘I think it can be exacerbated by various environmental factors, like…how much support,
emotional support and guidance kids are given and probably also diet’ (Hannah, LSA,
Secondary).
Environmental causes and exacerbating factors mentioned by practitioners included
home/parenting; diet; and school, which are discussed in the following subthemes.
Home/parenting. A number of practitioners talked about parents and the home
environment as being the cause of many of the behaviours seen in children with ADHD: ‘I would
say it was to do with upbringing or amount of contact with parents’ (Kate, TA, Primary). This
attribution was often framed negatively: ‘It could be bad parenting, it could be absent parenting’
(Sally, TA, Primary); ‘What he’s…come from and experienced is really quite crippling for any
child’ (head teacher, Primary). This finding is in contrast to previous research, where teachers
and education students were more likely to endorse statements that placed the cause of ADHD as
biological rather than consider parenting as a cause (Bekle 2004; Couture et al. 2003).
There were instances where practitioners were empathetic towards parents, whilst still
holding them responsible for their child’s symptoms, as Ryan sympathises:
‘the parents of these children are just people as well who come with their own baggage…
you may see that parent doing things which aren’t healthy and aren’t great for the child,
actually maybe it’s because they’re struggling to really make sense of how to parent as
well’ (pastoral leader, Primary).
This resonates with literature around the challenges of parenting a child with ADHD, and
the criticisms and stigma endured by such parents (Peters and Jackson 2009), as well as parents’
opinions that others blame them for their child’s difficulties (Harborne, Wolpert, and Clare
2004).
Most of the practitioners who blamed environmental factors considered the behaviours
shown by the children to be learned from home, Sparky sums up her experiences:
‘All the children that I’ve worked with ADHD, my opinion would be that it’s very…learnt
behaviours from birth, in the sense that they have no structure, they have no boundaries,
they haven’t ever learnt to sit still and listen…and then they can’t cope later on in life
with sitting still and listening’ (deputy head teacher, Primary).
Diet. Although practitioners did not often explicitly name diet as a cause of ADHD, it
was discussed several times due to the perceived role practitioners thought it plays in
exacerbating children’s hyperactive behaviour, as Kate emphasises: ‘If you gave them certain
foods, they would be completely uncontrollable and you would not have any…sort of ability to
keep up with them’ (TA, Primary). In a different school setting Bryony reflects on the same issue:
‘We’ve got some of course that possibly have ADHD behaviours but have a high sugar intake…
which cannot be helping [their] behaviours’ (teacher, PRU). Whilst empirical evidence has
shown no causal association of diet with ADHD, the current findings are in line with evidence
that fatty acid supplementation and exclusion of artificial food colourings may be effective
methods for improving symptoms of ADHD (Bloch and Qawasmi 2011; Sonuga-Barke et al.
2014).
School. Few practitioners mentioned the role that school can have in creating or
exacerbating behaviours. Aspects of the school that practitioners did speak about included school
context, classrooms, peers and particular lessons. TAs were most likely to discuss the
implications of context on behaviour; Jemima presents a broad view: ‘I don’t think classrooms
are necessarily the best, they are not set up really…to suit children, they’re set up to suit adults’
(TA, PRU); whereas Alice discusses specific examples where she sees her pupil’s behaviour
worsen: ‘German lessons…because it’s a language lesson they are encouraged to call out
things…and that’s when she goes completely…hyper’ (LSA, Secondary). This lack of explicit
mention of the school context by teachers is found in other research (Gwernan-Jones et al. 2015).
Potential explanations for this are that because practitioners are unable or unwilling to alter this
context they do not discuss its role in children’s behaviour. This might explain why it is
practitioners in support roles who are more likely to acknowledge the role of school in ADHD
symptoms. Alternatively, because school practitioners are immersed in the same context as the
child, they may not see how this context impacts the child’s behaviour (Gwernan-Jones et al.
2015).
2. How do educational practitioners conceptualise the causes of ADHD?
Practitioners went further than listing simple causal factors of ADHD as discussed in
section 1. We now describe how practitioners theorise how this range of causes fit together in the
context of their experiences with students with ADHD. These lay-theories about the precise
causes of ADHD and what exactly should be diagnosed as ADHD are interpreted in this section.
These ideas include a continuum with ‘True’ ADHD at one end and Environmental ADHD at the
other, as well as alternative theoretical explanations: Biology exacerbated by environment and
Environment becoming biology.
Extremes of the spectrum: ‘True’ ADHD and environmental ADHD
Several focus groups discussed the idea of there being a pure, real or true form of ADHD
that would be characterised by several aspects. Practitioners considered true ADHD as:-
•biologically caused/innate: ‘true ADHD people who have either got a chemical
imbalance or the genetic disposition’ (Kate, TA, Primary)
•rarely seen: ‘Probably about 10% of the children [with ADHD have] that pure’ (Tommy,
teacher, Primary)
•the child has a perceived lack of control over their behaviour: ‘Those that seem not to be
able to help themselves’ (unknown, Primary)
•symptom intensity is severe: ‘really active or…extreme [symptoms]’ (Katie, SENDCo,
Primary).
This ‘true’ ADHD is considered to represent ‘The end of the end of the continuum’
(Victor, teacher and co-ordinator, Primary) of ADHD-like behaviours. Practitioners describe this
type of ‘true’ ADHD as pure, or high, contrasting with other literature where pure ADHD is
defined as when a child has no coexisting disorders in addition to their ADHD (Kadesjö and
Gillberg 2001).
At the far end of the spectrum away from ‘true’ ADHD, practitioners consider there to be
ADHD that is currently clinically diagnosed yet is caused by the environment:
‘A lot of the children that I’ve worked with who’ve had that diagnosis…a lot of it I would
say was to do with upbringing or amount of contact with parents or…almost like
attachment’ (Kate, TA, Primary).
Several practitioners express the opinion that if this is indeed the cause, a diagnosis of
ADHD should not be given, either because a developmental or attachment-related disorder is
more appropriate, or because they consider this as labelling bad behaviour with no evidence of a
medical cause:
‘I wonder if it is misdiagnosed and I see similarities between children with ADHD and
children with developmental disorders, ones that have had trauma in their lives, family
breakdowns, mothers not always there’ (Laura, student support co-ordinator, Secondary)
‘It would be nice if it was a medical problem you could then call it ADHD and if it wasn’t
a medical problem and you grew up and you’ve learnt it or something, it’s just “you’re a
little bit naughty”’ (Tommy, teacher, Primary).
Only one participant overtly rejected ADHD as a concept, with practitioners in general
having ‘no doubt ADHD exists’ (Laura, student support co-ordinator, Secondary); this contrasts
with findings that 20% of SENDCo’s surveyed in the UK in 2008 did not believe that ADHD is a
‘real’ neurological condition (O’Regan 2009). This may be due to increased social visibility of
ADHD or to an increase in rates of diagnosis (Akinbami, Liu, Pastor, & Reuben, 2011; Atladottir
et al., 2015).
One method that practitioners used to differentiate between true and not-true ADHD was
to speculate: for example Tommy questions his colleagues ‘and if that child had been taken at
birth and given to another parent, would that child mentally be different?’ (teacher, Primary).
Webb (2013) puts forward the idea that there may be two discrete aetiological pathways
to ADHD: one due to genetics, and the other due to severe adverse childhood experiences.
Practitioners’ theory of ‘True’ ADHD reflects these two groups. However, unlike the
practitioners that endorsed ‘True’ ADHD, Webb also acknowledges that there will be a group of
children who overlap, those who have a genetic predisposition toward ADHD-like behaviours
and environmental factors which exacerbate this. This is reflected in the findings of a separate
theory proposed by practitioners, described in the following theme (Biology exacerbated by
environment).
Biology exacerbated by environment
Many practitioners conceptualise ADHD as being caused by a biological entity, but state
that environmental conditions that the child grows up in can ameliorate or exacerbate their
behavioural problems: Alice describes her own theory: ‘it’s something that you’re born with …
however I think that home situations can improve it or make it worse’ (LSA, Secondary).
In general, practitioners talked more about the exacerbating factors than those that may
help the child overcome the problems:
‘it’s genetic and then the way you’re brought up your sort of channelled in the right
direction …you could turn it down a bit … but if you then have that kind of upbringing
it’s going to make it worse’ (Jane, SENDCo/teacher, PRU).
Research supports associations between environmental adversity and ADHD (Russell,
Ford, and Russell 2015; Biederman, Faraone, and Monuteaux 2002; Webb 2013), and indeed
focus on building resilience and ameliorating risk may be an effective management approach for
children with ADHD who have also experienced environmental adversity (Alvord and Grados
2005).
Environment becoming biology
Several practitioners discussed how things that happen early in a child’s life can become
biologically hardwired and therefore not alterable by changing the environment:
‘I think the child’s younger years [before age six] as well are so formative in their lives…
that I think possibly by the time a child is that much older, that it, the patterns are so
entrenched, perhaps hard to tell the difference between what was nature and what was
nurture... so fundamentally it actually has become a physical part of how they work’
(Ryan, pastoral leader, Primary)
This appeared to be linked to knowledge of attachment and attachment disorders with
which practitioners seem more familiar than ADHD, as Laura says: ‘I’ve done a little bit about
attachment disorders and I think there are similarities there’ (student support co-ordinator,
Secondary). Practitioners also imply that there is a critical or sensitive period of development
(Bornstein 1989), whereby by the age of six they believe that further changes to environment
will not change the child’s underlying pathology. Anna discusses both of these ideas in
combination, putting forward the idea that neurological changes occurring because of poor
attachment early in life lead to ADHD behaviours later in childhood ‘you know links in your
brain that don’t happen because of poor attachment…so I do think it’s all to do with those first’
(teacher, Primary).
Discussion
Summary
Practitioners in this study represented a range of experience, roles and viewpoints around the
topic of ADHD. When discussing what causes ADHD, practitioners endorsed two points of view:
that it was either biological in nature, or it was environmentally constructed, often due to an
adverse home environment. The views held by practitioners were nuanced and sophisticated, and
the range of theories put forward reflects current research literature, despite practitioners’
opinions that they lacked knowledge regarding the specific biological causes of ADHD.
However, practitioners emphasised more their understanding of theories that have less empirical
support (e.g. those of Webb) and were likely to dismiss well-supported theories (e.g. the high
heritability of ADHD) as not applying to the majority of children they have worked with. It is
important not to consider the lay-theories of practitioners and empirical evidence as representing
‘right’ or ‘wrong’; indeed, they can be viewed as complementary.
Practitioner theories as evidenced by this study can inform future research directions
about the causes of ADHD. Educational practitioners have a wealth of experience working with
children with these difficulties, and their understandings could allow epidemiologists to take
advantage of expertise of those with direct and personal knowledge of ADHD by incorporating
the ideas about causes and nosology into future research designs. In addition this study
contributes to understanding dilemmas educational practitioners face when working with
children with ADHD and enables us to identify reported gaps in their knowledge.
Further theoretical elaboration
Based on the views of the practitioners around causes of ADHD, we have constructed a
model to capture beliefs about the causes of ADHD (see Figure 1.). Theory 1 reflects that severe
ADHD symptoms (in the presence of a good environment) are due to solely biological
predisposition; these were considered by practitioners to be ‘True’ ADHD. At the other extreme
(Theory 4), symptoms can be caused entirely by the environment with minimal or no biological
contribution; practitioners considered this to be a misdiagnosis of ADHD. Practitioners believe
severe adversity early in life can become biologically ‘hardwired’ (Theory 3); these thoughts
were based on practitioners’ knowledge of child development and attachment disorders, where
early experiences are thought to alter the formation of neural pathways. It would therefore be of
interest to explore and further understand whether educational practitioners’ causal beliefs
moderate their adherence to treatments for children with ADHD.
Figure 1: Practitioners’ causal explanations for ADHD
Notes: 1– ‘True’ ADHD characterized as biologically caused, severe, uncontrolled and rare. 2a–
Biological predisposition to ADHD ameliorated by good environment, symptoms are milder. 2b–
Biological predisposition to ADHD exacerbated by poor environment, symptoms are more severe. 3–
Poor environment causes symptoms, becomes hardwired and therefore a biological condition. 4–
Symptoms caused entirely by poor environment, considered by educational practitioners to be a
misdiagnosis of ADHD.
Theories 2a and 2b focus on how the environment affects biological predisposition and
encompasses symptom severity. In both 2a and 2b all children with ADHD have a biological
predisposition to the constellation of symptoms. This in turn can then be ameliorated (2a) or
exacerbated (2b) by the environment that the child grows up in. Most practitioners acknowledged
home and parents to be key elements of this, and some mentioned the impact of peers and the
school context as other pertinent factors.
How do these beliefs compare to the current empirical literature on ADHD?
ADHD is currently thought to be a highly heritable disorder, with environmental factors
impacting on risk and resilience (Faraone et al. 2015). However, recently the idea that there may
be two discrete causes for ADHD, or types of ADHD has been forwarded (Webb 2013; Russell,
Ford, and Russell 2015); one environmentally caused by extreme adversity and one with
biological origins. If this is indeed the case it is of interest that practitioners consider
environmentally-caused ADHD to be a ‘misdiagnosis’ rather than the same disorder with
different aetiological pathways. Practitioners do however propose a separate environmental
pathway to ADHD, whereby early adversity has negative impacts on the developing brain that
lead to symptoms becoming irreversible. Whether or not they would consider this to then be
‘True’ ADHD is unknown. We suggest that participants’ theories around this subject appear to be
based on their understanding of the impact of attachment on development, and the impacts of
early problems with attachment on brain development. On the whole however, practitioners were
vaguer about biological concepts than environmental. We suggest that this is because educational
practitioners feel most comfortable talking about their field of expertise, but also that this reflects
their knowledge; practitioners are likely to have more experience of how environmental
adversity affects children than knowledge of the specific biological mechanisms of ADHD, thus
they draw on their knowledge in order to conceptualise and form an understanding of the causes
of ADHD.
Our findings somewhat reflect those of Couture et al. (2003) in that the majority of
practitioners felt that ‘True’ ADHD had a biological cause. However, practitioners in our study
rarely reflected on and endorsed societal level explanations for ADHD, unlike those in Couture
et al.’s study. The themes ‘biological’ and ‘environmental’ also reflect the findings of Hillman
(2011) where practitioners’ classifications fell into two categories of cause: medical or non-
medical. However, unlike Hillman, we found an interaction between these two classifications as
some practitioners described ADHD being primarily caused by biological factors but exacerbated
by environmental factors, as well as the concern that early adversity may predispose children to
develop entrenched behaviours.
The source of information and theory generating among practitioners was often
interesting. Because practitioners are aware that the medicines used to treat ADHD work ‘in the
brain’, they reason that ADHD must have some biological root. The interviewer was often asked
questions before and after the data collection about how Ritalin works and how it was developed,
and practitioners were often surprised when informed that it was discovered to work by chance
and not because of an elaborate neurochemical understanding of ADHD (Lange et al. 2010).
Practitioners discussed obtaining information from a variety of sources that they drew upon in
order to form their own conceptualisations of the causes of ADHD including parents, media and
direct experience, although they considered their knowledge of biological causes of ADHD
under-developed.
How practitioners’ beliefs about the causes of ADHD align with the school ethos and
behavioural management practices may play a role in how the practitioner responds to the
individual child (Ajzen and Fishbein 1977). This is supported by one focus group run in a
secondary school where the practitioners had a very clear stance on ADHD as a medical disorder.
This allowed them to put forward a coherent plan as to how both the school and individual staff
could best support any child with this diagnosis whilst allowing for the individual needs of each
child. Taken together with the lack of (and thirst for) knowledge of ADHD displayed by
practitioners in the study, research and development of accessible psychoeducational programs
for practitioners as well as evidence based guidelines for schools are called for.
Strengths and Limitations
This study is the first qualitative study of UK teachers’ attitudes and experiences of
ADHD. The methodology and recruitment had a variety of strengths; schools of varying
provision were included covering the full age range of compulsory education in the UK, and
tapping into specialist provisions for children who were not educated within the mainstream
setting. We also recruited any educational practitioner who had experience working with children
with ADHD, not just teachers. Limitations are that the study was conducted in a relatively small
geographical area, and the sample cannot be inferred to be representative of all educational
practitioners, so generalisability of findings is limited. However, conceptualisations of ADHD
were validated within other focus groups and interviews within the study, which allows us to
tentatively infer that these views may be present in the wider educational community in the UK.
Our sample was self-selected, therefore they might not be representative of those who would not
volunteer to participate in research or engage in a focus group with colleagues. However, we
believe we have managed to capture the views of those with a wide range of experience by
including all educational practitioners and by the participation of those with a spectrum of years
of experience.
Recommendations for future research
This study has a variety of implications. Firstly, if educational practitioners believe that
when a child’s ADHD difficulties are seen to be caused by an adverse home life this may be a
misdiagnosis of ADHD, they may then be less likely to take the child’s problems seriously.
However, multiple routes to health outcomes are not unknown. For example diabetes can be
caused by both heritable and lifestyle factors: the cause does not influence how we treat
individuals. Therefore any child with a diagnosis of ADHD should be able to access treatment.
However this may be compromised by the beliefs of educational practitioners if they block
access to treatment or stigmatise the child for the perceived cause of their behaviour. Further
research would also benefit from extending the ideas and models presented here with both
qualitative and quantitative research techniques.
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