Psychology in the Schools, Vol. 48(2), 2011 C© 2010 Wiley Periodicals, Inc.View this article online at wileyonlinelibrary.com DOI: 10.1002/pits.20536

THE IMPACT OF TEACHER CREDENTIALS ON ADHD STIGMA PERCEPTIONS

LINDSAY BELL, SUSANNE LONG, CYNTHIA GARVAN, AND REGINA BUSSING

University of Florida

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most frequently diagnosed psychi-atric disorders in childhood and adolescence. It is associated with high levels of stigma, which maylead to treatment barriers, self-fulfilling prophecies, and social rejection. This study established thereliability of the ADHD Stigma Questionnaire (ASQ) when applied to teachers by evaluating itsinternal consistency and confirmed the previously reported factor structure. In addition, the studyexamined the extent to which holding a special education certification and having years of teachingexperience impact teachers’ perceptions of ADHD stigma. Results indicated that teachers holdingspecial education certification endorsed higher ratings, which indicated high stigma perceptions, onthe Overall Stigma score, as well as the three subscales, Disclosure Concerns, Negative Self-Image,and Concern with Public Attitudes; however, years of teaching experience was not related to stigmascores. Implications for teacher training practices are discussed. C© 2010 Wiley Periodicals, Inc.

Individuals suffering from a mental illness may not only encounter challenges related to thespecific symptomatology of the disorder. Emotional turmoil, including shame, may also ensue fromthe stigma that others have regarding the disorder (Byrne, 2000). Stigma can be described as a set ofnegative, and often inaccurate, beliefs held by a person or group. The fundamental core of stigma mayperhaps rest on the simple notion of individual differences (Goffman, 1963). People are naturallyinclined to notice disparities between themselves and others, and biases may result when thesedifferences are not understood. Stigma may also be conceptualized as a discrediting attribute that isgiven to an individual based on a physical deformity or blemishes of individual character (Goffman,1963). Stigma can be conceptualized on two different levels—public and individual. Public stigmais often manifested in the forms of prejudice, stereotypes, and discrimination. Self-stigma mayresult when the stigmatized individual begins to accept the beliefs that others hold (Corrigan, 2004).The effects of stigma are not confined to the targeted individual, but may also impact the familiesand friends of the stigmatized individual who may in turn experience courtesy stigma resultingfrom an affiliation with the stigmatized person (Goffman, 1963). According to Rusch, Angermeyer,and Corrigan (2005), stigmatizing beliefs may stem from false suppositions, such as assuming thatindividuals from certain groups are incompetent and inept to make their own decisions and oughtto be feared and excluded. Stigma may be held toward individuals of a variety of backgrounds,including ethnicity, gender, religion, cultural groups, and physical and mental illnesses.

Stigma and Mental Illnesses

A recent review (Angermeyer & Dietrich, 2006) demonstrated the extent to which stigmasurrounds mental illness, particularly for depression, schizophrenia, and bipolar disorder. From theirreview, Angermeyer and Dietrich concluded that misconceptions about mental disorders still exist,intercultural attitudes and beliefs about the disorders vary, and beliefs and attitudes are markedlydifferent depending on the disorder. Additional studies have found discrepancies in public viewsof different mental illnesses; for example, the National Stigma Study (Pescosolido et al., 2008)found that more participants see depression as a serious disorder that is less likely to improve thanAttention-Deficit/Hyperactivity Disorder (ADHD). In the National Stigma Study, fewer than half ofthe respondents could identify what ADHD is and almost one in five rejected the label of mentalillness for ADHD symptoms. Individuals suffering from a mental illness are also more likely to be

Correspondence to: Lindsay Bell, 2000 SW 16th Street, Apt. 24, Gainesville, FL 32608. E-mail: belll@ufl.edu

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held accountable for causing their illness, and are more likely to be victims of stigmatization, thanare those with a physical illness (Rusch et al., 2005).

Costs of Stigma

Research has shown that the effects of stigma are often pernicious. Perhaps one of the mostconcerning impacts of stigma for individuals with mental illnesses is that it serves as a barrier to help-seeking behavior (U.S. Department of Health and Human Services, 1999). Many mental disorderscan be treated with the current advancements of psychiatric and psychosocial treatments; however,many individuals avoid seeking treatment or cease current treatment for fear of being regarded ascrazy or given other negative attributes based on their diagnostic label. Persons who avoid stigma byavoiding psychiatric services are referred to as “potential consumers” (Rusch et al., 2005). Potentialconsumers assume that, to avoid stigma, they must avoid any association with a “mentally ill” group,including through receipt of mental health treatments and services.

Corrigan (2004) identified two reasons individuals may seek to avoid the stigma associated withmental health treatment: it (1) deprives one of social opportunities and (2) decreases self-esteem.Possibly due to a misconception that they are incompetent or irresponsible, individuals with mentalillnesses are often unable to secure jobs or adequate housing conditions. They are also more likelythan others to be arrested (Teplin, 1984), and spend more time incarcerated (Steadman, McCarthy,& Morrissey, 1989). In an attempt to not be deprived of social opportunities, individuals withmental disorders may try to completely avoid the label and the institutions affiliated with the label(i.e., mental health care). Self-stigma may also take a toll on one’s self-esteem, self-efficacy, andconfidence about the future (Corrigan, 1998; Holmes & River, 1998). The quality of life of targetedindividuals undoubtedly suffers when they begin to question their own capabilities.

Stigma and Youth

Relative to the literature on mental health stigma and adults, there is still a dearth of researchfocusing on stigma’s impact on children (Hinshaw, 2005). In addition to a lack of research, thevariability of research methodologies has made it quite difficult to formulate conclusions regardingchildren and stigma (Law, Sinclair, & Fraser, 2007). Findings from a study addressing this difficulty(Adler & Wahl, 1998) highlight the need for more research in this area. Adler and Wahl found thatchildren with mental health issues were described more negatively by peers than were children withphysical disabilities. Children and adolescents with mental disorders are subjected to stigmatization,possibly even more so than peers who are marginalized for other reasons. These authors posit thatthis may be due to the incorrect notion that persons suffering from a mental illness should be heldaccountable for causing their illness. Considering that childhood and adolescence are critical tosocial and emotional development and self-identity formation, the effects of stigma on youth maybe even more profound than has been demonstrated for adults, which only underscores the need formore research in this area.

Stigma and Self-Perceptions of Youth

Although the full impact of stigma on youth has yet to be explored, it appears that childrenreadily internalize negative perceptions held by others about their disorders. For instance, stigma hasbeen shown to result in feelings of isolation and hopelessness (U.S. Department of Health and HumanServices, 1999). Self-esteem and self-confidence were also highly sensitive to perceptions held bypeers, family, and teachers (Guevremont & Dumas, 1994; Wheeler & Carlson, 1994). Similar resultswere found in a sample of college students with symptoms of ADHD (Shaw-Zirt, Popali-Lehane,Chaplin, & Bergman, 2005) who reported lower levels of self-reported social skills and self-esteem

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than their peers without ADHD symptoms. When children and adolescents accept negative beliefsheld by others about them and their disorder, a process of self-fulfilling prophecy may result. Arecent book addressing stigma (Heatherton, Kleck, Hebl, & Hull, 2003) presented three necessaryconditions for a self-fulfilling prophecy to occur: a perceiver holds an inaccurate expectation, theexpectation influences how he or she treats targets, and the targets respond in a way that is consistentwith the expectation. Findings regarding the accuracy and frequency of self-fulfilling prophecies invarying conditions are mixed (Jussim & Harber, 2005). In the case of research on teacher expectationsand self-fulfilling prophecies, this inconclusiveness may be due to internal study flaws (Jussim &Harber, 2005).

ADHD and Stigma

ADHD refers to a diagnostic category characterized by inattentiveness, hyperactivity, andimpulsivity, and it is one of the most frequently diagnosed psychiatric disorders in children and ado-lescents (American Psychiatric Association, 2000). Recent attempts have been made to study andconceptualize the stigma associated with ADHD. In one recent study (Martin, Pescosolido, Olafs-dottir, & McLeod, 2007), participants responded to vignettes portraying individuals with ADHD,depression, “normal troubles,” and a physical illness. ADHD had the highest social rejection rate,followed (in respective order) by depression, “normal troubles,” and a physical illness. The rejec-tion rates were also higher for adolescents than for children. Finally, when participants labeledthe condition as a mental illness, a higher preference was expressed for social distance than whenthe condition was labeled as a physical illness or “normal” situation. In another study (Law et al.,2007), child participants read vignettes about a same-aged peer exhibiting symptoms of ADHD, andthen completed self-reports of attitudes and behavioral intentions. Findings revealed that the childparticipants’ attitudes were predominately negative of the described peer (e.g., perceived as careless,lonely, crazy, and stupid), and a positive correlation was found between attitudes and willingness toengage in social, academic, and physical activities.

Teachers’ Perceptions of Children with ADHD

Besides understanding how children perceive their peers with ADHD, interest has also beendirected toward understanding how teachers may perceive affected students. Considering that ADHDsymptoms are often most salient in classrooms where students are expected to be attentive and calmand to demonstrate self-control, the need for stigma research in an educational setting is quite clear.Research has shown that teachers’ perceptions of a student with ADHD can impact other students’perceptions of the student (Atkinson, Robinson, & Shute, 1997). Teachers may also perceive studentswith ADHD as needing extra instructional time and effort and may be pessimistic about teachingchildren with ADHD (Atkinson et al., 1997; Kauffman, Lloyd, & McGee, 1989). Similarly, Eisenbergand Schneider (2007) found that both teachers and parents held negative perceptions about theacademic skills of students with ADHD.

Furthermore, Chi and Hinshaw (2002) found that these negative perceptions affect teachers’ andparents’ interactions with students with ADHD, which in turn often influences children’s behaviorand academic success. In fact, several studies have addressed the potential for adults’ expectationsto create self-fulfilling prophecies that affect the level of education that the child attains (Madon,Guyll, Spoth, & Willard, 2004). This threat of self-fulfilling prophecy appears particularly salientfor children with ADHD, as Eisenburg and Schneider (2007) found that both teachers and parentsheld more negative perceptions of the academic skills of a child who is diagnosed with ADHDthan of those of a child not diagnosed with ADHD, even if those children have equal academicskills (as measured by standardized assessment instruments) and identical externalizing behaviors

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(as assessed by teachers). Research investigating factors influencing teachers’ perceptions of studentswith ADHD indicates that the more competent teachers feel about their teaching abilities, the morefavorable their attitudes may be about teaching students with the disorder (Rizzo & Vispoel, 1991).

The Present Study

The first study objective is to assess the reliability of the ADHD Stigma Questionnaire (ASQ)when applied to teachers by evaluating its internal consistency as well as confirming the factorstructure reported in a previous study (Kellison, Bussing, Bell, & Garvan, in press). The secondstudy objective is to assess whether teacher perceptions of ADHD stigma encountered by studentswith ADHD vary by teacher credentials and by years of teaching experience. Because specialeducation training conveys in-depth knowledge about children with special needs, including thosewith ADHD, we hypothesize that holding a special education certificate influences teachers’ overallASQ ratings and their the ASQ subscale ratings (Disclosure Concerns, Negative Self-Image, andConcern with Public Attitudes). We expect that teachers holding special education certification willhave increased sensitivity to the issues experienced by children with ADHD, and thus will producehigher ratings on each of the ASQ subscales. Our second hypothesis is that teachers with more yearsof teaching experience will produce higher ASQ ratings as they may have witnessed more eventsindicative of stigma that students with ADHD may have to endure.

METHOD

Participants

The teachers included in this study were identified by students participating in a longitudinalcohort study entitled “ADHD: Detection and Service Use” (Bussing, Zima, Gary, & Garvan, 2003).Students in that study provided a list of several of their academic subject teachers’ names, and theseteachers were invited to complete a behavior rating scale and to participate in the present stigmastudy. If the first teacher on the list did not respond, the next teacher was contacted until a behaviorrating scale was collected. Due to this recruitment method, estimates of participation rates for thecurrent study are difficult to calculate, although we were able to collect behavior rating scales for355 of the 392 child participants (90.56%). Teachers may have completed behavior rating scales formultiple children; however, they only completed the ASQ once. Two hundred sixty-eight teacherselected to participate in the stigma study. Of these, 32% (n = 85) were men and 68% (n = 183)were women. The ethnic composition of the sample was 90.64% (n = 242) White, 6.75% (n = 18)Black, and 2.62% (n = 7) other race/ethnicities. The teachers’ mean age was 42.32 years (standarddeviation [SD] = 12.61 years) and mean years of teaching experience was 14.02 (SD = 11.40).Fifty-three (20.15%) of the participating teachers held special education certificates. This sampleappears to be representative of the population of teachers within the school district, of whom 80.94%are White, 13.82% are Black, and 5.24% are of other races/ethnicities. The gender composition ofthe school district teaching population is 21.4% male and 78.6% female. The mean age for teachersin the school district is 44.81 years (SD = 12.61 years), and the average years of teaching experienceis 14.44 (SD = 11.45). Approximately 18.89% of teachers within the school district hold specialeducation certificates.

Measure

The ASQ is a 26-item adaptation of the 40-item human immunodeficiency virus (HIV) StigmaScale, which was developed to assess stigma experiences among individuals diagnosed with HIV.Further details regarding the development and validation of the original HIV Stigma Scale may

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be found in Berger, Ferrans, and Lashley (2001). To convert this scale to one appropriate forthe assessment of teachers’ perceptions of the stigma that students with ADHD may face, eightclinicians and educators in the fields of psychiatry, clinical psychology, social work, education,school psychology, counseling, and statistics reviewed items from the HIV Stigma Scale that werereworded for use in an ADHD population. These reviewers were asked to determine the relevanceof the items for the purposes of assessing perceived stigma associated with a diagnosis of ADHD.Items with poor conceptual fit (i.e., those items referring to infectious etiology) or statistical fit wereeliminated. The language was transformed from first person to third person because the ASQ wasintended for use with individuals who may not have been diagnosed with ADHD, including teachers.By transforming the language in this manner, the focus was shifted from self stigma to perceptions ofpublic stigma (e.g., “I work hard to keep my ADHD a secret” was changed to “People with ADHDwork hard to keep it a secret”). This way, individuals completing the survey are not required to havepersonally experienced ADHD.

The resulting ASQ includes 26 items and yields a total stigma score as well as three subscales:Disclosure Concerns (7 items; e.g., “People with ADHD work hard to keep it a secret”), NegativeSelf-Image (6 items; e.g., “People with ADHD feel ashamed of having ADHD”), and Concern withPublic Attitudes (13 items; e.g., “People with ADHD are treated like outcasts”). As in the originalscale, participants are instructed to select their response from a 4-point Likert scale (1 = stronglydisagree, 2 = disagree, 3 = agree, and 4 = strongly agree) with higher scores indicating higherstigma perceptions. A copy of the ASQ is shown in the Appendix.

The psychometric properties of the ASQ were evaluated among a community sample of 301adolescents ages 11–19 years at high (n = 192) and low risk (n = 109) for ADHD (Kellison et al., inpress). The scale demonstrated adequate internal consistency (Cronbach’s α = 0.93). Confirmatoryfactor analysis (CFA) using random parceling supported the three-factor structure [χ2 (24) =47.74, p = .003] with highly correlated subscales of Disclosure Concerns, Negative Self-Image,and Concern with Public Attitudes (goodness-of-fit index [GFI] = 0.96; root mean square errorof approximation [RMSEA] = 0.06), and a Schmid–Leiman analysis supported the overall stigmafactor. Test–retest reliability was found to be adequate for all three subscales when assessed fora 2-week interval (n = 45). The time interval between the 2-week test sessions ranged from 9 to32 days, with a median of 15 days and a mean of 17.7 days. The 2-week test–retest intra-classcorrelation for the overall measure was 0.71. Intra-class correlations for the subscale scores rangedfrom 0.55 to 0.73 for 2-week test–retest stability.

Construct validity was supported by relationships with related constructs, including clinicalmaladjustment, depression, self-esteem and emotional symptoms, and the absence of a relationshipwith a largely unrelated concept, school maladjustment (Kellison et al., in press). Convergentconstruct validity was assessed by examining relationships between stigma and emotional constructsthat have been shown to be related (Berger et al., 2001; King et al., 2007; Link, Struening, Neese-Todd, Asmussen, Phelan, 2001; Quinn & Wigal, 2004), including the Behavior Assessment Systemfor Children, Self Report of Personality (BASC-SRP) scores of Clinical Maladjustment, Depression,Self-Esteem, and Emotional Symptoms. Comparison of the slopes of the relationship betweenBASC-SRP Emotional Symptoms Index and ASQ Disclosure Concerns for an ADHD Problemgroup (n = 176) versus a No Problem group (n = 125) revealed a significant moderating effect suchthat increasing Disclosure Concerns were related to increasing Emotional Symptom scores for theADHD Problem group only (p = .002). Similar results were found when comparing the EmotionalSymptoms with the Concern with Public Attitudes subscale as well as with the full ASQ. Comparisonof the slopes for the relationship between Emotional Symptoms and ASQ Negative Self-Imagereached trend level (p = .06). Evidence for a significant moderating effect of a history of ADHDproblems on relationships between stigma perceptions and Clinical Maladjustment, Depression, and

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Self-Esteem was also found as well as a trend level effect for the relationship between ClinicalMaladjustment and Negative Self-Image (p = .10).

Divergent validity is represented by examining the relationship between the instrument ofinterest (in this case the ASQ) and an instrument measuring a different construct (in this case theBASC-SRP School Maladjustment score). Evidence for divergent validity is supported by a lack ofa significant correlation between the two measures (Kazdin, 1998). Kellison and associates chosethe School Maladjustment score because, despite the claim that the composite reflects resentmenttoward teachers, low academic achievement, and disruptive and impulse-control problems at school,fully 14 of 33 items come from the Sensation Seeking subscale, which describes behaviors thatare not clearly school-related (e.g., “Stealing something from a store is exciting,” and “I like to bescared”). The results of their study indicated no significant relationship between adolescent reportsof School Maladjustment and the ASQ or any of its subscales for either the ADHD Problem groupor the No Problem group (see Table 4; all values of p > .05).

Procedure

Student participants of the study “ADHD: Detection and Service Use” were asked to providenames of teachers to receive the ASQ. The ASQ and an informed consent form were then mailedto the teachers, accompanied by a letter inviting them to participate in the study. Demographicand background information was obtained for each teacher through a series of questions precedingthe questionnaire (e.g., “Do you have a Special Education Certificate?”). The ASQ instructs theteachers to complete the questionnaire by circling the answer that best expresses his or her thoughts,opinions, and experiences. Teachers who elected to participate returned the ASQ by mail. The studywas approved by the University Institutional Review Board and the school district research officeand, due to the minimal risk, written informed consent was waived. Consent was obtained by mailingan informed consent form with study information to each teacher, explaining the voluntary nature oftheir study participation, and indicating that return of the completed questionnaire signaled teacherconsent to participate. Participants received $5.00 gift cards for completing the questionnaire.

Data Analysis

Frequency analyses were conducted to reveal which items received the highest number ofendorsements. Coefficient α values were calculated for the total ASQ score and for the threeASQ subscales to assess internal consistency. CFA was performed using random parceling (Little,Cunningham, Shahar, & Widaman, 2002). Random parcels were created due to factor-solution andmodel-fit advantages and in consideration of the psychometric characteristics of the items comparedto the parcels (e.g., item-level data tend to violate distributional assumptions). Once items wererandomly selected from the same domain, the average of the items represented a parcel to be loadedonto the latent variable.

The fit of the three-factor model was examined through the use of several fit statistics. ForRMSEA (Steiger, 1990), values ranging from 0.080 to 0.051 are said to represent “a reasonable errorof approximation,” and values of 0.050 or below represent a “close fit” (Browne & Cudeck, 1993).The GFI (Joreskog & Sorbom, 1996) demonstrates the degree of improvement of fit gained by themodel compared to no model. Similarly, the comparative fit index (CFI; (Bentler, 1990) representsthe improvement in model fit compared to the null model. For each of these indices, values greaterthan or equal to 0.90 are conventionally considered indicative of good fit. Response data were thenanalyzed using bivariate analysis and Spearman correlation procedures.

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FIGURE 1. Percentage of item endorsement by certification status. Roman numberals indicate factor loadings.

RESULTS

Frequency Analysis

Figure 1 illustrates the percentage of teachers with and without special education certificationwho endorsed each item. Items were considered endorsed if they had been rated “Agree” or “StronglyAgree.” A greater percentage of teachers with special education certification endorsed all items exceptone; that item refers to children with ADHD feeling guilty about the disorder. On the remainingitems, between 4% and 31% more teachers holding special education certification indicated thatthey agree with the item than teachers not holding the certification. On many items, the percentageof teachers with special education certification endorsing the item was nearly twice that of teacherswithout certification. On one item, “People with ADHD are rejected when others find out,” certificateholders endorsed the item over four times more frequently.

Overall, the items most frequently endorsed by the entire sample are those related to worryabout others’ reactions to the individual with ADHD and hesitation to reveal the disorder. Theleast frequently endorsed items included those involving actual experiences of rejection, such as jobloss and social exclusion. For each of the five least endorsed items, teachers holding certificationendorsed the item more frequently by a factor of at least 1.8. Thus, a much larger proportion ofteachers holding special education certification than of non-certificate holders feel that children withADHD are experiencing actual rejection related to the disorder.

Factor Structure

The three-factor structure was supported by the CFA. No items were permitted to load on morethan one factor, unlike in the original HIV Stigma Scale. The results of the CFA for the three-factormodel are illustrated in Figure 2. The CFA resulted in satisfactory fit indices with GFI = 0.92,

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FIGURE 2. CFA.

CFI = 0.94, and Non-normed Index = 0.91. The RMSEA fell below the level of “a reasonable errorof approximation” with RMSEA = 0.10; however, this statistic is said to be the most conservativeestimate of fit (Browne & Cudeck, 1993). The results of the factor analysis are illustrated in Figure 2.

Internal Consistency Reliability

Internal consistency reached adequate levels for the Total Score (α = 0.92) and the subscalescores (Disclosure Concerns: α = 0.83; Negative Self-Image: α = 0.80; Concern with Public Atti-tudes: α = 0.84). These internal consistency estimates did not increase with removal of any item;specifically, the ranges of α (if item deleted) for the subscales were as follows: Disclosure Concerns(0.79–0.82), Negative Self-Image (0.76–0.80), and Concern with Public Attitudes (0.82–0.84).The number of items included in each subscale and internal consistency results are demonstrated inTable 1.

Bivariate Analysis

The results of bivariate analysis indicate that the mean Overall Stigma score was 2.41 (SD =0.32). The mean scores for the subscales were as follows: Disclosure Concerns, 2.64 (SD = 0.38);Negative Self-Image, 2.44 (SD = 0.41); and Concern with Public Attitudes, 2.27 (SD = 0.33). These

Table 1Internal Consistency

Factor Name Number of Items Coefficient α (Range of α if Items Deleted)

Disclosure Concern 7 0.83 (0.79–0.82)Negative Self-Image 6 0.80 (0.76–0.80)Concern with Public Attitudes 13 0.84 (0.82–0.84)All Items 26 0.92 (0.91–0.92)

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scores did not vary significantly according to teacher gender, age, or race. In addition, years ofexperience did not influence the levels of Overall Stigma or any of the three stigma subscales (allvalues of p > .25).

Teachers who held special education certificates reported significantly higher (p < .0001)levels of Overall Stigma, with a mean rating of 2.59 (SD = .33) compared to a mean rating of 2.37(SD = 2.30) from teachers who did not hold special education certificates. In addition, teacherswho held special education certificates reported significantly higher ratings on each of the stigmasubscales than did teachers without this certification: For Disclosure Concerns, the mean ratingswere 2.8 and 2.6, respectively (p = .0004); for Negative Self-Image, the mean ratings were 2.62and 2.38, respectively (p < .0001); and for Concern with Public Attitudes, the mean ratings were2.45 and 2.23, respectively (p < .0001).

DISCUSSION

The results of the internal consistency analysis and CFA indicate that the ASQ demonstratesadequate reliability when administered to teachers. These results were congruent with results ofa previous study investigating the psychometric properties of this measure when administered toadolescents (Kellison et al., 2010).

The findings regarding special education certification supported our first hypothesis. As ex-pected, teachers holding special education certifications produced higher ratings on each of thesubscales as well as the overall scale on the ASQ. When interpreting these results, it is important tokeep in mind that the ratings reflect teachers’ perceptions of how their students experience stigma,and not the teachers’ stigmatizing beliefs about their students. These results are consistent with thoseof other studies reporting that specific training, professional development, and in-service trainingsignificantly increase teachers’ knowledge about ADHD and the difficulties that students with thisdisorder face (Jerome, Gordon, & Hustler, 1994; Jones & Chronis-Tuscano, 2008; Vereb & DiPerna,2004; West, Taylor, Houghton, & Hudyma, 2005). Research has also demonstrated that attitudestoward students with ADHD improve as knowledge improves (Ghanizadeh, Bahredar, & Moeini,2006). Perhaps the additional experiences and knowledge acquired during the teachers’ specializededucation training influenced their expectations and beliefs regarding the stigma that students withADHD may encounter.

Besides being attributable to the specialized education experiences of teachers who hold specialeducation certification, our findings may also be explained by the unique instructional environmentin which many special education teachers work. Many of the teachers holding special educationcertification function as teachers in special education classrooms. Thus, they may have increased in-teractions with children with ADHD whose symptomatology is sufficiently severe to require specialeducation accommodations and who may have additional comorbidities. These teachers may haveincreased exposure to students who are experiencing rejection due to the severity of their problems.In contrast, general education teachers’ experience with children with ADHD may be limited to thosestudents whose symptoms are controlled enough to allow them to function in a general educationclassroom. Therefore, special education certification holders may endorse higher ratings regardingthe stigma that their students encounter based not only on their additional education and increased ex-posure to students with ADHD, but also based on their experiences with more severe cases of ADHD.

Our findings regarding years of teaching experience were contrary to our second hypothesis.We expected that teachers with more years of experience would produce higher ASQ ratings becausethey may have witnessed more events indicative of stigma, including stigmatizing beliefs that othersmay hold regarding ADHD. Instead, we found that years of teaching experience did not influenceratings on the overall measure or any of the subscales. Although, to our knowledge, no studies haveexamined the relationship between teaching experience and perceptions of the stigma that students

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with ADHD may encounter, findings from the current study are consistent with findings that teachingexperience was not related to teachers’ ADHD knowledge (Kos, Richdale, & Jackson, 2004; Power,Hess, & Bennett, 1995; Vereb & DiPerna, 2004). Interestingly, Jerome and his colleagues (1994)actually found that recently qualified younger teachers, with less teaching experience, had a sounderknowledge of ADHD than did teachers with more years of experience. A possible explanation forthis finding is that exposure, and not years of experience, may serve as a better predictor of teachers’perceptions of ADHD. Although it is a common assumption, exposure should not be equated withyears of experience, as it is not guaranteed that teachers will have significant interactions over thecourse of their career with students with ADHD. This has been documented by research showing thatthe actual number of students with ADHD taught was not significantly related to years of teachingexperience (Kos et al., 2004). Additionally, teachers who had prior exposure to students with ADHDwere found to have more knowledge about the disorder than did those with no prior exposure (Koset al., 2004; Sciutto, Terjesen, & Bender Frank, 2000). Knowledge and attitudes about ADHD alsoimproved in practicing teachers with the number of ADHD students taught (Bekle, 2004). Perhaps itis the experience of working with students with ADHD, and not years of general teaching experience,that enhances teachers’ perceptions of the stigma that students with ADHD may encounter.

Implications

Although ADHD is one of the most commonly diagnosed psychiatric disorders among childrenand adolescents, teachers’ knowledge and understanding are often still poor regarding some aspectsof students with ADHD and their disability. Unfortunately, general education teachers typicallydo not receive professional development opportunities or specific training related to ADHD. Onestudy found that 77% of practicing teachers reported having no opportunity to learn about ADHDduring their formal teacher preparation training; however, 77% of practicing teachers agreed thatthey would benefit from extra training in ADHD (Bekle, 2004). Just over half had received someform of in-service training related to ADHD, although it was reported to be brief. Similarly, Kosand colleagues (2004) found that 99% of their in-service teacher participants reported that theywould like to receive additional training regarding ADHD, but only 29% of them had actuallyengaged in such training. Many teachers instead rely on television, friends and relatives, periodicals,newspapers, and magazines as their primary sources of knowledge about this disorder (Ghanizadehet al., 2006). As demonstrated in our findings, teachers with additional special education trainingendorsed higher ratings on the ASQ, indicating a heightened awareness of the stigma that thesestudents encounter. Because the teachers with special education certification likely had additionaleducational opportunities and/or exposure to students with ADHD, these findings suggest a needto address education and exposure opportunities for all teachers to improve outcomes for studentswith ADHD. For teachers to better serve students with ADHD, they must be sensitive to andknowledgeable about the vast challenges and stigma that these students may experience, and beaware of their own beliefs and personal biases about this disorder.

One strategy to improve teachers’ knowledge of the stigma that this special population ofstudents may face is to offer additional professional development opportunities, including seminarsand workshops, online instructional courses, and continuing education courses. Teacher educationprograms may also consider incorporating core ADHD-specific units for education students andoffer related pre-service teaching experiences to better prepare teachers to work with studentswith ADHD. There are only a few high-quality studies that examine how teacher professionaldevelopment experiences enhance student outcomes despite the existing ample research on teacherprofessional development (Whitehurst, 2002). Although these studies (Brown, Smith, & Stein,1996; Cohen & Hill, 2000; Kennedy, 1998; Wiley & Yoon, 1995) primarily examined academic

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outcomes, their findings hold promise for using professional development opportunities to improveteachers’ knowledge and ability to work with students. Incorporating ADHD training into universitystudies may also be beneficial. Darling-Hammond (2000) argues that quality teacher education doesmatter for teacher effectiveness, and it is even more important as the student population becomesincreasingly diverse. Bekle (2004) agrees that teacher education is important for improving studentoutcomes. Bekle found that teachers had gaps in their knowledge about ADHD and suggested usingthe university as a place to increase teachers’ theoretical knowledge of ADHD. For these reasons,teacher education programs may consider incorporating core ADHD-specific units for educationstudents to better prepare teachers to work with students with ADHD.

Although ADHD-related education and training may be useful for teachers who work withstudents with ADHD, it may not sufficiently prepare them to meet the diverse needs that theseindividuals experience. Additional opportunities to gain exposure to children with ADHD may benecessary. It should not be assumed that teachers with many years of experience have received thisexposure. As mentioned earlier in this article, years of experience does not guarantee exposure. Forthis reason, veteran teachers with varying years of experience should be afforded, and not exemptfrom, such learning opportunities. Teacher education programs may consider offering pre-serviceteachers practicum placements and volunteer opportunities that offer such exposure. School admin-istrators may help in-service teachers gain additional exposure by giving thoughtful considerationduring classroom placements.

Further investigation into other variables that may be related to teachers’ knowledge, attitudes,and perceptions regarding the stigma that students with ADHD may encounter is necessary. Futureresearch should also be directed toward evaluating existing teacher preparation programs and pro-fessional development activities related to promoting knowledge and accurate beliefs about ADHD.Through these endeavors, a better understanding will be gained about the characteristics and teach-ing credentials that promote quality practice, ultimately providing a context supporting positiveoutcomes for students with ADHD.

Limitations

As is the case with any adaptation of a disease-specific measure for use with a differentcondition, questions arise about the integrity of the adaptation. In this case, we adapted an HIVstigma assessment tool for use in a population of teachers irrespective of their own experiences withADHD. One limitation of this adaptation is that we did not augment the measure with additionalquestions that may be important in an ADHD population. For example, we did not inquire aboutstigma associated with medication. Questions about stigma associated with medication may beparticularly important in this population, and could include beliefs that physicians overmedicatechildren for behavioral problems, fears about stigma stemming from receiving treatment for mentalhealth issues during childhood, and concerns about physical effects of medication on children(Pescosolido et al., 2008). Stigma related to treatment of mental illness might also vary based oncultural background, with reports suggesting that Blacks and Latinos prefer counseling for depressionover medication (Dwight-Johnson & Lagomasino, 2007). Furthermore, no personal health historyinformation was collected from the teachers themselves. Personal experiences related to ADHD orother mental illness may have influenced individual teachers’ ratings on this measure.

APPENDIX

Attention Deficit Hyperactivity Disorder (ADHD) STIGMA QuestionnaireThis study asks about some of the social and emotional aspects of having ADHD. For most

of the questions, just circle the letters that go with your answer. There are no right or wrong

Psychology in the Schools DOI: 10.1002/pits

ADHD Stigma 195

answers, we would just like your opinions. Feel free to write in comments as you go through thequestions.

This set of questions asks about some of the experiences, feelings, and opinions people withADHD might have and how they are treated. Please do your best to answer each question.

For each item, circle your answer: Strongly disagree (SD), disagree (D), agree (A), or stronglyagree (SA).

Strongly Disagree Agree StronglyDisagree (SD) (D) (A) Agree (SA)

1. People who have ADHD feel guilty about it. SD D A SA2. People’s attitudes about ADHD may make persons with ADHD

feel worse about themselves.SD D A SA

3. Someone who has ADHD would think it’s risky to tell othersabout it.

SD D A SA

4. People with ADHD lose their jobs when their employers findout.

SD D A SA

5. People with ADHD work hard to keep it a secret. SD D A SA6. Someone with ADHD feel they aren’t as good a person as

others because they have ADHD.SD D A SA

7. People with ADHD are treated like outcasts. SD D A SA8. People with ADHD feel damaged because of it. SD D A SA9. After learning they have ADHD, a person may feel set apart

and isolated from the rest of the world.SD D A SA

10. Most people think that a person with ADHD is damaged. SD D A SA11. A person with ADHD feels that they are bad because of it. SD D A SA12. Most people with ADHD are rejected when others find out. SD D A SA13. People who have ADHD are very careful about who they tell. SD D A SA14. Some people who learn of another person having ADHD grow

distant.SD D A SA

15. After learning they have ADHD, people worry about othersdiscriminating against them.

SD D A SA

16. Most people are uncomfortable around someone with ADHD. SD D A SA17. People with ADHD worry that others may judge them when

they learn that they have ADHDSD D A SA

18. People with ADHD regret having told some people that theyhave ADHD.

SD D A SA

19. As a rule, people with ADHD feel that telling others that theyhave ADHD was a mistake.

SD D A SA

20. People don’t want someone with ADHD around their childrenonce they know that person has ADHD.

SD D A SA

21. Some people act as though it’s the person’s fault that theyhave ADHD.

SD D A SA

22. People with ADHD have lost friends by telling them they haveADHD.

SD D A SA

23. People with ADHD have told others close to them to keep thefact that they have ADHD a secret.

SD D A SA

24. The good points of people with ADHD tend to be ignored. SD D A SA25. People seem afraid of a person with ADHD once they learn

they have ADHD.SD D A SA

26. When people learn that someone has ADHD, they look forflaws in their character.

SD D A SA

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196 Bell et al.

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