Effects of Child Gender and Symptom
Type on Referrals for ADHD by
Elementary School Teachers
MARK J. SCIUTTO, CARA J. NOLFI, AND CARLA BLUHM
Estimates of the prevalence of attention-
deficit/hyperactivity disorder (ADHD)
have consistently indicated that boys are
diagnosed more frequently than girls, re-
gardless of the population sampled (Amer-
ican Psychiatric Association [APA], 2000).
However, the ratio of boys to girls is con-
siderably higher (6:1 to 9:1) in clinical
(i.e., referred) samples than in nonreferred
samples (2:1 to 3:1), indicating that boys
are being referred disproportionately more
frequently than girls (Gaub & Carlson,
1997; Gershon, 2002). This study exam-
ines whether a bias in teachers’ percep-
tions of boys’ and girls’ behaviors may
contribute to gender differences in ADHD
referrals.
Some researchers have suggested that
the discrepancy between referred and
nonreferred samples may be the result of
gender differences in the expression of
ADHD symptoms (Arcia & Conners,
1998; Biederman et al., 2002; Gaub &
Carlson, 1997). Boys with ADHD typi-
cally exhibit higher levels of hyperactiv-
ity, conduct problems, aggressiveness,
and other externalizing symptoms, which
teachers perceive to be more disruptive
and stressful (Gaub & Carlson, 1997; Ger-
shon, 2002; Greene, Beszterczey, Katzen-
stein, Park, & Goring, 2002). Girls with
JOURNAL OF EMOTIONAL AND
I
n this study, the authors investigated the effects of child gender and attention-deficit/hyperactivity dis-
order (ADHD) symptom type on elementary school teachers’ referral decisions. Participants (N =
199) read a profile of a fictional child’s academic record and rated the likelihood of referring the child
for an evaluation. The profiles varied by the child’s gender and the type of symptoms the child was ex-
hibiting (inattention, hyperactivity, or hyperactivity plus aggression). Results indicated that teachers were
more likely to refer boys than girls, regardless of symptom type, but that the largest gender difference in
referrals was for children who exhibited hyperactivity without inattention or aggression. These results
suggest that differences in teacher perceptions of boys’ and girls’ behaviors may contribute to gender dif-
ferences in ADHD referrals.
ADHD, however, tend to exhibit lower In studies of referred samples, there have
levels of disruptive behavior and higher been few gender differences in the symp-
levels of inattentiveness, internalizing toms of ADHD (Breen & Altepeter, 1990;
symptoms, and social impairment (Bie- Nolan et al., 1999; Sharp et al., 1999).
derman et al., 2002; Carlson, Tamm, & Some researchers have argued that the rel-
Gaub, 1997; Gaub & Carlson, 1997; Ger- ative lack of gender differences in symp-
shon, 2002). This pattern of symptoms is toms within referred samples may indi-
less likely to disrupt the classroom and cate that only the most impaired girls are
may be more readily overlooked. Conse- being referred (Arcia & Conners, 1998;
quently, discrepancies in the prevalence of Gaub & Carlson, 1997; Nolan, Volpe,
ADHD in referred and nonreferred sam- Gadow, & Sprafkin, 1999).
ples may simply reflect differences in the Given that boys exhibit more disrup-
types of symptoms that are prominent in tive symptoms of ADHD and have a
boys compared to girls. higher frequency of comorbid disruptive
Evidence for the symptom expression behaviors, the discrepancy between re-
explanation comes from findings that gen- ferred and nonreferred samples is not sur-
der differences in the expression of prising. However, it is unclear whether
ADHD have been most pronounced in the symptom expression explanation ac-
studies using nonreferred samples (Carl- counts for the full magnitude of differ-
son et al., 1997; Gaub & Carlson, 1997). ences in prevalence between referred and
B E H AV I O R A L DISORDERS, WINTER 2004, VOL. 12, NO. 4, PAG E S 247–253 247
nonreferred samples. It is also possible
that girls are less likely to be referred be-
cause teachers have different thresholds
for referring boys, as compared to girls. In
other words, it is not solely that boys and
girls differ in the nature of the symptoms
they exhibit but that teachers view the
same symptoms differently in boys and
girls.
Although this “threshold” hypothesis
has not been tested directly, the potential
for bias in teacher (and parent) ratings of
behavior is well documented (Hinshaw &
Nigg, 1999; Stevens, Quittner, & Abikoff,
1998). There is evidence that teacher rat-
ings are subject to a number of specific
cognitive processes that may impact re-
ferral including “halo effects” (Abikoff,
Courtney, Pelham, & Koplewicz, 1993;
Schachar, Sandberg, & Rutter, 1986; Stev-
ens et al., 1998) and cultural expectations
(Mann et al., 1992; Reid et al., 1998). Fur-
thermore, research on referral decisions
has indicated that teachers’ decisions to
refer a child are frequently related to
factors other than to the problem behav-
ior itself including age (Wisniewski, An-
drews, & Mulick, 1995), height and
weight (Andrews, Wisniewski, & Mulick,
1997), race (Andrews et al., 1997), and so-
cioeconomic status (SES; Meijer & Fos-
ter, 1988; Podell & Soodak, 1993). Simi-
larly, teachers’referral decisions may also
be influenced by gender (Breen & Alte-
peter, 1990; Podell & Soodak, 1993).
Some support for a potential gender
bias in teachers’ referral decisions comes
from studies of treatment acceptability. In
their study of teachers’ perceptions of
ADHD interventions, Pisecco and his col-
leagues found that child gender affected
teachers’ perceptions of interventions for
ADHD (Pisecco, Huzinec, & Curtis, 2001).
Specifically, teachers believed that med-
ication would be more effective and work
more quickly for boys than for girls. How-
ever, teachers perceived behavioral inter-
ventions to be more effective and to work
more quickly for girls than for boys.
Pisecco and colleagues suggested that
pretreatment beliefs about the effective-
ness and timeliness of ADHD interven-
tions may influence referral decisions.
Consequently, to the extent that teachers
differ in their perceptions of appropri-
248 JOURNAL OF EMOTIONAL AND
ate interventions for boys and girls, we
might expect to see gender differences in
referral.
Although several researchers have spec-
ulated about a potential perceptual bias as
an explanation for gender differences in
referral rates for ADHD, researchers have
not investigated this question using an ex-
perimental methodology. Because symp-
tom expression differs by gender, studies
of children actually diagnosed with ADHD,
although higher in ecological validity,
would not permit more definitive causal
statements about the effects of gender on
referral. Therefore, in this study, we used
an analogue methodology similar to Pi-
secco et al. (2001) to examine the effects
of child gender and symptom type (i.e.,
inattentive, hyperactive, and hyperactive
plus aggression) on teachers’ recommen-
dations to refer a child to a school psy-
chologist. If gender differences in refer-
rals are solely a function of differences in
the expression of symptoms, then we
would not expect differences in teachers’
decisions to refer boys and girls exhibit-
ing the same behavior. However, if gen-
der differences in referrals remain when
symptoms are held constant, then there
would be evidence that gender bias may
also contribute to teachers’ decisions to
refer boys and girls with ADHD symp-
toms.
METHOD
Participants
Participants were 199 elementary school
teachers (18 men, 181 women) from
northeastern Ohio. Teachers’ ages ranged
from 23 to 66 (M = 44.63, SD = 9.88) and
their years of teaching experience ranged
from 1 to 40 years (M = 18.11, SD = 9.93).
A majority of the sample had earned at
least a master’s degree (69%), and most of
the sample (80%) taught in Grades 1
through 4. With regard to ADHD experi-
ence, 74% of the sample reported making
at least one previous ADHD-related re-
ferral, and nearly all (99%) of the teach-
ers reported teaching at least one child
with ADHD. Most of the teachers (89%)
taught in public schools, and these schools
B E H AV I O R A L DISORDERS, WINTER 2004,
were generally located in suburban areas
(56% suburban, 29% city, 15% rural).
Materials and Measures
Child Background Profile and Ques-
tionnaire. The child background profile
contained an excerpt from a fictional
child’s academic record. Each profile was
approximately two pages long and de-
picted a 7-year-old child who was experi-
encing significant impairment in his or her
school functioning. Specifically, grades,
teachers’ comments, and standardized
achievement test scores were included for
each year depicted in the profile (kinder-
garten, first grade, current grade). In terms
of academic performance, each profile de-
picted a child who exhibited inconsistent
performance with several very low grades.
For each year, teacher comments included
a paragraph (5–6 comments) describing
the child’s behavior in class. After review-
ing the child’s information in the profile,
each teacher rated the likelihood that he
or she would refer the child to a school
psychologist for evaluation on a scale of
1 (definitely would not refer) to 6 (defi-
nitely would refer). We also asked each
teacher to rate how disruptive this child
would be in a typical classroom environ-
ment on a scale of 1 (not at all disruptive)
to 6 (extremely disruptive).
To test the effects of child gender and
symptom type, we altered the child’s gen-
der (John vs. Jennifer) and the type of
symptoms the child was exhibiting (inat-
tentive, hyperactive, or hyperactive plus
aggression). All other information in the
child’s profile (e.g., grades, test scores)
was identical across conditions. To ma-
nipulate child gender, the child’s name
and relevant pronouns were changed
throughout the background profile. To
manipulate ADHD symptom expression,
we altered teacher comments across the
three symptom-type conditions to reflect
the desired forms of symptom expression.
Table 1 contains sample teacher comments
from each of the three symptom-type con-
ditions. We included the inattention and
hyperactivity conditions to reflect hall-
mark symptoms of ADHD according to
the Diagnostic and Statistical Manual of
Mental Disorders–Text Revision (DSM-
VOL. 12, NO. 4
IV–TR) criteria (APA, 2000). Because the
higher rates of comorbid aggression
among ADHD boys has been linked to
gender differences in ADHD referrals, we
also included a hyperactivity plus aggres-
sion condition. This condition allows for
a direct test of the effects of child gender
on referrals when comorbid aggression is
present.
For the symptom-type manipulation to
be interpretable, it was necessary to ver-
ify that the teacher comments contained
in the background profile accurately re-
flected the intended symptoms. As a ma-
nipulation check, we asked a sample of ex-
pert judges (8 practicing psychologists, 16
psychology graduate students) to review
the experimental materials. Specifically,
we randomly assigned one of the six ver-
sions of the profile to each judge. Each
judge used a 7-point scale (1 = Mild, 4 =
Moderate, 7 = Severe) to rate the levels of
inattention, hyperactivity, and aggression
exhibited by the child in the profile. Re-
sults supported that each level of the
symptom-type variable was in fact pri-
marily measuring the desired symptom.
For instance, expert ratings of the inatten-
tive profile resulted in significantly higher
ratings of inattention than of hyperactiv-
ity and aggression. Likewise, the hyper-
active only and hyperactive plus aggres-
sion profiles differed only in ratings of
aggression.
ADHD Knowledge. The Knowledge
of Attention Deficit Disorders Scale
(KADDS; Sciutto, Terjesen, & Bender
Frank, 2000) is a 36-item scale that mea-
sures teachers’ knowledge of the symp-
toms, associated features, and treatment
of ADHD. In previous studies, internal
consistency of the KADDS total score has
ranged from .81 to .86 (Bender, 1996;
Sciutto et al., 2000). Cronbach’s alpha for
the KADDS in this study was .84. With
regard to validity, researchers have found
that KADDS scores are sensitive to edu-
cational interventions and are positively
related to relevant teacher characteristics
(e.g., prior experience, self-efficacy; Ben-
der, 1996; Sciutto et al., 2000).
Demographic Questionnaire. Teach-
ers supplied information regarding their
age, gender, teaching experience (e.g,
JOURNAL OF
TABLE 1
Sample Teacher Comments From the Child Background Profile
Symptom type condition
Inattention
Hyperactivity
Hyperactivity plus aggression
years of experience, grades taught), and
the characteristics of the school in which
they taught (e.g., location, type). Teachers
also provided information about their pro-
fessional and educational experience with
ADHD children (e.g., number of articles
read, number of ADHD children taught)
and the number of ADHD-related refer-
rals that they made in the past. To account
for the possibility that teachers with more
years of experience may have made more
referrals, we computed a referral history
score, in which we divided the total num-
ber of ADHD-related referrals by the
number of years of teaching experience.
Higher numbers represent a higher rate of
prior referrals for ADHD-related issues.
Procedure
We recruited teachers from 15 elementary
schools in northeastern Ohio. After we re-
ceived permission from the school super-
intendent, we identified a contact person
from each participating school to distrib-
ute the experimental packets and consent
EMOTIONAL AND B E H AV I O R A L DISORDERS,
Sample teacher comments
“Occasionally, I have to specifically draw his/her at-
tention to what I’m explaining because s/he seems
to be in a daze.”
“The slightest noise or movement distracts his/her
attention from his/her work and s/he has trouble
refocusing after the distraction.”
“S/he is easily excitable and is unable to calm down
after recess or free play.”
“John/Jennifer has a difficult time sitting quietly during
class.When given an assignment, s/he often fidgets,
talks, and stands up while trying to complete
his/her work.”
“John/Jennifer is a child who seems to have trouble
staying in his/her seat during class. Oftentimes, in
the middle of a lesson, s/he starts taunting the
other students by calling them names and teasing
them.”
“John/Jennifer has difficulty with self-control during
class. Sometimes, s/he threatens the children in the
class.”
forms. A total of 300 packets were dis-
tributed across the 15 schools. Teachers
who received the experimental packets
constituted our target sample. Of the 300
packets distributed to the target sample,
200 were returned. Data from one teacher
were discarded due to response inconsis-
tency and missing information, resulting
in a usable response rate of 66%. Re-
spondents in this study did not receive any
form of incentive for their participation.
The relatively high response rate was
likely the result of having an easily ac-
cessible contact person at each school.
Participating teachers first completed the
child background profile and question-
naire, followed by the KADDS and the
demographic questionnaire. Upon com-
pletion of the materials, teachers returned
the packet to the contact person and re-
ceived a debriefing form.
RESULTS
Although we randomly assigned each
teacher in the target sample to one of the
WINTER 2004, VOL. 12, NO. 4 249
six versions of the child background pro- nality, which is not the case with unbal-
file, returned responses were distributed anced designs (Keppel, 1991). One method
unevenly across the six experimental con- of analyzing unbalanced designs is to con-
ditions (see Table 2). According to Kep- duct an analysis of unique sources of vari-
pel (1991), two primary problems are as- ability (Howell, 2002; Keppel, 1991). To
sociated with unbalanced designs. First, if analyze our data, we used sums of squares
the unequal sample sizes resulted from that reflected unique sources of variabil-
factors that are systematically related to ity for each effect, which was accom-
the experimental methods, then the bene- plished by specifying the Type III sum of
fits of random assignment are lost. In our squares option available in SPSS®. Be-
study, the differential response rate across cause these sums of squares reflect vari-
conditions does not appear to be due to ability unique to each effect, the prob-
any systematic methodological factors, and lematic interdependence of treatment
there were no significant differences in effects in the unbalanced design is mini-
teacher characteristics across the six con- mized (Keppel, 1991).
ditions. Specifically, comparisons across
the six experimental conditions revealed
no significant differences in age, F(5,
Perceived Disruptiveness
193) = 0.38, p = .865; years of teaching Because gender differences across re-
experience, F(5, 193) = 0.44, p = .819; ferred and nonreferred samples have been
knowledge of ADHD, F(5, 193) = 1.47, attributed to differences in the nature of
p = .202; or number of ADHD children the symptoms expressed (i.e., boys exhibit
taught, F(5, 193) = 0.68, p = .641. Second, more disruptive symptoms), we con-
unequal cell sizes in a two-factor ANOVA ducted a 2 (child gender) × 3 (symptom
are also potentially problematic because type) analysis of variance using teachers’
traditional computations for the sums of ratings of perceived disruptiveness as the
squares assume the property of orthogo- dependent measure. There was no signif-
TABLE 2
Adjusted Means and Standard Errors for Likelihood of
Referral Ratings by Teachers
Symptom type Boy Girl Total
Inattentive
M 4.74 4.52 4.63
SE 0.249 0.230 0.177
N 29 38 67
Hyperactivity
M 5.45 4.12 4.79
SE 0.257 0.240 0.177
N 26 30 56
Hyperactivity plus aggression
M 5.17 4.86 5.02
SE 0.194 0.254 0.163
N 49 27 76
Total
M 5.12 4.50
SE 0.133 0.135
N 104 95
Note. Referral ratings were made on a 6-point scale (1 = definitely would not refer, 6 = definitely would
refer). Covariate = ratings of perceived disruptiveness.
250 JOURNAL OF EMOTIONAL AND B E H AV I O R A L DISORDERS, WINTER 2004,
icant main effect of child gender, F(1,
193) = 0.59, p = .445, d = 0.111 (see
Note 1), and no gender by symptom in-
teraction, F(2, 193) = 0.87, p = .422, d =
0.19. However, there was a significant
main effect of symptom type, F(2, 193) =
31.67, p < .001, d = 1.15. Post-hoc com-
parisons, using the Hochberg (1988; see
also Jaccard & Guilamo-Ramos, 2002)
modification of the Bonferroni correction,
indicated that, regardless of child gender,
teachers perceived the inattentive profile
to be significantly less disruptive than the
hyperactive, t(193) = 5.90, p < .001, d =
0.85, and the hyperactive plus aggression
profiles, t(193) = 7.56, p < .001, d = 1.09.
There was no significant difference in per-
ceived disruptiveness between the hyper-
active and hyperactive plus aggression
conditions, t(193) = 1.23, p = .221, d =
0.18.
Not surprisingly, teachers’ perceptions
of the disruptiveness of the child’s behav-
ior were positively related to likelihood of
referring the child for evaluation, r(197) =
.26, p < .001. Ratings of disruptiveness
were not related to years of experience,
r(197) = –.05, p = .526; ADHD knowl-
edge, r(197) = –.03, p = .655; or teachers’
referral history (i.e., number of ADHD-
related referrals per year of experience),
r(195) = .02, p = .776. Men and women
teachers did not differ in their ratings of
perceived disruptiveness, F(1, 197) = 0.02,
p = .904, d = 0.02.
Likelihood of Referral
Because perceived disruptiveness was re-
lated to likelihood of referral, we ran a
2 (child gender) × 3 (symptom type)
analysis of covariance using perceived
disruptiveness as the covariate and likeli-
hood of referral as the dependent measure.
Controlling for perceived disruptiveness
provides a direct test of whether a gender
bias exists independent of the manage-
ment challenges associated with the dif-
ferent types of symptoms. Descriptive sta-
tistics for referral ratings are presented in
Table 2.
After controlling for perceived disrup-
tiveness, the likelihood of referring the
child for an evaluation was influenced by
child gender, F(1, 192) = 10.68, p = .001,
VOL. 12, NO. 4
d = 0.47. Teachers were more likely to
refer boys than girls, regardless of the
symptom type. However, there was also a
significant gender by symptom interac-
tion, F(2, 192) = 3.30, p = .039, d = 0.37.
Interaction contrasts indicated a signifi-
cantly larger gender discrepancy in teacher
ratings in the hyperactive profile com-
pared to the inattentive and hyperactive
plus aggression profiles. Specifically,
teachers were more likely to refer boys
than girls for all symptom types, but this
difference was statistically significant
only for the hyperactivity condition. Teach-
ers were approximately 1.5 times more
likely to refer a hyperactive boy than a
hyperactive girl (odds ratio = 1.55) (see
Note 2). Parameter estimates and inferen-
tial statistics for the interaction contrasts
are presented in Table 3. It was also of the-
oretical interest to analyze differences
across symptom types within each gen-
der (i.e., simple main effects contrasts).
Analysis of the contrasts, using the Hoch-
berg (1988; see also Jaccard & Guilamo-
Ramos, 2002) modification of the
Bonferroni correction, indicated that hy-
peractive girls were less likely to be re-
ferred than girls with hyperactivity plus
aggression (odds ratio = 1.31). None of
the remaining simple main effects con-
trasts were statistically significant after
applying the Hochberg correction (see
Table 3).
Teachers’ decisions to refer the child
depicted in the profile were positively re-
lated to teachers’ referral history (i.e.,
number of ADHD-related referrals per
year of experience), r(195) = .22, p = .002.
Referral ratings were not related to years
of experience, r(197) = .07, p = .355;
ADHD knowledge, r(197) = .01, p = .890;
or number of ADHD children taught,
r(197) = .09, p = .226. Men and women
teachers did not differ in their likelihood
of referring the child described in the pro-
file, F(1, 197) = 1.04, p = .310, d = 0.15.
DISCUSSION
Boys are diagnosed with ADHD more fre-
quently than girls, regardless of the pop-
ulation sampled. However, the ratio of
boys to girls diagnosed with ADHD is
considerably higher in clinical (i.e., re-
ferred) samples than in nonreferred sam-
ples. Some researchers have proposed that
this discrepancy is a reflection of boys
typically exhibiting more disruptive be-
haviors than girls (Arcia & Conners, 1998;
Biederman et al., 2002; Gaub & Carlson,
1997). The results of the present investi-
gation suggest that a gender bias in teacher
perceptions of children’s behavior may
also contribute to referral bias. When pre-
sented with the same symptom profile,
teachers in this study were more likely to
refer a boy than a girl, particularly when
the child displayed symptoms of hyper-
activity without inattention or aggression.
Because teachers (within each level of
symptom type) all read the same descrip-
tion of the child’s behavior, any differ-
ences are attributable to the child’s gender
and not the actual symptoms.
In this study, teachers were more likely
to refer boys than girls for all symptom
types, but this difference was statistically
significant only for the hyperactivity con-
dition. Gender differences in the inatten-
tion and hyperactivity plus aggression
conditions, although in the same direc-
tion, were considerably smaller in magni-
tude and not statistically significant. This

TABLE 3
Parameter Estimates and Inferential Statistics for Likelihood of Referral Interaction
Contrasts and Simple Main Effects

95% CI
Contrast Parameter SE t p Lower Upper

SME: I – H/O for boys −0.71 0.352 2.02 .045 −1.41 −0.02
SME: I – H/O for girls 0.40 0.319 1.26 .211 −0.23 1.03
SME: I – H/A for boys −0.43 0.306 1.41 .161 −1.03 0.17
SME: I – H/A for girls −0.34 0.328 1.04 .302 −0.99 0.31
SME: H/O – H/A for boys 0.28 0.317 0.89 .377 −0.34 0.90
SME: H/O – H/A for girls −0.74 0.346 2.14 .034a −1.42 −0.06
IC1: I – H/O for boys and girls −1.11 0.475 2.34 .020a −2.05 −0.17
IC2: I – H/A for boys and girls −0.09 0.449 0.20 .841 −0.98 0.80
IC3: H/O – H/A for boys and girls 1.02 0.469 2.18 .031 0.10 1.95

Note. CI = confidence interval; SME = simple main effect contrast; IC = interaction contrast; I = inattention condition; H/O = hyperactivity only condition;
H/A = hyperactivity plus aggression condition. Degrees of freedom = 192.
aStatistically significant using the Hochberg (1988) modification of the Bonferroni correction.

JOURNAL OF EMOTIONAL AND B E H AV I O R A L DISORDERS, WINTER 2004, VOL. 12, NO. 4 251
pattern of results suggests that if a gender
bias in teacher perceptions exists, it may
be primarily in response to symptoms of
hyperactivity and not to milder (inatten-
tion) or more severe (hyperactivity plus
aggression) impairments. However, we
also found that hyperactivity (with and
without aggression) was perceived as
more disruptive than inattention alone.
This finding is consistent with evidence
that gender differences in referral reflect
gender differences in symptom expres-
sion. Therefore, our results do not dispute
the effects of gender differences in symp-
tom expression but suggest instead that a
bias in teacher perceptions may also in-
fluence referral decisions.
Although our data suggest that teach-
ers may view the behavior of boys and
girls differently, it is not clear specifically
how teacher perceptions influence refer-
ral decisions. For a teacher to initiate a
clinical referral, he or she must first iden-
tify that there is a problem and then de-
cide whether outside assistance is war-
ranted. A gender bias in teacher referrals
may occur at either step in this process.
For instance, gender differences in teacher
referrals may be the result of increased
problem identification in boys. Specifi-
cally, teachers may notice certain behav-
iors more readily in boys and may be more
likely to label those behaviors as prob-
lematic. Alternatively, teachers may not
differ in their identification of problem be-
haviors in boys and girls but may differ in
their self-efficacy or in what they see as
the most appropriate course of action. A
gender bias in either the identification or
decision steps might lead to boys being re-
ferred more frequently than girls. Based
on our data, we cannot definitively con-
clude whether any potential gender bias in
referrals is due to a bias in the problem
identification step or in the decision step
of the referral process. Additional re-
search that examines the reasoning pro-
cess that teachers use when making refer-
rals is necessary to more definitively
evaluate the reasons for a gender bias in
teacher referrals. Specifically, future re-
search should examine factors that might
mediate teachers’ referral decisions, such
as self-efficacy (Martin, Linfoot & Steph-
252 JOURNAL OF EMOTIONAL AND
enson, 1999; Meijer & Foster, 1988; Po-
dell & Soodak, 1993) and beliefs about
appropriate interventions (Pisecco et al.,
2001).
A significant limitation of this study
was that it used an analogue methodology.
Our results are based on teachers’ re-
sponses to a hypothetical written descrip-
tion, which may not reflect the complex-
ity of information that teachers typically
face when considering a referral. Teach-
ers’ referral decisions in this study may
differ in important ways from their deci-
sions in school settings. However, the pur-
pose of this study was to examine whether
a bias in teacher perceptions exists and
how it might contribute to gender differ-
ences in referral. Because clinical studies
typically look at gender differences among
already referred children, differences in
symptom expression are confounded with
gender, which complicates an examina-
tion of bias. Analogue methodologies,
such as the one used in this study, may pro-
vide unique and important information
about decision-making processes, par-
ticularly when investigating questions of
bias (Huebner, 1991). Analogue method-
ologies will be most useful when they
are used to supplement more naturalistic
methods. Therefore, future studies in this
area should replicate and extend our find-
ings, using more diverse methodologies
(e.g., videotapes of a child’s behavior; see
Abikoff et al., 1993).
Because our sample consisted of pri-
marily women teachers from northeastern
Ohio, the results of this study may not gen-
eralize to other populations. Although the
sample was representative in some as-
pects (experience, grades taught, experi-
ence with ADHD), replication with a
more diverse sample of teachers would
also be valuable. In particular, future stud-
ies should attempt to obtain a larger sam-
ple of men teachers to examine if a
teacher’s gender plays a role in referrals
of boys and girls. Although men and
women teachers in this study did not dif-
fer in their likelihood of referral, it is pos-
sible that the effect of the teacher’s gen-
der in referral decisions depends on the
gender of the child. Although the ratio of
women to men teachers in our sample is
B E H AV I O R A L DISORDERS, WINTER 2004,
similar to national statistics for elemen-
tary school teachers (U.S. Department of
Education, National Center for Educa-
tion, Statistics, 2002), our study did not
include a large enough sample of men
teachers to reliably evaluate the possibil-
ity of an interaction effect.
Finally, teachers initiate nearly 75% of
all special education referrals (Lloyd,
Kaufman, Landrum, & Roe, 1991), and
they are often seen as the most valuable
source of information about a child’s be-
havior (Loeber, Green, & Lahey, 1990).
Because teachers are such an integral part
of the referral process, any bias in teacher
perceptions may have important conse-
quences for the child and for the school.
To minimize inaccuracies or omissions in
referrals for ADHD, particularly among
girls, future research should extend the re-
sults of this study by examining the spe-
cific mechanisms through which teach-
ers’ beliefs and experiences influence the
referral of children with ADHD.
About the Authors
MARK J. SCIUTTO, PhD, is an assistant
professor of psychology at Muhlenberg Col-
lege. His research interests include factors
influencing the referral, assessment, and di-
agnosis of childhood disorders. CARA J.
NOLFI, MA, is currently a graduate student
in school psychology at John Carroll Univer-
sity. Her interests include learning disabilities,
ADHD, and autistic spectrum disorders.
CARLA BLUHM, PhD, is currently a visit-
ing assistant professor of psychology at Al-
legheny College. Her interests include child
development, human–animal interaction, and
environmental psychology. Address: Mark J.
Sciutto, Department of Psychology, Muhlen-
berg College, Allentown, PA 18104; e-mail:
sciutto@muhlenberg.edu
Notes
1. Effect sizes (Cohen’s d ) were computed
using POWPAL (Gorman, Primavera, &
Allison, 1995), a computer program for es-
timating effect sizes, statistical power, and
sample size from summary statistics.
2. To compute an odds ratio for this compar-
ison, we used a linear transformation to
convert the original referral likelihood
scores (1–6 scale) to a 0 to 1 scale (i.e,. 0,
0.2, 0.4, 0.6, 0.8, 1.0). Regression analyses
VOL. 12, NO. 4
 using these transformed scores provided
probability estimates for each cell (i.e.,
using the unstandardized regression coeffi-
cients). The odds ratio for this contrast was
calculated by using a ratio of the probabil-
ities for the two cells involved. Specifically,
the probability of referring a hyperactive
boy was .754, and the probability of refer-
ring a hyperactive girl was .487. The re-
sulting odds ratio was (.754/.487) = 1.55.
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