The Teacher Says ADHD, the Mother Says Fine: Resolving Informant Disagreement in the Evaluation of a Seven-Year-Old Girl, and Finding a Reading Problem and a Divorce Behind the Referral
[Student Name]
University of Phoenix
PMH/505: Psychiatric Management Of Children And Adolescents
Week 1 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Lily, age 7, was referred by her pediatrician after her second-grade teacher reported that she does not finish work, stares out the window, gets up often and has cried twice in class. The teacher's Vanderbilt rating is positive for inattention. Her mother, Ms. K., rates her in the normal range and says Lily is "the same happy kid at home." Ms. K. is frustrated with the school and wants to know whether Lily has ADHD. What follows describes how the evaluation reconciled these accounts and what it found.
Why Informants Disagree
Achenbach et al. (1987) meta-analyzed correlations between informants rating children's behavioral and emotional problems and found that agreement between similar informants, such as two parents, was substantially higher than agreement between a parent and a teacher, and that children's own reports agreed only modestly with those of adults. They concluded that children's behavior varies by situation and that each informant contributes information the others cannot. De Los Reyes and Kazdin (2005) reviewed the research on informant discrepancies and argued that such differences affect assessment, classification and treatment and should be studied and interpreted, not dismissed as error.
A Disagreement as a Clue
Lily's teacher sees attention problems during seat work; her mother sees none at home. Rather than choosing between them, I ask what differs between the two settings. At home, Lily plays, draws and helps cook, all tasks without much reading. At school, most of her day now involves reading independently, a demand that increased this year.
The disagreement was not noise in the data; it was the most useful thing in the chart.
Developmental History
Pregnancy and birth were uncomplicated. Her motor and language milestones arrived on time, with first steps near her first birthday and short sentences before her second. Her father has dyslexia. In kindergarten, she was slow to learn letter sounds, and her first-grade teacher noted she guessed at words from pictures. She has had no hearing or vision screening since age 4.
The Child's Own Account
Children are informants too. Alone with me, using drawings, Lily says reading makes her "feel stupid" and that she looks out the window because "the words jump around." She also says she worries about her dad, who moved out in the fall, and that she cries at school "when I miss him." Her mother had not mentioned the separation because she did not think it mattered to the referral.
Screening for Adversity
Felitti et al. (1998) found that more than half of adults surveyed reported at least one category of adverse childhood experience, such as abuse or household dysfunction, and that the number of categories showed a graded relationship with later health risks. Parental separation is one of those categories. Lily has one, recent and ongoing. It does not explain all her difficulties, but it explains her crying and some of her distraction.
Gathering More Information
With Ms. K.'s consent, I request the school's reading benchmark data, which place Lily in the lowest 10% of her grade, and ask the teacher to note whether inattention occurs during math and art as well as reading. It is much less frequent in those subjects. Hearing and vision screening in the office are normal.
Formulation
Lily's inattention is concentrated in reading tasks, began when reading demands rose, is absent at home and in nonreading subjects and coexists with a family history of dyslexia and early phonological difficulty. Her tearfulness began with her father's departure. ADHD requires symptoms in two or more settings and is not the best explanation. The more likely picture is a specific learning disorder with impairment in reading, pending formal testing, and an adjustment reaction to her parents' separation.
Recommendations
The plan includes a written request from Ms. K. to the school for a special education evaluation, including psychoeducational testing for dyslexia; structured literacy intervention, which can begin while testing is pending; brief child-centered therapy to help Lily talk about her feelings about her parents' separation, with guidance for both parents on supporting her through the transition; and repeat Vanderbilt ratings from both parent and teacher in three months, after reading support starts.
Why Not Start a Stimulant
A stimulant trial might have improved Lily's seat work a little, since stimulants improve attention in many children, but a partial response would have been misread as confirming ADHD. Her reading problem would have gone unaddressed, and she would have kept feeling "stupid" as her classmates moved ahead. The cost of a wrong diagnosis at seven is years of the wrong help.
Structured Instruments
The evaluation used parallel parent and teacher forms so that the same behaviors were rated in each setting, plus a brief child interview adapted to her age with pictures and feeling faces. Using the same questions for both adults made the setting difference visible instead of hiding it inside different tools.
Sharing the Findings
I meet with Ms. K. and, with her agreement, speak with the teacher by phone. Both are relieved: the teacher to know why Lily struggles and the mother to learn that her observations were accurate for home. Each informant was right about the setting they saw.
Her Father's Role
Lily's father is invited to the feedback meeting and attends. His own history of dyslexia, and how he struggled without help, makes him an ally for early reading support. Both parents agree to tell Lily together about the testing so she hears it as help, not as a sign that something is wrong with her.
When to Reconsider ADHD
Dyslexia and ADHD co-occur often. If Lily's inattention persists in nonreading tasks after reading support, or if her parent begins to see it at home, ADHD will be reconsidered with new ratings from both adults and a fresh interview with Lily herself.
Development in Context
At seven, children are expected to move from learning to read to reading to learn. A child whose reading lags will look inattentive at the exact point when the curriculum demands independent reading. Knowing the typical sequence helps separate a skills problem from an attention problem.
Cultural and Family Context
Ms. K. grew up in a family where school problems were handled privately, which partly explains her frustration with the teacher's referral. Acknowledging that she knows her daughter best at home, while the teacher knows her best at school, eased the tension and let both adults work together.
Conclusion
Research shows that parents and teachers often disagree because children behave differently across settings, and those differences can reveal causes. In Lily's case, the disagreement pointed to reading tasks, and developmental and family history pointed to dyslexia and a recent separation. The evaluation replaced a presumed ADHD diagnosis with a plan for reading assessment and support for a child coping with a family change.
References
Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101(2), 213-232. https://doi.org/10.1037/0033-2909.101.2.213
De Los Reyes, A., & Kazdin, A. E. (2005). Informant discrepancies in the assessment of childhood psychopathology: A critical review, theoretical framework, and recommendations for further study. Psychological Bulletin, 131(4), 483-509. https://doi.org/10.1037/0033-2909.131.4.483
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8
How this PMH 505 Week 1 example is structured
The PMH/505 Week 1 work usually covers developmental assessment and gathering information from several informants. This paper shows why parents and teachers often disagree, how a clinician uses that disagreement rather than choosing a side, and how development and family events shape the formulation. Students search this week as PMH 505 Week 1, PMH505 Wk 1 or PMH/505 Wk 1; all three are the same assignment.
PMH/505 Week 1 questions, answered
What does PMH/505 Week 1 usually ask for?
Many sections ask students to complete a developmentally informed psychiatric assessment of a child, gathering and reconciling reports from parents, teachers and the child.
How well do parents and teachers usually agree about a child's problems?
A classic meta-analysis found modest agreement between different types of informants, such as parents and teachers, and higher agreement between similar informants, such as two parents.
Should a clinician decide which informant is right?
Not usually; differences between informants often reflect real differences in how a child behaves across settings, and those differences can point to the cause of the problem.
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