Social Injustice
We can define social injustice as occurring when people who are perceived to fit into one or more marginalized groups are treated differently than others not belonging to those groups (Timimi, 2005). The objective of social injustice is to maintain the status quo through any means possible. or move backwards, to a less equitable society through censorship, misinformation and media propaganda. For these marginalized individuals, there is no questioning those in power and the actions of the dominant group are believed to be right by default. Marginalized groups experience a label of inferiority and are expected to comply. Perhaps no group of children is more marginalized than those who are diagnosed with Attention Deficit Hyperactivity Disorder (Timimi, 2005).
Attention Deficit Hyperactivity Disorder
Attention Deficit Activity Disorder (ADHD) is a heterogeneous neurodevelopmental disorder as there are three subtypes of the disorder that can present quite differently (American Psychiatric Association [APA], 2013). Moreover, some of the symptoms must occur before the age of 12 and as a rule a child should not be diagnosed with ADHD unless the main symptoms of the disorder have been present early in life and these symptoms create significant problems in at least two different environments (e.g., at home and at school). Children who are diagnosed with ADHD have been symptomatic for a relatively long period of time (diagnostic criteria state for at least six months). These children often exhibit difficulties during stressful and mentally demanding situations or during activities that command sustained attention. Typically children with ADHD will exhibit difficulties with reading (loner passages), performing math or arithmetic problems, or playing certain games such as board games (surprisingly they may do well at video games as many of these games involve rapid shits of attention).
Although ADHD is usually considered a childhood disorder there is more current research that suggests that in nearly of half of children with ADHD the symptoms undergo some alteration and persist into adulthood (Zavadenko & Simashkova, 2014). Epidemiological studies indicate that in most areas about five percent of children and two and a half percent of adults have ADHD. In children it is diagnosed twice as often in males than females and in adults 1.6 times as often in males (Zavadenko & Simashkova, 2014).
ADHD Subtypes
Contrary to what many believe, there is no specific medical test to diagnose ADHD. The assessment is accomplished by gathering information about the child’s behavior from several different sources and there may even be formal psychological testing involved. In order to fulfill the diagnostic criteria for ADHD the child must meet the criteria that are listed in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5; APA, 2013). In order to be diagnosed with ADHD the child would need to have at least six symptoms from one of two categories below or six or symptoms from each of the two categories (for individuals over 17 years old there only need be five symptoms in each category). These symptoms affect individuals at the individual, familial, community, and societal levels. The major symptom categories are:
Inattention. The symptoms here have to do with attentional difficulties such as: the child often fails to give close attention to details or makes careless mistakes in schoolwork and other activities, often exhibits difficulty sustaining attention in tasks or play activities; does not often appear to listen when spoken to directly; does not often follow through on instructions and fails to finish schoolwork or chores (this is not due to oppositional behavior or due to a failure to understand directions/instructions); often experiences difficulty organizing tasks and activities; regularly avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework); frequently loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books); Is habitually easily distracted; frequently is forgetful in daily activities.
Hyperactivity and impulsivity. These are the behavioral features of ADHD that often receive the most attention from parents and teachers. These features include the child: frequently fidgeting with hands or feet or squirms in seat; repeatedly leaving seat in classroom or in other situations in which remaining seated is expected; regularly runs about or climbs excessively in situations in which it is inappropriate; habitually has difficulty playing or engaging in leisure activities quietly; regularly “on the go” often acting as if “driven by a motor”; habitually talks excessively; frequently blurts out answers before questions are completed; regularly exhibits difficulty awaiting turn; frequently interrupts or intrudes on others.
The symptom presentation can lead to the child diagnosed with one of the three subtypes of ADHD in order to target the predominant problems. These subtypes are:
1. ADHD predominantly inattentive-type: Many people wrongly refer to this as ADD, but the DSM-IV does not recognize ADD as a separate disorder (outside of lay terminology ADD does not exist). Instead a child with this subtype of ADHD has at least six symptoms from the inattention category sand few from the hyperactivity/impulsivity category.
2. ADHD predominantly hyperactive-impulsive-type: Here the child has at least six symptoms from the hyperactivity and impulsivity category and few inattentive symptoms.
3. ADHD combined type: The child has six or more symptoms from each of the two categories.
Treatment
Treatment for ADHD falls into two categories: Pharmacological and behavioral treatment.
Pharmacological treatments for ADHD include medications like Ritalin, Adderall, Strattera and others. Most of these like Ritalin and Adderall are stimulant medications. The hypothesis behind these medications is that the brain of the ADHD child in “underaroused” so the child self-medicates by maintaining high levels of activity and shifting attention. The stimulant effect normalizes brain functioning and the child’s behavior normalizes (Sadock & Sadock, 2007). That is probably why these medications work better for hyperactivity and impulsivity and not as well for attentional issues only.
The only non-stimulant medication approved by the FDA for the treatment of ADHD is Strattera, which has shown to be effective in treating inattention. Other medications may be used such as antidepressants, but these are not approved for the treatment of ADHD specifically. The major drawback to medications is their potential side-effect profile which can range from sleeplessness to anxiety, Obsessive Compulsive disorder, psychosis, or Tourette-disorder like symptoms (Sadock and Sadock, 2007). Side-effects are the main reason many psychotropic medications are discontinued. Moreover, often the response to a side-effect by a physician is to add another medication which can result in overly medicated children.
Behavioral treatments have been empirically demonstrated to be effective with treating ADHD children, but require an investment of time and energy on the part of parents, teachers, and others. Some of the more effective treatments for school include:
The Daily Report Card (DRC): The DRC is an empirically supported intervention wherein specific behavioral goals are set for the child in the classroom and the child is rewarded in class with positive reinforcement and at home based on their realization of those goals (O’Leary, Pelham, Rosenbaum, & Price, 1976). The goals are set at an attainable but still challenging level and can be made increasingly difficult (at the child’s pace) until the child’s behavior is within developmentally acceptable levels. These programs are based on the shaping principle of behavioral psychology. The beneficial effects of DRC on improving behaviors in ADHD children are well-documented (Fabiano & Pelham, 2003; O’Leary et al., 1976).
Social Skills Training: Interpersonal difficulties are prevalent in children with an ADHD diagnosis. Children with hyperactivity, aggression, or noncompliance are rated negatively by their peers and are more likely to be rejected by them (Hinshaw & Melnick, 1995). Poor peer relationships predict long-term negative outcomes for these children. Consequently, improving social skills can be an important goal of a comprehensive treatment program for ADHD. Social skills training is a technique that aims at developing and reinforcing the use of appropriate social skills both in and out of the classroom. This includes improving communication skills, learning cooperation and participation in groups, and validation skills (Kavale, Forness, & Walker, 1999).
Behaviorally-based classroom interventions target issues such as engagement in classroom tasks and disrupting behaviors. Academic interventions for children with ADHD concentrate on improving both behavioral and academic issues. Some of these are:
Task and instructional modifications: These methods involve procedures such as reducing the length of a task either by breaking it up or cutting steps (e.g., dividing long assignments into smaller units), setting goals for the child to complete in shorter time intervals by using amplified stimulation (e.g., using color, different textures, or changing the instructions to match student’s learning style (DuPaul & Eckert, 1998). These techniques have been in use for many years and still provide benefits.
Computer-assisted instruction: ADHD children often can benefit from computer-assisted instruction that offers specific objectives, highlights the essential material they need to learn, uses multiple sensory modalities that help to keep the child engaged, divides material into smaller chunks, and offers immediate feedback about their responses (DuPaul & Eckert, 1998).
Peer Tutoring: During peer tutoring a trusted student provides instruction, assistance, and feedback to another student. This can be surprisingly effective. It has been found that peer tutoring simultaneously works on both academic skills and social skills and gives teachers a slight reprieve (DuPaul & Eckert, 1998).
The combination of behavioral interventions and medication appears to work better than either used alone (Sadock & Sadock, 2007). Working with children with ADHD can be challenging, but at the same time rewarding as it is not impossible as many believe.
According to the majority of treatment protocols physicians, psychologists, teachers, persons, etc. should recognize that ADHD is a chronic condition, thus the behavior is out of the diagnosed person’s control (American Academy of Pediatrics, 2011; APA, 2013). This conclusion leads to the premise that children and adolescents with ADHD should be categorized as children and youth with special healthcare needs (Saul, 2014).
Controversy
The term attention deficit disorder [ADD] was officially part of the DSM-III and later editions changed the label to ADHD, so the ADD is no longer used (Hatfield, 2013). Moreover, the subsequent editions of the DSM have expanded the diagnostic criteria such that the prevalence rates for this disorder have skyrocketed. For example rates are reported as 7.8% in 2003, in 2007 9.5%, and as high as 11% in 2011 (Saul, 2014). Major racial and ethnic disparities occur in which children or adolescents are diagnosed with ADHD compared to being considered oppositional or difficult when the same or similar symptoms are displayed (see Morgan, Hillemeier, Farkas, & Maczuga, 2014) and boys diagnosed with are more commonly medicated than are girls (see Visser, Blumberg, Danielson, Bitsko, & Kogan, 2013).
Critics of the diagnosis state that it is a crutch that pathologizes normal behavior in children, especially in young boys (Breggin, 2007; Saul, 2014). One of the biggest criticisms of ADHD is that the diagnosis is simply designed to induce compliance in young children by medicating them (Breggin, 2007; Saul, 2014). Moreover, it has been suggested that often when children exhibit severe ADHD symptoms these are often the manifestation of some other neurological or medical issue and are not reflective of a specific attention-deficit disorder (Saul, 2014). Critics have charged that the diagnosis of ADHD was developed in order to market specific drugs to children with behavioral issues and the argument was only fueled when psychiatrist Leon Eisenberg, often labeled the “scientific father of ADHD,” in an interview several months before his death stated “ADHD is a prime example of a fictitious disease” (Saul, 2014). Before his death Eisenberg became a harsh critic of the medical model that dominates psychiatry and urged for researchers to investigate social causes/contributions to psychiatric issues.
ADHD and Social Injustice
Certainly if the critics are correct and ADHD is not a real psychiatric disorder but instead represents the pathologizing of normal behavior or that the diagnosis is a sham diagnosis being substituted for some other real issue, then individuals who are diagnosed with ADHD are victims of severe social injustice. Moreover, it has been suggested by some researchers and clinicians who believe that the diagnosis is valid that ADHD is severely over-diagnosed and is often used as a crutch or excuse by parents, teachers, and others to induce a forced method of control over normally energetic and distractible children (Hatfield, 2013; Saul, 2014). Recall that once a child receives an ADHD diagnosis the child is considered to have a chronic condition. Thus, there is the potential for the simple diagnosis of ADHD to promote social injustice even if the diagnostic category is valid, but the diagnosis is overused or inappropriately given.
In addition, even if we consider that the diagnostic category is valid and majority of diagnoses genuine the demarcation between normality and disability is severely blurred in the field of psychiatry and with psychiatric diagnoses. Children diagnosed with ADHD are labeled as having a chronic condition, which often becomes part of their self-definition as well as a stigmatizing label for them. Both the person and others will automatically define themselves in terms of the diagnostic label which will lead to certain expectations, conclusions, and excuses. These receive special education, are branded and stigmatized by others, and are defined in light of a diagnostic label. The potential and expectations of the individual can become artificially defined in light of their diagnosis and of course there is the potential for the label to severely limit an individual in terms of their productivity, contribution to society, and even their participation in social activities. The limitations can be self-induced or induced by others as a result of in-group and out-group attributions. Children diagnosed with ADHD as adults demonstrate higher rates of substance abuse, criminal behavior, unemployment, and social service use, while obtaining lower levels of education and social economic status than non-ADHD children (Saul, 2014).
Thus, whether or not the diagnosis is valid, people with ADHD are significantly marginalized and suffer from significant social injustices.
Empowerment for Individuals with ADHD
Rees (1998) proposed that homeless youth could be helped to gain a sense of empowerment by assisting them through the four stages of empowerment. This model can be applied to assist in empowering individuals diagnosed with ADHD:
1. Understanding powerlessness involves the ability to express one’s disappointment, despair, hurt, and fear before one can gain a sense of empowerment. This means that a person must be able to express and share their feelings to others before they can move towards positive change.
2. Awareness and mutual education involves articulating and sharing experiences assists a person to organize their thoughts and identify the themes that have characterized their past experiences. This allows for the person to construct their experiences in a manner that allows them to think of different choices in their lives. Typically these stories reconstruct feelings of powerlessness, but the person can be directed to think of different choices that could have been made as well.
3. Dialogue and solidarity involves continuing to share information and relating one’s story to others. This allows the person to see their experience in a broader light, learn from others, and get new perspectives. At the stage the person can be assisted to formulate plans in order to empower themselves.
4. Action and political identity involves the development of self-confidence in the person’s ability to make progress, change one’s conditions, and improve the quality of their lives. The political identity portion of this stage acknowledges the right and power to seek changes and better oneself.
Thus, the connections one makes are understanding one’s experiences, verbalizing them, understanding choices, identifying alternatives, and developing the know-how and confidence to make a change. It begins with making internal feelings external, and then via the support and understanding of others recognizing the potential to change and making positive choices to do so.
Counseling and psychotherapy can be sues to empower victims of social injustice. One can also draw from the psychotherapy literature to understand that empathy is an extremely important element for instilling positive change in a person (Rogers, 1959). Empathy requires one to be able to understand the situation of another from that person’s viewpoint (Westen, Novotny, & Thompson-Brenner, 2004). Empathy certainly allows one to be compassionate to others. However, empathy requires a genuine concern for others that cannot be feigned and is not simply feeling sorry for someone or believing that someone has been I an unfortunate situation. True empathy results in a connection with another person that can help form an alliance (Rogers, 1959). It is a necessary, but not sufficient quality, in psychotherapy and certainly this applies to social advocacy as well. Unless one has true compassion for another and can identify with that person’s condition on some level similar to how the person experiences their condition, it would be very difficult to advocate for them.
Given the above discussion of empathy, it would follow that a person that has gone through similar experiences of another would have an easier time empathizing with them. Certainly a recovering alcoholic can find it easier to readily identify with another alcoholic. However, just because someone is a recovering alcoholic does not guarantee that they will empathize with other alcoholics. Likewise, just because one acquires a Ph.D. in psychology or an M.D. this does not guarantee that they can display empathy to their clients. So while it certainly is easier for one to identify and empathize with a person who shares similar experiences, it is not a requirement. Psychotherapists are in a sense, social advocates of their clients, but there is no literature that has identified that they must have experienced the same experiences that their clients have experienced in order to understand them, feel for them, and help them as well as someone who has been through similar experiences (Westen et al., 2004). Likewise, while a social advocate who shares similar experiences with the group they advocate for may be able to identify with them more easily than one who does not, it does not mean that they will be more effective advocates than a person who is capable of true empathy and compassion for others.
References
American Academy of Pediatrics. (2011). ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention deficit hyperactivity disorder in children and adolescents. Pediatrics, 128, 1007 -1022.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition. Washington, DC: Author.
Breggin, P. (2007). Talking back to Ritalin: What doctors aren’t telling you about stimulants and ADHD. Cambridge, MA: Da Capo Press.
DuPaul, G. J., & Eckert, T. (1998). Academic interventions for students with attention deficit hyperactivity disorder: A review of the literature. Reading and Writing Quarterly, 14(1), 59-82.
Fabiano, G. A., & Pelham, W. E. (2003). Improving the effectiveness of behavioral classroom interventions for attention deficit hyperactivity disorder: A case study. Journal of Emotional and Behavioral Disorder, 11, 122?128.
Hatfield, R. C. (2013). The everything guide to the human brain. Avon, MA: Adams.
Hinshaw, S. P., & Melnick, S. M. (1995). Peer relationships in boys with attention deficit hyperactivity disorder with and without comorbid aggression. Development and Psychopathology, 7, 627?647.
Kavale, K. A., Forness, S. R., & Walker, H. A. (1999). Interventions for oppositional defiant disorder and conduct disorder in the schools. In H. C. Quay, & A. E. Hogan (Eds.), Handbook of disruptive behavior disorders (pp. 441?454). New York: Kluwer Academic/Plenum Publishers.
Morgan, P. L., Hillemeier, M. M., Farkas, G., & Maczuga, S. (2014). Racial/ethnic disparities in ADHD diagnosis by kindergarten entry. Journal of Child Psychology and Psychiatry, 55(8), 905-913.
O’Leary, K. D., Pelham, W. E., Rosenbaum, A., & Price, G. H. (1976). Behavioral treatment of hyperkinetic children: An experimental evaluation of its usefulness. Clinical Pediatrics, 15, 510?515.
Pelham, W. E., Fabiano, G. A., Gnagy, E. M., Greiner, A. R., & Hoza, B. (2004). Intensive treatment: Summer treatment program for children with ADHD. In E. D. Hibbs, & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically-based strategies for clinical practice, (2nd ed.). Washington, DC: American Psychological Association Press.
Rees, S. (1998). Empowerment of youth. In Parson, R.J.; Gutierrez, L.M., & Cox, E.O. (Eds.), Empowerment in social work practice: A source book (pp. 130-145). Pacific Grove, CA: Brooks/Cole Publishing Company.
Rogers, C. R. (1959). A theory of therapy, personality and interpersonal relationships, as developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of science Vol. 3 (pp. 184-256). New York: McGraw Hill.
Sadock, B. J., and Sadock, V. A., (2007). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th edition). Philadelphia: Lippincott Williams & Wilkins.
Saul, R. (2014). ADHD does not exist. New York: Harper Collins.
Timimi, S. (2005). Naughty boys: Anti-social behaviour, ADHD and the role of culture. New York: Palgrave Macmillan.
Visser, S. N., Blumberg, S. J., Danielson, M. L., Bitsko, R. H., & Kogan, M. D. (2013). Peer
Reviewed: State-Based and Demographic Variation in Parent-Reported Medication Rates for Attention Deficit Hyperactivity Disorder, 2007-2008. Preventing chronic disease, 10, 1-5.
Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631-663.
Zavadenko, N. N., & Simashkova, N. V. (2014). New Approaches to the Diagnosis of Attention
Deficit Hyperactivity Disorder. Neuroscience and Behavioral Physiology, 45(7), 837-842.
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