ADHD, Social Injustice, and Empowerment Strategies

Introduction: Social Injustice and Marginalized Groups

Social injustice can be defined as occurring when people who are perceived to belong to one or more marginalized groups are treated differently from those not belonging to those groups (Timimi, 2005). The objective of social injustice is to maintain the status quo through any means possible — or to move backwards toward a less equitable society — through censorship, misinformation, and media propaganda. For marginalized individuals, there is no questioning those in power, and the actions of the dominant group are assumed 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 diagnosed with Attention Deficit Hyperactivity Disorder (Timimi, 2005).

Understanding ADHD: Definition and Prevalence

Attention Deficit Hyperactivity Disorder (ADHD) is a heterogeneous neurodevelopmental disorder with three subtypes that can present quite differently (American Psychiatric Association [APA], 2013). Some symptoms must occur before the age of 12, and as a rule a child should not be diagnosed with ADHD unless the main symptoms have been present early in life and create significant problems in at least two different environments (e.g., at home and at school). Children diagnosed with ADHD have typically been symptomatic for at least six months, as specified by the diagnostic criteria. These children often exhibit difficulties during stressful and mentally demanding situations, during activities requiring sustained attention, with reading longer passages, performing math or arithmetic problems, or playing certain games such as board games. Interestingly, they may perform well at video games, as many of these involve rapid shifts of attention.

Although ADHD is usually considered a childhood disorder, more current research suggests that in nearly half of children with ADHD the symptoms undergo some alteration and persist into adulthood (Zavadenko & Simashkova, 2014). Epidemiological studies indicate that in most areas approximately five percent of children and two and a half percent of adults have ADHD. In children, it is diagnosed twice as often in males as in females, and in adults 1.6 times as often in males (Zavadenko & Simashkova, 2014).

ADHD Subtypes and Diagnostic Criteria

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 formal psychological testing may also be involved. To fulfill the diagnostic criteria for ADHD, the child must meet the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013). Specifically, the child would need to have at least six symptoms from one of two categories, or six or more symptoms from each of the two categories (for individuals over 17 years old, only five symptoms per category are required). These symptoms affect individuals at the individual, familial, community, and societal levels. The two major symptom categories are:

Inattention

The symptoms in this category involve attentional difficulties, including: often failing to give close attention to details or making careless mistakes in schoolwork and other activities; often having difficulty sustaining attention in tasks or play activities; often appearing not to listen when spoken to directly; often failing to follow through on instructions and failing to finish schoolwork or chores (not due to oppositional behavior or failure to understand directions); often having difficulty organizing tasks and activities; regularly avoiding, disliking, or being reluctant to engage in tasks requiring sustained mental effort (such as schoolwork or homework); frequently losing things necessary for tasks or activities (e.g., toys, school assignments, pencils, books); being habitually easily distracted; and being frequently forgetful in daily activities.

Hyperactivity and Impulsivity

These are the behavioral features of ADHD that most often attract attention from parents and teachers. They include: frequently fidgeting with hands or feet or squirming in the seat; repeatedly leaving one's seat in the classroom or in other situations where remaining seated is expected; regularly running about or climbing excessively in inappropriate situations; habitually having difficulty playing or engaging in leisure activities quietly; regularly being "on the go," often acting as if "driven by a motor"; habitually talking excessively; frequently blurting out answers before questions are completed; regularly having difficulty awaiting one's turn; and frequently interrupting or intruding on others.

The symptom presentation determines which of three subtypes of ADHD a child is diagnosed with, in order to target the predominant problems:

1. ADHD predominantly inattentive type: Many people mistakenly refer to this as ADD, but the DSM-5 does not recognize ADD as a separate disorder — outside of lay terminology, ADD does not exist. A child with this subtype has at least six symptoms from the inattention category and few from the hyperactivity/impulsivity category.

2. ADHD predominantly hyperactive-impulsive type: 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 Approaches for ADHD

Treatment for ADHD falls into two broad categories: pharmacological and behavioral.

Pharmacological Treatments

Pharmacological treatments for ADHD include medications such as Ritalin, Adderall, and Strattera, among others. Most, like Ritalin and Adderall, are stimulant medications. The hypothesis behind these medications is that the brain of the child with ADHD is "underaroused," causing the child to self-medicate by maintaining high levels of activity and rapidly shifting attention. The stimulant effect normalizes brain functioning, and the child's behavior normalizes accordingly (Sadock & Sadock, 2007). This likely explains why these medications work better for hyperactivity and impulsivity than for attentional issues alone.

The only non-stimulant medication approved by the FDA for treating ADHD is Strattera, which has been shown to be effective in treating inattention. Other medications, such as antidepressants, may also be used, but these are not specifically approved for ADHD treatment. The major drawback of medications is their potential side-effect profile, which can range from sleeplessness and anxiety to Obsessive-Compulsive Disorder, psychosis, or Tourette's disorder-like symptoms (Sadock & Sadock, 2007). Side effects are the main reason many psychotropic medications are discontinued. Moreover, a physician's response to a side effect often involves adding another medication, which can result in children being overly medicated.

Behavioral Treatments

Behavioral treatments have been empirically demonstrated to be effective with children with ADHD, but require an investment of time and energy on the part of parents, teachers, and others. Some of the more effective school-based treatments include:

The Daily Report Card (DRC): The DRC is an empirically supported intervention in which specific behavioral goals are set for the child in the classroom. The child is rewarded in class with positive reinforcement and at home based on the realization of those goals (O'Leary, Pelham, Rosenbaum, & Price, 1976). Goals are set at an attainable yet challenging level and can be made progressively more difficult — at the child's pace — until the child's behavior falls within developmentally acceptable levels. These programs are grounded in the shaping principle of behavioral psychology. The beneficial effects of the DRC on improving behaviors in children with ADHD 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. Social skills training is a technique that aims to develop and reinforce the use of appropriate social skills both in and out of the classroom, including improving communication skills, learning cooperation and participation in groups, and developing validation skills (Kavale, Forness, & Walker, 1999).

Behaviorally-based classroom interventions also target issues such as engagement in classroom tasks and disruptive behaviors. Academic interventions for children with ADHD concentrate on improving both behavioral and academic outcomes. Some of these include:

Task and instructional modifications: These methods involve procedures such as reducing the length of a task by breaking it into smaller units, setting goals for the child to complete within shorter time intervals, and using amplified stimulation — such as color, different textures, or modified instructions matched to the student's learning style (DuPaul & Eckert, 1998). These techniques have been in use for many years and continue to provide benefits.

Computer-assisted instruction: Children with ADHD can often benefit from computer-assisted instruction that offers specific objectives, highlights essential material, uses multiple sensory modalities to maintain engagement, divides material into smaller chunks, and provides immediate feedback about responses (DuPaul & Eckert, 1998).

Peer tutoring: During peer tutoring, a trusted student provides instruction, assistance, and feedback to another student. This approach can be surprisingly effective. Research has found that peer tutoring simultaneously addresses both academic skills and social skills, while also giving teachers a degree of relief (DuPaul & Eckert, 1998).

The combination of behavioral interventions and medication appears to work better than either approach used alone (Sadock & Sadock, 2007). Working with children with ADHD can be challenging, but it is also rewarding — it is far from impossible, as many assume.

According to the majority of treatment protocols, physicians, psychologists, teachers, parents, and others should recognize that ADHD is a chronic condition, meaning that the behavior is outside the diagnosed person's direct control (American Academy of Pediatrics, 2011; APA, 2013). This conclusion supports the premise that children and adolescents with ADHD should be categorized as children and youth with special healthcare needs (Saul, 2014).