Challenging Dogma


...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

Changing Pedagogy For Children With ADHD: Moving Away From Individual Medical Interventions and Towards Institutional Changes-Raphael Adamek

Attention Deficit Hyperactive Disorder is a condition defined by inattention, hyperactivity, and impulsivity that affects approximately 2 million children (1). Although the prevalence of ADHD varies depending on the diagnostic criteria, the prevalence rate generally falls between 4% to 12% in the population of 6 to 12 year olds (2). Children who suffer from ADHD often struggle in school and have difficulty socializing with peers. A study by Barkley et al. found when compared to non-hyperactive children, by the age of 15 at least three times as many hyperactive children have been suspended or expelled from school or have been in behavior support classes (3).

Children with ADHD are susceptible to difficulties in school (4) and can strain school resources (5). Despite the connections between ADHD and schools, ADHD has been framed as a medical problem. As a result, most of the children who received treatment for ADHD are prescribed medication (6). While the biologic component of ADHD may be addressed by medication, the use of medication can also have significant side effects including the development of substance dependency after the use of stimulant medication (7). The failure to identify ADHD as an institutional problem has led to an over dependency on medical interventions that fail to address the complex social issues surrounding the disorder.

Behavioral Interventions and ADHD

Although medical interventions may be necessary for some children with ADHD, medical interventions alone fail to teach children with ADHD the appropriate behaviors, skills, and self-efficacy necessary to succeed. Parents, teachers, and counselors need to teach the behaviors and skills necessary to cope with school environments to all students. For children with ADHD, these behaviors and skills are even more important.

One way to contextualize this problem is to use Social Cognitive Theory. Social Cognitive Theory states that self-efficacy determines individuals’ behaviors (8). One can examine the scenario of a class taking notes in school as an example of how self-efficacy relates to a student with ADHD. Taking notes usually requires focus and impulse control, things that are particularly difficult for students with ADHD. Medication may improve students’ focus and impulse control; but, medication will not teach students how to identify the important parts of a lecture and write them down in their notes. As a result, even a medicated student with ADHD may have low self-efficacy regarding note taking behavior. If students had trouble taking notes in the past, perhaps getting in trouble for disrupting class, their self-efficacy may be even lower. But if the students were taught specific ways to cope with note-taking perhaps their self-efficacy would increase. With increased self-efficacy, students would find it easier to take notes and could use this confidence to build on other positive behaviors.

The value of combining behavioral and medical interventions has been investigated in many studies. Abramowitz et al. studied the effects of a simple behavioral intervention both alone and in combination with stimulant medication. They found that for some children with ADHD intense behavioral interventions produced results similar to the results achieved by medical interventions. Abramowitz et al. also found that some children responded well to medication used in combination with behavioral interventions (9). Another study examined the effects of self-management procedures on three boys with ADHD in a general education classroom. This behavioral intervention focused on improving the classroom preparation skills of three male students in a public secondary school. In this study, each of the three participants showed improved preparation, even as the intervention was systematically faded out over time (10).

Although medication may be necessary for some students to improve their impulse control, attention, and hyperactivity, medication alone does not teach children with ADHD the behaviors necessary to succeed in school. Behavioral interventions can be effective way to increase children’s self-efficacy and provide the tools for success in school.


Stigma and Distinctiveness

In addition to causing unintended consequences such as substance dependency (7), the simple act of taking ADHD medication at school may be stigmatizing for some children. Stigma theory was first conceptualized by Erving Goffman in his 1963 book Stigma: Notes on the Management of Spoiled Identity. In this work Goffman defines stigma as “an attribute that is deeply discrediting within a particular social interaction” (11). A study by Nelson and Klutas examined “distinctiveness” in the context of social interaction. This study found that individuals were judged based on information provided about their supposed distinctiveness, and in some cases these judgments set off a self-fulfilling prophecy process (12). In the case of ADHD, the stigma or distinctiveness can be attached to children with the disorder.

For children with ADHD even the process of taking medication can be stigmatizing. As Modi, Lindemulder, and Gupta note, taking two to three doses of medication during a school day can stigmatize a child with ADHD (13). Additionally, the process of taking medication multiple times a day can make children with ADHD distinct. This distinctiveness may create a cycle of self-fulfilling prophecies for the children with ADHD. If teachers see children leave the classroom to take medication multiple times a day, the teachers may treat those students differently. If the students with ADHD feel as if they are being treated unjustly by their teachers, ADHD-like behavior may emerge resulting in a self-fulfilling prophecy. Medical interventions do not address the stigma or distinctiveness students with ADHD may experience, and in some cases medical interventions may exacerbate the problem.

The Social Environment and Its Impact On Behavior

Within schools or other structured social environments, there is a process of reciprocal feedback between the environment and behavior of the individuals in the environment. In the case of ADHD in schools, the school culture can have a negative impact on individuals’ behaviors if the school lacks a cohesive discipline program or if the behavior expectations are not clearly communicated to students (14). On the other hand, school culture can have a positive impact on individuals’ behaviors if expectations are clear, behavior and discipline approaches are consistent, and parents and guardians are involved in their children’s education. While the environment can impact individuals’ behavior, medical interventions for children with ADHD do not change the social or school environment in which these children function.

While individual medical interventions may help individual students with attention, hyperactivity, and impulse control, they do nothing to change the behaviors of all the students in a school. One way to change behavior in a school is to institute a school-wide behavior management system. Molina, Smith, and Pelham showed that a comprehensive school-wide behavior system can yield impressive results. In this example, consultants from the University of Pittsburgh worked with a middle school to develop a behavior management program that gave privileges to students who followed the rules and revoked privileges to those who did not follow the established rules. The results were impressive. Half-way through the school year the teachers were surveyed and 90% felt that the program had improved student behavior, 73% saw improved behavior outside of the classroom, and 59% reported improved student behavior within the classroom (15). There was also a delayed effect on student discipline. While there was an increase in the number of suspensions during the first year of the program (up by 9%) during the second year of the program there was a 24% decrease, and by the third year there was a 46% decrease.

The Molina study shows that institutional changes to schools can create widespread behavior change among students. Not only do ADHD students benefit from behavior management programs like this, but all students benefit from an improved learning environment. By framing the issue of ADHD as a school problem, a school based solution is developed. Medical interventions for children with ADHD may help individual children; but, if their school environment is reinforcing inattentive, hyperactive, or impulsive behavior, the problem has not been solved.

Conclusions

ADHD is a serious disorder that affects approximately 2 million children. Children with ADHD often struggle in school and have difficulty establishing social relationships. For many of these children medical interventions may be necessary to treat their ADHD; but, by framing ADHD as an individual problem, the reciprocal relationship between ADHD and schools remains ignored. Medical interventions for students with ADHD do not teach students the appropriate behaviors, may attach stigma and distinctiveness to students, and do not change the overall culture of a school. Medical interventions for ADHD seek to change the students so they will fit in the school, but do not seek to change the school to fit the students. There is no single solution to treat the growing number of children with ADHD, but by re-framing the issue at a social level and using a combination of social and individual interventions it may be possible to stem the tide.

References

(1) “Attention Deficit Hyperactive Disorder.” National Institutes of Mental Health: National Institute of Health. http://www.nimh.nih.gov/publicat/adhd.cfm
(2) Brown RT, et al. 2001. “Prevalence and Assessment of Attention-Deficit/Hyperactivity Disorder in Primary Care Settings.” Pediatrics 107(3):e43
(3) Barkley RA, Risher M, Edelbrock CS, Smallish L. 1990. “The adolescent outcome of hyperactive children diagnosed by research criteria:I. An 8-year prospective follow up study. Journal of the American Academy of Child and Adolescent Psychiatry 29:546-557
(4) Dupaul JD, McGoey MC, Kara E, Eckert TL, VanBrackle J. 2001.” Preschool Children With Attention-Deficit/Hyperactivity Disorder: Impairments in Behavioral, Social, and School Functioning.” Journal of the American Academy of Child and Adolescent Psychiatry. 40(5)
(5) Lankes, T. 2004. “ADHD Putting Strain on Schools.” Herald Tribune. http://www.heraldtribune.com/apps/pbcs.dll/article?AID=/20040627/NEWS/60127007
(6) Olfson M, Gameroff MJ, Marcus SC, Jensen PS. 2003. “National Trends in the Treatment of Attention Deficit Hyperactivity Disorder.” American Journal of Psychiatry 160:1071-1077
(7) Horner BR, Scheibe KE. 1997. “Prevalence and implications of attention-deficit hyperactivity disorder among adolescents in treatment for substance abuse.” J Am Acad Child Adolesc Psychiatry. 36(1):30-6.
(8) Bandura A. 1991. “Social Cognitive Theory of Self-Regulation.” Organizational behavior and human decision processes 50(2):248-287
(9) Abramowitz AJ, Eckstrand D, O’leary SG, Dulcan MK. 1992. “ADHD Children’s Reponses to Stimulant Medication and Two Intensities of a Behavioral Intervention.” Behavior Modification 16(2):193-203
(10) Gureasko-Moore S, DuPaul GJ, White GP. 2006. “The Effects of Self-Management in General Education Classrooms on the Organizational Skills of Adolescents With ADHD.” Behavior Modification 30(2): 159-183
(11) Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York, New York: Simon & Schuster Inc. 1963
(12) Nelson LJ, Klutas K. 2000. “The Distinctiveness Effect in Social Interaction: Creation of a Self-Fulfilling Prophecy.” Personality and Social Psychology Bulleting 26: 126-135
(13) Modi NB, Lindemulder B, Gupta SK. 2000. “Single- and Multiple- Dose Pharmacokinetics of an Oral Once- a- Day Os motic Controlled- Release
OROS® (methylphenidate HCl) Formulation.” Journal of Clinical Pharmacology 40:379-388
(14) Hallinger P, Murphy JF. 1986. “The Social Context of Effective Schools.” American Journal of Education. 94(3):328-355
(15) Molina BSG, Smith BH, Pelham Jr. We. 2005. “Development of a School-Wide Behavior Program In a Public Middle School: An Illustration of Deployment-Focused Intervention Development, Stage 1” Journal of Attention Disorders (9)1: 333-342

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