ADHD label – helpful or harmful?

Controversies about ADHD

As with many ‘labels’ around mental health and neurological conditions, there is debate about the helpfulness and accuracy of labels. Attention Deficit Hyperactivity Disorder (ADHD) is no exception. ADHD seems to raise issues around whether it is more of a medical issue or a social issue, and therefore how society, schools, and families need to respond. The following arguments for and against ADHD as a label are intended as points for discussion.

History

ADHD as a recognised diagnosis has undergone many evolutions to reach its current definition. Some believe British paediatrician Sir George Still was talking about children with ADHD in 1902 when he wrote about ‘an abnormal defect of moral control in children’. Thankfully, we have become more enlightened as a society since that time. In 1968, the second edition of the Diagnostic and Statistical Manual (which clinicians still use today, in its 5^th edition) described ‘hyperkinetic impulse disorder’. ADHD as we recognize it today first featured in the DSM 4^th edition in 2000. Today, we can talk about 3 subtypes: ADHD combined type, predominantly inattentive or predominantly hyperactive-impulsive.  

Against the label

o   It brings blame and stigma

Some argue a label of ADHD invokes blame, stigma and assumptions to be made about the family. Is ADHD simply a ‘disorder of poor parenting’? Indeed, parents are often offered parenting courses before children are considered for assessment of ADHD, and clinicians need to be aware of the developmental impact that early childhood trauma can have as it can look like the symptoms of ADHD.

o   The label is biased

A review of 42 studies into ADHD diagnosis and disadvantage suggest that children living in disadvantaged families are up 2x more likely to be diagnosed than children from more privileged families (Russell, Ford, Williams & Russell, 2016). This relationship is not causal (living in a disadvantaged family does not cause a child to have ADHD), but rather is accounted for by various difficulties that may be experienced disproportionately by families in disadvantaged situations – such as financial difficulty, insecure housing, lower levels of involvement in the parenting of the child, and other adversities.

This raises questions about whether ADHD is a disorder, or is it a way to label children from certain backgrounds whose response to their situation means their behaviour does not ‘fit’ in with what society deems ‘normal’? Indeed, 11% of children with ADHD have received a permanent exclusion from school (UK ADHD Partnership), which will disproportionately affect children from lower SES families. Some may argue that giving the label of ADHD is a convenient way to make the child a ‘problem’, rather than address the underlying social disadvantage which put the child at a higher risk. 

o   Is our education system to blame?

Is ADHD simply a mismatch the expectations upon children and their ability to live up to these expectations? Compulsory schooling in the UK begins earlier than in other countries, and arguably involves more pressure and testing. There is also the ‘relative age effect’, whereby the gap between the oldest and youngest children in a year group can represent 20% of the youngest child’s total lifespan. Are teachers and parents misattributing the relative immaturity of summer born children as early warning signs of ADHD? One study found that the years’ youngest boys are 26% more likely to be diagnosed with ADHD than their older peers, and girls 31% more likely (Sayal et al, 2017).

o   The label leads to medicating children

There is controversy surrounding the idea of medicating children for ADHD. Some claim giving a drug such as Ritalin (which is a Class B drug in the UK, carrying a 5-year prison sentence for those buying or selling it) to children is not only morally wrong but brings up safeguarding concerns. Others would say medication helps their child and is a way for them to achieve their potential.

For the Diagnosis

A label can be empowering

• Research on the experiences of parents and children with an ADHD diagnosis reveals the label can provide relief from blame, and an explanation of their difficulties. It can empower families to begin the process of understanding and acceptance (Dr Frances Knight, 2019).

A label can change perceptions

• If a child has a label, it may help the adults who support them to find more empathy, understanding and patience to support the child, rather than view the child as ‘naughty’, which can lower children’s self-esteem (Flack, 2018) 

A label is necessary for shared understanding

• In order to further study the causes of ADHD, and to be able to offer effective support, we need a shared understanding of the cluster of symptoms and behaviours we call ‘ADHD’. Parents, teachers, professionals and scientists can all communicate reasonably well if a label is used. Boys are currently 4x more likely than girls to be diagnosed, and further study is needed to understand whether presentation in girls is different (National Institute for Clinical Excellence). 

Conclusion

There are no easy answers about whether a diagnosis of ADHD is helpful or harmful, and each circumstance surrounding a suspected or confirmed diagnosis will be unique. While in the medical world, ‘disorder’ is the term used, in the educational world ‘difference’ may be a better way to view individuals with ADHD-type behaviours. ‘Difference’ implies that we need to make reasonable adjustments and not view the individual as in any way ‘less than’ peers. We also need to be aware of the child’s relative age in the year, gender, home background and early childhood experiences to ensure we are not inadvertently seeing their behaviours in a biased way. ADHD is not solely a medical issue, or solely a social issue, but rather is the result of complex interacting factors – a biological-psychological-social holistic view is most likely the most helpful way to try and understand the needs of children.

Considering the child’s executive functioning (ability to plan, consider consequences, start and finish tasks, self-organise) can help teachers and parents understand how the child may be experiencing their day to day difficulties, and can lead to teaching them lifelong ways to manage their difficulties.

What do children with ADHD say helps them?

• Having a strong relationship to an understanding member of staff – preferably a teacher. Children need to feel they are understood and that they are not going to be blamed and told off every time they do something impulsively or are staring out the window
• Being involved in discussing what helps them, and choice in how adults support them
•  Simple classroom strategies that benefit all children, including those without and with SEN, can make a real difference

 

September 2019 – Hannah Harvest, Educational Psychologist

 

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