Keywords: ADHD; social construct; strengths-based theory; reframing; stigma; negative label; medicalization; positive psychology
he concept of social construction, as defined by Berger and Luckman (1966), starts with people in the social system who interact together. These interactions create concepts of each others actions over time, and people become accustomed to these roles by frequent exposure or repetition. As these roles or experiences are introduced to other members of society and are understood and practiced by society at large, these interactions become institutionalized and adopted by society as knowledge. The method of transmission of this knowledge is through language. Berger and Luckman (1966) explain how only a portion of human experience is retained in the conscious mind. They explain that as these experiences are retained, they become sedimented, as in settled or deposited in a more stable state. As these experiences are shared with others, intersubjective sedimentation occurs as more and more individuals share this common biography. These shared experiences are made available to an entire community, and,
. . . language provides the means for objectifying new experiences, allowing their incorporation into the already existing stock of knowledge, and it is the most important means by which the objectivated and objectified sedimentations are transmitted in the tradition of the collectivity in question. (pp. 6364)
Social construction theory includes interpretive examination of contemporary social phenomena in which people describe or explain the world in which they live. Social
2012 Springer Publishing Company
http://dx.doi.org/10.1891/1559-4343.14.1.15
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construction theory involves discourse around the social interactions that occur and form a socially constructed relationship. Based on contemporary events and interpretations of these events, the theory holds that peoples beliefs about the world are social inventions. Reality is socially constructed based on peoples definitions (Cheung, 1997, p. 332). Similarly, an organisms condition that has been determined to be not normal or not operating at a level that society expects is believed to be abnormal and labeled as such. The language pertaining to this abnormality or disorder may warrant this condition or disease to be proven abnormal through empirical evidence, and the results declared scientifically valid. It is through the social construction of mental illnesses that I present examples of what has been defined as abnormal or outside societys acceptance of normal human experience by the American Psychiatric Association (APA).
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the early 1980s. Social structural changes that were, and continue to be, a goal of this social movement include shifts in the allocation of health and social service resources for persons with the disease and their care givers (p. 65). Alzheimers disease became the seventh leading overall cause of death for all ages during 20032004; and for ages 65 and older, the fifth leading cause of death in the United States (Centers for Disease Control, 2007). The changes reflected in the DSM with each newly minted publication are reflective of American societal and cultural trends. The preceding discussions are shortened examples of the American Psychiatric Associations methodology, but the purpose is to reflect a progression of changes that have significantly impacted society. The case of homosexuality demonstrates that diagnostic criteria may be socially constructed when there is no causal biomarker to scientifically validate it as a psychiatric disorder but that which is based on syndrome or behaviors. This is the central issue surrounding the discourse on ADHD diagnoses because there also is no blood test or biomarker to determine the presence of any form of a disease or biological or chemical disorder.
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characteristic of individuals diagnosed with ADHD. They present scientific analysis of the specific benefits from ADHD for society, by presenting evidence that unpredictable behavior by a minority may bring beneficial results to the group. An example of an unpredictable behavior is in risk-taking borne primarily by one individual; if successful results occur, a group as a whole may benefit. When sufficient information can be obtained by a minority and passed on to the group, there is no longer any need for all individuals to explore (Williams & Taylor, 2006, p. 402). The reader is encouraged to read this scholarly, scientific account of the evolutionary status of ADHD if this is a topic of interest to him or her.
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Cultures differ, for example, in the degree to which their members accept emotional distress or tolerate underperformance . . . As Ive noted, the ADD diagnosis and Ritalin use remain overwhelmingly a phenomenon of white, suburban, middle- and upper-middle-class children. Its in this slice of society, of course, that expectations run highest and anxieties about performance shortfalls lately have become acute. (p. 317)
The third and final perspective does not support the biological premise of ADHD and is critical of the idea of ADHD as a syndrome. These medical professionals view varying degrees of childhood behaviors as a function of psychological and behavioral development. Those following this ideology express concern over the use of psychostimulants to medicate small children and view it as highly suspect. This group of medical professionals sees the overdiagnoses of ADHD as a catchall when overdiagnosis cannot be established and as a means of labeling and controlling children who exhibit difficult behaviors. Followers of this third view believe that children are being given drugs unnecessarily to control their behaviors. In short, using medication as a means of social control (Norris & Lloyd, 2000, p. 133). Thom Hartmann advocates for this perspective. Hartmann (2003) presents a positive, hopeful view of ADHD as a trait, not a syndrome. He believes that Thomas Edison demonstrated ADHD traits and discusses the hunter and farmer traits of society of past centuries. The farmer skills were important to the livelihood of society as were the hunters abilities. It was the hunter with a short attention span who could monitor the environment against dangerous threats. The hunter was innovative, yet impatient, and thrived in an adventurous and changing world (Hartmann, 2003). The controversy between these groups generates considerable research and discourse. For purposes of this article, my preference is to agree with the third group. One of the primary reasons for my position on ADHD is the countless numbers of individuals with ADHD who are highly successful in life. In many of these cases, individuals with ADHD have not suffered the stigmatization by others and, in fact, have been celebrated and highly successful even though they have ADHD-like traits. It is unlikely that this discourse will be quieted and settled until society and the scientific community can agree and resolve the myriad of complex issues relative to ADHD.
ADHD Diagnosis
In the case of ADHD, it is through the collective social responsibility of physicians, parents, and other members of society that defines the diagnostic threshold (Amaral, 2007). The present criteria for the diagnosis of ADHD are defined by the APA through the DSMIV. The prevalence of incidence rates and the medical and psychological practices used to treat those diagnosed with ADHD are based on American standards. Many European countries do not use DSM criteria for ADHD but instead define behaviors as hyperkinetic disorder or HKD (Lloyd & Norris, 1999). To understand the differences between United States and Europe, it is important to consider the method and criteria for diagnosis. For instance, Polanczyk et al. (2007) discovered a significant difference in diagnostic criteria in their research. European researchers use the stricter International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) for diagnosis, whereas United States researchers use DSMIV. The ICD-10 requires that a child must exhibit all three dimensions of inattention, hyperactivity, and impulsivity; and they must meet these criteria both at home and school. In contrast, the DSMIV criteria is considerably more lenient, requiring that
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a child must meet one of the three dimensions and exhibit symptoms either at school or home (Polanczyk, et al., 2007).
STIGMA AND SOCIAL IDENTITY: REFRAMING OF ADHD Effects of Negative Labeling on Social Development
Goffman (1963) is renowned for his work in defining stigma. He writes of societys categorization of people with attributes that are deemed ordinary or natural for members of a particular category. Goffman defines social identity as a way to code the persons attributes. However, it may be over time in getting to know this person that one may realize the person does not possess the expected attributes for his or her particular category. So in effect, in ones mind, that person is tainted and discounted as less than what is expected. This failing, shortcoming, or handicap creates an overall discrediting of the person or what has become know as stigma (Goffman, 1963).
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Goffman discusses three types of stigma: (a) various physical deformities; (b) individual character blemishes that arise from weakness of characteras in dishonesty or unnatural beliefsor caused by imprisonment or mental disorders; and (c) a form of tribal identification based on race, religion, ethnicity, or other lineage. Goffman (1963) writes,
The attitudes we normals have toward a person with a stigma, and the actions we take in regard to him, are well known, since these responses are what benevolent social action is designed to soften and ameliorate. By definition, of course, we believe the person with a stigma is not quite human. On this assumption we exercise varieties of discrimination, through which we effectively, if often unthinkingly, reduce his life chances. We construct a stigma-theory, an ideology to explain his inferiority and account for the danger he represents, sometimes rationalizing an animosity based on other difference. . . . (p. 5)
In a recent research study on social reactions to children with mental health problems, researchers proposed a general model of stigma and studied the results of what individuals bring to social interactions with others in a series of vignettes. Martin, Pescosolido, Olafsdottir, and McLeod (2007) report through clear evidence that the
disturbing behaviors associated with ADHD and depression increase preferences for social distance, a pattern that, in the case of ADHD, persisted across all models . . . the label of mental illness has a significant negative impact on the publics willingness to socially engage with children with [perceived] mental health problems. (pp. 6162)
The authors call for the stigma surrounding childrens mental health issues to be addressed by society through political, legal, and research agendas (Martin et al., 2007). The behaviors of children diagnosed with ADHD children may be uncontrolled, impulsive, hyperactive, or disruptive in educational or other settings. Through the lenses of children diagnosed with ADHD, one may see environments that are overwhelmingly negative. The messages that these children receive regularly are from the multiple systems that interact to regulate or control the childs behaviors. On behalf of themselves and their children, parents look for support from others to recognize the difficulties and struggles of their children diagnosed with ADHD (Norris & Lloyd, 2000). These negative messages from others contribute to the individuals low self-esteem and poor self-confidence over the long-term. Many succeed in overcoming those earlier negative messages received related to their diagnosis of ADHD, whereas many others will struggle and suffer from low self-esteem, poor self-image, and inability to self-regulate their entire lives. Recognition of the cumulative effect of ones history can sometimes lead to permanent internalization of these messages, leaving adults with AD[H]D believing that they are indeed lazy, stupid underachievers (Murphy & LeVert, 1995, p. 20). Goffman (1963) discusses the concept of social identity and group alignment. For one who is aware and understands, there are stigmatizing labels that have been applied to himself or herself, it is important to understand and give consideration to the role of information in stigma management. Although maintaining ones personal identity is essential, the more allied the individual is with normals, the more he will see himself in nonstigmatic terms (p. 107). Goffman recommends that the stigmatized individual find a way out of his or her dilemma. If unable to do this on his or her own, Goffman recommends trained professionals to help the stigmatized individual develop an appropriate attitude
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regarding the self. Authenticity of self, recognizing the strengths and positive attributes of self is crucial to overcoming stigmatization.
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the practitioners attention away from pathology and pain and directs it toward a cleareyed concentration on strength, vision, and dreams (p. 220). Kauffman notes, despite this focused intent, positive psychology practitioners still find it difficult to transcend the medical model because much of psychological training, language, and assessment tools are grounded in pathology and problems.
CONCLUSION
This article addresses a critical review of the literature on ADHD and integrates theories to propose an alternative way to understand and treat ADHD. Included here is discussion on the social construction and ideologies surrounding ADHD, the stigma associated with its symptoms, the reframing of ADHD, and the consideration of strengths-based theory as an alternative approach to treating those diagnosed with ADHD. As society plays a
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significant role in the way children diagnosed with ADHD are treated, it is incumbent upon all of us to make improvements in the lives of children who have been unfairly stigmatized and in many cases, ostracized from positive childhood development efforts. Our purpose should be to reexamine the responsibilities and activities of researchers, health practitioners, educational professionals, and parents to encourage the understanding of the problems facing individuals who have been labeled with a form of mental illness ADHD. Parents should not have to worry about sharing information about their childs attention differences and having the child suffer from negative consequences. Children should not be recipients of negative labels from educators, friends, teammates, neighbors, or other members of society. We need to develop the skills within our children to help them deal with misguided and damaging comments from those who have been entrusted to care, nurture, and assist them in developing. Another goal for society should be to help others in the rethinking and reframing of ADHD from a disorder or deficiency to that of an attention differenceattempting to remove the negative labeling that has harmed so many by categorizing us as possessing a form of a mental illness. Only then can we enable members of society to begin the dialogue around the question of what is the process by which a disorder like ADHD can be redefined as strength?
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Spinelli, C. G. (1998). Facilitating and promoting academic and social success for the adolescent with Attention Deficit Disorder. US Department of Education. Weiss, L. (2005). Attention deficit disorder in adults: A different way of thinking (4th ed.). Lanham, MD: Taylor Trade. Williams, J., & Taylor, E. (2006). The evolution of hyperactivity, impulsivity and cognitive diversity. Journal of the Royal Society Interface, 3(8), 399413. Zucker, K. J., & Spitzer, R. L. (2005). Was the gender identity disorder of childhood diagnosis introduced into DSMIII as a backdoor maneuver to replace homosexuality? A historical note. Journal of Sex & Marital Therapy, 31(1), 3142. Barbara A. Mather is an organizational change, certified management consultant and is in the final stages of obtaining her PhD in Human and Organizational Systems from Fielding Graduate University, Santa Barbara, CA. Her dissertation research question addresses the workplace challenges of young adults diagnosed with ADHD. More information about Mather and her consulting firm may be found at www.matherconsulting.com. Correspondence regarding this article should be directed to Barbara A. Mather, MBA, MA, CMC, President, Mather Consulting Group, Inc. E-mail: bam@matherconsulting.com