Stigmatization of ADHD

Abstract

Objective: In recent years, the stigmatization faced by people with mental disorders has received considerable attention in the empirical literature. However, individuals with different disorders are subject to distinct types of negative attitudes, necessitating examinations of stigma that treat specific disorders individually. Method: This article reviews recent empirical literature concerning the stigmatization of ADHD. Further specificity is achieved by taking a developmental perspective, reviewing studies of stigmatizing attitudes as a function of the age of the target and perceiver. Results: Findings from nationally representative data sets, experimental investigations, surveys, and qualitative studies indicate that individuals of all ages who exhibit symptoms of ADHD are the recipients of substantial stigmatization. Conclusion: Although the stigmatizing attitudes of children and adolescents appear to differ in some ways from those of adults, negative perceptions toward people with ADHD appear to generally be present at all stages of development.

Keywords

ADHD stigma attitudes development

The widespread stigmatization of people with psychiatric disorders has been identified as a primary concern in the field of mental health (Hinshaw & Cicchetti, 2000). Negative attitudes toward the mentally ill are commonplace throughout the world and impose a host of negative impacts, including disruption of family functioning, widespread reticence to seek mental health care, and limited funding for psychopathology research (Stier & Hinshaw, 2007). Stigma also acts directly as a major negative force in the lives of the mentally ill, predicting low levels of employment and poor access to housing, increasing the burden of shame and misery they must endure, and giving rise to the added stress of attempting to conceal their psychiatric problems (Hinshaw & Stier, 2008).

The stigma of psychiatric illness is often characterized by social rejection and stereotyped perceptions of people with mental disorders as incompetent and dangerous (Hinshaw & Stier, 2008). However, it has been noted that assuming all mental disorders to face exactly the same type of stigmatizing attitudes can itself be stigmatizing (Hinshaw, 2005), and there is considerable evidence that not all mental disorders are stigmatized in the same way (Sadler, Meagor, & Kaye, 2012).

ADHD is one of the most common childhood behavioral disorders, estimated to affect approximately 9% of children in the United States (Froehlich et al., 2007). Internationally, the disorder appears to persist into adulthood for approximately half of individuals with childhood ADHD (Lara et al., 2009). It is characterized by inattention (difficulty focusing on tasks or paying sustained attention, disorganization, distractibility, forgetfulness, absentmindedness) and/or hyperactivity and impulsiveness (difficulty sitting still or remaining quiet when appropriate; American Psychiatric Association, 2000).

Stigmatizing attitudes toward ADHD are relatively common and have been posited to play a role in socially and clinically important outcomes, such as treatment seeking and social functioning among people at all stages of development (Bussing, Zima, Mason, Porter, & Garvan, 2011; Hinshaw, 2005; Kooij et al., 2010; Martin, Pescosolido, Olafsdottir, & Mcleod, 2007; Paulson, Buermeyer, & Nelson-Gray, 2005). Moreover, a need for increased understanding of how development affects attitudes toward people with mental disorders and of the stigma-related experiences of children and adolescents with psychiatric illnesses has been identified in the literature (Hinshaw, 2005). This article will review the empirical literature on the stigma of ADHD with an emphasis on relevant developmental factors, exploring negative attitudes as a function of the developmental stage of both the perceiver and target wherever possible. Studies with other relevant samples, such as teachers and parents, are also examined separately.

Attitudes of Adults Regarding ADHD

Adults’ Attitudes Toward Children With ADHD

Much of the existing literature regarding American adults’ stigmatizing attitudes toward childhood ADHD has come from Pescosolido, Martin, and colleagues’ analyses of data from 2002’s National Stigma Study–Children (NSS-C). This survey module was administered to a subset of participants in the nationally representative General Social Survey and provides a rich source of information about the attitudes of U.S. adults toward children with ADHD and other conditions.

An analysis of these data (Pescosolido et al., 2008) showed that 41.9% of adults were able to correctly identify ADHD based on a vignette describing a child with symptoms meeting diagnostic criteria. Compared with the symptoms of a child described as suffering from depression, however, childhood ADHD symptoms were less likely to be seen as “serious,” less likely to be identified as a mental illness, and less likely to be viewed as requiring treatment. Even among those who correctly identified the constellation of symptoms described in the vignette as ADHD, approximately a fifth of respondents (19.1%) did not consider it to be a mental illness. A minority (38.4%) of respondents considered the ADHD symptoms to represent a “very serious” problem, compared with 83.6%—more than twice as high—for the depression symptoms.

On the NSS-C, approximately a fifth of adults indicated that they would be “probably” or “definitely” unwilling to interact with a child with ADHD symptoms described in a fictitious vignette (Martin et al., 2007). Specifically, such desire for social distance was reported by 22.19% of respondents when asked about having such a child move in next door, 16.9% when asked about having the child spend an evening with their family, 23.47% when asked about their own child befriending the child with ADHD, and 19.3% when asked about having the child with ADHD as their child’s classmate. These responses were comparable with those in which the target child suffered from depression, but were significantly more negative than responses to a hypothetical child with asthma. Notably, independent of the disorder described in the vignette, respondents reported stronger desire for social distance when the child was depicted as 14 years old (vs. 8 years old) and when the child was described as a boy (vs. as a girl). This suggests that boys and older children or adolescents are stigmatized more strongly than girls and younger children, possibly because they are more likely to be seen as threatening or dangerous. Also of note, desire for social distance was not significantly predicted by respondents’ endorsement of biological, chemical, genetic, or medical causes for the symptoms. Those who attributed the symptoms to bad character, poor discipline, or exposure to violent television or video games were significantly more rejecting of the child in the vignette. Additional predictors of increased desire for social distance included labeling symptoms as a “mental illness” (as opposed to “normal ups and downs”), holding stigmatizing beliefs about mental health treatment and perceiving children with mental disorders as dangerous.

Further analyses of the same data set specifically examined this attribution of dangerousness to children with mental health symptoms, finding that 31% of respondents believed a child with ADHD symptoms was “somewhat” or “very” likely to be violent toward others, while 36% were similarly concerned that the child could harm himself or herself (Pescosolido, Fettes, Martin, Monahan, & McLeod, 2007). These perceptions of dangerousness were approximately twice as common for children with ADHD than for children described as having typical “daily troubles,” and tended to be lower when the target child was a girl rather than a boy, providing a potential explanation for the observed difference in social distance as a function of the target child’s sex. A depressed child was rated as dangerous, both to others and to himself or herself, by an even greater proportion of respondents than the child with ADHD symptoms. In an apparent contradiction of the data on social distance, the vignette child was more likely to be perceived as dangerous to others when described as 8 years old versus 14 years old. Coercive measures for forcing a child with ADHD symptoms to see a clinician, take medication, or be hospitalized were endorsed by 17%, 12%, and 11% of respondents, respectively. The latter two rates were not significantly higher than those observed when the vignette described a child with “daily troubles,” suggesting that respondents may not have viewed ADHD as requiring particularly urgent treatment. Perhaps this stance is related to the observation, reviewed above, that Americans tend not to view ADHD as particularly “serious.” Across disorders, endorsement of coercive treatment measures tended to be higher among respondents who perceived the target children as dangerous or labeled their symptoms as a “mental illness.” Support for coerced hospitalization or outpatient treatment, but not medication treatment, was significantly higher when the vignette described a 14-year-old versus an 8-year-old.

A more recent set of vignette experiments focused on the effects of causal explanations for a child’s ADHD symptoms on adults’ attitudes toward the child described (Lebowitz, Rosenthal, & Ahn, 2016). Across three experiments, participants who viewed an explanation of the child’s symptoms as stemming from poor parenting and media exposure were subject to greater desire for social distance than those to whom the symptoms were presented as the result of biological factors. The lesser social distance among participants who viewed the biological explanation was found to be a function of their ascribing less blame to the child for his condition. However, the biological explanation, compared with the psychosocial one, yielded perceptions of the child’s symptoms as more difficult to treat. These findings may suggest that biological conceptualizations of ADHD, which are in ascendancy, may be a double-edged sword, reducing perceived blameworthiness and thus social rejection, while increasing prognostic pessimism.

Adults’ Attitudes Toward Adults With ADHD

Although national survey data on adults’ stigmatization of other adults with ADHD do not appear to be available, some experimental studies have been conducted to examine these types of attitudes. In one study of undergraduates at an American university, participants rated the likelihood that they would wish to interact with (i.e., collaborate on a group project with, get to know, become friends with, live with, work with, or date) a peer described as having ADHD, a general medical problem, or an ambiguous flaw such as perfectionism (Canu, Newman, Morrow, & Pope, 2008). Targets with ADHD were rated as less socially desirable than targets with the other two “weaknesses.”

In another study, university undergraduates watched a video segment depicting a young adult woman displaying symptoms of ADHD, another mental disorder, or no psychopathology (Paulson et al., 2005). As demonstrated by participants’ ratings of their liking of and willingness to interact with the individual depicted, social rejection was significantly higher for the target with ADHD than for the target with no psychopathology. Consistent with the previously reviewed findings regarding adults’ desire for social distance from children with mental disorders, social rejection of peers with ADHD was comparable with that of peers with depression.

As true experiments that systematically manipulated whether or not targets displayed symptoms of ADHD and compared attitude ratings against control targets without ADHD, these studies provide valuable evidence that other studies using observational methods can only suggest. Specifically, they demonstrate that perceiving a person with ADHD actually causes more stigmatization than characteristics other than mental disorders, though the strength of the stigma is comparable with other mental disorders. However, because these studies both used undergraduate samples, their findings may not be readily generalizable to other populations, such as older adults who may have less familiarity with ADHD or its treatment.

Attitudes of Clinicians

The European Adult ADHD Network’s 2003 consensus statement cited stigma—attributed to the perception of ADHD as a childhood disorder, the high levels of regulatory controls on medications effective against ADHD, and inadequate instruction about ADHD in programs that train mental health professionals—as a likely explanation for clinicians’ fears and concerns regarding the treatment of ADHD (Kooij et al., 2010). There is indeed evidence to suggest that some clinicians may be wary of treating patients with ADHD (especially using controlled stimulant medications) and that those who do treat the disorder may often contravene existing professional practice guidelines in diagnosing it (Lanham, 2006; Secnik & Perwien, 2001). However, actual empirical studies of clinicians’ stigmatizing attitudes regarding ADHD appear to be scarce. Moreover, at least among pediatricians, national survey data from the United States suggest that most (66%) enjoy treating patients with ADHD and that few report disliking or avoiding such patients (Kwasman, Tinsley, & Lepper, 1995). Further study of clinicians’ attitudes could be helpful in elucidating the role of stigma in any concerns they may have about treating patients with ADHD, as well as whether any such stigma might vary as a function of a patient’s age or other demographic characteristics.

Attitudes of Teachers

Nationally representative survey data from the United States suggest that teachers’ perceptions of their students’ academic ability varies as a function of a student’s ADHD diagnostic status. Specifically, findings from the Early Childhood Longitudinal Survey (ECLS) indicated that teachers perceived male and female third graders with ADHD to be less successful in reading and math than their classmates without ADHD (Eisenberg & Schneider, 2007). In fact, these perceptions were found to be more negative than would be expected based on actual differences in test scores, suggesting that negative attitudes regarding ADHD may influence teachers’ evaluations of their students’ academic abilities.

Attitudes and Experiences of Parents

Like teachers, parents appear to evaluate their children’s academic abilities more negatively if their child is diagnosed with ADHD, even when controlling for actual differences in test scores, suggesting that negative attitudes regarding the ADHD diagnosis may color parents’ perceptions of children’s scholastic talents (Eisenberg & Schneider, 2007).

Historically, parents have often been blamed for their children’s mental disorders, and the case of ADHD has been no exception (Hinshaw, 2005). Unsurprisingly, then, the existence of stigma in society at large is one of the principal factors shaping parents’ attitudes toward ADHD and its treatment (Klasen, 2000). In one survey of 48 parents with children who were diagnosed with ADHD, 77% of participants reported having experienced stigmatization, 44% reported concerns about how society would label their child, 40% report feeling socially isolated or rejected, and 21% reported that health care and school personnel were dismissive of their concerns (dosReis, Barksdale, Sherman, Maloney, & Charach, 2010). Furthermore, 21% of these survey respondents held stigmatizing beliefs about the use of stimulants in treating ADHD—often mentioning media “horror stories” and images of “zombielike,” “drugged” children—and 17% reported mistrust of medical assessments used to diagnose ADHD.

As indicated by these findings, parental concerns about the use of medication to treat childhood ADHD and the attendant stigma represent an important dimension of parents’ attitudes. One study of 365 parents whose children were prescribed ADHD medication found that parents’ perceptions of stigma were associated with perceiving ADHD medication as having fewer benefits and more costs (Harpur, Thompson, Daley, Abikoff, & Sonuga-Barke, 2008).

A qualitative study using focus groups of mothers and fathers of adolescents with ADHD found that many parents considered stigma to greatly affect their teenagers’ lives, citing its impact on the adolescents’ self-confidence and attitudes toward their disorder (Koro-Ljungberg & Bussing, 2009). So-called “courtesy stigma” applied to parents themselves was also reported and was described by some as motivating them to deny their children’s diagnoses, although social support (which requires disclosure) was reported to help with the effects of stigma. In general, parents reported that stigma added additional concerns to the already difficult task of managing their children’s disorder.

In related research, a study of 23 mothers of children with ADHD and 28 mothers of children without ADHD revealed that although the two groups actually did not differ on measures of stigmatizing attitudes toward ADHD, the mothers whose children had ADHD perceived other parents as holding more stigmatizing attitudes (Norvilitis, Scime, & Lee, 2002). Mothers of children with ADHD were more likely to report having their parenting criticized by others, and this reported frequency of critical comments was significantly associated with greater depressive symptomatology and lower perceived social support among these mothers.

Attitudes of Children and Adolescents Regarding ADHD

Perspective of Those With ADHD

The perception of ADHD as a stigmatized condition among children and adolescents with the disorder are of significant social and clinical import. For instance, research has demonstrated a significant inverse relationship between ADHD stigma perceptions and treatment utilization among adolescents with ADHD (Bussing et al., 2011). That is, the more adolescents with ADHD viewed their disorder as stigmatized by society, the less likely they were to have received mental health services in the past year. Many children who receive treatment for ADHD discontinue treatment during adolescence (Bussing et al., 2011), and the finding that stigma perceptions predict receipt of treatment among adolescents—who tend to be highly sensitive to how they are perceived socially—may help to explain this trend. In a more recent study, Bussing et al. (2012) found that while adolescents with ADHD and their parents often rated treatment for the disorder as a potential source of stigmatization and embarrassment, these ratings (among adolescents) were not a significant predictor of willingness to undergo treatment. However, because perceptions of stigma was measured with only a single item (the view of treatment as potentially embarrassing), this finding may be hard to interpret. For example, willingness to undergo treatment may be more related to other aspects of stigma besides embarrassment, such as potential social rejection.

A qualitative study using focus groups and interviews with British youth between the ages of 9 and 14 found that a majority had been bullied or called names as a result of their ADHD diagnosis (Singh et al., 2010). This bullying often resulted in physical fights. The participants also described feeling “exposed” and made to feel “different” by their need to take medication, especially in school. In general, they reported believing that others—including teachers, peers, and peers’ parents—viewed them negatively and were unsympathetic, perceived them as stupid, and treated them differently because of their diagnosis (Singh et al., 2010).

Analyses of data from the ECLS found, however, that children with ADHD diagnoses did not tend to differ significantly from their nondiagnosed counterparts in self-perceptions of skills and interest in reading and mathematics, with the exception that boys diagnosed with ADHD rated their skills and interest in math more negatively than their undiagnosed peers (Eisenberg & Schneider, 2007). Although limited in their scope, these data may suggest that despite youths’ well-documented awareness of the social stigma of ADHD, children with the disorder do not, for the most part, have significantly less academic self-confidence than their peers.

Other research has specifically examined the views of children and adolescents with ADHD regarding the stigma of taking medication to treat the disorder. A study of 123 children and adolescents aged 5 to 18 years who had been prescribed ADHD medications found that perceptions of stigma surrounding ADHD treatment were significantly associated with perceiving their medication to have more “costs” (e.g., negative side effects) and with resistance to taking their medication (Harpur et al., 2008).

Perspective of Peers in the General Population

An online survey conducted with a nationally representative sample of American children and adolescents found significant stigmatization of peers with ADHD and depression (described in fictitious vignettes), as compared with peers with asthma (Walker, Coleman, Lee, Squire, & Friesen, 2008). Specifically, survey participants endorsed negative attributions (e.g., “is more violent” than a typical classmate) more strongly for both mental disorders than for asthma; one item (“gets into trouble more often”) was also endorsed more strongly for ADHD than for depression, a pattern also reflected by the mean of all negative-attribution items (although the latter was a small effect). The respondents also indicated differentially strong attributions of positive traits to individuals with the different disorders, for example, rating the peers with asthma and depression “smarter” than the one with ADHD, and rating the peer with asthma “more caring” than those with ADHD and depression. Measures of social distance (e.g., gauging willingness to “work with him on a school project”) also revealed more stigmatization of the peers with depression and ADHD than the peer with asthma; the two mental disorders were rated differently on only one item (“invite him to a party or outing”), which yielded less favorable ratings of the depressed child. This largely replicates findings regarding the previously reviewed findings concerning American adults’ desire for social distance from a child with ADHD, which tended not to differ significantly from attitudes toward children with depression. The respondents also provided ratings of their families’ endorsement of several negative attitudes (e.g., the person’s disorder is “something to be ashamed of” or “means the parents are not good parents”). These responses indicated that the respondents believed their families to hold more negative views about depression than ADHD and more positive views about asthma than either mental disorder. This seems to further support the notion that children with mental disorders, including ADHD, are stigmatized more strongly than children with general medical conditions.

Another vignette study, this one using a sample of 120 children aged 11 and 12 years in the United Kingdom, found that respondents chose more negative than positive adjectives to describe a peer with ADHD symptoms, selecting “careless,” “lonely,” “crazy,” and “stupid” most frequently (Law, Sinclair, & Fraser, 2007). Endorsement of negative adjectives was significantly associated with less willingness to share activities with the child described in the vignette. Notably, none of the dependent variables differed significantly as a function of whether the vignette included a diagnostic label, suggesting that the behavioral symptoms of a child with ADHD, rather than receipt of the diagnosis, was the principal driver of stigmatizing attitudes. This appears consistent with other research suggesting that boys’ social perceptions of and behaviors toward peers with ADHD—which were mainly characterized by rejection—were largely determined by the latter groups’ actual behaviors (Erhardt & Hinshaw, 1994). However, other research does suggest that being told a peer has ADHD symptoms, before actually observing any, can also affect social attitudes. In one study, elementary school boys with no ADHD diagnosis who worked on a task in pairs were less friendly and less talkative when previously told that their partners had symptoms of ADHD, and were less willing to give their partners credit for doing well on the task (Harris, Milich, Brady, Corbitt, & Hoover, 1992). These findings suggest that expectancies, in addition to actual behavior, can have significant effects on children’s perceptions of and behaviors toward peers with ADHD.

A more recent study examined the stigmatization of peers with ADHD among 385 Irish children and adolescents, measuring both their explicit (self-reported) attitudes and their implicit attitudes (attitudes that are not consciously reported but can be gauged using indirect measures such as reaction time; O’Driscoll, Heary, Hennessy, & McKeague, 2012). Explicit measures of perceived dangerousness, personal responsibility for symptoms, fear, anger, and social distance revealed more stigmatization of an age-matched peer with ADHD compared with one with “normal issues.” Social distance and attributions of personal responsibility were also generally stronger for the peer with ADHD than the one with depression. The measure of implicit stigma also revealed significantly more negative attitudes toward the peers with ADHD and depression, as compared with one with “normal issues.”

Conclusion

The clearest conclusion that emerges from the literature examined here is that there is significant stigmatization of adults, adolescents, and children with ADHD, and these negative attitudes appear to be present among individuals at all stages of the life span. Many empirical studies have documented widespread reluctance to interact socially with individuals experiencing the disorder. This type of stigma—the desire for social distance from people with ADHD—has been documented in a variety of different types of samples, and seems generally to be at least as strong as the same attitudes as expressed toward individuals with depression. Despite the many ways in which the two conditions differ, the fact that both are mental disorders appears to garner them comparably strong social rejection from individuals of varying ages. However, adults appear to view depressed people as more likely to be violent than those with ADHD, while children rated a peer with ADHD as more responsible for their problems and more liable to get into trouble than one with depression, exemplifying ways in which distinct forms of stigma can be directed toward different disorders.

Teachers and parents have also been shown to be vulnerable to negative biases in evaluating children with ADHD, particularly with regard to their academic abilities. Parents of children with ADHD also bear the burden of substantial stigmatization themselves, but some research suggests that they may overestimate the intensity of others’ negative attitudes toward them. This, in turn, seems to play a role in some parents’ decision to be secretive about their children’s diagnoses, which may have the paradoxical effect of decreasing the social support that research shows could help them manage the negative effects of stigma.

Notably, a considerable proportion of the available empirical work on the stigma of ADHD has used samples from the United States and the United Kingdom. More cross-cultural data could shed light on the universality of these attitudes. Also, as noted by Hinshaw (2005), the diverse methodologies and sampling approaches used by researchers in the field limits the feasibility of direct, absolute comparisons among the attitudes of individuals at different stages of development. Future research specifically designed to address this question could serve to clarify the role of developmental factors in the stigmatization of people with ADHD and other mental disorders.

However, based on the existing empirical research, there appears to be at least some continuity in the valence and intensity of at least some forms of negative attitudes toward people with ADHD over development. As this prejudice appears to begin early in life, research that investigates interventions aimed specifically at reducing such stigmatizing attitudes among children—which appears to be relatively scarce—could be particularly beneficial.

Footnotes

Acknowledgements

The author would like to acknowledge Julia Kim-Cohen for providing invaluable feedback on an earlier version of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Matthew S. Lebowitz is currently a doctoral student at the department of psychology at Yale University. His areas of research include conceptualizations of mental disorders, causal attributions for psychopathology, and the stigma of psychiatric illness.

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