Why are ADHD drugs so stigmatized

Stigma and ADHD

Under Stigma (of stigma, Greek στíγμα for stitch, wound mark) is understood as a social process in which individuals negatively evaluate or discriminate another individual, or a group of other individuals, on the basis of otherness, undesirable behavior or other deviating characteristics.

People with ADHD are often victims of social stigma. On the one hand, ADHD, as a psychiatric disorder, is often associated with negative attributions; On the other hand, because of the social prejudice against the disorder and its difficulties, those affected are more often not taken in.

Origin of the term

Tattooed prisoner number on the arm of an Auschwitz survivor

Stigmatization originally served to publicly humiliate and ostracize delinquents who violated the law. This included, for example, cutting off body parts that are always visible, such as ears (loss of honor), fingers or hands (theft). Branding to identify marginalized social groups was still in use in the western world in the 20th century. French galley prisoners were branded with the French lily for life. During the Nazi era, numbers tattooed on the left arm of inmates were brutally used to identify them.[1] Some surviving ex-prisoners from the time of National Socialism still have these numbers (2014).[2]

Stigma in society

Sociologist Erving Goffman * 11. June 1922; † November 19, 1982

The term social stigma was largely coined by the Canadian sociologist Erving Goffman, who defined three criteria, at least one of which must be met in order for a person to be stigmatized:[3]

  • Abominations of the body (e.g. physical disabilities, deformities, illness)
  • Individual character defects (e.g. addiction, aggressiveness, homosexuality)
  • Phylogenetic characteristics (e.g. nation, religion)

Goffmann suspects that stigmatization processes have a stabilizing function in society as a reaction to norm expectations that have not been met. Thus, the establishment and maintenance of social agreements is only achieved through the creation of a desirable social status that contrasts with a stigmatized status.[4] In doing so, Hohmeier postulates that stigmata serve to provide orientation in and predictability of social interactions. In this way, expectations and assumptions are made regarding the behavior of the interaction partner, which influence one's own behavior towards the person and pre-structure the situation.[5]

Cloerkes highlights the economic aspects of stigmatization processes. Stigmata regulate the interaction between different social groups and access to scarce goods such as status, career opportunities, etc. and thus serve to stabilize the system. Furthermore, stigmata regulate power and domination relationships between different social groups.[6]

Stigmatization can arise on the basis of every conceivable otherness or deviation from the norm, provided that the deviating characteristic is not socially desirable.

Examples of social stigmas

Examples of social stigmata can be sexual orientation, nationality, religion, homelessness, social origin, physical or mental disabilities or illnesses and mental disorders, including ADHD.

Stigmatized features can become visible in more subtle or obvious ways. A certain way of speaking (e.g. speaking with a dialect or accent) can indicate a certain social origin. A residential area that is increasingly affected by social housing implies the unemployment of the residents. It should be mentioned here that poverty already becomes a social stigma if it is attributed as a lack of willingness to perform and possible external circumstances that have led to the disadvantage are not questioned or even ignored ("Fair world belief")[7]. A similar pattern is occasionally found in ADHD, when the level of suffering associated with the disorder is invalidated by the environment or not taken seriously.

Clothing is considered to be one of the most visible characteristics that can contribute to the formation of stigma among young people as well as adults, as full membership of a social group is often largely determined by external characteristics such as clothing.

In groups of adults, however, the network required for group membership is much more finely meshed than in adolescent peer groups. Here other key factors such as socio-economic status, a related occupation, leisure activities, certain social rituals, educational backgrounds and other external factors play a role that characterize the adult individual. The stigmatization among adults becomes clearly visible when dealing with a person is avoided by the group after an important key factor has ceased to exist.

Stigma and ADHD

rating

Mental disorders like ADHD can act as social stigmas. Not only the syndrome-related deviant behavior, but also the often negatively attributed label associated with the diagnosis can lead to rejection and social exclusion.

ADHD is recognized and classified as a mental disorder.[8] The pharmacotherapy, which is mainly used for the severely affected, is present in the collective consciousness, especially in connection with the preparation Ritalin. At the turn of the millennium in particular, the methylphenidate-containing Ritalin was discussed controversially after five class action lawsuits were filed against the manufacturer Novartis in the USA. This triggered controversial media coverage around the world on the subject of ADHD. Plaintiffs' undifferentiated classification of Ritalin as a "dangerous drug" [9] has held up to the present[10] and parents of severely and severely affected children can make the decision about medication, but also about a diagnosis to be initiated, even more difficult because of the fear of being socially ostracized, excluded or not taken seriously; Affected adults with greater distress are more likely to hesitate to take the medication if they believe that taking Ritalin, which the plaintiffs describe as a "dangerous drug", could endanger their health.

Even against these backgrounds, there is a risk of stigmatization processes. In addition, however, the general clichés that lead to the exclusion of mentally ill people also work, as these also affect ADHD. The lay conception of mental illnesses is characterized by attributes such as "strange appearance and behavior", "thought disorders", "criminality", "unpredictability", "aggressiveness" or "limited social functionality". The picture of those affected is often perceived as "not normal" and deviating from the norm, although these dimensional characteristics in ADHD on the one hand rarely appear so clearly, and on the other hand are not necessarily true, since ADHD is not a homogeneous disorder. The symptoms and their severity as well as accompanying comorbidities (the clinical picture) can be phenotypically and in their severity very different.[11]

consequences

Stigmatizing a person affected by ADHD comes into question in the form of widespread clichés, even if the person affected is not even known as a person. In this way, all behavior and the biography of the stigmatized person can be justified reductionistically with the stigma (ADHD), without other biographical factors being taken into account in the development of, for example, negative character traits. There is also the risk that certain prominent character traits are no longer perceived as such, but rather as “typical for ADHD” caused by the disorder, which can imply identity conflicts on the part of the person concerned. Here, the psychoeducation recommended in the treatment guidelines also plays a role for prevention, in which, in addition to the person affected, at least the immediate environment (and, if applicable, the class teacher at the school) should be informed as comprehensively and specifically as possible about the individual ADHD problems of the person affected.

At the same time, the widespread doubts about the diagnostic validity of ADHD and its reputation as an inflationary diagnosis also harbor the risk of stigmatization, as there is a risk that the psychological stress that can go hand in hand with ADHD is not taken seriously and children and adolescents through early treatment from the proven long-term effects[12][13][14][15] an untreated ADHD cannot be preserved. Even adults who suffer from ADHD symptoms and do not take their self-suspicions seriously due to the aforementioned reservations - and who subsequently do not undergo any clarifying diagnostics - may not benefit from treatment.

In many cases, the ADHD diagnosis is preceded by a long history of suffering, which was also associated with stigmatization, the cause of which in turn may lie in the ADHD symptoms. Here, together with the responsible therapists and doctors, it should be weighed up whether a diagnosis with subsequent therapy makes sense and is promising.

ADHD diagnosis: comparison of diagnostic benefits and stigmatization

With the diagnosis of ADHD - against the background of ADHD as a mental disorder with corresponding implications for the labeled person - a stigma effect can be associated.[16]Russell Barkley points out the ambivalence of the ADHD diagnosis, but emphasizes that the advantages of a correctly made diagnosis outweigh: Although labeling always carries the risk of stigmatization, the identification of the various difficulties associated with ADHD has the advantage that those affected have the advantage Become aware of the cause and nature of your problems and are therefore more likely to seek help.[17] The American psychologist Harvey Parker adds (translated from English):

“We should be happy that schools across the country have started paying attention to students with ADHD and taking their problems seriously, and that we can offer effective therapies. We should be happy that the general public no longer perceives affected children and young people as 'cheeky and angry children', but as young people with problems that they can solve and would like to solve! ".

—Harvey Parker

Brandau, Schmela and Spitczok von Brisinski also conclude that the diagnosis of ADHD does not necessarily have to result in a negative process of labeling and stigmatization. Depending on the context, the diagnosis can also have an excusing, explanatory and intra-family conflict-solving effect and thus reduce stress.[18].

Abuse and self-stigmatization

The diagnosis of ADHD and the associated clarity about the cause of the often lifelong problems can be a significant relief for many parents of affected children as well as for adults affected in view of the therapy options that are now available. However, according to a study in Bochum, the diagnoses, which are often improperly carried out, harbor the risk of further increasing misdiagnoses, which in turn contain a relatively large spectrum of risks if the actually underlying, primary disorder is not detected in the context of differential diagnostics. This can also include, for example, abuse on a physical and emotional level, which remains undetected as a result of the ADHD diagnosis[19] - Up to 30% of all children and adolescents are victims of sexual abuse alone.[20] According to the hypothesis, both a true-positive and a false-positive ADHD diagnosis in the environment of the symptom-carrying child affected by abuse could lead to any abuse taking place no longer receiving any further attention. In both cases, especially in the case of abuse that is difficult to detect (emotional / narcissistic abuse, subtle forms of sexual exploitation, "corporal punishment" / punishment without obvious wounds), there is a risk that it will not be discovered for a long time, and not even as such by the victim himself is identified because it is stigmatized and labeled as a "difficult to raise child" with a monocausal neurobiological genesis due to the ADHD diagnosis[21][22] and has developed a corresponding, distorted sense of guilt[23]whose structure is sustained into adulthood in the form of self-stigmatization.

Self-fulfilling prophecies

Moderate or severe ADHD symptoms usually cause distress, at least in isolated areas of life. Recurring failures, setbacks and experiences of failure, which are often accompanied by stigmatizing reproaches and punishments, lead to self-image and self-efficacy disorders in the course of a person's life. The diminished expectations of self-efficacy are then often expressed in self-fulfilling prophecies, in which the self-image of those affected gradually begins to correspond to the external image suggested by others through the constant awareness of their own otherness. Taking on the assigned role sets a self-contained vicious circle in motion, as the expectations of the stigmatizing environment are fulfilled, this continues to stigmatize those affected and vice versa.

However, this scheme also occurs in connection with the positive ADHD diagnosis known in the community. Affected people can be labeled with negative expectations, stereotypes and role models ("bad student", "class clown", "dream babe", "clumsy", "fidgety philippy", "troublemaker") that may be implied by the diagnosis, which internalizes the role model assigned and the actually undesirable behavior is further intensified (Pygmalion effect).[24]

Dynamic of Self-Fulfilling Prophecy

Milich et al. observed the process of interaction between couples of children who did not know each other in 1992. Some children were told before the event that their interaction partner was behaviorally disordered. In these cases, the child described as having behavioral disorder was treated less friendly and more likely to be excluded from the game than children whose interaction partners had not received this information. The affected children felt the rejection of their interaction partners and then intensified the negative reactions through their own behavior, which in turn intensified their own negative behavior and so on.[25]

ADHD sufferers usually react very intensely to social reinforcement stimuli, which is why this negative reinforcement in the form of role assignment should be avoided at all costs. Instead, those affected should be praised and encouraged as often as possible, and their personal strengths should be emphasized so as not to further diminish their already mostly battered self-esteem. Whether it makes sense to highlight possible ADHD-specific strengths in view of previous stigmatization processes should be considered, as these can be perceived as positive characteristics, but on the other hand also as counterparts that complete a role model. This depends on whether and to what extent stigmata have already been internalized in connection with the diagnosis of ADHD.

medication

The additional drug treatment used in severe cases can accelerate and improve the progress of the therapy, which in turn also improves the ADHD-related difficulties. In some cases, pharmacotherapy only allows therapy to be started. On the other hand, taking medication in children and adolescents - especially if this is done regularly in front of classmates - can contribute to stigmatization, as psychostimulants, especially in connection with the diagnosis of ADHD, are often associated with negative attributions in society. Switching to slow-release preparations can be helpful here, so that taking the medication is reduced to a single intake in the morning.

Unfavorable expectations of medication on the part of parents, teachers or other people can also have a stigmatizing effect. For example, undesirable behavior should never be responded to by asking whether the prescribed medication has already been taken.

Overcoming stigma

If an individual experiences stigmatization, they usually develop strategies to cope with it in order to maintain or restore their own identity in the society by which they want to be recognized or accepted. Various coping strategies can often be observed here, not only in the case of problematic ADHD.

Correction of the stigma

The stigmatized tries to hide the stigma as well as possible and to adapt to the prevailing normalcy.[26] In the case of ADHD, this meant, for example, in the context of social interactions, consciously suppressing the impulsiveness that is otherwise increasingly apparent (cannot be talked out of it, frequent changes of topic, outbursts of anger). Those affected often succeed in doing this very well, but often only for a short time limited to an approach phase and usually only as long as external (especially social) stress factors are largely reduced.

Splitting off the stigma

Affected people reconstruct their own normality and do not come to terms with the stigma. For example, they do not try to hide their ADHD symptoms, but rather redefine them for themselves and for others into a specific condition of otherwise normal behavior.[27] Explanations by the person concerned during or after the onset of the problematic symptoms can be helpful. This strategy can make those affected gain acceptance from their fellow human beings and help them to understand them better.

Self-stigmatization / identification with the stigma

If those affected are exposed to a particularly aversive and incomprehensible psychosocial environment in which there are few effective ways to compensate for the stigma, they often only have an arrangement with the role model assigned to them. In doing so, those affected begin to identify with the stigma, which can lead to a reshaping of the personality, especially in the childhood and adolescent development phases. The role image of the "class clown", "troublemaker" or the "clumsy" is then perceived by those affected as an integral, if not a cardinal component of the personality and also put on display, because at least these maladaptive character traits are (even if only marginal) social Acceptance can be experienced. ADHD sufferers in adulthood are more likely to show regressive and age-appropriate, sometimes even reckless or rebellious behavior that is experienced as an ego-synton. This does not always have to be due to the ADHD, but can also be explained as a relic of a coping strategy learned at an early stage or by possible comorbid disorders.

There is also a risk of developing narcissistic personality accents or even comorbid narcissistic personality disorders.[28]

Social withdrawal

As a mental disorder, ADHD is not immediately apparent to other people. Based on their experiences, however, those affected are aware that other people, as soon as their stigma becomes visible, could show pejorative, stigmatizing behavior towards the person concerned. Those affected can perceive this possibility as a great danger, so that they are always tense and on alert in social interactions due to the fear that their stigma might become visible. It is not uncommon for comorbid social fears to develop as a result, including social phobias.[29]

Public actions against stigma in ADHD

With the Real Voices Report The ADHD Future Alliance (2014) pharmaceutical campaign aimed to help prevent and combat stigmatization and discrimination in connection with ADHD.

Studies and scientific publications

Movie and TV

See also

literature

  • Unlike the others: What makes our children's souls sick, Franz-Joseph Freisleder, 2014, Piper, ISBN: 978-3492055352
  • Krutzk, D .: Regulartory Disorders in Children and Stigmatization in School Environments. Cologne 2012.
  • Michaela Amering / Margit Schmolke: Recovery. The end of incurability, Psychiatrie-Verlag, Bonn 2007, ISBN 978-3-88414-421-3
  • Manfred Brusten / Jürgen Hohmeier (eds.): Stigma 1 + 2. For the production of marginalized groups - Luchterhand Verlag, Darmstadt 1975
  • Asmus Finzen: Psychosis and Stigma: Overcoming stigma - how to deal with prejudice and blame, Psychiatrie-Verlag, Bonn 2000
  • Wolfgang Gaebel, Hans-Jürgen Möller, Wulf Rössler (eds.): Stigma - Discrimination - Coping. Dealing with social exclusion of the mentally ill, Kohlhammer, Stuttgart 2004
  • Erving Goffman: Stigma. About techniques of coping with damaged identity, Frankfurt am Main, 1967 Orig. 1963]

Web links

More interesting articles

Individual evidence

  1. ↑ Focus.de, unknown person gives Nazi stamp from Auschwitz concentration camp, March 14, 2014. Retrieved: September 8, 2014
  2. ^ Westfälische Nachrichten, interview with contemporary witnesses: Holocaust survivor Leslie Schwartz "Number 71253", August 29, 2014. Retrieved: September 8, 2014
  3. ↑ GOFFMAN, ERVING: Stigma, On Techniques for Coping with Damaged Identities. S12. Frankfurt am Main 1975
  4. ↑ Goffman et al. a. O., New York, p. 138
  5. ↑ Hohmeier, J., Brusten, M .: Stigmatization 1, On the production of marginalized groups, p.10. Darmstadt 1975
  6. ↑ Cloerkes, G .: Sociology of the Disabled, An Introduction, p.171, Heidelberg 2007.
  7. ↑ https: //de.wikipedia.org/wiki/Gerechte-Welt-Glaube
  8. ↑ http: //www.bundesaerztekammer.de/page.asp? His = 0.7.47.3161.3163.3164
  9. ↑ http: //www.royalrife.com/ritalinfraud.html
  10. ↑ Example from the tabloid media: RTL.de, Ritalin: This is how dangerous the ADHD drug is, 02/10/14. Accessed: 09.09.2014
  11. ^ Krützek, D. (2012). Regulartory Disorders in Children and Stigmatization in School Environments. Cologne.
  12. ^ Biederman J, Mick E & Faraone SV: Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry 157; 2000: 816-818
  13. ↑ Barkley RA: Attention-Deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment, Guilford Press, New York 1998 3) Biederman J, Wilens T, Mick E et al: Is ADHD a risk factor for psychoactive substance use disorders? Findings from a four-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 36; 1997: 21-29
  14. ↑ Cunningham CE et al: Family functioning, time allocation and parental depression in the families of normal and ADHD children. Journal of Clinical Child Psychology and Psychiatry 17; 1998: 169-177
  15. ↑ Wilens TE, Prince JB, Biederman J, Spencer TJ, Frances RJ: Attention-deficit hyperactivity disorder and comorbid substance use disorder in adults. Psychiatr. Serv. 46 (8); 1995: 765
  16. ↑ http://www.berkeleywellness.com/healthy-mind/mood/article/adhd-overdiagnosed
  17. ↑ http://www.pbs.org/wgbh/pages/frontline/shows/medicating/interviews/barkley.html
  18. ↑ http: //tinyurl.com/qdahgk4
  19. ↑ http: //intl-ccp.sagepub.com/content/early/2012/10/26/1359104512458228
  20. ↑ http: //www.mikado-studie.de/index.php/sexueller-missrauch.htm
  21. ↑ http: //www.medscape.com/viewarticle/731970_3
  22. ↑ http: //tinyurl.com/adhd-abuse
  23. ↑ Heiliger, A., perpetrator strategies for sexual abuse and approaches to prevention (PDF) in: Contributions to feminist theory and practice 56/57, 2001, pp.81-82. Accessed: 09.09.2014
  24. ↑ Wikipedia; Pygmalion Effect, accessed: 09/10/2014
  25. ↑ See http://tinyurl.com/pb3h7zp
  26. ↑ Abels, H .: Identities, in: Willems, Herbert (Ed.): Lehr (er )buch Soziologie, For pedagogical and sociological courses, Volume 2, p.522, Wiesbaden 2008.
  27. ↑ Abels, H .: Identities, in: Willems, Herbert (Hrsg.): Lehr (er )buch Soziologie, For Pedagogical and Sociological Study Courses, Volume 2, S.522, Wiesbaden 2008.
  28. ↑ [www.psychosoziale-gesundheit.net/pdf/faust1_narzissmus.pdf Faust, F., Narcissism - From time-typical egoistic self-love to narcissistic personality disorder], in: Psychiatrie heute (PDF), accessed: 09.09.2014
  29. ↑ https: //web.archive.org/web/20101011113255/http: //www.csun.edu/~gk45683/ADHD%20and%20Anxiety.pdf