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Owning up to Complexity:

A Socio-cultural Orientation to ADHD

Jack S. Damico, Ph.D., Nicole Müller, DPhil,.

And

Martin J. Ball, Ph.D.

The University of Louisiana at Lafayette

Address: Jack S. Damico, Ph.D. P.O. Box 43170 The University of Louisiana at Lafayette Lafayette, Louisiana 70504-3170 (337) 482-6551 jsdamico@louisiana.edu

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Abstract

To enrich our conception of ADHD, it is necessary to take a wider orientation to this

disability category than has traditionally been advocated. Over the past decade there has been an

emerging conception of ADHD from a social-cultural perspective and this orientation, when

linked to the traditional bio-medical perspective, provides a more accurate and authentic

construct of ADHD. In this article, we advocate that speech-language pathologists approach

ADHD with a mindset that is open to the complexities of context-bound human functioning at all

levels. Four sources of data demonstrating the richness of the socio-cultural orientation are

presented and clinical implications are detailed

Keywords: ADHD, complexity, socio-cultural perspective

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Attention Deficit Hyperactivity Disorder (ADHD) has been discussed as a medical

condition with various psychological and educational implications since its first entry as a

diagnostic category in the Second Edition of the Diagnostic and Statistical Manual of Mental

Disorders (DSM-II) (American Psychiatric Association, 1968). From this first mention as

“hyperkinetic reaction of childhood” until the more commonly recognized label of ADHD, the

assumption has been that this disability category represents a subtle neurological deficit resulting

in a negative impact on affect, behavior and learning (e.g., Cantwell, 1996; Castellanos, 1997).

Consistent with this orientation, the vast majority of articles focusing on this disorder take a bio-

medical perspective (Damico, Damico, & Armstrong, 1999).

This predominant medical orientation has created a set of beliefs about the nature of

ADHD that have informed both our perceptions of ADHD and our clinical practices. As a result,

ADHD is listed in both the Diagnostic and Statistical Manual for Mental Disorders (DSM IV-

TR) (American Psychiatric Association, 2000) and the 10th edition of the International

Classification of Diseases (ICD-10) (World Health Organization, 2002) as a medical condition

and it has a long history of medical diagnosis and pharmacological treatment (e.g., Frick &

Lahey, 1991; Reid, Maag, & Vasa, 1994; Klasen, 2000; Safer, 1997). For the most part, this

perspective has been successful. Many of the issues currently addressed in the literature of

ADHD and even the majority of the articles in this volume show the advantages of this

traditional orientation and its various clinical applications.

The Emerging Social Perspective on ADHD

Over the last decade, however, an emerging orientation has gained attention and appears

to hold promise for extending and enhancing our clinical practices regarding ADHD; namely the

consideration of ADHD from a socio-cultural perspective. This orientation views ADHD as

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multi-faceted and more complicated than originally conceived (e.g., Cantwell, 1996; Hill &

Cameron, 1999; Klasen, 2000). For example, Whalen and Henker (1997) have advocated a view

of ADHD as a unique constellation of problems arising from both biological and social/

contextual variables that often result in negative impact in multiple domains of functioning. For

this reason, an individual diagnosed as ADHD may not present apparently consistent symptoms.

Rather, he/she may exhibit different symptoms at different times and in different situations. This

is due to the fact that the manifestations of ADHD are heavily influenced by various contextual

variables (Jensen, Mrazek & Knapp, 1997). Indeed, multiple experiences with this observation

have prompted some researchers and clinicians to refer to ADHD as an “environmentally

dependent disorder” (Powler, 1994). Based on experiences like this one, there is a call for

greater variation in conceptualization of ADHD and in how this conceptualization informs both

the kinds of treatment advocated and the contexts within which treatment occurs (e.g., Barkley,

1998; Cherkes-Julkowski, Sharp, & Stolzenberg, 1997; DuPaul & Eckert, 1997; Mulligan, 2001;

Pelham & Gnagy, 1999).

Thus there is now a body of work that advocates the description and interpretation of the

behavioral symptom-complex collectively labeled as ADHD within the multiple, nested complex

systems represented by the human organism interacting with its environment. Complex systems

have been variously defined (see e.g. Bar Yam, 1997; 2003). A classic definition of a ‘problem

of organized complexity’ is that of a problem that involves ‘dealing simultaneously with a

sizable number of factors which are integrated into an organic whole’. (Weaver, 1948: 539).

A readiness to embrace the notion of complexity in general and the importance of socio-

cultural variables operating within ADHD specifically is effectively demonstrated in Barkley’s

(1997a) “biopsychosocial model” of ADHD. As an attempt to create a unified model of ADHD,

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Barkley has woven together the different elements of this disability condition and stressed the

need to focus on the potential biological substrate, its psychological operational impact, and the

social reactions that might act to reduce or exacerbate these psychological manifestations (see

Damico, Tetnowski & Lobdell, this volume). As a leading researcher and author in the area of

ADHD, Barkley’s increased emphasis on social and contextual variables has significantly

extended the awareness of the socio-cultural facet of ADHD. Importantly, such an emphasis

encourages a richer perspective on ADHD; one that involves the more complex and socially

relevant phenomena that are so important to our understanding of ADHD and how it operates in

the real world. By employing such a socio-cultural perspective, we are better able to recognize

the complexity of issues involved with ADHD and its impact on individuals identified as

exhibiting this disability. This awareness and knowledge, in turn, can increase the effectiveness

and efficacy of our ADHD service delivery.

Given the promise and importance of the socio-cultural orientation to ADHD, this article

will highlight some of the emerging issues within the socio-cultural perspective. By reporting on

some of the social and cultural issues involved in ADHD, we aim to provide the practicing

clinician with a richer conception of this disability category, its social implications, and a

perspective of how ADHD operates as a component of social action. Based upon these

considerations, some specific implications for ADHD service delivery will be discussed.

Relevant Data Sources Generated by the Socio-cultural Orientation

While there are a number of important socio-cultural issues and data points that can

enrich our conception of ADHD and inform our service delivery, we will discuss only a few.

However, through these examples of relevant data and concepts we hope to illustrate the

advantages and necessity of employing this more inclusive socio-cultural orientation to ADHD.

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ADHD as a Synergistic Phenomenon

Within the last decade the emerging orientation to ADHD as a more socio-cultural

phenomenon has employed an application of systems-theory as an explanatory mechanism. This

particular version of systems-theory recognizes that social phenomena such as the behaviors

manifested by students with ADHD are synergistic in nature. That is, they are dependent on the

complex and dynamic interplay between the genetic/biological traits of the individual and the

myriad variables available in the environment (e.g., Bateson, 1972; Weaver, 1993). In fact, it is

this very interplay between the internal and external environments that uniquely characterizes

those behaviors that are symptomatic of ADHD. Within this synergistic conception, there is

little need to engage in a debate regarding the impact of the biological/neurological variables

versus environmental/contextual variables as causal factors in ADHD. Rather, this disability

condition is viewed as consisting of both dimensions. That is, the individual’s traits and

characteristics (e.g., lack of inhibitory capacity) interact with environmental/contextual factors

(e.g., classroom teacher’s expectations) to influence one another and create the behavioral

manifestations that we have come to expect in ADHD. In fact, one might even suggest that a

strict dividing line between internal and external factors, or factors pertaining to an individual

human being versus factors pertaining to the environment in which this human being functions is

an artificial construct. A human being does not function ‘context-free’, and every observed

behavior should therefore be described and analyzed as a contextualized, rather than an isolated

phenomenon.

Weaver (1993; 1994) has discussed the implications of a systems-theory approach to

ADHD. She suggests that the best understanding of ADHD is as a social construct and that it

should be viewed not so much as a disorder but, rather, as a “set of dysfunctional relationships

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between an individual with certain predispositions and an environment that generates certain

expectations, demands, and reactions.” (1993: 80). Perhaps the most important point taken from

this socio-cultural concept is that the synergistic characterization of ADHD is consistent with

Barkley’s emphasis on environmental/contextual variables. That is, the impact of the complex

internal states summarized and diagnosed, or labeled, as ADHD will interact with, and may be

exacerbated by environmental/contextual constraints, demands, and expectations. The key, then,

would be to recognize the transactional impact of not only the individual’s behavioral

predispositions but also the impact of the environment on these predispositions.

ADHD as a Contested Diagnostic Category

Once ADHD is viewed from a socio-cultural perspective, even the concept of ADHD as a

disability category becomes a more complex issue. In reality, ADHD is not an objective and

easily verifiable empirical construct, that would be comparable to and quantifiable in the same

way as, for example, brain damage after CVA. Rather, it is a social construct and it has been

argued that the diagnostic criteria employed for its identification have been constructed on the

basis of a number of socio-cultural factors that mirror the prevailing ideologies in vogue at any

given time (e.g., Reid, Maag, & Vasa, 1994; Shaywitz, Fletcher, & Shaywitz, 1994). This means

that the diagnostic category of ADHD may be complicated by ambiguity and subjectivity and

this lack of definitional rigor may result in various types of problems.

Most relevant to the clinical context, the socio-cultural perspective situates ADHD as a

potentially contested diagnosis. That is, there may be controversy surrounding the legitimacy of

ADHD as an authentic disability category. In his book, Illness and culture in the postmodern

age, Morris (1998) has discussed this possibility for a number of illnesses and/or diagnostic

categories. He has suggested that ADHD and some other socially constructed diagnostic

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categories (e.g., Gulf war syndrome, chronic fatigue syndrome, multiple personality disorder)

may be defined as “postmodern illnesses”. This term is used for categories of illness or

behavioral states that are vaguely and subjectively defined and that are controversial with regard

to their legitimacy as real illnesses. According to Morris, these diagnostic categories often

puzzle mainstream medicine, are sensationalized and augmented by the popular media, are

confusing to the general public and have a tendency for abuse by working professionals.

Morris explains this pattern of attention and abuse by suggesting that rather than

legitimate and objective disease states or disability conditions, these specific illnesses represent

changing patterns of human experience and affliction that are shaped by the convergence of

biological states, cultural beliefs and social actions. In fact Morris and others (e.g., Armstrong,

1997a; Breeding & Baughman, 2001; Klasen, 2000) express concern regarding whether these

postmodern illnesses are real biomedical conditions or just exaggerated responses to other socio-

cultural stresses or expectations. For example, Armstrong (1997b) has suggested that the

labeling of a child as ADHD may often be less the result of a neurological condition and more

due to a developing tendency of society to treat teachers’ and parents’ anxieties regarding

childhood by routinely drugging children into good behavior; that is, social control through

medication.

In the case of ADHD, there are legitimate concerns regarding the actual diagnostic

category. A number of researchers have expressed concern regarding ADHD’s vague set of

behavioral criteria and the lack of basic biological diagnostic certainty. This research indicates

that as a diagnostic entity, ADHD’s behavioral criteria are too vague and confusing to provide a

clearly delineated disability construct (e,g, Damico, Augustine & Hayes, 1996; Reid, Maag, &

Vasa, 1994; Shaywitz, Fletcher, & Shaywitz, 1994) and the existence of a biological etiology for

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ADHD is not substantiated; much of the research into the etiology of ADHD is inconclusive and

even contradictory. As stated by Reid, Maag, and Vasa, “...the nature of presumed underlying

organic deficits (if any) remains a mystery, and evidence in support of any particular etiology is

sparse.” (1994, p. 202).

As a general disease state or diagnostic category, of course, there are far more research

findings and publications that support the existence of ADHD. At worst, it is a controversial

topic. On an individual basis, however, the qualities inherent in this social construct (e.g., vague

and confusing diagnostic criteria, a tendency to employ to medication for behavioral control, the

ease of shifting responsibility to a disease state rather than parental or teacher effectiveness, or

other environmental factors such as the organization of the school day) may result in an over-

identification or misdiagnosis of children as ADHD. This tendency for the social construction of

disability, the assignment of handicapping labels, and an abuse of this social construct has

certainly been documented in other areas such as learning disabilities (Coles, 1988; Taylor,

1991). Of course, disabilities and handicaps are to an extent always socially constructed, in that

their perceived severity is context-dependent, and at least partly context-created. A quantifiable

impairment such as age-related reduction in hearing (even within ‘age-normal’ limits) may

constitute a career-destroying handicap for the conductor of a symphony orchestra, but not for

someone in a different walk of life. Consequently, as clinicians we should not simply reify

labels such as ADHD and consider them as ‘absolute’, objective categories. Rather, we should

be circumspect with regard to our beliefs about the validity of this diagnostic category. Above

all, we should carefully consider how important it is to properly identify children with true

ADHD and we should avoid the tendency to label children without definite and objective data to

support a diagnosis.

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Too often we operate within our cultural milieu without a critical analysis of our practices

and the conceptualizations that underlie them. The problem with this, of course, is that we might

become blind to our poorly justified practices or tendencies or we might ignore new or

inconsistent data that could potentially undermine our assumptions about what ADHD is and

how it should be addressed, and indeed who should be labeled ADHD. Therefore, we must be

circumspect with our current conceptualizations and practices. By employing a more socio-

cultural orientation, we can turn our analytic powers onto the very contexts and assumptions that

we often take for granted when working with ADHD and we can better serve the needs of our

clients.

The Influence of Social/Contextual Variables on ADHD

Inherent in the socio-cultural orientation to ADHD is the contention that the behaviors,

the diagnostic indices, and the consequences of ADHD do not exist or operate in isolation,

devoid of context or functionality; to make an impact, ADHD literacy must operate in a situated

context. This is the primary point of the synergistic description previously discussed.

On a practical level, this means that we must recognize that there are numerous social and

contextual variables that influence the impact of ADHD, and the severity of the symptoms so

labeled. Jensen, Mrazek and Knapp (1997) emphasize this point when they describe ADHD as a

“disorder of adaptation”. Based upon their research and experience, they discuss the fact that

ADHD may manifest itself differently in different environments. That is, a child may exhibit

different kinds of symptoms, at different degrees of severity, and even greater or lesser degrees

of success at a given constellation of tasks, depending on how the context (both physical and

social) reacts to his/her behavioral predispositions. In one context, the impact of the ADHD

might be significantly reduced while in another the problems might be exacerbated. In each

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case, it is the interaction of contextual variables with behavioral predispositions that make the

difference. An unfavorable constellation of factors (for example, repeated insistence on timed

activities carried out in sequence, in an inflexible schedule without sufficient ‘downtime’ on the

one hand, and a predisposition towards short attention span, and distractibility on the other) can

result in a positive feedback loop of reactions and behaviors that neither the child nor the persons

around him/her are capable of deconstructing. A review of the literature in ADHD does support

this “disorder of adaptation” contention (e.g., Cooper, 1997; DuPaul & Eckert, 1997; Mandal,

Olmi, & Wilczynski, 1999). Hill and Cameron (1999), for example, documented that the time-

on-task and the level and degree of over-activity in ADHD children are highly dependent on how

interested they are in a task initially and the kind of social encounter that is involved. Based

upon their data, they provide detailed instructions on how to be cautious in the screening and

identification of children with ADHD tendencies. Similarly, the comprehensive research of

Bussing and colleagues (e.g., Bussing, Schoenberg, & Perwien, 1998; Bussing, Schoenberg,

Rogers, et al, 1998; Bussing, Zima, Gary, & Garvan, 2003) details the influence of cultural,

racial, gender, and ethnicity factors in the identification and the assessment of ADHD. In much

of this research these variables tended to impact identification and the judgment of severity

regardless of whether the differences existed in the children being assessed or in the adults doing

the evaluations.

Social and contextual variables were even more pronounced when their impact on the

accessibility and effectiveness of treatment was studied. Ingram, Heckman and Morgenstern

(1999) found that the prognosis for treatment success for ADHD was heavily influenced by

many factors including the socioeconomic status of the family, the social interactions within the

family constellation, the ways that the family handled adversity, the personality traits of the

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individuals that interacted with the ADHD child. Research has documented many other socio-

cultural variables as well. The type, degree and frequency of intrinsic rate of reward during

treatment (e.g., Corkum, Rimer, & Schachar, 1999; Damico, Augustine & Hayes, 1996), the

kinds of explanatory models that the family has regarding ADHD (e.g., Bussing, Schoenberg, &

Perwien, 1998; Bussing, Schoenberg, Rogers, et al, 1998; Corkum, Rimer, & Schachar, 1999),

the ease of accessibility to treatment (Bussing, Zima, & Berlin, 1998a), the cultural, racial, and

ethnic backgrounds of the children (Bussing, Zima, Berlin, 1998b; Weisz, Suwanlert, Chaiyasit,

et al, 1988 ), even the parents perceptions of ADHD and the efficacy of the interventions (e.g.,

Barkley, Anastopoulos, Guevremont, & Fletcher, 1992; Bussing, Schoenberg, Rogers, et al,

1998; Bussing, Zima, Gary, & Garvan, 2003; Weisz, Suwanlert, Chaiyasit, et al,1988) are all

examples of how ADHD service delivery is influenced by social and contextual variables. To

best meet the needs of our clients with ADHD, therefore, it is essential that we account for as

many of these variables as is possible. The socio-cultural perspective provides us with the best

opportunity meet these requirements.

The Impact of ADHD on Significant Others

Our final example of socio-cultural issues that can enrich our ADHD service delivery

involves the impact of ADHD on the social context itself. In a very detailed analysis of the

social facets of ADHD, Frederick and Olmi (1994) noted that not only are children with ADHD

more likely to be rejected by their peers, the ADHD operates to modify the social context so that

all social interaction is negatively affected. Campbell, Endman, & Bernfeld (1977), for example,

found that teachers who focused on the behaviors of a child with ADHD tended to direct more

negative attention to their classes in general than when compared with teachers that did not have

children with ADHD present. Similarly, Cantwell (1996) Barkley (1997b), and Powler (1994),

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documented problems with the social relationships and the contexts within which social

encounters occur as a result of ADHD.

One area of detailed research looks at the effects of ADHD on the family constellation

and the social context that is created and employed in homes where an individual with ADHD is

present. In this work, Lewis-Abney (1993) found significant negative correlates of family

functioning in the presence of ADHD and Kendall (1997; 1998; 1999) found similar difficulties

when investigating the impact of ADHD on the diagnosed child’s siblings, on the ways in which

the social aspects of ADHD negatively affected the families, and on how much additional effort

families were required to employ to reduce the negative influence of ADHD in the social context

of the home. This negative influence was present across the age range from young children

through to adolescence. Indeed, Barkley, Anastopoulos, Guevremont & Fletcher (1992) noted

significant negative changes in mother-adolescent interactions that carried over to family belief

systems. Clearly, the ADHD negatively influenced not only the social abilities of the identified

individuals but the abilities of those around them as well. Given the importance of social and

contextual variables in treatment accessibility and prognosis, this information is quite

problematic.

Clinical Implications from the Socio-cultural Orientation to ADHD

While these four data sources reveal only a portion of the valuable information that can

be derived from the socio-cultural orientation to ADHD, the data described and the concepts

employed suggest several important implications for ADHD service delivery.

First, these data sources support the conception of ADHD as a complex social

phenomenon. Consequently, it is important that the practicing clinician adopt a more robust

conception of ADHD, one that is more socially situated and more contextualized. It is not

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enough to take a biomedical perspective; as with all human phenomena, social and cultural

factors do hold sway and must be taken into account.

Second, with regard to service delivery, the approaches to both assessment and

intervention must be more reflective of the underlying complexity of ADHD as situated in the

socio-cultural context. Assessment must be more functional, descriptive, and contextualized

(e.g., Damico, Damico & Armstrong, 1999; Hill & Cameron, 1999; Maag & Reid, 1994;

Mandal, Olmi, & Wilczynski, 1999) and there needs to be a move away from a reliance on norm-

referenced tests that are poorly suited to describe the behaviors noted in ADHD (Barkley, 1998).

Additionally, care should be taken when employing singular approaches to assessment and this

caveat applies most specifically to rating scales (Vitaro, Tremblay & Gagnon, 1995; see Pierce

and Reid, this issue). Since the context is so important to the impact of ADHD, any assessment

should strive to employ comparisons within the classroom contexts and comparison “norms”

should always be determined (Fabiano & Pelham, 2003). As the phenomenon under analysis,

ADHD is simply too complex to allow a simplistic notion of assessment.

With regard to treatment, the approaches employed must be specifically designed to fit

the needs of the particular child (Conners, 2000) and to account for the constellation of variables

that affect prognosis. Barkley (1995) has advocated a ten principle-centered approach and while

it has been primarily directed toward parents, it is designed to address both the synergistic nature

of ADHD and the need for incorporating the socio-cultural context. By striving for consistency

and focusing on the actual symptoms, these principles create both a developmental and a

functional intervention framework.

Third, in order to learn more about the complexity of ADHD from a socio-cultural

perspective, there needs to be a greater focus on research and research methods that can address

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the complexity of ADHD and that can do so within an authentic context. This can be

accomplished by employing qualitative research methodologies that are designed to address

complexity rather than ignore it (Damico & Simmons-Mackie, 2003). Within the area of ADHD

research there have been a number of excellent demonstrations of how qualitative research can

be employed (e.g., Bussing, Schoenberg, & Perwein, 1998; Bussing, Schoenberg, & Rogers,

1998; Damico & Augustine, 1995; Fabiano & Pelham, 2003; Kendall, 1997; 1998; 1999;

Kendall, Hatton, eckett, & Leo, 2003; Reid, Hertzog, & Snyder, 1996; Weisz, Suwanlert,

Chaiyasit el at., 1988) but much more is needed.

Finally, the practicing speech-language pathologist must be circumspect in how they

approach the construct of ADHD. Once we employ a socio-cultural orientation that may

enhance the bio-medical perspective, we must be willing to constantly employ all our analytic

skills to ensure that we account for this enriched construct and its complexity. To do otherwise

reduces our effectiveness and the potential improvement of our ADHD clients.

Conclusion

When dealing with children diagnosed as ADHD we will be more efficient and effective

in the long run if we embrace the reality of the multiply nested complex system that interacts in

all aspects of human functioning. We need to be capable of contextualizing a medical diagnosis,

such as a diagnosis of ADHD, and then we should strive to discover the reality behind the label

and the individuality of each client’s condition. As we mentioned above, each handicapping

condition and disability is a social construct. We may add here that how we deal with

handicapping conditions and disabilities is equally socially constructed, and the ideological, or

theoretical, orientation of the ‘expert’ (the pediatrician, child psychologist, speech-language

pathologist) is of crucial importance here. A context-bound, socio-cultural outlook on ADHD of

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necessity needs to adopt the stance reminiscent of what Luria (1987b, p. 6) calls “romantic

science”, namely an approach that attempts “neither to split living reality into its elementary

components nor to represent the wealth of life’s concrete events in abstract models that lose the

properties of the phenomena themselves. It is of utmost importance to romantics to preserve the

wealth of living reality, and they aspire to a science that retains this richness.” This “wealth of

living reality”, the functioning of a child diagnosed with ADHD, and her/his family members, in

the multiple contexts of daily life, may not lend itself to a reductionist approach of quantification

(in Luria’s terms (1987a) the “classical” approach in science) as biological or physiological

factors that can be measured in a controlled setting. However, this does not mean that we can

ignore this ‘messy’ and complex reality. Indeed, this complexity is what socio-cultural

functioning is all about and to ignore it in our ADHD service delivery would be both

unsatisfactory and non-efficacious.

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Self Evaluation Questions for Owning up to Complexity:

A Socio-cultural Orientation to ADHD

1. The Emerging Perspective of ADHD a. Provides a clearer vision of pharmacological issues in ADHD b. Employs an experimental research format as its primary innovation c. Provides a socio-cultural view of ADHD d. Requires a focus on bio-medical issues

2. Barkley’s biopsychosocial model of ADHD: a. Focuses greater attention on pharmacological treatment b. Stresses the impact of prior schooling c. Provides a greater emphasis of a triad of variables d. Reduces the focus on social variables in ADHD

3. A “post-modern” critique of ADHD:

a. Reviews the literary contributions of authors with ADHD b. Questions the existence of ADHD as a diagnostic category c. Advocates a language arts approach to intervention d. Provides an analysis of ADHD as portrayed in fiction

4. Which of the following may be seen as a cognate of ADHD in terms of its identity as a

postmodern illness? a. Heart Disease b. Diabetes c. AIDS d. Multiple Personality Disorder e. Traumatic Brain Injury

5. When referring to ADHD as a “disorder of adaptation”, the intent was to highlight:

a. The manifestations of ADHD are overt b. The manifestations of ADHD require conscious effort to exhibit c. ADHD is independent of the context d. The manifestations of ADHD are context dependent e. The manifestations of ADHD are medically fragile

Answers: 1-c 2-c 3-b 4-d 5-d