ADHD Atten Def Hyp Disord DOI 10.1007/s12402-015-0179-9
ORIGINAL ARTICLE
ADHD stigma among college students Amanda Chi Thompson1,2 • Elizabeth K. Lefler1
Received: 25 August 2014 / Accepted: 18 June 2015 Springer-Verlag Wien 2015
Abstract The current study examined ADHD stigma within a college-enrolled young adult population, including the debate regarding the cause of stigma: label or behavior. In Phase 1, 135 college students rated stigma toward one of the four fictitious partners described as having either: the label of ADHD alone, the behaviors associated with ADHD alone, the label of ADHD and a set of behaviors associated with ADHD, or neither the label nor behaviors. In Phase 2, 48 college students rated stigma toward one of the two assigned fictitious partners described as having either: the label of ADHD and a set of behaviors associated with ADHD, or the label of Depression and a set of behaviors associated with Depression. It was hypothesized that the interaction between the label and the behaviors would cause the highest levels of ADHD stigma and that ADHD would elicit more stigma than Depression. In Phase 1, stigma was associated with the behaviors of ADHD, but not the label. In Phase 2, ADHD and Depression were found to be equally stigmatized. Implications, limitations, and future directions are discussed. Keywords College
ADHD Adult ADHD Stigma Labels
Introduction Stigma can be defined as a negative bias against an individual or group of individuals that has been developed through expectations or past experiences and may cause prejudice and/or discrimination toward members of the group (Crocker et al. 1998; Link and Phelan 2001). For example, there is a stigma associated with individuals who suffer from mental illness, which elicits higher ratings of dangerousness and differentness and higher levels of social isolation (Feldman and Crandall 2007; Kobau et al. 2009). Stigma has been shown to have a negative impact on individuals with mental illness, such that the stigma may exacerbate a person’s symptoms, may make a person believe they are to blame for their disorder, and may actually lead to treatment avoidance (Dinos et al. 2004; Feldman and Crandall 2007; Jorm and Griffiths 2008; Kobau et al. 2009). One mental health disorder that elicits stigma is attention-deficit/hyperactivity disorder (ADHD). Although ADHD was historically considered a childhood condition, it is now understood that a majority of individuals with ADHD continue to have the symptoms of, or impairment caused by the disorder into adulthood (Barkley et al. 2008; DuPaul et al. 2009; Ramsay 2010). Thus, the current study aims to explore ADHD stigma in a sample of young adults. Stigma and ADHD
& Amanda Chi Thompson [email protected] 1
Department of Psychology, University of Northern Iowa, Cedar Falls, IA, USA
2
Present Address: Learning Services Department, Kirkwood Community College, 6301 Kirkwood Blvd. SW, Cedar Rapids, IA 52406, USA
Children and adolescents with ADHD are negatively impacted in their social relationships due to the stigma associated with ADHD. The stigma of ADHD elicits higher levels of social distance preference, making it difficult for children with ADHD to make friends, as children with ADHD are shown to be less preferred as friends by other
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children (Hoza et al. 2005). In addition, children without mental illnesses rated children with ADHD more negatively than individuals with asthma (Walker et al. 2008) and children with ADHD are stigmatized to a higher degree than youth with Depression (O’Driscoll et al. 2012). Children with ADHD are perceived to be more dangerous than other children, as rated by their peers, and are thought to be more violent, and at a greater risk of self-harm (Pescosolido et al. 2007). Children with ADHD are even rated negatively by parents of children without ADHD. Specifically, one in five parents of children without ADHD reports being unwilling to have their children in a class with other children with ADHD, have a child with ADHD live next door, or have their child be a friend to a child with ADHD (Martin et al. 2007). Despite increased interest in the stigma associated with ADHD in children and adolescents, less research has been conducted on adults with ADHD. Canu et al. (2008) conducted a study to examine ADHD stigma in college students. Findings showed that college students rated other young adults with ADHD more negatively than those without ADHD. Specifically, young adults with ADHD were rated more negatively when the participant was asked whether they would like to work in an academic or professional setting as a team. In terms of sex differences, men with ADHD were rated more harshly than women with ADHD. Additionally, Chew et al. (2009) found that college students assigned significantly more negative adjectives than positive adjectives to their peers (i.e., other college students) with ADHD. Interestingly, those who reported more contact with individuals who have ADHD were less likely to endorse negative adjectives, and participants with ADHD endorsed even more negative adjectives to describe ADHD (Chew et al. 2009). Labels versus behaviors Stigma can be thought of as involving both a label and a stereotype that identifies individuals with a set of characteristics (Link and Phelan 2001). Labels contribute to the development of stigma and can lead to stereotypes (Corrigan 2004). Stigma is developed through a labeling process (Link and Phelan 2001) which includes four components: identifying and labeling differences between individuals, linking those differences to known stereotypes, a social label which separates individuals into groups of ‘‘us’’ and ‘‘them,’’ and status loss and discrimination. Within this process, the label is necessary before stigma can be attached to a set of characteristics (Link and Phelan 2001). There is some debate, however, whether the label of a mental illness elicits the stigma associated with it, or whether it is observable behaviors that lead to the stigma
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(Link et al. 1987). For example, does the label ‘‘schizophrenia’’ cause stigma, or is it the observation of a person with active hallucinations that causes stigma? Research has found that simply the label ‘‘mental illness’’ increases the general public’s preference for social distance and that the perception of dangerousness is found to mediate the relationship between stigma and social distance (Angermeyer and Matschinger 2003; Link et al. 1987; Piner and Kahle 1984). On the other hand, a description of the behaviors associated with mental illness has also been shown to elicit stigma. Specifically, Yap et al. (2013) found evidence of stigma after participants read vignettes describing behaviors of various mental illnesses. In addition, Law et al. (2007) found that the mere label of ADHD had no impact on children’s ratings of a peer with ADHD described in a vignette with both behaviors associated with ADHD and the label itself. Conversely, Ohan et al. (2013) found small but significant increases in the amount of stigma when a label was added to a set of behaviors that were already stigmatized, suggesting that the label adds some incremental stigma above and beyond behaviors alone. Thus, it seems that both labels and behaviors affect stigma ratings. It might follow that an individual identified with both a label and a set of atypical behaviors would be doubly stigmatized.
The current study Overall, there is a lack of research on the stigma associated with adult ADHD. Therefore, this study aims to investigate ADHD stigma among a subset of the young adult population—college students—in two ways. First, it was hypothesized that participants would show more stigma toward a fictitious partner with ADHD than a fictitious partner without ADHD when presented with the prospect of completing an academic task together. More specifically, because of the debate regarding the origin of stigma: labels or behavior, Phase 1 of this study included four conditions in which the presence or absence of ADHD label and behaviors was manipulated. It was hypothesized that the label and behaviors together would elicit the highest level of stigma. Second, previous research has shown that mental illnesses elicit stigma at different rates (Day et al. 2007; Reohrig and McLean 2010). Moreover, it is not surprising that two negative descriptors of a person (i.e., a label and a set of atypical behaviors) would be more stigmatizing than one negative descriptor (i.e., a label or a set of atypical behaviors alone). Therefore, it was hypothesized that ADHD would elicit more stigma than Depression, even when both disorders included a label and a set of atypical behaviors. Depression was used as it is a
ADHD stigma among college students
well known, often studied condition, and has been found to differ from ADHD in terms of stigma (O’Driscoll et al. 2012). These hypotheses were addressed in two separate, sequential phases: Phase 1 and Phase 2.
Materials and methods: Phase 1 Participants Participants for Phase 1 included 135 undergraduate students recruited from the psychology department participant pool of a mid-sized Mid-Western Public University (70.4 % female). Participants received research credit for participating in the study. Participants’ ages ranged from 18 to 25 years (M = 18.66). A majority of participants considered themselves non-Hispanic, Caucasian (93.3 %). Participants with ADHD were excluded from the analyses (see Table 1 for demographic information). Procedure Phase 1 employed an experimental design. All participants gave their informed consent. Participants completed the study individually and were told they would be working with a partner on an academic task later in the hour. This partner did not exist, but an Information Form was filled out by the researchers in advance to deceive the participant (see Fig. 1 for visual of this Information Form). The fictitious partner was supposedly down the hall in another room with another research assistant. The independent variable (IV) was how the fictitious partner described their academic weakness on the Information Form, which had four levels: (1) label of ADHD alone; (2) behaviors associated with ADHD alone; (3) label of ADHD and a set of behaviors associated with ADHD; and (4) neither the label nor behaviors associated with ADHD. The real participant filled out an identical Information Form, and the forms were ostensibly exchanged by the research assistants between the two partners. This Information Form, filled out by the researchers in advance (Fig. 1), included the academic weakness (i.e., one of the four levels of the IV), as well as some information that was held constant (e.g., major, hobbies, academic strengths). The fictitious partner’s gender was also held constant; the partner was always identified as male. Participants were randomly assigned to Table 1 Phase 1 and Phase 2 demographics
one level of the independent variable. They were told the purpose of the study was to determine how accurately individuals are able to predict the success of an academic partnership based on receiving some basic information about a partner. There were two dependent variables: (1) anticipated behavior ratings; and (2) social distance scale ratings. After receiving their fictitious partner’s form, the participants answered questions regarding their feelings about being partnered with this individual via the Anticipated Behaviors Form and the Social Distance Scale. The participant was then asked to fill out a Demographics Form. After the participant completed the questionnaires, the participant was told the true nature of the study. At this point, the research assistant informed the participant that they would not be working with a partner. The participants were asked what they believed the study was about and whether they guessed there was not a partner. Notably, 100 % of participants reportedly believed they would be working with a partner until they were told otherwise. Measures Anticipated Behavior Form (ABF) This form was created by the authors for the current study and measured what the participant believed would happen while working on the academic task with their partner (Table 2). The ABF includes 11 items with a Likert-type scale ranging from 1 (Very Unlikely/Very Low) to 7 (Very Likely/Very High). Summary scores were created, with a range of 11–77. See Table 2 for a list of all items. Internal consistency reliability for the current study, as measured by Cronbach’s alpha, was good (a = 0.85). Social Distance Scale (SDS) The SDS (informed by Link et al. 1987, 1999) includes 12 items (Table 3) and measures a person’s willingness to socially engage with another person on a Likert-type scale ranging from 1 (Definitely) to 7 (Definitely not). Summary scores were created, with a range of 12–84. See Table 3 for a list of all items. Internal consistency reliability for the current study, as measured by Cronbach’s alpha, was good (a = 0.86).
Data analytic plan
n
Mean age
Female (%)
Caucasian (%)
Phase 1
135
18.66
70.4
93.3
Phase 2
48
18.44
64.6
89.6
Two-way factorial analysis of variance (ANOVA) tests were used to examine the data in Phase 1. One ANOVA was conducted with the Anticipated Behaviors Form (ABF)
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Fig. 1 Information Form presented to participants with manipulated independent variables. The first six items were constant in all conditions; the last item was manipulated as noted. In the study, the responses were handwritten on the form by a research assistant
as the dependent variable, and a second ANOVA was conducted with the Social Distance Scale (SDS) as the dependent variable. In Phase 2, independent samples t tests were used to examine the data. One t test compared means on the ABF, and a second t test compared means on the SDS.
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Results: Phase 1 A two-way factorial ANOVA was used to examine the effects of the label of ADHD and the behaviors associated with ADHD on ABF mean scores (Table 4). Behaviors associated with ADHD had a significant main effect on
ADHD stigma among college students Table 2 Anticipated Behavior Form (ABF) items
Table 5 Phase 1: two-way factorial ANOVAs for Anticipated Behavior Form (ABF) and Social Distance Scale (SDS)
How likely is it that…
Independent variable
1. The workload will be fairly distributed? 2. You will like working with this person?
ABF
SDS
F(1,127)
p
F(1,131)
p
10.69
.001
3.87
.051
0.64
.425
0.17
.678
1.46
.230
1.32
.253
3. There will be good communication between you and this person?
Behaviors of ADHD
4. You and this person will finish the project in a timely manner?
Label of ADHD
5. This person will be as creative as you?
Behaviors and label of ADHD
What are the chances…
Four participants did not complete the back side of the ABF, and thus, n = 131 (rather than 135) for all ABF analyses in Phase 1
6. This person will put in as much effort as you? 7. That you will work well with this person? 8. This partnership will work out? 9. You and your partner will be able to complete the project correctly? 10. Would you choose this person for a project in the future if you could? 11. Will this person take on a leadership role in this project?
Table 3 Adapted Social Distance Scale (SDS) items How likely would you be to… 1. Sit next to this person in class? 2. Exchange numbers with this person? 3. Ask this person to take notes for you in class on a day that you would be absent? 4. Hang out with this person outside of class? 5. Get to know this person better? 6. Become friends with this person?
F(1,127) = 0.64, p = .425. There was not a significant interaction, F(1, 127) = 1.46, p = .230 (Table 5). A two-way factorial ANOVA was used to examine the effects of the label of ADHD and the behaviors associated with ADHD on SDS mean scores (Table 4). The behaviors associated with ADHD did not have a significant main effect on SDS mean scores, F(1, 131) = 3.87, p = .051, nor did the label of ADHD have a significant main effect on the SDS mean scores, F(1, 131) = 0.173, p = .678 (Table 5). Although the main effect for behaviors of ADHD on SDS mean scores was not significant at p \ .05, it does appear that the scores are trending toward being significant such that those provided with behaviors of ADHD endorsed more stigma. There was not a significant interaction, F(1, 131) = 1.32, p = .253 (Table 5).
7. Live in the same dormitory as this person? 8. Want to live next door to this person?
Materials and methods: Phase 2
9. Be roommates with this person? 10. Want to be a co-worker to this person? 11. Want to go on a date with this person?
Participants
12. Consider having a serious relationship with this person?
Table 4 Phase 1: means and standard deviations for Anticipated Behaviors Form (ABF) and Social Distance Scale (SDS) Independent variable
ABF
SDS
M
SD
M
SD
Behaviors of ADHD
50.03
7.29
40.86
10.16
Label of ADHD
52.90
5.97
44.53
8.59
Behaviors and label of ADHD Control (no label or behaviors)
50.55 56.06
8.54 6.78
43.44 46.25
9.18 9.95
Participants in Phase 2 were 48 undergraduate students recruited from the psychology department participant pool of the same Mid-Western University as in Phase 1 (64.6 % female). Participants received research credit for participating in the study. Participants’ ages ranged from 18 to 22 years (M = 18.94). A majority of participants considered themselves non-Hispanic, Caucasian (89.6 %; see Table 1 for demographic information). Participants with ADHD and Depression were excluded from analyses. Procedures and measures
Low scores suggest more stigma
ABF mean scores, F(1, 127) = 10.69, p = .001 (see Table 5), such that those provided with behaviors of ADHD endorsed more stigma. The label of ADHD did not have a significant main effect on ABF mean scores,
The procedures and measures in Phase 2 were identical to those described in Phase 1 including providing informed consent prior to the inclusion of the study. There was one exception in the procedure. Participants still participated alone, were deceived into believing they would be working with a partner on an academic task, filled out and received
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an Information Form, and completed the ABF and SDS. However, instead of four levels of the independent variable, there were only two. Specifically, the two levels of the IV were (1) the label of ADHD and a set of behaviors associated with ADHD; and (2) the label of Depression and a set of behaviors associated with Depression (some of which overlapped with the ADHD behaviors, such as difficulty paying attention; see Fig. 1).
Results: Phase 2 Two independent samples t tests were conducted to determine whether there was a difference in stigma ratings between ADHD and Depression on the two measures (i.e., ABF and SDS). There was no significant difference in stigma ratings between ADHD (M = 47.41; SD = 9.65) and Depression (M = 52.00; SD = 8.21) on the ABF, t(41) = 1.40, p = .168 (Table 6). Likewise, there was no significant difference in stigma ratings between ADHD (M = 39.94; SD = 8.97) and Depression (M = 42.13; SD = 7.54) on the SDS, t(46) = 0.81, p = .420 (Table 6). Thus, ADHD and Depression were rated equally on the ABF and SDS.
Discussion Results of the current study suggest that (a) the behaviors associated with ADHD—not the label of ADHD—drive stigma among college students, (b) very little ADHD stigma was found in this sample, and (c) ADHD and Depression are stigmatized at the same rate among college students. These results have several potential explanations and implications. In Phase 1, it was determined that the label of ADHD did not produce stigma on either measure. Thus, it seems that the label of ADHD alone did not cause stigma in the current study. In terms of the behaviors associated with ADHD, there was a significant main effect found on the Anticipated Behaviors Form (ABF) and a trend toward significance on the Social Distance Scale (SDS). This might suggest that college students who are told the behaviors of a person with ADHD have a bias against working with that person, as was found in previous Table 6 Phase 2: t tests for ABF and SDS Measures
n
ADHD
Depression
M
SD
M
SD
t
p
ABF
48
47.41
9.65
52.00
8.21
1.40
.168
SDS
48
39.94
8.97
42.13
7.54
-.81
.420
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studies (e.g., Canu et al. 2008; Chew et al. 2009). In particular, college students were worried about workload being equally distributed, partner’s communication skills, and partner putting forth equal effort. However, surprisingly, the interaction of label with behaviors was non-significant for both measures. It is possible that the label of ADHD provides an appropriate context to certain behaviors that are occurring and could explain why more stigma was reported when the ADHD behaviors were not accompanied by the label. College students may know they should not hold stigma against individuals with ADHD, so when they see the label they do not endorse high levels of stigma. Alternatively, the participants may have seen the label as a reasonable explanation for the behaviors. Indeed, as was found by Henderson et al. (2012), a social desirability bias may now extend to mental health disorders in certain groups of people. It is possible that when presented with the label ‘‘ADHD,’’ college students in the current study did not feel it was socially appropriate to report any stigma and therefore reported their views in a more positive light. This may increase the importance of studies of implicit ADHD stigma, as college students may not explicitly report mental illness stigma. On the other hand, the low rates of stigma found in the current study could represent a true lack of stigma about working with another college student with ADHD. ADHD is relatively common among this generation; perhaps college students are simply accepting of the disorder. Also, the label of ADHD may be associated with positive attitudes about treatability and controllability of an ADHD diagnosis, factors that have been shown to reduce stigma (Ben-Porath 2002; Corrigan et al. 2000; Feldman and Crandall 2007; Reohrig and McLean 2010). Alternatively, however, it is possible that when the potentially negative behaviors of ADHD were listed on the Information Form, our participants were accurately rating their hesitation to work with someone who reports being disorganized and distracted. In terms of the similar levels of stigma found between ADHD and Depression, we could be seeing some of the aforementioned trends (social desirability, low stigma in this population), or it could be that college students have had contact with many people with both of these disorders. Brown (2012) found that the more contact a rater has with a person with severe mental illness, the lower the rating of stigma. It follows that this would extend to both ADHD and Depression. In an era where ADHD and Depression in the media are ubiquitous, and some suggest that both are over-diagnosed (Bruchmu¨ller et al. 2012; Aragone`s et al. 2006 respectively), college students may feel that neither disorder warrants a second thought.
ADHD stigma among college students
Implications College students with ADHD have a harder time adapting to college, have less developed social skills, and have lower self-esteem than students without ADHD (Shaw-Zirt et al. 2005), and these things would likely be exacerbated by any real or perceived stigma from their classmates or professors. By providing education and coping mechanisms to the students with ADHD, and potentially antistigma campaigns to the campus community at large, students with ADHD may be perceived less negatively by their peers and instructors. In fact, as our study demonstrated, it was the behaviors—not the label—that produced stigma against individuals with ADHD. Thus, if college students with ADHD were able to limit their outward, observable ADHD behaviors (e.g., distractibility, disorganization, procrastination), stigma against them might be limited in turn. Unfortunately, although we have a vast amount of information about effective ways to treat children and adolescents with ADHD (Evans et al. 2014; Sibley et al. 2014) and an increasing amount of information about how to treat adults (Pallanti and Salerno 2013; Ramsay and Rostain 2008), we know considerably less about how to effectively manage ADHD symptoms in college students (Green and Rabiner 2012). In fact, literature on medication and psychosocial treatments in this group is extremely limited, and there is reason to believe that treatments will need to be tailored to meet the needs of college students who are in a unique developmental phase and who face unique challenges (Green and Rabiner 2012). Therefore, effective treatments for college students with ADHD may be the first step in reducing stigma, as these students will be better able to manage their observable, undesirable symptoms. Limitations and future directions Several study limitations should be noted. First, participants in the study were primarily Caucasian female college students. This may limit the generalizability of our findings. In fact, given that some researchers have found that ratings of stigma differ based on the rater’s sex and race (Latner et al. 2005), this is particularly important. Further, most participants in this study were Introduction to Psychology students who may have been learning about mental illness, perhaps making them more sympathetic to our fictitious partner. Next, the current study used a fictitious partner described on paper, and although no participants reported doubting the deception, a more robust manipulation might have shown different results. For example, interacting with a real person portraying the symptoms of ADHD might have a different outcome in terms of stigma ratings. Finally, the questionnaires used
were created specifically for this study, and although they were informed by previous measures and had good reliability, the psychometric properties have not been fully examined. In sum, the current study—despite some limitations— showed that ADHD stigma in college students is driven by the behaviors associated with ADHD, not the label of ADHD itself. More research in this area is warranted to further elucidate ADHD stigma in adults. This study was approved by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All persons gave their informed consent prior to their inclusion in this study.
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from children and adolescents with mental health problems. J Health Soc Behav 48:50–67. doi:10.1177/ 002214650704800104 O’Driscoll C, Heary C, Hennessy E, McKeague L (2012) Explicit and implicit stigma towards peers with mental health problems in childhood and adolescence. J Child Psychol Psychiatry 53:1054–1062. doi:10.1111/j.1469-7610.2012.02580.x Ohan JL, Visser TW, Moss RG, Allen NB (2013) Parents’ stigmatizing attitudes toward psychiatric labels for ADHD and depression. Psychiatr Serv 64(12):1270–1273. doi:10.1176/ appi.ps.201200578 Pallanti S, Salerno L (2013) Pharmacological treatment and management of attention deficit hyperactivity disorder (ADHD) in adults. Minerva Psichiatr 54(4):297–315 Pescosolido BA, Fettes DL, Martin JK, Monahan J, McLeod JD (2007) Perceived dangerousness of children with mental health problems and support for coerced treatment. Psychiatr Serv 58:619–625. doi:10.1176/appi.ps.58.5.619 Piner KE, Kahle LR (1984) Adapting to the stigmatizing label of mental illness: foregone but not forgotten. J Pers Soc Psychol 47(4):805–811. doi:10.1037/0022-3514.47.4.805 Ramsay JR (2010) Nonmedication treatments for adult ADHD: Evaluating impact on daily functioning and well-being. American Psychological Association, Washington, DC Ramsay JR, Rostain AL (2008) Adult ADHD research: current status and future directions. J Atten Disord 11(6):624–627 Reohrig JP, McLean CP (2010) A comparison of stigma toward eating disorders versus depression. Int J Eat Disord 43:671–674. doi:10.1002/eat.20760 Shaw-Zirt B, Popali-Lehane L, Chaplin W, Bergman A (2005) Adjustment, social skills, self-esteem in college students with symptoms of ADHD. J Atten Disord 8:109–120. doi:10.1177/ 1087054705277775 Sibley MH, Kuriyan AB, Evans SW, Waxmonsky JG, Smith BH (2014) Pharmacological and psychosocial treatments for adolescents with ADHD: an updated systematic review of the literature. Clin Psychol Rev 34(3):218–232. doi:10.1016/j.cpr. 2014.02.001 Walker JS, Coleman D, Lee J, Squire PN, Friesen BJ (2008) Children’s stigmatization of childhood depression and ADHD: magnitude and demographic variation in a national sample. J Am Acad Child Adolesc Psychiatry 47:912–920. doi:10.1097/CHI. 0b013e318179961a Yap MBH, Reavley N, MacKinnon AJ, Jorm AF (2013) Psychiatric labels and other influences on young people’s stigmatizing attitudes: findings from an Australian national survey. J Affect Disord 148:299–309. doi:10.1016/j.jad.2012.12.015
ORIGINAL ARTICLE
ADHD stigma among college students Amanda Chi Thompson1,2 • Elizabeth K. Lefler1
Received: 25 August 2014 / Accepted: 18 June 2015 Springer-Verlag Wien 2015
Abstract The current study examined ADHD stigma within a college-enrolled young adult population, including the debate regarding the cause of stigma: label or behavior. In Phase 1, 135 college students rated stigma toward one of the four fictitious partners described as having either: the label of ADHD alone, the behaviors associated with ADHD alone, the label of ADHD and a set of behaviors associated with ADHD, or neither the label nor behaviors. In Phase 2, 48 college students rated stigma toward one of the two assigned fictitious partners described as having either: the label of ADHD and a set of behaviors associated with ADHD, or the label of Depression and a set of behaviors associated with Depression. It was hypothesized that the interaction between the label and the behaviors would cause the highest levels of ADHD stigma and that ADHD would elicit more stigma than Depression. In Phase 1, stigma was associated with the behaviors of ADHD, but not the label. In Phase 2, ADHD and Depression were found to be equally stigmatized. Implications, limitations, and future directions are discussed. Keywords College
ADHD Adult ADHD Stigma Labels
Introduction Stigma can be defined as a negative bias against an individual or group of individuals that has been developed through expectations or past experiences and may cause prejudice and/or discrimination toward members of the group (Crocker et al. 1998; Link and Phelan 2001). For example, there is a stigma associated with individuals who suffer from mental illness, which elicits higher ratings of dangerousness and differentness and higher levels of social isolation (Feldman and Crandall 2007; Kobau et al. 2009). Stigma has been shown to have a negative impact on individuals with mental illness, such that the stigma may exacerbate a person’s symptoms, may make a person believe they are to blame for their disorder, and may actually lead to treatment avoidance (Dinos et al. 2004; Feldman and Crandall 2007; Jorm and Griffiths 2008; Kobau et al. 2009). One mental health disorder that elicits stigma is attention-deficit/hyperactivity disorder (ADHD). Although ADHD was historically considered a childhood condition, it is now understood that a majority of individuals with ADHD continue to have the symptoms of, or impairment caused by the disorder into adulthood (Barkley et al. 2008; DuPaul et al. 2009; Ramsay 2010). Thus, the current study aims to explore ADHD stigma in a sample of young adults. Stigma and ADHD
& Amanda Chi Thompson [email protected] 1
Department of Psychology, University of Northern Iowa, Cedar Falls, IA, USA
2
Present Address: Learning Services Department, Kirkwood Community College, 6301 Kirkwood Blvd. SW, Cedar Rapids, IA 52406, USA
Children and adolescents with ADHD are negatively impacted in their social relationships due to the stigma associated with ADHD. The stigma of ADHD elicits higher levels of social distance preference, making it difficult for children with ADHD to make friends, as children with ADHD are shown to be less preferred as friends by other
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children (Hoza et al. 2005). In addition, children without mental illnesses rated children with ADHD more negatively than individuals with asthma (Walker et al. 2008) and children with ADHD are stigmatized to a higher degree than youth with Depression (O’Driscoll et al. 2012). Children with ADHD are perceived to be more dangerous than other children, as rated by their peers, and are thought to be more violent, and at a greater risk of self-harm (Pescosolido et al. 2007). Children with ADHD are even rated negatively by parents of children without ADHD. Specifically, one in five parents of children without ADHD reports being unwilling to have their children in a class with other children with ADHD, have a child with ADHD live next door, or have their child be a friend to a child with ADHD (Martin et al. 2007). Despite increased interest in the stigma associated with ADHD in children and adolescents, less research has been conducted on adults with ADHD. Canu et al. (2008) conducted a study to examine ADHD stigma in college students. Findings showed that college students rated other young adults with ADHD more negatively than those without ADHD. Specifically, young adults with ADHD were rated more negatively when the participant was asked whether they would like to work in an academic or professional setting as a team. In terms of sex differences, men with ADHD were rated more harshly than women with ADHD. Additionally, Chew et al. (2009) found that college students assigned significantly more negative adjectives than positive adjectives to their peers (i.e., other college students) with ADHD. Interestingly, those who reported more contact with individuals who have ADHD were less likely to endorse negative adjectives, and participants with ADHD endorsed even more negative adjectives to describe ADHD (Chew et al. 2009). Labels versus behaviors Stigma can be thought of as involving both a label and a stereotype that identifies individuals with a set of characteristics (Link and Phelan 2001). Labels contribute to the development of stigma and can lead to stereotypes (Corrigan 2004). Stigma is developed through a labeling process (Link and Phelan 2001) which includes four components: identifying and labeling differences between individuals, linking those differences to known stereotypes, a social label which separates individuals into groups of ‘‘us’’ and ‘‘them,’’ and status loss and discrimination. Within this process, the label is necessary before stigma can be attached to a set of characteristics (Link and Phelan 2001). There is some debate, however, whether the label of a mental illness elicits the stigma associated with it, or whether it is observable behaviors that lead to the stigma
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(Link et al. 1987). For example, does the label ‘‘schizophrenia’’ cause stigma, or is it the observation of a person with active hallucinations that causes stigma? Research has found that simply the label ‘‘mental illness’’ increases the general public’s preference for social distance and that the perception of dangerousness is found to mediate the relationship between stigma and social distance (Angermeyer and Matschinger 2003; Link et al. 1987; Piner and Kahle 1984). On the other hand, a description of the behaviors associated with mental illness has also been shown to elicit stigma. Specifically, Yap et al. (2013) found evidence of stigma after participants read vignettes describing behaviors of various mental illnesses. In addition, Law et al. (2007) found that the mere label of ADHD had no impact on children’s ratings of a peer with ADHD described in a vignette with both behaviors associated with ADHD and the label itself. Conversely, Ohan et al. (2013) found small but significant increases in the amount of stigma when a label was added to a set of behaviors that were already stigmatized, suggesting that the label adds some incremental stigma above and beyond behaviors alone. Thus, it seems that both labels and behaviors affect stigma ratings. It might follow that an individual identified with both a label and a set of atypical behaviors would be doubly stigmatized.
The current study Overall, there is a lack of research on the stigma associated with adult ADHD. Therefore, this study aims to investigate ADHD stigma among a subset of the young adult population—college students—in two ways. First, it was hypothesized that participants would show more stigma toward a fictitious partner with ADHD than a fictitious partner without ADHD when presented with the prospect of completing an academic task together. More specifically, because of the debate regarding the origin of stigma: labels or behavior, Phase 1 of this study included four conditions in which the presence or absence of ADHD label and behaviors was manipulated. It was hypothesized that the label and behaviors together would elicit the highest level of stigma. Second, previous research has shown that mental illnesses elicit stigma at different rates (Day et al. 2007; Reohrig and McLean 2010). Moreover, it is not surprising that two negative descriptors of a person (i.e., a label and a set of atypical behaviors) would be more stigmatizing than one negative descriptor (i.e., a label or a set of atypical behaviors alone). Therefore, it was hypothesized that ADHD would elicit more stigma than Depression, even when both disorders included a label and a set of atypical behaviors. Depression was used as it is a
ADHD stigma among college students
well known, often studied condition, and has been found to differ from ADHD in terms of stigma (O’Driscoll et al. 2012). These hypotheses were addressed in two separate, sequential phases: Phase 1 and Phase 2.
Materials and methods: Phase 1 Participants Participants for Phase 1 included 135 undergraduate students recruited from the psychology department participant pool of a mid-sized Mid-Western Public University (70.4 % female). Participants received research credit for participating in the study. Participants’ ages ranged from 18 to 25 years (M = 18.66). A majority of participants considered themselves non-Hispanic, Caucasian (93.3 %). Participants with ADHD were excluded from the analyses (see Table 1 for demographic information). Procedure Phase 1 employed an experimental design. All participants gave their informed consent. Participants completed the study individually and were told they would be working with a partner on an academic task later in the hour. This partner did not exist, but an Information Form was filled out by the researchers in advance to deceive the participant (see Fig. 1 for visual of this Information Form). The fictitious partner was supposedly down the hall in another room with another research assistant. The independent variable (IV) was how the fictitious partner described their academic weakness on the Information Form, which had four levels: (1) label of ADHD alone; (2) behaviors associated with ADHD alone; (3) label of ADHD and a set of behaviors associated with ADHD; and (4) neither the label nor behaviors associated with ADHD. The real participant filled out an identical Information Form, and the forms were ostensibly exchanged by the research assistants between the two partners. This Information Form, filled out by the researchers in advance (Fig. 1), included the academic weakness (i.e., one of the four levels of the IV), as well as some information that was held constant (e.g., major, hobbies, academic strengths). The fictitious partner’s gender was also held constant; the partner was always identified as male. Participants were randomly assigned to Table 1 Phase 1 and Phase 2 demographics
one level of the independent variable. They were told the purpose of the study was to determine how accurately individuals are able to predict the success of an academic partnership based on receiving some basic information about a partner. There were two dependent variables: (1) anticipated behavior ratings; and (2) social distance scale ratings. After receiving their fictitious partner’s form, the participants answered questions regarding their feelings about being partnered with this individual via the Anticipated Behaviors Form and the Social Distance Scale. The participant was then asked to fill out a Demographics Form. After the participant completed the questionnaires, the participant was told the true nature of the study. At this point, the research assistant informed the participant that they would not be working with a partner. The participants were asked what they believed the study was about and whether they guessed there was not a partner. Notably, 100 % of participants reportedly believed they would be working with a partner until they were told otherwise. Measures Anticipated Behavior Form (ABF) This form was created by the authors for the current study and measured what the participant believed would happen while working on the academic task with their partner (Table 2). The ABF includes 11 items with a Likert-type scale ranging from 1 (Very Unlikely/Very Low) to 7 (Very Likely/Very High). Summary scores were created, with a range of 11–77. See Table 2 for a list of all items. Internal consistency reliability for the current study, as measured by Cronbach’s alpha, was good (a = 0.85). Social Distance Scale (SDS) The SDS (informed by Link et al. 1987, 1999) includes 12 items (Table 3) and measures a person’s willingness to socially engage with another person on a Likert-type scale ranging from 1 (Definitely) to 7 (Definitely not). Summary scores were created, with a range of 12–84. See Table 3 for a list of all items. Internal consistency reliability for the current study, as measured by Cronbach’s alpha, was good (a = 0.86).
Data analytic plan
n
Mean age
Female (%)
Caucasian (%)
Phase 1
135
18.66
70.4
93.3
Phase 2
48
18.44
64.6
89.6
Two-way factorial analysis of variance (ANOVA) tests were used to examine the data in Phase 1. One ANOVA was conducted with the Anticipated Behaviors Form (ABF)
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Fig. 1 Information Form presented to participants with manipulated independent variables. The first six items were constant in all conditions; the last item was manipulated as noted. In the study, the responses were handwritten on the form by a research assistant
as the dependent variable, and a second ANOVA was conducted with the Social Distance Scale (SDS) as the dependent variable. In Phase 2, independent samples t tests were used to examine the data. One t test compared means on the ABF, and a second t test compared means on the SDS.
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Results: Phase 1 A two-way factorial ANOVA was used to examine the effects of the label of ADHD and the behaviors associated with ADHD on ABF mean scores (Table 4). Behaviors associated with ADHD had a significant main effect on
ADHD stigma among college students Table 2 Anticipated Behavior Form (ABF) items
Table 5 Phase 1: two-way factorial ANOVAs for Anticipated Behavior Form (ABF) and Social Distance Scale (SDS)
How likely is it that…
Independent variable
1. The workload will be fairly distributed? 2. You will like working with this person?
ABF
SDS
F(1,127)
p
F(1,131)
p
10.69
.001
3.87
.051
0.64
.425
0.17
.678
1.46
.230
1.32
.253
3. There will be good communication between you and this person?
Behaviors of ADHD
4. You and this person will finish the project in a timely manner?
Label of ADHD
5. This person will be as creative as you?
Behaviors and label of ADHD
What are the chances…
Four participants did not complete the back side of the ABF, and thus, n = 131 (rather than 135) for all ABF analyses in Phase 1
6. This person will put in as much effort as you? 7. That you will work well with this person? 8. This partnership will work out? 9. You and your partner will be able to complete the project correctly? 10. Would you choose this person for a project in the future if you could? 11. Will this person take on a leadership role in this project?
Table 3 Adapted Social Distance Scale (SDS) items How likely would you be to… 1. Sit next to this person in class? 2. Exchange numbers with this person? 3. Ask this person to take notes for you in class on a day that you would be absent? 4. Hang out with this person outside of class? 5. Get to know this person better? 6. Become friends with this person?
F(1,127) = 0.64, p = .425. There was not a significant interaction, F(1, 127) = 1.46, p = .230 (Table 5). A two-way factorial ANOVA was used to examine the effects of the label of ADHD and the behaviors associated with ADHD on SDS mean scores (Table 4). The behaviors associated with ADHD did not have a significant main effect on SDS mean scores, F(1, 131) = 3.87, p = .051, nor did the label of ADHD have a significant main effect on the SDS mean scores, F(1, 131) = 0.173, p = .678 (Table 5). Although the main effect for behaviors of ADHD on SDS mean scores was not significant at p \ .05, it does appear that the scores are trending toward being significant such that those provided with behaviors of ADHD endorsed more stigma. There was not a significant interaction, F(1, 131) = 1.32, p = .253 (Table 5).
7. Live in the same dormitory as this person? 8. Want to live next door to this person?
Materials and methods: Phase 2
9. Be roommates with this person? 10. Want to be a co-worker to this person? 11. Want to go on a date with this person?
Participants
12. Consider having a serious relationship with this person?
Table 4 Phase 1: means and standard deviations for Anticipated Behaviors Form (ABF) and Social Distance Scale (SDS) Independent variable
ABF
SDS
M
SD
M
SD
Behaviors of ADHD
50.03
7.29
40.86
10.16
Label of ADHD
52.90
5.97
44.53
8.59
Behaviors and label of ADHD Control (no label or behaviors)
50.55 56.06
8.54 6.78
43.44 46.25
9.18 9.95
Participants in Phase 2 were 48 undergraduate students recruited from the psychology department participant pool of the same Mid-Western University as in Phase 1 (64.6 % female). Participants received research credit for participating in the study. Participants’ ages ranged from 18 to 22 years (M = 18.94). A majority of participants considered themselves non-Hispanic, Caucasian (89.6 %; see Table 1 for demographic information). Participants with ADHD and Depression were excluded from analyses. Procedures and measures
Low scores suggest more stigma
ABF mean scores, F(1, 127) = 10.69, p = .001 (see Table 5), such that those provided with behaviors of ADHD endorsed more stigma. The label of ADHD did not have a significant main effect on ABF mean scores,
The procedures and measures in Phase 2 were identical to those described in Phase 1 including providing informed consent prior to the inclusion of the study. There was one exception in the procedure. Participants still participated alone, were deceived into believing they would be working with a partner on an academic task, filled out and received
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A. C. Thompson, E. K. Lefler
an Information Form, and completed the ABF and SDS. However, instead of four levels of the independent variable, there were only two. Specifically, the two levels of the IV were (1) the label of ADHD and a set of behaviors associated with ADHD; and (2) the label of Depression and a set of behaviors associated with Depression (some of which overlapped with the ADHD behaviors, such as difficulty paying attention; see Fig. 1).
Results: Phase 2 Two independent samples t tests were conducted to determine whether there was a difference in stigma ratings between ADHD and Depression on the two measures (i.e., ABF and SDS). There was no significant difference in stigma ratings between ADHD (M = 47.41; SD = 9.65) and Depression (M = 52.00; SD = 8.21) on the ABF, t(41) = 1.40, p = .168 (Table 6). Likewise, there was no significant difference in stigma ratings between ADHD (M = 39.94; SD = 8.97) and Depression (M = 42.13; SD = 7.54) on the SDS, t(46) = 0.81, p = .420 (Table 6). Thus, ADHD and Depression were rated equally on the ABF and SDS.
Discussion Results of the current study suggest that (a) the behaviors associated with ADHD—not the label of ADHD—drive stigma among college students, (b) very little ADHD stigma was found in this sample, and (c) ADHD and Depression are stigmatized at the same rate among college students. These results have several potential explanations and implications. In Phase 1, it was determined that the label of ADHD did not produce stigma on either measure. Thus, it seems that the label of ADHD alone did not cause stigma in the current study. In terms of the behaviors associated with ADHD, there was a significant main effect found on the Anticipated Behaviors Form (ABF) and a trend toward significance on the Social Distance Scale (SDS). This might suggest that college students who are told the behaviors of a person with ADHD have a bias against working with that person, as was found in previous Table 6 Phase 2: t tests for ABF and SDS Measures
n
ADHD
Depression
M
SD
M
SD
t
p
ABF
48
47.41
9.65
52.00
8.21
1.40
.168
SDS
48
39.94
8.97
42.13
7.54
-.81
.420
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studies (e.g., Canu et al. 2008; Chew et al. 2009). In particular, college students were worried about workload being equally distributed, partner’s communication skills, and partner putting forth equal effort. However, surprisingly, the interaction of label with behaviors was non-significant for both measures. It is possible that the label of ADHD provides an appropriate context to certain behaviors that are occurring and could explain why more stigma was reported when the ADHD behaviors were not accompanied by the label. College students may know they should not hold stigma against individuals with ADHD, so when they see the label they do not endorse high levels of stigma. Alternatively, the participants may have seen the label as a reasonable explanation for the behaviors. Indeed, as was found by Henderson et al. (2012), a social desirability bias may now extend to mental health disorders in certain groups of people. It is possible that when presented with the label ‘‘ADHD,’’ college students in the current study did not feel it was socially appropriate to report any stigma and therefore reported their views in a more positive light. This may increase the importance of studies of implicit ADHD stigma, as college students may not explicitly report mental illness stigma. On the other hand, the low rates of stigma found in the current study could represent a true lack of stigma about working with another college student with ADHD. ADHD is relatively common among this generation; perhaps college students are simply accepting of the disorder. Also, the label of ADHD may be associated with positive attitudes about treatability and controllability of an ADHD diagnosis, factors that have been shown to reduce stigma (Ben-Porath 2002; Corrigan et al. 2000; Feldman and Crandall 2007; Reohrig and McLean 2010). Alternatively, however, it is possible that when the potentially negative behaviors of ADHD were listed on the Information Form, our participants were accurately rating their hesitation to work with someone who reports being disorganized and distracted. In terms of the similar levels of stigma found between ADHD and Depression, we could be seeing some of the aforementioned trends (social desirability, low stigma in this population), or it could be that college students have had contact with many people with both of these disorders. Brown (2012) found that the more contact a rater has with a person with severe mental illness, the lower the rating of stigma. It follows that this would extend to both ADHD and Depression. In an era where ADHD and Depression in the media are ubiquitous, and some suggest that both are over-diagnosed (Bruchmu¨ller et al. 2012; Aragone`s et al. 2006 respectively), college students may feel that neither disorder warrants a second thought.
ADHD stigma among college students
Implications College students with ADHD have a harder time adapting to college, have less developed social skills, and have lower self-esteem than students without ADHD (Shaw-Zirt et al. 2005), and these things would likely be exacerbated by any real or perceived stigma from their classmates or professors. By providing education and coping mechanisms to the students with ADHD, and potentially antistigma campaigns to the campus community at large, students with ADHD may be perceived less negatively by their peers and instructors. In fact, as our study demonstrated, it was the behaviors—not the label—that produced stigma against individuals with ADHD. Thus, if college students with ADHD were able to limit their outward, observable ADHD behaviors (e.g., distractibility, disorganization, procrastination), stigma against them might be limited in turn. Unfortunately, although we have a vast amount of information about effective ways to treat children and adolescents with ADHD (Evans et al. 2014; Sibley et al. 2014) and an increasing amount of information about how to treat adults (Pallanti and Salerno 2013; Ramsay and Rostain 2008), we know considerably less about how to effectively manage ADHD symptoms in college students (Green and Rabiner 2012). In fact, literature on medication and psychosocial treatments in this group is extremely limited, and there is reason to believe that treatments will need to be tailored to meet the needs of college students who are in a unique developmental phase and who face unique challenges (Green and Rabiner 2012). Therefore, effective treatments for college students with ADHD may be the first step in reducing stigma, as these students will be better able to manage their observable, undesirable symptoms. Limitations and future directions Several study limitations should be noted. First, participants in the study were primarily Caucasian female college students. This may limit the generalizability of our findings. In fact, given that some researchers have found that ratings of stigma differ based on the rater’s sex and race (Latner et al. 2005), this is particularly important. Further, most participants in this study were Introduction to Psychology students who may have been learning about mental illness, perhaps making them more sympathetic to our fictitious partner. Next, the current study used a fictitious partner described on paper, and although no participants reported doubting the deception, a more robust manipulation might have shown different results. For example, interacting with a real person portraying the symptoms of ADHD might have a different outcome in terms of stigma ratings. Finally, the questionnaires used
were created specifically for this study, and although they were informed by previous measures and had good reliability, the psychometric properties have not been fully examined. In sum, the current study—despite some limitations— showed that ADHD stigma in college students is driven by the behaviors associated with ADHD, not the label of ADHD itself. More research in this area is warranted to further elucidate ADHD stigma in adults. This study was approved by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All persons gave their informed consent prior to their inclusion in this study.
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