Sunday, May 15, 2005

What Can We Do About Uninformed Stereotypes of Mental Illness?

Stereotypes applied to persons with brain disorders tend to be unfair and counterproductive (1 2 3).  Although the problem is common is all areas of medicine, it has proven to be particularly persistent and malicious when the problems produce no outwardly visible signs of impairment.  In this post, I look at an example of such a stereotype, as expressed by someone who really ought to know better, provide scientifically-based refutation of the specific stereotype, then mention what steps can be taken to combat the problem.

Dr. Adams is an associate professor in Criminology at University of North Carolina at Wilmington.  In a recent Townhall column, he voiced his opinion about a student who claimed to have ADHD.  This provides us with an example of an uninformed stereotype.  Perhaps it is a little unfair of me to pounce on this, since it wasn't the main point of his article.  Perhaps if he had thought about it some more, and perhaps tried to be more informed, he wouldn't have come across as being so nasty.  It may be that, in person, he comes across as being more reasonable.  In fact, we may get an opportunity to hear more: Dr. Adams will be visiting Michigan soon:
Upcoming Events:
Dr. Adams will be speaking at the Right to Life annual fund-raising dinner in Lansing, Michigan on May 11. He will address the N.C. State Republican convention in Ashville, NC on May 20 and will be signing books at the convention on May 20 and 21.  He will then speak at Kalamazoo College in Michigan on May 25th.

I missed the event on the 11th.  Too bad the 25th is a Wednesday.  I won't be able to make it to Kalamazoo then.  But then, maybe I don't have enough shame containers.  That may be a bit harsh.  It might hurt his feelings to see his picture like this.  On the other hand, he probably can take care of himself.  In one article, he speculates that liberals have not thrown a pie at him because they may know he carries a .357 magnum revolver.

I don't know Dr. Adams, but poking around on the 'net reveals many intolerant, angry invectives he has authored, and nothing nice.  A recent column on Townhall.com bugged me enough to motivate me post about his writings.  His columns are listed here.  Much of it is anti-diversity, anti-liberal, and seemingly anti-human being: a strange perspective for someone who characterizes himself as pro-life.  I guess he's in favor of life, so long as the person who is living agrees with him.  I reached this conclusion based upon a subset of his writings, which is a biased sample.  But the bias is a result of his own selection: the material I encountered was the material he has promoted most avidly.  Everything I found was a complaint of some sort.  He appears to spend a lot of time complaining about things he doesn't like, and little if any talking about what he does like.

In his favor, I must say he writes reasonably well, and uses sarcasm effectively.  The pictures he posted of himself (on DrAdams.org) indicate that at least some people like him, even when he speaks in half-empty lecture halls.  His biography indicates that he has overcome some adversity in life, which is always commendable.  It mentions that he was given a Faculty of the Year award.  I noticed that he backs up his arguments with his own direct observations.  As an empiricist, this is something I appreciate.

Unfortunately, in the case of the column I linked above, he did not research his subject matter very well.  He implies that a student with ADHD is making himself out to be a victim, and disparages his attempts to help himself.  It seems counterproductive for him to do so: if someone recognizes a problem and makes an effort to fix the problem, shouldn't his professor support that effort? 
Yesterday, I received your email explaining the reasons for your poor performance in my class this semester. While I was pleased that you refrained from asking for a change of grade, I was disappointed that you attributed your bad grade to adult ADHD.

I hope you were kidding when you said that you plan to join an adult ADHD support group. Since you are an 18 year old male, I would suspect that a trip to nearby Wrightsville Beach [link added] could cure your "disorder." If you can't pay attention to the environment there, you may really have a problem.
What is worse, he implies that the problem, ADHD, is not a real problem and that it was basically made up by the medical profession, while the treatments are promoted by the self-serving pharmaceutical industry.
Adult ADHD is another one of those problems we didn't have to deal with when I was growing up. But, now that a few doctors and drug companies have let us know it is out there, everyone seems to be getting it. The list of these disorders just keeps growing, doesn't it?
There is a grain of truth to this.  Probably the most common view, among people who actually know about this subject, is that adult ADHD is overdiagnosed in some cases.  However, those same knowledgeable people believe that, while it is overdiagnosed in some cases, it is underdiagnosed in others:
Statistics Confirm Rise in Childhood ADHD and Medication Use

Peter Jensen, who has headed major National Institute of Mental Health (NIMH) studies on ADHD and is an assistant professor of psychiatry at Columbia University, agrees with Angold and Costello's findings that the majority of children receiving stimulant medication may not fully meet the criteria.
"It's likely there is a bit of both [under diagnosis and over diagnosis]," Jensen told Education World. "This always happens when public awareness increases that there could be some over diagnosis. But under diagnosis and under treatment are still happening."
Psychiatry On Call
California Psychiatric Association
Briefing Papers on Diagnosis & Treatment of Brain Disorders

"Overdiagnosis" refers to children being diagnosed with ADHD when they do not have it. This can occur when an incomplete evaluation takes place, either because the clinician is not fully trained or because he/she is not allowed adequate time to do a complete assessment, often because few health insurers cover this, and because special education does not have a funded category for ADHD. To complicate matters, when a child is highly disruptive at home or in the classroom, the parents or teacher may put pressure on the physician to "fix the problem" by making a diagnosis of ADHD and prescribing medication.

Even as we recognize that ADHD is over diagnosed, the under diagnosis - children having ADHD but not being diagnosed and treated - is actually much more common. This is due to a number of barriers such as lack of information about the symptoms and causes of ADHD, the stigma of mental illness, the myth that mental illness does not exist, and misperception of the child's behavior as intentional and willful. The symptoms of ADHD - hyperactivity, inattention and impulsive behavior - can profoundly interfere with a child's ability to learn, to make and keep friends, and to feel good about himself. Yet thousands of these children are never seen by an appropriate professional for evaluation.
In clinical practice, a fairly common scenario occurs with children who are highly intelligent, and who do not exhibit oppositional behavior.  They are intelligent enough to do well in primary and secondary school, when the academic demands are not very great.  Often, their report cards will contain comments, such as "doesn't reach full potential."  But if their grades are OK and they aren't causing trouble, their problem goes unrecognized.  If they go on to college, however, they eventually take classes in which the ADHD problem outweighs their ability to compensate. 

In such cases, the student may be accused of being lazy, or of looking for an excuse.  But for many of them, if you take the time to do a complete history, you learn that they actually are trying as hard as their classmates.  Often they will say that they have had to study harder than their classmates, just to get average grades.  Sure, if a student skips class to go to the beach, or whatever, that is their fault.  However, that usually is not the case.

In order to understand the problem with ADHD in college students, you need experience and training.  Illustrative of this, PBS has posted an interview with Dr. Jensen here.  He refutes Dr. Adams' concerns, pretty effectively in my opinion. 
Frontline: And yet, for probably hundreds of years, there have been people with this disorder. And they have lived and survived, I assume, without medication.

Jensen: We've had diabetes for hundreds of years, and we've had hypertension for hundreds of years, and we've had asthma for hundreds of years. . . . We've had cancer. We've had lots of things for hundreds of years. That doesn't necessarily make it a good thing. And when you sit back and you allow yourself to be informed by research . . . our studies show that these kids have bad outcomes when we don't help them.
Skeptics are encouraged to review recent information of the neurobiology of ADHD.  There is abundant evidence from genetic studies (Medscape article, free registration required), and from neuroimaging studies, to support the validity of the diagnosis. 

Those who are really interested could peruse the abstracts on the subject, using Medline. 

Of course, I have no idea whether Dr. Adams' student actually has ADHD, nor do I know if the student is inappropriately trying to adopt a victim role.  My argument is not about the specific student; rather, I object to Dr. Adams casting his student as part of a group (as though the student is just like all those other kids who make excuses), then disparaging the entire group.  Persons with brain disorders have struggled against this kind of thing for centuries, and it is a disservice to our entire society for a professional educator to be complicit in perpetuating such stereotypes.

What can be done to mitigate the damage done by uninformed stereotypes?  The most important intervention is for people to speak up when such stereotypes are used.  Being a passive listener is not a good strategy: it perpetuates the problem.  Rather, it is more productive to clarify the intent of the one who expresses the stereotype, then express constructive criticism.  The second most important strategy is to acquaint oneself with the facts.  Note that, in the sidebar, I have a link to my prior post, Tips For Researching Medical Topics On The 'Net (which is updated periodically). 

Doing the background research is important, and it is easy if you have access to the Internet.  Presumably, if you are reading this, you do have access.  There's no substitute for the facts, and no excuse for rendering judgment without first examining the facts.  I suppose I sound like a criminologist when I say that, but it's really true.

(Note: The Rest of the Story/Corpus Callosum has moved. Visit the new site here.)
E-mail a link that points to this post:

As a teacher myself, I agree that one shouldn't jump to conclusions and stereotype students. However, students do come up with the most outlandish stories from time to time in order to extract a higher grade from a teacher. The professor you speak of definitely shouldn't be so judgemental (but with a resume like his, it's probably just his personality to judge). There are proper avenues to follow that don't include publicly lambasting a student for something that may be truly affecting their life. I've found in similar situations that it works to find out if the student has been clinically diagnosed, or is making his/her own conclusion about symptoms. IF there is a doctor involved, get the student to furnish a note from the doctor. I don't know why, but it does seem to be a common pattern for students to come up with disorders or difficult situations after it's too late to help them (maybe they are intimidated about the idea of approaching a professor?). Most teachers are much more willing to help a student who is up front about their problems from the beginning than one who only brings them up at the end because then it seems like they are trying to find an extra edge for their final grade.
The Dr.'s comments seem to be mean spirited, whether true or not. This doesn't help anyone.

Unfortunately, a
showed that increased public awareness of the true causes of a mental disorder (in this case, schizophrenia) actually made people less tolerant of those suffering from the disorder. In Dr. Adams' case, though, ignorance doesn't seem to be bliss.
Oh, for heaven's sake! The bulk of the article was devoted to Adams' description of a paraplegic student's typical day, and all the difficulties she has to navigate. In spite of everything, she is graduating this year.

Yes, Adams was harsh with the whiny student, but he was just as laudatory of the paraplegic student. Is that fair? I certainly think the paraplegic student is worthy of admiration. I don't know the situation with the Adult ADD student, but I do agree with Adams' final words, in which he hopes that the student with Adult ADD doesn't let it determine for him what he can and cannot do with his life.

That was the point of the column, but I have the impression that you only read the first couple of paragraphs.
I do appreciate hearing from an educator on this topic; although I do some education myself, it is mostly with medical students. They are not really representative of the entire student body. Certainly, it would not have occurred to me to think that it would be common for students to make excuses for poor performance.

THX's comment is a good one. I did not know about that study, but I am familiar with an older one, the DART (depression awareness recognition and treatment) study. THe NIH spent millions of dollars, with one goal being to educate the public about depression. Before and after studies showed that public attitudes did not change at all. There were benefits, but improved public understanding was not one of them.

Regarding Joan's comment: I know you're a fan of Townhall, and I don't mean to imply that all of the columns there are objectionable. They do have good columns.

Also, I think I tried to present a balanced view of Dr. Adams' column. After all, I did point out:

"Perhaps it is a little unfair of me to pounce on this, since it wasn't the main point of his article."

His story about the paralyzed student's efforts indeed was inspiring. I suppose I could have mentioned that. But 1) it did not illustrate the point I was trying to make, and 2) I did not really have anything to add to what he already had said about the subject.

It was never my intention to write a comprehensive critique of his work. If I had, I would have said that his work as a whole might have more impact if he would sometimes write pieces that are purely inspirational, or at least ones that are predominantly positive. Then, if something came up that he really wanted to be critical of, his comments would make more of an impression.
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