DISABLING LABELING:
A SOCIAL WORKER'S RESPONSE TO ATIENTION DEFICIT DISORDER
by
Brent Douglas Goerz
B.S.W ., The University of Manitoba, 1991

A PROJECT SUBMITTED IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK
In the College of
Arts, Social and Health Sciences
University of Northern British Columbia

© Brent Douglas Goerz, 1999
THE UNIVERSITY OF NORTHERN COLUMBIA
April1999
All rights reserved. This work may not be
reproduced in whole or in part, by photocopy
or other means, without the permission of
the author.

l

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LiBRARY

11

ABSTRACT

Attention Deficit Disorder (ADD) is a childhood psychiatric diagnosis that
has exploded within the last decade. The literature written to address this topic
is dominated by the medical perspective and for the most part contains few
references from a social worker's perspective.
The goals of this paper are to question some of the fundamental
assumptions of this disorder and explore the treatment strategies utilized in
dealing with this problem. I then apply some of these treatment approaches to
two separate groups of 6 to 9 year old children diagnosed with ADD. This
project looks at how the treatment strategies evolved within my own practice
and then provides some radical suggestions that social workers need to
consider when working with this population of children.

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111

.

Table of contents
Abstract

ii

Table of Contents

iii

Preface

v

Introduction

1

Chapter One

Overview of diagnosis of ADD

3

Chapter Two

Overview of treatment approaches
Individual treatment
Play and art therapy
i)
Cognitive and behavioural therapy
ii)
Social skills training
iii)
Pharmacological treatment
iv)
Multimodal social work treatment
Social worker role within this approach
Reducing misdiagnosis
i)
ii)
Case manager
Advocacy
iii)
Example of multimodal treatment model
Strengths based approach
i)
Impact of DSM Label
ii)
Constructivist therapy
iii)
Use of more empowering labels
Abandoning the ADD label

7
7
8
9
10
11
15
17
17
18
18
19
20
20
22
22
25

Chapter Three

Case study
Overview structure of the group

31
34

Chapter Four

Summary
Implications for social work practice

42
44

References

49

Appendix 1

ADHD family support/training program

53

Appendix 2

ADHD parent group

54

Appendix 3

ADHD sibling group

55

Appendix 4

ADHD children's group: Age 6-9

56

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Appendix 5

Summary of ADHD game questions

57

v

Preface
I believe that it is important for me to share how I came to select
Disabling Labeling as my project topic. I began my MSW program with little
thought on what my topic would be except to know that I wanted it to be in a
clinical field with children. To accomplish this goal I chose a practicum
placement at Intersect Youth and Family Services Society. At this agency I
was able to work on my clinical skills with children and had the opportunity to
co-facilitate several different children's groups. These groups included two
treatment groups for children who had been diagnosed as having Attention
Deficit Disorder (ADD). I was fascinated when I listened to the children's
stories. They spoke of the conflicts that they were experiencing with their
parents and within their school environments. During the course of this clinical
work and through subsequent readings, I began to examine my own life
experiences. I identified with these children and recognized some similarities
between their lives and my own childhood experience. This encouraged me to
engage in self-reflection into the meanings of these experiences. I recognized
that if my circumstances were different I could have ended up being diagnosed
with ADD and been on the other end of this clinical experience.
At this point I began having discussions with my parents who are both
teachers. My mother works with special needs kids, some identified as having
ADD. I asked her what she thought about ADD and whether or not she saw

Vl

any of these behaviours in me when I was a young child. She shared some of
the struggles that she had with me and related some stories about my
educational issues. What made the difference in my situation was that I had
parents who were very proactive and had knowledge and expertise within the
educational system. When teachers identified a problem, my parents took the
necessary steps to rectify it. I sometimes think about what the outcome would
have been if my parents were not as well educated or if there had been other
mitigating factors in my upbringing. I look back at my school years and
recognize how fortunate I was not to have picked up a label.
Does this mean I had or have ADD? I don't know. In some ways it
would explain some of the frustrations my spouse has with me at times. It
might explain why it has taken me almost three years to write this paper. A
diagnosis of ADD may provide a lot of insight for why I do the things I do. Is
the diagnosis of ADD as concrete as many professionals suggest or are there
other variables? What happens if someone does not quite fit the criteria but
still has significant problems in certain situations? Does this mean that this
person would not benefit from some of the services that are given to those
children diagnosed as ADD? The process of asking these questions helped
me understand the multiple factors that need to be considered when assessing
and treating this condition . This insight also encouraged me to recognize and
identify some of the resiliency within these children and how they, compared to
other children , had more to overcome to experience success in their life. I also

Vll

recognized how important it would be for these children to have significant
people in their lives who refused to focus on their short-comings and instead
focused on a positive future.
In hindsight, I believe that this project has been an invaluable
experience. I have learned much about myself. I have come to terms with
some of my short-comings and recognize that some of the traits that I have
attempted to change in my life may never disappear, however I am still
responsible to compensate and modify my situation in such a way as to
minimize the impact these challenges have on my life. I also recognize how
indebted I am to my parents for being patient and long suffering. They never
gave up on the positive future they saw for me and provided me with the
necessary love and acceptance.

I am extremely thankful to my spouse who

faces my short-comings on a daily basis and through it all refuses to give up
and inspires me to become the person she believes I am.

I cannot forget

Baxter, Noah, and Jakob the three sons God has given me in order that I might
remain humble and recognize that when all is said and done, I still have much
more to learn about parenting, and life in general.

Disabling Labeling 1

Introduction
As I poured over the thousands of pages written about ADD, sorted
through pamphlets and watched videos, I began to have a sense of
helplessness and despair for the future of children diagnosed as ADD. My
experience and knowledge as a social worker told me that there was much
lacking within this literature, especially from a social worker's perspective.
felt that it is paramount that I as a social worker advocate for the needs of
children diagnosed with ADD and encourage others to do the same. I felt what
was necessary for these children was for someone to believe in them and
have a positive outlook for their future.
The first chapter of this report looks at the etiology of ADD and how this
diagnosis has exploded within the last decade. This current diagnosis will be
defined and described within the context of its evolution in the past century.
In chapter two I will look at what skills and tools social workers can offer
children diagnosed as ADD . I will consider the following:
1. why social workers are well suited to work with these children and their
families.
2. a continuum of treatment approaches available to a social worker and
suggest why certain approaches may be more consistent with a social worker's
values and knowledge base.
3. some suggestions as to why certain approaches appear to be more effective
than others, an evaluation of these approaches from an ethical perspective,
and an analysis of each approach using social work theory and practice.
In chapter three, I will show how these treatment approaches were put
into practice in a mental health setting here, in Prince George along with the

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Disabling Labeling 2

consequences of each approach to the lives of children and their families . I
will also demonstrate how I struggled with each approach and resolved the
conflict between knowledge and practice. The reader will see how the
treatment evolved as it was applied in the context of two treatment groups.
Chapter four suggests that most approaches do not go far enough in
creating hope for real change for children diagnosed with ADD. There are
many pitfalls when working with this population and I suggest as social
workers, it is important that we must continually reevaluate our practice and
come to terms with the consequences of our methods and assumptions. It
sometimes feels impossible for ethical social workers to balance the needs of
their clients while meeting the goals and objectives of their employer. Finally, I
will suggest areas that require further research and point out how this
knowledge impacts social work practice.

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Disabling Labeling 3

Chapter One
Overview of diagnosis of Attention Deficit Disorder
Attention Deficit Disorder (ADD) is one of the most talked about, written
about, and misunderstood childhood mental health conditions (Frick & Lahey
cited in Cramond,1994). As of 1995, there were over 6000 scientific articles
published on ADD and more than 50 books (Barkley, 1997). This does not
take into consideration thousands of other books, articles and multi-media
reports that refer to the ADD diagnosis. This being said, the label ADD, and
subsequent medical intervention, continues to be quite controversial as
professionals from various backgrounds argue over a basic understanding of
how ADD should be defined and then how children diagnosed should be
treated. While many professional groups suggest they have some expertise in
this condition , the dominant view throughout the literature is from the medical
perspective. It is the medical diagnosis that determines whether or not
someone fits the criteria of ADD and it is the same profession that treats the
disorder with medication (the most utilized treatment approach with these
children) . This being said , it is difficult to discuss this topic without referring to
the medical diagnosis. I would hope that the reader keeps an open mind
towards this controversy and a critical attitude regarding the viewpoints
expressed from the medical perspective. In order to respond to the medical
perspective it is important to see how ADD is currently defined and diagnosed.
The first place to look for a description of ADD is within the Diagnostic
and Statistical Manual of Mental Disorders. (DSM-IV, 1994) This manual is
published by the American Psychiatric Association and is the dominant
reference manual for most medical practitioners. According to the DSM-IV

Disabling Labeling 4

(1994) children with ADD display an inability to sustain attention, have a
higher level of activity (although this may or may not be the case) and find it
difficult to control their impulsive behaviour as compared to their same age
peers. An estimated 3-5% of all children have th is disorder (Barkley, 1990).
These children exist within all cultures although professionals may describe
and categorize them differently. Barkley suggests that in Great Britain,
children are told they have a "conduct problem," in eastern Europe they are
seen as "undisciplined". Barkley argues that by labeling all of these children
as having a conduct disorder, a misunderstanding is created suggesting that
these children have a deficit of personal character as opposed to a
neurologically determined condition. It has been widely accepted by the
medical community that this disorder is primarily passed on genetically and not
influenced significantly by environmental factors (Barkley, 1997). However
environmental factors such as prenatal exposure to cigarette smoke and lead
poisoning may contribute to the child exhibiting similar behaviours (Milberger,
Biederman , Faraone, Chen , & Jones, 1996).
Throughout the past 100 years th is label has gone through several
transformations. As we will soon realize, the many labels created for these
children provide some insight into what causes the condition. As etiological
theory changes, so too do the labels used to describe these children . Each
label provides some insight into how the medical profession viewed the cause
and main symptomology of the disorder. One of the first people to categorize
these children was Still (Barkley, 1990). In 1902, he observed a group of
children that had similar behavioural characteristics that he considered a
"defect in moral control". After Still's diagnosis of "defect in moral control",

I

Disabling Labeling 5

"

came other scientists; Shirley, Meyer, Beyer, Levin, Blau, Werner, and Strauss

..

(cited in Barkley, 1990), who suggested that these behaviours were caused
by some type of brain injury. Professionals challenged this view when it was
recognized that most children who exhibited these difficult behaviours had not
suffered a specific head injury. The theory was modified to suggest that these
behaviours were as a result of a non-measurable injury. These children were
then described as having minimal brain damage. This term later evolved into
"minimal brain dysfunction" or MBD. After much time studying these children,
the professionals began to question whether or not these children were

:(

actually born with this disposition. From this point forward, the term was

;

changed to hyperkinetic reaction, which was later modified to the term
hyperactive child syndrome (DSM-11 ,1968). After further research it was found
that the consistent symptoms of these children were not their activity levels.
What was found was some children were hyperactive and others were not.
The issue that researchers focused on was the ability these children have in
sustaining attention.
As a result, the label was modified and described as attention deficit
disorder (DSM-111, 1980). A further change has resulted in the current label.
The DSM IV (1994) specifies three subtypes of the disorder:
1. attention deficit/hyperactivity disorder combined (inattention and
hyperactivity-impulsivity)
2. attention deficit/hyperactivity disorder primarily inattentive;
3. attention deficit/hyperactivity disorder primarily hyperactive-impulsive.
It can be assumed that this label will continue to transform as researchers and
medical professionals modify their understanding of these children. This is
why someone would find numerous labels describing the same condition. For

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Disabling Labeling 6

the purpose of this paper I will use the label ADD . When looking at ADD, it is
important to recognize that this is a label utilized by the medical professionals
in North America and there continues to be dissention within this community.
In addition, other professionals question the relevance of labeling. These
opposing views suggest that the medical model is only one way of viewing
these children and maybe if we look at other models we might create a more
positive and productive way of seeing these children.

Disabling Labeling 7

Chapter Two
Overview of treatment approaches
I believe that unlike most other professionals, social workers have
several options when working with children who have been labeled ADD.
These options or approaches include: 1) assessing and treating ADD within
an individual perspective; 2) working from a broader multimodal perspective;
3) minimizing or attacking the ADD label while utilizing a strength-based
approach. As you can see by the order in which I listed these approaches,
there is a progression towards the most radical practice.
Individual Perspective
The early literature on ADD shows us that the first treatment strategy
was treatment of the individual. The problem was defined in the context of the
individual child's behaviour. This approach lacked consistency as outlined by
Bogas (1993),
For too many families , treatment remains fragmented : the diagnosis
and treatment of a child and family still depend to a great extent on the
discipline and tra ining of the person from whom they first seek treatment
The reason is the diagnosis directs the treatment. With ADD, to a large
extent, "the diagnosis is the treatment" (Hallowell & Ratey, 1994, p. 216). If a
medical professional is the first one to assess the child, chances are the
treatment option will be medication. A psychologist may look at information
processing problems and treat the condition with behaviour modification and
focus on compensating for skill deficits (Bogas, 1993). On the opposite side of
the spectrum may be a family therapist who instead of focusing on the child's

Disabling Labeling 8

shortcomings, may focus on the family structures and communication
strategies. The danger with any one of these perspectives is that the
professional may attribute all the causality to one factor and not recognize the
multitude of contributing variables. Social workers are the ideal professionals
to evaluate and balance these factors (Bernier & Siegel , 1994). Social workers
are trained in general systems theory and are encouraged to take a broader
approach when looking at causality. This includes an assessment of the
individual as well as the family, the environment, and broader structural
factors.
Some present day examples of approaches used with these children
that maintain an individual focus include such child centered therapies as play
therapy, art therapy, cognitive/behavioural therapy, social skills training,
educational strategies, psychotherapy, and pharmacological treatment. This is
not to say that these methods cannot be utilized in conjunction with other
methods. These individually centered approaches may be implemented oneto-one with the child or include a group focus. I would like to take a brief look
at each of these therapies and suggest how they apply to children labeled
ADD.
i) Play therapy and art therapy
Play therapy and art therapy are well accepted methods of working with
children. What the therapist attempts to do in this approach is to use the
medium of play and art to resolve problems the child is experiencing. The

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Disabling Labeling 9

therapist and the child engage in this play together and in most cases, the
parents are not involved directly within this process. Most play and art
therapists also suggest that it does not take too long before the presenting
problem behaviours are controlled within therapy. "I find it interesting that
when I work with a child who is considered hyperactive, he is very rarely
hyperactive in my office .. .there's very little of what's commonly thought of as
hyperactivity in a one-to-one situation" (Oaklander, 1978, p. 224). This is
consistent with what we know about this problem in that the symptoms are not
apparent in all contexts, especially when the environment is unique and
interesting for the child (Barkley, 1990). This explains why the symptoms
seem to disappear in the therapist's office. The problem is that these changes
do not always transfer to the school or home environments (Basu & Deb,
1996). That is not to say that art and play therapy are not effective tools in
dealing with childhood depression, anger, self-esteem, grieving, and other
issues that the child with ADD may be experiencing. For this reason, it is my
belief that art and play therapy are effective methods of treating the secondary
problems that arise within these children, however, they are not effective as a
primary treatment tool.
ii) Cognitive, behavioural, and cognitive behavioural therapies
Therapies that were designed to deal directly with the symptoms of
ADD include cognitive, behavioural , and cognitive behavioural therapy.
Although I have placed these three similar therapies within the same category

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Disabling Labeling 10

it is important to differentiate between each approach. In the cognitive
approach, the therapist attempts to get children to "think and learn how they
make choices that result in what and how they speak, and do things" (Roth,
1993, p. 41 ). In this approach , the therapist attempts to modify the
dysfunctional beliefs the child may have towards their situation.
Behavioral therapy with ADD children includes reinforcement,
environment restructuring, and time outs (Cocciarella, Wood, & Low, 1995). In
this approach, good behaviour is rewarded and bad behaviour is ignored or
punished.
A third approach is one that uses cognitive and behavioural theories
and integrates them into a single therapy. Cognitive behavioural therapies
appear sound on face value; however most of the research suggests that
these approaches at best may only create marginal results with ADD children
(Abikoff cited in Yelich & Salamone, 1994). My hypothesis is that the reason
this treatment is ineffective is not due to the method but rather the individual
focus and the resulting sense of blame these children may experience.
iii) Social skills training
Social skills training is another approach used to work with ADD
children. The rationale for this therapy is that most children who have been
labeled ADD have few friends and have difficulties responding to social cues.
Sheridan, Dee, Morgan, McCormick, & Walker found that lack of peers can be
a risk factor for later problems in life (1996). If it is possible to teach ADD
children the necessary skills for making friends, then these future problems
could be avoided. This therapy is usually applied with a group approach. A
criticism of this approach is that social skills are only a small part of the

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Disabling Labeling 11

problem ADD children experience and although the approach may be
somewhat effective, it does not go far enough to create lasting change
(Guevremont, 1990).
I have only included a short statement of the limitations of approaches
discussed thus far since a thorough analysis of each approach could fill a
paper such as this. At this time, there is no consensus in the general literature
that suggests that any one of these approaches is the best way to treat ADD
children. It is my intention for the reader to recognize that although therapists
might experience success with some children using these treatment strategies,
each approach has significant shortcomings when applied to all the children
who have ADD.
iv) Pharmacological treatment
I stated in the previous summary of the first three treatment strategies
that no one treatment is considered to be a stand alone treatment for ADD.
There is one exception to this statement that should be noted: the use of
medication to treat children who have ADD. This approach is the most
dominant perspective in treating children labeled as ADD, however, I believe
that this treatment option also has it's shortcomings. The treatment of children
labeled as ADD has been highly influenced by the medical profession. In most
situations, medication is the only treatment modality utilized for the child.
Many strong proponents of this position suggest that in most situations,
medication should be tried as a first treatment option and if the results are
favorable, other strategies may not be necessary (Barkley, 1997). This
attitude significantly limits many children and parents from seeking other
treatment options. Although it is suggested that medication can have a positive

Disabling Labeling 12

impact on the child's behaviour, we must ask ourselves about the cost of this
treatment. One such cost is having a child labeled with a mental disorder.
While the benefits might outweigh the cost for some children, it is important
that parents recognize that this is only one of many options in the treatment of
their children.
Another limitation is the nature of the stimulant medication itself.
Medication has been seen as highly effective for approximately 80% of
children (Barkley, 1990). It is important to recognize that most stimulant
medication, apart from the newer slow release medication, is only effective 4
to 6 hours following ingestion. One of the side effects of taking this medication
is that it may inhibit sleep, and as a result, most children take their last dose
shortly after lunch. This means that the effects are usually worn off by the
time the children come home from school. This leaves the parent with a child
who is not medicated (Anastopoulos, Shelton, DuPaul , & Guevremont, 1993).
The problem with this is that the school benefits from the medication but the
parents do not. For this reason , many parents need additional resources in
working with their children.
Hechtman, Weiss, and Perlman (as cited in Basu & Deb, 1996) have
recently questioned the long term benefits of stimulant medication and now
believe that it is more of a short term management tool. One of these findings
comes from looking at the long term outcome studies of children on
medication. These children were found to have similar rates of dropping out of
school and being incarcerated as the untreated population (Diller, 1998).
Weiss and Hechtman (1993) completed a summary of the outcome literature
and found that:

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Disabling Labeling 13

The hyperactives continue to have educational and work difficulties.
Their increased residential moves, job changes, and debt may reflect
their more impulsive lifestyles. They have more emotional problems
and more problems with aggression ... stimulant treatment in childhood
may not eliminate educational work, and life difficulties" {pp. 255-256)
In summary, as a social worker, I believe it is important to see how the
individual approaches described above fit with our knowledge base and ethics.
If we take a look at the history of the social work profession, we see that this
conflict between the individual focus (micro perspective) and the broader
system focus (macro perspective) has existed from the beginning. In the early
years, it was Mary Richmond who argued that significant shortcomings
resulted when workers maintained an individual focus. "Richmond translated
her conviction about the importance of the family into her conception of
practice ... good results of 'individual treatment would crumble away' if
caseworkers failed to take into account the family" (Hartman & Laird, 1983. p.
13). In 1930, Robinson (cited in Hartman & Laird, 1983) suggested that the
struggle was between broader sociological theory and the individual focus of
psychology. Instead of looking to the value and meaning from an individual
perspective he suggested that the focus should instead be on environmental
circumstances.
In the 1960's, general systems theory emerged as the dominant
theoretical framework for social work. "The development of systems theory
and the integrative power of the general systems framework have given social
workers the potential tools needed to fashion practice theory which can take
into account the immensely complex reality of person/in family/in situation
(Hartman & Laird, 1983). Although most social workers would subscribe to the
importance of taking a broader macro focus when defining problems, in

Disabling Labeling 14

practice, most social workers get caught up with spending the majority of their
time at interventions directed at the individual (Long, 1995). The
consequence of this practice is that either change is short lived, or the child's
condition is worsened as a result of being seen as "the problem". The reason
for this is that the individual is only a small part of the greater system. In order
to create lasting second order change, the therapist must address the ...
systems of the children with ADD (Bernier & Siegel , 1994). "Practitioners must
attempt to understand the complex interactions among family members and
the societal institutions and forces surrounding them" (Bernier & Siegel, 1994,
p. 142). As social workers, I believe that we have an obligation to
acknowledge that the individual perspective is not consistent with the systems
perspective nor does it make sense from an ethical perspective. If we also
include our findings regarding the outcome of most of these individual
approaches, we should conclude that this perspective should not be a primary
option for social workers .
... hyperactive children have a multiplicity of problems; however, no
single treatment has had a satisfactorily broad therapeutic impact. Few
studies have used concurrent treatments for an extended time, though a
multimodal approach seems optimal (Weiss & Hechtman, 1993, p. 382).
Multimodal social work treatment
This brings us to our second approach to dealing with ADD in children.
The second approach taken by social workers is to acknowledge the medical
diagnosis, but utilize their systems framework to assess and treat the children
in the context of their family and broader societal institutions. It is important to
recognize that social workers do not have the authority to diagnose anyone
using the DSM-IV (1994) . The social worker is only directly involved in the

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Disabling Labeling 15

diagnosis when the setting is multidisciplinary and they can contribute to a
team assessment and treatment plan. In this approach, social workers would
be working within the dominant paradigm of the DSM-IV (1994).
In order for us to determine whether or not it is appropriate for social
workers to advocate the use of the multi modal treatment approach, it is
imperative for us to understand what this treatment strategy looks like. Equally
important is to ask whether or not it is effective in dealing with the child's
issues along with related family and educational issues. As suggested in the
previous chapter, the multi modal treatment theory arose when it was clear that
a single treatment model would not create lasting change. A multimodal
approach looks at treating several components of the system and if effectively
implemented, can help create primary and secondary change in the individual
and the relevant systems. This includes utilizing methods directed at the
individual child, the parents, and the family system, as well as advocating for
changes in the school system and broader social systems. Research has
shown that parents of children diagnosed as ADD are more prone to the
following problems (Bernier & Siegel , 1994):
1. family instability and marital disruption
2. conflict laden parent-child interactions
3. high levels of parental stress
4. maternal depression
5. decrease in parental self-esteem
As a result of these findings, professionals began to modify their approach and
teach caregivers to use specific strategies in order that the gains made would
benefit the context in which children spent most of their time. The interesting
thing that researchers found was that although the children's behaviour rarely

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Disabling Labeling 16

changed, (consistent with our understanding of this trait) parents noted
improved communication and planning skills. This reaction could create a
lasting change in how the parent viewed their child's behaviour. The method
utilized to teach the parents these tools was from a psycho-educational
perspective taught within a group setting. They attempted to provide the
parents with the necessary tools to deal with children who were perceived to
be difficult. I would suggest that these skills would be of benefit to any parent
who is having difficulty parenting a child not only those who have children who
are seen as having ADD.
These children might also experience decreased self-esteem and other
related behaviour problems such as conflict with authority and rules. In
addition, one cannot forget the serious lack of resources within the school
systems which focusing on children's individual needs. To address some of
these issues, a multimodal approach may include the following components:
medication for the child , cognitive support and play therapy for the child to
develop self-esteem and interpersonal problem solving skills. Day treatment
including special education for children , art therapy, social skills training, and
occupational training might also be beneficial for these children . For the
parents, there is behavioural management training and supportive counseling
along with psychoeducational groups where parents could be taught parenting
strategies (Bernier & Siegel , 1994). This approach also includes family
therapy in some cases (Grizenko, 1997). Teachers can also benefit from
some of the strategies directed at the parents in order to develop the
specilized skills necessary for dealing with children diagnosed with ADD.
Obviously, this approach can be time consuming and demands good

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Disabling Labeling 17

communication and planning skills. It requires all people involved to work
towards a common goal. While this does not necessarily mean all people
must have a similar theoretical framework, they must be committed to working
as a team for the well being of the child.
Social worker's role within this approach
Social workers have much to offer the children and families where ADD

----

is present. They can reduce the chance of misdiagnosis, they can provide

---

-

-

case management skills, and they can advocate for change.
i) Reducing Misdiagnosis
Misdiagnosis can result from a number of factors: inexperienced
clinicians, biased reporting , insufficient time spent on assessment and lack of
collaboration on the information ie. relying on only one source, not recognizing
~

confounding variables. For example, Edwards, Schulz and Long (1995)
studied how long clinicians spent in assessing this condition. General
Practitioners spend on average 38 minutes in the initial evaluation, and
specialists spend 73 minutes. Within a multidisciplinary clinic, diagnosis
occurs after as much as 18 hours of evaluation. Social workers are in an
invaluable position in minimizing the chances that misdiagnosis occurs. As a
result of their training and orientation, social wor er_s_t_en.cltoJ.o.Qk_gLothe
/

variables when it comes to dia nosing ADD . A competent social worker would
not allow a diagnosis to occur without a comprehensive assessment. This
would include taking into consideration feedback from multiple sources and
settings along with a thorough social/developmental history (Aust, 1994).
Other co-morbid conditions would be ruled out by either being referred out to
other specialists, or by completing a detailed and comprehensive assessment.

Disabling Labeling 18

These co-morbid conditions include; depression, Fetal Alcohol
Syndrome/Effect, borderline personality, bi-polar disorder, and hyper-thyroid
effects. (Grizenko, 1997)
ii) Case Manager
The case manager's role is quite consistent with social workers' training
and experience "(the case manager's role) includes assessment, planning,
linking, monitoring, and , if necessary, direct provision of service" (Long, 1995,
p. 47). The social worker's role within this group was to ensure that everyone
(professionals and family) was informed and working towards the same goals.
Social workers could also ensure that a balanced perspective be maintained
by offsetting a child's limitations through including some of their strengths.
When the focus of other professionals becomes directed only at the child's
short-comings, the social worker can balance this viewpoint by including some
of the child's strengths. As well , the social worker can remind the other
workers to maintain a positive future outcome for the child in order to instill,
within the child, a strong hope for their future. This becomes especially
important when the parent or the child gets caught up in the negative
outcomes suggested in much of the literature. Social workers can direct these
people to tangible examples of more hopeful situations. As well, they can
suggest ways in which real change can be achieved.
iii) Advocacy
The numerous advocacy roles are also important for social workers to
consider. Since social workers have experience in community development,
they could put some of this training to work by bringing parents, professionals,
and community leaders together in order to break down some of the existing

--- --

~

~

Disabling Labeling 19

communication barriers. Social workers could work towards social change by
advocating for societal awareness and adequate funding to deal with children

--------

labeled as ADD (Long,1995). This includes both work at a community level
and societal level. Social workers could also work towards dealing with any
~

_________ --

misinformation that permeates from the assessment and treatment of ADD.

They can advocate for other professionals......_ to maintain a balanced perspective;
also, they can advocate for changes in the broader system including changes
in the schools, community groups, legislative and public awareness forums
An example of multimodal treatment model
To illustrate, Barkley utilizes techniques and principles from sociallearning-based parent training programs, social cognitive psychology, and
family systems theory (1990). Barkley suggests treatment for the child should
include a children's group, parental strategies, medication, school based
strategies, and family therapy. Barkley stated that the purpose of a children's
group approach is to:
1. formulate, rehearse, and apply their own solutions to the problems
being solved by parents
2. improve their understanding of peer and parent-child relationships,
3. increase their commitment to change
4. build the skills needed to solve problems collaboratively with
parents and teachers and
5. familiarize themselves with the types of point systems that parents
and teachers may implement.
It is reasoned that if the children learn about these skills in group, they are
more likely to respond positively when the parents implement these
approaches. In addition to a children's group, Barkley employs a cognitivebehavioural parental training program. This includes providing parents with

Disabling Labeling 20

tangible parenting strateg ies, including giving the parents homework
assignments to practice with their child(ren) , and creation of a context in the
group to get feedback on how these strategies are or are not working. These
strategies include: attending skills, giving commands effectively, teaching
principles of behaviour management, establishing a home token system, using
time outs, and tips on handling children in public places.
Strength based approaches
Although most social workers have been trained from a "strengths"
perspective, few actually put it into practice (Saleebey, 1992). The reason that
this is so important is because the language and the discourse of the other
therapies rarely empower the client and usually result in immobilizing and
stigmatizing them instead (Szasz cited in Saleebey, 1992).
"When the adults who had been hyperactive were asked what had
helped them most to overcome their childhood difficulties, their most
common reply was that someone (usually a parent or teacher) had
believed in them " (Weiss & Hechtman, 1986, p.378).
i) Impact of DSM Label
The multi modal systems treatment seems to fit much of the theory
within social work, however, there is still one issue that remains unresolved.
How is it possible that social workers can work within a perspective in which
the dominant paradigm is based on a disease model? I believe that for many
social workers, this issue is never seriously considered as being an ethical
\

conflict and as a result, they use the DSM without question. Kirk and Kutchins

Disabling Labeling 21

(1992), suggest that approximately 25% of social workers employed in clinical
settings use the DSM daily. The argument supporting this approach is that

--------

-----

social workers are an accepted partner within the mental health field and if
............

..__

-----

they do not acknowledge or utilize this standard manual (DSM IV,1994) it

would put their relationship with the mental health field at risk. If this would
occur, social workers would relinquish their leadership position which would
leave the mental health field without a useful and successful perspective in
working with a challenging population (Anello, 1992).
The opposing argument on the use of the DSM by social workers
suggests that the process of diagnosis is very different when social workers
complete an assessment. The problem is that the DSM is written from an
individual perspective. By embracing it as a necessary tool, social workers
minimize the impact of taking an ecological systems perspective. Although
proponents of the DSM would argue that the last two axes contained in the
DSM IV (1994) include other psychosocial factors , this aspect is underutilized
and also inadequate from a social worker's perspective (Kirk & Kutchins,
1992). When researching this point, I was surprised by how little the social
work literature speaks to this issue. The process of labeling a child as being
ADD should not be considered a benign phenomenon and social workers must
recognize the implications of such a practice. The social workers who do not
use the DSM system must look to another approach when dealing with this
population.

Disabl ing Labeling 22

ii) Constructivist therapy
One option for social workers is to minimize the ADD label. This may
be achieved by utilizing some of the constructivist models of helping. Social
construction theory suggests that "belief and knowledge is socially,
historically, and culturally situated" (Dean cited in Levine 1997, p. 198).
Objective fact cannot be determined within this approach; what becomes
important is the role that the therapist takes in constructing meaning for their
clients.

Instead of taking an expert position, these therapists provide

alternative viewpoints or interpretations of events within the client's life.
"Constructivist therapy is not so much a technique, as a philosophical context
within which therapy is done .. ." (Anderson cited in Neimeyer, 1993, p. 268)

Included in social constructivist therapies are Narrative therapy and
Solution Focused therapy. Narrative therapy attempts to reframe the problem
and direct the child to name the label as part of the problem. The Solution
Focused approach would discuss what the situation would look like if the
problems associated with ADD did not exist or disappeared.
iii) Use of more empowering labels
The social worker may also choose to use more empowering labels.
Historically, we know that children who now would be described as having
ADD , would have been described in a predominantly negative way. Some of
these informal labels are: "all boy", incorrigible, strong-willed, stupid, lazy, and
undisciplined. These labels enerally attempted to provide explanations as to
why the child did not comply with societal standards. They rarely provi ed any
insight or direction as to how to deal with these children and contributed to

Disabling Labeling 23

disabling the child and destroying

-

-

r:~

vision

r

~ ~

future for these

children. Barkley would suggest that once these labels were formalized and
put within a professional context, most of the stigma was removed (1990). I
would disagree with this perspective and remind the reader that these labels
are not benign but have an incredible impact on how these children are

-

perceived b others. This in turn impacts how the children perceives
themselves. These labels are highly i

i~;

------------

b}!...the social context in which

;..--

1 ey are formed . The soc;ietal value of conformity creates an expectation that
1chi areri should be seen and not heard".

Instead of modifying our societar-

expectations we place the focus on the child's behaviours that we perceive as
problematic. In researching this topic, however, I was able to find some
authors who modified their individual expectations by having a positive outlook
and instead of using the ADD label, they created positive labels. Some of
these more positive labels include: spirited (Kurcinka, 1991 ); hunter
(Hartmann, 1993); and creative (Cramond, 1994).
Kurcinka in her book "Raising your Spirited Child" differentiates
between ADD children and "Spirited" children, although after reading her book,
I believe that she is describing many of the same children, some of whom,
would fit into the DSM-IV (1994) and others who would be on that end of the
continuum. Not only does she create a new label for children, but she takes
each attribute and reframes it in a more positive light. For example, instead of
using the term, "hyperactive" she refers to these children as having high
energy levels; instead of "distractible" she sees these children as perceptive.
Hartmann (1993) takes a very different approach to these children.
Although not attacking the medical profession directly, he provides an

Disabling Labeling 24

alternative approach regarding the etiology of these characteristics. He
suggests that researchers still do not totally understand ADD. Within this lack
of understanding, Hartmann creates a metaphor and places these traits in an
historical context. He suggests that many of the qualities exhibited by an ADD
person may have been more adaptive within a simpler society that is less
technologically based in which the primary roles are hunting and gathering.
For example, the qualities of impulsivity could instead be understood as the
ability to think quickly and respond accordingly; restlessness or getting into
trouble could instead be understood as risk-taking ; distractibility may instead
be described as hyper-focusing, which is an extremely valuable trait for a
hunter. Hartmann suggests that as society became more agriculturally based,
the virtues of patience, avoiding risks, and being focused on details became
more valuable. One such example that embraces some of these positive traits
came when he spoke with a professional from India and described
characteristics that we would label ADD. He then asked this person if there
existed similar people in India. This person acknowledged these
characteristics and suggested that those people were considered very holy. It
is believed that those people were:
old souls, near the end of their karmic cycle ... In our religion, we
believe purpose of reincarnation is to eventually free oneself from the
worldly entanglements and desire. In each lifetime we experience
certain lessons, until finally we are free of this earth and can merge into
the oneness of what you would call God. When a soul is very close to
the end of those thousands of incarnations, he must take a few lifetimes
and do many, many things, to clean up the little threads left over from
his previous lifetimes. (Hartmann, 1993, p. 12)
Cramond (1994) suggested that when she took this approach, she
found that many children who had been diagnosed as ADD were found to be

Disabling Labeling 25

highly creative. She argued that by providing a more positive label, like
"creative" for these children , it could lead to a more positive outcome. Instead
of the child seeing themselves as having a disorder, they would see
themselves having a unique and highly regarded trait. Why is the label we
use to describe these children so important? One obvious fact is that the
labels that we use are not neutral and have consequences when applied to
children.
We must remember that the labels that we use reflect human values
and, therefore, are a matter of culture and perception. (Wakefield cited
in Maag & Reid, 1994, p. 6)
Cramond argues that the reason ADD is used instead of a label like creative is
a result of pressures from schools and parents who focus on maladaptive
behaviours. She argues that the same behaviour qualities can be interpreted
in two opposite ways. A child can be viewed as participating in dangerous
activity while at the same time may be seen as willing to step out and take
chances. A child may have difficulty organizing their work, or they may be
~

viewed as having a tolerance for ambiguity. Cramond suggests that in
particular, the children who are bright and creative may not respond to the
treatment regimes of more structure-breaking down tasks, since this creates
boredom and may exacerbate the symptoms. These are the strategies that
many experts recommend in treating ADD children. We may need to "rethink
the labels that we assign to children, and search for the strengths in their
differences" (Cramond, 1994).
Abandoning the ADD label
The last and most radical approach within a strength based perspective
is one in which social workers do not allow the medical perspective to define

Disabling Labeling 26

the problem but instead, begin to look at the broader social systems and
analyze how these systems contribute to the problem ADD children
experience. These social workers do not focus all the attention at the
individual child when trying to understand the situation; they look at structural
issues that many families and children face . Some of these issues include:
crowded and under-funded schools, poverty, children who have witnessed
violence, overburdened families , and sexism (Levine, 1997). In addition it is
important to recognize that cultural factors might influence an ADD diagnosis.
(I have heard some anecdotal evidence that a high proportion of First Nation
children are diagnosed as having ADD)
When we examine the broader issue of disability, it is clear that the
concept is largely a social construction. Wendell (1996) stated that people
with disabilities have a unique knowledge, perspective and experience that
others in society should value. Instead these people are marginalized and
isolated from mainstream society. Similarly Stratford (1995) argued that no
person is truly disabled within the scope of their own existence, but they
receive this label because of social beliefs and attitudes. This perspective has
far reaching implications for any person who has received a label, whether it
be ADD , Down syndrome, or Schizophrenia.
Once these issues are explored and understood, social workers
challenge some of the basic assumptions of the medical label. Instead of
accepting the status quo, they focused on good clinical intervention which
included the construction of new, more empowering narratives in describing
these children. It is important to remember that labels are not permanent but
static. What is currently being suggested is that ADD may not even be a

Disabling Labeling 27

categorical disorder but should be seen more on a continuum. It is the
"extreme of a behavior that varies genetically throughout the entire population
rather than as a disorder with discrete determinants" (Levy, Hay, McStephen,
Wood, & Waldman, 1997, p. 737) .
Since the characteristics within the label ADD are found in all children
to some degree, it is the comparable intensity and frequency of the behaviour
that determines the label. The line drawn between a normal range of
childhood behaviour and ADD is arbitrary and dependent on the criteria within
the definition. There is also a measurement problem caused by observer bias
and pre-determined standards of normal behaviours in each profession
(Mann , ldeda, Mueller, & Takahashi , 1992). Although the medical profession
is attempting to limit this problem by creating clearer criteria, we must
remember that the behaviours that make up an ADD diagnosis continue to be
defined within a social context (Edwards, Schulz, and Long , 1995). The
professional completing the assessment is dependent on others for gathering
information on the child's behaviour. The method most commonly employed
for this task is the behaviour checklist, however, this method can be flawed in
some situations as a result of observer bias. For example, it is well known that
parents of difficult children suffer problems of self-esteem (Anastopoulos et al,
1993; Edwards et al , 1995) along with family stress and other psychological
difficulties. We also know that depressed mothers tend to oyer-report
~

~

behavior problems in their children (Richters, 1992 cited in Edwards et al ,
'"---

1995). Parents who are trying to handle their difficult children are looking for

external/affirmation and any possible help. In order to get this help, they may
exaggerate their child's symptoms.

Disabling Labeling 28

I would suggest that the medical profession does not have a
monopolistic perspective on these children. As a social worker, I believe that
we can not immediately jump into treatment and accept the assumptions
conta ined in this label, we must be part of the process that attempts to
understand who these children are and look to developing more positive
paradigms in describing these children. As social workers, we must first
understand why this label is used to describe these children: who benefits by
the use of this label? The first obvious group are the professionals for whom
the label is of significance. According to these professionals, labels help to:
summarize and order observations; to facilitate communication among
professionals with different backgrounds; to guide treatment strategies
in a global fashion ; to put therapists in touch with a pre-existing relevant
body of more detailed research and clinical data and; consistent with
scientific goals, to facilitate etiologically, epidemiological-logical, and
treatment outcome studies (Rains, Kitsuse, Duster, & Friedson, 1975).
Some people would argue that these reasons are just fancy rationalizations so
that the professional can exploit their power and create a perception that they
are the expert.
The most significant advocates for the use of this perspective are the
parents themselves. I would suggest that this is typically because parents
have been blamed by others and look to themselves as the cause of their
child's misbehaviour. This perspective takes the focus off of the parents and
suggests that these children are genetically different from most children. This
removes much of the blame and misplaced guilt that these parents previously
~

~~

------------- -

experienced (Bogas, 1993). The other group who strongly advocate the

medical perspective are school personnel; schools benefit by using this label
-

since it provides a legitimate explanation why some children perform so poorly.

Disabling Labeling 29

As well , this label suggests that intervention should take place at the individual
child's level and remove the responsibility from the teachers and principals to
modify the school environment in order for the child to succeed. Some
suggest it is the schools who create much of the negative impact on these
children.
I strongly recommend that therapists do whatever they can to modify
our educational system. This would be a good example of 'preventive
psychiatry'. Otherwise we will just continue to 'pick up the pieces' and
attempt to treat the necessary sequelae of an iatrogenic disorder that
need not have existed in the first place. (Gardner, 1987, p. 89)
It is interesting to note that it is assumed that the child will benefit from the
application of the medical label. I was unable to find any research that
explores the impact that this label has on the child's sense of self. While it
can be argued that a parent who seeks help to become a more effective parent
will have a beneficial impact on their child, we must look to the impact this
perspective has on the child's view of his or herself. It is well documented that
children who have been labeled ADD haye poor self-esteem (Bogas, 1993;
Cramond, 1994). It is not clear, however, which part of this poor self-esteem is
because of the child's adjustments to the outside systems, and which part is
due to the impact of their label? I would argue that a child's self-esteem
suffers in part because of the impact of the labelling process and how that
impacts the children's view of his/herself. We know that the diagnosis of this
model focuses on the weaknesses or deficits of the child and does not look to
the areas of strength. Behaviour checklists are inherently negative in their

Disabling Labeling 30

focus; one approach that I found looked at taking a strength assessment
approach . The other problem that children have within this perspective is
caused by a misunderstanding of their condition. Many children that I came
into contact with thought that this label suggested they were crazy or stupid or
both. As well , parents attributed any positive behaviours the child had to the
medication and the bad behaviour was more indicative of normal behaviour.
Many of these attitudes came to be addressed within treatment, however, they
came as a result of a system which is quick to label a child ADD and may
never be able to provide the support and multimodal treatment.
In summary, in the literature I reviewed , I found three approaches for
treating ADD children. The first approach was an individual perspective and
the second, a broader multimodal perspective. In the third, strengths-based
approach, it was suggested the social worker minimize or ignore the ADD label
and embrace more positive metaphors for describing this behaviour. This last
approach attacks the label ADD directly and focuses on changing the
structures and institutions that reinforce the labeling process. In the next
chapter, I will look at a case study of ADD-labeled children and the treatment
of these children with the second multi modal perspective. As I implemented
this strategy, I found this perspective lacking and began to de-emphasize the
ADD label and use a more positive, constructivist approach.

Disabling Labeling 31

Chapter Three
Case study
As part of my MSW program, I had decided to do a practicum at
Intersect Youth and Family and Services Society. Intersect is the local agency
mandated to provide children with mental health services within Prince
George. Intersect utilizes a multi-disciplinary approach. Psychiatrists
prescribe medication; psychologists test for disabilities and cognitive issues;
social workers provide family therapy and child care workers offer individual
support. I worked at Intersect from September 1995- April, 1996. During this
time at Intersect, I was involved in working with two groups of children who had
been labeled ADD. In the first group, which ran in the fall of 1995, I worked
along side a child psychologist, Dr. Laurie McKinnon, and learned the basic
skills and techniques to help these children within a group setting. In the next
group that was offered in the winter of 1996, I was able to lead a similar group
along with a SSW student, Barbara Guay, who was doing her practicum at
Intersect. It was during this time that I began to evaluate my current
understanding of ADD and question whether or not it was in the child's best
interest to provide them with a label and then attempt to provide treatment for
them. The group treatment model that was developed at Intersect was an
adaptation of the treatment approach utilized by Barkley. (As outlined in the
previous chapter). I would suggest that Barkley and his perspective played a
key part in the development and implementation of this group. The group was
developed just five months after Barkley had come to Prince George and
presented a workshop on ADD . Most of the therapists at Intersect attended
this workshop as did I. As a result of this workshop, many more families came

Disabling Labeling 32

forward and sought help for themselves and their children. Several key people
at Intersect determined that a group approach was the most effective way of
handling these additional referrals. The group approach developed at Intersect
employed five separate groups that met concurrently. There were three
groups set up for the children labeled as ADD; the first group was for children
ages six to nine; the next group ages ten through twelve, and a teenagers'
group for children thirteen and older. There was a group for the siblings of
these kids as well as a parent group. Each group met for a total of eight
weeks with the exception of the parent group which met two additional times
before the other groups started. These sessions were open to all parents who
had contact with Intersect and were informative in nature. (see Appendix 1)
The parents' groups followed a psycho-educational model as suggested
by Barkley (1990). An added benefit of this approach was that it could
accommodate the high number of parents who were part of this group. As a
result of the large group there was a limited amount of group interaction,
however, there was some attempt to break into smaller groups when it came to
the discussions. Many misunderstandings about ADD were addressed in this
context, and positive parenting approaches were taught and modeled. (see
Appendix 2) During the sessions some informal connections developed
between parents in the group.
The siblings' group was set up to provide support and direction for a
much neglected component within the family system. Siblings can play many
different roles within this system. Sometimes these siblings play the "angel"
role and create an even more significant contrast between themselves and
their sibling who exhibits ADD characteristic behaviour. At other times, these

Disabling Labeling 33

siblings feel ignored and alone. Some siblings even report that the only way
to get attention from their parents is to misbehave. As a result, it is not long
before some of these children pick up a label of their own. The siblings' group
played a vital role in helping these children both understand themselves and
encouraged them to take a new perspective when looking at their ADD
affected sibling. It was hoped that through group sessions, these siblings
could develop greater empathy and understanding, and learn strategies to
help them cope with their unique struggles within the family. (see Appendix 3)
At this point in my practicum, I was at the beginning of my learning
curve in understanding these children. I was pouring through the literature
and attempting to integrate my social work experience and knowledge base
with these children. I was also looking to the numerous therapists who were
involved with this group, trying to assess their abilities at working with ADD
children. The background and training of the therapists was diverse. Conflict
that arose between therapists in our weekly discussions was due to the
divergent values of these therapists. For example, in one of the groups, the
two co-facilitators were having significant difficulty. One therapist was trained
in a very child centered, non-directive approach, the other therapist was much
more hands-on and directive. Unfortunately this conflict did not resolve itself
until one of the therapists bowed out. As the weeks progressed, we were able
to resolve most of the conflicts and created consensus on some of our
approaches. For the most part, the team did not hold fast to the medical
model. They questioned the validity or usefulness of this approach and looked
at ways in which this dominant framework could be modified to include a more
positive strengths based model. It was my experience that before the group,

Disabling Labeling 34

there was not a clear theoretical orientation shared by these therapists and it
was only during the running of these groups that some of the theoretical
frameworks began to evolve. In hindsight, I now recognize that we were all
struggling together to work with this challenging group of children and their
families. It was not until my work was almost completed with these children
that I felt clear about my own theoretical framework. I will describe how some
of the theoretical knowledge expressed in the first part of the paper
materialized into tangible practice.
Overview structure of the group (see Appendix 4)
Some of the goals I developed after working with the first group of
children were to:
1. Help children recognize that they are not alone, that many other
children and adults struggle with similar issues.
2. Provide a safe environment in which children can express their
feelings they experience as a result of their unique characteristics.
3. Encourage the children to recognize the strengths within themselves
along with providing them with a realistic view of their short-comings.
4. Encourage the children to take responsibility for their own behaviour
when it effects others in a negative way. Focus on teaching the
children to recognize the consequences their behaviour might have on
others.
5. Have fun .
Another goal that I had when running the group the second time was to
use a strengths perspective right from the first contact I had with these
children. I was concerned that many of these children either had a negative
perception regarding counselling or felt that this would just be another context
in which they could be blamed for misbehaving. In the first session after
introductions I gave each child a small box wrapped in gift paper. I told each
child that the reason that they were here was because of this gift. In each box

Disabling Labeling 35

I had written a piece of paper which stated that their gift was that they had
ADD . When the kids opened up their gift they were quite confused. One
reason is because they only got a lousy piece of paper, unlike a typical gift but
they also were confused as to how their ADD was a gift. I explained to them
that I believe that their ADD is a gift, and that although most of the time people
talked about ADD as being bad that in group we were going to explore ways in
which ADD could be seen as something unique and special. We then asked
the children what they understood ADD to mean. We also asked them how
they thought they had gotten ADD. I was quite surprised that not one of the
children was clear about how they got ADD and what it means to have ADD.
had assumed that as a result of these children receiving a label, someone
would have sat them down to explain to them in clear terms what their label
means and why they have been labeled. It was at this point that I asked
myself the question, who benefits from the label?
One of the activities in our group was to view a video. This video was
used as a discussion starter for different aspects of ADD. One of the videos
that we found useful and relevant for the kids was Robert Munsch's, "Pigs".
Not only was this video entertaining for the kids in our group, but there were
several significant themes that came out of the video. The video is a story
about a girl who lives on a pig farm. One day her father asks the girl to go and
feed the pigs. As part of his instructions to the girl, he warns the girl not to
open the gate as the pigs are actually quite smart. The girl has little
knowledge about pigs and assumes that these pigs are stupid, lazy, dirty with
no redeeming qualities whatsoever. As she is feeding the pigs her curiosity
gets the best of her and she opens the gate. Her theory that the pigs are

Disabling Labeling 36

stupid and non-attentive is put to the test as she does so and yells, "Hey you
dumb pigs! " The pigs storm out of the gate and escape. She then turns her
blame onto the pigs when she misses the bus and arrives late for school. The
pigs end up creating total destruction and chaos as they overtake the home
and school. In the process they drive the principal nuts and they make a total
fool of the teacher. Throughout these circumstances, the girl realizes that the
pigs don't like being called stupid and get even more out of control when this
happens. She also begins to recognize that one of the pigs is actually very
intelligent at math. This pig's unique abilities are not obvious to other people
because of the disruption the other pigs create. At the conclusion of the video,
the little girl names her pig Einstein and becomes lifelong friends with this pig.
Some of the discussion questions we asked the kids were:
1. Why did the pigs get out of the pen?
2. What happened when the pigs got out?
3. What similarities did you see between your actions and the pigs?
4. How do you think the pigs felt when the girl called them dumb? Has
anyone ever made you feel like this? What did you do?
5. What are your hidden gifts that people don't often recognize?
6. How would you feel if people looked at your gifts instead of only focusing
on your misbehaviour?
7. What would help you get your pigs in control?
We found that the pigs metaphor provided a wonderful opportunity for
the children to vent some of their frustrations. Children who had difficulty
expressing their own feelings of pain and rejection were able to speak through
this powerful metaphor. Once they felt safe in exploring this feedback within
the group, many of them were able to go on and express their own negative
experiences and feelings. All of the children could relate to getting in trouble
at home, in their classroom and with the principal. Once the children

Disabling Labeling 37

expressed their feelings they were more open to explore positive solutions that
could help them keep their pigs in control. The pig metaphor used in group
allowed the children to see themselves as separate from their behaviour. This
video was one of the building blocks used within the group to encourage the
children to look at their abilities and gifts and recognize why others get hung
up on their shortcomings. For many of these children this was a very new way
of looking at themselves.
In addition to the videos we used art materials to provide another
medium for children to express their thoughts and feelings . Given the age of
participants of this group it was determined that it would be of benefit to utilize
these other methods. These children used these tools to express their
feelings and helped us gain further insights into the child's world. Some of the
activities included:
1. asking the children to draw an animal that would describe their ADD.
2. asking the children to draw what they looked like before and after taking
their medication.
3. asking the children to describe their ADD story or how they were diagnosed
with ADD.
The other method that was beneficial in helping modify the children's
view of themselves was the use of the ADD game. This was a cognitive
strategy that was developed by Dr. McKinnon when she ran the previous
children's group with me. The goal of this activity, using a board game format,
was to encourage the children to think about their assumptions about ADD.
They would roll the dice and move around this game board each time taking a
card with a question on it. These questions attempted to debunk some of the

Disabling Labeling 38

myths that are perpetuated regarding ADD. I have included a list of these
questions in Appendix 5. The children appeared to get into the spirit of the
game and enjoyed the competition. This game format was very successful in
gaining all of the children's interest; the kids enjoyed the game to the point
that many of them requested they be able to play it during the last session of
group. This was when the children were given the choice to play any game
they chose. They were eager to share their answers with their teammates
when they were stumped. I think that this was a fun method to teach these
children that may have a long lasting effect on their view of themselves.
Another goal I had for the group was to have them determine the rules
and ways to enforce those rules. Given the age of the participants, the cofacilitators helped the group define the rules and determined some positive
consequences for obeying these rules . What we came up with was that after
every 15 minutes, we would stop the session and assess how everyone had
done during this time. The kids would vote on who should get a Pog (this was
the reward that had been decided at the beginning of group). I had decided
that once a child earned a Pog, that it could not be taken away for disruptive
behaviour. I found it interesting that many of the kids during the group
feedback were very punitive and harsh towards their fellow group members. It
was my belief that they were modeling some of the behaviour that had been
used with them for most of their life. As co-facilitators, we found it important to
reframe some of the questions and ask how a certain child's behaviour had
improved since the last time frame and reminded the child that he or she had
an opportunity to vote on his or her own behaviour. This helped deal with
some of this negative feedback. Please note that I am consciously using the

Disabling Labeling 39

term "disruptive behaviour" and not misbehaviour because I felt that their
behaviour would only be a problem if it distracted others from benefiting from
the group. I am sure that if most people joined our group during certain times
they would have assumed that the group was totally out of control. For
example, at the end of every group we would allow the children to freely
interact with each other (while we were waiting for their caregivers to pick them
up). Sometimes this interaction was relaxed and conversational, other times it
included making paper airplanes and throwing them around the room . There
were a few times in which we had to intervene to ensure the safety of the
children but otherwise we let them make their own choices. We also felt it was
important for the group to be interesting and rewarding so that the opportunity
for misbehaviour would be reduced .
Another good example of "appropriate behaviour" would be to insist that
the kids remained in their seats at all times ... we did not enforce this standard.
One child in particular had a difficult time sitting still. I remember on one
occasion he was sprawled spread eagle across the table. At this point, I
asked this child a question regarding what we were currently discussing and
this child responded in such a way that it was obvious that they were attending
to the discussion. It was also important to note that their behaviour was not
disruptive to the other members in the group. As a result, I felt that if this child
could participate fully and not create a disturbance to the other members of
the group, I should not focus on this behaviour. I did wonder how this child
coped with being placed in a more structured environment like school.
Another child had a strong oppositional disposition; this was readily
apparent after meeting with the child for the first time. This child purposefully

Disabling Labeling 40

told us that they were going to misbehave in group. The child appeared to
take pleasure in pushing the limits and disregarding the direction we were
trying to encourage with the other children. One thing that I noticed is that
when this child would misbehave, he would be scanning the faces for their
reactions. What seemed to work well for this child was peer feedback. His
misbehaviour would escalate when the other kids in group would acknowledge
and participate with this child. At other times, the behaviour would come to an
abrupt end when the child received negative feedback from another group
member. It was our goal to create a safe context and encourage the other
children to be honest with their feedback when they felt this child's behaviour
to be inappropriate and to the point of impacting them in a negative way.
One of the struggles that I had working with these children was when
the parents would come and pick them up. A limitation of this group was that
there was little time to interact directly with the parents apart from the short
time before and after group when they dropped off or picked up their child.
When the parents would come to the room to pick their child up, if there was
feedback to be given I would try to focus on the more positive attributes of the
child. In some cases this feedback was acknowledged but in several
situations the parent would try to rebut this and provide additional examples of
the child's shortcomings. I remember one parent in particular who appeared to
have little hope for their child. Through the course of my brief encounters with
this parent there were several comments that suggested that they had little
hope their child would graduate from school and that their child would
probably end up in jail anyway. It was also interesting to note that this child's
parent once dropped them off at the beginning of one of the sessions and

Disabling Labeling 41

suggested that they would be well behaved today since they took an extra
dose of medication before coming to group. I was caught off guard by this
comment and unfortunately, was not quick enough to come up with a
response. I realized later how significantly this attitude contributed to this
child's problem. This statement suggested that when this child is good it is as
a result of the medication, no reflection on the child making good choices.
When the child is bad, it is because their medication is wearing out or there is
a need to increase the dosage or change the medication. W ith both scenarios
the child does not own up to the outcome. There is little motivating the child to
improve their choices.

Disabling Labeling 42

Chapter Four
Summary
This project has taken the very complex, multifaceted issue of ADD and
attempted to summarize some of the current treatment approaches. It is
unfortunate that most therapists spend the bulk of their energy and time
utilizing treatment strategies that are incomplete or inappropriate at creating
lasting change for these children and their families. One of the reasons that I
believe that this occurs is because the treatment of ADD is dominated by the
medical model. One must really search through the literature in order to find
alternative approaches that do not subscribe to this dominant paradigm.
Within my case study I looked at the group treatment of 6 children who
had been diagnosed as having ADD . This approach initially utilized an
approach presented by Barkley (1990), however, by the end of the second run
of the group, many changes had taken place. As a result of the fact that most
of the therapists were social workers by training , the model evolved towards
integrating more social work principles. Some of these principles included, 1.
de-emphasis of the disease model , 2. the inclusion of strengths assessments
and, 3. the recognition of individual differences among these children. I think
that as social workers, we cannot emphasize this perspective enough. "We
need a list of strengths as powerful and as validating as the florid vocabulary
of diseases found in the DSM-IV to combat our national obsession with
pathology" (Wolin & Wolin in Selekman, 1997, p. 24). After completing this
project, I recognized that much more significant changes need to be
implemented to truly take a complete social work approach to this problem.
In addition to these broader changes, I also recommend making the

Disabling Labeling 43

following modifications to the group treatment approach to ensure a more
positive outcome for this population. First, children and families can benefit
from a thorough social work assessment before joining the groups. I think one
of the most significant things that we learned in these groups was that more
time needed to be spent in the screening of these individual children and their
families. What we found in the running of the groups was that a few children
had been misdiagnosed, other children were deemed inappropriate in group,
and still other children felt forced into group by either their therapist or
caregiver. Dealing with some of these issues before the children started group
could have ensured a more positive outcome.
Second I believe that we could have spent more time focusing on
creating a positive future for these children; we should spend more time
talking about their goals and dreams. As therapists, it is important to
encourage the parents to think about past successes and have them try to
visualize what a more positive future would look like and then work towards
that view (Selekman , 1997). As well, we could have included examples of
successful people who have been diagnosed as having ADD. These people
could explain how their unique personalities have provided the opportunity to
excel within their particular job. I also believe that parents need to receive this
message since they are in the most influential position for their children. I
would suggest that their aspirations for their ch ildren have a direct impact on
how their children turn out. Obviously, this is an area that would require more
research with groups of families.
Implications for social work practice.
I believe that this project has significant implications for social workers

Disabling Labeling 44

who are working with these children and their families. I began this work being
quite ignorant about ADD. In time, I became fascinated with the dominant
treatment approach and was a strong proponent for it. This was before I
began to take a broader focus and look at the impact this approach has on the
children themselves. I also started to recognize that "this problem" that I
believed was an individual and family issue, was actually more symptomatic of
problems that have become increasingly obvious within our society. The more
I focused my attention on analyzing the broader systems, the more I became
aware that for lasting change to occur for these individuals, more change must
occur at a systemic level. Real change cannot occur at this level as long as
we frame this problem as residing in individual children. The ADD label
supports this individual viewpoint and therefore, must be eventually abolished
in order to place the focus where it belongs, at the broader social systems
level and within the dysfunctional beliefs and attitudes we hold as a society. In
hindsight, this is quite an obvious conclusion, especially for someone who has
been trained as a social worker. I cannot understand why it was not apparent
to me sooner. I can only presume that the same biases that precluded me
from seeing this sooner, also are present for most of the social workers who
work with these children and families on a daily basis. The metaphor "can't
see the forest for the trees" describes this problem most succinctly. If my
assumption is correct, the next obvious question is, "what would be the most
effective way to spread this new paradigm?" While we work to accomplish this
task, the realist in me also questions what should be done in the meantime to
continue to provide help for the numerous families in crisis. I believe that to be
ethical social workers, we must work on these two issues concurrently without

Disabling Labeling 45

neglecting either goal.
The first obvious step I believe is to minimize, as much as possible, the
misdiagnosis of this condition. There are numerous factors that contribute to
the misdiagnosis of ADD , many of them, I have already briefly discussed in
this project. Some of the medical factors include:
1. Many professionals do not spend the necessary time gathering the
information and doing a comprehensive assessment.
2. Most children are diagnosed by a family doctor who may not have the
expertise and training to diagnose this condition. It is understandable why
these professionals are eager to diagnose this condition; they are on the front
lines, hearing the complaints and concerns of the parents. Their expertise and
competence is with treating biological conditions, not emotional and
psychological conditions.
3. The system is set up to financially reward physicians who can "successfully
treat" clients inlhe least amount of time. This same system is structured to
create professionals who are quite independent and who are not accountable
to professionals from different backgrounds.
4. The specialized system that has been set up to deal with mental health
issues is "crisis orientated" and is primarily directed at more serious chronic
mental health disorders.
In order to remedy these problems, the solutions are obvious, however,
they have far reaching implications and challenge some of the traditions of the
medical profession. My first suggestion would be to limit the number of
professionals who would be allowed to diagnose ADD . The best case
scenario would be that no diagnosis could be made outside of a

Disabling Labeling 46

multidisciplinary mental health team . This would ensure that all factors would
be taken into consideration to ensure an accurate diagnosis is obtained.
Opponents of this position would state that this option would not be feasible
given the number of children who fall within the categories of the DSM-IV
(1994). I would agree with them. I would also suggest that it is unethical for
any professional to provide a diagnosis when comprehensive treatment is not
readily available. As a result oHhis recommendation , it would be hoped that
eventually, the entire label of ADD would be deemed inappropriate and
subsequently ignored or thrown out of the DSM all together.
I would hope that the reader does not conclude that I believe family
doctors and some medical professionals are incompetent or unethical. Most of
these people are genuinely caring and have pure motives. The problem as I
see it, exists in the systemic structures in which these professionals work. It
also is important to recognize the contributions that social workers have had to
the problem of misdiagnosis. It has been noted that in some situations, social
workers overdiagnose certain psychiatric conditions in their clients if it would
enable the client to receive additional services not previously available
(Sands, 1991 ).
The schools also have to take responsibility for contributing to the
pressure exerted on the parents and the medical profession to label children
as ADD and medicate them. Given the demands of an overburdened school
system with crowded classrooms, it is no wonder that some teachers see the
medicating of children as a tool to help them cope with the classroom
demands. Administrators have a responsibility to ensure that their staff are
adequately trained in having a balanced perspective on ADD. We also know

Disabling Labeling 47

that teachers are in a highly influential position of observing and noting ADD
behaviour in children. Should teachers abuse their position and suggest that a
high number of children are exhibiting ADD symptoms (far above any
statistical anomaly), it would be the administrator's role to monitor and respond
to this situation. In order to remedy this situation, social workers employed
within the school system or who come into contact with this system have a
significant role. They can provide some of the checks and balances on a case
by case basis to ensure that problem teachers and schools can be identified.
As well, they can work with parents to ensure that they are aware of other
educational options that might be available should problems not be addressed
appropriately. Another option is for social workers to advocate accountability
within the classroom regarding ADD children. By creating a process that
keeps track of the number of children labeled as ADD , and including ways in
which these children could be followed, there would be ways in which
problematic areas could be located and addressed.
When it comes to the treatment of children who have already been
labeled as ADD, I believe that it is important for social workers to move
towards the evolving approaches I outlined within the literature review.
Instead of focusing on individual treatment approaches, social workers should
move towards a more macro practice model. It is important to recognize the
impact the labeling process has on these children and to minimize the damage
of this approach. This can be accomplished by focusing on the individual
strengths of the child and on the more constructivist ways of helping. I also
looked at how this treatment approach would be operationalized with a group
of children labeled ADD. I found that the traditional treatment approach does

Disabling Labeling 48

not go far enough in dealing with the issues of all of these children. If we are
to create lasting change in these children, we must turn our focus towards
changing the structures and systems that support the ADD label. I think that
as social workers we must continue to dialogue and discuss this perspective in
the context of our ethical commitment to our clients.

Disabling Labeling 49

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z

Disabling Labeling 53

Appendix 1
ADHD Family Support/Training Program
Information Evenings
The purpose of these two information evenings will be to focus on general information
regarding Attention Deficit Hyperactivity Disorder. Some of the topics to be discussed include:
- What is ADHD and how is it diagnosed
- General Parenting Strategies
- General strategies for success in school
- Medication
- Dealing with related issues. For example: difficulty with bladder or bowel control,
oppositional defiant disorder, etc.
There will be time allotted for specific questions. Parents must attend these workshops in
order to participate in the 8 week parent training program.

Disabling Labeling 54

Appendix 2
ADHD Parent Group
Group Overview
Objectives- What parents will acquire from this group:
Gain information on ADHD as a disability.
Develop successful parenting strategies to deal with this disability
Improve strategies for helping children be successful in the school environment.
Increase positive communication between family members.
Enhance actions that promote self-esteem
Group Outline:
Session 1:
A. Introduction/logistics for group
B. ADHD : reframe as a disability
C. Grief and loss associated with ADHD
Homework: Home proofing for success
Session 2:
A. Analogy of house structure to successful home environment.
B. How positive and negative reinforcement affects behavior.
C. 20 minute exercise to teach positive attending .
Homework: Practice 20 minute exercise with child .
Session 3:
A. Act don't Yack: emotional distancing (123 Magic).
B. Successful strategies for adapting environment.
C. Brainstorm strategies that have worked.
Homework: Try something new
Session 4:
A. Training parents in methods of attending to positive child behavior while
differentially ignoring negative behavior.
B. Identify strengths in family-worksheet.
Homework: Family worksheet
Session 5:
A. Discuss benefits of token system for ADHD children .
B. Discuss format for creating token systems.
Homework: Develop token systems.
Session 6:
A. Continuation of discussion on token systems.
Session 7:
A. Discuss solution resource book
B. Exercise on using solution book.
C. Discussion on effective school strategies.
Session 8:
A. Wrap up, where to go from here
B. CHADD
C. Evaluation of group.
Source :

Del Mar, W. (1986) . Outline of structure and plan for group at Intersect Youth and
Family Services Society.

Disabling Labeling 55

Appendix 3
ADHD Sibling Group
Goals, objectives, and tasks:
1. Know what ADHD is:
- Brainstorm the behaviors (or lack thereof) of the ADHD-affected sibling, that
are bothersome. Then , using this list, divide them into groups and write up as
three ADHD dimensions (hyperactivity, inattentiveness, and attention deficit).
- Show video "Jumping Johnny"
2. Know if they are ADHD .
- Complete ADHD rating scale.
- Score and discuss ADHD as a dimension.
- Create a huge scale of the three main components and have them place
self and sibling on it.
3. Know how ADHD affects their lives.
- Pros and cons of having a sibling with ADHD.
- Fighting for parents time.
- Able to get away with more (the "angel").
- Use popular video to demonstrate how "angel" can get away with stuff.
- Use book "My brother's a world-class pain"; show on overhead.
4. Understand changes at home, both due to implementing behavioral modification
strategies and the use of medication .
-Explain behavior modification charts. Create one for self (to track parent's
attention , their own behaviors, behaviors towards siblings) .
- Discuss various types of medication and their effects. Clear up any myths.
Again , may create overhead from book, "my brother's a world-class pain"
- Use the analogy of inoculations or diabetes.
5. Know how to handle their ADHD-affected sibling.
- Time-outs for self.
- Behavior modification chart for self and for ADHD-affected sibling
- Identify times of day and situations which are the most difficult. Problem
solve
6. They will feel better about selves.
- Hear and acknowledge their concerns/stresses, questions, issues, fears,
hopes.
- They partake in the new home strategies.
- Enjoyable activities.
- Self-care : enjoying some privacy/quiet; spending some time with parents;
their own activities, hobbies, interests, friends , etc.
Session structure:
Opening activity: ice-breaker/energizer.
Check in : Everything for the past week. Then re : ADHD
Topic:
Closure : What's one th ing you want to remember from tonight?
Source:

(1996) . ADHD Sibling Group . Outline of structure and plan for group at Intersect
Youth and Family Services Society.

Disabling Labeling 56

Append ix 4
ADHD Children's Group: Age 6-9
Group Outline
Session 1: Introduction and Overview for group
A. Create name tags.
B. Presentation of "the gift" (this answers the question why children are
here?)
C. Introducing Pog chart
D. Develop Group rules
E. Good news/ bad news
Session 2: Understanding your ADHD
A. Jumping Johnny video and discussion
Session 3: Understanding how your behavior impacts your parents
A. Brainstorm activities for creating a tool to control behavior
B. Mrs. Doubtfire video
Session 4: Building self-esteem
A. Write your ADHD story
B. Share story with group
Session 5: Controlling and externalizing behavior
A. Traffic signs
B. Sharing what situations are difficult to stay in control.
Session 6: Mastery of your ADHD
A. Playing the ADHD board game
B. Pigs video
Session 7: Medication
A. Discussion of medication.
B. Draw picture of before and after take medication .
C. Plan party for last group
Session 8: Celebration and Summary
A. Kid planned activity (show and tell hobbies, play favorite games, etc.)
B. Awards presentation
C. Party
Session Structure
Good News// Bad News
Behavior Pog chart check in every 15 minutes
Agenda
Pog trading time and free time
Source:

Goerz, B. & Guay, B. (1996) . Outline of structure and plan for group at Intersect
Youth and Family Services Society.

Disabling Labeling 57

Appendix 5
Summary of ADHD Game questions
Does your ADHD mean that you are not smart?
How old were you when you found out you had ADHD?
If your ADHD was an animal what animal would it be?
If your ADHD was a color what color would it be?
Do you have friends who have ADHD?
When is the hardest time to stay in control?
What is one way you can stay in control?
What is the best part of having ADHD?
What is the worst part of having ADHD?
If you could change something about yourself, what would it be?
What names have you been called when you are not in control?
What kind of car would your ADHD be?
Does anyone else in your family have ADHD?
What is the best day of your life?
How does your ADHD make you different?
What was the worse day of your life?
What is something you do well?
What is something you do not do well?
Does having ADHD make you a bad person?
What does your parent say when you are not in control?
What does your teacher say when you are not in control?
What street sign helps you stay in control?
If you could get rid of your ADHD magically, how would you do it?
If you could bury your ADHD , where would you bury it?
If you could throw your ADHD away, where would you throw it?
If your ADHD was a bullet, how far would it go?
Do you have ADHD when you are sleeping?
Does ADHD ever go away?
What is your favorite food?
What is your favorite color?
Do others make fun of you because you have ADHD?
What happens when you have too much sugar?
Have you ever made someone mad because of your ADHD?
Have you ever made someone sad because of your ADHD?
How are you different than others who do not have ADHD?

I