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Bullying and ADHD: Which Came First and Does it Matter?

Keder, Robert MD; Sege, Robert MD, PhD; Raffalli, Peter C. MD, FAAP; Augustyn, Marilyn MD

Journal of Developmental & Behavioral Pediatrics: February/March 2017 - Volume 38 - Issue - p S6–S8
doi: 10.1097/DBP.0000000000000011
Behaviors That Concern Parents
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CASE: Aiden, a 13-year-old boy in the sixth grade who is relatively new to your practice, is seen for follow-up after his routine physical last month when you noted concerns for possible attention-deficit hyperactivity disorder (ADHD) and gave the family Vanderbilt Scales to complete. Aiden has a family history of ADHD, specific learning disabilities, and mood disorder.

His mother reports that she is concerned about how Aiden is doing at school; his teachers are complaining that he is not doing his work, and she is worried that he may be kept back in school. Aiden first began having trouble in the third grade. He was retained in the fourth grade for academic and behavioral reasons. Now his mother has been receiving calls about him not paying attention, distracting others, and staring at his paper. At home, he does not want to do homework and gets very frustrated. In fifth grade, he had a psychoeducational evaluation and was found not eligible for services. His achievement testing showed average scores in reading, math, and writing. Cognitive testing demonstrated average scores for verbal and nonverbal abilities and memory but was significantly below average for processing speed. Aiden continues to have problems now in into the sixth grade.

You speak with Aiden in the office and ask him about school. He says, “It's bad. I'm failing.” He believes his major problems at school are that he is not doing his homework, he easily becomes frustrated, and he argues with the teachers. He has supportive relationships with his family and friends at school. He gets along well with some of his teachers, noting that he loves his science teacher even though she is tough and “gives hard homework.” He describes his history teacher as “annoying.” When you ask what he means he states this teacher “Can be not nice and says mean things. She picks on me a lot.” His description is consistent with the use of shaming as a behavior he experiences at school.

You review the completed parent and teacher Vanderbilt forms; both are consistent and concerning for combined type ADHD. You discuss the diagnosis of ADHD with his mother and both agree to revisit pharmacotherapy in September when the school year resumes. You give her resources on ADHD and classroom accommodations and discuss requesting a 504 plan at school. You also discuss behavioral therapy to better address his self-regulation skills.

A week later, you receive a telephone call from Aiden's mother. “Aiden got home today and he is more upset than I have ever seen him! His teacher told him in front of the class that he would probably stay back a year and now he is saying there is no point in going to school.” She is not aware if retention has been recommended for Aiden.

What would you say to Aiden's mother? What would you do next?

*Department of Pediatrics, Boston Medical Center, Boston University School of Medicine; and

Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA.

Disclosure: The authors declare no conflict of interest.

Reprinted with permission from J Behav Ped 2013;34:623–625. DOI: 10.1097/DBP.0000000000000011.

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DISCUSSION

Robert D. Keder, MD, and Robert Sege, MD, PhD

This case illustrates the need to address individual circumstances when devising a treatment plan for a child with attention-deficit hyperactivity disorder (ADHD). Aiden's mother's telephone call demonstrates poor communication between the school, family, and medical home and repeated difficulties with a particular teacher.

Treating Aiden's ADHD is important. Stimulant medications can decrease the risk for subsequent comorbid psychiatric disorders and academic failure in a child with ADHD.1 School accommodations (i.e., preferential seating, additional time on tests, etc.) and behavioral therapy offer important additional advantages.

Although Aiden struggles more in school than has been reported, retention is not a recommended course of action. Further information is needed and meeting with his teachers is recommended. Although he did not qualify for special education services using a discrepancy model, further evaluation using a Response-to-Intervention (RTI) approach may find that he qualifies for additional services. RTI involves a preventive framework to provide immediate support to children who are struggling academically. Aiden's parents should request a 504 plan be developed. Repeat testing may uncover an emerging learning disability as both writing and reading disorders are commonly associated with ADHD.2

Low self-esteem is common in children and adolescents with ADHD.3 Regardless of her intentions, Aiden's teacher's use of shame complicates his behavioral and academic challenges, creating a negative school environment.

School climate refers to the quality and character of school life. It is thought of in 5 dimensions: safety, relationships, teaching and learning, physical environment, and school improvement process. Positive school climate is associated with academic achievement, effective risk prevention efforts, health promotion, and positive youth development.4,5 Assessing school climate in cases like this is an important component of the clinical picture.

The question of whether Aiden's teacher is bullying him is a challenging one. Bullying is defined as negative behaviors among children that involve power imbalance and occur repeatedly over time.6 Bullying typically involves peer behaviors; however, Aiden, who is targeted by his teacher, may have subjective experiences similar to those experienced by targets of peer bullying.

When approached in clinic about a negative teacher-student interaction, we recommend first inquiring about aspects of the school climate from the child and the parent and get their permission to collect further information from the school. A call to a school nurse, teacher, special education coordinator, or administrator will add to your understanding of the school climate. Sharing his diagnosis may help staff understand Aiden's behavior and performance. A school counselor may provide both child-centered play therapy and teacher consultation; both reduce teacher-student dyad problem characteristics.7 If the school climate appears unresponsive, it may be in the best interest of the family to consider a school transfer.

1. Biederman J, Monuteaux MC, Spencer T, et al Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. Pediatrics. 2009;124:71–78.

2. Yoshimasu K, Barbaresi WJ, Colligan RC, et al Written-language disorder among children with and without ADHD in a population-based birth cohort. 2011;128:e605.

3. Mazzone L, Postorino V, Reale L, et al Self-esteem evaluation in children and adolescents suffering from ADHD. Clin Pract Epidemiol Ment Health. 2013;9:96–102.

4. Thapa A, Cohen J, Guffey S, et al Rev Educ Res. 2013;83:357–385.

5. National School Climate Center. Guidelines and Resources. Available at: http://http://www.schoolclimate.org/guidelines. Accessed October 4, 2013.

6. Committee on Injury, Violence, and Poison Prevention. Policy statement—role of the pediatrician in youth violence prevention. Pediatrics. 2009;124:393–402.

7. Ray DC. Two counseling interventions to reduce teacher-child relationship stress. Professional School Counseling. 2007;10:428–440.

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Peter C. Raffalli, MD, FAAP

Aiden's plight is very typical for a child with attention-deficit hyperactivity disorder (ADHD), particularly before the diagnosis is firmly established and adequate treatment is in place. He is a frustrated boy who is rapidly losing self-esteem right at the time when he is entering the dreaded middle school zone of growing up. The information provided certainly points to a diagnosis of ADHD, combined type. Aiden is struggling both academically and behaviorally—the disorder is clearly having a negative impact on his academic progress but is also impacting his relationships at school.

The clinician evaluating Aiden will have to consider whether the ADHD symptoms represent ADHD or are secondary to some other condition such as a sleep disorder or other psychological condition. Fortunately, he seems to be otherwise cognitively capable of grade-level work, at least according to the school district's evaluation. It is important to note that the slow processing speed can be secondary to ADHD but sometimes may represent a separate learning disorder of slow processing. If with time he does not improve as expected with ADHD treatment alone, a repeat psychological evaluation may be needed to rule out a mild learning disability that was not evident on the first testing.

This case brings up a second but equally important dilemma: What to make of the teacher's behavior? Her remark is one of frustration and anger. Because it is meant to embarrass, most would agree it is inappropriate although the teacher may argue that she is just trying to “light a fire” under a boy who seems to be lazy and disruptive. It is important to consider the relative risk versus benefit of any intervention before applying it. The potential benefit of embarrassing or shaming a student in front of his peers is dubious, at best. The potential risk, however, is considerable. There is, naturally, the negative impact on the child's self-esteem but perhaps an even bigger harm is the establishment of an atmosphere of intolerance toward Aiden. After all, if the teacher finds Aiden annoying, then why should his peers feel good about him? ADHD kids often feel “stupid” when they are not, even without the endorsement of that opinion from teachers or peers. Imagine how Aiden feels about himself after the incident described in his History class that day!

Although inappropriate, do his teacher's comments constitute bullying, per se? Certainly there is a power imbalance. However, if one recognizes the generally accepted definition of bullying as peer victimization, then it is difficult to apply the term to aggression that is adult on child. In the world of cyberbullying, for example, mean behavior toward a child online, perpetrated by an adult, is legally termed “cyber-harassment” and not “cyber-bullying” in many jurisdictions. Also, bullying by definition is repetitive victimization and our case presentation does not establish that this teacher has repeatedly targeted Aiden, although we know he is not fond of her because she is “mean.”

Why be so compulsive about the definition? Because like anything else, overuse of a term breeds contempt for it. The schools are already inundated with parents overusing the term “bullying” for any slight committed against their child and we need to be accurate in our usage. It may be more productive to drop the labels and focus on addressing the bigger problem.

Children with ADHD, when it comes to bullying, “wear both hats.”1,2 They are at risk for bullying behavior (low frustration tolerance, impulsivity) and also for being victimized. They are often referred to as “provocative victims.” Sometimes even schools get caught in the trap of blaming the victim and tell the parent the reason their child is bullied is essentially because he or she is “annoying.” It is important that children understand that bullying is NEVER the victim's fault. Bullying is defined medically and legally as abuse behavior; no matter how annoying a person may be, no one deserves to be abused.

1. AbilityPath.org. Walk a Mile in Their Shoes: Bullying and the Child with Special Needs. 2011. Available at: http://http://www.abilitypath.org/areas-of-development/learning--schools/bullying/articles/walk-a-mile-in-their-shoes.pdf. Accessed October 4, 2013.

2. Holmberg K, Hjern A. Bullying and attention-deficit hyperactivity disorder in 10-year-olds in a Swedish community. Dev Med Child Neurol. 2008;50:134–138.

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Marilyn Augustyn, MD

This case brings home 2 important themes: clinicians may only hear about what we ask, as evidenced by a recent study that showed 57% of parents are worried about bullying and yet we do not have a clear practice guideline on when and how to talk about bullying.1 In this case, it was critical that the clinician listened to Aiden's concern and responded compassionately that his mother felt comfortable calling the clinician back a week later when the incidents occurred.

Second, whether we call it “bullying” or “ostracism” or “mean,” the teacher's behavior had an impact on Aiden's functioning and is an important aspect of his treatment plan. Caring for children with special health care needs who are at high risk for this behavior,2 it is important we remain vigilant, informed, and most important compassionate in recognizing its occurrence.

1. Garbutt JM, Leege E, Sterkel R, Gentry S, Wallendorf M, Strunk RC. What are parents worried about? Clin Pediatr (Phila). 2012;51:840–847.

2. Twyman KA, Saylor CF, Saia D, Macias MM, Taylor LA, Spratt E. Bullying and ostracism experiences in children with special health care needs. J Dev Behav Pediatr. 2010;31:1–8.

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