Boys will be boys? ADHD and “normal behavior”

Between us, Amber and I are raising three elementary-middle school sons. We counter our very busy professional lives with weekends and evenings of martial arts, soccer, homework, and play dates. For anthropologists, the right way to raise our children is always a challenging and interesting proposition.  Anyone who has spent time in the field knows that kids can turn our great when raised under very different cultural rules than the prevailing ones we live with in Tempe, Arizona. Consider the young Ituri Forest kids who ran around with machetes as toddlers and the Inuit kids that breastfeed until six or seven years of age – and turned out to be delightful, civic-minded, psychologically balanced, and fully employed adults. Viewed in cross-cultural perspective, American society is very coddling of children. We helicopter like mad. There’s two good books by anthropologists that give you all you need to put our obsessive parenting in perspective: The Anthropology of Childhood: Cherubs, Chattel, Changelings by David F. Lancy and the Levines’ Do Parent’s Matter (2016). You can hear the latter talk about why American parents really just need to RELAX here.

Boys in a classroom, Xalapa, Mexico 2000

But, relaxed parenting or not, one of the most challenging aspects of daily life for many young boys in US is the middle school classroom. For hours every day, kids are expected to sit still, listen, focus, and complete sequential tasks. For many boys, this is not easy. But the rules of our schools demands the behaviors, and kids who don’t follow them will usually end up failing academically and/or unpopular with teachers and their peers. To deal with the extreme consequences of hyperactivity and inattention, many American kids end up on prescribed psychoactive drugs like Ritalin and Adderall. Around 11 percent of US kids have ADHD (Attention Deficit Hyperactivity Disorder) diagnoses, the majority boys. This is the highest rate in the world. The characteristic behaviors of ADHD include fidgeting, easily distracted,  “running about as driven by a motor,” and not following social rules.

Conditions with vague etiologies and symptoms thought to be under individual control, just like ADHD, tend to be stigma-magnets. Parents face courtesy stigma for their kids’s behaviors. ADHD-associated behavior is often seen as some product of poor parenting:  too much sugar, too many video games, too little discipline. For parents, the ADHD diagnosis can be de-stigmatizing and a huge relief (“it wasnt us!”). But it’s different for kids. Both the behaviors, and people knowing they are medicated, lead to kids being stigmatized, and hence being rejected, feeling rejected, and ultimately to lower self-esteem.

Our team doing ethological observing in Xalapa, 2000

All this brings up the very important question: what exactly is “normal” boy behavior? If a good chunk of boys need to be medicated to behave “normally,” be socially acceptable, and avoid stigma, what is going on?

Two decades back, I collaborated with fellow biological anthropologist  Karen Schmidt on collecting cross-cultural data to address this problem. Karen had done her dissertation on observer’s reactions to the behaviors and language of people with schizophrenia in three countries, and was really interested in how mental illnesses came to be  socially defined as “abnormal” pathologies. We were highly influenced by Jerome Wakefield’s fascinating thinking on how signs of mental illness become defined as “harmful” dysfunctions (and so pathologized) based on social expectations of normality.

So, we worked in US and Mexican schools, using the contrast to begin to unravel the ADHD mystery. We used what is termed an ethological approach to characterize children’s behavior patterns at school. This is the systematic coding of their action through cultural-neutral rubrics: basically you treat the kids as small animals and document behavior assuming you understand nothing of their intentions or the social meanings of their behaviors. We spent hundreds and hundreds of hours in classrooms tracking inattentive and hyperactive behaviors. We then also tracked and coded and how other social actors (peers, teachers) reacted to them when they presented different sets of inattentive and hyperactive behaviors. We tracked every kids in every class in one large school ten two-minute sampling periods during supervised, regular, structured class activities. We also did activity monitoring by pinning a small monitor (the Actiwatch) to children’s backs while they completed a 20-minute seated task. And each child completed a computerized attention test called the TOVA. And we chased them around the schoolyard at recess and lunchtime to see what they were doing in free time.

We had a couple of  really interesting findings: Gender differences in inattention and impulse control measures on the computerized test among were not significant in the Mexican kids, in contrast to the findings of previous US studies in which boys performed poorly compared with girls. Mexican children also made significantly more attention errors than American children, indicating greater degrees of characteristic inattentive and impulsive behaviors in childhood. Yet they just didn’t have the same “problems” in the classroom.

Classroom in session, Xalapa 2000

Mexican elementary school classrooms, at least when we were observing in them in 2001, were very different to US ones. Activity was common and normal. Kids moved around all the time, and assignments were often done by groups of children collaborating. The class hours were also arranged in a less linear fashion, without the teacher having a set start, middle, and finish to the lesson. Under these looser conditions, we found that the same behaviors that led to being told off and sent to the principal’s office in the US (getting up, not following instructions, etc) were not a problem for kids in the Mexican schools.

The most telling single event of the difference was when I spent an hour observing informally in a classroom with the American educational psychologist who had designed one of the main ADHD screener tools used in US schools. After class finished, he noted to me that he counted off at least six kids in the class that showed all the classic signs of ADHD. He approached the teacher afterwards to ask her how on earth she managed with that level of behavior problems manifest in her classrooms. Her response: “What problem?”

Ethological observation using focal follows during recess

But where does this leave us with the US boys who are having so much trouble succeeding in the stricter, more structured US classrooms? There’s no easy answer. Meeting local behavioral norms and social expectations — and so avoiding stigma and rejection and academic failure —  is most easily done through medication. For parents, the benefits they see will often outweigh the costs. For the kids, the equation is more complex, and the answers less black and white. I haven’t seen studies unraveling how children themselves understand and balance the complex social and personal costs and benefits of ADHD. That is, we really need more child-focused ethnographic approaches that put children at the center of understanding hyperactive-inattentive behaviors and their consequences for children themselves in a cultural context that is applying psychoactive medication as a technological solution to cultural problems.

Our studies in Mexico were certainly very external to children’s world views – in part because we had to treat them as noted as “little animals” to be able to properly measure the actual behaviors.We did do brief interviews with the kids about their friendships and do asocial network analysis, but the results didn’t tell us much of use so we never published them.

This child-focused ethnography is actually really hard to do because it requires a set of special data collection tools we don’t have well defined as a discipline yet. Amber, Abigail Sullivan, and I have been working on cataloging the types of ethnographic approaches that can best access these worlds of middle childhood, which we hope will be in press shortly. Stay tuned.

Alex’s first trip to Xalapa, Mexico in 1998