ADHD is one of the most prevalent and impairing disorders in adolescence, with an estimated prevalence of 4-7 % (American Psychiatric Association, 2013).

Individuals with ADHD are subject to stigmatization on a regular basis (Lebowitz, 2016), facing either public stigma (what a naive public does to the stigmatized group when they endorse the prejudice about that group) or self-stigma (what members of a stigmatized group may do to themselves if they internalize the public stigma). Both types of stigma interact and augment each other and have a negative impact on social functioning and mental well-being of the stigmatized individual (Corrigan, 2004; Lebowitz, 2016)

Research shows that adolescents with ADHD experience more peer stigma than adolescents with other mental health conditions (O’Driscoll et al., 2012, 2015; Sadler et al., 2012). Stigmatization in the classroom is seen in the preferences of peers for not having to work together with a student with ADHD, peers bullying and calling names (Bussing et al., 2011), in the systematic underestimation of performance by teachers and in being negatively judged by teachers (Fuermaier et al., 2014; Tatlow-Golden et al., 2016).

Current programs like buddy systems and psychoeducation are thought to have a limited remediating effect on stigma towards ADHD in the classroom , but methodologically sound research to support their effectiveness on reducing stigma is lacking. Altogether, the remediation of stigma towards ADHD in adolescents is underexplored (Mellor, 2014). It is theorized that the stigmatizing process builds on three attitude-components: the cognitive component (the assumption that a peer with ADHD is lazy), the affective component (feelings of resistance, frustration or anger when having to work with a student who has ADHD) and the behavioral component (ignoring a peer with ADHD when they ask you a question). Ideally, an intervention that aims to remediate stigmatization should target all three components to maximize its effectiveness (Smith & Triandis, 1972). However, both psychoeducation (focus on the cognitive component) and buddy systems (focus on the behavioral component) fail to target the affective component. In sum, there is still room for improvement in effective classroom interventions, aiming to improve attitude towards ADHD by including the third, affective component of stigma.

Therefore, in this study we evaluated the effectiveness of an ADHD Awareness Training (AAT) as a stigma remediation intervention in comparison to traditional psychoeducation. In addition to the cognitive component of attitude (i.e. psychoeducation), AAT targets the affective component, by providing teacher-led, first-hand ADHD experiences in the classroom (e.g. experiencing inattention, inhibition problems and planning problems). As a result, we expect a larger, positive change in attitude towards ADHD for students participating in AAT as opposed to psychoeducation. In addition to measuring student attitude outcomes towards ADHD, attitude towards functional disabilities in general (far-effect) was measured as well. Also for the teachers that led the AAT or psychoeducation, attitude towards functional disabilities was assessed, as well as the teacher’s self-efficacy related to inclusive practices.

A pre post intervention design (RCT) was used, assigning 116 students aged 14-16, from 17 secondary schools, to one of the two experimental conditions: AAT (n=63) vs psychoeducation (n=53). The students were randomly assigned to the conditions per class (i.e. per teacher that led the intervention for that class). Both the AAT and the psychoeducation were given in two sessions of 50 minutes in the classroom. Psychoeducation covers topics on ADHD such as symptoms and impairment, development, etiology and intervention. In AAT, through a series of six exercises that reflect several aspects of ADHD, the students are can experience e.g. failing despite efforts, being laughed at, inattention, organizing problems, inner restlessness, inhibition problems. Each exercise was followed by a debriefing wherein essentially the same educational content in terms of themes related to ADHD was covered as in the psychoeducation condition, albeit a shortened version. For each participant, sociodemographic information was collected (e.g. age, gender, curriculum type), as well as information on whether they know someone with ADHD or whether they are diagnosed with ADHD themselves. To assess stigma towards ADHD (near effect) among the students, the ADHD Stigma Questionnaire (ASQ) was used. The ASQ consists of 26 items, measured by a four-point Likert scale (1 = ‘strongly disagree’ to 4 = ‘strongly agree’) and assesses one’s perceptions on public stigma towards ADHD (Kellison et al., 2010). A measure of stigma towards functional disabilities in general (far-effect), was assessed among the students using the Chedoke-McMaster Attitudes Towards Children with Handicaps (CATCH) which consists of 36 items on a five-point Likert scale (0 = ‘strongly disagree’ to 4 = ‘strongly agree’) (Rosenbaum et al., 1986). Teachers filled in the Sentiments, Attitudes, Concerns regarding Inclusive Education-Revised (SACIE R), a questionnaire assessing perceptions of inclusive education (Forlin et al., 2011) and the Teacher Self-efficacy for Inclusive Practice (TEIP), as a measure for the teachers’ perceived efficacy to teach in inclusive classrooms (Sharma et al., 2012). The data were analyzed in R (R Development Core Team, 2016): Pre-analyses were conducted to check for baseline differences between conditions. Pre and post intervention outcome measures were analyzed using repeated measures ANOVA. Potential effects of teacher on student outcomes were analyzed using a multilevel modelling approach.

Repeated measure ANOVA outcomes showed a significant time-x-condition interaction for ASQ scores (F(1,102) = 15.13, p = .029). Post hoc t-tests revealed a significant, positive change in the AAT condition (t(61) = -3.37, p = .001), whereas this change was not found for psychoeducation (t(51) = 0.51, p = .613). Furthermore, analysis showed that the effectiveness of the AAT interacted with curriculum type (F(2,102) = 5.16, p = .007). We found significant pre to post differences in ASQ scores for technical (t(13) = -2.27, p = .041) and vocational (t(14) = -2.55, p = .023), but not for general curriculum type. CATCH scores did not differ significantly pre compared to post intervention. Low intra-class correlation coefficients (ICC < 0.05) showed little to no effect of teacher on student outcomes. A small significant pre-post difference was found for teacher TEIP scores in the AAT condition (F(1,17) = 5.84, p = .027), while none was found for psychoeducation. Teacher scores on the SACIE-R showed no significant change. In sum, AAT facilitates stigma remediation among students, supporting the value of supplementing cognitive educational content of stigma interventions with an affective component. Effectiveness of AAT however, interacts with curriculum type, facilitating attitude change particularly in the vocational and technical curriculum type. Suggested by high baseline scores on the SACIE R and due to potential selection bias, teachers seemed to already hold a more positive attitude towards special educational needs pre intervention, leaving little room for improvement in attitude towards functional disabilities. A positive change was found however, for teachers’ self-efficacy ratings for inclusive practices. After leading the AAT sessions, teachers reported higher efficacy to teach in inclusive classrooms than before. Future studies might seek to further improve on the intervention in terms of appeal to all adolescents (for example by gamification of ADHD experiences) and to include top-down policies at the school level to further increase effectiveness.

American Psychiatric Association. (2013). American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders Fifth Edition. In Arlington. Bussing, R., Zima, B. T., Mason, D. M., Porter, P. C., & Garvan, C. W. (2011). Receiving treatment for attention-deficit hyperactivity disorder: Do the perspectives of adolescents matter? Journal of Adolescent Health, 49(1), 7–14. Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. Forlin, C., Earle, C., Loreman, T., & Sharma, U. (2011). The Sentiments, Attitudes, and Concerns about Inclusive Education Revised (SACIE-R) Scale for Measuring Pre-Service Teachers’ Perceptions about Inclusion. Exceptionality Education International, 21(3), 50–65. Fuermaier, A. B. M., Tucha, L., Mueller, A. K., Koerts, J., Hauser, J., Lange, K. W., & Tucha, O. (2014). Stigmatization in teachers towards adults with attention deficit hyperactivity disorder. SpringerPlus, 3(1), 1–9. Kellison, I., Bussing, R., Bell, L., & Garvan, C. (2010). Assessment of stigma associated with attention-deficit hyperactivity disorder: Psychometric evaluation of the ADHD Stigma Questionnaire. Psychiatry Research, 178(2), 363–369. Lebowitz, M. S. (2016). Stigmatization of ADHD: A Developmental Review. Journal of Attention Disorders, 20(3), 199–205. Mellor, C. (2014). School-based interventions targeting stigma of mental illness: systematic review. The Psychiatric Bulletin, 38(4), 164–171. O’Driscoll, C., Heary, C., Hennessy, E., & McKeague, L. (2012). Explicit and implicit stigma towards peers with mental health problems in childhood and adolescence. Journal of Child Psychology and Psychiatry and Allied Disciplines, 53(10), 1054–1062. O’Driscoll, C., Heary, C., Hennessy, E., & McKeague, L. (2015). Adolescents’ beliefs about the fairness of exclusion of peers with mental health problems. Journal of Adolescence, 42, 59–67. Rosenbaum, P. L., Armstrong, R. W., & King, S. M. (1986). Children’s attitudes toward disabled peers: A self-report measure. Journal of Pediatric Psychology, 11(4), 517–530. Sadler, M. S., Meagor, E. L., & Kaye, K. E. (2012). Stereotypes of mental disorders differ in competence and warmth. Social Science and Medicine, 74(6), 915–922. Sharma, U., Loreman, T., & Forlin, C. (2012). Measuring teacher efficacy to implement inclusive practices. Journal of Research in Special Educational Needs, 12(1), 12–21. Smith, H. W., & Triandis, H. C. (1972). Attitude and Attitude Change. Contemporary Sociology. Tatlow-Golden, M., Prihodova, L., Gavin, B., Cullen, W., & McNicholas, F. (2016). What do general practitioners know about ADHD? Attitudes and knowledge among first-contact gatekeepers: Systematic narrative review. BMC Family Practice, 17(1), 1–16.