or Making Excuses?
and Community Support
and Ritual as Structure and Focus
have linked the increased awareness of ADHD to a decline in personal
responsibility and traditional morals. They feel that the medical
community, in bestowing the diagnosis of ADHD or other mental illness, is
giving the affected individual permission
to continue objectionable behavior. The patient seeks medical absolution
in the therapy room, abandoning the traditional values of church or
temple. Some individuals who seek special accommodations in school or in
the workplace are held up to public ridicule. Such individuals are said to
be lazy or are trying to style themselves as victims. Some will point to
themselves as good examples. They were impulsive "bad boys" in school.
Once they got out of school and met the realities of having to make a
living, they "straightened up" and overcame their moral shortcomings.
these charges may make one's blood start to boil, we need to take such
criticisms seriously. Often a little self-examination can be useful. This
raises several important questions. What is the meaning of
"being diagnosed"? Are you still the same person? If one has
a neurobiological condition that predisposes one to impulsivity, where
does personal responsibility fit in? Where does reasonable accommodation
end and "making excuses or being prickly" begin?
that there is no conflict between the need for personal responsibility and
the need to understand one's diagnosis. Most moral systems value the
concept of self-knowledge. Understanding one's strengths and weaknesses is
necessary for one to function as a moral being. Once one becomes aware
that one has ADHD, it becomes a responsibility to learn more about the
condition. Then, one can try, through increased self-knowledge, to avoid
impulsive acts that might offend or injure others. The same principle
holds for parents of a child with ADHD. When to punish, when to
accommodate and when to try to gradually shape behavior?
dealing with individuals with long-standing, severe ADHD, I sometimes
encounter those who have become so used to their own impulsivity and
failure that they have ceased to care about the rights of others. They
have learned to associate with impulsive, antisocial peers. At their
worst, they can function as predators. Such an individual might use his or
her diagnosis as an "excuse" but this is usually part of an
over-all antisocial pattern. I have treated a number of such individuals.
For them, the road to recovery is longer and more agonizing. Some regain
their self-esteem, and with extensive academic, medical and social help,
achieve successful lives. Others end up in the juvenile or adult penal
are some individuals who seek a specific psychiatric diagnosis to try to
explain long-term life problems. Whether or not they actually have the
ADHD, the diagnostic and process does not satisfy them. Each professional
who does not deliver the expected miracle is eventually devalued. Such an
individual might be one of the rare people who will ask for unreasonable
accommodations. This person might swing from the pole of extreme guilt to
the pole of feeling of constantly victimized. Such an individual would
benefit from long term individual psychotherapy with a therapist who can
tolerate being both idealized and devalued.
experience, the majority of those diagnosed with ADHD do not misuse their
diagnoses to get undeserved accommodations. Indeed, the individual may be
wracked with shame and anxiety about their inability to contain their
disorganization and impulsivity. This sense of
and secrecy can paralyze an individual and make him or her unable to
ask for reasonable assistance. This person, hearing public criticism of
ADHD, may retreat further into shame and secrecy. In particular, I have
found that deeply religious individuals can be much harder on themselves
than their elders or clergy.
the increasing diagnosis of ADHD has been criticized as a move away from
traditional morality, it might be interesting to consider various
religious perspectives on the subject of psychiatric diagnosis, religious
communities, and personal responsibility. (For this discussion, I will be
excluding the tiny minority of mentally ill individuals who truly cannot
understand the nature of their actions).
the years, I have worked with many deeply religious people from a variety
of faiths. They have often been gracious enough to bring in literature to
educate me about their beliefs. When appropriate, I have
their clergy or religious community in the treatment. This
collaboration between clergy and psychiatry has almost always been
positive. Once there is a climate of mutual trust and respect, a
particular religious community can be an invaluable source of structure
and support. In my experience, most clergy are more accepting of the
diagnosis of ADHD than their more conservative parishioners. A few clergy
needed education about ADHD, but almost all were eventually supportive.
certain individuals with ADHD, daily prayers and other
rituals provide a good way to handle transitions, and to frame the
experiences of the day. The church, temple or mosque is a source of
interpersonal support and a ready place for structured social activities.
Religious communities can have all of the same foibles as can individuals.
Like other social institutions, they can be prone to cliques, and petty
prejudices. However, good clergy and lay leaders function to remind the
community to look beyond prejudices and to constantly strive to imitate
have used Jesus' dealings with the Apostle Peter as a model for how one
might deal with a child or an adult with ADHD. Some have wondered whether
Peter himself had some of the characteristics of ADHD. He loved Jesus and
desperately wanted to be more like him. However, on several occasions, he
acted impulsively and was unable to follow through. For example, on the
night Jesus was betrayed, Peter cut off a soldier's ear. He also promised
to stick with Jesus no matter what happened. However, by the morning
cockcrow, he had betrayed Jesus three times. In other situations, Jesus
called Peter by name, gently pointed out the mistake and suggested a
correction. In the case of the three denials, a piercing look was enough
to remind Peter of his error. The later books of the Christian scriptures,
written about the time after Jesus, give hope in that they show a more
mature, confident man who has clearly learned from Jesus' encouragement
and gentle setting of limits.
contemporary Christian ministers suggest that faith can relate to
individuals with psychiatric diagnoses. Once one becomes aware of a
psychiatric diagnosis, it becomes one's responsibility to learn more about
the condition. Through knowledge, one might be able to minimize impulsive
acts that might offend or injure others. Prayer can lead to a sense of
forgiveness and freedom from shame. Even if one feels forgiven, there is
still the obligation to attempt to make amends to other people who might
have been hurt by one's impulsive acts. When one is freed from shame and
secrecy, it is often easier to make meaningful amends to others. Prayer or
meditation can be a source of quieting and centering. Some distractible
individuals may not be able to sustain a lengthy, focused prayer. However,
in the Screwtape Letters, C.S. Lewis indicates that the most
powerful prayer is a simple brief prayer for the grace to manage the daily
celebration of Pesach, (Passover) commemorates the deliverance out of
bondage in Egypt. It is one of the earliest examples of interactive
learning. The participants should experience the deliverance from slavery
as if it were happening to them that evening. There is particular
attention to teaching the children. There are stories, breath-holding
contests, hunting for a hidden object and songs to keep children and other
distractible folk involved. The Haggadah, (order of service), describes
four types of children and commands the adults to teach each type of child
in a way that he will learn best. The four sons are the wise son, the
simple son, the wicked son and the son who is too young to ask questions.
The Haggadah describes specific teaching techniques for each son so that
each will understand the experience of the Exodus.
Seder meal it suddenly struck me that these commandments were the Divine
blueprint for the special education laws; 94-142 and subsequently IDEA.
Over two millennia ago, there was a commandment to give each individual
instruction that he or she could understand and apply! Particularly
interesting is the instruction for dealing with the wicked son. One might
see him as the distractible, impulsive defiant child. He says, "What
mean ye by these commandments?" The teachings command one to
point out that he has, by his language and attitude, excluded himself.
This gentle rebuke is interpreted as pointing out his self-exclusion. The
eventual goal of this is to encourage him to rejoin the family group and
participate in the miraculous deliverance. Much of the subsequent games
and playful contests also function to draw in such an individual.
Jewish rituals cover a wide variety of every day and unusual events. These
prayers and rituals can be very centering and can help structure the day.
The Bar and Bat Mitzvah, coming of age ceremonies, welcome young people
into the community. The preparation can be academically intense. The
Jewish community recognizes this and there a number of tutorials and other
accommodations so that a broader range of individuals are able to join the
Suni Moslem believes that at birth, one is assigned
two angels who record all of one's good and bad deeds. However the
"pen is lifted" in three circumstances. These are youth, sleep
and insanity. Individuals with mental illness who can distinguish right
from wrong are not exempt from the recording of their deeds. However,
Islam tends to be understanding about an individual's limitations, and
will accept a sincere effort to obey the laws of Islam. If one Moslem does
something offensive to another Moslem, the recipient may shun the
offending individual for only three days. After that one must forgive.
individual commits an impulsive negative act, he or she must make a
sincere prayer of repentance to Allah, and then ask the offended
individual for forgiveness. Muhammad said that one must then follow the
offensive action with a good deed. Islam is often quite specific about
expected behaviors and responses. For instance, if one is unable to fast
during Rammadan because of one's psychiatric medications, one could
instead feed a hungry person each day during the fast.
often, I find that individual believers of many faiths are harder on
themselves than would be their clergy. For example, several religious
groups have special fast days. Certain medications and medical conditions
make fasting impractical or actually dangerous. Most clergy feel that it
would be a sin to endanger one's health for the sake of a fast day.
Frequently, the patient needs to hear this directly from the clergy or lay
elders. In the case of most medications for ADHD, one can stop them for a
day or rearrange the dosing to facilitate a one-day religious fast. The
month long, dawn-to-dusk Moslem observance of Rammadan is more
challenging. However, I have managed, with community help and some
pharmacological maneuvering, to see patients through this important
who have the diagnosis of ADHD are often relieved that there is an
explanation for their fogginess, fidgetiness, and impulsivity. However,
when they attempt to get accommodations, they are often accused of
laziness or making excuses. Some commentators have seen the diagnosis of
ADHD as the medicalization of morality. However it is appropriate to
consider psychiatric treatment as responsible stewardship of one's body
and mind. Those with ADHD, like everyone else, should always try to take
responsibility for their actions, and make amends for any offenses.
However, those who condemn this diagnosis are not representative of most
liberal or conservative religious leaders.
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