Children's behavior:
personality, action or
diagnosis?
A qualitative study of how professionals
interprets and understands children's behavior as signs
on ADHD or exposure to violence
Preface
This is a master's thesis in social work at the Center for Social Work (CESAR), Uppsala
university, written in the spring of 2020.
We would like to thank the people who made this study possible. Above all, we would like to extend a big thank you to everyone
interviewees who took the time and enabled the implementation of the study. We also want to thank
our supervisor Stina Fernqvist, for all the help you contributed during the process, as well as ours
university comrades for the feedback and support you have given us.
Jenny Gudmunds & Michaela Janemon
Title: Children's behavior: personality, action or diagnosis? A qualitative study on
how professionals interpret and understand children's behavior as signs of ADHD or
exposure to violence
Authors: Jenny Gudmunds & Michaela Janemon
Summary
That a child exhibits an extravagant behavior, difficulties in regulating emotions,
Impulsivity and hyperactivity can be due to various things. Among other things, it can be one
indication that a child has ADHD, a diagnosis that is becoming more common, but it can
also be an expression that a child has experienced violence or developed PTSD as a result.
The purpose of the study was to investigate how professionals in social work interpret
and understand children's behavior as a sign of ADHD or exposure to violence and how these
interpretations affect the work. This is because previous research has shown large knowledge gaps
regarding the similarity between these and a risk of malpractice. To investigate this
has conducted seven interviews with social work professionals who meet
children in their daily work. The theoretical framework of the study consisted of social constructivism,
stamp theory and systems theory. The results of the study showed that the professionals
has an accepting approach to children's behavior. The professionals saw the child
behavior as a consequence of the environment rather than the child's own personality.
As a result of this approach, the professionals worked mainly with the relational
aspect and interaction regardless of the problem that caused the behavior. The
there were divided opinions about what is the basis for the increase
the diagnosis, mainly ADHD, but common was that they did not differ on their own
treatment and work significantly based on a diagnosis. The study further problematized
this is because it is important that children with ADHD or PTSD get different
treatment specialized based on the problem but that many children can benefit from that
get a stronger interaction with their parents, positive encouragement and other support like them
professionals worked with regardless of causation.
Keywords: Children's behavior, professional interpretations, ADHD, exposure to violence.
1 INTRODUCTION
Children who are unwell can show it in many different ways and there can be several explanations for it
why children behave the way they do. In the field of social work, professionals come daily
in contact with children who feel unwell for any reason where their interpretations and observations of
children's behavior can be of great importance. According to the Social Services Act (2001: 453), the social services must
provide efforts and support on a democratic and solidary basis so that all children have the opportunity
to grow up in a social and economic security. The social services' area of responsibility is also to intervene
when a child's development and health are endangered. Child and adolescent psychiatry [BUP] is also responsible
for support and treatment for children and young people who are mentally ill (Broberg, Almqvist,
Risholm Motander & Tjus, 2015, pp. 500–501).
Today, more and more children are diagnosed with ADHD [Attention Deficit Hyperactivity Disorder]
(Broberg et al., 2015, p.430). In the social services, the influx of reports of anxiety is also increasing, including
concern for children who are doing badly (National Board of Health and Welfare, 2019). There are great similarities between the symptoms of ADHD
and behavioral signs that a child is exposed to violence (Lundström, 2018, 19 March). There is
also difficulties in determining whether the symptoms that may indicate ADHD have occurred
in a child who has been or witnessed violence before or after the violence (Sanderud, Murphy,
& Elklit, 2016, p.2). ADHD is a diagnosis that falls under the umbrella term neuropsychiatric
disabilities [NPF]. ADHD affects, among other things, a person's attention and
concentration ability and impulse control (Broberg et al., 2015, p.418-419). In the treatment of
ADHD is an initial focus on a pedagogically oriented parental support and an adapted schooling.
If this is not enough, the child can be medicated with central stimulant drugs that have
proved to have an effect on the symptoms (Swedish National Agency for Medical and Social Evaluation [SBU]
In Sweden, studies where children have been asked if they have been exposed to violence have shown that approximately
15-30% of the children have been subjected to violence by their parents at some point and that 3-7% state that they
become so repeatedly or often (Broberg et al., 2015, p.359). When a child is subjected to violence
it is common for the child's development to be disrupted. One of the most common consequences is that of the child
attachment patterns to the parents become disoriented, which among other things means that the child does not
can use the parents as support even though they are physically present. This can have consequences
in the child who may express himself through difficulties in regulating emotions and aggressive behavior
(Broberg et al., 2015, pp.367-368). PTSD [post-traumatic stress disorder] is a diagnosis that can
attributed to a person who has experienced traumatic events in the form of, among other things, exposure to violence.
It is common for children who have been through nasty experiences to show symptoms that match
with PTSD a shorter time after the event, but if these become persistent and affect the child's daily
functioning for over a month after the event, there is a great risk that the experience will affect the child
development. A child's reactions as a result of PTSD may impede the development of the child
which makes it important to pay attention to symptoms that may be signs of a trauma disorder
(Broberg et al., 2015, p.277).
Sometimes there are clear signs that someone is exposed to violence, which gives the environment the opportunity
to discover this. But it's not always that these signs are clear, or so can the signs
exist to stand for something other than what they are first interpreted as. Many of the symptoms of exposure to violence
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may overlap with the symptoms of illness or disability and it is required that people
who work with this have knowledge of violence to increase the probability that the exposure to violence will
discovered (National Board of Health and Welfare, 2014a, p.21).
Problem formulation
There is an interesting aspect to how professionals come into contact with children in their work
interprets and observes certain behaviors as well as what they read into these behaviors. For example
extravagant behavior, impulsivity and difficulty concentrating, which can be both signs that
a child gets sick but also signs of ADHD. Due to this, it can be argued that
There is a knowledge gap around this area and that it can pose a risk of ADHD and
Violence can be mixed up or end up in the shadow of each other, which can be problematic in
several respects. On the one hand, the children can receive the wrong treatment and medication, and on the other hand, it can lead to
the children who are harmed are not noticed or come to professionals who work with children
knowledge when signs they show are interpreted as something else. Children who experience violence are in themselves one
central theme in today's social work, even the risk that children do not receive the right support in time makes this topic
relevant to pay attention. Likewise, the interpretations of professionals and what these interpretations can be
have for consequences a relatively unexplored topic which also justifies the importance of this study.
Purpose and questions
The purpose of this study is to investigate the ways in which professionals in social work interpret
and understands children's behaviors that may be signs of ADHD and violence and how
their work is influenced by these interpretations.
• In what way do adults who work with children interpret different behaviors (for example, acting out?
behavior, difficulty concentrating and impulsivity) in children?
• What explanations do professionals attribute to these behaviors?
• What tools and preconceptions will be central to the work and assessment?
Definitions
Violence: The concept of violence includes many different types of violence. Including physical violence, psychological violence,
sexual abuse, violations, neglect and more (National Board of Health and Welfare, 2016, p. 28). We also have
chose to use the term "children who have experienced violence". Experiencing violence means both to the child
have seen violence but also if the child, for example, has heard violence between his parents. In the former
research often uses the term “child maltreatment”, we have chosen to use in the translation
the concept of "children who get sick".
Disposition
The essay is divided into six different sections. The first introductory section is presented as relevant
background facts as well as purpose and issues that the study intends to investigate. In the second section
previous research in the subject is presented. This is followed by a third section where the research approach
and theoretical framework is described. In the fourth section, we describe our research method. After
follows section five, which is the main part of the essay, where results are presented and analyzed in
Jenny Gudmunds & Michaela Janemon
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relation to previous research and theory. Finally, in the sixth section, a discussion follows
of the study in its entirety.
2. PREVIOUS RESEARCH
The present section aims to account for the previous research that exists in the subject. From
In the research we have collected, we have divided the content into four headings. The headlines are themed
partly directly based on our questions to give us a basis to be able to answer these in the results and analysis part, but partly also based on themes we have found as recurring in the studies we
reviewed. These are norm-breaking behaviors in childhood, ADHD and exposure to violence, the relationship
and risk of misdiagnosis as well as the role and competence of professionals in ADHD and
exposure to violence. The first three themes address norm-breaking behavior, criteria for diagnoses and
causes and consequences of ADHD and exposure to violence. Then there is limited research on how
professionals interpret children's different behaviors as extravagant behavior,
concentration difficulties and impulsivity, the text is therefore supplemented with a section on the connection
between ADHD and exposure to violence and how the role of professionals and work with children experienced
violence or children with ADHD looks like. Finally, there is a summary and a map
discussion of the research field
Search process
The search process has mainly been based on Uppsala University Library's database. Furthermore, keywords
such as "ADHD", "trauma", "children" and "violence" have been used, as well as keywords such as "professional",
"Children", "observation" and "interpretation". In English, the keywords “child maltreatment” and
"ADHD". Search has also been done through the database PsycINFO and there the keywords were used
"ADHD + PTSD" and "ADHD + PTSD + misdiagnosed" and "maltreatment + ADHD". At
search for supplementary studies used words like "ADHD + gender" and "ADHD + girls"
and also "professionals + children + interpreter". Chain search based on other publications
references have also been implemented. After the search was completed, the hit list was handled by
to limit to peer-reviewed articles to ensure reliable studies. The content
was then supplemented with reports from the National Board of Health and Welfare as the established research can be seen
as deficient on some fronts.
Norm-breaking behavior in childhood
Norm-breaking behavior in children can be both aggression and extravagant behavior but also
when a child violates rules and laws. These behaviors are most common in adolescents in
ages 15-17 years but also occurs in smaller children. Behaviors should be noted in good
time when early norm-breaking behavior tends to persist over a longer period of time. It is common, for example
that adults in crime have shown norm-breaking behavior in early childhood (Andershed &
Andershed, 2005, p.17-20). Many studies have shown that there is a great deal of heredity when it comes to
mainly aggressive but also non-aggressive norm-breaking behavior in children. The risk of having children
develops such behavior can, however, be influenced by both genetic and social factors (Andershed &
Andershed, 2005, pp.66-67). Both children with an ADHD diagnosis and children who have experienced or been exposed
Jenny Gudmunds & Michaela Janemon
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for violence is at high risk of developing norm-breaking behavior in childhood (Andershed &
Andershed, 2005, pp. 101 and 142).
ADHD and exposure to violence
The onset of ADHD is mainly due to hereditary factors, although psychosocial factors are also
of importance (Nigg, 2012). The diagnosis of ADHD has increased significantly in recent years and is
nowadays a relatively common diagnosis where approximately 2-5% of all school-age children have the diagnosis (Broberg
et al., 2015, p.430). To be diagnosed with ADHD, the symptoms must be severe and lasting
and that they are noticeable in several different parts of everyday life (SBU, 2005, p.15). Simplified can ADHD
is described as a condition with difficulty in regulating its behavior. The symptoms of ADHD
changes over time and depends on age and severity. As children grow and that
the school work's demands for concentration increase, among other things the attention problems become more
noticeable (National Board of Health and Welfare, 2014b, p.13). The diagnosis is three to four times more common than among boys
than girls, indicating that girls may be underdiagnosed. Most likely the reason for this
It is believed that girls show more introverted symptoms such as depression and anxiety while boys
are considered to be more hyperactive and impulsive, which attracts more attention (Broberg et al.,
When diagnosing ADHD, there can be talk of various main symptoms. These different main symptoms
may be hyperactivity, attention deficit disorder or a combination of the two (Broberg et al.,
2015, pp.421-422). The hyperactivity, or overactivity as it is sometimes called, is manifested by
the children move more than others and that they have difficulty being still. Children, or mainly young people, with
ADHD is usually not visibly overactive but is more often expressed in that they easily become restless
and impatient. The attention problem is shown by the children easily losing focus and having
difficult to concentrate. They have difficulty following simple instructions and planning and organizing
their existence. Impulsivity is manifested by children having difficulty controlling their emotions and
hold back their reactions. The impulsivity allows them to expose themselves to dangerous situations when they have
difficult to think long-term (Kadesjö, 2010, p.19-20).
Some signs that children are exposed to physical violence can include poor hygiene, then
language development, poor growth, poor learning ability, difficulties interacting with other children and
contact-seeking behavior towards adults. Additional signs are difficulty concentrating,
overactivity, impulsivity and aggression as well as repetitive behavior. The latter points emphasize
the importance of examining whether the behavior is a consequence of ADHD as the symptoms are similar
(Janson, 2010, pp.25-26). It is possible to see strong connections between crime, PTSD and the general public
behavioral problems during adolescence and depression in adults who have been exposed to physical violence
as a child (Janson, 2010, p.23). About 20% of children who are exposed to violence develop some type of
norm-breaking behavior. In children with norm-breaking behavior, children who have been exposed to or
experienced violence an overrepresented group. One reason for this may be that the children imitate
parents' aggressive actions and ways of resolving conflicts (Andershed & Andershed, 2005,
p.101).
A risk factor for a child to be exposed to physical violence at home is if the child suffers from prolonged
illness or disability. Children belonging to these categories have been exposed about twice as much
often for physical violence in the home compared to children without illness or disability (Janson,
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2010, p.19). Furthermore, Jansson (2010) describes that possible reasons for this may include that
these children may have poorer social networks and therefore fewer people who can detect violence. The
may also be due to the fact that children with, for example, ADHD can be perceived as challenging for the parents
and that parents in these cases may have difficulty understanding that the behavior has with one
disability to do. Children with difficulties in attention and concentration
are particularly vulnerable to corporal punishment (Janson, 2010, p.19). When it comes to health factors can
there is talk of strong physique, cognitive ability and social skills. Something that has a clear connection
with the child's ability to cope with difficult growing up conditions is a safe and lasting relationship with one
affirmative adult (Broberg et al., 2015, p.363).
If a child experiences domestic violence, it can also lead to the child becoming mentally ill. Children who
experienced violence is at higher risk of developing mental illness than children who have not experienced violence (Broberg
et al., 2011, p.9). There are similarities in the consequences if a child is directly exposed to or experiences
violence. The child may develop mental illness such as depression, anxiety, aggression,
difficulty concentrating and hyperactivity. It can also lead to the child getting a disoriented one
connection to the parents and risks developing PTSD and chronic stress (National Board of Health and Welfare,
2016, p.30). When children themselves have been asked about the usual consequences of being exposed to violence, they have
mentioned fear, anxiety, low self-esteem, stigma and insecurity (Buckley, Holt & Whelan, 2007, pp. 301–
304).
The symptoms for children affected by PTSD look different but in many cases some type of
behavior change (Broberg et al., 2015, p.277). Then it is common for children to experience
Scary events react in any way, it may be important to wait about a month for
to see how the symptoms develop before a therapist starts any type of treatment or
investigation of PTSD. In the meantime, however, the child's support should focus on comfort, in general
care and practical support for both the child and the family (Broberg et al., 2015, p.329). One
Some children continue after this time are affected by what happened to them in a way that can be classified as
PTSD. This is characterized by the child involuntarily reliving painful memories from one
traumatic event and can thereby be put in the same fear as when the event occurred
(Broberg et al., 2015, pp.330-331). These experiences can cause physiological reactions in the form of
irritability, restlessness, difficulty concentrating, difficulty relaxing and difficulty
fall asleep. It can also lead to avoidant symptoms.
The child's development is an ongoing process where individual differences, biological conditions, the child's interaction history and its emotional and thought life come into play. In the behavioral analysis, the interaction between the child's environment and its own reactions is investigated. The therapist systematically maps how situational factors, behavioral patterns and the consequences of the child's behavior affect each other. The behavioral analysis thus aims to gather knowledge about how the child is affected by and affects his environment.
After the analysis, the treatment can be carefully planned with regard to the child's uniqueness and to the family and the environment in general. The goal is not only to eliminate problem behaviors and associated suffering, but even more to help the child develop lasting useful skills. The most effective results are achieved when the treatment is focused on both children, family and the environment.
In the 1950s and 1960s, behavioral therapy began to be used more systematically in the treatment of children and families. In the beginning, they worked mostly with developmentally disabled and severely disturbed children and young people, often in institutions. Many of the basic learning psychological principles that were then applied still have bearing capacity - such as gradual approach, model learning and positive reinforcement.
What has come to be known as the behavior-system perspective was formed in the 1970s and 1980s on the basis of well-documented research. The treatment goals and application were expanded and became more general in clinical child psychology, family treatment, health psychology and behavioral pediatrics. The behavior-system perspective meant that the treatment required efforts on many levels, in different environments and with a number of people involved.
During the 1990s, the development has continued, with more detailed analysis methods and an extension of the treatment to include such diverse issues as juvenile delinquency, prevention of mental illness in children, classroom problems and learning difficulties.
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