Power relations in a school context: Resistance of Chinese caregivers of school-aged children with attention-deficit hyperactivity disorder

Family–school interaction

Interaction with the school system is a significant experience for parents of children with ADHD. However, it is an under-explored area in research. A few studies illuminate the voices of parents of children with ADHD and highlight their marginalized position of interacting with school systems (Bacon and Causton-Theoharis, 2013; Broomhead, 2013; Honkasilta et al., 2015). A systematic review of six qualitative studies shows that parents, especially mothers, are silenced in their interaction with various school personnel and are forced to submit to the school’s authority, rather than having their opinions and grievances heard (Gwernan et al., 2015). Parents have little say in defining whether their children’s behaviors are acceptable at school. Teachers’ professional expertise is given priority and parents’ knowledge regarding their children with ADHD is insufficiently recognized. Teachers are perceived as having domineering power over parents of children with ADHD, even in relation to home–school collaboration (Honkasilta et al., 2015). In addition, parents are held responsible for the symptomatic behaviors of their children with ADHD at school and are blamed for inappropriate parenting (Broomhead, 2013). This appears to constitute a global phenomenon, as even in developed countries, such as Canada, the United Kingdom, the United States, and Australia, parents of children with ADHD are largely discontent and powerless in family–school interactions (Gwernan et al., 2015). The extant literature views parents as powerless and inadequately captures the complexity of family–school interactions in modern societies worldwide, including Hong Kong.

Social work research that explores and responds to the difficult situations of parents of children with ADHD in their interaction with the school system is rare. Prevailing social work studies on parents of children with ADHD concern parenting (Corcoran et al., 2017) and management of children’s symptoms (Barlow and Coren, 2018). There is a lack of both Western and local research devoted to understanding the dynamics of parent–teacher interactions at school, particularly exploring how parents can be empowered in encounters with the school system.

Taking account of the sociocultural context of Hong Kong, family–school interaction provides a significant area to explore as children with ADHD receive whole-day schooling in mainstream schools under the inclusive education policy executed in 1997. Children with ADHD are more likely to experience rejection at school than students with other special learning needs (Hong Kong Institute of Education, 2012). Lack of adequate training for and support of teachers about ADHD, the rigid education curriculum, and teachers’ negative attitude toward diversity in the classroom limit the ability of inclusive education to cater for children with ADHD (Chan and Lo, 2017).

The Foucauldian concept of power relations

In contrast to his counterparts Max Weber (1968) and Steven Lukes (2005), who adopt a dichotomous view of the powerful and the powerless, Foucault describes the fluid nature of power, leading to diverse forms of power relations, with no absolute division between the powerful and the powerless. He promotes the study of the ‘micro-physics’ of power relations in the social process:

The study of this micro-physics presupposes that the power exercised on the body is conceived not as a property, but as a strategy, that its effect of domination is attributed not to ‘appropriation’, but to dispositions, manoeuvres, tactics, techniques, functionings; that one should decipher in it a network of relations, constantly in tension, in activity, rather than a privilege that one might possess; . . . in short this power is exercised rather than possessed. (Foucault, 1979: 26)

In his discussion of power relations, Foucault (1979) conceptualizes discipline as a combination of ‘docility and utility’ (p. 137), and states that institutions, such as schools, adopt disciplinary power to ensure surveillance over individuals (Foucault, 1979). Individuals are made to be both obedient and useful subjects through three disciplinary instruments: (1) hierarchical observation, (2) normalizing judgment, and (3) examination. Those who do not measure up to the standard are labeled as ‘abnormal’ and are subjected to treatment.

Children with ADHD in school constitute a good illustration of the exercise of modern disciplinary power. The symptomatic behaviors, such as inattention and hyperactivity, disqualify these children from being considered ‘normal’ in an orderly classroom (Comstock, 2011). The school system borrows the power of the medical system to make children conform to the norms of the school through the administration of drugs. However, it is not only children with ADHD who are affected by the disciplinary power of the school system, as parents who fail to make their children with ADHD conform to schools’ disciplinary power can also face negative feedback from the school.

‘Resistance’ is an important concept in the microdynamics of power relations, as ‘every power relationship implies a strategy of struggle’ (Foucault, 1982: 794). From Foucault’s (1982) perspective, a fundamental driving force of resistance in power relations is to ‘assert the right to be different’ and make ‘individuals truly individual’ (p. 781). Children with ADHD are perceived to be different from other children, as they tend to be inattentive and impulsive and exert poor self-control. These children and their parents are situated in a school system in which normative discourse defines the appropriateness or otherwise of specific behaviors.

‘Freedom’ is a significant element that endows individuals with a range of options for responding to power relations, as ‘power is exercised only over free subjects . . . slavery is not a power relationship when man is in chains . . . the relationship between power and freedom’s refusal to submit cannot be separated’ (Foucault, 1982: 790).

However, freedom is not a fundamental concept in Chinese Confucianism. Submission and obedience to hierarchical authority are culturally ingrained in order to promote social order and harmony in families and society (Wang, 2013). Although Hong Kong has been influenced by Western ideas due to colonial rule, Confucian values are still dominant and exert a subtle influence in social relationships (Lieber et al., 2006). Taking these together, this study explores the following research questions: (1) How do caregivers of Chinese children with ADHD interact with the school system regarding the child’s ADHD? (2) How do Chinese caregivers respond to the school system if there is any disagreement between teachers and caregivers?

Sampling design

This study was part of a project conducted jointly by the Department of Psychiatry and the Department of Social Work in The Chinese University of Hong Kong. Purposive sampling was used to recruit research participants. The inclusion criterion was Chinese caregivers of school-age children aged between 6 and 12 years diagnosed with ADHD. Caregivers whose children were diagnosed with limited intelligence were excluded from the study as their interactions with the school system may be different from those parents whose children have ADHD only. The majority of research participants were referred by the child and adolescent mental health clinic in the Alice Ho Miu Ling Nethersole Hospital in the New Territories, which serves approximately 20 percent of children with ADHD in Hong Kong (Lai, 2006). Other research participants were referred by social welfare agencies, or were self-referrals. These caregivers joined the study on a voluntary basis with written informed consent.

Study participants

Study participants were 58 caregivers from 47 Chinese families with school-aged children diagnosed with ADHD according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013). The majority of caregivers were mothers (72.4%), predominantly married (72.4%), and with secondary school education (55.2%). Most (46.6%) were low-income families with a monthly household income ranging from HK$10,000 to HK$20,000 (£842–£1685). Table 1 shows the sociodemographic profiles of the study participants. Most children were boys (87%) aged 7 (36.2%) and 8 (29.8%). Table 2 shows the profile of the children of the study participants. All children studied in mainstream primary schools under the integrated education policy.

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Table 1.

Profile of participants of this study (total N = 58).

Characteristic	No. of participants (%)
Relationship with the child
Mother	42 (72.4)
Father	14 (24.1)
Others
Grandmother	1 (1.7)
Elder sister	1 (1.7)
Marital status
Married	42 (72.4)
Single	12 (20.7)
Unknown	4 (6.9)
Education level
Primary	4 (6.9)
Secondary	32 (55.2)
Post-secondary	17 (29.3)
Unknown	5 (8.6)
Household monthly income
On social welfare	5 (8.6)
<HK$10,000 (£842)	1 (1.7)
HK$10,000–HK$20,000 (£842–£1685)	27 (46.6)
HK$20,000–HK$30,000 (£1685–£2527)	5 (8.6)
>HK$30,000 (£2527)	15 (25.9)
Unknown	5 (8.6)

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Table 2.

Profile of children of participants (total N = 47).

	No. of children (%)
Sex of children
Boys	41 (87.2)
Girls	6 (12.8)
Age of children
6–7 years old	22 (46.8)
8–9 years old	20 (42.6)
10–12 years old	5 (10.6)

Data collection

Written informed consent was obtained from participants, who were made aware of their right to confidentiality, anonymity, and to withdraw from the study. This study was granted ethical approval by the Survey and Behavioral Research Ethics Committee of our university.

Focus group interviews were adopted as the means of data collection so as to gain a broad understanding of and a wide range of perspectives on the phenomenon under study (Linhorst, 2002). Data were collected from seven focus group interviews, each of which was audio-recorded with group members’ prior consent. The duration of each focus group interview was between 1.5 and 2 hours. The first and second authors, together with a professional consultant and a PhD student, both of whom are experienced in child mental health, acted as moderators of the focus group discussions. Initially, the moderators asked open-ended questions to allow participants to freely talk about any significant experiences in their interaction with the school system during the diagnosis and treatment process. The moderators then employed exploration and focusing skills to elicit diverse perspectives from different participants and to probe for more detailed information relating to issues of power relations, such as all forms of disagreement with the school system. The moderators were sensitive to group dynamics and the need to build a mutual feeling that ‘we are all in the same boat’, while at the same time recognizing the unique experience of each participant in order to encourage them to share their experiences. Each participant was given space to share his or her voice and was listened to with respect.

Data analysis

The focus group discussions took place using Cantonese, the principal dialect spoken in Hong Kong, so as to capture participants’ original meaning as far as possible. Transcripts of the audio recordings of the sessions were then translated into English by the first author. Verbatim extracts from these interviews are used in this article to illustrate key themes that emerged from subsequent data analysis.

Thematic analysis is a pragmatic and convenient method of identifying key patterns or themes from data in a qualitative study (Braun and Clarke, 2006). Interview transcripts were read and reread to generate initial codes across the entire dataset. Codes were then further categorized into fundamental themes. The themes were revisited once more to ensure that they connected to the codes and the entire dataset. The initial analysis gave rise to a comprehensive analysis of the entire dataset. Building on this analysis, dominant themes related to the research questions were further identified, and literature relevant to the dominant emergent themes was studied. This process was repeated several times until the themes fully emerged from the data. A recursive process of literature and data-driven analysis allowed the researchers to obtain a deeper understanding of the data. During the process of analysis, reflexivity was upheld and introspective dialogue of the first author was conducted to create space for the unknown and to ensure that the identified themes were not constrained by the preoccupied perspective or the emotional involvement of a single author (Probst and Berenson, 2014).

Emerging themes

As informed by the Foucauldian concept of the micro-physics of power relations (Foucault, 1979), the power of caregivers in this study is expressed through their exercise of strategies or struggles in the face of the school system’s domination. Three levels of resistance strategies representing varying degrees of struggle emerged from the data: (1) cognitive resistance, in which the struggles occur at the intellectual level, (2) behavioral resistance, in which the struggles are enacted, and (3) a transcendent vision of education, in which the parents project an alternative mission of education.

Inappropriate school rules

Some parents struggled cognitively with the imposition of school rules and showed their disapproval of them. Children with ADHD have difficulty conforming to a strictly disciplined school, and the parents challenged school rules that were inappropriate for their children, such as the prohibition of running in school. One mother expressed disapproval of the school rules as her child was punished simply for walking fast in school:

My child has difficulty at school. He was even punished for walking fast to the toilet. His misbehavior was marked in his student handbook. (Mrs U, mother of a 7-year-old child)

Lack of support for children with ADHD

Some parents struggled cognitively with the domination of the school system that provided insufficient support for their child. Children diagnosed with ADHD often require special learning support from the school. In Hong Kong, children are only provided with learning support if parents submit proof of the diagnosis from a psychiatrist in a public hospital. However, there is no guarantee that the school will offer learning support even if such proof is provided. One mother showed cognitive disapproval of this situation:

It is unacceptable that even though my child has received a diagnosis of ADHD, he still cannot receive any support from the school. (Mrs L, mother of an 8-year-old child)

Claim of the professionalism of teachers

Some parents struggled cognitively and questioned the way teachers managed their children. Parents have their own perspectives regarding the needs of their children, which may be incompatible with the school’s guidelines for teachers. For example, one mother initially followed the advice from the school about the proper management of her child, but later found this to be detrimental to her son due to the labeling effect of the special treatment:

My son was asked to sit in the front of the classroom in primary three. Yet, the effect was bad as he was labeled and his academic performance dropped significantly. My son doesn’t need this kind of special arrangement. He only needs some opportunities for physically serving the school . . . (Mrs O, mother of a 10-year-old child)

Parents questioned the professional expertise of teachers on ADHD and whether they had sufficient professional knowledge or competence to offer advice on diagnosis of ADHD and to adopt appreciation and recognition to manage their children at school. Teachers were expected to enrich their professional knowledge of ADHD through attending psychoeducational sessions in which knowledge about the symptoms and management of ADHD are shared:

One thing is crucial: teachers should attend psychoeducational talks to understand more about ADHD children . . . If teachers can understand him, using appreciation and recognition will be very different from condemning him during this developmental stage. (Mrs R, mother of a 9-year-old child)

My eldest son is now in primary six . . . When he was in primary one . . . the teacher said my son’s behavior was not so serious to warrant such an assessment . . . I trusted the teacher’s professional judgment. I . . . wonder why I didn’t act against the teacher’s advice at that time. (Mrs W, mother of a 10-year-old child)

Lack of collaboration and blaming parents

Parents of children with ADHD struggled cognitively with the domination of teachers at school. They do not expect teachers to hold them totally responsible for the symptomatic behaviors of their children at school. One-way communication, with teachers complaining about the problems of the child at school, instilled in parents that there is a lack of mutual cooperation, and they disagreed that they should be blamed as negligent and incapable of disciplining their children:

There was also no support for the parents. The teachers only phoned me to complain about the problem caused by my child. (Mrs J, mother of an 8-year-old child)

There was no collaboration from the school. (Mrs I, mother of a 10-year-old child)

The teachers themselves are smart, and . . . they do not understand those who are not smart. They think that it must be the parents who do not teach their children well; parents who spend long hours at work and entrust their children to domestic helpers. (Mrs G, mother of a 9-year-old child)

Identification of ADHD in children

It was often school teachers who identified ADHD and initiated the process of assessment and diagnosis when children showed dysfunctional school behavior. However, at times there were divergent understandings of the symptomatic behaviors and the school refused to make a referral for assessment of ADHD. One father acted against the recommendations of the school and took the initiative to seek a diagnosis for his son:

I watched TV and found that my son’s behavior fell neatly into the definition of ADHD. So I asked the school to refer my son for assessment. The school called me to complain about my son every day since he was in grade two, but the school said that my son’s school results were satisfactory, and his conduct was fine without any demerits. However, I knew that my son had problems, and I went to an assessment center to request an assessment. (Mr C, father of a 9-year-old child)

Psychostimulant medication for children with ADHD

Psychostimulant medication is effective in controlling symptoms in children with ADHD, and medicalizing children with ADHD is often perceived as a sign of parental cooperation by the school authorities. However, some parents resist medication, seeing it as a last resort to help their children adjust in school. Parents were worried about the side effects of medication, overreliance on medication, and damage to their child’s physical and psychological development:

I resist medicating my child. I am afraid of its side-effects. It is also not good for their physical and psychological development. Over-reliance on medication and using it as an excuse is not good. I hope to try other treatments such as behavioral therapy before trying medication. (Mr D, father of an 8-year-old child)

Negotiations with school teachers

Despite the phenomenon of parent-blaming, parents resist the disciplinary powers of the school by negotiating with the teachers. A diagnosis does not guarantee understanding of the condition, and effective teacher–family collaboration does not always occur. One mother reported the following experience with a teacher who did not accommodate her son’s special needs:

My son was admitted to the tutorial class at school. The psychologist advised that he should be given rest time during the tutorial class. I found that the teacher did not follow these instructions . . . I phoned the teacher to express my concerns and was blamed for not telling her sooner. (Mrs L, mother of an 8-year-old child)

Parents also take action to resist when they find that their children are psychologically harmed by the mismanagement of the teachers. One mother confronted a teacher about injuring the dignity of her child. When the teacher did not show any signs of regret, the mother finally complained to the principal:

I told the class teacher that my son had ADHD because she always said that my son was bad . . . Once my child caused the whole class to misbehave. The class teacher announced in front of the class that my child had ADHD and asked the whole class to pity my son . . . I confronted the teacher on the phone. I told the teacher that she should not say this to my son. I expected cooperation with the teacher when I revealed my son’s diagnosis to her . . . The teacher still said that it was not her fault. After tolerating this for half a year, I reported it to the school. (Mrs K, mother of an 8-year-old child)

This mother hid the negotiation with the teacher from her son, as she did not want him to have a negative image of the teacher:

Even though I am wrestling with the teacher, I do not want my son to see it. As she was my son’s teacher, I would not say something negative about the teacher in front of my son.

Changing schools for children with ADHD

Parents are concerned about finding a suitable and supportive school for their children with ADHD. Contrary to the dominant cultural value that the ‘goodness’ of a child can be measured by his or her academic performance, one father planned to change his son’s school to one that was less academically oriented and more tolerant of children with ADHD, in order to help his son improve his self-confidence:

I find that the current school is not very accepting of my son. I plan to change to a school that is not so academically focused and can be more accepting of my son. At least then his self-confidence can be built up. (Mr B, father of a 7-year-old child)

Imbalanced educational system

They considered that the existing educational system was ill-suited to children with ADHD. Educational policy and society in general are regarded as being academically obsessed, as every child is pushed toward better academic performance. The whole-day school system, in which a child is expected to sit in the classroom, learn passively for long periods of time, and is given a lot of homework to do after school, is not suitable for children with ADHD. Less homework and more freedom is more favorable to children with ADHD:

Society has given us lots of pressure. I want to give my children more freedom. (Mr A, father of a 7-year-old child)

The most difficult thing that makes my head ache is to do homework with my son. It always takes me three hours to finish his homework with him. (Mrs F, mother of a 7-year-old child)

Alternative provision of education

Parents proposed alternative education provision that could cater to the needs of their children. It represents a paradigm shift of fundamental values and orientation of education to create a more accommodating ecological niche for children with ADHD. From the perspective of the parents, the alternative approach to education recognizes, appreciates, and develops the strengths of children with ADHD, rather than focusing only on academic and behavioral performance:

Appreciation is paramount . . . in fact, he has other strengths that deserve appreciation. (Mrs T, mother of an 8-year-old child)

In addition, an education that includes more physical exercise and is activity-based to accommodate the characteristics of children with ADHD is envisioned:

The curriculum should be designed according to the needs of our children. If they want to run, just let them run. (Mrs O, mother of a 10-year-old child)

The curriculum is filled with too much passive studying in the classroom instead of activity-based learning . . . It was so dull . . . (Mrs J, mother of an 8-year-old child)