Stigma and Stigma Resilience: Role of the Undergraduate and the Campus Environment

Abstract

Rationale:

Stigma permeates disability experiences and compounds disability-related challenges.

Objective:

Identify individual and environmental factors of stigmatizing experiences of college students with learning disabilities (LD) and attention-deficit/hyperactivity disorder (ADHD).

Methodology:

A qualitative descriptive design was used with a thematic analysis of 30 transcripts from group discussions among four cohorts of undergraduates with LD/ADHD (N = 52). The Person-Environment-Occupation-Performance Model was used in interpreting the stigmatizing experiences.

Findings:

The themes Perceived Misconceptions and Stigmatizing Actions describe key social-environmental factors. The theme Overcoming Stigmatizing Experiences elucidates key skills and processes for developing stigma resilience. These skills and processes were anchored in self-awareness and personally contextualized understanding of disability-related challenges and strengths, which were fostered during positive interactions with supportive others such as instructors and mentors.

Implications:

Findings illustrate the biopsychosocial nature of stigma and highlight the role of individual and social-environmental factors in building stigma resilience among young adults with LD/ADHD.

Plain Language Title:

Understanding Stigma and Resilience Among College Students with Learning Disabilities and ADHD

Plain Language Summary:

We studied how college students with learning disabilities (LD) and attention-deficit/hyperactivity disorder (ADHD) experience stigma, which means feeling judged or treated unfairly because of their disabilities. We talked to 52 undergraduates in four groups to understand their experiences and found three main things related to stigma. First, students feel like others have wrong ideas about them and their disabilities. Second, they experience actions from others that make them feel stigmatized. Third, they develop ways to overcome these experiences. Students became more resilient to stigma when they understood themselves better and had support from others like teachers and mentors. Stigma is not just a personal thing for students with LD/ADHD; it’s also influenced by the people around them and how they see themselves.

Background

Stigma surrounds disabilities and compounds disability-related challenges (Daley & Rappolt-Schlichtmann, 2018; Grue, 2016). Young people with learning disabilities (LD) and attention-deficit/hyperactivity disorder (ADHD) face disability-related challenges (i.e., person factor) to their college success (i.e., occupation factor) that extend beyond the classroom (i.e., environment factor) to the broader aspects of their new and emerging adult roles and contexts (Kreider et al., 2018; Kreider et al., 2015). Challenges place students with LD/ADHD at risk for not meeting personal, classroom, and social expectations, which may impact abilities for autonomous engagement and constrain participation in all that college and emerging adulthood entails (Kreider et al., 2019; Kreider et al., 2015; Sharfi & Rosenblum, 2014).

LD and ADHD refer to developmental neurological conditions that are highly prevalent and frequently co-occur, with each having prevalence estimates of 5% to 10% of the general population (Centers for Disease Control and Prevention, 2017; Cortiella & Horowitz, 2014; DuPaul et al., 2013; Skokauskas & Gallagher, 2012). Notably, the prevalence jumps to 20% when including those whose learning and attention challenges are enough to negatively impact school and daily-life performance, but not necessarily severe enough to warrant a clinical diagnosis or special education supports (Horowitz et al., 2017). Despite similar post-secondary attendance rates (Cortiella & Horowitz, 2014), completion rates remain significantly lower for young adults with LD/ADHD (41%) compared to those without disabilities (52%) (Horowitz et al., 2017).

Stigma is a complex social construct entailing negative attitudes and beliefs about individuals that are communicated and acted on in ways that lead to lower self-esteem (Kasturkar et al., 2021), mental distress (Dolezal, 2022), reduced quality of life (Kasturkar et al., 2021), and, for clinical populations, barriers to healthcare (Dolezal, 2022) and health promoting social support (Rueda et al., 2016). Stigma is also a social determinant of health that creates added burden for individuals with disabilities (Hatzenbuehler et al., 2013). For those with LD/ADHD, stigma is underpinned by a lack of public understanding about LD/ADHD, which contributes to misconceptions surrounding the conditions and can increase risks for not graduating (Horowitz et al., 2017).

Negative psychological impacts stem from three primary types of stigmas. Intra-personal stigma occurs when the negative perceptions of others are internalized by the individual, resulting in negative self-perception (Corrigan & Rao, 2012). Inter-personal stigma is common and range from overt actions such as name calling to subtle microaggressions that invalidate symptoms (Gonzalez et al., 2015). Structural sigma stems from societal views, cultural norms, and institutional policies that impact inequalities and constrain access to supports (Goldberg, 2017). The existence of stigma toward individuals with hidden disabilities is well documented and can exacerbate disability-related challenges experienced during college (Kenyon et al., 2014; May & Stone, 2010; Orr & Goodman, 2010; Shapiro & Margolis, 1988; Varma & Wiener, 2020). Resilience is a key resource for coping with stigma (Boarman et al., 2011; Fletcher et al., 2020).

Resilience is a protective factor that is strongly associated with positive health outcomes and increases in social functioning for individuals with disabilities (Silverman et al., 2015). Resilience is both an outcome, whereby individuals achieve a state of being resilient or achieving competencies for overcoming adversities (van Breda, 2018), and a process used to manage significant sources of stress or trauma (Windle, 2011). The process entails the effective navigation of and adaptation to the stress or trauma. This capacity for adaptation and ability to bounce back from adversity requires the activation of resources from within the individual and from the environment (Windle, 2011; van Breda, 2018).

We sought to examine stigma through the lens of the Person-Environment-Occupation-Performance (PEOP) Model (Baum, 2015) whereby individuals’ characteristics (e.g., young adult with LD/ADHD), environmental factors (e.g., social climate), and activities they engage in (e.g., managing stigma) are interconnected factors influencing occupational performance of young adults with LD/ADHD in college. We aimed to explicate individual and environmental factors and to explore impacts on the occupation of developing resilience to stigmatizing events.

Methods

A qualitative descriptive design (Vaismoradi et al., 2016) was used to examine the stigma-related aspects of everyday life experiences for undergraduates with LD/ADHD. This study reports on analysis of existing data that were collected as part of a larger study. An earlier publication reports details of the original study (Kreider et al., 2018); the study’s design and procedures are briefly summarized here.

Study Overview

Study activities occurred on a large research-intensive university in the southeastern United States. Oversight was provided by the University’s Health Science Center Institutional Review Board with informed consent obtained prior to engaging in study procedures. The original study was designed to implement and test a multi-level and multi-component model of holistic supports for undergraduates with LD/ADHD enrolled in science, technology, engineering, and math (STEM), which included the social, behavioral, and economic sciences. The model had three levels of supports that included study activities at the undergraduate level, mentor level, and campus personnel and administration level.

Undergraduates with LD/ADHD were enrolled for two academic years. Supports included monthly group meetings, mentorship, and engagement in LD/ADHD-related advocacy activities with group meetings open only to active study participants. Disability-related information and resources were presented and discussed during group meetings. Meeting topics such as time management, academic accommodations, cognitive styles, and symptom manifestations were presented. Following topic presentation, facilitated discussions were held to understand experiences relative to the topic. Facilitators encouraged critical thinking about challenging experiences shared by participants.

The undergraduates with LD/ADHD were also matched with a graduate student mentor in the same or similar field of study. Mentor/mentee dyads met one-to-one every other week. Topical information provided to the undergraduate mentees were shared with mentors.

At the campus level, study activities involved development and engagement in campus-based disability-awareness events, dissemination of LD/ADHD-related information materials developed by undergraduate participants, and the development of a campus-wide committee focused on improving supports for students with disabilities in classrooms and student service offices.

Participants

Undergraduate participants totaled 52 (n = 26 male, n = 24 female, n = 2 not reported; age 21.2 ± 3.5 years, 18 – 33 years; Table 1). Inclusion criteria were (1) registration with the campus disability office and eligible to receive accommodations related to learning disabilities, which was categorized by the campus disability office to include disorders of reading, writing, math, coordination, auditory processing, language processing, and/or attention disorders; (2) anticipated graduation ≥ two years from study enrolment; and (3) majoring in STEM as consistent with the funder’s priorities.

Table 1.

Participant Characteristics

Characteristic	Count (%)
Diagnostic category
LD	22 (42)
ADHD	18 (35)
LD & ADHD	12 (23)
Gender
Male	26 (50)
Female	24 (46)
Not reported	2 (4)
Race
White	37 (71)
Black	8 (15)
Asian	1 (2)
Other	4 (8)
Not reported	2 (4)
Field of Study
Physical/Biological Sciences∞	22 (38)
Social/Behavioral/Economic Sciences	17 (30)
Technology	1 (2)
Engineering	15 (26)
Mathematics	2 (4)

^∞includes chemistry, physics, astronomy, earth/ocean/atmospheric, agricultural, environmental, life, health science

Data

Undergraduate group meetings were audio recorded and transcribed. Data were 30 transcripts and field notes from these meetings collected over the four-year study period. Topical content areas presented did not include stigma, and thus no information specific to stigma was presented nor were discussions facilitated specific to stigma. The study team noted that each transcript contained extensive information regarding stigma experiences, and thus all transcripts were analysed.

Analysis

Stigmatizing experiences were operationalized as the perceived disparaging communications and/or attitudes of others regarding LD/ADHD symptoms and/or experiences. We utilized the PEOP Model to guide conceptualization of how stigmatizing experiences may impact undergraduates with LD/ADHD. The components of the PEOP model were not employed as a coding framework to avoid initially narrowing the analytic focus and to capture all data related to participant’s stigmatizing experiences. All the coders were practicing occupational therapists (OT) or doctoral level OT trainees, thus, the PEOP model was used to conceptually understand results that emerged from the data and guided our discussions about emerging themes and subthemes.

Thematic analysis was conducted with an analytic goal of identifying and explicating latent patterns related to participants’ stigma-related experiences (Sandelowski & Barroso, 2003; Vaismoradi et al., 2016). Structural coding was used to identify passages containing descriptions of stigmatizing experiences followed by cycles of in vivo and process coding. In vivo coding involved identifying words or short phrases describing experiences verbatim (Saldana, 2013). Process coding entailed the assignment of gerunds to identify participants’ interpretations of others’ stigmatizing actions and strategies described in response to overcoming stigmatizing experiences (Saldana, 2013).

Themes were developed through constant comparison of the data to emerging conceptualizations, involving initial code development, ongoing theme identification, and defining and refining themes (Vaismoradi et al., 2013). Weekly meetings among the lead coder and the senior researcher involved discussion and verification of codes and developing conceptualizations. NVivo version 12 qualitative data analysis software (QSR International Pty Ltd, 2018) supported data analysis. Trustworthiness was further enhanced through (1) reaching data saturation of themes and subthemes regarding stigma misconceptions and others’ actions, (2) thick descriptions, (3) peer debriefing of evolving conceptualizations to interdisciplinary qualitative researchers, (4) presentations of preliminary findings at scientific conferences, and (5) prolonged engagement with participants (Nowell et al., 2017).

Results

Two themes, Perceived Misconceptions and Stigmatizing Actions, describe the different forms of stigmatizing experiences recounted by participants, which explicate environment factors at interpersonal and societal levels. Occurrences were experienced across classroom, family, interpersonal, and workplace situations. A third theme, Overcoming Stigmatizing Experiences, describes experiences of coping with stigmatizing experiences. This theme describes relationships among key person and environment factors and the occupation of coping with stigma.

Theme 1: Perceived Misconceptions

The theme “Perceived Misconceptions” describes primarily environment factors that reflect participants’ assessment of others’ motivations, verbal communications, and actions resulting in stigmatizing situations (Table 2). Misconceptions were identified in the areas of (1) intelligence, (2) abilities to control LD/ADHD symptoms, (3) legitimacy of the LD/ADHD diagnosis, and (4) attributions of LD/ADHD symptoms as personal traits. The names selected to categorize the types of perceived misconceptions (i.e., sub-theme) reflect participants’ words regarding experiences.

Table 2.

Perceived Misconceptions Regarding Learning Disabilities and Attention-Deficit/Hyperactivity Disorder

Type of Misconception*	Description of Misconception	Perceived Impact	Representative quote
“LD/ADHD∞ Reflects Intelligence”	Misunderstanding that LD/ADHD affects a person’s intelligence: making them less intelligent than those without LD/ADHD.	Undermining the student results in feelings of inferiority and self-doubt. Students may question their intelligence or seek to prove themselves to others.	“People…assume that because I am slow, I am stupid or incompetent, but I understand things really well when given enough time.” [U1]
“LD/ADHD Can be Stopped”	Others’ beliefs that LD/ADHD can be controlled or cured.	Misunderstanding involuntary behaviors can make students feel guilty, frustrated, and misunderstood which can lead to issues with discipline in the classroom and negative feelings about self.	“It would be nice if people would understand not only is it something that I can’t control but it is something that is frustrating for me as well.” [U24]
“LD/ADHD is Not Real”	Misconception that LD/ADHD is not real because it is not physically manifested.	Societal ignorance can make students feel rejected and may cause them to harbor negative feelings that they need to cope with internally.	“People sometimes said that LD doesn’t exist. Because you cannot like physically see anything.” [U45]
“Diagnosis Defines the Individual”	Misunderstandings that were specific to the various diagnostic categories of LD/ADHD, such as dyslexia and attention deficit hyperactivity disorder.	Participants expressed feeling that the label of learning disability or attention disorder was inaccurate; they expressed frustrations over the assumption that LD/ADHD only affects learning or concentration and does not impact the other aspects of their lives.	“I wish that people understood not only how [LD/ADHD] affects academics, but how it affects everyday life, especially personal relationships and being able to relate to others.” [U48]

^*Names selected as types of misconceptions reflect the participants’ words regarding their experiences and represent participants’ perceived misconceptions

^∞LD/ADHD = Learning disability/Attention-deficit/hyperactivity disorder

“LD/ADHD reflects intelligence”.

This sub-theme reflects perceptions of mistaken beliefs of others regarding the extent that LD/ADHD impacts capabilities. Participants spoke of teachers, peers, and family members who assumed they were “stupid” [U34], “retarded” [U1], or “dumb” [U6] because they processed and understood classroom materials differently or at slower rates. “When you say you are slow, people automatically think you are stupid… [it’s as if] slow equals stupid, fast equals smart.” [U1]

Participants described feeling inferior to peers without LD/ADHD, with some fighting feelings of being incorrectly admitted to a competitive research-intensive university. Some described coping with the stigmatizing misconceptions regarding their intelligence by pointing to indicators of their intellectual, creative, and emotional intelligence. “Having an LD doesn’t mean you’re at a disadvantage; it means you see things differently, and that is what makes you special.” [U46]

“LD/ADHD can be stopped”.

This perceived misconception reflects impacts on participants stemming from others’ beliefs that LD/ADHD symptoms can be controlled or cured. Suggestions from others included (1) trying harder in school, (2) learning to speed read, (3) completing extra practice problems, (4) attending tutoring sessions, (5) reading more, and (6) taking more medication. “This is not something that I can just fix; it’s who I am…The fact that [LD/ADHD] still affects me after all these years is not a sign of laziness. It is a sign that I refuse to give up.” [U1] While some shared feelings of resentment toward their diagnosis, most considered their LD/ADHD integral to who they are and understood it to shape positive aspects of self, such as determination, work ethic, and creativity.

“LD/ADHD is not real”.

This sub-theme reflects interactions with others that were understood to be based on mistaken beliefs regarding the existence of LD/ADHD. Participants described wishing they could provide tangible evidence of LD/ADHD and spoke of the intuitive nature of understanding challenges around physical disabilities. “A lot of people who don’t have learning disabilities aren’t aware [that it is] an invisible disability…people don’t know what [we] have to go through.” [U43]

Several spoke of feeling stigma regarding use of academic accommodations, such as extended time for tests. They experienced stigmatizing behaviors that were rooted in denial of symptoms and impacts of LD/ADHD. This was done by indicating to participants the accommodation of extended time for test-taking was a “cop-out” [U8], an excuse, and an unfair advantage that enabled them to “manipulate the system.” [U50] As stated, “People don’t understand we need the accommodations provided to succeed; not because we want an easy way out.” [U40]

Some spoke of feeling such misconceptions were made worse when they performed well on exams, thus giving the impression that they did not need their accommodations. As described, “…telling people that I [take] advantage of [accommodations] because I need it, now changes the perception that other people have of me.” [U14] Regardless of decisions to conceal or pursue accommodations, participants overwhelmingly considered the disability accommodations to be integral to college success.

Participants also described feeling stigma around using medications such as medications for attention and/or anxiety symptoms. “I’m ashamed of my medication… I even fall prey to negative societal views. I wish I didn’t have to take it… [U14]

Participants also spoke of peers and instructors who made them feel as if manifestation of symptoms could or should be better controlled within the classroom, and that symptom manifestations were behaviors that reflect their motivation or level of classroom engagement. Symptoms related to attention were misinterpreted as not listening or not being engaged in the class. Some described feeling as if others viewed them as lazy or not trying – especially with regards to social flow or group work, where some had difficulty keeping pace due to issues of slower information processing speed. “…It’s really frustrating…people just don’t understand that I just need more time to organize my thoughts…” [U45] Several spoke of intentionally working to overcome classroom misperceptions by ensuring that they spoke up during class discussions and asked questions during lectures. Many felt their classroom and homework efforts were easily overlooked by teachers.

“Diagnosis defines the individual”.

This sub-theme reflects perceived misunderstandings by others that are specific to the diagnostic categories of LD and ADHD. Participants expressed feeling that the label learning disability or attention disorder was inaccurate and constrains understanding of LD/ADHD to affecting only school and abilities to pay attention. Participants spoke of the need for others to understand that LD/ADHD impacts all aspects of life, such as during social interactions and in organizing daily routines.

Theme 2: Stigmatizing Actions

Stigmatizing actions describe primarily environment factors that are drawn from participants’ interpretation of others’ actions. Stigmatizing actions included those that (1) were understood by participants to be based on inaccurate assumptions about LD/ADHD, and those that (2) feed societal stereotypes and discount the LD/ADHD condition (Table 3).

Table 3.

Stigmatizing Actions that Exacerbate Feelings of Stigma Around Having a Learning Disability or Attention Disorder

Type of Stigmatizing Action	Description of Action	Perceived Impact	Representative Quotations
Actions and/or communications indicating that understanding or assumptions about LD/ADHD are not correct	When people without LD/ADHD∞ make false assumptions about the person with LD/ADHD based on LD/ADHD stereotypes or prior experiences with others who have LD/ADHD.	Assumptions made by people without LD/ADHD can affect their attitudes toward students with LD/ADHD. Misunderstanding LD/ADHD symptoms is exhibited by teachers who make unhelpful recommendations to students who are experiencing LD/ADHD-related challenges.	“They shouldn’t assume that the student wasn’t paying attention. They shouldn’t assume the student is stupid. They should… wonder if the student has a learning disorder of some sort. But not to assume anything about anybody, and not to embarrass anybody or say anything catty or sassy or sarcastic.” [U8]
Actions that feed societal stereotypes	Media portrayals and/or website-based characterizations of LD/ADHD.	Media representations of LD/ADHD foster LD/ADHD stereotypes and overgeneralization of LD/ADHD symptomatology.	“Learning disabilities and ADHD and ADD… [get] oversimplified in the media. … By the time it comes down to treating others as individuals, others automatically go…to stereotypes.” [U6]
Actions and/or communications that discount LD/ADHD	When people without LD/ADHD misappropriate LD/ADHD as their own and/or minimize LD/ADHD-related challenges.	Dismissing and/or minimizing LD/ADHD symptoms can lead to a lack of appropriate support and contribute to the overall societal misunderstanding of LD/ADHD.	“A lot of people appropriate this kind of identity, so they’ll just spew out, “Oh, I have trouble paying attention. I must be ADD,” or “I must be ADHD.” [U13]

^∞LD/ADHD = Learning disability/Attention-deficit/hyperactivity disorder

Actions based on inaccurate assumptions.

Participants described ways in which others made inaccurate assumptions about LD/ADHD, such as acting as if LD/ADHD affects everyone in the same way. “… having the same LD as someone else doesn’t mean that it manifests itself in the same ways.” [U9] As articulated by another, “…overgeneralizing learning disabilities…undermines having a learning disability.” [U6] Participants spoke of how difficult it is to overcome an instructor’s preconceived notions of them. Some described interactions wherein the instructor’s previous experiences with other students with LD/ADHD resulted in the teacher inaccurately ascribing previous experiences as applicable to them. Dealing with such assumptions caused several to feel frustrated with their instructors, which contributed to participation constraints and discomfort in the classroom.

“…teachers, some are very flexible and understanding, but others are very difficult. I don’t know if they feel like we should challenge ourselves more, or if we are trying to rip off the system; but both ways it is [an] uncomfortable situation.”

[U50]

Actions that feed societal stereotypes and discount LD/ADHD.

Several expressed frustrations in how LD/ADHD is misrepresented on screen and spoke of ADHD as being portrayed in oversimplified ways, which they felt perpetrated stereotypes and overgeneralizations. They spoke of others using phases such as “I’m so ADHD” [U13] to describe transient difficulty with focusing. They shared how such use of the diagnosis as an adjective minimized or discounted their LD/ADHD challenges. “You…say how you feel it affects you, and then everyone [identifies] with that too. But it’s not really the same.” [U9]

Several spoke of experiences where their LD/ADHD was not just minimized, but also overlooked, and at times dismissed by peers, family, and instructors. “If I mention [my LD/ADHD], [my parents] don’t say anything because they don’t think it’s real.” [U8] Participants shared experiences of instructors dismissing requests for accommodations or refusing to provide the accommodations altogether. “I had professors…tell me…’you don’t need this,… you’re using [accommodations] as a scapegoat…It just made me feel really uncomfortable….A lot of professors…don’t understand, [they] assume that you’re…making it up and they’re so quick to judge you.” [U44]

Some reported instructors’ change in demeanor after revealing accommodation letters. “[Some professors say] …passive aggressive things… [they have] a kind of attitude about them or the way they say it,…it’s like they’re silently judging you… [and] don’t believe…your need for extra time.” [U34] While many coped with difficult instructors by defending their accommodation needs, participants also described instances of realizing when advocacy efforts were futile. Some found that it sometimes worked better to shift discussions away from needed accommodations to sharing with instructors how they learn best and which teaching methods were most helpful.

Theme 3: Overcoming Stigmatizing Experiences

The theme Overcoming Stigmatizing Experiences provides description of the interrelatedness of overcoming stigma and key person and environment factors. Important person factors include self-awareness, disability-related awareness, positive experiences advocating for needs, and abilities to articulate personal strengths. The critical environment factor was social support from mentors and teachers. This theme describes mental processes and strategies used in coping when encountering stigmatizing situations. Participants shared experiences in working toward, and for some achieving, the psychological task of overcoming stigmatizing experiences encountered. Experiences with perceived misconceptions occurred often and permeated all aspects of life. Misconceptions regarding LD/ADHD challenged participants to recognize that the stigmatizing misconceptions were not personal traits.

Coping with misconceptions required awareness of both positive and disability-related aspects of self. This understanding was foundational to abilities to advocate for LD/ADHD-related needs and articulate strengths. Integral to the process of learning to overcome misconceptions were participants’ positive experiences when they interacted with mentors and instructors who understood the LD/ADHD condition. Supportive instructors and mentors, who understood the need for academic accommodations created a welcoming environment in which participants felt more comfortable in articulating their needs. As shared,

“…one time I told this professor my symptoms, and she’s like, ‘Oh yeah, my son has ADHD. This is what we do to help him…Then halfway through the semester I was like, ‘Look, this isn’t working. Can we change the way you’re teaching the class?’ She totally changed the entire class format... really beneficial.”

[U19]

Supportive campus personnel provided vital opportunities for participants to advocate for needs and articulate - and thus strengthen - understanding of personal strengths. Positive experiences with understanding campus personnel, in combination with practice in articulating and framing for others one’s personal strengths when advocating to instructors (as opposed to describing or disclosing their disability condition), served to bolster positive self-conceptualizations. Positive self-conceptualizations underpinned abilities to resist internalizing the societal stigmas experienced.

Coping with stigmatizing actions was underpinned by understanding about oneself and the LD/ADHD condition. In discussing personal impacts of the stigmatizing experiences, one expressed,

“It’s definitely made me more assertive…I’ve had… instances where a professor or a [teaching assistant] really tried to blow me off…So, I had to really talk to myself and be like, ‘…These are office hours. You deserve this time’.”

[U15]

Vigilance to stigmatizing attitudes and actions, in combination with awareness about self and the LD/ADHD condition, enabled participants to better advocate in the moment.

Coping with stigma involved a combination of knowledge, skills, and strategy use that entailed a focus on personal strengths, self-advocacy, and self-reflection (Table 4).

Table 4.

Key Skills for Coping with Perceived Misconceptions and Stigmatizing Actions of Others

Skill Category	Description	Application	Representative Quote
Focus on personal strengths	Participants expressed acceptance and appreciation of LD/ADHD∞-related attributes.	Determination that comes from successes with persevering and overcoming LD/ADHD challenges Being able to think creatively to solve problems Thinking differently than peers without LD/ADHD to add a new perspective to a team Understanding preferred cognitive and learning styles (e.g., “big-picture thinking”) and situations in which preferred styles work best	“… it used to … make me feel bad and little inferior because I had to try harder than my peers, but then I… turned it around … I have to try harder but it builds character.” [U8]
Self-advocacy	Participants demonstrated advocacy for LD/ADHD-related attributes.	Validating their own intelligence against others’ misconceptions Justifying the amount of effort they put into academic endeavors Articulating their worth to others Defending their use of accommodations Rationalizing their need for medications Advocating for the acceptance of individuals with LD/ADHD	“A learning disability may hold me back at times, but it does not define me or slow me down in all areas.” [U3]
Self-reflection	Participants reflected upon instances of stigmatizing experiences and recalled actions, emotional responses, and beliefs that helped them cope with stigmatizing events.	Reflecting on how they reacted to a stigmatizing experience and contemplating potential future responses during similar situations Acknowledging how they perceive themselves after a stigmatizing event Expressing openness to understanding others’ perspectives Articulating how they feel after a stigmatizing event	“I don’t think [LD] needs to be fixed. It’s about learning how to cope with it and learning your strengths and weaknesses, how to deal with that.” [U43]

^∞LD/ADHD = Learning disability/Attention-deficit/hyperactivity disorder

In coping with stigmatizing situations, effective strategy use involved knowing when and how to apply the key skills of self-advocacy and self-reflection in combination with LD/ADHD-related knowledge as part of the process of appraising the situation. LD/ADHD-related knowledge (e.g., symptom understanding) in combination with personalized understanding of the LD/ADHD (i.e., understanding symptom-related impacts within personal situations) enabled participants to distinguish between LD/ADHD symptoms and personal characteristics. “It may be more helpful not to say… I have ADHD… It’s more about describing what it is you need so that they know how to help you.” [U9]

Regardless of participants’ strategy, skill, and knowledge levels, the pervasiveness of societal stigma compelled them to be vigilant to the stigmatizing attitudes, messages, and actions of others to better advocate for themselves and for their LD/ADHD-related needs. Successful experiences in advocating for self against the stigmatizing experiences involved re-framing for oneself the misconception or underlying assumptions, and at times correcting another’s misconceptions. As reframed by one,

“When I am getting ready to solve a problem, if the teacher shows me one way and the class does it that one way, I don’t get it that way. I find [an]other way to do it, and my teacher will look at it and be like oh I see what you did. I just learn different”

[U46]

These mental processes and advocacy actions bolstered stigma resilience.

Discussion

We examined stigma as lived by undergraduates with LD/ADHD and elucidated factors influencing the development of resilience to stigmatizing encounters. For participants, stigma centered on LD/ADHD-related differences that result in observable behaviors and performance challenges that are judged by others and self and thus stigmatized. We used the PEOP model to understand interactions amongst the neurobiologically driven symptoms of LD/ADHD, participants psychological responses to stigmatizing experiences, and the range of social contexts in which undergraduates with LD/ADHD experienced and responded to stigma. Despite the pervasive nature of stigmatizing experiences, (1) knowledge of personal strengths and condition-related symptoms and challenges (i.e., person factors), (2) the presence of supportive others (i.e., environment factors), and (3) engagement in self-advocacy communications (i.e., occupation) worked together to support participants’ performance and participation in their college student roles, which is consistent with the PEOP model.

Findings provide deep understanding of the lived experiences of young people with LD/ADHD who faced prevalent stigmatizing messages and actions from instructors, peers, and family members. Participants primarily described two of the three primary stigma types: 1) intra-personal, such as feeling stigma around taking medications, and 2) inter-personal stigma, such as when instructors and classmates denied the LD/ADHD symptoms and impacts. A few experiences were so commonplace that some did not readily recognize the stigmatizing and symptom-minimizing nature of the interactions, such as when others described themselves as “feeling ADD”. Results corroborate findings from prior studies that describe the prevalent and nuanced nature of stigmatizing occurrences, which have been shown to require continuous efforts to combat negative effects (Kenyon et al., 2014).

While most stigmatizing experiences stemmed from misunderstanding, misinformation, and/or misperception of others about the LD/ADHD condition and its impacts, the ubiquity of the occurrences across contexts and experiences psychologically challenged participants, and at times, constrained performance and participation. Constraints to self-advocacy for disability accommodations were also exacerbated by others’ stigmatizing actions. Constraints manifested as hesitations, concerns, and/or negative experiences when accommodation-seeking and/or self-advocating for LD/ADHD-related needs with instructors, classmates, peers, and for some participants, family.

Stigma Resilience

Our understanding of stigma resilience was anchored in conceptualizations of the occupation of social and emotional health promotion and maintenance (AOTA, 2020). This conceptualization guided examination of the role of self-advocacy, self-reflection, and focus on personal strengths, as well as the role of supportive others in fostering the performance of this occupation and the development of stigma resilience. As such, we viewed stigma resilience to be a skill needed in performance of the health maintenance occupation (American Occupational Therapy Association, 2020). Stigma resilience is a person factor skill and attribute that facilitates participation in important health promoting occupations.

We found that stigma resilience involves three key skills - self-advocacy, self-reflection, and a focus on personal strengths. Supporting development of these skills involved supporting abilities for critical thinking in determining when and how to apply skills of self-advocacy and self-reflection. For participants, the group discussions involved critical thinking applied to understanding 1) oneself, specifically areas of strengths and challenges; 2) how, to whom, and under which situations to communicate challenges or needs; and 3) one’s behaviors, emotional responses, and beliefs during or in response to stigmatizing situations. Discussions were targeted to bolster abilities to deeply comprehend the contexts of college and young adulthood, and thus, foster abilities to self-organize within the various social environments experienced throughout participants’ daily lives.

While stigma-related experiences challenged personal identity, they also provided opportunities to better discern and articulate a definition of self that centered on one’s positive aspects. Group meetings were a source of social support that afforded opportunity to interact with peers sharing similar experiences and to discern positive aspects of having LD/ADHD. Participants’ use of focusing on personal strengths has similarities to studies reporting benefits to maintaining a positive outlook when dealing with stigma associated with mental health conditions (Martin, 2010).

For participants, having a clear and positive self-identity was anchored in having sufficient disability-related knowledge and personalized understanding of disability-related challenges and strengths. Practicing the emotional competence skill of self-reflection, as fostered during the group meetings, enabled participants to discern symptoms from potentially stigmatized personal characteristics, which was important in fostering development of stigma resilience. Critical components and processes for fostering stigma resilience identified in this study contributes to conceptual understanding of resilience theory articulated by van Breda (2018). Findings locate the resilience process as a series of transactional incidences occurring within the student who is acted upon and acts on the surrounding network of social relationships, such as when interactions with supportive instructors and mentors fostered positive understanding of self. Unintentional and intentionally enacted stigma from others provided opportunities to discern and articulate positive aspects of oneself and or the LD/ADHD condition.

The Context of Young Adulthood

The high-stakes challenges faced by young adults with LD/ADHD are illustrated in this study. Earning disparities are known to exist for individuals with LD, as they face higher risks of adult underemployment and earning disparities compared to those without disabilities (Gerber, 2012). Educational attainment, employment, and stigma are fundamental causes of health inequalities (Hatzenbuehler et al., 2013) placing young people with LD/ADHD at greater risk for negative adult outcomes. Findings illustrate the ways in which formative adult experiences are shaped, in part, by experiences and responses to stigma.

While the topics of each facilitated group discussion were about university resources or relevant knowledge and skills, each discussion contained descriptions of participants’ experiences with the topic at hand that also included plentiful descriptions of stigmatizing experiences relative to the topic. This illustrates the ubiquitous nature of stigmatizing experiences and elucidates ways in which stigma affects every aspect of daily life. It highlights how supports for understanding oneself and the LD/ADHD condition, as well as how connections with supportive others can be leveraged to build the knowledge, skills, and strategies needed for combating stigma’s negative effects and support students’ educational progression.

Implications for Personal and Environmental Interventions

Current environmental level approaches for combating stigma center on anti-stigma mass media campaigns and educational interventions targeting groups such as health service provider (Gronholm et al., 2017). Fewer interventions work at the individual level in targeting correction of self-stigmatizing thoughts or prevention of internalization of societal stigma (Thomas et al., 2015). Findings are important for informing future development of individualized stigma resilience interventions.

Biopsychosocial approaches to combatting negative impacts of LD/ADHD-related stigma are needed whereby the interventions address both person (e.g., biologically driven symptom challenges in combination with psychological responses to the challenges) and social-environmental factors. Such interventions, as underpinned by the PEOP model, would focus on fostering performance and participation through development of stigma resilience and related knowledge, skills, and strategy use while also fostering development of supportive relationships. Findings also signal the potential impact of socially based approaches that directly address misunderstandings and stigmatizing actions regarding LD/ADHD in supporting individual-level efforts for coping and fostering positive development through stigma resilience.

For study participants, person factors such as identity development and understanding of self were shaped by growing up with LD/ADHD and related challenges. These challenges include needing to cope with stigma that is pervasive within their past, current, and likely also into their future anticipated social environments at both interpersonal and societal levels. We found that stigma, if not overcome, constrained participation in the needed occupation of symptom and condition management. This happened when they chose to forgo seeking academic accommodations and/or self-advocating within their interpersonal interactions because of anticipated negative responses. The PEOP model, with its emphasis on client-centered practice, social factors, and ecological influences can serve to guide development of stigma resilience interventions that support performance and participation across the client’s social roles and contexts.

Limitations and Future Research

Interpretation of study findings are limited by the single university context of the original study and the enrolment of STEM students. STEM instructors’ have been found to be less receptive to requests for academic accommodations (Bettencourt et al., 2018; Riggs, 2022), which may have painted a picture of more intense stigma experiences compared to non-STEM students. Additionally, our study sample was diverse across symptom manifestations and challenges, as well as racial, ethnic, gender, and STEM identities. Questions remain as to the impact of the various intersecting identities on stigma experiences, development of resilience to stigma, and impacts on participation and performance.

While theoretical saturation of the data was achieved with regards to stigmatizing misconceptions and actions of others, the data provided only initial insights into salient strategies for coping and building resilience to the stigma. Future studies should focus on gaining greater understanding of the strategies used coping with stigma in higher education and as they shape their early career trajectory.

At the individual level, findings point to the combined importance of disability-related knowledge, personalized understanding of the disability-related impacts and strengths, and strategic application of self-advocacy and self-reflection skills in bolstering abilities to overcome stigma, and thus foster positive development and health; additional investigations are merited. Future individual-level investigations should also encompass strategies used for managing stigma that is experienced across the broad range of young adult roles and contexts.

Conclusion

The in-depth understanding of the structure and nature of key person and social-environmental factors of stigma, together with person-level experiences of coping, illustrates the biopsychosocial nature of both stigma and the development of resilience. Coordinated individual-level interventions and societal-level actions and programs are needed. The strengths of the PEOP Model (Baum et al., 2015) can be leveraged to investigate and shape relationships among individual and social environmental factors to lessen stigmatizing situations and strengthen psychological and communicative responses to stigmatizing occurrences, thus supporting performance and participation.

Data availability statement:

Due to privacy requirements, data used in this analysis are not available.