Abstract
Background: The global prevalence of attention deficit hyperactivity disorder (ADHD) is increasing. Children with ADHD are exposed to various risk factors that adversely affect their quality of life. Treatment is paramount to counteract these risks. Current research focuses on how parents and teachers perceive children’s experience of living with and taking ADHD medication. This study included children as participants, enabling their agency.
Objectives: This study aimed to investigate whether ADHD medication is a risk or resilience factor for children diagnosed with ADHD.
Method: A qualitative approach and a phenomenological research design were used in this study. Nine children taking ADHD medication in a mainstream private school were purposefully sampled as the study’s participants. Data were obtained using semi-structured interviews, focus groups and children’s drawings and analysed using thematic analysis.
Results: Participants identified that experiencing somatic side effects of ADHD medication and not taking prescription medication for ADHD were both risks, while taking prescription medication for ADHD was reported to enable their resilience. The study found that although children with ADHD face risks associated with taking medication for ADHD, they also reported that their medication helped them cope with the ADHD symptoms.
Conclusion: These findings demonstrate that medication serves as both a risk and a resilience factor for children with ADHD. Thus, interventions must be implemented to mitigate the risks and maintain the resilience factors associated with taking prescription medication.
Contribution: These findings can inform interventions to support children in mitigating the risks associated with ADHD medication and foster children’s resilience.
Keywords: ADHD; children; medication; private mainstream school; resilience factors; risk factors.
Introduction
Globally, children are increasingly diagnosed with attention deficit hyperactivity disorder (ADHD), commonly referred to as ADHD. A recent study by Salari et al. (2023) indicates that 7.6% of children between the ages of 3 years and 12 years old worldwide have been diagnosed with ADHD. In South Africa, Schellack, Meyer and Chigome (2019) estimated that between 8% and 10% of the population is living with ADHD. These statistics show that ADHD is becoming a grave mental health concern in children worldwide (Ayano, Yohannes & Abraha 2020). According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition–Text Revision (DSM-5-TR 2022), ADHD ‘is a neurodevelopmental disorder characterised by inattention, hyperactivity and impulsivity, or a combination of the two’ (American Psychiatric Association [APA] 2022:37). Inattention involves difficulties with focus, following instructions, complying with classroom rules, completing schoolwork or chores (Roth et al. 2017) and organisation (Strålin et al. 2022). Hyperactivity-impulsivity includes restlessness, excessive talking, fidgeting and trouble staying seated, poor planning, difficulty waiting one’s turn and risky behaviour (APA 2022).
Attention deficit hyperactivity disorder is influenced by a combination of genetic, social, environmental, cultural and gender-related factors (Liu et al. 2022). The disorder is highly heritable, with a 74% genetic influence (APA 2022). Social factors, such as parental psychiatric history and socio-economic status, play a role, as do environmental risks like low birth weight, prenatal toxin exposure and infections (Ali et al. 2022). Cultural factors affect diagnosis because of differing attitudes towards behaviour and limited health care access, particularly in South Africa, where some communities do not have access to diagnostic assessments or treatment for ADHD (Vrba, Vogel & De Vries 2016). Gender differences exist, with boys diagnosed more often than girls (3:1 ratio) as inattention, more common in females, is less noticeable (Israel, Malatras & Wicks-Nelson 2020).
A study by Balan-Moshe and Gothelf (2021) shows that ADHD negatively impacts individuals’ social, familial and scholastic domains of functioning. Tsantilas et al. (2022) found that ADHD affects children’s ability to learn at school. They are more likely to break road safety rules, be injured or hospitalised, be involved in car accidents and have shorter life expectancy than their peers (Faraone et al. 2021). They are less likely to complete secondary education or attend tertiary education than their peers (APA 2022:74). Left untreated, ADHD places a financial strain on families, the economy and society as they require access to health services, specialised education and support within the criminal justice system (Freire et al. 2021; Nyundo et al. 2020).
To combat the effects of ADHD discussed above, health care professionals such as psychologists, paediatricians, neurologists and psychiatrists work in multidisciplinary teams to make a diagnosis, guided by the diagnostic criteria from the DSM-5-TR (APA 2022). This includes conducting a range of assessments, interviews and observations. Once a diagnosis has been made, interventions are critical to enable the child’s overall functioning. Non-pharmacological interventions focus on behaviour modification (Maguvhe, Mphahlele & Moonsamy 2021), psychotherapy, neurofeedback, diet, herbal supplements and exercise (Jeyanthi, Arumugam & Parasher 2019). Clinical guidelines recommend pharmacological treatment, which includes stimulant and non-stimulant medications. However, the Multimodal Treatment of ADHD Study (MTA) identified two major challenges of pharmacological treatments. The first is adherence, with only 7% of individuals with ADHD regularly taking their medications (Yearwood, Pearson & Newland 2021). The second challenge is persistence (Khan & Aslani 2019).
Despite the benefits of medication, children taking ADHD medication face several risk factors. It is important to identify these risk factors because resilience can only be conceptualised in the presence of risks (Ungar 2011). According to Dvorsky and Langberg (2016), ‘Risk signifies an elevated probability of a negative developmental outcome for individuals of a designated risk group’ (p. 370). Risk factors in this study refer to the side effects of ADHD medication. It is well documented that children suffer from the adverse effects of ADHD medication, such as appetite suppression, stomach pain (Santos et al. 2021) and sleeping difficulties (Storebø et al. 2018).
Some children who have been diagnosed with ADHD have been found to cope well, irrespective of these risks (Chan et al. 2022). This is referred to as resilience. Resilience is a complex concept to define as there is no single definition of resilience; it varies across disciplines, cultures and person to person, and it can be viewed as both a process and an outcome. South African scholars such as Theron and Van Breda view resilience as a process. Theron (2016) states that ‘resilience is the process of adapting to significant adversity’ (p. 636), while Van Breda views resilience as a process leading to a resilient outcome (Van Breda 2017). Earlier studies into resilience focused on individual factors, ignoring a child’s social ecologies (Masten 2011). For Ungar (2011), individual factors refer to self-efficacy, problem-solving skills, self-awareness, internal locus of control and self-confidence. This approach to resilience does not apply to the South African context where the concept of ‘Ubuntu’ and collectivity are highly regarded (Mawila 2022). On the contrary, Ungar argues that resilience should be viewed holistically. Ungar (2008) defines resilience as:
… the child’s capacity to navigate their way to social, cultural, psychological and physical resources that sustain their well-being in the context of exposure to adversity and their ability to negotiate for these resources to be provided to them in culturally meaningful ways. (p. 225)
This definition aligns well with the African proverb that ‘It takes a village to raise a child’. This proverb illustrates that an entire community must provide for and interact positively with children for them to grow in a safe and healthy environment. In the South African context, we cannot ignore the contributions of a child’s parents, teachers, peers, friends, religion and culture (Nyamnjoh 2017). Ungar states that resilience is possible through the interaction between individual, relational and contextual factors present in a child’s social ecology (2011). Thus, Ungar’s definition of resilience is the most suitable for this study, as looking at resilience through this lens highlights the importance of targeting all systems surrounding a child in order to foster resilience. This would involve all stakeholders working collaboratively to prevent or reduce the side effects of medication, including booking regular doctor’s appointments, consistently administering medication, monitoring and communicating with children and each other about side effects and titrating doses.
Children are rarely asked about their first-hand experience of living with the disorder and its medication. A vast amount of research into ADHD over the last decade has centred on exploring parents’ and teachers’ knowledge and perceptions of ADHD (Fried & Amrami 2023), with data traditionally collected from the children’s parents and teachers using Parent and Teacher Rating Scales (Adaralegbe et al. 2022). Although most children are prescribed medication as the first line of treatment, they are not active participants in their treatment. The United Nations Convention on the Rights of the Child (UNCRC 1986) states, ‘Children have the right to say what they think should happen when adults are making decisions that affect them, and to have their opinions taken into account’ (Article 124). Moreover, Munongi (2016) argues that children should be seen as social participants and be allowed to share their ideas and make decisions about things that concern them. As few studies focus on the lived experiences of children living with ADHD (Fried & Amrami 2023), it is paramount to respect children’s agency and their rights to participate in their treatment. The UNCRC (1986:4) states that children should participate in the medical management of their ADHD (Article 12:4). Participation includes taking an active role in discussions with health professionals (Fumagalli et al. 2015). This indicates a gap in this research field, which this study sought to address by focusing on social justice and children’s agency and giving them a voice to share their experiences of taking ADHD medication. Thus, this study aimed to find out from children who have been diagnosed with ADHD whether ADHD medication was a risk or resilience factor for them. These insights could be used to inform interventions to combat risk factors accompanying the usage of ADHD medication and to promote the resilience of children with ADHD.
Research methods and design
A qualitative, interpretivist approach was used in this study as it was suited to understanding the risk and resilience factors that the participants experienced because of their ADHD medication (Pope & Mays 2020). Qualitative research is best suited to increasing children’s participation and giving them the right to express their experiences on issues that affect them. Thus, this research was carried out in such a way that prioritised the participants’ values, perceptions and feelings. A phenomenological design was used to involve the participants in the generation of data. In phenomenology, the researcher ‘collects data from the participants about their lived experiences, including their interpretations of those experiences’ (Saunders et al. 2019:140). In this study, we sought to offer learners to express their lived experiences on whether ADHD medication poses as a risk or resilience-enabling resource for children with ADHD.
The sampling site
This study took place at a private, Christian, mainstream school, which is located on the East Rand. The school accommodates children from Grade 000 to Matric, and 558 children are enrolled at the school. The school’s ethos is based on the gospel values of respect, justice and freedom. The rights of all children and staff are respected, and the school takes the responsibility of protecting the children very seriously. The school promotes the quality and dignity of all staff and children. In addition, the school participates in outreach programmes, such as collecting money for the poor, children’s homes or animals. Religious Education is a compulsory subject, and everyone in the school community is required to attend weekly Mass.
The school’s demographics are not very diverse as about 84% of the children are black South Africans, 9% are white, 3% are Coloured, 2% are Indian and 2% are classified as ‘Other’. The term ‘Coloured’ is a racial classification used in South Africa to refer to an ethnic group with mixed ancestry, including African, European and Asian heritage (Thumbran 2021). Although it is a private school, not all the children come from wealthy homes. Some children do not live in the suburbs and instead live in townships. Many children live with their grandmothers who raise them and pay their school fees from their pensions.
As the researcher was employed as a health care practitioner at the research site, relational ethical dilemmas were anticipated. However, none became apparent as the participants had no difficulty in distinguishing between the researcher’s two roles (Goodwin, Mays & Pope 2020).
Sampling method
Purposeful sampling was used in this study to select participants according to four criteria. Nine participants met the following criteria. Firstly, they had been diagnosed with ADHD either by a psychologist, paediatrician, neurologist or psychiatrist and that they were prescribed ADHD medication, as the study was about children’s lived experiences of ADHD medication. Secondly, the children had to be enrolled in a private, mainstream primary school, as this was the research site where data were collected. Thirdly, they had to be between the ages of 8 years and 13 years old because this age group is historically underrepresented in studies on ADHD. Finally, they should not have been therapy clients of the researcher as this would constitute a multiple relationship.
Nine children participated in this study. Seven participants were male, and two participants were female. The participants ranged from 8 years to 13 years old. In terms of race, most of the participants were black Africans, with one child being Coloured. All the children, except one, belonged to African cultural groups. Eight of the children were Christian and one was Muslim. All the children, except one, speak an African language as their home language. However, they all speak English as their first additional language and attend a school where the medium of instruction is English. This information is represented in Table 1.
| TABLE 1: Demographic characteristics of the study sample. |
Data collection
Data were collected in English, a language the children were proficient in and the language of teaching and learning at the school. All data collection sessions took place at school, after school. They were audio-recorded with consent and assent from both the parents and children, and the recordings were stored electronically in a password-protected folder. This qualitative study focused on obtaining rich in-depth data, using three different data collection methods that allowed for the results to be triangulated, which increases the credibility of the findings (Alele & Malau-Aduli 2023). These were semi-structured interviews, focus groups and children’s drawings.
Firstly, the nine participants were interviewed separately and asked several questions about the risk and resilience factors they experienced because of their diagnosis, in 30 minutes, individual, semi-structured interviews. In semi-structured interviews, the researcher develops a guide of interview questions but also encourages the participants to add more details to their answers (Hinton & Ryan 2020). The researcher asks questions that allow a participant to share their experiences, thoughts and perceptions (Hinton & Ryan 2020), which aligns with the aims of this study. Interviews were chosen as a data collection method because they allowed children to be actively involved in the generation of knowledge by sharing their experiences and opinions about living with ADHD.
The children were asked the following questions in both the individual interviews and the focus groups:
- How does your medicine make you feel?
- What do you struggle with at school?
- What makes your ADHD worse?
- What do you do at home if things get difficult for you?
- What do you need to cope better?
- How does your medicine help you?
Secondly, the participants were divided into two focus groups based on their ages. Because some children were absent, there were three children in Group 1 aged 8–10 years old and four children in Group 2 between the ages of 10 years and 11 years old. The questions posed to the groups for discussion elicited the risk factors they experienced because of ADHD medication and how this medication helped them cope. Each focus group lasted 30 minutes. The session could not be prolonged because of the challenges of ADHD for the participants. The purpose of focus groups is to find out more about an issue by generating data from a group of participants who have sought-after knowledge (Tritter & Landstad 2020).
Focus groups were chosen for several reasons. A focus group is used to generate data different from what is obtained in individual interviews. They can elicit information that the researcher has not anticipated to thicken the description (Howitt 2016). Collecting data from participants in a group context enables the researcher to examine the subjective meanings that the participants ascribe to their experiences (Tritter & Landstad 2020). The children’s shared diagnosis increased compatibility within the group, eliciting feelings of belonging and acceptance, and the peer environment made them more open to sharing their stories about a stigmatised topic (Tritter & Landstad 2020). In this way, the researcher was able to collect rich information from them about their experiences of living with ADHD. Focus groups are useful; they can be empowering as participants are given a voice and a platform to talk about issues that affect them.
Lastly, drawings were incorporated into the data collection as a child-friendly and age-appropriate technique to gain a deeper insight into their lived experiences. In a 1 hour group session, the participants were given a sheet of A3 paper, which they folded in half. On the left-hand side, they were asked to draw pictures or symbols of the difficulties they experienced related to ADHD medication. On the right-hand side, they were asked to draw pictures or symbols of how the ADHD medication made life easier for them. The participants were then asked to label their pictures. Arts-based activities, commonly used in action research (AR), are effective data collection methods with children, as they allow age-appropriate participation and knowledge sharing (Mayaba & Wood 2015). These drawings provided visual data to complement interview findings. Using a modified ‘draw-and-write’ technique (Wood, Theron & Mayaba 2012), children described their drawings verbally because of potential challenges with writing or language ability (Wood et al. 2012).
Data analysis
The audio-recorded data collection sessions were each transcribed, word-for-word, using orthographic transcription (Tritter & Landstad 2020). Thematic analysis (TA) is a technique used to analyse data by identifying codes and themes found within a qualitative dataset in such a way that trustworthy findings are produced (Braun & Clarke 2012). Thematic analysis assists the researcher in making sense of the shared meanings and experiences of the participants by identifying themes (Braun & Clarke 2012). Thematic analysis is useful as it draws out themes that are anticipated from a review of the literature, but it can also elicit other themes that can be added to an existing body of knowledge in a particular field of study (Pope, Ziebland & Mays 2020). The data were analysed in six phases.
In phase one, the recorded data were listened to several times and transcribed. In phase two, the researcher generated codes for segments of data. These codes are both descriptive (derived from what was said by the participants) and interpretive (derived from interpreting what was said by the participants) (Braun & Clarke 2012). In phase three, themes were generated from the codes. These consisted of data that answered a research question (Braun & Clarke 2012). The drawings were perused, and themes were assigned according to the labels provided by the participants. The data were interpreted in relation to the literature. In phase four, the themes were reviewed to check that they were credible. In phase five, the themes were named and defined. Finally, the data were reported in phase six.
Ethical considerations
Ethical clearance was granted for the study by the Research Ethics Committee of the Faculty of Education at the University of Johannesburg (SEM 2-2023-045). Written permission was obtained from the school principal to conduct research at the school after school hours. Informed, written consent was obtained from the children’s parents or guardians. Thereafter, the study was explained to the participants, and they could assent, in writing, or decline to participate in the study. The participants were told that they could withdraw assent at any time without consequences. Protecting research participants is paramount, especially in qualitative studies involving vulnerable participants, such as children. Because the participants knew each other from attending the same school and working in groups, their involvement in the study was not fully anonymous. To address this, firstly, the researcher asked them to keep each other’s identities and contributions confidential, explaining this in an age-appropriate way and asking them to sign a non-disclosure form. Secondly, talking about their experiences could elicit strong emotions (Arifin 2018). Therefore, an educational psychologist was on standby during the data collection sessions in case the participants experienced distress while talking about the risks they experienced related to ADHD medication. None of the participants reported distress during or after data collection, and none of the children needed to consult the available psychologist. Pseudonyms were used, and data were stored securely to ensure confidentiality and anonymity.
Results
The findings of this study are presented according to the themes that were identified through the analysis of the individual interviews, focus groups and drawing activities. These three themes reflected the participants’ views on whether ADHD medication was a risk or resilience factor. The first theme identified was experiencing somatic side effects of ADHD medication. The second theme was not taking prescription medication for ADHD, and the third theme was the benefits of taking prescription medication for ADHD.
Experiencing somatic side effects of attention deficit hyperactivity disorder medication
The findings showed that the participants identified the side effects of their ADHD medication as a risk factor. As the children were very young, they only shared their experiences of somatic side effects. The participants reported that their medication suppressed their appetite, caused bouts of diarrhoea, affected their ability to fall asleep and stay asleep, resulted in frequent headaches and stomach aches, and affected the way they felt by making them feel ‘serious’ and less playful.
In the focus group discussion, the participants were asked, ‘How does your medicine make you feel?’ One of the participants shared that his medication caused stomach upsets. He said:
‘On the weekends, I always have to watch diarrhoea [sic].’ (Praise)
Another shared that his medication affected his appetite and caused him to experience headaches and tummy aches, saying:
‘The doctor says you will not eat because of the medicine. It makes my head and tummy sore.’ (Harry)
Someone else described her experience on how ADHD medication has severely resulted in a lack of appetite. She said:
‘Well, I can be very hungry, but I don’t feel like it [eating], that my [sic] tummy can even be making noises, and I won’t feel like it. I don’t drink the whole day. I don’t eat the whole day, and I wake up sometimes in the middle of the night.’ (Tiana)
The effect the medication had on them physically and how it adversely impacted their concentration, was described as follows:
‘Uh, it makes you feel like, OK, you lose your appetite, it makes you feel serious as in, [sic] if someone talks to you, you feel like you can’t concentrate properly and you’re just very serious. I would not be having [sic] any appetite.’ (Tom)
Furthermore, one of the participants mentioned that he also experienced headaches and stomach aches and that he lost his appetite. He added:
‘Uh, it gives me headache [sic] and uh stomach-ache sometimes. And then sometimes it takes away my appetite’. (Jake)
The participants’ drawings also depicted and labelled the above-mentioned side effects as follows: Harry’s picture (Figure 1), labelled, ‘When I drink my pills it makes me full. It makes my tummy sore’. Tiana found it difficult to draw the way her medication suppressed her appetite and chose to describe it in words, ‘Lost Appetite [sic]’ (Figure 2).
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FIGURE 1: When I drink my pills, it makes me full. It makes my tummy sore – Harry. |
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Ashley, a 9 year old female, labelled her picture (Figure 3), ‘Not eating breakfast’. Furthermore, Tiana drew a picture (Figure 4), labelled, ‘Makes me very serious’.
Not taking prescription medication for attention deficit hyperactivity disorder
From the results above, it is evident that the participants experienced several somatic side effects because of their ADHD medication and that these risks need to be mitigated as this causes children taking ADHD medication to feel unwell in their quest to quell their symptoms. However, the participants also claimed that not taking their medication presented risks to their functioning at school. They shared how difficult it was to remember things, to focus on their schoolwork and to concentrate in class.
To illustrate, in the individual interviews, the participants were asked, ‘What do you struggle with at school?’ One shared how they struggled to concentrate in class when they did not take his medication:
‘I sometimes forget so it’s hard for me to remember because other things [are] distracting me in the class. Many kids do not close their uh pencil bags; they mostly fall down [sic] on the ground and then now I keep on, I cannot focus on my work [without taking medication], especially when I lose concentration on my favourite subjects.’ (Praise)
Furthermore, the participants described their difficulties with executive functions at school when they did not take their medication. Executive functions include remembering things, sustaining attention when studying for tests or exams and emotional regulation. In the focus group discussion, the participants were asked: What kinds of things are difficult for you at school? One of the response showed that they found executive functions, such as remembering things and working memory, difficult. They said:
‘Remembering things is difficult if I don’t take my pills and I struggle with Maths.’ (Praise)
Another’s reply showed that they found it difficult to sustain attention when studying for tests or exams, in addition to difficulty keeping track of their personal belongings:
‘Um, some of the some of the times [sic] it’s studying, sometimes. Some of the times when I don’t take my pills, I feel more sleepy and tired during the day when I’m at school, also losing things often.’ (Messi)
One shared that he found it difficult to study and that he struggled with emotional regulation; he felt that he took things more personally than his peers and became easily upset by little things. He shared the following:
‘Hmm, just studying, ma’am. Ma’am, not taking my meds, can one of the side effects be anger? Ma’am, most of the times [sic] I take things more seriously, out of it, I take things more personally than other people.’ (Jake)
When the participants were asked to draw pictures of what makes their ADHD worse, they reported that not taking their ADHD medication was detrimental to their functioning. Tiana’s picture (Figure 5), labelled, ‘When I don’t take my tablet’, illustrates her opinion that not taking her medication makes her ADHD worse and that her medication protects her against her ADHD symptoms. Of particular significance is Praise’s picture (Figure 6), which he labelled, ‘When I don’t drink my pills, I go crazy’. Praise’s drawing captured what his behaviour looked like when he did not take his medication. He drew himself acting ‘crazy’, standing on a chair in the classroom, illustrating his hyperactive and impulsive behaviour there.
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FIGURE 5: When I don’t take my tablet – Tiana. |
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FIGURE 6: When I don’t drink my pills, I go crazy – Praise. |
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The benefits of taking prescription medication for attention deficit hyperactivity disorder
Participants spoke about the role their ADHD medication played in facilitating their resilience in the face of the risks associated with their diagnosis. It is evident from the data collected that the participants felt that their medication was beneficial in improving their ability to pay attention, focus and perform better at school. Their medication was a coping mechanism for children presenting with ADHD. In the individual interviews, participants were asked, ‘What do you do at home if things get difficult for you?’ One of the participants’ reply illustrated how they rely on their medication to help them feel more alert:
‘… sometimes when I’m tired and I take my medicine then I can concentrate …’ (Tom)
Another question the participants were asked was, ‘What do you need to cope better?’ They all responded that their medication helped them to cope and bolstered their resilience. One replied:
‘I think medicine.’ (Tom)
Another agreed:
‘To have my vitamins [medicine].’ (Messi)
Someone else responded:
‘Taking my pills.’ (Jake)
Another also concurred, saying:
‘Uh, I just need pills.’ (Thiago)
In the focus group discussions, the participants were asked how their medication helped with their core ADHD symptoms of inattention, hyperactivity and impulsivity. One of the participants expressed that their medication helped them concentrate and listen better when someone spoke to them and said:
‘It [medication] makes you feel serious as in if someone talks to you, you feel like you can concentrate properly … and you’re just very serious.’ (Jake)
Someone else described the benefits they felt from taking their medication. They reported that their medication helped them to focus and study for longer periods. They said:
‘It usually helps me to stay awake, focus and it keeps my energy up for me to study properly.’ (Messi)
One agreed:
‘It keeps me awake and helps me focus.’ (Tom)
Another stated they experienced feeling smarter and more attentive when they took their medication and said:
‘It makes me feel a little more smart [sic]. And sometimes energetic.’ (Ashley)
In the drawing activity, the participants were asked, ‘What people, places or things make your ADHD easier to cope with?’ The participants’ drawings showed that they understand that taking their medication is beneficial in terms of mitigating their ADHD symptoms. Tom lbelled his picture (Figure 7), ‘Taking my pill’.
The above results clearly showed that the participants recognised that their medication helped to alleviate their ADHD symptoms and was therefore a resilience enabler. They reported that they could feel a difference on days when they took their medication and days when they did not. They pointed out that their medication helped them to cope with symptoms of inattention, hyperactivity and impulsivity. There was a consensus among the participants that they preferred to take their medication, as it helped them cope despite the adversities they faced.
Discussion
The findings of this study provide insights into children’s experiences of taking ADHD medication. In this study, medication was found to be both a risk and a resilience factor for children with ADHD. The findings revealed that experiencing somatic side effects of ADHD medication and not taking prescription medication for ADHD were identified as risk factor themes, while the benefits of taking prescription medication for ADHD were identified as resilience factors. This study confirms that risk and resilience factors are subjective (Ungar 2019). What one child might perceive as a protective factor, another child might perceive as a risk factor, depending on the child’s context and situation (Van Breda 2018:10). For example, Naslund et al. (2014, as cited in Ungar 2019:5) found that youth with severe mental illness experienced peer support through social media to be a protective factor. However, increased internet usage among youth who do not have a mental illness could contribute to poor mental health (Ungar 2019).
The participants of this study listed several somatic side effects their prescription medication caused. These included difficulty falling asleep and staying asleep, appetite suppression, gastrointestinal complaints, and head and stomach aches. These side effects can negatively affect children’s daily lives as feeling unwell could interfere with their ability to tend to their schoolwork or play. In this case, ADHD medication had adverse effects on children. The somatic side effects described by the participants in this study are supported by the literature. To demonstrate, Maguvhe et al. (2021) found that children taking ADHD medication complained of similar side effects. In their study, Santos et al. (2021) found that stomach pain is a side effect of ADHD medication. As noted in this study, participants also reported that their medication affected their sleep. They frequently had difficulty falling asleep and staying asleep at night. Furthermore, Israel et al. (2020) found a link between poor sleep because of ADHD medication and poor academic performance. The adverse impact of medication on appetite was repeatedly expressed by participants of this study. A study by Balan-Moshe and Gothelf (2021) elucidated that both sleep disorders and poor appetite were side effects of the prescription medication for ADHD. Contrary to previous studies that reported the impact of medication on social, emotional, academic (Chang et al. 2019) and psychological functioning (Storebø et al. 2018), this study only revealed somatic side effects of ADHD medication. One reason for this could be that the participants in this study were very young, ranging from 8 years to 13 years old, and might not have the cognitive ability to name or identify these side effects. Moreover, existing studies show that children with ADHD struggle with emotional regulation, which relates to difficulty experiencing emotions and expressing emotions (Israel et al. 2020).
The participants reported that there were days or periods when they did not take their medication. They identified not taking their prescription medication for ADHD as a risk factor because their ADHD symptoms of inattention, hyperactivity and impulsivity were left untreated. They reported that paying attention, focusing, remembering and controlling their anger were more difficult to do on days that they did not take their ADHD medication. Roth et al. (2017) found that children with ADHD struggle to stay focused on a task, remember instructions, complete schoolwork or chores, and sustain focus. Studies show that children with ADHD are disorganised and often lose their belongings (APA 2022:71; Strålin et al. 2022). The findings of this study echo previous studies that showed that children with ADHD have difficulty regulating their emotions, which results in them being reprimanded or punished regularly (Israel et al. 2020). Poor emotional regulation often results in conflicts that affect their relationships with their parents, teachers and friends (Lopez-Pinar et al. 2018). Sayal et al. (2018) also found that children with ADHD display externalising difficulties such as aggression and oppositional behaviour, which cause conflict in their relationships.
The findings affirmed that the participants viewed the benefits of taking prescription medication for ADHD as protective against the risks posed by their diagnosis. The participants explained how their medication made them feel serious, less playful and better able to concentrate. They shared how their medication helped them stay awake and focused. They reported that they often took their medication when they felt that they were struggling to cope. These findings align with those of Ringer (2020), who found that children viewed their ADHD medication as helpful in controlling their symptoms. According to the National Institute for Health and Clinical Excellence (NICE 2018) guidelines, the gold standard of treatment for ADHD is a combination of pharmacological and psychosocial interventions. Pharmacological interventions are still the most widely utilised by health professionals, and studies show that they help reduce the core symptoms of ADHD, including risky behaviours, and improve a child’s social functioning (Coghill, Werner-Kiechle & Farahbakhishian 2020). Left untreated, ADHD can result in adverse effects on a child’s life, which also impacts their families and includes poor performance at school, school dropout, poor employment prospects and possible criminality (Kellock 2020). Academically, children with ADHD are prone to low academic achievement, school failure and dropout (Lopez-Pinar et al. 2018). These poor prospects could extend into adolescence and adulthood. Difficulties in concentration may lead to job loss and contribute to high unemployment in South Africa (Israel et al. 2020). Unemployment may drive individuals towards criminal activity, which could result in an overcrowded prison system (Sayal et al. 2018), homelessness an incarceration (Kellock 2020), which could in turn burden their family’s finances, the economy and society (Nyundo et al. 2020). Attention deficit hyperactivity disorder is also linked to antisocial personality disorder, substance abuse and increased incarceration rates (APA 2022). Additionally, ADHD increases the risk of major depression, bipolar disorder and suicidal behaviour (Nyundo et al. 2020). Early identification and treatment are essential to mitigate these long-term consequences.
Limitations and recommendations for further research
Although the findings of this study have made a valuable contribution to research, this study had limitations. In terms of the sample, a key limitation of the study was its small sample size from a single school, which may affect the generalisability of the results. However, by using multiple qualitative data collection methods to triangulate findings (Alele & Malau-Aduli 2023), the study still provided valuable insights into children with ADHD. The first researcher, although an insider at the study site, addressed potential bias by clarifying her role to participants and parents and interpreted findings using an established resilience framework to ensure objectivity (Braun & Clarke 2022). Because the participants knew each other from the same school, complete anonymity could not be ensured. To address this, the researcher asked the children to keep each other’s identities and contributions confidential, explaining the importance of privacy in age-appropriate language (Pope & Mays 2020).
In terms of methodological limitations, two children were absent from the focus group discussions but participated in individual interviews and a group drawing activity. Using multiple data collection methods ensured that the study’s data remained robust. Although the group setting limited participant anonymity, the peer interactions led to richer data. During group activities, younger participants with ADHD became distracted and required breaks, but this did not negatively affect the quality or richness of the data collected for the study. This presented a procedural limitation. Future research should cover more school types (government, rural, non-religious) and use larger, more diverse samples from several South African provinces. Studies should also include teenagers and use data collection methods suited to their attention span, like shorter sessions with breaks.
Conclusion
This study investigated whether ADHD medication is a risk or resilience factor for children diagnosed with ADHD. This study deepens our understanding of resilience in South African children with ADHD. Using qualitative, child-centred methods and allowing children to share their experiences and participate in treatment decisions aligns with principles of social justice. Guided by Ungar’s socio-ecological framework and the philosophy of Ubuntu, the research demonstrates that resilience is shaped collectively and that multidisciplinary teamwork is essential to support children with ADHD. The findings of this study revealed that ADHD medication can serve as both a risk and a protective factor for children diagnosed with ADHD.
Participants in the study reported that they experienced physical side effects from ADHD medication, which resulted in frequent headaches and stomach aches, and affected the way they felt by making them feel ‘serious’ and less playful. To address these, children with ADHD would benefit from understanding their challenges and working collaboratively with parents, teachers and health professionals. Multidisciplinary support involving parents, teachers, health professionals and service providers is recommended. Enhanced monitoring by all stakeholders, careful dose adjustments by doctors, and proactive, consistent management of medication by parents are suggested to reduce risks and improve outcomes for children on ADHD medication. Parents need to be more proactive in mitigating these risks by ensuring open communication with their children and regularly scheduling doctors’ visits to assess the effects of medication. This will balance children’s rights to participation with the principle of acting in their best interests.
On the contrary, the participants shared that not taking their prescription medication for ADHD was a risk to their functioning. Although the participants identified that they experienced side effects of ADHD medication as a risk factor, they also identified the benefits of taking their prescription medication for ADHD. They expressed a need for consistent access to ADHD medication. Parents should take note of this important finding and be more consistent in administering their children’s ADHD medication. Parent education is necessary to ensure consistent administration of medication to improve the outcomes for children taking ADHD medication. The parents of the children in this study could afford privately funded medical aid. However, many South African families rely on government health services. This highlights a need for improved access to mental health care to foster resilience in children with ADHD.
Acknowledgements
This article is partially based on the author’s thesis entitled ‘Risk and resilience factors of children living with ADHD in a mainstream primary school’ towards the degree of Doctor of Education in Educational Psychology, University of Johannesburg, South Africa on 30 October 2024, with supervisor Dr Daphney Mawila-Chauke. The authors would like to acknowledge all the children who willingly participated in this study as well as their parents who consented to their involvement in this study. The authors would also like to thank Ruth Nicola for editorial assistance.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
M.C. is the first author and was primarily responsible for conceptualising the study, collecting the data, conducting the analysis, and writing and editing the manuscript. D.M-C. provided supervision, guidance, discussed the results and critical revisions, and is listed as the second author. The final version for submission and publication was edited and approved by both authors.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The data that support the findings of this study are not openly available because of reasons of sensitivity and are available from the corresponding author, D.M-C., upon reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or publisher. The authors are responsible for this study’s results, findings and content.
References
Adaralegbe, N.J., Okobi, O.E., Omar, Z.T.O., Segun, E., Evbayekha, E.O., Abolurin, A. et al., 2022, ‘Impact of adverse childhood experiences on resilience and school success in individuals with autism spectrum disorder and attention-deficit hyperactivity disorder’, Cureus 14(11), e31907. https://doi.org/10.7759/cureus.31907
Alele, F. & Malau-Aduli, B., 2023, An introduction to research methods for undergraduate health profession students, James Cook University, viewed 15 January 2025, from https://researchonline.jcu.edu.au/77845/.
Ali, A.Y., Inyang, B., Koshy, F.S., George, K., Poudel, P., Chalasani, R. et al., 2022, ‘Elements that influence the development of attention deficit hyperactivity disorder (ADHD) in children’, Cureus 14(8), e27835. https://doi.org/10.7759/cureus.27835
American Psychiatric Association (APA), 2022, ‘Neurodevelopmental disorders’, in Diagnostic and statistical manual of mental disorders, 5th edn., Text rev., pp. 35–37, 68–76, APA, Arlington, VA.
Arifin, S.R.M., 2018, ‘Ethical considerations in qualitative study’, International Journal of Care Scholars 1(2), 30–33. https://doi.org/10.31436/ijcs.v1i2.82
Ayano, G., Yohannes, K. & Abraha, M., 2020, ‘Epidemiology of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents in Africa: A systematic review and meta-analysis’, Annals of General Psychiatry 19, 21. https://doi.org/10.1186/s12991-020-00271-w
Balan-Moshe, L. & Gothelf, D., 2021, ‘Minding the gap between clinical guidelines and real-life clinical work’, European Child & Adolescent Psychiatry 30, 681–683. https://doi.org/10.1007/s00787-021-01765-y
Braun, V. & Clarke, V., 2012, ‘Thematic analysis’, in H. Cooper, P.M. Camic, D.L. Long, A.T. Panter, D. Rindskopf & K.J. Sher (eds.), APA handbook of research methods in psychology, research designs: Quantitative, qualitative, neuropsychological and biological, pp. 57–71, APA, Washington, DC.
Braun, V. & Clarke, V., 2022, Thematic analysis. A practical guide, Sage, London.
Chan, E.S.M., Groves, N.B., Marsh, C.L., Miller, C.E., Richmond, K.P. & Kofler, M.J., 2022, ‘Are there resilient children with ADHD?’, Journal of Attention Disorders 26(5), 643–655. https://doi.org/10.1177/10870547211025629
Chang, Z., Ghirardi, L., Quinn, P.D., Asherson, P., D’Onofrio, B.M. & Larsson, H., 2019, ‘Risks and benefits of ADHD medication on behavioral and neuropsychiatric outcomes: A qualitative review of pharmacoepidemiology studies using linked prescription databases’, Biological Psychiatry 86(5), 335–343. https://doi.org/10.1016/j.biopsych.2019.04.009
Coghill, D.R., Werner-Kiechle, T. & Farahbakhishian, S., 2020, ‘Functional impairment outcomes in clinical trials of different ADHD medications: Post hoc responder analyses and baseline subgroup analyses’, European Child & Adolescent Psychiatry 30, 809–821. https://doi.org/10.1007/s00787-020-01586-5
Dvorsky, M.R. & Langberg, J.M., 2016, ‘A review of factors that promote resilience in youth with ADHD and ADHD symptoms’, Clinical Child & Family Psychology Review 19(4), 368–391. https://doi.org/10.1007/s10567-016-0216-z
Faraone, S.V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M.A. et al., 2021, ‘The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder’, Neuroscience and Biobehavioural Reviews 128, 789–818. https://doi.org/10.1016/j.neubiorev.2021.01.022
Freire, J.V.C., Cerqueira, R.A., Sousa, D.F., Novaes, J.F.A., Farias, T.M. & Cal, S.F.M., 2021, ‘Resilience and ADHD: What is new?’, Research Trends and Challenges in Medical Science 9, 1–15. https://doi.org/10.9734/bpi/rtcms/v9/7765D
Fried, T. & Amrami, G.P., 2023, ‘Not all diagnoses are created equal: Mothers’ narratives of children, ADHD, and comorbid diagnoses’, Social Science & Medicine 323, 115838. https://doi.org/10.1016/j.socscime.2023.115838
Fumagalli, L.P., Radeaelli, G., Lettieri, E. & Masella, C., 2015, ‘Patient empowerment and its neighbours: Clarifying the boundaries and their mutual relationships’, Health Policy 119(3), 384–394. https://doi.org/10.1016/j.jealthpol.2014.10.017
Goodwin, D., Mays, N. & Pope, C., 2020, ‘Ethical issues in qualitative research’, in C. Pope & N. Mays (eds.), 4th edn., pp. 27–43, Qualitative research in health care, John Wiley & Sons, New York, NY.
Hinton, L. & Ryan, S., 2020, ‘Interviews’, in C. Pope & N. Mays (eds.), Qualitative research in health care, 4th edn., pp. 43–55, John Wiley & Sons, Oxford.
Howitt, D., 2016, Introduction to qualitative research methods in psychology, 3rd edn., Pearson, Harlow.
Israel, A.C., Malatras, J.W. & Wicks-Nelson, R., 2020, Abnormal child and adolescent psychology, viewed 18 December 2025, from http://www.vlebooks.com/vleweb/product/openreader?id=none&isbn=9789000198324.
Jeyanthi, S., Arumugam, N. & Parasher, R.K., 2019, ‘Effect of physical exercises on attention, motor skills and physical fitness in children with attention deficit hyperactivity disorder: A systematic review’, ADHD Attention Deficit and Hyperactivity Disorders 11(2), 125–137. https://doi.org/10.1007/s12402-018-0270-0
Kellock, A., 2020, ‘Children’s well-being in the primary school: A capability approach and community psychology perspective’, Childhood 27(2), 220–237. https://doi.org.10.1177/09075628220902516
Khan, M.U. & Aslani, P., 2019, ‘A review of factors influencing the three phases of medication adherence in people with attention-deficit/hyperactivity disorder’, Journal of Child and Adolescence Psychopharmacology 29, 398–418. https://doi.org/10.1089/cap.2018.0153
Liu, Q., Liu, M., Yao, J. & Zhao, Z., 2022, ‘Environment factors of children’s attention deficit hyperactivity disorder’, MEDS Clinical Medicine 3(7), 59–62.
Lopez-Pinar, C., Martinez-Sanchis, S., Carbonell-Vaya, E., Fenollar-Cortes, J. & Manchez-Meca, J., 2018, ‘Long-term efficacy of psychosocial treatments for adults with attention-deficit/hyperactivity disorder: A meta-analytic review’, Frontiers in Psychology 9, 638. https://doi.org/10.3389/fpsyg.2018.00638
Maguvhe, M., Mphahlele, R.S. & Moonsamy, S., 2021, Empowering students and maximising inclusiveness and equality through ICT, Brill, Pretoria.
Masten, A.S., 2011, ‘Resilience in children threatened by extreme adversity: Frameworks for research, practice and translational synergy’, Developmental and Psychopathology 23(2), 493–506. https://doi.org/10.17575/rpsicol.v30i2.1122
Mawila, D., 2022, ‘The mediation role of caregivers and context on individual factors in enabling resilience among learners with specific learning disability’, Interchange 54, 81–94. https://doi.org/10.1007/s10780-022-09484-2
Mayaba, N.N. & Wood, L., 2015, ‘Using drawings and collages as data generation methods with children: Definitely not child’s play’, International Journal of Qualitative Methods 14(5), 1–10. https://doi.org/10.1177/1609406915621407
Munongi, L., 2016, ‘An investigation of children’s rights and responsibilities as known by grade 9 learners and their significant adults’, Doctoral thesis, University of Johannesburg, viewed 24 November 2024, from https://hdl.handle.net/10210/214619.
Naslund, J.A., Grande, S.W., Aschbrenner, K.A. & Elwyn, G., 2014, ‘Naturally occurring peer support through social media: The experiences of individuals with severe mental illness using YouTube’, PLoS One 9(10), e110171. https://doi.org/10.1371/journal.pone.0110171
National Institute for Health and Clinical Excellence (NICE), 2018, Attention deficit hyperactivity disorder: Diagnosis and management, viewed 05 January 2025, from https://www.nice.org.uk/guidance/ng87.
Nyamnjoh, F.B., 2017, ‘Incompleteness: Frontier Africa and the currency of conviviality’, Journal of Asian and African Studies 52(3), 253–270. https://doi.org/10.1177/0021909615580867
Nyundo, A., Manu, A., Regan, M., Ismail, A., Chukwu, A., Dessie, Y. et al., 2020, ‘Factors associated with depressive symptoms and suicidal ideation and behaviours amongst sub-Saharan African adolescents aged 10–19 years: A cross-sectional study’, Tropical Medicine & International Health 25(1), 54–69. https://doi.org/10.1111/tmi.13336
Pope, C. & Mays, N. (eds.), 2020, Qualitative research in health care, 4th edn., John Wiley & Sons, New York, NY.
Pope, C., Ziebland, S. & Mays, N., 2020, ‘Analysis’, in C. Pope & N. Mays (eds.), Qualitative research in health care, 4th edn., pp. 111–134, John Wiley & Sons, Hoboken, NJ.
Ringer, N., 2020, ‘Living with ADHD: A meta-synthesis review of qualitative research on children’s experiences and understanding of their ADHD’, International Journal of Disability, Development and Education 67(2), 208–224. https://doi.org/10.1080/1034912X.2019.1596226
Roth, K., Zittel, L., Pyfer, J. & Auxter, D., 2017, Principles and methods of adapted physical education and recreation, 12th edn., Jones & Bartlett Learning, Burlington, MA.
Salari, N., Ghasemi, H., Abdoli, N., Rahmani, A., Shiri, M.H., Hashemian, A.H. et al., 2023, ‘The global prevalence of ADHD in children and adolescents: A systematic review and meta-analysis’, Italian Journal of Pediatrics 49(1), 48. https://doi.org/10.1186/s13052-023-01456-1
Santos, G.M., Santos, E.M., Mendes, G.D., Fragoso, Y.D., Souza, M.R. & Martimbianco, A.L.C., 2021, ‘A review of Cochrane reviews on pharmacological treatment for attention deficit hyperactivity disorder’, Dementia & Neuropsychologia 15, 421–427. https://doi.org/10.1590/1980-57642021dn15-040001
Saunders, M.N.K., Bristow, A., Thornhill, A. & Lewis, P., 2019, ‘Understanding research philosophy and approaches to theory development’, in M.N.K. Saunders, P. Lewis & A. Thornhill (eds.), Research methods for business students, 8th edn., pp. 128–171, Pearson Education, viewed 15 January 2025, from http://www.pearsoned.co.uk/bookshop/detail.asp?ite….
Sayal, K., Prasad, V., Daley, D., Ford, T. & Coghill, D., 2018, ‘ADHD in children and young people: Prevalence, care pathways and service provision’, The Lancet Psychiatry 5(2), 175–186. https://doi.org/10.1016/S2215-0366(17)30167-0
Schellack, N., Meyer, J.C. & Chigome, A.K., 2019, ‘The management of attention-deficit hyperactivity disorder in children’, South African Pharmaceutical Journal 86(5), 17–27.
Storebø, O.J., Pedersen, N., Ramstad, E., Kielsholm, M.L., Nielsen, S.S., Krogh, H.B. et al., 2018, ‘Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents – Assessment of adverse events in non-randomised studies’, Cochrane Database of Systematic Reviews 5(5), CD012069. https://doi.org/10.1002/14651858.CD012069.pub2
Strålin, E.E., Thorell, L.B., Syzbek, K., Lundgren, T., Bölte, S. & Bohman, B., 2022, ‘Cognitive-behavioural group therapy for ADHD predominantly inattentive presentation: A feasibility study of a new treatment protocol’, Nordic Psychology 74(4), 1–15. https://doi.org/10.1080/19012276.2021.2020683
Theron, L.C., 2016, ‘Toward a culturally and contextually sensitive understanding of resilience: Privileging the voices of Black, South African young people’, Journal of Adolescent Research 31, 635–670. https://doi.org/10.1177/0743558415600072
Thumbran, J., 2021, ‘Forging an alternative to separate development: Afrikaner sociology, the apartheid state, and the “coloured” question (c.1932–1984)’, South African Historical Journal 73(4), 836–858. https://doi.org/10.1080/02582473.2022.2055130
Tritter, J.Q. & Landstad, B.J., 2020, ‘Focus groups’, in C. Pope & N. Mays (eds.), Qualitative research in health care, 4th edn., pp. 57–67, John Wiley & Sons, Oxford.
Tsantilas, D., Ilie, A., Waldon, J., McGonnell, M. & Corkum, P., 2022, ‘The contributions of cognitive abilities to the relationship between ADHD symptoms and academic achievement’, Brain Sciences 12(8), 1075. https://doi.org/10.3390/brainsci12081075
Ungar, M., 2008, ‘Resilience across cultures’, British Journal of Social Work 38(2), 218–235. https://doi.org/10.1093/bjsw/bcl343
Ungar, M., 2011, ‘The social ecology of resilience: Addressing contextual and cultural ambiguity of a nascent construct’, American Journal of Orthopsychiatry 81, 1–17. https://doi.org.10.1111/j.1939-0025.2010.01067.x
Ungar, M., 2019, ‘Designing resilience research: Using multiple methods to investigate risk exposure, promotive and protective processes, and contextually relevant outcomes for children and youth’, Child Abuse & Neglect 96, 104098. https://doi.org/10.1016/j.chiabu.2019.104098
United Nations Convention on the Rights of the Child (UNCRC), 1986, Article 12, viewed 14 January 2025, from http://www.ohchr.org/en/professionalinterest/pages/crc.aspx.
Van Breda, A.D., 2017, ‘A comparison of youth resilience across seven South African sites: A comparison of youth resilience in South Africa’, Child & Family Social Work 22(1), 226–235. https://doi.org/10.1111/cfs.12222
Van Breda, A.D., 2018, ‘A critical review of resilience theory and its relevance for social work’, Social Work/Maatskaplike Werk 54(1), 1–18. https://doi.org.10.15270/54-611
Vrba, K., Vogel, W. & De Vries, P.J., 2016, ‘Management of ADHD in children and adolescents: Clinical audit in a South African setting’, Journal of Child & Adolescent Mental Health 28(1), 1–9. https://doi.org/10.2989/17280583.2015.1128437
Wood, L., Theron, L. & Mayaba, N., 2012, ‘Read me to resilience: Exploring the use of cultural stories to boost the positive adjustment of children orphaned by AIDS’, African Journal of Aids Research 11, 225–239. https://doi.org.10.2989/16085906.2012.734982
Yearwood, E.L., Pearson, G.S. & Newland, J.A., 2021, Child and adolescent behavioural health: A resource for advanced practice psychiatric and primary care practitioners in nursing, John Wiley & Sons, Hoboken, NJ.
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