Attention Deficit-Hyperactivity Disorder in Children: The Medicalization of Childhood

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Overview

Attention deficit-hyperactivity disorder, or ADHD, is one of the most common and debated disorders of childhood. Since its debut as "hyperactivity" or "minimal brain dysfuction" in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM),[1] ADHD has been rising in prevalence.[2] Due to technoscientific advances and changes in environmental determinants, its definition and diagnosis has remained elastic over the years. Today, opinions on ADHD remain divided. On the one hand, there is marked skepticism around ADHD as a legitimate disorder and that it is being over-diagnosed. On the other hand, it is argued that scientific evidence clearly points to neurobiological correlates and that the fears around overdiagnosis are not backed by recent reviews (see section on "The ADHD Debate" below).

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Medicalizing ADHD

From Hyperactivity To ADHD

Long before the twentieth century, physicians had begun to note that some individuals seemed to be afflicted by a "disease of attention".[3] The growing interest in this condition eventually to its medicalization, the process by which a non-medical condition is redefined as a medical one that can be treated and diagnosed.[1] ADHD first emerged in the form of various diagnoses in the 1950s, during which it was sometimes termed "minimal brain damage" or "minimal brain dysfunction" (MBD) "hyperactive syndrome", "hyperkinesis", and "hyperactive disorder of childhood".[1] In DSM-II, this group of disorders were "characterized by over-activity, restlessness, distractibility, and short attention span, especially in young children".[4] Although the definition of ADHD would often shift to reflect changing realities, hyperactivity and inattention persisted as distinguishing features of the disorder. Over time, however, ADHD would overstep its classification as a psychiatric illness that pertained mostly to children and adolescents. In recent years, the persistence of hyperactivity into adulthood has given greater prevalence to adult ADHD.[5]

A timeline of the history of ADHD

In DSM-5,[6] ADHD is currently identified as a "persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by 1) inattention and/or 2) hyperactivity and impulsivity".[6] The two categories may include behaviours such as inattention to details, difficulty organizing tasks and activities, a propensity for distractions, fidgeting, or an inability to remain seated.[6] According to DSM-5, clinicians can now look back to symptoms since age 12 instead of age 7 to officially diagnose older adolescents and adults (above age 17) with ADHD.[6] A succinct outline of the most updated definition and diagnosis of ADHD can be found on the Centres for Disease Control and Prevention site.[7]

In the following video, Matt Smith from Strathclyde’s School of Humanities explores a brief history of ADHD and the factors influencing its diagnosis.[8]

The Engines That Drive the Medicalization Of ADHD

In his empirical analysis of the process of medicalization, Conrad hypothesized that the construction of ADHD would be the result of interplay among three forces: "(1) the pharmaceutical revolution, (2) trends in the medical profession, and (3) government action”.[9] In alignment with his predictions, pharmaceutical industries have shown a flair for advertising medication for ADHD and promoting "disease awareness" campaigns. The progression in scientific research has further facilitated the incorporation of ADHD into the medical realm. Indeed, DSM-5 announces that the updated descriptions for ADHD "will help clinicians better identify typical ADHD symptoms at each stage of patients’ lives".[6] Furthermore, federal legislation now recognizes ADHD as a "disability" that warrants special accommodations.[10] An important aspect of the disability perspective is that it places the locus of control beyond the individual. By adopting the sick role, children who are diagnosed with ADHD are exonerated from personal responsibility for deviance. At the same time, responsibility is lifted from social environments (e.g. the school, the home) that could potentially be aggravating the deviant behaviour.

Conrad's argument was particularly apt at the time it was proposed. The 1970s saw a spike in press reports of public school boys taking medications.[11] [12] [13] Several prominent lawsuits of the time had also drawn attention to schools as a primary institution that constructed and maintained the ADHD classification; some students were being pressured by their school to take medication as a condition for continued enrolled.[14] [15]

Medicalization of ADHD satisfied a broad range of interests and can be understood as a collaboration among medical professionals, schools, and parents.[16] [17]. Medical professionals and pharmaceutical companies benefited from the increase in demand for medical services and drugs.[9] For schools, drugs like Ritalin removed the need for special accommodations in the classroom. [18] [14] Parents accepted the label because diagnosis provided a legitimate explanation for their kid’s poor performance at school.

Authoritarianism and Medicalization: The School As a Primary Institution

ADHD is often diagnosed in particular institutional contexts, most commonly the school. A comparison between two different forms of authoritarianism sheds light upon the cultural specificity of ADHD. In England, the educational institution employs "traditional authoritarianism" under which "unruly" children are disciplined using conventional corrective measures.[10] Students who do not conform to school expectations are shamed, socially isolated, and subjected to corporal punishment.[10] On the other hand, schools in North America exercise "medical authoritarianism", which frames childhood troubles as a medical problem. While disruptive behaviour is considered to be a normal phase of growing up under traditional authoritarianism, it is an "extension of mental or emotional disability"[10] under medical authoritarianism. In agreement with this perspective, England shows significantly lower rates of ADHD than the United States and Canada.[18]

Children and Childhood As Medical Objects

Children and childhood have long been objectified to be compartmentalized and dissected for scientific study. Instead of "little adults", children were cast as almost a different species entirely and have inspired multiple papers and theories from philosophers and scientists such as Rousseau, Freud, and Ainsworth. [19] [20] Discourses about the physical, emotional, and psychological development of children have propagated two concepts that will feed into the construction of ADHD: 1) the types of troubles that are a normal part of childhood; 2) the age-appropriateness of the child's behaviour.[10]

ADHD From Different Perspectives

Because researchers have yet to identify an organic marker for ADHD, diagnosis is given by stakeholders, professionals including teachers, and parents.[21] Their interactions play an integral role in the diagnosis and treatment of ADHD and position ADHD at the "centre of collision of different statements constructing distinct versions of reality".[21] These voices in turn shape how the children experience their diagnosis.

ADHD From the Professionals' Perspective

Clinicians show ambivalence towards the physical and social-psyhcological side-effects of stimulant medication and express different opinions on how diagnosis and treatment should be approached.[22] Many call attention to the epistemological uncertainty in the language used by the DSM and say that the DSM is a guide, but not the final authority on ADHD.[22] Rather than relying on the diagnostic guidelines provided by ADHD, clinicians often examine each case individually and provide recommendations accordingly. Some clinicians do not use the DSM at all in their diagnosis of ADHD. These clinicians are skeptical of the ADHD diagnosis and ascribe the child's symptoms to their unique environment.[22] Whether or not they believe in using the DSM as an aid in ADHD diagnosis, clinicians feel a pressure to apply the DSM ADHD criteria from third parties. For example, application of the DSM criteria may be bureaucratically necessary for parents to receive any financial accommodation from insurance companies.[22]

Clinicians and other professionals involved in the diagnosis process have often been confronted with concerns about the rise in ADHD prevalence. In a study exploring the positioning of professionals, teachers and parents in the ADHD "blame game", data was collected from 102 adults through interviews, focus groups and non-participant obvservations of natural group meetings. Of the 102 adults, 13 mental health professionals participated. In talking about ADHD diagnosis, these professionals often stressed the objectivity of their work and used neutral language. Using a "rhetoric of expertise", they defined ADHD as a medical event and presented themselves as "mere executors of predetermined (medical) procedures".[21]

ADHD From the Teachers' Perspective

Teachers found the behaviour of children with ADHD to be "destabilizing"[21] as it challenged their professional role and social position. Common sentiments of uncertainty, frailty, and lack of self-confidence created room for intervention from mental health professionals.[21] While teachers respect mental health professionals as an authority on the medical context of ADHD, they are conflicted: Should they do what they feel they are obligated to do as a educator or should they do what they believe the specialists are suggesting to them? The struggle to find an appropriate space for action is captured by one teacher:

The frustration of thinking, 'What the hell, we're here to teach something, we have an educational role here'...the rules, it's true that he (the child) can't internalize them, but what are you gonna do? Let him be? (Frigerio et al., 2013)[21]

ADHD From the Parent's Perspective

Parents who have children with ADHD find their identities and their parenting capabilities challenged.[21] They feel responsible for their child's state of being and stigmatized when schools and professionals refuse to acknowledge ADHD as a legitimate disorder and to address it in a standardized way. In the study on the ADHD blame game conducted by Frigerio et al., narratives from parents revealed three main characterizations: parents as "self-sacrificers", parents as the only "real experts" who understand their kids, and parents as "lonely fighters" against the ignorance of others. Mothers spoke of how much they loved their children and that they were ready "to do everything".[21] Parents described how they were the first to recognize a problem, demonstrating their ability to understand their children.[21] Parents also shared their struggles to have their children's ADHD recognized and to obtain the support and resources necessary for their children.[21] [18]

ADHD From the Child's Perspective

In 2011, Bingewatt published a paper that studies narratives from adolescents who were diagnosed with ADHD in childhood. Participants found their diagnoses to be stigmatizing and empowering at the same time.[23] Although some participants found the label stigmatizing, describing how they felt the need to hide it because they were afraid it would make them "different", many participants also benefited from the diagnosis.[23] Knowing what it was they were dealing with made ADHD more manageable for them. Some participants described their parents delivering and/or explaining their diagnosis to them. Other participants had their parents withholding information about ADHD from them. Parents, it was shown, played an integral role in influencing how the participants experienced ADHD. Participants emphasized the importance of tools for coping with ADHD, that parents and practitioners should play an integral role in providing these tools to their children, and that ADHD should be explained to the children as a "disorder" rather than "disease".[23]

The ADHD Debate

The ADHD debate is driven by a myth-reality dichotomy.[24] Studies show evidence for the neurobiological basis[25] [26] [27] and hereditability of ADHD.[28] However, the variable nature of its definition and diagnostic criteria, the high rate of comorbidity[29], and the lack of a standardized biological test for diagnosis has drawn criticism against the validity of ADHD as a legitimate psychiatric diagnosis.

Ideologies On the Diagnosis and Treatment Of ADHD

Three main ideologies on the diagnosis and treatment of ADHD presently exist. The first espouses a biological perspective and ascribes ADHD to an underactive frontal lobe, the part of the brain that is responsible for decision-making, problem solving, impulse control, and social and sexual behavior.[30] [31] In a 2007 study conducted by Shaw et al., MRI scans of the brains of 446 children showed underdevelopment in those diagnosed with ADHD. [25] A more recent study suggests that cortical thinning of the brain may be a neurobiological marker for ADHD.[26] This ideology supports the use of medication to correct biological functioning. Psychosocial treatments such as educational and behavioural programs are seen as supplemental to a medical regimen. The second ideology accepts that a biological trigger in the brain is responsible for ADHD but is concerned with the excessive use of drugs such as Ritalin. While medical professionals who support this ideology feel that medication can be moderately useful for severe cases of ADHD, they are cautious of prescribing psychostimulant drugs to small children. Instead, they recommend behavioural therapy treatments and educational programs.[30] The third ideology is critical of ADHD as a legitimate syndrome. It does not support the biological premise of ADHD and contends that ADHD is a label used to control children who exhibit deviant behaviour. An advocate of this ideology is Thom Hartmann, who frames ADHD as a "trait" instead of a syndrome. In his 2003 paper, Hartmann discusses how a short attention span worked to the advantage of the hunter, who needed to be alert in a constantly changing world.[32]

Criticism On the Medicalization Of Childhood

A great amount of literature has been critical of the medicalization of ADHD. Some argue that ADHD is not a disorder but a social construct maintained by environmental forces, each with their own interests (see Engines That Drive the Medicalization OF ADHD). Rather than asserting a medical explanation for ADHD, diagnosis of ADHD begs a crucial question: are its symptoms an abnormal response to a normal environment, or a normal response to an abnormal one?[10] Those who see ADHD as a form of social control feel that ADHD should be normalized as a phase of childhood. This is aptly captured in a short film from CCHR International:[33]

A Divided Opinion On the Overdiagnosis Of ADHD

In 1998, Lawrence Diller wrote extensively on his concerns with the high rate of ADHD diagnosis and consumption of Ritalin by children in the United States.[34] His apprehension has been echoed by medical sociologists and the public alike.

According to Child Trends Data Bank, in the United States, the percentage of children diagnosed with ADHD increased from 1997 (5.5 percent) to 2012 (9.5 percent), an increase of nearly 75 percent. The rate declined slightly in 2013, to 8.8 percent. For more statistics on ADHD from the same article, click here.
Brendan Saloner discusses race, health, and disadvantage in his article on the case of ADHD.

In response to the common conception that ADHD is overdiagnosed, recent studies have been conducted to evaluate the validity of this claim. A 2007 review of prevalence studies and research on factors affecting diagnostic accuracy showed that false negatives (children who had ADHD but were not diagnosed or identified) significantly exceeded false postives (children who had been incorrectly diagnosed with ADHD).[35] In 2011, Daniel F. Connor published an article in Psychiatric Times discussing the evidence for and against overdiagnosis and overprescribing in ADHD. Connor writes "Continued controversy over whether ADHD is overdiagnosed and stimulants overprescribed despite much scientific data to the contrary reflects ongoing public discomfort about ADHD as a valid and legitimate disorder."[36] Researchers suggest that cognitive biases contribute to the persistent perception that ADHD is overdiagnosed.[35] Media coverage of ADHD, personal experiences, and anecdotal evidence may not be representative of diagnostic accuracy of ADHD and lead to biased iews. Furthermore, there appears to be a general confusion about ADHD. Not only is its definition always changing, its classification is shifting as well. Is it a medical illness, psychiatric syndrome, behavioural problem, or a school-based laerning and socialization problem? This uncertainty encourages the general perception that ADHD is not a valid neurobiological disorder, but a socially constructed one. Fears of drug abuse and diversion and limited resources to support evidence-based standards of ADHD evaluation and treatment further propel the unease with ADHD's designation as a legitimate disorder.

Today, the debate continues. Despite scientific evidence supporting the legitimacy of ADHD as a neurobiological disorder and the lack of statistical evidence showing that ADHD is indeed overdiagnosed, skeptical voices of concern continue to be raised in the media. Articles often participate in the "blame game", pointing fingers at social agents that are supposedly responsible for the overmedicalization of ADHD. In 2013, a New York Times article titled "The Selling of Attention Deficit Disorder" criticized pharmaceutical companies for "selling to doctors" and "selling to patients".[37] A couple of months following the publication of this article, Dr. Jeffrey Liebbermann spoke on Medscape News, providing alternative reasons for the rise in ADHD:[38]

References

  1. ↑ 1.0 1.1 1.2 Conrad, P. (2007). "The medicalization of society: On the transformation of human conditions into treatable disorders." Baltimore: Johns Hopkins University Press.
  2. ↑ Mann, A. (2016). "Beyond medicalization: Explaining the increased prevalence of attention deficit-hyperactivity disorder."
  3. ↑ Don Baker. (2015, July 3) "ADHD Definition TImeline - New Infographic." Retrieved from http://www.unpackingadhd.com/adhd-definition-infographic/.
  4. ↑ American Psychiatric Association (APA). (1968). "Diagnostic and Statistical Manual of Mental Disorders: DSM-2 (2nd ed.)". Washington, D.C.: APA.
  5. ↑ Conrad, P., & Potter, D. (2000). From hyperactive children to ADHD adults: Observations on the expansion of medical categories. Social Problems, 47(4), 559-582.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 PsychiatryOnline Premium Package, American Psychiatric Association. DSM-5 Task Force, & American Psychiatric Association. (2013). "Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.)". Washington, D.C: American Psychiatric Association.
  7. ↑ Centre for Disease and Control and Prevention (CDC). (2016, January 8) "Attention-deficit/Hyperactivity Disorder." Retrieved from http://www.cdc.gov/ncbddd/adhd/diagnosis.html.
  8. ↑ University of Strathclyde Research Impact. (2016, Jun. 22). "The History of ADHD". Retrieved from https://www.youtube.com/watch?v=Yxqx6DamhuU.
  9. ↑ 9.0 9.1 Conrad, P. (2006). "Identifying Hyperactive Children: The Medicalization of Deviant Behavior." Aldershot, UK: Ashgate Publishing, Ltd.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Rafalovich, A. (2013). "Attention deficit-hyperactivity disorder as the medicalization of childhood: Challenges from and for sociology." Sociology Compass, 7(5), 343-354. doi:10.1111/soc4.12034
  11. ↑ Fraser, Gerald. (1970). "Official Is Disputed Over Drugs He Says Pupils Get for Control." Retrieved from http://timesmachine.nytimes.com/timesmachine/1970/11/22/102288223.html?page-Number=50.
  12. ↑ Maynard, Robert. (1970). Omaha Pupils Given ’Behavior’ Drugs. The Washington Post p. A1.
  13. ↑ Ross, D. & Ross, S. (1976). "Hyperactivity: Research, Theory, and Action." New York: Wiley.
  14. ↑ 14.0 14.1 Mayes, R., Bagwell, C., & Erkulwater, J. (2008). "ADHD and the Rise in Stimulant Use Among Children." Harvard Review of Psychiatry 16:151–166
  15. ↑ Schrag, P. & Divosky, D. (1976). "Myth of the Hyperactive Child: And Other Means of Child Control." New York: Dell Publishing
  16. ↑ Brancaccio, M.T. (2000). “Educational Hyperactivity: The Historical Emergence of a Concept.” Intercultural Education 11:165–177.
  17. ↑ McLeod, J. & Pescosolido, B. (2004). “Public Attitudes toward the Use of Psychiatric Medications for Children.” Journal of Health & Social Behavior 45:53–67.
  18. ↑ 18.0 18.1 18.2 Malacrida, C. (2004). Medicalization, ambivalence and social control: Mothers' descriptions of educators and ADD/ADHD. Health, 8(1), 61-80. doi:10.1177/1363459304038795
  19. ↑ Hogan, J.D. "Developmental psychology: History of the field". In Alan E. Kazdin (Ed). (2000). Encyclopedia of Psychology. Volume 3. pp. 9, 13. doi:10.1037/10518-003.
  20. ↑ Gale. (2005, Jan. 1). "Ainsworth, Mary D. Salter." Psychologists and Their Theories for Students. Retrieved from HighBeam Research: https://www.highbeam.com/doc/1G2-3456300011.html
  21. ↑ 21.0 21.1 21.2 21.3 21.4 21.5 21.6 21.7 21.8 21.9 Frigerio, A., Montali, L., & Fine, M. (2013). Attention deficit/hyperactivity disorder blame game: A study on the positioning of professionals, teachers and parents. Health, 17(6), 584-604.
  22. ↑ 22.0 22.1 22.2 22.3 Rafalovich, A. (2005). Exploring clinician uncertainty in the diagnosis and treatment of attention deficit hyperactivity disorder. Sociology of Health & Illness, 27(3), 305-323. doi:10.1111/j.1467-9566.2005.00444.x
  23. ↑ 23.0 23.1 23.2 Bringewatt, E. H. (2011). Hidden diagnosis: Attention deficit hyperactivity disorder from a child's perspective. (pp. 259-279) Emerald Group Publishing Limited. doi:10.1108/S1057-6290(2011)0000012016
  24. ↑ Baily, S. (2009). "Producing ADHD: An ethnographic study of behavioural discourses of early childhood." PhD Thesis, University of Nottingham, UK.
  25. ↑ 25.0 25.1 Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J.P., Greenstein, D., et al. (2007). "Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation." Proceedings of the National Academy of Sciences of the United States. 104(49), 19649-1965
  26. ↑ 26.0 26.1 Shaw, P., Gilliam, M., Liverpool, M., Weddle, G., Malek, M., Sharp, W., et al. (2011). "Cortical development in typically developing children with symptoms of hyperactivity and impulsivity: Support for a dimensional view of attention-deficit/hyperactivity disorder." American Journal of Psychiatry, 168(2),143-151.
  27. ↑ Rhode, L., Szobot, C., Polanczyk, G., et al. (2005). Attention deficit/hyperactivity disorder in a diverse culture: Do research and clinical findings support the notion of a cultural construct for the disorder?" Biological Psychiatry, 57(11), 1436-1441.
  28. ↑ Swanson, J.M., Kinsbourne, M., Nigg, J., et al. (2000). "Dopamine genes and ADHD." Neuroscience and Biobehavioural Reviews, 24(1), 21-25.
  29. ↑ Newcorn, J.H., Halperin, J.M., Jensen, Ps.S., et al. (2001). "Symptom profiles in children with ADHD: Effects of comorbidity and gender." Jornal of the American Academy of Child and Adolescent Psychiatry, 40(2): 137-146.
  30. ↑ 30.0 30.1 Mather, B.A. (2012). The social construction and reframing of attention-Deficit/Hyperactivity disorder. Ethical Human Psychology and Psychiatry, 14(1), 15-26. doi:10.1891/1559-4343.14.1.15
  31. ↑ Chayer, C., & Freedman, M. (2001). Frontal lobe functions. Current neurology and neuroscience reports, 1(6), 547-552.
  32. ↑ Hartmann, T. (2003). The Edison gene; ADHD and the gift of the hunter child. Rochester, VT: Park Street Press.
  33. ↑ CCHRInt. (2010, Dec 20). “CCHRInt: Childhood is Not a Mental Disorder .” Retrieved from https://www.youtube.com/watch?v=Wv49RFo1ckQ
  34. ↑ Diller, L.H. (1998). Running on Ritalin: A physician reflects on children, society, and performance in a pill". New York: Bantam Books.
  35. ↑ 35.0 35.1 Sciutto, M. J., & Eisenberg, M. (2007). Evaluating the evidence for and against the overdiagnosis of ADHD. Journal of attention disorders, 11(2), 106-113.
  36. ↑ Connor, D.F. (2011, Aug. 11). "Problems of Overdiagnosis and Overprescribing in ADHD". Retrieved from Psychiatric Times: http://www.psychiatrictimes.com/adhd/problems-overdiagnosis-and-overprescribing-adhd/page/0/1.
  37. ↑ Schwartz, A. (2013, Dec. 14) "The Selling of Attention Deficit Disorder". Retrieved from the NYTimes:http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?pagewanted=all&_r=0.
  38. ↑ Medscape. (2014, Feb. 10) "Explaining the Rise in ADHD". Retreived from Youtube: https://www.youtube.com/watch?v=dnPed1SEOgQ
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