Critical New Perspectives on ADHD

Gwynedd Lloyd, Joan Stead, David Cohen

• Publisher: Routledge
• Year: 2006
• ISBN:
  9781134238033
• Edition: 1
• Topic: Education
• Subtopic: Education General

Experts from all over the world take a critical, highly international and often controversial perspective on the ADHD phenomenon – a condition that has reached global proportions, significantly affecting the lives of children, parents and teachers worldwide. This book raises a number of concerns often not covered by the material currently available to parents and practitioners.

Critical New Perspectives on ADHD unpicks the myths surrounding the development of this phenomenon and leaves no stone unturned in its search for answers. An in-depth exploration into the reasons for the emergence and maintenance of ADHD lead to suggested explanations of the dominance of US psychiatric models and the need for new markets for major pharmaceutical companies, as well as the functions that ADHD diagnoses fulfil in families, classrooms and communities.

In a world where moves to educational inclusion are paradoxically paralleled by the ever-increasing use of medication to control children's behaviour, this book scrutinises current accepted practice and offers alternative perspectives and strategies for teachers and other education professionals. This in an invaluable resource for anyone with a serious interest in ADHD and other behavioural difficulties.

Chapter 1
Critiques of the 'ADHD' enterprise

David Cohen

At first glance, the reality of 'Attention-Deficit/Hyperactivity Disorder' (ADD or ADHD) seems obvious. The world's 'psychiatric bible,' the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) (DSM-IV, American Psychiatric Association 1994) describes the mental disorder ADHD in detail. The manual lists four distinct ADHD diagnoses that can be derived using combinations from among eighteen behavioral signs. According to the DSM-IV, ADHD is a discrete member of the class of 'Disruptive Behavior Disorders.' It is characterized by persistent inattention and/or hyperactivity/impulsivity occurring in several settings and more frequently and severely than adults judge to be typical for children at the same chronological stage of development. Symptoms are said to begin before age seven and to cause serious difficulties in home, school, or work life. Based on these and previous DSM criteria, approximately two dozen behavioral checklists are in use by teachers, parents, physicians, and other health, mental health, and social service professionals to assess or 'test for' ADHD – although no actual test of any sort besides a behavioral checklist establishes or confirms the diagnosis. Nonetheless, Russell Barkley (1998: 67), a leader in the field, gives the latest definition of ADHD as a 'developmental failure in the brain circuitry that underlies inhibition and self-control.'

Like many other medical-psychiatric-educational labels, the ADHD label gives meaning to countless activities and leaves large traces. It is applied to millions of children around the world and recorded in millions of computerized and paper records in government and insurance company data banks, in educational institutions of all types and sizes, doctors' offices, clinics and hospitals, residential treatment centers, and in courts.

To millions of modern families, the label provides a legitimate justification to 'outsource' some responsibilities related to raising children, a task whose objectives, rules, and methods have changed dramatically over the last half-century, along with the typical composition of families. Messages about ADHD destined for parents have strong guilt-dissolving, 'natural calamity' components, as in Consumer Reports' health website (MedicalGuide.org): 'Learning that your child has ADHD can be distressing. But ADHD is nobody's fault. Nothing you or your child has done has caused it.'

The ADHD label serves to justify the disbursement of substantial public and private funds (about $3.5–4.0 billion annually by the end of the 1990s) to fund special services in schools in the United States (Hinshaw et al. 1999). The label also provides schools yet another alibi to explain why they regularly fail to make some children fit in the only societal institution designed exclusively for children.

The ADHD label spurs enormous research activities and programs: thousands of drug treatment studies and experimental pharmacology and neuroscience studies of ADHD have been published since the 1960s. Each month, about twenty articles related to ADHD appear in scientific journals internationally. Hundreds of investigators from the health and social sciences currently study the cognitive performances of children diagnosed with ADHD. As of this writing, clinical trials conducted at the National Institute of Mental Health in the US are recruiting participants for investigations in the genetics of ADHD, brain processes in ADHD, herbal treatments for ADHD, and preventive interventions for ADHD. Using the keyword 'ADHD' for a search in a famous US online bookstore in mid-2005 yielded over 4,800 hits.

Last but not least, the ADHD label fuels the manufacture, promotion, regulation, and prescription of a dozen psychotropic pharmaceuticals, such as Ritalin and Concerta (two brand names for methylphenidate), Adderall (a mixture of four amphetamine salts), and Strattera (a 'non-stimulant' norepineprine reuptake inhibitor) in a worldwide market estimated to exceed $3 billion annually (CNS Drug Discoveries 2004). A parallel industry of herbal, natural, complementary, and other 'alternative' diagnostics and remedies for ADHD also flourishes.

Together, these and other social facts too numerous to list make ADHD as tangible as any condition can be. They are the social bodyguards of ADHD, surrounding and protecting its integrity as an actual discrete entity, as an abnormality or disorder of childhood development and functioning, or as a 'severe neurobehavioral disorder,' as ADHD is regularly described in popular and professional literature. These social facts serve to dissuade would-be critics from analyzing the concept ADHD too critically and from scrutinizing it logically, ethically, sociologically. Commenting solely on the number of monthly scientific publications related to ADHD, Barkley and colleagues (2004: 65) write that 'the genuineness of ADHD as a disorder appears to be alive, well, and on solid scientific ground… Any "debate" over the legitimacy of ADHD as a valid disorder exists only in some segments of the popular media, not in the scientific community.' Put another way, the myriad activities undertaken to manage ADHD in familial, educational, clinical, scientific, bureaucratic, and commercial systems constitute insurmountable evidence pointing to a single conclusion: ADHD exists!

Yet the very popularity of ADHD has given rise to accounts expressing great skepticism that so many children in our cognitively and educationally affluent societies should be afflicted with a disorder rarely if ever mentioned merely 25 years ago. Raising and teaching children is something about which everyone has an opinion, usually a firm opinion, and the idea of ADHD leaves few people neutral. Every effort to cement ADHD into the social consciousness has been resisted or derided to some extent. The notion of ADHD as a disorder or disease of childhood evokes resistance because it defies the common twin beliefs that all children are hyperactive, impulsive, and inattentive and that adults' primary task is precisely to raise them to act differently (Oas 2001). Besides an undercurrent of lay resistance, some sociologists, psychologists, pediatricians, psychiatrists, and psychologists have vigorously questioned the existence of a genuine condition 'ADHD' in all its previous and actual definitions since the 1960s. Facing psychologist Russell Barkley's (1995: 17) claim that 'ADHD is real, a real disorder, a real problem, often a real obstacle' stands neurologist Fred Baughman's (1998) counterclaim that 'ADHD is total, 100% fraud.'

The US, epicenter of the ADHD enterprise, is also epicenter of critiques of the ADHD enterprise. In this chapter, I summarize ten arguments emanating from North American authors and researchers who show one fault or another with various assumptions or conclusions concerning ADHD – its nature, its manifestations, its recognition, and its treatment via medications.

Not all countries have embraced the ADHD construct. My selective reading of the scant and necessarily retrospective epidemiological evidence suggests that at present, the construct is well established in the US, Canada, Australia, New Zealand, Switzerland, Norway, Sweden, Denmark, the United Kingdom, Germany, Holland, Israel, Spain, and Taiwan. In parallel, great international disparities exist in the use of stimulants as treatments for ADHD. It is estimated that fully 97 percent of the global sales of drugs for ADHD were derived from the US only, the rest from Europe (CNS Drug Discoveries 2004). Notably, certain countries with high rates of adult psychiatric drug use, such as France and Italy, appear so far to have resisted using stimulants with children in any significant manner, although in both countries key medical and educational institutions and parents' groups are just beginning to promote them – and the ADHD construct – vigorously (Bonati, this volume; Cohen 2000; Saget 2003). Systematic explanations of these puzzling international differences are still lacking. Possibly, the 'reality' of ADHD might assume different forms in nations just beginning to embrace the construct. The present summary of critiques of ADHD constitutes a modest effort toward the goal of shaping such alternative realities.

So far, the diagnosis of ADHD and the prescription of stimulants are inseparable phenomena. Without historical analysis, it is difficult to ascertain which preceded which, but it is reasonable to argue that the diagnosis is frequently a post hoc justification for the use of stimulants (Cohen, this volume; Conrad 1976). The figures from England (i.e. not Scotland, Wales, or Northern Ireland) illustrate just how rapidly their use can flourish on virgin soil: from 6,000 prescriptions for stimulants in 1994 to 186,200 in 2000, to 458,200 in 2004 (Prescription Cost Analysis 2005). To my knowledge, this 7600 percent increase in one decade represents the fastest ever anywhere on record. Taking into account their respective populations, England in 2004 still used stimulants about five times less than the US, where about 13 million prescriptions were written in 2003. If recent growth rates persist, however, there is every reason to expect England's rate of use to equal or exceed that of the US when this book appears in print.

The use of drugs increases the popularity of the ADHD label, which in turn reinforces the use of drugs and other interventions. Given the considerable short-term benefits that accrue from these practices to the influential mental health, educational, and drug industry communities, their members are likely to increase proclamations that those who question the validity of ADHD as a genuine disorder requiring lifelong treatment are flat-earthers.

The critiques included in this chapter were chosen mostly on the basis of their familiarity to this author; they do not represent the full spectrum of opposition and critical analysis (see, for example, Kiger 1985; Armstrong 1995; Maté 1999; Stein 1999; Timimi 2003). Broadly speaking, the critiques emanate from the fields of sociology, medicine (pediatrics, neurology, psychiatry), psychology, and clinical epidemiology. I have included authors who completely call into question the validity of the ADHD construct along with authors who appear to accept the construct while questioning how ADHD-diagnosed children are managed. Some critiques emphasize broad societal tendencies, others focus on methodological shortcomings of studies purporting to identify brain differences between ADHD and normal children. Most are scholarly critiques, in the sense that their authors have spent considerable time marshalling evidence and constructing logical arguments and submitting them to peer or public review. Together, these critiques represent what I believe is a compelling case for continuing critical examination of, and skepticism toward, the 'ADHD enterprise.'

ADHD as result of socio-cultural mutations

Medicalizing deviant and ordinary behavior

In Medicalization of Deviance: From Badness to Sickness (first edition 1980), sociologists Peter Conrad and Joseph Schneider argued that several socially problematic conducts formerly characterized as sins or crimes, such as homosexuality, excessive drinking, and suicide, had been or were in the process of being medicalized. Conrad and Scheider defined medicalization as defining or describing a socially deviant condition using medical terms, attributing a medical cause to it, or managing it with medical means such as hospitalization, drugs, or psychotherapy.

Conrad and Schneider hypothesized a series of sequential steps in the medicalization of deviance, from initial 'claims-staking' by early proponents to the final 'institutionalization' of the fully medicalized 'condition.' Interestingly, before publishing the complete theory of medicalization, Conrad's first case study of the phenomenon focused on what he termed the modern medical 'discovery' of hyperkinesis. Conrad (1976) argued that this discovery was built principally around the use of behavior-controlling drugs such as the stimulants.

In the intervening period since Conrad's study, and as reflected in American psychiatry's third edition of its Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 1980), hyperkinesis eventually became 'Attention-Deficit/Hyperactivity Disorder,' to be defined using eighteen different behavioral signs. As some critics have pointed out, taken singly, these eighteen components of ADHD represent instances of ordinary, normal childhood behavior that would not be expected to cause distress or impairment to any individual manifesting them. With DSM-III, the actual diagnostic signs became a frequency and combination of signs.

Moreover, the continued extension of medical boundaries that theoretically characterizes medicalization appears in the emergence, in the mid-1990s, of the category of 'ADHD adults' (Hallowell and Ratey 1994). This grouping, arguably designating certain forms of adult incompetence and vocational failure, remarkably allows 'for the inclusion of an entire population of people and their problems that were excluded by the original conception of hyperactive children' (Conrad and Potter 2000: 559). Over the last few years in the US, the validity of 'adult ADD' has been promoted in skillfully crafted television commercials by Eli Lilly and Company, the manufacturers of Stratter...

Table of contents

• Contents
• Acknowledgements
• Contributors
• Introduction
• Chapter 1 Critiques of the ‘ADHD’ enterprise
• Chapter 2 Canaries in the coal mine
• Chapter 3 Disability, childhood studies and the construction of medical discourses
• Chapter 4 ADHD as the new ‘feeblemindedness’ of American Indian children
• Chapter 5 A brief philosophical examination of ADHD
• Chapter 6 Inclusion and exclusion in school
• Chapter 7 ‘ADHD’ and parenting styles
• Chapter 8 The Italian saga of ADHD and its treatment
• Chapter 9 How does the decision to medicate children arise in cases of ‘ADHD’?
• Chapter 10 ADHD from a cross-cultural perspective
• Chapter 11 Pedagogy in the ‘ADHD classroom’
• Chapter 12 Managing attention difficulties in the classroom
• Chapter 13 Conclusion
• Index