ADHD – What’s in a name?
PhD research student, Nottingham University
Paper presented at the British Educational Research Association Annual Conference, University of Warwick, 6-9 September 2006
In recent years, Attention Deficit Hyperactive Disorder (ADHD) has become one of the most commonly diagnosed psychiatric conditions amongst children; estimates from treatment records suggest diagnostic rates as high as 30-40% in some schools in America (BBC, 1999), while estimates in the UK are usually reported at around 5% (BBC, 2003a). Of these, the vast majority are given some form of pharmaceutical treatment – most commonly methylphenidate (Ritalin), of which around 250,000 preparations are prescribed in the UK (BBC, 2003b). The prominence of these treatments along with the fact that diagnosis is made chiefly within the discourses of psychology, psychiatry and paediatrics, reflects the dominance which the biological model of mental disorder holds over current understandings of ADHD, a notion also supported by the industry dependence on the Diagnostic and Statistical Manual for Mental Disorder. Currently in a text revision of its fourth edition and written by an elite task force of members of the American Psychiatric Association, who recently also took over the writing of the other major published criteria for ADHD – the International Classification of Diseases (ICD-10).
This paper concerns the increasingly popular psychiatric taxonomy ADHD and its connections and contingencies within the educational context – from where a child is most likely to enter the diagnostic process. The main focus of this paper is the Diagnostic and Statistical Manual for Mental Disorder (DSM-IV-TR), which contains the criteria most often used for a diagnosis of ADHD in children. Using socio-cultural theories of risk, and Latour’s concept of translatability (Latour, 1987) I will argue for a radical overhaul of this current politics of psychiatric regulation. Through a brief re-telling of the history of the DSM, and its place in the context of psychiatry and education I will present an analysis of some of the practices through which the manual has gained and retains a legitimate truth telling function regarding children. One such practice I shall argue is the manual’s distinctive use of language, through which abstract taxonomy is connected to a broad range of school and class based situations. Experimenting with some re-translation, I shall briefly explore the possibility of re-equating this seemingly value free language of science with the oppressive consequences it implies for those most directly affected by it. In conclusion I shall return to the current translation and the implications of the practices it helps to conceal.
Despite, or perhaps in part owing to, the pre-dominance of the bio-psychiatric model for mental disorder, there exists a broad and varied critical literature on ADHD. Questions concerning the aetiology, diagnosis and treatment of ADHD have frequently been posed by academics and professionals, medical and otherwise (Breggin, 2002, Fone & Nutt, 2005, Rafalovich, 2001, 2005, Singh, 2002b, Stein, 2002, Tait, 2005, Weathers, 2001). There is also a growing literature concerning the varied experiences of the teachers, children, parents and families who have become entangled in this discourse (Bussing et al., 2003, Daley et al., 2005, G. Edwards et al., 2001, Harborne et al., 2004, Johnston & Mash, 2001, Johnston et al., 2002, Maniadaki et al., 2005, Nolan et al., 2001, Singh, 2003, 2005, 2006 (Submitted), Whalen et al., 2006, Whalen et al., 2002). The sociological critique which emerged on the back of theses on medicalisation and anti-psychiatry has grown into a substantial body of knowledge, increasingly extending into areas such as critical theory, historiography and genealogy (Danforth & Navarro, 2001, Harwood, 2003, 2005, Laurence & McCallum, 1998, Lloyd et al., 2006, Prosser, 2006a, 2006b, Singh, 2002a).
Nevertheless, the bio-psychiatric model steamrollers on, levels of diagnosis keep going up and professionals become more and more reliant on the DSM; polarising the dominant and critical discourses on ADHD in which one often confronts "not a partner in the search for truth, but an adversary, an enemy who is wrong, who is harmful and whose very existence constitutes a threat" (Foucault, 1984, p. 382).
Risk consciousness and natural development
There are those who claim that among the most important concepts to our social order and the practice of our everyday lives, is risk (Beck, 1992, Gabe, 1995, Giddens, 1991, Lupton, 1999). Risks and risk analysis have become embedded on a discursive plain of contested knowledge, which breeds a dependency on those with the right knowledge and the ability to communicate it effectively into the language of everyday social action. The aggressive mistrust of welfarism and lack of faith in collective action which some claim characterise our current political state (Fraser, 1997, Young, 1990) has individualised our political environment, furthering this dependence on, and helplessness in the face of, authority. Our daily lives are perforated by the constant injunction to make a choice – from the daily budgeting of time and resources to the long term management of work, family and education to the often critical decisions regarding health – choices never free of restrictive circumstances, never free of the opportunity cost of the choice we didn’t make, never free of the necessity of making a choice. As Beck states, "even where the word ‘decisions’ is too grandiose, because neither consciousness nor alternatives are present, the individual will have to ‘pay for’ the consequences of decisions not taken" (Beck, 1992, p. 135).
In this so called reflexive modernisation (Beck, 1992, Giddens, 1991) every choice involves risks of one sort or another, and this places a high premium on the ability to calculate the danger value of a given choice. When risk is a primary and ever present consideration then we become anxious slaves to knowledge; it becomes the tool with which we can ‘search for certainty’ (McWilliam & Singh, 2004) colonise the immediate threats and render them relatively danger free. If a domain of knowledge proves persuasive in its account of risk management then that domain stands to gain heavy alliance, and what could in that case be seen is the inter-imbrications of knowledge and power (Foucault, 1975, Foucault & Gordon, 1980).
One such domain of knowledge which has had particular salience with some of the phenomena I am dealing with today is developmental psychology. Within education, this domain is most commonly associated with the genetic epistemology of Jean Piaget. Through his stages of cognitive development, Piaget created our view of how children think in their early years. From sensorimotor, to preoperational through concrete to formal operational, Piaget constructed a matrix through which he claimed children learned to think conceptually and hypothetically (Piaget, 1976). What Piaget also constructed in this process was a normative and ordinal grid into which children could be distributed according to their perceived powers of perception. The axis of this grid is a dual one in which children are subjected to "not just iniquitous comparison with their peers…but also a constant evaluation against a 'gold standard' of the normal child." (James et al., 1998, p. 19).
A principle concern with these ideas that remains largely unheeded today is the ghosts of theories past: degeneracy theory, whose pathogenic communities had secured psychiatry’s place in the medical establishment in the mid-19th century (Goodson & Dowbiggin, 1990); a ‘dangerous’ social Darwinism (Dennet, 1996), by which institutional eugenics could be justified through the assertion of nature’s order (Baker, 2002); and Binet’s intelligence quotient, first devised as a means to identify ‘retarded’ learners and now promoted to a standardized, generalized examination in mental competence – according to one author it was during his time working on a French version of this test that Piaget observed the rhythms and regularities of the contents of children’s minds which "would drive his life’s work" (Mooney, 2000, p. 60).
In constructing childhood as a set of developmental stages on the way to proper maturation, Piaget unwittingly cast children as inferior to and dependent on adults (Jackson & Scott, 1999, James et al., 1998). In setting up a normative and ordinal ideal, against which the supposedly observable contents of a child’s mind could be compared, he also created the possibility of ‘taming’ some chance (Hacking, 1990).
The huge influence that Piaget’s stages and developmental psychology in general have on education is illustrative of a trend which can be understood in terms of the attempted relief of ‘risk anxiety’ (Jackson & Scott, 1999) through the progressive colonization of children and childhood (Cannella & Viruru, 2004). A plethora of techniques have emerged to augment this strategy, each concerned to understand, nurture and shape the future via manipulation of the present, and it is to one of these techniques I would like to turn now.
I have argued so far that discursive practices associated with risk combined with prevalent domains of knowledge currently serve to make the school, classroom, teacher and child legitimate spaces for moral and political intervention. Through this analysis, risk becomes "a calculative rationality tethered to assorted techniques for the regulation, management, and shaping of human conduct" (Dean, 1999, p. 132). To this idea I would like to introduce Bruno Latour’s concept of translatability (Latour, 1987).
I have already illustrated some of the ways in which ‘risk consciousness’ (McWilliam & Singh, 2004) defines the need for calculable spaces, through which the seemingly intractable present and future dangers of everyday life can be rendered manageable. We ‘know’ about some of these spaces – these "troubled places" (Thomson, 2002), you may know them as the ex-coalfield community, the inner-city estate, the school on special measures and the child with low self-esteem.
Within the classroom, this calculative regime can be seen to operate through the habituation of the routine school day, through which order and norm are translated into a regulative strategy which functions to distribute, divide, separate and mark out those who do not accept its rationale. While from a distance one can see that this rationale lies in nothing more than obedience to the routine itself, and as such is no more than a "mechanism by which authorities instantiate government" (Rose & Miller, 1992, p. 183), at the level of the everyday experience of the powerless it represents the constant injunction to regulate oneself, temper unruly subjectivities and forfeit the freedom to determine one’s actions or the conditions of those actions (Young, 1990, p. 38).
The legitimation for these practices in the classroom can once again be found in the domain of the psy-sciences. The extent to which it seems natural to think of children and schooling in terms of the developmental paradigm is illustrative of the way in which psychology’s foothold in the practice of schooling is not just beyond reproof but goes almost un-noticed. The psy-sciences make up a kind of "intellectual machinery" which renders thinkable childhood and schooling under certain descriptions, and provides through an "array of techniques of inscription" a rational assemblage of ways in which translation occurs – when lived experience can be made calculable, and calculation makes what is lived governable (Rose, 1998, p. 54). One such technique in this strategic translation, I argue here, is the Diagnostic and Statistical Manual.
Before I come onto the language games of the DSM it is perhaps worth noting the presence of the ‘S’ in DSM – something that my pre-occupation with the ‘D’ has often led me to obscure, however, it is a powerful way in which the ‘facts’ of one’s life become translated into the art of government. Statistics emerged as a science with a powerful truth telling capacity in the early eighteenth century with the birth of civil society and emergence of ‘the problem of population’ as the primary question facing the science of government (Foucault, 1979, 1991). Through the gathering of numerical information on events and happenings this new ‘science of state’ revealed regularities by which order and governance could be kept, forging what would be a "lasting relation between knowledge and government" (Rose, 1998, p. 58). When combined with a domain of knowledge such as psychology this concrete science of state is able to construct "moral topographies of the population" (Rose, 1998, p. 74), ‘taming the wild profusion’ (Foucault, 1974) of unrule and disorder, domesticating it through the natural rhythms and regularities of statistics (Hacking, 1990). The heavy usage of statistics to legitimate the diagnosis of mental disorder is a key illustration of an alliance with a governmental rationale – the numbers provide the intelligence with which to assess the condition of its chosen population – the first step in the attempt to "materialize the mind" (Rose, 1998, p. 109) which a project like the DSM represents. As the words of the creators of the first DSM attest: "the collection of statistics on mental illness and morbidity has long been a stepchild of Federal Government" (APA, 1952, p. x)
The emergence of the DSM
The DSM first appeared in 1952, prepared by the Committee on Nomenclature and Statistics of the American Psychiatric Association and designed to succeed the Statistical Manual for use of Institutions of the Insane, first published in 1918. As such progressive editions (APA, 1968, 1980, 1987, 1994, 2000) aimed to provide not only a "structural grid of demarcation for action on the action of others, but also substantiate the science of psychiatry" (Harwood, 2005, p. 67). This period from around the turn of the century to the 1950s is significant for a number of contextual reasons which may be elaborated through a brief history.
The turn of the century had seen the first educational provision for children with ‘special needs’ the guidance from this was grounded in the "dividing practices" of the medical profession which linked the educational provision of this new population "very firmly with a prior medical examination" (Copeland, 1997, p. 713). In 1902 George Stills made his accounts of "a morbid ‘passionateness’ in children lacking ‘inhibitory volition’" (Laurence & McCallum, 1998, p. 184) – now commonly cited as the medical genesis of ADHD.
This account was part of a wider debate concerning unruly children – the explanatory argument for which raged between the psychoanalytic and bio-psychiatric model of explanation (Kirk & Kutchins, 1992, Singh, 2002a). The latter model won two significant victories: first, in the 1930s, Bradley’s successful experiments on the therapeutic use of amphetamines to modify behaviour in children (Laurence & McCallum, 1998, Singh, 2002a) and secondly in the ‘discovery’ of cerebral trauma (Hacking, 1994) and the means to measure it in the Electroencephalogram (EEG) which benefited from the mass experimentation made possible by the Second World War (Laurence & McCallum, 1998).
The 132-paged DSM-I appeared via a seven-man task force, with no input from over half the APA's members and was met with some indifference. Organizations were unwilling to transfer their classifications over from the ICD and criticism was made of the lack of guidance on childhood mental disorder (Jenkins, 1973). The second edition of the manual, which was published in 1968, sought to address these criticisms. However the popularity which it, and to a greater extent its successor, gained was again contingent on changing social practices. One significant decade of events was the pharmaceutical revolution, where, by 1961, 150,000 pharmacological preparations were available, of which 90% had not existed ten years earlier (Singh, 2002a, p. 592). This included the first emergence of methylphenidate in 1955 as a treatment for depression, and had by the 1970s helped establish mental disorder as a formidable industry.
This context of a kind of battle ensuing between the psychoanalytic and bio-psychiatric discourses represents not just two competing explanations for mental disorder, but two entirely competing epistemologies. The psychoanalytic model as represented most famously by Freud, sought aetiological explanation for mental disturbance in childhood development, the dynamic model of the mind and the now commonsense theories of ambivalence and repression. The bio-psychiatric model represented less famously by the German psychiatrist Emil Kraepelin was concerned less with aetiological theorisation and more with descriptive efforts to classify and categorize psychiatric disorders symptomatically. What the mass emergence of psychopharmacology; the rise to dominance of the bio-psychiatric model of mental disorder; and, the mass expansion and take-up of the DSM classification system all share is an instrumental rationality – a "what works" reasoning that rather than attempt to theorise aetiologically instead reverses the logic and takes the existence of a cluster of symptoms and an effective treatment as all the proof of the aetiological and diagnostic validity it needs. Thus the claim that "the shift from DSM-II to DSM-III marked an important moment in the history of psychiatry, as the bio-psychiatric model came to dominate over the psychoanalytic model" (Cooksey & Brown, 1998, p. 527) needs to be fully acknowledged for the epistemological slippage that it implies.
So, 1980 and the appearance of the third DSM. The largest increase in diagnostic categories – the biggest increase of which came in mental disorders of childhood and adolescence (Kirk & Kutchins, 1992, p. 101), which included the first appearance of "Attention Deficit Disorder". That the epistemological shift described above had gone by largely unacknowledged is illustrated by the following quote from "the highest ranking psychiatrist in the federal government"(Kirk & Kutchins, 1992, p. 6):
"The decision of the APA first to develop DSM-III and then to promulgate its use represents a significant reaffirmation on the part of American psychiatry to its medical identity and its commitment to scientific medicine...There is not a textbook of psychology or psychiatry that does not use DSM-III as the organizing principle for its table of contents and for classification of psychopathology" (Klerman, 1984, In Kirk & Kutchins, 1992, p. 6)
Translating the DSM
With regards nosology, the DSM is a categorical classificatory system, in which children are paired off against clusters of clinical criteria which are either present or absent – as one critic puts it, this process "strictly speaking, is a yes-or-no, an either-or affair" (Hempel, 1965, p. 151); and this reflects the ‘anti-epistemology’ described above. In the face of the complex and changing reality it seeks to pin down, this type of classification encourages "an ongoing process of definition and refinement" (Rapoport & Ismond, 1996, p. xvii). This rationale appears to leave a somewhat open remit as to what behaviour or symptoms may or may not be one day construed as reflecting mental illness – one only has to go back to DSM-I, for example, to find homosexuality given it’s own pathology (Lafferty, 2000). This argument is also substantiated by the DSM’s ill-defined concept of ‘mental disorder’ – again in the words of the creators of the most recent manual: "although this manual provides a classification of mental disorder, it must be admitted that no definition adequately specifies precise boundaries for the concept of ‘mental disorder’" (APA, 2000, p. xxx). And if one is puzzled over this rather casual approach "over what might be the most elemental of details" (Harwood, 2005, p. 37) then one need look no further for explanation than the potential diagnostic freedom which it denotes – it’s potential for translatability (Latour, 1987).
(Source: APA, 2000)
These criteria are qualified by the statement that "symptoms need to manifest themselves in a manner and degree which is inconsistent with the child’s current developmental level…persisting for at least 6 months to a degree that is maladaptive and immature" (APA, 2000).
Without any strong underlying concept of what actually constitutes mental disorder and what does not, the first thing that is striking about these criteria is the ease with which a diagnosis could be made. I have extracted twelve of the eighteen criteria above – but six matching criteria from each section is enough to make a diagnosis of ADHD. The criteria are also densely clustered – the inattention criteria are all to do with an inability to focus on, organize or carry through tasks, it is almost as though the same thing is being said in six slightly different ways. What the DSM, has achieved with this criteria is a highly visual and rational tool, thoroughly practiced at "knowing and speaking its objects into existence" (Harwood, 2005, p. 48), of making its objects translatable. And because several concerning elements of this diagnostic practice go unquestioned – the non-existent aetiology; the "what works" epistemology; the vaguery of underlying constructs and the contingency of the classroom – a convincing diagnostic argument will continue to be made on the extent to which one can recognise a problem child within these criteria. As such the DSM represents a convincing "act of persuasion" by which an actor confers on themselves "authority to speak or act on behalf of another actor or force" (Callon & Latour, 1981, p. 279).
Thus through its ability to reformulate the objects, instruments and tasks of bio-psychiatry with reference to this specific domain of the school – the DSM aids the psy-sciences in achieving the government of action at a distance (Rose & Miller, 1992).
Discussing a text of La Perriere, Foucault remarks "that a good ruler must have patience, wisdom and diligence. What does he mean by patience? To explain it, he gives the example of the king of bees, the bumble-bee, who, he says, rules the bee-hive without needing a sting." (Foucault, 1991, p. 96). What I propose here is that the government from a distance that the DSM achieves is partially contingent on its ability to remove its sting. Therefore I would like to conclude this section with a brief reflection on how one might go about putting the sting back in.
The DSM – ‘beyond good and evil’
I have argued that one of the ways the DSM has become an expert in speaking its objects into existence and telling the truth about ‘disordered’ children is through its embodiment of a neutral and wise authority. What I have tried to highlight is some of the contingencies that the authority of this truth telling depends on – social and discursive practices which have made the child’s head a legitimate calculable space, and conferred the authority upon certain competent professionals to make inscriptions upon such a space. My desire is to make these processes a little more visible, as such I would like to propose a new nomenclature for ADHD, which re-acquaints the discourse with its oppressive implications.
The first thing that is being implied with the label ADHD is a deficiency. This denotes a pathological inability to complete tasks and activities according to the normative structure available within the classroom. Given the generality of the criteria, many 5-7 year olds must at some time or another display enough of the behaviours listed above to qualify for a diagnosis, therefore the pathology must lie in the fact that the behaviour has been observed for at least six months as well as the opinion that the behaviour is developmentally inappropriate (as gauged against the child’s peers). Thus, this child’s deficiency differs from the ‘normal deviance’ one expects, and they can therefore be described as not only deficient but abnormally so.
It is obvious that the ADHD child represents a danger – to themselves, their peers, their teachers and their parents. However, as I have argued here, our social order as a whole is suspended by risk anxiety in a perpetual state of perceived danger. What makes the ADHD child a particular danger is the location of their psychopathology to internal origins. As slaves to the degenerate genes and structural abnormalities that this biologically derived rationale implies, "there is little hope of change and every chance of future pathology" (Harwood, 2005, p. 57). Thus, this child’s danger represents more than the common threat one expects, and they can therefore be described not only as dangerous but highly so.
What this gives us is Abnormally Deficient and Highly Dangerous, which, by happy coincidence, means we need not change the acronym. However, having Abnormally Deficient and Highly Dangerous doesn’t make sense. Fortunately what I have been talking about here in the ADHD label is a mode of subjection which seeks to tether identity to a simple construct. As such we can emphasise the ontological shift involved and talk about the child as being Abnormally Deficient and Highly Dangerous.
The neutral language of ADHD as represented in the DSM allows what should be seen as a highly concerning set of practices to become specks on the "all too familiar and poorly known landscape" (Foucault, 1997, p. 144) of action upon action and the conduct of conduct. The sting of psy-science - deficit, stigma, fatalism, essentialism and dependency are all introduced to the child at the earliest possible age, concealed behind the supposedly empowering language of special needs (Corbett, 1996) and the "incontrovertible factuality" (M. Edwards, 2004) of biological inheritance.
Childhood and Danger
The emergence of the dangerous ADHD child is made possible through the discursive practices justified by risk consciousness (McWilliam & Singh, 2004); the perceived threat of the unruly child; troubled community; failing school – unified perhaps only through the means by which they have been fabricated – for, it is "only in the analysis of risks that the hazard comes into existence" (Fox, 1999, p. 20). What dominant translations of experience such as the DSM obscure is the extent to which children – ‘mentally ill’ or otherwise – and the institution of childhood itself has become something of a "targeted population" (Dean, 1999, p. 148).
Childhood, it has been observed, inhabits something of an ambivalent plane in our attitudes and practices. As fearful of notions of ‘lost innocence’ as we are of deviance and the "barbaric future" (Popkewitz & Lindblad, 2004) it heralds, childhood is increasingly constructed "as a precious realm under siege from those who would rob children of their childhoods, and as being subverted from within by children who refuse to remain childlike" (Jackson & Scott, 1999, p. 86). Propelled by the will to protect, nurture and keep from harm; empowered by domains of knowledge through which we understand such notions as ‘development’ and ‘socialization’, and ever vigilant for the tell tale signs that spell a future of educational failure, unemployability, deviance and criminality; a colony of risk anxiety has been constructed in which children – their movements, spaces, utterances, and habits are divided, safe from dangerous (Cannella, 1999).
The institutionalisation of children in compulsory schooling serves to exclude them from full participation in adult society and re-inscribes relations of dependence. School also provides an important arena in which domains of knowledge have developed with their associated implications for political structure and moral practice (Foucault, 1984, pp. 387-388, Rose & Miller, 1992, p. 178). And when through the wholly accepted wisdoms of the developmental paradigm (James et al., 1998) and the effects of low self-esteem (Cruikshank, 1996) one can see so many spectres of theories past; "pathogenic communities", "degenerate genes" (Goodson & Dowbiggin, 1990) – then one understands the extent to which these divisions, this protection, these well intentioned acts of kindness, have contributed to the perceived need for constant vigilance and the encountering of the contents of the child’s mind as a legitimate space of invasion.
Within this context of risk anxiety the ADHD child emerges as a danger from several perspectives. They disrupt classroom life, put other’s education on hold, marginalise the teacher’s ability to keep order, and through the association of ADHD with other ‘learning difficulties’ they endanger their own educational future as well. For parents of an ADHD child the task becomes accounting for oneself in the face of having produced such a phenomenon (Singh, 2004); for parents of other children the task becomes making sure that their own child is not being lead astray or in any other way having their education jeopardised (Armstrong, 2003, Benjamin, 2002). For teachers the task of inclusion is constantly foreshadowed by the need to produce results, the extensive network of accountability and performance tying the everyday experience of the classroom to the future of the school (Benjamin, 2002, Curtis, 2006, McWilliam & Singh, 2004, Selwyn, 2000, Slee, 1997, 1992).
Thus, social and discursive practice, the focus on that which threatens the prescriptive order and norm, open up spaces of perceived disruption and unruliness, and states the case for political and moral intervention. Viewed through the lens of risk anxiety, problems of regulation and management such as ADHD, appear everywhere and it is easy to see how enclosures of expertise may establish themselves with their "tranquil yet seductive territory of truth" (Rose & Miller, 1992, p. 188).
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This document was added to the Education-Line database on 13 October 2006