Background:
Many people have known someone who has been diagnosed with attention deficit hyperactivity disorder, or ADHD, whether it be a family member, friend or classmate. This is because it is quite prevalent in children in the United States, with about 5% of children diagnosed with ADHD (Selikowitz 2). More current studies from 2010, estimate that the prevalence of ADHD in the United States ranges from 11.4-16.1% (Lecendreux). In this entry, I will primarily focus on childhood ADHD in the United States and how it compares to other countries. However, ADHD can also be diagnosed in adults.
In 1980, the American Psychiatric Association coined the term attention deficit disorder (ADD) to describe the symptoms of inattention in children (Lange). There was controversy about whether hyperactivity was related to ADD or a separate syndrome altogether (Lange). However, in 1987, the Diagnostic and Statistical Manual of Mental Disorders III (DSM-III), which is the standard for psychiatric diagnoses in the United States, renamed the disorder ADHD (Lange). Now, the diagnosis ADHD covers the range of inattention and hyperactivity disorders (Lange). The Centers for Disease Control and Prevention defines ADHD as a “persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning of development” as is stated in the DSM-V (“Symptoms and Diagnosis”).
About ADHD:
Individuals with ADHD typically have difficulty staying focused, concentrating on tasks and exhibit restless behavior (Selikowitz 9). In children, ADHD is more commonly diagnosed in males than females (Brewis 377). Currently, there are three major forms of ADHD as dictated by the DSM-5. These include the predominantly inattentive presentation, the predominantly hyperactive presentation, and the combined presentation (Brewis 377, CDC). The inattentive form primarily affects learning while the hyperactive form primarily affects behavior (Selikowitz 6).
In children, the symptoms of ADHD present in many ways. They are very prone to being distracted and for this reason may have difficulty staying focused in a classroom environment where there are numerous distractions (Selikowitz 6). Children with ADHD specifically have difficulty focusing on things to which they have to listen rather than view (6). Other forms of ADHD see children focusing well at the start of a task, but later their attention wanes as they become tired (6-7). In relation, many times children with ADHD do not complete tasks which is a problem seen often in the context of chores or schoolwork (7). Disorganization and forgetfulness are also characteristic of children with ADHD (7). The hyperactivity-impulsive type of ADHD has other symptoms that present. Children act impulsively, whether it be in their speech or their physical actions due to lack of self-control (8). Furthermore, such children may be overactive and cannot stay seated or squirm in their seat in restlessness (8).
One of the most common way that ADHD is approached, is through a scientific mindset. According to recent research, there are a number of biological and chemical factors that cause ADHD. Currently, scientists believe that the frontal region of the brain is responsible for actions such as planning and self-control (Selikowitz 73). Scans show that children with ADHD have an underactive frontal region of the brain when performing these actions (73). Furthermore, patients with ADHD have depletion in the neurotransmitter, dopamine, which is a chemical messenger that performs important functions in brain signaling (73). There are also possible genetic causes for ADHD that have been demonstrated in heritability studies (74). Specifically, it has been shown that individuals with ADHD also have a higher rate of family members with ADHD (74). Also, twin studies show that if one twin has ADHD the other has an increased risk of also having ADHD (74).
One of the most common treatments for children with ADHD is through a scientific way: medication to combat the neurotransmitter imbalance, such as Ritalin (Selikowitz 122-123). This drug works to combat the dopamine deficiency that is one of the causes of ADHD (123). In addition, behavioral therapy can be used to help ADHD patients in combination with drugs to help teach the children good forms of behavior (116).
Perspectives:
A prevalent controversy surrounding ADHD is the medicalization and demedicalization of the disorder (Conrad 3). There is a great deal of scientific evidence showing that the disorder has biological origins, but some researchers believe that it is not a true disorder and is within the norm of adolescent behavior (Elliot 139).
Some scientists consider ADHD to be a public health concern because the disorder has long term effects in an individual’s life in regards to academics, professional tasks and social interaction (Brewis 378. Furthermore, scientific evidence from hereditary studies and the pattern of development of the disorder indicate that ADHD has origins in the nervous system, suggesting a biologic basis (378). Evidence supports that ADHD is a genetic disorder and requires drug therapy and behavior therapy to treat (Taylor). Further evidence of the biologic basis of ADHD has been shown through brain scan analysis and clinical trials (Taylor). On the other hand, some scientists do not agree that ADHD is a mental disorder. Fred Baughman believes that the ADHD in and of itself is not a disorder because the symptoms are within the range of normal behavior (Faraone). However, the symptoms can cause dysfunction on social and professional aspects of life. Thus, people who face these disruptions should receive treatment (Faraone). It is important to understand this debate because it affects the different perspectives that view the disease and the treatments used to help people who have significant life disruptions because of the symptoms.
Another controversy surrounding ADHD is the rates of Ritalin prescription. In the 1990s, there were 2.4 million American people taking Ritalin, including toddlers (Elliot 149). The rates of Ritalin use are significantly higher than other developed countries (149). The scientists who are against such wide use of Ritalin in children believe that many children who are given Ritalin to manage certain symptoms are just behaving how a child should (139). Teachers who see a child acting out in class may recommend they get seen in order to be prescribed Ritalin, but these kids may not actually have a medical condition (150). The theory behind this perspective is that modern American culture is trying to make children behave like adults (139). This is apparent in other aspects of life, such as how children dress, but also in behavior (139). Still, there are many physicians who believe that ADHD is not being over diagnosed and even believe that Ritalin prescription rates should increase even more because it works (150). However, further research shows that taking stimulants like Ritalin, would cause any person to become more alert and focused, therefore the effects are not isolated just to people with ADHD (153).
Credit: Science Museum, London
Ritalin is a stimulant drug that is commonly used to treat ADHD. It was once thought that Ritalin had calming effects in ADHD patients but acted as a stimulant in non-ADHD individuals. However, subsequent studies show that ADHD serves to increase focus and improves alertness in most people regardless of if they have ADHD (Elliot 139)
Overall, it seems that many scientists within the United States agree that ADHD is a condition that has effects on an individual’s life. However, there are disagreements on how prevalent it is and how widespread the treatment for ADHD should be. There is a different outlook of ADHD when comparing the United States and other countries, however.
In France, ADHD is seen as being caused by social contexts and instead of using medications to treat the problem; they focus on changing and fixing the environment of the children (Wedge). France takes a broader approach and investigates many factors of children’s lives including home life and diet (Wedge). In fact, France does not even use the DSM model of diagnosis (Wedge). This contrasts with the United States, where slightly atypical behavior is seen as abnormal and pharmaceuticals are given to treat the problem. In France, about 4.0% of the population presents with ADHD, whereas in the United States this number is tripled (Lecendreux). Furthermore, the cultural differences between France and the United States can account for why the U.S. has more instances of ADHD (Wedge). French culture instills more self-discipline earlier on in childhood and therefore children are better behaved, and ADHD symptoms do not emerge as often(Wedge). This view does not take into account any of the biological evidence of ADHD (Wedge).
Furthermore, Ken Jacobson has conducted studies to research the differences in ADHD diagnosing in the United States and England because England has lower rates of diagnosed ADHD than the United States (Jacobson 283). Teachers are one of the primary individuals that refer children to be tested for diagnosis, so Jacobson conducted his studies in the classroom (283). He suggests that one factor that can explain the difference in rates of diagnosis is the tolerance of the teachers and what they find to be normal (284). The heart of Jacobson’s argument explains that culture defines something as abnormal or normal, not biology (283). He argues that categories are created by humans to help us organize people, and label those slightly different with having disorders (283). Thus, in different cultures, such as American and British, there are different guidelines for what is normal or abnormal and thus, different levels of diagnosing of ADHD.
Stephen Tonti discusses how he was first diagnosed with ADHD, not by a doctor, but by an elementary school teacher. He discusses how different people respond to ADHD in different ways and how this changes the way ADHD affects the individual. This directly shows the impact of the social influence of ADHD diagnosis and manifestation. (“ADHD As A Difference In Cognition, Not A Disorder”).
Moreover, there seems to be large gender differences in the diagnosing of ADHD which supplements the idea that ADHD diagnosis is more socially based (Brewis 377). Alexandra Brewis conducted studies in Mexican school children to determine how ADHD symptoms are interpreted between boys and girls by parents and teachers (377). She found one major factor that impacts ADHD diagnoses is that boys and girls are treated differently socially and different types of behaviors are associated with each gender (378). Furthermore, teachers are more likely to recognize symptoms as being hyperactive or inattentive in boys over parents (378). This may be because teachers have more experience with how each group is “supposed” to behave. However, the checklist system provided by the DSM-V leaves interpretation for clinicians as well (377). Studies show that boys are more likely to be diagnosed as hyperactive or inattentive than girls exhibiting the same symptoms (Brewis 378). There is room for flexibility in the diagnosing of ADHD which leads to the opportunity for bias.
Thus, there is a great deal of disagreement among academics about how prevalent ADHD really is and what the best way to treat the condition is. There are views that are based concretely on the idea that ADHD is directly a biological condition and medication is the best treatment. Others believe that diagnosing of ADHD is less of a science and heavily influenced by social factors.
Historical Context:
ADHD can be viewed through a lens of the ideas of childhood and development. Dating back to the eighteenth century, philosopher Jean Jacques Rousseau saw children as inherently good and that they “need protection from a corrupting society” (Taylor). In the next century, Sigmund Freud, had a contrasting view that children were impulsive and needed to learn to be controlled (Taylor). This depicts the precursors to the idea that children need to develop discipline, an idea that many modern theorists suggest is against the nature of children. This leads to the critique that children are not allowed to behave as children and their behavior is pathologized. Examples of abnormally behaved children date back to the eighteenth century and many times these children were treated with violence in order to control them (Taylor). However, in the nineteenth century, unruly children were treated as insane and sent to psychiatric hospitals instead (Taylor). Thus, this began the preliminary connection of undisciplined behavior with mental illness, a trend that continues to this day.
George Frederick Still was a professor of childhood medicine who identified symptoms of ADHD in children, but characterized them as “defects of moral control” (Taylor). Some of his descriptions of these children were that they were aggressive, impulsive and could not stay focused (Taylor). These findings did not have a significant impact during that time, but were supportive of the biological origins of the disease (Taylor). This biological disorder developed into Minimal Brain Damage (MBD) in the twentieth century (Taylor). The idea behind Minimal Brain Damage was that some children had a type of brain damage that manifested in in hyperactivity (Lange). The controversial part of this concept was that this underlying brain damage was inferred even if there were no physical signs of damage (Lange). Then, researchers in the 1960s decided that a better diagnosis was Minimal Brain Dysfunction which didn’t assume neurological damage (Lange). Eventually, Minimal Brain Dysfunction was connected to attention deficit and ADD/ADHD was born (Taylor). In the twentieth century, certain chemical compounds were discovered to have positive impacts on children’s mental states and decades later became a treatment for hyperactivity (Taylor).
The first treatment of hyperactivity was developed by Charles Bradley (Lange). He was studying treatments for headaches but discovered that stimulants, Benzedrine particularly, had no effect on headaches but managed to have a calming effect on hyperactivity (Lange). Bradley found that Benzedrine had a “remarkable” effect on the “school performance” of children (Lange). However, Bradley’s discovery had little impact during his time because mental disorders were thought to not be caused by biological factors (Lange). However, 25 years later stimulants became a treatment for hyperactivity. At this time Benzedrine was not used but another stimulant Methylphenidate was the preferred medication, now marketed as Ritalin (Lange).
It is important to understand the history of behavioral disorders because it shows how the different perspectives developed and why the disorder is characterized the way it is today. The history of ADHD shows a strong a biological background in research but less social and environmental research influence (Taylor). There is more to be learned about biological and environmental interactions and how they impact the severity and the effects of ADHD (Taylor).
Politics of Health:
ADHD relates to the themes of medicalization and pharmaceuticalization, discussed in Politics of Health. ADHD directly fits the definition of medicalization as presented by Peter Conrad: “defining a problem in medical terms, usually as an illness or disorder, or using a medical intervention to treat it” (3). Conrad describes the example of Ritalin when describing how “pharamaceutical innovation and marketing” were present even before the shift to medicalization. However, many of the aspects of the shift to medicalization apply to ADHD. Conrad describes the increase of third parties and how patients begin to seek out health services more themselves (4). The third party notion connects to the practice of teachers referring students to get evaluated or parents believing that their child is hyperactive and seeking a medical opinion. Furthermore, the rise in Ritalin prescriptions in children is referenced in Conrad’s piece as an example of the biotechnology engine of medicalization (7). Children are an important target for the pharmaceutical industry, especially for psychotropic drugs such as stimulants and antidepressants (7). Conrad also discusses medical enhancements as a growing field for pharmaceuticals and medical treatments (7). Ritalin is often used by high school and college students go get an advantage over other students because it can help them study harder or focus for longer times (Elliot 139). Conrad also discusses ADHD as an example of the consumer engine for medicalization (Conrad 9). In this case, adults are increasingly asking doctors to be evaluated for ADHD (9). Furthermore, drug companies indirectly advertise to adults by funding organizations such as Children and Adults with Attention Deficit and Hyperactivity Disorder (9).
ADHD was observed as a behavioral abnormality and then defined as a disorder that is now treated with drugs. As seen in the perspectives section of this entry, there is debate over whether ADHD is a disorder or a variant of behavior that is considered abnormal by a society that wants everyone to conform. In fact, Conrad refers to ADHD as the “medicalization of underperformance” (Elliot 155). Furthermore, ADHD fits the idea of medicalization because the rates of diagnoses and Ritalin use have increased significantly over the past few decades, showing that the disorder has become more pathologized (Elliot 149).
Dr. William Graf of Yale University discusses the rise in ADHD diagnosis and what does this means for the disorder and medicating children (“Tracking A Rise In ADHD Diagnosis”).
ADHD is also closely related to pharmaceuticalization. Pharmaceuticalization refers to human conditions being “translated or transformed… into opportunities for pharmaceutical intervention” (Williams 20). The rise of Ritalin prescriptions in the United States shows that ADHD has turned into a way for pharmaceuticals to be heavily distributed among the population. Furthermore, Ritalin is used by people in school or work settings who don’t have ADHD in order to get an edge. (hyperlink: http://onlinelibrary.wiley.com/doi/10.1111/etho.12167/pdf), which goes along with the enhancement idea of pharmaceuticalization (Elliot 155, Williams 20). In fact, Scot Danforth writes, “the medicalization of child misbehavior would have been impossible without the development of psychoactive medications like Ritalin” (Danforth 168). Further, he asserts that the increase in diagnosis of the disorder was a consequence of developing a medication for it (Danforth 168).
Additional Resources:
How is ADHD affected by the language associated with it?
How does an ADHD diagnosis affect an individual’s overall mental health?
Statistics about Ritalin:
Works Cited:
“Attention-Deficit / Hyperactivity Disorder (ADHD)– Symptoms and Diagnosis.” Centers for Disease Prevention and Control, 31, Aug. 2017. https://www.cdc.gov/ncbddd/adhd/diagnosis.html
Brewis, Alexandra. “Gender Variation in the Identification of Mexican Children’s Psychiatric Symptoms.” Medical Anthropology Quarterly, vol. 17, no. 3, 2003, pp. 376-393, 10.1525/maq.2003.17.3.376. Accessed 3 February 2018.
Conrad, Peter. “The Shifting Engines of Medicalization.” Journal of Health and Social Behavior, vol. 46, pp. 3-14. Accessed 11 February 2018.
Cooper, Amy. “At Such a Good School, Everybody Needs It”: Contested Meanings of Prescription Stimulant Use in College Academics.” Ethos, vol. 45, no 3, 2017, pp. 289-313, http://onlinelibrary.wiley.com/doi/10.1111/etho.12167/pdf. Accessed 16 February 2018.
Danforth, Scot. “Hyper Talk: Sampling the Social Construction of ADHD in Everyday Language.” Anthropology and Education Quarterly, vol. 32, no. 2, pp.167-190, 10.1525/aeq.2001.32.2.167. Accessed 4 February 2018.
Elliot, Carl. Better than Well. W.W. Norton and Company Inc., 2003.
‘Empty bottle for Ritalin tablets, England, 1954-1970’ by Science Museum, London. Credit: Science Museum, London.
Faraone, Stephen V. “Disorder or Discipline Problem?” Science, vol. 291, no.5508, 2001, pp. 1488-1489, http://www.jstor.org/stable/3082484. Accessed 12 February 2018.
Goldstein, Sam. Clinician’s Guide to Adult ADHD : Assessment and Intervention. Elsevier Science, 2002.
Jacobson,Ken. “ADHD in Cross-Cultural Perspective: Some Empirical Results.” American Anthropologist, vol. 104, no. 1, 2002, pp. 283-287. JSTOR, http://www.jstor.org/stable/pdf/683780.pdf?refreqid=excelsior%3Ac742b222412003a8626dd48be50f13c6. Accessed 3 February 2018.
Lange, Klaus. “The history of attention deficit hyperactivity disorder.” ADHD Attention Deficit and Hyperactivity Disorders, vol. 2, no.4, 2010, pp. 241-255, https://link.springer.com/article/10.1007%2Fs12402-010-0045-8. Accessed 11 February 2018.
Selikowitz, Mark. ADHD. Oxford University Press, 2009.
Suren, Pal. “Autism Spectrum Disorder, ADHD, Epilepsy, and Cerebral Palsy in Norwegian Children.” Pediatrics, vol. 130, no. 1, 2012, pp. 152-158, http://pediatrics.aappublications.org/content/130/1/e152. Accessed 16 February 2018.
Taylor, Eric. “Antecedents of ADHD: a historical account of diagnostic concepts.” ADHD Attention Deficit and Hyperactivity Disorders, vol. 3, no. 2, 2011, pp. 69-75, https://link.springer.com/article/10.1007/s12402-010-0051-x. Accessed 5 February 2018.
“Tracking A Rise In ADHD Diagnosis.” Talk of the Nation from NPR 5 April 2013, https://www.npr.org/2013/04/05/176339684/tracking-a-rise-in-adhd-diagnosis.
Tonti, Stephen. “ADHD As A Difference In Cognition, Not A Disorder.” Youtube, uploaded by TEDxTalks, 10 April 2013, https://www.youtube.com/watch?v=uU6o2_UFSEY.
Wedge, Marilyn. “Why French Kids Don’t Have ADHD.” Psychology Today, 08 March 2012. https://www.psychologytoday.com/blog/suffer-the-children/201203/why-french-kids-dont-have-adhd
Williams, Simon J. “The Pharmaceuticalization of Society? A Framework of Analysis.” The Pharmaceutical Studies Reader. John Wiley and Sons, 2015.
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