by Laurie Scarborough
University of Cape Town
Attention-Deficit Hyperactive Disorder (ADHD) symptoms began to be documented about a century ago (Kos & Richdale, 2004). Epidemiological studies show that prevalence rates have soared since then with rates increasing from 3% in 1980 (American Psychiatric Association, 1980), to modern prevalence rates reaching as high as 18% (Rowland et al., 2002). Why the sudden spike in prevalence rates? There are multiple reasons. One could be that ADHD has become a desired diagnosis to certain parties. Another is that modern society has facilitated an environment in which behaviours associated with ADHD thrive.
ADHD: A desired diagnosis
With ADHD prevalence on the rise one must ask why these prevalence rates are so high. Is it simply that more and more people with ADHD being noticed? Rather, perhaps there are factors that make ADHD a desired diagnosis to certain parties. This may be a foreign concept in the realm of mental illness because nobody wants to have a mental illness, and of course when I say “desired” I do not intend to mean that the child desires the diagnosis or that the parent, teacher or anyone else wishes the behaviour on the child. But instead that certain parties may have agendas and interests that motivate seeking out diagnoses and this continues to increase prevalence rates of the disorder.
Parents, for example, may grow tired of having an inattentive, hyperactive, or what they perceive as a “badly behaved” child, and a diagnosis allows the blame of bad parenting to shift away from them and onto the child (Blackman, 1999; Graham, 2006; Stolzer 2007; Timimi & Taylor, 2004), thus a diagnosis meets the needs of parents who do not want to take responsibility for bad parenting or for their child’s behaviour (Smelter et al., 1996). With the help of a diagnosis, parents have access to medication for their children which is seen as an easy way out of parenting – a quick fix. The problem can be solved with a pill and suddenly the parent becomes the model parent with a well-behaved child (Rafalovich, 2005; Smelter, at el., 1996). The absolution of effort and blame on behalf of the parents of ADHD children may be motivating parents to get diagnoses for their children.
Teachers are another motivating factor in diagnoses. Teachers want control of their classroom and want to control the deviant child in their class who is being disruptive. Teachers have become very involved in a diagnosis of ADHD (Saddichha, 2010) and they could also be pushing parents to get their children seen by clinicians. Schools in America receive funding from the government for educating disabled children, including children with ADHD (Stolzer, 2007), so it is in their interests to educate more children with ADHD. This could lead schools to motivate parents and teachers to get children taken to specialists and get diagnoses. The financial implication of medical aid reimbursements for ADHD medications are also making a diagnosis in ADHD more relevant to parents and adults with ADHD who need these rebates (Blackman, 1999; Rafalovich, 2005).
There is incredible pressure to perform in an educational sphere and at a professional level (Manne, 2001) and the idea of abusing ADHD medication has risen in modern culture. Adults and teenagers may therefore seek diagnoses of ADHD in order to gain access to these ADHD medications in order to boost performance in school, university or at work, even if perhaps they do not truly meet the criteria for ADHD. This would obviously inflate prevalence rates of the disorder in the teenage and adult cohort.
Studies show that 99% of people diagnosed with ADHD are treated with stimulant medication (Stolzer 2007; Stolzer, 2009). This means that pharmaceutical companies also have something to gain every time someone is diagnosed with ADHD and so it is in their interests to push for more diagnoses to be made (Stolzer 2007; Stolzer 2009). Saddichha (2010) goes so far to suggest that pharmaceutical companies “disease monger”, or convince people that they are sick in order for people to meet criteria for diagnosis when they in fact do not. More worrying still is that our own diagnostic manual, the DSM, has been influenced by these pharmaceutical companies. Lardizbal (2012) reports that 56% of the APA members who contributed to the DSM-IV and DSM-IV-TR diagnostic criteria have financial ties with pharmaceutical companies. This means that they have their own financial agenda to keep disorders that are commonly treated with psychoactive drugs in the DSM. As I previously mentioned, ADHD is one such disorder. This is a clear conflict of interest. This is just another party that has an interest in seeing ADHD diagnoses being made.
As we can see there are several groups that have interests in promoting the continued diagnosis of ADHD. Parents, teachers, schools, medical aids, adults seeking medications, and pharmaceutical companies all have their reasons. I think it is important to mention that of course the child does not want a diagnosis of ADHD. As Hacking puts it, human kinds have moral value, and so we care about how we are labelled and categorised (Hacking, 1995), and that is why we must be careful and mindful of these diagnoses. While giving someone a diagnosis may give someone sympathy, and make people want to help (Smelter et al., 1996), it could also lead to stigmatisation and bullying.
The integrity of the ADHD diagnosis
The incidence rates of ADHD are ever increasing and the fact that ADHD is such a highly diagnosed disorder may be due to the way that it is diagnosed. Perhaps clinicians are too easily diagnosing or are misdiagnosing. Are they really diagnosing disordered behaviour or are they just noting individual differences in people and pathologizing these behaviours?
Diagnostic tests need to be valid, reliable, normed on appropriate samples and used under standardised conditions (Hunsley et al., 2003). However, there are often discrepancies in diagnosis between assessors (Armstrong, 1996) showing that the tests do not always correlate and are not very reliable.
The assessment for ADHD is very subjective (Stolzer, 2009) because there are no physical, biological, metabolic or “disease” markers of ADHD (Baughman & Fred, 1999; Grigg, 2003; Stolzer, 2007). The assessments are based on the subjective opinions of teachers and parents (Stolzer, 2007), who have vested interests in the outcome of the assessments, instead of speaking to the child in question (Bratter, 2007), bringing into question the integrity of the eventual diagnosis. A teacher wants the child to behave in their classroom, while a parent wants a well-behaved child. The teacher also does not want to appear incompetent or simply as if they are boring the child into being an inattentive, hyperactive monster (Bratter, 2007). The opinion of the teacher thus becomes biased and problematic in a diagnostic situation. The questionnaires used for ADHD diagnosis usually have phrases followed by “ never”, “rarely”, “often”, “sometimes”, “always” (Stolzer, 2007). However, “rarely”, “often” and “sometimes” are not objectively quantifiable values; they are subjective linguistic terms that could be interpreted in various ways (Stolzer, 2007), further subjectifying an ADHD diagnosis. Tests like these also bring into question whether traits and behaviours like those prevalent in ADHD are really quantifiable and whether we should be measuring them in such a way that abstracts them quantitatively (Horntstein, 1988). Are we essentially losing something about these qualities by doing this to make them more “scientifically measurable”, when actually they are qualitative concepts, such as behaviour patterns (Hornstein, 1988)? Perhaps assessments for ADHD should rather not use such subjective questionnaires that attempt to quantify qualitative concepts, and should be more child-focused, at the very least involve the child in part of the interview by asking them questions about their own behaviour.
Another criticism of ADHD diagnoses is that often ADHD appears to pathologize normal childhood behaviour (Grigg, 2003). Studies in Canada found that being born in December as opposed to January was a strong predictor for a diagnosis in ADHD (Frances, 2012). A similar study in Virginia found that 68% of children young for their grade were medicated for ADHD (Watson, et al., 2013). This means that children simply younger than their peers are being diagnosed for ADHD. This is very worrying because it means that clinicians are singling out children and pathologizing normal developmental immaturity (Frances, 2012). In the DSM-5 criteria it specifically states “to a degree that is inconsistent with developmental level” (APA, 2013), so why are clinicians struggling to maintain this criterion? It is because of the subjectivity of the diagnostic criteria. How can we define what is and is not exactly age appropriate? Again this is a tricky situation for teachers and clinicians and it brings into question the integrity of an ADHD diagnosis.
Boys are ten times more likely to receive an ADHD diagnosis than girls (Luise, 1997; Stolzer, 2007; Stolzer, 2009), with prevalence rates reaching as high as 20% (Watson et al., 2013). Are we not simply pathologizing what might simply be more masculine behaviour? Is hyperactivity and inattention just a set of behaviours that are associated with being male? In this case again we are pathologizing normal behaviour, and an ADHD diagnosis in these cases would be irrelevant.
Whether we are pathologizing typical developmental youth or normal masculine behaviours, people are being diagnosed with ADHD, when in fact they may just have behaviours that are normal or can be attributed to simple individual difference. If these people do not in fact have ADHD but are being diagnosed this obviously inflates prevalence rates and brings into question the integrity of the diagnostic category.
The ADHD ecological niche
ADHD has only recently risen to epidemic proportions. A hundred years ago, nobody was singled out as having ADHD, and the DSM categorical system did not yet exist so people were not being classified using this system. Does this mean that people are actually changing and have recently become more hyperactive and less attentive, or are we just becoming better at noticing it? I would argue that society has changed to facilitate an ecological niche in which behaviours associated with ADHD are more easily noticed, and that perhaps ADHD is a transient mental illness (TMI) that has surfaced because of this ecological niche. In his book, Mad Travellers, Ian Hacking described a TMI as an illness that appears for periods due to an environmental factor (or an ecological niche) that facilitates its appearance (Hacking, 1998). TMI can also prefer certain genders, class or other factors (Hacking, 1998), which is relevant for ADHD which seems to favour male cohorts.
The advent of compulsory schooling and the abolition of child labour at the end of the 19th century in Europe and the beginning of the 20th century in America (Van Drunen & Jansz, 2004a), saw children enter the education system sometimes for the first time. Before this period, childhood was not an idea – children were thought of as small adults, and it was only after the publication of Ellen Kay’s childcare book The Century of the Child in 1900 that the idea of childhood as a time for play and education began to rise (Van Drunen & Jansz, 2004a). Children started being seen as young people in need of protection and guidance rather than economic agents (Van Drunen & Jansz, 2004a). The first Child Guidance Clinic opened in the 1920s which was concerned for the mental health of children only emphasised this (Van Drunen & Jansz, 2004a). Social management (the direction and organisation of social life in terms of society and individuals (Van Drunen & Jansz (2004b)) specifically towards children intensified (Van Drunen & Jansz, 2004a), and education was one relevant area of this management.
Observability is important to an ecological niche (Hacking, 1998). Purposive parenting became an area that developed because of new ways that children were being understood. Teachers and parents were paying more attention to children, and their behaviour was more closely monitored and observed. Deviance would therefore be more easily noticed, and ADHD symptoms would be noticed quickly in settings like the school environment that demanded conformity.
For the first time children needed to sit quietly, concentrate for long periods of time on quiet and perhaps boring tasks, with few breaks, and conform to classroom regulations. Individualisation, in which the individual distinguishes himself from the collective with his own idiosyncrasies, feelings, ideas about the world and distinct behaviours (Jansz, 2004), was an idea that had come to maturity by the time compulsory education had reached society. Because the idea of the individual was conceptualised, in the classroom setting that meant that individual deviance was noticed easily, and symptoms associated with ADHD would stand out.
From the 1920s to the 1960s length of the school career began to lengthen because society demanded more complex education to prepare children for the outside world (Van Drunen & Jansz, 2004a). Some researchers have begun to question whether we have put too much pressure on children by expecting them to conform to behaviours that may not be natural to them at certain developmental stages, and have postulated that perhaps ADHD is a function of modern day society (Manne, 2001; Stolzer, 2007). Modern life and schooling may in fact illicit ADHD symptoms (Manne, 2001) in children and be a symptom of a disordered society (Stolzer, 2007), rather than a disordered mind.
More recently there has been a shift in society that has seen an emergence of emotionality and the psychologization of society (Furedi, 2004). Problems once thought of as social are now psychologised and the problem now sits with the individual rather than the collective (Furedi, 2004). Because of this, emotions and behaviour are taken much more seriously. There has also been a rise in therapeutic language and “deficit talk”, resulting in psychological language becoming more prevalent and commonplace in the layman’s vocabulary (Furedi, 2004), meaning that the everyday person has the vocabulary to talk about psychological distresses, including ADHD. This means that an ecological niche has arisen in which it is more likely that behaviours associated with ADHD may be spoken about more openly and thus identified more easily.
The opening of the aforementioned mental health clinic, the Child Guidance Clinic, highlights the beginnings of a psychologization of children (Van Drunen & Jansz, 2004a), meaning that the problems of children have become thought of a psychological or mental rather than economic, physical, social or anything else. This means that any behavioural problems noticed in a child may be automatically thought of as psychological, so when a teacher or parent notices something like ADHD symptoms, they may think of it as a psychological problem with the individual (Furedi, 2004) rather than as a problem with the system, such as compulsory education, social problems, or a problem with society. The problem with psychologization is the tendency to pathologize normal experiences and assign psychological and therapeutic labels to typical behaviour (Furedi, 2004). I think that this is a danger with ADHD that many researchers and clinicians are now beginning to become concerned about; that clinicians are pathologizing normal developmental immaturity or normal masculine behaviour.
Evidence shows that media coverage of certain disorders is linked to increased prevalence of these disorders. The rate of Dissociative Identity Disorder for example was found to increase in America rapidly after the release of Flora Rheta Schreiber’s 1973 book about the disorder and the subsequence TV movie (Lilienfeld & Lynn, 2003). One only needs to scan briefly through parenting magazines to see that media coverage of ADHD has taken off recently. From 1988 to 1997, one media outlet mentioned specific DSM ADHD symptoms in articles 403 times (Schmitz et al., 2003). Certainly more people know about the disorder now than they did several decades ago and this could be because of media coverage. In any case, more and more people, including laymen, are able to recognise the symptoms of ADHD and can notice these behaviours in their children or in themselves, making an ADHD diagnosis more likely.
Whether it is through the advent of compulsory schooling, the psychologization of society and the rise of therapeutic language, or an increase in media coverage resulting in heightened awareness about the disorder, an ecological niche for ADHD to thrive has arisen. The disorder may well recede in years to come because of changes in society but because of current environmental factors, ADHD has become a deviance that is easily noticed and identified.
ADHD as an official classification has been under constant change since it entered the DSM system. It first entered the DSM-II in 1968 as Hyperkinetic Reaction to Childhood, and was only required to be in one setting (Kos & Richdale, 2004). It was then amended to Attention Deficit Disorder (ADD) in the DSM-III and DSM-II-R, with distinctions between hyperactivity, impulsivity and inattention (APA, 1980). The DSM-IV and DSM-IV-TR classified it as either ADD or ADHD, without a distinction between impulsivity, and hyperactivity, but the disorder needed to be displayed in two settings or more (APA, 1994). What do all these changing criteria mean? A longer discussion is beyond the scope of this essay, but I think that Ian Hacking’s looping effects is relevant here. Perhaps while the category was changing, so were the category holders. The category changed because society did and this evolution propelled a further change to the category which in turn saw more changes to the people who hold this category (Hacking, 1995). Because people are constantly changing, the category needed to be constantly changing too.
The prevalence rates of ADHD are ever rising, and there are a myriad of reasons for this. ADHD as a desired diagnosis could explain why the disorder is continually being diagnosed by the people who have the power to do so. An ecological niche that facilitates ADHD as a disorder only enhances its ubiquitous prevalence and the integrity of the ADHD diagnosis should be constantly put under scrutiny to question whether the assessment is really pathologizing what is actually disordered behaviour and not simply normal experience or a disordered society.
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