ADHD What S in a Name?

ADHD – What’s in a name?

Paper presented at the British Educational Research Association Annual Conference, University of Warwick, 6-9 September 2006

Simon Bailey

PhD research student, Nottingham University

Introduction

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.

Translating risk

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.