Feature

The politics of attention deficit hyperactivity disorder

Why is it that the diagnosis of ADHD among boys has risen so dramatically in Western societies? Sami Timimi suggests that the answer is as likely to be cultural and political as medical

Something strange has been happening to children in Western society in the past couple of decades. The diagnosis of attention deficit hyperactivity disorder (ADHD) has reached what many consider to be epidemic proportions, particularly among boys in North America. In the UK the diagnosis is usually made by a child psychiatrist or paediatrician, with advocates of the diagnosis claiming that children who display over-activity, poor concentration and impulsivity are suffering from a medical condition that needs treatment with medication.

The main medications used for children with a diagnosis of ADHD are psychostimulants such as methylphenidate (Ritalin), whose chemical properties are virtually indistinguishable from the street drugs speed and cocaine. Boys are four to 10 times more likely to receive the diagnosis and be prescribed psychostimulants than are girls, with children as young as three being diagnosed and prescribed psychostimulants.

By 1996, over six per cent of school-aged boys in the US were taking psychostimulant medication.¹ More recent surveys show that in some US schools over 17 per cent of boys have been diagnosed with ADHD and are taking psychostimulant medication.²

In the UK, prescriptions for psychostimulants increased from 6,000 in 1994 to more than 150,000 by 1999, suggesting we are rapidly catching up with the US.³ Health professionals and parents are increasingly vocal in their criticism of the excessive use of psychostimulants. In a failed attempt to silence their critics, ADHD advocates recently published an extraordinary consensus statement, in which prominent professionals accuse those who raise questions about the science and ethics of ADHD diagnosis and medication use of being unscientific.⁴

But critics of the diagnosis point to the contradictory nature of the medical evidence available and conclude that the growth in popularity of the concept owes more to cultural dynamics than it does to any groundbreaking medical discovery.

There are no medical or psychological tests that act as markers for this condition. Uncertainty about how to define ADHD has led researchers to conclude that anywhere between 0.5 per cent and 25 per cent of children have the ‘disorder’. Brain scans of children with an ADHD diagnosis show that they have clinically normal brains, and where differences between the brains of those diagnosed with ADHD and normal controls have been found, no consistent pattern is revealed.

There is neither any unique genetic marker for children with ADHD nor any unique outcome. And the vast majority of studies suffer from a narrow biomedical perspective that neglects the child’s social context.⁵

The role of social factors

There are two possible reasons why the rate of ADHD diagnosis has increased so dramatically in recent years. First, it could be due to the way we view children’s behaviour, such that behaviour previously felt to be normal or given another meaning is now felt to represent a medical disorder. Second, the increase could be due to a real increase in ADHD-type behaviour among children, in which case there must be an environmental cause.

Of course it is possible the increase is due to a combination of both reasons. Either way, an exploration and understanding of environmental, social and cultural factors that could lead to a change in the way we view childhood behaviour or/and cause ADHD-like behaviour is central to the task of understanding the current epidemic.

Childhood is socially constructed — in other words, what we define as a normal childhood is shaped by our cultural belief system. We can see this by looking at the history of childhood in any culture and by comparing beliefs about childhood in different cultures. In Western societies, our view of what childhood is has changed enormously over the past 300 to 400 years. Indeed, some historians have suggested that childhood did not exist in Western culture until the early 16th century, with children before this viewed as miniature adults.

If we compare contemporary Western beliefs about childhood and child-rearing methods to non-Western cultures, a number of broad differences are apparent. In most non-Western cultures the period of infancy is more prolonged. Conversely, adult responsibilities and duties come earlier in most non-Western cultures, with children in Western cultures usually having a more prolonged transitional phase into adulthood (thus Western-style adolescence does not exist in many non-Western cultures).

The early expectation in Western cultures for children to show autonomy and demonstrate independent abilities creates a burden for many children, particularly once they enter the education system where they are expected to demonstrate self-control, verbal and cognitive reasoning abilities and socialisation skills from an early age. These skills develop earlier in girls, so boys in our culture find themselves at the sharp end of a competitive system of winners and losers from early in their lives.

There is a considerable ambivalence towards children in Western society. On the one hand children are viewed as potential victims who are vulnerable and need protection from the state. Many observers believe we are witnessing the end of the innocence of childhood, for example through the greater sexualisation and commercialisation of childhood interests.

Children have almost total access to the world of adult information, leading to a collapse in adults’ moral authority. From this perspective, childhood is seen as increasingly polluted by adult interests from which children need rescuing. On the other hand, there are many who see children themselves as dangerous, and their crime and drug abuse as the cause of social problems. Some commentators believe we have become too lenient and that children need to be subject to tighter controls and discipline.

As a result, the task of child rearing has become loaded with anxiety in the past few decades. Parents and teachers feel they must act to control unruly children but at the same time feel inhibited from doing so for fear of the consequences, now that families can be ruined and careers destroyed should the state decide to intervene.

All this provides the ideal cultural preconditions for a growth of the idea that the real problem lies with a medical condition in the child – thus sparing parents, teachers and governments from blame.

Of course the story does not end there. Our society has been built on a value system that is central to maintaining capitalist free market economies. We grow up with the idea that individual freedom and ‘looking after number one’ are of paramount importance. This helps to free those with economic power from having to consider notions such as social duty and responsibility, and the interdependent nature of human society.

This value system has become embedded in our collective unconscious and has led to the breakdown of the extended family and, increasingly, the nuclear family. Many children are growing up with loose and transient family ties; a problem that is particularly apparent for boys deprived of male role models.

And it has also opened the door to allowing the pharmaceutical industry to have an increasing impact on how we view children and their problems.

The profit motive

The pharmaceutical industry is second only to the military industrial complex in size. Many aspects of everyday life have become medicalised as drug companies aggressively market their new drugs. One of the biggest growth areas has been childhood disorders, and there has been no bigger growth area in childhood disorders than psychostimulants. Some observers have even accused the drug industry of manufacturing the diagnosis of ADHD to create a market for its drugs.

The battle for the psychostimulant market has become more heated since 1996, when Novartis lost its licence to be the sole producer of the main psychostimulant, methylphenidate (Ritalin). This has led to other companies producing ‘new generation’ versions of methylphenidate, such as long-acting preparations. The manufacturers advertise their products as ‘safe, effective and non-addictive’. In addition they provide funds for pro-medication support groups, sponsor conferences, give financial incentives to researchers and selectively report favourable drug trials to help create a buoyant multimillion-dollar market for psychostimulants.

Alternatives to bad medicine

Psychostimulants are highly addictive, cause side effects including anorexia, growth retardation, and cardiovascular and psychiatric problems. No long-term benefit from taking them has been demonstrated. An unholy alliance between drug companies and doctors is putting millions of children at risk and reinforcing a ‘pill for life’s problems’ attitude that will mainly benefit drug company profit margins.

By colluding with our cultural ambivalence to childhood, the ADHD industry becomes part of the problem rather than the solution. This must be resisted. Parents should be encouraged to question doctors who make a diagnosis of ADHD and refuse to allow their child to be put on psychostimulants. By using multiple perspectives that celebrate rather than stifle diversity, children, families and their local communities can be empowered to overcome their problems without needing such toxic medication.