Medicalised Selves: ADHD and children's identities

1. Medicalised Selves: ADHD and children's identities

2. This lecture will explore current critical frameworks for understandings ADHD. Constructions of ADHD as a neurochemical imbalance ‘within’ the brain will be explored alongside critical understandings of the construction of ADHD as a category for social control, for ‘managing’ children constructed as a ‘problems’. This lecture will draw on videos of parents discussing the impact of medication on children’s lives and literature that documents children’s own experiences of taking medication. It aims to explore how children understand the diagnosis of ADHD and document the impact of medication on their lives and identities.

3. What are the signs? Royal College of Psychiatrists (UK): Children with ADHD/hyperkinetic disorder: • are restless, fidgety and overactive • continuously chatter and interrupt people • are easily distracted and do not finish things • are inattentive and cannot concentrate on tasks • are impulsive, suddenly doing things without thinking first • have difficulty waiting their turn in games, in conversation or in a queue. This type of behaviour is common in most children. It becomes a problem when these characteristics are exaggerated, compared to other children of the same age, and when the behaviour affects the child's social and school life. Often the signs will have been obvious since the child was a toddler. (Royal College of Psychiatrists, Fact Sheet on ADHD, UK) http://www.rcpsych.ac.uk/mentalhealthinfo/mentalhealthandgrowingup/adhdhyperkineticdisorder.aspx

4. ADHD in the DSM • A. Either (1) or (2) • 1) Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with the developmental level: • Inattention • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • often has difficulty sustaining attention in tasks or play activities • often does not seem to listen when spoken to directly • often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure of comprehension) • often has difficulty organizing tasks and activities • often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • often loses things necessary for tasks or activites at school or at home (e.g. toys, pencils, books, assignments) • is often easily distracted by extraneous stimuli • if often forgetful in daily activities

5. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level: • Hyperactivity • often fidgets with hands or feet or squirms in seat • often leaves seat in classroom or in other situations in which remaining seated is expected • often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) • often has difficulty playing or engaging in leisure activities quietly • often talks excessively • is often 'on the go' or often acts as if 'driven by a motor' • Impulsivity • often has difficulty awaiting turn in games or group situations • often blurts out answers to questions before they have been completed • often interrupts or intrudes on others, e.g. butts into other children's games • B. Some hyperactivity - impulsive or inattentive symptoms that cause impairment were present before the age of 7 years. • C. Some impairment from the symptoms is present in more than two or more settings (e.g. at school or work or at home). • D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. • E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Timimi (2005) points out how subjective the diagnosis of ADHD is, as there are no biological tests. So who decides how often is often (everyday? Every 10 minutes?), who decides when ‘normal’ inattention becomes ‘exaggerated’ and so a ‘problem’?

6. History DSM-II (1968) included diagnosis - "Hyperkinetic Reaction of Childhood". DSM-III (1980) "ADD (Attention-Deficit Disorder) with or without hyperactivity“. In 1987 this was changed to ADHD in the DSM-III-R, and in the current edition. Ritalin (brand name for methylphenidate – a stimulant) came on the market in the USA in 1955; at that time medicating children for behaviour was rare and the category ADHD did not exist.

7. Has ADHD always existed? 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 epidemic proportions, particularly amongst boys in North America. (Timimi and Radcliffe, 2005:63) • A. There were no children with ADHD before the 1980s; there were many in 1987. • B. Before the 1980s, the diagnosis of ADHD was not a way to be a person, people did not experience themselves in this way, they did not interact with their children and families, their doctors and their patients, in this way; but from the beginning of the 1980s this became a way to be a person, to experience oneself, one’s child, and to live in society. • (I have adapted this from Ian Hacking’s (2006) discussion of Obesity, Multiple personality disorder and Autism.)

8. ‘the discovery of ADHD represents not so much an unveiling of a condition that has been waiting to be discovered, but rather a convergence of complex social, political, economic, medical and psychological factors coming together at the right time’ (Armstrong, 1995: p8)

9. ‘making up’ people Ian Hacking: interested in classifications of people, how they affect the people classified, and how this in turn changes the classifications. Human ‘sciences create kinds of people that in a certain sense did not exist before. I call this “making up people”’ (Hacking, 2006). • Five part framework: • The Classifications • The people who are classified • The institutions • The knowledge • The Experts

10. ‘making up’ ADHD • Classification: ADHD, seen as a ‘disorder’ • The people who are classified: children who are inattentive, restless, emotionally distressed – they constitute a moving target • The institutions: schools, clinics, talk shows, pharmaceutical companies, parent advocacy groups • The knowledge: assumptions taught, refined and disseminated within the institutions (especially by pharmaceutical companies); seminars and conferences. • The Experts: who generate the knowledge, who judge if it counts as knowledge, and put it into practise. Then back round, in a circle – ‘the looping effect’ The knowledge (4) that the experts generate within institutions (3) that guarantee their status as experts, these experts study, advise or control the people / children (2) who are classified as having a ‘disorder’, such as ADHD. ‘new category of childhood’ (Timimi and Radcliffe, 2005: p68)

11. Case Study: A new drug to promote A pharmaceuticalcompany (Company X) has recently produced a new psychotropicdrug, which has just received its licence to be prescribed forchildren diagnosed with ADHD. A couple of years ago, in anticipationof this drug coming onto the market, Company Y (a separate companywhich received funding from Company X) arranged a discussionday for local paediatric and child psychiatric consultants andspecialist registrars, offering participants a fee if they attended.The discussion was carefully managed to highlight some of theproblems encountered with existing drug treatments and was followedby a presentation about the forthcoming new drug, which, itwas claimed, would be able to address some of these concerns. Nowthat the drug is available, local doctors have received an invitationto fill in a questionnaire about their prescribing practices(with a fee paid for doing this), have been sent informationabout the new drug, and received telephone calls from the localpharmaceutical company representative offering a presentationand a free lunch. At the same time, Company Z (which claimsto help services by facilitating meetings), set up with fundingfrom Company X, has contacted various service managers in thelocality offering to help them produce a local coordinated carepathway for ADHD. Two meetings take place with various servicemanagers and local consultants in a nice hotel and with a goodlunch, and conclude that in addition to working more closelytogether, staff in these services require more ‘education’.Company Z, together with a local consultant who favours thenew medication, arrange two half-day conferences for a varietyof staff and one local (pro-medication) parent support groupduring which there are, among other things, presentations aboutthe new drug. (Timimi, 2008)

12. Indeed some argue that ADHD has been conceived and promoted by the pharmaceutical industry in order for there to be an entity for which stimulants could be prescribed. It is after all a multimillion dollar industry (Timimi and Radcliffe, 2005:67) In 1993, 3,500 prescriptions were given in the UK for Ritalin; by 2006 the NHS gave out approx 250,000 prescriptions; and in the USA doctors write 2 million prescriptions a month[1]. If we bear in mind that the National Institute for Health and Clinical Excellence (NICE) estimates that using the DSM-IV criteria, ADHD is thought to affect 3-9% of school-age children[2], then we can glimpse the wide impact this medicalisation of childhood could potentially have. 2.5% of school children in the UK were prescribed Ritalin in 2003 (Timimi, 2005) [1] G. Fowler, ‘Turning Children into Mental Patients: ADHD in the UK’ (2010) 17 (2) Asylum 20. [2] National Institute for Health and Clinical Excellence, ‘Attention Deficit Hyperactivity Disorder: Diagnosis and Management of ADHD in children, young people and adults’ (2008) Clinical Guidance 72.

13. Increases number of people who see themselves / their children in biological terms, and who then present to doctors with ‘ready-made’ diagnoses (Timimi, 2008). Parents often seek medical within-child based explanations for behaviour difficulties (Maras, et al. 2002) However – no conclusive evidence as to genetic differences, brain anomalies, or brain chemical differences (see Timimi, 2005; ). So if there is little evidence why is it perpetuated? http://www.youtube.com/user/LivingWithADHD?v=DaEyuicY_nM&feature=pyv&ad=5403603750&kw=ADHD Pharmaceutical promotion of ‘within the brain’ explanations works against previous theories about bad parenting / ‘cold’ and ‘toxic’ mothers.

14. “we mustn’t feel guilty” (Parent discussing the effects of medication on her child) “He is – well he has been on everything but he’s been Strattera, Ritalin. Also they use the Epilim for the epilepsy, they also use some of that for the ADHD because it can control. And now he is on Imipramine which is three tablets taken at night time and basically what the Imipramine does is it helps him concentrate a little bit better but it mainly helps him to sleep and if he doesn’t take them he is awake because that was the other thing, that the first six, seven years, he would be up at three, up at four, up at two in the morning, you know completely wide awake. So you know it was affecting all our sleep patterns. Then having another baby was like the baby waking up every hour and a half plus the child waking up as well, plus my husband having to wake up at 5.30 to go to work. So it was very, very intensive in that respect. We were all very tired. So I felt that although it doesn’t control his behaviour as much as probably I would like to, I think the fact that he is sleeping has got to be better, so that is why with the psychiatrist we are trying to stay on that at the moment, because I think if he has a good night’s sleep then you are able to cope with things better during the day, but I think during the day, he could do with having another one, but it is just the fact that it affects, it has other side effects. It could affect his heart beat, so that is other thing, is that you know you give them medication on one hand, and it helps with certain things but it could aggravate others and one of the things that the medication can aggravate as well is the epilepsy, so you are forever having to juggle this decisions and medication is a very complex subject as well. A lot of parents don’t want to medicate but if you don’t medicate when they get to be teenagers all the problems are a lot worse. So it is a very fine line, it is a very, very difficult one, and one that we feel guilty about as well. Until my psychiatrist said, “Would you feel guilty of giving insulin to a diabetic child?” This medication for the brain is for the chemical reaction in the brain so we mustn’t feel guilty. But you know you are always still borderline with that. So yes….” http://www.healthtalkonline.org/disability/LifeontheAutismspectrum_Parents/People/Interview/11/Category/324/Clip/9798/adhd#adhd

15. ‘He became like a zombie’ (Mother discussing the effects of Ritalin on her son) So … and he would sit still, he would sit still for hours. He will watch a film from beginning to end and it is just at school really he is hyperactive, but there is so much going on at school and so we went to the clinic and they wanted to put him on Ritalin. Oh I have forgotten all that, yes. So and we didn’t really want him to go on Ritalin but we thought well if it would benefit Sam it would help him access education more. We thought ‘oh well, we will give it a try’ and so he went on it for six months as a trial but it was just horrendous. He was alright at school but it was at home. It was just awful. It completely changed Sam as a person. There were lots of things. He used to cry. Sam is not a child for crying. He is always very happy. And sometimes at night he would cry at bedtime and say he couldn’t stop seeing things in his head and he wouldn’t go to sleep. He would rock. Go like this in his bed and that distressed him because being a child that would normally just go to bed, have a story and go to bed and he would be awake for hours. He would be up and down, up and down, and then he started having physical…. I don’t know whether it was the Ritalin but it is to do with his continence. Sam was very good. He was very good in the daytime with his continence. He would always go to the loo but at night he would wet his bed quite a lot. So I don’t think that was the Ritalin but he’d have pull ups. But when he was on the Ritalin for a while, he would start like messing his pants at night. Not in the day time, just at night and we just couldn’t figure out why he would start doing that and he would wake up… he wouldn’t wake up once he was asleep. He would stay in bed, but in the morning you would find that he had smeared faeces everywhere, all over his bed, all over his sheets, on the wall. And it was really... he got really upset about it. He would hate it. He would cry about it. And we got really upset about it because it was just so unusual and we didn’t know why. The consultant at the hospital wondered whether it was the Ritalin because we didn’t associated with the Ritalin but he did. He said he wondered whether it was because of that and there were lots of side effects to Ritalin. Although we kept a journal for the other doctor and so we went back to the ADHD clinic and said that we weren’t happy. We were going to stop him taking it. And so they didn’t, there wasn’t any improvement at school so much to her distress - she didn’t want Sam to stop taking it - we just stopped him having it and he just went back to his normal self. He became much happier.  He stopped doing any of that with the faeces at night. It just stopped so obviously we decided that that was the cause of that. http://www.healthtalkonline.org/disability/LifeontheAutismspectrum_Parents/People/Interview/23/Category/325/Clip/9913/adhd-medication#adhd-medication

16. Children’s Understandings of ADHD and medication Little research into children’s understandings of ADHD. Arora and Mackay (2004) ask: • How do children view ADHD? • How do they experience diagnosis? • How do they perceive pharmaceutical intervention ? • How do they perceive the impact of medication on their behaviour? (p114)

17. Strong medical / biological orientation “Its cos I’ve got this thing missing in my brain called dopamine and its at the back there” “It’s a disease that just comes up. Mum didn’t know that I had it until I went to that Doctor”. ‘its in the blood’ ‘it’s in your nerves, but they [children with ADHD] haven’t got the same nerves’. ‘it’s what some kids are born to get’ (all quotes from Arora and Mackay, 2004)

18. Children saw a strong link between their behaviour and medication. Asked, ‘what if you’re behaviour gets worse?’, one child replied, ‘then he’ll [the doctor] put my tablets up’ (Arora and Mackay, 2004: p118). “I might get better because I get older and then I’ll grow out of it. I might grow out of being bad”. ‘if I do more than six bad things I deserve more than one of my pills’ (p120). Teaches children that ‘conformity is health and deviance is illness’ (Schrag and Divoky, 1981: p60) Asked what it would like not to have ADHD, children said: ‘I wouldn’t have to take the tablets’ ‘hooray’ ‘I’d be a lot happier. I wouldn't have to go out of my lessons to take tablets earlier. That would make me feel more better’. (p119) Children thought that medication (such as Ritallin) had the power to alter their naughty behaviour, however they also said that since taking medication they still thought they behaved badly.

19. Implications for children’s identities On being diagnosed with ADHD many felt ‘scared’, ‘confused’ and ‘different’. Diagnosis invariably led to medication, leading many children to feel they were impaired in some way; Many children experienced negative self-image and felt angry ‘I had no friends at all. I had no one to play with. No one wants you…It’s not a nice feeling at all’ (: p117) Taking meds singled them out ‘I don’t take them. People make fun of me so that’s when I don’t take them’ (p120) Teaches children to see themselves as not responsible for their behaviour and rely on drugs to control that behaviour: ‘The Doctor tells Frank: “ It’s not that you won’t sit still. You can’t sit still”. “No”, Frank insists, “I won’t...because I don’t want to”. (Schrag and Divoky, 1975: p94) Children saw themselves as passive recipients in a process where they had little control. Children lacked control to define the ‘problem’, and to decide whether or not they wanted to takemedication (Arora and Mackay, 2004) Children felt they were given tablets because of the problems they caused for others. In fact, lower doses are needed to increase attention than for inappropriate behaviour (Arora and Mackay, 2004: p122)

20. What are the effects of embracing practices that impose descriptions such as ADHD onto children’s behaviour? Children quickly become objects of such descriptions. (68) Whose interests are best served by medication? ‘places the onus of change solely on the child and presents medication as the only support available’ (Arora and Mackay, 2004: p122) ‘there now appears a generation of children in school who internalise descriptions of behaviours by believing themselves to be bad and who look to the power of tablets to control this internal deficiency’ (Arora and Mackay, 2004: p123).

21. ADHD as social control Shift from traditional behaviour management to psychochemical techniques Serve social control by making children docile Through diagnosing an medicating children are being taught that its normal to be assessed. Diagnosed and medicated. This is justified in children’s ‘best interests’, as ‘treatment’. Thus the social control is subtle, made to seem reasonable and legitimate, making it harder to resist (p37) Frames non-conformity as a medical problem – acting as a ‘political sedative’ to prevent challenges to the school system and the State. It may be destigmatising for parents to locate problems in the brain but this creates new ‘problem’ groups; those parents who won’t medicate their children come to be seen as problems. (See Schrag, Peter. and Divoky, Diane. (1981) The Myth of the Hyperactive Child and other means of Child Control. Penguin, Middlesex; also see Coppock, V. (2002) 'Medicalising children'sbehavior', pp.139-154 in B. Franklin (ed.) The New Handbook of Children's Rights. London: Routledge).

23. ADHD as a cultural construct To explain the recent rise, to epidemic proportions, of rates of diagnosis of ADHD, a cultural perspective is necessary. The way children’s behaviour is understood and made meaningful is a fact of culture (See Timimi, 2005). More boys than girls Boys are four to ten times more likely to get an ADHD diagnosis in practice (Timimi, 2004) Cultural Differences Despite attempts to standardise diagnosis , there are major differences in how doctors professionals from different countries rate symptoms of ADHD, and thus in rates of diagnosis. Because of uncertainty about definition, epidemiological studies produce hugely differing prevalence rates: from 0.5% to 26% of children (Timimi, 2004). Cultural norms of how children are expected to behave etc. Singh (2002: p578); In modern Western culture many factors adversely affect the mental health of children and their families. These include loss of extended family support, mother blame (mothers are usually the ones who shoulder responsibility for their children), pressure on schools..., parents being put in a double bind on the question of discipline, family life being busy and ‘hyperactive’, and a market economy value system that emphasises individuality, competitiveness and independence (Prout & James, 1997). Does society, then, cause ADHD? What are the implications of this?

24. The emergence of ADHD has created a ‘new category of childhood’ (Timimi, 2005) and blurs the boundaries of what counts as ‘normality’. Subsequently, ‘millions of children are no longer regarded as part of the ordinary spectrum…but as people who are qualitatively different from the “normal” population’ Peter Schrag and Diane Divoky, The Myth of the Hyperactive Child: and other means of child control (Penguin, Harmonsworth, 1981) 36.

25. ‘getting your child back ’ Ritalin is often described by pharmaceutical companies alongside parent groups and children themselves not as coercive or constraining, but as enabling the child to live a full life, ‘restoring the child to his or her true self again’ (Rose, 2007:211; Singh 2002). But who is this true self? Medications, such as Ritallin, are ‘entangled with certain conceptions of what humans can or should be’, norms and judgments are internalized in the molecular makeup of these drugs, and ‘the drugs embody and incite particular forms of life in which the “real me” is both “natural” and to be produced’ (Rose, 2007:222). ‘the drugs used to treat ADHD are the same [chemically] as speed and cocaine. We react with horror to the idea that our kids would use such drugs, but don’t react about drugs such as Ritalin being given to them’, by doctors. (David Healy cited in G. Fowler, ‘Turning Children into Mental Patients: ADHD in the UK’ (2010) 17 (2) Asylum 21).

26. Should we change the child or change the system? Reliance on medication makes it harder to imagine alternatives (Schrag and Divoky, 1981) Genetic studies not found any evidence of genes, only that certain behaviours seem to inherited (like some personality traits) whether these behaviours are perceived as a problem or diagnosed as ADHD is shaped by social / cultural factors If the problem is not innate or inside the individual child but perhaps a mismatch between child and school environment – then should we change the child / or the school? Even if there were innate or biological anomalies, these ‘anomalies (if there are such) cause a person to be autistic. They do not determine the ways of life for autistic people’ (Hacking, 2006). ‘rather than focus on the label, it is much more meaningful to try and determine what the child’s strengths and weaknesses are, what is in the environment which may help or hinder learning and behaviour and, in partnership with the child and significant others, to remove barriers’ (Arora and Mackay, 2004: p111).

27. Reading Coppock, V. (2002) 'Medicalising children'sbehavior', pp.139-154 in B. Franklin (ed.) The New Handbook of Children's Rights. London: Routledge). Hacking, Ian. (2006) ‘Making up people’ Published in the London Review of Books, Vol. 28 No. 16: 17 August 2006 (available online) http://www.generation-online.org/c/fcbiopolitics2.htm Rowe, D. (2005). ADHD – Adults’ fear of frightened children. Journal of Critical Psychology, Counselling and Psychotherapy, 5, 1, 10-13 Schrag, Peter. and Divoky, Diane. (1981) The Myth of the Hyperactive Child and other means of Child Control. Penguin, Middlesex; Singh, I. (2002b) Bad Boys, Good Mothers, and the “Miracle” of Ritalin. Science in Context 15, 577–603. (available online) Timimi, Sami. (2008) Child psychiatry and its relationship with the pharmaceutical industry: theoretical and practical issues, in Advances in Psychiatric Treatment, Vol.14, pp. 3-9. (available online) Timimi, Sami. and Radcliffe, Nick. (2005) The Rise and Rise of ADHD. (available online) Timimi, Sami. and Taylor, Eric. (2004) ADHD is best understood as a cultural construct (In Debate), in BRITISH JOURNAL OF P SYCHIATRY , Vol. 1 8 4 , pp. 8 – 9 . (available online)

28. Further refs / resources • Asylum Magazine for Democratic Psychiatry (especially Vol. 17, No. 2, Summer 2010, for articles on ADHD and statistics and debates about prescribing medication to children) • Health talk online. Videos and transcripts of parents talking about experiences of ADHD and medication (and of other experiences of mental health problems) http://www.healthtalkonline.org/ • Youtube videos ‘The Truth behind Medication’ parts 1,2 and 3

30. Thank you for listening... • Any Questions???

31. Critically assess the value of the construct 'personality' with reference to one specified theory of 'personality' in psychology Here are some points of clarification which also provide the specific criteria that will be used by the Personality II course team to mark the essay. 1. We know this is a difficult question, and we have deliberately asked a question for which a ready-made answer could not be copied or downloaded, giving you the task of thinking this through. 2. You need to draw on what you know from other areas of the degree to answer this, and we expect you to show initiative in answering the question demonstrating that broader understanding of debates in psychology. 3. You need to be clear what you mean by ‘construct’ as a presupposition or conceptual framework (and you may find it useful to think, for example, about ‘hypothetical constructs’ and ‘social constructionism’). 4. You need to step back and think critically about the advantages and disadvantages of the term ‘personality’ to describe what individuals have in common and how they differ from each other. 5. Choose ONE theory of personality in psychology (we put ‘personality’ in scare quotes because we are asking you to step back and think about that notion) to answer the question (which could be one we cover in the course). 6. You should define what you mean by a ‘theory’ (taking, for example, ‘humanistic’ or ‘social learning’ or ‘psychodynamic’ OR being more specific and referring to, for example, the theory of Rogers or Bandura or Freud). 7. Do NOT just describe the theory (you will fail) or just assess the theory (we have not asked you to do that), think about how the theory in relation to the question (with the theory you choose as an example to answer the question). 8. Remember that this is asking you to ‘critically assess’, and so you should weigh up advantages and disadvantages (of the value of the notion of ‘personality’) in the course of your answer. 9. Structure your answer so that you briefly say what you are going to do, set out the steps in the argument (referring to the theory you have chosen) and end with a conclusion, summing up what your answer to this question is. 10. You can write in first person but, as with all other pieces of work for the degree, you must make clear that you are basing your argument on your reading, and you should reference the reading you refer to at the end of the essay (in BPS format).