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Society at risk

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Title:
Society at risk a conceptual analysis of ADHD
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Soltysik, Susan
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English
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v, 96 leaves : illustrations ; 28 cm

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Attention-deficit hyperactivity disorder ( lcsh )
Attention-deficit hyperactivity disorder ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 92-96).
General Note:
Department of Humanities and Social Sciences
Statement of Responsibility:
by Susan Soltysik.

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University of Colorado Denver
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Auraria Library
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ocm50727825
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Full Text
SOCIETY AT RISK:
A CONCEPTUAL ANALYSIS OF ADHD
by
Susan Soltysik
B.A., University of Northern Colorado, 1973
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Social Science
2002


This thesis for the Master of Social Science
degree by
Susan Soltysik
has been approved
by
W /*7
O TLs
Date


Soltysik, Susan (M.S.S., Social Science)
Society at Risk: A Conceptual Analysis of ADHD
Thesis directed by Professor Maijorie Levine-Clark
ABSTRACT
This thesis is a critical analysis of the biomedical concept of Attention
Deficit/Hyperactivity Disorder. ADHD is commonly known as a medical-psychiatric
label ascribed to the descriptive behavioral triad of inattention, impulsivity and
hyperactivity. Its diagnosis is predicated on these behaviors, particularly by children,
being perceived and reported as disruptive or non-conforming in a specific
environment, typically at school or at home.
As millions of American children are being diagnosed with ADHD, the market
for their prescribed use of psycho-stimulant drugs, especially Ritalin, has exploded.
While the diagnosis and pharmacological treatment of ADHD are highly contentious
issues in both the professional and private sectors, their utilization continues to
increase unabated. This thesis is an exploration of the phenomenon of ADHD and its
ideological and practical implications.
Critical medical anthropology calls for the analysis of illness designations and
biomedicine from the macro level perspective of social, political, and economic
111


dynamics. In that light, I begin by framing ADHD as a designation of social
deviance that has been medicalized through socio-political and economic forces. I
then address how ADHD can be seen to be exploited by government and industry to
advance their political and economic agendas. Underlying this analysis is a critique
of the traditionally held belief that science, and so biomedicine, is an objective,
value-free enterprise. The promulgation of ADHD clearly supports the opposing
feminist argument that the production of scientific/medical knowledge is not
necessarily objective or value-free, but is a cultural enterprise.
The implications of institutionalizing the biomedical construct of ADHD
demand further macro level research from all aspects of social and liberal studies.
This thesis is an effort to suggest some of these critical research needs.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Signed
Marjorie Levine-Clark
JV


DEDICATION
To my friends and family, whose unwavering support and encouragement
made the completion of this project possible.


ACKNOWLEDGMENT
With deepest gratitude, I especially thank Maijorie Levine-Clark and Paul Ilecki
for being my mentors through the development of this thesis and the completion
of my graduate program.


CONTENTS
CHAPTER
1. INTRODUCTION.................................. 1
The Problem...................................4
Philosophical Perspective.....................9
2. SOCIAL IATROGENESIS...........................13
Framing ADHD as a Deviance Designation.......13
Legitimizing Deviance as a Medical Issue.....31
3. THE WORKING OF ADHD.........................50
Political Rhetoric...........................51
Economic Drivers.............................57
Social Implications..........................62
4. CONCLUSION....................................68
CHRONOLOGY.......................................72
NOTES............................................76
BIBLIOGRAPHY
92


CHAPTER 1
INTRODUCTION
It has been estimated that within the past twenty-five years, the number of
American children taking the psychotropic drug, Ritalin, has surged from 150,000 to
3 million.1 This proliferation of pharmaceutical consumption is due to the rampant
diagnosis of a psychiatric condition labeled Attention Deficit/Hyperactivity Disorder
(ADHD), a diagnosis based upon the descriptive behavioral triad of inattention,
impulsivity and hyperactivity. According to the National Institutes for Mental
Health (NIMH) and Centers for Disease Control (CDC), ADHD is now the most
common diagnosis of behavioral disorders in children. And, the U.S. Drug
Enforcement Administration (DEA) reports that the United States accounts for 90%
of the worlds consumption of methylphenidate (Ritalin).2
In an effort to understand the growing epidemic of ADHD, I have directed my
analysis outside of the predominant discourse that typically positions ADHD as
either a nature or nurture issue. Instead, my thesis skews these perspectives by
suggesting that the behaviors attributed to ADHD, in order to warrant social and/or
medical intervention, must primarily be considered as deviant by institutional social
and medical authorities. With the advent of ADHD, typical childhood behaviors such
as inattention, impulsivity, and hyperactivity are framed as moral flaws and/or
disease markers that must be rectified or, at least, medically controlled. The
l


inference, therefore, is that socially or politically desired behavior is biologically
normal, and those who have difficulty conforming to institutional demands,
particularly in school settings, must be considered as somehow physiologically brain
impaired. The contemporary turn to medicating massive numbers of children for
behavioral issues marks an extension of pharmacological intervention and
conditioning into young lives that is both psychologically and physiologically risky,
as well as socially degrading.
To date, a biological basis for the symptoms of ADHD has not been
established, yet ADHD has been declared a biomedical condition that warrants
pharmaceutical intervention.3 Though scientific theories of a biological etiology for
ADHD abound, my concern is with the dearth of social-political analyses of the
significance of medicalizing common childhood behaviors. My project, therefore,
has been to explore ADHD from the broad perspective of social iatrogenesis, a
concept of human causation forwarded by Ivan Illich in his classic critique, Limits to
Medicine. Though Illich applied this term to socio-political transformations within
medicine and the health care system, and their impact on individuals,4 I have
expanded his frame of reference to include general political and economic activities,
such as legislative actions and mass marketing strategies, and their impact on society
at large. From this perspective, I mean to suggest that the medical concept of ADHD
is a product, not only of scientific, but political-economic ideologies and actions, as
well. One outcome of pursuing this perspective is that the contemporary emergence
2


of ADHD may be seen as evidence of an escalating trend to construct and enforce a
deviance designation around childhood behaviors that may be interpreted as non-
conforming. I develop this perspective through an integrative, historical review and
analysis of political, social, and economic activities and events that converge(d) to
support the establishment of ADHD as a widespread, disabling medical condition.
This presentation is intended to raise awareness of the political and cultural
significance of ADHD and the enduring ramifications of normalizing the practice
of drugging children into the American way of life.
I begin this thesis with an exploration of ADHD through the conceptual
lenses of the social designation of deviance and the medicalization of behavior.
Together, these processes are at the heart of the creation of ADHD. I am using
Illychs term social iatrogenesis to reference the processes whereby socio-political
pressures are exerted to categorically reffame certain social behaviors as illness
symptoms. The social perception of deviance as illness is constructed through the
process of medicalization, whereby a non-medical problem becomes redefined as an
illness, and therefore, a medical disorder. As shown by Peter Conrad and Joseph
Schneider in Deviance and Medicalization: From Badness to Sickness, this process
does not unfold in the isolation of scientific research, but flourishes under certain
social, political, and economic influences and conditions.
Upon publication in 1980, Deviance and Medicalization was recognized as an
excellent text for the study of deviance definitions and the starting point for the
3


resolution of such problems as the definition and causes of medicalization and its
interrelationship with other trends in social control.5 As such, the following
discussion of ADHD as a deviance designation and its medicalization is structured,
informed, and guided by Conrad and Schneiders seminal work in these areas. Their
research addresses not only how certain behaviors come to be defined as deviant, but
how social institutions forge the paradigm shift that is necessary to reframe behavior
as deviant. They also consider the socio-historical processes that support the
medicalization of such behaviors. Throughout their work, Conrad and Schneider
hold the perspective of labeling-interactionist theory, that deviance is a social
construction. In turn, I frame ADHD as a deviance designation that has been shaped
by politically and economically motivated forces. Within the framework of deviance
designation and the dynamics of medicalization, issues surrounding ADHD can be
appreciated far beyond the popular preoccupation with arguing the pros and cons of
medical intervention on a strictly scientific basis. In this way, the concept of social
iatrogenesis may be better understood.
The Problem
Every day, the minds and bodies of millions of American children diagnosed
with ADHD are altered by psycho-pharmacological interventions. Meanwhile,
medical and scientific authorities acknowledge that, after nearly fifty years of
extensive research, reliable evidence to support the concept of ADHD as an organic,
4


biological condition remains not only inconclusive, but non-cohesive.6 In turn, the
efficacy, risks, and long-term effects on children ingesting psychotropic drugs
remain effectively untested and unknown. Yet, in spite of this clinical uncertainty,
ADHD is represented and promoted as a scientific reality in the public mindset and
marketplace.
The ongoing effort to legitimize a scientific, biological foundation for the
psycho-pharmaceutical treatment of ADHD suggests that the driving force behind its
presence in American society is situated outside of the biomedical domain itself.
This assertion is supported by the fact that the pharmaceutical formulation of
methylphenidate (Ritalin) preceded the medical diagnostic criteria for ADHD by
nearly twenty years. Unlike the traditional sequence of disease presentation leading
to medical/scientific response (as witnessed during the concomitant rise of
industrialization and infectious diseases in the latter 19th century), ADHD is a
condition that reached epidemic proportions after the synthesis of chemical
treatment. In essence, the medical diagnosis and pharmaceutical treatment hit the
market simultaneously. The diagnosis of functional behavior problems in children
was initially promoted to physicians and teachers in the 1960s by the Ciba
pharmaceutical corporation to develop a market for its product, Ritalin.7
On the heels of this commercial enterprise, it appears that research
foundations and academic institutions are now entrenched in research to justify the
widespread use of drugs to control childrens behavior, an enterprise that is shown to
5


be heartily supported and funded by the federal government. It is against this
background that numerous theories to explain a clinical etiology for ADHD have
emerged from the fields of neurobiology, psycho-pharmacology, and genetics, and
millions of (tax) dollars are being expended to support the biomedical contention that
childrens behavior can be reduced to inherent biological factors. It is this
application of traditional scientific reductionism to the complexities of childhood
development, both psychologically and physiologically, that raises my concern about
the construction of ADHD. The biomedical focus on identifying a fixed neuro-
chemical or genetic factor denies the integrity of children as sensory beings
responding to their conditions or environment. By targeting the children as
neurologically defective, attention is deflected away from the myriad of social,
environmental factors that may contribute to their behavioral expression of
deviance.
While the scientific alliance focuses its research efforts on discovering a
biology of ADHD, the pharmaceutical industry continues to gamer impressive
profits. Ritalin sales alone were estimated at $349.3 million in 1995, up from $95.3
million in 1991.8 By financially supporting the American Psychiatric Association
(APA), authoritative experts/spokespersons such as C. Keith Conners and Russell
Barkley, and citizen lobbying groups such as CHADD (Children and Adults with
ADHD), Novartis (formerly Ciba-Geigy) has effectively established ADHD as an
industry that now involves and has an impact not only on the functional practices of
6


medicine, but the conduct of society at large. With the endorsement and support of
the federal government and the public education system, the diagnosis of ADHD and
its pharmaceutical treatment are directly promoted and marketed to the American
public. Under guidance and pressure from these institutional authorities, the personal
lives and practical parenting decisions of American families are being challenged, as
parents are coerced to buy into the concept of ADHD and a pharmaceutical solution
for behavior control.
In the chapter entitled, The Working of ADHD, I bring attention to
specific, contemporary political, economic and social activities that support the
creation of diagnoses and medical treatments for ADHD while disclosing the
deviance designation attached to it. These discussions serve to illustrate how
deeply the ADHD movement has been institutionalized and provide insights into the
consequences of its continued expansion.
To demonstrate the political scope of ADHD, I present a brief a content
analysis of documents from federal institutions such as the National Science
Foundation (NSF/NSB), and the National Institutes of Health (NIH/NIMH). The
NSBs Science and Engineering Indicators 2000 offers some insights into the
philosophical underpinnings of national leadership and the justifications of the power
elite to mandate the guidance and control of public education. Attention Deficit
Hyperactivity Disorder: Decade of the Brain, a product of the NIMH, exemplifies
7


government support for the agenda to medicate children in lieu of investigating non-
medical factors that influence and elicit the deviant behaviors marked by ADHD.
I consider the economic aspects of ADHD primarily in terms of the System of
National Accounts (SNA), an international model of economic measurement
explained by Marilyn Waring in her seminal book, If Women Counted. Mandated for
use by all members of the United Nations, the SNA records a pattern of economic
activity that is composed solely of cash generating activities. The ramifications of
this single rule of economic measurement run wide and deep, as the statistics it
generates provide the grist for policy-making decisions in both the government and
corporate boardrooms. Using the framework provided by Waring, I examine the cash
generating capacity (or economic value) of ADHD in terms of the rationale behind
government policies and the marketing practices of the medical/pharmaceutical
industry.
To gauge the social implications of institutionalizing ADHD, I address recent
legislative and judicial actions, as these have the most profound effect on the shaping
of societal guidelines. For example, having gained support and recognition through
the Rehabilitation Act of 1973 and the Individuals with Disabilities Education Act
(IDEA), the diagnosis and approved medical treatment of ADHD is positioned to
generate widespread institutional controls over American society. As noted by
Lawrence Diller in The Run on Ritalin, people designated as disabled with a
diagnosis of ADHD cannot legally face discrimination and are entitled to the
8


benefits of special services...Parents find that the only way to get extra help for their
children is to have them labeled with a disorder. 9 As millions of children are being
raised under the psychological umbrella of entitlement, court actions are beginning
to change the shape of the educational system, social services, and the workplace.
Transcripts from government sponsored conferences, such as the 1998 NIH
Consensus Development Conference on ADHD, and, 'ADHD: A Public Health
Perspective, conducted by the Developmental Disabilities Branch of the CDC in
1999, not only reveal the political and scientific truths regarding ADHD, but also
provide invaluable insights into the voices that are determining and guiding national
administrative/policy decisions.
The scope of the practical conflicts and social controversies attached to ADHD
cannot be addressed solely from the perspective of medical science. Therefore, I
have taken an interdisciplinary approach to identifying the philosophical framework,
historical circumstances, and political-economic factors that have contributed to the
emergence of ADHD as a contemporary social phenomenon.
Philosophical Perspective
A basic premise of critical theory is that it could unearth the false
presumptions that heretofore held humanity in its sway.10 This is a key concept
underlying my approach to the issue of ADHD. It seems that much of the public
confusion and controversy surrounding ADHD is due to the fact that its discourse is
9


fragmentary and is conducted from diverse, often contradictory viewpoints. Within
the scientific community itself, explanatory models have been developed from
evolutionary, genetic, and neurological perspectives, yet none can claim biological
certainty. Nonetheless, media reports and public information resources (such as
government publications, professional literature and ADHD websites, of which there
are now hundreds) are typically grounded in the assumption that ADHD is
universally recognized and accepted as a scientifically legitimate, organic disease.
On the other hand, ADHD is often medically referred to as a concept that intimates
behavioral disorder. These offerings confuse the framework for understanding what
the term ADHD actually references: is it physiological or a consequence of lifestyle?
Since a biological basis is unknown, our growing social investment is actually in the
reification of a set of behaviors called ADHD, a conception that is itself based on
highly politicized science. My project is an effort to unearth the false presumptions
about ADHD by analyzing it from a broad perspective that challenges taking the
dominant medical model of ADHD for granted.
As the feminist viewpoint is one that challenges the status quo of
establishment ideology, it is the cornerstone of my analysis. The biomedical
condition of ADHD is arguably a product of our patriarchal, Enlightenment heritage,
a tradition that holds the aspiration to dominate and control nature. This mandate is
grounded in the belief that the methodology of scientific discovery and knowledge
production is an objective, value-free enterprise. Feminist critics, however, adhere to
10


the alternative view of science as a cultural institution,11 a perception that is central
to my argument for the social iatrogenesis of ADHD.
Scientist Ruth Hubbard has pointed out that there is a pretense of scientific
objectivity that pervades the male-dominated world of science (and so, medicine).
This pretense conceals the fact that scientists set the terms of their research, that they
make choices and those [are] affected by economic constraints, cultural
commitments, [their] position and role in the culture, and [their] personal history.12
Feminists, on the other hand, recognize that subjectivity and context are unavoidable
factors in scientific research;13 this is a perspective that deems the ideal of objective,
value-free science an Enlightenment myth.
In the context of my thesis, the popular belief that science is the bulwark of the
truth behind medical realities is challenged as human political enterprises are shown
to be the designers, creators, and exploiters of these realities. In short, the
circumstances surrounding the reality of ADHD vindicate the feminist view that
science is not an objective rendering of facts, but a social practice, subject to
cultural and political norms.14 It seems to me that popular recognition of the socio-
political and economic aspects of biomedicine is key to diminishing the mystique
and conferred authority of institutional science. With the understanding that
biomedicine is not a value-free scientific enterprise, individuals could make more
critically-informed and confident decisions regarding medical intervention,
particularly when the health and vitality of their children is called into question.
ll


In The Handbook of Critical Theory, David Rasmussen points out that critical
theory was to distinguish itself by addressing the political oppression of the day.15
My thesis suggests that the institutional promulgation of ADHD and the concomitant
campaign to encourage the psychotropic drugging of children may be considered an
insidious form of such oppression.
12


CHAPTER 2
SOCIAL IATROGENESIS
The term iatrogenesis is rooted in the Greek iatros meaning physician, and
genesis, meaning origin.1 Prefacing this term with the word social suggests that by
framing behaviors as deviant, and in turn, medicalizing them, the hierarchy of
medicine over an illness origin is trumped by social and political forces that exploit
scientific medicine to serve certain non-medical agendas. In Ritalin Nation, Richard
DeGrandpre essentially identifies social iatrogenesis when he states, What this
diagnosis [ADHD] by fiat really signifies is that the authority of American psychiatry
operates largely as a social and political force, relegating to science only an affirming
role.2 In other words, ADHD is more an institutional construct than a biological one,
a concept formulated under political circumstances in advance of substantiating
scientific evidence. The following discussion of ADHD as a deviance designation and
its legitimization as a medical issue illustrates the resilience of science when it is in the
service of authoritative social and political powers.
Framing ADHD as a Deviance Designation
In order to situate ADHD as a deviance designation, it is important that I
establish the perspective I am taking on deviance itself. I concur with Peter Conrad
that deviance is a social construction, an ascribed status, and not the essence of certain
13


behaviors; it is a quality attributed to behaviors and not the behaviors themselves.3
This distinction is critical to my discussion. Typically, children are labeled as
ADHD based on their behavior in school as reported by teachers. In everyday life,
episodes of inattention, hyperactivity, and impulsivity are not unusual childhood
behaviors. However, in a particular context, such as a classroom, where there is an
expectation that the child sit still, be quiet, and concentrate, these behaviors are judged
to be deviant as they are non-conforming to the rules.
In Deviance and Medicalization, Peter Conrad and Joseph Schneider distinguish
between the processes of deviance designation and the medicalization of deviant
behaviors. In the case of ADHD, however, the two are inextricably tied together: the
medical framing, in essence, precedes and so obscures the implication of deviance.
This situation creates an inherent conflict in conceptualizing ADHD. Viewed as
deviance, ADHD is contextual in that it is related to a particular environment. As
illness, it is non-contextual. Biomedicine, being a scientific enterprise, implicitly
denies context, as disease forms are considered biological, material conditions that
are global in the sense that they are either there or not. With ADHD, biomedicine is
faced with the philosophical dilemma of arguing a contextual disease. This
dilemma seems to be at the core of the nature vs. nurture arguments. Advocates of
ADHD in essence are supporting the notion that the medical construction and
deviance are one and the same, that behavior is biologically motivated. Detractors, on
the other hand, are sensitive to the dilemma and recognize that deviance is a social
14


designation, not a biological one.
The process of creating a deviance designation is essentially one of reification,
whereby the behaviors or actions of certain persons are transformed into a
terminology, a label that signifies some thing.4 This process of reification is
inherent in the medicalization of deviance. Prior to their medicalization, inattention,
hyperactivity, and impulsivity were perceived as a childs response to his or her
situation or environment. Since being medicalized, these behaviors are perceived as
symptomatic of a condition, the thing called ADHD.
As the scientific enterprise in general strives to establish and maintain a
depersonalized, objective authority, so medicine, through its adoption of scientific
language and discourse, follows suit. As observed by Ruth Hubbard, the grammar of
depersonalized description tricks us into submission to facts of nature,5 while
denying or deleting human agency from the scientific formulation.6 The samples of
medical writing on ADHD contained in this section show that not only is the
experience of the child dismissed, but the selfhood of the child is effectively deleted
from the discourse. Instead, the focus is on the manifestation of ADHD.
The behaviors currently associated with ADHD were initially framed as
symptoms of illness by the medical scientific community in the early twentieth
century. At that time, the perception of illness was particularly associated with
children who demonstrated hyperactive behaviors in the aftermath of suffering a
central nervous disease, such as encephalitis, or traumatic head injuries. Biomedical
15


research was focussed on institutionalized children who exhibited extreme, chronic
behavioral control problems compared to their pre-illness/trauma deportment. In
society at large, unafflicted children who had episodes of hyperactivity, impulsivity,
and/or inattention were typically viewed as spirited, misbehaving, or perhaps even
mildly deviant. When perceived as annoying or disruptive, such behaviors elicited
some disciplinary action. Mostly, the management of childrens behavior was an
individualized, inter-personal issue negotiated between the child and the authority
figure, whether parent or teacher. When medical scientists generalized institutional
case findings and declared that such common behaviors were symptomatic of a
biological disorder, they not only depersonalized adult/child interactions, but
globalized non-conforming behaviors as problematic: they were no longer a personal
issue, but a societal one. Under the label of ADHD, inattention, hyperactivity, and
impulsivity are transformed from contextually-elicited behaviors to markers of a
universal biological disorder that allegedly causes such deviant behaviors. In
sociological terms, once a label of deviance is construed as a public problem, its
status as a problem must be understood.
When the trend toward medicating school aged children for behavioral control
began to emerge in the late 1960s and early 70s, Conrad conducted a study at the
Hyperactivity-Learning Disabilities Clinic of Northeastern Pediatric Hospital. In 1976,
o
he published Identifying Hyperactive Children. According to Conrads findings,
behaviors such as inattention, impulsivity, and hyperactivity in children are considered
16


problematic either by parents, teachers, or both. When parents become concerned, it is
usually in terms of their childs role performance when compared to that of his/her
peers. In the context of a classroom situation, however, these same behaviors are
viewed by teachers as a management problem, (p. 34) Though behavioral issues
may be first noticed by parents, it is usually through a teacher reporting on school
performance that the majority of medical diagnoses are initiated.(p. 36) However, as
noted, teacher reports stem from a different frame of reference than that of parents. As
such, the deviance issue associated with ADHD may be classified as one of
institutional management.
Conrads findings suggest that school-defined children are more likely to be
labeled hyperactive than family-defined children...[and] that the school is a more
powerful definer and has greater influence in achieving a medical label of
hyperactivity than does the family. (p. 49) The importance of these findings is the
intimation that institutional guidelines have been a significant factor in the formulation
and application of a medical diagnosis of behavioral disorders in children since the
preliminary constructions of ADHD. (It should be noted that at the time of Conrads
work, the diagnostic and treatment focus was on the singular deviant behavior of
hyperactivity. Though issues of attention and impulsivity were not yet included in the
diagnostic criteria, the contemporary application of an ADHD diagnosis can be
deemed to have its roots in the management of hyperactive behavior).
As a behavior management device, a diagnosis of ADHD is based on the
17


interpretation of behaviors by a particular audience, parents and/or teachers, who have
specific performance/management objectives for their children. Conrad noted that
when the deviance becomes a management problem, the family or school turns to the
medical sphere for help.(p. 49) At this point, the child enters the jurisdiction of the
medical system, whereby the definition and control of deviant behavior moves from
the educational or family system to that of medicine. (p. 38) This turn to medicine is
motivated by the fact that medicine has constructed a diagnostic framework to
accommodate such behavioral issues. It therefore offers an option that was previously
unavailable to the general public for dealing with matters of behavior management.
From the perspective of deviance designation, ADHD represents a change in
how behavior is defined, not a change in behavior as such. More specifically, as stated
by Conrad, it is a change in the significant audience, rather than merely a change in
the childs behavior, that leads to a medical definition of deviance.(p. 49) For
children, the move from their home environment to a school situation marks a
significant change in audience from parents to teachers, as well a change in behavioral
expectations and interpretations.
There have always been children who are challenged by and, in turn, challenge
the structure of institutional settings. Going back to the 17th and 18th centuries,
Lockes and Rousseaus writings on education acknowledge and offer guidelines for
positively influencing such spirited children.9 However, with the advent of medical
diagnoses such as ADHD, we have a shift from the formerly explicit moral judgement
18


of behavior to the implicit and subtle morality of sickness. With ADHD, the issue
of non-conforming behavior becomes focussed on an assumed impairment of the
physiology of the child rather than the possible failure of the institutional environment
or adult caregivers to meet or accommodate the childs needs. By considering these
children as sick, they are neither criminal nor morally responsible for their
disease. However, as sick people, they are both obligated and entitled to be
helped.10 With this implicit social understanding in play, the field is thrown open for
exploitation by major and powerful institutional forces, such as the health care system,
the educational system, and government agencies. By supporting the concept of
ADHD, these authorities encourage parents to interpret their childrens non-
conforming behaviors as symptomatic of biological disorder, a connotation that
immediately points them toward medical evaluation and intervention. The implicit
appeal of this scenario is that parents may be relieved of having any perceived
responsibility for the deviant behavior of their children. However, for the children
inducted into the domain of medical/pharmaceutical control for behavioral issues, the
message is the same: that their behavior is not within the scope of personal
responsibility or control, but is triggered by a biological aberration. To be raised with
this belief could engender limiting psychological issues as these children reach
adulthood. Being medically marked as mentally disabled during their developmental
years may also invoke limitations to their future choices for careers or lifestyles in
19


currently unforeseen ways. I address this issue further in the section on the social
implications of ADHD.
In the Enlightenment tradition, the scientific bent toward positivism and
objectification allows for deviance, as exemplified by ADHD, to be considered as
real. It can therefore be conceptualized not only as a form of material reality, but in
turn, as a commodity. It is from this perspective that the medical model claims the
capacity to identify deviance as organic disease and the pharmaceutical enterprise
claims the ability to manipulate it through psychotropic drugs. As an objectified
concept, ADHD and its behavioral symptoms have effectively displaced the
experience and welfare of the child as the primary clinical concern. This reduction of
experience to a biological event is demonstrated by the language of the American
Academy of Child and Adolescent Psychiatry in their 1996 review of ADHD :
Across children the symptoms may vary in their frequency of
occurrence, in their pervasiveness across settings, and in the degree
of functional impairment in various areas. Also with the same child
some settings may enhance or decrease symptom manifestation.11
Such statements reveal not only the disease-centered perspective of the medical
model, but also the range of ambiguity that surrounds an ADHD diagnosis. The
linguistic turn to scientific jargon distorts what is being conveyed: that some
childhood behaviors can be considered normal in some situations and deviant in
others. It is from environmental circumstances and the degree of symptom
manifestation that a physician must, in Conrads terms, construct a medical
20


reality.12 He notes that Of great importance in the evaluation for hyperactivity are
behavioral and developmental history reports from the parents, and behavioral and
achievement reports from the school... the reliability and validity of this lay evidence
is of course extremely variable and open to interpretation.13 In the twenty-five years
since Conrads study, no reliable diagnostic method for ADHD has been developed.
As stated in 1998 at the NIH Consensus Conference on ADHD, We do not have an
independent, valid test for ADHD, and there are no data to indicate that ADHD is due
to a brain malfunction. Further research to establish the validity of the disorder
continues to be a problem.14 Todays doctors are as reliant upon subjective reports
and standardized questionaires as those who faced the initial construction of a medical
designation for deviant childhood behaviors. According to a clinical review in the
journal American Family Physician, behavior rating scales are a mandatory part of
the [clinical] assessment...the most useful are the 48 item Conners Parent Rating
Scale and the 28 item Conners Teacher Rating Scale.15 Although a study of the
efficacy and reliability of the Conners system concluded that Overall, parent and
teacher agreement on ratings of child behavior problems, including hyperactivity, is
entirely modest,16 such scales remain central to achieving an ADHD diagnosis. It is
noteworthy that another study found the Conners Teacher Rating Scale to be more
sensitive to the effects of drug treatment.17 (Interestingly, C. Keith Conners, the
author of these scales, conducted his research through funding from Ciba-Geigy.18
Considered a major authority on ADHD, Conners is a staunch proponent of
21


psychotropic medication for children).
In contrast to the positivist view of medical science that deviant behavior is
biologically driven, the sociological labeling-interactionist tradition does not regard
deviance as an objective condition, but as a social product. Conrad argues that
Those who have comparatively more power are typically more
able to create and impose their rules and sanctions on the less
powerful. In consequence, deviance becomes actions or
conditions that are defined as inappropriate to or in violation
of certain powerful groups conventions.19
In essence, definitions of deviance are a political matter. Success in achieving such a
definition is decided by those who have the power to legitimate it. The public
definition of a problem of deviance is the outcome and continual object of claims
that interested groups put forth.20 From this perspective, ADHD represents a
phenomenon that elicits the attention and endorsement of more than a few powerful,
interested groups. For example, while corporate/pharmaceutical interests are
primarily profit motivated, specialists in psychiatry, pediatrics, and research inflate
their professional status by making careers out of their advocacy for ADHD and
pharmaceutical treatments. School administrations receive financial aid through
federal funding programs by identifying students with ADHD who therefore require
special education ($400 per year per child), while teachers get occupational relief
from increasing performance-rating pressures. (School funding under the just-passed
Leave No Child Behind Act is contingent upon raising student performance as
measured by quantitative rating scales).21 Government research institutes, such as the
22


NIH and the National Institutes of Mental Health (NIMH) are heavily invested in
funding scientific studies of ADHD, along with the Department of Health and Human
Services and the Department of Education.
In society at large there are also enterprising groups that serve to forward the
construction and legitimization of ADHD as a deviance designation. Borrowing from
the work of sociologist Howard S. Becker, Conrad refers to moral entrepreneurs,
groups that work with or through institutional systems to reinforce such designations
and who crusade for the creation of new rules. Currently, the most dominant and
vocal public group promoting the recognition of ADHD is CHADD (Children and
Adults with ADHD). Founded in 1987 in response to the frustration and sense of
isolation experienced by parents and their children with ADHD,23 CHADD now
ranks as a major political lobby to promote and influence legislative activities at the
national, state and local level.24 Their prominence as public educators and
advocates of stimulant medication led to their being named as co-defendents (along
with the American Psychiatric Association and Novartis) in a recent class-action suit
claiming conspiracy to create a disease (ADHD) and promote drug prescriptions.25
These institutions and moral entrepreneurs exert tremendous pressure on
American parents to concede that their childrens deviant behavior is not a response
to their life and/or environmental situations but is symptomatic of sickness. Under
their collective influence, the use of Ritalin alone has increased 700 percent since
1990.26
23


The connection between socially-defined deviance and medical legitimacy must
be intentionally forged. According to Conrad,
As in the scope of general politics, the medical decisions to
define certain behaviors, activities or conditions as deviant still
emerge from a political process that produces and subsequently
legitimates the imposition of deviant categories. And most
often, the consequences of medical definitions are also
political.27
This observation is exemplified by the evolution of the diagnostic criteria that
now comprise ADHD. According to the diagnostic history related by Russell Barkley
in his handbook for the diagnosis and treatment of ADHD, the precursors to
contemporary ADHD first appeared in the bible of American psychiatry, the
Diagnostic and Statistical Manual (DSM) II, in 1968, as the Hyperkinetic Reaction of
Childhood Disorder.(p. 10) This designation marked the shift in scientific research
from focusing on the association between behavior and organic brain damage to that
between behavior and brain mechanisms (i.e., neuro-chemistry), (p. 10) Barkley, an
advocate and public spokesperson for the ADHD/medication movement, states that
there developed in the early 1970s a disenchantment with the exclusive focus on
hyperactivity.(p. 13) At this time, the defining features of HRCD had been
broadened to include impulsivity, short attention span, low frustration tolerance,
distractability, and aggressiveness.(p. 13) Most research at that time was being
conducted and/or financed by the pharmaceutical industry. Finding that inattention and
impulsivity were most influenced by stimulant medication, these symptoms were moved
24


to the diagnostic forefront.(p. 13) In 1980, the DSMIII responded with the label ADD,
Attention Deficit Disorder, giving formal recognition to inattention and impulsivity as
having greater significance than hyperactivity in diagnosing children as requiring
medication.(p. 14) A revised DSMIII, published in 1987, reintroduced hyperactivity
into the diagnostic criteria by creating the current label of ADHD, (p.26) With the
latest edition, DSMIV-R, ADHD is now divided into three sub-types inattention,
hyperactivity-impulsivity, and combined.
The consequences of jockeying the medical categorizing of childhood behaviors
has been the ability to enlarge the umbrella for inclusion in the diagnosis, to then
argue increasing statistical proof of the existence of ADHD, and to sell more drugs. In
addition, the medical authority conferred on the DSM and its categorizations of mental
disorders/deviance designations also serves to legitimate research and determine the
allocation of federal and corporate funding. In the words of recent DSM authors,
It is often pointed out that DSM-II and DSM-III-R have been
major facilitators of research efforts in a number of areas that
might have remained much more obscure and
unresearched....While the major goal of DSM-IVis clinical,
research and education utility, we will be especially cautious
about new diagnoses that might be stigmatizing or have an
adverse forensic impact.29
Such statements highlight the pervasive role of politics in the use and production of the
DSM, an allegedly scientific, objective tool of psychiatric medicine.
The diagnostic evolution of ADHD supports Conrads observation that the
medical profession takes an active role in influencing deviance definitions and
25


designations, discovering new illnesses, and intervening with appropriate medical
treatment.30 To justify the rapid changes in the formal diagnostic criteria for ADHD
C. Keith Conners stated at the 1998 NIH Consensus Conference,
The fact that the concept of ADHD has evolved with changing
evidence should be taken as a strength, not a sign of
unreliability or vague conceptualization... that diagnostic
criteria for ADHD... lead to the diagnosis of a syndrome with
high interrater reliability, good face validity, and high
predictability of course and medication responsiveness.31
Conners statement is indicative of the objective, biomedical view of ADHD, one
that obfuscates the designation of social deviance that is implicit in the diagnostic
criteria.
In his discussion of the politics of designating deviance, Conrad raises the
question of territory, that is, in whose turf does the deviance lie? His belief is that
this unacknowledged political dimension of refraining behavior as deviant is the
source of controversy and debate that emerges with major pressures to change a social
designation.32 A look at ADHD from the perspective of territory not only corroborates
his opinion, but takes it a step further.
As previously stated, the process for achieving an ADHD diagnosis may be
initiated from within either the family system or the educational system. While they
often provide a united front by jointly defining the childs behavior as requiring
medical attention, they often do not. If parents disagree with a school-defined
assessment or pre-labeled opinion, there may be a prolonged conflict between the
26


parents and the school.33 However, Conrad found that the school has more power to
achieve a medical definition of the situation than do parents.34 Under the recent
amendments to the Individuals With Disabilities Education Act (IDEA 97), school-
initiated evaluations and assessments of students have legal priority over parental
objections.35 ADHD is now recognized as a legitimate diagnosis under this
legislation, giving school personnel the power to initiate such evaluations and
assessments based on their interactions with students.
Social Services has recently entered into the territorial fray. Lawrence Diller,
MD., reports that cases are beginning to emerge whereby parents unwilling to give
their kids drugs are being reported by their schools to local offices of Child Protective
Services, the implication being that by withholding drugs, the parents are guilty of
neglect.36 These cases presage an unprecedented opportunity for the legal
establishment of biomedicine as a primary mechanism of state control over personal
freedom of choice. The demonstrated willingness of government agencies to
jeopardize the integrity of families in favor of the scientific enterprise is ominous at
best.
As these scenarios demonstrate, the turf battle for ADHD is being waged
between parents, schools, and government agencies. However, on an unspoken level,
the conflict is also about whom has the authority to define deviance as ADHD. The
advantage here is clearly held by social institutions as they side with the authoritative
knowledge of science and biomedicine. By fiat, they have the power and authority to
27


challenge, and/or overrule parental dissent or resistance to an ADHD diagnosis and
medicating children with psychotropic drugs.
Within the medical community itself, there are issues surrounding who is
qualified to make an ADHD diagnosis and on what grounds. Psychiatrists are the
primary specialists to claim rights to diagnosis, having created the criteria as
forwarded in the DSM. However, primary care pediatricians, as the physicians most
frequently called upon, have designed their own guidelines that appear to capitalize on
the diagnostic and prescriptive power of ADHD. In October 2001, the American
Academy of Pediatrics (AAP) released their Clinical Practice Guidelines for the
Treatment of School-Aged Children with ADHD?1 While the recommendation is that
evaluations be based primarily on the explicit criteria for the diagnosis using the
DSM-IV criteria, they also emphasize the importance of obtaining information about
the childs symptoms in more than one setting [especially from schools].(p. 1033)
This policy is not only a concession to the subjectivity of an ADHD diagnosis, but
confers inordinate weight (still) on the non-clinical observations of teachers and
parents in achieving the diagnosis. As stated earlier, both teachers and parents may
have a vested, personal interest in seeking an ADHD diagnosis and pharmacological
control of their children. The AAP guidelines call for ongoing communication with
parents, teachers, and other school-based professionals,(p. 1033) while promoting a
treatment program that recognizes ADHD as a chronic condition,(p.l033) and
28


recommend[s] stimulant medication. (p. 1036) The determination of the AAP to
advance the pharmaceutical agenda is evident in their treatment recommendations:
At least 80% of children will respond to one of the
stimulants... Children who fail to show positive effects or who
experience intolerable side effects on one stimulant
medication should be tried on another...children who fail 2
stimulant medications can be tried on a third, (p. 1039)
The promotion of such experimental prescribing raises questions about the validity of
the diagnosis, as well as the possibility that medications themselves are being used as
a device to confirm the diagnosis; as soon as one works, the diagnosis is valid.
Turf wars are also being played out in the research community. With the
sophistication of modem medical technology, neurobiology and genetics are gamering
the bulk of todays research investment, while inquiries into social/environmental
factors, nutrition, allergies, etc. are challenged, discounted, and/or abandoned. This
practice became apparent in 1973 when Dr. Benjamin Feingold conducted extensive
research that scientifically validated the link between food additives and learning and
behavior disorders. After he reported his findings to the American Medical
Association, Feingolds hypothesis was publicly refuted in 1981 by C. Keith Conners,
who published a book, Food Additives and Hyperactive Children, in an effort to quell
popular skepticism (of the pharmaceutical solution) that was instigated by an
increasing awareness of the Feingold Diet.38
As a whole, government-funded research is dedicated to promoting and
achieving a pharmacological solution for behavioral issues. In its largest clinical trial
29


to date (1999), the NIMH, in collaboration with the Department of Education,
conducted a Multi-Modal Treatment Study of Children with ADHD (MTA) and
concluded that medication management is more effective than behavioral treatment for
ADHD.39 Career researchers of ADHD, Drs. William Pelham and Laurence
Greenhill, jointly stated at a CDC Workshop on Public Health Issues in the
Treatment ADHD in 1999, Drug-only treatment, administered by medical doctors, is
the most prevalent form of treatment for ADHD. The most prevalent psychosocial
treatments have no studies supporting their effectiveness.40 Underlying this
statement is the fact that, while studies of psychosocial treatments for ADHD may
have positive outcomes, they are not considered scientifically valid, and so are
discounted in terms of authoritative biomedical and pharmacological research, the
primary focus of institutional science.
It has been suggested by Howard Becker that those who work toward the
establishment of a deviance designation may have a hidden agenda which is of equal
or greater import and not immediately obvious.41 By these lights, the institutional
commitment to and investment in, the scientific-medical model and a pharmacological
treatment regarding ADHD is of particular concern. While extolling the merits of
scientific advances in medical knowledge, the fact that deviance is an element of the
ADHD concept, and that social management is its functional purpose, is obscured.
From a socio-political perspective, the powers of social control conferred through the
30


medical designation of ADHD are enormous. These issues are addressed in Chapter 3,
The Working of ADHD.
Legitimizing Deviance as a Medical Issue
In her book, The Politics of Womens Biology, Ruth Hubbard discusses a
feminist view on how facts are made in science. There are a number of points she
makes that are particularly relevant to the story of ADHD and should be kept in mind
throughout the following discussion. They are: 1) that scientific facts are true only to
the extent that they can be applied and used, 2) that these facts are related to the
ideological and social commitments of the scientists, (3) that to be believed, they must
fit the world view of the times, and 4) that public accountability is not built into the
system.42
In order to review the clinical history and social dynamics that enforce the
concept of ADHD, I present them within the framework of Conrad and Schneiders
Inductive Theory of the Medicalization of Deviance.43 This model proposes a
sequence of political stages by which a deviance designation achieves objectified
status and becomes ensconced in the medical domain. The following discussion is
guided by the five key markers in this process that are identified in Conrad and
Schneiders theory. These markers are: 1) defining behavior as deviant, 2)
prospecting: medical discovery, 3) claims-making: medical and non-medical interests,
4) legitimacy, securing medical turf, and (5) institutionalization of a medical deviance
31


designation.44 The evolution of ADHD demonstrates that this process is not strictly
linear as different stages may converge or overlap. However, the significance of this
model is that it identifies the dynamics involved in successfully transforming the
perception of a social behavior into a medical entity.
1) Defining Behavior as Deviant
Typically, a behavior or activity is defined as deviant before the emergence of a
medical definition. In the case of ADHD, this is not a clear-cut situation. In Conrads
opinion, restless, disruptive, and overactive children were surely considered deviant in
most school classrooms, but it was the application of a medical label that gave shape
to these vague forms of deviance 45 While the evolution of medical definitions for
child behaviors can be traced back to the early 1900s, their application to the general
population was not initiated until the late 1960s. According to Barkleys history of
ADHD,46 childhood survivors of an encephalitis epidemic in 1918 were described as
being impaired in attention, regulation of activity, and impulse control (the holy
trinity of ADHD to the present day).(p. 6) The condition was labeled
postencephalitic behavior disorder, and was clearly the result of central nervous
system damage. However, the emergent medical perspective was that behavior
patterns were a reliable indicator of underlying CNS etiology or damage, even where
evidence of such was lacking. (p. 7) This perspective evolved into the concept of
minimal brain damage and eventually minimal brain dysfunction (MBD) by the
32


1950s and 1960s. (p. 7) Meanwhile, the pharmaceutical industry had begun
synthesizing and manufacturing psychoactive drugs in the 1930s. By the early forties,
researchers were publishing academic papers that reported on the efficacy of the
amphetamines in reducing the disruptive behavior and improving the academic
performance of [psychiatrically hospitalized] behaviorally disordered children. (p. 8)
In the mid-1940s, Ciba Pharmaceuticals had synthesized methylphenidate (Ritalin), an
amphetamine-like stimulant that was originally intended for treatment of adult
narcolepsy, appetite control, mild depression, and fatigue. It was approved by the FDA
for adult use in 1955.47 In 1957, psychiatrist Maurice Laufer announced the discovery
of a new syndrome called hyperkinetic impulse disorder. He wrote, ...hyperactivity
is the most striking item...There are also a short attention span and poor powers of
concentration, which are particularly noticeable under school conditions...poor school
work is frequently quite prominent.48 In The Myth of the Hyperactive Child, Schrag
and Divoky state,
Laufers description of the hyperkinetic impulse disorder
was the major break between the classic medical description
of hyperkinesis (as applied to organically/physically disabled
or injured children) and the vague set of ailments now
attributed to millions of children...The sickness, in brief, was
the inability to function in school.49
In 1961, Ciba began an aggressive promotional campaign of Ritalin that targeted
medical and educational professionals, touting functional behavior problems in
children.50 The company ran ads one to six pages long to educate physicians on the
33


hyperkinetic syndrome, supplying diagnostic and treatment information.51 The FDA
approved Ritalin for use with children that same year. It was not until 1962, however,
with the adoption of the Kefauver-Harris Drug Amendment, that, for the first time,
pharmaceutical companies were required to prove the effectiveness of their products
before they could market them. C. Keith Conners, a clinical psychologist, and Leon
Eisenberg, a psychiatrist, began research on Ritalin and its use with children in 1963,
two full years after Ritalin was being dispensed to children on the basis of Cibas
advertising. Initially conducting studies on institutionalized children, by 1967
Conners and Eisenberg moved their experiments into public schools. In 1968,
Hyperkinetic Reaction Syndrome made its first appearance in psychiatrys
Diagnostic and Statistical Manual II (DSMII). Also in 1968, the medical framing of
deviance implied by certain childhood behaviors received its first publicity in the mass
media under the labels of hyperkinesis and/or minimal brain dysfunction (MBD),
the evolutionary foundations for ADHD.53 Until this time, the general public was
unaware of these labels, or of the medical/pharmaceutical alliance and its investment
in transforming the perception of the hyperactive behaviors of their children from a
social/psychological or developmental issue to a fixed, chronic, medical condition
requiring pharmaceutical intervention. In one sense, the construction of the medical
definition pre-empted the popular, vague definition of common non-conforming
behaviors in children as deviant. Conrad suggests that, in (another) sense, medical
designations serve to validate commonsense definitions of deviance54 However, this
34


perception can only be held by those who ascribe to the conviction that behaviors are
biologically motivated.
2) Prospecting: Medical Discovery
The scientific discovery of a medical conception of deviant behavior is first
announced in a professional medical journal in one of three ways: as a new diagnosis,
through the proposal of a medical etiology for such behaviors, or the report of a new
medical treatment. At this point, the new knowledge is situated as what Conrad calls
an academic challenge.55 The term prospecting refers to the academic response,
as different viewpoints are forwarded and integrated into the knowledge pool. The
notion that ADHD is the product of prospecting becomes plausible by reviewing the
chronology of key clinical research that was being published within the professional
journals as pharmacologists began to experiment with drugs for behavioral effects.
The beginnings of medication therapy for behaviorally-disordered children, as
well as the origins of the field of child psychopharmacology, were marked by a
significant series of papers that appeared in 1937-1941.56 In 1937, Charles Bradley
reported that an amphetamine drug (Benzedrine) had a spectacular effect in altering
the behavior of (institutionalized) school children who exhibited behavior disorders or
learning disabilities. He termed this effect as paradoxical, since the expectation was
that amphetamines would stimulate the children as they stimulated adults.57 Bradleys
35


work marked the first reports of a new medical treatment for problem behaviors.
However, as Schrag and Divoky point out,
For more than a decade, Bradleys work was almost
forgotten...the most promising psychoactive drugs seemed to
be tranquilizers...In 1963, however, a group of researchers at
the Johns Hopkins University (including the aforementioned
Conners and Eisenberg), ...turned to the stimulants and began
to report what they regarded as positive results.58
As stated above, it was not until 1957 that a specific diagnostic category for childhood
behavior disorders was introduced by Laufer, et al. as the hyperkinetic impulse
disorder. Finding that the salient characteristics of the behavior pattem...are
strikingly similar to those with clear-cut organic causation they went on to describe a
disorder with no clear cut history or evidence for organicity, although also
presenting a case for the possible organicity of the disorder.59 Laufers work was
pivotal to the future development of ADHD and the ensuing controversy. He provided
the first formal description of a new diagnosis, thereby establishing the foundation for
the diagnostic labeling of childhood behaviors, as well as proposing the ambiguity of
medical etiology that continues today: childhood behaviors may or may not be
organically rooted. In an academic and scientific sense, the challenge was on.
Writing in 1976, Conrad observed, There has been a virtual flood of papers and
research published since the early sixties...By far the largest number of these
publications has been concerned with drug treatment of the disorder.60 Schrag and
Divoky concurred, stating that,
36


Most of the research dealing with behavior problem children
has been drug research experiments designed primarily to find
out more about the effects of the drugs and not about the
institutionalized children who became the subjects of the
experiments. The leap that created hyperkinetic impulse
disorder was drug related, a test to determine whether the
medication that helped control erratic behavior in organically
brain-damaged adults would produce similar effects on pediatric
patients, many of whom had no history of organic illness.61
Under the auspices of authoritative research, prospecting for a medical
explanation for ADHD continues today. The most active area is still drug centered as
neurologists are focused on the brain-chemical imbalance theory, although
geneticists are gaining popularity (and funding) as they search for the genetic markers
for ADHD.62
Obviously, academic publication and discourse alone do not assure the
recognition or acceptance of a new deviance designation. It needs champions or, in
Beckers term, moral entrepreneurs, to bring the problem and its new definition to
public attention. However, in the case of ADHD, it was not moral, but industrial
entrepreneurs who initially championed the recognition and acceptance of attentional
disorders as being at a level of deviance belonging to the medical/pharmaceutical
domain. As stated above, once armed with FDA approval for the use of Ritalin with
children, Ciba began its promotional campaign of Ritalin for use with children who
exhibited functional behavior problems, a category so vague that most children could
be considered eligible.63 The company employed aggressive tactics, including
presentations to PTA meetings and other parent groups by teams made up of a
37


physician and a Ciba salesperson.64 In 1972, however, federal regulations were put
in place that prohibited drug companies from promoting products like Ritalin directly
among parents and teachers. (This was perhaps in response to the U.S. Drug
Enforcement Administration (DEA) classifying methylphenidate (Ritalin) as a
Schedule II controlled substance in 1971, equating it with addictive street drugs
such as methamphetamine and cocaine.) The new marketing regulations, however, did
not prevent the firms from promoting the ailment or from defining it in the broadest
possible terms, a process that is reinforced by the extensive set of relationships
between the drug companies, certain doctors and research teams and the lay
movement.65 Under the new constraints, Ciba began to promote the diagnosis of
minimal brain dysfunction (MBD) by publishing fliers, such as The MBD Child: A
Guide for Parents and a ninety-six page Physicians Handbook: Screening for
MBD.66 Researchers such as Conners and Eisenberg began to be recognized as
authorities, and the mass media increased its publicity from one article each in 1968
and 1969, to forty between 1970 and 1974.67 The public relations strategy of the
medical champions was beginning to take hold. By 1975, an estimated 150,000
/*j
American children were taking Ritalin.
3) Claims-making: Medical and Non-medical Interests.. .the key stage.
Up to this point, the focus has been on activities within the scientific-research
and pharmaceutical communities, primarily because, until the marketing of
38


medications began in the sixties, there was no public awareness or participation in
claims-making for the reframing of childhood behaviors as deviance requiring
medical intervention. However, that is not to say that public champions did not exist.
The institutions of government and education were at the ready to organize and
support the biomedical construct of deviant behaviors. For example, with support from
a division of the Public Health Service and the Easter Seal Research Foundation, a
team of national academic authorities published a monograph in 1966 which was to
become a key document establishing the concept of minimal brain dysfunction (MBD)
as a commonplace disease and converting unacceptable behavior into a medical
ailment.69 Samuel Clements, the head of this government sponsored research team,
stated,
We cannot afford the luxury of waiting until causes can be
unquestionably established by techniques yet to be developed.
We cannot postpone managing as effectively and honestly as
possible the large number of children who present chronic
differences we feel are more related to organicity variables than
others.70
According to Schrag and Divoky, this document not only became a staple in
educational theory, it legitimized the diagnosis of MBD and seemed to give teachers
and physicians scientific authority to stigmatize any difficult or disruptive child with a
new ailment [and] to prescribe drugs.71 Clements went on to create the
aforementioned Physician's Handbook on MBD for Ciba-Geigy Pharmaceuticals in
1973.72
39


Concurrently, the founding in 1964 of the Association for Children with
Learning Disabilities marked the emergence of a major interest group within
education. In time, learning disabilities (LD) became associated with or
synonymous with MBD, hyperkinesis, impulse disorder, etc. According to Schrag and
Divoky, Before 1965 almost no one had heard of it (LD), but by the beginning of the
seventies it was commanding the attention of an armada of pediatricians, neurologists
and educational psychologists.73 Each of these groups has developed into a major
champion of the contemporary ADHD movement.
Perhaps most significantly, the momentum behind the focus on and reframing of
childhood behaviors was reinforced by the attitude in the federal government. In the
wake of the social unrest of the sixties, the Viet Nam War, and the breakdown of
Lyndon Johnsons Great Society agenda, proposals were being set forth to initiate
sweeping social/behavioral controls. The infamous Hutschnecker Memo, (dated
12/30/69), was given to President Nixon by his personal psychiatrist proposing that
the government should have mass testing done on all 6-8 year old children...to detect
those who have violent or homicidal tendencies...and that children identified as
showing delinquent tendencies be subject to corrective treatment.74 Four months
later, James Allen, the Assistant Secretary for Education and U.S. Commissioner of
Education, proposed to the National School Boards Association that every child be
evaluated at age 2 lA for an educational and medical diagnosis. As noted by Schrag
and Divoky, the two proposals,
40


...indicated a profound change in ideology and practice. By
1974, the spirit and often the substance, of the Hutschnecker
and Allen proposals would be institutionalized in research
programs, teacher training courses, experiments in behavior
modification, conferences on delinquency and learning
disabilities, and in thousands of programs involving millions of
children.75
Claims-making for a deviance designation by medical champions is usually
carried out under the auspices of professional conferences. The degree to which this
practice had occurred regarding ADHD is indicated by the NIH/NIMH sponsorship of
a Consensus Development Conference held in 1998. No fewer than 70 specially-
selected participant-panelists were called in from academia and government agencies
to deliberate the issues of ADHD. The fundamental theme of the conference was
established by the introductory remarks of C. Keith Conners, who emphasized a
biological basis and endorsed a medication protocol for the treatment of ADHD.
According to Peter Breggin, MD, the only known critic of ADHD invited to the
conference, the outcome desired by the NIH was the resolution of all scientific
controversies surrounding the diagnosis and treatment of ADHD, to once and for all
76
validate it as a legitimate, biological disease, and pursue pharmaceutical treatments.
(In Talking Back to Ritalin, Breggin details the politics of the conference and the
distortion in public reports of its actual outcome, which was, in fact, no consensus for
a biological basis for ADHD).
One year later, the CDC held the Public Health Issues in the Treatment of
ADHD Conference, which was co-sponsored by the Department of Education. The
41


stated agenda of this confemce was to further define and develop a public health
research agenda for ADHD.77 The speakers included many of the advocates who
participated in the NIH Consensus Conference. (Non-advocates were not invited) In
spite of the failure of the NIH to achieve a scientific consensus for the diagnosis and
treatment of ADHD, this forum proceeded is if the NIH had succeeded in legitimizing
a biological basis and pharmacological treatment protocol. At the CDC, the medical
claims-makers concluded that ADHD is a chronic condition of high prevalence that
requires long term intervention and that the impact of this disorder...needs
considerable research effort.78 The conclusions of the CDC seem to justify Ruth
Hubbards comment that Science is made, by and large, by a self perpetuating
group.79 By holding to the definition of ADHD as a biomedical condition of high
prevalance, the CDC is justifying its interest in the ADHD project and staking its
claim to funding for considerable research.
While these professional events usually take place without the awareness of the
general public, their agendas and contents are followed and translated for public
consumption by the non-medical claims-makers. These advocates play an overtly
important role in the promotion of a medical designation for deviant behavior. The
ADHD advocacy group, CHADD, exemplifies such claims-makers. However, while
presenting itself primarily as an information-support resource for parents of children
diagnosed with ADHD, CHADDs activities also cloud the distinction between efforts
to educate the public and marketing. (It has now been widely reported that the
42


pharmaceutical industry is the major financial supporter of CHADD).80 For example,
while it proudly adheres to the medical model and grounds its educational materials in
the "evidence-based science of diagnosis and treatment of ADHD,81 CHADD has
also sponsored an annual conference since 1988. Solicitation for conference
attendance reads:
This is a perfect opportunity for medical suppliers and
practitioners, publishers, educational institutions, technology
companies, care givers, allied nonprofit organizations and
others who provide services to the ADHD community to reach
important and interested target audiences.82
With 35,000 members, the CHADD conference provides an uncommon opportunity
for medical and non-medical claims-makers to promote their joint advocacy for
ADHD. Prominent medical supporters, such as the Director of NIMH, have delivered
keynote speeches at this venue.83
CHADD is not the only group that carries significant influence in the promotion
of ADHD. The National Alliance for the Mentally 111 (NAMI) is also gaining
recognition for its support of the ADHD movement, focusing their efforts on an anti-
stigma campaign and greater federal funding for research. NAMI stresses its position
that ADHD is not caused by dysfunctional parenting, but is a biologically-based
disorder that needs to be treated with medication.84 It has been reported that NAMI
received upwards of $11 million dollars from the pharmaceutical industry between
1996 and 1999.85
Though Conrad contends that the popular media can play a role in disseminating
43


information or creating public pressure in favor of a new deviance designation and/or
creating a demand for medical treatment, he does not see it as central to the political
struggle.86 While this may have seemed plausible in 1980, modem technology,
particularly the Internet, has placed media and the dissemination of information at the
center of the struggle today. It is now common practice for the public to search the
internet for more information. I have found the great majority of ADHD-related
websites not only endorse the medical model and pharmacological treatment, but
market them along with a plethora of ADHD merchandise, from video tapes and
books to do-it-yourself assessment tools and T-shirts.87 Novartis (formerly Ciba-
Geigy) and other industry leaders consistently submit press releases to the general
media that reinforce the diagnosis of ADHD and its treatment with medication, while
newspaper, periodical, and television advertising promoting ADHD is on the rise.
Scores of books have been published to explain ADHD to the lay public with hardly a
few challenging the official medical line.88 Attempts at critical analysis have been
pursued by PBS with broadcasts such as, ADD: A Dubious Diagnosis in 1995, and
Medicating Kids in 2001, programs intended to trigger debate and public dialogue.
Prior to the broadcast of A Dubious Diagnosis, Ciba assumed a pre-emptive,
defensive posture by issuing a press release stating that,
the program will misrepresent some of the facts about
ADHD, our product, Ritalin, and Ciba Pharmaceuticals
role in health education...in particular our support for
patient support groups, such a Children and Adults with
44


Attention Deficit Disorder (CHADD).89
Such publicity is indicative of corporate determination to shape public thinking
while protecting their market. Contrary to Conrads observation, it seems the
media today is central to the political struggle. As the President of CHADD stated
at the 1999 ADHD Conference, Despite all we know, the media persists in
elevating controversy surrounding the disorder to a level that calls into question
both its legitimacy and its treatment.90 It seems that CHADD and Ciba find
public dialogue and debate to be obstructive and threatening to their focus and
mission to establish psycho-pharmacology as a normal part of childhood.
4) Legitimacy: Securing medical turf
The legitimacy of a deviance designation and its medical categorization is
conferred by the state and signifies the official recognition of one viewpoint over
another. Perhaps this milestone was technically marked for ADHD when it was
formally included as a disability under the IDEA 97 Act, which took effect in 1999.
However, the government has conferred legitimacy in spirit for many years. In fact,
the original label of minimum brain dysfunction was the product of the
aforementioned US Public Health Service study in 1966. The legitimacy of a
diagnostic label for behavioral issues had been, and still is, taken for granted. The
federal government views ADHD through the scientific lens of biomedicine and
science. As such, most of its discourse is centered, not on the legitimacy of the
45


diagnosis, but on the statistical evidence of drag use, prescriptive and otherwise.
Quantitative studies in this area have guided much government policy since the 1971
HEW report on stimulant drag use in the school age population. As recently as May
2000, a congressional hearing convened to address Ritalin use, particularly in regard
to its increasing use among 2-4 year olds. In the opening statement by the chairman,
the validity of an ADHD diagnosis was never questioned, though acknowledgement
was given that an accurate one is difficult to make.91 The central issue was the
degree of drag use, not whether psychotropic drags were even an appropriate option
for young children. That issue seems to be consistently overlooked. To date, I have not
encountered any legislative documents that question the legitimacy of the formulation
of the ADHD diagnosis or the propriety of medicating children to manipulate their
behavior. It seems to be assumed that ADHD is a real medical problem, even
though the governments own medical-scientific research branch, the NIH, has failed
to achieve a consensus that ADHD is a legitimate biological condition.
The official federal position on ADHD was reinforced through the judicial
branch when a class action suit brought against Novartis, the APA, and CHADD was
struck down in 2001. In brief, the lawsuit charged that these three entities conspired
and colluded to create, develop and promote the diagnosis ADHD in a highly
successful effort to increase the market for Ritalin.92 The case was heard in only two
of five states in which it was filed. In California, a US District Judge dismissed the
case under that states anti-SLAPP statute on the grounds that the plaintiffs attacked
46


the defendants for their speech about an issue of public interest and ruled that the
plaintiffs pay legal fees for all defendants. One month later, a US District Court in
Texas dismissed the case on the grounds that the allegations had no merit.93 These
court rulings sent a clear message of vindication for the pro-ADHD movement and its
protection under federal law.
5) Instititionalization
The official recognition of ADHD by the federal government affirms and
legitimates the medical viewpoint to the general public. As such, it satisfies the basis
for one type of institutionalization that Conrad calls codification.94 That is, it has
become accepted as part of the official medical and/or legal classification system
which provides both a symbolic and instrumental acceptance of a deviance designation
as a medical category. At this stage, a deviance designation reaches a state of fixity
and semi-permanence. Conrad refers to a second type of institutionalization as
bureaucratization, the creation of large scale agencies that in effect, provide
institutionalized support for medicalization. Although Conrad seems to suggest that
such bureaucracies are created in response to the successful establishment of a new
deviance designation, ADHD has effectively been adopted by existing organizations.
Agencies such as NIH and the CDC have become the vested interests that Conrad
describes as bureaucratic industries with large budgets and many employees that
depend for their existence on the acceptance of a particular deviance designation.95
47


As a part of NIH, the NIMH alone had a budget of $1.107 billion dollars for
FY2001.96 In 2000, $5 million was allocated for research into ADHD and the use of
methylphenidate in preschool children.97 In 1998, over 500,000 prescriptions were
written for pre-schoolers,98 in spite of the fact that methylphenidate is not approved or
recommended for use with children under the age of six. The commitment of
government research into the efficacy of medicating pre-schoolers is indicative of its
alliance and support of the medical-pharmaceutical enterprise, as the cost burden for
such research is shifted from industry balance sheets to taxpayer expense.
According to the Inductive Theory of the Medicalization of Deviance,
childhood behaviors of inattention, hyperactivity, and impulsivity have been officially
recognized as deviant and institutionalized as a public, medical issue. These behaviors
have been reified as ADHD, an allegedly inherent, disabling biomedical condition that
calls for psycho-pharmacological treatment.
Through the politicking and media power of social institutions, industries and
moral entrepreneurs, ADHD is being packaged and sold to the American populace.
The campaign to persuade parents that their childrens deviant behavior is a fixed,
biological action (rather than a reaction), encourages the dismissal of personally-
controllable factors, such as lifestyle, diet, environment, etc., that may elicit such
behavior. It appears that the biomedical argument for the fixity of ADHD as
chronically chemical or genetic is central to the perpetuation of pharmaceutical
interventions. This scientific viewpoint denies the fluidity of physiology and its
48


adaptations to environmental conditions. ADHD may, in fact, have a biological aspect
in the sense of manifesting neuro-chemical reactions to dietary or environmental
pollutants; but, these are transitory and may be alleviated by removal of the irritant.
This scientific viewpoint, however, disavows pharmacological treatment, and so is
antithetical to the enterprise.
Through the Inductive Theory of the Medicalization of Deviance, the socio-
political dynamics involved in medicalizing behavior can be seen as self-serving
machinations to bolster the power elite. In the meantime, children are being
chemically manipulated to conform to illusive cultural ideals.
49


CHAPTER 3
THE WORKING OF ADHD
In this chapter, my focus changes from the overt social and scientific production
of ADHD to the ideology and directives of national leadership that support the success
of the ADHD movement in the United States. The following analyses of the political
rhetoric, economic drivers, and social implications of ADHD reveal the adherence to
certain Enlightenment doctrines that American institutional government continues to
endorse: 1) that science and technology are the engines of progress, and 2) that
markets and property are the dominant public concern in a commercial society.1
However, Enlightenment liberalism also intended to set the individual free
politically, intellectually and economically.2 In the words of Isaac Kramnick, the
Enlightenment sought to free the individual from all varieties of external corporate or
communal constraints.3 The institutionalization of ADHD may be seen as a betrayal
of this primal element of the Enlightenment legacy, as federal authorities seem to be
shaping a social system that mandates popular subjugation to biomedical dogma and
practices. It may be said that the institutional working of ADHD indicates that the
sanctity of individualism is being eroded; and that through the power of science,
technology and commerce, the forces of government and industry are beginning to
rival those of the aristocracy the designers of the Enlightenment sought to destroy.
50


Political Rhetoric
The ultimate institutionalization of ADHD under the jurisdiction of scientific
medicine is contingent upon a receptive climate at the highest level of the state. My
research shows that the philosophical stance of the federal government is not only
conducive to the promulgation of a concept such as ADHD, but would, as such,
embrace it in the Enlightenment spirit of scientific progress. One of the most distinct
revelations contained in federal publications is the unwavering contention of the
government that the scientific enterprise is a value-free, socially-neutral undertaking.
In spite of compelling evidence and arguments to the contrary, (particularly by
feminists and environmentalists), the conservative, patriarchal leadership of the
American political system continues to be guided by an unbridled commitment ito the
scientific enterprise. On the basis of this commitment, federal policies have effectively
supported the institutionalization of ADHD. A brief content analysis of documents
from the National Science Board and the National Institute of Mental Health supports
this assertion.
Since its creation in 1950 (in the wake of WWII), the National Science
Foundation (NSF) has been mandated to promote the progress of science. Its
responsibility is to gather, analyze, and disseminate quantitative, statistical information
regarding the condition of the scientific enterprise for the express purpose of guiding
public (Executive/Legislative) and private (corporate) policymaking.4 As such, it
51


wields tremendous power and influence, not only in national policymaking, but in
research funding allocations and curriculum development at all levels of education,
from elementary to post-graduate. By law, the National Science Board (NSB), the
policymaking body of the NSF, must produce a biennial report on indicators of the state
of science and engineering in the U.S. The following discussion is based on the most
recent edition, The Indicators 2000, a special report marking the 50th anniversary of the
Foundation.
In recognition of the anniversary, Indicators 2000 includes an historical review
of the Foundation, and so an insight into its world-view and influence. This document
provides an opportunity to appreciate the ideology that is entrenched in the inner
sanctums of American government. The most dominant tenet is that of a value-free
science. During the conception of the NSF in 1948, President Truman urged that to
the greatest extent possible, the pursuit of research should be insulated from day to day
political concerns.5 This primary directive endorsed the ideological denial of social
and political realities that, in fact, guide scientific inquiry and theory. In 1999, the social
detextualization of the scientific enterprise was reiterated by the NSF, when it stated
its position that It is no longer acceptable for race, ethnicity, gender, language or
economic disadvantage to be used as excuses for the poor academic achievement of
particular groups of children.6 While denying fundamental aspects of social context,
the agenda put forth by the NSB reflects a firm commitment to objective materialism;
science and technology are seen primarily as the key to economic growth,
52


competitiveness, and jobs, while generally maintaining an emphasis on issues of war
and national defense.7
A significant part of the NSF mission is to rationalize the American public by
promoting the acceptance of scientific thinking (and knowledge) as the basis for
formulating beliefs and decision-making. Having come to the conclusion that
pseudoscientific beliefs can have a detrimental effect of the well-being of society, the
foundation is supportive of efforts to disavow, discredit, and eliminate such irrational
beliefs from public consideration, particularly those related to health and healing
o
practices alternative to biomedicine, such as homeopathy and therapeutic touch.
Although certain alternative modalities appear to be gaining acceptance within the
institutional health care system, their recognition may be attributable to public
sentiments and economics, rather than ideological acknowledgement or agreement.
For nearly fifty years, federal interest and involvement in education has been
steadily increasing. The initial involvement of the NSB in framing a national system of
education and curriculum development occurred in 1958 with the Russian launch of
Sputnik. Perceived as a threat to American Cold War leadership and dominance in
science and technology, Sputnik turned federal attention to education and reforms that
would establish science and math studies as top educational priorities. With the Apollo
moon landing in 1969, pressure for educational reforms waned. However, in 1983, the
National Commission on Excellence in Education issued a report entitled A Nation at
Risk declaring that others are matching and surpassing our educational attainments.9
53


The Commissions recommendations included developing and implementing rigorous
and measurable standards as well as initiatives that focused on empowerment strategies
for teachers.10 By 1990, the legislature demanded higher, quantitative achievement
from schools by passing the Goals 2000: Educate America Act, an edict proclaiming
(among other things) that U.S. students will be first in the world in mathematics and
science achievement.11 When results from the Third International Mathematics and
Science Study in 1995 indicated that international students generally outperformed their
American counterparts, reform strategies recommenced.12 Classroom instruction time
became an area of analysis where it was determined that discipline problems
considerably reduce the amount of allocated instruction time compared to other
nations.13 With this finding, behavior issues became a factor in national strategies for
education reform. Based on extensive quantitative analysis, the NSB has since
concluded that although students are performing at higher levels than their counterparts
in the 1970s, they are below expectations based on new educational standards.14
However arbitrary that conclusion (or the standards) may be, it empowers (and
excuses) the federal government to continue to exert pressure on educational
institutions to provide statistical evidence of improved achievement. This directive
demands not only intensive testing and assessments, but, in turn, exerts excessive
performance pressures on teachers and students alike. The promise of Ritalin to reduce
disruptions to allotted classroom time, as well as its claim to improve academic
performance, fit well into the progressive, competitive ideology of national leadership.
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While the functions and actions of the NSF are not particularly well publicized,
those of the NIH & NIMH are more visible to the general public. Spawned from the
same political seeds that gave rise to the NSF, the National Institute of Mental Health
was established in 1949 as one of the first four NIH institutes. Committed to the
scientific enterprise, the NIMH states that its mission is To understand mind, brain,
and behavior, and thereby to reduce the burden of mental illness through research.15
In the reductionist spirit of science, the mission statement declares A thrust of this
research will be to eliminate the effects of disparities that impinge on the mental
health status of all Americans, including women, children, elderly people, and
ethnic/cultural minority groups.16 This statement is especially revealing in two ways:
first, it implies first Americans to be white males, while women, children, etc. are
specially categorized; and second, that the proclaimed role of NIMH is to eliminate
the effects of disparities, implying that the disparities themselves are expected to
remain in force.
From this establishment standpoint, the literature from NIMH on ADHD can
be appreciated as part of the concerted effort of the federal government to advance the
rationalization of Americans, its science based agenda, and so, the biomedical
enterprise. The following discussion is based on Attention Deficit Hyperactivity
Disorder: Decade of the Brain}1 a publication of the NIMH. Although this document
alleges a basis in scientific authority, its clear intention is to point parents in the
55


rational direction of biomedical intervention and pharmaceutical control of their
childrens behavior.
According to the NIMH, ADHD affects 3-5% of all children, 2-3 times more
boys than girls, at least one child in every American classroom, and often causes a
lifetime of frustrated dreams and emotional pain....but, there is help, since
research on ADHD has become a national priority.(p. 1) Since the President and
Congress declared the 1990s as the Decade of the Brain, it is possible that scientists
will pinpoint the biological basis of ADHD. (p. 1) Playing on the^scientific ^
assumption that behaviors symptomatic of ADHD are biologically based, this
publication persists in coercing the reader into believing that ADHD is a medical truth
by describing fragmentary research, from PET scans to pursuits in genetics. Beyond
reviewing such scientific proof of ADHD, educational issues and options (such as
seeking benefits through the Individuals with Disabilities Act) are elaborated upon.
While dietary or allergy treatments are deemed controversial and unscientific,
(p.21) pharmaceutical medication is exhorted as the treatment of choice. As a
national, authoritative voice, the NIMH soundly endorses the use of stimulant drugs,
as well as anti-depressants and other medications. Among its recommendations is
contacting CHADD for suggestions on how to help children view medication in a
positive way. (p. 18) As the following statement demonstrates, the NIMH is not
simply disseminating medical information; it is guiding thinking and selling ADHD
and pharmaceutical treatment:
56


Health professionals stress that since no one knows what causes
ADHD, it doesnt help to look backward to search for possible
reasons. There are too many possibilities to pin down the cause
with certainty...When you think about it, theres no clear
relationship between home life and ADHD.(p. 6)
On the whole, this document exemplifies intentional political propaganda that serves
the govemment/biomedical/pharmaceutical complex and its cooperative effort to
advance not only the scientific, biomedical enterprise in general, but the agenda for
normalizing the practice of medicating children for behavioral control.
Economic Drivers
ADHD is a clear marker not only for the modem ideological shift of deviant
childhood behaviors from the domain of morality to medical science, but from
morality to market, as well. The Enlightenment era economist, Adam Smith,
distinguished moral value from market value by identifying the market as the
place where values are expressed.18 Therefore, value is perceived in terms of the
market. In the language of economics, the determination of value is based on costs
and benefits relative to lost or gained production. Within this framework, ADHD has
great value to the federal government and the pharmaceutical industry. With respect to
the quantifiable education reforms instigated by A Nation at Risk (ANAR), a
diagnosis of ADHD and treatment through medication can be viewed to have a
positive impact on academic measurement and statistics. (It is also interesting to note
that in ANAR, students are referred to as human capital).19 The concept of ADHD
57


promotes conformity and compliance in children. Extensive use of the diagnosis and
medication suggests to the government that it can expect not only a reduction in
school drop out and juvenile deliquency rates, but an increase in future
employability, as well. As proclaimed by the NSF, There is no greater challenge
than renewal of a skilled workforce.20 In addition, engineering a conforming,
compliant population would theoretically free up monies consumed by social welfare
programs and the judicial/penal system. From the perspective of the power elite, the
controlled investment costs of research and the promotion of ADHD and drugs may
seem to be an efficient, prudent alternative to compromising their status by addressing
and endorsing the correction of social, economic, and environmental inequities that
challenge individuals in their daily lives. As revealed by the NIMH, the objective is to
alleviate the effects of the disparities, not the disparities themselves.
To the pharmaceutical industry, ADHD is a crucial marketing device. Without
ADHD, there is no way to frame a purpose or target a mass market for its otherwise
illicit product, Ritalin. With ADHD, federal laws prohibiting the direct marketing of
Schedule II drugs are rendered meaningless. Ironically, being free to promote ADHD
under the guise of public education and biomedical sanction, the pharmaceuticals
actually gain marketing opportunities through venues that would be otherwise
impractical. For example, hundreds of Internet sites exist to explain ADHD, while
promoting pharmaceutical interventions.
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In her seminal book, If Women Counted, Marilyn Waring explains the workings
of the National System of Accounts (NSA), the global accounting system mandated
for use by all members of the United Nations. As an extension of the Enlightenment
philosophy of economics as put forth by Adam Smith, the NSA adheres to the notion
that the market determines value, which is in turn measured by the ability to generate
cash. The NSA itself was formulated to provide economic justification for war.21
To illustrate how value works according to this system, Waring provides the
following scenario. You see a mountain; if minerals were found there, the mountain
would still be worthless until a mining operation commenced. As the mountain was
decimated to get to the minerals, it would be of value its value would be the price the
minerals get on the market. However, no price would be put on the violation of the
mountain and its beauty or the depletion of mineral resources. Warings example
provides an interesting template for presenting the economic viability of ADHD in
terms of national accounting practices. In economic terms, young children are not
productive in the workforce; they do not generate cash; therefore, they have no value.
They are the mountain. They are diagnosed with ADHD (minerals), but they are still
of no value until the commencement of drug therapy (the mining operation). While
they are taking the drugs, they have value their value would be the price ADHD gets
on the market. As of2001, the US market for ADHD therapies has been estimated at
one billion dollars.23
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While the above may be argued as rational in the economic scheme of the NSA,
it denies the fact that psycho-stimulant medications have been contra-indicated for use
by children. Peter Breggin argues that drug-induced docile behavior is caused by
chemically blunting or subduing the childs higher brain function.24 Psycho-
stimulants suppress not only spontaneous behavior, but emotional expression as well,
virtually numbing a childs capacity to express and respond to her/his conditions and
feelings.25 As with the mountain, no price is put on the violation of the children. As
Waring points out, the system cannot respond to values it refuses to recognize.
Though ADHD and Ritalin were gaining an economic foothold by the 1980s, an
explosion of diagnoses and prescriptions occurred in the 1990s. This was due in part
to a policy shift initiated by the Clinton/Gore administration. According to the NSBs
Indicators 2000 report, Clinton was the first president to establish institutional links
between science and technology policy and economic policy, emphasizing the need
for strengthened partnerships between science and other national sectors. A 1994
report by Clinton/Gore entitled Science in the National Interest included the goal to
stimulate partnerships that promote investments in fundamental science and
engineering and effective use of physical, human and financial resources.
Subsequently, the House Science Committee was commissioned to outline a
framework for an updated national science policy that can serve as a policy guide to
the Committee, Congress, and the Nation.30 Their report, Unlocking Our Future,
noted that three basic components of the scientific enterprise needed to be
60


strengthened. First, ensure that the well of scientific discovery does not run dry, by
facilitating and encouraging advances in fundamental research; second, assure that
discoveries from this well must be drawn continually and applied to the development
of new products or processes, to solutions for societal challenges; and third,
strengthen the lines of communication between scientists and engineers and the
American people.31 In relation to ADHD, the federal commitment to this refined
scientific/economic policy is evidenced by the FDA approval of no less than three new
methylphenidate products, including a generic Ritalin, within the first six months of
2001 alone; and, the granting of a patent to Noven/Novartis for a transdermal delivery
system of methylphenidate for treatment of ADHD. The initial market for the generic
version of Ritalin alone is estimated at $185 million, surpassing the $147 million of
patented Ritalin sales in 2000.32 Meanwhile, pharmaceutical giants, such as Eli Lilly,
Glaxo Wellcome and Abbott Laboratories are developing and conducting trials on new
treatments for ADHD.33
While federal and medical authorities declare that ADHD effects at least 3-5% of
school children, pharmaceuticals are enticed to exploit this market. When the US
Surgeon General declares that fewer children are being treated for ADHD than suffer
from it,34 when the American Medical Association (AMA) reports that more cases
of ADHD are being recognized and treated, and the duration of treatment is
increasing,35 and, when nationally recognized ADHD authority Russell Barkley
asserts that the behavior patterns that typify ADHD usually arise between the ages of
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36
3 and 5, the pharmaceutical industry is assured not only that the existing ADHD
market is huge, but that the potential for expansion and growth is strong and promising
as well.
Social Implications
The critical feminist contention that science is not a value-free enterprise, but that
it is a cultural product is verified by the institutionalization of ADHD. In the service of
political and economic powers, medical science has chosen to direct its research
toward discovering a biological basis for ADHD and promulgating pharmaceutical
interventions. This choice reflects the dominant masculine, enlightenment view that
science and technology are the sole arbiters and measures (the engines) of progress, in
both social and economic terms. The value of subjectivity and context, however, is
denied by the reductionist tendencies of rational, scientific methodology. In her
collection of essays on the current scientific enterprise, Profitable Promises, Ruth
Hubbard states,
Most of the time, biology cannot be sorted out from social and
economic realities, because they build on each other and
become so intertwined as to be inextricable. When we pretend
that we can examine the biological factors in isolation, we
oversimplify and distort the situation.
Since the modem scientific enterprise is not designed to recognize these inter-
relationships, it is blinded to alternative directions for research. For example, the leap
to genetics and neurochemistiy denies exploring the possibility that a biological basis
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for symptoms of ADHD may be found to be the result of modem medical practice
itself. There seems to be a lack of critical research into the impact of interventionist
birthing and immunization practices on fetal and infant nervous systems. Such
reflection is antithetical to the spirit of scientific progress, as well as the professional
and economic viability of established biomedical norms. The leap to neurobiology and
genetics also directs primary research away from studies in nutrition, environmental
toxins, etc. and their impact on the central nervous system of children. Though reports
of significant studies in these areas can be found in journals such as Alternative
Therapies,38 they are ignored or discredited by institutional science. In short, an
apolitical science would not be couched in labels such as ADHD or unilaterally
committed to promoting a singular mode of treatment. However, the dominant model
for doing science is, in fact, intertwined with political and economic enterprises, and
therefore has a tremendous impact on the structure, operation, and rules of society.
The following will suggest some of the social complexities and problems inspired by
ADHD.
The ramifications of institutionalizing ADHD are beginning to emerge through
legislative and judicial policies and actions. From the outset, the recognition of ADHD
as a disability through the Individuals With Disabilities Education Act 97 (IDEA) has
produced repercussions in education that not only inflate the number of those eligible
for benefits, but dilute the funding pool for those who are disabled in the traditional
sense. This legislation essentially equates an inattentive, hyperactive, impulsive child
63


with one who is blind or crippled, and so, asserts their eligibility for special education
status and the benefits that status implies.
In a sense, IDEA may be interpreted as part of the A Nation At Risk strategy
for empowering teachers. Without parental consent, teachers may initiate an
evaluation to determine the special needs of a disruptive child. The evaluation is
followed by the development of an Individualized Education Program (IEP) which
specifies the services to be provided, as well as a schedule of goals by which the
performance of the child is periodically assessed and re-evaluated. For the child
who is brought into the system with a diagnosis of ADHD, medication is often
included in their IEP. Not only does this procedure extend the reach of pharmaceutical
interventions to children, it establishes a permanent record that they have been
identified as deviant, implying all the predictions of failure and delinquency
associated with untreated ADHD. The effects of this program on the future choices
available to these children are as yet unknown. The length of time they remain under
the dictates of an IEP that includes psycho-stimulant medication will surely be a
factor. However, an indication of possible limitations is evidenced by the fact that the
current policy of the US Department of Defense is to refuse military enlistment to
those diagnosed with ADHD and on medication within two years of their
application.40
The inclusion of ADHD as a disability under IDEA regulation came after the
Drug Enforcement Administration issued a statement in 1995 recommending greater
64



caution and more restrictive use of methylphenidate (MPH). Its warning was based on
findings that MPH is abused by diverse segments of the population, from health care
professionals and children to street addicts.41 This report also stated that a
significant number of children and adolescents are diverting or abusing MPH
medication intended for the treatment of ADHD. In the words of a Ciba spokesman,
The abuse speaks more to societys problems than to the medication,42 a statement
that asserts the authoritative position that science is neutral and operates outside of
social context.
However, in spite of reporting on these problematic social realities, the DEA
increased the production quota of MPH almost 6-fold between 1990 and 1995 43
Anticipating a Ritalin shortage in 1993, Ciba-Geigy issued a public statement that it
was working closely with the DEA to address this problem, and will commence
round-the clock production upon a final decision from the DEA to increase the
allowable quota (of MPH),44 indicating the corporations confidence in its
negotiating position and power.
As a division of the U.S. Department of Justice, the DEA makes public
statements that give the illusion of federal policing and control of methylphenidate
production and distribution. Yet the Food and Drug Administration (FDA) continues
to approve MPH products that will force further increases in methylphenidate
production. As demonstrated by their actions in the nineties, the DEA is vulnerable to
commercial pressures. The Ritalin shortage never materialized.
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In an effort to stop the legalized proliferation of a controlled substance, a class
action suit against Novartis, CHADD, and the APA was filed in 2001. As mentioned
earlier, the case was dismissed in two U.S. District courts, sending a resounding
message that the ADHD movement was clear to move forward unimpeded. While the
plaintiffs case stemmed from claims that their children had been harmed by their use
of Ritalin, their case was deemed to have no merit, and in fact, was interpreted not as a
liability case, but as an issue of free speech. As reported by Novartis, The case was
dismissed under Californias anti-SLAPP statute that provides for dismissal of
lawsuits that attack defendants for their speech about an issue of public interest.45 In
the view of Novartis General Counsel, this lawsuit and others like it are an
unmerited attempt to promote an agenda that flies in the face of scientific and medical
consensus,46 a tenuous opinion clearly supported by the courts. These rulings
effectively halted any imminent legal challenge to the ADHD/medication agenda (that
in fact lacks a scientific and medical consensus) as the plaintiffs dropped their charges
in three pending lawsuits.
In effect, these rulings provided a nod of protection for the medical-
pharmaceutical enterprise. If this case had been allowed to proceed, the possible risks
to the enterprise would have been profound. The APA would have had to provide
medical and scientific data that prove ADHD is biologically real. If they failed,
Novartis could have been forced to return millions, perhaps billions of dollars to
consumers. Such a legal outcome would put an end to diagnosing ADHD and
66


prescribing drugs.47 However, the concept of ADHD has become virtually
indispensable to powerful institutional and economic sectors, and so will not be
dispelled through judicial means. The courts decisions have made that clear.
Meanwhile, following in the spirit of Hutschnecker and Allen, the Centers for
Disease Control has forwarded recommendations for population-based studies of
ADHD interventions, and for the establishment of a mechanism [possibly a registry]
of treated individuals to monitor the health effects and potential benefits of long term
treatment for ADHD, particularly among pre-school age children. In essence, the
CDC is calling for the lifetime, institutional monitoring of individuals: the
mechanism would be a repository of personal outcomes, such as school
attainment, interface with the judicial system, work performance, and other pertinent
variables.48 Under the guise of scientific research, children so registered would
spend most of their lives medicated and monitored.
The above examples are merely a sampling of the myriad of social implications
that can be ascribed to ADHD. However, it is clear that in cultural terms ADHD is not
a passing fad. It is embedded in institutional agendas and is poised to influence the
functioning (and control) of society far into the future.
67


CHAPTER 4
CONCLUSION
Through the lenses of deviance designation and medicalization, the diagnosis
and pharmacological treatment of ADHD can be seen as a construct of the medical-
pharmaceutical enterprise. Its public inculcation as a medical issue obscures the fact
that dominant socio-political forces, in the form of government and industry, have
enlisted biomedicine to extend the reach of institutional social control and economic
viability. Under the guise of ADHD, a constellation of childhood behaviors has been
deemed deviant, and so qualifies for institutional interventions. Through the process
of medicalization, inattentive, impulsive, and/or hyperactive behaviors have been re-
framed from being responses to environmental conditions to being markers of
inherent, biological disorder. In this alternative context, behavior is no longer a
socio-political issue, but an enterprise of science.
In the tradition of the Enlightenment, American patriarchal leadership is guided
by a rational commitment to the concept of science as a value-free enterprise. As
such, science has been publicly ordained as the ultimate source of authoritative
knowledge. In this light, ADHD and its pharmacological treatment have been
packaged by the establishment for popular consumption. However, feminist
scientists and theorists posit that science is not a value-free enterprise, but a cultural
product. This argument is substantiated by the case of ADHD. Given the cultural
68


authority conferred upon scientific medicine, the lack of a known biological basis for
ADHD has not deterred its promulgation as a biomedical issue. In fact, the biological
question itself has given rise to a whole new industry of scientific research, one that
is dedicated to popular, widespread pharmacological control of behavior.
Through its commitment to the medical/pharmaceutical construct of ADHD,
the establishment can be seen to be engineering mass compliance and conformity to
institutional designs. Back in 1975, Schrag and Divoky warned that,
An entire generation is slowly being conditioned to distrust its
own instincts, to regard its deviation from the narrowing
standards of approved norms as sickness and to rely on the
institutions of the state and on technology to define and
engineer its health.1
As of2002, the acceleration of this conditioning is evidenced by the ADHD
epidemic that is fueled by the policies and actions of the federal government. Under
the banner of scientific progress, research is being steered toward justifying the
practice of medicating ever-younger children for behavioral issues.
In Dialectic of Enlightenment, Max Horkheimer and Theodor Adorno state,
What men want to leam from nature is how to use it in order
wholly to dominate it and other men. That is its only aim.
Ruthlessly, in despite of itself, the Enlightenment has
extinguished any trace of its own self consciousness....On the
road to modem science, men renounce any claim to meaning.
They substitute formula for concept, rule and probability for
cause and motive.2
69


By these lights, the objectifying and commodifying of human behavior through
endeavors such as the legitimization of ADHD may be seen as the germinating,
perhaps the unfolding, of the seeds of self destruction that Horkheimer and Adorno
argue are inherent to the formulations of Enlightenment doctrine. The ambition to
know and control nature through science has now forged beyond material, empirical
boundaries and invaded the realm of human consciousness, a move that shifts the
power of individual subjectivity into the control of those external forces that guide
knowledge production and its dissemination. Under these conditions, individuality
has lost the centrality and freedom of expression originally espoused by the
Enlightenment.
Given that government policymaking is grounded in Enlightenment dogma, the
future of American society may be foreshadowed by the insights forwarded by these
critical theorists. The dialectic of the Enlightenment may be seen as coming into
play. By legitimizing the pathology of common childhood behaviors, medicating
developing minds, and deeming them disabled, the human attributes of
consciousness, free will, and individual choice, as well as the cultural grounds of
accountability and responsibility are both challenged and diminished.3
ADHD is a product of science that serves a bilateral political and economic
agenda, both as an arbiter of behavioral and social control and as a commodity rife
with commercial potential and professional opportunity. The epidemic proportions of
70


ADHD diagnoses and psycho-pharmaceutical prescriptions calls for the veil of
neutrality to be lifted from the popular conception of biomedicine and science, or
society will remain vulnerable to the political manipulation and economic
exploitation exercised in its name. As simply stated by Lawrence Diller, the rising
use of [pharmaceutical] stimulants is alarming and signals an urgent need for
American society to reevaluate its priorities.4
71


CHRONOLOGY
1918 Encephalitis Epidemic.
1930s Production of psycho-active drugs begins.
1937 Bradley reports on amphetamines and behavior.
1940s Ciba Pharmaceuticals synthesizes methylphenidate (Ritalin).
1949 National Institute of Mental Health established.
1950 National Science Foundation formed.
1952 First DSM published.
1953 United Nations adopts System of National Accounts.
1955 FDA approves Ritalin for adult use.
1957 Laufer discovers hyperkinetic impulse disorder.
1958 Russian launch of Sputnik.
1961 FDA approves Ritalin for use with children.
Ciba begins direct marketing of Ritalin to doctors & teachers.
1962 Kefauver-Harris Drug Amendment: proof before marketing.
1963 Conners and Eisenberg begin research on Ritalin.
1964 Association for Children with Learning Disabilities founded.
1966 Public Health Service documents minimal brain dysfunction.
Ciba promotes minimal brain dysfunction (MBD).
72


1967 Conners and Eisenberg take research into public schools.
1968 DSMII: Hyperkinetic Reaction of Childhood Disorder.
1968 First publicity for Hyperkinesis and MBD.
1969 Hutschnecker Memo.
Conners develops first parent/teacher rating scales.
Apollo moon landing.
1970 James Allen proposals for education and medical evaluations.
1971 DEA classifies methylphenidate as Schedule II drug.
1972 Prohibition of direct marketing of Ritalin.
1973 Ciba publishes Physician's Handbook on MBD.
1973 Feingolds Food Additive Hypothesis.
1975 150,000 children on Ritalin.
1976 Conrad publishes Identifying the Hyperactive Child.
1980s APA forges alliance with pharmaceutical industry.
1980 DSM III: Attention Deficit Disorder (ADD).
1981 Conners publishes Food Additives and Hyperactive Children.
1983 A Nation at Risk report.
1987 CHADD founded.
DSM III-R: Attention Deficit/Hyperactivity Disorder.
1988 First annual CHADD conference.
73


1988 Estimated 1 million children on Ritalin.
1990 Goals 2000: Educate America Act.
1991 Ritalin Sales at $95.3 million.
1993 Ritalin Shortage.
1994 Clinton/Gore report, Science in the National Interest.
1995 Ritalin Sales at $349.3 million.
6-fold increase in methylphenidate production since 1990.
DEA publicly calls for more restrictive use of methylphenidate.
PBS broadcast, ADD: A Dubious Diagnosis.
Third International Mathematics and Science Study.
Individuals with Disabilities Act formally recognizes ADHD.
1998 NIH Consensus Development Conference on ADHD.
500,000 prescription for pre-schoolers.
1999 CDC Conference, ADHD: A Public Health Perspective.
Multi-Modal Study released by NIMH.
IDEA 97 regulations take effect, ADHD legitimate diagnosis.
2000 NIMH allocates $5 million toward ADHD in pre-schoolers.
Class action lawsuit filed against APA, Novartis and CHADD.
2001 PBS broadcast, Medicating Kids.
Class action lawsuit against APA, etal., struck down.
74


2001 FDA approves generic and transdermal Ritalin.
Market value of ADHD therapies estimated at $1 billion.
NIMH budget of $ 1.107 billion.
75


NOTES
Chapter One: Introduction
1. The estimate of 3 million represents a conservative average. Some estimates
range as high as 6 million or as low as 1.2 million. As noted by Peter Breggin,
While there are no comprehensive statistics concerning the total number of
children taking stimulants, it probably is reaching 4-5 million...some drug
advocates believe that 8 million of Americas children should be taking some kind
of psychiatric medication. Talking Back to Ritalin, 3. (see note 2 below). It was
acknowledged by the CDC that there is disagreement as to prevalence and precise
characteristics of children with the disorder. (see chap. 3 n. 68).
2. Peter Breggin, Talking Back to Ritalin, rev. ed. (Cambridge, Mass: Perseus,
2001), 13.
3. David Nylund, Treating Huckleberry Finn (San Francisco: Jossey-Bass,
2000), 9. In one of the few new books to challenge the construct of ADHD, Nylund
states, There is no scientific basis for the widespread belief that ADHD is
neurological defect. (see note 6 below).
4. Ivan Illich, Limits to Medicine (1976; enlarged edition, London: Marion
Boyars, 1995), 40.
5. Allan V. Horwitz, The Medicalization of Deviance, review of Deviance
and Medicalization: From Badness to Sickness, by Peter Conrad and Joseph W.
Schneider, Contemporary Sociology 10, (November 1981): 750-752.
6. Peter S. Jensen, Epidemiologic Research on ADHD: What We Know and
What We Need to Learn, (abstract of presentation at the Developmental
Disabilities Branch of the Centers for Disease Control Public Health Perspective
Conference on ADHD, Atlanta, Ga., September 23-24, 1999),
(7 March 2001).
Jensen stated, In truth, we know little concerning etiology. At the same
conference, Thomas Achenbach stated, Its precise nature, etiology, prevalence,
developmental course, and appropriate treatment remain subject to debate.
76


7. Peter Schrag and Diane Divoky, The Myth of the Hyperactive Child (New
York: Pantheon, 1975), 57.
8. Peter Breggin, Talking Back, 222.
9. Lawrence Diller, The Run on Ritalin: Attention Deficit Disorder and
Stimulant Treatment in the 1990s, The Hastings Center Report 26 (March-April
1996): 12-19.
(14 March 2001).
10. David M. Rasmussen, ed., The Handbook of Critical Theory (Oxford:
Blackwell, 1996), 13.
11. E. Doyle McCarthy, Engendered Knowledge: Feminism and science, in
Knowledge as Culture (New York: Routledge, 1996). In this chapter, McCarthy
reviews the work of feminist critics, such as Donna Haraway, Ruth Blier, Helen
Longino, et al. Though their theoretical perspectives may vary slightly, they are
similar in their insistence that science be understood and examined as a
thoroughly social and cultural activity. (p. 94).
12. Ruth Hubbard, Profitable Promises (Monroe, Maine: Common Courage
Press, 1995), 149.
13. Ibid., 207
14. Ibid., 187
15. Rasmussen, Critical Theory, 21.
Chapter Two: Social Iatrogenesis
1. Illich, Limits, 3 (see chap. 1, n. 4).
2. Richard DeGrandpre, Ritalin Nation (New York: Norton, 2000), 140.
In the early 80s, the American Psychiatric Association created an economic and
political partnership with drug companies to promote the medical model, psycho-
pharmacology and the authority and influence of psychiatry; it has become a front
for corporate interests, (see Breggin, Talking Back, 217-218. Chap. 1, n. 2).
77


3. Peter Conrad and Joseph W. Schneider, Deviance and Medicalization: From
Badness to Sickness (St. Louis: C. V. Mosby, 1980), 6.
4. Ruth Hubbard, The Politics of Womens Biology (New Brunswick: Rutgers
University Press, 1990), 12.
5. Ibid., 13.
6. Ibid., 12.
7. Joseph R. Gusfield, foreword to Deviance and Medicalization: From
Badness to Sickness, by Peter Conrad and Joseph W. Schneider (St. Louis: C.V.
Mosby, 1980), v.
8. Peter Conrad, Identifying the Hyperactive Child (Lexington, Mass.: D.C.
Heath, 1976).
9. John Locke, Some Thoughts Concerning Education and Jean-Jacques
Rousseau, Children and Civic Education, in The Portable Enlightenment Reader,
Isaac Kramnick, ed. (New York: Penguin, 1995).
10. Gusfield, foreword to Conrad, Deviance, vii.
11. Dennis P. Cantwell, Attention Deficit Disorder: A Review of the Past 10
Years, Journal of the American Academy of Child and Adolescent Psychiatry 35
(August 1996): 978-988.
12. Conrad, Identifying, 51.
13. Ibid., 55.
14. House Subcommittee on Oversight and Investigations, Behavioral Drugs in
Schools: Questions and Concerns, 106th Cong., 1st sess., 29 September 2000.
(4
October 2001).
Testimony of Patti Johnson, Colorado State Board of Education member 2nd
Congressional District.
78


15. Steven R. Pliszka, Attention Deficit Hyperactivity Disorder: A Clinical
Review, American Family P/rysician 43 (April 1991): 1267-1276.
(18 September 2000).
16. Roslyn A. Glow, Cross-Validity and Normative Data on the Conners
Parent and Teacher Rating Scales, in Psychosocial Aspects of Drug Treatment for
Hyperactivity, ed. Kenneth D. Gadow and Jan Loney (Boulder, Colo.: Westview
Press, 1981), 107-150.
17. Ronald Trites, et al., The Conners Teacher Rating Scale: An
Epidemiologic, Inter-rater Reliability and Follow-Up Investigation, in
Psychosocial Aspects ofDrug Treatment for Hyperactivity, ed. Kenneth D. Gadow
and Jan Loney (Boulder, Colo.: Westview Press, 1981), 151-205.
18. Schrag, Myth, 57.
19. Conrad, Deviance, 2.
20. Gusfield, foreword to Conrad, Deviance, vi.
21. The figure of $400 per student was given by Patti Johnson of the Colorado
Board of Education during testimony to the House Subcommittee on Oversight and
Investigations (see note 14 above). The Leave No Child Behind Act, which
became law on January 8,2002, states, The purpose of this title is to assure that all
children...reach at a minimum, proficiency on challenging State academic
achievement standards and state academic assessments, (and)...holding schools,
local educational agencies, and States accountable for improving the academic
achievement of all students. Full text of legislation available online at
(18 January 2002).
22. Conrad, Deviance, 22.
23. Children and Adults with ADHD Homepage. About Chadd,
(22 February 2002).
24. Ibid.
25. Thomas B. Johnson and Andrea Canter, Ritalin on Trial: Class Action
Lawsuit Filed Against Drug Company, Psychiatrists and ChADD, NASP
79


Communique 29, no. 4.
(16 January 2002).
Naspoline is the website for the National Association of School Psychologists.
26. Lawrence Diller, Medicate or Else Schools Pressure Parents to Force
Ritalin Use, Special to MSNBC, (March 4,2001).
(4
October 2001).
27. Conrad, Deviance, 23.
28. Russell A. Barkley, Attention Deficit Hyperactivity Disorder: A Handbook
for Diagnosis and Treatment (New York: Guilford Press, 1990).
29. Harold Alan Pincus, et al., DSM-IV and New Diagnostic Categories:
Holding the Line on Proliferation, American Journal of Psychiatry 149 (January
1992): 112-116.
30. Conrad, Deviance, 23.
31. C. Keith Conners, Overview of Attention Deficit Hyperactivity Disorder,
(paper presented at the NIH Consensus Development Conference on Diagnosis and
Treatment of Attention Deficit Hyperactivity Disorder, Bethesda, Md., November
16-18,1998).
(30 July 2001).
32. Conrad, Deviance, 25.
33. Conrad, Identifying, 44.
34. Ibid., 44-45.
35. Per Sec. 300.505 of the Amendments to IDEA 97, If the parents of a child
with a disability refuse consent for initial evaluation or re-evaluation, the agency
may continue to pursue those evaluations by using the due process procedures or
mediation procedures.
(16 January 2002).
36. Diller, Medicate, (see note 26 above).
80


37. American Academy of Pediatrics, Clinical Practice Guideline: Treatment of
the School-Aged Child With Attention-Deficit/Hyperactivity Disorder, Pediatrics
108 (October 2001): 1033-1044.
38. Feingold Hypothesis-Food Additives Cause Hyperactivity,
(30
July 2001).
39. The MTA findings were cited by Steven E. Hyman, Director of the NIMH,
during his testimony at the House Education and Workforce Hearings, May 16,
2000 (see note 80 below). Hymans testimony can be found at
. The findings have also been
reported in the Surgeon Generals, Report on Mental Health, (see chap. 4 n 33).
However, under scrutiny, the methodology used in the MTA has been criticized as
highly flawed: There were no placebo controls, no double blind, etc. These issues
are discussed by Peter Breggin in Talking Back to Ritalin, p. 142-148 (see chap. 1 n
2).
40. William Pelham, Jr. and Laurence Greenhill, Public Health Issues in the
Treatment of ADHD Workshop, (abstract from Centers for Disease Control
Workshop on ADHD, Atlanta, Ga., June 15, 1999).
(8 March 2001).
41. From Howard S. Becker, Outsiders; Studies in the Sociology of Deviance,
(New York: The Free Press of Glencoe, 1963) in Conrad, Deviance, 22.
42. Hubbard, Politics, 24-25.
43. Conrad, Deviance, 266.
44. Ibid.
45. Ibid., 267.
46. Barkley, Handbook, (see note 29).
47. Conrad, Identifying, 13, and Breggin, Talking Back, 227.
81


48. Schrag, Myth, 42.
49. Ibid.
50. Ibid., 57. Ciba promoted Ritalin, as such, until 1970, when federal
regulations were tightened. Subsequent Ciba literature promoted MBD (minimal
brain dysfunction.
51. Conrad, Identifying, 16.
52. Schrag, Myth, 81.
53. Conrad, Identifying, 11.
54. Conrad, Deviance, 267.
55. Ibid.
56. Barkley, Handbook, 8.
57. Conrad identifying, 10.
58. Schrag, Myth, 79.
59. Conrad, Identifying, 11.
60. Ibid.
61. Schrag, Myth, 56.
62. Breggin, Talking Back, Chapter 10, Scientific Evidence for a Biological
Cause of ADHD, details the current state of ADHD research.
63. Schrag, Myth, 57.
64. Breggin, Talking Back, 226.
65. Schrag, Myth, 57.
82


66. Ibid., 58.
67. Conrad, Identifying, 11.
68. Diller, Run, 1 (see chap. 2, n. 2).
69. Schrag, Myth, 43.
70. Sam D. Clements, Task Force I: Minimal Brain Dysfunction in Children:
Terminology and Identification, National Institute of Neurological Diseases and
Blindness, Monograph No. 3, U.S. Department of Health, Education and Welfare,
1966, in Schrag, Myth, 44.
71. Schrag, Myth, 45.
72. Ibid, 58.
73. Ibid., 30.
74. Ibid., 3.
75. Ibid., 7.
76. Breggin, Talking Back, 11-12.
77. Catherine A. Lesesne, et al., Attention deficit/hyperactivity disorder: A
public health research agenda, concluding statement to Developmental Disabilities
Branch of the Centers for Disease Control Public Health Perspective Conference on
ADHD, Atlanta, Ga., September 23-24,1999. (March 15,2000).
(7 March 2001).
78. Ibid.
79. Hubbard, Politics, 24.
80. The financial ties between CHADD and Ciba were first publicly exposed on
the PBS broadcast of ADD: A Dubious Diagnosis, in October, 1995. Since then,
many mainstream periodicals have reiterated the story, particularly in relation to
83


coverage of the class action lawsuit against the American Psychiatric Association,
Novartis, and CHADD.
81. CHADD Homepage (see note 23 above).
82. Ibid., (conference link) (8 January
2002).
83. Steven E. Hyman, director of the NIMH delivered the closing keynote
address at the 12th Annual Conference on ADHD, Nov. 4,2000 in Chicago.
(24 January 2002).
84. National Alliance for the Mentally 111 Homepage.
(19 January 2002).
85. Kelly Patricia OMeara, Writing May Be on Wall for Ritalin, Insight
Magazine, The Washington Times, (Oct. 16,2000).
(13 January 2002).
86. Conrad, Deviance, 269.
87. Major ADHD websites, such as One A.D.D. Place and ADDMed
provide links to scores of other sites via headings such as, books/tapes/products,
valuable resources, professional services, etc.
88. Mary Eberstadt, Why Ritalin Rules, Policy Review (April-May 1999):
NA. (14 March 2001).
Noting the publishing boom dedicated to ADHD/Ritalin, Eberstadt suggests that
noteworthy dissent didnt appear until 1995 with Thomas Armstrongs, The Myth
of the ADD Child (Dutton, 1995) marking a 20 year lapse of notable opposition
since the publication of Shrag & Divokys, Myth of the Hyperactive Child
(Pantheon, 1975/. She notes but two subsequent, dissenting publications,
Lawrence Dillers, Running on Ritalin (Bantam Books, 1998) and Richard
DeGrandpres, Ritalin Nation (Simon and Schuster, 1999). A third, Peter
Breggins, Talking Back to Ritalin (Perseus, 2001) originally appeared in 1998,
though the subsequent revised edition received more notice.
89. Todd Forte, Ciba Pharmaceuticals responds to PBS program on Attention
Deficit Disorder, PR Newswire, (October 19,1995).
84


(30 January 2002).
90. Matt Cohen, CHADD President, Plenary Speech (delivered at 12th
Annual Conference for Children and Adults with ADHD, 1999)
(24 January 2002).
91. House Committee on Education and the Workforce, Subcommittee on Early
Childhood, Youth and Families, hearing on Ritalin Use Among Youth: Examining
the Issues and Concerns, 106th Cong. 1st sess., Washington, D.C., May 16,2000.
(18
January 2002).
Chairman Castle reviewed problems associated with Ritalin, such as abuse,
increased use by 2-4 year olds, etc. However, the diagnosis was considered valid.
Castle stated, At the very least, we need to be very cautious in both the
identification of all ADD/ADHD children and their treatment.
92. Johnson, Ritalin on Trial, (see note 25 above).
93. Novartis, Judge Dismisses Class-Action Lawsuit Against Makers of Ritalin
- Texas Federal Judge Rules Plaintiffs Complaint Unclear and Invalid, Press
Release (May 18,2001).
(26 July 2001).
94. Conrad, Deviance, 270.
95. Ibid.
96. National Institute of Mental Health, Fiscal Year 2002 NIMH Budget
Request to Congress, (18
January 2002).
Steven Hyman, Director of the NIMH, requested $1,238,305,000 in 2002, an
increase of $131,576,000 over the budget granted in 2001.
97. Michael McCarthy, USA to Improve Care of Children With ADHD, The
Lancet 355 (April 1,2000): 1161.
98. Laurence L. Greenhill, The Use of Psychoactive Medication in
Preschoolers: Indications, Safety and Efficacy, Canadian Journal of Psychiatry,
43 (1998): 576-581.
85


Chapter Three: The Working of ADHD
1. Isaac Kramnick, ed, introduction to Enlightenment Reader, xii. (See chap. 2,
n. 9).
2. Ibid., xvi.
3. Ibid., xii.
4. National Science Board, introduction to Science and Engineering Indicators
2000, Washington D.C. 2000. (1 March
2001): 1.
5. NSB, Presidential Statements, chap. 1 in SEI2000.
(1 March 2001): 4.
6. NSB, introduction to Elementary and Secondary Education, chap. 8 in SEI
2000. (1 March 2001): 9.
7. NSB, Indicators, 2. (see note 3). Though the NSB publicly disavowed any
direct NSF involvement with defense related research, it was abundantly clear that
both the Congress and the Administration would thenceforth accord a high priority
to defense related research and development. (p. 3) However, considered as a
substantial cutback in 1998, the US Government still devoted 54% of its $74 billion
R&D investment to national defense, (p. 1, chap. 2, International Comparisons of
Government R&D Priorities).
8. NSB, Belief in the Paranormal or Pseudoscience, chap. 8 in SEI 2000.
(1 March 2001).
9. NSB, Indicators, 5 (see note 5).
10. Ibid.
11. Ibid., 8.
86


12. NSB, Student Achievement, chap. 5 in SEI2000.
(1 March 2001).
13. NSB, Curriculum and Instruction, chap. 5 in SEI 2000.
(1 March 2001):1.
14. NSB, Indicators, 2 (see note 11 above).
15. U.S. Department of Health and Human Services, The NIH Almanac-
Organization: National Institute of Mental Health: Mission, (November 11,2001)
(17 December
2001).
16. Ibid.
17. National Institute of Mental Health, Attention Deficit Disorder: Decade of
the Brain, Bethesda, Md. (9 August
2001).
18. Marilyn Waring, If Women Counted: A New Feminist Economics (San
Francisco: Harper, 1988), 22.
19. Susan Ohanian, Goals 2000: Whats in a name?, Phi Delta Kappan, 81
(Jan 2000): 344-355.
cgi-bin/webspirs.cgi?sp.usemumber.p=397884&url=yes> (30 January 2002).
20. NSB, Indicators, 2 (see note 3 above).
21. Waring, Women, 54.
22. Ibid., 25.
23. Business Editors/Medical Writers,Noven Issued U.S. Patent for
Transdermal Methylphenidate; Patent for Once-Daily Methylphenidate Patch for
ADHD Effective Through 2018, Business Wire, (May 23, 2001): 0074.
(30 January 2002).
$1 billion market estimate by Robert C. Strauss, Novens President, CEO and Co-
Chairman.
87


24. Peter Breggin, Upcoming Government Conference on ADHD and
Psychostimulants Asks the Wrong Questions,
(6 February 2002): 1.
25. Ibid.
26. Waring, Women, 4.
27. Eberstadt, Ritalin Rules, (see chap. 3, n. 78). Eberstadts report is an effort
to explain why Ritalin use doubled in the first half of the decade only, production
increased 700 percent since 1990 and that the number of schoolchildren taking the
drug may now, by some estimates, be approaching the 4 million mark. One
conclusion was that, By the end of the 90s, thanks largely to CHADD and its
allies, an ADD/ADHD diagnosis could lead to an impressive array of educational,
financial, and social service benefits.
28. NSB, Indicators, 5 (See note 4 above).
29. NSB, Current Visions/Key Policy Documents, chap. 1 in SEI2000.
(1 March 2001): 2.
30. Ibid., 5.
31. Ibid., 6.
32. Business Editors/Medical Writers, DynaGen Commences Shipment of
Methylphenidate Tablets Following Recent FDA Approval; Generic Version of
Ritalin has Estimated Market of $185 Million, Business Wire, (April 27,2001):
2115 and Ritalin May Have Long-term Effects on Brain, Marketletter, (Nov. 26,
2001): NA. (30 January 2002).
Market analysts responded to this report by stating that it will have little impact on
Novartis performance since the drug is no longer a growth driver for Novartis.
Sales of $147 million in 2000 were expected to decline slightly by 2004. However,
Novartis is partnered with Noven to market the transdermal delivery system, which
is expected to outpace sales of traditional oral modes of delivery.
33. The Royal Society of Chemistry, Biotechnology Newswatch: Promising
compounds may offer treatment choice for fidgety kids, Asia Intelligence Wire,
88


(Nov. 20, 2000).
(30 January 2002).
34. U.S. Department of Health and Human Services, Mental Health: A Report
of the Surgeon General, Rockville, Md., December, 1999.
(18
January 2002).
Although this report was publicly released under the auspices of the Office of the
Surgeon General, it is the product of an invigorating collaboration between two
federal agencies: The Substance Abuse and Mental Health Services Administration
(and) the MH/NEMH.
(18 January
2002)
35. Larry S. Goldman, et al, Diagnosis and Treatment of Attention-
Deficit/Hyperactivity Disorder in Children and Adolescents (American Medical
Association Council on Scientific Affairs Report), JAMA, The Journal of the
American Medical Association 279 (April 8,1998): 1100-1107.
36. Russell A. Barkley, Attention-Deficit Hyperactivity Disorder, Scientific
American, (Sept. 1998).
(3 August 2001): 2.
37. Hubbard, Profitable Promises, 32 (see chap. 1, n. 10).
38. Martha Miller, Diet and Psychological Health, Alternative Therapies, 2
(September 1996): 40-48. Miller states that Although clinical case reports and
promising research findings have been reported, the impact of diet of psychological
health is neither widely accepted nor integrated into mental health treatment
methods. (p. 40).
39. Free Appropriate Public Education (TAPE) Homepage.
(21 January 2002).
Full disclosure of final regulations set forth in the amendments to IDEA 97 are
explained by FAPE at this website.
40. Annette Lansford, ADHD and the Military, Special Education Advocacy
& Consulting Alliance, (February 22,2002):
(26 February 2002).
89


Landsford cites the Department of Defense directive 6130.3 of May 1994, that
states, Current use of medication to improve or maintain academic skills
(example: methylphenidate) is disqualifying. However, in practice, recruiters give
highly variable (and often erroneous) information to potential recruits. Different
branches of the military have different degrees of strictness regarding the
disqualifying policy. The Airforce and Marines use the two year rule, while the
Army and Coast Guard are more lenient. The policy of disqualification applies to
all branches for people on medication at the time of enlistment. Landsford
recommends that those considering military enlistment should plan to discontinue
stimulant medication at least the last year of high school.
41. U. S. Department of Justice, Drug Enforcement Administration,
Methylphenidate, DEA Press Release (October 20,1995)
(6 February 2002).
42. National Drug Strategy Network, DEA Warns of Ritalin Abuse; Drug
Manufacturers Contributions to Advocacy Group Investigated, Newsbrief,
(March 1996). (31 July 2001).
Ciba-Geigy spokesperson, Todd Forte, quoted in a Newsbrief article.
43. DEA, Press Release, (see note 39 above). By 1999, the production quota
increase was at 700 per cent (see note 26 above).
44. Business Editor, Ciba Pharmaceuticals issues statement on Ritalin
shortage, PR Newswire, (Oct. 5,1993):
(30 January 2002).
45. Novartis, Judge Dismisses Class-Action Lawsuit Against Makers of
Ritalin-Califomia Federal Judge Rules Plaintiffs Complaint is Unclear and
Unmerited. Press Release (April 26,2001).
(26 July 2001).
46. Ibid.
47. Johnson, Ritalin on Trial, 4 (see chap. 3 n. 25 above).
48. Lesesne, Public Health, 6 (see chap. 3 n 68 above).
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Chapter Four: Conclusion
1. Schrag, introduction to Myth, xvii (see chap. 1 n. 6).
2. Max Horkheimer and Theodor Adorno, Dialectic of Enlightenment, 2d ed,
trans. John Cumming, (New York: Continuum, 1999), 4-5.
3. Diller, Run, (see chap. 2 n. 2).
4. Ibid.
91


BIBLIOGRAPHY
American Academy of Pediatrics. Clinical Practice Guideline: Treatment of the
School-Aged Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics
108, no. 4 (October 2001): 1033-1044.
Barkley, Russell A. Attention Deficit Hyperactivity Disorder: A Handbook for
Diagnosis and Treatment. New York: Guilford Press, 1990.
Attention-Deficit Hyperactivity Disorder. Scientific American, Sept. 1998.
(3 August 2001).
Breggin, Peter. Talking Back to Ritalin. Rev. ed. Cambridge, MA: Perseus, 2001.
Cantwell, Dennis P. Attention Deficity Disorder: A Review of the Past 10 Years.
Journal of the American Academy of Child and Adolescent Psychiatry 35
(August 1996): 978-988.
Children and Adults with ADHD. Homepage.
(22 February 2002).
Clements, Sam D. Task Force I: Minimal Brain Dysfunction in Children:
Terminology and Identification. National Institute of Neurological Diseases
And Blindness. Monograph No. 3. U.S. Department of Health, Education and
Welfare, 1966. Quoted in Peter Schrag and Diane Divoky, Myth of the
Hyperactive Child (New York: Pantheon, 1975), 44.
Conner, C. Keith. Overview of Attention Deficit Hyperactivity Disorder.
Paper presented at the NIH Consensus Development Conference of Diagnosis
And Treatment of Attention Deficit Disorder. Bethesda, Md., November 1998.
(30 July 2001).
Conrad, Peter. Identifying the Hyperactive Child. Lexington, Mass.: D.C. Heath,
1976.
Conrad, Peter, and Joseph W. Schneider, Deviance and Medicalization: From
Badness to Sickness. St. Louis: C. V. Mosby, 1980.
DeGrandpre, Richard. Ritalin Nation. New York: Norton, 2000.
92


Developmental Disabilities Branch of the Centers for Disease Control. Attend on-
Deficit/Hyperactivity Disorder: A Public Health Perspective Conference.
September 23-24,1999.
(7 March 2001).
Diller, Lawrence, The Run on Ritalin: Attention Deficit Disorder and Stimulant
Treatment in the 1990s. The Hastings Center Report 26 (March-April 1996):
12-19. (14 March 2001).
Medicate or Else Schools Pressure Parents to Force Ritalin Use. Special to
MSNBC. (March 4,2001)

(4 October 2001).
Eberstadt, Mary. Why Ritalin Rules. Policy Review (April-May 1999): NA
(14 March 2001).
Feingold Hypothesis-Food Additives Cause Hyperactivity.

(30 July 2001).
Free Appropriate Public Education. Homepage.
(21 January 2002).
Glow, Roslyn A. Cross-Validity and Normative Data on the Conners Parent and
Teacher Rating Scales. In Psychosocial Aspects ofDrug Treatment for
Hyperactivity, edited by Kenneth D. Gadow and Jan Loney, 107-150. Boulder,
Colo.: Westview Press, 1981.
Goldman, Larry, et al. Diagnosis and Treatment of Attention-
Deficit/Hyperactivity Disorder in Children and Adolescents (American Medical
Association Council on Scientific Affairs Report). JAMA, The Journal of the
American Medical Association 279 (April 8, 1998): 1100-1107.
Greenhill, Laurence, L. The Use of Psychoactive Medication in Preschoolers:
Indications, Safety and Efficacy. Canadian Journal of Psychiatry, no. 43
(1998): 576-581.
Horkheimer, Max and Theodor Adorno. Dialectic of Enlightenment. 2d ed.
Translated by John Cumming. New York: Continuum, 1999.
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Full Text

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SOCIETY AT RISK: A CONCEPTUAL ANALYSIS OF ADHD by Susan Soltysik B.A., University of Northern Colorado, 1973 A thesis submitted to the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Social Science 2002

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This thesis for the Master of Social Science degree by Susan Soltysik has been approved by -1-/ /:J..jo")..; Date

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Soltysik, Susan (M.S.S., Social Science) Society at Risk: A Conceptual Analysis of ADIID Thesis directed by Professor Matjorie Levine-Clark ABSTRACT This thesis is a critical analysis of the biomedical concept of Attention Deficit/Hyperactivity Disorder. ADIID is commonly known as a medical-psychiatric label ascribed to the descriptive behavioral triad of inattention, impulsivity and hyperactivity. Its diagnosis is predicated on these behaviors, particularly by children, being perceived and reported as disruptive or non-conforming in a specific environment, typically at school or at home. As millions of American children are being diagnosed with ADHD, the market for their prescribed use of psycho-stimulant drugs, especially Ritalin, has exploded While the diagnosis and pharmacological treatment of ADHD are highly contentious issues in both the professional and private sectors, their utilization continues to increase unabated. This thesis is an exploration of the phenomenon of ADHD and its ideological and practical implications. Critical medical anthropology calls for the analysis of illness designations and biomedicine from the macro level perspective of social, political, and economic ll1

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dynamics. In that light, I begin by framing ADHD as a designation of social deviance that has been medicalized through socio-political and economic forces I then address how ADHD can be seen to be exploited by government and industry to advance their political and economic agendas. Underlying this analysis is a critique of the traditionally held belief that science, and so biomedicine is an objective, "value-free" enterprise. The promulgation of ADHD clearly supports the opposing feminist argument that the production of scientific/medical knowledge is not necessarily objective or value-free, but is a cultural enterprise. The implications of institutionalizing the biomedical construct of ADHD demand further macro level research from all aspects of social and liberal studies This thesis is an effort to suggest some of these critical research needs. This abstract accurately represents the content of the candidate's thesis. I recommend its publication. iv

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DEDICATION To my friends and family, whose unwavering support and encouragement made the completion of this project possible

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ACKNOWLEDGMENT With deepest gratitude, I especially thank Maljorie Levine-Clark and Paul Ilecki for being my mentors through the development of this thesis and the completion of my graduate program.

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CONTENTS CHAPTER 1 INTRODUCTION ..... ... ..... .... ..... ..... ....... .... ..... ... ...... .. .............. ... 1 The Problem .... .................. . .... .... .... . ............ . . . ... ... ......... 4 Philosophical Perspective . ........... ..... .... . ........ ... . ......... .......... 9 2 SOCIAL lA TROGENESIS ... ...... ................ ......... . ... .. ... . ...... . 13 Framing ADHD as a Deviance Designation .. .. ...... ........ ........ l3 Legitimizing Deviance as a Medical Issue .... ......... . ... ........ 31 3 TIIE "WORKING" OF ADHD ... ....... ............. ..... ........ ......... 50 Political Rhetoric ................... ...... ... .. ...... . ................ . .... .... 51 Economic Drivers ...................................... .... ... ...... ............... 57 Social Implications ............... ................. . ... . . ............. ....... 62 4 CONCLUSION .................... .... .... .... . .......... ........... .............. 68 CIIR.ONOLOGY .................................... ................ .... ..... ... . ...... . 72 NOTES ....... .... ........... ........ .... ....... . .... ...... ..... ............ .... ......... ..... 76 BIBLIOGRAPHY ..... ........ ............ ...... ..... ........ .......... .... . . ..... ..... 92 v

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CHAPTER 1 IN1RODUCTION It has been estimated that within the past twenty-five years, the number of American children taking the psychotropic drug, Ritalin, has surged from 150,000 to 3 million. 1 This proliferation of pharmaceutical consumption is due to the rampant diagnosis of a psychiatric condition labeled Attention Deficit/Hyperactivity Disorder (ADHD), a diagnosis based upon the descriptive behavioral triad of inattention, impulsivity and hyperactivity. According to the National Institutes for Mental Health (NIMH) and Centers for Disease Control (CDC), ADHD is now the most common diagnosis ofbehavioral disorders in children. And, the U.S. Drug Enforcement Administration (DBA) reports that the United States accounts for 90% of the world's consumption of methylphenidate (Ritalin).2 In an effort to understand the growing epidemic of ADHD, I have directed my analysis outside of the predominant discourse that typically positions ADIID as either a nature or nurture issue. Instead, my thesis skews these perspectives by suggesting that the behaviors attributed to ADHD, in order to warrant social and/or medical intervention, must primarily be considered as deviant by institutional social and medical authorities. With the advent of ADHD, typical childhood behaviors such as inattention, impulsivity, and hyperactivity are framed as moral flaws and/or disease markers that must be rectified or, at least, medically controlled. The

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inference, therefore, is that socially or politically "desired" behavior is biologically "normal," and those who have difficulty conforming to institutional demands, particularly in school settings, must be considered as somehow physiologically brain impaired. The contemporary turn to medicating massive numbers of children for behavioral issues marks an extension of pharmacological intervention and conditioning into young lives that is both psychologically and physiologically risky, as well as socially degrading. To date, a biological basis for the symptoms of ADHD has not been established, yet ADHD has been declared a biomedical condition that warrants pharmaceutical intervention. 3 Though scientific theories of a biological etiology for ADHD abound, my concern is with the dearth of social-political analyses significance of medicalizing common childhood behaviors My project, therefore, has been to explore ADHD from the broad perspective of social "iatrogenesis," a concept of human causation forwarded by Ivan Illich in his classic critique, Limits to Medicine. Though Illich applied this term to socio-political transformations within medicine and the health care system, and their impact on individuals,4 I have expanded his frame of reference to include general political and economic activities, such as legislative actions and mass marketing strategies, and their impact on society at large. From this perspective, I mean to suggest that the medical concept of ADHD is a product, not only of scientific, but political-economic ideologies and actions, as well. One outcome of pursuing this perspective is that the contemporary emergence 2

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of ADHD may be seen as evidence of an escalating trend to construct and enforce a "deviance designation" around childhood behaviors that may be interpreted as "non conforming." I develop this perspective through an integrative, historical review and analysis of political, social, and economic activities and events that converge( d) to support the establishment of ADHD as a widespread, disabling medical condition. This presentation is intended to raise awareness of the political and cultural significance of ADHD and the enduring ramifications of"normalizing" the practice of drugging children into the American way of life. I begin this thesis with an exploration of ADHD through the conceptual lenses of the social designation of deviance and the medicalization of behavior. Together, these processes are at the heart of the creation of ADHD. I am using lllych's term "social iatrogenesis" to reference the processes whereby socio-political pressures are exerted to categorically reframe certain social behaviors as illness symptoms. The social perception of deviance as illness is constructed through the process of medicalization, whereby a non-medical problem becomes redefined as an illness, and therefore, a medical disorder. As shown by Peter Comad and Joseph Schneider in Deviance and Medicalization: From Badness to Sickness, this process does not unfold in the isolation of scientific research, but flourishes under certain social, political, and economic influences and conditions. Upon publication in 1980, Deviance and Medicalization was recognized as an "excellent text" for the study of deviance definitions and "the starting point for the 3

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resolution of such problems as the definition and causes of medicalization and its interrelationship with other trends in social control. "5 As such, the following discussion of AD liD as a deviance designation and its medicalization is structured, informed, and guided by Conrad and Schneider's seminal work in these areas. Their research addresses not only how certain behaviors come to be defined as deviant, but how social institutions forge the paradigm shift that is necessary to reframe behavior as deviant. They also consider the socio-historical processes that support the medicalization of such behaviors. Throughout their work, Conrad and Schneider hold the perspective of labeling-interactionist theory, that deviance is a social construction. In tum, I frame AD liD as a deviance designation that has been shaped by politically and economically motivated forces. Within the framework of deviance designation and the dynamics of medicalization, issues surrounding AD liD can be appreciated far beyond the popular preoccupation with arguing the pros and cons of medical intervention on a strictly scientific basis. In this way, the concept of"social iatrogenesis" may be better understood. The Problem Every day, the minds and bodies of millions of American children diagnosed with AD liD are altered by psycho-pharmacological interventions. Meanwhile, medical and scientific authorities acknowledge that, after nearly fifty years of extensive research, reliable evidence to support the concept of ADHD as an organic, 4

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biological condition remains not only inconclusive, but non-cohesive. 6 In turn, the efficacy, risks, and long-term effects on children ingesting psychotropic drugs remain effectively untested and unknown. Yet, in spite of this clinical uncertainty, ADIID is represented and promoted as a scientific "reality" in the public mindset and marketplace. The ongoing effort to legitimize a scientific, biological foundation for the psycho-pharmaceutical treatment of ADHD suggests that the driving force behind its presence in American society is situated outside of the biomedical domain itself This assertion is supported by the fact that the pharmaceutical formulation of methylphenidate (Ritalin) preceded the medical diagnostic criteria for ADHD by nearly twenty years. Unlike the traditional sequence of disease presentation leading to medical/scientific response (as witnessed during the concomitant rise of industrialization and infectious diseases in the latter 19th century), ADHD is a condition that reached epidemic proportions after the synthesis of chemical treatment. In essence, the medical diagnosis and pharmaceutical treatment hit the market simultaneously. The diagnosis of "functional behavior problems" in children was initially promoted to physicians and teachers in the 1960s by the Ciba pharmaceutical corporation to develop a market for its product, Ritalin. 7 On the heels of this commercial enterprise, it appears that research foundations and academic institutions are now entrenched in research to justify the widespread use of drugs to control children's behavior, an enterprise that is shown to 5

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be heartily supported and funded by the federal government. It is against this background that numerous theories to explain a clinical etiology for ADHD have emerged from the fields of neurobiology, psycho-pharmacology, and genetics, and millions of (tax) dollars are being expended to support the biomedical contention that children's behavior can be reduced to inherent biological factors. It is this application of traditional scientific reductionism to the complexities of childhood development, both psychologically and physiologically, that raises my concern about the construction of ADHD. The biomedical focus on identifying a fixed neuro chemical or genetic factor denies the integrity of children as sensory beings responding to their conditions or environment. By targeting the children as neurologically defective, attention is deflected away from the myriad of social, environmental factors that may contribute to their behavioral expression of "deviance." While the scientific alliance focuses its research efforts on discovering a biology of ADHD, the pharmaceutical industry continues to gamer impressive profits. Ritalin sales alone were estimated at $349.3 million in 1995, up from $95.3 million in 1991.8 By financially supporting the American Psychiatric Association (AP A), authoritative experts/spokespersons such as C. Keith Conners and Russell Barkley, and citizen lobbying groups such as CHADD (Children and Adults with ADHD), Novartis (formerly Ciba-Geigy) has effectively established ADHD as an industry that now involves and has an impact not only on the functional practices of 6

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medicine, but the conduct of society at large. With the endorsement and support of the federal government and the public education system, the diagnosis of ADHD and its pharmaceutical treatment are directly promoted and marketed to the American public. Under guidance and pressure from these institutional authorities, the personal lives and practical parenting decisions of American families are being challenged, as parents are coerced to buy into the concept of ADHD and a pharmaceutical solution for behavior control. In the chapter entitled, "The 'Working' of ADHD," I bring attention to specific, contemporary political economic and social activities that support the creation of diagnoses and medical treatments for ADHD while disclosing the "deviance designation" attached to it. These discussions serve to illustrate how deeply the ADHD movement has been institutionalized and provide insights into the consequences of its continued expansion. To demonstrate the political scope of ADHD, I present a brief a content analysis of documents from federal institutions such as the National Science Foundation (NSF/NSB), and the National Institutes ofHealth (Nlli/NIMH) The NSB's Science and Engineering Indicators 2000 offers some insights into the philosophical underpinnings of national leadership and the justifications of the power elite to mandate the guidance and control of public education Attention Deficit Hyperactivity Disorder: Decade of the Brain, a product ofthe NIMH, exemplifies 7

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government support for the agenda to medicate children in lieu of investigating non medical factors that influence and elicit the "deviant" behaviors marked by ADHD. I consider the economic aspects of ADHD primarily in terms ofthe System of National Accounts (SNA), an international model of economic measurement explained by Marilyn Waring in her seminal book, If Women Counted. Mandated for use by all members of the United Nations, the SNA records a pattern of economic activity that is composed solely of cash generating activities. The ramifications of this single rule of economic measurement run wide and deep, as the statistics it generates provide the grist for policy-making decisions in both the government and corporate boardrooms. Using the framework provided by Waring, I examine the cash generating capacity (or economic "value") of ADHD in terms of the rationale behind government policies and the marketing practices of the medical/pharmaceutical industry. To gauge the social implications of institutionalizing ADHD, I address recent legislative and judicial actions, as these have the most profound effect on the shaping of societal guidelines. For example, having gained support and recognition through the Rehabilitation Act of 1973 and the Individuals with Disabilities Education Act (IDEA), the diagnosis and approved medical treatment of ADHD is positioned to generate widespread institutional controls over American society. As noted by Lawrence Diller in "The Run on Ritalin," people designated as "disabled" with a diagnosis of ADHD "cannot legally face discrimination and are entitled to the 8

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benefits of special services ... Parents find that the only way to get extra help for their children is to have them labeled with a disorder." 9 As millions of children are being raised under the psychological umbrella of"entitlement," court actions are beginning to change the shape of the educational system, social services, and the workplace. Transcripts from government sponsored conferences, such as the 1998 NIH Consensus Development Conference on ADHD, and, "ADHD: A Public Health Perspective," conducted by the Developmental Disabilities Branch of the CDC in 1999, not only reveal the political and scientific "truths" regarding ADIID, but also provide invaluable insights into the voices that are determining and guiding national adrninistrntive/policy decisions. The scope of the practical conflicts and social controversies attached to ApHD cannot be addressed solely from the perspective of medical science. Therefore, I have taken an interdisciplinary approach to identifying the philosophical framework, historical circumstances, and political-economic factors that have contributed to the emergence of ADHD as a contemporary social phenomenon. Philosophical Perspective A basic premise of critical theory is that it could "unearth the false presumptions that heretofore held humanity in its sway."10 This is a key concept underlying my approach to the issue of ADIID. It seems that much of the public confusion and controversy surrounding ADIID is due to the fact that its discourse is 9

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fragmentary and is conducted from diverse, often contradictory viewpoints. Within the scientific community itself, explanatory models have been developed from evolutionary, genetic, and neurological perspectives, yet none can claim biological certainty. Nonetheless, media reports and public information resources (such as government publications, professional literature and ADHD websites, of which there are now hundreds) are typically grounded in the assumption that ADHD is universally recognized and accepted as a scientifically legitimate, organic disease. On the other hand, ADHD is often medically referred to as a concept that intimates behavioral disorder. These offerings confuse the framework for understanding what the term ADHD actually references: is it physiological or a consequence of lifestyle? Since a biological basis is unknown, our growing social investment is actually in the reification of a set of behaviors called ADHD. a conception that is itself based on highly politicized science. My project is an effort to "unearth the false presumptions" about ADHD by analyzing it from a broad perspective that challenges taking the dominant medical model of ADHD for granted. As the feminist viewpoint is one that challenges the status quo of establishment ideology, it is the cornerstone of my analysis. The biomedical condition of ADHD is arguably a product of our patriarchal, Enlightenment heritage, a tradition that holds the aspiration to dominate and control nature. This mandate is grounded in the belief that the methodology of scientific discovery and knowledge production is an objective, value-free enterprise. Feminist critics, however, adhere to 10

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the alternative view of science as a "cultural institution,"1 1 a perception that is central to my argument for the social iatrogenesis of ADHD. Scientist Ruth Hubbard has pointed out that there is a "pretense of scientific that pervades the male-dominated world of science (and so, medicine). This pretense conceals the fact that scientists set the terms of their research, that they make "choices and those [are] affected by economic constraints, cultural commitments, [their] position and role in the culture, and [their] personal history."12 Feminists, on the other recognize that subjectivity and context are unavoidable factors in scientific research; 13 this is a perspective that deems the ideal of objective, "value-free" science an Enlightenment myth. In the context of my thesis, the popular belief that science is the bulwark of the truth behind medical realities is challenged as human political enterprises are shown to be the designers, creators, and exploiters of these "realities." In short, the circumstances surrounding the reality of ADHD vindicate the feminist view that "science is not an 'objective' rendering of 'facts,' but a social practice, subject to cultural and political norms. "14 It seems to me that popular recognition of the socio political and economic aspects of biomedicine is key to diminishing the mystique and conferred authority of institutional science. With the understanding that biomedicine is not a value-free scientific enterprise, individuals could make more critically-informed and confident decisions regarding medical intervention, particularly when the health and vitality of their children is called into question. II

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In The Handbook of Critical Theory, David Rasmussen points out that critical theory "was to distinguish itself by addressing the political oppression of the day."15 My thesis suggests that the institutional promulgation of ADHD and the concomitant campaign to encourage the psychotropic drugging of children may be considered an insidious form of such oppression. 12

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CHAPTER2 SOCIAL lA TROGENESIS The tenn iatrogenesis is rooted in the Greek iatros meaning "physician," and genesis, meaning "origin."1 Prefacing this tenn with the word social suggests that by framing behaviors as deviant, and in turn, medicalizing them, the "hierarchy" of medicine over an illness origin is trumped by social and political forces that exploit scientific medicine to serve certain non-medical agendas. In Ritalin Nation, Richard DeGrandpre essentially identifies social iatrogenesis when he states, "What this diagnosis [ADHD] by fiat really signifies is that the authority of American psychiatry operates largely as a social and political force, relegating to science only an affinning role. "2 In other words, ADHD is more an institutional construct than a biological one, a concept fonnulated under political circumstances in advance of substantiating scientific evidence. The following discussion of ADHD as a deviance designation and its legitimization as a medical issue illustrates the resilience of science when it is in the service of authoritative social and political powers. Framing ADHD as a Deviance Designation In order to situate ADHD as a deviance designation, it is important that I establish the perspective I am taking on deviance itself I concur with Peter Conrad that deviance is a social construction, an ascribed status, and not the essence of certain 13

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behaviors; it is a quality attributed to behaviors and not the behaviors themselves. 3 This distinction is critical to my discussion Typically, children are labeled as "ADHD" based on their behavior in school as reported by teachers. In everyday life, episodes of inattention, hyperactivity, and impulsivity are not unusual childhood behaviors. However, in a particular context, such as a classroom, where there is an expectation that the child sit still, be quiet, and concentrate, these behaviors are judged to be deviant as they are non-conforming to the rules. In Deviance and Medicalization, Peter Conrad and Joseph Schneider distinguish between the processes of deviance designation and the medicalization of deviant behaviors. In the case of ADHD, however, the two are inextricably tied together: the medical framing, in essence, precedes and so obscures the implication of deviance. This situation creates an inherent conflict in conceptualizing ADHD. Viewed as deviance, ADHD is contextual in that it is related to a particular environment. As illness, it is non-contextual. Biomedicine, being a scientific enterprise, implicitly denies context, as disease forms are considered biological, "material" conditions that are global in the sense that they are either there or not. With ADIID, biomedicine is faced with the philosophical dilemma of arguing a "contextual disease." This dilemma seems to be at the core of the nature vs. nurture arguments. Advocates of ADIID in essence are supporting the notion that the medical construction and deviance are one and the same, that behavior is biologically motivated Detractors, on the other hand, are sensitive to the "dilemma" and recognize that deviance is a social 14

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designation, not a biological one. The process of creating a deviance designation is essentially one of reification, whereby the behaviors or actions of certain persons are transformed into a terminology, a label that signifies some thing. '"' This process of reification is inherent in the medicalization of deviance. Prior to their medicalization, inattention, hyperactivity, and impulsivity were perceived as a child's response to his or her situation or environment. Since being medicalized, these behaviors are perceived as symptomatic of a condition, the "thing" called ADHD. As the scientific enterprise in general strives to establish and maintain a depersonalized, objective authority, so medicine, through its adoption of scientific language and discourse, follows suit. As observed by Ruth Hubbard, "the grammar of depersonalized description tricks us into submission to 'facts of nature' ,''5 while denying or deleting human agency from the scientific formulation. 6 The samples of medical writing on ADHD contained in this section show that not only is the experience of the child dismissed, but the selfhood of the child is effectively deleted from the discourse. Instead, the focus is on the manifestation of ADHD. The behaviors currently associated with ADHD were initially framed as symptoms of illness by the medical scientific community in the early twentieth century. At that time, the perception of illness was particularly associated with children who demonstrated hyperactive behaviors in the aftermath of suffering a central nervous disease, such as encephalitis, or traumatic head injuries. Biomedical 15

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research was focussed on institutionalized children who exhibited extreme, chronic behavioral control problems compared to their pre-illness/trauma deportment. In society at large, unafllicted children who had episodes of hyperactivity, impulsivity, and/or inattention were typically viewed as spirited, misbehaving, or perhaps even mildly deviant. When perceived as annoying or disruptive, such behaviors elicited some disciplinary action. Mostly, the management of children's behavior was an individualized, inter-personal issue negotiated between the child and the authority figure, whether parent or teacher. When medical scientists generalized institutional case findings and declared that such common behaviors were symptomatic of a biological disorder, they not only depersonalized adult/child interactions, but globalized non-conforming behaviors as problematic: they were no longer a personal issue, but a societal one. Under the label of ADHD, inattention, hyperactivity, and impulsivity are transformed from contextually-elicited behaviors to markers of a universal biological disorder that allegedly causes such deviant behaviors In sociological terms, once a label ofdeviance is construed as a public problem, its "status" as a problem must be understood.7 When the trend toward medicating school aged children for behavioral control began to emerge in the late 1960s and early 70s, Conrad conducted a study at the HyperactivityLearning Disabilities Clinic of Northeastern Pediatric Hospital. In 1976, he published IdentifYing Hyperactive Children. 8 According to Conrad's findings, behaviors such as inattention, impulsivity, and hyperactivity in children are considered 16

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problematic either by parents, teachers, or both. When parents become concerned, it is usually in terms of their child's "role performance" when compared to that of his/her peers. In the context of a classroom situation, however, these same behaviors are viewed by teachers as a "management" problem.(p. 34) Though behavioral issues may be first noticed by parents, it is usually through a teacher reporting on school performance that the majority of medical diagnoses are initiated.(p. 36) However, as noted, teacher reports stem from a different frame of reference than that of parents. As such, the deviance issue associated with ADHD may be classified as one of "institutional management." Conrad s findings suggest that school-defined children are more likely to be labeled hyperactive than family-defined children ... [and] that the school is a more powerful definer and has greater influence in achieving a medical label of hyperactivity than does the family."(p 49) The importance of these findings is the intimation that institutional guidelines have been a significant factor in the formulation and application of a medical diagnosis of behavioral disorders in children since the preliminary constructions of ADHD. (It should be noted that at the time of Conrad's work, the diagnostic and treatment focus was on the singular deviant behavior of hyperactivity. Though issues of attention and impulsivity were not yet included in the diagnostic criteria, the contemporary application of an ADHD diagnosis can be deemed to have its roots in the management of hyperactive behavior). As a "behavior management device," a diagnosis of ADHD is based on the 17

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interpretation of behaviors by a particular audience, parents and/or teachers, who have specific performance/management objectives for their children. Conrad noted that when "the deviance becomes a management problem, the family or school turns to the medical sphere for help."(p. 49) At this point, "the child enters the jurisdiction of the medical system, whereby the definition and control of deviant behavior moves from the educational or family system to that ofmedicine."(p. 38) This turn to medicine is motivated by the fact that medicine has constructed a diagnostic framework to accommodate such behavioral issues. It therefore offers an option that was previously unavailable to the general public for dealing with matters of behavior management. From the perspective of deviance designation, ADHD represents a change in how behavior is defined, not a change in behavior as such. More specifically, as stated by Conrad, "it is a change in the significant audience, rather than merely a change in the child's behavior, that leads to a medical definition of deviance."(p. 49) For children, the move from their home environment to a school situation marks a significant change in audience from parents to teachers, as well a change in behavioral expectations and interpretations. There have always been children who are challenged by and, in tum, challenge the structure of institutional settings. Going back to the 17th and 18th centuries, Locke's and Rousseau's writings on education acknowledge and offer guidelines for positively influencing such "spirited" children. 9 However, with the advent of medical diagnoses such as ADHD, we have a shift from the formerly explicit moral judgement 18

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of behavior to the implicit and subtle morality of"sickness." With ADHD, the issue of"non-conforming" behavior becomes focussed on an assumed impairment of the physiology of the child rather than the possible failure of the institutional environment or adult caregivers to meet or accommodate the child's needs. By considering these children as "sick," they are "neither criminal nor morally responsible for their 'disease.' However, as sick people,' they are both obligated and entitled to be helped. "10 With this implicit social understanding in play, the field is thrown open for exploitation by major and powerful institutional forces, such as the health care system, the educational system, and government agencies. By supporting the concept of ADHD, these authorities encourage parents to interpret their children's non conforming behaviors as symptomatic of biological disorder, a connotation that immediately points them toward medical evaluation and intervention The implicit appeal of this scenario is that parents may be relieved of having any perceived responsibility for the deviant behavior of their children. However, for the children inducted into the domain of medicaVpharmaceutical control for behavioral issues, the message is the same: that their behavior is not within the scope of personal responsibility or control, but is triggered by a biological aberration. To be raised with this belief could engender limiting psychological issues as these children reach adulthood Being medically marked as mentally disabled during their developmental years may also invoke limitations to their future choices for careers or lifestyles in 19

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currently unforeseen ways. I address this issue further in the section on the social implications of ADHD. In the Enlightenment tradition, the scientific bent toward positivism and objectification allows for deviance, as exemplified by ADHD, to be considered as "real." It can therefore be conceptualized not only as a form of material reality, but in turn, as a commodity. It is from this perspective that the medical model claims the capacity to identify deviance as organic disease and the pharmaceutical enterprise claims the ability to manipulate it through psychotropic drugs. As an objectified concept, ADHD and its behavioral symptoms have effectively displaced the experience and welfare of the child as the primary clinical concern. This reduction of experience to a biological event is demonstrated by the language of the American Academy of Child and Adolescent Psychiatry in their 1996 review of ADHD: Across children the symptoms may vary in their frequency of occurrence, in their pervasiveness across settings, and in the degree of functional impairment in various areas. Also with the same child some settings may enhance or decrease symptom manifestation. 11 Such statements reveal not c;>nly the "disease-centered" perspective of the medical model, but also the range of ambiguity that surrounds an ADHD diagnosis. The linguistic tum to scientific jargon distorts what is being conveyed: that some childhood behaviors can be considered normal in some situations and deviant in others. It is from environmental circumstances and the degree of symptom manifestation that a physician must, in Comad's terms, "construct a medical 20

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reality."12 He notes that "Of great importance in the evaluation for hyperactivity are behavioral and developmental history reports from the parents, and behavioral and achievement reports from the school. .. the reliability and validity of this 'lay' evidence is of course extremely variable and open to interpretation."13 In the twenty-five years since Conrad's study, no reliable diagnostic method for ADHD has been developed. As stated in 1998 at the Nlli Consensus Conference on ADHD, "We do not have an independent, valid test for ADHD, and there are no data to indicate that ADHD is due to a brain malfunction. Further research to establish the validity of the disorder continues to be a problem."14 Today's doctors are as reliant upon subjective reports and standardized questionaires as those who faced the initial construction of a medical designation for deviant childhood behaviors According to a clinical review in the journal American Family Physician, "behavior rating scales are a mandatory part of the [clinical] assessment...the most useful are the 48 item Conners' Parent Rating Scale and the 28 item Conners' Teacher Rating Scale."15 Although a study of the efficacy and reliability of the Conners' system concluded that "Overall, parent and teacher agreement on ratings of child behavior problems, including hyperactivity, is entirely modest,"16 such scales remain central to achieving an ADHD diagnosis. It is noteworthy that another study found the Conners' Teacher Rating Scale to be "more sensitive to the effects of drug treatment. "17 (Interestingly C. Keith Conners, the author of these scales, conducted his research through funding from Ciba-Geigy. 18 Considered a major authority on ADHD, Conners is a staunch proponent of 21

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psychotropic medication for children). In contrast to the positivist view of medical science that deviant behavior is biologically driven, the sociologicallabeling-interactionist tradition does not regard deviance as an objective condition, but as a social product. Conrad argues that Those who have comparatively more power are typically more able to create and impose their rules and sanctions on the less powerful. In consequence, deviance becomes actions or conditions that are defined as inappropriate to or in violation of certain powerful groups' conventions.19 In essence, definitions of deviance are a political matter Success in achieving such a definition is decided by those who have the power to legitimate it. The public definition of a problem of deviance is '"the outcome and continual object of claims that interested groups put forth."2 From this perspective, ADHD represents a phenomenon that elicits the attention and endorsement of more than a few powerful, interested groups. For example, while corporate/pharmaceutical interests are primarily profit motivated, specialists in psychiatry, pediatrics, and research inflate their professional status by making careers out of their advocacy for ADHD and pharmaceutical treatments. School administrations receive financial aid through federal funding programs by identifying students with ADHD who therefore require special education ($400 per year per child), while teachers get occupational relief from increasing performance-rating pressures. (School funding under the just-passed Leave No Child Behind Act is contingent upon raising student performance as measured by quantitative rating scales).21 Government research institutes, such as the 22

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Nil! and the National Institutes of Mental Health (NIMH) are heavily invested in funding scientific studies of ADHD, along with the Department of Health and Human Services and the Department of Education. In society at large there are also enterprising groups that serve to forward the construction and legitimization of ADHD as a deviance designation. Borrowing from the work of sociologist Howard S. Becker, Comad refers to "moral entrepreneurs," groups that work with or through institutional systems to reinforce such designations and who "crusade for the creation of new rules. "22 Currently, the most dominant and vocal public group promoting the recognition of ADHD is CHADD (Children and Adults with ADHD). Founded in 1987 "in response to the frustration and sense of isolation experienced by parents and their children with ADHD;m CHADD now ranks as a major political lobby "to promote and influence legislative activities at the national, state and local level. "24 Their prominence as public educators and advocates of stimulant medication led to their being named as co-defendents (along with the American Psychiatric Association and Novartis) in a recent class-action suit claiming conspiracy to create a disease (ADIID) and promote drug prescriptions.25 These institutions and "moral entrepreneurs" exert tremendous pressure on American parents to concede that their children's deviant behavior is not a response to their life and/or environmental situations but is symptomatic of"sickness." Under their collective influence, the use of Ritalin alone has increased 700 percent since 1990.26 23

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The connection between socially-defined deviance and medical legitimacy must be intentionally forged. According to Conrad, As in the scope of general politics, the medical decisions to define certain behaviors, activities or conditions as deviant still emerge from a political process that produces and subsequently legitimates the imposition of deviant categories. And most often, the consequences of medical definitions are also political.27 This observation is exemplified by the evolution of the diagnostic criteria that now comprise AD liD. According to the diagnostic history related by Russell Barkley in his handbook for the diagnosis and treatment of ADIID,28 the precursors to contemporary ADIID first appeared in the "bible" of American psychiatry, the Diagnostic and Statistical Manual (DSM) II, in 1968, as the "Hyperkinetic Reaction of Childhood Disorder "(p.l 0) This designation marked the shift in scientific research from focusing on the association between behavior and organic brain damage to that between behavior and brain "mechanisms" (i.e., neuro-chemistry).(p.lO) Barkley, an advocate and public spokesperson for the ADHD/medication movement, states that there developed in the early 1970s "a disenchantment with the exclusive focus on hyperactivity."(p.13) At this time, "the defining features of'HRCD' had been broadened to include impulsivity, short attention span, low frustration tolerance, distractability, and aggressiveness. "(p.l3) Most research at that time was being conducted and/or financed by the pharmaceutical industry. Finding that inattention and impulsivity were most influenced by stimulant medication, these symptoms were moved 24

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to the diagnostic forefront.(p.13) In 1980, the DSM III responded with the label ADD, Attention Deficit Disorder, giving formal recognition to inattention and impulsivity as having greater significance than hyperactivity in diagnosing children as requiring medication.(p.14) A revised DSM III, published in 1987, reintroduced hyperactivity into the diagnostic criteria by creating the current label of ADHD. (p.26) With the latest edition, DSM IV-R. ADHD is now divided into three sub-types inattention, hyperactivity-impulsivity, and combined. The consequences of jockeying the medical categorizing of childhood behaviors has been the ability to enlarge the "umbrella" for inclusion in the diagnosis, to then argue increasing statistical proof of the existence of ADHD, and to sell more drugs. In addition, the medical authority conferred on the DSM and its categorizations of "mental disorders/deviance designations" also serves to legitimate research and determine the allocation of federal and corporate funding. In the words of recent DSM authors, It is often pointed out that DSM-1/ and DSM-III-R have been major facilitators of research efforts in a number of areas that might have remained much more obscure and unresearched .... While the major goal of DSM-IV is clinical, research and education utility, we will be especially cautious about new diagnoses that might be stigmatizing or have an adverse forensic impact. 29 Such statements highlight the pervasive role of politics in the use and production of the DSM, an allegedly scientific, objective tool of psychiatric medicine. The diagnostic evolution of ADHD supports Conrad's observation that "the medical profession takes an active role in influencing deviance definitions and 25

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designations, discovering new illnesses, and intervening with appropriate medical treatment."30 To justify the rapid changes in the fonnal diagnostic criteria for ADHD C. Keith Conners stated at the 1998 NIH Consensus Conference, The fact that the concept of ADIID has evolved with changing evidence should be taken as a strength, not a sign of unreliability or vague conceptualization .. that diagnostic criteria for AD liD ... lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness. 31 Conners' statement is indicative of the objective, biomedical view of ADHD, one that obfuscates the designation of social deviance that is implicit in the diagnostic criteria. In his discussion of the politics of designating deviance, Conrad raises the question of "territory," that is, in whose turf does the deviance lie? His belief is that this "unacknowledged political dimension" of reframing behavior as deviant is the source of controversy and debate that emerges with major pressures to change a social designation. 32 A look at AD liD from the perspective of territory not only corroborates his opinion, but takes it a step further. As previously stated, the process for achieving an ADHD diagnosis may be initiated from within either the family system or the educational system. While they often provide a united front by jointly defining the child's behavior as requiring medical attention, they often do not. If parents disagree with a "school-defined" assessment or "pre-labeled" opinion, there may be a prolonged conflict between the 26

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parents and the schoo1.33 However, Conrad found that "the school has more power to achieve a medical definition of the situation than do parents. "34 Under the recent amendments to the Individuals With Disabilities Education Act (IDEA 97), school initiated evaluations and assessments of students have legal priority over parental objections. 35 ADHD is now recognized as a legitimate diagnosis under this legislation, giving school personnel the power to initiate such evaluations and assessments based on their interactions with students. Social Services has recently entered into the territorial fray. Lawrence Diller, MD., reports that cases are beginning to emerge whereby "parents unwilling to give their kids drugs are being reported by their schools to local offices of Child Protective Services, the implication being that by withholding drugs, the parents are guilty of neglect." 36 These cases presage an unprecedented opportunity for the legal establishment ofbiomedicine as a primary mechanism of state control over personal freedom of choice. The demonstrated willingness of government agencies to jeopardize the integrity of families in favor of the scientific enterprise is ominous at best. As these scenarios demonstrate, the turf battle for ADHD is being waged between parents schools, and government agencies However, on an unspoken level, the conflict is also about whom has the authority to define deviance as ADHD. The here is clearly held by social institutions as they side with the "authoritative knowledge" of science and biomedicine. By fiat, they have the power and authority to 27

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challenge, and/or overrule parental dissent or resistance to an ADHD diagnosis and medicating children with psychotropic drugs. Within the medical community itself, there are issues surrounding who is qualified to make an ADHD diagnosis and on what grounds. Psychiatrists are the primary specialists to claim rights to diagnosis, having created the criteria as forwarded in the DSM However, primary care pediatricians, as the physicians most frequently called upon, have designed their own guidelines that appear to capitalize on the diagnostic and prescriptive power of ADHD In October 2001, the American Academy ofPediatrics (AAP) released their Clinical Practice Guidelines for the Treatment of School-Aged Children with ADHD.31 While the recommendation is that evaluations be based primarily on the "explicit criteria for the diagnosis using the DSM-IV criteria", they also emphasize the "importance of obtaining information about the child's symptoms in more than one setting [especially from schools]."(p. 1033) This policy is not only a concession to the subjectivity of an ADHD diagnosis, but confers inordinate weight (still) on the non-clinical observations of teachers and parents in achieving the diagnosis. As stated earlier, both teachers and parents may have a vested, personal interest in seeking an ADHD diagnosis and pharmacological control of their children. The AAP guidelines call for "ongoing communication with parents, teachers, and other school-based professionals,"(p. 1033) while promoting a treatment program that "recognizes ADHD as a chronic condition,"(p.l033) and 28

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"recommend[ s] stimulant medication. "(p. 1 036) The determination of the AAP to advance the pharmaceutical agenda is evident in their treatment recommendations: At least 80% of children will respond to one of the stimulants ... Children who fail to show positive effects or who experience intolerable side effects on one stimulant medication should be tried on another ... children who fail2 stimulant medications can be tried on a third. (p 1039) The promotion of such experimental prescribing raises questions about the validity of the diagnosis, as well as the possibility that medications themselves are being used as a device to confirm the diagnosis; as soon as one "works," the diagnosis is "valid Turf wars are also being played out in the research community With the sophistication of modern medical technology, neurobiology and genetics are garnering the bulk oftoday's research investment, while inquiries into social/environmental factors, nutrition, allergies, etc are challenged, discounted, and/or abandoned. This practice became apparent in 1973 when Dr. Benjamin Feingold conducted extensive research that scientifically validated the link between food additives and learning and behavior disorders. After he reported his findings to the American Medical Association, Feingold's hypothesis was publicly refuted in 1981 by C. Keith Conners, who published a book, Food Additives and Hyperactive Children, in an effort to quell popular skepticism (of the pharmaceutical solution) that was instigated by an increasing awareness of the Feingold Diet.38 As a whole, government-funded research is dedicated to promoting and achieving a pharmacological solution for behavioral issues. In its largest clinical trial 29

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to date (1999), the NIMH, in collaboration with the Department of Education, conducted a Multi-Modal Treatment Study of Children with ADHD (MT A) and concluded that medication management is more effective than behavioral treatment for ADHD. 39 Career researchers of ADHD, Drs. William Pelham and Laurence Greenhill, jointly stated at a CDC "Workshop on Public Health Issues in the Treatment ADHD" in 1999, "Drug-only treatment, adririnistered by medical doctors, is the most prevalent form of treatment for ADHD. The most prevalent psychosocial treatments have no studies supporting their effectiveness. ,.4o Underlying this statement is the fact that, while studies of psychosocial treatments for ADHD may have positive outcomes, they are not considered "scientifically" valid, and so are discounted in terms of authoritative biomedical and pharmacological researchJ the primary focus of institutional science. It has been suggested by Howard Becker that those who work toward the establishment of a deviance designation may have a hidden agenda "which is of equal or greater import and not immediately obvious. '.41 By these lights, the institutional commitment to and investment in, the scientific-medical model and a pharmacological treatment regarding ADHD is of particular concern. While extolling the merits of scientific advances in medical knowledge, the fact that deviance is an element of the ADHD concept, and that social management is its functional purpose, is obscured. From a socio-political perspective, the powers of social control conferred through the 30

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medical designation of ADHD are enormous. These issues are addressed in Chapter 3, The "Working" of ADHD. Legitimizing Deviance as a Medical Issue In her book, The Politics of Women's Biology, Ruth Hubbard discusses a feminist view on how facts are made in science. There are a number of points she makes that are particularly relevant to the story of ADHD and should be kept in mind throughout the following discussion. They are: 1) that scientific facts are true only to the extent that they can be applied and used, 2) that these facts are related to the ideological and social commitments of the scientists, (3) that to be believed, they must fit the world view of the times, and 4) that public accountability is not built into the system.42 In order to review the clinical history and social dynamics that enforce the concept of ADHD, I present them within the framework of Conrad and Schneider's "Inductive Theory of the Medicalization ofDeviance.'.43 This model proposes a sequence of political stages by which a deviance designation achieves "objectified" status and becomes ensconced in the medical domain. The following discussion is guided by the five key markers in this process that are identified in Conrad and Schneider's theory. These markers are: 1) defining behavior as deviant, 2) prospecting: medical discovery, 3) claims-making: medical and non-medical interests, 4) legitimacy, securing medical turf, and ( 5) institutionalization of a medical deviance 31

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designation.44 The evolution of ADHD demonstrates that this process is not strictly linear as different stages may converge or overlap However, the significance of this model is that it identifies the dynamics involved in successfully transforming the perception of a social behavior into a medical entity. 1) Defining Behavior as Deviant Typically, a behavior or activity is defined as deviant before the emergence of a medical definition. In the case of ADHD, this is not a clear-cut situation. In Conrad's opinion, restless, disruptive, and overactive children were surely considered deviant in most school classrooms, but it was the application of a medical label that gave shape to these vague forms of deviance 45 While the evolution of medical definitions for child behaviors can be traced back to the early 1900s, their application to the general population was not initiated until the late 1960s. According to Barkley s history of ADHD,46 childhood survivors of an encephalitis epidemic in 1918 were "described as being impaired in attention, regulation of activity, and impulse control (the "holy trinity" of ADHD to the present day)."(p. 6) The condition was labeled "postencephalitic behavior disorder," and was clearly the result of central nervous system damage. However, the emergent medical perspective was that behavior patterns were "a reliable indicator of underlying CNS etiology or damage, even where evidence of such was lacking." (p. 7) This perspective evolved into the "concept of 'minimal brain damage' and eventually 'minimal brain dysfunction' (MBD) by the 32

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1950s and 1960s." (p. 7) Meanwhile, the pharmaceutical industry had begun synthesizing and manufacturing psychoactive drugs in the 1930s. By the early forties, researchers were publishing academic papers that "reported on the efficacy of the amphetamines in reducing the disruptive behavior and improving the academic performance of [psychiatrically hospitalized] behaviorally disordered children." (p. 8) In the mid-1940s Ciba Pharmaceuticals had synthesized methylphenidate (Ritalin), an amphetamine-like stimulant that was originally intended for treatment of adult narcolepsy, appetite control, mild depression, and fatigue It was approved by the FDA for adult use in 1955 .47 In 1957 psychiatrist Maurice Laufer announced the discovery of a new syndrome called "hyperkinetic impulse disorder He wrote, ... hyperactivity is the most striking item ... There are also a short attention span and poor powers of concentration, which are particularly noticeable under school conditions ... poor school work is frequently quite prominent. ,,4s In The Myth of the Hyperactive Child, Schrag and Divoky state, Laufer's description of the "hyperkinetic impulse disorder" was the major break between the classic medical description of hyperkinesis (as applied to organically/physically disabled or injured children) and the vague set of ailments now attributed to millions of children ... The sickness, in brief, was the inability to function in school. 49 In 1961, Ciba began an aggressive promotional campaign of Ritalin that targeted medical and educational professionals touting "functional behavior problems in children."50 The company ran ads one to six pages long to educate physicians on the 33

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"hyperkinetic syndrome," supplying diagnostic and treatment information. 5 1 The FDA approved Ritalin for use with children that same year. It was not until1962, however, with the adoption of the Kefauver-Harris Drug Amendment, that, for the first time, pharmaceutical companies were required to prove the effectiveness of their products before they could market them. C. Keith Conners a clinical psychologist, and Leon Eisenberg, a psychiatrist, began research on Ritalin and its use with children in 1963, two full years after Ritalin was being dispensed to children on the basis of Ciba' s advertising. Initially conducting studies on institutionalized children, by 1967 Conners and Eisenberg moved their experiments into public schools. 52 In 1968, "Hyperkinetic Reaction Syndrome" made its first appearance in psychiatry's Diagnostic and Statistical Manual II (DSM II). Also in 1968, the medical framing of deviance implied by certain childhood behaviors received its first publicity in the mass media under the labels of"hyperkinesis" and/or "minimal brain dysfunction" (MBD), the evolutionary foundations for AD liD. 53 Until this time, the general public was unaware of these labels, or of the medicaVpharmaceutical alliance and its investment in transforming the perception of the hyperactive behaviors of their children from a sociaVpsychological or developmental issue to a fixed, chronic, medical condition requiring pharmaceutical intervention. In one sense, the construction of the medical definition pre-empted the popular, vague definition of common non-conforming behaviors in children as deviant. Comad suggests that, in (another) sense, medical designations serve to validate commonsense definitions of deviance. 5 4 However, this 34

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perception can only be held by those who ascribe to the conviction that behaviors are biologically motivated 2) Prospecting : Medical Discovery The scientific discovery of a medical conception of deviant behavior is first announced in a professional medical journal in one of three ways: as a new diagnosis, through the proposal of a medical etiology for such behaviors, or the report of a new medical treatment. At this point, the "new knowledge" is situated as what Conrad calls an "academic challenge." 55 The term "prospecting" refers to the academic response, as different viewpoints are forwarded and integrated into the knowledge pool. The notion that ADHD is the product of prospecting becomes plausible by reviewing the chronology of key clinical research that was being published within the professional journals as pharmacologists began to experiment with drugs for behavioral effects. The beginnings of medication therapy for behaviorally-disordered children, as well as the origins of the field of child psychopharmacology, were marked by a significant series of papers that appeared in 1937-1941.56 In 1937, Charles Bradley reported that an amphetamine drug (Benzedrine) had a spectacular effect in altering the behavior of(institutionalized) school children who exhibited behavior disorders or learning disabilities. He termed this effect as "paradoxical," since the expectation was that amphetamines would stimulate the children as they stimulated adults. 57 Bradley's 35

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work marked the first reports of a new medical treatment for problem behaviors. However, as Schrag and Divoky point out, For more than a decade, Bradley's work was almost forgotten ... the most promising psychoactive drugs seemed to be tranquilizers ... In 1963, however, a group of researchers at the Johns Hopkins University (including the aforementioned Conners and Eisenberg), ... turned to the stimulants and began to report what they regarded as positive results. 58 As stated above, it was not until 1957 that a specific diagnostic category for childhood behavior disorders was introduced by Laufer, et al. as the "hyperkinetic impulse disorder." Finding that" 'the salient characteristics of the behavior pattem ... are strikingly similar to those with clear-cut organic causation' they went on to describe a 'disorder with no clear cut history or evidence for organicity', although also presenting a case for the possible organicity of the disorder. "59 Laufer's work was pivotal to the future development of ADHD and the ensuing controversy. He provided the first formal description of a new diagnosis, thereby establishing the foundation for the diagnostic labeling of childhood behaviors, as well as proposing the ambiguity of medical etiology that continues today: childhood behaviors may or may not be "organically" rooted. In an academic and scientific sense, the "challenge" was on. Writing in 1976, Conrad observed, "There has been a virtual flood of papers and research published since the early sixties ... By far the largest number of these publications has been concerned with drug treatment of the disorder.'.6 Schrag and Divoky concurred, stating that, 36

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Most of the research dealing with "behavior problem" children has been drug research experiments designed primarily to find out more about the effects of the drugs and not about the institutionalized children who became the subjects of the experiments. The leap that created "hyperkinetic impulse disorder" was drug related, a test to determine whether the medication that helped control erratic behavior in organically brain-damaged adults would produce similar effects on pediatric patients, many of whom had no history of organic illness.'.61 Under the auspices of authoritative research, "prospecting" for a medical explanation for ADHD continues today. The most active area is still drug centered as neurologists are focused on the "brain-chemical imbalance" theory, although geneticists are gaining popularity (and funding) as they search for the genetic markers for ADHD.62 Obviously, academic publication and discourse alone do not assure the recognition or acceptance of a new deviance designation. It needs champions or, in Becker's term, "moral entrepreneurs," to bring the problem and its new definition to public attention. However, in the case of ADHD, it was not "moral," but "industrial entrepreneurs" who initially championed the recognition and acceptance of attentional disorders as being at a level of deviance belonging to the medical/pharmaceutical domain. As stated above, once armed with FDA approval for the use of Ritalin with children, Ciba began its promotional campaign of Ritalin for use with children who exhibited 'functional behavior problems,' a category so vague that most children could be considered eligible.63 The company employed aggressive tactics, including presentations to PTA meetings and other parent groups by teams made up of a 37

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physician and a Ciba salesperson. ,,64 In 1972, however, federal regulations were put in place that prohibited drug companies from promoting products like Ritalin directly among parents and teachers. (This was perhaps in response to the U.S. Drug Enforcement Administration (DEA) classifying methylphenidate (Ritalin) as a Schedule IT controlled substance in 1971, equating it with addictive "street" drugs such as methamphetamine and cocaine.) The new marketing regulations, however, did not prevent the firms from promoting the ailment or from defining it in the broadest possible terms, "a process that is reinforced by the extensive set of relationships between the drug companies, certain doctors and research teams and the lay movement. ,,6s Under the new constraints, Ciba began to promote the diagnosis of minimal brain dysfunction (MBD) by publishing fliers, such as "The :MBD Child: A Guide for Parents" and a ninety-six page Physician's Handbook: Screening/or MBD.66 Researchers such as Conners and Eisenberg began to be recognized as authorities, and the mass media increased its publicity from one article each in 1968 and 1969, to forty between 1970 and 1974.67 The public relations strategy of the medical champions was beginning to take hold. By 1975, an estimated 150,000 American children were taking Ritalin.68 3) Claims-making: Medical and Non-medical Interests ... the key stage. Up to this point, the focus has been on activities within the scientific-research and pharmaceutical communities, primarily because, until the marketing of 38

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medications began in the sixties, there was no public awareness or participation in "claims-making" for the reframing of childhood behaviors as deviance requiring medical intervention. However, that is not to say that public champions did not exist. The institutions of government and education were at the ready to organize and support the biomedical construct of deviant behaviors. For example, with support from a division of the Public Health Service and the Easter Seal Research Foundation, a team of national academic authorities published a monograph in 1966 which was to become a key document establishing the concept of minimal brain dysfunction (MBD) as a commonplace disease and converting unacceptable behavior into a medical ailment. 69 Samuel Clements, the head of this government sponsored research team, stated, We cannot afford the luxury of waiting until causes can be unquestionably established by techniques yet to be developed. We cannot postpone managing as effectively and honestly as possible the large number of children who present chronic differences we feel are more related to organicity variables than others.70 According to Schrag and Divoky, this document "not only became a staple in educational theory, it legitimized the diagnosis ofMBD and seemed to give teachers and physicians scientific authority to stigmatize any difficult or disruptive child with a new ailment [and] to prescribe drugs."71 Clements went on to create the aforementioned Physician's Handbook on MBD for Ciba-Geigy Pharmaceuticals in 1973.72 39

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Concurrently, the founding in 1964 of the Association for Children with Learning Disabilities marked the emergence of a major interest group within education. In time, "learning disabilities" (LD) became associated with or synonymous with MBD, hyperkinesis, impulse disorder, etc. According to Schrag and Divoky, "Before 1965 almost no one had heard of it (LD), but by the beginning of the seventies it was commanding the attention of an armada of pediatricians, neurologists and educational psychologists. ,m Each of these groups has developed into a major champion of the contemporary ADHD movement. Perhaps most significantly, the momentum behind the focus on and reframing of childhood behaviors was reinforced by the attitude in the federal government. In the wake of the social unrest of the sixties, the VietNam War, and the breakdown of Lyndon Johnson's "Great Society" agenda, proposals were being set forth to initiate sweeping social/behavioral controls. The infamous "Hutschnecker Memo," (dated 12/30/69), was given to President Nixon by his personal psychiatrist proposing that "the government should have mass testing done on all 6-8 year old children ... to detect those who have violent or homicidal tendencies ... and that children identified as showing 'delinquent tendencies' be subject to 'corrective treatment'. "74 Four months later, James Allen, the Assistant Secretary for Education and U.S. Commissioner of Education, proposed to the National School Boards Association that every child be evaluated at age 2 for an "educational and medical" diagnosis. As noted by Schrag and Divoky, the two proposals, 40

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.. .indicated a profound change in ideology and practice. By 1974, the spirit and often the substance, of the Hutschnecker and Allen proposals would be institutionalized in research programs, teacher training courses, experiments in behavior modification, conferences on delinquency and learning disabilities, and in thousands of programs involving millions of children. 75 Claims-making for a deviance designation by medical champions is usually carried out under the auspices of professional conferences. The degree to which this practice had occurred regarding ADHD is indicated by the NIH/NIMH sponsorship of a Consensus Development Conference held in 1998. No fewer than 70 speciallyselected participant-panelists were called in from academia and government agencies to deliberate the issues of ADHD. The fundamental theme of the conference was established by the introductory remarks of C. Keith Conners, who emphasized a biological basis and endorsed a medication protocol for the treatment of ADHD. According to Peter Breggin, MD, the only known critic of ADHD invited to the conference, the outcome desired by the Nill was the resolution of all scientific controversies surrounding the diagnosis and treatment of ADHD, to once and for all validate it as a legitimate, biological disease, and pursue pharmaceutical treatments. 76 (In Talking Back to Ritalin, Breggin details the politics of the conference and the distortion in public reports of its actual outcome, which was, in fact, no consensus for a biological basis for ADHD). One year later, the CDC held the "Public Health Issues in the Treatment of ADHD Conference", which was co-sponsored by the Department of Education. The 41

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stated agenda of this confemce was to "further define and develop a public health research agenda for ADHD."77 The speakers included many of the advocates who participated in the NIH Consensus Conference. (Non-advocates were not invited) In spite of the failure of the Nlll to achieve a scientific consensus for the diagnosis and treatment of ADHD, this forum proceeded is if the Nlli had succeeded in legitimizing a biological basis and pharmacological treatment protocol. At the CDC, the medical claims-makers concluded that "ADHD is a chronic condition of high prevalence that requires long term intervention" and that "the impact of this disorder ... needs considerable research effort."78 The conclusions of the CDC seem to justifY Ruth Hubbard's comment that "Science is made, by and large, by a self perpetuating group."79 By holding to the definition of ADHD as a biomedical condition of"high prevalance," the CDC is justifYing its interest in the ADHD project and staking its claim to funding for considerable research. While these professional events usuaiiy take place without the awareness of the general public, their agendas and contents are foiiowed and translated for public consumption by the non-medical claims-makers. These advocates play an overtly important role in the promotion of a medical designation for deviant behavior. The ADHD advocacy group, CHADD, exemplifies such claims-makers However, while presenting itself primarily as an information-support resource for parents of children diagnosed with ADHD, CHADD's activities also cloud the distinction between efforts to educate the public and marketing. (It has now been widely reported that the 42

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phannaceutical industry is the major financial supporter of CHADD). 8 For example, while it proudly adheres to the medical model and grounds its educational materials in the "evidence-based science of diagnosis and treatment of ADHD,"81 CHADD has also sponsored an annual conference since 1988 Solicitation for conference attendance reads: This is a perfect opportunity for medical suppliers and practitioners, publishers, educational institutions, technology companies, care givers, allied nonprofit organizations and others who provide services to the ADHD community to reach important and interested target audiences. 82 With 35,000 members the CHADD conference provides an uncommon opportunity for medical and non-medical claims-makers to promote their joint advocacy for ADHD. Prominent medical supporters, such as the Director of NIMH, have delivered keynote speeches at this venue. 83 CHADD is not the only group that carries significant influence in the promotion of ADHD. The National Alliance for the Mentally lll (NAMI) is also gaining recognition for its support of the ADHD movement, focusing their efforts on an "antistigma" campaign and greater federal funding for research. NAMI stresses its position that ADHD is not caused by dysfunctional parenting but is a biologically-based disorder that needs to be treated with medication.84 It has been reported that NAMI received upwards of $11 million dollars from the phannaceutical industry between 1996 and 1999 .85 Though Conrad contends that the popular media can play a role in disseminating 43

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information or creating public pressure in favor of a new deviance designation and/or creating a demand for medical treatment, he does not see it as central to the political struggle 86 While this may have seemed plausible in 1980 modem technology, particularly the Internet, has placed media and the dissemination of information at the center of the struggle today. It is now common practice for the public to search the internet for more information I have found the great majority of ADHD-related websites not only endorse the medical model and pharmacological treatment but market them along with a plethora of ADHD merchandise, from video tapes and books to do-it-yourself assessment tools and T-shirts.87 Novartis (formerly CibaGeigy) and other industry leaders consistently submit press releases to the general media that reinforce the diagnosis of ADHD and its treatment with medication, while newspaper, periodical, and television advertising promoting ADHD is on the rise Scores of books have been published to explain ADHD to the lay public with hardly a few challenging the official medicalline.88 Attempts at critical analysis have been pursued by PBS with broadcasts such as, "ADD: A Dubious Diagnosis" in 1995, and "Medicating Kids" in 2001, programs intended to trigger debate and public dialogue. Prior to the broadcast of"A Dubious Diagnosis," Ciba assumed a pre-emptive, defensive posture by issuing a press release stating that, the program will misrepresent some of the facts about ADHD our product Ritalin, and Ciba Pharmaceuticals' role in health education .. .in particular our support for patient support groups, such a Children and Adults with 44

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Attention Deficit Disorder (CHADD). 89 Such publicity is indicative of corporate determination to shape public thinking while protecting their market. Contrary to Conrad's observation, it seems the media today is central to the political struggle. As the President of CHADD stated at the 1999 ADHD Conference, "Despite all we know, the media persists in elevating controversy surrounding the disorder to a level that calls into question both its legitimacy and its treatment. "90 It seems that CHADD and Ciba find public dialogue and debate to be obstructive and threatening to their focus and mission to establish psycho-pharmacology as a normal part of childhood. 4) Legitimacy: Securing medical turf The legitimacy of a deviance designation and its medical categorization is conferred by the state and signifies the official recognition of one viewpoint over another. Perhaps this milestone was technically marked for ADHD when it was formally included as a disability under the IDEA 97 Act, which took effect in 1999. However, the government has conferred legitimacy in spirit for many years. In fact, the original label of"minimum brain dysfunction" was the product of the aforementioned US Public Health Service study in 1966 The legitimacy of a diagnostic label for behavioral issues had been, and still is, taken for granted. The federal government views ADHD through the scientific lens of biomedicine and science. As most of its discourse is centered, not on the legitimacy of the 45

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diagnosis, but on the statistical evidence of drug use, prescriptive and otherwise. Quantitative studies in this area have guided much government policy since the 1971 HEW report on stimulant drug use in the school age population. As recently as May 2000, a congressional hearing convened to address Ritalin use, particularly in regard to its increasing use among 2-4 year olds. In the opening statement by the chairman, the validity of an ADHD diagnosis was never questioned, though acknowledgement was given that "an accurate one is difficult to make. "91 The central issue was the degree of drug use, not whether psychotropic drugs were even an appropriate option for young children. That issue seems to be consistently-overlooked. To date, I have not encountered any legislative documents that question the legitimacy of the formulation of the ADHD diagnosis or the propriety of medicating children to manipulate their behavior. It seems to be assumed that ADHD is a "real" medical problem, even though the government's own medical-scientific research branch, the Nlli, has failed to achieve a consensus that ADHD is a legitimate biological condition. The official federal position on ADHD was reinforced through the judicial branch when a class action suit brought against Novartis, the AP A, and CHADD was struck down in 2001. In brief, the lawsuit charged that these three entities "conspired and colluded to create, develop and promote the diagnosis ADHD in a highly successful effort to increase the market for Ritalin. "92 The case was heard in only two of five states in which it was filed. In California, a US District Judge dismissed the case under that state's anti-SLAPP statute on the grounds that the plaintiffs attacked 46

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the defendants for their speech about an issue of public interest and ruled that the plaintiffs pay legal fees for all defendants. One month later, a US District Court in Texas dismissed the case on the grounds that the allegations had no merit.93 These court rulings sent a clear message of vindication for the pro-ADHD movement and its protection under federal law. 5) Instititionalization The official recognition of ADHD by the federal government affirms and legitimates the medical viewpoint to the general public. As such, it satisfies the basis for one type of institutionalization that Conrad calls "codification. "94 That is, it has become accepted as part of the official medical and/or legal classification system which provides both a symbolic and instrumental acceptance of a deviance designation as a medical category. At this stage, a deviance designation reaches a state of fixity and semi-permanence. Conrad refers to a second type of institutionalization as the creation of large scale agencies that in effect, provide institutionalized support for medicalization. Although Conrad seems to suggest that such bureaucracies are created in response to the successful establishment of a new deviance designation, ADHD has effectively been adopted by existing organizations. Agencies such as NIH and the CDC have become the "vested interests" that Conrad describes as "bureaucratic industries with large budgets and many employees that depend for their existence on the acceptance of a particular deviance designation. "95 47

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As a part of NIH, the NIMH alone had a budget of $1.107 billion dollars for FY200 1. 96 In 2000, $5 million was allocated for research into ADHD and the use of methylphenidate in preschool children.97 In 1998, over 500,000 prescriptions were written for pre-schoolers,98 in spite of the fact that methylphenidate is not approved or recommended for use with children under the age of six. The commitment of government research into the efficacy of medicating pre-schoolers is indicative of its alliance and support of the medical-pharmaceutical enterprise, as the cost burden for such research is shifted from industry balance sheets to taxpayer expense. According to the "Inductive Theory of the Medicalization of Deviance," childhood behaviors of inattention, hyperactivity, and impulsivity have been officially recognized as deviant and institutionalized as a public, medical issue. These behaviors have been reified as ADHD, an allegedly inherent, disabling biomedical condition that calls for psycho-pharmacological treatment. Through the politicking and media power of social institutions, industries and moral entrepreneurs, ADHD is being packaged and sold to the American populace. The campaign to persuade parents that their children's deviant behavior is a fixed, biological action (rather than a reaction), encourages the dismissal of personally controllable factors, such as lifestyle, diet, environment, etc., that may elicit such behavior. It appears that the biomedical argument for the "fixity" of ADHD as chronically chemical or genetic is central to the perpetuation of pharmaceutical interventions. This scientific viewpoint denies the fluidity of physiology and its 48

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adaptations to environmental conditions. ADHD may, in fact, have a biological aspect in the sense of manifesting neuro-chemical reactions to dietary or environmental pollutants; but, these are transitory and may be alleviated by removal of the irritant. This scientific viewpoint, however, disavows pharmacological treatment, and so is antithetical to the enterprise. Through the "Inductive Theory of the Medicalization of Deviance," the socio political dynamics involved in medicalizing behavior can be seen as self-serving machinations to bolster the power elite. In the meantime, children are being chemically manipulated to conform to illusive cultural ideals. 49

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CHAPTER 3 THE "WORKING" OF ADHD In this chapter, my focus changes from the overt social and scientific production of ADHD to the ideology and directives of national leadership that support the success of the ADIID movement in the United States. The following analyses of the political rhetoric, economic drivers, and social implications of ADHD reveal the adherence to certain Enlightenment doctrines that American institutional government continues to endorse: 1) that science and technology are the engines of progress, and 2) that markets and property are the dominant public concern in a commercial society. 1 However, Enlightenment liberalism also intended to "set the individual free politically, intellectually and economically."2 In the words oflsaac Kramnick, the Enlightenment "sought to free the individual from all varieties of external corporate or communal constraints. The institutionalization of ADHD may be seen as a betrayal of this primal element of the Enlightenment legacy, as federal authorities seem to be shaping a social system that mandates popular subjugation to biomedical dogma and practices. It may be said that the institutional "working" of ADIID indicates that the sanctity of individualism is being eroded; and that through the power of science, technology and commerce, the forces of government and industry are beginning to rival those of the aristocracy the designers of the Enlightenment sought to destroy. 50

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Political Rhetoric The ultimate institutionalization of ADHD under the jurisdiction of scientific medicine is contingent upon a receptive climate at the highest level of the state. My research shows that the philosophical stance of the federal government is not only conducive to the promulgation of a concept such as ADHD, but would, as such, embrace it in the Enlightenment spirit of scientific progress. One of the most distinct revelations contained in federal publications is the unwavering contention of the government that the scientific enterprise is a value-free, socially-neutral undertaking. In spite of compelling evidence and arguments to the contrary, (particularly by feminists and environmentalists), the conservative, patriarchal leadership of the American political system continues to be guided by an unbridled commitment to the scientific enterprise. On the basis of this commitment, federal policies have effectively supported the institutionalization of ADHD. A brief content analysis of documents from the National Science Board and the National Institute of Mental Health supports this assertion. Since its creation in 1950 (in the wake ofWWIT), the National Science Foundation (NSF) has been mandated to "promote the progress of science." Its responsibility is to gather, analyze, and disseminate quantitative, statistical information regarding the condition of the scientific enterprise for the express purpose of guiding public (Executive/Legislative) and private (corporate) policymaking. 4 As such, it 51

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wields tremendous power and influence, not only in national policymaking, but in research funding allocations and curriculum development at all levels of education, from elementary to post-graduate. By law, the National Science Board (NSB) the policymaking body of the NSF, mu,st produce a biennial report on indicators of the state of science and engineering in the U.S The following discussion is based on the most recent edition, The Indicators 2000, a special report marking the 50th anniversary of the Foundation. In recognition of the anniversary, Indicators 2000 includes an historical review of the Foundation, and so an insight into its world-view and influence. This document provides an opportunity to appreciate the ideology that is entrenched in the inner sanctums of American government. The most dominant tenet is that of a value-free science. During the conception of the NSF in 1948, President Truman urged that "to the greatest extent possible, the pursuit of research should be insulated from day to day political concerns "5 This primary directive endorsed the ideological denial of social and political realities that, in fact, guide scientific inquiry and theory. In 1999, the social "detextualization" of the scientific enterprise was reiterated by the NSF, when it stated its position that "It is no longer acceptable for race, ethnicity, gender, language or economic disadvantage to be used as excuses for the poor academic achievement of particular groups of children .6 While denying fundamental aspects of social context, the agenda put forth by the NSB reflects a finn commitment to objective materialism; science and technology are seen primarily as the key to economic growth, 52

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competitiveness, and jobs, while generally maintaining an emphasis on issues of war and national defense. 7 A significant part of the NSF mission is to "rationalize" the American public by promoting the acceptance of scientific thinking (and knowledge) as the basis for formulating beliefs and decision-making. Having come to the conclusion that "pseudoscientific beliefs can have a detrimental effect of the well-being of society," the foundation is supportive of efforts to disavow, discredit, and eliminate such irrational beliefs from public consideration, particularly those related to health and healing practices alternative to biomedicine, such as homeopathy and therapeutic touch 8 Although certain alternative modalities appear to be gaining acceptance within the institutional health care system, their recognition may be attributable to public sentiments and economics, rather than ideological acknowledgement or agreement. For nearly fifty years, federal interest and involvement in education has been steadily increasing. The initial involvement of the NSB in framing a national system of education and curriculum development occurred in 1958 with the Russian launch of Sputnik. Perceived as a threat to American Cold War leadership and dominance in science and technology, Sputnik turned federal attention to education and reforms that would establish science and math studies as top educational priorities. With the Apollo moon landing in 1969, pressure for educational reforms waned However, in 1983, the National Commission on Excellence in Education issued a report entitled "A Nation at Risk" declaring that "others are matching and surpassing our educational attainments. "9 53

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The Commission's recommendations included developing and implementing rigorous and measurable standards as well as initiatives that focused on empowerment strategies for teachers.10 By 1990, the legislature demanded higher, quantitative achievement from schools by passing the "Goals 2000: Educate America Act," an edict proclaiming (among other things) that "U.S. students will be first in the world in mathematics and science achievement. "1 i When results from the Third International Mathematics and Science Study in 1995 indicated that international students generally outperformed their American counterparts, reform strategies recommenced 12 Classroom instruction time became an area of analysis where it was determined that discipline problems considerably reduce the amount of allocated instruction time compared to other nations. 13 With this finding, behavior issues became a factor in national strategies for education reform. Based on extensive quantitative analysis, the NSB has since concluded that although students are performing at higher levels than their counterparts in the 1970s, they are below expectations based on new educational standards.14 However arbitrary that conclusion (or the standards) may be, it empowers (and excuses) the federal government to continue to exert pressure on educational institutions to provide statistical evidence of improved achievement. This directive demands not only intensive testing and assessments, but, in turn, exerts excessive performance pressures on teachers and students alike. The promise of Ritalin to reduce disruptions to allotted classroom time, as well as its claim to improve academic performance, fit well into the progressive, competitive ideology of national leadership. 54

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While the functions and actions of the NSF are not particularly well publicized, those of the NIH & NIMH are more visible to the general public. Spawned from the same political seeds that gave rise to the NSF, the National Institute of Mental Health was established in 1949 as one of the first four NIH institutes. Committed to the scientific enterprise, the NIMH states that its mission is "To understand mind, brain, and behavior, and thereby to reduce the burden of mental illness through research. "15 In the reductionist spirit of science, the mission statement declares "A thrust of this research will be to eliminate the effects of disparities that impinge on the mental health status of all Americans, including women, children, elderly people, and ethnic/cultural minority groups."16 This statement is especially revealing in two ways: first, it implies first Americans to be white males while women children etc. are specially categorized; and second, that the proclaimed role of NIMH is to eliminate the "effects of disparities," implying that the disparities themselves are expected to remain in force. From this establishment standpoint, the literature from NIMH on ADHD can be appreciated as part of the concerted effort of the federal government to advance the rationalization of Americans, its science based agenda, and so, the biomedical enterprise. The following discussion is based on Attention Deficit Hyperactivity Disorder: Decade of the Brain,17 a publication ofthe NIMH. Although this document alleges a basis in scientific authority, its clear intention is to point parents in the 55

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"rational" direction of biomedical intervention and pharmaceutical control of their children's behavior. According to the NIMH, "ADHD affects 3-5% of all children, 2-3 times more boys than girls, at least one child in every American classroom, and often causes a lifetime of 'frustrated dreams and emotional pain' .... but, 'there is help,' since 'research on ADIID has become a national priority'. "(p.l) Since the President and Congress declared the 1990s as the "Decade of the Brain," it is "possible that scientists will pinpoint the biological basis of ADHD." (p.l) Playing on assumption that behaviors symptomatic of ADIID are biologically based, this publication persists in coercing the reader into believing that ADHD is a medical truth by describing fragmentary research, from PET .scans to pursuits in genetics. Beyond reviewing such scientific "proof' of ADIID, educational issues and options (such as seeking benefits through the Individuals with Disabilities Act) are elaborated upon. While dietary or allergy treatments are deemed "controversial" and "unscientific," (p.21) pharmaceutical medication is exhorted as the treatment of choice. As a national, authoritative voice, the NIMH soundly endorses the use of stimulant drugs, as well as anti-depressants and other medications. Among its recommendations is contacting CHADD for suggestions on how to "help children view medication in a positive way." (p. 18) As the following statement demonstrates, the NIMH is not simply disseminating medical information; it is guiding thinking and selling ADHD and pharmaceutical treatment: 56

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Health professionals stress that since no one knows what causes ADHD, it doesn't help to look backward to search for possible reasons. There are too many possibilities to pin down the cause with certainty ... When you think about it, there's no clear relationship between home life and ADHD.(p. 6) On the whole, this document exemplifies intentional political propaganda that serves the government/biomedical/pharmaceutical complex and its cooperative effort to advance not only the scientific, biomedical enterprise in general, but the agenda for normalizing the practice of medicating children for behavioral control. Economic Drivers ADHD is a clear marker not only for the modem ideological shift of deviant childhood behaviors from the domain of morality to medical science, but from morality to market, as well. The Enlightenment era economist, Adam Smith, distinguished "moral value" from "market value" by identifying the market as the place where values are expressed.18 Therefore, value is perceived in terms of the market. In the language of economics, the determination of"value" is based on costs and benefits relative to lost or gained production. Within this framework, ADHD has great value to the federal government and the pharmaceutical industry. With respect to the quantifiable education reforms instigated by "A Nation at Risk" (ANAR), a diagnosis of ADHD and treatment through medication can be viewed to have a positive impact on academic measurement and statistics. (It is also interesting to note that in ANAR, students are referred to as "human capital").19 The concept of ADHD 57

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promotes conformity and compliance in children. Extensive use of the diagnosis and medication suggests to the government that it can expect not only a reduction in school drop out and juvenile deliquency rates, but an increase in future "employability," as well. As proclaimed by the NSF, "There is no greater challenge than renewal of a skilled workforce "20 In addition, engineering a conforming, compliant population would theoretically free up monies consumed by social welfare programs and the judicial/penal system. From the perspective of the power elite, the controlled investment costs of research and the promotion of ADHD and drugs may seem to be an efficient, prudent alternative to compromising their status by addressing and endorsing the correction of social, economic, and environmental inequities that challenge individuals in their daily lives. As revealed by the NIMH, the objective is to alleviate the effects of the disparities, not the disparities themselves. To the pharmaceutical industry, ADHD is a crucial marketing device. Without ADHD, there is no way to frame a purpose or target a mass market for its otherwise illicit product, Ritalin. With ADHD, federal laws prohibiting the direct marketing of Schedule II drugs are rendered meaningless. Ironically, being free to promote ADHD under the guise of public education and biomedical sanction, the pharmaceuticals actually gain marketing opportunities through venues that would be otherwise impractical. For example, hundreds oflntemet sites exist to explain ADHD, while promoting pharmaceutical interventions. 58

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In her seminal book, If Women Counted, Marilyn Waring explains the workings of the National System of Accounts (NSA), the global accounting system mandated for use by all members of the United Nations. As an extension of the Enlightenment philosophy of economics as put forth by Adam Smith, the NSA adheres to the notion that the market determines value, which is in turn measured by the ability to generate cash. The NSA itself was formulated to provide economic justification for war.21 To illustrate how "value" works according to this system, Waring provides the following scenario: You see a mountain; if minerals were found there, the mountain would still be worthless until a mining operation commenced. As the mountain was decimated to get to the minerals, it would be of value-its value would be the price the minerals get on the market. However, no price would be put on the violation of the mountain and its beauty or the depletion of mineral resources.22 Waring's example provides an interesting template for presenting the economic viability of ADHD in terms of national accounting practices. In economic terms, young children are not productive in the workforce; they do not generate cash; therefore, they have no value. They are the mountain. They are diagnosed with ADHD (minerals), but they are still of no value until the commencement of drug therapy (the mining operation). While they are taking the drugs, they have value-their value would be the price ADHD gets on the market. As of2001, the US market for ADHD therapies has been estimated at one billion dollars. 23 59

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While the above may be argued as rational in the economic scheme of the NSA, it denies the fact that psycho-stimulant medications have been contra-indicated for use by children Peter Breggin argues that "drug-induced docile behavior is caused by chemically blunting or subduing the child's higher brain function. "24 Psycho stimulants suppress not only spontaneous behavior, but emotional expression as well, virtually numbing a child's capacity to express and respond to her/his conditions and feelings. 25 As with the mountain, no price is put on the violation of the children. As Waring points out, "the system cannot respond to values it refuses to recognize "26 Though ADHD and Ritalin were gaining an economic foothold by the 1980s, an explosion of diagnoses and prescriptions occurred in the 1990s. 27 This was due in part to a policy shift initiated by the Clinton/Gore administration. According to the NSB 's Indicators 2000 report, Clinton was the first president to establish institutional links between science and technology policy and economic policy, emphasizing the "need for strengthened partnerships between science and other national sectors. "28 A 1994 report by Clinton/Gore entitled Science in the National Interest included the goal to "stimulate partnerships that promote investments in fundamental science and engineering and effective use of physical, human and financial resources. "29 Subsequently, the House Science Committee was commissioned to outline a "framework for an updated national science policy that can serve as a policy guide to the Committee, Congress, and the Nation. "30 Their report, Unlocking Our Future, noted that three basic components of the scientific enterprise needed to be 60

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strengthened. First, "ensure that the well of scientific discovery does not run dry, by facilitating and encouraging advances in fundamental research;" second, assure that "discoveries from this well must be drawn continually and applied to the development of new products or processes, to solutions for societal challenges;" and third, "strengthen the lines of communication between scientists and engineers and the American people. "31 In relation to ADHD, the federal commitment to this refined scientific/economic policy is evidenced by the FDA approval of no less than three new methylphenidate products, including a generic Ritalin, within the first six months of 2001 alone; and, the granting of a patent to Noven/Novartis for a transdermal delivecy system of methylphenidate for treatment of ADHD. The initial market for the generic version of Ritalin alone is estimated at $185 million, surpassing the $14 7 million of patented Ritalin sales in 2000.32 Meanwhile, pharmaceutical giants, such as Eli Lilly, Glaxo Wellcome and Abbott Laboratories are developing and conducting trials on new treatments for ADHD.33 While federal and medical authorities declare that ADHD effects at least 3-5% of school children, pharmaceuticals are enticed to exploit this market. When the US Surgeon General declares that "fewer children are being treated for ADHD than suffer from it,"34 when the American Medical Association (AMA) reports that "more cases of ADHD are being recognized and treated, and the duration of treatment is increasing,"35 and, when nationally recognized ADHD authority Russell Barkley asserts that "the behavior patterns that typify ADHD usually arise between the ages of 61

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3 and 5,36 the pharmaceutical industry is assured not only that the existing ADHD market is huge, but that the potential for expansion and growth is strong and promising as well. Social Implications The critical feminist contention that science is not a value-free enterprise, but that it is a cultural product is verified by the institutionalization of ADHD. In the service of political and economic powers, medical science has chosen to direct its research toward discovering a biological basis for ADHD and promulgating pharmaceutical interventions. This choice reflects the dominant masculine, enlightenment view that science and technology are the sole arbiters and measures (the engines) of progress, in both social and economic terms. The value of subjectivity and context, however, is denied by the reductionist tendencies of rational, scientific methodology. In her collection of essays on the current scientific enterprise, Profitable Promises, Ruth Hubbard states, Most of the time, biology cannot be sorted out from social and economic realities, because they build on each other and become so intertwined as to be inextricable. When we pretend that we can examine the biological factors in isolation, we oversimplify and distort the situation. 37 Since the modem scientific enterprise is not designed to recognize these interrelationships, it is blinded to alternative directions for research. For example, the leap to genetics and neurochemistry denies exploring the possibility that a biological basis 62

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for symptoms of ADHD may be found to be the result of modem medical practice itself There seems to be a lack of critical research into the impact of interventionist birthing and immunization practices on fetal and infant nervous systems. Such reflection is antithetical to the spirit of scientific progress, as well as the professional and economic viability of established biomedical norms The leap to neurobiology and genetics also directs primary research away from studies in nutrition, environmental toxins, etc and their impact on the central nervous system of children. Though reports of significant studies in these areas can be found in journals such as Alternative Therapies, 38 they are ignored or discredited by institutional science. In short, an apolitical science would not be couched in labels such as ADHD or unilaterally committed to promoting a singular mode of treatment. However, the dominant model for doing science is, in fact, intertwined with political and economic enterprises, and therefore has a tremendous impact on the structure, operation, and rules of society. The following will suggest some of the social complexities and problems inspired by ADHD. The ramifications of institutionalizing ADHD are beginning to emerge through legislative and judicial policies and actions. From the outset, the recognition of ADHD as a disability through the Individuals With Disabilities Education Act '97 (IDEA) has produced repercussions in education that not only inflate the number of those eligible for benefits, but dilute the funding pool for those who are disabled in the traditional sense. This legislation essentially equates an inattentive, hyperactive, impulsive child 63

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with one who is blind or crippled, and so, asserts their eligibility for special education status and the benefits that status implies. In a sense, IDEA may be interpreted as part of the "A Nation At Risk" strategy for empowering teachers. Without parental consent, teachers may initiate an evaluation to detennine the special needs of a disruptive child. The evaluation is followed by the development of an Individualized Education Program (IEP) which specifies the services to be provided, as well as a schedule of goals by which the performance of the child is periodically assessed and re-evaluated 39 For the child who is brought into the system with a diagnosis of ADHD, medication is often included in their IEP. Not only does this procedure extend the reach of pharmaceutical interventions to children, it establishes a pennanent record that they have been identified as "deviant," implying all the predictions of failure and delinquency associated with "untreated" ADHD. The effects of this program on the future choices available to these children are as yet unknown. The length of time they remain under the dictates of an IEP that includes psycho-stimulant medication will surely be a factor. However, an indication of possible limitations is evidenced by the fact that the current policy of the US Department of Defense is to refuse military enlistment to those diagnosed with ADHD and on medication within two years of their application. 40 The inclusion of ADHD as a disability under IDEA regulation came after the Drug Enforcement Administration issued a statement in 1995 recommending greater 64

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caution and more restrictive use of methylphenidate (MPH). Its warning was based on findings that MPH is "abused by diverse segments of the population, from health care professionals and children to street addicts. ,,41 This report also stated that "a significant number of children and adolescents are diverting or abusing MPH medication intended for the treatment of ADHD." In the words of a Ciba spokesman, "The abuse speaks more to society's problems than to the medication,',42 a statement that asserts the authoritative position that science is neutral and operates outside of social context. However, in spite of reporting on these problematic social realities, the DEA increased the production quota of MPH almost 6-fold between 1990 and 1995.43 Anticipating a Ritalin shortage in 1993, Ciba-Geigy issued a public statement it was "working closely with the DEA to address this problem, and will commence round-the clock production upon a final decision from the DEA to increase the allowable quota" (of MPH),44 indicating the corporation's confidence in its negotiating position and power. As a division of the U.S. Department of Justice, the DEA makes public statements that give the illusion of federal policing and control of methylphenidate production and distribution. Yet the Food and Drug Administration (FDA) continues to approve MPH products that will force further increases in methylphenidate production. As demonstrated by their actions in the nineties, the DEA is vulnerable to commercial pressures. The Ritalin shortage never materialized. 65

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In an effort to stop the legalized proliferation of a controlled substance, a class action suit against Novartis, CHADD, and the AP A was filed in 2001. As mentioned earlier, the case was dismissed in two U.S. District courts, sending a resounding message that the ADHD movement was clear to move forward unimpeded While the plaintiffs case stemmed from claims that their children had been harmed by their use of Ritalin, their case was deemed to have no merit, and in fact, was interpreted not as a liability case, but as an issue of free speech. As reported by Novartis, "The case was dismissed under California's anti-SLAPP statute that provides for dismissal of lawsuits that attack defendants for their speech about an issue of public interest. ,,4s In the view of Novartis' General Counsel, ''this lawsuit and others like it are an unmerited attempt to promote an agenda that flies in the face of scientific and medical consensus,',.u; a tenuous opinion clearly supported by the courts. These rulings effectively halted any imminent legal challenge to the ADHD/medication agenda (that in fact lacks a scientific and medical consensus) as the plaintiffs dropped their charges in three pending lawsuits. In effect, these rulings provided a nod of protection for the medical phannaceutical enterprise. If this case had been allowed to proceed, the possible risks to the enterprise would have been profound. The AP A would have had to provide medical and scientific data that prove ADHD is biologically "real." If they failed, Novartis could have been forced to return millions, perhaps billions of dollars to consumers. Such a legal outcome would put an end to diagnosing ADIID and 66

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prescribing drugs. 47 However, the concept of ADIID has become virtually indispensable to powerful institutional and economic sectors, and so will not be dispelled through judicial means. The courts' decisions have made that clear. Meanwhile, following in the spirit of Hutschnecker and Allen, the Centers for Disease Control has forwarded recommendations for "population-based" studies of ADHD interventions, and for the establishment of"a mechanism [possibly a registry] of treated individuals to monitor the health effects and potential benefits of long term treatment for ADHD, particularly among pre-school age children In essence, the CDC is calling for the lifetime, institutional monitoring of individuals: the "mechanism" would be a repository of personal "outcomes," such as "school attainment, interface with the judicial system, work performance, and other pertinent variables. ,,4s Under the guise of scientific research, children so "registered" would spend most of their lives medicated and monitored. The above examples are merely a sampling of the myriad of social implications that can be ascribed to ADIID. However, it is clear that in cultural terms ADHD is not a passing fad. It is embedded in institutional agendas and is poised to influence the functioning (and control) of society far into the future. 67

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CHAPTER 4 CONCLUSION Through the lenses of deviance designation and medicalization, the diagnosis and pharmacological treatment of ADHD can be seen as a construct of the medical pharmaceutical enterprise. Its public inculcation as a medical issue obscures the fact that dominant socio-political forces, in the form of government and industry, have enlisted biomedicine to extend the reach of institutional social control and economic viability. Under the guise of ADHD, a constellation of childhood behaviors has been deemed deviant, and so qualifies for institutional interventions. Through the process of medicalization, inattentive, impulsive, and/or hyperactive behaviors have been re framed from being responses to environmental conditions to being markers of inherent, biological disorder. In this alternative context, behavior is no longer a socio-political issue, but an enterprise of science. In the tradition of the Enlightenment, American patriarchal leadership is guided by a rational commitment to the concept of science as a value-free enterprise. As such, science has been publicly ordained as the ultimate source of authoritative knowledge. In this light, ADHD and its pharmacological treatment have been packaged by the establishment for popular consumption. However, feminist scientists and theorists posit that science is not a value-free enterprise, but a cultural product. This argument is substantiated by the case of ADHD. Given the cultural 68

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authority conferred upon scientific medicine, the lack of a known biological basis for ADHD has not deterred its promulgation as a biomedical issue. In fact, the biological question itself has given rise to a whole new industry of scientific research, one that is dedicated to popular, widespread phannacological control of behavior. Through its commitment to the medical/pharmaceutical construct of ADHD, the establishment can be seen to be engineering mass compliance and conformity to institutional designs. Back in 1975, Schrag and Divoky warned that, An entire generation is slowly being conditioned to distrust its own instincts, to regard its deviation from the narrowing standards of approved norms as sickness and to rely on the institutions of the state and on technology to define and engineer its 'health.' 1 As of2002, the acceleration of this conditioning is evidenced by the ADHD epidemic that is fueled by the policies and actions of the federal government. Under the banner of"scientific progress," research is being steered toward justifying the practice of medicating ever-younger children for behavioral issues. In Dialectic of Enlightenment, Max Horkheimer and Theodor Adorno state, What men want to learn from nature is how to use it in order wholly to dominate it and other men. That is its only aim. Ruthlessly, in despite of itself, the Enlightenment has extinguished any trace of its own self consciousness .... On the road to modem science, men renounce any claim to meaning. They substitute formula for concept, rule and probability for cause and motive. 2 69

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By these lights, the objectifying and commodifying of human behavior through endeavors such as the legitimization of ADHD may be seen as the germinating, perhaps the unfolding, of the "seeds of self destruction" that Horkheimer and Adorno argue are inherent to the formulations of Enlightenment doctrine. The ambition to know and control nature through science has now forged beyond material, empirical boundaries and invaded the realm of human consciousness, a move that shifts the power of individual subjectivity into the control of those external forces that guide knowledge production and its dissemination. Under these conditions, individuality has lost the centrality and freedom of expression originally espoused by the Enlightenment. Given that government policymaking is grounded in Enlightenment dogma, the future of American society may be foreshadowed by the insights forwarded by these critical theorists. The dialectic of the Enlightenment may be seen as coming into play. By legitimizing the pathology of common childhood behaviors, medicating developing minds, and deeming them "disabled," the human attributes of consciousness, free will, and individual choice, as well as the cultural grounds of accountability and responsibility are both challenged and diminished. 3 ADHD is a product of science that serves a bilateral political and economic agenda, both as an arbiter of behavioral and social control and as a commodity rife with commercial potential and professional opportunity. The epidemic proportions of 70

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ADHD diagnoses and psycho-pharmaceutical prescriptions calls for the veil of neutrality to be lifted from the popular conception of biomedicine and science, or society will remain vulnerable to the political manipulation and economic exploitation exercised in its name. As simply stated by Lawrence Diller, "the rising use of [pharmaceutical] stimulants is alarming and signals an urgent need for American society to reevaluate its priorities. ,,4 71

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CHRONOLOGY 1918 Encephalitis Epidemic 1930s Production of psycho-active drugs begins. 1937 Bradley reports on amphetamines and behavior. 1940s Ciba Pharmaceuticals synthesizes methylphenidate (Ritalin). 1949 National Institute of Mental Health established 1950 National Science Foundation formed. 1952 First DSM published. 1953 United Nations adopts System of National Accounts. 1955 FDA approves Ritalin for adult use. 1957 Laufer discovers "hyperkinetic impulse disorder." 1958 Russian launch of Sputnik. 1961 FDA approves Ritalin for use with children. Ciba begins direct marketing of Ritalin to doctors & teachers. 1962 Kefauver-Barris Drug Amendment: proof before marketing. 1963 Conners and Eisenberg begin research on Ritalin 1964 Association for Children with Learning Disabilities founded. 1966 Public Health Service documents "minimal brain dysfunction." Ciba promotes "minimal brain dysfunction" (MBD). 72

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1967 Conners and Eisenberg take research into public schools. 1968 DSM II: "Hyperkinetic Reaction of Childhood Disorder." 1968 First publicity for "Hyperkinesis" and ":MBD." 1969 Hutschnecker Memo. Conners' develops first parent/teacher rating scales. Apollo moon landing. 1970 James Allen proposals for education and medical evaluations. 1971 DEA classifies methylphenidate as Schedule II drug. 1972 Prohibition of direct marketing of Ritalin. 1973 Ciba publishes Physician's Handbook on MBD. 1973 Feingold's Food Additive Hypothesis. 1975 150,000 children on Ritalin. 1976 Conrad publishes Identifying the Hyperactive Child. 1980's APA forges alliance with pharmaceutical industry. 1980 DSM III: "Attention Deficit Disorder" (ADD). 1981 Conners publishes Food Additives and Hyperactive Children. 1983 "A Nation at Risk" report. 1987 CHADD founded. DSM III-R: "Attention Deficit/Hyperactivity Disorder." 1988 First annual CHADD conference. 73

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1988 Estimated 1 million children on Ritalin. 1990 Goals 2000: Educate America Act. 1991 Ritalin Sales at $95.3 million. 1993 "Ritalin Shortage." 1994 Clinton/Gore report, Science in the National Interest. 1995 Ritalin Sales at $349.3 million. 6-fold increase in methylphenidate production since 1990. DEA publicly calls for more restrictive use of methylphenidate. PBS broadcast, "ADD: A Dubious Diagnosis." Third International Mathematics and Science Study. Individuals with Disabilities Act formally recognizes ADHD. 1998 NIH Consensus Development Conference on ADHD. 500,000 prescription for pre-schoolers. 1999 CDC Conference, "ADHD: A Public Health Perspective." Multi-Modal Study released by NIMH. IDEA 97 regulations take effect, ADHD legitimate diagnosis. 2000 NIMH allocates $5 million toward ADHD in pre-schoolers. Class action lawsuit filed against AP A, Novartis and CHADD. 2001 PBS broadcast, "Medicating Kids." Class action lawsuit against APA, etal., struck down. 74

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2001 FDA approves generic and transdermal Ritalin. Market value of ADHD therapies estimated at $1 billion. NIMH budget of $1.107 billion 75

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N01ES Chapter One: Introduction 1. The estimate of 3 million represents a conservative average. Some estimates range as high as 6 million or as low as 1.2 million. As noted by Peter Breggin, "While there are no comprehensive statistics concerning the total number of children taking stimulants, it probably is reaching 4-5 million ... some drug advocates believe that 8 million of America's children should be taking some kind of psychiatric medication." Talking Back to Ritalin, 3. (see note 2 below). It was acknowledged by the CDC that ''there is disagreement as to prevalence and precise characteristics of children with the disorder." (see chap. 3 n. 68). 2. Peter Breggin, Talking Back to Ritalin, rev. ed. (Cambridge, Mass: Perseus, 2001), 13. 3. David Nylund, Treating Huckleberry Finn (San Francisco: Jossey-Bass, 2000), 9. In one of the few new books to challenge the construct of ADHD, Nylund states, "There is no scientific basis for the widespread belief that ADHD is neurological defect." (see note 6 below). 4. Ivan Illich, Limits to Medicine (1976; enlarged edition, London: Marion Boyars, 1995), 40. 5. Allan V. Horwitz, "The Medicalization of Deviance," review of Deviance and Medicalization: From Badness to Sickness, by Peter Conrad and Joseph W. Schneider, Contemporary Sociology 10, (November 1981): 750-752. 6. PeterS. Jensen, "Epidemiologic Research on AD liD: What We Know and What We Need to Learn," (abstract of presentation at the Developmental Disabilities Branch of the Centers for Disease Control Public Health Perspective Conference on ADIID, Atlanta, Ga., September 23-24, 1999), (7 March 2001 ). Jensen stated, "In truth, we know little concerning etiology." At the same conference, Thomas Achenbach stated, "Its precise nature, etiology, prevalence, developmental course, and appropriate treatment remain subject to debate." 76

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7. Peter Schrag and Diane Divoky, The Myth of the Hyperactive Child (New York: Pantheon, 1975), 57. 8. Peter Breggin, Talking Back, 222. 9. Lawrence Diller, "The Run on Ritalin: Attention Deficit Disorder and Stimulant Treatment in the 1990s," The Hastings Center Report 26 (March-April 1996): 12-19. (14 March 2001). 10. David M. Rasmussen, ed The Handbook of Critical Theory (Oxford: Blackwell, 1996), 13. II. E. Doyle McCarthy, "Engendered Knowledge: Feminism and science," in Knowledge as Culture (New York: Routledge, I996). In this chapter, McCarthy reviews the work of feminist critics, such as Donna Haraway, Ruth Blier, Helen Longino, et at Though their theoretical perspectives may vary slightly, they are "similar in their insistence that science be understood and examined as a thoroughly social and cultural activity." (p. 94 ). I2. Ruth Hubbard, Profitable Promises (Monroe, Maine: Common Courage Press, 1995), 149. I3. Ibid., 207 14. Ibid 187 I5. Rasmussen, Critical Theory, 21. Chapter Two: Social Iatrogenesis 1. Illich, Limits, 3 (see chap. I, n. 4). 2. Richard DeGrandpre, Ritalin Nation (New York: Norton, 2000), 140. In the early 80s, the American Psychiatric Association created an economic and political partnership with drug companies to promote the medical model, psycho pharmacology and the authority and influence of psychiatry; it has become a front for corporate interests. (see Breggin, Talking Back, 217-218. Chap. 1, n. 2). 77

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3. Peter Conrad and Joseph W. Schneider, Deviance and Medicali z ation: From Badness to Sickness (St. Louis: C.V. Mosby, 1980), 6 4 Ruth Hubbard, The Politics of Women's Biology (New Brunswick : Rutgers University Press, 1990), 12. 5. Ibid., 13. 6. Ibid., 12. 7 Joseph R. Gusfield foreword to Deviance and Medicalization: From Badness to Sickness, by Peter Conrad and Joseph W. Schneider (St. Louis: C.V. Mosby, 1980), v. 8. Peter Conrad, Identifying the Hyperactive Child (Lexington, Mass : D.C. Heath, 1976). 9. John Locke, "Some Thoughts Concerning Education" and Jean-Jacques Rousseau, "Children and Civic Education", in The Portable Enlightenment Reader, Isaac Kramnick, ed. (New York: Penguin, 1995). 10. Gusfield, foreword to Conrad, Deviance, vii. 11. Dennis P. Cantwell, "Attention Deficit Disorder: A Review of the Past 10 Years," Journal of the American Academy of Child and Adolescent Psychiatry 35 (August 1996): 978-988. 12. Conrad, Identifying 51. 13. Ibid., 55. 14. House Subcommittee on Oversight and Investigations, Behavioral Drugs in Schools: Questions and Concerns, 106th Cong., 1st sess., 29 September 2000. ( 4 October 2001 ). Testimony of Patti Johnson, Colorado State Board of Education member 2nd Congressional District. 78

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15. Steven R. Pliszka, "Attention Deficit Hyperactivity Disorder: A Clinical Review," American Family Physician 43 (April1991): 1267-1276. (18 September 2000). 16. Roslyn A. Glow, "Cross-Validity and Normative Data on the Conners' Parent and Teacher Rating Scales," in Psychosocial Aspects of Drug Treatment for Hyperactivity, ed. Kenneth D. Gadow and Jan Loney (Boulder, Colo.: Westview Press, 1981), 107-150. 17. Ronald Trites, et al., ''The Conners' Teacher Rating Scale: An Epidemiologic, Inter-rater Reliability and Follow-Up Investigation," in Psychosocial Aspects of Drug Treatment for Hyperactivity, ed. Kenneth D. Gadow and Jan Loney (Boulder, Colo.: Westview Press, 1981), 151-205. 18. Schrag, Myth, 57. 19. Conrad, Deviance, 2. 20. Gusfield, foreword to Conrad, Deviance, vi. 21. The figure of $400 per student was given by Patti Johnson of the Colomdo Board of Education during testimony to the House Subcommittee on Oversight and Investigations (see note 14 above). The ''Leave No Child Behind Act," which became law on January 8, 2002, states, "The purpose of this title is to assure that all children ... reach at a minimum, proficiency on challenging State academic achievement standards and state academic assessments, (and) ... holding schools, local educational agencies, and States accountable for improving the academic achievement of all students." Full text of legislation available online at ( 18 January 2002) . 22. Conrad, Deviance, 22. 23. Children and Adults with ADHD Homepage. "About Chadd," (22 February 2002). 24 Ibid. 25. Thomas B. Johnson and Andrea Canter, "Ritalin on Trial: Class Action Lawsuit Filed Against Drug Company, Psychiatrists and ChADD," NASP 79

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Communique 29, no. 4. (16 January 2002). Naspoline is the website for the National Association of School Psychologists. 26. Lawrence Diller, "Medicate or Else Schools Pressure Parents to Force Ritalin Use," Special to MSNBC, (March 4, 2001). (4 October 2001 ). 27. Conrad, Deviance, 23. 28. Russell A. Barkley, Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (New York: Guilford Press, 1990). 29. Harold Alan Pincus, et al., "DSM-IV and New Diagnostic Categories: Holding the Line on Proliferation," American Journal of Psychiatry 149 (January 1992): 112-116. 30. Conrad, Deviance, 23. 31. C. Keith Conners, "Overview of Attention Deficit Hyperactivity Disorder," (paper presented at the Nlli Consensus Development Conference on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder, Bethesda, Md., November 16-18, 1998). (30 July 2001). 32. Conrad, Deviance, 25. 33. Conrad, IdentifYing, 44. 34. Ibid., 44-45. 35. Per Sec. 300.505 of the Amendments to IDEA '97, "Ifthe parents of a child with a disability refuse consent for initial evaluation or re-evaluation, the agency may continue to pursue those evaluations by using the due process procedures or mediation procedures., (16 January 2002). 36. Diller, "Medicate," (see note 26 above). 80

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37. American Academy of Pediatrics, "Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder," Pediatrics 108 (October 2001): 1033-1044. 38. "Feingold Hypothesis-Food Additives Cause Hyperactivity," (30 July 2001). 39. The MIA findings were cited by Steven E. Hyman, Director of the NIMH, during his testimony at the House Education and Workforce Hearings, May 16, 2000 (see note 80 below). Hyman's testimony can be found at . The findings have also been reported in the Surgeon General's, "Report on Mental Health," (see chap. 4 n 33). However, under scrutiny, the methodology used in the MTA has been criticized as highly flawed: There were no placebo controls, no double blind, etc. These issues are discussed by Peter Breggin in Talking Back to Ritalin, p.l42-148 (see chap. In 2). 40. William Pelham, Jr. and Laurence Greenhill, "Public Health Issues in the Treatment of ADHD Workshop," (abstract from Centers for Disease Control Workshop on ADHD, Atlanta, Ga., June 15, 1999). (8 March 2001). 41. From HowardS. Becker, Outsiders; Studies in the Sociology of Deviance, (New York : The Free Press of Glencoe, 1963) in Conrad, Deviance, 22. 42. Hubbard, Politics, 24-25. 43. Conrad, Deviance, 266. 44. Ibid 45. Ibid., 267. 46. Barkley, Handbook, (see note 29). 47. Conrad, Identifying, 13, and Breggin, Talking Back, 227. 81

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i 48. Schrag, Myth, 42. 49. Ibid. 50 Ibid., 57. Ciba promoted Ritalin, as such, until1970, when federal regulations were tightened. Subsequent Ciba literature promoted MBD (minimal brain dysfunction. 51. Comad, Identifying, 16. 52. Schrag, Jvfyth, 81. 53. Comad, Identifying, II. 54 Comad, Deviance, 267. 55. Ibid. 56. Barldey, Handbook, 8. 57 Comad, Identifying, 10. 58. Schrag, Myth, 79 59 Comad, Identifying, II. 60. Ibid 61. Schrag, Myth, 56 62. Breggin, Talking Back, Chapter 10, "Scientific Evidence for a Biological Cause of ADHD," details the current state of ADHD research. 63. Schrag, Myth, 57. 64 Breggin, Talking Back, 226. 65. Schrag, Myth, 57. 82

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66. Ibid 58. 67. Conrad, IdentifYing, II. 68. Diller, "Run," I (see chap. 2, n. 2). 69. Schrag, Myth, 43. 70. Sam D. Clements, "Task Force I: Minimal Brain Dysfunction in Children: Terminology and Identification," National Institute of Neurological Diseases and Blindness, Monograph No.3, U.S. Department of Health, Education and Welfare, I966, in Schrag, Myth, 44. 71. Schrag, Myth, 45. 72. Ibid, 58. 73. Ibid 30. 74. Ibid ., 3 75. Ibid., 7. 76. Breggin, Talking Back, II-I2. 77. Catherine A Lesesne, et al., "Attention deficit/hyperactivity disorder: A public health research agenda," concluding statement to Developmental Disabilities Branch of the Centers for Disease Control Public Health Perspective Conference on ADHD, Atlanta, Ga., September 23-24, I999. (March I5, 2000). (7 March 200 I). 78. Ibid. 79. Hubbard, Politics, 24. 80. The financial ties between CHADD and Ciba were first publicly exposed on the PBS broadcast of"ADD: A Dubious Diagnosis," in October, I995. Since then, many mainstream periodicals have reiterated the story, particularly in relation to 83

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coverage of the class action lawsuit against the American Psychiatric Association, Novartis, and CHADD. 81. CHADD Homepage (see note 23 above). 82. Ibid (conference link) (8 January 2002). 83. Steven E. Hyman, director of the N1MH delivered the closing keynote address at the 12th Annual Conference on ADHD, Nov. 4, 2000 in Chicago (24 January 2002) 84. National Alliance for the Mentally Ill "Homepage". (19 January 2002) 85. Kelly Patricia O'Meara, 'Writing May Be on Wall for Ritalin ," Insight Magazine, The Washington Times, (Oct. 16, 2000). (13 January 2002). 86. Conrad, Deviance, 269. 87 Major ADHD websites, such as "One A.D.D. Place" and "ADDMed" provide links to scores of other sites via headings such as, "books/tapes/products", valuable resources, professional services, etc 88. Mary Eberstadt, "Why Ritalin Rules," Policy Review (April-May 1999): NA. (14 March 2001) Noting the publishing boom dedicated to ADHD/Ritalin, Eberstadt suggests that noteworthy dissent didn t appear until1995 with Thomas Armstrong's, The Myth of the ADD Child (Dutton, 1995) marking a 20 year lapse of notable opposition since the publication of Shrag & Divoky' s, Myth of the Hyperactive Child (Pantheon, 1975) She notes but two subsequent, dissenting publications, Lawrence Diller's, Running on Ritalin (Bantam Books, 1998) and Richard DeGrandpre's, Ritalin Nation (Simon and Schuster, 1999). A third, Peter Breggin's, Talking Back to Ritalin (Perseus, 2001) originally appeared in 1998, though the subsequent revised edition received more notice. 89. Todd Forte, "Ciba Pharmaceuticals responds to PBS program on Attention Deficit Disorder PR Newswire, (October 19, 1995). 84

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(30 January 2002). 90. Matt Cohen, CHADD President, "Plenary Speech" (delivered at 12th Annual Conference for Children and Adults with ADHD, 1999) (24 January 2002). 91. House Committee on Education and the Workforce, Subcommittee on Early Childhood, Youth and Families, hearing on "Ritalin Use Among Youth: Examining the Issues and Concerns," 106th Cong. 1st sess., Washington, D.C., May 16,2000. ( 18 January 2002). Chairman Castle reviewed problems associated with Ritalin, such as abuse, increased use by 2-4 year olds, etc. However, the diagnosis was considered valid Castle stated, "At the very least, we need to be very cautious in both the identification of all ADD/ ADHD children and their treatment." 92. Johnson, "Ritalin on Trial," (see note 25 above). 93. Novartis, "Judge Dismisses Class-Action Lawsuit Against Makers of Ritalin -Texas Federal Judge Rules Plaintiffs Complaint Unclear and Invalid," Press Release (May 18, 2001 ) (26 July 2001 ). 94 Conrad, Deviance, 270. 95. Ibid. 96. National Institute of Mental Health, "Fiscal Year 2002 NIMH Budget Request to Congress," ( 18 January 2002). Steven Hyman, Director of the NIMH, requested $1,238,305,000 in 2002, an increase of $131,576,000 over the budget granted in 2001. 97. Michael McCarthy, "USA to Improve Care of Children With ADHD," The Lancet 355 (April 1, 2000): 1161. 98. Laurence L. Greenhill, "The Use ofPsychoactive Medication in Preschoolers: Indications, Safety and Efficacy," Canadian Journal of Psychiatry, 43 (1998): 576-581. 85

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Chapter Three: The "Working" of ADHD 1. Isaac Kramnick ed, introduction to Enlightenment Reader, xii. (See chap. 2, n. 9). 2. Ibid., xvi. 3. Ibid., xii. 4. National Science Board, introduction to Science and Engineering Indicators 2000, Washington D.C. 2000. (I March 200I): I. 5 NSB, "Presidential Statements," chap. I in SEI 2000. (1 March 200I): 4. 6. NSB, introduction to "Elementary and Secondary Education," chap 8 in SEJ 2000. (I March 200I): 9. 7. NSB, Indicators, 2. (see note 3) Though the NSB publicly disavowed any direct NSF involvement with defense related research, it was "abundantly clear that both the Congress and the Administration would thenceforth accord a high priority to defense related research and development." (p. 3) However, considered as a substantial cutback in I998, the US Government still devoted 54% of its $74 billion R&D investment to national defense (p. I, chap. 2, "International Comparisons of Government R&D Priorities). 8 NSB, "Belief in the Paranonnal or Pseudoscience," chap. 8 in SEI 2000. (1 March 2001) 9. NSB, Indicators, 5 (see note 5) 10. Ibid. 11. Ibid., 8 86

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12. NSB, "Student Achievement," chap. 5 in SEI 2000. (1 March 2001). 13. NSB, "Curriculum and Instruction," chap. 5 in SEI 2000. (1 March 2001):1. 14. NSB, Indicators, 2 (see note 11 above). 15. U.S. Department ofHealth and Human Services, "The NIH Almanac Organization: National Institute of Mental Health: Mission," (November 11, 2001) ( 17 December 2001). 16. Ibid. 17. National Institute of Mental Health, Attention Deficit Disorder: Decade of the Brain, Bethesda, Md. (9 August 2001) 18. Marilyn Waring, If Women Counted: A New Feminist Economics (San Francisco: Harper, 1988), 22. 19. Susan Ohania:ri, "Goals 2000: What's in a name?," Phi Delta Kappan, 81 (Jan 2000): 344-355. (30 January 2002). 20. NSB, Indicators, 2 (see note 3 above). 21. Waring, Women, 54. 22 Ibid' 25. 23. Business Editors/Medical Writers,"Noven Issued U.S. Patent for Transdermal Methylphenidate; Patent for Once-Daily Methylphenidate Patch for ADHD Effective Through 2018," Business Wire, (May 23, 2001): 0074. (30 January 2002). $1 billion market estimate by Robert C. Strauss, Noven's President, CEO and Co Chairman. 87

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24. Peter Breggin, "Upcoming Government Conference on ADHD and Psychostimulants Asks the Wrong Questions," (6 February 2002): 1. 25. Ibid. 26. Waring, Women, 4. 27. Eberstadt, "Ritalin Rules," (see chap. 3, n. 78). Eberstadt's report is an effort to explain why Ritalin use "doubled in the first half of the decade only, production increased 700 percent since 1990 and that the number of schoolchildren taking the drug may now, by some estimates, be approaching the 4 million mark." One conclusion was that, "By the end of the 90's, thanks largely to CHADD and its allies, an ADD/ ADHD diagnosis could lead to an impressive array of educational, financial, and social service benefits." 28. NSB, Indicators, 5 (See note 4 above). 29. NSB, "Current Visions/Key Policy Documents," chap. 1 in SEI 2000. (1 March 2001): 2. 30. Ibid., 5. 31. Ibid., 6. 32. Business Editors/Medical Writers, "DynaGen Commences Shipment of Methylphenidate Tablets Following Recent FDA Approval; Generic Version of Ritalin has Estimated Market of$185 Million," Business Wire, (April 27, 2001): 2115 and "Ritalin May Have Long-term Effects on Brain," Marketletter, (Nov. 26, 2001): NA. (30 January 2002). Market analysts responded to this report by stating that it will have little impact on Novartis' performance since the drug is no longer a growth driver for Novartis. Sales of$147 million in 2000 were expected to decline slightly by 2004. However, Novartis is partnered with Noven to market the transdermal delivery system, which is expected to outpace sales of traditional oral modes of delivery. 33. The Royal Society of Chemistry, "Biotechnology Newswatch: Promising compounds may offer treatment choice for fidgety kids," Asia Intelligence Wire, 88

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(Nov. 20, 2000). (30 January 2002). 34. U.S. Department of Health and Human Services, "Mental Health: A Report ofthe Surgeon General," Rockville, Md., December, 1999. ( 18 January 2002). Although this report was publicly released under the auspices of the Office of the Surgeon General, it is "the product of an invigorating collaboration between two federal agencies: The Substance Abuse and Mental Health Services Administration (and) the NIH/NIMH. (18 January 2002) 35. Larry S. Goldman, et al, "Diagnosis and Treatment of Attention Deficit/Hyperactivity Disorder in Children and Adolescents (American Medical Association Council on Scientific Affairs Report)," JAMA, The Journal of the American Medical Association 279 (April8, 1998): 1100-1107. 36. Russell A. Barkley, "Attention-Deficit Hyperactivity Disorder," Scientific American, (Sept. 1998). (3 August 2001): 2. 37. Hubbard, Profitable Promises, 32 (see chap. 1, n. 10). 38. Martha Miller, "Diet and Psychological Health," Alternative Therapies, 2 (September 1996): 40-48. Miller states that "Although clinical case reports and promising research findings have been reported, the impact of diet of psychological health is neither widely accepted nor integrated into mental health treatment methods." (p. 40). 39. Free Appropriate Public Education (F APE) "Homepage." (21 January 2002). Full disclosure of final regulations set forth in the amendments to IDEA '97 are explained by F APE at this website. 40. Annette Lansford, "ADHD and the Military," Special Education Advocacy & Consulting Alliance, (February 22, 2002): (26 February 2002). 89

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Landsford cites the Department of Defense directive 6130.3 of May 1994, that states, "Current use of medication to improve or maintain academic skills (example: methylphenidate) is disqualifying., However, in practice, recruiters give highly variable (and often erroneous) information to potential recruits. Different branches of the military have different degrees of strictness regarding the disqualifying policy. The Airforce and Marines use the two year rule, while the Army and Coast Guard are more lenient. The policy of disqualification applies to all branches for people on medication at the time of enlistment Landsford recommends that those considering military enlistment should plan to discontinue stimulant medication at least the last year of high school. 41. U.S. Department of Justice, Drug Enforcement Administration, "Methylphenidate," DEA Press Release (October 20, 1995) ( 6 February 2002). 42. National Drug Strategy Network, "DEA Warns of Ritalin Abuse; Drug Manufacturer's Contributions to Advocacy Group Investigated," Newsbrief, (March 1996). (31 July 2001). Ciba-Geigy spokesperson, Todd Forte, quoted in aNewsbriefarticle. 43. DEA, "Press Release," (see note 39 above). By 1999, the production quota increase was at 700 per cent (see note 26 above). 44. Business Editor, "Ciba Pharmaceuticals issues statement on Ritalin shortage," PR Newswire, (Oct. 5, 1993): (30 January 2002). 45. Novartis, "Judge Dismisses Class-Action Lawsuit Against Makers of Ritalin--Califomia Federal Judge Rules Plaintiff's Complaint is Unclear and Unmerited." Press Release (April26, 2001). (26 July 200 I). 46. Ibid. 47. Johnson, "Ritalin on Trial," 4 (see chap. 3 n. 25 above). 48. Lesesne, "Public Health," 6 (see chap. 3 n. 68 above). 90

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Chapter Four: Conclusion I. Schrag, introduction to Myth, xvii (see chap I n. 6) 2. Max Horkheimer and Theodor Adorno Dialectic of Enlightenment, 2d ed, trans John Cumming, (New York : Continuum, I999), 4-5. 3. Diller, "Run," (see chap. 2 n. 2). 4. Ibid. 91

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BffiLIOGRAPHY American Academy of Pediatrics. "Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder." Pediatrics 108, no. 4 (October 2001): 1033-1044. Barkley, Russell A Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press, 1990 ---"Attention-Deficit Hyperactivity Disorder." Scientific American, Sept. 1998. (3 August 2001 ). Breggin, Peter. Talking Back to Ritalin. Rev. ed. Cambridge, MA: Perseus, 2001. Cantwell, Dennis P. "Attention Deficity Disorder: A Review of the Past 10 Years." Journal of the American Academy of Child and Adolescent Psychiatry 35 (August 1996): 978-988. Children and Adults with ADHD. "Homepage." (22 February 2002). Clements, Sam D. "Task Force I: Minimal Brain Dysfunction in Children: Terminology and Identification." National Institute of Neurological Diseases And Blindness. Monograph No. 3. U.S. Department of Health, Education and Welfare, 1966. Quoted in Peter Schrag and Diane Divoky, Myth of the Hyperactive Child (New York: Pantheon, 1975), 44 Conner, C Keith. "Overview of Attention Deficit Hyperactivity Disorder." Paper presented at the NIH Consensus Development Conference of Diagnosis And Treatment of Attention Deficit Disorder. Bethesda, Md., November 1998. (30 July 2001). Conrad, Peter. identifying the Hyperactive Child. Lexington, Mass.: D.C. Heath, 1976. Conrad, Peter, and Joseph W. Schneider, Deviance and Medicalization: From Badness to Sickness. St. Louis: C.V. Mosby, 1980 DeGrandpre, Richard. Ritalin Nation. New York: Norton, 2000. 92

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Developmental Disabilities Branch of the Centers for Disease Control. "Attention Deficit/Hyperactivity Disorder: A Public Health Perspective Conference September 23-24, 1999. (7 March 2001) Diller, Lawrence, The Run on Ritalin: Attention Deficit Disorder and Stimulant Treatment in the 1990's." The Hastings Center Report 26 (March-April1996): 12-19. (14 March 2001). ---"Medicate or Else-Schools Pressure Parents to Force Ritalin Use." Special to MSNBC. (March 4, 2001) ( 4 October 2001). Eberstadt, Mary. "Why Ritalin Rules." Policy Review (April-May 1999): NA (14 March 2001). "Feingold Hypothesis-Food Additives Cause Hyperactivity." (30 July 2001). Free Appropriate Public Education. "Homepage." (21 January 2002) Glow, Roslyn A. "Cross-Validity and Normative Data on the Conners' Parent and Teacher Rating Scales." In Psychosocial Aspects of Drug Treatment for Hyperactivity, edited by Kenneth D. Gadow and Jan Loney, 107-150. Boulder, Colo.: Westview Press, 1981. Goldman, Larry, et al. "Diagnosis and Treatment of Attention Deficit/Hyperactivity Disorder in Children and Adolescents (American Medical Association Council on Scientific Affairs Report) JAMA, The Journal of the American Medical Association 279 (April 8, 1998): 1100-1107 Greenhill, Laurence L. "The Use of Psychoactive Medication in Preschoolers: Indications, Safety and Efficacy." Canadian Journal of Psychiatry, no. 43 (1998): 576-581. Horkheimer, Max and Theodor Adorno. Dialectic of Enlightenment. 2d ed. Translated by John Cumming. New York : Continuum 1999. 93

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