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Identifying Hyperactive Children: The Medicalization of Deviant Behavior
Peter Conrad
ISBN: 0-754645-18-5 2006 160 pages Ashgate
Kevin White
Senior Lecturer, Department of Sociology, Australian National University, Canberra, ACT
This is a re-issue in a new series (Ashgate Classics in Sociology) of Peter Conrad's classic study of attention deficit disorder (ADD) first published in 1976. This volume contains an introduction to this expanded edition and a new chapter (with Deborah Potter) detailing the rise of adult Attention Development Hyperactivity Disorder (a process that Conrad and Potter refer to as medicalised category expansion). Developing out of labeling theory, Conrad's was the first of the case studies of the medicalisation of everyday life, examining how the deviant behavior of children in the classroom was reconstituted from naughty to sick. Rather than adopt a clinical or psychological approach to the issue, he asks the sociological question: what actions in what contexts become ADD? In making this move Conrad could point to the fact that there is no identifiable underlying biological cause for the condition and that the clinical assessment of the ‘disease' was based entirely on the social evaluation of the children's behavior developing out of the interaction of the parents, teachers and doctors. This lack of biological base was confirmed in the Diagnostic and Statistical Manual of the American Psychiatric Association (1994) where the condition is defined as ‘developmentally inappropriate inattention and impulsivity'.
Conrad draws attention to the impact of the medicalisation of social problems, in that it individualises and depoliticises the issue, and prevents the development of a social system approach to explaining what is going on. A social systems approach would point to issues such as the student-teacher ratio in the classroom, the structure of an age based schooling system, the need for middle class parents to provide an account of why it is that their children are not performing well at school, and the search by psychologists for a toe-hold inside the medical system.
What is striking about Conrad's book thirty years on is its continuing pertinence to the issue of ADHD today. While it is still diagnosed in the USA at ten to thirty times the rate of other countries, it has spread to countries like Australia, where prescriptions for the drug of choice in treatment, methyl phenidate, have jumped from 13,000 in 1980 to 96,000 in 1990, with five million children now diagnosed as having the condition. It is now diagnosed in girls (in 1970 the gender ratio was nine boys to one girl; now it is three to one) and has been extended to be a life-long condition affecting adults (with some estimates suggesting that up fifty per cent of affected children will continue into adult life with the diagnosis). And all this notwithstanding the fruitless search for a neurological or biological basis for the condition: though a genetic explanation is now postulated and being sought. Along with the increase in the diagnosis of ADHD have gone a widespread medicalisation of everyday life and the increasing spread of psychotropic treatments. Conrad points out in his new introduction that the activities of the drug companies have been central, especially in the American context of direct marketing to consumers on TV and elsewhere. He also notes that these companies target woman's and parent's magazines exhorting their readers to ‘ask your doctor if this drug (name of drug) is right for (you or your child)'. (Conrad's work has continued in the area of the medicalisation of deviant behavior and the role of the pharmaceutical companies with the recent publication of the Medicalisation of Society: On the Transformation of Human Conditions into Treatable Disorders (Johns Hopkins University Press, 2007) in which he shows the medicalisation of ageing, menopause, alcoholism, erectile dysfunction and a range of other topics including short stature!) In the current volume, the additional chapter authored with Potter provides an analysis of the ‘domain expansion' of ADHD to adults, in the context of the ‘prozac era', the legitimacy achieved by claiming a genetic basis (without evidence) and the rise of managed care in which it is cheaper to prescribe for patients than to consult with them. Conrad could also have observed that a similar domain expansion has gone on in ADHD in children, where DSM IV now has it as a subset of Attention Deficit and Disruptive Disorders, comprised of Oppositional Defiant Disorder, Conduct Disorder, and Attention Deficit Hyperactivity Disorder. As Conrad says of adults, and as this demonstrates in children, medicalised categories can be further medicalised.
Not only is Conrad's book a classic in social theory - built on Parsons' insight that illness is deviance and reversing it, so that deviance can be shown to be illness - it is a masterful account of qualitative research. Based on six months of field work in a Hyperactivity-Learning Disabilities Clinic, and using participant observation, in-depth interviews and documentary sources such as doctors' referrals and school reports, it is a model of how to report qualitative research, with adept use of extensive quotations. In this context I recommend it to every student doing a PhD in qualitative health sociology. To my colleagues I will refresh their memories and remind them that it is a delight to read: and was a pleasure to re-read since I first read it twenty years ago.
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