Parents often agonize over a child’s behavior, wondering if their child is just unruly or if there might be a medical cause to problems experienced in school and other rigid settings. Increasingly, parents are finding a diagnosis—attention deficit hyperactivity disorder (ADHD)—to account for some of the behavior issues that make parenting a particularly challenging activity. According to the medical community, ADHD is a neurological disorder primarily characterized by inattentiveness, hyperactivity, and impulsivity. ADHD is generally detected in childhood, but increasing numbers of individuals are being diagnosed in adulthood. The vast majority of identified ADHD sufferers are male. A heated debate centers on the nature of the disorder, including whether a medical label is appropriate and how it should be treated.
ADHD has received increased attention in the professional and popular literature in recent years. Most sources agree that ADHD diagnoses are on the rise in the United States. Comparing two similar data sources illustrates this increase. According to a 1987 study, the weighted national estimate of children receiving treatment for ADHD was approximately a half million. A follow-up to this research in 1997 reported a weighted national estimate of children receiving ADHD treatment of more than 2 million. These figures can be loosely compared to the most recent data available from the Centers for Disease Control and Prevention on the number of children in the United States ever diagnosed with ADHD. According to this source, this distinction applied to 4.5 million youth in 2006 (the most recent estimate). From this illustration emerges a general idea of the rate of change surrounding ADHD diagnoses in the United States.
I. Three Contested Perspectives on ADHD
1. ADHD as a Disease
2 The Medicalization of ADHD
3. ADHD as Social Construction
II. Children with ADHD and Their Parents
Three Contested Perspectives on ADHD
A crucial element of the ADHD debate involves its definition. Many physicians and psychologists believe that ADHD is a medical issue with neurological implications and genetic causes. Others—those who favor a more holistic approach to life or who may not have parented—feel that ADHD is a creation of overzealous practitioners and pharmaceutical companies. Still others see the phenomenon as social in origin, arising from changing values and ideals regarding childhood. Th us, three main perspectives exist in the ADHD controversy. The first is the medical perspective that views ADHD as a physiological disease. The second perspective describes ADHD as subject to the medicalization process that transforms many behavioral issues into medical problems. The third perspective portrays ADHD as a social issue arising from changing interpretations of behavior rather than children’s physical disabilities.
1. ADHD as a Disease
The underlying assumption of a medical model of a disorder is that some recognized standard of behavior, one that is displayed by the majority of the populace, is absent in an individual. The absence of the expected behavior is attributed to an illness or disease, which, once properly diagnosed, can be treated to help bring about more desired behavior.
Many psychologists, psychiatrists, physicians, and other clinicians, as well as parents, teachers, and members of the general public, believe this model is appropriate for ADHD. The idea that inattentiveness and hyperactivity in children indicate a disorder originated near the turn of the 20th century. The condition, then termed hyperkinetic reaction of childhood, was officially recognized by the American Psychiatric Association in the second edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-II) in 1968. For the DSM-III, the label was revised to attention deficit disorder (ADD). The terminology changed again for the revision of the third addition, the DSM-III-R, when the disorder was given the more inclusive title of attention deficit hyperactivity disorder or ADHD.
The current DSM-IV lists inattentiveness, hyperactivity, and impulsivity as the three primary characteristics of ADHD. The manual also indicates that an ADHD diagnosis is not appropriate unless symptoms have been present for at least six months, these symptoms occur to a degree that is developmentally deviant, and these symptoms were developed by the time the individual was seven years old.
The medical community has been searching for a verifiable physiological cause of ADHD for some time. Although no exact biological origin has been determined, researchers and clinicians have focused their efforts on the brain for answers to the root of the disorder. Among the proposed possibilities are chemical imbalances and brain deficiencies that may arise from low birth weight or premature birth. Some notable investigation has also been done on the frontal lobe, the area of the brain responsible for behavioral and emotional regulation. As this area matures, individuals gain the ability to plan before acting and, when necessary, to ignore the desire to act. Scientists have observed a difference in the size and shape of the frontal lobe in ADHD individuals compared to non-ADHD individuals. These variations may indicate a diminished capacity for self-control in people with the disorder. Yet this research has also proven inconclusive, even leading some who accept the medical view of ADHD to admit that no irrefutable biological cause has been discovered to explain it—a point that critics and skeptics are quick to emphasize.
In addition to the argument for neurological markers of ADHD, researchers have also proposed a genetic factor for the disorder. As science learns and understands more about human DNA, the quest to locate particular genetic sources for illnesses has expanded beyond physiological disease to behavioral disorders like ADHD. No one has yet pinpointed an ADHD gene, but many believe it will be discovered eventually. Other proponents of the medical understanding of ADHD see it as more complicated than that, feeling that a single ADHD gene is not likely to be identified. Those who hold this point of view assert that science is beginning to realize that mental disorders originate from complex interactions of genes, chemicals, and other neurological components, meaning that the isolation of a specific ADHD gene is not likely.
Strong arguments asserting that ADHD is a disease come from individuals, or from the relatives of individuals, who have ADHD. According to many of these advocates, ADHD causes much pain for those it touches, especially when not diagnosed and medical treatment can bring relief. ADHD literature contains a large number of personal stories by individuals dealing with the disorder. Many of these report that they were considered stupid, lazy, and unmotivated as children. They also describe deep feelings of guilt and isolation because they were unable to meet academic and social expectations. For these individuals who found relief and understanding after being diagnosed with ADHD, the validity of the medical model is unquestionable. The stories of ADHD sufferers can often be found alongside reports from family members who describe distress over not knowing how to relate to or help their loved one with ADHD. These personal accounts available in the literature give human voices to an issue that is dismissed by some critics as a myth and others as invention.
2. The Medicalization of ADHD
Another perspective on ADHD is that it, like a number of other social issues, has been subjected to the process of medicalization. Prominent medicalization researchers and others cite as key elements of the medicalizing of ADHD the changing views of children in the United States, the unprecedented power of the medical profession, and the clout of pharmaceutical companies offering so-called miracle drugs to fix behavioral problems.
Prior to the Industrial Revolution, children were seen as miniature adults rather than members of a special life stage prior to adulthood. Children were considered responsible and were expected to become productive members of society at early ages, for most this meant joining the labor force or helping on the family farm. At this time, the realms of child care and management rested squarely within the family.
But with urbanization came a decreased need for child labor and a greater emphasis on education. Eventually, society came to see children’s proper place as in the classroom, and compulsory education arose. As youth were being thrust into schools, their parents were coming to view them as innocent creatures with little social power, dependent on the protection and care of adults. Over time, as people began to place more stock in the word of professionals and specialists over the teachings of folkways and tradition, parents more often sought out these specialized groups for ideas about how to properly rear children. This view of youth as innocent and dependent coupled with a loss of authority in the family is described by some as a prime contributor to the medicalization of untoward child behavior. Furthermore, because children are not considered mature enough to be culpable, their unacceptable actions cannot be labeled crimes, leaving only illness labels to explain their deviant conduct.
Before medicine gained respect as a scientific field, bad children were thought to be under the devil’s influence, morally lacking, or subject to poor parenting. Religion and the family had the main responsibility for shaping society’s views on appropriate and inappropriate behavior. However, once physicians began to make medical breakthroughs, including the advent of vaccinations, the profession began to build expert power. Over the last century or so, the medical field has acquired great authority and now has almost absolute control over how U.S. society defines disease, illness, and treatment. Th us, when physicians approach behavioral difficulties, such as those displayed with ADHD, as medical issues requiring medical treatment, most people accept this definition without question.
The makers of pharmaceuticals have also been gaining influence in society. Some now see these companies as a driving force behind the medicalization of a host of issues, including ADHD. Many people believe that if a drug exists that treats symptoms, then it proves disease is present. Such is often the case with ADHD. Psychostimulants, such as Ritalin and Adderall, have been shown to be very effective at helping children calm down and pay attention. Because of this success, despite the positive effects found for alternative treatments such as parent training programs, medications are considered the most useful method of curbing ADHD difficulties. Critics contend, however, that the efficacy of psychostimulants for adjusting the behavior of children diagnosed with ADHD is not valid evidence of a biological deficit, because these drugs produce similar results in children who do not have ADHD as well.
Following the view of some proponents, one primary reason aspects of human behavior are being increasingly tied to genetic explanations is because this is financially beneficial for drug manufacturers who are supposedly able to offer the only solutions to medical defects. Supporting this argument is the fact that, in the 1960s, pharmaceutical companies began to aggressively market psychostimulants for children with ADHD by using print advertisements in medical journals, direct mailing, and skilled representatives who promoted their products to doctors. These tactics proved effective, and more doctors and clinicians looked to psychostimulant medications as solutions for problematic behavior in children. Today, millions of people in the United States take these medications, causing some to fear that drugging children has become a new form of social control or that doctors are handing out prescriptions haphazardly to anyone claiming to have trouble concentrating or sitting still.
3. ADHD as Social Construction
In addition to the perspectives of ADHD as disease and the medicalization of ADHD is the view of ADHD as social construction. According to social psychology, humans are driven by the desire to make sense of the world around them. Individuals observe one another’s behavior, interact in situations, and perform acts, all to which they constantly try to attach definitions to help them understand the world and their place in it. This process is social and varies based on situational, historical, and other factors, which means that society’s understandings can change over time. Several authors believe this has occurred with the interpretation of youthful conduct.
Ideas about desirable and undesirable child behavior vary within and between cultures. Th us, no universal definitions of good and bad conduct exist. Some claim that, in the United States, children’s actions have not changed so much as society’s interpretations of them. U.S. society used to be more understanding of variations in children’s behavior and allowed them outlets for excess energy, such as time for recess and physical education built into the school day. Recently, however, following the No Child Left Behind Act of 2001 and the thrust to improve standardized test scores, most schools have done away with these sanctioned play times.
In a scholastic atmosphere now calling for more productivity from even the youngest students, inattentiveness and hyperactivity are considered more of a problem than they were formerly. Some critics of this social development, such as Armstrong (2002), are troubled by the demands that they believe society places on children to be more like machines than human beings. Following this and some others’ views, society, with pressure from experts, no longer sees disruptive students as exuberant or eccentric but rather as sick and in need of medication to put them back on the path to success, almost as if these children are broken and in need of repair.
The emergence of the field of developmental psychology also may have engendered a change in the social definitions of childhood conduct (Timimi 2005). Developmental psychology offers standardized ideals for child development. Milestones are prescribed based on age, and deviation from these standards is considered cause for alarm and is often approached from a medical standpoint. This discipline promotes developmental markers not only for areas such as physical growth, language use, and motor skills but for maturity, ability to attend to stimuli, and social interaction.
Some argue that, due to the prescriptions of developmental psychology, parents, teachers, and physicians are now more likely to view behaviors that are not deemed age appropriate or acceptable as highly problematic. What may have once been considered simply a difficult personality is often pathologized today. Authors who hold this view seem to apply a version of the Thomas Theorem to the issue, the basic idea of which is that anything perceived as real is real in its consequences. Following this, it appears to some that people, accurately or not, view ADHD as a real disorder and thus look for symptoms confirming it, causing real consequences for children who are given the resulting pathological label.
A final illustration of society’s changing definitions surrounding this issue deals with the locus of blame for children’s misbehavior. Some researchers today support the view that poor home environments can impact children such that they display symptoms of ADHD. According to these authors, chaos, disharmony, hostility, and dysfunction at home can cause children to have trouble focusing in class or to act out irrationally. Supporters of this view, however, are in the minority. Furthermore, prior to the medical diagnosis, behavioral difficulties characterizing ADHD were frequently thought to result from poor parenting, especially by mothers. Today, however, the prevailing professional opinion is that mothering behaviors are a consequence, not a cause, of children’s behaviors. Thus, less desirable actions and reactions on the part of parents are now seen as a consequence of stress that builds up from dealing with a troubled child rather than a poorly behaved child being seen as a symptom of poor parenting. The emphasis on biology over parenting has taken responsibility away from parents and placed it on intangible sources deep within the child’s brain.
Children with ADHD and Their Parents
While the debate rages on about the proper conceptualization of ADHD behaviors, parents and children are caught in the middle. Much research has found that actions consistent with ADHD in a child have negative implications for that child’s relationship with his or her parents. In general, households with children who have ADHD are characterized by higher parental stress and distress and more parent-child conflict than households without children who have ADHD. Studies of parents’ self-reports find that mothers and fathers of these children have trouble relating to their off spring, often lack a sense of closeness with the child, and view themselves as less skilled and competent as parents. Commonly, these parents experience feelings of hopelessness and desperation to find help. In efforts to address the challenges they face, some parents display negative reactions to their children, including being excessively controlling, viewing the youths less positively, and resorting to more authoritarian discipline styles.
In addition to these joint concerns, studies have found issues unique to mothers and to fathers regarding their children with ADHD. For example, research has found a correlation between depression in mothers and parenting children with ADHD. Following a social tradition of disproportionate responsibility for rearing children, many mothers internalize the notion that they are to blame when their sons or daughters misbehave. This history of mother blaming has been somewhat relieved by the rise of the medical model for ADHD, which takes the liability away from mothers and places it on the child’s internal defects that are outside their control. Despite this, a number of mothers today are still deeply troubled when their children behave negatively, both out of concern for the quality of life of the child and for others’ potentially hurtful perceptions about their parenting.
Many fathers of children with ADHD experience their role differently from mothers. For example, one study found that fathers were much less willing than mothers to accept the medical view of their children’s difficulties. Additionally, this research noted that many fathers were not active in the diagnostic and treatment process of their children’s disorder, but they did not stand in the way of it either. Often they were sidelined during this progression, some by choice and others in an effort to avoid conflict in the marital relationship.
One notable finding by researchers, such as psychiatrist Ilina Singh, is that a number of fathers feel guilt in connection to their sons’ ADHD. The medical model for this behavioral disorder proposes a genetic linkage that passes ADHD from father to son. Due to this, some fathers blame themselves for causing their sons’ problems. One consequence of acknowledging their possible responsibility is that men think back to their own childhoods, in which they behaved similarly to their sons, and question whether they should have been given the same diagnosis.
Finally, discord can arise between a husband and wife as they struggle to deal with their child with ADHD for a number of reasons. One example is a disagreement over the true nature of their off spring’s problems. Also, trouble can emerge simply from the general stress of the environment. Partners who are feeling upset about issues with their child may take out their emotions on one another. Another source of conflict might be a husband’s opinion that his wife is at least somewhat responsible for their child’s unruly behavior because she is too indulgent, a sentiment some fathers report they have.
Critics of the medical model and of the medicalization of ADHD sometimes condemn parents for their willingness to accept such a label for their children. Some of these critics believe that parents today take the easy way out, choosing to take their children to a doctor for medication rather than altering their parenting styles to address difficult behavior. Contrary to this perception, however, many parents report experiencing great worry over the decision to seek treatment for their children. Many would likely report that these actions were a last resort. A great number of ADHD diagnoses are initiated at school. Parents are often called to school repeatedly to address a child’s unruly behavior, and eventually a teacher or administrator suggests an ADHD evaluation. If a parent is reluctant, this suggestion may continue to be made until he or she gives in. Regardless of whether they feel the ADHD label is appropriate, if a practitioner tells a parent that a son or daughter has ADHD, that parent has additional pressure to take steps to address it. Many parents, who may see themselves as grossly unqualified to determine the nature of their children’s problems, eventually defer to the opinion of the experts (teachers, doctors, psychologists) and accept the ADHD diagnosis and treatment. Despite critics’ claims, these parents would surely report that this decision is anything but easy.
ADHD is an issue touching more and more lives in the United States each day. Extensive research has been done on this topic, ranging from medical investigation to social interpretation, yet it remains an area ripe for exploration and debate. Science continues to seek definitive proof that a deficiency or imbalance in the brain, transmittable by DNA, causes recognizable unwanted behaviors that can be labeled and treated as a disease. At the same time, those opposed to this view continue to study and question the social factors surrounding this issue and disprove any biological basis. Neither side has had absolute success, so the controversy continues.
Regardless of where one stands in the debate, it is hard to deny that an increasing number of parents and children are being faced with the ADHD label. Those parents who hear competing information from various sources in the controversy often feel torn over the right thing to do and experience negative feelings, regardless of their decision. Perhaps one day an irrefutable medical discovery will be made to mark ADHD as a disease. Perhaps social opinion on children’s behavior will shift, and more rambunctious or unruly behavior will not be considered as problematic as it is today. Either of these events could result in an end to the debate surrounding ADHD. However, at this point, there is no indication that either type of solution will occur any time soon. Thus, ADHD diagnoses are sure to continue, with proponents’ blessings and critics’ curses.
Nicole D. Garrett
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