Previous sociological discussions have asserted that clinical ambivalence pertaining to illness diagnosis and treatment stem from the interactivity between macro-level contexts and the micro-level dynamics of clinical settings (Waitzkin 1989). Such macro-level contexts are characterised by a litany of popular and academic discussions, and/or trends in conceptualising clinical problems, which influence how clinicians realise their professional aims. More specifically, popular and academic debates surrounding the validity of illness categories and their treatments affect the manner in which diagnoses are made and treatments provided. Recent discussions in medical sociology argue that clinical settings are not unaffected by contrasting types of knowledge, or by public outcries against established medical practices, but are instead embedded in these reflexive social circumstances. As shown by Arnetz (2001) and Pescosolido and Kronenfeld (1995), today's public reception of clinical settings is characterised by an ambivalence that was absent a generation ago. Making extensive use of two theoretical positions from Anthony Giddens, first concerning social reflexivity and the uncertainty of modern scientific conclusions (Giddens 1991), the second concerning uncertainty as it applies to knowledge in general (Giddens 1994), Williams and Calnan (1996: 1612) contend that modern clinical practice is subject to a constant onslaught of ‘reappraisals, re-assessments and revisions’ which insert a new complex set of problems into the clinical sphere. Continuing with this line of discussion, Fox (2000: 419) argues that there is a profound ‘epistemological uncertainty’ that affects clinical practices. As alternatives to established clinical practices have been given a more significant voice in a variety of forums, Fox (2000) argues that the presuppositions which establish a clinical phenomenon as ‘knowable’ rest on increasingly shaky ground.
Given these assertions, the medical sociology purview has widened to include a discussion of uncertainty as a social phenomenon that is managed by clinical students and professionals. For example, Timmermans and Angell (2001) contend that the management of uncertainty is an established part of the routines of medical students – a condition that is integral to professional success. In this sense, the management of uncertainty is not a preparation for a more ‘certain’ professional life, but is pertinent to being an effective clinical practitioner. As such, when practitioners encounter and manage ambivalence, the implementation of diagnostic and treatment protocols may become problematic. Studies by Berg et al. (2000), Lynch (2002) and Timmermans and Berg (1997) support this position by arguing that diagnostic protocols are multi-faceted, socially-influenced phenomena. For example, manuals such as the American Psychiatric Association's (APA's) DSM IV (1994) which offer an authoritative diagnostic voice are perceived as one aspect of the diagnosis and treatment process, rather than its guiding principle. In the face of clinical nomenclature whose objectivity may be more suspect, the definition of said protocols becomes more nebulous. How clinicians interpret and apply a diagnostic label may be a far cry from how texts provide the confines for a diagnosis.
The presence of ambivalence and negotiation in clinical settings is especially visible within the context of diagnosing mental disorders, which have been the subject of fierce sociological criticism (Goffman 1961, Scheff 1999, Warren 1987, amongst many others). Such criticism contends that the definition, diagnosis and treatment of mental disorders may result from the levelling of culturally-biased judgements upon deviant individuals – judgements which are exercised through marked power asymmetry between diagnostician and diagnosed. Following the aforementioned stances in medical sociology, it can be asserted that the scepticism surrounding the validity of mental disorders, such as clinical depression, oppositional defiant disorder, schizophrenia and so on, have a significant impact upon clinical practices. This is especially true in the case of attention deficit hyperactivity disorder (ADHD)1, whose diagnosis and treatment epitomises today's ‘epistemological uncertainty’ towards clinical practices.
The uncertainty surrounding ADHD
It has been estimated that five million school-age children are prescribed stimulant medication for ADHD in North America – a 700 per cent increase in such prescriptions since 1990 (Diller 1998). This dramatic accretion in medication treatment represents the significant influence of neurologically-oriented perspectives towards ADHD, claiming that the disorder is reducible to brain structure abnormalities (Barkley 1997, Castellanos, Giedd and Marsh 1996, Fisher 1996, Fuster 1997, Mataro 1997). Administering medications for ADHD may be seen by many mental health practitioners as akin to prescribing antibiotics for bacterial infections: physiological problems require pharmacological attention. The history of ADHD, however, has demonstrated that researchers and clinicians have been far from unified in adopting a strictly neurological perspective towards the disorder (Rafalovich 2001a). Though neurology has attained a degree of dominance in the discussion of ADHD (Gwynedd and Norris 1999), the disorder has been, and remains, mired in controversy on both aetiological and treatment fronts.
First, aetiological stances implicating brain structure abnormalities in children exhibiting symptoms of hyperactivity and inattention have encountered significant resistance. After the neurological perspective towards such problems had begun to take hold in the 1920s (Abrahamson 1920, Ebaugh 1923, Kennedy 1924, Strecker 1929, Stryker 1925), scepticism towards such perspectives arose from those adopting an environmental, psychologically-oriented posture in the 1940s and ‘50s (Bender 1949, Greenacre 1941, Rank 1954). As staunch advocates of psychotherapy, such critics of neurology asserted that excessively overactive and generally misbehaving children may be responding to environmental problems, rather than direct neurological impulses. Other critics linked children's hyperactivity problems to food additives (Feingold 1974) and hence, implicated not brain structure, but diet, in ADHD-like behaviour. The ‘Feingold Diet’ has been argued to effectively reduce children's problematic behaviour without the aid of medication (Rowe 1988). The international mental health community has also questioned the validity of the ADHD diagnosis, as a working party from the British Psychological Association recently concluded that ADHD was a diagnosis replete with nosographic inaccuracies and cultural bias (Reason 1999). In the United States, a 1998 National Institutes of Health conference between experts in ADHD research and treatment came to the unsettling conclusion that the ADHD diagnosis had alarming reliability and validity problems (Goldman et al. 1998). Such conclusions about ADHD stem from marked inconsistencies in discerning the presence of the disorder from Positron Emission Tomography (PET) scans of the brain, and from the mainstay of clinical assessments for ADHD, the Conners Scale2, which many researchers claim may reveal childhood behavioural problems, but fails to substantiate brain structure defects (Goldman et al. 1998).
Second, the predominant treatment methods for ADHD, primarily comprising the administration of stimulant medications, such as Adderall, Benzedrine, Dexedrine, and Methylphenidate (Ritalin), have been continuously embroiled in debate. Concurrent with the widespread use of stimulant medication beginning in the 1960s were clinical accounts of children having psychotic reactions to such drugs (Lucas and Weiss 1971, Ney 1967). Such accounts have fuelled research associated with the ‘anti-Ritalin’ movement, most notably represented by Peter Breggin's (1998) bestselling Talking Back to Ritalin (also see Armstrong 1995, DeGrandpre 1999, and Diller 2001 for additional anti-Ritalin perspectives). Partially to summarise Breggin's perspective, the use of Ritalin is a means by which adults have exonerated themselves from responsibility for their children's behaviour, and is tantamount to child abuse. The effects of the anti-Ritalin movement have been compounded by recent California and New Jersey class-action lawsuits in which parents argued that the patent owner of Ritalin, Novartis Pharmaceuticals, conspired with the APA to produce a market for Ritalin (Charatan 2000). Finally, considerable discussion has also arisen concerning the addictive qualities of Ritalin (Nicklin 2000) and that using Ritalin as a child may lead to chemical dependency later in life (Marks 2000).
Given this historical and contemporary context of scepticism it is fitting to investigate the extent to which the uncertainty that surrounds ADHD is demonstrated through clinical practices. As an empirical example of medical sociology perspectives which focus upon uncertainty in clinical practices, this paper investigates how clinician experiences in diagnosing and treating ADHD-suspected children are affected by the well-publicised concern about the validity of ADHD and the chemical means by which the disorder is most commonly treated.
Through analysing in-depth interview data from 26 clinicians, this study demonstrates how many mental health practitioners harbour varying degrees of ambivalence about the diagnostic criteria, treatment methods, and biological basis of ADHD. In providing a qualitative account of clinician experiences, this study seeks to contribute to the growing sociological literature on ADHD (Conrad 1975, 1976, Conrad and Potter 2000, Malcacrida 2002, Rafalovich 2001b) by elucidating aspects of the ‘social arrangements’ of mental disorder (Horowitz 2002: 143), specifically, how clinicians interpret and apply the various and sundry ADHD discussions in everyday practice. As data from the interviews convey, 24 of the clinicians interviewed express various types of uncertainty regarding the ADHD diagnosis and/or the ways in which they treat the disorder in clinical practice.
The findings of this study discuss clinician uncertainty as it is expressed in two ways that reflect the aforementioned epistemological crisis about what constitutes ADHD. First, this uncertainty can be seen through the incertitude most clinicians express regarding ADHD as a diagnostic category as it is encapsulated by the APA's (1994) DSM IV criteria. Second, this ambivalence is prevalent in clinician discussions of their many reservations about pharmacological approaches to ADHD. Included here are issues clinicians raise concerning the possible over-prescription of stimulant medication and its social psychological and physiological side-effects in children.