Exploring clinician uncertainty in the diagnosis and treatment of attention deficit hyperactivity disorder

Authors


Address for correspondence: Adam Rafalovich, Texas Tech University, Department of Sociology, Anthropology and Social Work, Box 41012, Holden Hall 158, Lubbock, TX, 79409-1012 USA e-mail: Adam.Rafalovich@ttu.edu

Abstract

Based upon analyses of interview data collected from twenty-six clinician respondents, this study explores two facets of clinician uncertainty related to the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in children. First, this study explores clinician reservations about the diagnostic validity of ADHD as it is described by the American Psychiatric Association (1994) in DSM IV. Second, this study explores clinician ambivalence regarding the physical and social-psychological side-effects of stimulant medications, such as Ritalin. In applying the sociological discussions that address uncertainty in clinical settings and through reviewing a sizable cross-section of the popular and research-oriented literature demonstrating the contentious nature of the ADHD phenomenon, this study illustrates that clinicians do not practice within a vacuum, but are instead largely affected by the marked scepticism that surrounds ADHD. In being affected by this scepticism, it is concluded that clinicians who assess and treat ADHD are autonomous in how they interpret the diagnostic and treatment protocols for this mental disorder.

Introduction

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.

Methods

In this study, clinicians are defined as persons with the accredited authority to make ADHD diagnoses, outline methods of treatment and administer such treatments. In utilising this definition, attention may be drawn to Sydney Halpern's (1990) discussion of the ‘boundary expansion’ in paediatrics, denoting an increased emphasis upon psychosocial and behavioural issues in paediatric practice and an increased complexity in the division of labour between paediatricians and other healthcare professionals (Halpern 1990: 28). It may be implied from Halpern's (1990) study that not only has paediatric practice changed, but there has also been a considerable blurring of clinical boundaries where children's psychological and behavioural problems are concerned. Hence, the ‘ADHD clinician’ may be a physician, psychologist, family therapist, and so on, all of whom may own similar levels of ADHD expertise. Accordingly, this sample represents a cross-section of clinical professions, including clinical psychologists, psychiatrists, paediatricians and general practitioners3. Over an 18-month period, beginning in August 2001, respondents were recruited from two North American cities with populations of 500,000 and 200,000. Participants ranged from 31 to 60 years of age; 10 were female and 16 were male4.

Clinicians were recruited according to a ‘snowball’ sampling approach (Biernacki and Waldorf 1981, Marshall 1996), denoting that the sample grew as respondents referred me to others whom they understood to have experience with ADHD. After being given an introductory letter summarising the purposes of the research, and showing a willingness to participate, all respondents were required to sign a consent form guaranteeing that the data obtained in the interview process would be held in confidence and that any publication or presentation of the material would protect their anonymity.

Completed over the phone or in person, interviews (lasting between 20 minutes and 1½ hours) were structured around an interview schedule, but were allowed to take on an open-ended, conversational tone in many cases. In an effort to avoid ‘waivering calibrations’ (Webb et al. 1966: 22) responses were taken down in note form and read back to participants in order to ensure that the field notes accurately represented their views. In some cases, follow-up interviews were scheduled to clarify certain contents of the field notes. Upon completion, the field notes were analysed for themes that could speak to generalisable discussions about clinician experiences (Glaser 1978, Glaser and Strauss 1967).

Ambivalence regarding ADHD as a diagnostic category

The shortcomings of DSM IV nomenclature

One of the most salient types of ambivalence towards the ADHD diagnosis that typifies ‘epistemological uncertainty’ (Fox 2000) concerns the accuracy of DSM IV's diagnostic nomenclature. The interview data indicate a rift between DSM IV's description of ADHD and the children with ‘unique circumstances’ whom many clinicians see in their offices. For many clinicians the myriad behavioural symptoms of ADHD (DSM IV criteria list 18 of them) may demonstrate validity issues with the ADHD diagnosis, particularly, that a diagnosis may conflate environmental/social struggles with truly neurological problems. In light of this, many clinicians – especially those practising in the areas of clinical psychology, psychiatry or family therapy – express the need to take an extended amount of time in assessing the nature of ADHD-suspected children's problems. This is exemplified in the interviews by clinicians’ discussion of the differences between ‘primary’ (neurological) and ‘secondary’ (environmental/social) types of ADHD – a dichotomy that is not discussed in DSM IV. As one respondent states: ‘I’ll try to find out if ADHD is a primary or secondary diagnosis. If it's secondary we probably don't have real ADHD – there's something else going on that needs to be addressed’ (Clinical Psychologist, female, age 51). Another clinician emphasises the distinction between real ADHD and a child's response to trauma: ‘Before you can really make an assessment, you need to get a feel for how your patients function. That simply takes longer than some people will allow, but you have to see what is a response to a trauma versus what is clearly something real’ (Psychiatrist, female, age 48). The perception that ‘ADHD-like’ symptoms may be environmentally-based and mimic the ‘real’ disorder speaks to the epistemological inadequacies of DSM IV, which offers no language regarding the differences between environmental and neurological causes for ADHD. In such cases, the degree to which DSM IV informs or bolsters the greater knowledge about what constitutes ADHD in clinical practice is inadequate.

Though DSM IV is argued to have a certain utility in clinical practice, many respondents contend that they use it in spite of concerns that the manual may be inadequate in describing ADHD concisely and exclusively. Such clinicians are inclined to describe DSM IV as a general guide to ADHD behaviours, but offer a disclaimer that it is not the final authority on the subject. As one clinician states: ‘The DSM is a guide, it doesn't account for all of the other variables that go into a diagnosis’ (Clinical psychologist, male, age 56). DSM IV, it is repeatedly argued in such discussions, is not enough to account for the multiplicity of factors that go into a case of suspected ADHD. In some instances, DSM IV may be so general that it fails to acknowledge that ADHD-like behaviours can arise from sources other than bona fide neurological impairments, and in others, DSM IV is argued to neglect additional problems affecting ADHD-suspected children:

Oh yeah, without a doubt we use it (DSM IV), but we try to look for a lot more than just a diagnostic label. I mean we look at each case really individually because there may be a lot more going on than what the DSM can explain. With ADHD kids there usually is a lack of fine motor skills and the DSM doesn't talk at all about that stuff, so we look for things beyond the call of duty in that sense (Psychiatric Nurse, manager of an ADHD clinic, female, age 35).

Clinicians also express a more specific criticism of how DSM IV's language may fail to translate to a unified interpretation of behaviour. As one man, a 45-year-old clinical psychologist explains: ‘I also think that ADHD is a loaded word. If a kid is unable to stay focused and on task, maybe there are some other reasons for this’. ADHD, this clinician contends, may not always be the correct term for problem behaviours, especially those that occur in a scholastic context. This respondent continues to state that: ‘A lot of times we might need to be focusing on the kid's learning process, rather than the problems he may have with attention or concentration’, denoting that what DSM IV calls ADHD may just be a way of problematising a different learning style. Addressing the expansive scope of ADHD symptoms, another clinician states: ‘I really think that ADHD is a garbage can diagnosis. . . . I wouldn't be surprised if we see the diagnosis changed within the next couple of years’ (Family therapist, male, age 52). Testimony of this type resonates with discussions of the early and present conceptualisation of ADHD which claim that the disorder has been continuously plagued by a lack of elegance in its symptomatology (Kessler 1980), and that its current DSM IV description represents a residual category in which a plethora of behaviours are unjustifiably unified under the ADHD rubric (Walker 1998). Such interview data demonstrate that the past and current interrogations of the ADHD category are reflexive with the everyday experience of mental health practitioners who may be confounded by the all-encompassing nature of ADHD nomenclature.

Reflected in clinical practice, epistemological uncertainty is more pointedly illustrated by clinicians who state that they avoid the use of DSM IV in cases of suspected ADHD because the manual is irrelevant to their clinical approaches. That is, the need to ‘know’ whether or not a child has ADHD, and diagnose him/her as such, is far less important than identifying and treating a child's unique situation. As one clinician explains, DSM IV is not relevant because his treatment of children emphasises behaviour, rather than specific diagnoses: ‘I don't [use DSM IV] because it's not really relevant to me. . . . I just want to look at what the needs of that child are. And, it may very well be Ritalin, but I try to examine some other lines of treatment’ (General Practitioner, male, age 60). Such sentiments do not denote a complete rejection of the conventional methods for treating ADHD – Ritalin, for example, is not ruled out as an option – yet this clinician exercises a certain degree of freedom in interpreting a child's behaviour. Another clinician, who is entirely sceptical of the ADHD diagnosis, found the DSM IV irrelevant, because it failed to describe a condition that was visible in contexts outside school:

I look at the child's environment, the child's basic needs. If you think about what these needs are they revolve around home and school, because that is where they spend most of their time. These are the areas that need to be evaluated, not the child. ADHD is just plain BS. When a person has diabetes they have it everywhere they go. With ADHD, we are supposed to believe that these symptoms only exist when they are in school? Nonsense (Paediatrician, male, age 49).

Such scepticism stems from the highly specific environments where suspicions of ADHD are garnered by adults. If ADHD is a somatic illness, this clinician asks, why do we only suspect it in classrooms?

Stated in a variety of ways, scepticism and incertitude regarding the physiological nature of ADHD permeate respondent accounts. Though eight clinicians convey a conventional neurological interpretation of ADHD, discussing brain under-activation and dopamine disregulation (Mate 1999: 40–1), the remaining 18 respondents express a range of uncertainty about such a position. When asked about what they understood to be the root causes of ADHD many respondents simply claim not to know. Some responses in this regard include statements such as: ‘I haven't really gone into it’, and, ‘I am not too sure what current causes are being considered’. Other respondents allude to a variety of physiological and psychological causes, but do not articulate a coherent theoretical approach to the disorder. For example, one respondent claims ADHD is caused by ‘erratic arousal patterns in the brain’, another states that ADHD children lack a ‘focus chemical’, and yet another clinician claims ADHD results from a collection of small or ‘little T’ traumas throughout a child's life. Reflecting some of the contrasting accounts of the disorder that exist in clinical and research literature, some clinicians argue that ADHD is simply not understood at this point by medical science: ‘I don't really think anyone knows what ADHD is at this point. The research doesn't seem very conclusive, but it's getting better’ (Clinical Psychologist, female, age 42). Such perspectives denote ADHD as a disease ‘in process’, the origins of which have yet to be entirely understood.

The interviews elucidate that in certain instances, a unified aetiology of ADHD is not an ultimate goal, and for some clinicians, is irrelevant to the way they practice. The accounts from clinicians who diagnose and treat ADHD, yet do not articulate a specific theory about what causes the disorder, demonstrate the difference between academic ADHD forums that continuously seek and debate a crystallised ADHD aetiology and the clinical forum, where the treatment of behaviour may be more important than understanding its origin. Underlying a great deal of the uncertainty about what causes ADHD is the belief that if ADHD-like behaviours cease, or are adequately contained, a greater understanding of the physiology of ADHD – if there even is such a physiology – is unnecessary.

The professional necessity of applying DSM IV ADHD criteria

The ‘official’ (Emerson and Messinger 1977: 121) diagnosis of ADHD may not always be a result of the nosographic acumen of DSM IV. In many instances, the ADHD diagnosis, and hence, the application of DSM IV criteria is viewed as bureaucratically necessary. As one clinician comments, DSM IV criteria are the basis for third-party recompense: ‘Insurance companies like to get some kind of diagnosis, and the plain fact is that they do cover ADHD, or just about anything in it [referring to the contents of DSM IV]. I guess you might say there is a pressure to use the letters “A-D-H-D”, so that we can move ahead and get a kid treated’ (Psychiatrist, female, age 48). Further emphasising the financial necessity of DSM IV, another respondent states: ‘We have to codify what they have, otherwise things can get mighty expensive’ (Paediatrician, female, age 40). Such accounts illustrate that beyond attaining a diagnosis that insurance companies view as legitimate and worthy of reimbursement, parents may incur tremendous financial expenses for their children's treatment.

According to Kirk and Kutchins (1992), the increasing financial pressure that is placed upon mental health practitioners may contribute to ‘deliberate overdiagnoses’ (Kirk and Kutchins 1992: 240), and of course, to misdiagnoses, of mental disorder. As Kirk and Kutchins (1992) argue, in the event that misdiagnosis occurs, ‘clients may have good reasons to believe that misdiagnoses are in their best interest’ (Kirk and Kutchins 1992: 240) because a mode of treatment will be financially accommodated. Though it is not articulated in the interviews as ‘misdiagnoses’, there clearly are cases in which the label of ADHD is given for the sole purpose of realising professional aims that could not be accomplished without the legitimacy of DSM IV and the financial compensation that that legitimacy facilitates.

Concerns regarding children and stimulant medication

Medication over-prescription

Because ADHD cannot be conclusively validated through a test in the same manner as somatic illnesses, many clinicians argue that ADHD is diagnosed too frequently, with inadequate information, and that more kids are on medication than is necessary. Clinician ambivalence, in this context, arises out of the potential for misdiagnosis and the possibility of inappropriate treatment measures. As one clinician states: ‘. . . the diagnosis is given way too freely. That means more kids on meds who are not supposed to be on them or are too young for them’ (Clinical Psychologist, male, age 47). And another clinician: ‘I think you have to take a look at how many kids are being told they are ADD, and just know that something isn't right with this in every case. . . . It does concern me that with as fast as the diagnosis is given out you have a lot more kids on medication who may not need to be. That's not to say that some kids don't need it, but there just seems to be so many kids on it these days’ (Paediatrician, male, age 52). Testimony of this sort draws suspicion towards the seemingly large number of children who are diagnosed with ADHD, and highlights the concern over the harm that can be brought upon children who are misdiagnosed and inappropriately given medication.

In accordance with the perception that Ritalin and similar drugs are administered too frequently, some clinicians explain the use of such drugs as a way of shirking issues that may underlie childhood behavioural problems: ‘It [medication] can be seen as a quick fix. Some people will go to a GP or a pediatrician and get a quick and dirty diagnosis and a packet of pills, which is malpractice in my opinion. A pediatrician can easily just become a medication consultant, rather than someone who is really treating a real problem’ (Psychiatrist, female, age 47). Relieving the immediate situation of children in crisis, some clinicians argue, is really to relinquish the responsibility of probing deeper into children's circumstances. The invocation of phrases, such as ‘medication consultant’, conveys a disdain for clinical practices that focus strictly on the mechanics of children's reactions to medication, rather than on those practices which address the litany of psycho-social issues troubled children encounter. Such sentiments coincide with previous claims about the rapidity with which ADHD children are given medication to the exclusion of psychotherapeutic treatment methods (Walker 1998).

Addressing the physiological and social psychological side-effects of medication

The data demonstrate pronounced concern about the possibility of negative physiological effects of stimulant medication. Exemplifying this, one respondent states: ‘It hasn't come up in a while, but some kids do not belong on meds. Some kids I've seen have developed other conditions. . . . One kid became unusually paranoid. He had some major unrealistic fears about other kids, about his siblings. We had to petition his parents . . . to get him off the drugs’ (Clinical Psychologist, female, age 45). Another respondent states: ‘A lot of the kids I've seen on meds are a lot more sombre, not as happy. When the meds wear off, the kids can become over-emotional, freak out, or get insomnia. You have to wonder how good the drug is working if that's what happens . . .’ (Clinical Psychologist, male, age 56).

In addition to issues concerning the physical side-effects of Ritalin and other drugs were concerns about such drugs’ social psychological impact. For example, some clinicians articulate that the development and maintenance of a child's behavioural ‘locus of control’ may become dependent upon the protracted use of medication: ‘And then there's the issue of parental responsibility. Mothers will often say: “He's acting like that because he didn't take his medication today”. There's no internal locus of control. It's all about the meds’ (Clinical Psychologist, female, age 42). In order to evaluate the level of loss of the internal locus of control, it is argued that children need to be evaluated in order to demonstrate the extent that improved behaviour remains after the cessation of medication:

One thing that is concerning me more and more is the dependency upon the medication for continued good behaviour. I sometimes see children whom I feel should stop taking the medication or should attempt it anyway, and they sort of refuse that. It's like the child cannot be a good boy unless the medication is around. . . . There needs to be more independence from the effects the drug has upon behaviour, allow people to kind of stand on their own and see how they do without it (Paediatrician, male, age 43).

As it is increasingly relied upon as the primary linchpin between ADHD children and appropriate conduct, medication may be a complex issue for clinicians: they must address the social demands that are placed upon ADHD children vis-à-vis the greater, long-term issue of the development of self concept that may become intertwined with medication.

The issue of internal versus external loci of control bespeaks the relationship between medication, behaviour and child identity. As many clinicians explain, an alteration in behaviour through stimulant medication will improve an ADHD child's social relationships. This, consequently, will relieve anxiety, improve confidence in social situations, increase self-esteem, and so on. In many ways, the value of these social successes overrides the myriad concerns clinicians have about medication. As one respondent states: ‘It's kind of like a give and take situation [referring to medication]. If you don't start getting the kid connected to something meaningful and give him a sense of success, it's not going to matter what we do later. . . . So, it's like you take the good with the bad’ (Paediatrician, male, age 52). In acting as mediators between an ADHD child's social successes and the chemical means to achieve them, clinicians are sometimes left with difficult decisions about when medication should be reduced or ceased. As another paediatrician explains: ‘I'd say that 80 per cent of the time I reduce the dosage of a kid's Ritalin, the parents are calling immediately to get him back on it. I think they see some of those bad behaviours again, and they want no part of it’ (Paediatrician, female, age 40). In such instances, outside parties may influence the way clinicians manage medication treatment. These issues resonate with Peter Kramer's (1993) concerns about ‘cosmetic psychopharmacology’ (1993: 15), denoting that psychoactive medications are no longer being prescribed strictly for health-related purposes, but are now also used for character flaws, social skill deficiencies and the like. Similarly to many of the respondents in this study, Kramer (1993) concedes his resistance to the cosmetic use of medications because both his patients and the people surrounding them inadvertently mandate it.

The medication holiday

Despite a plethora of external pressures, clinicians retain considerable agency in regulating when stimulant medications are taken, in what dosages and for what duration of time. As it is corroborated by the ADHD clinical literature and clinician accounts in this study, ADHD behaviours are understood to be largely location specific, most commonly exhibited in the school context (Black 1992, Bloomingdale 1985, Burnley 1993, Dowdy 1998). Following this, the majority of clinicians state that when the demands of school are not present, medication becomes less necessary and warrants what one respondent calls a ‘medication holiday’. The times for such a holiday vary, but may include weekends, Thanksgiving, Christmas and summer vacations, and so on. Clinician accounts of how they recommend this temporary cessation of medication is often encased in language that alludes to the physiological and psychological effects of stimulant drugs, and hence further illustrates how clinicians manage the perceived risk of harming children. As one clinician states: ‘We do recommend that parents take their kids off the meds when the environment isn't as demanding. Holidays are always a good time to get off the meds and allow the body to readjust’ (Clinical Psychologist, male, age 45). And another clinician:

During summer time they should take breaks and wash ‘em out a little bit. I'm often curious to know what kind of learning explorations they do during those breaks. I think that seeing how kids behave without structure can help us see what kind of learners they are (Clinical Psychologist, female, age 39).

In using phrases, such as ‘allow the body to readjust’, and ‘wash ‘em out a little bit’, such responses allude to the potential toxicity of stimulant medication. In addition, during the medication holiday, clinicians express that a child may be allowed to engage in explorations that are not mediated by medication. ADHD children, from this perspective, can be better understood through less-structured, un-medicated experiences.

Other respondents, whose treatment protocols include temporary cessation of stimulant medication, voice concerns about the adverse effects of such medication in more specific terms. Many claim that even though it may rectify problem behaviour, medications are still a foreign and potentially damaging element in the body: ‘We can't constantly remain on a drug. Our bodies will start to break down’ (Clinical Psychologist, male, age 45). Another clinician, whose son is diagnosed with ADHD, shares this opinion: ‘. . . kids are on it too bloody long. I used to have my kid's teacher make him run laps when he acted out. He was never medicated and he really got into shape from all of the running. We still joke about that’ (Clinical Psychologist, male, age 56). Another respondent voices concern about Ritalin acting as an appetite suppressant:

I will recommend a break from the meds if there is a consistent lack of caloric intake. That is one of the common side effects, lack of appetite. With the younger ones we have to really watch that. We give them a break so they can eat normally and get their calorie count on par with others their age (Paediatrician, male, age 47).

Another reason for clinicians to recommend a break from medication is drug tolerance, described as a condition in which the effectiveness of a drug is maintained only through increasingly larger doses. Though the drug's effectiveness declines, the potential toxicity for the drug remains the same. For clinicians specialising in ADHD, care is often taken to rectify this problem. As one clinician states: ‘When tolerance is built up the drugs are far less effective and that often means an increase in the dosage. It's better to allow the child to take a break from the medication and let his body readjust rather than to change the dosage’ (Paediatrician, male, age 52).

Respondents also contend that taking a break from one medication might mean switching to another to see if the tolerance is alleviated. For example: ‘Sometimes instead of taking a break altogether you may want to switch medications. They say with kids you get about 15 per cent tolerance per year. That means constantly upping the dosage’ (General Practitioner, male, age 55). The process of removing a child from medication depends on the type of dosage the child is currently taking and how they uniquely respond to it: ‘It . . . depends on the metabolism of the child. Some of the kids we see are only taking five mgs of Ritalin per day, but we have some others who are taking 60 mg per day. You don't just take a kid who is on 60 mg a day off the meds and see what happens. In that case, we may just lower the dosage to lessen the tolerance’ (Psychiatric Nurse, Manager of an ADHD clinic, female, age 35).

Conclusion

The clinician accounts presented here demonstrate a considerable ambivalence within the context of diagnosing and treating ADHD in children. As a necessary supplement to previous sociological analyses that describe the ‘construction’ of ADHD as a result of the concerted effort of particular agents (Conrad 1975, 1976), this study reveals that the contentions which continue to plague validity claims about ADHD and its treatment may have a visible impact upon clinician opinions and practices. Hence, the ambivalence elucidated in this study may demonstrate the reflexivity between clinical realms and the broader discursive contexts that affect, and are affected by, such realms. As the diagnostic category of ADHD and its most conventional methods of treatment remain mired in debate, the many points of contention that characterise the modern discussion of ADHD may become visible in the way clinicians realise their professional aims.

Clinicians do not practice in a vacuum. The broad scepticism about ADHD influences the manner in which clinicians diagnose and treat ADHD-suspected children. Within the clinical context, the diagnosis and treatment of ADHD is a forum for an array of interpretations that are replete with uncertainty. Examples of this can be seen from clinicians who separate ‘real’ and ‘false’ ADHD, and from those who express concern about the use-value of DSM IV's ADHD nomenclature. Uncertainty regarding the ADHD diagnosis can also be seen in the breadth of different theories clinicians posit about the origins of the disorder – including whether or not the disorder is organic or strictly psychological – and also in the accounts from clinicians who treat ADHD, but fail to describe a unified theory about the disorder. As it is an approach imbued with the potential for physiological and/or psychological harm, the treatment of ADHD with stimulant medication appears equally problematic. In recommending and/or administering medications, clinicians may practice cautious restraint, and negotiate how medications should be taken and when temporary cessation of them is necessary. Such caution speaks to the social organisation of ADHD, illustrating that the large numbers of ADHD-diagnosed children and the wide use of stimulant medications are not automatic, mechanical phenomena, but rather, are preceded by processes of negotiation and interpretation.

Clinical practices are at the heart of disputes over validity claims describing how medical records should account for someone's physical and/or mental health (see Berg and Bowker 1997). If the ‘condition’ of ADHD is supposed to reflect discernible and consistent problems in social life, we must inquire to what extent the diagnostic protocols (those primarily found in DSM IV) are sufficient for definitive assertions about whether or not a child has ADHD. As the data from this study suggest, the protocols for diagnosing ADHD are influenced by a variety of factors (see Berg et al. 2000, Lynch 2002, Timmermans and Berg 1997) and the directions given by ‘protocol statements’ (Lynch 2002: 203–4) do not always find a perfect application in clinical settings. Indeed, the guidelines that dictate ADHD diagnoses and treatment may be negotiated in ways that demonstrate significant clinician autonomy. Applying these assertions to the analysis of how clinicians in this study regard DSM IV, it is clear that many clinicians ‘look past’ the diagnostic criteria of the manual, and instead, examine ADHD-suspected children in a nuanced fashion. As the findings here indicate, this more cautious approach to such children is influenced by at least two related factors. The first concerns the potential for misdiagnosis if the mandates of DSM IV are applied too rigidly, or with inadequate background information about a child. The second concerns the threat of psychological and/or physiological harm that can result when medications are incorrectly administered to children.

Ambivalence about the diagnostic validity of ADHD is displayed rather paradoxically within a broader clinical context in which medication is a staple treatment. This contradictory state reveals the more general condition of clinical practice, of which uncertainty is an inherent part (Fox 2000). Clinicians are the chief negotiators of ‘high-risk’ professional environments (Fox 2000: 417) that may involve dangerous interfaces between the people who seek help in these environments and the technologies that give the tentative promise of this help. The medication technologies associated with ADHD are crucial in this regard. We may conclude that the administration of stimulant medication follows an assessment of risk and a negotiation with the greater ambivalence that surrounds ADHD. As reflected in the interview data, this greater ambivalence may be regarded as an extension of the ‘epistemological uncertainty’ (Fox 2000: 419–20) and the ‘anxiety, ambivalence, and perplexity’ (2000: 420) that surrounds Western clinical practices.

Notes

  • 1

    ADHD is a mental disorder most commonly detected in children and is characterised by problems in maintaining attention and/or problems with impulsive behaviours. For a complete symptomatic description of ADHD, please see American Psychiatric Association (1994: 79–85).

  • 2

    The Conners Rating Scale (CRS) was originated by C. Keith Conners (1969) and has become the most utilised method of trying to diagnose ADHD and other problem childhood behaviour. This scale, originally intended to provide a basis for prescribing stimulant medication for children, has gone through many revisions in its 30-plus year history. Currently, it follows DSM IV guidelines to try and tease out problem childhood behaviour. In the long version of the forms (there are forms for teachers and parents, both of which are gender-specific), a white to red shading scheme reveals the possible presence of a DSM IV diagnosis. If the score falls within the red colour, the clinician may be alerted to a possible disorder. There is also a Conners ‘Self Report’ that children themselves fill out.

  • 3

    Respondents per clinical occupation include: nine psychologists (eight clinical psychologists and one area school psychologist), six paediatricians, four general practitioners, four psychiatrists, one psychiatric nurse who manages an ADHD clinic, one family therapist and one psycho-educational assessor (note: because the clinical role of a psycho-educational assessor is somewhat marginal, data from this respondent, though interesting, are not included in this report).

  • 4

    As this study is based on intensive interviewing and draws from a relatively small sample in comparison with other methodological procedures that are better suited to the development and analysis of data from larger samples, it should be noted that certain social variables would be inadequately addressed if analysed in this forum. Hence, studies cross-tabulating the race, class and gender of respondents may be better suited to a quantitative approach, and would indeed be a welcome addition to the sociological study of ADHD. As shown, excerpts from respondents mention age, gender and occupation. This is meant to show more of a human face to the respondent group. A similar method of description is also used in the award-winning work of David Karp (1996).

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