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Framing the ADHD child : history, discourse and everyday experience Rafalovich, Adam 2002

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F R A M I N G T H E A D H D C H I L D : H I S T O R Y , D I S C O U R S E AND E V E R Y D A Y E X P E R I E N C E By Adam Rafalovich B.Sc. Southern Oregon University, U.S.A., 1993 M . A . Northern Arizona University, U.S.A., 1995 A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE F A C U L T Y OF G R A D U A T E STUDIES (Department of Anthropology & Sociology) We accept this thesis as conforming to the required standard T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A July 2002 © Adam Rafalovich, 2002 UBC Rare Books and Special Collections - Thesis Authorisation Form Page 1 of 1 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the Un i v e r s i t y of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I further agree that permission for extensive copying of t h i s thesis for sc h o l a r l y purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or pu b l i c a t i o n of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The U n i v e r s i t y of B r i t i s h Columbia Vancouver, Canada Date 9/2/2002 11 Abstract Through employing a two-faceted approach to the sociological study of Attention Deficit-Hyperactivity Disorder (ADHD), this thesis seeks to further the study of this mental illness and also to elucidate new methodological directions for the sociology of similar phenomena. Past approaches in the sociology of mental disorder have considerable merit, but may also be limited in the type of analyses they offer. One particular limitation concerns sociological accounts of mental illness that portray the meaning of such illnesses as unified and that this unification results from the collusion of special interests. Sociologists who address mental illnesses as social problems, for example, appear wont to portray such illnesses as social constructions which arise from specific agents of labeling. With regard to A D H D , previous sociological accounts often make a case for the rhetorical and political power of government agencies, medical practitioners, and pharmaceutical companies. Though such agents are certainly influential in shaping public conceptions of A D H D , this thesis demonstrates that A D H D is interpreted in various ways. These assertions are supported through the analysis of two different data sources: 1) textual data; and 2) interview data. The textual data for the first part of the thesis comprises the subject matter for a genealogy of A D H D . Through examining past and contemporary texts that frame this disorder, including medical journal articles, medical manuals, popular writings, and parental guidebooks, the author argues that the historical and current discussions of A D H D are replete with differing interpretations of the causes and treatments for ADHD. These A D H D discourses, as they are seen through written accounts, offer a variety of perspectives towards the disorder, drawing from many opposing schools of thought. Most notable in this regard are psychodynamic and neurological approaches to A D H D . I argue that even though the neurological perspective towards ADHD appears to be the most dominant in diagnosing and treating the disorder, it is far from monolithic. ' The second part of the thesis draws upon interview data from sixty-two respondents associated with cases of A D H D : twenty clinicians, twenty parents, and twenty-two teachers. I l l Each of these groups of respondents were asked questions designed to solicit their subjective experiences with the disorder, including how they perceived A D H D children and their sources of ADHD knowledge. The analysis of such data is placed against the backdrop of the genealogical part of the thesis. Responses from participants are examined as reflecting A D H D discourses. Some respondents, for example, demonstrate a commitment to neurological perspectives towards ADHD, while others gravitate towards psychodynamic or combined understandings of the disorder. Through combining these two data sources, this thesis analyzes A D H D discourses that give rise to conceptions of the disorder and shows how these discourses influence attitudes and actions towards A D H D . By giving less salience to the collusive relationships between government agencies, medical practitioners, and pharmaceutical companies, and by putting more focus on the relationship between the three major groupings directly involved in the A D H D experience—clinicians, teachers, and parents—this thesis furthers the sociological study of ADHD. Table of Contents Abstract i i Table of Contents iv List of Tables xv Acknowledgements xviii Part I: Past and Current ADHD Discourses 1 Introduction 1 Chapter 1: Critiquing Social Constructionism: Introduction to the Genealogical Method 11 Addressing social constructionism 11 Focusing on A D H D 14 Previous A D H D nomenclature 14 Problematic.epidemiology 15 Addressing Peter Conrad 15 Reflexivity and Foucault 20 Introducing the genealogical method 20 Genealogy and Foucault's dependencies 23 Chapter 2: Linking Immorality to the Disordered Brain 30 Idiocy vs. imbecility 32 Examining the work of George F. Still 37 Encephalitis lethargica as explanation of childhood immorality 40 Chapter 3: Psychodynamic and Neurological Perspectives on ADHD: Exploring Strategies for Defining a Phenomenon 48 Psychodynamic perspectives Psychoanalytic perspectives: Anna Freud and Melanie Klein Compulsion neuroses Psychological perspectives The dominance of neurology Neurology's response to the psychodynamic perspective Charles Bradley and Benzedrine Paradoxically speaking Neurological discourse today Antagonism and the absent center of A D H D Laclau and the irony of the 'undecidables' Chapter 4: ADHD Discourse in the Domestic Realm: Parental Guidebooks and the Disciplining of Domesticity Examining the A D H D parental guidebook... Articulating experience and credibility Framing the A D H D child 1 A D H D children and the disciplinary moment 1 Volatile children 1 The narrative of domestic management 1 Negotiation and contract 1 Token economies and points systems 1 Alternative explanatory frames for A D H D 1 Diet 1 Television and video games '. 117 Guidebooks and the disciplined A D H D body 121 Part II: The Everyday Framing of ADHD 123 Chapter 5: Methodology and Profile of Interview Respondents 123 Respondent recruitment 125 Respondent Profile 129 Parents 129 Teachers 131 Clinicians 132 Interviewing 132 Procedure 135 Staying on task 136 Analysis .' 137 Coding , 139 Chapter 6: Clinician Frames for ADHD Children 144 Addressing the length of time clinicians had become familiar with A D H D 147 Suspecting parties and referral sources 148 School counselors and teachers 149 Parents 151 Factors in providing diagnoses for A D H D 153 Diagnosis time depends on the complexity of the case 153 Clinicians who report a regimented time for providing A D H D diagnoses 155 Clinicians who report that they are not diagnosing, just collecting information... 157 Clinician opinions on DSMIV 158 Clinicians who use DSM IV, but find it inadequate to entirely describe the A D H D condition 159 Clinicians who have reservations about specific DSM IV nomenclature 160 Unquestioning use of DSM IV 161 Clinicians who do not use DSM IV. 161 Discussion of treatment methods for A D H D 163 Behavior modification 165 Combining behavior modification and medication 168 Medication therapy 169 Clinicians' perceived acceptance of their treatment methods 171 Perception that treatment methods have a tentative or conditional acceptance 172 Clinicians who state that their methods of treatment are not accepted 174 Reservations about medication 174 Stimulant medications are overprescribed/the A D H D diagnosis is inadequate 175 Concerns about side effects 177 Concerns that the medication removes internal locus of control 178 Concerns over chemical dependency in later life 180 Clinicians with no reservations about prescribing stimulant medication 181 Addressing the issues of the duration of medication treatment 182 Medication duration depends on severity and complexity of A D H D condition 183 Clinicians who state that it is impossible to function without meds 184 Clinician perspectives on the temporary cessation of medication 185 Temporary cessation from medication is always recommended 186 Cessation whenever there is tolerance 189 The question of A D H D eradication 189 ADHD can be eradicated i f managed effectively 191 A D H D cannot be eradicated i f it is truly neurological 193 Clinician opinions on the role of educators in A D H D 194 Teachers need to recognize that A D H D is real and learn more about the disorder 195 Teachers need to modify curricula to suit A D H D children 197 Teachers are not qualified to provide diagnoses of A D H D and should stay within their field 199 Clinician opinion on the role of parents in relation to their A D H D children 200 Parents must keep a disability perspective when dealing with their child's behavior 201 Parents must involve themselves in the treatment process 203 Parents must learn to empower themselves 205 Clinician descriptions of the physiological process of A D H D 205 Clinicians who felt they could not adequately describe the physiology of A D H D . 206 Clinicians describing dopamine disregulation/brain underactivation as a cause of A D H D 207 Concluding remarks 209 Chapter 7: Educator Frames for A D H D Children 212 Conceptualizing A D H D children 216 i x A D H D children differ in their on-task behavior and general ability to focus 217 A D H D children have an excess of mental activity 219 A D H D Children have specific social problems 220 Teacher discussion of A D H D children's disciplinary problems 222 Teachers who stated that A D H D children disturb others, especially in the process of learning 222 Teachers who stated that A D H D children engaged in anti-social behavior, especially fighting 223 Connecting behavioral and academic troubles 225 Teachers who explain A D H D children's problems as a combination of academic and behavioral difficulties 225 Neurology or will : teacher perceptions of what motivates A D H D 227 A D H D children can control themselves to some degree 227 It is impossible for A D H D children to control themselves 229 A D H D children eventually outgrow the behavior 230 Teachers and other social actors surrounding a suspected case of A D H D ...231 School-based team 232 Speaking directly with parents 235 Discussion of teaching techniques for A D H D children 235 Teachers who modify assignment structure to suit A D H D children's needs 236 Teachers who employ a general effective method of teaching 238 Teachers who advocate building self-esteem and self-awareness 239 Classroom restructuring 240 Teachers who state that they do not implement structural changes to the classroom for A D H D children 241 Change proximity of the A D H D children to the teacher and other students 242 Particular teaching environment already accommodates children with A D H D and other disabilities 243 Teacher discussion of DSM IV 245 Teachers who never heard of DSM IV 246 Teachers who have heard of DSM IV and utilize these criteria in suspecting children of having A D H D 246 Teachers who have heard of DSM IV, but do not use it 248 Teacher perceptions of school consensus regarding A D H D 248 Teachers who feel there is no consensus in their school about how to deal with A D H D 249 Teachers who feel there is some degree of consensus about how to deal with ADHD children 252 Teacher discussion of the process of labeling kids "ADHD" 253 Teacher concerns about labeling children as A D H D 254 Teachers who stated that they had no major concerns about the A D H D label 258 Teacher concerns about the effects of failing to treat A D H D 260 Teachers who stated that untreated A D H D may lead to academic failure 261 Discussing A D H D and gender.... ; 263 Teachers who stated that the children with A D H D in their classrooms were predominantly boys 264 Concluding remarks 266 Chapter 8: Parental Frames for A D H D Children 270 Parent impressions of their A D H D children's social and academic competence 272 Parents who described their child's academic performance as poor in comparison to kids from the same age group 273 Parents who stated that their children had considerable gaps in their learning 276 Parents who described their child as academically superior to others from the same age group 277 Parents who described considerable immaturity in their child's social interactions 279 Parents who describe that their A D H D child demonstrated aggressive behavior in social situations 280 Parents who stated that their A D H D child's social development was normal in comparison to other kids 281 Parent discussion of whether or not their A D H D children expressed resentment at going to school 281 Parents who stated that their child expressed resentment towards school 282 Parents who stated that their child did not express any resentment towards school 284 Precipitating incidents leading to the suspicion of A D H D and their location 285 Parents who stated that their child showed signs of academic failure 286 Parents who stated that their child demonstrated specific anti-social behavior 288 Parents who stated that their child was generally disruptive during class time 291 The dominance of the school as the primary context in which incidents precipitating the suspicion of ADHD'occur 292 Addressing the absence of incidents outside of school 293 Discussing the first formal suggestions of A D H D 294 Instances where the suggestion of A D H D was made by a teacher, or some other school representative 296 Instances where the suggestion of A D H D was made by the parent 297 Instances where the suggestion of ADHD was made by a clinician 298 Sources of knowledge about A D H D symptoms 299 The connection between suggesting party and A D H D knowledge acquisition 300 Parental pursuit of literature 301 Finding out 303 Feelings of relief 304 Feelings of shock/devastation 305 Mixed emotions: being "scared for him" 307 Nipping the illness in the bud 308 Parents' discussion of alternative diagnoses and treatment 310 Parents who conveyed that they did not seek any alternative diagnoses to their children's A D H D condition 311 Parents who conveyed that they did seek alternative diagnoses to their children's A D H D condition 312 Breakdown of treatment methods 315 Parents who do not use any behavior modification techniques 316 Parents who use behavior modification 317 Parents' theories about the nature of A D H D 317 Parents who claimed that A D H D was an unspecified genetic condition 318 Parents who claimed that A D H D was a result of physiological processes 320 Parents who claimed that A D H D was a result of trauma 322 Concluding remarks '. 323 Chapter 9: Analyzing the Interaction between Respondents: Suspicion, Social Role Acknowledgement and ADHD Discourse 326 Discourse and group identity 327 Exploring cases of respondent interaction 330 Smooth transitions from suspicion to treatment: case #1 331 Experiencing formal intervention, semi-formal suspicion: case #2 336 Resistance at the point of pharmacological treatment: case #3 343 A psychodynamic interpretation and treatment for A D H D : case #4 349 Concluding remarks 354 Chapter 10: Conclusions 357 Revisiting social constructionism 359 The articulation of colluding forces 359 The dichotomy between the experts and the non-experts 360 Discounting discourse 361 Supplementing social constructionism: towards a synthetic methodology 362 Discourse analyses and interview schedules as mutually-influential 363 Inclusion of discourse in the analysis of interview data 364 Clarifying some key findings of this thesis in relation to the specific phenomenon xiv of ADHD . ...366 The contested nature of A D H D 366 The processes of A D H D suspicion and the framing of A D H D children 368 Suggestions for further research 370 The need for longitudinal analyses 371 The potential for in-depth empirical analyses of the transfer of knowledge 371 The empirical study of mechanisms of suspicion ..373 Studying children 374 Final remarks ....374 Bibliography 376 Appendix I: Introductory Letter for Respondents 394 Appendix II: Respondent Consent Form 395 Appendix III: Interview Questions for Parents of A D H D Children 397 Appendix IV: Interview Questions for Educators 398 Appendix V: Interview Questions for Clinicians 399 X V List of Tables Table 6-1. Length of time clinicians reported familiarity with A D H D 147 Table 6-2. Most common referral sources as reported by clinicians 148 Table 6-3. Breakdown of clinician opinions on the utility of DSM IV 159 Table 6-4. Breakdown of clinicians' treatment methods for A D H D 165 Table 6-5. Perceived conventionality of treatment measures by clinicians 172 Table 6-6.Breakdown of clinicians' reservations about prescribing medication for A D H D 175 Table 6-7. Length of time clinicians feel a child should take medication for ADHD. . . . 183 Table 6-8. Perspectives on the temporary cessation of medication 186 Table 6-9. Clinicians' perspectives towards the possibility of treatment that would eradicate A D H D 190 Table 6-10. Clinician opinions on the role of educators in relation to A D H D children 195 Table 6-11. Clinician opinions on the role of parents in relation to A D H D children 201 Table 6-12. Clinician descriptions of the physiological nature of A D H D 206 Table 7-1. Teacher descriptions of how A D H D children differ from normal children.. 217 Table 7-2. Teacher perceptions of disciplinary problems with A D H D children 222 Table 7-3. Teacher description of children's problems as academic, behavioral, or a combination of the two 225 Table 7-4. Teacher opinions on whether or not A D H D children can control their own behavior 227 Table 7-5. Teacher descriptions of the parties they initially contact when they X V I suspect a child may have A D H D 232 Table 7-6. Teacher description of teaching techniques employed for A D H D children. 236 Table 7-7. Teacher response to question concerning restructuring the classroom for A D H D children 241 Table 7-8. Teacher description of knowledge and/or relevance of DSM IV. 245 Table 7-9. Teacher opinions on the level of consensus in their school about how to deal with A D H D children.. 249 Table 7-10. Teacher responses on whether or not they are concerned about labeling children "ADHD" ..' 253 Table 7-11. Teacher concerns about untreated A D H D 260 Table 7-12. Teacher description of the gender of A D H D children in their class 264 Table 8-1. Parent description of their ADHD child's academic performance in comparison to their child's peers....:. 273 Table 8-2. Parent description of their ADHD child's social skills in comparison to their child's peers 279 Table 8-3. Parent discussion of child resentment towards school 282 Table 8-4. Parent discussion of specific incidents that led to suspicions that their child may have A D H D 285 Table 8-5. Location of incidents that precipitated parental suspicion of A D H D 292 Table 8-6. Parent description of parties who made the first suggestion that their child may have A D H D 296 Table 8-7. Parent responses when asked whether or not they sought alternative diagnoses for their children's condition 310 xvii Table 8-8. Parents' responses to whether or not they used behavior modification techniques to treat their children's A D H D 316 Table 8-9. Breakdown of parent's opinions on the origins of A D H D 318 XV1U Acknowledgments I would like to express my thanks to those who have made this thesis possible. Without their persistent efforts, patience, and care, this project would simply not exist. I want to convey unyielding gratitude to my Ph.D. supervisor, Bob Ratner. You guided me through every aspect of this project, helping me to negotiate all the angles of the Ph.D. program. Your efforts helped me become a better writer and showed me so many possibilities for my academic future. In addition, I would like to thank the other two members of my thesis committee, Janice Graham and Tom Kemple, who have seen this project from its proposal stages through to its current form. Your collective efforts for the stylistic and conceptual improvement of this thesis have been indispensable. I also want to express my sincere thanks to all of the respondents who participated in the interviews for this project. These folks have made me see how complex A D H D really is, and how we have just begun to have awareness of its many meanings. A sincere thanks goes to the staff at the wonderful libraries at the University of British Columbia, U C San Francisco, and Southern Oregon University. Not one of my questions went unanswered, thank you. A special thanks also goes to Ryan Kenny for the moral support (your M A thesis turned out excellent!), and Roy Battie for the beautiful inspiration. Finally, I would like to thank my life partner and fiancee, Nell, whose belief in me dispelled any of my fleeting self doubt. M y sweetheart, I love you more than I can express. 1 Part I: Past and Current ADHD Discourses Introduction In his book, Ritalin Nation (1999), Richard DeGrandpre claims that the prevalence of attention deficit hyperactivity disorder (ADHD) 1 is symbolic of modernity. We live, according to DeGrandpre, a contradictory life, as we are forced into intensified "on-task" behavior in work and school, and simultaneously, with an addict-like willingness, we are bombarded by the technicolor onslaught of modern society's digitized, shifty, and distracting images. A D H D , according to DeGrandpre, is a product of this social environment—an environment that defines success as having the ability to gracefully respond to markedly contradictory demands. To internalize and regard as a kind of reality rapidly shifting media images, and to be able to- separate these virtual experiences from the actual world, is to be successful. A D H D , according to this argument, is a moniker for those who lack this success, that is, A D H D is a way of pathologizing those who do not live up to the difficult standards modern society mandates. Ritalin, the perennial treatment for ADHD, serves as a great equalizer, consumed en masse by a society that fails to see its own role in creating ADHD. ' According to DeGrandpre, rather than addressing the inhuman and perhaps inhumane effects of what he terms "rapid fire culture," we engage in a kind of self-serving groupthink, in which we pat ourselves on the back for discovering ADHD, and regard the discussion of the disorder as one amongst many in modern medicine. Instead of looking at contemporary culture as potentially harmful to children and adults alike, we take solace in modern psychiatry and its ability to continuously elucidate those mental aberrations that impede productivity and lower the quality of life. Rapid fire culture fails to ponder A D H D in any critical way because it lacks the time. !It is estimated that diagnoses of ADHD and prescriptions for stimulant medications have increased 7-fold 1990. See Diller (1998). ' 2 DeGrandpre's and numerous other books (most of which will be addressed in this thesis) define ADHD as a cultural problem, cast in myriad ways. Amongst these, A D H D is argued to be cultivated through flaws in parenting, that is, by parents who are so wrapped up in the demands of modern life that they decide it is easier to "drug" their children than to deal with their children's deeper emotional and intellectual needs. At other moments it is argued that A D H D reflects the state of public education, in which bloated classrooms and stressed-out teachers foster an intolerance towards children who cannot sit still. A D H D is also perceived to reflect medical perspectives in which children are equated to a mechanical device easily subdued through appropriate chemical intervention. With these and many other perspectives on the nature of ADHD, an accusing finger is wagged: rapid fire culture, it is implied, may succeed in entertaining children—it successfully gets them in front of the TV until mom or dad come home-but it fails to care for them. For children who cannot successfully negotiate the experience of rapid fire culture, the care they receive is pharmacological. As important and relevant as such cultural commentaries are for the discussion of ADHD, they paint a picture of modern life which is as bleak as it is one-sided. Through varying degrees of rhetorical mastery, such perspectives portray us as the perpetual victim of our culture, and therefore of ourselves. Such self-victimization continuously prevents our own critical reflection. Our knowledge about A D H D , for example, is only that which has been spoon-fed to us by the same culture that invented ADHD. In addition, such perspectives provide a limited view on the nature of A D H D and implicitly discount other perspectives towards the disorder. Through an "Us vs. Them" sentiment, we are implored to choose a position regarding ADHD. The discussion of ADHD becomes confined to an allegiance to one of two camps: A D H D is either a bona fide neurological reality, or A D H D is a falsehood. The discussion of A D H D need not be this simplistic. Given the prevalence of the disorder (more than 4 million school-age children are assumed to be diagnosed with A D H D in North America) it is imperative that A D H D be examined in multifarious ways. Through examining 3 historical and contemporary A D H D discourses, combined with a qualitative analysis of people's everyday experiences, this thesis offers a unique social perspective on the disorder. A D H D will be studied using two methodologies, one for elucidating the textual discursive framework of the disorder, the other for conveying the manner in which these discourses frame A D H D children in everyday life. The first section of this thesis utilizes a genealogical approach to ADHD, focusing on the textual discourses throughout the last 140 years that claim an understanding of the disorder. These discourses are mainly characterized by two different camps—one psychodynamic, the other neurological—which oppose each other in their discussion of what causes A D H D and how it should be remedied. The antagonism between these schools of thinking is based upon different members from each adopting and perpetuating a "master frame" (Snow and Benford, 1988; Carroll and Ratner, 1996) for ADHD. For the neurological approach this master frame regards A D H D as a strictly physiological phenomenon, whereas the master frame for A D H D from a psychodynamic perspective views A D H D as attributable to environmental conditions. This genealogical approach culminates with an analysis of contemporary texts that embody parenting discourses addressing the needs of A D H D children. The second part of the thesis which analyzes the everyday ways A D H D children are framed is based upon interview data from the adult authorities involved with A D H D suspicion, diagnosis and management. This set of respondents includes educators, parents and clinicians of A D H D children. The empirical emphasis upon these adult authorities is crucial to understanding how discourses influence the way ADHD children are perceived by adults in their lives and how these perceptions prompt various types of action in diagnostic and treatment capacities, but also in familial, nurturing ones. Both the genealogical and everyday accounts of A D H D in this thesis analyze two related, yet different objects of knowledge. The textual discourses that examine the collection of symptoms believed to indicate A D H D give rise to A D H D as an object of knowledge. That is, the historical and contemporary discussion of ADHD examined in the first part of this thesis reveals how the phenomenon of A D H D is constituted. Etiological stances towards A D H D are crucial in this regard, and are contingent upon many different and often conflicting perspectives that have 4 sought the ownership of what causes the disorder and how it should be treated. The everyday accounts of the authorities in an A D H D child's life give rise to the A D H D child as object of knowledge. According to adult authorities, A D H D children are believed to have something fundamentally wrong with them, but the ways in which they are perceived appear to vary. Such frames for A D H D children stem largely from the base of past and present knowledge about ADHD, but are also influenced by other factors, such as the personality of the child, the circumstances under which the child is suspected of having A D H D , the specifics of their learning and social difficulties, and so on. Through everyday accounts of the adults who are associated with ADHD children we see the master framing of neurology and also the master framing of psychodynamic perspectives. Some respondents view A D H D as a strictly neurological phenomenon and hence, give accounts of the disorder that strongly resonate with neurological perspectives, whereas other respondents attribute A D H D symptoms to environment. The interview data also reveal points at which these different master frames appear to be hybridized, combining neurological and psychodynamic perspectives. In sum, the past and present textual discussions of A D H D view this disorder mechanically, as a type of solvable puzzle, whereas everyday accounts of the disorder, though clearly influenced by these discussions, are infused with certain subjective elements that contribute to a multifaceted framing of A D H D children. By uniting textual accounts with everyday accounts this thesis will demonstrate how discourses influence people's perception of ADHD children, and also how people negotiate between these bases of knowledge and the actual children they treat, teach and parent. Chapter one provides an introduction to the genealogical method. Of primary importance in this chapter is the way a genealogical approach can effectively lay the groundwork for a qualitative analysis of respondent data. I argue that genealogical analyses, such as those employed by Hacking (1995) and Young (1995) are indispensable when analyzing the social vicissitudes of mental disorder. However, many genealogical analyses fall short of a practical application in that they do not present the "lay discourses" expressive of mental disorder, that is, the voices of those for whom the label of mental illness is highly consequential. This chapter 5 argues, therefore, that the genealogical perspective is a crucial and necessary component to a more penetrating analysis of ADHD, yet it does not suffice as a holistic way to address such social phenomena. Beginning the genealogical analysis, chapter two provides an historical, examination of the medical discourse that addressed the problem of childhood immorality, starting with the late 19th century discussion of imbecility and idiocy and culminating in the medical discussion of the psychological sequelae of the disease encephalitis lethargica, or "sleepy sickness." M y contention in this chapter is that A D H D was not "discovered" in 1902 by George F. Still, as many publishing in the A D H D field have asserted. Instead, I argue that the early discussion of ADHD symptoms rested upon the medical concepts of idiocy and imbecility that predated Still's work by at least 24 years. In the same sense that we can say the contemporary discussion of ADHD was possible because of the work of Still and others, we can say that the moral shortcomings in children Still saw as problematic were not solely the result of his efforts. G.F. Still's "discovery" was being hammered out in British medicine even before he began to practice as a doctor. The genealogical analysis continues in chapter three to include psychodynamic discussions of ADHD-like symptoms during the 1930's and 1940's. The term "psychodynamic" is divided into two categories: psychoanalytic and psychological. Psychoanalytic interpretations, it will be shown, sought little information for organic causes of childhood immorality or maladjustment. Such perspectives, epitomized by the work of Anna Freud and Melanie Klein, relied heavily upon the concepts of compulsion neuroses, ego demarcation, and the latency period in childhood development. Psychological perspectives also rejected the idea that immoral behavior was directly linked to a chemical condition, and framed such childhood behavioral problems as part of a coping strategy in the face of interpersonal or institutional failings. Psychologists argued that ADHD-like symptoms could be seen in pronounced types of personal difficulties, often signalled through scholastic shortcomings. This perspective is typified by the work of Lauretta Bender and Phyllis Greenacre—two psychologists who argued that ADHD-like 6 symptoms could be alleviated through psychotherapeutic intervention. An emphasis on psychotherapy also characterizes the treatment stance towards ADHD-like symptoms adopted by psychoanalysts during that time. However, in contrast to psychoanalysis, psychological perspectives often affirmed that ADHD-like symptoms could be linked to organic trauma, such as those caused by head injuries. The difference between psychological and psychoanalytic perspectives towards A D H D symptoms rested largely on a disagreement regarding the etiology of the disorder in the person exhibiting A D H D symptoms. For psychologists, it was the response to an organic trauma that manifested itself as a mental disorder, not an unconscious mechanism buried deep in the psyche, as psychoanalysts asserted. For psychoanalysis, the problem was addressed and treated through the discovery of an overdetermining cause deep within the mind. For psychology, remedy was sought by means of one of various techniques of behavioral modification. Chapter three continues with an examination of the neurological discussion which has comprised the dominant etiological position towards A D H D . Beginning with an analysis of how neurology dismantled psychodynamic reasoning, this chapter describes how neurology came to dominate popular and academic perspectives on ADHD. Due to neurology's influence, A D H D is today considered largely to be a discernible organic phenomenon, more linked to brain chemistry than to an effect of one's social environment. Crucial to the neurological perspective is the subscription to medication as providing both confirmation of and treatment for a diagnosis. The "paradoxical effect"—stating that children with ADHD-like symptoms will be calmed by stimulants rather than "sped up" by them--is a case in point. I provide an examination of the many interpretations of the paradoxical effect, both from proponents and critics of stimulant use by children. This dominance of the neurological perspective greatly deflated the claims of psychoanalysis as a bona fide cure for many mental illnesses, including ADHD. With the profusion of medications for the mentally i l l beginning in the 1950's, the neurological discussion of minimal brain dysfunction (the medical term prior to "ADHD") in the 1970's had acquired a 7 considerable momentum. In conjunction with the expanding influence of psychopharmacology, neurological perspectives transformed the A D H D debate. The treatment of A D H D solely by psychotherapeutic or behavioristic methods was now seen as antiquated. A D H D was viewed as a physiological impairment, having a pharmacological cure. This chapter closes with a brief discussion of some of the dissenting opinions in research and clinical circles against the dominant neurological perspectives. For example, the diagnosis of ADHD as formulated by the American Psychiatric Association has come under considerable scrutiny in recent years. Amongst the many criticisms of the diagnosis is the argument that there is no incontrovertible method for diagnosing ADHD, particularly since the diagnosis is arguably made according to cultural standards rather than physiological ones. Because of these diagnostic validity issues, many researchers have claimed that A D H D may be over-diagnosed in North America and that Ritalin and other stimulants are given too freely. This chapter concludes that although North American psychiatry has been instrumental in formulating the A D H D debate, it is not an exclusive source of A D H D knowledge. The genealogical analysis culminates with the examination of texts that are geared for ADHD parents. In addressing the "ADHD parental guidebook," chapter four demonstrates how the various discourses (psychological, psychoanalytic, and neurological) find their way into manuals that help parents negotiate the experience of parenting an A D H D child. This can be seen in the way such guidebooks provide a frame for parents within which to understand or have special insights into the nature of their ADHD children. The domestic sphere, these guidebooks argue, is a crucial location for the employment of disciplinary techniques with A D H D children, including behavior modification, dietary intervention, and TV/video game regulation. After the genealogical analysis of A D H D is presented in chapters one through four, I provide contemporary, "everyday" accounts of the disorder. The purpose of such accounts is to demonstrate how psychological, psychoanalytic, and neurological discussions of A D H D make their way into everyday life. In addition, the analysis of these interviews provides glimpses into the daily experience of people embroiled in a case of A D H D that are not registered in an analysis 8 of discourse. Chapter five offers a detailed explanation of the methods employed in interviewing the 20 clinicians, 22 teachers, and 20 ADHD parents.2 The voice of clinicians associated with ADHD, heard in their responses to interviews, forms the groundwork for chapter six. Various themes are explored in this chapter, including clinicians' attitude towards the efficacy of the A D H D diagnosis, their perspectives on the administration of medications, and their opinions on the so-called "alternative" methods for diagnosing and treating A D H D . Surprisingly, clinicians were the respondents most skeptical of the ADHD diagnosis. This skepticism demonstrates how the attitudes of clinicians reflect the ongoing A D H D debate within the lay, clinical and research communities. Though there was considerable variability, the majority felt that ADHD was a disorder still "in process." That is, they felt the disorder was slowly becoming understood by medical science, and that the visible drawbacks of medication treatment (through drugs like Ritalin, Cylert, and Adderall) were part of the process of mastering A D H D , its causes and treatments. Chapter seven continues the analysis of interviews, this time focusing on teacher respondents. As they are perhaps the most significant actors in the process of labeling ADHD, teacher depictions of A D H D children and how they differ from others are crucial in displaying how psychological, psychoanalytic, and neurological perspectives on A D H D influence the way such children are conceptualized. I contend that teachers are "semi-formally" suspicious, representing a hybridized role between clinician and lay person. Teachers embody an awareness of ADHD symptoms and certainly convey this in their conception of A D H D students: their accounts of A D H D behavior mirror many of the things mentioned in clinical textbooks covering the disorder.3 2The specific profiles of respondents based upon gender, occupation, and race are not offered in chapter five for the purposes of preserving respondent anonymity. Moreover, in chapters six through nine, minimal information is provided about specific respondents. For clinicians, I only describe a respondent's profession, omitting their age and gender, for teachers I only describe the grade level at which they teach, and for parents, no specific information is offered. ^However, most of the teachers I interviewed had not heard of the APA's DSM IV criteria for ADHD. To supplement the discussion of teacher interviews, I have interspersed an analysis of literature that addresses some of the 9 Chapter eight concludes the interview analysis portion of the study with the examination of data from parent respondents. As they are the negotiators between their A D H D children and the institutional worlds that apply the diagnosis to them, parents provide the richest and most subjective account of the disorder. Similar to chapters six and seven, this chapter demonstrates how the lived experience of parents with A D H D children is influenced by the discourses that have comprised the history of ADHD. Some of the major themes from the interviews with parents included how they saw their children's social and academic competence in relation to their children's peers; who introduced them to knowledge about A D H D ; what were some of their emotional experiences upon hearing about their child's diagnosis, and what they felt was the root cause of the disorder. Chapter nine analyzes the interactions between respondent groups. Within this analysis is a discussion of how particular narratives for ADHD are revealed through the dynamics between clinicians, teachers, and parents. Crucial here is the extent to which neurological and/or psychodynamic perspectives towards ADHD provide definitions of the situation for such respondents, prompting the adoption of particular perspectives towards A D H D and the adoption of treatment strategies. Four cases of respondents are illustrated in this chapter which exemplify the most prevalent themes from the interviews. These cases typify the process of suspecting and ultimately diagnosing ADHD. Chapter ten is the concluding chapter in which I discuss some of the contributions I feel were made by this thesis and where this type of research can continue. Through reiterating some of the shortcomings of traditional social constructionist accounts of mental disorder, this chapter highlights how the thesis has furthered the social study of A D H D . These contributions are comprised by: 1) the assertion that ADHD, though understood largely to be a neurological condition, is still a contested topic and consequently, has multiple interpretations in everyday life, 2) the argument that A D H D is largely suspected and diagnosed within specific institutional educational issues with A D H D , including how teachers should suspect A D H D , through what channels to direct this suspicion once it is felt, and how they should tailor their classroom strategies for children with A D H D . 10 confines, namely the school, and 3) that the various discourses comprising the conceptual history of ADHD frame the experience of A D H D children in their everyday worlds. In examining the implications for further study, this chapter provides arguments for the analyses of A D H D respondent data over a longer period of time (perhaps over a five year, period) that can show the changes in a respondent's relationship to ADHD, the empirical studies of how knowledge circulates amongst social actors, and the benefits of studying A D H D children themselves. 11 Chapter 1 Critiquing Social Constructionism: Introduction to the Genealogical Method Addressing social constructionism ADHD has had a limited discussion in sociology. With a notable exception or two, ADHD has been virtually ignored both as a topic of discourse and as a diagnosis with palpable consequences. Previous discussions of A D H D have invoked sociological accounts of mental deviance, especially those models which denote processes of "labeling" and of "medicalization." Influenced by the work of Goffman, Lemert, Becker, and the like, sociologists and social critics need merely "insert" the mental disorder of ADHD into an already established niche of the sociology of deviance lexicon. A study of hyperactivity, like the study of other mental disorders becomes a forum for an "empirical account" of previous sociological positions. The work of Peter Conrad (1975, 1976) in his study of hyperkinesis ("hyperkinesis" being part of the medical nomenclature which came before that of A D D and ADHD) stands as a strong example of this type of research. We are, then, left with a well-accepted structure with which to discuss ADHD, offer commentary and advocate awareness. Much of the sociological interpretation of mental illness derives from the Symbolic Interactionist perspectives of George Herbert Mead and Charles Horton Cooley and has evolved into what is now called (perhaps aphoristically) "social constructionism".4 In a general discussion of deviant behavior, Jack Douglas (1970) provides a summary of some of the tenets of this perspective: Human social order is necessarily problematic. Since we must have social order to exist, but cannot achieve it by simply living naturally, it becomes 4It is important to note that this thesis refers to the type of social constructionism that came to dominate deviance theory in sociology in the late 1950's and still serves as a perspective for current studies in the sociology of deviance. Such deviance theory needs to be distinguished from the poststructural strains of social constructionism that more generally characterize contemporary social theory or cultural studies. The former emphasizes that meanings are constructed by powerful agents and heavily influence the perspectives of lay people, while the former emphasizes a universal relativism. 12 a crucial problem of our existence which we must solve i f we are to exist at all. Man is also necessarily a symbolic animal, for it is only his capacity to create and work with symbols which he takes in some way to be real that allows him to solve the necessary problem of social order. Being unable to rely on shared instincts (or shared imprintings) to coordinate his interactions with his fellows, man must substitute a shared universe of (symbolic) meanings to achieve that coordination (p. vii). Implied in this preface is the notion that human interaction is based upon a shared symbolic interpretation of the world. Humans act according to a symbolic order, constituting the stability of social life which sociologists can analyze on many different levels: interpersonal, institutional, and cultural. These analyses examine the specific grammar of the symbolic order, that is, how the collectively interpreted symbolic matrix weaves its way into daily consciousness and prompts repeated, somewhat predictable, behavior. Social constructionists are often concerned with the mechanisms that are used to deploy a particular symbolic device. Peter Conrad's (1975) "content analysis" of hyperactivity, for example, measures the symbolic power of the pharmaceutical industry by counting the number of advertisements in medical journals such companies use to sway clinical belief. Attached to the analysis of the deployment of symbols is an examination of the power relations associated with them. More often than not, social constructionists place themselves in a position of advocacy for those who become objectified or dehumanized by the symbolic order. This advocacy often prompts social constructionists to articulate (and critique) the "source" of symbolic power. Erving Goffman's Asylums (1961) and Thomas Scheffs Being Mentally III (1984) serve as two prominent examples. In both these works, and countless others, comprising the enterprise known as the "sociology of mental health", mental disorder is not 13 viewed as a "thing" to be studied and interpreted, but rather as a result of certain "possibilities" within social life. Predominant theoretical positions in the sociology of mental deviance are characterized by a duality, which places the "informal" or everyday realm against the "formal" or medicalizing realm. Previous studies have asserted that medicalization shifts interpretations of deviant behavior from seeing such behavior as "bad" to seeing it as "sick"(Conrad and Schneider 1980). The informal realm constitutes "cultural scripts" for personal conduct, prescribing what is normal/abnormal behavior within a certain context. Thomas Scheffs (1984) famous application of Goffman's (1964) "residual rule breaking" exemplifies this conception. The formal realm, on the other hand, is often described institutionally, and is the basis of official mental disorder diagnoses. The formal realm has a profound interdependence with the informal. For example, Scheff contends that behaviors become formally described as states of mental illness when undefined or "residual" rules are consistently broken in the informal context. Violation of these rules is not defined as criminal or impolite, yet these violations represent something which "just isn't quite right" with the individual. It is argued that medical practices exploit these ambiguities in the informal realm and apply a label which offers a technical explanation for why "something wasn't quite right" with a particular person's behavior. From the perspective of the formal medical realm the informal label of "weirdo" represents a misunderstood phenomenon. He/she may not be "weird" at all, but perhaps "hebephrenic," "bi-polar," or "attention deficient." From this perspective mental disorder is seen as a product of the interplay between formal and informal forces. Mental disorder, it is argued, is a phenomenon whose etiology can be discussed through an examination of cultural and institutional antecedents rather than psychological or physiological ones (Grosky and Pollner 1981). Hence, many sociological accounts of mental illness implicate an intolerant culture, or an out-of-control mental health industry, or profit-hungry pharmaceutical corporations, or any combination of these. 14 Focusing on ADHD A more comprehensive examination of A D H D must provide a significant break from previous sociological accounts. Considerable effort will be expended in order to not point the finger at some party responsible for either creating A D H D or, conversely, not granting it enough clinical significance. A D H D will instead be discussed as a topic with a vast array of conflicting and converging interpretations, each of which might be better regarded as a specific "research narrative" (Young 1995). Because of these various interpretations this thesis will demonstrate that ADHD is far from being unified by an all-encompassing discourse. A D H D , in the clinical sense, is a nomenclature used to summarize a plethora of symptoms. Previous ADHD nomenclature Since the early 1900's these symptoms have included, but are certainly not limited to: 1) poor performance in school; 2) extreme extroversion; 3) outbursts of violent behavior; 4) inability to "stay on task"; 5) thievery; 6) disturbances in sleep patterns; 7) morality inconsistent with age; 8) forgetfulness. Some of these may not seem remotely related to today's conceptions of ADHD, and yet these symptoms are inextricably linked to today's clinical interpretations of this disorder. A l l of these symptoms and many more have comprised a variety of diagnoses over the years, depending on historical period, and again, the system of logic underneath the discourse which provides the diagnosis. Some of these disease names include: 1) Encephalitis Lethargica (the sequelae thereof); 2) Minimal Brain Damage; 3) Minimal Cerebral Palsy; 4) Mild Retardation; 5) Minimal Brain Dysfunction; 6) Hyperkinesis; 7) Atypical Ego Development; 8) Attention Deficit Disorder (ADD); 9) Attention Deficit Hyperactivity Disorder (ADHD). These categories, in that they represent the historical antecedents of today's discussion of ADHD should not be considered interchangeable, however, they should be regarded as nomenclature addressing very similar problems of childhood that would ultimately crystallize into what the American Psychiatric Association currently calls ADHD. The fact that the collection of symptoms we today call ADHD have had so many different names over the years suggests that it may be reasonable 15 to expect that the nomenclature describing these childhood problems may change yet again in the future. Problematic epidemiology The epidemiological breakdown of ADHD in the United States and Canada is constantly changing, partially due to the fact that A D H D is nebulous and comprises so many symptoms, but also because the presentation of the data of those who are afflicted tends to serve the ideological interests of the researcher. The "anti-Ritalin" camp, for example, has estimated that between 10 and 12% of school-age children are diagnosed with A D H D and taking medications (Breggin 1998, Diller 1998), while proponents of Ritalin treatment estimate that only between 3 and 5% of school-age children are diagnosed with the disorder (Shaffer et al. 1996). Controlling for gender, the epidemiological breakdown has an estimated male-female ratio of 5:1 (Arnold 1995, 1996), but the prevalence of the disorder in females remains unclear5 (Biederman et al. 1999). In addition, the difference in rates of A D H D is marked when clinic-referred data are compared with community samples, with male-female ratios of 10:1 and 3:1, respectively (Gaub and Carlson 1997). Controlled for race, recent studies argue that the cases of ADHD in African American children is proportional to the cases in the white population.6 Addressing Peter Conrad The primary sociological text to date which examines hyperactivity from a sociological perspective is Peter Conrad's Identifying Hyperactive Children (Lexington Books, 1976). In this 5The gender discrepancy in ADHD cases is a major obstacle to a neurological etiology of this disorder. The fact that so many more boys than girls appear to have this disorder fails to be adequately explained by the neurological discourse which so readily contends ADHD is physiological. For example, no substantial study brings forth scientific evidence to demonstrate that the gender discrepancy in ADHD cases is related to differences in male and female endocrine systems. Furthermore, sociology and cultural anthropology have established that within the realm of gender we see discernible forms of social constructionism. With regard to boys being so much more afflicted by ADHD, we must inquire what role culture plays in making the disorder "possible" in Blum's (1970) words. 6 Data which describe the incidence of ADHD by other racial categories, such as Latino, Asian, and Native American could not be located. In addition, class-specific data were also unavailable. 16 text, which Conrad claims to be the "first empirical analysis of the process of medicalization" (p. 5) the author wishes to examine the process by which medical professionals construct a medical problem from deviant behavior. It exemplifies the informal/formal duality which has come to dominate previous discussions of mental disorder. Conrad's position rests upon an interest in the growing sphere of medical practice and its encroachment upon social life: What is significant, however, is the expansion of the sphere where medicine now functions as an agent of social control. In the wake of a general humanitarian trend, the success and prestige of modern medicine, the increasing acceptance of deterministic social and medical concepts, the technological growth of, the twentieth century and the diminuation of religion as a viable institution of control, more and more deviant behavior has come into the province of medicine (pp. 4-5). • Conrad's work claims that the "discovery" of hyperactivity, or hyperkinesis can be attributed to the interplay of three social factors. These are "(1) the pharmaceutical revolution, (2) trends in the medical profession, and (3) government action" (pp. 12). Conrad's "pharmaceutical revolution" analysis points the finger at the party responsible for the synthesis and marketing of Ritalin, Ciba corporation (Ritalin is now produced and marketed by Novartis corporation), which in the 1960's, addressed a large-scale advertising campaign to the medical and educational sectors alike. His examination of medical trends7, though slightly unclear, generally refers to the increased interpretation of behavioral problems as biochemical or organic in origin. The "government action" side of Conrad's analysis directs attention towards government agencies, in this case the U.S. Public Health Service, who were responsible for formally labeling hyperkinesis as "minimal brain dysfunction." By discussing the role of this government agency, Conrad is 7In Identifying Hyperactive Children, Conrad asserts little about the specifics of trends in medical practice and even less about how they relate to the diagnosis of hyperactivity. For example, he presents no empirical evidence to establish that medical practices had in fact gone through some significant changes that would make the diagnosis of hyperactivity more prevalent. 17 clearly describing the power of a public institution to contribute to medicalization through decreeing a "unified" diagnosis. This three-fold description of the agents which contribute to the discovery of the hyperkinesis phenomenon shows hyperkinesis as a specific project of a somewhat concerted effort on behalf of these agents. From Conrad's perspective, the three social factors reflect the sizable disparity in power between lay actors and formal organizations. A D H D , then, can be seen as a product of "expert control", in which lay actors have been removed from the debate. This system of experts use language which is obscure and inaccessible to lay actors. Conrad (1975) states: "By defining a problem as medical it is removed from the public realm where there can be discussion by ordinary people and put on a plane where only medical people can discuss it" (18). In defining a problem as medical rather than "ordinary" in Conrad's terms, there is a profound separation between those who articulate hyperkinesis as a problem and their lay audience. It is not surprising that Conrad (1976) gives credence to Howard S. Becker's discussion of "moral entrepreneurs"~agents who further the medical cause by bringing attention to a problem: There were, however, also agents outside the medical profession itself that were significant in "promoting" hyperkinesis as a disorder that was within the medical framework. These agents might be conceptualized in Howard S. Becker's terms, "moral entrepreneurs," those who crusade for creation and enforcement of the rules whose violation constitutes deviance. In this case the moral entrepreneurs were the pharmaceutical companies and the Association for Children with Learning Disabilities (p. 15). Through describing a combination of the formal nomenclature of modern medicine and the passionate voice of moral entrepreneurs, Conrad sets the stage for an analysis of hyperactivity which stays within the confines of what has now become "classic" deviance theory. Many of the assertions posited by Conrad and others tend to view knowledge systems as originating in one arena and disseminating to another. As one realm accumulates knowledge, it is 18 argued, this realm becomes a kind of resource for the segments of society which comparatively lack this type of knowledge. Within this asymmetrical knowledge relationship, many argue, is the potential for the abuse of power, perhaps through the literal fabrication of social problems. For example, the medical realm, according to Conrad, is a place where A D H D had effectively originated and is—through medicine's own invention—the location of the solution for ADHD. The medical realm, in this instance, invents a problem and then claims ownership to the most feasible rectifying measure. As the problem and solution become more known and legitimate this further maintains the assymetry between medical and lay realms. The ultimate result of this is a kind of dependency in which the lay realm seeks out the medical to provide information and direct the most legitimate path for action. With his perspective firmly rooted in the established sociology of deviance lexicon, Conrad then begins his specific empirical study of hyperactivity. This is done through qualitative analyses of interviews with parents of children being treated at the Hyperactivity-Learning Disabilities Clinic (HA-LD) in a Northeastern city. Throughout this interview process, using a grounded theory approach, Conrad describes the interactions between various social agents and how they ultimately label a child as being hyperactive. These primary agents are schools, parents, and to a lesser extent, physicians. It is not my intention to review all of Conrad's research, its conclusions, and its implications for further analysis, but rather to highlight some of his theoretical positions and methodology. In bringing an awareness to the process by which hyperactivity is constructed as a medical phenomenon, Conrad has us in his debt. But, I believe there is much more to the story of what we today call A D H D . Conrad's analysis illustrates only a segment of how A D H D can be perceived through sociological inquiry. Conrad's research demonstrates one side of a power struggle between social critique and institutional practice. In what is really one faction in a war of etiologies, Conrad's "social constructionism" perspective opposes the biological or naturalistic perspectives. As soon as clinicians deem a mental disorder to be a definite physical reality this position is debunked by 19 those who view this disorder as wholly contingent upon social dynamics. The work of the sociology of mental health, with its foundations in social constructionism, is often a reaction-formation against the clinical perspectives of mental health. The rather reactionary stance of social constructionism is epitomized in Asylums (1961), which was the first in-depth discussion of the mechanisms of "informal" and "formal" suspicion. Asylums is a treatise on how social processes can construct a deviant subject through formal apparatuses of control. Social constructionist etiological stances, in that they are reactive towards clinical perspectives, commonly offer analyses which smack of conspiracy. We envision moral entrepreneurs plotting their manipulation of public belief and clinicians who give institutional legitimacy to the moral entrepreneurs' vision. For example, Conrad's (1976) study analyzes the prevalence of advertisement campaigns of pharmaceutical companies and the number of alarmist television programs which discuss hyperactivity. Mental disorders, like A D H D , are seen as a project for profit-making on behalf of pharmaceutical companies and a source of professional esteem for research-minded clinicians. A D H D is depicted as the result of a concerted and collusive effort, inviting sociological criticism. This highly reactive stance has even been taken up by those within the medical profession. Peter Breggin's Talking Back to Ritalin (1998), Thomas Moore's Prescription for Disaster (1998) and Sydney Walker's The Hyperactivity Hoax (1998) serve as three recent examples. The position of these authors , i f not denoted by their titles, can be summarized in a few points, not unfamiliar to social constructionists: 1) Attention disorders are a biological myth; 2) this myth is perpetuated and has served the interests of pharmaceutical companies which have grown enormously wealthy; 3) the American Psychiatric Association's Diagnostic and Statistical Manual (1994) is a blatant example of politics, cultural judgments and out-right quackery; and 4) the administration of Ritalin is tantamount to child abuse. 20 Reflexivity and Foucault It is pertinent to examine the relationship between the realms of medicine and everyday life as reflexive. In invoking the term "reflexive" I mean that the relationship between the medical realm and the everyday realm is mutually influential. Taking this idea to its logical extension, reflexivity tends to blur the distinctions between the realms which many in sociology perceive to be distinct from each other. A Foucauldian analysis of power/knowledge is highly relevant to a reflexive critique of ADHD. In Foucault's analysis, knowledge does not have a point of origination or a consistent source of production. The system of power/knowledge is entirely reflexive, and in a constant state of flux. To portray one group or collection of experts as "owning the power and therefore the knowledge" is an impossibility in this regard. Similarly, the knowledge that has been generated about A D H D is as much a function of medical practice and research as it is one of public legitimation. From Foucault's perspective, people embrace the medical apparatus, not because of some overpowering ideology, but because medicine has achieved a degree of legitimacy. Medicine has become a "validated" source of knowledge. In seeing the public subscription to the knowledge generated by modern medicine we have an insight into the raison d'etre of power (see Foucault 1978; 90-102), namely, that a moment of knowing is synonymous with a moment of power realizing its aim. These moments of knowing are highly visible, for example, when an "account" of mental illness is provided. As Dorothy Smith (1978) asserts in her essay, "R is Mentally 111: An anatomy of A Factual Account," the way that an interpretation of a mental illness is provided is not as factual as it is political. Smith and Foucault both contend that the truth value of an assertion about mental illness is rooted in nomenclature that is an extension of power relations. Introducing the Genealogical Method / A sociological perspective that avoids some of the theoretically subjective obscurity of recent works and at the same time avoids ad hominum attacks on the medical establishment 21 needs to employ alternative theoretical and methodological perspectives. Mental disorders must be discussed not only as effects of specific social agents, organizations, institutions, etc., but also as discursive formations. That is, mental disorders should be examined as a collection of historically-contingent concepts and statements, which do not necessarily adhere to one discipline or institutional context, and cannot be traceable to any specific social agent. As the "social product" of discursive formations, mental disorders should be discussed as in a state of flux, always contested and contestable. The contest between etiological stances needs no new addition (there has been enough debate for the time being, with no resolution point in sight); rather, the contest itself, its history, and its contemporary character need discussion. In examining A D H D as a discursive phenomenon, the disorder can be viewed as a topic of contention, rather than a socially-constructed medical falsehood or, conversely, as a clinical reality. The conclusions from such a perspective might not be suitable for those determined to debunk clinicians or, conversely, those who wish to champion the cause of modern medicine. One of the goals of a discursive perspective is to step outside of the etiological debate and objectify the debate itself, or more specifically, to objectify parts of the debate. Instead of proposing an ontology of A D H D , it would be more pertinent to examine the discourse which has constituted A D H D as an object. This calls for an application of the genealogical method which characterized the later work of Michel Foucault.8 In Foucault's words genealogy "will cultivate the details and accidents that accompany every beginning; it will be scrupulously attentive to their petty malice; it will await their emergence, once unmasked, as the face of the other" (1984: 80). Genealogy, then, does not seek to force a continuity among historical events, rather, it sniffs out things like "accidents" and the dynamics of the petty malices which constitute the beginnings of a historical object. From Foucault's perspective, the discussion of any object of knowledge might begin by paying attention to the aggressive politics between differing perspectives towards that object. 8See especially Discipline and Punish and the Birth of the Clinic as examples of this method. 22 In addressing mental illness discourse, genealogy has proved to be a valuable methodology. Foucault's genealogical studies of institutions, such as the clinic, the hospital, and the prison provide the starting point for a critique of the knowledge bases and practices of such institutions. Foucault's writings on these institutions demonstrate that their influence is a result of the interplay between the infusion/generation of knowledge systems and how those make their way into institutional practice. As the categories of mental illnesses have become legitimated, they largely function as institutions. Hence, a genealogical perspective is particularly effective in analyzing mental illnesses. Ian Hacking's examination of Multiple Personality Disorder (MPD) in Rewriting the Soul (1995) and Allan Young's analysis of Post-Traumatic Stress Disorder (PTSD) in the Harmony of Illusions 1995) reflect Foucault's influence, but also represent a considerable advancement of genealogical methods, and new directions of study in mental health. In both Harmony and Rewriting, neither author makes an etiological or philosophical commitment to the mental illness in question. Instead, both authors elaborate a narrative of each of these mental illnesses, presenting historical and contemporary discourses. With each text, the reader is left well-informed on the etiological, symptomatic, and epidemiological discourses which comprise MPD and PTSD. Because neither author "takes sides," Hacking and Young are free to address all discussions of MPD and PTSD, rather than ignoring arguments which may invalidate their stance. ? The work of Hacking and Young is a contemporary example of Foucault's work. Their methodological foundations stem from Foucault's analysis of the shape and dynamics of knowledge systems. In addressing discourse, Foucault studies the ways in which different disciplines or actors within the same discipline contest objects of knowledge, and at the level of the extradiscursive, how lay actors are affected by the manifestations of those disciplines. This position was a way for Foucault to offer an alternative to the concept of ideology which was such a deterministic force for his Marxist critics. Foucault states: "I would like to substitute this whole play of dependencies for the uniform, simple notion of assigning a causality; and by suspending the indefinitely suspended privilege of the cause, in order to render apparent the polymorphous 23 cluster of correlations" (in Michelle Barret The Politics of Truth, 130). Ideology, from a classic Marxist perspective, is dispensed unidirectionally from those in positions of economic power to the masses who internalize these belief systems and act in accordance with them. Sociological examinations of mental illness (Conrad's study of hyperactivity serving as our most relevant example) also discuss notions of mental illness as ideological. Corporate and medical realms, it is argued, control public perception, hence, the idea of a mental disorder is dispensed to a susceptible public. Genealogy and Foucault's dependencies There are three dependencies Foucault (1978) outlines: the intradiscursive, inter discursive, and extradiscursive. The intradiscursive refers to the objects, systems of concepts, and methodologies within one discursive formation or discipline. The interdiscursive refers to interactions between different discursive formations, for example, the polarities taken between social constructionists and clinicians towards mental illness diagnoses. The extradiscursive refers to the relationship between discourse and everyday experience, for example, the way lay people are affected by the established disciplines' institutional manifestations, such as prisons, mental asylums, hospitals, schools, vand so on. These three dependencies are the basis of genealogical accounts and have proven to be particularly relevant to mental health. Mental disorders are peculiar cases of social phenomena because the nomenclature surrounding them seems to change according to political and social climates. They are a distinct representation of discursive formations which have established a sort of legitimacy in clinical and lay realms, and are manifested very strongly in everyday lived experience. Because mental disorders can be heavily analyzed on the discursive end, as well as within the less-discursive field of lived experience, the topic is a unique opportunity for a nexus between genealogy and ethnography. 24 Genealogical analyses of mental disorder can cultivate awareness of such phenomena which would prove difficult through other methods. There are at least two reasons for this, both of which separate genealogical accounts of mental disorder from other accounts. First, genealogical accounts of mental disorder do not profess any etiology of mental illness, falling on neither side of the mental illness "validity question." Such studies are not concluded by stating that a specific mental disorder is a bona fide truth or falsehood. In lieu of the temptation to lay claim to a mental illness etiology, genealogical accounts instead provide elaborate discussion of the various statements which have strategized to lay claim to one etiology or another. In short, genealogical accounts avoid etiological arguments by "objectifying" the multitude of etiological positions. Genealogical studies stand on the outside of what has been labeled the "discursive field," discussing the players within this field, and these players' strategies to account for an object of knowledge. Genealogists objectify the process through which statements are made about a mental illness, and, to a lesser degree, the methods which propel those statements. Hence, those who provide genealogical accounts of a mental disorder are inclined to discuss the phenomenon at hand as a result of "narratives" crafted by the warring factions in the discursive field.9 The use of the term "narrative," many argue, reduces a mental illness to a kind of story, rather than a lived social reality. I believe this is a point at which empirically-based sociology tends to withdraw support from genealogical methods, because the experience of mental, disorder is not articulated. Genealogical studies become relegated to the amorphous category of "postmodern methodology," and are argued to be more suitable for literary criticism and cultural studies forums. Second, genealogical accounts have a tremendous variability in the types of "data" with which they engage. This stems from the theoretical positions about the discursive field, specifically that this field is enormous—to the point of being impossible to quickly summarize in one study-and is comprised by extreme variability. Genealogists scrutinize the sets of statements 9Young, Allan. (1995) The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press, (p. 270). 25 to be objectified at the admitted exclusion of others. There is a sort of faith that they will examine the discourses which appear the most dominant in a contemporary understanding of mental disorder (i.e. an examination of neurochemical discourses in relation to disorders such as ADHD, schizophrenia, and depression) and analyze such a disorder in terms which contemporary social actors can understand. But, there is simply no guarantee. This is an exciting methodological space. Genealogy is induction to an extreme, of sorts. It defies much of the ideas of research design, hypothesis creation/testing, theory generation, and so on, but frees a researcher to explore data sources which might otherwise be ignored. The exploration of concepts and systems of statements inherent to the genealogical method would be wrongly equated to a "new social constructionism." Genealogical methods are divergent from social constructionist studies, mainly due to the source from which the construction stems. Social constructionists are commonly inclined to link the understanding of a mental disorder to specific political locations. For example, in Peter Conrad's article "the Discovery of Hyperkinesis," childhood hyperactivity is argued to be "medicalized" through the political dominance of certain institutions, primarily government agencies, and pharmaceutical corporations.10 Conrad leads the reader to a point of origination for hyperkinesis, using the term "discovery" in a disingenuous way. Hyperkinesis, from this perspective, was never discovered, but fabricated out of special, focused interest. It is a mental disorder rooted in conspiracy. The perspective embodied in Conrad's work is nowhere to be found in the work of those doing genealogical studies. For example, Allan Young's The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder(\995)uses the term "inventing" very differently than a social constructionist. Post-Traumatic Stress Disorder is not "invented" because of the efforts of particular agents, but rather, PTSD is an artifact of the discursive field. A contemporary understanding of PTSD is not the result of a selfish investment of a special interest group, but instead stems from multiple interests in the disorder. Such a claim reinvents the word "invention" 1 0 Conrad, Peter (1975) "The Discovery of Hyperkinesis: Notes on the Medicalization of Deviant Behavior," Social Problems 23: 12-21. 26 and portrays an examination of PTSD as an eye gazing into a kaleidoscope, rather than a uni-directional, "telescopic" perspective. Through focusing on a history of multiple discourses, genealogy promotes a "less-taken-for-granted" perspective on mental illness. Issues of validity become secondary to another analytical context in which discourses are placed within a political arena, portrayed as working within and against each other, always in motion, always propagating new sets of statements. Articulating the constant and seemingly arbitrary shifts in discursive motion, genealogy subverts notions of truth or even the notion of "progress" towards some semblance of truth. This has been interpreted as a "political aim" of genealogy, not because it seeks to invalidate a discourse as "self-serving," or "conspiratorial," but because such an analysis demystifies contemporary dominant discourses. For sociologists who wish to undermine dominant narratives towards mental illness, this method is highly disconcerting. The reason for this feeling on behalf of sociologists is that their own discourses about a mental disorder—for example, ones which invoke a social constructionist nomenclature—are also subject to genealogy's inherent politics. The political normativity of social constructionism, or any "ism" for that matter, cannot reign within a genealogical framework. Because genealogy eliminates the efficacy of alternative discourses it is a methodology subject to considerable criticism. Hence, Nancy Fraser playfully calls Foucault's genealogy a great "lover" but terrible "husband,"11 and Jurgen Habermas labels the method "cynical." 1 2 After presenting the discourse-scape, genealogy bids us farewell, telling us to "do what we will" with the information which has been given to us. For sociologists who would much rather align themselves with a "critical realist" rather than "postmodernist" perspective, this is simply inadequate. Sociologists, myself included, find a continuous need to ground information "Nancy Fraser, Nancy. (1989) Unruly Practices: Power, Discourse and Gender in Contemporary Social Theory Minneapolis: Minnesota Press, (p. 64, 65). 1 2 Habermas, Jurgen. (1984). The Philosophical Discourse of Modernity: Twelve Lectures. Cambridge, Mass: MIT Press (p. 253). 27 in some type of empirical account. If this is an impossibility, it is argued that the data either needs to be rethought or collected from a different methodological standpoint. The first part of this thesis,will address ADHD from a genealogical perspective in a style similar to both Hacking and Young. The reader should not be deceived into thinking that the genealogy of A D H D I will present is a comprehensive history of A D H D . Such a history, I believe, would be an impossibility. Instead, I have documented some examples of neurological, psychological, and psychoanalytic discourse which have relevance to contemporary understandings of A D H D . In addition, this thesis will examine the conflation of those discourses with those that lay actors internalize in the form of education manuals and parental guidebooks. This thesis will be devoted to studying some of the "higher profile" discourses surrounding ADHD-like symptoms since the turn of the century. More appropriately labeled "textually mediated" discourses, these discourses will mainly be drawn from books and journal articles. The discursive depiction of ADHD will clearly demonstrate that A D H D is far from being uniformly understood. Even as concerted and unified as the treatments for A D H D are, this disorder's etiology remains highly contested within the same discursive formation, for example, within the discourse of Western medicine in which similar concepts and methodologies are used as points of reference. This exemplifies Foucault's "intradiscursive dependency." Therefore, this study will examine the reactive, "anti-Ritalin" stances of researchers such as Peter Breggin and Sydney Walker as they contrast with the positions of researchers such as Russel Barkley and Barbara Fisher. A D H D and ADHD-like symptoms, described in the past as hyperkinesis, minimal brain dysfunction, hyperactivity, etc., has also been highly contested between disciplines with markedly different points of reference, or, what Foucault would call the "interdiscursive" dependency. Obviously, the opposition between social constructionists and those in the field of medicine can be analyzed from an interdiscursive standpoint, but there are other, less polarized discourses which have contested the etiology of A D H D and have contributed to its contemporary 28 v form. For example, the rift between neurological and psychodynamic perspectives towards ADHD will be given considerable regard. The neurological perspective, I will argue, solidified its position through a physiological interpretation of childhood behavior problems. Initially, this interpretation was linked to the diagnosis of encephalitis lethargica, beginning in the 1920's. From the medical discussion of the psychiatric sequelae of encephalitis, the neurological camp constructed a nomenclature which eventually led to the sophisticated discourse influential in the discussion of A D H D today—a highly physiological, scientific stance providing the foundation for the current dominance of medicinal treatments for A D H D . Psychodynamic perspectives, on the other hand, did not link ADHD-like symptoms directly to brain chemistry, but instead saw them as behavioral responses to a personal incapacity to cope with life as "normal" people do. Because of an analysis which focused on behavior, psychodynamic practice and theory continue to argue for psychotherapy, rather than medicines, as treatment for ADHD. The genealogical component of this thesis is meant to provide more than a simple "background" to the A D H D phenomenon. Rather, it is meant to be an examination of a cross-section of some of the many discourses which served to create the modern ideas of ADHD. Such a perspective is highly relevant to sociology for at least two reasons. First, historical examinations of mental disorder often lead to conclusions which implicate well-known social institutions, such as the family, the economy, medicine, and government. Given the breadth of available literature which provides analyses of these and other institutions, a historical account of mental disorders like A D H D would engender a useful context to further such critque. It is my belief that the history of a mental disorder and the institutions with which it intertwines work together to give us the "current" discussion of both the disorder and those institutions. A D H D is an excellent example of this because it has been so closely tied to the institutions we have always perceived to be so valuable. In fact, the diagnosis of A D H D is in many ways synonymous with an individual failure in institutional contexts. The kids with ADHD are the kids we perceive to have "problems" with school, family, and everyday social life. 29 With a rich historical account we can separate ourselves from the apparent legitimacy of institutional demands and place A D H D (and the inability to function within the confines of conventional institutions) into a larger discursive context. Second, a historical account of A D H D sheds light on the everyday discourse which can be seen in the discussions of social actors surrounding the disorder. The other half of this thesis, which analyzes interview data from a variety of respondents, including parents, teachers, and clinicians of A D H D children, is meant to provide an empirical account of the various academic discussions of A D H D . This complement to the historical account shows the importance of balancing interview data with with its greater socio/historical context. If the aim of this analysis is realized, the lineage of A D H D , or the discourses which have and continue to strategize for ownership of the term, will be shown as a history accented with contest and controversy. In this regard, a unified history of A D H D , that is, one that need merely serve as a monolithic background for some ideological discussion of the phenomenon, will be shown as a much more daunting task than previous authors have presented. The genealogical account of A D H D may be better served with a discussion of some of the conceptual antecedents that gave rise to the later discussion of ADHD, rather than through discussing a predictably linear sequence of events. This is the undertaking of chapter two, in which a discussion of the medical concepts of idiocy, imbecility and encephalitis lethargica are argued to have laid the groundwork for contemporary discussions of ADHD. 30 Chapter 2 Linking Immorality to the Disordered Brain As common as a specific case of ADHD, is an opinion by someone who has "made up their mind" about the phenomenon. Virtually everyone I interview or casually discuss the topic with has some degree of conviction about this disorder, whether that conviction be about the "horrors of TV" or those "poor disabled children" or the "sham of psychiatry" or the "devastating effects of bad parenting" or the "pill-popping society." These generalizations, which are so readily available in the popular discussion of ADHD, seem to be made in haste. Few people I interviewed purported to have knowledge about the history of A D H D , and the same number were unaware of the current scientific narrative about the disorder. I must admit to a certain uneasiness in hearing this cross-section of opinions. ADHD, whether "real" or "constructed", is a disorder with tremendous educational and interpersonal implications, whose discursive history needs careful analysis. Failing such an analysis limits the potential depth at which the disorder may be understood. A D H D is an acronym embedded in popular culture, yet its conceptual history is little discussed both in the popular realm and in academia. Brief histories of A D H D have been provided by researchers in the field (Kessler 1980; Barkley 1990, 1997) and also by those opposed to clinical discourse (Schrag and Divoky 1975; Conrad 1976). Shrag and Divoky (1975) for example, treat the history of A D H D as one of "child control"; Conrad (1975), taking a sociological analysis presents the history of A D H D as being directly linked to the exercise of institutional power, such as that found in schools and in government organizations. On the other hand, historical accounts by Kessler (1980) and Barkley (1990, 1991, 1997), discuss the history of A D H D as one characterizing the progress of modern clinical practice, slowly honing its nomenclature to greater levels of scientific validity and practical effectiveness. The medical concepts prior to A D H D , such histories imply, are stepping stones to increased knowledge and decreased human suffering. 31 There are two qualities which unify each of these historical accounts of ADHD. First, they are plainly ideological; each account appearing to serve the agenda of the authors' perspective on the legitimacy of A D H D as a disease category. Second, each of these accounts is all too brief, perhaps irresponsibly so. These histories are written as introductions to the aforementioned authors' books, serving as a "background" for their readership rather than as a significant topic of inquiry. The most common starting point for historical accounts of A D H D are a series of lectures given by George Frederic Still in 1902. Both skeptics of A D H D validity (Shrag and Divoky 1975, Breggin 1998) and advocates (Barkley 1990, 1997) trace the lineage of the study of A D H D to these lectures. Though this chapter will address the work of G.F. Still, I will not begin a conceptual history of A D H D with this document. Instead, I will discuss the clinical distinction between two medical terms of the 19th century: idiocy and imbecility. It will be argued that the discourse of "imbecility" marked an early point of connection between marked and unmarked nervous disorders. Imbecility was part of the medical nomenclature which enabled medical science to begin inquiries into the mental health of persons, who were not drastically maldeveloped or mentally handicapped. Medical discourse also began addressing the moral aspects of imbecility, eventually coining the term "moral imbecile" around the turn of the century. As will be shown, "imbecility" was a medical diagnosis which included persons who could not function within conventional institutional structures, and engaged in behaviors which were socially inappropriate, often criminal. This included, to a large extent, the behaviors of children—something in which G.F. Still took particular interest. This chapter will examine the work of Still as a conglomeration of the many medical discourses surrounding imbecility and morality in the late 19th and early 20th century. After providing a description of the discourse of imbecility and idiocy, I wil l demonstrate how Still's work was significant for the particular medical study of child immorality. It will be argued that Still was the first to link notions of moral imbecility to children, even though he failed to provide an official diagnosis for this childhood behavior. 32 The latter half of this chapter will be devoted to an examination of the discourse surrounding encephalitis lethargica or "sleepy sickness" in children during the 1920's. According to Kessler (1980) and Barkley (1990, 1997), the medical discussion of this disease is crucial in understanding the formulation of the concept of A D H D . The psychological sequelae of this disease were supposed to be the root of a litany of childhood behavioral problems including many of the things we today associate with ADHD: inability to study, overactivity, impulsivity, etc. Hence, the nomenclature which addressed the residual effects of encephalitis lethargica realized much of Still's suspicions in 1902. What Still had suspected as an organic manifestation or lesion in the immoral child, those who studied encephalitis lethargica made into a clinical reality. Idiocy vs. imbecility Today both idiocy and imbecility are so popularized that their clinical meanings have all but been forgotten. Interestingly, those who wrote about idiocy and imbecility in the medical literature of the 1870's also struggled to keep its meaning within the confines of medical nomenclature (see Ireland, 1877). The idiot was a type of person who needed to be clarified and understood as a medical phenomenon, not jeered and mocked as a social misfit or catch-all typology for someone deemed socially inept. The discussion of imbecility was engaged in a partial effort to provide clarity to the diagnosis of idiocy, and later gave rise to imbecility owning its own clinical place in mental health nosology. William Ireland (1877) provides a distinction between the two terms: Idiocy is mental deficiency or extreme stupidity, depending upon malnutrition or disease of the nervous centres, occurring before birth or before the evolution of the mental faculties in childhood. The word imbecility is generally used to denote a less decided degree of mental incapacity. Thus, when a man distinguishes between an 33 idiot and an imbecile, he means that the mental capacity of the former is inferior to that of the latter (p. 1). Imbecility here denotes a condition much less severe than that of idiocy but the extent of the difference between the two terms is unclear. The idiot is presented as someone who has an organic disorder of some kind, the onset of which occurs at the earliest phases of life. The imbecile is presented as someone with a lesser degree of the same symptoms as the idiot. The imbecile can certainly demonstrate "mental deficiency" or "stupidity," yet not as much as the idiot. What is missing in this rudimentary analysis by Ireland is some form of conceptual standard by which a more calculated distinction can be made between the idiot and the imbecile. British physician Charles Mercier (1890) expands on the distinction between these two mental affectations. Lumping both idiocy and imbecility into the category of "congenital mental deficiency" or dementia naturalis (286), Mercier provides a more sophisticated analysis of the distinction between the two diagnoses. His analysis is one which rests upon the premises of mental development in the individual: The first thing the child learns is to avoid physical danger—to keep from falling into the water, running against obstacles, burning and cutting itself, and all forms of physical injury. ...when the activities answering to this class of circumstances has been thoroughly acquired, then, and not till then, begins the acquisition of those activities by which the livelihood is to be earned. Then begins the formal process of education, which is the first step in fitting the individual to get his living. When this has been done, when sufficient time has been spent daily in the acquisition of these activities, then what remains over can be devoted to recreation and other purposes (p. 289,290). Mercier claims that the development of certain faculties throughout the early part of life will enable the individual to function at increasingly higher levels. The lowest level of functioning is denoted by the individual's ability to display minimal self preservation, therefore avoiding 34 physical injury. The higher levels of functioning include things like receiving an education and finding adequate employment. Mercier claims that the idiot is a type of individual who demonstrated poor development at the most basic level of human existence. Idiots are to be watched and cared for; they are a danger to themselves because of their total lack of awareness of their surroundings. Imbeciles represent a slightly higher, though inadequate, level of development: In idiocy the deficiency is still greater. The imbecile fails to adapt himself to his vital environment, he fails to complete the second step in his intellectual development; but he surmounts completely the first step, that which enables him to adapt himself to his physical environment (p. 290, emphasis in original). Imbeciles could avoid dangerous moving objects, but could not be adequately educated to make a living. The imbecile personifies a failure to meet the demands of social and institutional expectations. Imbecility as a category of mental defect became widely known in the medical community as a specific phenomenon not to be confused with the more obvious and impairing condition of idiocy. The definition of imbecility was decreed by the Royal College of Physicians in England (arguably the most esteemed collection of physicians in Europe during that time) in 1912. From the Royal College's official definition an imbecile " incapable from mental defect, existing from birth or from an early age, (a) of competing on equal terms with his normal fellows, or (b) of managing himself or his affairs with ordinary prudence" (Goddard 1915, p.12). The ineptitudes described in the discussion of imbecility were eventually linked to an individual's inability to display moral restraint and lawful behavior. In what became known as "moral imbecility"1 3 medical practitioners conceptualized the acquisition of morality as a problem of human biological development. William Ireland (1900) provides a description: • 1 3Charles Mercier (1917) has stated that it was he who coined the term "moral imbecility". The date of the inception of the term could not be found in my research. Due to no findings of another to stake claim of the origin of the term, 35 We now and then read of a "moral imbecility," a variety of the unhappy invention styled "moral insanity," originally intended to signify a total want of moral feelings as proved by reckless and shameless conduct without any intellectual impairment. ...The title "moral imbeciles," however, is so far correct that there are certain children who show from the beginning a proness to evil, a callous selfishness, and a want of sympathy with other people, which is the most striking part of this disorder (p. 287). This passage represents much of the literature which addressed moral imbecility around the turn of the century. Such writing presents a new direction of study for medical science. The inability to demonstrate moral behavior, in that it fell under the rubric of imbecility, could be understood as a medical problem. Ireland (1900) describes a case of moral imbecility—a boy, K . N . , housed in a hospital dormitory: The first symptom of insanity was his smashing of panes of glass in the passage and other places where he would not be readily noticed. When asked why he did so he said that he liked to see the glass fly. This went on for about six months. One day he took out of his pocket a knife which he had got hold of and deliberately made an incision in a boy's hand (p. 288). The imbecile represents one more piece in the historical tapestry of discourse which has objectified the "nature" of the criminal, the uneducated, or the undisciplined. In Discipline and Punish (1977) Foucault discusses such processes of objectification as constructing the "modern soul". This modern soul represents the perceived essence of those who engaged in deviant behavior~an essence believed to be understandable and malleable only through the administration of scientific techniques. Foucault's work in Discipline is mainly credited with analyzing modern science's examination and objectification of the criminal (what Foucault calls perhaps credit at this time, for placing "moral imbecility" into medical discourse, should be awarded to the late doctor. 36 homo criminalis), but this process of seeking the essence of the deviant through scientific study encompasses virtually anyone who has persistent troubles with conventional institutions. Within the discourse of imbecility during the later 19th and early 20th centuries, there is particular attention given to children. An examination of medicine's focus upon the moral propensity of children is crucial in drawing a bridge between this early discourse and the gradual unfolding of the discourse which has surrounded ADHD. The A D H D child, much like homo criminalis, represents an object of study who could not fit into the institutional frameworks of everyday life, and needed, in one way or another, to be molded to meet the demands of these institutions. Moral imbecility evolved as a concept both medically and legally. It was formally inducted into the British Mental Deficiency Act of 1913 constituting a class of "Persons who from an early age display some permanent mental defect coupled with strong vicious or criminal propensities on which punishment has had little or no deterrent effect" (Tredgold 1917, 43). The continued failure of reformative intentions of punishment, or the threat thereof, led many medical, practitioners to believe that the moral imbecile represented a case of incorrigibility in the face of the disciplinary mechanisms of that time period. Hence, there was an increasing pressure on the medical establishment to conceptualize and re-conceptualize moral imbecility in an effort to apply more effective techniques of reform. Part of the later conceptualization of the moral imbecile involved the discussion of this type of imbecile being, in many cases, of normal or even superior intelligence. The moral imbecile, physicians argued, was a more complex creature than physicians had initially thought. Physician Alfred Tredgold (1917) in an article on moral imbecility states: "Many undoubted moral imbeciles are so cunning, so plausible, and so seemingly intelligent, that mental defect, as normally understood, would appear to be, and in truth, is, quite out of the question" (43). Charles Mercier (1917) in an article covering the same topic two months later states: "...I would go farther than Dr. Tredgold, and say that some moral imbeciles are not only seemingly intelligent, but really intelligent. I have met more than one who have engaged me in a battle of wits, in which I did not win every round" (303). This discussion on behalf of medical practitioners is ironic 37 given the conceptual history of