ADHD, or the Medicalization of Social Problems

Global Perspectives on ADHD: Social Dimensions of Diagnosis and Treatment in Sixteen Countries By Meredith R. Bergey, Angela M. Filipe, Peter Conrad, and Ilina Singh, eds.

Baltimore, MD: Johns Hopkins University Press, 2018 416 pages; $64.95 ISBN-13: 9781421423807; ISBN-10: 1421423804

Any diagnosis that goes from being a relative rarity to the “most common developmental or psychiatric diagnosis among school-age children and adolescents, with worldwide prevalence estimates of 5% and 7.2%” (p. 1) over just two decades deserves the kind of ambitious, nuanced, and unique analysis that this excellent edited book provides. Global Perspectives on ADHD makes a valuable contribution to the massive literature on attention deficit–hyperactivity disorder (ADHD) and the dominant treatment of it: stimulant medications. The book follows the social, cultural, and health system contours of ADHD’s “spread” from the United States to 15 other countries. With the exception of Ghana, the countries are developed and high income.

Along the way, readers learn that significant intercountry variation in ADHD diagnosis rates and stimulant use can be largely the result of comparatively minor differences in regulatory factors, such as which drugs are approved for use in treating ADHD; which clinicians are allowed to diagnose and treat children with ADHD; which nonmedical services and accommodations for children diagnosed with the disorder are available; whether ADHD is classified as a disability; whether hyperactivity is listed first in the translated term (with attention deficit second); which forms of pharmaceuticals (i.e., short-acting stimulants, long-acting extended release stimulants, nonstimulant selective norepinephrine reuptake inhibitors) are accessible; and what cultural preferences for nonpharmaceutical treatments, such as cognitive behavioral therapy, exist.

COLONIAL PSYCHIATRY

Global Perspectives on ADHD complements other analyses of the Americanization of mental illness, which suggests that pharmaceutical companies, patient advocacy groups, and the standardizing influence of the Diagnostic and Statistical Manual of Mental Disorders fosters a form of colonial psychiatry. Mental disorders that are fundamentally social problems are “medicalized” and then matched with pharmaceuticals that address the symptoms of these problems. Other conditions that are medicalized include menopause, normal pregnancy, infertility, erectile dysfunction, and obesity. Another term for this phenomenon is “disease mongering.” Once medicalization has occurred in the United States, it can spread to countries that have similar social problems. How it spreads and the different ways medicalization evolves in other countries become a fascinating function of the unique cultural, economic, professional, educational, and health system characteristics of each country.

As the book’s editors explain, mental disorders like ADHD are particularly good examples of medicalization. Why? Because unlike other diseases (e.g., HIV) and conditions (e.g., pregnancy) for which there are objectively verifiable diagnostic tests, mental disorders are primarily diagnosed on the basis of a variety of symptoms that fall along a normal spectrum of “more” or “less”: anxious, depressed, obsessive, fearful, impulsive, inattentive, hyperactive, and so on. Moreover, in the case of ADHD, educators and clinicians estimate a child’s ratings on these symptoms that then have an arbitrary cutoff on the spectrum between normal and abnormal. Thus, most mental diagnoses are inherently and unavoidably subjective. This makes for fertile territory for increased medicalization of normal life problems. It also explains why, in the specific case of ADHD, researchers keep finding that, controlling for other factors, younger children in every grade are more likely to be diagnosed with ADHD than are their older classmates because of arbitrary birthday cutoffs; there is a 34% higher rate of ADHD diagnosis among US kindergarteners born in August than those born in September.^1(p2125)

PALEOLITHIC SUCCESS STORY

Another possibility is that children’s environments, especially in schools for all children with compulsory attendance, have changed far more rapidly than has the rate of physiological evolution. As Richard Friedman argues:

Consider that humans evolved over millions of years as nomadic hunter–gatherers. It was not until we invented agriculture, about 10 000 years ago, that we settled down and started living more sedentary—and boring—lives. As hunters, we had to adapt to an ever-changing environment where the dangers were as unpredictable as our next meal. In such a context, having a rapidly shifting but intense attention span and a taste for novelty would have proved highly advantageous in locating and securing rewards—like a mate and a nice chunk of mastodon. In short, having the profile of what we now call A.D.H.D. would have made you a Paleolithic success story.^2(SR1)

Today, however, that Paleolithic profile of risk seeking with short bursts of intense attention is ill suited for long days of sedentary academic drudgery with stressful, high-stakes standardized testing.

Options for addressing this new problem are primarily binary: change the child’s environment or change the child’s neurochemistry. If it is an evolutionary mismatch between our brains and our environments, then people

with ADHD are walking around with reward circuits that are less sensitive at baseline than those of the rest of us. Having a sluggish reward circuit makes normally interesting activities seem dull and would explain, in part, why people with A.D.H.D. find repetitive and routine tasks unrewarding and even painfully boring.^2(pSR1)

Obesity might be a similar phenomenon. Our food environments have changed far too rapidly for our physiological evolution and adaptation to catch up, resulting in skyrocketing rates of obesity and type 2 diabetes. We can change the food environments or we can develop drugs and surgeries to address the downstream symptoms of radically new environments. What makes obesity different from ADHD, however, is that people’s weight and where they stand on a standard measure of obesity (such as the body mass index, or BMI) can be objectively measured. Anyone assessing a person’s weight with a scale will reach the same numerical conclusions. With ADHD, however, different clinicians will invariably reach different diagnostic conclusions on the basis of subjective scoring of children’s symptoms on Likert rating scales.

LIMITS OF CLINICAL KNOWLEDGE

Ultimately, as Global Perspectives on ADHD suggests, criticism of mental disorders like ADHD are criticisms both of the limits of clinical knowledge and of the extraclinical (social, cultural, economic) forces that influence diagnostic decision making. At the heart of the controversy over ADHD are timeless and universal questions of psychiatric boundary drawing. To the extent that the boundary between sickness and health is—as in the case of ADHD—demarcated without the ability to reference objective clinical signs or indicators (e.g., blood tests, urine tests, diagnostic imaging, such as MRI [magnetic resonance imaging]), debates about under- and overdiagnosis invariably tap into society’s ambivalence and skepticism about some mental disorders. Although scientific research can inform our understanding of mental disorders and our approach to making better diagnoses, where the boundary between ADHD and typical childhood behavior is located is ultimately a political and social choice, not a scientific one. No amount of scientific research can resolve this question for us. Multiple authors and editors make for a bumpy read, but for those who want to better understand how ADHD and stimulants play out in multiple countries, this book will serve as a very good starting point.