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Related Topics
Identifying Hyperactive ChildrenReview - Identifying Hyperactive Children
The Medicalization of Deviant Behavior
by Peter Conrad
Ashgate, 2006
Review by Edmund O'Toole
Aug 29th 2006 (Volume 10, Issue 35)

ADHD has now become widely accepted as a clinical disorder.  Although Peter Conrad's study was initially published in 1976 it still remains relevant and provocative.  The validity of the disorder comes under scrutiny with Conrad's study.  He questions the tendency to treat the non-confirming behavior as a medical problem rather than viewing behavior as deviancy.  This expanded edition includes an epilogue offering additional consideration in view of the diagnostic expansion of the disorder since the original study, which now includes adults, and some of the attendant sociological issues.  

The methodology by which ADHD was identified was the focus of Conrad's study.   His concern was with the sociological issues implicit in the recognition of the disorder.  It was to be an examination of how the medical establishment arrived at the labeling of ADHD as a disorder, and came to be an investigation into the medicalization of deviant behavior.  The initial study was conducted at a time when anti-establishment thought was challenging the labeling of individuals and the social construction of disorders and syndromes.  Thomas Szasz, Michel Foucault and the anti-psychiatric movement inspired many to question medical and psychiatric authority and the legitimacy in defining illness.  While such influences are widely recognized in attacking the medicalization of deviant behavior, Conrad's study is in many ways providing a template for how a sociological study of such an assertion of a disorder could be analyzed.  Such a position seems particularly appropriate and relevant to ADHD, significantly so in light of the growth of ADHD as an illness and an industry.    

The study examines the process and procedures in the diagnosis of ADHD at a Hyperactivity-Learning Disabilities clinic in a major pediatric centre.  Over a six month period Conrad and a research assistant observed evaluations carried out in the clinic by staff.  They also conducted interviews with parents and had them answer questionnaires.  The size of the sample group of patients was 38. 

This book is quite small and concise.  The attention to detail provides much to think about, offering insight not only into the flaws and inconsistencies within the methodology of diagnosis, but also revealing the prejudice and bias that cloud the issue of certainty and validity.  Conrad accepts that uncertainty is a feature of medicine, yet he emphasizes the hypothetical nature of the disorder.  There maybe various reasons for the manifestation of such behavior.  While the body of the book is a critical analysis on the diagnostic approach to hyperactivity, he does offer a possible etiological breakdown between environmental and constitutional dimensions.  Hyperactivity is divided further into subtypes where hyperactivity is either the primary problem or symptomatic of another underlying one.  While this is a workable approach to clarifying the concept of hyperactivity it is an extremely brief part of the book, covering only a page in the Appendix.  It is disappointing that it wasn't developed further, it could have proved beneficial, but as it is it can easily be overlooked, which would be regretful, coming as it does as a final Appendix.  Indeed it remains to this part of the book to explicitly offer his position on hyperactivity and its etiology.  Prior to this one could be forgiven for believing that he viewed the disorder purely as a social construct. 

Conrad develops only one element of environmental hyperactivity in the body of the book.  He devotes one chapter to an analysis of situational hyperactivity, which is obviously important in relation to his sociological perspective.  He points out that some children would be better described as ''situational hyperactives'' instead of hyperactive. 

ADHD symptoms had generally been considered to diminish with age, but this is a (small) point of contention in Conrad's critique of adult ADHD: when considering the primary constitutional etiology, rather than considering it to be the result of minimal brain dysfunction such behavior might also be considered as a consequence of immaturation; this, in turn, would also undermine the attempt to ground ADHD in pathology.  In relation to claims about the age-of-onset offered for this disorder, and other disorders, it is worth stating the obvious: biological or cognitive development does not necessarily coincide with chronology.  For the most part Conrad's analysis make it obvious that diagnosis is not straight forward but is reached through negotiation, when behavior in one or more social setting is unmanageable.  But it must be noted that the criteria seems more arbitrary than definitive.   

Conrad also investigates the socio-economic culture and normalization of ADHD through vested interest.  ADHD is big business, with many promoters desiring to legitimize and expand the disorder for a multitude of reasons.  Conrad, in his Epilogue with Deborah Potter, captures the extent to which ADHD has become a social reality, where many actors chasing different agendas make it so.  Unlike childhood diagnoses of ADHD the Adult disorder is actively sought by the individuals themselves, with self diagnosis contributing to the expansion and legitimization of the disorder. As with childhood ADHD, responsibility for behavior becomes attributable to a disorder rather than the individual.   

He is critical of the use of medicine as a means of social control, something which he, rightly, believes to be a rising trend.  The easiest solution is not always the right solution.  Pharmacological treatment as a social control mechanism provides management not only for deviant behavior, but also for other maladies intensified by social stressors.  The sociological issues highlighted in the epilogue recognize that attendant problems arise with legitimization, such as the legal considerations of disabilities.

This book is both challenging and sobering.  Rather than freely accepting the authority of medical jurisdiction it questions the objectivity and methodology involved in diagnosing a disorder.  Yet much of his analysis of ADHD may pertain more particularly to the American model rather than the medical establishment in general.  As Conrad acknowledges, diagnosis for ADHD in Britain, for example, is more rigorous.  

I was somewhat disappointed that there was very little discussion on the pharmacological treatment itself other than to indicate its effectiveness in only 60% of cases.  While he details the economic benefits to companies who produce the stimulant medication there is nothing by way of deliberation on the effects of medication.  There should also have been some discussion on the comorbidity with other disorders.  The DSM-IV-TR points out that over half of those clinically diagnosed with ADHD also have Oppositional Defiant Disorder or Conduct Disorder.  These disorders are also evidence of the medicalization of deviant behavior.   While current classifications distinguish the two, debate about the distinction of ADHD and CD are still ongoing.  Some advocates of ADHD view CD as resulting from problems of socialization rather that the cognitive impairment attributed to ADHD.  There is also high comorbidity with high functioning autism such as Asperger's.  The DSM-IV-TR states that ''overactivity and inattention are frequent in Asperger's Disorder, and indeed many individuals with this condition receive a diagnosis of Attention-Deficit/Hyperactivity Disorder prior to a diagnosis of Asperger's Disorder'' (p.81.).  To neglect these considerations undermines some of the objectivity of Conrad's worthwhile project.  However the book does provide a critical examination of the subject, and informs on many levels.  It offers a caution to the acceptance of influences claiming authority without questioning the validity of such claims.  In the thirty years since the initial study took place much of the knowledge surrounding ADHD still remains speculative and yet Conrad's original criticisms remain.    


© 2006 Edmund O'Toole


Edmund O'Toole is a Philosophy PhD student at the National University of Ireland in Galway.


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