University of California Press Society For The Study of Social Problems

From Hyperactive Children to ADHD Adults: Observations on the Expansion of Medical
Categories
Author(s): Peter Conrad and Deborah Potter
Source: Social Problems, Vol. 47, No. 4 (Nov., 2000), pp. 559-582
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From Hyperactive Children to ADHD
Adults: Observations on the Expansion
of Medical Categories
PETER CONRAD, BrandeisUniversity
DEBORAH POTTER, BrandeisUniversity
Medicalizationis,bydefinition,abouttheextensionofmedicalboundaries.Analogousto "domainexpan-
sion,"extantmedicalized can expandtobecomebroaderand moreinclusive.
categories Thispaperexaminesthe
emergence ofAttention
Deficit Disorder(ADHD) in adults.ADHD, commonly
Hyperactivity knownas Hyperac-
becameestablished
tivity, in the1970sas a diagnosis
forchildren;itexpandedfirsttoinclude"adulthyperactives"
and, in the1990s,"ADHD Adults."Thisallowedfortheinclusionofan entirepopulationofpeopleand their
problems thatwereexcludedbytheoriginalconception ofhyperactivechildren.Weshowhowlay,professional,
and mediaclaimshelpestablishtheexpandeddiagnostic Weidentify
category. particularaspectsofthesocial
contextthatcontributedtotheriseofadultADHD and outlinesomeofthesocialimplications ofADHD inadults,
especiallythemedicalizationofunderperformance and theavailabilityofnew disability AdultADHD
rights.
servesas an exemplarofseveralcasesofdiagnostic
expansion,an importantavenueofincreasing medicalization.
Over the past thirtyyearstherehas been keen sociologicalinterestin the medicalization

of deviance and social problems(Conrad 1992, 2000; Conrad and Schneider1992; Zola 1972).
By now, thereare dozens ofcase examplesofmedicalizationand a body ofliteraturehas accu-
mulatedthathas looselybeen called "medicalizationtheory"(see Williamsand Calnan 1996).
At thispoint,it is importantto build on thiscorpus of knowledgeto betterunderstanddiffer-
ent aspectsof medicalization.Medicalizationis, by definition,about the extensionof medical
jurisdictionor the expansion of medical boundaries. In different situations,medical profes-
sionals (Halpern 1990), politicalreformers(Haines 1989), lay activists(Schneider 1978), or
social movements (Scott 1990) have promoted boundary expansion. Most medicalization
studiesfocus on how nonmedicalproblemsbecome definedas medical problems,usually as
illnesses or disorders.But there has been less examination of how medicalized categories
themselvescan be subjectsof expansion,thus,engenderingfurthermedicalization.
It seemsclearbynow thatmedicalization ofsocialproblemsis notan either/orphenomenon,
but thatit is betterconceptualizedin termsof degreesof medicalization.Some conditionsare
almost fullymedicalized (e.g., death, childbirth),others are partlymedicalized (e.g., opiate
addiction,menopause), and still others are minimallymedicalized (e.g., sexual addiction,
spouse abuse). One dimensionof the degreeof medicalizationis the elasticityof a medical cat-
egory."While some categoriesare narrowand circumspect, otherscan expand and incorporate
a number of other problems"or be applied to new populations (Conrad 1992, p. 221). For
example,Alzheimer'sDisease (AD) was once an obscuredisorder,but withtheremovalof "age"
as a criteria(Fox 1989), therewas no longera distinction
betweenAD and seniledementia.This
Our thanksto JoelBest, LibbyBradshaw,Phil Brown,Allan Horwitz,and the anonymous reviewersforcomments

on earlierdraftsof thispaper. Directcorrespondenceto: PeterConrad,Departmentof Sociology,MS-071, Brandeis Uni-
versity,Waltham,MA 02425-9110. E-mail: conrad@brandeis.edu.
SOCIAL PROBLEMS, Vol.47, No. 4, pages 559-582. ISSN: 0037-7791

@ 2000 by SocietyfortheStudyofSocial Problems,Inc. All rightsreserved.
Send requestsforpermissionto reprintto: Rightsand Permissions,University
ofCaliforniaPress,
JournalsDivision,2000 CenterSt.,Ste. 303, Berkeley,CA 94704-1223.

560 CONRAD/POTTER
increased
sharply thenumber
ofcasesofAD,nowincluding
casesofseniledementia
over60
yearsold. As a result,AD has become one of the top fivecauses of death in the UnitedStates.
Psychiatricand medicaldiagnosesare the productof socio-historical circumstancesand the
claims-makingofparticularinterestgroups.New diagnosesrarelyemergesimplyas a resultof
new scientificdiscoveries.Medicalizationstudieshave demonstratedthatagents such as self-
help and advocacy groups, social movements,health-relatedorganizations,pharmaceutical
companies,academic researchers,and clinicianscan be centralin creatingspecificdiagnoses.
Medicalizationis usually a productof collectiveaction, ratherthan a resultof "medical
imperialism"(Conrad 1992). Whateverthe extentof medicalization,it is not simplydoctors
colonizing new problems or labeling fecklesspatients. Reissman (1983) and others have
assertedthatpatientsand otherlay people can be activecollaboratorsin theirown medicaliza-
tion, although sympatheticprofessionalsare usually needed for successfulclaims-making
(Brown 1995). Numerousstudiesshow how affectedpartiescan make criticalcontributions to
the medicalizationprocess. Conrad and Schneider (1992) outlined the role of organizedlay
interestsin the medicalizationof alcoholism and the demedicalizationof homosexuality.
Otherstudiesdemonstratethe importanceof the mobilizationofpeople who are diagnosedin
collectivelypromotingand shapingtheirmedical diagnoses.This kind of diagnosticadvocacy
is oftenaccomplishedby or directlyconnected to an extant social movement:premenstrual
syndrome(PMS) with the women's movement(Reissman;Figert1996); post traumaticstress
disorder(PTSD) withthe VietnamVeteransmovement(Scott 1990); and AIDS treatmentwith
the Gay and Lesbian movement (Epstein 1996). In each case, an explicitpoliticizationof the
medical diagnosisand the activemobilizationof the social movementapparatuspropelledthe
new categoryforward.Self-helpand patientadvocacy groups are legion, and some of these
have been activein promotingthe acceptanceoftheirown illnesscategories.But the difficulty
thatsupportersofmultiplechemicalsensitivity disorder(MCSD) (Kroll-Smith1997) or sexual
addiction (Irvine 1995) have encounteredin theirattemptsto achieve acceptance as medical
diagnoses highlightssome limits of lay advocacy. Without being able to draw upon the
resources of a larger movement, lay claims about medical diagnosis seem to have more
difficulty becomingmedicallyacknowledgedand institutionalized.
A wide rangeofnew medical categoriesthatdid not existpreviouslyhave emergedin the
past fourdecades: attentiondeficit/hyperactivity disorder(ADHD), anorexia and eatingdisor-
ders,chronicfatiguesyndrome(CFS), repetitionstraininjury,fibromyalgia, PMS, PTSD, and
MCSD. Many of these diagnoses have been promotedactivelyby sufferersand theiradvo-
cates, with some achievingsubstantialmedical acceptance while othersremain contestedor
controversial(Singer,et al. 1984). By the close ofthe 20th century,patientshave become more
engaged in their own treatmentand more demanding in what they want fromphysicians
(Guadagnoli and Ward 1998). Moreover,as Barskyand Boros (1995) pointout, the American
public'stoleranceformild symptomsand benignproblemshas decreased,which may be lead-
ing to a furthermedicalizationof ills.
There are numerous reasons forseekingnew medical diagnoses.Life'stroublesare often
confusing,distressing, debilitating, and difficultto understand.Michael Balint (1957) pointed
out manyyearsago thata medicaldiagnosistransforms an "unorganizedillness,"an agglomera-
tion of complaintsand symptomsthatmay be unclear,unconnected,and mysterious,into an
entitythatis a moreunderstandable"organizedillness."As Broom and Woodward (1996) show
withCFS, sufferers willoftenseek a diagnosis,whichwillbothlegitimatetheirtroublesand pro-
vide themwithan understanding of theirproblem.In some instancesa diagnosiscan be a kind
of self-labelingthatprovidesa new public identityas havinga particularillnessor disorder.In
othercases, it may facilitatemedicaltreatmentsthatcan have a substantialimpacton individ-
embracingmedicalization.
ual's lives. When these occur,it is hardlysurprisingto see sufferers
The emergenceof so many new medical categoriesraises the question of what happens
to them over time.It is likelythatsome just become establishedand a partof regularmedical
practice,othersmay be challenged,disappear,or become vestigialfromnonuse, while others

FromHyperactive
ChildrentoADHD Adults 561
may expand in new ways. Medical diagnosticcategories,perhapsespeciallypsychiatriccatego-

ries (Horwitz forthcoming),are often fluid and subject to expansion or contraction.The
extensionof establisheddiagnosesis especiallyinteresting forit can occur almostunnoticedas
a partof regularmedicalpracticeand, at the same time,expand the realmofmedicalizationin
significantways. To examine this phenomenon, we can finda similarprocess in the social
constructionistframeforstudyingsocial problems.
"Domain expansion" describesa processby which definitionsof social problemsexpand
and become more inclusive(Best 1990; Loseke 1999). Domain expansionencompassesclaims-
making work that extends the definitionalboundaries of an establishedsocial problem to
include similaror relatedconditions.Best (1990) examined the emergingdefinitionsof child
abuse and found that "by 1976, the issue encompassed a much broader arrayof conditions
threateningchildren.The more generalterm'child abuse' had replacedthe earlier,narrower
concept of 'batteredchild' and the even broader expression 'child abuse and neglect' had
gained currencyamong professionals"(Best 1990, p. 67). Jenness (1995) has argued how
activismby the gay and lesbian movementbroughtattentionto the scope and consequences
of anti-gayand lesbian violence. She suggeststhat domain expansion accompanied social
movementgrowthand was key in reframingviolence against gays and lesbians as a "hate
crime"and as a specificpublic issue in the United States.While domain expansion need not
always be linked to a social movement,the activitiesof champions and claims-makersare
likelyto be criticalto the expansion of definitionalboundaries.'
This paper examines an analogous processformedicalization,focusingon the emergence
of the diagnosis of AttentionDeficit-Hyperactivity Disorder (ADHD) in adults in the 1990s.
How did hyperactivity, which was deemed largelya disorderof childhood, become adult
ADHD? This researchfollowson Conrad's studyof the medicalizationof hyperactivity pub-
lishedin the 1970s (Conrad 1975, 1976). Our interesthere,however,is also to investigatethis
case as an example of how medicalizedcategories,once established,can expand to become
broaderand more inclusive.This categoryexpansion is one means forincreasingmedicaliza-
tion and providesus with an opportunityto explore how this aspect of medicalizationoper-
ates. This paper will focus on key claims and counter-claimsmade by mental health and
medicalprofessionals,as well as lay leaders,supportgroups,and conferences.2Afterreviewing
the state of childhood hyperactivity as a medicalized diagnosis in the 1970s, we trace the
emergence of "adult hyperactives"among those whose childhood symptomspersistedinto
adulthood,and then examine how thiswas transformed into the category"ADHD adults."We
show how lay, professional,and media claims helped establish the expanded diagnosis.
We identifyparticularaspectsof the social contextthatcontributedto the riseof adult ADHD,
and then outline some of the consequences of the medicalizationof ADHD in adults and the
social implicationsof expandingdiagnosticcategories.
The DSM as a Categorical Touchstone
Psychiatricdiagnosesare historicallyand culturallysituated.Certaindiagnosticcategories

appear and disappear over time, reflectingand reinforcingparticularideologies within the
1. More recently,Best (1999) has drawn on the work of Stallihngs (1990) to make a distminction
between "domain
expansion" and "domain elaboration,"the latterbeing a process related to domain expansion, which "involves the
identificationof new aspects of a problem" (Best, 1999, p. 169) The terms"domain elaboration"and "domain expan-
sion" overlap considerablyin theirmeamng and both referto the way in which expanding categoriesof social problem
resultsin additionalclaims-makersand advocates identifying with the problem,promotingits continuedproblematiza-
tion,and keepingthe problemalive in the public eye. To maintainconsistencythroughoutthispaper,we have chosen to
use the more familiarterm"domain expansion."
2. A recentstudyby Leffers(1997) focuses on how individualswith ADHD come to understandtheirproblems
and how the social constructionof the disorderaffectsthis understanding.The presentpaper is more of a sociological
account of the expansion of the ADHD diagnosisto adults.

562 CONRAD/POTTER
"diagnosticproject"(the professionallegitimizationof diagnoses),as well as withinthe larger

social order (Cooksey and Brown 1998, p. 550). As numerousresearchershave noted,psychi-
atric diagnoses are not necessarilyindicatorsof objective conditions,but are a productof a
negotiatedinteractiveprocessinfluencedby socio-politicalfactors(Caplan 1995; Cooksey and
Brown 1997; Kirkand Kutchins1992; Kutchinsand Kirk 1997). Diagnoses relatedto behavior
or involvingcognitivesymptomsare frequently contestedor controversial and, as such,diagno-
sis of "functionaldiseases" can "representan implicitlynegotiatedsolutionto the problemof
idiosyncraticsuffering thatis not explainableby specificpathology"(Aronowitz1998, p. 16).
Most psychiatricdisordersbecome legitimatedin the AmericanPsychiatricAssociation's
Diagnostic Manual (DSM), the officialguidebookforpsychiatric
and Statistical diagnoses.Although
DSM does not contain all medical diagnoses,when it comes to behavior, it can be seen as a
repositoryof medicalizedcategories.Despite psychiatricclaims,it is not a scientificdocument,
but a "mix of social values, politicalcompromise,scientificevidence and materialforinsur-
ance forms"(Kutchinsand Kirk 1997, pp. 11, x). As the authoritativevoice of psychiatry, the
DSM has been used as a mechanismto "securepsychiatricturf"(Kirkand Kutchins1992) and
to sanctionpsychiatriccategories.
The variousrevisionsofDSM have reflected distinctapproachestakenby mentalhealthpro-
fessionalstowardunderstanding human troublesas psychiatricconditions.In 1952, the original
versionofthe DSM reflectedthe dominanceofpsychoanalytic thoughtand soughtto "providea
broaderset oflabelswhichwould be inclusiveof the whole society"(Cookseyand Brown 1998,
p. 530). A major shiftin psychiatricthinkingoccurredwiththe publicationof DSM-llmin 1980,
when thelargelypsychoanalytic orientationwas abandonedand replacedwithan avowedlybio-
medical and categoricalapproachto diagnosis."The fundamentalpremiseof DSM-Imwas that
different clustersof symptomsindicateddistinctunderlyingdiseases such as schizophrenia,
depression,panic disorderand substanceabuse" (Horwitzforthcoming, p. 2). The "diagnostic
project"was now heraldedas a scientific endeavor,a claim thathas increasedwiththe publica-
tionofDSM-IV (1994), a revisionthatidentifies nearly400 distinctmedicaldiagnosticentities.
The DSM provides a useful touchstonefor the sociological task of understandinghow
behaviors are defined medically,especially for documentinghow criteriafor diagnosinga
problem change over time and thoroughvarious revisededitions.In this way, we can track
some of the elasticityof a diagnosissuch as ADHD.
Hyperactivity in the 1970s
AlthoughADHD's roots are oftentracedto earlyin the twentiethcentury(Goldman, et

al. 1998), it only emerged as a diagnosticcategoryin the 1950s (see Conrad 1975). It was
termedat various timesMinimal Brain Dysfunction(MBD), HyperactiveSyndrome,Hyperki-
nesis, HyperactiveDisorder of Childhood, among several other diagnosticcategories.While
there were slightdifferencesamong the categories,in practice,they were interchangeable.
The termsHyperactivity and MBD were mostcommonlyused.
Beginningin 1968, the DSM-II identified"minimalbrain damage" and otherproblems
such as "hyperkinetic reaction"as a childhooddisorder"characterizedby overactivity, restless-
and shortattentionspan, especiallyin youngchildren;the behaviorusually
ness, distractibility,
diminishesin adolescence" (APA, 1968,p. 50). The disorders,thus,were definedby bothhyper-
activityand inattention,two distinguishing featuresthatwould persistin variouscombinations
throughout the next 30 years (see also, Stewart,et al. 1966; Stewart 1970; Wender 1971).
Althoughthis officialclassificationclearlyplaced the hyperactivity withinthe realm of child-
hood psychiatric illnesses,it also allowed forthe possibilityof persistenceinto adolescence.For
example,hyperactivebehavior"usually"(butnot always) "diminished"(thoughnot necessarily
disappeared)by the timethe patiententeredadolescence.While therewas no solid evidenceof
biologicalcausation,therewas an assumptionthattherewas some typeof organicpathology.

Childrento ADHD Adults
FromHyperactive 563
The most significantcriterionfordiagnosis was a child's behavior,especiallyat school.

The emphasis in identificationwas on hyperactiveand disruptivebehaviors (Conrad 1976).
The major treatmentsforhyperactivity were stimulantmedications,especiallyRitalin.During
the 1960s, the disorderbecame increasinglywell known, due, in part,to publicityit received
concerningcontroversiesabout drugtreatment.By the middle 1970s, it had become the most
common childhoodpsychiatricproblem (Gross and Wilson 1974) and special clinicsto iden-
tifyand treatthe disorderwere established,although most childrenwere diagnosed by their
pediatricianor primarycare physician.
While therewere no methodologicallysound epidemiologicalstudiesin the 1970s, it was
widely estimatedthat 3-5% of elementaryschool studentswere hyperactive(occasionally
estimateswere as high as 10%). Frequentlymentionedestimatessuggestedbetween 250,000
and 500,000 childrenwere identifiedas hyperactive.The disorderwas believed to affectboys
more oftenthan girls,perhapsat a ratioof 8 to 1. In sum, hyperactivity was seen, fundamen-
tally,as a disorderof childhood,typicallyidentifiedin the early years of school, which most
childrenwere expectedto "outgrow"by adolescence.
The Emergenceof "Adult Hyperactives"
Beginningin the late 1970s, several cohortstudieswere publishedwhich followedchil-

dren who had been originallydiagnosed with hyperactivity a decade or more earlier and
tracedtheirdevelopmentinto adulthood.These studiesestablishedthatforsome hyperactive
children,the symptomspersistedinto adolescence and even into adulthood. Thus emerged
the notion of what we call "adult hyperactives,"hyperactivechildrenwho did not "outgrow"
theirsymptomsand stillmanifestedsome problemsas adults.
Weiss and colleagues (1979) followed75 hyperactivechildrenand 45 matched controls
for 15 years.When comparedto a matchedcohort,theyfoundthatclear symptomspersisted
formany hyperactivechildreninto adulthood; 66 percenthad at least one symptom(Weiss
and Hechtman 1986). Most notable was the persistenceof restlessnessand poor concentra-
tion. Despite criticismsthatonly 60 percentof the childrenwere followedinto adulthood,the
studyremainswidelycited,and mis-cited.3A second prospectivestudyfound31 percentwere
stilldiagnosableas hyperactivein late adolesence (Gittleman,et al. 1985; see also Mannuzza,
et al. 1991; 1998). A follow-upat youngadulthood,however,showed a significant decrease of
ADD symptoms,to about one-thirdthe ratereportedby Weiss. The media has tendedto focus
on the higherprevalenceratesreportedin the Weiss data.
Followingthe publicationofthese seminalstudies,otherresearchersinvestigatedthe per-
sistenceof symptomsinto adulthood (e.g., Biederman,et al., 1996) to furtheridentifywhat
they believed to be confoundingfactors(such as co-morbiditywith other disorders).These
studiesreflectthe dominantthinkingof the late 1980s: any diagnosisofAttentionDeficitDis-
order(ADD, as the diagnosiswas renamed) was foundonly among adultswhose disorderper-
sistedfromchildhoodand, thus,was nota disorderthatwas either"missed"duringchildhood
or was of adult onset. All ADD adultswere hyperactivechildrengrown-up.
The 1980 update, DSM-III, both reflectedand facilitatedan interestin hyperactivity
beyond childhood.4First,in line with the general trend in DSM-III to define disordersby
symptoms,ratherthan etiology,the updated manual reclassifiedthe disorderaccordingto its
3 For example, although the cohortcontinued to exhibitsigns of hyperactivity, a twenty-yearfollow-upfound
36% of the cohortsymptomatic-a less widelyreportedstatistic(e.g., Newsweek,1990). Even "experts"(such as Edward
Hallowell) are cited m the popular literaturereferringto "seventypercentof the kids who have it continue to suffer
symptomsas adults" (Stich 1993, p. 77). The figureof 70% appears to come froma studypublishedby Wenderin 1995,
but is not the most accepted estimateofpersistenceof symptoms.
4. DSM-III, the thirdrevision,aimed formore rigorousdiagnoses and representedthe dominance of the biopsy-
chiatncviewpointin psychiatryover otherperspectives(Cooksey and Brown 1998).

564 CONRAD/POTTER
primarysymptoms:eitherhyperactivity orinattention.Thus,the diagnosisfocusedon attention

deficitswithtwo major subtypes:Attention-Deficit DisorderwithHyperactivity and Attention-
DeficitDisorder without Hyperactivity(deemed the less severe of the two categories).The
symptomswere focusedlargelyon children'sactivities(e.g., "runs about or climbson things
excessively,""frequentlycalls out in class," "has difficulty
concentratingon schoolworkor
othertasksrequiringsustainedattention").To be diagnosed,patientsneeded to exhibitsymp-
tomsbeforeage seven.
Secondly,the rangeofbehaviorsincludedwithinthe officialdiagnosisbecame more com-
prehensive.Some symptomswere relatedto school-basedbehavior,such as "frequentlycalls
out in class"; whereas otherswere more interpersonaland ephemeral in nature,e.g., "often
acts beforethinking"or "is easily distracted."These changes in the diagnosticcategorymeant
thatindividualswho may not have "qualified"fora diagnosisofhyperkinetic reactionor min-
imal brain damage under DSM-II, now could now be thoughtof as havingADD under DSM-
III. Both subtypesof ADD permittedcourses of the disorderin which "all symptomspersist
into adolescence or adulthood" or that "hyperactivity disappears,but other signspersistinto
adolescence or adulthood" (APA 1980, p. 42). Thus, the DSM-III definitionexpanded the
diagnosticcriteriain termsof necessary"symptoms,"while allowingforthe possibilityforper-
sistenceinto adulthood.
The Development of "ADHD Adults"
In the 1987 revision,DSM-IIIR, ADD was renamed "AttentionDeficitHyperactivity Dis-

order" (ADHD) to reassertthe conditionof hyperactivity as one possible,but not mandated,
symptomof the disorder.ADHD enabled childrenwho were hyperactiveand impulsive,but
less inattentiveto meet the diagnosticcriteria.Over 50% more childrenreceivedADHD diag-
noses under these criteria(Newcorn,et al. 1989). The reviseddiagnosticcriteriadid not refer
to the disorderin adulthood,but opened the door slightlyforan expanded definitionbeyond
"adult hyperactives"to "ADHD adults" who had no childhood diagnosis. For example, the
environmentin which ADHD symptomsoccurredhad expanded to the workplace: "In the
classroomor workplace,inattentionor impulsivenessare evidenced . . ." (APA 1987, p. 50).
There was less emphasis on school-aged behaviors: "frequentlycalls out in class" (DSM-III)
became "oftenblurtsout answersto questionsbeforetheyhave been completed."The criteria
of exhibitingsymptomsbeforeage seven was retained,and although the revisionobliquely
acknowledged the possibilityof post-childhoodADHD, adult ADHD was not highlightedin
the manual.
Early Claims
In the same yearthatthe DSM-III-R was published,two publicationsaimed at lay readers
heralded a new categoryof "ADHD Adults"-adults who had not been diagnosed as children,
but had sufferedfromsymptoms.Althoughlater claims would be made by those who could
not trace theirsuffering to theiryouth,these early claims were made eitherby or forthose
who, retrospectively, could identifysignsof ADHD in theirchildhood.
In 1987, Paul Wender,a longtimehyperactivity researcher,publisheda book that exam-
ined hyperactivity throughoutthe lifespan. Althoughthe book was entitled,TheHyperactive
Child,Adolescent and Adult,only one chapterdescribedadultswithADHD symptoms.Nonethe-
less, the book targeteda lay audience and would be citedfrequentlyin subsequentyears.
The same year,FrankWolkenberg(1987), a free-lancephotographerand pictureeditor,
wrote a first-person account in the New YorkTimesMagazineabout his discoverythat he had
ADHD despite his apparentlysuccessfullife.When he sought treatmentfordepressionand

FromHyperactive
Childrento ADHD Adults 565
suicidal ideation,he was diagnosed with ADHD by a psychologistwhose specialtywas learn-

ing disorders.Wolkenbergthen began reinterpreting several clues fromearlyin his life (e.g.,
impulsivity, disorganization,and emotional volatility)as signs of the disorder.
distractibility,
This highlyvisibletestimonyof someone not previouslydiagnosed with ADHD as a childput
the idea of "ADHD Adults"into the publicrealm.No one had diagnosedhim as hyperactiveas
a child,yet now, he was attributing "seeminglyinexplicablefailures. . . all unnecessaryand
many inexcusable" (p. 62) to ADHD. He suggestedit was a neurobiologicaldysfunction"of
geneticorigin,"thus attributing his lifeproblemsto a chemicalimbalance.
As the notion of ADHD in adulthoodwas filtering into the public,the psychiatric
profes-
sion was also turningattentionto thisnew problem.ClinicsforadultswithADHD were estab-
lishedat Wayne StateUniversity in 1989 and two yearslaterat theUniversity ofMassachusetts
in Worcester(Jaffe1995).
In 1990, Dr. Alan Zametkinof the National Instituteof Mental Health and several of his
colleagues published an often-citedarticle in the New England Journalof Medicine.Using
positron-emission tomography(PET) scanningto measure brain metabolism,Zametkindem-
onstrateddifferent levels of brain activityin individualswith ADHD comparedto those with-
out the disorder,providingnew evidence fora biologicbasis forADHD. Because of the risks
inherentin researchinvolvingradiologicimages,the researchersused adult subjectswho both
had childhood historiesof hyperactivity and were biologicalparentsof hyperactivechildren.
Althoughnot theirintention,Zametkin'swork became one of the key professionalsources
citedby othersto demonstratethe presenceof ADHD in adults (e.g., Bartlett1990; and News-
week,December 3, 1990), since it appeared to bolsterclaims thatADHD could persistinto or
develop duringadulthood.5While the studymade national headlines, additional follow-up
studieswhich did not confirmthe strengthof the initialstudy'sfindings,received no wide-
spreadpublicityfromthe professionaland lay press.6
AdultADHD in thePublic Sphere

Writingabout ADHD as a disorderin adultshas been increasingin the professionallitera-
ture foryears. As can be seen in Table 1, by the middle 1980s therewere over 40 articlesin
the medical literatureand about a dozen in the psychologicalliteraturepublished per year
(with some overlap). Many of these articleswere minorand nearlyall dealt with the persis-
tence of symptomsin hyperactivechildrenas they reached adulthood. The issue of "ADHD
adults"perse did not reach the popular media untilthe 1990s (see Table 1) and in a moderate,
but growingnumberofarticles.But the idea thatadultscould have ADHD did spreadwiththe
help of a varietyof media.
By the early 1990s, several books writtenfora popular audience looking specificallyat
ADHD adults were published.PsychologistLynnWeiss (1992) identifiedher adult subjectsas
those who were diagnosablewith ADHD, not merelygrown-uphyperactivechildrenhaving
remnantsof the symptomscarried over froman earlier condition.Another popular book
quicklyfollowedwith the provocativetitleof, YouMean I'm NotLazy,Stupidor Crazy?!(Kelly
and Ramundo 1993), emphasizingthe shiftin responsibility thatbeing diagnosed with adult
ADHD can bring.Thom Hartmann (1994), writingin a somewhat esoteric,but essentially
sociobiologicalframe,associatedADHD withan evolutionaryadaptationto the social environ-
ment.He likenedthose withADHD to hunters(who are nomadic,scanningthe environment
forsustenance,seekingofsensation,reactingquicklyand decisively)adaptingto a more mod-
5. Referencingthe work of others,Zametkinnoted that"the disorderis probablyinhentedin certainfamilies"and

"symptomspersistinto adulthood in 40 to 60 percentof the persons with childhood hyperactivity," but these claims
were primarilyin the contextofjustifyingusing an adult sample (Zametkin,et al. 1990, p. 1361).
6 The follow-upstudies using adolescent populationsproduced vaned results(e.g., Ernst,et al 1994, Zametkin,
et al. 1993). Additionally,withmore evidence in, scientistsare less sure thatPETs establisha clear markerof ADHD-nm
childrenor in adults.

566 CONRAD/POTTER
Table 1 * AdultADHD in theProfessionaland Lay Media Mean ArticlesPer Year, 1975-1999 (in
fiveyear intervals)*
Media
Professional LayMedia
Medline Psychinfo AcademicUniverse
Year WireService NE Regional Magazines
1975-1979 34.4 3.4 0 0 0

1980-1984 41.6 7.6 0 0 0
1985-1989 43.6 11.4 0 0.4 0.2
1990-1994 50.0 13.8 5.8 6.0 0.4
1995-1999 95.6 42.6 25.2 28.6 3.2
* For thistable, we do not distinguishbetween articleson "adult hyperactives"or "ADHD Adults."Search criteria:
Medlineand Psychinfo databases:adult and (ADHD or "attentiondeficithyperactivity disorder"or "attentiondeficit
disorder"or hyperkinesis).AcademicUniverse: in textsearchfor "Attentiondeficitdisorderor ADHD or hyperkine-
Press,United
sis" and in headline or lead paragraph:"adult." Sources are dividedamong wire service (e.g , Associated
PressInternational),New England Regional Newspapers (e.g., BostonGlobe,New YorkTimes),and Popular Magazines
(e.g., LadiesHomeJournal,Newsweek).
ern farmingcommunity(which requires greaterstabilityand focus). This hypothesis,by its

nature,supportsthe notion of ADHD adults.
Furthersupportcame fromthe televisionnews media reportson the spread of ADHD in
adults. Major news shows put theirown spin on the prevalenceof the disorder.For example,
on "20/20," CatherineCrierattributedADHD to a "biologicdisorderof the brain" in adults
(September2, 1994). Dr. TimothyJohnsonon "Good MorningAmerica" (March 28, 1994)
was quoted as sayingthatexpertsestimateas many as 10 millionadult Americansmay have
ADHD (Vatz and Weinberg 1997, p. 77). The new face of the disorderwas not limitedto
hyperactivechildrengrown-up,but included a new group of "ADHD adults" who came to
reinterpret theircurrentand previousbehavioralproblemsin lightof an ADHD diagnosis.
The message was reiteratedin popular magazines. A featurearticle in Newsweek,for
example, describeda 38-year old securityguard who held more than 128 jobs since leaving
college afterbeing enrolledin the academic institutionfor13 years (Cowley and Ramo 1993).
He finally"receiveda diagnosisthatchanged his life"at the adult ADHD clinicat the Univer-
sityof Massachusettsin Worcester.Similarly,an articlein Ladies' HomeJournal(Stich 1993)
describeda husband who would continuallybe firedfromjob afterjob, constantlyinterrupted
his wife,and forgotdetails of conversations.Then "Two years ago, the Pearsons' discovered
therewas a medical reason forChuck's problems.Aftertheirson was diagnosed with atten-
tion deficitdisorder(ADD) ... theylearned Chuck also had the condition"(Stich 1993, p. 74).
The articledoes not mentionthe factthatChuck,who was diagnosed at age 54, also went on
to found the Adult AttentionDeficitFoundation,which acts as a clearinghouseforinforma-
tionabout adult ADHD (Wallis, 1994, p. 47).
Adult ADHD was given a greatboost in 1994 with the publicationof a best-sellingbook
DriventoDistraction by Edward Hallowell and JohnRatey (1994), two psychiatristswithpresti-
Hallowell offeredhis own experienceas the springboardfor
gious organizationalaffiliations.
the book: although successfulas a medical student,and later as a practicingpsychiatrist,he
came to believe he had ADHD. Rateyalso statedhe had ADHD. The book has become a crucial
touchstoneamong the lay public. Using theirclinicalexperience as the basis fortheirbook,
Hallowell and Ratey (1994) argue that ADHD takes various forms.Based upon theirclinical
experience, Hallowell and Ratey propose "suggesteddiagnosticcriteriafor attentiondeficit
disorderin adults" (p. 76). These criteriarecognizethe disorderwithouthyperactivity. They

FromHyperactive
presentthirteensub-typesof the disorder,a set of "suggesteddiagnosticcriteria,"and offera

100-questiontest(withelusive criteria7)forreadersto assess whetheror not theymay need to
seek evaluationforADHD. The authorsurgereadersnot to self-diagnose, but seek professional
assessmentoftheircondition.NeitherHallowellnor Rateyis a hyperactivity researcher-Ratey
published only one article on the topic in a professionaljournal (Ratey, et al. 1992) and
Hallowell, none. Both remain very active in promotingtheir work in public circles.Their
affiliation
with HarvardMedical School gave them some academic legitimacy,but theycame
to the area of ADHD adults more as professionaladvocates than as scientificresearchers.In a
sense, theyare moral entrepreneurs forthe adult diagnosis(Leffers1997).
The coverofJuly18, 1994 Timemagazine issued a clarioncall forADHD adults: "Disorga-
nized? Distracted?Discombobulated? Doctors Say You Might Have ATTENTION DEFICIT
DISORDER. It's not just kids who have it." The 9-page articledisseminatedthe criteriaand
possibilitiesof ADHD in adults to a wide audience, includingspeculationsthat Ben Franklin,
WinstonChurchill,AlbertEinstein,and Bill Clintonmay have had the disorder(Wallis 1994).
Organizational stake-holders.
Over the years a number of parents and advocacy groups
emergedaround ADHD in children,includingthose involvedin the learningdisabilitiesmove-
ment (Erchak and Rosenfeld 1989). The largestADHD supportgroup, Childrenand Adults
with AttentionDeficitDisorder(Ch.A.D.D.), has grownsignificantly over the last decade and
owes much of its growthto its adult membership,specifically,those adult members with
ADHD. In its activities,as well as its framingof ADHD, the organizationhas helped expand
the categorizationto include adults. In 1990, the parent organizationsponsoreda national
meetingthatfeaturedthreeadults with ADD and fourprofessionalsas speakers(Jaffe1995).
In 1993, the organizationadded the "and adults"to itsname to reflectitsbroadened focus.In
May 1993, a Ch.A.D.D.-sponsored national conferenceentitled,"The Changing World of
Adultswith ADD," attractedrepresentatives from30 statesand two Canadian provinces.The
organizationnow sees educationand supportof adultswithADHD as partof itscore mission.
For example, on its web page, the organizationproclaims,"With relativecertainty,we can
predictthat AD/-HD will continue to influencethe behavior and attitudeof an individual
throughouthis or herlife...." (http://www.CHADD.org/attention/attnv5n4p12.htm). In addition
to lobbyingforeducationalservicesforchildren,Ch.A.D.D. advocates legislationthatprovides
workplaceprotectionforadults withADHD.8 In all officialpublicationsand communications,
Ch.A.D.D. has positionedADHD as a medical condition,a "neurobiologicaldisorder,"rather
than as a psychiatricor behavioraldisorder(Diller 1997, p. 130; http://www.CHADD.org), so
it can be perceivedas havinga more legitimateclaim to disabilityentitlements.
Ch.A.D.D. played a significantrole in bringingthe lay and professionalclaims-makers
togetherto promotebetterunderstanding, acceptance,and treatmentofADHD (Leffers1997).
Additionally, not only does Ch.A.D.D. promotethe existenceof adult ADHD to the public,the
organizationlegitimatesthe disorderforsufferers, almostas much as the individualdiagnosis
does. Similarto othercontroversialillnesses(e.g., Kroll-Smithand Floyd 1997), the organiza-
tion is both a haven and advocate forthose who believe theysufferfromthe disorder.
Anotherorganizationalstakeholderis the pharmaceuticalfirmof Ciba-Geigythatmanu-
facturesRitalin(methylphenidate), the drugmostwidelyprescribedfortreatingADHD. Ciba-
Geigy has long been involved in promotinghyperactivity and now, ADHD as a medicaldisorder
(Conrad 1975; Schrag and Divoky 1976). As early as 1971, Ritalinprovided as much as 15
7. Questions include: "Do you change the radio stationin your car frequently?"and "Are you always on the go,
even when you don't really want to be?" The authors provide no normativestandardsagainst which to judge the
answers.
8. As a claims-maker,Ch.A.D D spans several significantsectors.Ch.A.D.D. is buttressedby both the academic
and businesssectorsoftheADHD community. The boardofdirectors ofCh.A D.D. includeswell-knownacademicresearchers
and physiciansworkingin the area of ADHD

568 CONRAD/POTTER
percentof Ciba's grossprofits(Conrad 1976, p. 16). While the originalpatenton the drughas
long expired,and methylphenidate is available in genericformulations,Ritalinis stillthe most
commonlyprescribedmedicationforADHD (Arnst 1999) and one of the three most com-
monlyprescribedstimulants(Ballard,et al. 1997). The amount of methylphenidatemanufac-
tured has increased sharply in the 1990s. From 1990 through 2000, the production of
methylphenidatein the United States grew by 800% (Wen 2000).9 One national surveyof
physicians' diagnoses,based on 1993 data, found that of the 1.8 million persons receiving
medicationsforADHD, 1.3 millionwere takingmethylphenidate(cited in Diller 1996, p. 12).
Othersourceshave variouslyestimatedthat2.6 millionchildren(Guistolise 1998) and 729,00
adults receivedprescriptionsforRitalin(Breggin1998, p. 160). The potentialmarket,with 3
million childrenand 4 million adults in the U.S diagnosed with ADHD (Arnst 1999), has
untappedpockets.'oBy redefiningADHD as a lifetimedisorder,the potentialexistsforkeeping
childrenand adults on medicationindefinitely. A recentreview articlenoted, "The eightfold
increasein the use of stimulantsin the UnitedStatesover the past decade stemsfromseveral
factors,includingthe continuationof treatmentfromchildhood into adolescence and the
treatmentof adults" (Zametkinand Ernst1999, p. 45). While it is difficultto accuratelyassess
what proportionofthishuge increaseof Ritalinuse is forADHD adults,it is likelyto be a sub-
stantialproportion.
These organizationalstakeholdershave workedboth independentlyand in consort.Ciba-
Geigy reportedlyhas provided significantfinancialassistance througha varietyof support
mechanismsthatassistadultswithADHD, includingthe supportgroup Ch.A.D.D. and a video
produced forthe Officeof Special Education Programs(OSEP) (Diller 1996). In 1995, The
Merrow Report,a public radio talk show, reportedthat Ch.A.D.D., receivedsignificant finan-
cial contributionsfromCiba-Geigy(PBS 1995). The public outcryand media attentionques-
tioned the neutralityof this group. Since then, Ch.A.D.D. continued to claim that the
percentageof its fundingfrompharmaceuticalcompanies never exceeded 17% and has been
decreased to less than 10%, and is used only for educational programs(www.CHADD.org/
presso4-13-98.htm).
DiagnosticInstitutionalization
By 1994, DSM-IV reflectedthe growingconsensus that adults could be diagnosed with
ADHD, providedtheyhad exhibitedsymptomsas childrenbeforethe age of seven. Two (out
of the five) diagnosticcriteriawere clearlyrelevantto adults. First,DSM-IV required that
"some impairmentmustoccur in at least 2 settings."While forchildren,these settingsusually
mean school and home, the range of settingsmay be greaterforadults and include home,
school,work,and othervocationalor recreationalsettings.Secondlyand related,"theremust
be clear evidence of interferencewith developmentallyappropriatesocial, academic, or occu-
pational functioning." The inclusionof work environmentsin the criteriasectionof the man-
ual reflectedthe centraland relativelyuncontroversialpositionthatthe diagnosisof ADHD in
adults now occupied."
9. Productionrates do not tell the entirestory:while not all of the methylphenldateproductionis consumed in
the U.S. produces and consumes more
thiscountry,a sizable portionis. Accordingto the UnitedNations 1993 statistics,
than 80% of the all methylphenidate(Guistolise1998), but the DEA has estimatedthatthe U.S. consumes over 90 per-
cent of the 8 5 tons produced worldwide (Livingston1997).
10 For many years,Ciba-Geigyactivelyproclaimedthe benefitsof Ritalinin advertisements.It is interestingthat
we have been unable to locate drug advertisingforRitalmforADHD adults in major psychiatricor medical journals.
EitherCiba-GeigyadvertisesRitalinforADHD throughotherchannels-e.g., "detail"representatives who call on physi-
cians or throughconferences-or they have not promotedRitalinforadult ADHD. Given the potentialmarket,thisis
curious and worthyof furtherinvestigation.
11 In keepingwiththe approach begun with DSM-III, however,such markersare not seen as establishingthe eti-
ology of the disorder Rather,they are diagnosticin nature. While the manual assertedthat no biologic markerscur-

FromHyperactive
ChildrentoADHD Adults 569
The new definitionallowed for more variations of symptomaticbehavior across and

withinsettings."It is veryunusual foran individualto displaythe same level of dysfunction
in
all settingsor withinthe same settingat all times" (APA 1994, p. 79). Adultswho mightbe
quite successfulat work,but highlyinattentivein particularinterpersonalrelationshipsand
recreationalactivities,could now be diagnosedwithADHD. As the more expansive criteriain
DSM-IV gained acceptance among mental health professionals,some advocated eliminating
the requirementthatadultsbe able to retrospectively reconstructa historyof ADHD (Barkley
and Biederman 1997). Thiswould permiteven greaterexpansion of the adult ADHD category.
Reportsfromthe American Medical Association (AMA) and the National Institutesof
Health (NIH) supportedan expanded ADHD diagnosis. In 1997, the Council on Scientific
Affairsof the AMA issued recommendationsfor treatingADHD, which were published in
JAMA(April8, 1998). The articlenoted:
Thecriteria ofwhatconstitutes ADHDin childrenhavebroadened, andthereis a growingapprecia-
tionofthepersistence ofADHD intoadolescenceand adulthood.As a result,morechildren(espe-
and adultsarebeingdiagnosedand treated
ciallygirls),adolescents, withstimulant and
medication,
childrenarebeingtreated forlongerperiodsoftime(Goldman, etal. 1998,p. 1100).
The reportconcluded therewas "littleevidence of widespread overdiagnosisor misdiagnosis
of ADHD or of widespreadoverprescription of methylphenidateby physicians"(Goldman, et
al., 1998, p. 1100). In November 1998, NIH convened a Consensus Conferenceon the Diag-
nosis and Treatmentof AttentionDeficitHyperactivity. While littlenew emerged fromthe
conference,two papersexplicitlyfocusedon adultswithADHD. Overall,the conferencereport
affirmedthe validityof ADHD, although recognizingscientificcontroversies,the need for
more basic and longitudinalresearch,and a lack of consensus on optimaltreatment(http://
odp.od.nih.gov/consensus/cons/110/110_statement.htm).
Furtherinstitutionalsupportforthe ADHD diagnosisin adultshas come fromprestigious
professionalpublications.A lead editorialin the AmericanJournalofPsychiatry (Shaffer1994)
and major review articlesin New EnglandJournalofMedicine(Elia, et al. 1999 and Zametkin
and Ernst1999), which includeddiscussionsof ADHD in adults,symbolizedthe acceptance of
the diagnosticcategoryin medical circles.
It is clear thatby 1994, the clinicaldiagnosisof ADHD had expanded to include adoles-
cence and adulthoodand had become institutionalized in psychiatryand medicine.One long-
time researchercalled it "the most common chronic undiagnosed psychiatricdisorderin
adults" (Wender 1998, p. 671).
Diagnosis
One of the starkestcontraststo the earlier historyof ADHD with childrenis the vast
amount of self-diagnosisof ADHD among adults. Virtuallyall childrenwere referredby par-
ents or schools to physicians(Conrad 1976). Among adults self-referrals
are the norm,and
many patientscome to physiciansapparentlyseekingan ADHD diagnosis.Frequently,adults
who encountera descriptionof the disorder,sense that"thisis me" and go on to seek profes-
sional confirmationof their new identity.Another common path to self-diagnosisoccurs
when parentsbringa child to a physicianfortreatmentand remark,"I was the same when I
was a kid..." and thus,begin to see themselvesand theirown difficulties
throughthe lens of
rentlyexist ("There are no laboratoryteststhat have been establishedas diagnostic.. ."), throughthe absence of such
markers,the manual gives creditability to such tests.Therefore,in refutingthe absence of any such tests,the manual
may have laid the groundworkforthe next version of the DSM to considerlaboratorytestssuch as PET or SPECT. In
fact,lay as well as professionalclaims-makershave been assertingthe presence of genetic,as well as other biologic,
markersofADHD

570 CONRAD/POTTER
ADHD. While thistrendappears to have been precipitatedby some of the popular press (e.g.,
Hallowell and Ratey 1994), it continues with legitimizationprovided by support groups
designedforadultswithADHD such as Ch.A.D.D.
Anecdotes in the popular literaturesuggestthatadultswho self-diagnose,may recognize
the condition in a popular media article or book. Hallowell and Ratey (1994) tell of one
woman who noted, "My husband showed me thisarticlein the paper" (p. 26). Commentson
Internetsitesstatedirectlythatit was one of the books on adult ADHD thatled individualsto
physiciansfora diagnosis.Diller (1997) relatesthatone of his patientscame to self-diagnosis
afterreadingDriventoDistraction. Diller pointsout that,while the physicianwho is presented
withsuch a self-diagnosedpatientmay have difficulty establishingthe existenceof symptoms
in theirchildhood (as opposed to a checklistof symptomsabsorbedthroughreading),the self-
diagnosis,itself,becomes an element that the professionaldiagnosismust take into account.
One psychiatrist wrotea colleague, "AdultADHD has now become the foremostself-diagnosed
conditionin my practice.I fearthat the conditionallows a patientto finda biologicalcause
that is not always reasonable, forjob failure,divorce,poor motivation,lack of success, and
chronicdepression"(Shaffer1994, p. 638).
Diagnosis-seekingbehavior is an integralfeatureof the emergenceof Adult ADHD. This
kindofself-labeling,information exchange,and pursuitofdiagnosisfuelsthe socialenginemed-
icalizingcertainadulttroubles.Withoutit,the spreadofAdultADHD would be seriouslylimited.
Skepticsand Counter-Claims
Critics,
Even with well-establisheddiagnoses such as ADHD in children,there may be skeptics
and criticswho dismissthe validityofthe diagnoses,criticizeover-diagnosis,or enumeratethe
dangers of pharmacologicaltreatment.Although such attemptsto reign in medicalization
have had littleimpacton Adult ADHD, theyremain a reservoirof counter-claimsthat could
affectdiagnosticexpansion.
Some therapistswho treatthose with ADHD, believe that the diagnosisis becomingtoo
prevalent. "Certainly,some people diagnosed with ADHD are neurologicallyimpaired and
need medication.But the disorderis also being named as the culpritforall sortsof abuses,
hypocrisies,neglects,and othersocietal ills thathave nothingto do with ADHD" (Bromfield
1996, p. 32). Alan Zametkin,a leading researcheron ADHD, has become quite criticalofwhat
he has called "a cottageindustryof adult ADD" (Kolata 1996).
Beginningin the late 1980s, the Church of Scientologylaunched a major media cam-
paign againstthe use of Ritalinwithchildren.Althoughthe controversialchurchremainedan
outsiderin the debate, forseveral yearstheyofferedcontinuouspublic criticismabout ADHD
(Leffers1997). Furthermore, a numberofpopularbooks criticalofthe "epidemic"ofADHD and
Ritalinusage have been published:Runningon Ritalin(Diller 1997), RitalinNation(DeGrandpre
1999), and TalkingBacktoRitalin(Breggin1998). While most of the books focusedtheircri-
tiques on the diagnosisand drug treatmentof children,they offeredsome skepticismabout
the disorderin general.
The popular media that had been activelyinvolved in publicizingthe prevalence of the
disorderamong adults in 1993 and 1994 has become more criticalin subsequent years.Lead-
ing the challenge was a prominent,front-pagearticle in TimeMagazine (Wallis 1994); the
synopsisbanner read, "Doctorssay huge numbersofkidsand adultshave attentiondeficitdis-
order.Is it forreal?" "60 Minutes" (December 10, 1995), produced segmentsthathighlighted
the absence of a definitivetestforADHD. Othermajor news shows focusedon controversies
about the subjectivityof ADHD diagnoses and the over-prescriptionof Ritalin (e.g., The
"Today" Show on October24, 1995; CNN on November2, 1995; "20/20" on December 20,
1995; and "ABC EveningNews" on March 28, 1996-reported in Vatz and Weinberg1997).
Most of the criticismhas been about the overdiagnosisand treatmentamong children.
And even in thiscontext,thereare also a steadynumberof articlessupportiveof treatingthe

FromHyperactive
disorder(e.g., Gladwell 1999). Only a small amount of the criticismhas been directedagainst
notionsof adult ADHD. Yet, ironically,controversyabout ADHD raisesthe public's awareness
and increasesthe diffusionof informationabout the disorder,which can indirectlycontribute
to diagnosticexpansion.
The Social Context for the Rise of Adult ADHD
The expansion of the hyperactivity diagnosisto adults is not,primarily,the resultof new

scientificdiscoveriesabout the biomedicalnature of the disorder.While a numberof studies
indicatedthatsymptomsin childrendiagnosed as ADHD could persistbeyond childhood,the
studiesalso showed thatthisoccurredin perhaps a thirdof the cases (Weiss, et al. 1979). To
the bestofour knowledge,therewere no breakthroughepidemiologicalor clinicalstudiesthat
identifieda populationofadultsas havingADHD who were not previouslydiagnosedin child-
hood. Yet it is clear that "adult ADHD" has become a more common and accepted diagnosis
in recent years. What would bringadults to physiciansseeking such a diagnosis and what
spursphysiciansto treatthem? Several social factorsappear to have contributedto the diag-
nosticexpansion.
TheProzacEra
Since the introductionofchlorpromazinein 1955, therehas been a psychopharmacologi-
cal revolutionin psychiatry(Healy 1997). Psychoactivemedicationsplayed a major role in
deinstitutionalization and became regularpartsof physicians'treatmentprotocolsforvarious
life problems,especiallyanxiety (e.g., Valium). Americanpsychiatrists preferreddrugs that
would be usefulin officepsychiatry, ratherthan medicationslimitedto inpatientpopulations
(Healy,p. 70).
In 1987, Prozac (fluoxetine)was introducedas a new typeof medicationto treatdepres-
sion. This drug is a selective serotoninreuptake inhibitorthat directlyaffecteda different
group of neurotransmitters with fewerunpleasant side effectsthan previous types of anti-
depressants.This drugquicklybecame a phenomenonin itself,and led to a whole new class of
drugsfortreatingpsychiatricand lifeproblems.PeterKramer'sbook, Listening toProzac(1993)
and the subsequentnews media coverage (e.g., cover storiesin Newsweek and New Yorkmaga-
zines, and dozens of TV and radio appearances), piqued the public interestin thisnew drug.
Prozac was increasinglydepictedas a medicationthatwas a psychicenergizerand that could
make people feel,in Kramer'sterms,"betterthan well." Prozac was not seen as a medication
only forthe seriouslydisturbed,but was a formulationthatcould improvethe lives ofpeople
withminordisturbancesand distresses.
The introductionand popularityof Prozac (and a series of relatedmedications)createda
contextwherebytakingmedicationsforlifeproblemswas more acceptable (cf.,Diller 1996).
Prozac was seen as a drug thatwas appropriatefora range of psychicdifficulties, and whose
use could even make an OK lifebetter.It led numerous people to redefinetheirlifewoes in
termsof mild depressionand seek treatment.A person did not have to be severelydisturbed
to benefitfromProzac. Similarly,Ritalinwas now available to adultswho had not been diag-
nosed as hyperactivein childhood, but who were now redefiningtheir life difficulties as
related to "inattention,""impulsivity,"and "restlessness."The possibilitythat adults could
"have" ADHD became common in partsofthe cultureand manyindividuals"recognized"that
they,too, sufferedfromthe disorderand soughttreatmentfromphysicians.For example,Hal-
lowell and Ratey (1994) recounta case in which a patientdemanded Ritalinfortheiras-yet-
to-be officiallydiagnosedcondition.As physicianshave come to view ADHD symptomsas not
limitedto children,theyare likelyto offeran ADHD diagnosisand a "trialon Ritalin"to adults
with certainkinds of lifedifficulties.
The key here, however, is that our cultureseems to be

572 CONRAD/POTTER
moving away from"pharmacologicalCalvinism" (Klerman cited in Healy 1997) to the idea

thatdesignerdrugsmightimprovethe functioningof mostanyone.
Genetics
Geneticsis the risingparadigmin medicine and an increasingnumber of human prob-
lems are being attributedto genetic associations,markers,or causes (Conrad 1999). Some
expertshave long believed that there is a geneticcomponentto ADHD and its predecessor,
hyperactivity, but to date, evidence is only suggestive,even thoughthe claims of inheritance
date back at least 25 years (Cantwell 1975; Wender 1971; Wood, et al. 1976). Afterreviewing
extant evidence, researchersnoted, "Family,twin, adoption, and molecular genetic studies
show that it has a substantialgenetic component" (Faraone and Beiderman 1998, p. 951).
Recent research has focused on a geneticallyinduced imbalance of dopamine. Researchers
posit a potential link between ADHD and three genes: D4 dopamine receptorgene, the
dopamine transportergene, and the D2 dopamine receptorgene (Faraone and Beiderman).
The thinkingis that people who carrythe gene overproducedopamine, which impairsself-
control.Some suggestedthatgeneticinheritancemightaccount foras much as 80 percentof
the likelihoodthatone has ADHD (Barkley1997, p. 39). Despite the researchand much pub-
lished testimony(e.g., parentsreiterating about theirADHD child,"I was just like thatwhen I
was his age"), the geneticnatureof ADHD is stillcontested.However,the greaterthe medical
and public acceptance of a genetic component of ADHD, the more adult ADHD becomes a
social reality.If the disorderis genetic,then it is deemed an intrinsiccharacteristic
of people
withthe gene. This supportsthe notionthatADHD is a lifelongdisorder,and the positionthat
adults could have the disorder,even thoughtheywere never diagnosedas children.12
TheRiseofManagedCare
Managed care affectsall aspects of medicine, including psychiatry.Health insurance
imposes strictlimitson the amount of psychotherapyfor individual patients.Psychiatrists,
now, must make use of utilizationreview,participatein medicationmanagement,consulta-
tion, or administering"carve-outprograms"(Domino, et al. 1998). Mental health advocates
and some researchersargue that,under managed care, thereis a growingrelianceupon vari-
ous formsof prescriptiontherapiesto treatall typesof psychiatricand lifeproblems(Johnson
1998). A recent study found that managed care mightfuel growthin the pharmaceutical
industry(Murray and Deardorff1998). Undoubtedly,there are now greaterincentivesfor
psychiatrists and otherphysiciansto treatall potentialmental health problemswith medica-
tion,ratherwith than some formof talkingor psychotherapy.Managed care tends to replace
psychiatrists with primarycare physicianswho are less versed in "talkingtherapies" (Stou-
demire 1996), and, thereby,increasingthe potentialforrelyingon medicationfortreatment.
Searightand Mclaren (1998) describea "pragmaticassessmentand treatment" thatoccurswhen
primary care physiciansdiagnose and treat ADHD children with pharmaceuticals.In fact,
there is some evidence that ADHD childrenare treatedwith stimulantmedicationsto the
exclusion of other "talkingtherapies" (Woolraich,et al. 1990). It is likelythere are similar
trendswithadult ADHD.
Furthermore,this apparenttreatmentpreferencemay encourage the expansion of drug
treatablediagnoses,since these are reimbursableunder managed care. It is feasiblethatprob-
lems thatmighthave been diagnoseddifferently two decades ago (e.g., adult adjustmentreac-
now can be diagnosed and treatedas ADHD. While we do
tion) or seen as lifedissatisfaction,
12 A recentarticlereporteda sharpincrease in Ritalhnuse among 2-4 year old childrenenrolledin two Medicaid
programs(Zito,et al. 2000). While safetyand efficacyforsuch young childrenis unknown,and diagnosticvalidityeven
more problematic,thissuggeststhatADHD may be expandingin two directionsage-wise, creatinga lifelongdisorder.

FromHyperactive
not claim thatmanaged care has caused the rise of adult ADHD, it is part of the contextthat
makes ADHD a more likelydiagnosisthan in the past.
Some Consequences of the Adult ADHD Diagnosis
In a paper over two decades ago, Conrad (1975) outlinedsome ofthe ramifications of the
medicalizationof hyperactivebehavior.These included: (1) the problemof expertcontrol;(2)
the uses of medical social control; (3) the individualizationof social problems;and (4) the
depoliticizationof deviantbehavior.To these, he lateradded the dislocationof responsibility
fromthe individualto the netherworldofbiophysiological functioning(Conrad and Schneider
1992). Most of these can be applied to adult ADHD as well. The self-initiated and even self-
diagnosednatureof mostadult ADHD puts a different emphasison some of these issues (e.g.,
depolitization)but does not neutralizethem.With adult ADHD, it may be the shiftfromper-
sonal responsibilityand the individualizationof lifeproblemsthatare mostcritical.Creatinga
"medical excuse" directsattentionaway fromsocial forcesto biogenic ones and shiftsblame
fromthe person to the body. Thus, adult ADHD carrieswith it some unique consequences,
especiallysince mostcases are self-referredadults.
TheMedicalization
ofUnderperformance
What is interesting about adult ADHD is thatmany of the individualswho are given the
diagnosisare, by some measures,successfulindividuals.Rateyand Hallowell,forexample,are
bothpsychiatrists affiliated
witha major medicalschool and authorsofa best-sellingbook, yet
identifythemselvesas havingADHD. FrankWolkenbergwas a successfulfreelanceartist.In a
widelypublicizedand controversialarticle,JamesTrilling(1999) characterizedboth himself(a
professorand author) and his late father,the renownedliterarycritic,Lionel Trilling,as suffer-
ing fromADHD. Both lay and professionalaccountsof adult ADHD commonlyprovideexam-
ples of adults who have achieved success by many conventional social measures (e.g.,
Hallowell and Ratey 1994; Leffers1997). There are, of course, individuals with limited
achievementwho are also definedas ADHD, but the issues remainsimilar.In fact,Hallowell
and Rateysee theiraudience as "chronicunderachievers"whose difficulties are caused, not by
a lack of self-discipline,
but by an inbornneurologicalcondition.
For adults, the issue surroundingADHD is performance,not behavior. As Diller (1997,
p. 277) notes:
In broadestterms,movingfromchildhoodto laterlifeforthosewithADD involvesa shiftfrom
problems withbehaviorto problemswithperformance. The simplefactofhyperactivityor impul-
is notthechiefconcernforteensand adults:rather,
sivity it'stheirdisorganization,
irresponsibility,
andinability
procrastination, to completetasks.
The adult ADHD diagnosis often stems froma perceptionof underperformance.This
underperformancecan be reflectedin how tasks are accomplished,continual problematic
adaptations,or the level of success achieved. Individualsfeelthattheycould/shouldbe doing
betterand seek help in improvingtheirperformance.The ADHD diagnosisprovidesa medical
explanationfortheirunderperformance, allows forthe re-evaluationofpast behavior,and by
shiftingresponsibilityforproblemsreducesself-blame.A man who has come to see his ADHD
as underlyingthe chaos in his lifesaid, "I always thoughtI was stupid" (quoted in Hales and
Hales 1993, p. 64). Laura, a minister,"always did verywell, was always at or near the top of
her class throughhighschool, and seminary..... But now, she told [thepsychiatrist],academ-
ics had always been a strugglefor her" (Hallowell and Ratey 1994, pp. 83-84). Another
woman reflected,"I had 38 yearsof thinkingI was a bad person. Now I'm rewritingthe tapes
of who I thoughtI was to who I reallyam" (Wallis 1994, p. 43).

574 CONRAD/POTTER
But beyond an explanation,Ritalinprovides a strategyforimprovingthe underperfor-

mance. Ritalin has been creditedwith saving marriages,rebuildingfalteringcareers, and
transforming what had been problematicpersonalities.For example, "once Sam's ADD was
diagnosed,he startedon Ritalinat a dosage of 10 mg threetimesa day, and it worked well in
helpinghim focusand reducinghis mood swings" (Hallowell and Ratey 1994, p. 111). A 43-
year old woman reports,"I was able to sit down and listento what my husband had done at
work. Shortlyafter,I was able to sit in bed and read while my husband watched TV" (Wallis
1994, p. 49). Some even describea personal epiphanyafterfirsttakingRitalin."The firstday
afterstartingto take the medication,walkingdown the Brooklynstreeton which I then lived,
I noticedthe skythroughthe leaves ofa treeand stoppedto look at it.Aftera minute,it struck
me that,forthe firsttimein mylife,I was lookingat somethingwithno sensationofhavingto
stop and move on" (Wolkenberg1987, p. 82).
A New Disability
A diagnosisof ADHD puts an individualinto the largercategoryof having a "disability,"
which can serve as a gateway to potentialclaims to certainbenefitsand accommodations.
Withinthis "rights"framework,the diagnosishas been interpreted,primarily,as a learning
disorder(ratherthan a psychiatricdisorder).While previousresearchhas analyzed the role of
ADHD-based claimsto rightswithinchildren'seducation (cf.,Searightand Mclaren 1998), the
expansion of the diagnosis permitsthe medicalizationof adult ADHD to gain furtherlegal
legitimizationwithinthe institutions ofmedicine,as well as employmentand adult education.
As ADHD was comingto be identifiedas a disorderamong adultsin the early 1990s, indi-
viduals began to pursue legal actionsto lay claim to rightsunder legislationsuch as the Amer-
icans withDisabilitiesAct and the RehabilitationAct of 1973. Althoughrightsare guaranteed
under these statutes,theyare only enforceablethroughcivilsuit.ADHD is not one ofthe con-
ditionsexplicitlycovered under the ADA, yet advocates have argued that the disorderfalls
under the umbrella of the law. When ADHD is of sufficientseverityto affectan otherwise
qualified individualby limitinga major lifeactivity,protectionsare affordedunder the ADA
(Latham and Latham 1995). IndividualswithADHD have filedsuitsso thattheymightreceive
reasonable accommodationsin education and in the workplace (Jaffe1995). For example, a
searchusingthe legal database ofLexis-Nexis,identified211 cases in federallaborlaw between
1980 and 1999 thatconcernADHD (many ofwhich includeschool boards or universities).
Clearlya diagnosisof adult ADHD carrieswith it a certaincurrencyin the public sphere.
The public is aware of these disability-relatedissues. A key articleappeared in the WallStreet
Journalin 1993 that outlined workplaceand criminaljustice issues forthose with ADHD. A
book on ADD relateddisabilitylaw was publishedforadvocates in 1992 (Latham and Latham
1992). Not only are individualswith ADHD the potentialbeneficiariesof a "medicalexcuse"
fortheirlifeproblems,but theymay be eligibleforspecificbenefitsunder the ADA. Individu-
als who, priorto diagnosis,would not have seen themselveshaving a disabilityfindthem-
selves reapingthe benefitsof disabilitylegislation.Underthe ADA, individualswithADHD are
entitledto "reasonable accommodations"if their disorderis sufficiently severe to interfere
with tasks that theyare otherwisequalifiedto perform.Accommodationscould include un-
timedtests,oral versuswrittenadministration additionaltimeto com-
of testsor instructions,
plete tasks, structuredwork assignmentswith writteninstructions,extra clerical support,
more frequentperformanceappraisals,checklistsfor multi-stagetasks, diminishedcapacity
argumentsin criminalsuits,and protectionagainst discrimination(taken fromLatham and
Latham 1995; Nadeau 1995). The 1997 guidelinesfromthe Equal EmploymentOpportunity
Commission(EEOC) led to a listof accommodationsforADHD-diagnosedemployees,includ-
equipmentsuch as tape recordersand laptops,and "organizational
ing special officefurniture,
schemes (color coding,buddy systems,alarm clocks,and other'reminders')designedto keep
such employeeson track"(Eberstadt1999).

FromHyperactive
On Adult ADHD and Medicalized CategoryExpansion

AdultADHD offersa clear example of how a medicalizedcategorycan expand to include
a wider range of troubleswithin its definition.ADHD's expansion was, primarily,accom-
plished by refocusingthe diagnosison inattention,ratherthan hyperactivity and stretching
the age criteria.This allowed forthe inclusion of an entirepopulation of people and their
problemsthatwere excluded by the originalconceptionof hyperactivechildren.
The expanded category,adult ADHD, has become what Ian Hacking (1995, p. 96) terms
"an object of knowledge" with discernablesymptoms,putativecauses, and particulartreat-
mentand care. AdultADHD is recognizedwidelyas an entitythatis real, a "naturalcategory"
that only needs properapplication.While thirtyyears ago adult ADHD mighthave been an
oxymoron,todayit is deemed a discretedisorderthatcan be claimed and diagnosed.
What is particularlyinterestingabout the adult ADHD case is the role of lay groups in
promotingthe expansivemedicalization.The lay-professional alliance (see also, Leffers1997),
best exemplifiedby Ch.A.D.D., but also evidentin the media presentations,suggestsan align-
mentbetween the claimsofsufferers and professionals.This contrastssharplywiththe case of
multiple chemical sensitivitydisorderwhere there is a clear-cut disjunctionbetween lay
claims-makersand skepticalprofessionals(Kroll-Smithand Lloyd 1997) and chronicfatigue
syndrome,where individualsmay have a difficult timegettingtheirsymptomsmedicallylegiti-
mated (Cooper 1997). The lay promotionofadultADHD and thepredominanceofself-diagnosis
contradictsome of the basic premisesof the labelingtheoryof psychiatricdiagnosing(Scheff
1984), whichsuggestsa fundamental conflict
betweensocialcontrolagentsand putativedeviants.
In the adult ADHD case, the diagnosisis embracedand promotedby the people who receiveit.
This suggeststhatthismay be a different kind of psychiatricdiagnosisfromthose sociologists
typically study,one thatis soughtout bythe verypeople to whom itis to be applied.In thiscase,
medicationtreatmentmaybe seen as much as an enhancementas a formofsocial control.
Studies have shown that the interactionof lay and professionalclaims-makers,rather
than "medical imperialism,"typicallyunderlies the medicalizationprocess. But the case of
adult ADHD indicatesthatpopularizationmay also play a partin diagnosticexpansion. Media,
includingTV,popularliterature,and now the Internet,spreadthe word quicklyabout illnesses
and treatment.This popularizationof symptomsand diagnoses can create new "markets"for
disordersand empowerpreviouslyunidentified sufferersto seek treatmentas new or expanded
medical explanationsbecome popularlyavailable. The widespreadpopular acceptanceof enti-
ties as illnessessuggestsa feedbackloop among professionals,claims-makers,media, and the
public in termsof the creation,expansion,and applicationof illnesscategories.Justas medi-
calizationresearchhas moved fromfocusingprimarilyon the claims and activitiesof physi-
cians, to examiningthe interplayof professionaland lay claims-makers,it behooves us to
investigatehow medical diagnosespenetratein the public consciousnessand become "taken-
for-granted as an objectivenaturalentity"in the public sphere (Horwitzforthcoming).Such
medical diagnosticentitiesare oftenaccepted withoutrecognizingtheirhistoryand with an
assumptionof theiruniversalcategoricalsignificanceregardlessof culturalcontext.Withinan
increasinglymedically aware public reside individuals who take identified"symptoms"as
revealingan underlyingdisease conditionand, in cases like adult ADHD, may seek to attain
theirdiagnosisof choice.
But in termsofdiagnosticexpansion,the ADHD case is not unique. We can pointto other
cases where medicalizedcategories,which were originallydeveloped and legitimatedforone
set of problems,were extended or reframedto include a broader range of problems.Several
examples come to mind.Post-TraumaticStressDisorder(PTSD) was originallyconceivedof as
a disorderof returningViet Nam war veteranswho sufferedfromthe afteraffectsof brutal
combat experience (e.g., with flashbacks,sleep problems,intense anxiety,etc.) (Scott 1990;
Young 1995). But in recentyears,PTSD has been applied to rape and incestsurvivors,disaster

576 CONRAD/POTTER
victims,and witnesses to violence. Alcoholism was medicalized, in large part, due to the
effortsof AA (Conrad and Schneider 1992), but the medicalizationhas expanded to include
adult children of alcoholics, enablers, and especially "codependency" (Irvine 1999). Child
abuse, which was originallylimitedto battering,has expanded to include sexual abuse and
neglect,and to lesser extent,child pornographyand exploitation(cf.,Best 1990 and 1999)
and, to a degree,spawned the largerdomain of domesticviolence (includingwoman battering
and elder abuse). In 1972, multiplepersonalitydisorderwas a rarediagnosis(estimatedat less
than a dozen cases in 50 years); by 1992, thousands of multipleswere diagnosed. This "epi-
demic" resultedfromthe diagnosticreconceptualizationto "dissociativeidentitydisorder"in
DSM-IIIR withless restrictive criteriaand an associationwith childabuse (Hacking 1995). 13
Definitionalcategoriesare potentiallyelastic and can be stretchedto include more phe-
nomena withintheirrealm.This may be particularly truewith medicalizedcategoriesbecause
of the social advantages of medical definitions(e.g., mitigationof personal blame, medical
excuse, health insurance,or disabilitybenefits),although fiscalconstraintsof medicine may
set limitson certainapplications(Conrad 2000). While, in general,the expansion of medical
categoriesmay be limitedby the carryingcapacityof the medical professionand the health
insuranceindustry(cf.,Hilgartnerand Bosk 1988), it appears thatwith active claims-makers,
committedstake-holders, and receptivepotentialclients,diagnosticexpansioncan occurreadily
and with minimalopposition.Similarto domain expansion,diagnosticexpansion begins with
establisheddisordersand moves toward more problematicclaims. One legitimatedmedical
categorycan beget others.
It is interestingto considerwhethera parallelprocessof diagnosticcontractionmay take
place. Some have suggestedthis narrowinghas occurredforserious mental illness.With the
increasedrelianceon primarycare providersin managed care,forexample,some researchhas
suggestedan underrecognitionof some serious mental disorders(Stoudemire 1996). Others
have noted that the "medical necessity"standardhas altered,not only treatment,but also
diagnosis (Ford 1998). It standsto reason that,in the age of managed care, shrinkageof the
medical domain is a likelyoutcome. Yet as noted in the adult ADHD example, managed care
may have paradoxicallyplayed a role in the emergenceof this new category.Whateverthe
ultimateoutcome of problemdefinitions, of certainmedical diag-
it seems clear the flexibility
noses allows forexpansion and, thus,the increaseof medicalizationin our society.
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From Hyperactive Children to ADHD Adults: Observations on the Expansion of Medical

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Over the past thirtyyearstherehas been keen sociologicalinterestin the medicalization

Our thanksto JoelBest, LibbyBradshaw,Phil Brown,Allan Horwitz,and the anonymous reviewersforcomments

SOCIAL PROBLEMS, Vol.47, No. 4, pages 559-582. ISSN: 0037-7791

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may expand in new ways. Medical diagnosticcategories,perhapsespeciallypsychiatriccatego-

The DSM as a Categorical Touchstone

Psychiatricdiagnosesare historicallyand culturallysituated.Certaindiagnosticcategories

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"diagnosticproject"(the professionallegitimizationof diagnoses),as well as withinthe larger

Hyperactivity in the 1970s

AlthoughADHD's roots are oftentracedto earlyin the twentiethcentury(Goldman, et

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The most significantcriterionfordiagnosis was a child's behavior,especiallyat school.

The Emergenceof "Adult Hyperactives"

Beginningin the late 1970s, several cohortstudieswere publishedwhich followedchil-

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primarysymptoms:eitherhyperactivity orinattention.Thus,the diagnosisfocusedon attention

The Development of "ADHD Adults"

In the 1987 revision,DSM-IIIR, ADD was renamed "AttentionDeficitHyperactivity Dis-

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suicidal ideation,he was diagnosed with ADHD by a psychologistwhose specialtywas learn-

AdultADHD in thePublic Sphere

5. Referencingthe work of others,Zametkinnoted that"the disorderis probablyinhentedin certainfamilies"and

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Medline Psychinfo AcademicUniverse

Year WireService NE Regional Magazines

1975-1979 34.4 3.4 0 0 0

ern farmingcommunity(which requires greaterstabilityand focus). This hypothesis,by its

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presentthirteensub-typesof the disorder,a set of "suggesteddiagnosticcriteria,"and offera

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The new definitionallowed for more variations of symptomaticbehavior across and

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The Social Context for the Rise of Adult ADHD

The expansion of the hyperactivity diagnosisto adults is not,primarily,the resultof new

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moving away from"pharmacologicalCalvinism" (Klerman cited in Healy 1997) to the idea

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Some Consequences of the Adult ADHD Diagnosis

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But beyond an explanation,Ritalinprovides a strategyforimprovingthe underperfor-

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On Adult ADHD and Medicalized CategoryExpansion

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Cooksey,Elizabeth and Phil Brown

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Guadagnoli,Edward and PatriciaWard

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Kelly,Kate and PeggyRamundo

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Ratey,JohnJ.,Mark S. Greenberg,JulesR. Bemporad,and Karen J. Lindem

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Williams,Simon J. and Michael Calnan

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