Institutionalized Intolerance of ADHD: Sources and Consequences

Author(s): SUSAN C. C. HAWTHORNE

Source: Hypatia , SUMMER 2010, Vol. 25, No. 3 (SUMMER 2010), pp. 504-526
Published by: Wiley on behalf of Hypatia, Inc.

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Institutionalized Intolerance of ADHD:
Sources and Consequences

SUSAN C. C. HAWTHORNE

Diagnosable individuals, caregivers, and clinicians typically embrace a biological

ception of attention-deficit/hyperactivity disorder (ADHD), finding that medi
treatment is beneficial. Scientists study ADHD phenomenology, interventions to
symptoms, and underlying mechanisms, often with an aim of helping diagnosed pe
ple. Yet current understanding of ADHD, jointly influenced by science and socie
has an unintended downside. Scientific and social influences have embedded neg
values in the ADHD concept, and have simultaneously dichotomized ADHD
diagnosable from non-diagnosable individuals. In social settings insistent on cer
types of success, the negative values associated with the diagnostic category are att
uted to people in the dichotomized "ADHD" group. Devaluation, institution
restrictions on "success" definitions and endpoints, and limited options for achie
success jointly constitute institutionalized intolerance of ADHD.

Attention-deficit/hyperactivity disorder (ADHD) is the most commonly di

nosed behavior disorder in children (Jensen et al. 2005), and it is increasing
diagnosed in adults as well. Millions of physician office visits are devoted
ADHD annually (Zito et al. 1999; National Center for Health Statistics 2006
pharmaceutical companies profit immensely from prescription sales, and th
ing basic and clinical research programs investigate aspects of the disorder
has become a fixture of U.S. culture as well, involving millions of parents, c
dren, diagnosable adults, teachers and school administrators, and la
enforcement and public health officials. The standard prevalence estimat
3-5% among children and adolescents (American Psychiatric Associat
2000), approximately half those numbers in adults. But recent studies sugge
prevalence of 8-10% in youth (Biederman and Faraone 2005; Froehlich et
2007), as does recent practice: about 7.8% of children and adolescents h
been diagnosed (Centers for Disease Control and Prevention 2005 J.1

Hypatia vol. 25, no. 3 (Summer, 2010) © by Hypatia, Inc.

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 Susan Q Q Hawthorne 505

The scientific, clinical, and cultural uptake of

welcome - the idea is that diagnosis and treatm
children and adults who struggle with the requir
social engagement. In earlier generations, ADHD
often have been judged "naughty," "lazy," or
adults would have been understood as "underachi
dominant ADHD concept and associated medi
scientific practices relax these forms of stigmat
individuals are typically conceived as having a bi
be ameliorated with proper treatment, especially
look at the current concept of ADHD (see the fir
institutions associated with it, and the effects o
gests that the uptake of ADHD may have less w
has, unintentionally, institutionalized a new form
entifically and socially sanctioned negative judg
individuals, together with limited options affor
and/or treatment, constrain diagnosable individ
this result is not simply a "social construction,"
entific or medical practice, or chiefly a ploy of
that the interplay of scientific, medical, social,
goals has given rise to institutionalized intolera
consequences for ADHD-diagnosable individuals.
My analysis of the new intolerance and the proc
work of feminist philosophers of science who ha
social bases and effects of holding certain false d
omy science:society is one of these. According to
is objective, disinterested, and rational, while s
partial, and non-rational. Helen Longino argues
not be dichotomized in this way. In her vie
maintained by the social practices of scient
dichotomized view - by the rationality of indiv
Adopting the non-dichotomized view helps illum
ences between science and society. Some of t
reinforced other false dichotomies, such as t
2001), genders, or social categories like divorced
For reasons explained in the first section, the d
and "non-ADHD" is another such false dichot
scribes the interactive processes that have c
negatively valenced ADHD category conducive t
tion explores how concepts, institutions, and atti
category, structuring ADHD-diagnosable people'
options.

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 506 Hypatia

Current Controversies, C

As much a part of the medical,

pects of understanding and prac
these venues, despite decades refi
ceived as a disorder of school-a
preschoolers and adults. The curr
Disorders (DSM; American Psyc
into three types: inattentive, hy
a diagnosis, a person must have si
from the list for hyperactivity/im
pair the individual's functioning
The DSM does not specify an et
emphasize behavioral, psychosoci
bilities. However, recent rese
ADHD, and recent medical practi
tion - that is, medication. For ex
of those receiving an ADHD diag
(Mayes et al. 2009). Of course, th
exclusive, and much overlap and
Although there is a relative c
scientists have not yet settled o
underlying mechanism(s). Researc
especially dopamine, are involved
though specific genes are not con
anatomical, electrophysiologic
ADHD-diagnosable and non-di
some environmental precursors,
relative consensus
efficacy o is the
tom control. Other aspects of tre
are less definitive: behavior thera
cost-effective relative to stimula
term studies of intervention eff
tive endpoints reached in the m
and multiple follow-ups]) are sim
protocols at the two-year point
2007).
There is also enough subjectivity in the diagnostic criteria that estimates of
prevalence have ranged from 2% to 26% (Froehlich et al. 2007). Although
inter-rater reliability can be high between similarly trained diagnosticians
(Biederman and Faraone 2005), the diagnostic criteria accommodate more or
less severe symptoms. For example, with criteria such as "often does not seem to

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 Susan C. C. Hawthorne 507

listen when spoken to directly," or "often has difficu

clear how frequently the symptom needs to be exp
arching requirement that the symptoms cause "im
diagnostician's (and the parent's, teacher's, or sym
unimpaired function. This is one reason some scie
the DSM's categorical conception of ADHD - accord
ther has ADHD or does not. An alternative is that
disorders, might be more accurately and/or fruitfu
mensions of functioning (a person is more or less ac
so on [Neuman et al. 1999; Nigg et al. 2002; First 2
ADHD category is also importantly heterogeneous
severity of symptoms is large, and, more often t
people also meet diagnostic criteria for another
morbidities include learning disabilities, anxiet
defiant disorder, and conduct disorder.
These multiple, unsettled aspects of ADHD conce
suggest that "ADHD" and "non-ADHD" cannot b
Scientists and clinicians therefore often consider t
heuristic, a pragmatic tool, or a hypothesis that w
Given the tentative nature of current understandi
ADHD should not be reified (Parens and Johnston
not be prematurely understood as a definitive, identi
cautious epistemic stance is consistent with variou
ADHD - in particular, with the predominant scien
logical basis). Despite the awareness and the wa
language, practice, and portrayal of ADHD all argu
reified, even by many professionals. For example,
emy of Child and Adolescent Psychiatry ( AACAP
disease "on a par with diabetes" (AACAP 2007), the
ADHD is a definitive entity, because diabetes is. C
treat ADHD seem to be dealing with an identifiab
make little sense.
Some controversies in the wider society follow
medicine. Discussions of the fuzziness of the catego
lack of consensus on etiology, and the reification (
formed into debates over whether ADHD is "real,"
under- or overdiagnosis. Medication use is perpetu
tional practices also inspire disagreement - over wh
accommodations, what form these should take, and
tific and clinical practice, though, relative consen
practice. "ADHD" is common parlance among indiv
with an apparent, agreed, core understanding. Ind

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 508 Hypatia

often self-refer for diagnosis a

means of detecting, referring, a
ble children.
The unsettled aspects of the un
sis, its heterogeneity, its prevale
are in tension with stable, pred
tices. The stable and institution
placeholder for a future, improv
sizes the biological basis of A
practices that rely on distinguis
ble. This relative consensus yield
that it is a biological dysfunctio
DSM criteria. The next section sh
cepts and practices have inter
ADHD," and have simultaneously
undesirable - a disorder that requ

DlCHOTOMIZATION, EMBEDDED

The current, predominant view

social influence. These are not se
including those of medicine and
ence; science informs social pr
feedback loop that reinforces th
reinforces the dichotomization a
In a larger project, I trace these
2010); here, I give examples that
building on the work of other sc

Social Interests Embedded in Science

A broad range of social support encourages the study of ADHD. The range
reflects a confluence of needs: those of children to cope with school, schools to
cope with children, adults to succeed at work, government to prevent delin-
quency, medical institutions to control costs, and drug companies to make a
profit. Over the past decade, the National Institutes of Health (NIH) have
contributed an average of U.S.$107 million annually to U.S. ADHD research.8
The pharmaceutical industry also funds much research concerning ADHD
medication; the extent of this support is proprietary, but it likely dwarfs gov-
ernment expenditures (Angeli 2004). On a smaller scale, school psychologists
and other educators also receive funding to investigate ADHD management in
schools. In brief, ADHD is a social priority.

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 Susan C. C. Hawthorne 509

The needs, interests, and other values of many so

ded in the DSM diagnostic criteria. Adult exp
prominent: A diagnosable child "makes careless m
through on instructions," "leaves seat in classroom
Psychiatric Association 2000, 92). Similarly, the i
criteria for adults emphasize behaviors considered
cess in the workplace. For example, the Adult AD
"How often do you have trouble wrapping up the f
the challenging parts have been done?" and "How o
keeping your attention when you are doing boring
et al. n.d.). The converses of socially sanctioned b
are part of what define the ADHD category. Beca
category, "ADHD" embeds these values, because di
up to the values, the valence of the category is neg
Neither social interest in studying ADHD nor th
entail that the resulting science embeds social inf
aspects of ADHD studied - the investigative trend
accumulated knowledge concerning ADHD, deep
nant concept. The scientific focus on biological as
emphasis. For example, in the recent prolific lite
40% of journal articles concerned biologically orie
psychopharmacology - while only 4% emphasized
behavior treatment, and 6% stressed academic or
The relative dearth of research concerning edu
noted as early as 1993 (Chesapeake Institute 1993)
the environmental influences on ADHD prevalenc
little long-term, longitudinal research on the disor
done, despite the fact that relevantly similar dis
tention deficit disorder [ADD]) have been char
These investigative trends - biological emphasi
and short-term studies - all support social intere
effective approaches to the perceived problems, a
level of the individual. In contrast, long-term inte
ventions, including intervention at a systems lev
alignment of the investigative trends with particu
egies ties the accumulated knowledge of ADHD
those interests and strategies.
Social influences extend deeper into the science
in the conclusions of individual researchers. As o
ence quite often embeds social needs and interest
methodology chosen for studying a phenomen
the background assumptions scientists bring to d

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510 Hypatia

Consider first an example of th

debate in ADHD research concern
diagnosable individuals have (1)
delay that "normalizes" over tim
have employed structural magne
single time point (a cross-section
ical characteristics present at the
be repeated in the same indivi
study), and the resulting images
developmental trajectories. Cross
dren have reported an 8.3% sma
(Mostofsky et al. 2002) and a 4%
et al. 2004). But at least one longi
tures "catch up" as children mat
on the pathophysiology of ADHD

More than one subdivision of

reduced in volume, suggesti
ADHD encompasses dysfunc
development of both premo to
ofsky et al. 2002, 785)

The reduction of intracranial

reduction in brain volume asso
relatively early effect. (Dursto

[Cross-sectional and longitudi

may also guide the future sear
than derail, cortical developm

The authors are well aware of th

their hypotheses about etiology
though, that Mostofsky et al. and
ology that embeds primary inter
toward a static view of ADHD's e
. . . volume" from "anomalous de
"relatively early effect." This con
their longitudinal research, that th
derail, cortical development." Sh
sizes interests in longer-term pr
delay (Hypothesis 2). None of the
esis over the other, but because
aspects of ADHD's phenomenolog
contrasting interpretations.

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 Susan Q C. Hawthorne 511

Some socially influenced background assumptio

tinely used concepts of clinical science. These ma
use of mixed descriptive/prescriptive terminology
contain both fact and value (Putnam 2002). Mixed
terms embedding social values are ubiquitous i
ture - "dysfunction," "deficiency," "disorder," "h
are a few examples. Such terms assume that a det
sirable}0 Disagreements over the boundaries of th
that there is not complete consensus on when obs
considered dysfunctions: that is, the relevant bac
shared.
Background assumptions about what counts as evidence can also alter scien-
tific conclusions (Longino 1990). Compare, for example, the conclusions of two
long-term intervention studies. Each found that their studied interventions
reduced ADHD-diagnosable children's overt behavioral symptoms, but did not
improve the children's academic achievement. The studies employ different
criteria for academic achievement, importing value-valenced background
assumptions about achievement via their respective operationalizations.
These assumptions are embedded in the conclusions. But other background
assumptions also guide the interpretation of the data. One study concludes that
"... there is no support for academic assistance and psychotherapy to enhance
academic achievement ..." (Hechtman et al. 2004, 812). While the authors'
discussion of the study's shortcomings acknowledges that their measures of ac-
ademic achievement are limited, their conclusion ("no support") is untempered
by this limitation. To reach this conclusion, Hechtman et al. must assume that
they need count as evidence only what they measured. The authors of the other
study soften their conclusions about intervention, saying: "Thus, the full extent
of effectiveness of the treatments for ADHD, as well as their limitations, may
not be captured by the ratings of symptoms. Important aspects of quality of life,
adaptive functioning, and tolerability may be missed by the operational defini-
tions of effectiveness . . ." (MTA Cooperative Group 2004b, 767). In other
words, the MTA authors leave room for considering evidence beyond their
"operational definitions of effectiveness." Their different background assump-
tion leads to a more flexible conclusion about treatment. (Notably, however,
this result does not mean that the MTA authors make no value-valenced as-
sumptions. Rather, their methodology takes into account a different set of social
needs and interests.)
Additionally, scientific study often reinforces social values by establishing
correlations of ADHD diagnosis with other devalued phenomena. In recent
literature, these problems include delinquency or criminality (Sourander et al.
2006; Molina et al. 2007), school failure (Hechtman et al. 2004; Yang
et al. 2004), reduced income potential (Biederman and Faraone 2006),

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 512 Hypatia

impaired social relations (Abikof

stance abuse (Wilens et al. 2003;
and accident (DiScala et al. 199
costs (Leibson et al. 2001; Birnba
ing cognitive traits (Sonuga-Bar
control (Dimoska et al. 2003; Fal
that is, these ADHD-associated t
ditively strengthen ADHD's neg

Scientific Conclusions Embedded in Society

The predominant view of ADHD as scientifically conceived, then, embeds a

negative valuation of ADHD, particular views of what constitutes function and
dysfunction, and social interests in short-term solutions and intervention at the
level of the individual. When scientists note positive correlations with ADHD-
associated phenomena, identify relevant mechanisms, or establish laboratory-
based efficacy of an intervention, they corroborate working models of ADHD
by scientific standards.11 Such successes reinforce the scientific research pro-
gram, enabling its continued existence. They also encourage the development
of institutions needed to implement practical extensions of the research, vin-
dicate the values embedded in the research, and sharpen the dichotomization
between ADHD and non- ADHD.
Institutional development. By helping to conceptualize ADHD, and by offer-
ing interventions for changing ADHD-associated behaviors, the sciences of
ADHD provide grounds for restructuring social practice and institutions. The
restructuring is a joint project: institutional change is not merely a consequence
of scientific achievement, it is a necessary condition for that achievement
(Rouse 1987; Cartwright 1999): real- world effectiveness requires control. For
example, a vaccine can be effective only when clinicians are educated, eco-
nomically and physically accessible clinics are established, and immunization
laws are enacted. Similarly, in the case of ADHD, physicians, teachers, and
parents need to be educated about diagnosis and treatment; systems must be in
place to reimburse clinicians for treatment; and schools must have mechanisms
for identifying and referring diagnosable children. Scientific results have influ-
enced society to make many such changes, allowing ADHD diagnosis and
treatment a degree of clinical efficacy.
Value vindication. Because of its multiple practical and conceptual successes,
science is held in high regard by many in U.S. society, making its categories and
conclusions influential. When science corroborates the ADHD category,
people's concern with ADHD-associated traits and behaviors is reinforced -
simultaneously reinforcing people's pre-existing concerns with ADHD-
correlated academic, employment, relational, cognitive, substance abuse, and

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 Susan Q C. Hawthorne 513

other difficulties. The salience of behavioral chan

treatment - a scientifically grounded intervention
Further, as we have seen, biological views embe
ments: when scientists interpret the physiologic
behaviors and their consequences as "dysfunctions
ply to the physiological bases (which would be me
the multiple correlated concerns. Importantly
ADHD are also conceived as persistent or permane
as well as of the concept. Biologization thus vi
something is "wrong" with diagnosable individua
has both normative and non-normative connotations.
Reinforced dichotomization. By drawing distinctions between people,
dichotomization abets the attribution of normative judgments. Conceptual
and practical dichotomization of "ADHD" from "non- ADHD" - and diagno-
sable from non-diagnosable individuals - is in part an artifact of the categorical
nosology of the DSM. But standard scientific practices also reinforce
dichotomized thinking and practice. One such practice is the common strat-
egy of finding differences between "ADHD" and "non- ADHD" (often termed
"normal" and "control") groups. Even if the detected differences are small, the
net result of finding many differences is divergence between the two groups:
gradually, what started as a distinction becomes a dichotomy. Data interpreta-
tion that concentrates on main effects - that is, reduction to an average of
variations within the ADHD-diagnosable group - also reinforces dichoto-
mization. This is because "ADHD" and "non-ADHD" groups, in this way of
thinking, are conceived as conforming to separate averages, rather than as
containing variable individuals with overlapping traits. Researchers are aware
of the variation within their groups. Nevertheless, when their methodologies
and language attribute an average finding to an experimental group,
dichotomization is abetted.
The effects spread widely: clinicians and clinical scientists use dichotomi-
zed thinking to formulate treatment algorithms, which are necessarily
non-individualized. Educators, like clinicians, need dichotomization as a
practical matter, to determine who is eligible for treatment, assistance, or
accommodation. Dichotomization is institutionalized to facilitate these prac-
tices, which further embed the interests in speed, cost-effectiveness, and
individual-focused intervention.
Public messages, public views. According to the foregoing interpretation,
then, the interactions of social and scientific values and concepts have rein-
forced a dichotomized and negatively valenced view of ADHD - and ADHD-
diagnosable individuals - that is further reinforced by institutionalization of
various practices. A recent systematic analysis of spoken, written, and media
narrative provides empirical evidence that ADHD-diagnosable individuals are

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 514 Hypatia

indeed perceived negatively (Dan

that lay people use the terminolo
of educators ("school discourse")
terms, such as "inattention" and
thology in the individual. For e
problem; instead, they endorsed
attributed difficulties to ADHD-
the clinical focus on negative as
fifty comments concerning ind
three framed ADHD-associated b
sociated ADHD with violence o
people accepted ideals of merito
achievement - three areas in w
difficulty.
Danforth and Navarro's data have limitations. They were presumably
gathered in the late 1990s, and the assistant researchers collecting commen-
tary were white university students, whose social and media circles were likely
limited in some ways. But more recent studies also suggest that negative per-
ceptions of ADHD-diagnosed people are prevalent. One research team asked
college students to respond to fictional descriptions of people. The students
said they would be less likely to want to work with, get to know, or become
friends with a person described as having ADHD than they would with a
person described as having no disability or minor medical disabilities (Canu
et al. 2008). Other researchers surveyed a national sample of youth ages eight
to eighteen. The children and teens responded negatively to vignettes pre-
senting people who have ADHD, speculating that the described person "is
more violent" and "gets into trouble more often," though no trouble or vi-
olence was included in the vignette (Walker et al. 2008). Another study
suggests that ADHD-diagnosed children are less well liked than their non-
diagnosable peers (Hoza et al. 2005).
How clear is it, though, that the cultural consensus about ADHD shapes
these perceptions? Is it more likely that the negative perceptions are based on
experience of someone's intolerable behavior, or of their struggles with work,
school, or relationships? Perhaps - but these are not mutually exclusive hy-
potheses. One way to see this is to consider alternative, less negatively
valenced views of ADHD. Edward Hallowell and John Ratey's attempted re-
framing is one possibility. These authors emphasize positive aspects of
ADHD. Their books, intended for non-expert audiences (e.g., Hallowell
and Ratey 2005), present the positive message that having ADHD need not
be a burden: "If you don't get help, ADD can curse you and make you
wretched. But if you work it right, ADD can enhance your life and make
you sparkle" (Hallowell and Ratey 2005, xxiii). Others suggest that even if

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 Susan C. C. Hawthorne 515

people continue to think some ADHD-associated

undesirable, they could be more tolerant of dif
(Parens and Johnston 2009). Similarly, a broader d
tolerance of failure - is also possible. If less negat
ple's interpretations of many ADHD-associated tra
could change - and their reactions to ADHD-d
well. In addition, it is important to remember the
ADHD category, the great heterogeneity within t
ation in observers' values that contributes to the
vary markedly, as do the views that characterize t
and practices - especially false dichotomization
The consistently negative portrayals of ADHD,
promptly manage it, instead push the interpretat
intolerance.
For the most part, the processes described here,
intentional. Clinicians, scientists, teachers, and
create negative judgments or stereotypes; they aim
people who are struggling. It is also important
static; the reciprocal science/society influences co
the present result unstable. Nevertheless, the soci
tions reinforce one another in the ways describ
feedback loop that has, over the past fifty years
current, predominant, ADHD concept and the a
rounding it.

Institutionalized Intolerance

The multiply influenced, dichotomized ADHD category is now part of our so-
cial world, molding options and judgments. Norms of achievement, control,
and attention are institutionalized, as is the social pressure to conform to these
norms. The effects are not the same for all ADHD-diagnosable people, or for all
their caregivers. Overall, though, the negative valuation of ADHD traits and
behaviors, and the people who exhibit them; the social goals of managing the
traits and behaviors quickly, inexpensively, and by intervention on individuals;
and the requirements that social structures impose on ADHD-diagnosable in-
dividuals and their caregivers, together constitute institutionalized intolerance
of ADHD and of those who "have" it.

Constraints

Institutional structures and policies - school environments, identification

strategies, workplace expectations, health-care access, availability and

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 516 Hypatia

accessibility of targeted inter

choices. With the predominan
institutions in place, a parent'
diagnosable child, or an adult's de
ent from what it would be in th
usually the easiest; those who que
culty. For example, some parent
thrive in typical school settings
or expectations over diagnosis
not widely available. Similarly,
different jobs, or different (rea
may exist. These constraints, bas
or on particular ways of fitting
intolerance.
The dearth of well-supported tr
that are supported scientifically
already discussed, pharmaceut
States. For example, the 2007
et al. 2007) provides much evide
against (some favoring) behavior
other proposed forms of treatmen
a diagnosed individual's environm
"additional school resources as a
that parents and the ADHD-diag
concerning ADHD (902). For m
pharmacotherapy without behav
psychoeducation) is the first an
algorithms have a similar emph
AACAP 2002). This focus on dru
support of behavioral therapy or

Social Pressures

ADHD-diagnosed people often feel strong social pressure to succeed relative to

academic, employment, family, or social norms. Carl Elliott (2003) points out
that even for children, the norms being reinforced are not just standards for
childhood and adolescence, such as keeping track of pencils and completing
homework and chores. Instead, the worry is also about the child as adult - his
or her success in relationships and career. Parents who pursue an ADHD diag-
nosis for their symptomatic children accept a set of norms for present and future
behavior and success that their children struggle with, and with which the par-
ents may or may not wholeheartedly agree. But the social pressure to achieve

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 Susan C. C. Hawthorne 517

the norms can be great, which "leaves many parents

of either buying into a standard they despise or prote
dren" (Elliott 2003, 248).
Diagnosable adults, too, can be pressured: they mig
standards embedded in the ADHD category, or the s
out of reach. One interpretation calls adult ADH
underachievement" (Conrad and Potter 2000). Medic
of social pressure - expectations are that diagnosed
not that they simply, say, "get their act together." B
ture of medicalization. And because current hy
underlying causes of ADHD-diagnosable individuals' s
culties as persistently dysfunctional, diagnosable p
persistently or permanently deficient in socially signi
The standards underlying the predominant ADHD
not universally - shared. Alternatives might put le
demic achievement, or give higher status to physica
of some scientific and clinical communities doubt t
and interventions can substitute for higher-level ap
cope with social or emotional struggles. Instead, in
social, psychoanalytic, cognitive, behavioral, or
disorder should ground clinical practice. Others - o
"lay" people or members of religious communities -
tion of behavior on the grounds that it dissolves m
measurable, while trivializing immeasurables such as
ships. The extent to which social pressures are aptly
varies conversely with the acceptability of ADH
diagnosable individuals.

Relief, Acceptance, Ambivalence

But for those who agree with the norms embedded

practice, diagnosis and treatment can come as a we
mayed with broken relationships, lack of success a
academic failures often embrace the biomedicai int
story. Media portrayals, at least in the 1990s, tended
light (Schmitz et al. 2003). Even in the case of agreem
be only one aspect of an individual's reaction. A
qualitative study of adults found that relief was fol
grief, and anxiety as they worked through what th
tunities and misunderstandings before their diag
Even after the final stage, acceptance, the participan
the stigma associated with diagnosis.

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 518 Hypatia

Agreeing with the norms may a

pragmatism. According to psycho
ing medication decisions for t
perspectives, at times justifying d
a dose. These parents may be weig
havior - compliance versus spon
valuable in one situation, one in
diagnosed adults, may also think
their children's lives, or their
straightforward way available. Th
the social norms and institutional
these limit available options, into
normative views on social institut

Internalizing

A potentially important effect of diagnosis and treatment is that people may

come to view themselves as exemplifying their diagnostic category. Philoso-
pher Ian Hacking (1995) described this as part of a looping effect; some
sociologists and psychologists study similar phenomena according to "labeling
theory" or "social representations theory." Internalizing the predominant view
of ADHD entails accepting the core features of that category: one's biology is
dysfunctional, and it is unlike that of the majority; one's social, academic, or
employment difficulties are due at least in part to this difference, and to that
extent not due to others in relationships, or to school or work circumstances. In
short, internalizing involves understanding oneself in relation to the values
embedded in the category.
Singh (2007) concluded from a qualitative study that eight- to twelve-year-
old ADHD-diagnosed children had an emerging sense of self that was in part
structured according to their ADHD diagnosis. As the author cautions, it is
important not to overgeneralize these results, as this was a pilot study involving
only twenty boys and three girls, with the sample importantly limited to white
children in the United Kingdom. Yet the interviews were suggestive: For ex-
ample, although the children thought of themselves as "good" and more
"normal" when taking Ritalin, "bad" when not, they also did not think that
Ritalin use transformed their "badness." Instead, they thought "badness" per-
sisted as a core dimension of their character. They said they were sad about
their inability to control themselves at times, and expressed worry at what oth-
ers thought of them.
Singh observes that the children described their experience in binaries -
good/bad, normal/abnormal, and happy/sad. She suggests that the binaries may
represent either cognitive immaturity or, more likely, an artifact of the way the

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 Susan C. C. Hawthorne 519

questions were presented. She observes as well th

gleaned their moral view of their own character f
caregivers. An alternative, though, is that the ch
racy, internalized the predominant biomedicai vi
The binary conception corresponds to dichotomiza
framing to an internalization of the embedded val
nalizing may be reluctant: although the children
being more "normal" when taking Ritalin, they als
when off medication, and sad when taking it.
Again, it is important not to overplay a single st
out, this study involved a limited and non-divers
would be important to determine how a comparis
but diagnosable children view themselves. This inf
among several hypotheses, such as ( 1 ) internalizin
children's binaries and the moral expressions, (2)
ceptions of pre-diagnosis behavior leads to the
internalizing more general features of the social e
of binaries and moral expressions - engenders the
It is at least unambiguous that the symptoms as
devalued, and that the ADHD category is a powerf
discussed, overt, and persistent. And of course, a c
treatment is to tamp down the symptoms - to cha
and behaves. It is hard to imagine, given this, that
image unaffected.

Why Uptake, Then?

If accepting the diagnosis really means bowing to

straints and internalizing negative self-perception
ADHD seems paradoxical. Why would such large n
nosis and treatment for themselves or their chil
The social pressures, practices, and institutions alr
toward answering this question: given these, diagn
the best option available. Speaking theoretically,
weigh a trade-off. They, or their children, face int
traits and behaviors with or without a diagnosis. W
avoid the permanence, biologizing, and stereotyp
bel - but they get no assistance with the struggl
diagnosis, they get the opposite. This means that t
tance plays a major role in the decision. If one en
forms of control, focused attention, and detail ori
ment, then treatment may make a positive differenc

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 520 Hypatia

of control are with long-term

achievement, the expected, tangi
weigh worries about the choice. B
fitting in with others in school o
(and often reap) a benefit is large.
Nevertheless, in the case of child
and treatment for themselves, an
being (Lawrence Diller, personal
make the request involves intolera
ure" in socially prescribed achieve
the parents, teachers, physicians,
change is for the best in the long r
their chosen criteria. This is beca
"right" is one that in principle co
to the child's behavior, or a differ
do typically request diagnosis and
tolerance" is more problematic. B
and treatment are constrained in
ness or vulnerability and the i
relationships and in the workplace
decisions for their children, their
I do not wish to overstate the cas
diagnosable people is not as great
who have severe mental illness. A
people studying or treating ADHD
dren, do not intend to judge or lim
or assist. Nevertheless, they want
change their ADHD-associated tra
portunity to do so. By this the
behaviors, tor at least they agree
change must be borne by the dia
child and parent), rather than by
the unintended result is institution

Alternatives?

I have argued that a confluence of needs, interests, and practices from across
the social and scientific spectrum has institutionalized intolerance of ADHD-
associated traits and behaviors, and of people who exhibit them. This has not
been the intention of the many people and institutions involved. But a positive
feedback loop has jointly reinforced the predominant biomedicai ADHD con-
cept, the social values embedded in that concept, and the institutional

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 Susan C. C. Hawthorne 521

structures that reflect those values and "manag

ADHD-associated traits and behaviors, together
structure views and actions in ways detrimenta
Yet, relative to earlier years, present ADHD-as
cies have decreased moralizing tendencies and in
This raises a question: what form should progres
thinking - take? Given the complexity of the issu
and I cannot address the question in detail here
one place to start, it would be to improve our sk
ing and practice - to become better at getting p
ADHD/non-ADHD. In this, the sciences, medi
individuals could all play a role. And the same s
study of other illnesses, and care for other people

Notes

Many thanks to Helen Longino, C. Kenneth Waters, Valerie Tiberius, Monica Luciana,
Carl Elliott, Patricia Ross, members of the Biological Interest Group at the University of
Minnesota, and Hypatia's anonymous reviewers for their insightful critiques of earlier
drafts. Peter Hawthorne helped with statistical analysis of the ADHD literature. The
Mark and Judy Yudof Fellowship, 2006-2007, and a Doctoral Dissertation Fellowship
from the University of Minnesota, 2007-2008, provided research support.
1 . Gender differences in diagnosis raise important questions, but those issues are
beyond the scope of this article.
2. I use the term "diagnosable" or "ADHD-diagnosable" for two reasons. First, I
want to avoid reifying ADHD. Second, some people who meet ADHD criteria are not
diagnosed, either by choice, or because they lack access to health care.
3. The term "value valence" avoids two connotations of the term "value laden":
that the values embedded are bad values, and that having values embedded is undesir-
able. In medicine and clinical science, neither is necessarily the case.
4. See Mayes et al. 2009 for the history of ADHD.
5. To quantify authors' views of ADHD etiology, I analyzed a random sample of
150 research articles on ADHD or ADD published between 1990 and 2009, inclusive,
and indexed in ERIC, PsychlNFO, or PubMed. If the article concerned drug interven-
tion, described etiology as "neuronal," or measured biological parameters (e.g.), this
suggested a primarily biological view (87/150); measurement of behavioral (7/150), psy-
chosocial (2/150), communication (2/150), educational (0/150), or other parameters
suggested emphasis on other views. Often, the view was ambiguous (28/150), or the
author specified a mixed understanding (15/150). (Nine articles were not available to
me online.) The biological majority is statistically significant by the Pearson j1 test.
Details available on request.
6. M. B. First and D. J. Kupfer favor categorical models, but they nicely summarize
arguments for dimensional criteria (First 2005; Kupfer 2005).

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 522 Hypatia

7. The "reality" of mental illness a

relation to physical illness or social cr
much debate in philosophy, but spac
8. A search of the NIH's Computer
(CRISP) site (http://crisp.cit.nih.gov
tion deficit hyperactivity disorder" a
NIH awarded an average of 105 feder
ADHD in the years 2000-2006.
9. This distribution was calculated f
cited in the education, psychology, a
INFO, and MedLine. Details of the m
10. A large literature on disease d
Wakefield 1992; Schwartz 2007) arg
separated from notions of dysfunction
section, and more thoroughly in Haw
11. There are several scientific m
fined ADHD contribute to reinforcin
DSM-defined ADHD do not necessar
12. Putnam (2002) marks the distin
fact versus value.

13. Clinicians adapt practice param

clinicians' time and resources encoura
14. ADD is an older term for ADH
15. Recommendation 10 reads: "If
psychopharmacological treatment a
academic, family, and social function
ADHD alone is satisfactory" (Pliszka
16. This is one reason ADHD has remained controversial. The standards under-
lying uncontroversial diseases often include (nearly) universally shared devaluations -
such as attitudes toward pain and early death (Fulford 2004).

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