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

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

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

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

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

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

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

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

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

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

© 2006 Edmund O’Toole

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

Categories: ChildhoodDisorders, Ethics, Psychology