What's in a name? ADHD and Social Role Valorization theory: its relevance for developing emancipatory practice
by Eileen Oak
Grounded in feminist discursive analysis, this paper seeks to evaluate the relevance of Social Role Valorization theory (SRV) to an understanding of the diagnosis of ADHD. This is done by exploring the discursive analysis of Rafalovich (1999) on the neurological and psychoanalytical nomenclature of the condition and contextualising this within a small case study of children accommodated within the public care system in a local authority in the UK. The experiences of these children is compared to the broader trends in ADHD in the UK and US, by locating the increase in diagnoses within the political economy of the pharmaceutical industry, with particular reference to methylphenidate production.
The paper then concludes with an examination of the adequacy of this kind of discursive analysis to an understanding of ADHD through comparison with SRV theory. In doing so it will be argued that SRV represents a viable theory for the deconstruction of oppressive discourses which goes beyond the social constructions of disability and the normalization debate (to which SRV is often simplistically related) and thus it provides a framework for the development of emancipatory practice.
Introduction: contemporary understandings of ADHD
Attention Deficit Hyper-Activity Disorder was first diagnosed and classified in 1994 by the American Psychiatric Association. According to the "Diagnostic and Statistical Manual Of Mental Disorders" (Fourth Edition) (DSM IV) (American Psychiatric Association 1994) ADHD manifests itself in three discrete forms: inattentive type, hyper-impulsive type and combined type. To assist lay people (i.e. those who are not medically qualified to diagnose the condition) identify which type of ADHD condition is being exhibited, the American Psychiatric Association identifies and classifies a range of behavioural characteristics which typify each category. For example, the ADHD inattentive type is characterised by the inability to: sustain attention, follow instructions, sustain mental effort, and give close attention to detail or to remember things in daily activities. While some of the main characteristics of the ADHD impulsive type are; fidgeting in seat, inability to remain seated, excessive talking, a predilection for interrupting others and difficulty waiting in turn in turn taking contexts. A child who exhibits a combination of characteristics that meet the criteria for both the inattentive and impulsive categories would be categorised as 'ADHD combined type'.
Historical and contemporary discourses of ADHD
The history of the diagnosis of ADHD is an illuminating example of how discursive practices shape social action even in what is often assumed objective scientific contexts. A number of authors such as Young (1995), Lloyd and Norris (1999), Rafalovich (1999) and Race (1999) have examined the impact of various discourses on ADHD, disability and the concepts of 'sickness' or 'disease'. The authors who discuss ADHD identify some common concerns. Namely: that the constantly changing nomenclature of ADHD is a consequence of discursive conflicts around diagnosis, which renders confusion and imprecision in estimates as to the extent of the problems. Secondly, the intervention of the medical profession and the pharmaceutical industry into ADHD treatment without any real public debate over questions of accountability. Thirdly, the lack of empirical evidence for a biological basis to ADHD and fourthly, the subjectivity of the assessment process. Taken collectively these authors argue, these factors contribute to the social marginalisation and oppression of ADHD diagnosed children.
Rafalovich (1999) argues that discursive analysis promotes a more critical discussion of ADHD. He contends that the history of the diagnosis of ADHD is characterised by a discursive conflict between the disciplines of psychoanalysis and neurology. Through this struggle between psychoanalysis (and its allied discipline psychology) on one side and neurology on the other, the nomenclature of ADHD has changed dramatically over the last eighty years. Its classification has developed from childhood neuroses to compulsive neuroses (psychoanalytical discourses), to anxiety (psychological discourses) and finally, to ADHD (neurological discourses). The outcome of this discursive conflict has been the dominance (though this has not be uncontested) of the neurological discourses, with psychological discourses a close second, at the expense of psychoanalysis.
In relation to this point Young (1995) suggests that these conflicting perspectives should be regarded as 'research narratives' each seeking to 'colonize' ADHD by attempting to lay claim and monopolize the 'disease' category of ADHD. This discursive battle in the history of ADHD has been littered with competing and contesting discourses. From Shrag (1975) and Barton (1997) who emphasize that the diagnosis represents an extreme form of child control, to Conrad's (1976) precursor to the Foucauldian model of panoptocism with his suggestion that ADHD represents an institionalised form of power manifest in schools and prisons. In contrast, the discursive arguments of Kessler (1980) and Barkley (1990) assert that ADHD is a testament to the scientific progress of neurology in the diagnosis, and classification and treatment of disease.
What this battle also demonstrates is that, though neurological discourses dominate over psychoanalytical ones, there is considerable struggle within the discipline of neurology itself for primacy over discursive ideas. Thus, neurological discourses should not be regarded as monolithic as this detracts from the complexity and contradiction in the diagnostic process of ADHD.
This complexity exacerbates the difficulty of diagnosing ADHD. However this is not simply due to the subjectivity of the assessment process, but also the conflicting classifications over symptoms between the DSM IV and the European Hyper-Kinetic Disorder (HKD) classifications which have been adopted in the International Classification of Diseases (ICD). This in turn has led to different rates for the incidents of ADHD. A further problem is the bias of the researcher, which also accounts for the fluctuation in the rates for ADHD; this fact is pointed out by Rafalovich who states:
"The epidemiological breakdown of ADHD in the United States is constantly changing, partially due to the fact that ADHD is nebulous and comprises so many symptoms, but also because the presentation of data of those who are affected tends to serve the ideological interests of the researcher." (Rafalovich 1999:415)
He supports this point with evidence of the discrepancies in rates between the 'Anti-Ritalin camp' who argue that ADHD accounts for 10-12% of the school population, while proponents of Ritalin argue the figure is nearer between 3-5%.
In the UK, estimates of the condition are more difficult to ascertain because as Prior (1997) notes, though the Department of Health (DOH) collates the figures on ADHD diagnosis, special permission form the DOH, is required to reproduce these- the contention being that the information is 'commercially sensitive.'
Mental illness, moral panics and the pathologisng of ADHD
Through the myriad of ever changing nomenclature, the subjectivity of the assessment process and the inconsistencies over symptoms; the ADHD child, parents, carers, teachers and other professionals have to negotiate their way in order to reach a definitive conclusion over diagnosis and treatment. This leaves them in the hands of the 'experts' drawn largely from the fields of neurology and psychology.
In this respect, contextualising ADHD historically, is of prime importance because one factor that has remained constant in the discourses, is the idea that there is a correlation between ADHD in childhood and mental health related disorders adulthood (Baving et al 1999). Though the rates are variable, Jensen (1997) shows that some studies demonstrate comorbidity rates to be as high as 93% .The discursive argument being developed here is the effort to 'nip the mental disorder in the bud' by addressing the ADHD condition in childhood. Hence through the discursive creation of what Cohen (1977) calls a 'moral panic', the legitimation for medical intervention is rendered, resulting in the pathologising of the ADHD diagnosed individual.
This pathologising has been amplified particularly in the US by the designation of ADHD as a disability. Disability activists both in the US and UK are highly critical of both medical and academic social constructions of disability as a form of 'sickness' which they argue contributes to the social marginalisation and oppression of disabled people. The discursive process by which this occurs it neatly summarized by Saraga:
"It is not the physical, sensory, cognitive or mental impairment of the
individual that disables, but rather the structural handicapping effects
of a society geared towards able-bodiedness as the norm... As a
consequence, medicine, according to its critics, has played a
key role in the process of naturalizing both able-bodiedness as
'health' and disability as 'individual sickness' or a 'pathological condition'
The 'reality' behind the discourse-- biological causes of ADHD
The neurological discourses assert that there is an organic or biological cause for ADHD. This argument is predicated on the belief that ADHD is due to a dopamine deficiency in the prefrontal cortex of the brain (Barkley 1991.) (Diller 1998). An assumed characteristic of this deficiency it impulsiveness. Thus because Ritalin I known to increase dopamine levels, Ritalin is postulated as the most effective treatment.
This argument is largely based on the work of Zametkin (1990) and Barkley (1993). Zametkin's study claimed to have discovered different metabolic rates between adults diagnosed with ADHD and so called 'normal adults'. The former group were found to metabolise glucose (the brain's main energy source) at a much slower rate than so called 'normal' adults. This reduced metabolic rate was most notable in the area of the brain responsible for fine motor skills such as handwriting. However, when Zametkin sought to replicate the study in adolescents he found no significant differences in the metabolic rates between those diagnosed with ADHD and so called normal adolescents.
Asides from the criticisms of the Zametkin's methodology from researchers at the University of Nebraska as to the lack of specificity on the metabolic rates: research undertaken by Genova (1979) questions the feasibility of measuring and assessing the functions of a healthy human brain because most research is undertaken on 'dead' brains.
Furthermore, research carried out by Rappaport (1978) contradicts the idea that ADHD is due to as chemical imbalance. She gave Dexedrine to both ADHD diagnosed and non-diagnosed school children and found that both groups responded similarly in terms of improving their attention span and controlling their physical activity.
A similar study carried out by Barkley was subject to equal criticism. He studied the metabolic rates of ADHD diagnosed children with so called 'normal' children and argued for a chemical cause to ADHD based on the chemical imbalance, which he though caused either impulsive or inattentive bahviour. Fisher (1996) has criticised him for failing to recognise that impulsiveness and poor attention span are the result of two completely different chemical processes in the body not variables of the same one.
Rafalovich contends that the credence given to neurological discourses on ADHD is due to the assertions that the findings are based on scientific evidence.. Thus, 'illnesses' like ADHD are ascribed empirical credibility through the way they are represented in neurological tests. The methodology employed focuses upon the specific nature of the neurological component. However, such tests cannot account for the contradictions in the findings, which question their external validity and replicability. For instance as Rafalovich points out, the Bender-Gestalt test proves adequate at discovering language impairment in cases of aphasia but fails to validate the hyper-activity diagnosis.
He also criticises the competency of neurological instrumentation to assess brain function. For example, Positron Emission Topography (PET) and Magnetic Resonance Imaging (MRI) scans fail to uncover specific evidence that would substantiate an organic cause of ADHD. More specifically, the do not identify any discernable legions that would evidence minimal brain dysfunction nor do they identify the specific area of the brain to be held accountable for the dysfunction. This lack of reliability led to, the National Institute for Health in the United States to conclude that " there remains no consistent test for ADHD that confirms its existence like other illness of the body " (Rafalovich 1999:414).
Similarly, with the psychological discourses, he takes issue with Diller's (1998) analysis of ADHD for postulating two contradictory positions. On the one ADHD is defined as a misunderstood 'over-diagnosed' social construct, yet on the other ADHD is a specific 'disease' with an organic etiology.
The subjectivity of the assessment process
The inconsistencies in both neurological and psychological methods, has caused heated professional debate over the classification of symptoms and the whole assessment process in relation to ADHD. In 1997, the Working Party of the British Psychological society reached some dissenting conclusions as to the universal application of the diagnosis of ADHD. Firstly, that ADHD is used indiscriminately to cover a multitude of symptoms as opposed to a specific mental disorder. Secondly, that cultural assumptions have been too influential in determining a diagnosis of ADHD. Thirdly, that ADHD should not be regarded as mental illnesses in the same way that other mental illness are conceptualized. Lastly, the prevalence of ADHD diagnoses, particularly in the United States tends to trivialize the more severe disorders found in other children.
In addition, the Working Party advocated to reject the DSM IV classification of ADHD symptoms arguing for the adoption of the European Hyper-Kinetic disorder classification adopted in the ICD on the grounds it provided criteria that are more stringent. This they contend is likely to reduce the prevalence of the diagnoses.
In the research field there has been a plethora of research concerning the subjectivity of the assessment process Nylund (2002) Reid (1994) Wolraich (1996) and Beiderman (1995). Nylund argues that, the main assessment tool for ADHD (in the United States) the Connor's Rating Scale, is highly subjective. The test asks the 'raters' usually teachers, parents or carers to evaluate the frequency of a series of problematic behaviours , which include 'fidgeting', inattention and the frequency with which a child loses their temper. It is Nylund's contention that these behaviour typologies could apply to a whole range of children. Moreover, the research undertaken by Reid (1994) illustrates the difficulties in establishing the objectivity of these criteria. In a study of two schools, he found that special education teachers were more tolerant of ADHD type behaviours than teachers in mainstream classrooms. Wolraich (1996) compared teacher-rating scales over a two-year period. In the second year there was a 48% discrepancy between the assessments with the new teachers classifying only 52% of the same group of children as meeting the ADHD criteria. The researchers could not account for the drop by comparing the children's Ritalin dosage.
Nylund asserts that the Connors Rating Scale is culturally bias and reflects:
"Norms form a white middle class bias... criteria such as restless
and 'fidgety' mean different things to different ethnic, racial and
socio-economic communities. It is possible that these diagnostic
tools result in an overrepresentation of poor, nonwhite racial and
ethnic groups among children diagnosed with ADHD."
It is difficult to prove or disprove this assertion empirically. In Britain there is (as Lloyd and Norris (1999) point out) a dearth of research on the ethnic, class and gender bias of children diagnosed with ADHD. However, the subjectivity regarding the assessment process was also noted by Beiderman (1995). He interviewed 57 children and parents regarding their diagnosis of ADHD. Children were diagnosed after the therapist interviewed the parents over the telephone. Nylund comments on his experiences working as a clinical social worker in a multi-professional team were frequently the psychiatrist meets with the parents and completes the Connors Rating Scale without even seeing the child.
This experience was mirrored in the local authority I worked in the UK. Only (3.7%) of children were subject to a statement of education needs for behavioural problems, under the 1996 Education Act. Though this was only a small cohort out of the Looked After Children group and still less (7 children) were diagnosed with ADHD, the parents of five of the children reported that a diagnoses of ADHD had been given through interview with the parents alone. Despite these practices which are overtly subjective, many children are diagnosed and subsequently treated for ADHD. The most common form of treatment is the prescription of Ritalin.
The Political Economy of the pharmaceutical industry
Ritalin is actually a form of 'speed' which can induce a 'high' which does however dissipate quickly but is highly addictive. In the UK it is categorised as a class "A" drug which is downgraded to a class "B" when the methylphenidate is transformed into a liquid an given in the form of Ritalin to children, in some cases as young as three. Question as to the side effects of Ritalin have been hotly debated by some researchers Swanson (1998) Lyons (1999). Some of the side effects include vomiting, dizzy spells, shortness of breath and feeling thirsty. The more significant ones include; decreased blood flow to the brain, disruption of growth hormones, addiction and substance misuse, psychosis, depression and insomnia.
In the US it is estimated that Ritalin production has increased by 700% (Diller 1998) accounting for up to $450 million worth of sales. This increase has however been accompanied by increasing vocal concerns about both Ritalin's administration and its side effects. In 1996 the UN Narcotics Control Board released it report urging the US government to exercise vigilance to prevent the over-diagnosing of ADHD and the "medically unjustified treatment with methylphenidate". Similarly in 1995, the US Drug Enforcement Agency cited evidence that Ritalin is in the top ten of the most frequently reported controlled pharmaceuticals that is stolen (Lloyd and Norris 1999).
The fiscal and global nature of the pharmaceutical industry should not be underestimated when evaluating the dynamics of ADHD diagnosis and treatment. In the US methylphenidate is produced in different forms by competing drug companies in the forms of Ritalin, Adderal and Medeva. For example the Richwood Company's treatment for Attention Deficit Disorder is Adderal which competes against Ciba Geigy's Medeva. Though in 1997 in its initial forays into the market is only took a 7% share this accounted for over 80,000 American children diagnosed with the disorder. Equally, when the share price of Medeva fall due to reports of a health risk connected with it, due to the lack of competition, its profits still rose by 6% to $54 million in 1997. (Lloyd et al 1999)
The need to expands markets due to competition has a direct correlation with
diagnoses. This is exemplified by recent research in US (Swanson 1999) that suggests
that up to six million adults now suffer from ADHD.
In recent years a number of researchers Prior (1997) Caplan (1995) DeGrandpre (1999)
Freedman (1996) have raised questions about both the lack of information about
methylphenidate production and more generally, the lack of public debate about the role
of the pharmaceutical industry and its relationship with the medical profession in the
treatment of ADHD. The power of certain interests groups is manifest in the Department
of Health's'(DOH) treatment on statistics for the diagnoses of ADHD in the UK. These
statistics are available but to reproduce them in research papers requires special
permission form the DOH-- the contention being that they could be 'commercially'
Contesting the discursive terrain
Despite the dissenting 'voices' in the form of the UN Narcotics Control Board, the Drug
Enforcement Agency, the ICD and the Working Party for the British Psychological
Society: neurological and psychological discourse continue to maintain a powerful
(though not uncontested) monopoly of the etiology and treatment of ADHD. But, why is
this the case?
It is important not to decontextualise these discourse form the socio-political 'realities'
in which they are located, nor from the demands that are placed upon any discourse. If it
is to succeed as dominant discourse it must be able to validate ideas, which legitimate
advantageous positions in the exercise of power relations.
Young (1995) points to the fact that the contemporary status of neurology reflects
Psychiatry's trend to 're-biologise' itself and realign itself with the natural sciences.
Neurology also meets the demand for empirical validity in a field where such criteria are
increasingly valued. Neurology fills the abyss between what he calls 'phenomena and explanation'. In doing so it must meet the need for scientific certainty by producing tangible solutions.
This process of discursive dominance is not however clear-cut. Like Gramsci's (1936) theory of hegemony- just as there is never any uncontested form of hegemony, so there is never any uncontested dominant discourses. As Rafalovich's discursive analysis illustrates:
"The anachronism "ADHD" is a representation of the discipline of
neurology its wide recognition reflecting neurology's substantial influence.
From Michael Foucault's (1978 p101,102) perspective, ADHD represents a
moment of dominance in the 'force relations' in which discourses
strategize to lay claim to particular objects of knowledge. Objects of
knowledge are realized simultaneously with the deployment of power... when we think we have reached comprehension about ADHD, we are subject to a relation of power. This moment of knowing designates one narratives
contemporary dominance over another."
In contrast to Rafalovich, Lloyd and Norris(1999) concentrate on the 'dominance' aspect of the discursive conflict rather than the way it is contested. They do this by examining the impact ADHD diagnosis has for inclusion policy. The power dynamics of this process are explored in terms of the control of the production and dissemination of knowledge by 'experts', by a focus upon the professional and academic literature presented on ADHD in the UK. This is drawn from medicine and psychology and is dominated by what is termed as the 'pro-medication perspectives'.
They argue that such discourses are presented as 'expert' discourses requiring specialist professional knowledge drawn from psychology and neurology which excludes other professionals such as teachers and GPs from the debate. This is reflected in the guidance for teachers on ADHD which Lloyd and Norris assert is tantamount to a 'dumbing down' of the issues(under the guise of avoiding jargon) and results in a model of ADHD which is biologically reductionist. This in turn serves as a smokescreen to mask the problems surrounding the controversy over the empirical evidence for an organic cause of ADHD.
In creating an organic cause in the etiology of ADHD this medical model also has a functional aspect. It creates what they term as 'labels of forgiveness' which serve to exonerate parents from any omissions in parenting skills, and also the individual for responsibility for their behaviour.
These labels also have the added potential of enabling professionals to distinguish between the 'deserving' parent and child and the 'difficult' parent and child, in the provision and allocation of resources. As they point out the medical model supplies constructions of 'worthiness' which are not explored in socio-economic terms in relation to poverty, deprivation, social disadvantage or learning difficulties, but purely in medical terms of etiology and biomedical causes of a condition. This Lloyd and Norris argue will have considerable implications for inclusion policy in a climate of league tables on performance and limited resources.
The problem with Lloyd and Norris discursive analysis is that, in referring to the medical and physiological dominance of the ADHD debate; they tend to present these discourses as monolithic and to thus fail to conceptualize and capitalize on the extent of dissent from this model in both academic and professional circles. Consequently they are unable to create a framework to achieve what they argue is an essential building block in the strategies for empowerment and inclusion, the development of a social perspective on disability.
Equally the critique of Rafolovich's discursive analysis is its emphasis on deconstructive processes in the analysis of discourse with no allowance for the need for reconstructive process to reframe the situation. Delanty (1997) argues one of the difficulties of a lack of reconstructive framework is that provides no process to address notions of solidarity and empowerment which help to generate social change, a key aspect of any work with service users. Further, this kind of constructivist methodology creates all kinds of epistemological problems both in the debate on ADHD and in the philosophy of social science. If ADHD diagnoses have no empirical reality, but are simply a product of competing research narratives, how can there be universally valid scientific and social scientific knowledge to enable us to develop strategies to address the oppression of this group of children?
SRV Theory and its potential for emancipatory practice
Wolfensberger (1998) describes SRV as "a high order concept for addressing the plight of socially devalued people, and for structuring human services." It is a testament to his perseverance that he has persisted with this theory despite the at times simplistic critique of his work in UK academia.
Race argues that if we were to examine an extensive range of current academic literature on SRV (including one source with a bibliography of approximately eight hundred sources) and take it on face value, then the phenomena known as normalization
'subsumes SRV'. Even a brief analysis of the mechanics and processes encompassed in SRV demonstrates that it has the potential to transcend the concept of normalization and address the oppression of a diverse range of socially marginalised groups.
The strength of SRV lies in its ability to account for the dimensions of power that lie at the heart of the devaluation process, namely the conceptual and emotional levels. Consequently it can examine not just devaluation at the individual level but through society as a whole. Thus it has the potential to address a multiplicity of oppressions not simply those predicated on disability alone.
The language of SRV has been open to criticism from feminist writers for its political incorrectness, while the criticism leveled at the concept of 'wounding' is that the terminology itself, contributes to the devaluation process. Race (2002) rebuts this criticism on two grounds. Firstly by reframing the term and by regarding it as both a framework for analysis and a social process. Thus, rather than regarding the term as pejorative and stigmatizing he suggests it provides a means, which enables us to explore the accounts of, devalued people in the empirical sense. As having validity in terms of real and lived experiences of the 'wounds' which represent the impact of this devaluation process in terms of their everyday experiences of oppression.
Secondly he contends, that, if we take issue with the language of 'wounding' this may have implications for emancipatory practice. To illustrate this point he cites the criticism of the word 'problems' in the white paper "Valuing People" (2001) in reference to the issues faced by disabled people. He argues that if we find terms like 'problems' contribute to devaluation processes does this mean by implication that no attempt should be made by Disabilities Services to develop and change?
On a structural level SRV theory has been criticised from the Marxist standpoint (Oliver 1999) for its outdated concepts of role theory which are no longer relevant to academic thinking, and for a 'functionalist account' of social relations (which because it ignores the socio-economic structures which produce these forms of devaluation) tends to legitimate the status quo.
Given the prominence of discursive analysis in modern academia that relies heavily on some form of labeling or role theory ,it is difficult to lend much weight to this criticism. The second criticism he makes concerns the argument that SRV unlike Marxism lacks the ability to analyse the social structure and account for social change. In the 1990's Marxism was being undermined in academic circles for its inability to account for the break up of communism in the Eastern Europe and for the persistence of capitalism in the West. Post-modernist like Foucault (1980) and Bourdieu (1990) criticise Marxists for their utopian view of the revolutionary potential of the working class and thus being unable to account for the precise nature of contemporary change. Also, as Race points out, the failure of Marxism to conceive of alternative futures beyond the promise of socialism, leaves us with the problem of how to assist the many devalued and socially marginalised groups in society who cannot afford to wait for the revolution to occur.
Considered in its fullest context and not as an appendage to normalization: SRV theory has the capacity to generate a range of anti-oppressive practice strategies. Through its concepts of 'wounding' and the ensuing processes of role ascription, stigmatization, and devaluation; SRV theory provides a variety of levels and dimensions through which this marginalization and oppression occurs such as the individual, social, psychological, historical and cultural.
In terms of an understanding of ADHD the specific aspects of SRV theory that are relevant are the concepts of role ascription (in terms of how ADHD diagnosed children are cast into the roles of 'menace', 'sick' or diseased') the symbolic stigmatizing ascribed to those diagnosed with ADHD, de-individualization and the importance of model coherence theory. This latter concepts is used to assess the adequacy of services provided to those diagnosed with ADHD.
The contexts being considered when assessing how ADHD diagnosed children are cast in the role of menace centre around the debates between parents, teachers and children over the question of whether to exclude because a child is refusing to take Ritalin or because their parents refuse to put them on it. A justification that has sometimes been given is that these children represent a 'menace' to other children because their behaviour disrupts the school routine interfering with other so called 'normal' children's educational progress.
In terms of being cast in the role of 'sick' or 'deceased' I have already referred to the reaction of the Disabilities Movements to the labeling of disability as a 'sickness'. A key element of SRV theory which expands the analysis beyond the social theory of disabilities, is the way it demonstrates how, society has been able to manufacture out of the simple term 'impairment' both the disabled identity and the impairment. The implications of this discursive argument are summed up by Race :
"Then the 'experts' and professionals who diagnose these disorders can also create
their own service empires around the treatment of such people:
This applies not only to the vast multi-national empires of the pharmaceutical companies that market methylphenidate, but also the vast multi-professional empires involved in the assessment of ADHD both in the UK and US. This is what Nylund (2002) refers to as the "ADHD- Ritalin machine."
The symbolic stigmatizing of ADHD
In terms of the symbolic stigmatizing of as person diagnosed with ADHD: Ritalin has become almost synonymous with ADHD almost like the 'lepers bell' in the middle ages. The taking of Ritalin is often administered by the classroom support assistant, which is a common Ritual for the 'ADHD diagnosed child. Thus reinforcing their stigmatization by marking them out as 'different' and by implication inferior.
The notion that children who are diagnosed with ADHD are all the same is reinforced, not only in terms of what SRV theory calls 'block treatment' i.e. being prescribed Ritalin despite the diversity of side effects. But also in the way it is believed it can be diagnosed irrespective of ethnicity, class, gender and environmental factors, using instruments such as the Connors Rating Scale.
Model coherency theory
Model coherency represents one of SRV theory's biggest contributions to an understanding of ADHD by providing an holistic framework to evaluate the adequacy of service provision.. Race defines model coherence as follows:
"The contents and processes of the model all stem from the assumptions
and, if these fit together the model is said to be coherent.
(Race 1999: 67)
In the medical model, the fit between the model and the assumption is as follows; that people are sick with a known medical condition, secondly that there will be people who will attempt to alleviate that sickness using technical processes and thirdly, that these people will be trained specialists with technical expertise, and, fourthly that technical procedures will be used in consultation with the person with the medical condition.
Despite the contention regarding the biological base of ADHD, it continues to be diagnosed as a form of brain dysfunction or 'disease'. The technical tools such as the Connors Rating Scale are culturally subjective and that the training of 'experts' is debatable depending on which discourse of expertise if being employed. In terms of the uses of the Connors Rating Scale in US this often comes down to teachers, carers or parents to assess using this tool, or even a telephone interview of the parents by the psychiatrist without even seeing the child. Thus the technical expertise and training of the personnel to assess ADHD is open to question. While the frequent decision not to see a child before a diagnosis is made, makes a mockery of notions of consultation.
Model coherency theory provides a valuable way to assess the extent to which services are or are not tailored to service-user's needs. This is yet another way SRV theory helps us evaluate the quality of service provision and its ability to promote social inclusion or merely serves to increase maginalization and oppression of vulnerable groups in society.
As Race states
" In services for vulnerable people examining the assumptions, contents and processes of various service models can be a powerful means of determining
the contribution of those services to devaluation or their attempts to address it'"
This is clearly evidenced in the case of ADHD.
Thus SRV goes way beyond social constructionism, normalization and social labeling theory, because it examines the consequences of oppression as much as the processes that contribute to its construction. It does this through a variety of dimensions, which allow for the 'interconnections' of ethnicity, class, gender, disability and sexuality and thus how they converge to generate specific experiences of oppression . Having done so it then contextualized the extent of these marginalisation processes in terms of model coherency, which enables us to assess how well service provision helps to address or reinforce this power imbalance. In doing so it provides a structured framework to develop emancipatory practice.
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Submitted by Eileen Oak, Salford Social Work Research Centre, University of Salford, UK
E-mail: Eileen Oak