Stimulant medication such as methylphenidate (Ritalin, Concerta and Equasym) and dexamfetamine (Dexedrine) is typically used to treat ADHD and it is the most common treatment within the USA (Rafalovich, 2008) and Australia and is officially recommended by NICE as a first-line treatment for adult ADHD in the UK
(Moncrieff and Timimi, 2013; Schubert et al., 2009). Recent years have witnessed a dramatic global increase in the prescription rates of these stimulants and NICE (2009:28) indicates that between the late 1970s and the late 1990s global
prescription rates rose from 0.5 per 1000 children to more than 3 per 1000 in the late 1990s (Horton-Salway, 2012). With regards to the UK, NICE (2009) reports a marked increase in prescription rates since the 1990s. Frankel (2010) suggests prescriptions rose from 6000 in 1994 to 461,000 in 2007. As mentioned at the start
of this chapter, recent media attention suggests there has been a 50% increase in Ritalin prescription in the last six years, rising from 420,000 prescriptions in 2007 to 657,000 in 2012 (Donnelly, 2013; Meredith, 2013; Saul, 2013).
Controversy has surrounded the use of stimulant medication since it was first discovered to be effective for hyperactivity in the 1930s. As NICE (2009:231) indicate ‘it is over 70 years since the serendipitous observation that stimulant drugs can improve hyperactive behaviour in children (Bradley, 1937)’. The use of the word ‘serendipitous’ points to the accidental nature of the discovery, which, in turn, contributes to its controversial status. Bradley noted that the use of
Benzedrine on a group of thirty boys, hospitalised for a range of mental disorder diagnoses, produced remarkable improvements in their academic performance and a greater engagement with their surroundings. As Rafalovich (2008:71) states, ‘Bradley’s findings opened a new path in child neurology in which the effects of stimulants upon child behaviour attained an immediate interest’.
Issues of validity
As Conrad observes (2006), the treatment preceded the disorder. However, once the disorder emerged, then many scientists seeking neurological explanations for hyperactivity argued that the success of stimulant medication was proof of the disorder (see Singh, 2002b). Yet, there is evidence to indicate that stimulant medication has an equally positive effect on all children, improving concentration and energy levels (Graham, 2008; Singh, 2005; Timimi and Taylor, 2004). This is supported by evidence which reveals a developing local trade (and subsequent use) of Ritalin amongst young people at school or university (Poulin, 2007;
Billington and Pomerantz, 2004; White, 2003) and its reported increased use as a ‘smart drug’ in the UK (Donnelly, 2013; Meredith, 2013; Saul, 2013). Concerns around the medical validity of pharmaceutical treatment appear frequently in the
critical literature around ADHD (Moncrieff and Timimi, 2013; Singh, 2008a). In particular, there is concern regarding the absence of longitudinal studies into the effectiveness of medication, an issue which, Moncrieff and Timimi (2013:59) argue is judiciously ignored in the NICE guidelines:
the guideline identified that drug trials have shown no long-term benefit in ADHD, but still recommended treatment with stimulant drugs for children with severe symptoms and for all adults claiming consensus for this position… [The guideline] demonstrates how contradictory data are managed so as not to jeopardise the currently predominant view that
ADHD… [is a] valid and un-contentious medical… [condition] that should be treated with drugs.
We have already seen how pharmaceutical activity might be implicated with the significant global variability in prevalence rates; pharmaceutical activity is also implicated with issues of validity. Doubts around the validity of stimulant
medication in the treatment of ADHD are fuelled by critiques which are sceptical of the role the pharmaceutical industry has played in promoting medicalization of certain childhood behaviour. Much of the literature points to the involvement and financial support of the pharmaceutical companies with parent support groups (Graham, 2008; Conrad, 2006, 2007; Lloyd and Norris, 1999; Billington and Pomerantz, 2004), and indicates the mutual financial benefit to both the drug companies and the parenting groups of such involvement. Conrad (2007) charts how, in the USA, the organisation Children and Adults with ADHD (CHADD) has been pivotal in expanding the categorisation of ADHD to include adults, and how this organisation has received considerable financial assistance from Ciba-Geigy (now Novartis), a leading manufacturer of Ritalin. As Conrad (2007) suggests, by
redefining ADHD as a lifetime disorder, the potential exists to keep children and adults on medication indefinitely.
Doubts around validity and financial reward inevitably raise considerations of ethics and morality with regard to the issue of medication. The pharmaceutical industry is further implicated with issues of morality through several litigation cases of class action taken by individuals against the industry, specifically, in relation to the physical harm said to have been caused by using the medication (Graham, 2008).
Physical harm
Concern around the potential physical harm caused by taking stimulant medication is well documented in the literature (Meredith, 2013; Frankel, 2010; Graham, 2008; Rafalovich, 2008; Billington and Pomerantz, 2004). The possible side effects identified include psychotic reactions, the development of tics, an increased tendency to self-harm and a suppression of appetite leading to reduced growth rates.
Uncertainty and, perhaps, unease around long-term medication of children is suggested by literature which reports clinicians’ ambivalence towards the effects of medication and which reveals how the ‘perceived risk of harming children’ is
managed through talk of ‘medication holidays’ (Rafalovich, 2005:316). Similarly, parents also reveal an uncertainty around medication, particularly, at weekends and holidays (Singh, 2004) and they too, talk of medication breaks (Neophytou and Webber, 2005; Singh, 2005) or describe how they assume responsibility for the monitoring and ‘fine-tuning’ of their child’s medication (Taylor et al., 2006; Litt, 2004).
Moral harm
In addition to the possible physical dangers of taking stimulant medication, there is also discussion within the literature of the moral repercussions of taking drugs to control behaviour. Concern is expressed over the possible addictive nature of these drugs, and the subsequent issues of stigma, autonomy and dependence that this raises for children (Singh, 2008a; Singh, 2005; Rafalovich, 2005).
Billington and Pomerantz (2004) suggest the medication reduces opportunities for children to practise the skills necessary for the development of self-control,
responsibility and self-regulation.
Despite these concerns over the physical and moral harm caused to children, Singh (2008a) queries whether this anxiety is a reflection of contemporary, socio- cultural (Western) conceptualisations of childhood. As she argues, our
understanding of childhood is that it is a time (and state) of innocence. Current ideology positions the child as vulnerable and in need of protection, and, consequently, society is vigilant to the potential dangers from which the child is considered to be at risk. This conceptualisation of childhood might, Singh argues, prejudice an open debate about the benefits of medication to the child. Indeed, there is evidence that suggests children express an acceptance of, if not desire for, (continued) medication (Singh, 2008a), and report moderate benefits to academic, social and concentration skills (Billington and Pomerantz, 2004).
Parents and medication
Parents are clearly implicated in contemporary understandings of the child as vulnerable, innocent and in need of protection. Within current neo-liberal ideology (see Chapter 3), parents are understood to (want to) assume prime responsibility for the care, protection and well-being of the child. The issue of (parental)
medication to control anti-social behaviour in children. Much of the existing literature suggests that parents seek medicalization for their children as a way of absolving themselves of responsibility for disciplining their children (Horton-
Salway, 2011, 2012; Rafalovich, 2005; Singh, 2005). Other literature queries who actually benefits from medication, suggesting that it is of more benefit to parents (and teachers) than it is to children (Graham, 2008). Finally, some literature demonstrates how parents are portrayed as abusive in some media accounts of parental ‘drugging’ of their children (see Horton-Salway, 2011:542).
The moral alignment of parents with the ADHD category is further considered in the final section of this chapter, along with a formulation of ADHD as a moral category.