However, alongside this willingness to take up medication as a way of regulating behaviour, there are indications of resistance to this. For example, uncertainty around long-term medication of children is sug- gested by reports of clinicians’ ambivalence, and 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) and ‘fine-tuning’ of their child’s medication (Taylor et al.
2006; Litt 2004). This resistance to the ‘complete’ medical ‘package’
may be indication of incomplete medicalisation, which occurs when there is medical uncertainty or only partial recognition (Gray Brunton et al. 2014; Malacrida 2004), and this may be linked to the existence of other competing discourses such as the psychological and the social, which we turn to next.
The ‘awkward alliance’ between psychiatry and psychology can be traced historically. In the early days of the discipline, between the two world wars, psychologists were ‘handmaidens’ (Rose 1999: 236) to medicine, required to carry out assessments to support psychiatric diag- nosis. However, psychology, in the 1950s, came to occupy a distinct professional position from psychiatry, one primarily informed by behav- iourism. As Rose says:
Neurotic disorders, personality disorders, and many types of criminal con- duct were not ‘illnesses’ but problems of behaviour acquired in large part by the processes of learning, unlearning, or failure to learn. Psychiatry was inappropriate to treat such problems, for the processes involved were out- side the scope of medical training and did not require the sophisticated and expensive clinical skills of the doctor. (Rose 1999: 237)
Biological explanations do not always, or entirely, remove responsibil- ity for pathological symptoms from individuals. Recent developments in genetics implicate parents in passing on the ADHD gene, and moth- ers are often implicated in biological-development accounts of ADHD (see Bailey 2014). However, psychology’s focus on psychosocial and environmental factors, implicates individuals and society with ADHD in additional ways. While biomedical explanations situate individu- als within a relatively blame free account of ‘pathological inheritance’
(Bailey 2014: 98), psychological explanations place focus on the indi- vidual or family environment.
Despite this difference in emphasis, much of psychological knowl- edge does not, necessarily, represent a challenge to medical knowledge, but can be understood as an extension of it (Radley 1994). Psychology works alongside medicine to provide alternative, but often, complemen- tary knowledge and explanations of pathology. Mainstream psychology’s close association with the medical model of disease is apparent in its methods, informed by the natural sciences to discover cause and effect relationships between cognitive behavioural risk factors and the devel- opment of disease or pathology.
While psychological interventions are predominantly aligned with the practice of medicine, with resident clinical psychologists embedded
within hospitals and clinics, the psychological technologies for self- improvement and regulation permeate all institutional contexts and fields of human experience, such as schools (educational psychologists), in organisations (organisational psychologists), therapeutic and social work contexts (psychotherapists) and even popular forms of self help.
As Rose (1999) argues, popular culture is saturated with psychological knowledge and, therefore, infuses all forms of human experience. The
‘giving away’ of psychological expertise is a good example of how the practices of governance and self regulation work by inviting individuals to take up methods of self improvement in order to become ‘better’ cit- izens. The ever expanding reach of psychological knowledge into differ- ent institutional sites and contexts can be seen in the history of ADHD.
The Family and the Psy Disciplines
Of particular relevance to ADHD, are the discourses of developmental psychology, embedded within the differentiating logic of the school and clinic, and psychotherapy. The category of ADHD has, until the most recent DSM (DSM-5, APA 2013), been predominantly identified as a disorder of childhood. The identification of ‘disorder’ in children is very much tied to the development of the ‘psy disciplines’ and the emerg- ing science of developmental psychology. This coincided with the emer- gence of psychoanalysis, originally located within the field of medicine, and its interpretations of childhood behaviours. Both psychology and psychotherapy produce theories which construct normalising notions of childhood and healthy development as well as normative assumptions about what constitutes appropriate parenting. Responsibility for iden- tification, prevention and management of irregular behaviours has been situated within schools and the family.
With mass education came the opportunity for the observation and normalisation of childhood behaviour with the ‘psy’ professions draw- ing on the statistical concept of the ‘normal distribution’ to describe human variability. Developmental psychology, in particular, has estab- lished a particularly powerful framework of physical, social and emo- tional developmental norms for children to be measured against,
‘enabling “appropriate” action to be taken by expert psychologists for any individuals falling outside of the “normal range”’ (O’Dell and Brownlow 2015: 297). The discursive practices around ‘appropriate’
developmental stages appear within healthcare and clinical practice, in educational settings and within policy, media and literature directed towards the family. Families are implicated in the successful develop- mental outcomes of their children, and the idea of normative devel- opment is a way of regulating not only children but also their parents, and mothers in particular (see Burman 2008; O’Dell and Brownlow 2015). Within this discourse, ADHD is positioned as a developmental problem to be treated within the context of the family.
Parents are similarly implicated within psychoanalytic discourses, especially in relation to their children’s social and emotional develop- ment. Psychoanalysis very much focuses on the dynamic relations within families. At the same time as biomedical explanations of chil- dren’s ‘anti-social’ behaviour were being proposed, psychodynamic explanations also located these problems within the context of dysfunc- tional family dynamics (see Rafalovich 2015). In particular, this dis- course focused on mother and child relations and was concerned with the effect of mothering styles on children’s emotional and psychological outcomes. The ‘refrigerator mother’ (Bettelheim 1959) became a well- known concept within popular discourse, aligning responsibility for children’s atypical development with maternal deficit. The emphasis on mother and child relationships runs through psychoanalytic and psy- chodynamic discourses, with a particular focus on mothers and emo- tionally disturbed sons. As we noted in Chapter 1, however, the practice of psychoanalysis had been regarded as ‘a hodgepodge of unscientific opinions, assorted philosophies and “schools of thought”…’ (cited in Engel 1977: 589) and this critique had led to the subsequent alli- ance of psychiatry with the biomedical model. Bradley’s (1937) work with institutionalised boys, for example, had combined psychoanalytic thinking with his biomedical exploration of stimulant medication to account for, and to treat, the behaviour of emotionally disturbed boys.
Singh points out that ‘throughout this period of experimentation with Benzedrine the possibility of mother’s toxicity and the necessity for
separating mother and child went unchallenged in published articles’
(Singh 2002a: 590). Maternal accountability for children’s developmen- tal outcomes extended beyond their attachment styles to the appropri- ate management of their children’s problems. For example, the problem of ‘emotional disturbance’ was used in the 1950s to define hyperactivity, inattention, moodiness, delinquency and impulsiveness (Singh 2002a).
Although a particularly vague term, the consensus was that emotional disturbance was a secondary symptom of an underlying disorder. This was thought to lead to ‘disturbed’ behaviour without appropriate inter- vention and mothers were accountable to be vigilant and alert to their children’s underlying difficulties and, so, manage them appropriately.
The influence of psycho-social (or environmental) factors on chil- dren’s disordered behaviours was a powerful idea within popular culture.
According to Singh (2002a), while medical terms such as MBD were more prevalent in scientific literature, the term ‘emotional disturbance’
was used more in popular literature. MBD was understood to be caused by organic factors and ‘emotional disturbance’ by anxiety and conflict.
However, despite these distinct understandings, they became closely entwined with one another. This convergence of discourses is reflected in the language used by the DSM-II (APA 1968), in which all child- hood disorders were described as ‘reactions’ to childhood (Mayes and Rafalovich 2007), and, specifically, the ancestor of today’s ADHD clas- sification was the label ‘hyperkinetic reaction of children’.
Although psychoanalytic concepts such as the ‘refrigerator mother’
are largely discredited today, the legacy of this discourse can be seen within psychological discourse of the early twenty-first century with, for example, a particular group of psychologists classifying ADHD as
‘attachment-deficit-hyper-reactivity disorder’, a consequence of the impact of post-natal depression on children’s behaviour (Halasz et al.
2002, see Bailey 2014: 101). Mothers are similarly implicated by recent psychological studies aligning ADHD with factors such as maternal mood (Vander Ploeg Booth et al. 2010) and mothers’ parenting style (Tancred and Greeff 2015; Moghaddam et al. 2013). The focus on mothers and their sons remains a notable feature of the contemporary discourse of ADHD, and it is replicated across a range of contexts that
we have explored in this book, through the use of psychosocial explana- tions of ADHD.
Psychosocial explanations of ADHD are linked with different kinds of interventions from biomedical ones. Psychological knowledge, in the form of cognitive behavioural therapy or parenting classes, informs interventions currently offered for individuals or families affected by ADHD. NICE guidelines (2016) suggest that for pre-school children
‘Healthcare professionals should offer parents or carers of pre-school children with ADHD a referral to a parent-training/education pro- gramme as the first-line treatment’, while for school-age children with moderate impairment ‘Group-based parent-training/education pro- grammes are usually the first-line treatment for parents and carers of children and young people of school age with ADHD and moderate impairment’ (NICE 2016).
The emphasis in psychological discourse on the role of the family in regulating their child’s behaviour is also (re)produced within prevalent neoliberal ideology, which situates responsibility for social problems with the individual, and the family. Francis (2012) argues that essential- ist notions of motherhood position mothers as particularly responsible for the ‘outcomes’ of their families and children. Neoliberal ideology, therefore, provides a context for the convergence of the medical dis- course around ADHD with other discourses around parenting and maternal blame. Science, and psychological discourse about ADHD and best parenting practices, has also entered the domestic space in the form of popular magazines, public health information and, in recent years, parenting groups. Parents (and mothers specifically) are impli- cated within political discourse as well as psychological discourse with their children’s disorder, and medicalization of ‘disordered’ childhood behaviour provides a release from condemnation and stigma (Conrad 2006) as the understanding of the deviant behaviour shifts from one of
‘badness’ to one of ‘illness’. As Conrad (2006: 5) states, ‘with badness the deviant was considered responsible, with sickness he [sic] is not’.
From this sociological, social constructionist view, a turn to biomedi- cine exonerates parents, particularly mothers, from blame for childhood deviance and misbehaviour.