Attention Deficit Hyperactivity Disorder in Australia: conceptual resources from the sociology of devianceDr Brenton ProsserSchool of SociologyAustralian National UniversityEmail: Brenton.Prosser@anu.edu.au

Abstract

In a matter of two decades, Attention Deficit Hyperactivity Disorder (ADHD) has emerged in the

United States and has grown from an obscure diagnostic label to the most commonly diagnosed

childhood disorder in Australia. Controversy rages over the 'reality' of the disorder and its links with

anti-social, violent or criminal behaviour, as well as its treatment with psychostimulant medication.

In a context where the medicalisation of behaviour and the influence of poststructuralism have

potentially flagged the death of the sociology of deviance, ADHD presents a fascinating case study

into what this branch of sociology still has to offer.

The paper will note the dominance of psycho-medical discourses and research into ADHD, as well

as the predominant response by sociologists to ADHD (namely that it is just another example of

medicalisation in western nations). It will argue that this fails to respond to the challenge for every

nation to evaluate ADHD its social context and consider the cultural influences behind its rise that

have been rendered invisible in the North American context. In particular, it will argue that past

sociological considerations have stressed structural perspectives and much be gained by visiting

examining the role of agency in acceptance and growth of ADHD in Australia. The paper will

review emerging sociological work on ADHD in the Australian context, before arguing that

conceptual resources drawn from within the sociology of deviance can provide a sound basis for

more rigorous consideration of the place of ADHD in Australia.

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is defined within the Diagnostic and Statistical

Manual of Mental Disorders (DSM) (American Psychiatric Association 2000) as a biological

dysfunction that results in hyperactive, inattentive and impulsive behaviour to such an extent that it

causes problems in home, school and work settings. Typically, ADHD in children is associated with

hyperactive and/or violent behaviour, a difficulty to form close relationships, poor social skills, low

school performance and lower school retention. If experienced lifelong, ADHD is associated with

dangerous driving, substance misuse, depression, criminality and suicide (Bailey 2010; Barkley

2006). While there remains ongoing debate about the reality and construction of the disorder, it is a

phenomenon that is linked to real social consequences.

The number of young people diagnosed and treated with psychostimulants for ADHD has grown

rapidly in the western world over the last two decades. Between 1993 and 2003, the use of

psychostimulants to treat ADHD grew by two hundred and seventy four percent worldwide

(Scheffler 2007 – Harwood) and between 1994 and 2000, the level of psychostimulant use to treat

ADHD grew by twelve percent per year in ten western countries (Berbatis et al 2002). Prevalence

of the label has been estimated to be as high as twenty percent of children in some nations, with

North America having the highest rates of drug treatment followed by Australasia (Berbatis et al

2002). Australian estimates of levels of diagnosis and drug treatment vary between four and seven

percent of children (Prosser & Reid 2009).

Historically, data has shown higher levels of diagnosis and drug treatment amongst boys (Harwood

2010). The ratio of boys to girls is commonly cited at between 6:1 and 4:1 (Reid et al 2002).

However, a recent longitudinal study within South Australia found that the ratio had fallen from

5.4:1 between 1990 and 2000, to 4.3:1 between 2001 and 2006 (Prosser & Reid 2009). This study

also found significant geographic variation in diagnosis and significant correlation between low

socio-economic status, high unemployment and higher medication rates over the period. There is

great variability in diagnostic levels between Australian jurisdictions, with one major international

study finding levels of diagnosis in Western Australia to be four times the Australian national

average (Berbatis et al 2002). There is also growing evidence to suggest that ADHD diagnosis and

medical treatment is linked to lower socio-economic status (Bailey 2010; Harwood 2010; Isaacs

2006; Sawyer 2002; Biederman 1995). The prevalence of ADHD diagnosis and drug treatment in

relation to ethnicity is still an emerging area of research. Within Australia, levels of ADHD

diagnosis have been lower in Asian and indigenous communities (Prosser 2006), while in New

Zealand past levels of diagnosis amongst the Maori community have reflected that of the broader

community (NZ Ministry of Health 2001). Recently it has been argued that there is a strong link

between ADHD and all forms of social disadvantage in Australia (Harwood 2010).

Until now, the most common understanding of ADHD has been that it is an individual deficit of

genetic origin which compromises a child’s ability to conform to the behaviour norms of society.

This is a construction that until recently has been left largely unchallenged due to the dominance of

psycho-medical discourses around ADHD (Prosser 2008). While the bio-psycho-medical discourse

is not inherently damaging in itself, its justification is not borne out in the case of ADHD (Abraham

2010) and its consistent dominance over other professional discourses raises concern (Ideus 1998;

Prosser 2008). In recent years, critical (Cohen 2006; Stead 2006), philosophical (Graham 2006; Tait

2006) and ethical (Halasz 2002; Tait 2005) critiques of the psycho-medical discourse have emerged.

I will not repeat these here except to note that if we ask only psycho-medical questions about

ADHD, we will get only psycho-medical answers and more drug treatment. However, if we also ask

sociological questions, we will not only gain a better understanding of ADHD, but also possibly

identify what is contributing to the aforementioned trends in ADHD diagnosis and treatment. What

is needed is alternative ways of conceptualising ADHD that answers the questions that the psycho-

medical explanation alone cannot and it is to this challenge that the rest of this paper turns its

attention.

Past sociological research into ADHD

The leader in sociological considerations of hyperactive behaviour has been Peter Conrad. His early

work traced the history of hyperactivity to explore the social factors behind the growing interest in

medical treatment. Amongst the factors identified were:

• the pharmaceutical revolution of the nineteen fifties and sixties;

• the increased use of drugs by the medical profession to treat mental illness;

• the growth of genetics research, government support for medical treatment; and

• a strengthening cultural view in the United States that individuals were not at fault for the

consequences of problems that had biological causes (Conrad 1976).

Specifically in relation to accepting drug treatment for hyperactivity, he found catalysts to the

growing interest via an increased capacity to distribute and market information to the public, the

immediately observable response to drug treatment, and the potential absolution from feelings of

guilt by parents. Conrad's thesis of medicalisation was that it is a process whereby social issues

come to be defined in medical terms, described in medical language, understood in medical

frameworks and treated with medical interventions. In essence, he argued that once a medical

means of social control existed, then it was only a matter of time before a label to justify its use as

treatment for a social condition would emerge. One such means of control was psychostimulants

and one such label was hyperactivity.

There were limitations in Conrad’s early work due to his emphasis on the process of medical

diagnosis and medicalisation. For instance, his focus was on the actions of the labellers and did not

examine in detail the agency of the labelled individual in relation to the label. Nor did he consider

the impact of the label and labelling process on those around the labelled person, such as family,

friends and peers. The other limitation that his early work has for contemporary use is that it

considered hyperactivity, rather than the revised and most recent diagnostic category ADHD.

However, Conrad (2007) has subsequently updated his work in line with this changing

nomenclature. Particularly, his recent work asks how hyperactivity (which was largely a disorder of

childhood), has increasingly developed into the emerging category of adult ADHD. It is a

consideration of how medicalised categories, once established can become broader and more

inclusive. In particular, Conrad shows how ADHD support groups and pharmaceutical companies,

the media and medical profession have contributed to the extension of ADHD to adults and the

popularisation of the disorder in late 1990s.The core of his argument is that the decision to include

inattention as part of the diagnostic cluster allowed for the inclusion of a whole group of people

who had been excluded by the previous hyperactive definition. In short, he reiterates the growth of

ADHD as an example of the growing medicalisation in contemporary society, along with other

examples such as post-traumatic stress, alcoholism, child abuse and domestic violence. More

recently, Conrad’s work on medicalisation has also been revisited and critiqued through the concept

of pharmaceuticalisation.

Pharmaceuticalisation is defined by Abraham (2010) as the process whereby social, behavioural or

bodily conditions are treated or deemed to become defined or treated with medication by doctors or

patients. While medicalisation theorists argue that medicalisation is now driven by pharmaceutical

companies rather than the medical profession, pharmaceuticalisation theorists argue that this newer

concept encompasses recent trends that medicalisation does not. The key example used by Abraham

to make this case (and to critique Conrad) is that of ADHD. While Conrad uses the rise in drug

treatment as an example of how behavioural categories are medicalised, Abraham notes that drug

use did not skyrocket until the late nineteen-eighties, twenty years after the drug became available.

He responds to Conrad’s claim that a label is the inevitable result of medical social control

becoming available by arguing that although some rise is drug treatment may be from increased

diagnosis, most of it is from a more recent popular preference for drug treatment (rather than

psychotherapy). Or in other words, even though the overall medicalisation of ADHD has changed

little, the pharmaceuticalisation of ADHD has grown dramatically, and hence the two can occur

independently. Abraham’s second critique is that Conrad overemphasised the role of direct

marketing of drugs as a factor in the medicalisation of ADHD. He notes that in most nations this

marketing is illegal, and hence the capacity to do so in the United States does not explain the rapid

growth in ADHD in other nations. Hence, Abraham proposes that pharmaceuticalisation can provide

a different view to medicalisation, one that encompass the increasing integration of senior medical

professional into marketing strategies and other promotion activities by industry. These initiatives,

argues Abraham, can contribute to pharmaceuticalisation, but not necessarily the expansion of the

powers of the medical profession or the marketing of diseases. Thus, Abraham considers the bio-

psycho-medical discourse of ADHD to find that it cannot be used to explain the expansion of

diagnosis and drug treatment. It is not a case of better understanding the condition or refining

diagnostic tools, as no such refinements have been made in the last twenty years (Reid & Prosser

2011; Prosser 2006) and it is not possible to disentangle the disorder through subjective assessments

from normal behaviour (Abraham 2010).

Abraham’s work also points to limitations within the bio-psycho-medical discourse of ADHD.

These limitations include the lack of advance in medical understanding or refinement of diagnostic

tools in the last twenty years (Reid 2011; Abraham 2010; Prosser 2006; Timmi 2005), the failure to

find a biomedical test for ADHD (Abraham 2010; Keane 2008) and the difficulty in disentangling

subjective assessments about the disorder from normal behaviour (Abraham 2010). Helen Keane

(2008) explores the inherent contradictions within the bio-psycho-medical discourse surrounding

ADHD. She notes the continuing controversy in relation to the treatment of ADHD with

methylphenidate (aka Ritalin) and argues that despite the extensive existing and emerging evidence

for the safety of treatment (as well as the lack of evidence for claims of abuse or addiction), this

controversy is unlikely to go away. The growing volumes of scientific research into safety and

efficacy will have little impact because Ritalin treatment for ADHD is enshrined in a broader

contradiction between the recreational use of amphetamines for pleasure/release and the medicinal

use of psychostimulants for discipline/control. She contends that although chemically the same,

there is a qualitative difference between methylphenidate in the laboratory and Ritalin in the

classroom. This difference is accentuated by authorities offering public warnings about addictive

potential while simultaneously endorsing its use to assist children to be more self-disciplined, able

and eager to work. In short, as long as Ritalin is used to reinforce self-regulation and not as a

reward, its status will be ambiguous and the subject of controversy.

While this past sociological work has provided important insights into medicalisation, its shared

emphasis on psychostimulant treatment has conceptualised ADHD as an illustration, rather than as a

social phenomenon for consideration in itself. With the latest edition of the DSM currently being

drafted, the nomenclature and diagnostic criteria for ADHD may change again. However, what is

different now from when it was first announced as ADD in 1980 and revised to ADHD in 1994, is

the prevalence of ADHD diagnosis in western society (Timmi 2005) and its emergence as a

phenomenon in online and popular culture (Harwood 2010; Prosser 2006). Perhaps the typifying

moment of the popularisation of ADHD was when the cartoon character Bart Simpson was labelled

with ADHD by Principal Skinner (Neufeld 2006; Hoong 2003). This marks a shift for ADHD from

an obscure diagnostic term to the popular symbol of any bad behaviour. Hence it is timely to

consider this category in its own right and from a broader sociological perspective, so that a

foundation may be laid for assessment of future social and definitional developments.

Considering ADHD in the Australian context

The potential contribution of sociology to future understandings of ADHD is significant and was

first raised by Katherine Ideus (1994). She explored ADHD as an ethnocentric and decontextualised

phenomenon which needed to be considered within the American cultural foundations from which it

emerged. She argued that the professionals of any country who would embrace ADHD must first

deal with the cultural considerations that have been rendered invisible in the North American

context. In doing so, she raises the important question of what social and cultural considerations of

ADHD have been conducted as during its rise to be the most diagnosed disorder in Australia?

The answer to this question is not difficult – relatively little. In the two decades since Ideus asked

how sociology might contribute to deeper cultural understandings of ADHD, little work outside the

field of medicalisation has been completed in Australia (or in western nations generally). What has

emerged has been primarily from within the discipline of education and focussed on the impact of

recent changes in schooling and schooling practices.

Roger Slee (2006) has argued that behaviour management has become the defining characteristic of

teacher-student relationships in contemporary schooling, and that the labelling of 'problem students'

has been used to mask inadequate responses to student diversity by school institutions. He argues

that the construction of the 'normal' child around preferred academic and behavioural standards has

drawn attention away from the practices of teachers and the power relations in schools. Slee argues

that deficit labels, like ADHD, can obscure the growing complexity in educational expectations and

the inadequacy of resourcing and school responses. In many ways, he echoes a critical perspective

within the sociology of education. This view argues that due to the desire of the ruling class in

capitalist societies to establish institutions and relationships that will align the interests of the

individual with the aims of production and profit, the ‘welding of education onto the economy’

(Smyth 2000, 5) is an important part of the schooling process. Slee also warns that this realignment

not only shapes mainstream schooling, but it also pervades the logic of contemporary inclusive

education.

Linda Graham (2008; 2010) takes up this theme of inclusive education in the Australian context.

Using ADHD as a case study, she argues that the contemporary rhetoric within inclusive education

is contradictory. Rather than using a notion of inclusion that accepts and caters for diversity, she

argues, that to 'include' has come to mean treating the 'abnormal child' to fit within the expectations

of mainstream schooling. The centre of Graham's work is poststructural as she deconstructs the

psycho-medical discourse of ADHD to explore its role in creating notions of inclusion within theory

and practice that are in reality exclusive in their logics of assimilation and integration. In doing so,

Graham also emphasises that there is a notable lack of consideration of the practices of schooling,

particularly in relation to pedagogy.

Independently, Prosser (2008; 2010) has raised the importance of pedagogical theory and practice in

the emergence and rise of ADHD in Australia. He considers ‘traditional pedagogies’ to be those that

rely heavily on the role of teacher as source of knowledge to be transmitted to the student, and

argues that it is such a traditional view of pedagogy that is assumed within the American Psychiatric

Association’s diagnostic criteria for ADHD. He notes that when one imagines the traditional ‘chalk

and talk’ classroom what is immediately apparent is the range of behaviours that are necessary for

success in that context are the opposite of those exhibited by children who are vulnerable to ADHD

diagnosis. It is perhaps not surprising then, that research identifies the classroom as the major site

where the social construction of ADHD occurs and pedagogy as a major factor in the success or

failure at school of students diagnosed with ADHD (Cooper 2005; Taylor 2006; Zentall, 2005).

Also taking a critical perspective, Prosser contends that because schooling is now so closely tied to

global economic competition and the employment prospects of youth, it is the economic

assumptions embedded in schooling that have contributed to the growth of ADHD diagnosis and

treatment in Australia over the last twenty years.

There have been contributions from within cultural studies in relation to the experiences of parents

in relation to ADHD diagnosis. Some studies have included consideration of the process whereby

parents slowly come to accept the diagnosis, moving through stages of guilt, denial, resignation and

then advocacy (X), while others have considered how the controversy over the existence of ADHD

acts primarily as a smokescreen to allow practices of depoliticised individual blame to continue

(Carpenter & Austin 2008). Like the aforementioned studies from within medicalisation and the

discipline of education, they have been limited in their consideration of ADHD in its own right.

What past considerations of ADHD in the Australian context have shared is an emphasis on

professions and application, rather than to the phenomenon in itself. To develop a better

understanding of the social side of ADHD, what is required is a more rigorous drawing on the

theoretical resources of sociology. What these past considerations have also shared is a focus on

structural or dominant discursive forces, and in doings so, they have underemphasised a

consideration of agency in the unprecedented acceptance and rise of this disorder in Australia.

Hence, if a more complete understanding of the social side of ADHD in the Australian cultural

context is to be gained, then a more thorough consideration of the range of conceptual resources

available from within sociology should be attempted.

In summary, past sociological research into ADHD has been limited to brief considerations through

the classical theoretical frameworks of sociology or as an example of the trend toward

medicalisation. As Abraham (2010) notes, ADHD is limited in its suitability as an example of this

trend. Further, as Ideus (1994) implies, there are a broad range of resources within sociology that

could provide greater conceptual rigour to alternative understandings of ADHD. The most obvious

of which, given that ADHD is commonly defined as a variation from behavioural norms, can be

found within the sociology of deviance.

ADHD and the sociology of deviance

Deviance, as a focus within the study of sociology, did not emerge until the nineteen fifties. Prior to

that time, a range of disparate terms were used to consider social disorder and social control, but in

deviance, sociology found a central, unifying concept. At the time, the concept seemed to be

incorporated easily into virtually any theoretical framework; hence it met little opposition as it

entered mainstream sociology (Best 2004). Giddens (2009) describes ‘deviance’ as non-conformity

to a given set of norms that are accepted by a significant number of people in a community or a

society. It is a flexible concept that can at its broadest be taken to be any behavior that violates

people’s expectations or any behavior that is subject to regulation or control (Tepperman 2010).

Advocates of the deviance concept argue that a significant portion of social life is concerned with

conformity, control and designations of abnormality, all of which affirm the importance of deviance

as a distinct sub-field of sociology and as a general analytical concept (like others such as gender,

stratification, interaction and culture) (Roach-Anleu 2006). It is its broadness and flexibility that

lends itself to a fuller consideration of the social and cultural implications of ADHD in the

Australian context.

Structural Functionalism & ADHD

Ideus (1994) reflected on the Structural Functionalist theoretical framework, to observe that it had

been this approach that has been closest to the position taken by the mainstream professions in

relation to ADHD. Based on the idea that society is like a well-oiled machine (built around

consensus and with each part its own specific function in meeting the needs of the majority), she

argued that views from within this framework assert that defining and treating ADHD is necessary

to both the wellbeing of individual and society. The enhancement of an individual’s ability to

succeed in a highly competitive economic meritocracy is paramount and the failure to treat

dysfunctional persons puts them at risk of long term personal, social and economic risk. In this

view, society’s demands for conformity are legitimate and compelling, while medical intervention

to allow greater conformity (as is the case with ADHD) is logical and desirable. The central concern

from within this framework is that all persons can compete in society on merit, and it is to this end

that functional assessment approaches for ADHD turn their attention (Reid et al 1998).

In addition to these key ideas, a few distinctions should be made in specific relation to the Structural

Functionalist approach to deviance. Structural Functionalism is a normative approach which views

deviance as all behaviour that breaks social norms (which are the product of the consensus of

society). This framework not only sees deviant behaviour as inevitable in any given society, it also

argues that social structures actually encourage some people to become deviant. Deviance has the

important function of fostering new ideas and change, as well as uniting the collective against

deviants and deviant acts, hence strengthening the social glue within society.

Highly influential within Structural Functionalist renditions of deviance has been the concept of

anomie. Emile Durkheim (1966) argued that rapid social changes can disrupt traditional norms, as

was seen during the Industrial Revolution, resulting in a state of normlessness, or anomie. This

situation, where traditionally accepted norms are incomprehensible in the context of people’s lives,

leaves them without a moral compass and put them at risk of deviance, criminality and in some

cases suicide. In the case of ADHD, this concept could be used to explore its emergence and

prominence in recent years. It aligns with arguments that the degree of social, economic and

technological change in the western world has been significant over the last thirty years, so

significant that there has not been the time for the human gene pool to adapt to these changes, with

ADHD being one result (Diller 1998; Hartmann 1993). Alternatively, one could look at the

dramatically changing expectations around masculinity and claims of cultural confusion about what

it means to be a man in modern western society. When applied to ADHD, this view might ask if

there is the guidance or the space in our modern societies for ‘boys to be boys’ (Prosser 2006) and if

the higher diagnosis of ADHD amongst boys may be in some part a result of this confusion over

norms. Consequently, ADHD might be seen as an evolutionary lag, in response to which

technological advances (such as the development of psychostimulant medication) are a perfectly

appropriate, even humane response (Barkley 2006). Conversely, it could be argued from within this

perspective that these recent changes are not likely to slow down and that Durkheim’s goal for a

better alignment between the living law, regulation and state law (Cotterrell 1992) should be

mirrored in the pursuit of a better alignment between contemporary experience, behavioural norms

and forms of social control.

Robert Merton (1938) adapted and extended Durkheim’s concept of anomie through his explanation

of anomic structural strain. This concept argued that modern society was not so much experiencing

a lack of norms as it was that existing traditional norms were no longer relevant. Merton explained

that when there is a social situation of strain between culturally approved goals and then means

available to attain them, then the response of humans is to adapt, with deviance being one possible

outcome. Merton lists conformity (achieving goals through legitimate means), innovation

(achieving goals through illegitimate means), ritualism (where legitimate means are followed with

no hope of achieving goals), retreatism (where both goals and means are rejected) and rebellion

(where new goals and means are sought through a new social system). In the case of ADHD, the

legitimation of psychostimulant intervention to allow people with ADHD behaviours to achieve

goals could be an example of providing an avenue to conformity. However, in my work with

students diagnosed with ADHD in secondary schools (Prosser 2006), examples of students

retreating into disengagement (following the rituals of school with no hope of success), and

examples of students demonstrating innovation (by using fearful responses to their behaviour as an

alternative avenue to achieve goals) were also present. There is also the potential that when in a

situation where total conformity is not possible (even with medication) and a child presents a threat

through its rebellion against collective norms (deviance), the more sympathetic diagnosis of

disorder is an example of innovation. These examples highlight the generative potential of Merton’s

strain theory for future sociological explorations into ADHD.

Other normative approaches, which span the sociology of deviance and criminology, could also be

used as important conceptual resources in understanding ADHD and potential later links with crime.

For instance, Control Theory (Hirshi 1969) reverses the question of why people deviate to ask what

assists them to conform. In the case of ADHD, problematic behaviours are not exhibited across all

settings all the time, and this theory would consider how attachment to significant others,

involvement in schedules or structures, commitment to gaining rewards for conforming behaviour,

and systems of belief may all contribute to reducing problematic or criminal behaviours. Of

particular interest could be the extent to which familial or cultural attachments and beliefs influence

rates of diagnosis and drug treatment. Another conceptual resource from with the sociology of

crime may be found in Routine Activity Theory (Cohen & Felson 1979), which seeks to examine

which features of daily life lead to more or less deviant or criminal behaviour. It argues that the

convergence of a predisposed person with an easy opportunity and the absence of a capable

guardian are central to criminal acts. Such theories when used in relation to ADHD would not just

look at immediate environmental factors, but recent changes in social conditions and community

networks that have changed the context of contemporary youth behaviour. They also highlight the

potential of other normative approaches from within criminology for better understanding ADHD.

Bridging Functionalist and Interactionist theoretical frameworks is the work of Erving Goffman.

Goffman (1963) explored how the diagnostic process in institutions could impact on the moral

career of psychiatric patients, emphasising that the attribution of 'sick' behaviour is related to the

distance between the person applying the label and the situation of the person being labelled. For

Goffman, stigma is a term that marks the discrediting of an individual due to physical disabilities or

character traits. As Carrington (2006) explains, the generational gaps between policy-makers or

professionals and today's youth are significant and growing, with differences in adolescent

experience more likely to be defined by those in authority as deficit or disorder than natural

diversity. In particular interest in the case of ADHD is Goffman's interest in how individuals

managed these labels once applied, through correcting, obscuring or distracting others from

stigmatising traits. In the visibly obvious case of hyperactivity and ADHD, the attribution of stigma

to behaviour by professionals and the responses of the individual may be an important factor.

Interactionism & ADHD

Views from within this theoretical framework seek to emphasise the meaning-making that occurs

from the interaction between individual agency and social structure. Ideus (1994) explained that in

this view, ADHD might be seen as a process whereby particular individual traits or behaviours,

through social interaction, are deemed abnormal or undesirable. Importantly, it is not the behaviour

itself that is in deficit, it is the attribution of a deficit label that makes it so. The central concerns

with ADHD in this view would be the ongoing lack of consensus around the definition of the

disorder, the influence of changing cultural priorities in redefining human diversity as psycho-

medical disorder and the potentially stigmatising impact of doing so. The aforementioned work of

Conrad (2007; 1976) has its origins in Symbolic Interactionism.

Although Lemert (1951) was the first from the Interactionist theoretical framework to note the gap

between primary deviance (committing the act) and secondary deviance (receiving a deviant label),

it was Becker (1963; 1973) who popularised this through Labeling Theory and the concept of

deviant careers. In short, Becker's contribution was to shift the focus of considerations of deviance

from the labelled individual to the labeller. He argued that social groups create deviance by making

the rules and then labelling those who break them as 'outsiders'. Hence, deviance is not related to

the act a person commits but the reaction of those around them, and the deviant is only one who has

been successfully labelled and accepted that label into their identity. Following Lemert, his

argument was that people were rarely labelled deviant for a single act, rather, they acted repeatedly

in what seemed a rational way, and it was society that defined them as deviant. Clearly ADHD, as a

label that is applied by those with power in society (often parents and medical professionals) to

those with 'deficit' behaviour (often children), can be understood through this theoretical

framework. .

To this, Becker adds the concept of deviant careers. He argued that the treatment of deviants denies

them the opportunity to behave 'normally' in everyday life and hence the deviant must devise

illegitimate routines of action. In this sense, he argued that behaviours associated with ADHD can

be considered as rational responses, given the constraints that those labelled face. One such

response is to redefine the negative label as a positive identity trait, with the result that the label

becomes further entrenched as a self-fulfilling prophecy. Thus, forces of social control often

produce the unintended consequences of making some persons defined as deviant even more

confirmed as deviant, with these social reactions to deviance creating deviant careers (Rist 1977).

In my research, I have explored the experiences of adolescents diagnosed with ADHD through a

Labelling Perspective (Prosser 2006; 2008). In doing so, I have seen youth acting as back against or

redefining their label as 'mild ADHD', as well as evidence of ADHD being reinforced as a positive

and defining identity trait as adolescents shift toward adulthood. More specifically, my research

found that youth who were provided with educational and social skill support prior to entering

secondary education often talked about 'growing out of ADHD', while youth who were provided

with only psychostimulant treatment continued to have difficulty and showed interest in 'adult

ADHD' (Prosser 2006). This would suggest while ADHD is a label applied by those in power, it is

also a label that must be accepted and integrated into the identity of the individual, which if not

responded to appropriately has the potential to be reinforced as a deviant career.

An important conceptual extension from Labeling Theory is that of moral panic. The key idea

behind moral panic is that labels are applied by those with power and that significant public concern

can emerge when the conditions are right. Cohen (1980) defines moral panic as a situation where a

group of persons become defined in a stereotyped fashion as a threat to society, usually based on the

concerns of the police and reporting of the media. The media tend to portray the risk of ‘crime

waves’ caused by 'folk devils' by exaggerating the numbers of people and degree of their threat to

society. There is a long tradition of moral panic around youth, and it is in this that we can see that

ADHD also has many of the characteristics of moral panic. Of particular interest is the role of the

current affairs media in its sensational reporting of the behaviour, drug treatment and potential

future criminality. However in the case of ADHD, the reporting of problem behaviours have not

emerged from the police in line with the classic definition of moral panic. Rather, reports emerge

from other professionals that are interested in maintaining social order, such as teachers, social

workers and medical professionals. This situation creates a conceptual link between moral panic

and poststructuralist perspectives, particularly with Foucault's concepts of governmentality and

diffusion.

Poststructuralism, Feminism & ADHD

The work of Michele Foucault was instrumental in the development of poststructural and

postmodern approaches within sociology. These approaches do not accept that all the advances of

science in the modern world have resulted in progress and that there are no underlying universal

laws to explain human experience, rather knowledge about experience is created through language

and power, making it diverse, contradictory and constantly changing. Through the concept of

governmentality, Foucault (1984; 1991) details the growth in the logics, surveillance and reach of

government due to the expansion of social science research and the powers of regulation in modern

society. Essentially, this new scientific knowledge is used to predict who might present a risk and to

intervene pre-emptively, with science both producing new objects to study and then to treat (Timmi

2005). This is a significant change to past approaches to deviance, where surveillance and social

control emerged in response to a deviant act. Another key concept associated with governmentality

is the shift from direct social control by traditional enforcement officers to the diffusion of power

amongst health and other professionals to supervise social order through categories of sickness and

mental illness.

Together surveillance and diffusion result in greater self-regulation, which Foucault describes as a

more efficient means of social control, but not necessarily an improvement in the lives of people.

How this fits with ADHD is the growing emphasis by teachers, social workers and psychiatrists on

developmental stages (Bailey 2010; Timmi 2005) and to define behaviour as a disorder (often prior

to this behaviour being deviant according to normative or diagnostic categories) and to set in place

interventions and treatments to seek better self-regulation (Keane 2008). Those working in the field

of ADHD will often come across cases of diagnosis made before the age of seven (which the DSM

has stipulated as the minimum standard to ascertain the difference between natural developmental

diversity and developmental delay) and earnest professionals seeking early interventions to

safeguard against future problems. Recently, these themes have been adopted by Bailey (2010) and

linked with the concept of risk society (Beck 1992) to produce a poststructuralist analysis of ADHD

and the DSM. Risk theories claim that risk is among the most important concepts in the thinking

about everyday life in modern society. Further, the negotiation of risk by the individual is central to

modern life and relies on the notion of individual choice. However, this is a depoliticised and

decontextualised choice. Or as Bailey (2010) has observed, risk theories have been used through the

DSM to encourage a focus on risk in early childhood, with a resultant depoliticised notion of choice

feeding into an emphasis on individualised deficit. And because the individual has greater

responsibility for self-regulation in modern society, it is these current and potential future risks that

constitute the deficit component in ADHD and underpin the discourses that justify the diagnostic

rationale of the DSM. In Adams' (2010) analysis of ADHD, he stresses the important role of

discourse. The concept of discourse extends beyond simple speaking and listening to encompass

how forms of language set limits on what we think and say and therefore what we are able to do and

what can be done to us. The notion of discourse is emerging to be a generative resource in the

alternative conceptualisation of ADHD (Abraham 2010; Bailey 2010; Graham 2008) and would

also important for poststructuralist and feminist renderings of the disorder.

Analysis of ADHD from within the discipline of gender studies has been limited to this time. Of

obvious interest from this perspective would be both the masculinist nature of the diagnostic

emphasis on hyperactivity and the neglect of the feminine experience in past renditions of ADHD.

Also of interest might be why young girls who misbehave are prone to being labelled 'mad, bad or

sad' (Easteal 2001), and why young boys who misbehave have a diagnostic category available to

excuse their problematic behaviour as biologically-driven. Further, examination of ADHD from

within gender studies might also look at the reported narrowing of the gap in diagnostic ratios to

ascertain if factors (such as including inattention in the diagnostic cluster or emphasising genetic

origin) have any correlation with more girls being diagnosed with and medicated for ADHD.

What the above highlights is that ADHD is much more than just an example of the medical and

psychiatric professions colonising a social issue. From classical theories on deviance, ADHD can be

understood as a variation from set behavioural norms, although the arguments for consensus around

or desirability of these norms varies between perspective, just as the level to which agents are seen

as passive receptors of social structure varies. Further, poststructural and feminist theories can be

applied to shift past the 'myth or reality' impasse with ADHD to note that all phenomenon are social

constructions. This emphasises that different discourses continually compete or interrelate in

different ways and in different places to create different social categories (such as ADHD) at

different points in human history. Hence, discourse analysis can provide new insights into the

sociological conditions of the emergence and popularisation of ADHD in recent years.

ADHD, Conflict & resources

The Conflict theoretical framework argues that society is a maelstrom of conflicting interests, which

power elites suppress to ensure their ability to own property and materials, as well as control

production and profit in capitalist society. Ideus (1994) explained that views from within this

theoretical framework might see ADHD as an ideological ploy to oppress individual interests in the

face of social machinery that manipulate life opportunities to maximise economic profit. In such a

view, medical intervention that is focused on re-aligning individual characteristics and behaviour

should be resisted and rejected as it is the further suppression of innate human qualities. Within the

sociology of deviance, conflict theories have adopted an interest in deviant labels, but paid attention

to power, class and political interests in a way interactionist theorists have not. The main

contribution of conflict approaches has been to understand who makes the rules, why deviance is

created and how economic and ideological power shape what is considered as deviant.

Conflict theories, at their core are about the unequal distribution of wealth and power; while

deviance is rule-breaking that is a response to or result of this inequality. From a conflict

perspective, deviance and crime only emerge to cover acts that are of direct threat to the

foundations of capitalism. One example of this can be found in the work of Richard Quinney.

Although primarily focussed on crime, Quinney (1974) explores the factors that influence which

behavioural patterns will be enshrined into law/regulation and emphasised as normal. He argued

that crime (and I would extend deviance), must be understood as descriptions of those behaviours

that conflict with the interests of segments of society that have the power to shape public policy. In

addition, legislation and regulation arises to further the interests of one group against another and

thus becomes a weapon in the inter-group and class struggles of society. It is in this context of law-

making, lobbying and interest groups that ADHD provides a fascinating example, firstly of the role

of ADHD as a tool for lobbying in contemporary western society, and secondly, of the role of

capitalism in the definition of deviant behaviour.

The links between pharmaceutical companies, ADHD advocacy groups and lobbying for

recognition of the disorder and access to psychostimulant treatment has been explored in depth

elsewhere (Abraham 2010; Conrad 2007; Timmi 2005; Armstong 1995). However, what also

requires analysis from a conflict perspective has been the role of ADHD in competing for resources

and support from social welfare institutions. Set in a post-welfare context that is reducing real term

funding and emphasizing devolution of responsibility to the individual or family (Adams 2010),

ADHD has become a category of contestation. In the face of this, politicians and policy-makers

have been careful to avoid specific action on ADHD because of its potential resource implications,

instead treating it like a political hot potato (Prosser 2006). The result is that in Australia there are

currently no specific policies or additional resources (other than medication) allocated to ADHD

(Prosser 2006; Prosser 2002). This has raised concern about gaps in service provision for ADHD in

Australia (Atkinson 1997; Prosser 2006; Prosser 2002). Despite this, errant perceptions that the

ADHD label provides additional welfare support persist (Prosser 2006; Reid & Katsiyannis 1995),

which drive passionate lobbying and advocacy efforts. Together these factors suggest a situation

where there is tension between parental desires for their child’s schooling success and the ability of

schools to ensure that success. It may be this tension between home and school that has contributed

to the emergence and explosion in ADHD as a tool to lobby for resources (Prosser 2008). Also,

because no subsidised resources other than subsidised medication are available with the diagnosis,

this may be behind the growth in drug treatment in Australia in recent years (Berbatis 2002) and

particularly in poorer economic regions (Prosser 2009). However, it may also be a realisation of the

limitations of ADHD as a tool for lobbying that have resulted in recent media reports that ADHD is

being replaced by autism as the most sought after diagnosis in Australia (Hansen 2010). While the

complex construction and nature of ADHD still requires more sociological consideration, it

demonstrates that ADHD may currently be an important part of the inter-group and class struggles

in western society.

Another perspective of relevance to ADHD from within conflict approaches is that of Left Realism.

Emerging from a revision of critical criminology by Taylor (1981) and Young (1975), this approach

refocused attention from the structural elements of crime to the harm caused, particularly to victims.

It also noted that these victims are often those committing crimes and their communities, rather than

between classes as had been advocated in previous conflict theories on crime. What it sought was a

holistic view of crime, especially given that different groups have different perspectives and

interpretations that may not align with the increasing reports of crime waves in the media and

growing public concern. Amongst the most important of these perspectives, as a source of crime,

was the role of lower-class subcultures (Tierney 2009). In the case of ADHD, my research has

found clear evidence of the experience of those labelled ADHD not aligning with media reports and

public concern about the nature of their lives, participation in violence and crime, or their use of

drugs (Prosser 2006). This research has also revealed the harm, heartache and guilt experienced by

young people labelled ADHD, highlighting that it is often they who are the greatest victims. As

mentioned previously, ADHD is constructed in a context of risk and future criminality. These

representations use a depoliticised set of behavioural descriptions as their core construct and gloss

over the social production of exclusion, which plays a vital role in the assignation of the disorder

and provides a more powerful explanation of future undesired behavioural outcomes (Bailey 2010).

In other words, the links between ADHD, crime and lower class subcultures are more likely to be

due to long term social and institutional alienation than any biological or inherent link with the

disorder (Prosser 2006).

Discussion

The above sections do not intend to provide a detailed or exhaustive sociological analysis of

ADHD, rather, they draw on concepts from within the sociology of deviance to point to potential

areas for future research. As such, they reinforce the potential role of the sociology of deviance in

providing new perspectives on ADHD. More importantly, they point to a potential response to the

question put by Ideus, namely - what cultural considerations have been influential in the adoption of

ADHD in the Australian context?

To consider this question, it is important to first note some of the similarities and differences

between the ADHD phenomenon in Australia and the United States. Australia closely mirrored

growing North American trends in psychostimulant treatment throughout the nineteen nineties

(Prosser & Reid 2009). In addition, the gender ratio of diagnosis and treatment is similar, with more

boys diagnosed that girls. Both countries have had a increasingly prominent presence of ADHD in

online and news media, as well as popular culture (Prosser 2006). Further, as the above sections

demonstrate, the psycho-medical discourse surrounding ADHD has been influential in both nations.

Clearly, there are grounds to argue that Australia has shared a similar pragmatic and reductionist

response. As noted above, the growing interest in behaviour management and ADHD within schools

can be viewed as pragmatic responses to recent neo-liberal changes to education, an example of

economic social structure impacting on the learning and opportunities of youth. As also noted

above, the growing influence of a psycho-medical ADHD discourse on health and inclusive

education professionals can be viewed a reductionist response to diverse behaviours, an example of

medicalisation reaching into new areas of social life. However, there remain some important factors

that give reason for caution in directly correlating the Australian and American ADHD experience

when responding to Ideus' question. While Australasia was quick to follow North American trends

in drug treatment of ADHD (Prosser & Reid 2009; Berbatis et al 2002), it is significant that other

western nations, particularly the United Kingdom (Bailey 2010; Timmi 2005), have only recently

started to see significantly increased levels of ADHD diagnosis and drug treatment (Prosser 2006).

This highlights the question, what is it in the Australian cultural context that was behind such a

swift replication of American diagnostic trends and to what extent were these trends identical?

Historically in the United States, ADHD prevalence has been more likely in upper middle and

middle classes (Prosser & Reid 2009; Diller 1998), while in Australia, ADHD has been more

closely linked to lower-classes and social disadvantage (Harwood 2010; Prosser & Reid 2009). In

the past, diagnosis and drug treatment has been lower in Afro-American communities due to

overactivity being associated with black racial stereotypes and the past negative experiences of

these communities with psychostimulant drugs (Timmi 2005; Bussing 1998). However, there is

increasing evidence of more Afro-American youth being labelled hyperactive (Stapp 2009 in

Harwood). In Australia, what evidence is available points to lower levels of ADHD diagnosis and

treatment amongst indigenous and Asian communities (Prosser 2006). Further, policy in relation to

support for ADHD differs between the two nations, which has an impact on diagnostic and

treatment levels (Prosser 2006). While there are requirements for individual support to be provided

in the United States based on ADHD diagnosis, the complexities of state and jurisdictional

legislation in Australia (Prosser 2002) see no such requirement in Australia. However, beyond these

demographic and policy differences, there are also other important sociological reasons to exercise

caution in correlating the Australian and American experience.

Two decades after Ideus' observations about the power of pragmatic and reductionist influences on

the professional acceptance of ADHD, controversy still rages amongst professionals. The

reductionist versus idealist positions on ADHD, where the former accepts the legitimacy of social

demands for conformity and the latter sees ADHD as ideologically illegitimate (Ideus 1994),

continue to clash in debate over the disorders myth or reality (Bailey 2010). In many ways this has

not been helped by sociological responses to ADHD being limited to considerations of

medicalisation, which perpetuates polarised responses (Laurence 1998). This 'black or white' view

on ADHD (Prosser 2006) results in break downs in communication between relevant professionals,

and can result in divisions between parents and professionals which impact on holistic response.

While some teaching and health professionals accept the reductionist view and advocate for the

label on pragmatic grounds, others do not accept ADHD and advocate support on the grounds of

learning or comorbid conditions alone (Prosser 2002). Meanwhile, medical practitioners are divided

on ADHD. This is borne out not only by the significant geographical variation in ADHD drug

treatment in Australia (Prosser & Reid 2009), but also by a small number of medical professionals

being responsible for the majority of prescriptions in Australia (Reid & Prosser X; Berbatis et al

2002). The above evidence suggests that the growth of ADHD in Australia is just a simple reflection

of pragmatic and reductionist trends in the United States.

Further, outside the realm of the professions identified by Ideus (1994), the responses of individuals

to ADHD vary greatly. As highlighted above, class and culture appear to influence group acceptance

of ADHD diagnosis and treatment. However, Australian research indicates that parents show

resistance to accepting the label ( ) and it is frustration with the responses of school institutions,

rather than the advice of a medical practitioner, that is the first step to ADHD diagnosis (Prosser

2010; 2006; Kos 2006). Further, Australian research shows that far from being passive receptors of

the reductionist ADHD label and psycho-medical discourse, youth reform, ignore or accept the label

on their own pragmatic ground (Prosser 2006). What these responses highlight is the importance of

recognising agency in our understanding ADHD, something that is neglected in the work of Conrad

and overlooked in much of the other work on ADHD as an example of medicalisation.

Admittedly, structural functionalists might point to the similar trends in growth of drug use between

Australia and the United States to argue, much as Durkheim (1951) did with suicide, that ADHD is

sui generis. Alternatively, conflict theorist might argue that legality of drugs for treatment and

expanding number of drugs accessible through the Australian Pharmaceutical Benefits Scheme will

undermine resistance to ADHD as a form of social control amongst disadvantaged groups, with the

requirements of structure increasingly becoming dispositions within the habitus of the individual

(Bourdieu 1984). Further, responses that emphasise medicalisation, be that through a dominant label

(Conrad 1976) or a dominant psycho-medical discourse (Bailey 2010), risk overlooking the

important role of individual response and counter discourses. Hence, each of the above can

perpetuate a lack of consideration of agency which has typified many of the previous sociological

considerations of ADHD.

This paper argues that the sociology of deviance has much to offer understanding of ADHD,

particularly in relation to the response of agents. To what extent is ADHD an example of Merton's

notions of conformity or innovation? How does Hirschi's explanation of familial or cultural

attachment relate to the many periods of control shown by those labelled ADHD? To what extent

can Becker's concepts of labelling and deviant careers explain the extent to which ADHD is

accepted or rejected, adapted or adopted, or becomes defining feature in one's identity? To what

extent might Left Realism refocus attention on the plight of those labelled ADHD as victims of the

economic situations and conditions in which they find themselves? And in a modern society

increasingly typified by risk and complexity, to what extent can 'at risk' and 'risky' ADHD be seen

through the growing emphasis on reflexivity and individualisation in the work of Beck and

Giddens? There is much that a closer consideration of the role of individual agency from

sociological theory can offer theoretical understandings of the social side of ADHD.

However, despite these insights we cannot, at this time, respond directly to Ideus' question in an

empirical way. Research is still needed to explore the potential contribution of theory from within

the sociology of deviance and to consider what cultural influences are important in the Australian

experience of ADHD. Such research may open up considerations of the influence of virtual and

online communities in the growth of ADHD in Australia, as well as the extend the consideration of

the role of popular culture identified by Abraham (2010) in his explication of pharmaceuticalisation.

Such research could lead to an examination of the impact of American cultural influence through

popular entertainment as a factor in Australia's adoption of ADHD. Further, consideration could be

given to the influence of Australian identity (both through traditional nationalist and contemporary

multicultural forms), to see the extent that this contributes to the acceptance or resistance to the

American ADHD construct. Perhaps, most importantly, such research could provide new

understandings of the role of agency which may lead to the identification of other cultural

influences on ADHD that are present in the Australian context, and which may prove worthy

avenues of further future research.

Concluding remarks

This paper argues that as ADHD has rapidly grown to become amongst the most diagnosed

childhood disorders in the western world, more rigorous conceptualisation is needed than that

provided through the body of writing about ADHD in medical and psychiatric disciplines. While

within sociology, there has been interest in ADHD through the lens of medicalisation, this has

tended to reinforce the ‘mediate’ or ‘not to medicate’ dichotomy and overlooked the important roles

of culture and agency. Thus, the paper contends that theoretical perspectives from within the

sociology of deviance should be brought to bear on ADHD to help us understand its place in

contemporary Australian culture and how the Australian experience might differ from that of the

United States. While a full review of these matters remains beyond the scope of this paper, it has

drawn on a range of conceptual resources to demonstrate that contrary to the claims of some

(Sumner X), the sociology of deviance is far from dead (Best 2004; Roach-Anleu 2006), but

actually provides generative potential for new sociological perspectives on ADHD. The paper has

done so with the intent of enhancing understanding of the social aspects of this prominent disorder,

to support shifts to a better understanding of ADHD and to encourage more empowering

conceptions that may lie beyond the existing deficit label.

References