James J. Hughes Deviance UConn – October 28, 2009

Medicalization of Deviance  Defining deviant behavior as a medical condition  Medical-industrial complex defining us as sick to sell us cures  Doctors claiming social “problems” Thomas Szasz: Mental illness is just deviance Peter Conrad: ADD is just deviance

Medicalization Controversies  Childbirth  Shyness  Aging  Depression  Addiction  ADD/ADHD  Aspergers Syndrome  Unusual Bodies Height, unusual genitals  Sexual Behavior

ICD: What is a Disease?  World Health Organization’s International Statistical Classification of Diseases and Related Health Problems  ICD-9 (WHO 1977) – 17,000 codes  ICD-10 (WHO 1992) – 155,000 codes  ICD-11 (WHO 2014) = rectal pain

Diagnostic and Statistical Manual Manual of official diagnoses of the American Psychiatric Association  DSM-I (1952)  DSM-II (1968)  DSM-III (1980)  DSM-III-R (1987)  DSM-IV (1994)  DSM-IV-TR (2000)  DSM-V (2012)

History of ADD  1930s stimulants prescribed to treat “minimal brain dysfunction”  1960s “minimal brain dysfunction” “learning/behavioral disabilities” and “hyperactivity”  Ritalin synthesized in 1950s, prescribed in 1960s  DSM-II (1968): “Hyperkinetic Reaction of Childhood”  DSM-III (1980): “ADD (Attention-Deficit Disorder) with or without hyperactivity”  DSM-III-R (1987): “ADHD”  ICD-10: “Hyperkinetic disorders”

Diagnosing ADHD  DSM-IV criteria diagnose 4x more ADHD than the stricter ICD-10 criteria  DSM-based prevalence estimates between 3-10 percent of children and 3- 6 percent of all adults 1. Inattentive & Hyperactive-Impulsive 2. Primarily Inattentive 3. Primarily Hyperactive-Impulsive

Inattentive Criteria Six+ for at least 6 months to a point that is disruptive and inappropriate for age: 1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. 2. Often has trouble keeping attention on tasks or play activities. 3. Often does not seem to listen when spoken to directly. 4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). 5. Often has trouble organizing activities. 6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). 7. Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools). 8. Is often easily distracted. 9. Often forgetful in daily activities.

Hyperactive-Impulsive Six+ for at least 6 months to a point that is disruptive and inappropriate for age: 1. Often fidgets with hands or feet or squirms in seat. 2. Often gets up from seat when remaining in seat is expected. 3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). 4. Often has trouble playing or enjoying leisure activities quietly. 5. Is often "on the go" or often acts as if "driven by a motor". 6. Often talks excessively. 7. Often blurts out answers before questions have been finished. 8. Often has trouble waiting one's turn. 9. Often interrupts or intrudes on others (example: butts into conversations or games).

Treatment  Behavioral  Stimulant Medication Ritalin/Concerta Adderall Dexedrine Strattera (atomoxetine - non- stimulant)

Diagnostic Creep  Where do we draw the line?

Conrad on ADD Conrad’s 1975 “The Discovery of Hyperkinesis”  “The process of medicalization, often seen as humanitarian reform, has another side:  (1) expert control;  (2) medical social control;  (3) the individualization of social problems; and  (4) the depoliticization of deviant behavior.

Is ADD a Disease?  There isn’t a sharp, clear indicator but…  Heritable  Comorbid with Tourettes, OCD, epilepsy and oppositional defiant disorder  Clear differences between ADD brains and non-ADD brains  ADD kids are helped by stimulants, while not all kids are

5 Squiffy Aspects of ADHD …that contribute to its controversial nature: 1. No laboratory or radiological confirmatory tests or specific physical features. 2. Diagnostic criteria have changed frequently. 3. There is no curative treatment, so long-term therapies are required. 4. Stimulant drugs are thought to have abuse potential. 5. The rates of diagnosis and of treatment differ across countries.

The ADD Lobby  Parent organizations Association for Children with Learning Disabilities (ACLD) Children and Adults with Attention Deficit Disorder (CHADD)  Drug Companies  Pediatricians and Psychiatrists

Anti-ADHD Theories  Parental/societal permissiveness  Decline of corporal punishment  Over-achiever parents  Medical capitalism  Demonizing boyish behavior  Neuroconfimism  Dysfunctional education system  Bad diet, toxins  Television’s effect on the brain  Hunter vs. farmer brains

Regulation of Psychoactive Drugs  DEA has 5 categories of scheduled drugs, then over the counter  ADHD stimulants are regulated the same as narcotics

Dopamine and Abuse  Antipsychotics and hallucinogens have little potential for abuse, but are still regulated  Caffeine and alcohol are not

Proposed British Reform

Decriminalization of Cannabis

Bell Curve of Brains  What if the right half of brains benefit from stimulants?  What if the right 95% does?

Dementia, Mild Cognitive Disorder  The aging of society will allow increasing medicalization of attention and memory disorders  ICD: Mild cognitive disorder - A disorder characterized by impairment of memory, learning difficulties, and reduced ability to concentrate on a task for more than brief periods. There is often a marked feeling of mental fatigue when mental tasks are attempted, and new learning is found to be subjectively difficult even when objectively successful.

Cognitive Enhancement  Therapy vs. Enhancement  5% to 35% estimates of the use of un-prescribed stimulants by college students as study aids

Cognitive Liberty  The right to control your own brains, vs.  Society’s obligations to Protect public safety, control selling of harmful substances Keep people from selling themselves into mental slavery  But what if a enhancing drug made you smarter without bad side effects?

Modafinil (Provigil)  Developed and approved as treatment for narcolepsy and “excessive day-time sleepiness”  Schedule 4 controlled substance

Review and Take Homes  3 types of ADHD according to ICD and DSM  Difference between ICD and DSM  Reasons for controversiality of ADHD  Conrad’s complaints  Alternative theories of ADHD  Irrational regulation of psychoactive drugs  Cognitive liberty  Modafinil