Review of "Medicating Children"

The vast literature on Attention-Deficit/Hyperactivity Disorder (ADHD) can be classified into three categories. In the first category we find most of the literature, which treats ADHD as a well-established medical condition whose validity is not in any doubt. Almost all of the scientific research on ADHD fits into this category, and most of the popular books on ADHD do as well. In a second, smaller category we find wholesale attacks on the concept of ADHD, which is described variously as a myth, a social construction, or the product of a conspiracy by drug manufacturers. There is occasional scholarly work in this vein, but most of the literature in the second category consists of books meant for a general audience. Finally, in what is by far the smallest category, we find literature that takes a position in the middle. The few authors in this last category understand that people with ADHD diagnoses often have very real cognitive and behavioral problems that make life difficult, but these authors also understand that determining who merits a formal diagnosis of ADHD is an extremely difficult process, misdiagnoses are common, and society plays a large role in deciding what behavior is abnormal and should be treated. In short, these authors admit that the issue of ADHD is complicated. Medicating Children is a contribution to this third category, and that alone is enough to celebrate its arrival.

Taking the via media in the ADHD debate is difficult to do well. It is easy enough to say that things are complicated, but exploring those complications in detail and emerging with convincing conclusions is the bolder task that Rick Mayes and his colleagues set out to complete. The result is an interesting hodgepodge of chapters, mostly historical in nature, and each focusing on a few central questions. The first full chapter is a review of the clinical literature on ADHD: its symptoms, epidemiology, causes, and treatment options. Mental health professionals may be familiar with this information, but given the book's broader audience, it is useful background for the remainder of the book. This chapter is also emblematic of the book's neutral tone and approach: research is reviewed clearly without the injection of opinion, and when extant findings are controversial or insufficient to draw conclusions, this is noted as well.

The next four chapters are the historical core of the book, taking us from 1900 to the present day. Most of the early history covered in the first of these chapters is found in most other standard texts on ADHD--events such as George Still's 1902 lectures on children without "moral control" and Charles Bradley's 1937 paper on stimulant medications. However, the authors also draw attention to less well known facts, such as the early conflation of ADHD symptoms and what would now be termed intellectual disability (or mental retardation), the initial use of Ritalin for narcolepsy in adult patients, and public debate (including congressional hearings) over stimulant medication in the early 1970s that foreshadow today's debates. The message from this chapter is that ADHD is not a recent "discovery" or "invention," even though the term is new.

After covering the early history, the authors devote a chapter to the 1980s and how changes in the official definition of ADHD (as seen in different editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or DSM) led to increases in the identification of ADHD. Again, some of the authors' presentation is standard; the core narrative in this chapter discusses the ways in which the DSM-III (1980) increased the objectivity and reliability of diagnoses, while at the same time hinting at their biological basis (and implying their amenability to amelioration through medications). However, there is also coverage of the interesting rise and fall of inpatient child psychiatric treatment, even for ADHD-related symptoms. For instance, the number of children in private inpatient wards rose 400% between 1980 and 1986, but then fell sharply by 1990.

The next chapter takes a detailed look at the relationship between ADHD and two social programs: special education and supplemental security income (the SSI program). In the early 1990s, ADHD advocates lobbied for ADHD to be included as a separate special education classification under federal law, and a variety of disability rights groups lobbied for a shift in disability policy from alternative placements (such as special schools) to accommodations in everyday life. Although these groups were not entirely successful in their missions, the federal government did alert schools to the needs of students with ADHD, the Americans with Disabilities Act was passed, and the Social Security Administration developed more lenient rules to use in determining which individuals qualified for disability services (including SSI payments). At the same time, ADHD diagnoses skyrocketed, more than doubling between 1990 and 1993. Medicating Children describes the logic behind the advocates' demands as well as trenchant criticisms of the changes they prompted, concluding that although changes in special education and SSI may explain some of the increase in ADHD diagnoses, it is unclear whether this increase signals careless overdiagnosis or is simply the result of many needy children finally getting the help that they need.

The fourth historical chapter focuses on the diverse criticisms aimed at ADHD diagnosis and treatment with medication. One of the interesting points made by this chapter is that different critiques of ADHD and medication placed blame on different parties. Some critics blamed drug companies for covering up the side effects of medications and overstating benefits, whereas others blamed schools and teachers for encouraging or coercing families to place their children on medication, and still others blamed society as a whole, for either pressuring children too much academically or being intolerant of behavior that is supposedly typical of young boys. The authors also point to sociological research showing that parents of children with ADHD diagnoses share some of these critical perspectives, not fully comfortable with the diagnosis of ADHD or the medications prescribed to treat it, but unable to deal effectively with their children's misbehavior in other ways.

I was impressed by the range of scholarship that the authors considered throughout the book, and the endnotes and bibliography (over 100 pages, together) are as useful as the text itself. More generally, the volume fills a unique spot in the ADHD literature, providing a detailed historical account of the controversy over ADHD and medication treatment options for it. The writing is clear and accessible, and I would recommend it to general readers who would like to understand the ADHD controversy. However, it does not really attempt to draw insightful, novel conclusions based on its review of literature, and the final chapter, titled "Conclusion" is a disappointment in this regard. The book's balanced tone comes from its unwillingness to take a side, rather than its crafting of an insightful and novel interpretation of the issue. Still, it is a valuable addition to the category of "balanced" books about ADHD and should be required reading for any researchers in the field.

© 2009 Benjamin J. Lovett

Benjamin J. Lovett, Ph.D., is an assistant professor of psychology at Elmira College, where he teaches classes on a variety of topics in applied psychology and his research focuses on the conceptual and psychometric foundations of psychoeducational assessment and psychiatric diagnosis.