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The Normalization of Productivity: A Philosophical Investigation into the Proliferation of ADHD and Stimulant Drugs

By: William Adamowicz

Advisor: Professor Michael Kelly In Partial fulfillment of the Perspectives Honors Sequence

Table of Contents: I. II. III. IV. V. VI. Introduction.......................................................................................................... 3 Postmodern Power............................................................................................... 5 What is ADHD? ................................................................................................ 10 The Birth of Normality...................................................................................... 17 The Power of Seeing.......................................................................................... 25 The Rise of Production...................................................................................... 33

VII. ADHD and Capitalism....................................................................................... 40 VIII. America in the World......................................................................................... 45 IX. A New Framework............................................................................................. 54

I - Introduction In order to understand the proliferation of attention-deficit hyperactivity disorder (ADHD) and stimulant drugs, one must examine how complex relations of knowledge and power manifest themselves in modern capitalist society. While it is possible to independently frame the current debates surrounding ADHD, contextualizing them in relation to Michel Foucaults general critique of modernity will allow us to understand the ADHD construct in a more profound way. At the same time, such an approach will reciprocally contextualize Foucaults work within contemporary society, thereby providing us with an empirical basis upon which one can understand his complex and, at times, abstract descriptions of how knowledge-power relations actualize themselves. Largely drawing on Foucaults body of work as well as the latest medical research, this investigation will elucidate the various disagreements within the ongoing debates regarding the pharmacology and pathology of ADHD. The purpose of clarifying these debates is twofold. Firstly, it will reveal that most of the controversy surrounding ADHD is precipitated by moralized judgments that are both relative and specific to contemporary society. Specific because they are contingent upon the contemporary power relations in America; and relative because they are created by patterns of thought that only arise from the knowledge produced by modern capitalist power relations. Secondly, the clarification of these debates will allow for a prognosis of how ADHD and stimulant drug use will be viewed in future generations, both in the US and on a more global scale. As it stands, ADHD is a highly controversial and, at times, taboo subject. The debates range anywhere from: disagreements about the medical legitimacy of the

condition, the ethics of using stimulants for educational gains, and the cultural implications of its highly endemic proliferation in the United States. These debates are largely the product of an amalgamation of ways of thinking that are produced by the current knowledge-power relations. At the most basic level, the currently established framework is grounded in a duality between abnormality and normality. It propounds a belief that individuals with personality types that diverge from established social normsor deviantsare abnormal in the sense that they cannot function within society without some form of intervention. From a sociocultural perspective, the current framework is also grounded in a belief that normality entails productivity. In modern America, unproductive personalities are not only undesirable due to their comparatively limited potential for social and material success, but are also considered anomalies that can be remedied through medical treatmentmore specifically, through the prescription of stimulant drugs. Given that the current understanding of ADHD is responsible for these manifold debates, an investigation of the arguments within the ongoing disagreements will reveal that most of the controversy is derived from moralized judgments that are both theoretically and empirically avoidable. By exposing these complications within the context of Foucaults critique, one may arrive at a more comprehensive understanding of this condition. Such an investigation will potentially provide an explanation for why the proliferation of ADHD and stimulant drug use is so highly endemic to the US, thereby allowing for a more accurate prognosis of the pharmacology and pathology of this condition in years to come.

II - Postmodern Power The term modernity is not merely a description of how an event or a phenomenon is temporally situated. It is also contingent upon an understanding of the symbolic departure from classical or traditional thought, and a movement towards the thought of contemporary society. What is postmodern, therefore, represents a departure away from contemporary thought. When we think of power in the modern age, one might look to the large corporations as the epitome of a new manifestation of power that did not exist in the classical age. Yet for Foucault, such a form of power is still measured in relation to the traditional conception of power. What Foucault is primarily interested in is an entirely conception of power that actualizes itself through new techniques. Postmodern power, therefore, is different from the modern power of corporations, which are still examples of traditional power in the modern age. For Foucault, postmodern power is a modern form of power that is not symbolic of contemporary thought, it is an altogether new understanding of power that bears no relation to traditional power in terms of how it actualizes itselfit differs from traditional power in three fundamental ways: it is ubiquitous, invisible, and inclusive. On the first point, Foucault understands postmodern powers ubiquity in relation to Jeremy Benthams panopticon. In Benthams panoptic prison system, the cells are organized in a cylindrical structure with a guard tower in the center, whereby the prisoners in the cells can never know whether they are being watched by the guards. On the surface, Foucaults analysis of the panopticon is meant to illustrate how observation is a technique through which postmodern power exercises itself, but the analogy primarily serves to illustrate how the guards and the prisoners are both subject to the disciplinary

power of the system that they are part of. In other words, while Foucault grants the notion of power as a nonegalitarian force, he deviates from the traditional conception of power as a force that is held to dominate a particular group from a strictly top-down relationship; rather, Foucault claims that power is multidirectional, that it is a general matrix of relations at a given time wherein power is exercised upon the dominant as well as the dominated (Dreyfus & Rabinow, 1983, p.185). In the panopticon, Foucault claims that the guards may think that they are in control and, therefore, in the possession of power, yet Foucault contends that power is not something that is held. In fact, just as corporations are shaped by the exercise of postmodern power, the guards may feel that they are the oppressors, yet they are invisibly oppressed by the control of the prison system that they are a part of. Inherent to this conception of postmodern power is the notion that we are all subject to this form of coercion, the source of which is an invisible sovereign that is inherent to the modern capitalist system. This brings us to the conception of power as an invisible exercise of oppression. The invisible manifestation of postmodern power is precisely the reason why the oppressor is unable to see that he is oppressed. Foucault claims: Traditionally, power was what was seen, what was shown, and what was manifested and, paradoxically, found the principle of its force in the movement by which it deployed that force (Foucault, 1991, p.199). Unlike traditional power, our modern form of power is unseen. Through various techniques, which I will elaborate on in the context of the medical discipline viz., hierarchization, examination, and normalizationpostmodern power is exercised through its invisibility. This dimension is closely related to the implication that there is this aforementioned third party, the invisible sovereign, driving the exercise of

postmodern power. These invisible techniques, finally, bring us to the third dimension of power that I will discuss: inclusivity. Foucaults thesis identifies the trends towards normalization not as an incidental byproduct of modernity, but as a deliberate effort to control the population through this new form of power. For Foucault, postmodern power is not an instrument of exclusion, but a pervasive pressure towards ever greater inclusion. It does not serve to objectify, exclude, coerce or punish, but rather to order and enhance life (Dreyfus, 2004). Although power is typically regarded as a violent force, Foucaults understanding of normalization as the oppressive force in postmodern power seems comparatively tame. But it is precisely this unintuitive aspect of his conception of power that serves to illustrate how the oppression of power in modernity is clandestine. In modern America, the process of normalization is a leveling force that shapes individuals in order to make them fit within the culturally accepted behaviors of society. The modern capitalist agenda is one that seeks to organize the population through a coercive exercise of normalization, which, in turn, enhances life by making individuals more productive. Lastly, we must understand that postmodern power is not an institution, and not a structure; neither is it a certain strength we are endowed with; it is the name that one attributes to a complex strategical situation in a particular society (Dreyfus, 2004). In order to arrive at a conception of power that will help us understand the current ADHD construct, one must examine the strategical relations of knowledge and power not as a way to arrive a specific definition of power, but as a way to analyze these relationships and uncover how postmodern power manifests itself. This is precisely why the aim, for

Foucault, is to move less toward a theory of power and toward a determination of the instruments that will make possible its analysis (Dreyfus & Rabinow, 1983, p.185). Through an investigation of ADHD, Foucaults analysis will come to life. While it is difficult to grasp Foucaults conception of power in the abstractwithout seeing exactly how it actualizes itself in the real worldthe current ADHD construct provides us with a canvas upon which Foucault philosophy can be grounded with empirical observation. By analyzing these phenomena in tandem with Foucaults schema of postmodern power, we may begin to see that the proliferation of ADHD and stimulant drugs is not only a model example of how such power manifests itself within society, but is also the most advanced example to this day. While Foucault identifies institutions and disciplines that exercise power in order to breed productivity and normalize individuals, the ADHD construct has gone a step further: it has created an internal drive for productivity and a framework wherein individuals are not passively normalized, but seek out normalization of their own accord. First, I will endeavor to draw out a basic genealogy of ADHD and trace out how the modern conception of the disorder has come into being. I will then discuss the changing conceptions of normality and productivity in the modern age in relation to the development of the medical discipline. I will examine these developments in relation to the ADHD construct by drawing a parallel to Foucaults understanding of postmodern power as an inherent aspect of the rise of modern capitalist society. Finally, I will situate the proliferation of ADHD and stimulant drugs within the discussion of what defines the modern capitalist agenda in order to understand why the ADHD construct is endemic to the US. The discussion will end with a prognosis of how the condition may be considered

through a new framework in the years to come, and whether its proliferation will remain circumscribed to the US, or if it will spread to other countries as well.

III - What is ADHD? The authority on mental disorders, the American Psychiatric Association (APA) classifies ADHD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as a: Persistent pattern of inattention and/or hyperactivityimpulsivity that is more frequently displayed and is more severe than is typically observed in individuals at comparable level of development (APA, 2000). The DSM-IV provides a list of nine symptoms for inattention: (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities (b) often has difficulty sustaining attention in tasks or play activity (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often looses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities and nine symptoms for hyperactivity-impulsivity: (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often on the go or often acts as if driven by a motor (f) often talks excessively (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games) It then divides ADHD into three subtypes: (1) Combined Type; (2) Predominantly Inattentive Type; (3) Predominantly Hyperactive-Impulsive Type. Those who meet six or


more criteria within the list of symptoms for inattention are classified as type (2) Inattentive, those who meet six or more for hyperactivity-impulsivity are classified as type (3) Hyperactive-Impulsive, and those who meet six within both categories are classified as type (1) Combined. If we examine the criteria for this current definition of ADHD more closely, we can see that the diagnosis is in fact socially relative. In other words, the diagnosis of ADHD depends on behaviors that are more frequently displayed and more severe than is typically observed; accordingly, it is classified as a behavioral disorder (APA, 2000). Although many conditions in the DSM depend on symptoms that are relative to socially accepted norms, it is important to note that such a category of disorders contains an inherent value judgment. In other words, the behaviors described by the symptoms that are higher than average, in this case, inattention and/or hyperactivity-impulsivity, are socially and medically regarded as undesirable qualities. While the symptoms described above do not necessitate medical attention in the way that a physical ailment might, they have been medicalized by both the medical discipline and society. The categorization of the ADHD subject as an individual that demands medical attention, therefore, directly implies that the values of modern American society reflect a judgment that impulsive and inattentive behaviors are not merely able to be changed, but that they ought to be corrected. This value judgment contained within the categorization of ADHD as a behavioral disorder not only denotes a societal belief that impulsive and inattentive personalities are undesirable, but also contains a belief that the behavior of the corrected individual reflects the norm. In other words, it would be ridiculous to assume that if it were not 16%, but 84% of the population exhibiting symptoms of persistent


inattention, that there would then be a condition known as attention-surplus disorder. We must necessarily understand the importance of the relation of the norm to the ADHD subject. In the case of a newly discovered physical disorder, there is no judgment that needs to take place; the minority of individuals affected by a physical ailment will seek out medical attention on the basis that they do not reflect the norm of how a healthy human being ought to function. In the case of ADHD we do not find a minority that seeks out medical attention, but a majority that defines the norm in relation to its own personality, and thereby imposes a belief that any deviations from this personality are undesirable, abnormal, and correctable. Should its diagnostic growth carry on at a similar rate, though, one would hope that these questions are addressed before ADHD prevalence reaches an integrity-threatening 50%. These are, quite clearly, purely speculative remarks, but their intention is to illustrate that ADHD, according to its definition, depends both on a majority that exhibits a pattern of symptoms, as well as a general opinion that the symptoms of inattention and hyperactivity-impulsivity are undesirable. Yet this was not always the case. It is widely accepted by historians of ADHD (e.g. Lange, Reichl, & Tucha 2010; Advokat, Baumeister, Henderson, & Pow, 2012) that a Scottish physician named Alexander Crichton first identified the condition in his work titled, An Inquiry into the Nature and Origins of Mental Derangement (1798). His early diagnosis, albeit surprisingly accurate in arriving at the modern conception of ADHD, described subjects who suffered damage in areas of the brain responsible for the faculty and the power of attention (Crichton, 1798). Although many scholars point to this text as the first example of symptoms of ADHD being described in a medical discourse, Crichtons agenda was


purely observational; it did not seek out to remedy individuals who exhibited an unusual lack of attention. In describing a deficiency in the faculty of attention, Crichton makes no mention of rectifying his subjects. In the modern discourse, however, ADHD is labeled as a behavioral disorder; it deals not with the observation of brain damage, but with the treatment of social behavior. According to the APA, an emotional or behavioral disorder (EBD) is diagnosed according to: A behavioral or psychological syndrome or pattern that occurs in an individual which is the first of five categorization of what can constitute a mental disorder. Our modern understanding of ADHD contains the inherent notion that behavior can and should be modified in subjects that exhibit these symptoms. This distinction primarily separates Crichtons reflections from the concept that behaviors can be medically treated. Thus, ADHD did not begin with the observation of inattention, it progressed to it only by way of attempting to remedy the hyperactive-impulsive personalities, which itself was only recently considered as a category of individuals that can and should be remedied for the betterment of society. In fact, while there is a long tradition of treating children with particularly high levels of hyperactivity, it is only until very recently that high levels of inattention have also constituted the need for medical intervention. One must, therefore, turn to the causes for behavioral control of individuals with hyperactiveimpulsive tendencies in order to account for the shift in medical knowledge from a purely observational science to a discipline that can remedy unwanted personality types. It was only until the 20th century that the denomination of deviant was attributed to individual who exhibited such socially obtrusive behaviors. As society recognized that there may be a way to correct, and not merely confine these individuals, the problem of


deviants captured the attention of the medical community. As Edward J. Comstock notes in his genealogy of the ADHD subject, George F. Stills Defect of Moral Control (1902) may be considered the first identifiable work that proposed medical intervention for hyperactive personalities. From the title itself, one can see that Stills account to correct deviant social behavior inherently contains a dimension of judgment. Still referred to his subjects as moral idiots, all of whom were children who had committed actual crimes or habitually transgressed clear moral boundaries, exhibiting reckless disregard for command and authority (Comstock, 2011). Although Stills subjectssome being criminalswere far more problematic to the well-being of society, his account represents the first initiative to medically rehabilitate deviant individuals. On the one hand, the criminal and the deviant can be differentiated by the fact that the former reflects a transgression of the law, while the latter reflects a transgression of social norms. On the other hand, while this distinction is important in considering Stills study in the modern context, we find that criminalitys dependence on the legal system makes it relative in the same way that deviant behavior is purely relative to what is considered socially accepted and desirable behavior. On the surface, it would seem that these behaviors are differentiated by the fact that criminality entails a transgression of a written law. Yet if we consider the behavior of a deviant child in a classroom, we find that the childs transgression of the rule that delineates proper classroom conduct in the schools handbook is analogous to the criminals transgression of the law. While the criminal transgressor may not be analogous to the modern ADHD subject in terms of the severity of the transgression, it is important to see how Stills study laid the foundations for an


understanding of scientific study as a method for changing social norms by moralizing unwanted behaviors and equating them with criminality. While Stills attempt provides us with an account of how medical knowledge changed in its self-estimation as a field that could uncover the primary causes for certain behaviors, it relies on a moralized premise. The proliferation of ADHD, in the modern context, was only enabled through a shift from the deviant subject being viewed as a morally or legally reprehensible individual to the deviant subject being viewed as an abnormal individual. Thus, Stills account can only be considered quasi-scientific in modern medical discourse; no modern scientific journal would seriously consider Stills study on the basis that it explicitly states its intentions as an examination of moral control. Yet when we consider how the diagnostic criteria for ADHD are moralized in the sense that they inherently consider hyperactive-impulsive and inattentive behaviors as abnormalities, we can see how the medical discipline, since Stills time, has learned to hide such moral judgments behind a veil of objectivity. While the modern medical discipline does its very best to stay away from any mention of morality, one should not be so nave as to assume that it is devoid of moral judgment. The fundamental difference between Stills description and that of the latest version of the DSM, therefore, is merely the fact that the former describes the ADHD subject as an individual that exhibits a lack of moral control, while the latter places the subject within the abnormal category. For this change to a occur, a new concept had to be introduced within the medical discourse, which would treat deviant subjects not as morally devoid individuals, but as exceptions to the rule: It was no longer the offence, the attack on the common interest, it was the departure from the norm, the anomaly; it was this that haunted the school, the court, the


asylum or the prison (Foucault,1991). This shift to the concept of normality would allow society to moralize deviants without dismissing them as incorrigible cases, to use Stills language, but rather, as anomalies. The deviant child was no longer primarily considered a problem to his peers. He became, above all, a problem to himself; one that could potentially affect society in a negative way; and one that, finally, could and should be reeducated and rehabilitated. Normality does not merely represent a lexical change. It was a new concept that restructured the medical discipline by making it the voice that defines the identity of the normal individual and a force that can shape a societys understanding of itself. Normality was not a concept that previously existed and was simply ignored in the medical field. It was a new form of measurement and estimation that would change the way in which humans situate themselves in society, thereby fundamentally undermining their own knowledge; it transferred the power of self-estimation from society to particular disciplines. While the conceptualization of the norm has fully integrated itself into the modern discourse, it bears a disconcertingly unshakable aspect of relativity. For what does it truly mean to be normal? Is it purely a relative measure, one that has no inherent meaning? To answer these questions, one must trace the development of the medical discipline as a body that has redefined social norms by shifting the structure of knowledge in modern America.


IV - The Birth of Normality In any civilization, cultural practices reflect a degree of truth, yet the source of their legitimacy greatly differs. For the Aztecs, the practice of human sacrifice reflected a belief in their religion, legitimized by the priest. In contrast, for the Japanese kamikaze bombers during World War II, the practice of human sacrifice reflected a belief in the principles of nationalism, legitimized by the emperor. In the case of modern medicine, the practice of seeking medical assistance reflects a belief in medicine itself, legitimized by the doctor. What is interesting about the case of modern medicine is that it underwent a radical transformation with the advent of psychiatry. The practice of seeking medical assistance was transformed on the basis that the notion of the medical condition was changing from the visible to the invisible. In other words, medical assistance no longer merely applied to the remedying of physical ailments; it became a way to evaluate conditions through the observation of deviant social behaviors that are caused by dysfunction in the mind. Although the practice of seeking medical assistance changed, the belief in medicine and the legitimization of the doctor remained. In fact, the advent of psychiatry gave the medical profession a newfound dimension of power by enabling the reintegration of individuals who deviate from the norms of society. It is important to note that this change did not come about fortuitously. The advent of the medical clinic in the 19th century, as a space where patients also became the objects of research for medical students, forever changed the doctor-patient relationship. This change occurred through a clearly identifiable progression. First, as the medical clinic develops into a space that educates the young in order to produce more efficient doctors, it gains a dimension of organization that inherently breeds rank and competition.


In turn, the organization of the medical discipline and the development of the clinic changes the way medicine is societally perceived, most prominently, by giving the doctor an unprecedented degree of legitimacy. Foucault identifies the root of this transformation as a need for qualification. When the medical field gained momentum in France during the 17th century, the government decided that certain measures had to be taken against malpractice. These medical reforms, i.e., Cabanis Intervention marked a stage at which ideology was to take an active, and often determining part in political and social restructuring (Foucault 1973, p. 78). As the need for qualification developed, the medical discipline became more organized and efficient. One need only look at the medical profession today in order to see how the qualifications of rank and competition have flourished within this highly structured discipline. The medical students who get the highest MCAT scores are allowed to choose the best medical schools. Those who get the highest scores on their medical exams may then choose the best hospitals to do their rotations. They are provided the best resources to treat their patients and may perhaps, one day, establish a practice of their own. In turn, this develops into a hierarchy on the side of the patients; in other words, the individuals who have the best access and the greatest economic means notwithstanding the power of having connections are able to see the most qualified professionals, conveniently ranked for them by the latest issue of: The Best Doctors in America.1 While the medical discipline is epitomic of the processes of hierarchization and examination, it is only one example of a process that was by no means specific to medicine; in fact, it reflects a broader movement in contemporary society as a whole.

Yearly publication founded in 1989 by the Harvard Medical School:


One need only look at the educational system in general to see the extent to which it is structured so as to differentiate and judge individuals based on performance. These processes give disciplines and institutions a certain degree of fluidity in the implementation of systematic procedures, thereby enhancing productivity. More importantly, with the establishment of the examination and the entire system of writing that accompanies it, every discipline is able to compare individuals by measuring their abilities according to a particular standardto a particular norm. By the middle of the nineteenth century, the normal is established as a principle of coercion in teaching with the introduction of a standardized education and the establishment of the cole normales2 (Foucault, 1991, p. 196). While it may seem overly polemic to describe the concept of normality as a principle of coercion, Foucault understands normality as a means to oppress individuals through classification. The effort to establish a hierarchical system not only gives the medical discipline a newfound legitimacy; it fundamentally undermined the power of self-knowledge. Medical treatment is no longer a question of a difference in the object, or the way in which the object is manifested, but of a difference of level in the experience of the knowing subject (Foucault, 1973, p. 81). In objectifying the patient, the medical discipline shifts the doctor-patient relationship away from mutual understanding and towards the sovereignty of the medical discipline. The conceptual introduction of the norm gives the doctor a new dimension of power in the estimation of the patient, and the doctor acts on behalf of the invisible sovereign power that normalizes society. In other words, the patient no longer measures her need for medical assistance through self-

Teachers training colleges


estimation; she simply provides all the information that would be used to decide whether she needs treatment, and places the ultimate decision in the hands of the doctor. This change is a microcosmic example of a broader epistemological shift away from the Cartesian values that placed self-knowledge at the apex of human understanding during the Enlightenment. Self-knowledge is gradually undermined in the face of the more complex and inaccessible knowledge of a body that grows and expands through collective, disciplinary knowledge. Despite the fact that we apply the concept of normality systematically in contemporary society across various disciplines and in everyday language, the introduction of this term represents much more than an expansion of vocabulary. The advent of normality as a perspectival change in knowledge, as a new method of selfunderstanding, is what places it at the crux of the transformation in medical discourse. Eighteenth century medicine related much more to health than to normality; it did not begin by analysing a regular functioning of the organism and go on to seek where it had deviated, what it was disturbed by, and how it could be brought back into normal working order; it referred, rather, to qualities of vigour, suppleness, and fluidity, which were lost in illness and which it was the task of medicine to restore Nineteenth century medicine, on the other hand, was regulated more in accordance with normality than with health; it formed its concepts and prescribed its interventions in relation to a standard of functioning. (Foucault, 1973, p. 35) In terms of power relations, the transformation from health to normality gave the medical discipline an unquestionable power of estimation. This shift in power was only possible through the accompanying epistemological shift that led the patient to understand illness not as measure of ones self-estimation, but as the measure of an organized body that decides on the individuals behalf whether medical attention is needed.


With the birth of the medical clinic, the doctor-patient relationship loses its reciprocity; it was no longer a matter of mutual effort, of the physician working with the patient to arrive at the goal of healing: It was no longer the gaze of any observer, but that of a doctor supported and justified by an institution, that of a doctor endowed with the power of decision and intervention (Foucault, 1973, p. 89). The patient, as the object of medical examination, no longer has any role in dictating the terms of his recovery; rather, he is analyzed by a doctor whose sole intention is to bring the patient back to what is considered normal. With introduction of psychology and its subsequent medicalization, the patients self-understanding is fundamentally undermined. While a person with a physical ailment may have a better grasp on her condition than the doctorfor example, in describing areas of her body that may be causing pain but that have no discernible injurya subject with a mental ailment is fundamentally undermined by virtue of the fact that the information she provides is subject to her mental deficiencies. While this is not necessarily the case, the psychological and psychiatric disciplines are structured in a way that gives the doctor complete autonomy in the process of diagnosis. This ideological shift allowed for the possibility of a constantly changing definition of normal. While the norm as defined in the 19th century represents physical suffering, psychiatry circumscribes the normal individual into a progressively tighter space. With every discovery of a new mental condition, the patient is exposed to an everexpanding world of seemingly endless classifications that gradually decreases the possibility of her being normal. It is this very circumscription that Foucault admonishes on the basis that it establishes a system that subordinates those who are outside of it. The creation of the normal type forms a hierarchy between normality and abnormality, which


thereby denies certain personality types an alternate form of reality. As processes and behaviors are normalized, Foucault fears that they are not merely considered medical judgments, but that they become more profoundly engrained within society as natural truthsas inevitabilities of human existence. Perhaps, humans are predisposed to transport their own cultural beliefs and practices from their status quo of how things are into a broader schema of how things ought to be. In any case, the tendency to place phenomena into this latter category inherently creates artificial conflicts and divisions. Be that as it may, the more society develops, the more complex and clandestine these judgments become. While most developed societies would unilaterally agree that it is irrational to persecute left-handed people on the basis that they are evil because humans ought to be right-handed, when we discuss whether society ought to correct inattentive individuals using stimulant drugs, opinions become divided. The modern conception of ADHD, on the one hand, normalizes the individual by proclaiming that inattentive and hyperactive-impulsive personalities are abnormal. While there is a primary concern that inattentive and hyperactive-impulsive personalities are stripped away the freedom to exist in their uninhibited mental states, the effort to rehabilitate them is simply the result of their inability to integrate themselves into society. The more profound concern is that the rest of society will generally accept ADHD personality types as anomalies, and will believe that qualities such as calmness, lawfulness, and productivity are not simply ways in which individuals have to behave in order to be accepted in contemporary society, but that they are ways in which human beings are naturally meant to be.


The semantic consequences of the perspectival change in medicine can also be observed in the etymology of the word physician. The term bears anachronistic nuances, precisely because traditional medicine related to a concept of medical professionals as healers of physical ailments. Since then, the term no longer carries the same weight in everyday language; this is because medicine no longer merely applies to physical processes. Instead, the term doctor has found its place in our modern discourse. The root of the word doctor comes from the Latin, docere, to teach. This denominative change directly reflects the primary designation of the doctor not as a healer but as a teacheras a member, de jure, of a medical clinic that is designed to educate and discipline its students. Likewise, the use of the term clinician has broadened its scope to describe psychologists, thereby reinforcing the professions medical legitimacy. The psychologist, previously confined within the space of theoretical studies, now retains the same stature in the clinic as a surgeonnot merely by virtue of her denomination, but also by that of her influence in the medical discipline. When we consider ADHD in the modern context, we are faced with the notion of a behavioral disorder as a list of symptoms that constitute unwanted social behaviors. The medicalization of social behavior that began with George Stills experiment is now ingrained within the discourse of modern medicine to the point that behavioral disorders have become just as important to medicine and to society as physical disorders. They are both identifiable, in some way; they can both be treated; and they can both be remedied in many cases. Yet the concept that unwanted patterns of behavior may constitute a medical condition was only possible once deviant or abnormal behaviors could be contextualized in the same way as physical ailments. This shift was only made possible


with the advent of psychiatry; it represented a new way of seeing, a new way of identifying illness and defining normality, as a result of which the relations of human knowledge to what is visible and what is invisible would be radically transformed.


V - The Power of Seeing The paradoxical nature of the power of normalization is that it imposes homogeneity by encouraging certain behaviors in terms of a new standard; yet at the same time, it individualizes by making it possible to measure gaps, to determine levels [introducing] all the shading of individual differences (Foucault, 1991, p. 197). Yet the birth of normality not only highlighted minor differences, it also created a new standarda benchmarkwhich was not previously understood. Inherently tied to the restructuration of various discipline through the processes of hierarchization and normalization is a change in what we consider visible. Aside from the movement towards greater organization and efficiency, the development of the medical discipline also had the secondary effect of shifting what Foucault calls the medical gaze. It should be noted that the original French term, regard, implies both visual gaze, but also the English term, regardas in estimation. This ambiguity, which is lost in translation, serves to illustrate how the medical discipline, underwent superficially identifiable changes regarding its increasing organization, but also made certain things visible in the sense of new ways of understanding. For example, the process of hierarchization renders qualifications visible in the first sense of the word: it establishes over individuals a visibility through which one differentiates and judges them (Foucault, 1991, p. 197). Yet in the second sense, it also indicates how through the process of hierarchization the medical discipline underwent broader and more complex changes in perception, both in terms of how society regards medicine, as well as the way in which medicine regards itself in relation to society.


The changes that constitute the reorganization of the medicinal discipline represent a change in power relations that, in turn, redefined our knowledge. Yet we should not understand such relations of power and knowledge as causally distinct phenomena; we should admit, rather, that power produces knowledge; that power and knowledge directly imply one another; that there is no power relation without the correlative constitution of a field of knowledge, nor any knowledge that does not presuppose and constitute at the same time power relations (Foucault, 1991, p. 175). The power that the medical discipline gained in its discernment and estimation of patients undermined the previously established framework of the Enlightenment. Self-knowledge, in the Cartesian tradition, stood at the apex of human understanding, but the changes in the medical discipline gave the doctor was only possible through an accompanying shift in the relations of visibility and invisibility in medical gaze. The establishment of the concept of normality in medicine precisely reflects such a change in what is visible, not in terms of observation but in terms of conceptual understanding. Likewise, one could understand the examination in the same sense as a process that makes visible the shading of individual differences, and thereby changes the way we measure ourselves and one another. At the earliest stages, the medicalization of psychoanalysis represents a shift from the visible to the invisible. Unlike the physician and the surgeon, both of whom are concerned, above all, with conditions that manifest themselves in visible ways, the psychoanalyst primordially operates in a domain that is inaccessible to the faculty of human eyesight. Medical treatment is, thus, no longer merely an empirical, quantitative science; it gains a dimension of qualitative measurement. Psychoanalysis is a discipline


that is discrete in its cyclicalityit is the human brain working to understand itself; the analyzing subject is the analyzed object and the analyzed object is the subject herself thus, the subject brings into question its own validity. Above all, psychoanalysis is a bottomless endeavor: [It forms] an undoubted and inexhaustible treasure-hoard of experiences and concepts, and above all, a perpetual principle of dissatisfaction, of calling into question, of criticism and contestation of what may seem, in other respects, to be established. For the first time, the medical field would delve into a domain of empirical uncertainty. While other sciences construct and reconstruct themselves through representation, psychoanalysis advances and leaps over representation (Foucault, 1970, p. 373-374). Yet with the technological advancements of the last several decades, the shift is reversed once more. By giving human eyesight the power to observe neurobiological processes, the causes for the conditions that were previously considered invisible became visible. This shift was not merely empirical; it was not simply that a veil was lifted with regards to the observation of physical processes in the brain; rather, the change was also fundamentally epistemological in the sense that the concept of understanding psychoanalysis through visibly identifiable procedures was not even a theoretical possibility. If we look back to Freuds conceptions of instinctive drives, we find that it is far removed from the conception of pleasure in contemporary medicine as a release of neurotransmitters. In fact, Freuds time not only reflected a lack of understanding, but an embracement of this uncertainty. One need only look at the concurrent Surrealist movement to see that human self-understanding operated in a domain of darkness and


uncertainty. In these early stages, though perhaps not explicitly stated, psychoanalysis represented a rejection of normality and an embracement of deviancy. Following in the footsteps of the Surrealists, the Dadaists subsequently mocked social convention, instead emphasizing the illogical and the absurd. Without the process of medicalization, psychoanalysis could only reveal truths that fundamentally questioned normality. As these movements came to an end, however, the empirical uncertainty of psychoanalysis was progressively demystified with every discovery in the field of cognitive science. The uncertainty that grounded the Surrealists and the Dadaists was undermined by causal and observable scientific explanations. Be that as it may, there is an extent to which the visibility of certain mental disorders still remains invisible to human understanding. In other words, the debates currently surrounding ADHD in the medical community are fundamentally rooted in the relation between the visibility of certain biological patterns in the brains of ADHD subjects, and the invisibility of the link between social behaviors and the increased activity of certain parts of the brain. Most of the debate surrounding ADHD in the medical community arises from the idea that visible brain activity constitutes a mental disorder. On this front, the medical community is highly divided: Despite being unable to point to a definitive link between specific biological regions or neurologic components, there is a strong foothold of individuals in the medical community who posits neurobiological dysfunction as the cause for behaviors said to indicate [ADHD] and psycho-pharmaceuticals as the solution (Graham, 2006). There is a clear discrepancy between the individuals who posit this model outlined by Graham, and the reality of the


matter; namely, that there are no specific cognitive, metabolic or neurological markers and no medical tests for ADHD (Timimi & Taylor, 2004). Because it is clear that there is a substantial lack of evidence for this model, there are many individuals who work to oppose such medical falsities. In a letter signed by sixteen Ph.D.s, all members of the American Psychological Association, certain concerns were raised to the attention of Dr. Alice Rubenstein, Director of The Brochure Project, a joint effort of Division 29 (Psychotherapy) of the APA and Celltech Pharmaceuticals to publish and distribute brochures on Attention Deficit-Hyperactivity Disorder (ADHD). The brochures supported by Dr. Rubenstein made three controversial claims: 1. ADHD is generally considered a neuro-chemical disorder. 2. Most people with ADHD are born with the disorder, though it may not be recognized until adulthood. 3. ADHD is not caused by poor parenting, a difficult family environment, poor teaching or inadequate nutrition. Citing an abundance of information as evidence, the doctors proceed to adamantly deny each claim, and conclude: As a body of practicing psychologists, we acknowledge before the public and one another that what we believe about ADHD is based on neither adequate nor established scientific fact but is instead a reflection of cultural and societal forces that have influenced our theoretical, research, professional, and practicing agendas (Galves & Walker, 2002). Thus, the ongoing medical debate regarding the etiology of ADHD can be broadly summarized as a case of the age-old correlation proves causation fallacy. In other words, researchers recently have discovered genetic, neurobiological correlations amongst patients diagnosed with ADHD and this data, in turn, is used to substantiate the claim that ADHD is a neurobiological disorder. This is precisely the sort of reasoning


that the sixteen psychologists in the letter referenced above are fighting against on the basis that one cannot use correlative brain functions to substantiate the causation of a dysfunction in the brain. Their counterproposal correctly argues that finding correlative links between patients does not validate the claim that ADHD is a neurobiological disorder. While there is an extent to which correlations of this type may indicate the existence of a neurobiological disorder, there must be a link between the evidence and a biophysical ailment in the brain. Alzheimers disease is a considered a mental disorder not because there is similar activity in parts of brain among various patients, but because the negative symptoms of the condition can be traced to an activity that is visibly and physically harmful to the brain. It is clear that the correlation of higher than average activity in parts of the brain for ADHD subjects is not analogous to the deterioration of the brain observed in Alzheimers patients. The same way that investigators from Harvard Medical School (McGreevey, 2012) recently identified similar activity in the response of the amygdala, a part of the brain that controls emotion, in a group of people who underwent meditation trainingweeks later even when they were not in meditative statessuch a correlation does not imply that meditation constitutes a neurobiological disorder. Likewise, the fact that inattentive subjects share similar activity in certain parts of the brain does not mean that ADHD is a neurobiological disorder. For Galves & Walker (2002), the cultural and societal forces represent a threat to the integrity of the medical discipline; yet these forces are more profoundly indicative of how the power relations in the modern American capitalism system engender the cultural value of production throughout society. Power, in this sense, not only reflects the knowledge of a society, but also defines certain cultural values and practices through that


very knowledge. Indeed, as Foucault tells us: Power produces; it produces reality, that is, it determines what it makes sense to believe and to do (Dreyfus, 2004). As the power to change how ADHD diagnosis functions in the medical discipline is exercised, the general view of ADHD in society is shaped to reflect the medical practices. The more doctors systematically prescribe stimulants for ADHD diagnoses, even in cases of mild inattention that may not necessarily demand drug-treatment, the more society believes that such cases of inattention warrant drug-treatment. This changing shift in knowledge is precisely why Foucault believes that postmodern power produces reality. It begins by changing the way we view certain personality traits, and eventually changes the way we treat the individuals who exhibit those traits. The power acquired by the psychiatric disciplines in the 21st century shapes the reality of a society by defining new beliefs and practices without its constituents having any awareness of it. The early conceptions of ADHD began with an effort to curb deviant behavior, yet at a broader level, the process of normalization represents a deliberate attempt to control the population in order to breed more productive individuals and enhance the conditions of life. As the diagnostic criteria for ADHD become more structured, the inattentive individual is led to believe that normality entails production, and that his lack of attention and focus is an anomaly. At the same time, one must also ask whether production enforces normalization. Although we may understand how the desire to enhance social order by leveling deviant behavior enables a more productive society, there is also an extent to which the value of productivity instills within society a desire to be normalized. Thus, we must contextualize the value of production within the development of modern American society, and in tracing the relationship between


production and normalization, we may understand how and why the modern framework of ADHD not only enhances productivity through normalization, but also normalizes productivity in itself.


VI - The Rise of Production According to the National Institutes of Health, a government agency, ADHD is the most commonly diagnosed behavioral disorder of childhood (NIMH, 2012); their latest reports reveal that the syndrome also affects 8.1% of the American adult population (NIMH, 2005). But more so than its prevalence, the rate at which ADHD diagnoses have increased in recent years is unprecedented. The Center for Disease Control and Prevention reports that ADHD prevalence rose from around 5% of the total U.S. population in 1976, up to 16% in 2000, with diagnoses increasing by 22% from 2003 to 2007 (CDC, 2012). The main courses of treatment for ADHD-diagnosed subjects are methylphenidate (Ritalin) and amphetamine (Adderall), both of which are psychostimulants. Data gathered by the Drug Enforcement Agency reports that prescriptions for both of these medications increased from less than 3 million in 1991 to over 15 million by 1999, with the U.S. producing and consuming 85% of the worlds methylphenidate (DEA, 2000). From these statistics, it is apparent that the proliferation of ADHD is correlated with a significant increase in diagnosis as well as in prevalence of stimulant drugs. But long before the advent of these drugs, there were various changes in the perception of how society should deal with deviant subjects. When George Still studied his patients he had the intention of rehabilitating them for their own sake. His intentions, while perhaps passively looking to the general well-being of society, were primarily intended to reeducate and understand moral idiocy. But as previously noted, there was already a shift in the social perception of the deviant subject that strayed away from moral character and its relation to the criminal act, instead, directing itself towards


understanding the subject in relation his or her deviation from the norm. At the same time, another shift occurred away from the seclusion of the deviant subject, and towards an interest in assimilation and social inclusion. It is important to note that the shift in the social perception of the deviant subject occurred long before the advent of stimulant drugs, and was actually initiated by a shift in the utility of confinement. During the seventeenth century, confinement acquired a new meaning. On the one hand, it maintained the repressive function that Still was concerned with, in terms of rectifying moral character, yet it was no longer merely a question of confining those out of work, but of giving work to those who had been confined and thus making them contribute to the prosperity of all work was not only an occupation; it must be productive (Foucault, 1991, p. 132). In this sense, it would not be irrational to consider ADHD diagnosis a method of psychological and behavioral confinement that is designed to enhance social order. In order to maximize general prosperity, in order to gain a return on the investments that society makes by dealing with the problem of deviants, the changing practices of prisons, penitentiaries, and detention centers alike represent the birth of a utilitarian drive that would continue to spread throughout various institutions and disciplines. This changing notion of workno longer as an end in itself but merely a means to the end of productionreflects an underlying agenda towards social order by way of increasing utility. This perspectival change is precisely the result of an exercise of modern power that seeks to include rather than quarantine deviant behaviors. While the shift in the social perception of the deviant subject may seem logical, or even natural, it is the result of a deliberate exercise of power that seeks to dominate


societynot through oppression, but through docility. Foucaults thesis identifies the trend towards normality and productivity not as incidental byproducts of modernity, but as a deliberate effort to control the population. Although he grants the notion that power is non-egalitarian, he deviates from the traditional conception of power as a force that is held to dominate a particular group from a strictly top-down relationship; rather, Foucault claims that power is multidirectional, that is a general matrix of relations at a given time wherein it is exercised upon the dominant as well as the dominated. In capitalist society the modern form of power is a complex strategical relationship; it is characterized by increasing organization of population and welfare for the sake of increased force and productivity (Dreyfus & Rabinow, 1983, p. 7-8). The modern capitalist agenda operates through power relations that control the population by normalizing the archetype of the modern American and by maximizing productivity through a process of ever-increasing organization. As this agenda gains momentum, the conception of productivity as a socially useful act converges towards the notion that productivity is a social norm. These changing knowledge-power relations, thus, redefine the objective reality of the modern capitalist society, culminating in a redefinition of self-understanding. In other words, the power that is tied to the control of deviant subjects produces reality by changing the societal understanding of production; this shift in knowledge, in turn, creates more productive individuals and a more productive society. Finally, at the most profound level, this process ingrains within the identity of the modern capitalist a belief that production, as a norm, is also a means to achieve a greater endthat is, happiness. Thus, the eudemonic drive that stands at the crux of human self-understanding is redirected.


In the context of ADHD, the normalization of productivity could only actualize itself into its current state through the medicalization of stimulant drugs. It was only until the mid-twentieth century that the benefits of using stimulants to reduce deviant behaviors would be observed more closely. Charles Bradley famously performed a series of Benzedrine Experiments in hopes that stimulants would supplement psychotherapy and work to reduce hyperactivity and other behavior problems, improve schoolroom adjustment and academic performance, and improve psychometric test scores. Yet Bradleys experiment also represented a shift in the intentions of rehabilitating deviant subjects. While rehabilitation was once, for Still, an attempt to understand the subjects reckless disregard for command and authority (Comstock, 2011), it soon became apparent that were various other advantages that go beyond the attempt to rectify moral character: namely, societal benefits. With regards to the benefits of ADHD diagnosis, few have summarized its advantages as well as Lawrie Reznek: Such a mental illness has many advantages. First, it enables us to treat such deviant behaviour with drugs millions of children have been sedated with methylphenidate. Second, the classroom disruption is cured teachers can now devote their time to more rewarding pupils. Third, the parents can avoid the guilt associated with producing an inferior child or with failing to raise their child correctly. They can explain away his or her poor school performance by reference to a disease that needs treatment. Fourth, the other children are able to benet from the decrease in classroom disruption What started o as being a problem for parents, teachers, and other children, ends up beneting everyone except those who end up being sedated and depressed on the drugs. (Reznek, 1991) Reznek does well to illustrate the extent to which the ADHD construct responds to various utilitarian motives. His summary shows us how the diagnosis and the use of stimulants resolves disruptive behavior and enhances the classroom environment for the teacher as well as for the other students. But Rezneks observations also capture another,


more nuanced form of utility. With respect to the parents being able to avoid guilt, we find an indirect motivation that comes from self-interested intentions. In other words, it makes sense that the teacher has a responsibility to maintain an ordered classroom vis-vis the school and the parents of the children; likewise, the children in the classroom should be entitled to an education without having to be disrupted by another child; thus, the parties involved are all directly affected by the deviant child. In the case of the parents, though, we find motivations that are neither conducive to social order nor directly affected by the behavior of the child. Were it socially acceptable to have an inattentive or impulsive child, the parents would not feel guilty in their being associated with the childs behavior. Rezneks observation thereby capture a surreptitious form of utility that depends more on social pressurein terms of how he parents social lives and social standing are indirectly affectedas opposed to the societal pressure associated with the correction of directly problematic behavior. While it would be unfair to assume this these observations reflect every case of ADHD diagnosis, we must recognize that this is a realistic characterization of how such a diagnosis may benefit the various parties involved. From the perspective of productivity, the efficiency of stimulant drug treatment for the treatment of deviant behavior is unparalleled. It is not merely that the deviant is no longer a problem to societyquarantine would achieve the same endrather, the deviant can now be assimilated into a society and made to contribute to the productive workforce. The utilitarian motives in Rezeks description are directly correlated with the evolution of ADHD with respect to its gradually expanding scope in diagnostic criteria over the last century. What started out as a the Hyperkinetic reaction of childhood


disorder in the 1968 publication of the DSM-II, would soon become attention deficit disorder (with or without hyperactivity) in the 1980 publication of the DSM-III (Lange et al., 2010). As ADHD developed into the condition that it is today, the diagnosis would no longer merely be used to maintain social order, but would represent a way to make inattentive individuals into productive ones; by the end of the century, deviant and antisocial behavior was no longer the sine qua non of the disorder maladjusted social behavior is a sufficient but by no means necessary diagnostic principle (Comstock, 2011). The intention of ADHD diagnosis, thus, gradually shifted away from a primary concern for social order, and towards the general breeding of more productive individuals. On the one hand, there is a superficially identifiable cause that accounts for the proliferation of stimulants. With respect to Rezneks observations, there is an underlyingyet unspokenargument that the ends of diagnosis justify the means. In other words, doctors begin to regularly prescribe stimulants on the basis that, even in the case of a misdiagnosis, the effects will generally be positive. While it may seem like this approach is socially accepted, the latest research reveals otherwise. In a survey3 conducted by Harold Koplewicz, MD., president of the Child Mind Institute, 32% of parents said they believe that ADHD is sometimes more a result of insufficient or absent parenting rather than a true medical condition, and 72% said they believe that doctors and parents are too quick to put kids on medication for ADHD rather than looking for other solutions (CMI, 2012). It seems odd, to say the least, that despite this apparent awareness and reluctance to prescribe stimulants, there should still be a rapidly increasing

In a sample of over 1,000 people


rate in diagnosis. Likewise, the evidence that Galves & Walker (2002) provide reveals that the medical community, while perhaps not unilaterally, is also opposed to the understanding of ADHD as a neurobiological disorder from the very same concern that the systematic prescription of stimulants can be harmful to children and adults alike. As we begin to trace the various sources for the proliferation of ADHD and stimulant drugs, it becomes apparent that while there is, on the one hand, a trend towards increasing diagnosis, which naturally entails more drug treatment, there is also, on the other hand, a motivation to seek out stimulant drugs that entails ADHD diagnosis. In other words, the rapid increase in diagnosis of ADHD and the proliferation of stimulant drugs should also be considered from the desire to acquire stimulant drugs for social and recreational endeavors, thereby suggesting that healthcare professionals are prescribing stimulants in cases that do not necessitate drug treatment but are, nonetheless, beneficial to the diagnosed subject for other reasons. These ulterior motives for ADHD diagnosis fundamentally rely on the capitalist drive towards productivity that is instilled in modern American society.


VII - ADHD and Capitalism The desire to assimilate the ADHD subject and breed productive individuals for the general prosperity of society is not an incidental occurrence; it results from a deliberate exercise of power. While one may understand this exercise of power as the product of modern capitalist society, in the case of ADHD, the question is whether we should attribute its proliferation to the modern capitalist agenda alone, or if it is also caused by certain values that are specific to American society. If we are able to answer this question, it may be possible to understand why the proliferation of ADHD and stimulant drugs is so highly endemic to the US. In attempting to unearth the underlying causes of the medicalization of the inattentive personality and the use of stimulant drugs, one must turn to the network of economic and political institutions within modern American society. When considering the perspectives outlined above in relation to the statistical data, one necessarily wonders whether the proliferation of ADHD can be attributed to over-diagnosis. However, recent scholarship reveals that there does not appear to be sufficient justification for the conclusion that ADHD is systematically over-diagnosed, yet, this conclusion is generally not reflected in public perceptions or media coverage of ADHD (Sciutto & Eisenberg, 2007). Be that as it may, the studies that examine overdiagnosis measure prevalence in relation to the criteria outlined by the DSM-IV. In all likelihood, this discrepancy between the public perception and the actual prevalence comes from a discrepancy in the interpretation of over-diagnosis. Unlike Sciutto & Eisenberg (2007), the public perception of over-diagnosis is rooted in a belief that symptoms of the inattentive-type ADHD subject do not constitute a medical disorder.


Of course, there are still many publications that consider the entire ADHD construct a fraudulent enterprise. In his best-selling book, The ADHD Fraud (2006), Dr. Fred Baughman argues that ADHD is an epidemic driven by economic profit motives. While there is something to be said about understanding the proliferation in terms of social and cultural influences, Baughmans skeptical account propounds the belief that the entire ADHD construct is a lie. Instead of trying to understand and resolve the ongoing debates, such accounts ignore the historically situated meanings we give to the behaviors that constitute this disorder, and tend toward a false dichotomy whereby we are forced to imagine the disorder as medical and real or socially constructed and unreal (Comstock, 2011). One must, therefore, evaluate the economic dimension not as a corporate conspiracy, but as a combination of social and cultural forces. While these skeptical accounts only reinforce the debates that prevent a new understanding of this condition, they are still right to point out that there is a clandestine system of economic motivations that enables and reinforces the rapid proliferation of ADHD. If we try to consider this notion of a cultural construct as not merely a fictitious construct in the sense that the aforementioned skeptical accounts proposes, we may begin to see that the source for the motivations behind the proliferation of ADHD goes beyond the corporate profit motive. A recent investigation of the financial ties between the pharmaceutical industry and panel members responsible for the revisions of the DSM revealed that 56.7% of panel members have nancial ties4 to the pharmaceutical industry, and in the category of

Financial associations of interest for this study include: honoraria, equity holdings in a drug company; principal in a startup company, member of a scientic advisory board or speakers bureau of a drug company; expert witness for a company in litigation; patent or copyright holder; consultancy; gifts from drug companies including travel, grants, contracts, and research materials.


disorders that includes ADHD, 61.9% have financial ties to the pharmaceutical industry (Cosgrove, Krimsky, Vijayaraghavana & Schneider, 2006). While there are certainly financial ties between the pharmaceutical companies producing stimulant drugs and those in charge of revising the diagnostic criteria for ADHD, one must acknowledge that there is an underlying motivation that brings us back to the normalization of the American population. In other words, the corporate motive is merely one component of a network of complex relations between the educational, the medical, the social, and the economic spheres of society, all of which can be chiefly attributed to a reevaluation and a normalization of values. If we attempt to frame the process of normalization in relation to the modern medical system, Foucaults conception of postmodern power as a clandestine method to order and enhance human life becomes all the more apparent. One of the fundamental aspects of Foucaults conception of power in modern capitalist society is that it is exercised through its invisibility (Foucault, 1991, p. 199). On the surface, we find that the financial ties described here are invisible in the sense that it becomes increasingly difficult for the medical discipline to identify and expose cases of doctors being influenced by economic agendas. While the letter referenced by Galves & Walker (2002) provides us with one example of such a case, there are many factors working against these doctors. Broadly speaking, what we find is a profit-dependent pharmaceutical industry and a high-status profession looking for new roles, both of which establish the ideal cultural preconditions for the birth and propagation of the ADHD construct (Timimi & Tayor, 2004). However, many people are even aware that the medical system is structured in this waythat pharmaceutical companies providing research grants to


doctors who control the diagnostic criteria for the conditions that allow for prescription of certain medications is neither illegal nor frowned uponin fact, it is so commonplace that more than half of the revisers are identified as having financial ties. While this system is invisible both in the sense that is becomes increasingly difficult to identify instances of unprofessional medical practices, it is also invisible in the sense that it occurs without the public being aware of its existence. That being said, there is a another, more pernicious, form of invisibility, which occurs as an exercise of postmodern power through the relationship between medical knowledge and the knowledge that defines the cultural values and beliefs of modern American society. This is precisely how we may contextualize Foucaults claim that power produces domains of objects and rituals of truth (Foucault, 1977). In modern America, the medical system self-propagates its power by establishing a reciprocal relationship between economic power and medical knowledge. In other words, the medical system has become structured so that the economic agenda of pharmaceutical industries producing stimulant drugs first affects the medical understanding of the conditione.g. (Galves & Walker, 2002)but it also begins to affect how society view the condition. In this sense, we find that the agenda that drives this modern capitalist productivity does not stop at the pharmaceutical company. Rather, the company is part of a broader system wherein the oppressor that is exercising visible powerviz. the medical financial tiesis unable to see that they are being oppressed by an exercise of invisible power; one that is pervasive throughout the entire modern capitalist system. This precisely reflects the multidirectional power structure that is described in Foucault analogy of the panopticon. The pharmaceutical company may very well believe itself to


be the oppressor, yet it fails to see that its agenda is not merely driven by financial gains, but by a systemic drive that engenders an agenda of normalization and productivity throughout modern American society. While it is possible to see how the modern medical system is a product of the form of postmodern power identified by Foucault, this would still fail to explain why ADHD is endemic to the US, for many other countries have adopted capitalist economies that are also driven by production and normalization. Considering that the US currently represents the most capitalist society in the world, it may be difficult to truly distinguish between modern capitalist values and American values. Despite the fact that the two may be intertwined, if we are able to roughly distinguish between the two, it may be the case that many of the stereotypes of American society may, in fact, only be contemporaneously specific to American culture by virtue of the fact that it is the most advanced capitalist societynot due to any primordially cultural differences. While this may seem like a debate about what we should label these values, if we understand particular aspects of modern American culture as inevitabilities in the development of modern capitalism, it would follow that other capitalist societies will begin to resemble and adopt these very same values. In fact, one need only look at the influence of American culture throughout younger generations around the world to see the extent to which capitalist societies may be predisposed to resemble contemporary American society.


VIII - America in the World The 21st century marks a period of great technological leaps in the United States, and with it comes a strong reinforcement of capitalist values. However one may choose to define the character of this nation, it would seem that one value stands above all the others: few would debate the contention that industriousness is at the cornerstone of the American identity. In the most general sense, industriousness has a goal; success, in all its complexities, whether it is defined through wealth, happiness, love, or good heath, is measured in terms of prosperity. And to achieve such prosperity, one must value industriousness as the fundamental ingredient, as the quintessential means to the proverbial end that is The American Dream. But what of industriousness, per se? The notion of hard work must necessarily be complemented by the object that is being worked on; and as such, it would seem that the object of industriousness is just as, if not more, important, than the act of exertion. Yet in our modern age, this view is quickly decreasing in popularity. As the value of industriousness continuously grows within the undercurrents of the modern American identity, it no longer becomes an ingredient, but rather, resurfaces as the recipe itself. It denies its own identity as a means to an end and seizes the opportunity to become the coveted end in and of itself. While this concept may not seem particularly striking, one need only look at the latest research comparing the success rates of intrinsic and extrinsic motivators to see how this ideology manifests itself. The extrinsic constitute material gains, like cash rewards, while the intrinsic constitute qualitative gains, like increased self-worth. In recent years, psychologists have begun to examine the relationship between productivity


and motivational factors to see whether individuals perform better when they are motivated by extrinsic or intrinsic gains. The results of many of these studies have shown that in intellectual processes, extrinsic motivators are harmful to performance: psychologists, experts in human resource management, and sociologists have long emphasized the central role played by intrinsic motivation in many social and economic interactions [calling] attention to the fact that explicit incentive schemes may sometimes backfire by undermining agents confidence in their own abilities (Bnabou & Tirole, 2003). By dissuading children, adolescents, and adults alike from extrinsic motivators whether it be a gold star, the right answer on calculus exam, a promotion in the office modern American society has adopted a new framework. The current system propagates the value of industriousness as an end in itself, but only to achieve the results and behaviors that the external rewards were initially designed to incentivize. By enhancing productivity in this manner, modern American society has redefined the value of success. One need only look at the educational system to see how this process actualizes itself. In theory, if a students puts in the standard amount of effort to learn a mathematical theory, she will receive an A on the problem set. But when a slightly dimmer student puts in, say, twice the standard amount of effort and is still unable to perform as well as she had hoped, what then? She becomes discouraged and never gains a passion for the subject. Today, teachers in mathematics classrooms across America tell students not to worry about getting the correct answer, but to make sure to show their work. Points are then accordingly awarded for each step in the problems, and not merely for the final answers. Hence the famous phrase: A for Effort. On the surface, this is a


harmless and effective way of motivating young minds to exercise their mental faculties without being discouraged by the initial struggles that come with learning a new subject. The student who continuously puts in the standard amount of effort, despite getting the wrong answer, will eventually learn the methodology, and hopefully catch up to the more gifted students so she, too, can get an A. Thus, A for Effort yields (an actual) A, wherein we find the underlying motivation for this methodology: namely, an increase in productivity. In the broader schema of modern America, institutions and companies alike are beginning to adopt this ideologyone that does not judge based on achievement but views productivity itself as an achievement. According to this methodology, though, one might wonder whether there is an upper limit to such an approach. In other words, at what point does the limitless growth of this ideology lead to diminishing returns of some kind? More importantly, what cost does a society incur for denaturing the value of achievement? Although the positive effects of this ideological shift are indicative of a generally more optimistic and confident youth, at a broader level, certain undesirable side-effects emerge. As productivity becomes the only concern, 21st century Americans are subconsciously normalizing the very notion accomplishment, and normalizing themselves in the process; they begin to measure success only in terms of how much they are able to produce and accumulate. The question, of course, is the extent to which this drive towards production is the product of capitalism. In fact, this relation between capitalism and production is certainly not unfamiliar. The Marxist thesis famously framed the entire development of society as the collective


economic production of goods and services from one generation to the next. But production, in the modern sense, carries a more nuanced meaning; it is not merely a measure of goods and services, but a measure of identity. Productivity not only applies to material goods, but is also the extent to which one is able to achieve material success. As a result, productivity and sociability are no longer seen as characteristics of personality types that come in varying degrees, but have been redefined as the new standard for the archetype of the 21st century American. As we see how these developments ingrain themselves within society, we begin to make sense of Foucaults claim that normalization is an instrument of power (Dreyfus & Rabinow, 1983, p. 185). Normalization not only makes individuals productive by making them more conducive to social orderit also creates breeds an internal desire to be more productive. Thus, modern American society has begun to normalize productivity; a process that is epitomized by the ADHD construct. One of the primary uses for stimulant drugs is that of social integration. Despite having no signs of ADHD, an individual who consumes a standard dose of stimulant drugs will exhibit increased levels dopamine, serotonin, and norepinephrine. While having a wide array of effects on the human brain, in the case of amphetamines like Adderall, these neurotransmitters affect areas of the brain that regulate reward-seeking, euphoria, confidence, wakefulness, and sociability. At this point, the prospect of taking amphetamines may sound rather enticing, but these are the same neurotransmitters that are stimulated by drugs like cocaine. As such, amphetamines have extremely high potential for abuse and are accordingly classified as controlled substances by the Drug Enforcement Agency. The effects described here are, of course, a highly simplified


account of a complex mechanism that is not yet fully understood, and the reality is that there are many side-effects, both mental and physical, that necessarily result in taking these drugs. Yet in spite of all this, stimulant drugs prescribed for ADHD generally produces sociable behavior in both ADHD-diagnosed and non-ADHD-diagnosed users. Just as the frame of reference through which success is viewed in this country has been redefined, so too has the notion of the social individual. The central agenda of modern America is one of connectedness. Social interaction is no longer a byproduct of living in society but a necessity. Before the advent of social networking, the degree of a persons socializing depended largely upon her interaction with actual human beings. But when socializing is possible at every moment through the objects that surround us, interaction is no longer a means or a byproduct, but a matter of engaging with a choice that is constantly presented. The degree of a persons sociability is not contingent upon her character and the extent to which people might gravitate towards her; it depends only on the desire and the will to interact. While character still plays a role in the value and the quality of the relationships and conversations that are fostered, the standard for the possibility of sociability is now marginal. While it would seem that this ideology would be indicative of a predominantly outgoing, social population, it is not sociability per se, but the value of sociability that is being normalized. In other words, it is not merely a matter of making individuals more social, but rather a general drive that seeks to redefine the value of sociability as a normal condition of how an individual should behave. As the world provides us with countless methods of interacting, it becomes apparent that being a social individual is the norm, and as a result, the drive towards increasing sociability fundamentally redefines the archetype


of the modern American identity. While it may seem that being a social, outgoing individual is the norm, i.e. the extrovert personality type, the most recent research suggests otherwise: We see ourselves as a nation of extroverts. Depending on which study you consult, one third to one half of Americans are introvertsin other words, one out of every two or three people you know. We live with [the value system of] the Extrovert IdealThe archetypal extrovert prefers action to contemplation, risk- taking to heed-taking, certainty to doubt Weve turned [the extroversion personality style] into an oppressive standard to which most of us feel we must conform. (Cain, 2012) Cains research suggests that this value systemthe Extrovert Idealis a selfperception that does not reflect the identity of the population. It is this sort of normalization that Foucault precisely admonished on the basis that it denies certain personality-types the opportunity to exist without having to shape themselves in order to fit into society, thereby psychologically confining certain individuals. Such a confinement oppresses the large minority of introverted individuals by making them believe that they ought to be more sociable, when in fact this would entail a purposeful detraction from their modus operandi. Yet when there is a general pressure that tells us that we ought to be social individuals, the reality of being anti-social becomes difficult to cope with. As sociability becomes normalized, the matter of what actually constitutes pain or harm is called into question, and it becomes apparent that there is a moral dimension within our current understanding of suffering. In the case of ADHD diagnosis, the inattentive or impulsive child may not necessarily experience pain, but due to her self-perceived abnormality, she may experience emotional suffering. At which point one must necessarily ask whether


the use of stimulants for coping with social pressures should be considered medically legitimate. Even if the majority of people may grant the stay true to yourself motto as an important moral principle, a fewer number would say with certainty that it should be upheld at the cost of not fitting in; and even less so in cases of depression or anxiety. The pressures imposed by the normalized individual in relation to the ADHD subject fundamentally calls into question the possibility of an objective threshold for what constitutes pain. While some may feel that not fitting in or failing at particular tasks is simply a reality of life, many clinicians and ADHD researchers emphasize that failure to t in or to live up to expectations can be very painful (Hawthorne, 2007). Thus, should a child exhibit suicidal tendencies caused by social pressures, it would be difficult to dismiss the use of stimulants as superficial or unethical. At what age, then, should we let a child consume amphetamines on a daily basis, thereby fundamentally reshaping her personality, because she is unable to make friends in school? Such a question becomes a matter of discretion, and should a psychiatrist prescribe medication for treatment, even in the case of a misdiagnosis, the child being able to cope better in social settings will substantiate the diagnosis. What started out as a potential case of medical malpractice ends up benefitting the child and the parents, and thereby further legitimizes the doctors word. In the case of ADHD, it becomes difficult to gauge what constitutes suffering, and the DSM criteria for a mental disorderthat [it] causes some sort of harm to the individual and that a mental disorder is the manifestation of a dysfunction in the individualseem to lose their footing. When we call into question the definition for a mental disorder by pointing to the subjectivity of what


constitutes pain, it becomes apparent that ADHDs classication as a mental disorder is found to be contentiously value-laden (Hawthorne, 2007). Once again, we find that the categorization of ADHD as a disorder inevitably depends on a value judgment, not merely in terms of correcting undesirable qualities, but of contending that such qualities cause harm to the individual. What we are left with is a debate surrounding the legitimate prescription of stimulant drugs that is based on a subjective conception of painone that is continuously increasing in scope. The modern ADHD construct is moving towards ever-greater diagnosis. In fact, according to the latest data, the proposed revision of ADHD by American Psychiatric Association added four new symptoms in the newly revised DSM-V, thereby increasing the scope of diagnostic criteria (Ghanizadeh, 2013). While this may not seem surprising, one must understand that the trend towards increasing ADHD diagnosis is no longer merely driven by institutional social order; the internal drive towards productivity and sociability and the pressure imposed by material success as a means to happiness has engendered a drive towards greater diagnosis on the side of the patients. While social integration may seem natural in contemporary society, it is a deliberate exercise of the postmodern power that seeks to order and enhance life through the pervasive pressure towards ever greater inclusion (Dreyfus, 2004). Once we contextualize these remarks within a schema of power-knowledge relations, what we find, yet again, is a transition from the visible to the invisible that follows Foucault panoptic model of power. While ADHD diagnosis was traditionally used as a method to coerce individuals in a visible sense through educational and correctional institutions, the drive towards productivity and sociability has instilled within society an invisible and


internal desire to be normalized. This exercise of postmodern power does not merely function by ordering and enhancing life through forceful methods, but by instilling within society a belief that a normal individual ought to be naturally productive and sociable. In order to arrive at a new understanding of ADHD, we must redefine what constitutes a legitimate diagnosis.


IX - A New Framework Though the economic and political power of medicine has played a significant role in the proliferation of stimulant medication, the reality is that the general use of stimulants, despite a lack of definitive research on their long-term effects on the human brain, has proven to be effective for other motives. While Rezneks (1991) observations showed us how parents may benefit socially from medically correcting their childs symptoms of inattentiveness or impulsivity, he concludes that drug treatment ends up beneting everyone except those who end up being sedated and depressed on the drugs. What has changed since then is this very notion that individuals taking stimulants will necessarily become depressed or sedated, which only applies to the administration of stimulants on hyperactive-impulsive personality types. Bradleys Benzedrine experiments were the first to identity this paradoxical correlationnamely, that using stimulants on hyperactive-impulsive individuals was, in fact, a way to calm them down. Yet for the newly established inattentive type, a dose of stimulants does not calm; it does precisely what its name entails; it stimulates in the same way that coffee acts as a stimulant thereby making the subject more alert and focused. In this sense, we find that in both cases, the subject will exhibit behavior that is more sociable and conducive to disciplinary environments, yet in the case of someone with no signs of ADHD, such sociable effects will still manifest themselves in the same way that cocaine acts as a stimulant. During Rezneks time, ADHD was still in its early stages; it was not yet at the point when the internal drive towards normalization would be enabled through the desire to be diagnosed for social benefits. Nowadays, we find that it is not merely parents and


teachers who seek to medicate certain individuals, but that the subjects seek diagnosis of their own accord in order to enhance their sociability through the use of stimulants. The driving motivation in such cases is not the remedying of symptoms, but the acquisition of stimulants, which thereby renders the diagnosis of ADHD as a means to an end. While classroom disruption entails a desire to correct social behavior, the internal desire for sociability materializes itself through two distinct modes: the recreational, and the academic. In order to arrive a new way of understanding the ADHD construct, we need to recognize the fact that ADHD stimulant medications are used as recreational drugs. Amphetamines were popularized in the 1960s as speed, and while they were outlawed, their ability to correct impulsive behavior has medicalized the drug and progressively reduced the stigma surrounding the administration of such stimulants. A recent study investigated recreational (non-medical) use of stimulant medication, such as methylphenidate and amphetamine salts, in a western United States university population, and found that of the 448 participants the results indicated that the overall prevalence rate for recreational stimulant use was 18%. In addition, recreational stimulant use correlated positively with illicit drug use (Sharp & Lee, 2007). Clearly, there are still a number of individuals using ADHD medication in the same way that other recreational drugs are used to enhance sociability, yet the rise in recreational stimulant use has been strongly enabled by the medicalization of stimulants. Since there are no specific cognitive, metabolic or neurological markers and no medical tests for ADHD (Timimi & Taylor, 2004), testing for the condition largely


consists of answering a series of qualitative questions measured on a Likert-type scale5 about difficulty concentrating or impulsive tendencies. While the psychiatrist has the power to deny the diagnosis for some particular reason, the diagnosis is ultimately rests in the hands of the individual taking the questionnaire. If the subject is made aware of this, ADHD ultimately becomes a self-diagnosable condition, and the ability to fake a diagnosis for the acquisition of stimulants for recreational purposes becomes extremely easy. In fact, David Berry, a professor and researcher at the University of Kentucky coauthored a study that compared two groups of college studentsthose with diagnoses of ADHD and others who were asked to fake symptomsto see whether standard symptom questionnaires could tell them apart. They were indistinguishable (Schwarz, 2013). Such data fundamentally calls into question the very definition of the ADHD-diagnosed subject. The motivation for recreational use is essentially rooted in a desire to be more talkative and more sociable, yet the other social motivation is to artificially increase ones mental capacities, which we may broadly characterize as the academic. As a result of the processes of hierarchization and normalization that Foucault identifies, there is an increased level of pressure that is placed on lack of performance. It is not merely the case that we measure ourselves in terms of a norm, we now wish to be above the norm, and stimulant drugs respond to this need. Being inattentive and unable to succeed in academic endeavors is no longer a fated reality; it is now possible to artificially increased ones academic capacities by ingesting a pill. Yet providing highly addictive drugs to individuals who are exhibiting no form of dysfunction or painful activity constitutes a

Likert-type scales employ questionnaires in which the user is asked to rank their answers as: strongly agree, agree, neither agree nor disagree, disagree, strongly disagree.


drug-induced change in character, and like any other drugs, there are inherent dangers to using stimulants. A recent article in the New York Times tells the story of a young man who was diagnosed with ADHD and committed suicide two weeks after his prescription ran out. That day, his father recalls his son telling him, The doctor wouldnt give me anything thats bad for me (Schwarz, 2013). This case is only one of many that highlight the dangers of enabling the psychiatric discipline to have such a degree of autonomic judgment in diagnosis, especially when considering conditions like ADHD wherein the underlying social force that is driving the increase in diagnosis is a an effort to render us into more productive individuals. When we attempt to predict the future of ADHD, it seems that beyond the various internet phenomena, the current American generation is leading the trend towards diagnosis and increasing use of stimulants. According to recent data from IMS Health, Young adults are by far the fastest-growing segment of people taking ADHD medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before (Schwarz, 2013). If we consider the proliferation of ADHD on a global scale, it seems that the trend towards increasing diagnosis will only increase in years to come. The drug that the young man referenced in the New York Times article was taking is called Vyvanse, a newly developed amphetamine that functions in the same way as older versions, but has been found to reduce immediate side-effects (Schwarz, 2013). This is the very same drug that was recently approvedDecember 18, 2012by seven European countries participating in a procedure (Denmark, Finland, Germany, Ireland, Norway, Spain and Sweden) as part of a comprehensive treatment programme for


attention deficit/hyperactivity disorder (ADHD) in children aged 6 years and over (Shire, 2012). There are, of course, many problems associated with stimulants to children. A list of the most common side effects for Vyvanse includes: slowing of growth (height and weight) in children anxiety, decreased appetite, diarrhea, dizziness, dry mouth, irritability, loss of appetite, nausea, trouble sleeping, upper stomach pain, vomiting, weight loss (Shire. 2012). While this extensive list of side-effects certainly raises many concerns, the underlying issue is that as a society, we are making choices as parents on behalf of children and denying them the opportunity to choose whether they want to value productivity and be normalized to fit within their social settings. These medicated children grow up having been shaped to think that if the medication places them in the norm, then they must necessarily be abnormal without medication. By failing to see that the ADHD construct is driven by a broader process, we are shaping knowledge without being aware of it, and crafting for the future generation an existence that they may not have chosen for themselves. Foucaults system has allowed us to see how individuals seeking out ADHD diagnosis in order to alter themselves by artificially increasing their productive or social capacities may feel that they are acting on their own accord yet, in reality, the very notion that they ought to alter themselves using stimulants is the product of the postmodern process of normalization. When we turn back to Foucaults claim that postmodern power attempts to order and enhance life, we begin to understand how the desire to fit in using stimulants recreationally, or the desire to perform better on examinations, are all part of a


drive towards making life more productive. In modern American society, what is being normalized is not merely the act of production, but the value of production. As ADHD diagnosis and stimulant prescriptions grow under these current conditions, it may seem that we are helpless in changing the way the condition is viewed since the ADHD construct fundamentally relies not on one party or one institution, but the entire sociopolitical and economic system that we are a part of. Yet Foucaults exercise also teaches us that we must first diagnose and understand the knowledge and power relations in our society in order to even begin attempting to dispose of the prejudices and judgments that lead to oppressive and coercive abuses of power. Especially when such exercises are not driven by individuals, but are more indicative of a systemic modern capitalist agenda. By viewing the ADHD construct in relation to Foucaults work, it becomes apparent that this is merely one facet of a general trend that is caught in the modern capitalist agenda of production and normalization, but also of a process that is specific to American culture. While we are a long way from societally recognizing the changes that need to take place, it is only through an understanding of our current condition that we may create a more authentic futureone wherein, as a society, our practices coincide with our values.


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