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Beyond Medicalization: Explaining the Increased Prevalence of Attention Deficit-Hyperactivity Disorder

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Beyond Medicalization: Explaining the Increased Prevalence of Attention Deficit-Hyperactivity Disorder Beyond Medicalization: Explaining the Increased Prevalence of Attention Deficit-Hyperactivity Disorder Allison Mann Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Graduate School of Arts and Sciences Columbia University 2016 © 2016 Allison Mann All rights reserved ABSTRACT Beyond Medicalization: Explaining the Increased Prevalence of Attention Deficit-Hyperactivity Disorder Allison Mann Attention Deficit-Hyperactivity Disorder diagnoses have been rising steadily since the early 1990s. Today, about 10 percent of the school-aged population has been diag- nosed with the disorder, and prevalence is increasing steadily among preschool children and adults. Most of the individuals diagnosed with the disorder use stimulant medications to treat the symptoms. Both the rapidly rising number of diagnoses and the substantial variation in prevalence and treatment utilization – across states, regions, gender, race, eth- nicity, and socioeconomic status – have attracted attention and raised concerns about un- der and over recognition and treatment. The implicit justification for the increasing awareness and recognition of the disorder is that it is a valid clinical object that matches medically-proven treatments with those reliably expected to benefit from them. From this perspective, the uptake in prevalence results from changes in environmental determinants or scientific advances in neurology, psychiatry, diagnostic protocols, or pharmaceutical research. But a widespread argument among teachers, parents, policy makers, the general public, and academic researchers – in- cluding sociologists – is that the development and success of the disorder results from a medicalization process. Medicalization encompasses a social construction critique that con- tradicts the environmental/scientific advance claims, but medicalization research also em- phasizes macro-level actors that forcibly advance the medical label and treatment. Tradi- tionally, medicalization studies focused on the disproportionate power of the medical pro- fession vis-a-vis patients, but more recently they have begun to emphasize a broader range of actors pursuing a medical label – pharmaceutical companies and even consumers influ- enced by new forms of advertising. Those arguments assume that educational institutions act in concert with those pushing the medical label. The goal of this dissertation is to provide an account of diagnostic prevalence and treatment utilization (and their uneven distribution) that debunks explanations based solely in science but that also demonstrates the insufficiency of the medicalization account. Together, the chapters show that there is no correlation in timing between the surge in diagnoses and the processes implied by either medicalization or scientific progress argu- ments, there is little support in the micro-level data for a strictly medicalization account, and there is substantial evidence that macro-level educational institutions and the school context play a significant role in reshaping the category. The chapters emphasize that the success of the category lies in the confluence of technoscientific innovation, social control of troublesome behaviors, the increased activism of parents along with direct-to-consumer pharmaceutical advertising, encroachments of the law into student discipline and into the health care industry, the institutional needs of schools, a cultural emphasis on high aca- demic achievement, and the influence of parallel and predecessor classifications, among other factors. The category – a result of multiple institutions working to recraft expertise –isaschool-specificmedicaldisorderthatincludesaheterogeneoussymptomcomplex, one that is understood differently within school and medical milieu. Although the chapters do not disprove medicalization, they suggest that the medicalization framework overstates the importance of medical professionals and medicine broadly defined for the success of the category. Contents List of Figures v List of Tables vi 1TheOriginsoftheMedicalModelforUnderstandingChildhoodAbnormal- ities of Attention, Hyperactivity, and Impulsivity 10 1.1 How the Disorder Is Articulated in Medicine . 16 1.1.1 CurrentDiagnosticCriteria . 16 1.1.2 EpidemiologicalProfile . 19 1.2 Understanding ADHD: Contested Narratives . 21 1.2.1 The Straight Path from Symptom Expression to Symptom Recognition to Diagnostic Standardization . 22 1.2.1.1 The Context for Early Symptom Recognition: Institutional Care of the Feebleminded and Emotionally Disturbed . 23 1.2.1.2 Early Brain Research, Methods, and Findings . 25 1.2.2 The Winding Path From Institutional Social Control to Performance En- hancementofMiddleClassChildren . 29 1.2.2.1 Early Use of Stimulant Drugs in Children and Its Discontinu- ity with the Current Epidemic . 29 1.2.2.2 From Brain Damage to Disability . 33 1.2.2.3 TheFirstEpidemic. 44 i 1.2.2.4 Triumph of Behavioral Diagnosis . 46 1.2.2.5 Response Inhibition Model and Adult ADHD . 55 1.2.3 Medicalization Explanations for Stimulant Drug Use . 68 1.3 Discussion . 71 2AnEmpiricalTestoftheMedicalizationHypothesisasanExplanationfor ADHD Prevalence 73 2.1 MedicalizationTheory .............................. 75 2.2 MedicalizationExplanationsofADHD . 77 2.3 MainHypotheses ................................. 80 2.4 DataandMeasurement.............................. 83 2.4.1 Data.................................... 83 2.4.2 Measurement ............................... 84 2.4.2.1 Diagnosis, Special Education, and Medication . 84 2.4.2.2 Individual Background Characteristics . 85 2.4.2.3 State-Level Resource Measures and Policies . 85 2.5 Analytical Strategy . 87 2.6 Results . 88 2.6.1 State Level Patterns . 88 2.6.2 State- and Individual-Level Predictors of ADHD Diagnoses . 90 2.6.3 Predictors of Drug Treatment and Special Education Enrollment . 94 2.6.4 Determinants of ADHD Drug Type . 97 2.6.5 Comparing Pediatric Mental Disorders . 101 2.7 DiscussionandConclusion . 103 3TheImportanceofParents,Teachers,andSchoolEnvironmentsforADHD Diagnoses 106 3.1 ExistingResearch................................. 109 ii 3.1.1 Schools and Teachers and the Identification of ADHD Symptoms . 110 3.1.2 Relative Age EffectsandADHDDiagnoses . 111 3.1.3 School and Teacher Attributes and ADHD Diagnoses . 113 3.2 MainHypotheses ................................. 113 3.3 DataandMethods ................................ 117 3.4 Results . 120 3.4.1 Individual Level Patterns . 120 3.4.2 School Level Patterns . 121 3.4.3 Importance of Teacher- and Parent-Ratings for Diagnosis . 130 3.4.4 The Importance of School Effects .................... 134 3.4.5 Relative Symptom Levels . 134 3.5 Conclusion..................................... 138 4WhereRegimesCollide:ADHDasanEducational,Medical,andLegalCat- egory 141 4.1 Introduction.................................... 143 4.2 ContestationattheInstitutionalLevel . 150 4.3 Background on Special Education Provisions Pertaining to ADHD . 152 4.3.1 History of Federal Involvement in Special Education . 152 4.3.2 Federal Regulation of Special Education Programs, Services, and Accom- modations for Students with ADHD . 156 4.4 Data........................................ 160 4.5 The Insufficiency of Medical Approaches for Educational and Legal Understand- ings of Disability . 164 4.5.1 DrugTherapies .............................. 164 4.5.2 DiagnosticCredibility . 170 4.5.3 Eligibility ................................. 179 4.5.4 Placement................................. 188 iii 4.5.5 Consequences ............................... 197 4.6 Conclusion..................................... 201 Bibliography 209 Appendix 243 iv List of Figures 2.6.1 Bubbleplot of State Medication Rate Against State IEP Rate . 89 2.6.2 Scatterplot Matrix for State-Level Correlates of ADHD Prevalence . 91 3.4.1 ADHD Prevalence, Drug Use, and IEP Placement, by Grade, 1998-1999 Cohort121 3.4.2 Scatterplots Depicting Relationships Among SES, ADHD Prevalence, and So- ciobehavioral Skills at School Level . 122 A.1 Map of ADHD Prevalence, Prescription Drug Use and IEP Status for Children, Ages4-17 ..................................... 245 A.2 Bar Chart showing Co-Morbid Conditions by Race, for Children, Ages 4-17, with an ADHD Diagnosis . 246 v List of Tables 2.1 Logistic Regression of ADHD Diagnosis on Individual- and State-level Predic- tors......................................... 92 2.2 Multinomial Logistic Regression of Pharmaceutical Treatment and IEP Status on Individual- and State-level Predictors, Conditional on ADHD Diagnosis . 96 2.3 Logistic Regression of Drug Type on Race, Gender, and Income, with State Fixed Effects....................................... 99 2.4 Mixed Level Logistic Regression of Diagnosis Type on Individual- and State- levelPredictors .................................. 102 3.1 Regression of Teacher- and Parent-Rated Inattention Based on Socio-Demographic Factors....................................... 124 3.2 Regression of Teacher- and Parent-Rated Impulsivity Based on Socio-Demographic Factors....................................... 125 3.3 Regression of Teacher-Rated Symptom Levels on Parent Ratings, Socio-demographic Measures,andTheirInteractions . 127 3.4 Regression of Teacher-Rated Symptom Levels On Parent Ratings and School SES(FirstGrade)................................. 129 3.5 Logistic Regression of ADHD Diagnosis On Race, Income Level, and Symptom Levels . 131 3.6 Logistic Regression of ADHD Diagnosis On Parent Over-Estimates of Symptom Levels . 133 vi 3.7 Logistic Regression of ADHD Diagnosis
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