ADD as a Social Invention
In 1851, a Louisiana physician and American Medical Association member, Samuel A. Cartwright, published a paper in the New Orleans Medical and Surgical Journal wherein he described a new medical disorder he had recently identified. He called it drapetomania (from drapeto, meaning "to flee," and mania, an obsession), and used it to describe a condition he felt was prevalent in runaway slaves. Dr. Cartwright felt that with "proper medical advice, strictly followed, this troublesome practice that many negroes have of running away can be almost entirely prevented."
In the last 20 years, we have witnessed the birth of a new medical disorder--attention-deficit disorder--which has grown from a relatively rare neurological condition (under other names) during the 1930s, 40s, and 50s to a condition today said to afflict millions of children and adults (a recent Time magazine cover story even suggested that President Clinton may have ADD and could be "only a pill away from greatness").
Attention-deficit disorder (or, more recently, "attention-deficit hyperactivity disorder"--the syndrome has changed names at least 25 times in the past 120 years) has the support of thousands of scientific studies, the American Psychiatric Association, the U.S. Department of Education, and many other solid institutions in this country and worldwide. Yet, like Dr. Cartwright's "drapetomania," ADD may in fact come clothed in scientific respectability yet have disturbing social overtones which are scarcely acknowledged by the wider educational community.
Social critic Ivan Illich once wrote that "each civilization defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness, or sin in another. For the same symptom of compulsive stealing one might be executed, tortured to death, exiled, hospitalized, or given alms or tax money." So far, few attempts have been made to analyze the social meaning of "attention-deficit disorder" in our time. However, one does not have to probe too far beneath the surface to discover some interesting--and troubling--features of ADD. (See Education Week, Feb. 22, 1995, and related story, page 8.)
Why, for example, does identification of ADD vary so widely from one social context to another? Studies reveal that up to 80 percent of the time, ADD cannot be identified in the physician's office, presumably because the one-to-one social context with a (frequently) male authority figure mediates against the occurrence of symptoms. In another study, trained clinicians from different countries were shown tapes of children and asked to diagnose them. In a country with stricter behavioral norms--for example, China--there was a greater likelihood of an ADD diagnosis than in a country such as the United States. On the other hand, in some countries, such as England, a diagnosis of hyperactivity is much less likely (one study on the Isle of Wight identified only two children out of 2,199 as hyperactive).
One has to ask, then, what are some of the underlying social influences that may have served to shape the invention of ADD as a category of disorder in our culture? The answer to that question, I believe, is complex and many-faceted. On one level, it's possible to revive some of the concerns that Nicholas Hobbs, a former president of the American Psychological Association, had in the mid-1970s concerning the labeling of children. Mr. Hobbs pointed out that "a good case can be made for the position that protection of the community is a primary function of classifying and labeling children who are different or deviant." He noted that the Protestant work ethic (as elaborated upon by social theorists such as Max Weber) may be one set of American values which may permeate our nation's penchant for classifying unruly children. Mr. Hobbs writes: "According to this doctrine ... God's chosen ones are inspired to attain to positions of wealth and power through the rational and efficient use of their time and energy, through their willingness to control distracting impulses, and to delay gratification in the service of productivity, and through their thriftiness and ambition." Such a society might well be expected to define deviance in terms of distractibility, impulsiveness, and lack of motivation--the same traits frequently used to describe children suffering from ADD.
Alternatively, ADD may have arisen in our society precisely because of the loss of those same values. As Harvard University professor Lester Grinspoon and his collaborator Susan B. Singer pointed out over 20 years ago, "our society has been undergoing a critical upheaval in values. Children growing up in the past decade have seen claims to authority and existing institutions questioned as an everyday occurrence. ... Teachers no longer have the unquestioned authority they once had in the classroom. ... The child, on the other side, is no longer so intimidated by whatever authority the teacher has." Mr. Grinspoon and Ms. Singer felt that "hyperkinesis [a term used in the 60s and early 70s to describe ADD-type behaviors], whatever organic condition it may legitimately refer to, has become a convenient label with which to dismiss this phenomenon as a physical 'disease' rather than treating it as the social problem it is."
Another cultural view might look at the rise of electronic media as a contributing factor in the emergence of "attention-deficit disorder." The fact is, we live in an attention-deficit society. During the 1992 political campaign, CBS News attempted to introduce an innovation in its newscasts: 30-second sound bites from the politicians to give the viewer more "depth" into their views. The project had to be abandoned because the average adult viewer could not sustain his or her attention that long (the industry average for sound bites is around seven seconds). If this is true of adults--who grew up during the days of radio and early TV--then how much truer it is of today's children, who are inundated with Nintendo, MTV, multimedia, and more.
These kids live life in the fast lane, and have evolved new ways of paying attention to cope with the increased pace. Media expert Tony Schwartz pointed out that "today's child is a scanner. His experience with electronic media has taught him to scan life the way his eye scans a television set or his ears scan auditory signals from a radio or stereo speaker." What kinds of cultural values, then, might be present in a situation where an adult brought up in Marshall McLuhan's linear, one-step-at-a-time, print-oriented culture is responsible for assessing ADD in a child who has been fed on fast-paced electronic information from birth?
Such children may have particular difficulties in traditional classroom environments where they must sit for long periods of time, listen to monotone lectures, and pore over textbook and worksheet material that bears little resemblance to real life. Interestingly, research suggests that children labeled ADD do most poorly in environments that are boring and repetitive, externally controlled, lack immediate feedback, or are presided over by a familiar, maternal-like authority: in other words, the typical conservative "back to basics" classroom (a classroom that currently seems to be undergoing a resurgence in popularity).
Unfortunately, this kind of classroom is deadly not only for the so-called ADD kid but for all kids. John Goodlad's monumental study of 1,000 U.S. classrooms in the 1980s was particularly instructive on this issue. The study, A Place Called School, was especially critical of the lack of exciting learning activities: "Students reported that they liked to do activities that involved them actively or in which they worked with others. These included going on field trips, making films, building or drawing things, making collections, interviewing people, acting things out, and carrying out projects. These are the things which students reported doing least and which we observed infrequently."
All children suffer from this deprivation, but it may be that children labeled ADD react most intensely to this lack of stimulation. Several studies, especially those by Sydney Zentall at Purdue University, suggest, in fact, that just as the amphetamine-like substance Ritalin may help stimulate many of these kids to an optimal level of arousal, so too can stimulating learning environments also help to focus and calm.
I'm reminded here of the canaries that were kept by coal miners deep in the mines. If the level of oxygen fell below a certain level, the canaries would fall over on their perches and die, warning the miners to get out fast. It's possible that children who have been labeled ADD are the canaries of modern-day education; they may be signaling us to transform our nation's classrooms into more dynamic, novel, and exciting learning environments. ADD may, then, be more accurately termed ADDD, or attention-to-ditto-deficit disorder.
Finally, just as it is essential to see Dr. Cartwright's drapetomania as a product of the racial bigotry of his times, so too it's critical that we not sidestep the way in which racial prejudices enter into the ADD controversy in today's admittedly less bigoted but nevertheless still racially troubled times.
ADD was in fact stopped from being declared an officially handicapping condition by Congress in 1990, largely because of the efforts of a coalition of 17 educational, social, and political organizations including the National Association for the Advancement of Colored People. Among the concerns raised by the coalition was the strong feeling that ADD could be used to stigmatize minority groups. Debra DeLee, then a spokesperson for the National Education Association, wrote: "Establishing a new category [ADD] based on behavioral characteristics alone, such as overactivity, impulsiveness, and inattentiveness, increases the likelihood of inappropriate labeling for racial-, ethnic-, and linguistic-minority students." The work of award-winning journalists such as Todd Silberman and his colleagues at the The Raleigh News and Observer in Raleigh, N.C., have shown how special-education classes are often disproportionately filled with minority students.
The issues that I've raised above are almost never discussed in the ADD community. The general consensus seems to be that ADD is a discrete medical entity that exists in any and all social contexts, but is harder to identify in some social settings (requiring more acute diagnostic skills), or simply wasn't identified in earlier times or in other cultures because of the lack of proper scientific knowledge. It holds stubbornly to its medical paradigm and resists the influence of other worldviews (including the sociological one presented here), hoping that the world will eventually unite in accepting ADD as a legitimate medical disorder. One wonders, however, as societal values and structures change over time, whether "attention-deficit disorder" will go the way of all historical labels (remember that "moron" was once a diagnostic term in the 1930s) and give rise to new terms, and new groups of "disordered children."