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Undivided attention: A book on ADHD

Susan Hawthorne examines the world of ADHD in her new book.
Susan Hawthorne examines the world of ADHD in her new book.
Photo by St. Kate's Photo Bureau.

Long before she became an assistant professor of philosophy at St. Catherine University, Susan Hawthorne was captivated by ethical issues surrounding medicine and science.

“I always wanted to understand our scientific knowledge of how the human body works,” she says, “and I always wanted to unravel the sticky ways we have developed to explain and treat different illnesses.”

In her earlier career as a medical editor, Hawthorne scoured texts and research on different physical and psychological disorders, but her overarching desire to study the ethical and epistemological quandaries inherent in such work ultimately drew her to graduate study, where she focused on the philosophy of biomedical science. She joined the University’s philosophy faculty in 2012.

In her just-published book, Accidental Intolerance: How We Stigmatize ADHD and How We Can Stop (Oxford University Press), Hawthorne examines treatment and research surrounding one of the most diagnosed disorders in the United States, arguing for revisions in scientific and societal attitudes toward ADHD and behavior associated with the disorder.

How did you develop an interest in Attention Deficit Hyperactivity Disorder (ADHD)?

I first got interested in mental disorders back in high school. Over the years, I followed research and writing on all kinds of mental health issues. With ADHD and other disorders, I noticed a changeover from a psychodynamic, Freudian perspective to a behaviorist perspective and then, ultimately, to a biochemical perspective.

Later, when I decided to go to graduate school and study philosophy of science, this morphing perspective on ADHD presented itself as a really fascinating puzzle for inquiry — because even though there was a robust science surrounding the disorder and an enormous uptake in rates of diagnosis, there was also all this controversy spilling out about ADHD and its methods of treatment.

How prevalent is ADHD in the United States?

Right now 20 percent of boys and 11 percent of children and teens overall are being diagnosed with ADHD. At that rate, we’re clearly on the end where there’s something else going on. It’s not just a natural occurrence.

What that “something else” is, is really complicated: We’ve got a system where educators are incredibly pressed for time and teaching big classes with not enough help. Parents and the medical system are also stressed for time and resources. Then there are expectations for kids about passing tests at a certain time and starting school at a certain age. It’s similar for adults. The expectations of how and what you achieve as an adult are pretty rigid. Meanwhile, drug companies are really pushing pharmaceutical options.

What’s the ideal way to diagnose and treat ADHD?

Today, there is a clear difference between standard practice and ideal practice. Ideal practice begins with a very careful psychological evaluation of the child or adult in question, and a careful study of medications and behavioral modification as needed. But that’s not what happens in the majority of cases.

Typically — and this is standard practice — a parent takes a kid into the pediatrician or the family practitioner and says, “We’ve got a problem.” Or the teacher has told the parent that there’s a problem. Then the doctor writes a prescription, and the kid takes the medication. But the medications are not a cure for ADHD and its associated behaviors. Without back up therapies that might help the child or adult learn some other coping skills, ADHD becomes a continuing medication process.

Arguing against the overuse of medication is timeworn and fraught. I think there are valid concerns about it. I argue that it is not benign to medicate 20 percent of boys. Yet, so far, there hasn’t been solid proof that any harm is being done.

You’ve put the word “intolerance” in your book’s title. How are people with ADHD treated intolerantly?

In American society, there’s basically a lack tolerance for difference and “different” behavior. And the behavior of people with ADHD can definitely be outside of the norm.

During the course of my research, I developed the theory that the modern diagnosis and treatment of ADHD were reinforcing intolerance of the disorder — making the assumption that ADHD behavior is flawed and must be changed. The intolerance in our ways of looking at ADHD and its behaviors already existed, and then the explanations for ADHD and its causes build the intolerance in. In my book, I turn that perspective on its head and lead with the ethical issue of this intolerance.  

Studies say that when polled, people who don’t have ADHD report that they have negative attitudes about people with the disorder. They say they’d rather not play with a child who has ADHD or work with a person with ADHD. The portrayal of ADHD is negative. If you are a person with ADHD, you are getting plenty of negative messages, learning that, at a minimum, your behavior is not OK. And it can be really hard to separate “Your behavior is not OK,” from ‘You are not OK.”

Are there groups working to offer alternatives to this negative perception?

People who favor a neurological approach to the treatment of ADHD argue that explaining the disease as a treatable disorder of the brain naturalizes the phenomena and takes away its stigma. The American Psychiatric Association even advocates the use of the phrase, “It’s on par with diabetes,” in the description of ADHD. This is an attempt to describe the disorder as a chronic illness and decrease the stigma that surrounds it.

Then there are mental illness advocacy groups that say that a large percentage of ADHD is misdiagnosed and overmedicated, that our obsession with a pharmaceutical approach means that far too many people are medicated.

Still, it’s important to recognize that many people who get an ADHD diagnosis are happy with the diagnosis. This may seem to fly in the face of my argument that the disorder is over-diagnosed and treated in this country. But the human need to fit in is powerful, and finding an official disorder to classify your behavior — plus a medication designed to treat it — goes a long way toward explaining why people would welcome such a diagnosis.

So maybe you are advocating for a new definition of ADHD, from a medical disorder to some thing more like a personality trait or way of thinking.

That’s not exactly what I’m talking about. I think it is progress to think of ADHD as something chronic, to shift away from the kind of blaming and shaming that used to surround around people with the diagnosis. I think that’s good. But if you shift away from that attitude and you still don’t tolerate difference in behaviors, you haven’t made a step forward. Until you tolerate difference you are not going to remove the stigma.

Accidental Intolerance: How We Stigmatize ADHD and How We Can Stop is available on Amazon and at the Oxford University Press website.

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Nov. 5, 2013 by Andy Steiner

See also: Faculty, Healthcare, Liberal Arts