‘Resisting’ Ritalin: Parental Talk about Treatment Medication in Childhood ADHD (Attention deficit hyperactivity disorder) /TDAH (trouble deficitaire de l’attention et/ou hyperactivite infantile).

Carol GraySchool of Nursing, Midwifery & Social CareEdinburgh Napier Universityc.gray2@napier.ac.uk

Acknowledgements:

• PhD supervisors at Queen Margaret University, Edinburgh: Dr Joyce Willock, Dr Chris McVittie, Dr Marion Ellison

• 3 year PhD studentship from department of Psychology, Queen Margaret University, Edinburgh

• Parent volunteers who participated in PhD study

Background:

• Wider PhD Study explored Lay and Professional Constructions of Childhood ADHD

• Focus: Health Policy & Medical Literature; Educational Policy & Literature; Sociological explanations & Critical work; Empirical study of everyday talk about ADHD by parents & teachers using Discourse analysis

Background:

• PhD study showed how parental talk constructed their child’s difficulties in terms of parental accountability by use of the ‘good parent’ device which focused on identity constructions of doing good parenting and a biological repertoire rather than due to parenting issues (environmental repertoire)

• How parents constructed contentious medication for ADHD

Introduction to “ADHD” / <<TDAH>>

• ADHD is a contested yet global phenomenon• Rising incidences predicated for UK due to greater use of

inclusive diagnostic criteria (i.e. DSM-IV, 1994, vs ICD-10, 1993)

• European guidelines • DSM-IV specifies 3 subtypes • Extensive research• Genetic predisposition implicated?

Ritalin and ADHD/ Ritalin et TDAH

• Traditionally psychostimulant medication advocated as ‘first line’ treatment (e.g. SIGN, 2001).

• ‘paradoxical’ effect by stimulating central nervous system • Scheduled 2 controlled drug• Psychostimulants such as Ritalin, Concerta;

amphetamines; Straterra

Critical Approaches to ADHD / Critique de TDAH

• Sociological: Conrad (1976/2006) “medicalisation” of childhood behaviours & ‘discovery’ of hyperactivity

• Educational: Lloyd, Stead & Cohen (2006): limited role of context

• Biopsychosocial perspective advocated for ADHD (e.g. Cooper, 2001; Singh, 2001)

• But critique centred on biological reductionism inherent in this model & dominance of medications for ADHD “treatments”

• New directions for health policy? E.g. NICE & SIGN to follow?

Critical Approaches to Ritalin / Critique de Ritalin• N. America: e.g. Breggin (1998) Talking Back to Ritalin;

Degrandpre (2000) Ritalin Nation: Rapid fire culture and the transformation of human consciousness; Diller (1998) Running on Ritalin: a physician reflects on children, society and performance in a pill.

• UK: e.g. Timimi (2002; 2005) Pathological child psychiatry and the medicalization of childhood; Naughty boys: anti-social behaviour, ADHD and the role of culture.

• Lupton (1997) interpretation of Foucault’s medicalisation – lay collusion as a dynamic process.

Gaps in the Literature / trous dans la littérature

• Parents and teachers play a important role in the management of children diagnosed with ADHD yet often remain on periphery

• Parents may have to make key decisions about treatment choices for ADHD yet this is also absent

• Harper (1999) highlighted how treatment choices tended to be neglected in social science research

• UK context ADHD as ‘incompletely medicalised’

Aims / Objectif

• Focus on how parents constructed controversial ADHD treatments

• Not to argue for ADHD as a ‘real’ condition • Experiential and qualitative approaches limited in ADHD –

useful but takes language for granted• Alternative tradition: focus on everyday language used

by parents to talk about ADHD medication

Method / Methode

Discourse analysis• Interdisciplinary but varied field• Broadly a focus on language and discourse• Origins in ethnomethodology; conversation analysis;

semiology; sociology of scientific knowledge; linguistic philosophy; post-structuralism

• Discourse= ‘a system of statements which construct an object’ (Parker, 1992)

Discourse Analysis / Analyse de discours• Wooffitt (2005) Bottom-up and

Top-down approaches in • Debates from DA on fine-

detailed vs broader focus

Bottom –up approaches

Top-down approaches

e.g. Conversation analysis; discursive psychology

Fine detailed/Micro

Talk-in-interaction - speaker

e.g. Foucauldian discourse analysis; Critical discourse analysis

Theoretical/Macro

Contextual/Critical

Critical discursive psychology / la psychologie discursive critique• Wetherell & Edley (1998; 2001): synthesis of DA -

empirical talk & broader context in which it occurs• Interpretive approach in DA tradition• Analytic framework:

1. Interpretive repertoires

2. Subject positions

3. Ideological dilemma

Method / Methode

• 12 Parents took part in semi-structured interviews (2005-2006)

• Volunteers from voluntary sector• Medical ethical approval obtained• Audio-recorded & transcribed verbatim• Simplified transcription conventions used (Jefferson, 1984)

e.g. (.) untimed pause

emphasised talk

Findings / Resultats

• Analysis focused initially on constructions of Childhood ADHD by parents; parent’s constructions of competing versions of ADHD & talk about treatment medication such as Ritalin

• CDP concepts used initially• SP explored further in relation to medication talk• Analysis of parental talk about treatment medication

indicated 2 differing patterns of talk:

RITALIN USERSData Extract 1: Parent 1

I: How did you feel about that [medication]

P: well (.) it was either you put up wi’ it or (.) the only other option was to hav’ medication (I: mhm) so there’s no really (.) no other way out eh (I: yes) really

Data Extract 2: Parents 2

I: How did you decide about that [medication] (.) …

F: well we thought anything (.) please () (I: yes)

M: uh huh

F: just to try and to help him as well as us I suppose (I: uh huh)

M: we didnae we didnae we didnae want medication obviously but we were at our wits end we didnae know what to do

1. Being ‘at our wits end’: Passive Acceptance / acceptation passive

Discursive features:• Prompted by interviewer, little detail• Talk oriented to tricky identity of being a ‘good parent’

and using controversial medication• Last resort – desperate; no choice; not liking it• Disempowered positioning

NON RITALIN USERSData Extract 3: Parent 3I: so what is your relationship like with Dr X [paediatrician]

P: It’s mainly Dr X and I don’t like her attitude (I: right) the last time my wife was down she more or less told her that she was

putting Liam on them [Ritalin] […] my wife said ‘well we’re not too keen on them at all’ she said ‘well I’ll give you leeway of 3 months or so’ (.) and when I heard that I was quite annoyed (I: yes) I won’t let anybody talk to my wife like that for starters (I: yeah) and secondly especially a professional doctor shouldn’t be (.) she’s there to advise you not to tell you (.) she was

more or less telling her (I: right) […] trying to force (I: yeah) these tablets on er my son basically our son (.) people some

people with maybe less stre (.) willpower than my wife let’s just say might have given in and said ‘well oh ok then’

Data Extract 4: Parent 4

P: …and there are loads of families out there that have been given the medication route and that’s it and left with it (I: mhm) without being given the other options […] my last meeting with Adam’s paediatrician um (.) I’m telling her things these days it’s actually peeving me off […] because her only (.) she’s so unimaginative (I: mhm) her only option is (.) medication (I: right) and at the end of every consultation (without fail) she alway says ‘well there’s always medication’

2. Having ‘options’: Active resistance / résistance active

Discursive features:• Elaborate & spontaneous accounts• Accounts of coercion (‘trying to force’)• Identity construction worked up as a ‘good parent’

(‘willpower’) to pursue options• Resources (‘other options’) - empowered

Resisting Ritalin / Resistance au Ritalin

• 2 differing patterns: Passive acceptance & Active resistance (disempowered/no choices vs empowered/choices)

• Common feature: accounts of force:• parental resistance to medication

1. Reluctant user: Not liking it but no other choice

2. Actively resisting medical coercion & pursuing other resources ‘options’

• Identity of the ‘good parent’

Conclusions/ Conclusions

• Focused on everyday language use about a controversial treatment by parents

• Contrasts with rhetoric of health policy: ‘treatment package’ (e.g. SIGN, 2001)

• Ultimately highlights the disempowered position for parents: narratives of being forced

Conclusions/ Conclusions

• Parental constructions of controversial medication should inform treatment guidelines

• Empirical analysis informs critical approaches in ADHD which emphasise limitations of dominant biomedical approaches

• Clinical application: awareness of empowerment issues and respect for parental choices in talk

Finally

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