Carol Gray School of Nursing, Midwifery & Social Care Edinburgh Napier University

1. ‘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 Gray School of Nursing, Midwifery & Social Care Edinburgh Napier University c.gray2@napier.ac.uk

2. 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

3. 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

4. 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

5. 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?

6. 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

7. 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?

8. 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.

9. 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’

10. 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

11. 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)

12. Discourse Analysis / Analyse de discours • Wooffitt (2005) Bottom-up and Top-down approaches in • Debates from DA on fine-detailed vs broader focus

13. 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: • Interpretive repertoires • Subject positions • Ideological dilemma

14. 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

15. 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:

16. 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

17. 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

18. 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

19. NON RITALIN USERSData Extract 3: Parent 3 I: 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’

20. 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’

21. 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

22. 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 • Reluctant user: Not liking it but no other choice • Actively resisting medical coercion & pursuing other resources ‘options’ • Identity of the ‘good parent’

23. 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

24. 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

25. Finally

26. References: