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PUSHING PILLS: The Medical Professions’ Role in Bio-Medicalizing ADHD

By: Manuel Vallee Ph. D. Candidate Sociology Department UC Berkeley

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INTRODUCTION Why do some medical treatments come to be accepted in one country but not another? Medicine is typically presented as being a rational, and depoliticized enterprise, one flowing unerringly from “science”. However, such a view is incomplete and misleading, for it conceals the social work and struggle that goes into the institutionalization of every diagnostic category, and every treatment. A corrected outlook would view each medical condition as being treatable through a variety of means, each of which with its own set of pros and cons, and, more importantly, its own set of lobbyists. Regarding the latter, these may include the producers of the treatment (as in the case of pharmaceutical manufacturers) as well as its administrators (such as physicians). If we take asthma, for example, we find a number of different types of healers, each of whom is promoting their own form of treatment, including physicians who promote steroid treatments, naturopaths who offer dietary intervention, hygienists who promote colon cleansing, and acupuncturists who offer their own acupuncture treatments. This brings me back to my opening question, “why is it that some medical treatments get accepted in some countries but not others?” How is it that some treatments come to be institutionalized in some societies, but not others? This is the central question towards which this paper is dedicated, and to shed light on this issue I examine the social acceptance of psychostimulant treatments (such as Ritalin) for treating Attention-Deficit Hyperactivity Disorder (ADHD), comparing the market development for these pharmaceuticals in France and the United States. These two countries are large consumers of other pharmaceuticals, but differ starkly in their usage of psychostimulants, and so make for ideal cases to contrast against each other. Moreover, accounting for their differences will be the overarching objective of this paper, and what I will show later is that a big piece of the puzzle is that each country‟s medical profession played a major role in the outcomes. However, before fleshing out that argument, the next section will be a short overview of the medicalization literature, followed by a discussion of why the psychostimulant market was a good case to shed light on the medicalization process, and why these two cases were picked, followed by a sketch of the two national cases.

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STATE OF KNOWLEDGE ON MEDICALIZATION Since the late 1940s an increasing number of life conditions have come to be seen through a medical lens, and in trying to account for this growing trend the sociological literature has identified a number of salient factors, with one being the medical profession‟s desire to expand their jurisdiction over day-to-day life (Conrad 1975, Pawluch 1983). A second factor has been the role played by social movements, as was the case for PostTraumatic Stress Disorder (Scott 1990), and Alzeimer‟s (Fox 1989). Still another important factor has been the role of third-party payers, whose willingness to pay for certain procedures can nourish the medicalization process, as was the case with the insurance providers‟ willingness to reimburse surgery for „gender dysporia‟ and obesity (Conrad 2004). A fourth important factor has been the role that pharmaceutical companies have played in the medicalization process (Koerner 2002, Moynihan 2005) Each of these four factors plays an important role in the medicalization process, and I would even argue that addressing all four is absolutely necessary if we are to fully understand the process by which illnesses come to be seen through a bio-medical lens (where disease is attributed to biological dysfunction), and treated accordingly. With that said, however, time and space limitations prevent me from addressing all four in this paper, and so I will limit myself to addressing the medical profession‟s role in the medicalization process. Regarding the latter factor, while much has been written on the medical profession‟s role, the sociological literature is sparse on cross-cultural analyses, yielding little on the question of why one country‟s medical profession will seek to medicalize a condition, without the same being done by the medical profession in another country. For example, in the case of ADHD the American medical profession has actively sought out to diagnose and treat this condition, while the same fails to hold true for France, a discrepancy that is significant, for it undermines the notion that the medical professions act in a coordinated manner across countries. Consequently, this underscores the subjective nature of the medicalization process, and calls for sociologists to obtain more nuanced understanding of the medicalization process, ones that account for the role of culture, collective memory, local economic pressures, as well as other contextual factors. Addressing this significant gap will be the goal of this paper, and towards that end I compare and contrast the US & French medical professions respective stances vis-à-vis the diagnosis and treatment of ADHD

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THEORETICAL DECISIONS Why Study the Psychostimulant market? From a theoretical perspective, there are four main reasons for studying this market: 1) the explosive market growth for this drug, both in the United States as well as elsewhere, 2) the national variability found in the demand for this medication, 3) this case can help us shed light on the market formation for other hazardous products, and 4) this case can help us elucidate how markets get formed for products aimed at children as well as others who depend on loved ones for care. Regarding the first of those factors, in recent years a tremendous growth has occurred in the consumption of Ritalin and other psychostimulants aimed at "treating"Attentional Deficit/Hyperactivity Disorder (ADHD). In the US alone the market growth has been explosive, for whereas 155,000 kids were on Ritalin as of 19751, by 1990 the total had reached nearly a million kids2, with the total surpassing 6 million by 2000,3 representing 2.8% to 3.1% of the child population. The US market growth for this drug product has been staggering, leading Leonard Sax to assert "No other medication in American history has had this kind of success in achieving and maintaining such a grip on its market: not Valium, not Prozac, not Viagra."4 Consequently, such market growth, in and of itself, constitutes a social phenomenon worthy of sociological analysis, both for studying the many social consequences that may proceed from this trend, as well as undertanding the causal mechanisms that produced the trend in the first place. Moreover, while such growth is most noteworty in the US, which represents between 85-90% of world consumption, consumption has also grown rapidly in a host of other countries, with the International Narcotics Control Board (INCB) reporting over 100% recent increases in over 50 countries.5 One such example is Britain, where prescriptions rose from 183,000 in 1991 to nearly 1.6 million by 1995.6 7 What's more, the INCB warned

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. Richard DeGrandpre, Ritalin Nation, (New York: WW Norton, 1999), p. 16 . ibid, p. 18 . Leonard Sax, MD, "Ritalin: Better Living through Chemistry?", The World and I, Nov. 2000 www.worldandi.com/public/2000/november/sax.html . Leonard Sax, MD, "Ritalin: Better Living through Chemistry?", The World and I, Nov. 2000 www.worldandi.com/public/2000/november/sax.html . International Narcotics Control Board, 1999 Annual Report, Release #2, Vienna International Center

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that, if recent trends weren't addressed, Britain and a number of the countries (Australia, Belgium Canada, Germany, Iceland, Ireland, the Netherlands, New Zealand, Norway, Spain and the United Kingdom) could experience drug consumption levels reaching as high as that found in the United States.8 In turn, the international breadth of this phenomenon is a second reason to study it. Thirdly, while the use of psychostimulants has grown in many countries, the prescription rates vary tremendously from country to country, with the United States holding the highest prescription rates with over 6 million of its kids being on psychostimulant treatments,9 which translates to about 2.8 - 3.1% of its kids.10 11 In contrast, other countries have far lower rates, with France, as one example, only having an estimated 4500 kids on the medications,12 which translates to 0.03% of its children.13 In turn, such national variability makes psychostimulants a unique case to study, for it is an instance where different outcomes are occurring when similar outcomes would be expected. More specifically, the American medical establishment has defined AttentionDeficit Hyperactivity Disorder (ADHD) as being biological in origin, and if they are right in their assessment, then we would expect different western nations to have similar rates of psychostimulant prescription. Such differences in outcome strongly suggests that psychostimulant markets are impinged upon by considerable social forces, and this market would therefore be a good site to study and understand those forces, The fourth theoretical interest for studying the psychostimulant market is that it is a hazardous product, which means that studying this case could shed light on the way other dangerous products come to market, get promoted, and eventually adopted. Regarding the hazards of the psychostimulants, as is the case with all pharmaceuticals, its consumption is associated with health risks. As one HMO doctor asserted in an interview:

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. Morris Zwi, Paul Ramchandani, Carol Joughin, "Evidence and Belief in ADHD", British Medical Journal, v. 321, October 21st, 2000, p. 975-976 . Parliamentary Office of Science and Technology. Treating problem behavior in children, London: OST, 1997 . International Narcotics Control Board, 1999 Annual Report, Release #2, Vienna International Center

9. Leonard Sax, MD, "Ritalin: Better Living through Chemistry?", The World and I, Nov. 2000 www.worldandi.com/public/2000/november/sax.html
10 11 12 13

. DJ Safer, M. Malever, "Stimulant treatment in Maryland public schools", Pediatrics 2000, 106 (3): p. 533-539 . Frances C., Hoizey G., Millart H., Trenque T., "L'utilisation du Methylphénidate (Ritaline®) en France, Thérapie, v 57, #2, mars-avril 2002, 189-193 . British Journal of Clinical Pharmacology, v. 57, #1, 2004, p. 115-116 . ibid

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"every single drug we use is a poison to the body, for while a drug may relieve symptoms at one site of the body, it will have noxious effects at other sites, such as the liver, stomach or other organs... The only reason we consume any of them is that some of them have beneficial side-effects..."14

Moreover, he wasn't alone in asserting this position, for it was one taken by a number of other doctors interviewed during that research project.15 Furthermore, theirs isn't a recent position, for as far back as 1973 Milton Silverman, the medical writer, observed that "there is clear-cut evidence that virtually any drug can hurt a patient"(Silverman, p. 23). Adding further weight to this concern is that not only are the Ritalin-type products pharmaceuticals, but they are prescription drugs, meaning that their health hazards are such that they are only to be acquired and consumed under the supervision of a trained medical expert. The potential health hazards associated with these products is long, and includes depression, drowsiness, anorexia, overactivity, confusion, drug dependency, hair loss, insomnia, blurred vision, blood disorders, skin disorders, liver disorders, abnormal movements, disruption of normal growth, and convulsions, to name but a few.16 Moreover, while each of the aforementioned health hazards is serious in its own right, the medication's high potential for drug addiction gives the issue even more significance, for the US Drug Enforcement Agency (DEA) classifies Ritalin, and its competitors, as Schedule II drugs, a classification that is reserved for drugs with the most extreme abuse and addiction potential, such as cocaine, opium, morphine and barbiturates.17 As a result of the product's hazardous nature of these products, the psychostimulant industry is heavily regulated, and studying such a heavily regulated industry could elucidate how markets develop for other hazardous products, such as genetically modified organisms, and nuclear energy, to name but two.

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. Drawn from an interview done in April 1997, where the topic of conversation was prescription drug advertising. . Manuel Vallee, “Side-Stepping the Doctors: The Rise of Direct-to-Consumer Advertising for Prescription Drugs”, MA Thesis, Sociology Department, UC Berkeley, filed 2003 . Peter Breggin, Talking Back to Ritalin, Perseus Publishing: Cambridge, Mass, 2001, p. 28-61 . ibid. p. 6

16 17

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The fifth theoretical interest for studying this case is that it is a product aimed at the childrens' market, thus providing potential insight in the market formation for other childrens' products. Giving the psychostimulant case even greater salience in this regard is the hazardous nature of these products, for if a market can be developed for a product with such a high number of side effects, it would surely shed light on how markets are formed for other products. In particular, it should shed light on how and why parents come to believe that such products are safe and worth acquiring for their children, shedding important light on the culture of childcare existing in each society. Moreover, the case should also shed light on how the marketing of such child products is mediated through the state regulatory apparatus, as well as by the advice of cultural authorities on childcare, such as physicians in this instance.

Why the French and American Cases? One reason for picking these two cases is that, as stated above, they stand diametrically opposed in the number of kids that they have on psychostimulant medication. In and of itself the difference between these cases is startling, as both countries adhere to the bio-medical paradigm of medicine and we would thus expect them to have similar outcomes. What makes the differences even more startling is that, outside of psychostimulants for kids, the French are one of the world's largest consumers of prescription drugs (Table 1) 18 19 20, with prescription rates for some products (such as hypnotics, sedatives and tranquilizers) being three to four times the rates found in comparable countries.21

18 19 20 21

. Alexander Dorozynski, British Medical Journal, April 20th 1996, 312, p. 997 . Professor Edouard Zarifian . Also, according to OECD figures, in 2001 France trailed only the US in prescription drug government expeditures. . For instance, "a recent study revealed that doctors in France prescribe about four times more sedatives, hypnotics and tranquilizers than doctors in Germany or the United Kingdom." International Narcotics Control Board (INCB). Annual Report for 2000, press release #4. Feb. 2000. Author United Nations Information Service; Vienna, Austria.

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TABLE 1 - Government Expenditure on Drugs 1980 to 2001
$30,000 France Germany Spai n UK Canada US

$25,000

$20,000
in US$ mn

$15,000

$10,000

$5,000

$1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Thus, we would expect that they would have prescription rates that are comparable to the American case. Given this fact, one wonders why the French would differ so markedly in their prescription of psychostimulants, a question whose answer I hope to tease out via the head-to-head comparison with the US case. In addition, teasing out that answer should shed considerable light on the key operating dynamics in the formation of psychostimulant markets in general. That is to say, not one factor or another, but rather the holistic interchange between factors. In turn, carrying out this project should also shed theoretical light on a number of larger conceptual categories, including how markets get constituted and fostered for the other psychiatric drugs aimed at controlling children's behavior, as well as for other prescription drugs marketed at children. Moreover, the project should also shed light on the prescription drugs that are marketed at the other defenseless segments of our society (including seniors as well as the disabled), as well as the market formation of prescription drugs aimed at the self-sufficient. At an even greater conceptual level, such investigations should shed light on the even larger conceptual category of the market formation for all "disease fighting" or "health enhancing" products.

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DESCRIPTION OF THE CASES The United States The American case is firmly rooted in the anglo-saxon tradition of viewing “hyperactivity” as an organic disorder; i.e. being caused by a dysfunction with the individual‟s biology. This perspective was developed through the writings of Hohman (1922), Strecker (1923), and was buttressed by C. Bradley‟s 1937 study, which suggested that amphetamines, a biology-altering treatment, were effective in calming “hyperactive” kids. The Americans‟ first widespread use of psychostimulants dates back to World War II, where, upon discovering that German generals were administering amphetamines to their soldiers, American leaders began administering amphetamines to their soliders.22 Ritalin itself didn‟t enter the US market until 1956, when it was approved for treating narcolepsy (i.e. a sleep disorder). Then, in the early 60s, the American medical profession accepted the use of psychostimulants in the treatment of “minimal brain dysfunction” (or what is now called ADHD)23, and American doctors followed the lead, with an estimated 50,000 kids being on the medication by the mid 1960s.24 Over the following years America‟s use of the medication grew, and by 1975 155,000 American children were on the medication25, with the total rising to one million by 1990. Over the course of the 90‟s, the proliferation rate increased dramatically, with experts estimating that 4 million kids were on the medication as of 1995, with the total climbing to 6 million kids by 2000 (which represents 2.8% to 3.1% of the child population).26 While considerable, these numbers are not representative of the whole United States, for considerable crossstate variation exists. For example, in 2000 6.5% of Louisiana‟s 6-14 year old population were on the medications, versus a 1.9% usage rate for Colorado.27 Moreover, DEA data suggests that from 1990-1995 some states had usage rates that were 6 times higher than other states.28 Besides inter-state variation, there is also high intra-state variation, as demonstrated by the Ohio case, where 3.6% of Summit County children were prescribed

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. B. Weiss, VG Laties, Pharmacological Review, v. 14, p. 1, 1962 . Wender, P., Bierman, J., French, F., et al, Minimal Brain Dysfunction in Children, New York: John Wiley & Sons, 1971 . LeFever, Gretchen, and Andrea Arcona “ADHD among American Schoolchildren: Evidence of Overdiagnosis and Overuse of Medication” . Richard DeGrandpre, Ritalin Nation, (New York: WW Norton, 1999), p. 16 . Leonard Sax, MD, "Ritalin: Better Living through Chemistry?", The World and I, Nov. 2000 www.worldandi.com/public/2000/november/sax.html . TM Burton, “Curious Variations in Prescription Drug Use”, Wall Street Journal, June 19, 2001. . Morrow RC, Morrow AL, & Haislip G, “Methylphenidate in the United States, 1990 through 1995”, American Journal of Public Health, 1998, 88: 121

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the drug in 2000 (3rd highest rate in Ohio), versus a 0.37% rate for Holmes County, which is only 30 miles away. What‟s more, some school districts have been found to have far higher prescription rates, with research showing elementary schools in one Virginia school district to have an 8-10% usage rate (for kids in grades two thru five).29 Apart from geographical variation, there is also substantial variation by gender, age and ethnicity, with boys being three times more likely to be treated with the medications,30 and whites being the largest users of the medication followed by African-Americans, and Hispanics, with the Asian population registering negligeable use of the medication. One large-scale study covering North Carolina found 8.2% of white kids on the medications, versus 5.1% of African-Americans, and 2.1% of Hispanic children.31 The latest development in the American case has been the young adults‟ surging use of psychostimulants, with their use doubling between 2000 and 2004.32

France Ironically enough, France is the country where hyperactivity was first described, with Dr. Désiré Bourneville documenting the first case at the end of the 19th century. In subsequent years, the condition was documented by other researchers (Demoor 1901, Heuyer 1914, Paul-Boncour 1919, Wallon 1925, Michaux 1950), solidifying the validity, and acceptance of hyperactivity as a disease classification. Similar to the American situation, in the early 1970s the French government approved Ritalin to treat hyperactivity33 and narcolepsy. However, the marketing license was heavily restricted, as only a handful of hospitals were authorized to dispense the medication, and they could only dispense one week‟s worth of medication. The French authorities imposed these restrictions out of concern for the drug‟s addiction potential, and the consequence of the restrictions was that the drug‟s market grew marginally, reaching only 3,000 patients.

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. LeFever, Gretchen, Keila Dawson, and Ardythe Morrow, “The Extent of Drug Therapy for Attention Deficit-Hyperactivity Disorder Among Children in Public Schools”, American Journal of Public Health, Sept. 1999, v.89 (9): 1359-1364. . “More Children on CNS Drugs”, Journal of the American Medical Association, April 17th, 2002, 287(15): 1930 . Rowland, Andrew, David Umbach, et al. “Prevalence of Medication Treatment for Attention Deficit-Hyperactivity Disorder Among Elementary School Children in Johnston County, North Carolina”, American Journal of Public Health, Feb. 2002, 92(2): 231-234 . Gardiner Harris, “Use of Attention-Deficit Drugs is Found to Soar Among Adults”, The New York Times, Sept. 15th, 2005, p. 18 Anne Debroise “Ritaline: Un Feuilleton a la Francaise”, La Recherche, n. 16, August 2004, p. 34-36

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In addition to stagnant market growth, the drug received bad press in subsequent years, prompting it‟s manufacturer to distance itself from the drug, and deciding to let it‟s marketing license lapse in 1985.34 In the following years the Ritalin medication underwent much scientific scrutiny, becoming the most studied subject in the children‟s psychiatry literature, prompting a few French specialists to seek the drug‟s re-approval 35, which Ciba-Geigy received from the French government in August 1995. Since its re-introduction to the French market, sales have only increased marginally, with recent estimates placing 6,000 to 7,000 kids (i.e. 0.04% to 0.05%) on the medication, which is far below the 3% to 5% figures found in the United States. 36

Contrasting the Cases Thus, we find ourselves with two countries that are the world‟s largest consumers for most pharmaceutical products, but which have very different histories vis-à-vis Ritalin. In trying to account for this divergence there are a number of different factors to consider, including those pertaining to the education system, parent associations, government agencies, and the medical profession. Although each of those factors warrants being studied more closely, the focus in this paper will remain on the medical profession, for while the other agents undoubtedly played an influential role, the medical profession is, arguably, the most important factor, for as the prescription writers, they determine whether a drug‟s use will expand or contract.

In contrasting the French and American medical professions, there emerge four distinct differences: 1) each medical profession favors a different causal explanation for hyperactivity, 2) each medical profession relies upon a different diagnostic system, 3) whereas Americans prioritize psychostimulant treatments, the French only use psychostimulants after exhausting all alternatives, and 4) the difference in healthcare systems (i.e. private versus social medicine). Regarding the first of those factors, the American medical profession, in general, embraces the biological interpretation of hyperactivity, accepting the hypothesis that hyperactivity is caused by a dysfunction with the

34

ibid. ibid. ibid.

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child‟s biology, which, in turn, predisposes the profession to embrace a biology-altering solution, such as Ritalin, amphetamines, and other psychostimulant medications. French doctors, on the other hand, are far more cautious about the ADHD diagnosis, citing the confusion in both the definition and understanding of the disorder, as well as what they believe are the heterogenous causes of hyperactivity.37 Far from attributing the disease to biological causes, French doctors believe hyperactivity to be an affective and relational disorder, and try to address the situation at that level. Professor David Cohen (author, social worker, and professor at Université de Montréal) reports that instead of going straight for the psychostimulants, the French rely on professional resources (such as psychologists and social workers), endeavoring to locate and to address problems in the family, in school and other social sites.38 Moreover, they display a strong reluctance to use Ritalin and other psychostimulants due to both the addictive potential of this medication (which has been found to be more potent than cocaine39 and which the DEA classifies in the category of most addictive medical substances), and the "lack of data about the safety of methyphenidate (i.e. Ritalin) in long-term use."40 Secondly, the American profession relies upon the APA (American Psychiatric Association) produced DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition), whereas the French rely on the WHO‟s (World Health Organization) ICD-10 (International Classification of Disease, 10th revision). 41 A key difference between these diagnostic systems is that whereas the DSM-IV provides a top-down, symptom-checklist approach to disease, the ICD promotes a less classificatory approach, one that takes greater stock in the person‟s developmental history.42 Consequently, the DSM‟s checklist approach nets a larger number of people who can be classified with disease, thereby making it easier to prescribe them with medication. As Dr McHugh argues, with such an approach

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. C. Frances, G. Hoisey, H. Millart & T. Trenque, "Paediatric Methylphenidate (Ritalin ®) Restrictive Conditions of Prescription in France", British Journal of Clinical Pharmacology, v. 57, #1, p. 115-116 . Pierre Dubuc, "Traitements: Le Ritalin, un Débat de Société," Le Champlain, vol. 6, #15, April 28th, 1999; URL: http://syndchamplain.educ.infinit.net/ . Brian Vastag, “Pay Attention: Ritalin Acts Much Like Cocaine”, Journal of the American Medical Association, vol. 286, n. 8, p. 905-06 . C. Frances, G. Hoisey, H. Millart & T. Trenque, "Paediatric Methylphenidate (Ritalin ®) Restrictive Conditions of Prescription in France", British Journal of Clinical Pharmacology, v. 57, #1, p. 115-116 . Ibid. Dr. Paul McHugh testimony, “Prescription Stimulant Use in American Children: Ethical Issues” President’s Council on Bio-Ethics, Dec. 12th, 2002, http://www.bioethics.gov/transcripts/dec02/session3.html

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“no one thinks about the consequences in the social network of the person. No one thinks about the character of the child, and no one thinks about the character of the family. No one gives advice on parenting and to a person about how they might overcome certain matters. And they do expose them to, after all, drugs that have serious consequences, including addiction.” 43

This would appear to be a very pertinent difference between the two cases, as it suggests that apart from any difference in disease incidence rates, what symptoms are present are interpreted differently in each society, with the Americans possessing an inclination towards pathologizing a greater range of behavior. This is undoubtedly an important piece of the puzzle, and as such deserves to be studied more carefully. However, in and of itself, it doesn't provide a complete explanation, for while lower diagnostic rates exist in France, other European countries (such as Belgium, Britain, and Norway, each of whom also uses the ICD-10) have experienced tremendous growth in the use of Ritalin, rivaling the market growth found in the United States. Thus, additional factors will also need to be considered. A third difference between the cases is that whereas the Americans are drawn to psychostimulant treatments, the French tend to save such treatments as a last resort, trying other treatment modalities first (such as psychotherapy, psychomotility and/or speech therapy). In addition, if the other treatment modalities fail to completely address the problem, psychostimulants are not used on their own, but rather as a complement to the other therapies being used. The fourth difference that may be pertinent is the different healthcare systems found in each country, for the French National Healthcare system may cover a greater array of treatment possibilities, whereas the American “managed care” approach might frown upon psychotherapy and other costly treatment services, in favor of the reductionist and cheaper pharmaceutical treatments.44

METHOD

43

ibid.

44

. Zito JM, Safer DJ, DosReis S., et al. “Psychotropic patterns for Youth: a 10-year Perspective”, Archives of Pediatrics & Adolescent Medicine, 2003, 157 (1): 17-25

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In deriving the stances of the French and American medical professions I relied upon three sources of data, with one being the medical professions‟ policy statements on ADHD diagnosis & treatment, which I obtained from the respective professions‟ web sites. Secondly, I utilized transcriptions from television shows, with those from American shows obtained either through Lexis/Nexis, or in other cases through the television stations that broadcast the shows (such as PBS). For the French case, transcripts weren‟t available from the internet, and so I obtained access to the audiovisual archives of the Bibliotheque de France a Paris, where I watched and transcribed every show that was broadcast from 1995 (when Ritalin first gained market approval in France), to 2002. From these transcripts I analyzed the commentary supplied by each physician, highlighting what each had to say about the ADHD diagnosis, as well as its recommended treatment. As for my third source of data, this consisted of the newspaper articles that pertained to ADHD. In the American case the newspaper articles were derived from Lexis/Nexis, while the French sample included articles from each of the major dailies, including Le Monde, Le Figaro (bourgeois perspective), Le Humaniste, and L‟Express. From these three data sources I formed a composite of each medical profession‟s position vis-à-vis the ADHD diagnosis and treatment.

THE FINDINGS Although quite preliminary, the findings at this stage are that the French medical professions have been reluctant to take a strong stance vis-à-vis the ADHD diagnosis or its accompanying psychostimulant treatment, for of the websites of the 5 medical professions analyzed, none provided any information regarding either ADHD, or the psychostimulant option. In contrast, their American counterparts have been much more vocal on the issue, for all five medical associations provided diagnostic and treatment information on their websites, with all five promoting a biological explanation of ADHD, as well as strongly endorsing the use of psychostimulants in addressing ADHD. This suggests that the stances taken by the American Medical professions have encouraged their practicing members to both actively apply the ADHD diagnose, as well as addressing the illness through psychostimulants. Similarly, on television the American doctors were quite forceful in advocating for a biological understanding of ADHD, for this was the position promoted in 70% of their television appearances. Correspondingly, the psychostimulant treatment was promoted in over 75% of those appearances. In contrast, the French took a
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different tack, for while they made themselves heard on television (appearing in 92% of all shows dedicated to the issue of ADHD, in over 85% of those appearances they were quite apprehensive about framing ADHD as a biological disorder, preferring to view it as a manifestation of affective and/or social disturbances. Correspondingly, the French are more predisposed to redressing the issue through psychotherapy, and social welfare intervention. One of the factors that helps account for this discrepancy is that in trying to account for psychological disturbances, the French have, historically, given much more weight to psychoanalysis, whereas Americans (as well as the rest of the Anglophone world) have relied more on biological explanations. What‟s more, the American inclination for bio-psychiatry was furthered in the 1970s, when the American Psychiatric Association (APA) formed an alliance with the pharmaceutical industry, where the latter provided funding for psychiatric research and the APA‟s organizational activities, in exchange for the profession developing a greater allegiance to the bio-medical paradigm, which included developing bio-medical explanations for disease, as well as researching bio-medical solutions for psychological illness. (Breggin, 2001)

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