ADHD, feeblemindedness, and pharmacop-outs

Opinion piece in the NYT today by the child psychologist L. Alan Stroufe discusses the use of Ritalin and Adderall in the treatment of Attention Deficit Hyperactivity Disorder in kids. Stroufe argues that the clinical evidence shows that these drugs do in fact work–for a while. A few weeks, on average. But he believes there is no good evidence that they are a long-term solution. In fact, he writes, what data there is suggests that these drugs eventually stop working.

To me as a historian, ADHD looks a lot like feeblemindedness. In the early twentieth century,  many human geneticists and psychologists believed this “disease” to be the root of a host of antisocial disorders, from poor academic performance to criminal activity to sexual promiscuity. Further, there was evidence that it was caused by a single Mendelian gene. In his landmark study of feeblemindedness, the psychologist Henry H. Goddard gathered the data, from his study of hundreds of students at the New Jersey school for feeblemindedness of which he was the head.

Feeblemindedness no longer exists.  The DSM, of course, is chocked with disorders that are consistent with feeblemindedness: below-average IQ, tendency toward antisocial behavior, and the like—and OMIM and GenBank contain plenty of genes that influence such behavioral traits. But Goddard is mocked for his foolish belief in a single gene for feeblemindedness, and one would be laughed out of the American Psychological Association if one now suggested doing a study of “feeblemindedness.”

It’s not just a matter of terminology. Nor is it a matter of getting the science “wrong.” Feeblemindedness was perfectly “real” in the 1910s–as were “hysteria,” “neurasthenia,” and other diseases we no longer believe in. Only a few decades ago, homosexuality was a clinically diagnosable disease. Malaria did not exist before agriculture. Cholera did not exist before cities.

Diseases have real biological substrates. But disease categories are socially constructed. The disease ADHD was created to solve medically a set of problems described by parents and teachers. The fact that we can find biological substrates and mechanisms that underlie it–and drugs that treat it–does not give the lie to the social construction of ADHD. Science and history can offer complete explanations of the same sets of facts.

Biomedicine works in part by finding mechanisms that underlie medical conditions. But what counts as a medical condition is negotiated by society as a whole. Disease entities are not natural categories; they are contingent, contextual, overdetermined. And drugs such as Ritalin and Adderall have not only biological side effects, but social ones.

Goddard, Henry Herbert. Feeble-Mindedness, Its Causes and Consequences.  New York: The Macmillan Company, 1914.

Maines, Rachel, and American Council of Learned Societies. The Technology of Orgasm: “Hysteria,” the Vibrator, and Women’s Sexual Satisfaction.  Baltimore, Md.: Johns Hopkins University Press, 1999. http://name.umdl.umich.edu/HEB00062.