This article describes the main discussions and contributions of the first workshop of the International Research Network on Disruptive Behaviours. The workshop was held at the “Centre for Research in Medicine, Science, Health, Mental Health and Society” (CERMES-3) in Paris, in January 2017. The second network workshop will be organised by the “Transdisciplinary Laboratory in Social Practices and Subjectivity” (LaPSoS) and will take place at the University of Chile (Santiago), in November 2018.
Behaviours qualified as “disruptive” in children such as “agitation”, “behavioural disorders”, “inattention”, “impulsivity” and the widely broadcast category of “Attention deficit hyperactivity disorder” (ADHD), have become a major social and health issue [1]. However, despite these behaviours having acquired a high social visibility, their definitions and treatments are still controversial within the mental health field [2].
In order to address these issues, a group of psychologists, psychoanalysts, anthropologists and sociologists met in Paris between January 24-27th, 2017, to participate in the international workshop: “Agitated children, turbulent trajectories: towards a comparison between Europe and South America”, organised by CERMES-3 (University Paris Descartes). The workshop aimed to discuss empirical research, conducted in different regions such as Campinas and Santos (Brazil), Santiago (Chile), Paris and Lille (France), and Stockholm (Sweden). From a comparative perspective, the discussion highlighted social, cultural and political dimensions that shape disruptive behaviours in children. Researchers interrogated how cultural representations become subjective experiences and how these experiences are related to different forms of family organisation, social structure, different moral frameworks and conceptions of childhood, and different health and education systems. They also discussed lived experiences and illness narratives of adults diagnosed during childhood, as well as institutional conflicts associated with the everyday management of children.
In this commentary, we will present the main discussions and contributions of this workshop. We have organised the material into four topics: (1) practitioners’ perspectives, local contexts and institutional networks; (2) the lived experiences and multiple meanings of ADHD; (3) children’s perspective and trajectories; and (4) practices of care.
Practitioners’ perspectives, local contexts and institutional networks
While European countries tend to present lower prevalence rates of ADHD than South American countries (for instance, ADHD in children ranges 3.5% to 5.6% in France and between 2.4% and 7.5% in Sweden [2, 3]), the social and political debates are usually stronger than they are in South America. Such debates are closely associated with controversies about the medicalization of children’s behaviour, mobilising families, health practitioners, social workers, the media and civil society organisations. In contrast, in South American countries as Chile, the prevalence rate of ADHD is three times higher than the world average (16% vs. 5%) in children aged 4 to 11 [4]. In fact, between 2002 and 2014, the purchase of methylphenidate by the Chilean state increased by 1000% (from 24.4 kg to 297.4 kg). For its part, in Brazil, the prevalence of ADHD ranges from 5.8 to 17.1% among students [5]. Similar to the Chilean case, Brazil had an increase of 1.616% in methylphenidate sales from 2000 to 2008 [6]. Nevertheless, South American civil organisations which focus on children’s health issues remain weak when faced with these social and health issues.
In this context, participants interrogated how social, cultural and political conditions within each country influence the different approaches to disruptive behaviours, especially ADHD. Highlighting the Chilean case, Esteban Radiszcz, Gabriel Abarca, Hugo Sir and Pía Uribe (LaPSoS, University of Chile) examined how several reforms from the late 1990s allowed the inclusion of “non-traditional” practitioners in schools, such as psychologists, differential educators, and social workers. These reforms have also promoted higher subsidies to those schools that receive children with certain diagnoses (Down syndrome, Autism, Asperger and ADHD). From 2011, the “Integral Care Program for children with ADHD” has been implemented in primary healthcare centres. As Radiszcz and his colleagues showed, these reforms and programmes have played a key role in shaping the social and subjective experience of children diagnosed with ADHD.
In France, as Jean-Sébastien Eideliman (CeRIES, University of Lille 3) described, the 2005 Law on Disability requires the recognition of a disability as a precondition to referral to specialised institutions, or to benefiting from specialised resources (for instance, human assistance in the classroom). Nonetheless, public mental health institutions are commonly dominated by psychodynamic approaches. In these institutions, practitioners have an understanding of “agitation” or “ADHD” as a symptom or syndrome that should be integrated into family dynamics and the “psychic economy” of the child. In this context, parents require significant resources in terms of time, money and abilities to understand complex institutions, because practitioners tend to oppose the ADHD diagnosis.
On the other hand, in Sweden, as Anders Gustavsson and Noam Ringer (Department of Education, Stockholm University) described, the ADHD biological-neuropsychiatric approach is dominant. Here the shaping of this diagnostic category has been mainly influenced by the strong tradition of disability services. Gustavsson and Ringer highlighted the relationships between the construction of the Swedish welfare state and the notion of “disability”, showing that the ADHD category is one of several so-called “weak groups”. Through this category, schools receive benefits such as financial support and additional resources.
On the whole, researchers highlighted the difference between European social protection systems and the institutional realities of South American countries. For example, despite recent attempts to improve equality in health and social protection, Brazil is experiencing a deep crisis in the public sector and a chronic increase of inequalities and poverty. As Eunice Nakamura and Tatiana de Andrade Barbarini (LICHSS, Federal University of Sao Paulo) pointed out, while in Brazil the anti-psychiatric movement has been strong and influential, the prescription of drug treatments and diagnosis of ADHD is increasing in healthcare centres.
The lived experiences and multiple meanings of ADHD
The second topic of discussion focused on semantic networks and cultural meanings of disruptive behaviours in children from the perspective of different actors (caregivers, teachers, parents and children). Esteban Radiszcz and his colleagues summarised the preliminary research outcomes aimed at describing the modes of detection, referral, diagnosis and treatment of ADHD among Chilean children. They conducted participant-observation in three different schools and discussion groups with teachers of primary schools. Additionally, they carried out interviews with adults (between 25 and 40 years) who had been diagnosed in their childhood with ADHD or an equivalent category.
The ethnographic material showed ADHD to be a specific configuration that assembles actions classified as “problematic” and involves the participation of a certain number of agents (e.g. school, health centre, parents, children and teachers). This configuration, named “ADHD-situation”, is characterised by a disruption of the continuity of the classroom, the change of the attention flow from the teacher to a child, and the subsequent connection between the child’s name and the disruption. This situation is indicative not of an “attention deficit” issue but rather of an “excess attention regime”. In some extreme cases, in order to preserve this regime, students must receive forced pharmacologic treatment to be able to continue their studies. Coherently, teachers’ discourses about ADHD were centred on the imposition of uniform rhythms within the classrooms, the inadequacy of spaces, the overload of extra-pedagogical demands and the schools’ economic interests.
Chilean adult men diagnosed with ADHD during their childhood emphasise instead the limitations imposed on the deployment of their “potentialities” by different social actors belonging to their educational community. This argument however would, at the same time, allow the diagnosed men to question their own diagnosis. The men state that the potentiality of their singularities was not recognised. This, far from being a disability, would constitute a “different capacity”. Where adult women are concerned, it is perceived as a medical condition that needs to be replaced with supplementary actions – physical activity, repetitive tasks, sustained movement and focalization, for instance – or medication.
From a different methodological approach, Aude Béliard, Jean-Sébastien Eideliman, Maïa Fansten, Nadia Garnoussi, Sarra Mougel and Maelle Planche (CERMES-3, University of Paris Descartes), talked about the ambivalent effects and moral dilemmas in French children and their families associated with the diagnosis of ADHD. They identified, from interviews with family members of the Association “HyperSupers TDA/H France”, three particular dimensions of the ADHD diagnosis. First, the diagnosis is not a sudden and radical break that means reconsidering and reconstructing everything. Second, it does not involve a passive trajectory but an active one (the families are looking for the diagnosis). Finally, ADHD can be considered as an interlude. Parents usually experience the diagnosis as a conversion from “bad parents” to “clairvoyant and tenacious” parents. For mothers, the official diagnosis makes it possible not to feel alone or guilty in relation to the problem of their sons and to request adjustments and more tolerance from their teachers. Thus, the diagnosis gives them the power to negotiate with the school. However, it also opens new moral dilemmas induced by the drug treatment and reduces social and academic ambitions. Finally, Béliard and her colleagues interrogated the effects of ADHD diagnosis on children’s school careers and daily experiences. They showed how a diagnosis opens up the possibility for the recognition of the disability, and allows parents to regain control of their children’s school trajectory and to avoid a specialised school environment. The diagnosis also allows for a reinterpretation of the family’s history.
Eunice Nakamura and Tatiana Barbarini described different meanings of disruptive behaviour in Brazilian children. They showed different social uses of mental health categories around the “agitaçao”. From data collected through medical records, interviews with health practitioners in Santos and interviews with practitioners, parents and “agitated” children in Campinas, they described the connections established between children’s behaviours, social problems and psychiatric categories. In Santos, disruptive behaviours were identified mainly as “extreme and excessive agitation” (“agitação excessiva”). These behaviours were related to the ideas of “disruptive” or “restless” and also associated with “aggressiveness” and “instability”. There were few mentions on these records of ADHD or hyperactivity categories. In Campinas instead, the main discourse underlying the definition of disruptive children’s behaviour and learning problems is based on the categories of biomedical psychiatry. In the schools, “hyperactive” was the most evoked term even by those teachers who have questioned the validity of psychiatric categories. The research outcomes showed how the social definition of disruptive behaviour underlies popular and technical uses of the category “agitation”, blurring the borders between technical and popular categories and the extent of institutions’ authority to define and explain what is considered a problem. Consequently, for Nakamura and Barbarini, different uses of “agitation” produce a diffuse and hybrid category, neither pathological nor normal, but natural (biological), social and cultural at the same time. Thus, “agitation” can be considered as a vague and hybrid category based on blurred definitions of children’s behaviours originated from the interaction and “permeability” of concepts and social roles.
Children’s perspectives and trajectories
The third topic of discussion focused on the perspectives and social trajectories of children diagnosed with ADHD. Reflection on the peculiarities of children’s discourses led Pablo Cottet and Isis Castañeda (LaPSoS, University of Chile) to criticise the work of Ilina Singh on “child’s perspective”, medication and “authenticity” [7]. Singh understands authenticity as determined by a perception of self-coherence, which would not necessarily be affected by the medication. As Singh recognises, the child’s relationship with the medication depends on the “socio-moral” frame of reference where it is prescribed. Thus, when adults explain to children the reasons for using the medication, children can perceive it as a way to obtain greater control and freedom over their actions. For instances, “to be able to choose”, to pay more attention or to behave better. However, Cottet and Castañeda pointed out that children faced with adults’ questions, more than having a perspective on the medication, are rather taking a stand in relation to the language offered by the adults. In other words, Singh overlaps “the child’s perspective” with the word of the adult who interrogates. However, it seems that the child’s answer is more related to the edges granted by the adult’s word, and less to the “real” effect of the medication. Therefore, the first condition for conducting research on children’s discourse seems to be the recognition that children are more than just subjects being interviewed; childhood is a subject position, a relation to language, “a position in language”. In fact, Cottet and Castañeda, instead of questioning the children about the “self” or asking direct questions about medication, seek to get children to speak without questioning them, trying to avoid putting them in the position of responding or obeying.
Pablo Reyes and Gabriela Jáuregui (LaPSoS, University of Chile) analysed the social and experiential trajectories of two children (identified by researchers as Alberto and Luciana). They understand trajectories not only as a pattern of physical movement but also as a “subjective movement”. For both children, traces of the “ADHD situation” are localized in the preschool period. However, for each of them, ADHD has different meanings and consequences. For Alberto, the “ADHD situation” is shaped in the discourse as a contingent response to dynamics of aggression, abandon and mistreatment, and his disruptive behaviour would become a defence mechanism against an authority, which he considers unfair. In Alberto’s trajectory, the diagnosis and the treatment are only functional for the school’s demand – the condition for the child’s continuing at school – but they are not functional for his medical trajectory. For Luciana instead, the consequences of parental failure are shaped in her identity as ADHD, becoming a “hyperkinetic child” or a “girl without self-control”. Through these cases, Reyes and Jáuregui showed how the medication’s administration would lead to a subjective division associated with the emergence of malaise in both parents and children, concerning the benefits of diagnosis and medical and school treatment.
Practices of care: between reflexivity, medication and control
The last topic of discussion centred on practices of care associated with disruptive behaviours in health centres and schools, as well as on sociocultural processes underlying the construction of clinical decisions and children’s relationship with medication. Amélie Turlais (Paris Nanterre University) described her work in a day hospital in Paris, and focused on the difficulties of the “talking cure” and on the process of recognition of a disability in the trajectories of agitated children. Turlais described the way in which caregivers are encouraged to put into words the children’s experience, in order to get them to gradually replace some of their inappropriate acts with words. This process needs a constant work of interpretation of the details of children’s behaviour, requiring the ability to maintain a close distance to them.
Sebastián Rojas (GHSM, King’s College London) addressed the multiple determinants of ADHD medication effects. From an ethnographic fieldwork in a high-income school in Santiago, Rojas described how the medication can produce something different than the commonly caricatured image of the medicated child. According to Rojas, the potentialities of the medication are not exclusively contained in the pill itself or linked with a pre-fixed ideal of school performance. Rojas used the term “pharmaceutical entanglements” to describe the interaction between ADHD medications, the children taking them, other actors that play a significant role as well as the institutional dynamics and forms of local knowledge that influence expectations of how and why the medications’ effects unfold. From his perspective, the presence of psychostimulants in the classroom is better described as the introduction of a potentiality, new modes of agency, and an interactional process that might lead a child to become different. In this context, the child has to learn to recognise physical and mental sensations that come along with the use of the drug, giving meaning and purpose to the medication in order to achieve a specific goal.
Finally, Livia Velpry (CERMES-3, University of Paris 8) spoke about restraint practices in an experimental specialised unit in “extreme situations” in Paris (cases of “extreme agitation” and violence, for instances). It is now widely accepted that constraining interventions such as physical restraint must be exceptional, locating this practice at “the limits of care”. Velpry interrogated the elements mobilised by professionals to ensure that interventions on extreme agitation are acceptable, identifying two general conditions: first, the space of possible interventions is defined in relation to a wider context, including architectural, human and material means; second, the implementation of collective reflexivity plays a key role in giving meaning, justifying and legitimising restraint practices.
Some final remarks
The international workshop “Agitated children, turbulent trajectories” addressed diverse topics, illustrating how different sociocultural processes influence the approach to children’s behaviours and the social attitudes towards diagnosis and socio-medical practices. This leads to thinking about the diverse forms in which the experiences and trajectories of children are shaped by institutional frameworks, clinical decisions, diagnostic processes, parents’ perception and the attitudes of children themselves.
The workshop also allowed participants to clarify research approaches to the disruptive behaviours in children. First of all, a large part of social science research starts from diagnosis categories -particularly ADHD. However, the discussion showed that the diagnostic process is just a way of qualifying and dealing with “disruptive behaviours”. It seems more productive to start from this general problem to understand how different actors take them into account.
Second, researchers interrogated the ways in which social and subjective meanings of disruptive behaviours are shaping the interaction between institutions and subjects in different fields (education, health and social care) and social frameworks (e.g. France and Sweden as countries with a strong social protection network; Brazil and Chile as countries with deep inequalities and a large vulnerable population).
Third, presentations made possible an analysis of the collective representations and values related to disruptive behaviours and the ambivalent moral significance of categories such as ADHD. For example, ADHD seems to be a disruptive but at the same time creative behaviour, in which a “cultural polarity” [8] underlies: it is a lack of self-control but related to a personal initiative.
Fourth, researchers also interrogated the social uses of the diagnosis and drug treatments in the everyday lives of children and their families. They highlighted how individuals use mental health categories and practices as well as how these uses could be related to transformation processes of norms and values in each society. This perspective allowed them to move away from a discussion centred solely on issues such as the “social construction” of the ADHD disorder and the “medicalisation” of the childhood.
Finally, the comparative exercise allowed researchers to explore local and micro-social dynamics (family dynamics, local relationships between schools and health centres, professional perspectives) and their relations to macro-social processes (changes in mental health and school policies, the configuration of healthcare provision, the local system of beliefs and norms). This constitutes the first step towards developing a major comparative research on disruptive behaviours in children, aiming to highlight by contrast some transnational differences and similarities and to explore the ways in which global trends influence the production of local issues.
Álvaro Jiménez Molina is a clinical psychologist and PhD student in Sociology at the Université Paris Descartes. His doctoral thesis consists of a comparative study on self-harm (suicide attempt and self-injury) in Chilean and French adolescents. In addition, he is lecturer and a young researcher at the Faculty of Social Sciences of the University of Chile. His research interests lie in the junction between clinical psychology, the sociology of mental health and medical anthropology, particularly around the social and normative dimensions of ‘mental’ symptoms. As part of his interest on the globalization of psychiatric categories and practices, he currently participates in a comparative anthropological study on attention deficit hyperactivity disorder (ADHD) in Chilean, French and Brazilian children.
Gabriel Abarca Brown is a PhD candidate at the Department of Global Health and Social Medicine at King’s College London (KCL). His research project explores and analyses the discourses and practices related to migration, multiculturalism and mental health of young Afro-Caribbeans in Chile as well as the ways in which these discourses and practices are shaping their subjectivity. The research is supervised by Dr Dominique Béhague and Dr Orkideh Behrouzan and funded by BecasChile Scholarship (CONICYT-CHILE). Prior to arriving in King’s, he lectured in the Department of Psychology and the Faculty of Medicine at the University of Santiago.
References
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