Prelims

Overview of the Investigation

The investigation presented in this book utilised an ethnographic approach, and the scholarship of Michel Foucault, João Biehl, Nikolas Rose and Carol Bacchi to reconnect the wider social, political and institutional factors that were influential in the formation of a particular form of ADHD-related health care. By utilising various strands of their theoretical and empirical material, the investigation aimed to reconnect the nexus of elements that conditioned the possibility for the everyday social practice of ADHD to be in place within an NHS region in Scotland in the present moment.

An overarching aim was to consider ADHD from outside its dominant biomedical explanation by examining the wider context and processes that conditioned the possibility for the emergence of a local social practice of ADHD diagnosis and treatment. The investigation made use of the ethnographic approach of Vita: Life in a Zone of Social Abandonment as a methodological guide. Vita reconnects the nexus of elements – the ‘invisible machinery’ – that allowed for the subject of the project to be represented as mentally defective in the present. This project attempts a similar methodological reconnection of the invisible machinery that conditioned the present, but with the social practice of ADHD as the focus.

The analytic approach made use of the concept of ‘problematisation’, which captures a two-stage process – the questioning of how and why certain ‘things’ become a problem, but also how these ‘things’ are shaped as the objects that they become. Objects are not considered as things that previously did not exist being created by discourse, but as things that become what they are because of their interconnected ‘apparatus’ – the totality of discursive and non-discursive elements that introduce them into the play of true and false. The object of interest for this project was ‘young people’ and how they were problematised and shaped as the target of certain knowledges. It was through this process, the how of their construction as a problem, that the project made the connections that provided the authority for particular problem explanations to be installed as ‘real’ over other possibilities.

The fieldwork was conducted in a small geographical region in Scotland and consisted of several periods in health and education services. Along with extended periods in these domains, further ethnographic tools utilised included observation of clinical appointments, document analysis, interviews and archival research. Multiple sources of information formed the qualitative data for the investigation, including audio recordings/transcription of clinical appointments, clinical case notes, health service management team meetings and health and education policies and guidelines. The different layers of qualitative material – from individual appointment to national policy – allowed for reconnection of the discursive field in which the current practice of ADHD emerged. The material was engaged with horizontally and vertically within and across the different layers of material, allowing for the examination of the changing discursive background and the problematisation of young people within education and health domains. The analysis revealed discontinuity in how the ‘problem’ of young people was constructed across time, what was legitimated as solution to these problems, what effects were created and what followed from these effects.

The study is considered a Foucauldian-inspired ethnographic ‘case study’. The thesis uses the various chapters to construct a genealogical account of the emergence of the local social practice of ADHD, one that maps and makes visible the multiplicity of events implicated in the construction of young people as particular types of problems and which conditioned the possibility for the social practice of ADHD to become the current means by which young people become known as problems. The account offered provides a theoretical redescription of the rise of ADHD diagnosis and treatment locally, one that aims to trouble accepted explanations by revealing the wider complex network from which the social practice emerged.

Connecting Analysis across Chapters

In Chapters 1 and 2, I establish the frame of reference for this investigation and outline the methodological plan that guided the investigation in the field. Chapter 1 is offered in place of a ‘literature review’. My rationale for not providing a ‘review’ of the ADHD literature is because I take the position that reviewing this material would be nothing more than a reproduction of the ‘scientific truth value’ of ADHD. Rather than viewing the material as providing access to a ‘real’ account of ADHD, I consider it as constructing a rhetorical truth value, based on an enactment of procedures of objectivity, that provides ADHD its authority and which allows it to remain a dominant way of constructing young people considered problematic. Instead, what is offered in place of a literature review is a brief account of the positivist literature and an expansion of the ontological and epistemological grounds for the rejection of this literature. The remainder of the chapter provides an account of the theory and concepts that underpin the approach that guided this investigation. This theoretical account is then expanded in Chapter 2, which is presented in two sections. In the first section, I expand the theoretical account, providing a detailed theorising of the main analytical concept that guides the investigation – the apparatus. The concept is then placed within an account of methodological precautions and analytical steps. In the second section of Chapter 2, I provide a detailed account of the procedures for enactment of the theoretical account offered in first part of the chapter.

In Chapter 3, I provide an overview of the changing politico-economic background of the region and the changing requirements of the young person within the new societal order that emerged from this process. The chapter documents the decline of industry in the region; the removal of traditional forms of employment for young people in the area; and the emergence of technologies for disciplining young people towards active citizenship, a form of subjectivity in which the young person would self-improve through vocationally focused learning in order to ‘fit’ with the emerging post-industrial society. This chapter was made possible by the analytical focus that informed Chapter 4: specifically, the emergence of disadvantage and poverty as a strategic aim the apparatus of education, something that was prominent throughout my discussions with educational professionals in the region. Its visibility in discussions took the form of accounts of the impact of disadvantage locally and ‘on’ the behaviour of children. These discussions connected to my consideration of ‘additional support needs’ and its role in solving the impact the ‘problem’ of ‘social exclusion’ and ‘disadvantage’ had on learning. My previous unquestioning acceptance of local disadvantage was disrupted through a conversation with an educational professional, which was made possible by the critical focus on social exclusion in Chapter 4. As such, there was a requirement to extend the critical focus further to understand some of the elements that conditioned the possibility of the problems social exclusion came to represent. The chapter is presented in two sections: one section is offered as a genealogical/topological account of the elements considered important in conditioning outcomes and effects implicated in the emergence of the local procedures of ADHD and a second section where the effects are considered in detail.

The analysis in Chapter 4 was situated within educational sites and documents the conditions that allowed for psychiatric knowledge to play a role within the school. The chapter considers the changing discursive background of ‘learning disability’, the emergence of the category of Additional Support Needs from within this discursive space, the role this category played in constructing young people as requiring ‘support to learn’ and how this opened up a discursive space in which psychiatric knowledge and technologies would function. This chapter was made possible by the analysis in Chapter 5: one of the pressing issues, and one that offered legitimacy to the procedures that allowed for psychiatric knowledge to become dominant in CAMHS, was the ‘problem’ of increased referrals from schools. The question in this chapter was to understand what was ‘done’ with regard to problems in school and to understand what conditioned the possibility for ADHD to become a solution. As with the previous chapter, this chapter is presented in a similar way: a genealogical/topological account of the elements considered important in conditioning outcomes and effects and a more detailed consideration of these effects.

The analysis in Chapter 5 documents the shifting explanation for young people’s behaviour within the Child and Adolescent Mental Health Service (CAMHS) through analysis of clinical case files and team meeting minutes. The analysis documents the conditions that allowed for the emergence of the everyday practice of ADHD within CAMHS, connects this to wider shifting health and education reforms and highlights how this was able to connect to the local schools through the concept/policy agenda of ‘well-being promotion’ and ‘multi-disciplinary working’. This was the starting point for the investigation. The single question that informed the entire investigation was ‘how it was possible to do what was done with regards to ADHD in the service in the present moment?’ I was aware of tensions in the service regarding ADHD, but yet the procedures for management of the problem appeared to be unquestioningly accepted and enacted. My aim was to attempt to understand what made this possible. As with the chapters above, this chapter is presented in two sections: the first section documents the initial steps of the analysis, highlighting the shifting background within the case notes and meeting minutes that highlight the emergence and influence of the procedures of ADHD that came to form the everyday social practice of diagnosis and treatment. The second section provides an analysis of the discursive background that allowed for the emergence of the procedures and which provided the invisible lines of authority upon which they were legitimated.

The analysis in Chapter 6 offers a conceptualisation of the medication review through the Foucauldian lens of disciplinary power. The chapter highlights the disciplinary process enacted through the ‘elements’ that formed the medication review by using Foucault’s account of panopticism to frame the process as a form hierarchical observation in which normalisation was enacted through discipline. This chapter was made possible through observing ADHD medication reviews, a required procedural component of the diagnostic process. Through these observations, I located a tension between the ‘ADHD presentation’ represented by formal institutional knowledges and the everyday ‘problems’ that came to be represented by ADHD. Another tension was the ‘treatment’ of ADHD. Formal institutional knowledge provides an account of the ‘action’ of the medication on the source of the ‘symptoms’, resulting in the behavioural symptoms being ‘treated’. The everyday reality of ADHD treatment in the service was at odds with this account, however. This chapter aimed to provide an account of the means by which ADHD continued to be fixed on the young person despite these tensions.

Chapter 7 concludes the investigation by drawing together the elements of the apparatus and situating these within a discussion of the merits of critical ethnographic approach informed by poststructuralist theory. The chapter leaves the investigation open by highlighting the changing nature of the problematisation of young people through the emergence of ASD as the new explanation for problematic behaviour. This new form of problematisation is situated within the elements of the apparatus that allowed for ADHD to emerge.

Summary

The investigation documented in this book relates to the mental health and well-being of children and young people. I am interested in how the knowledges and practices that structure everyday social action relating to mental health and well-being emerge from within an ‘apparatus’ of interconnected cultural, political, and economic factors. What is offered is a critical ethnographic ‘case study’, one that connects everyday social actions to a multitude of influencing historic and current social, institutional, political/policy factors and which documents their role in conditioning the possibility of these everyday practices to be possible. The investigation was influenced by and overlaps with an emerging area within global mental health studies. There have been calls within this theoretical domain for approaches that consider cultural, political and economic factors and their interaction with local contextual factors. The approach I adopt is an ‘at-home’ ethnography, one that utilises the constructs and theoretical approach emerging within the global health movement to explore how contemporary ‘problems’ have come to be understandable as they are currently known.