What Does 'Normal' Mean?

A review of the Concept of Normality with regards to the diagnosis of Attension Deficit Hyperactivity Disorder (ADHD) In the 'Western' World.

Attention Deficit Hyperactivity Disorder is- according to the American PsychiatricAssociation(DSM-5,2Oi3), a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity and impulsivitythat interferes with daily functioning. As of 2018, 5% of children and 4% of adults across Europe have been diagnosed with ADHD (ADHD Europe, 2018); if we take the most recent population statistics in Europe (Eurostat, 2018), this means that over 4 million children and over 16 million adults in Europe are currently diagnosed with ADHD. In the United States a recent study by Guifeng et al. (2018) has found that 10.2% of children were diagnosed with ADHD in 2016. These statistics are staggering, especially when considered that these statistics were nowhere near this high 3 decades ago. There has been a dramatic increase in ADHD diagnoses in most ’Western’ countries in the past few decades and what’s more, there’s been a coinciding increase in prescription stimulant drugs for treatment of ADHD (Timimi & Leo, 2009), as demonstrated in figure 1. The reasons for this increase in ADHD levels are widely contested: Some say that these ADHD levels were always present but they simply were not being diagnosed; another view is that the increasing levels of ADHD like behaviour is a result of the environment of modern western society; and yet another view is that modern western society has developed new ways of viewing, classifying and handling children’s behaviour (I say children and not people because even though adults can have ADHD, symptoms have to have been present from childhood for an ADHD diagnosis (DSM-5, 2013).), leading to an increase in ADHD diagnoses (Timimi & Leo, 2009). The stance of this essay is in favour of the third view; our society is constantly undergoing modifications in how we think and act and the most recent of these modifications has lead to a change in the way we classify and handle children’s behaviour, leading to the overdiagnosis of ADHD.

The Figure 1 was removed by the editors for copyright reasons

Figure 1 Satirical photo advertising "Ritalin-O's". Ritalin is the generic stimulant drug for treating ADHD in children. The photo aims to mock how easily physicians and parents turn to pharmaceutical treatment even in very young children.

This essay will primarily use Canguilhem’s notion of the concepts of normality and pathology, as well as Hackings ideas on dynamic nominalism, to explain how the concept of ’normality’ in psychiatry has lead to the creation of the diagnosis ADHD, and how these concepts help us understand the increasing prevalence of this diagnosis and its subsequent treatment, particularly in the ’Western’ world. The first part of this essay will first explain the place of normality and pathology in biology to explain how the field of medicine has come to view illness in general, and more specifically mental illness, and explain howthis has lead to the over-medicalisation of everydaybehaviours, ultimately creating the field of mental illness and, more specifically, ADHD. The second part of this essay will examine how Hackings concept of dynamic nominalism accounts for the increase in ADHD diagnoses. The third part of this essay will explain why the ’Western’ world’s current socio-political economic structure is to blame for why ADHD rates are much higher in the ’Western’ (also referred to as ’global north’) world today.

Normality and Pathology

The Oxford dictionary (2015) defines normal as "conforming to a standard; Usual, typical or expected." The latin roots of the word reveal it to mean ’right-angled’ (Oxford Dictionary of English, 2015), demonstrating its roots as a word used to explain what is ’right’ and ’correct’. However it is an ambiguous term with 2 conflicting definitions; It is both an ideal to be achieved and a mathematical average to be used as a point of reference. (Canguilhem, 1966). When regarding anything in terms of normality you are either setting it within a norm that is the standard, or you are stipulating a norm to which it is to achieve to. Pathological is thought to be the opposite of normal, hence abnormal. But the term pathological carries a negative connotation- a few synonyms of the word are: unreasonable, morbid, diseased (Oxford Dictionary of English, 2015), hence highlighting the issue; The normal state is considered to be good, and, by default, the pathological state becomes bad.

The concepts ofNormality and Pathology have vital implications in the fields of medicine and biology; as Canguilhem (2008) put it, "A physicians thought and activity are incomprehensible without the concepts of the normal and the pathological." The pathological state of the body is the diseased state and the normal state is the healthy state (ibid). However up until the middle of the 19th century, the pathological state and the normal state were thought to be inherently different, until the Broussais principle; which established that the phenomena of disease was essentially the same as that of health, and that it only differed in quantity (Canguilhem, 1966), later followed by Bernards principle, which insinuated the same thing: "The disturbance of a normal mechanism, consisting in a quantitative variation, an exaggeration, or an attenuation, constitutes the pathological state." This way of thinking about the normal and the pathological revolutionized the field ofbiology and medicine. However Canguilhem had some critiques to viewing health in this light.

His main critique was that medicine and biology are not objective sciences; pathology cannot purely be determined through calculations (Canguilhem, 1966). While he agreed that the pathological state of the body was in factjust a quantitative variation of the normal state, the qualitative variation resulting- the pathological states actual presentation- was different, for it changed an organism’s ability to live in its environment, and this change could not be calculated (ibid). Canguilhem viewed life as normative activity, meaning we as living things are constantly imposing norms upon ourselves to be able to react to imposed circumstances (Greco, 1998). He viewed normality and pathology in terms of normativity rather than normality; both the normal and the pathological state consisted of norms, but the way these norms differed established the difference between the normal and pathological state. He deemed that a healthy or diseased state was determined by the bodies ability to institute norms to best thrive in its environment (ibid). In essence, health is the bodies ability to be flexible in response to its environment, and pathology limits this flexibility. This implication demonstrates that the field of medicine and biology cannot be objective. Determining the severity of a symptom with regards to how it impairs an organism’s ability to survive and thrive in its environment is a value judgement, examples of some behaviors characteristic ofADHD (DSM-5, 2013) ), andjudging them to be pathological behaviours and thus the result of a disease due to their rendering people with reduced capability to function in their environment in comparison with ’healthy’ people. An ’expert’judges that a person with these symptoms is rendered less capable than their ’normal’, ’healthy’ counterparts in academic and occupational settings, therefore their condition is pathological and requires medical treatment, as represented in figure 2.

The Figure 2 was removed by the editors for copyright reasons

Figure 2: An cartoon of a young boy looking distressed while being branded with a stamp labeled ADHD, the stamp is held by an arm in a white button down shirt, demonstrating an authority figure passing down a value judgement and branding a child with ADHD..

In i960, American Psychologist Thomas Szasz made the radical claim that mental illness is not real in his paper titled, "The Myth ofMental Illness". While this essay does not entirely support his stance, he did excellently sum up the problem with our interpretation of normality and pathology:

"In actual contemporary social usage, the finding of a mental illness is made by establishing a deviance in behavior from certain psychosocial, ethical, or legal norms. Thejudgment may be made, as in medicine, by the patient, the physician (psychiatrist), or others. Remedial action, finally, tends to be sought in a therapeutic «—or covertly medical-framework, thus creating a situation in which psychosocial, ethical, and/or legal deviations are claimed to be correctable by (so-called) medical action." (Szasz, i960).

This quote explains Canguilhem’s main criticism of our use of the concepts or normality and pathology in the biomedical field; we cannot deem something that’s expressed qualitatively as pathological or normal without using our value judgement, and when wejudge something we judge it with regards to certain internalised psychosocial, ethical, and legal norms present in external environment- our society, which unavoidably affect ourjudgement. ADHD is diagnosed with a clinical diagnosis (ADHD Europe, 2012), meaning that there are no brain scans or blood tests to be done to diagnose ADHD as one could do for, say, cancer. The diagnosis is done through a comprehensive assessment by a qualified psychologist or developmental specialist. So the diagnosis of ADHD- as well as many mental illnesses it should be noted- is determined solely on thejudgment of a ’qualified expert’. This clearly demonstrates whyADHD prevalence is varied globally; diagnosis is determined by the expertsjudgement, which is influenced by norms in society, different societies worldwide have different norms, and therefore different levels of acceptance or rejection ofADHD symptoms as ’normal’.

Dynamic Nominalism

Another concept that can help account for the increase in ADHD diagnoses in the last 3 or so decades is the concept of dynamic nominalism. In his essay titled ’Making up People’ (2006), Ian Hacking discussed what he called Dynamic Nominalism; which examines the interactions between the phenomena of the human world and our classifications of them, or as he puts it, "How names interact with the named." (Hacking, 2006). This concept is different from traditional nominalism- which is the doctrine that universals or general ideas are mere names without any corresponding reality (Oxford Dictionary ofEnglish, 2015)- in the sense that it is not static, it acknowledges that with continuous social change comes change in our classifications, and these categories are continuously evolving; hence the term dynamic (Hacking, 2006). According to Hacking, we inherently categorize all things; but social categorization only began in the 19th century. The reason only social categorization has given rise to this dynamic version of nominalism is because humans respond to this categorization unlike any other organisms or things for two essential and obvious reasons: Humans have the mental capacity to be aware that they’re being categorized unlike other organisms or mere objects, and humans, being more aware, are also more value-laden than other organisms, and put more importance towards being categorized (ibid). This leads to what Hacking called "the looping effect": Our creation of categories and investigation into them interacts with the people in the category, leading them to change their behaviour in response to their categorization, leading to a change in the category, hence the looping effect, as Hacking puts it, “classifying people works on people, changes them, and can even change their past.”(ibid)

Once we understand the concept of the looping effect described by Hacking we can clearly see how this could explain an increase in ADHD diagnoses, especially considering that this social categorization only arose in the 19th century, and the first example of a disorder resembling ADHD being recorded was in 1798 by Sir Alexander Crichton in Scotland (Lange et al. 2010). The looping effect essentially states that by giving people with the behaviours that we now consider symptoms of ADHD the label of ADHD we essentially gave them a mold to fit into, the label lead to a change in their behaviours, leading to a modification of the criterion for ADHD, broadening the criterion to fit more people, and so the loop continues. We can clearly see evidence of this occurring every day, especially in the last 20 years with the birth of the internet. The Diagnostic and Statistical Manual ofMental Disorders (DSM-5), which is the diagnostic and taxonomic tool used by psychiatrists and psychologists in America, is available publicly online, anybody can look up the diagnostic criteria for ADHD, or any other mental disorder for that matter; human nature is to categorize and label behaviours, so when faced with labels for possible behaviours, according to Hacking, people "reinvent themselves" to fit new realities, which in this case would be "reinventing" pre-existing behaviours to make them fit an ADHD diagnosis.

The 'Western' World

This paper has illustrated how the concepts of normality and pathology in biomedicine and dynamic nominalism have accounted for the increasing diagnoses and pharmaceutical treatment of ADHD, however both these concepts were explained in relation to strictly ’Western’ society and societal norms. For the last few decades our market society has been rather neoliberalist, which essentially means that, "all aspects of social, cultural, and economic life are shaped by what is sometimes referred to as “market rationality”—that is, evaluating the merit of all actions according to what is deemed as valuable, acceptable, or desirable by “the market.” (Esposito & Perez, 2014). The features of our neoliberalist societyinclude a strong emphasis on utilitarianism, consumerism, and individualism, as well as increased secularization; these four individual aspects of our society I believe could strongly explain how this rise in ADHD diagnoses is much more drastic here than in the ’Global South’.

As Cohen explains in his book Psychiatric Hegemony:A Marxist Theory ofMental Illness (2016), psychiatry is a form of social control, introduced post industrial revolution to create and maintain an obedient and productive workforce. This is completely in line with post-modern utilitarian values: making everything as efficient as possible. The same applies to schools, the ADHD diagnosis is handed out as a form of social control, so the children with behaviours that are seen as disruptive and less productive are given drugs to control them and maximise efficiency. As Dutch poet Martinus Hendrikus Benders wrote “Something went greatly wrong in our collective history and the starting point of it was the industrial revolution. Our school systems are focussed on a single objective: to produce model citizens for society in order to feed this machine and prevent its breakdown."

Although individualism seems like the exact opposite of utilitarianism- the concept of having an individual identity does not fit in with the idea of streamlined education and workforce for maximum efficiency- it is highly valued in ’Western’ post-modern society (Esposito & Perez, 2014). This individualism contributes to consumerism and hence the médicalisation and pharmaceuticalization of all mental illnesses: Our desire for individuality and uniqueness leads to increased consumerism- which is the foundation capitalism runs on- Our society is structured so that consumerism is considered the path to happiness; and the medical and pharmaceutical industry has prayed on this consumerism, marketing drugs and treatments to us that will give us labels, providing us with a more individualised identity for ourselves (Rose, 2009. Esposito & Perez, 2014) This is visually represented in figure 3. One last point on the ’Western’ Worlds Postmodern neoliberalist society is that it has become increasingly secularized, as postmodern values do not align with religion at all; the result of this is that, "Medicine has replaced religion as the ’social guardian of morality.’" (Turner, 1984) The result of this seems to be that people are turning to science to solutions for problems considered ’moral’ problems, which is howwe could define many mental health problems these days- depression, anxiety, ADHD- and science is medicalising them and making them medical conditions the same way religion took moral problems and turned them into sins- like when the catholic church blamed witches for ’moral’ problems with men a few hundred years ago. (Szasz, 2010) This breakdown of some of the main ’Western’ economic, political and societal norms demonstrates how the concepts of the normal and the pathological and dynamic nominalism made the diagnosis and treatment of ADHD such an epidemic in the ’Global North’ compared to the ’Global South’.

The Figure 3 was removed by the editors for copyright reasons

Figure 3: image showing a person completely made up of pills, preparing to consume another pill. Effectively illustrating the juxtaposition of utilitarianism and individualism creating our desire for maximum efficiency as well aa uniqueness leading to the médicalisation and pharmaceuticalization of our daily lives.

Conclusion

In conclusion, this essay explained how concepts of normality and pathology in the field of medicine and explained that these are not objective judgements, which has lead to a problem with how we view illness in general, and more specifically mental illness. This has lead to the over-medicalisation of everydaybehaviours, ultimately creating the field of mental illness and, more specifically, ADHD. It then examined how Hackings concept of dynamic nominalism and the looping effect also account for the increase in ADHD diagnoses. The third part of this essay elaborated on how the structure of postmodern ’western’ society today made the concepts of normality and pathology and dynamic nominalism particularly applicable. However, I would like to reiterate that this paper is not refuting the idea of mental illness in the sense that it refuses to acknowledge the millions of people suffering everyday. Rather, it aims to highlight that the way we view the normal and the pathological has lead to an error in the way we view medicine, and the implications for that in the mental health field is that we are going about the diagnosis and treatment of mental illness entirely wrong, in fact mental illness may not even be the right term for these ’problems in living’ as Thomas Szasz (2010) calls them.

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