Minutes of the FIA Council Meeting held on Tuesday 10th May 2005 at The Saracens Head Hotel, Towcester at 10.00 a.m. Mike Phillips – ChairmanMike Gilmore – TreasurerPeter LythgoeJohn ColtonLee FunnellDr. Nick Channon 1. Apologies Minutes of the previous meeting held on 9th March 2005 The minutes of the previous meeting held on 9th March 2005 were taken as read and agreed and we
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Microsoft word - document3Setting The Frame Of The ADHD Epidemic:
Childhood Under the New Capitalism
A Public Seminar presented by:
BMedSc(Hons) MBBS(Hons) MRCPsych FRANZCP
Royal Children's Hospital, Melbourne
Sunday, 18 November 2001
• What Is The New Capitalism? • Case One: The Distortion of The Profit Motive • Case Two: Efficiency and the triumph of the managerial ethos. • Case Three: The Time Bind or The Speed Up Of Family Life • Case Four: The Winner Take All Mentality and Performance Anxiety. • Conclusion: Childhood in The New Capitalism • References When I was young, a turbulent social movement centring on the possibilities of human flourishing open to women was in full swing. One of the issues it raised was the treatment of "suburban neurosis"- the depression that isolated and frustrated housewives experienced - by the routine popping of analgesics and tranquillisers. So commonplace was the taking of such medications they gained a popular name; "mother's little helper." The women's movement, rather than accept that the need for medication was normal, framed the whole question of women's dependence on tranquillisers differently. Such behaviour, they argued, has meaning. Women's stories needed to be told. Women had a right to be heard. Doubtless the causes of depression among women are more complex than those early feminist critiques allowed. Yet they caught something important- psychological distress in those times was telling us something profoundly important about a fundamental problem in women's role; the way marriage forever foreclosed the world of achievement. In modern parlance, one might say these women were not suffering from a biochemical imbalance in the brain, but a living imbalance. That approach, based on a critique of the circumstances which gave rise to the symptoms, left me with a powerful sense of the need to be attentive to the social and economic frame in which psychological distress is occurring. Like another social movement of that time concerned with the institutionalisation and treatment of those with a mental illness, it raised for me the moral dilemmas of patient's autonomy, their control over, or at least input into the medication they received, and the broader pursuit of social and economic circumstances which might help them to flourish. The fundamental importance of asking the question why there were so many cases of female distress was clear. Hence, when I first read of the exponential increase in American children diagnosed and medicated for Attention Deficit and Hyperactivity Disorder, as well as the rising incidence of childhood depression, my ears pricked. On a daily basis American children line up in ordinary primary schools for their dose of Ritalin or other medication for ADD. The little bottles are neatly labelled with their photos and name so as to get the right dose. Sometimes so many children are on medication they must come up in shifts. From 1990 to 1998 the number of American children and adults diagnosed with ADD, who are now, as the paediatrician Lawrence Diller put it "running on Ritalin," jumped from about 900 hundred thousand to almost five million. This resulted in a 700-fold increase in Ritalin production. Like wise the numbers of children prescribed Prozac for depression quadrupled in the same period. In Australia a similar dramatic rise in prescriptions of anti depressants through pharmacies rose over the period 1990- 1998; from nearly 5,000 to over 3 and a half million for all age groups- a seven hundred fold increase. Prescriptions for Ritalin jumped from 24, 335 to 345, 868 while another medication dexamphetamine has seen a 24 fold increase.1 While the specialists I have spoken to do not seem to doubt that there is some kind of ADHD type condition which may respond to drugs like Ritalin, a wide range of specialists have expressed their concern over the sudden increase in apparent sufferers, the possibility of a manufactured epidemic, the grey area of possible misdiagnosis, and the nebulous nature of the symptoms. One of the world's most eminent child psychiatrists, Sir Michael Rutter, has expressed his concern that for a diagnosis to be useful it must be distinctive from other disorders in its causation, natural progression and treatment. He feels ADHD as currently defined does not satisfy these requirements.2 One behavioural checklist for self assessment for ADD, drawn from the best selling Driven to Distraction,3 for example, was full of questions which ranged from the vague to the ridiculous. "Are you left handed or ambidextrous? Do you drum your fingers a lot, tap your feet, or pace? Do you tune out a lot ? Do you love to travel, and even "Are you hypersexual?" Then there is the problem of how diagnosis varies wildly from community to community in America. It is a largely white and middle to upper middle class phenomenon, and often among children who are in institutional settings where there are strong performance demands. Very few African American children take Ritalin.4 In Canada the increase in Ritalin prescriptions seemed to flow closely on the heels of a reduction in spending on special education teachers, psychologists and social workers in the education system, leading some to wonder whether we were now treating behavioural problems by drugs rather than specialised support staff!5 There is also the problem Peter Kramer, author of Listening to Prozac called "diagnostic bracket creep" – the phenomenon where it takes less and less behavioural problems to receive a psychiatric diagnosis and to qualify for medication. Most importantly, why have so many children in America, Canada and Australia suddenly showed up just at this particular historical moment with conduct disorders, with disturbances in emotional regulation, with aggressive behavioural problems, problems of school underperformance or childhood depression? Just as the feminists prompted a new kind of attentiveness to the condition of women, what are the contemporary conditions of childrearing that so many are diagnosed? I suggest that as a society we should stop dead in our tracks and ponder why. What I want to do is to set the frame for that discussion. When you put a canary down a mine its delicate respiratory system tells the miner very fast what noxious fumes damaging to human health are lurking in the mineshaft. Children, perhaps, are our contemporary canaries. Their mental health is telling us all is not well. We must ask why so many children now need Ritalin or related medication – or one might say "junior's little helper." The aspect I want to concentrate on in this paper is the social and economic habitat in which children, parents and their caregivers now live, or to use the words of my title; Childhood under the New Capitalism. What Is The New Capitalism?
Over the last decade and a half societies like America and Australia have undergone the profound restructuring we call in Australia economic rationalism, or what one overseas sociologist Richard Sennett calls the new capitalism.6 I want to first sketch in a general way some of its chief characteristics, then follow that with particular case studies, utilising each element to show how such broader social and economic factors profoundly affects the diagnosis and treatment of ADHD. The New Capitalism, or economic rationalism as we call it here in Australia, has a number of central elements, and with them a set of values which profoundly affect our lives. The first element of economic rationalisation to be considered is the efficiency drive. That one principle of economic efficiency is elevated above all other values - of equity and social justice, for example. We live within the tyranny of the bottom line. It is that principle which is behind the radical drive to organisational efficiency, where reducing costs and shedding labour is the chief means profit is pursued. That drive to increasing efficiency and productivity has affected public institutions like hospitals and schools. A crucial part of the new capitalism is the reduction of state expenditure on those same core institutions. One consequence is the speed up of workplaces where more productivity is expected of individual workers, where a greater volume of work is expected to be accomplished in a shorter time, or in unpaid overtime. The second element to be considered is what one sociologist, Arlie Hochschild called in a brilliant book of the same title, The Time Bind.7 Many families find themselves in a time bind between work and family life as they devote ever greater amounts of parental time to paid work. The new capitalism is a high consumption society, fuelled by credit and a kind of consumer arms race, locking many of us into a work/spend/work cycle that stretches our capacity to cope. Greater inequality, higher risk of divorce all means incentives for men and women to maximise our time in the market place to keep pace. For an increasing number of families, the home realm is sped up and submitted to industrial principles of efficiency in order to fit all family life into a dramatically shortened time frame. And related to the time bind are the many new services where aspects of family responsibilities may be contracted out, outsourced to profitable institutions, nursing homes for example or for profit childcare centres The third aspect of economic restructuring is what one economist called the winner take all society.8 The financial rewards for high performance in sport or business or any other field have never been higher. The difference between coming first and second in sport for example may amount to millions of dollars in sponsorship advertising and future opportunities. The old ideas of participation or handling a character building defeat have shrunk accordingly. In business the chief executive who works obscene hours in shedding a significant proportion of their labour force is rewarded not only by an increase in share price but also increasingly astronomical salaries. In 1998 the Chief Executive of West Pac was earning through shares salary and dividends $142,000 per week while his downsized staff joined the unemployment queues. This high tensile performance culture has a trickle down effect on children. The next aspect to be considered is the "culture of no long term." One dimension to the profound restructuring we have all experienced is a new and radical job insecurity. The land of tenure and the long weekend are no longer. Under the new capitalism there is a shortened period of a working life – most careers are made and come to an end by the age of fifty sometimes forty five.9 There has been a sharp decline in employment for people over 50 across the Western world- and a great deal of that decline involuntary. This enhances the urgency with which people during the peak family formation years of 25-40 feel they must compete fast and hard to survive the new risk society. 10 The last aspect of contemporary society I want to consider is the reshaping of our values in relation to issues like altruism, our attitudes to dependency and vulnerability, creating to a certain extent a sea change in the way we think about children and childhood. How we "do" parenting, how we experience motherhood or fatherhood, and the landscape of childhood, are all deeply shaped by the interlocking social and economic aspects of the new capitalism. I will now take some of these characteristics of the economic frame, and link them to specific cases in the literature on ADHD. I want to try to show how this broader context of social and economic change can have an impact- especially in cases of ambiguous diagnosis – on the preferred treatment. Case One: The Distortion of The Profit Motive
The first example is a very straightforward one concerning the profit motive. It concerns the collusion between an American parent support group for Children with Attention Deficit Disorder or CHADD, and the drug company Ciba-Geigy which manufactures Ritalin. Pharmaceutical companies profits from the sale of Ritalin have increased an estimated 500 percent since 1990. The expanding market has drawn in three more drug companies in addition to the two manufacturing Ritalin, and another four have expressed the desire to enter the field. Advertisements to physicians of one new stimulant, Adderall, boasted over a million prescriptions in it first year of use.11 This particular scandal was over the participation of CHADD in petitioning the Drug Enforcement Administration agency in the US to liberalise or decontrol the prescribing Ritalin by removing it from a Schedule 11 drug to a schedule 111. This change would have placed the drug on a similar status to headache tablets with codeine and low dose opiates, readily available over the pharmacy counter. On Schedule 111 drug companies would no longer have to seek approval on production quotas from the Drug Enforcement Administration. And parents could by pass the procedure of getting triplicate forms to get a prescription. The push to liberalise Ritalin's scheduling would have made its use as a part of illicit drug abuse that much easier. As it turned out CHADD's inventive and energetic campaign to liberalise the control of the drug was funded massively by the manufacturer of Ritalin Ciba –Geigy to the tune of almost one million dollars. CHADD had failed to disclose the existence of the money, or its source, to most of its own members and the general public. The scandal left painful questions over how much the parents' campaign agenda was shaped by the interests of the drug companies in expanding market share and of course increasing profit. This example, is one amongst many worrying developments in the ADD epidemic that we must consider. It concerns the straightforward distortion of how we regard, classify, and schedule powerful psychotropic drugs by the profit motive. It concerns the political and economic clout of the pharmaceutical industry, but also the growing constituency dependent on their products. It is a clear example of the danger to the proper public administration of a drug, if the powerful pharmaceutical industries have too much input into the scheduling and categorisation of drugs. A related concern in Australia- not to ADD specifically but to the issue of proper control of drugs without undue economic pressure- is the addition of a pharmaceutical industry representative to the specialist committee advising the government as to which drugs should be on the pharmaceutical benefits scheme. Case Two: Efficiency and the triumph of the managerial ethos.
Last century an engineering genius, called Frederick Taylor first attempted to apply the scientific management of time to enhance business efficiency and profitability. He studied a steel worker, whose name was Schmidt, measuring and quantifying, exactly and precisely, the arc of his shovel swing, the speed to the last second of each swing, the weight of each scoop, and the number of rest periods needed. By scientific calculation, Taylor found 47 tons of pig iron could be shovelled in the same time Schmidt had previously shovelled twelve and a half. Schmidt's shovelling, by controlling tiny every aspect of his movements, could be multiplied by four. Taylor was so clever that time and motion studies, the whole impulse towards the speed up and rationalisation of processes to create greater efficiency and through put within organisation, we now often call Taylorisation. An extraordinary surge of Taylorisation has occurred within economic restructuring. Most importantly, those principles of efficiency have been applied to areas of human services such as schools, hospitals, child psychiatry, medical care, psychotherapy and so on, where they are much more difficult to apply, if not downright inappropriate. Taylorisation has shaped the emergence of managed care, where in essence the control over all kinds of decisions is not being decided by the physician on the basis of the patient's welfare but on the basis of cost, on the tyranny of the bottom line. It is one thing to speed up the assembly line which produces sausages, it is quite another to apply those principles of efficiency and rationalisation to difficult and sometimes intractable human problems; curing or helping the mentally ill for example, or helping troubled children diagnosed with ADD. Taylorisation and the desire for efficiency not only is a part of a managerial ethos taking over health care It affects our treatment of all psychological problems by making the biological paradigm - that mental illness or psychological difficulties have a physical or biological or genetic cause and an equally straightforward pharmacological cure- economically attractive. A biological diagnosis seems clear cut, the causes simple and removed from the messy, vexed areas of human relationships, economic inequality or childhood traumas long ago. We can avoid thinking about the ways that behaviour has meaning. So in the example of mother's little helper above, it is much quicker to dole out Prozac than consider issues of gender equity, or where a depressed housewife's life sits on the continuum of human flourishing. We treat the symptom but do nothing about the underlying social cause. The triumph of Taylorisation in the new capitalism means it is no accident that we have seen the restriction of Medicare benefits for patients with psychological problems, a hostility to and frustration with long term psychotherapy, demands for evidence based medicine, and the affection for drug treatments which promise improvements if not cures within the shortest possible time. Administrators, politicians, the managed care bureaucrats watch doctors and psychiatrists with the sharp, eagle eye to ruthless efficiency that Frederick Taylor once watched poor old Schmidt. The problem is, even when physical changes in the brain are detected by our sophisticated imaging techniques, changes in brain architecture and biochemistry may have psycho social causes. Those psychosocial causes may play an important role, along with drug treatment or without it, in dealing with a patient. The biological and the psychological are in a way false opposites. The knowledge we now have on the physical changes in the brain due to child abuse, wholesale neglect, or post traumatic stress disorder just to name a few, reveal that psychosocial trauma can have physical, biological consequences. 12Often psycho social events – a marriage breakdown, being sacked at work, a traumatic family event – may interact with someone's difficult past which left them with fewer psychological resources to cope with set backs, humiliation and injury than others. Those psychosocial traumas may mean the difference between a disposition to something remaining a potential, and becoming an eventuality. In a number of recent papers, researchers like Sebastian Kraemer, Myron Hofer, Redmond Williams, Glen Gabbard, Alan Schore, Isla Lonie, Robert Post, Felicity De Zulueta and George Halasz,13 have all shown the ways that concepts like security or insecurity of attachment, separations and losses may have far reaching biological consequences. There may be long lasting physical consequences in the brain of spectacular failures in the nurturing environment. What may begin in a psychosocial trauma can then, via the permanent transformation of brain function, result in an altered brain function such that biological cause really does have meaning. Thus Robert Post highlights the way one severe depressive episode, with a psycho social cause as an initial trigger may create a kind of spontaneous "kindling effect" with triggers bearing less and less relation to the original cause and more to the transformation in the brain's own biochemistry. The original psychosocial origin trauma of course should not be overlooked either in the treatment or the diagnosis. And the enormous pressure towards speeding up the outcome may rob patients of the psychotherapeutic help they need in dealing with those deeper underlying issues. Can we find similar examples in the diagnosis of ADD which also show the imperatives of models of business, of efficiency or speed, of the managerial ethos which are quite inappropriate when related to therapy or human affairs? Halasz has pointed out in a case study of childhood depression in the book She Still Won't Be Right Mate how supportive therapy and not drug treatment was required to deal with a case of unresolved grief in a little girl. The outcome was deeper self-understanding on the part of the girl and the parents. He points out that under current managed care guidelines in the U.S. an application to seek therapeutic treatment, as opposed to the quick fix of peppermint flavoured Prozac would have been rejected. He makes a profound point; " a moment's reflection will highlight the enduring effects of denying children their existential experiences and even transient clinical depression. Instead of offering human understanding and solace, the "magic pill" solution to relieve mental pain risks raising a generation of children bereft of self understanding and ability to cope with life's challenges, as well as the effects of learning the lesson that emotional support is not to be had from other human beings." Lawrence Diller likewise gives several instances of his young patients diagnosed as ADD and who are given medication because the more time-consuming talk therapy is just not allowable unless medication is considered or offered. Managed care, Diller argues, " has intensified pressure on physicians to prescribe a drug rather than spend time with a patient or his family. Even before managed care, insurance reimbursement schedules paid physicians more for "cutting" or zapping" than for talking with the patient, otherwise known as "cognitive time." Especially for primary care doctors – paediatricians, internists, or family practitioners…the economic incentives to ascertain and treat problems quickly is immense. In health coverage today, the overriding principle is value for money, and for the mental health community, this means an overwhelming emphasis on the use of medication in preference to other treatment."14 Diller cites the case of a young seven year old boy who, although impulsive and intense and in conflict with his parents, who in turn are in conflict with each other, nonetheless could be given successful alternative treatments. In Diller's view it is help with parenting that is really needed. His young patient, he feels, could manage without resorting to Ritalin. Yet the HMO permitted doctor visits for mental health problems only if medication was being considered or offered to the child. The family cannot afford further visits without medical benefits from their health plan. They would be forced to turn elsewhere, despite Diller's expertise in ADHD cases, unless he prescribes Ritalin. As Diller puts it, "All Roads lead to Ritalin." For him treatment without drugs should be explored first, but the managed care guidelines which highlight efficiency, at every point lead to medication being the option of first rather than last resort. As Leon Eisenberg, a professor of social medicine at Harvard outs it " managed care and psychotropic drugs are a Satanic mix." Case Three: The Time Bind or The Speed Up Of Family Life
The process resulting in the speed up of work – where a greater intensity of work effort is expected to produce the same outcome in a shorter time- sociologists have also found to affect family life. Job insecurity, the consumer arms race, the credit explosion and so on all mean a greater commitment of adult work time is needed to maintain living standards in a consumer society. Here I will draw on the book The Time Bind by the sociologist and feminist Arlie Hochschild I mentioned earlier. In the families she studied, the "emotional magnets between home and workplace were in the process of being reversed." People, women included, fled the mess and the dirty laundry and the unfinished quarrels to the "managed cheer of work". It went deeper with some families with others- with the more extreme version of people "marrying" their work" "investing in work the emotional significance once reserved for family, hesitating to trust loved ones at home" amounting to about a fifth of her company families. A less extreme version, "when work becomes home and home becomes work" was still an "important theme," in over one half of all her "Amerco" families. Hochschild found the social world that held sway -work - imparted deep patterning to time. The austerity of industrial time dominated by deadlines and efficiency considerations was now penetrating and speeding up the home realm. The more collective family hours put into paid work, the more rushed, harried and strained parents became, with the private realm locked into a time bind. Over time the "juggling act" was so intense that the cultural valuing of work over family gains further strength by the sheer pleasurelessness of the "sped up" family realm- trying to do in one quarter of the time what housewives used to do all day. Hochschild concluded that the lives of the families in her study showed "the social world which draws a person's allegiance also imparts a pattern to time. The more attached we are to the world of work, the more its deadlines, its cycles, its pauses and interruptions shape our lives and the more family time is forced to accommodate to the pressures of work…Family time …has taken on an "industrial tone." Family life under the new capitalism, she found, was now submitted to a cult of efficiency, just like the work realm I mentioned earlier. It is particularly hard on women. She found mothers sitting on bathtubs hurrying children while they answered e- mails and checked mobile phone messages. She found women hurrying laggardly children, cribbing a little bit of time here, sniping a bit there, always with one eye on the clock, and always trying to make little efficiencies. There was a new sense of self-supervision. All the necessary activities of family life - the meals and nurturing, the conversations, the bedtime rituals, the sporting and cultural activities, all were jammed into an ever-smaller block of time. If the problem for the 1950's housewife might be too much time, this was a problem of too little time. Quality time, in a way is a brilliant example of the way the logic of "industrial time" and increased productivity had leapt the fence from work and come home. Hochschild says of quality time "quality time holds out the hope that scheduling intense periods of togetherness can compensate for an overall loss of time is such a way that the relationship will suffer no loss of quality. But this too is a way of transferring the cult of efficiency from office to home, Instead of nine hours a day with a child, we declare ourselves capable of getting the "same result" with one more intensely focused total quality hour. As with Frederick Taylor and the hapless Schmidt, our family bonds are being recalibrated to achieve greater productivity in less time. As well as acting as their own time and motion experts Amerco parents found themselves also spending time doing the "third shift" of emotional "work" repairing the damage caused- especially to children- by the time bind." Let me take two cases of the Time Bind in relation to ADHD, again within the territory of uncertain diagnosis. The very first time I came across the problems associated with ADHD was when a specialist professional, who worked with troubled kids in Australian childcare, said how concerned she was that children who were indeed troublesome were increasingly being diagnosed with ADHD. She felt that they were not really ADHD. She felt their difficulties concerned the intertwining of multiple factors of disadvantage, poverty, absent fathers, relationship breakdowns and insecure attachments, and most importantly separation anxiety – these vulnerable children were simply not ready for anything like the long hours they were putting in childcare. In another example, Lawrence Diller in his book Running On Ritalin offers the case of a little boy whose family has separated, then reunited. The marriage is rocky but for the moment they are together. The father is a typical absentee parent, leaving most of the active parenting to the boy's mother. Both parents have demanding jobs with long hours. The consequence is that time at home must be sped up. There is very little time either parent has for parenting, and certainly not much parental energy left over after work. Had the mother been a male worker in such a tough job in the 1950's, she would have had a full time housewife to smooth the vicissitudes of her daily life, absorb all the stresses and strains of the kids and create a haven in the heartless world to come home to. She has none of these things. This combined with the father's emotional absenteeism s that her temper is on a permanent short fuse. Her child certainly has a difficult temperament but is also clear that ten hours a day in a structured academically orientated daycare centre, longer it should be noted than most of our nine and ten year olds deal with in primary school, is too long. Ten hours is more than Johnny can cope with. Diller notes" In my own experience, most referrals for ADD in very young children do involve those who attend large daycare centres" although he notes that daycare is now so common in America that we need a sample of children who do not attend daycare for comparison. When Hochschild interviewed caregivers in daycare centres they all nominated about six hours as the maximum time for children to derive any benefits from such programs. That a large quantity of care, regardless of quality, can have deleterious effects is also shown from the latest and most sophisticated longitudinal study every undertaken by the American National Institute of Child Health and Development.15 The NICHD study, which began in 1990, is being conducted by a team of over twenty of the world's most eminent child psychologists, (overwhelmingly women and most of them pro childcare), and involves more than 1,100 children from ten US cities. At age four and a half, children in over thirty hours of care in all ranges of quality of care and including father care showed three times as many aggressive behavioural problems as children in care for less than ten hours. All variables like quality of care, type of care, mother attributes and stability of care were carefully taken into account. Quantity, not quality, was the issue. There was a straightforward linear relationship; the more time in care, the higher the problem behaviour. It is then, these broader contextual factors we should consider when we learn that Diller's young patient is fidgety in childcare, won't sit still on mat or listen, is non compliant, is aggressive with kids on the playground and is on the verge of being expelled from his first preschool school at the age of three. We should note here that there is often a preponderance of boys diagnosed with ADD compared with girls. Economic and social changes like the ones affecting this family mean we now have much higher expectations and demands of children. They must be ready for group care at younger and younger ages. Boys, with a higher degree of mobility and slower development in verbal and social skill areas than girls may find a school like atmosphere for extremely long hours of such care very difficult. Their ADHD type behaviour may be considered a protest at the unnatural demands placed on them. One of the characteristics I mentioned earlier is the way increasingly family functions are transferred to the marketplace via nursing homes and childcare centres. The culture of job insecurity and the long hours corporate culture can mean parents work hours that severely strain a child's capacity to cope. At the same time, the economically rationalised world means government's priority is to reduce state expenditure. This has reduced the capacity to have quality substitute care in terms of ratios, the wages given to caregivers influencing the quality of recruits as well as turnover, and the overall size of the centre. And most importantly neither in Australia nor in America do we have nothing like the three years of job protected parental leave, in some cases paid leave, which most European countries have. Case Four: The Winner Take All Mentality and Performance
There is a rather dreadful TV show on at the moment, called The Weakest Link. The competition works on a group of contestants working together to boost the prize money by answering quiz questions. But it's not real teamwork, because the name of the game is to clamber across the other contestants or team members in order to win. After a set time they stop to expel the least able team member. It involves a public shaming for a poor performance, where they hold up placards with the name of the person who has performed least well, and vote them out. The Presenter says "You are the weakest link" Go, take the walk of shame." Not to perform well, at one's optimum is to be, to use a popular word, a "loser." As it happens it is precisely this kind of "teamwork" which Richard Sennett highlights as a key component of the new capitalism. Bonds between people are marked by "the strength of weak ties, " where fleeting forms of association are more useful to people than long term connections, and "detachment and superficial cooperativeness" were" better armour" than personal qualities like reciprocity, mutual commitment, trust, and loyalty. Performance demands in the winner take all society, fuelled by a society where the rewards for getting into the right school, the right course, with unemployment, the right job, are immense. It adds to the intensely competitive nature of our society, and for children can lead to intolerable stress. Those performance demands are also enhanced by that aspect of the new economy I cited earlier, the new job insecurity. We live in a culture of "no long term". People feel bound to continually prove their worth, feel insecure even when they remain in work when their colleagues are sacked, and feel driven to a remorseless, ever continual demonstration of their worth as an employee. Their lives, even when they are not downsized, may be beset by what Richard Sennett calls a "dull continual worry" – a sense that they may be good enough today but not tomorrow, that they must always perform at their peak. The literature on ADD is full of examples of the consequences of this mentality on both adults and children. The already rather nebulous nature of diagnosis becomes something even more dubious, of a kind of cosmetic pharmacology. Cosmetic interventions rely on the notion that although it's not a disease to have a big nose you'll do better in life without it. Likewise, although it is not really a disease to be a bit dreamy, or to have learning difficulties, or to be more sociable than academic, or to be talented but a little slower to complete projects than your employer demands, a little lift from Ritalin may give you the competitive edge. Ritalin and other medications are stimulants, which enhance performance, speed of response, motivation and concentration. Such stimulants are sold on the black market to enhance examination or sporting performances. Parents often are made to feel anxious about a child falling behind and that academic success is the best guarantee of economic success. There is much anxiety in the winner take all society about getting the right grade, getting into the right school or the right tertiary course. Thus in several cases Diller shows how he felt forced to give medication when he felt it was not appropriate, but to help both adults and children to deal with a hyper competitive atmosphere. He mentions issues like large numbers of children in open plan classrooms with inadequate staffing levels, minimal support for more difficult kids which place higher demands on children for internal impulse control, cooperativeness, and high demands for emotional regulation of their own behaviour. The classrooms are ones where the expectations of academic achievement are made earlier, early than for Swedish children, for example, who begin school at seven. Some borderline ADD children, he feels may just tip over the edge of tolerable behaviour in large classrooms with minimal teaching aide support. One of his patients is kind, empathetic, with good social skills and well liked. In fact she shows up as high in emotional intelligence. In a different world her attributes might be valued. She's not hyperactive or impulsive or aggressive. She's slow, or rather slower than her classmates in a high-speed world, slow to complete tasks, especially academic ones. She's rather day dreamy, and had some learning difficulties. She is in a rather large classroom with thirty-three other kids, which doesn't have time for slowness. The parents don't have money for extra tutoring. Diller says " the pressure I felt to prescribe Ritalin was subtle but hard to resist, given their circumstances" So she ends up on Ritalin. Ritalin seems to improve her performance a little. Everyone is pleased. But the underlying learning difficulties are not addressed, somehow everyone has lost interest in them. Diller continues "Jenny made me wonder about the expectations we uniformly have for middle class children today. Here was a girl who was successful and well adjusted in many areas of her life, but who had to be medicated because she couldn't keep up academically. Did it make sense?" In this context I have had a number of parents tell me, of the pressure they are placed under to seek an ADHD diagnosis to put their children on medication, in order to ease classroom management. Conclusion: Childhood in The New Capitalism
The last aspect of the new capitalism I want to draw attention to, is what Richard Sennett describes as our contemporary hostility to dependency. 16Such hostility is manifest in attack on the welfare state, in the depiction of those needing welfare as parasitic losers and dependents who will leech vitality from the body corporate. To be dependent is a despicable state. The word dependence in our society invariably has a negative meaning. Drug dependence. Alcohol dependence. Welfare dependence. The word independence, in contrast, invariably has a positive meaning. Yet they are false opposites. Sennett draws on the work of the great child psychiatrist, John Bowlby, to show how strange our valorisation of independence really is. Bowlby pointed out that "the truly self reliant person proves to be by no means as independent as cultural stereotypes suppose…healthy self reliance( for adults)" consists of being able to depend upon others " when occasion demands and to know on whom it is appropriate to rely." Across a life span every person has periods of both being dependent - in childhood, old age, sickness- and being depended upon - as a parent, in relationships, as an adult child of elderly parents. Mutual interdependence, Bowlby suggested, was our natural state. Bowlby also believed that hostility to dependency in the West distorted our relationships to children. Their natural state is, after all, dependence. Ruthlessly forcing independence before children are ready creates an adult disposition which despises vulnerability in themselves and others. They "feel it shameful to be needy" internalise the anger and contempt which the dependent, needy part of themselves aroused in their caretakers. Growing into compulsively self sufficient adults, they lack empathy for the vulnerable, criticising the needy as "losers" and parasitic bludgers. This touches on a subject I have raised previously- the ways in the social relations of economic restructuring,17 combined with radical individualism, is not only transforming the landscape of childhood but profoundly changing the way we see children and even childhood itself. Here I would point to a sea change in the literature on child development and childcare over the last few decades which invents a new child. A new child who fits the times. This new child is sassy, independent, street wise and street smart, and like the McCauley Culkin character in the hit movie Home Alone. They do not need protection, nurture, or even parents, to survive. Such attitudes reveal our society's great ambivalence towards children. Whether you look at growing rates of childlessness, the aggressively childfree, or the values expressed in social attitude surveys which show the declining importance of having children to adult fulfilment, or the increasing degree to which children are cared for by outside institutions, children have a diminished place in our culture. Part of that is a limited patience with their dependency needs. Children must grow up fast and not press us too much with their needs. I remind you here of George Halasz's fine words earlier of the noxious effects of reaching for drug treatments as substitutes for empathic care of children – " the effects of learning the lesson that emotional support is not to be had from other human beings." In this context, we need to consider what we expect of children and the lessons we are teaching them. Here I would like to offer as my prize cultural exhibit of the new sensibility and attitudes towards children in the new capitalism, an example from an American paediatrician Berry Brazelton. His bestselling book Working and Caring is drawn from real life cases in his own practise. Brazelton does not engage at all with the deeper underlying economic structuring of everyday family life, the work spend cycle and the economic inequality which was clearly harming his patients. He gives a portrait of a working class woman who is one of the new working poor- both parents work but they are still poor. She has no choice but to work and can only afford very poor substitute care, the consequence of which is that her baby suffers a full blown anaclitic depression. Brazelton acquiesces in all this. He writes with an air of fatalism. Of her decision not to breast feed he says simply ""She had to go back to work and knew she had better save all the strength she had for her "two jobs". Anyway, she thought of breast-feeding as a bit too intimate. If you are going to leave your baby to go back to work, you can't get too intimate with him. It would lead him to expect more than he would get out of life." I want to leave my case studies of ADHD at this point and ask this question of the society in which such cases occur. What has gone wrong when in the richest nation on earth, the richest nation in human history, a famous paediatrician says of a baby, that breast feeding might teach him to expect more than he is going to get out of life. The physical nutritional qualities of breast-feeding are not what interest me here. It is the breast as a metaphor for what we may expect in relation to nurturing, emotional support, the acceptance of dependency, of human vulnerability or frailty, and the deep irreducible human need for intimacy. What the child must not be taught to expect in the world of the new capitalism where both parents must work. My point here is to draw us back to my opening remarks and the social movement which drew attention to the way women's needs were not being met, the way popping tranquillisers and analgesics were no solution to a living imbalance. Clearly all is not well in the state of childhood. We need to consider the ways the sudden expansion of the numbers of children receiving "juniors little helper" mean children are accommodating a new living imbalance. I have emphasised those cases where it is clear that alternative help, structural change, a reflection on the way we live now, is needed. Doubtless that does not account for all the cases of ADHD. But it highlights how we need to consider as a community what best creates the conditions for children's flourishing. It demands action on an individual and public level to recreate the tools for a convivial childhood. It will mean tackling adequate parental leave provisions, involving fathers as well as mothers in family life, economic support for families, a reasonable work/family balance, and investment in early childcare. I close with some troubling words from Lawrence Diller. We no longer beat children into compliance. But are we willing nowadays, to drug them into it? 1 See Anne Manne 18th December, The Australian Focus section p2, also George Halasz "Voltaire's Bastard's" and the rights of the child: the manufacture of epidemics" in Psychiatrists Working Group She still Won't Be Right, Mate! Melbourne, Australia 1999. 2 L. Diller, Running On Ritalin, (New York: Bantam Books, May 1999) quoting Sir Michael Rutter p63 3 E. Hallowell and J.Ratey, Driven To Distraction: Recognising and Coping with Attention Deficit Disorder From Childhood Through Adulthood (New York: Pantheon Books 1994, p209-14 6 R. Sennett, The Corrosion of Character: The Personal Consequences of Work in the New Capitalism.New York W.W. Norton & Co 1998 p 7 Arlie Russell Hochschild; The Time Bind; When Work becomes Home and Home becomes Work. New York, Metropolitan Books 1997 8 Robert H. Frank and Phillip J. Cook 1995 The Winner Take All Society New York, The Free Press and Robert H. Frank 1999, Luxury Fever: Why money fails to satisfy us in an Era of Excess New York, The free press 10 Suzanne Franks 1999; Having None of It Women, Men and the Future of Work, London ,Granta 12 Isla Lonie 1999; "Unshrinking the Hippocampus: evidence based medicine ignores the meeting of neurobiology and psychodynamics." P106 in Psychiatrists Working Group She STILL won't Be Right Mate! Melbourne, Australia, 13 For example Robert Post, 1992: " Transduction of Psychosocial stress into the neurobiology of recurrent affective disorder. American Journal of Psychiatry, 149, p999-1010, Glen Gabbard, "Psychodynamic Psychiatry In the "Decade of the brain ." American Journal of Psychiatry, 149. 991-998, Felicity De Zulueta 1994 From Pain to Violence: The Traumatic Roots of Destructiveness Northvale New Jersey, Jason Aronson Inc, Us Edition., A. Schore 1994 Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development, Hillsdale New Jersey Lawrence Erlbaum Associates, Myron Hofer 1995 " Hidden Regulators: Implications for A New Understanding of Attachment, Separation, and Loss" p203 in S. Goldberg et al, eds, 1995 Attachment Theory: Social Developmental and Clinical Perspectives, London The Analytic Press, Isla Lonie, op cit and George Halasz op cit in She STILL Won't Be right mate! 15 NICHD Early Child Care Research Network, 'Quantity of child care and problem behaviour', Paper presented at the biennial meetings of the Society for Research in Child Development, Minneapolis, MN, 2001 17 see my "Electing a New Child," Quadrant Magazine, Jan – Feb summer edition, 1996 and "Disposable Childhood" Australian Review of Books, May edition, 1999. - National Association of Practising Psychiatrists Telephone: 02 9556 2534 Fax: 02 9567 4681
Instructions for use Estradiol ELISA FR E-2000 Estradiol ELISA INTENDED USE For the direct quantitative determination of Estradiol by enzyme immunoassay in human serum. For in vitro diagnostic use only. PRINCIPLE OF THE TEST The principle of the following enzyme immunoassay test follows the typical competitive binding scenario. Competition occurs between an unlabeled