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Medicating Normality: The Psychiatric Colonization of Childhood

by Antony Black

In the popular lexicon 'normality' has come to express a paradoxical meaning. Having cleverly eluded confinement within the official compass, it now resonates with the mocking echo of a diversity that will not be denied. What is 'normal' one asks? And the unlettered shrewd among us reply, 'nothing' - or at least, very little.

In the medical lexicon, however, 'normality' has, over the last few decades, beaten a sharp, 180 degree retreat into a highly specialized, bureaucratically defined cell. This has led to the proliferation of countless new diagnoses and, in turn, to the spawning of endless psychiatric sub-specialties by which to profit from a diversity that has been exiled into the scientifically dubious, politically reactionary, yet highly lucrative firmament of medical abnormality.

That the 'disease' modality has virtually hi-jacked modern psychiatry, and infiltrated to the core of popular culture may, of course, be readily apparent to the reflective reader. What is often less appreciated, however, is just how scientifically unsubstantiated, how philosophically and ethically untenable, and how medically indefensible this modality is. And nowhere is its defence more questionable than in its application to that class of involuntary patients - children.

Drugging Kids, Legally

It is an irony completely lost on the mainstream political and media culture that whilst a vicious, absurdly punitive 'war' is waged against illegal drugs, the state should itself be engaged in a vast, legal, drug laundering operation1.

Thus, ignoring the staggering arsenal of regular prescription and over-the-counter medications, a conservative estimate of the proportion of the adult population in the US and Canada now taking *prescription psycho-active* drugs is well over ten percent2.

Indeed, the introduction in the late 1980's of the modern serotonin-specific anti-depressants (i.e. Prozac and kin), spurred a sharp rise in the use of legally sanctioned mind-altering medications, due in large part to the extraordinary media fanfare and scientific claims - almost entirely bogus - accompanying them. For though this was not the first time that a class of drugs had been alleged to specifically target the presumed biological cause of a complex psychological function (depression), it was the first to benefit from the notion that it had, finally, got it right, -and- that it might, moreover, enhance the normal human condition as well. Suddenly, the stigma of taking a psychiatric pharmaceutical was largely lifted. It became 'okay', even sexy or cool. A quick, efficient, and cost-effective way to boost performance in an increasingly competitive world.

Paralleling these trends in the adult population was, over the same time period, an explosion in the practice of medicating children. In 1980, for instance, it was estimated that, in the US, between 300,000 and 500,000 elementary school children were receiving stimulants (either Ritalin or Dexedrine). By 1997 that figure had ballooned to roughly 5,000,000. The actual production of Ritalin itself, just over the last decade, has increased by a whopping 700%. Fifteen tons of Ritalin are now distributed to children in America every year. In some communities, at some grade levels 1 in 6 children (mostly boys) are drugged - legally.

In Canada, heavily influenced as it is by cultural trends south of the border, there has been (conservatively estimated) a quadrupling of Ritalin usage since 1990. And though the per capita rate here is still only half that of the United States, the fact remains that there has, in the same time era, been no significant increase in Ritalin use in Western Europe and the developed nations of Asia. This combined with the fact that 90% of Ritalin usage worldwide occurs here in North America clearly argues for a cultural as opposed to a scientific basis for the Ritalin phenomenon. The question then is why? What constellation of forces have contributed to this runaway 'drug crisis'?

Numerous social factors have been cited to account for this steep rise in the number of children targeted by psychotropic drugs. The socially rapacious nature of 'globalization', including the acceleration in the pace of working life and the conservative assault on social programs, has clearly added to the stress impacting kids and their caregivers. The high incidence of divorce and separation, the well documented epidemic of abuse and neglect, and the continuing rise in child poverty rates have all borne heavily on the young who then bring their emotional travails into crowded, under-resourced classrooms taught by overburdened and increasingly frazzled teachers. On top of this are piled the overweening expectations of the overachieving baby boomers who sense, only too accurately, the need for greater competitive efforts from offspring destined for future combat in a cutthroat world. In this uncertain and harsh social milieu, both parents and teachers, faced with behavioural malfeasance, are then predisposed, it is argued, to opt for a quick, clean, technical solution to an otherwise messy problem. After all, far easier to medicate children than change society.

Then, of course, there is the notion that the far ends (or at least one end3) of the normal spectrum of human physiology and temperament fail, quite simply, to find a proper fit within the narrow and conformist confines of post-industrial society. Children, in this scenario it is proffered, were never really designed to sit like little toy soldiers in rows for hours on end, and though many manage, under constant surveillance and correction, to do it rather well there is bound to arise some failure of adaptability within the broad bounds set by human variation and human 'normality'. In this sense one can, under present normative definitions, consider this 'failure of adaptability' as a social "disorder" though hardly one of individual "disease".

That there is much to recommend these psycho-social-political and normative forces in both the defining and aetiology of childhood behavioural 'abnormalities', as a proximal cause of the 'stimulant epidemic' itself they fail to convince. This because they do not explain why such an epidemic is absent from the rest of the developed world for whom much the same broad social and economic conditions obtain as in North America. A more immediate causal schema is to be found, then, in a nexus of historical and philosophical trends peculiar to the American experience.

Of Physics Envy and Biological Reductionism

It is by now an old story that from the very beginning of their careers as scientific disciplines, both psychology and psychiatry were plagued by an intellectual inferiority complex as they sought desperately to attain the standing and pre-eminence of the 'hard' sciences4. That this was a futile endeavour, given both the spectacular advances in early 20th century physics (and later biology), and given the intrinsically artful nature of their own field, seems never to have twigged on them. Instead, the drive to achieve 'scientific' respectability blew as a constant wind fanning a reductionist philosophy.

Now whereas in Europe the Freudian psychoanalytic revolution eventually established itself as the dominant model of scientific psychology, in North America, psychoanalysis and its brethren quickly ran into competition from the empiricist school exemplified by Watsonian behaviourism and, later, Skinnerian conditioning. Very much influenced by the philosophy of logical positivism emanating from physics this school saw value, not so much in what could be *observed* (as is often claimed), but in what could easily and meticulously be *measured*. Such a program naturally consigned to oblivion the entire contents of the little 'black box' wherein lay such trifles as emotion, character analysis and, indeed, the whole field of human psychology as commonly understood by the layperson5.

By the early 1970's the pressure on psychiatry to demonstrate its medical/scientific credentials had grown particularly acute, and it was then that the maturing reductionist program finally succeeded in winning the day; a victory that was symbolically enshrined in 1980 with the publication of the third edition of psychiatry's bible, the Diagnostic and Statistical Manual of Mental Disorders6. DSM III signalled both a power shift away from the neo-Freudian old guard and a return to a pre-Freudian classification shame dominated by the commitment to a purely medical orientation.

Though one might be tempted into thinking that a stuffy medical manual could have little bearing on society at large, one would be misthought. For it is precisely from this dusty tome that such weighty matters as the direction of research, the framing of legal rights, the adjudication of disability claims and the like, are decided. More to the point, it is through its authoritative imprimatur that a 'particular definition of human nature' is given official, political voice. A definition, which in this case, has blossomed into the full-blown biological reductionist cultural movement we see before us today.

How often does one hear, for instance, that alcoholism is a 'disease', that depression is a 'bio-chemical' imbalance, or that reading difficulties are 'neurological'. That these maunderings go much further into positing such absurdities as that war is a matter of 'aggressive' genes (rather than a matter of power and profit) or that the rich are more intelligent than the poor (rather than that wealth and poverty exist in inverse causal relationship), and we begin to see the outlines of the 'invisible hand' of capitalist market philosophy and capitalist social relations. Social Darwinism has never been very far from the surface of the biological psychiatric paradigm and it is clear that in addition to helping rationalize the manifest inequalities of societal wealth and privilege7 the paradigm is strategically poised to divert attention from any genuinely social and political problem by reformulating it as a concern of the individual.

Moreover, just as psychiatric reductionism has buttressed the capitalist state, so has capitalist ideology8 - whose very essence is to partialize and fragment one's perception of reality - come to nurture an over-arching reductionist scientific philosophy.

In addition to this sort of general incubation provided by capitalist ideology - an ideology of a particularly virulent American form - North American psychiatry has, of course, received some rather more specific capital assistance. Over the last forty years institutional psychiatry has developed an increasingly, one might say scandalously, intimate association with the pharmaceutical industry. Not only are the former's journals, conventions and professional associations now substantially underwritten by the latter, but the drugs provided psychiatrists, by integrating them ever more tightly into what they perceive as the fraternity of 'objective' science (indeed, by returning psychiatry to a state of pre-Freudian neurology), serve only to bias any true scientific objectivity. The full measure of this bias needs some exploration.

Myths of Efficacy and Safety

No better example of the success of biological psychiatric propaganda can be evinced than in the now widely held belief among the general public that the aetiology of depression is primarily, if not strictly, a biochemical phenomenon. The idea that fundamentally new ontological properties and behavioural laws emerge at higher levels of organizational structure, a fact clearly manifest from atoms to galaxies, is, in this instance (all hedging and tokenism aside), flatly denied to the human mind, the most complex organizational structure of all. Instead, the notion is earnestly advanced that depression involves a point source, or sources, in the brain upon which exquisitely refined anti-depressant drugs act like magic bullets surgically targeting the offending region(s). The tiny wrinkle in this crisp, scientific scenario is that there is absolutely no evidence to support it. Instead, the overwhelming weight of clinical and physical evidence suggests that the drugs act not by targeting any hypothetical 'depression center', but by blunting affect and emotion generally. Indeed, these drugs have more or less the same effect on everyone, patient and non-patient alike. This is significant because it makes a mash of the argument that such medications are 'targeting' some sort of hypothesized deficit. If one successfully takes aspirin for a headache it's nonsense to then conclude that one was suffering from an aspirin deficiency. But this is precisely the level (i.e. reverse causal reasoning) on which many of the arguments for these drugs have been and are being made. Apart from this, it takes malign dedication to believe that the vast majority of depressions are anything other than higher order, psychological responses to real-life conditions.

If the arguments for the efficacy and mode of action of most psychiatric drugs are deeply suspect, then so too is the claim for their safety. Thus, in 1980, twenty-five years after the introduction of neuroleptic (antipsychotic) medication, an American Psychiatric task force report finally, grudgingly confirmed what a number of previously neglected studies had attempted to call attention to, namely, that roughly 40% of chronic users of these drugs went on to develop tardive dyskinesia, a Parkinsonian-like movement disorder indicative of permanent brain damage. One might have expected from this sobering experience that biological psychiatry would henceforth have exercised the pre-cautionary principle in its future endeavours. Instead, it has simply set about expunging crimes of Christmas past whilst denying the risks of Yuletides to come.

Its proponents continue to claim, for instance, that electro-shock therapy is harmless, this despite overwhelming experimental and clinical evidence to the contrary and despite the vociferous condemnation of a legion of former patients9. They also continue to ignore the commonsense potential for (and experimental evidence indicating) permanent changes in physiology whenever the brain's dynamic homeostasis is chronically altered or upset10 - as it often is while taking the 'new, improved' psychiatric medications. Constantly advised against screwing around with our brains when it comes to the casual, intermittent use of recreational drugs, we are yet urged to believe that ingesting legal psychotropic drugs on a continuous, round-the-clock basis, often for years on end, is without peril.

Still, biopsychiatrists will argue, and most people believe, that these medications have undergone rigorous testing under the auspices of the American FDA to insure their efficacy and safety. Nothing could be further from the truth.

First of all, the experimental studies of these drugs are constructed, financed, and supervised entirely by the drug companies themselves. Their vaunted independence is a complete myth11. Second, the timelines of the trials are so unreasonably short as to fly in the face of the most elementary scientific reasoning. Prozac, for instance, was released onto the market with only six weeks of clinical trials. In essence, anyone now taking the drug for more than six weeks is involved in his or her own study into its long-term effects. Third, the experimental protocol and statistical design of many of these studies are a complete scandal in their own right. In the case of Prozac, among other statistical shenanigans: data were pooled from different sources, then massaged into shape; additional confounding medications were administered simultaneous to the test drug; and the dropout rate of roughly 50% was neither factored into the results nor explained in the final reports12.

It is pertinent to note here that Prozac and company are increasingly being given to children13 despite their never having been part of the original experimental protocols, and despite the added risk that accrues from the interference with the developing brain.

* * * * *

The general public, it need hardly be emphasized, would have to root long and hard through the civic archives to unearth even the faintest trace of these controversial matters; the corporate media are hardly disposed to attack one of their own (the pharmaceutical /medical complex). Let off the hook by the press and abetted by the state, biological psychiatry has remained impervious to criticism, electing, instead, to simply expand its frontiers by seeking new markets in which to ply its trade.

ADD, The Incredibly Expanding Diagnosis

It may be disconcerting for educators to realize that they have been the thin edge of the wedge wherein children have become biopsychiatry’s largest population of involuntary patients. But so it is, for much of the driving force behind children's mental health referrals has come from the problems that children - mostly boys - are causing teachers. Chief amongst their complaints, naturally, is manageability for which the medical profession has conveniently supplied a diagnosis, Attention Deficit Disorder or ADD14.

To be fair, ADD, or at least its associated syndrome, has a long historical pedigree whose narrative suggests that it may not entirely be the biological reification of a normatively defined behavioural set. The story begins in 1902 when the first report on the syndrome was made by the British physician George Still. His suggestions were lent some support when researchers, following an outbreak of encephalitis in 1917, recorded among the other symptoms of affected children: hyperactivity, impulsivity and impaired attention - the very trio of symptoms that later came to characterize the modern diagnosis. By the 1950's the syndrome became subsumed under the term MBD ("minimal brain damage") a term which reflected the presumed organic nature of the disorder. The problem was that no one, try as they might, could identify any such organic damage so the term was later revised to Minimal Brain Dysfunction. When no actual physiological dysfunction could be proven either the term withered away to be replaced in 1980 (in DSM III) by ADD.

Significantly, however, the new diagnosis substantially broadened its net by de-emphasizing impulsivity and concentrating, instead, on distractibility and poor attention. Suddenly the doors were thrown wide open to diagnostic abuse. After all, given a little emotional trauma, say, from strife in the family, poverty, abuse, neglect, hospitalizations or a dozen other such commonly occurring life contexts, what child could or would not present as distractible or poorly attending?

Moreover, not only are the diagnostic criteria vague and open to wide interpretation, but ADD has no definitive medical or psychological marker. A diagnosis is thus often made almost exclusively on the basis of a patient's history, which, as things usually work out, is given by someone likely to be highly biased as to the desired conclusion. Why desired? Because a finding of ADD relieves both parents and society from any complicity in or responsibility for their children's' problems. Indeed, the very presumption of a biological basis for a child's behaviours automatically precludes the notion, or the search for, psycho-social aetiological factors. In addition, not only is there less stigma attached to a neurological as opposed to a psychiatric diagnosis, but being labelled ADD allows entitlements to special education services and (especially in the US) to disability and insurance rights.

A vivid example of these three factors in action is to be found in the United States in the highly influential and messianic group known as CHADD (Children and Adults with Attention Deficit Disorder). Dedicated almost solely to the proving and propagandizing of a purely biological basis for ADD, its lobbying efforts virtually single handedly oversaw the introduction of the Disabilities Education Act in 199115. The ensuing stampede to take advantage of the new entitlements afforded by the Act has undoubtedly been the prime driving force in the explosion in the number of ADD diagnoses over the past decade. And, of course, more ADD means more Ritalin.

Anatomy of a Wonder Drug

Ritalin, produced by Novartis (formerly Ciba-Geigy), is the brand name of a drug called methylphenidate and is classified as a stimulant. It is very closely related to amphetamine though, according to biopsychiatrists, devoid of amphetamine's addictive properties. Apparently, no one told this to the DEA (the Drug Enforcement Agency, in the US) which lists it as a Class II drug with a high potential for addiction or abuse16. Still, proponents like to emphasize that Ritalin has a long history (since the early 1960's) of safe usage. It's physical side effects, which include tics, spasms and chronically elevated heart rates and blood pressure, are acknowledged, but said to be more or less insignificant or inconsistently found at the dosages (5mg - 20mg) usually dispensed. It is said to have no long term risks17. This may indeed be the case - or it may not. The problem with taking the word of biopsychiatrists on this matter is simply that they have such a dismal track record when it comes to both unearthing and admitting the damaging nature of their magic potions and pills18. Much of the exculpating research is, of course, conducted or financed by the very companies making the drugs. And, unfortunately, the time honoured adage of 'buyer beware' suffers in translation when the drugs primary consumers are neither the buyers, nor aware. They are children.

All this said, it must be admitted that Ritalin and company (Dexedrine, Cylert and Clonidine) are, in their own way, effective - at least in the short run. Stimulants have always been effective. At the turn of the 20th century cocaine was (for a while) hailed by Sigmund Freud as a miracle drug; a panacea for all psychic ills. From the 1930's on amphetamines were extensively studied and were found to improve vigilance, accuracy, endurance, speed - and these improvements occurred across the board on everyone who tried them. And so it is with Ritalin. It has the same effect on all individuals regardless of their psychiatric status. Once again, this belies the claim that it is correcting some sort of biochemical imbalance. Moreover, there is considerable doubt as to its mode of action, for among its principal emotional side effects are flattening of affect, depression, loss of energy and diminution of creative thought. Given that no chemical imbalance has ever been demonstrated for ADD, nor is even likely to exist in the vast majority of those so labelled, it is highly probable that these "subduing 'side' effects" are, in fact, the drug's primary agency. Far from treating a medical problem, it is very likely we are simply medicating a problem child.

But what of long term prognoses? All of the long term studies to date have consistently demonstrated there to be no benefits whatsoever when medication is employed 'alone' as a treatment of ADD. There is no improvement in outcome as measured by rates of school failure, juvenile delinquency, drug abuse or later success in holding down jobs or maintaining relationships. Improvement has been demonstrated only when medication was allied with intensive individual and family counselling in conjunction with the provision of special educational services. The further disentangling of these ‘curative’ factors is, at present, an ongoing project19.

* * * * *

The foregoing discussion has focused almost solely on Ritalin and company. But, of course, children are subject to the full range of the biopsychiatric arsenal. As mentioned earlier, the new spectrum anti-depressants (the SSRI’s)20 are now widely given to children. In institutional settings (i.e. youth correctional facilities) the anti-depressants and amphetamine-like prescriptions are dispensed in epidemic proportions, and these are liberally supplemented with anti-anxiety medications, often including the infamous neuroleptics. That these kids often present as depressed, irritable or anxious is hardly surprising. One straight look at their circumstances and life history is enough to suggest a reason. Still, there are many who would challenge this -and coolly reverse the causal arrow.

Nature vs. Nuture

The question of whether constitutional or contextual factors are central to the defining of human personality is, it hardly bears repeating, as old as the hills. In this sense the debate between biological psychiatry and its critics is yet another chapter in a very long and probably unending story. Nevertheless, let me brazenly offer, at this point, a preliminary solution to the riddle of nature vs. nuture.

It is clear that genes and biochemistry have *something* to do with moods and behaviour, just as it is clear that the psyche is based in a physical substrate and that constitutional factors manifestly influence everything from temperament to potential intellectual limits. But where biopsychiatry sees these as *determining* factors, holistic philosophers# mark them as merely *bracketing* ones. The rather large difference is that to see biological parameters as framing human potential is a far cry from believing that we have uncovered - or that there even exist - specific, localized chemical substrates of complex emotional and psychological states. It is, furthermore, naive to suppose that the drugs in question could ever act in a functionally specific (i.e. fine tuned) way. In addition, the notion of conceiving of ourselves primarily as biochemical mechanisms is, I would posit, a profoundly - and dangerously - dehumanizing one21.

Still, it is arguable that this is all of little moment and even less comfort to a family or parent caught in the vice of turmoil and stress attendant upon a child’s slow descent into a vortex of oppositional behaviour and academic failure. And it is true that it would be cruel to withhold a treatment - however spuriously conceived - that might save the day in the short run when other interventions hold promise, perhaps, only in the longer run. Interventions which, moreover, might entail efforts that the principal protagonists are unwilling or incapable of fulfilling.

The problem with this saving (if ideally exaggerated) scenario is that, for the most part, the principal protagonists - the doctors, the parents, the teachers, and for that matter, the media, the courts etc. - actually *believe* that what their doing is other than an emergency tactical manipulation of a decidedly non-medical phenomenon. And this incongruence between ideation and action is not just some philosophical quibble. It has very tangible and far reaching social consequences.

It means that all problem behaviour is now in danger of being swept up in a pathologically defined net. Seen through such a biological determinist lens, what modern Tom Sawyer or Huckleberry Finn is likely to roam unhindered, free from the paternalistic embrace of medical science?

It also means that potential social policies and research that might bear on these matters are rendered null and void before they even reach the drawing board. How many studies, for instance, have brought the bright beam of science to bear on the relationship between, say, class size and ADD? None to my knowledge. And yet the experience of myself and many of my colleagues suggests the relationship is a profound one.

Or what researcher has given earnest lucubration as to just how destructive to a child's self-image, and sense of identity (and, indeed, efficacy and responsibility)#, are the stigmatizing effects of taking a medication over the long term. Again, none that I am aware of, though common sense and experience suggest these effects are substantial.

That in a better world a mature *bio-psycho-social* model of human nature could find wise and judicious employment within a culture of non-reductionist social relations, is so much hypothetical grist for the speculative mill. The plain fact of the matter is that the widespread drugging of children is now being played out against an Orwellian background of pseudo-scientific claims, evidential suppression, corporate/medical entwinement, and crudely simplistic social and scientific philosophies. Perhaps, then, it is time to start talking less about the ’pathology’ of children, and more about the pathology of values.

Antony Black

Notes 1. In fact, the ’drug laundering’ metaphor is more apt than one might, at first, suppose. It is widely conceded that between $500 billion and $1 trillion of ’dirty’ money flows through the major US banks - with their conscious connivance - every year and that this is a prime buttress of the US imperial economy, offsetting their $300-400 million yearly trade deficits.

2. Thus, a Wall Street Journal report of 1997 reported that 28 million Americans were taking Prozac or one of its SSRI cousins. The number of those partaking of the rest of the psychotropic arsenal would boost these numbers substantially. Many of these figures, by the way, are not obtained directly, but by indirect means, i.e. production amounts divided by average dosages etc.

3. There are, of course, no drugs for kids who are too quiet, or too conforming, or who are internalizing psychosomatizers. After all, they don’t present a control problem.

4. The term ‘hard sciences’ reflects, naturally, the blatant sexual machismo at the heart of these matters.

5. This discrepancy between the common perception of ‘psychology’ and its actual academic representation is particularly evident in the universities. After all, there are no undergraduate curriculums (to my knowledge) in North America that allow a student to study ‘real‘ human psychology i.e. character analysis etc. Not one student in a thousand properly understands this, and not one university curriculum calendar tells them.

6. DSM III came out in 1980, followed by DSM-III-R in 1987, and DSM IV in 1994.

7. It bears noting here that our culture, all odes to democratic ideology aside, is deeply imbued with anti-democratic sentiment. Eliltist ideals and sympathies are, indeed, so omnipresent as to fail to prick the sensors of the average citizen.

8. Capitalism is unique as an ideological structure in that it claims not to be one. Claiming is one thing, of course, and reality is another.

9. The original animal studies on ECT in the 1940’s and 50’s were damning, as were many studies carried out in former Soviet Russia. Memory loss from shock therapy is widely attested by former patients. It’s actually easy to confound a proponent on this matter. Just ask them to demonstrate once and for all the procedure’s eminent safety - by having it done on themselves. I ‘ve never had any takers.

10. Experimental evidence in animal studies indicates that chronic down-regulation results in the permanent loss of serotonin receptors.

11. Only last year a number of leading medical journals publicly announced that they were suspending acceptance until further notice of studies associated with the major pharmaceutical companies.

12. For a full discussion of this fascinating topic see, ‘Talking Back to Prozac’, by Peter R. Breggin (1994).

13. It takes a strong kid to go against the pressure exercised by a prison psychiatrist to take one of these drugs. Nevertheless, many are savy enough to recognize that something is askew - and that it isn’t them. The daily rounds for dispensing pills, in some of these places, reminds one, in all honesty, of scenes from One Flew Over the Cuckoo's Nest.

14. Actually, ADD was changed to ADHD (the “H” for hyperactivity) in DSM IV. But most everyone still refers to it as ADD.

15. CHADD and Ciba-Geigy were actually involved in an open scandal in 1995 when it was revealed that the latter had contibuted $900,000 to the former over 5 years without having disclosed this to either the public or to the CHADD membership. It is also worthy of note here that ADD is not the only disorder to have been given a boost from a parent’s organization. The LD (Learning Disorder) syndrome was largely driven by such an organization. Indeed, there is little evidence to support, this syndrome as neurological phenomena either.

16. CHADD lobbyied heavily, though unsuccessfully, to have Ritalin moved to Schedule III which would have made it much easier to obtain.

17. Indeed, a 1986 study by Henry Nasrallah et al. published in Psychiatric Research suggested possible cortical atrophy in subjects all of whom had been subject to long term treatment with stimulants. To my knowledge this research has not been followed up.

18. This relates directly to the preceeding note. Not starting up, not following up, and not admitting when something *is* up, is one of the key threads running through biopsychiatric history over the past fifty years.

19. A study sponsored by the National Institute of Mental Health in the US to determine which of, or which combination of, treatment modalities *were* effective in helping those diagnosed as ADD has been ongoing for a number of years now. At the time of writing I had not been able access to its results.

20. SSRI’s - Selective Serotonin Reuptake Inhibitors.

21. I have used the term ‘reductionist’ and ‘reductionism’ throughout, assuming the reader to understand the term. But just for the record, 'reductionism' as here used refers to the notion that in studying any higher organizational entity the properties of the whole can be deduced from the parts, the complex explained by the simple, the higher derived solely from the lower. Though much of modern science has, in its practice, employed reductionist methodology, it is now widely conceded that science is, in some areas, now reaching the workable limits of reductionist ideation. Evolutionary theory is a prime example. Human psychology, many would assert, is another.

Antony Black is a freelance writer concentrating, for the most part, on international issues from a 'radical' left perspective. Having incubated first in an intellectual context of psychology and psychiatric theory, then veered into the sciences, thence to writing and teaching, he has yet retained an abiding interest in his first 'career'.