Ilina Singh

Biomarkers in psychiatry

The use of biomarkers to predict human behaviour and psychiatric disorders raises social and ethical issues, which must be resolved by collaborative efforts.

In Search of Biomarkers for Autism: Scientific, Social and Ethical Challenges

There is widespread hope that the discovery of valid biomarkers for autism will both reveal the causes of autism and enable earlier and more targeted methods for diagnosis and intervention. However, growing enthusiasm about recent advances in this area of autism research needs to be tempered by an awareness of the major scientific challenges and the important social and ethical concerns arising from the development of biomarkers and their clinical application. Collaborative approaches involving scientists and other stakeholders must combine the search for valid, clinically useful autism biomarkers with efforts to ensure that individuals with autism and their families are treated with respect and understanding.

Bad Boys, Good Mothers, and the “Miracle” of Ritalin

Argument Contemporary debates around Attention Deficit/Hyperactivity Disorder (ADHD) and the most common form of drug treatment, Ritalin, are rarely placed in the context of the social-scientific history of diagnosis and drug treatment. This is possibly due to the fact that brain talk and brain imagery have replaced earlier theories about children’s psychopathology that had mainly focused on the toxic effects of the mother. These theories and their psychoanalytic roots are considered somewhat embarrassing and certainly unscientific in a contemporary light, and modern biological psychiatry has worked hard to demonstrate that physiological and genetic factors underpin this contested disorder. Such theories have tended to make the history of ADHD and Ritalin seem irrelevant to scientific progress and understanding of disorder, as well as to public understanding and acceptance of disorder and drug treatment. Examining this history, however, clarifies the relation between social, cultural, and scientific values in constructing a need for medical intervention within the domestic realm. When Ritalin came on the United States market in 1955, neither psychiatric diagnosis of children’s behaviors, nor drug treatments for children’s behavior were commonplace. Mothers especially were located in the center of active political, moral, and scientific debates over boys’ normative behaviors. These debates helped codify an intimate association between a problem boy and his problematic mother in relation to ADHD diagnosis and Ritalin treatment. The story I tell here suggests that this association may have supported mothers’ acceptance of medical intervention and drug treatment for their boys’ troublesome, but arguably not pathological, behaviors. In the concluding sections I argue that the lack of attention to these social-scientific roots means that we miss seeing their potential relevance to the contemporary predicament of rising ADHD diagnoses and Ritalin use.

A disorder of anger and aggression: Children’s perspectives on attention deficit/hyperactivity disorder in the UK

This article investigates the social and moral dimensions of Attention Deficit/Hyperactivity Disorder (ADHD) diagnosis, asking what ADHD means in UK children’s everyday lives, and what children do with this diagnosis. Drawing on interviews with over 150 children, the analysis examines the influence of a UK state school-based culture of aggression on the form and intensity of diagnosed children’s difficulties with behavioral self-control. Diagnosed children’s mobilization of ADHD behaviors and their exploitation of the diagnosis shows how children’s active moral agency can support and compromise cognitive, behavioral and social resilience. The findings support a proposal for a complex sociological model of ADHD diagnosis and demonstrate the relevance of this model for national policy initiatives related to mental health and wellbeing in children.

Neuroenhancement in Young People: Proposal for Research, Policy, and Clinical Management

Psychotropic neuroenhancement by young people under 18 is growing, and is certain to increase further with the availability of effective drugs and increasing tolerance for neuroenhancement practices. Use of these agents by young people for purposes of enhancement has social and ethical implications that require scrutiny and analysis. It is particularly important that these analyses do not simply translate normative judgments on adult neuroenhancement practices or intentions to young people. In this article, we outline the key social and ethical concerns raised by the use of stimulant drugs for neuroenhancement in young people and make specific research, practice, and policy recommendations. We also suggest a rationale for clinical management of psychotropic drug neuroenhancers for young people, attending closely to the necessary boundaries on such practice asserted by organizational and clinical factors, as well as by potential ethical conflicts.

Psychopathology as adaptive development along distinctive pathways.

Contrary to the standard assumption that psychopathology stems from developmental immaturity (retardation, fixation, regression), people diagnosed with psychopathology typically develop along distinctive pathways in which they build complex, advanced skills. These pathways are based on adaptation to trauma, such as maltreatment, or to problems in affective-cognitive regulation, such as those in autism. They do not fit normative developmental frameworks. Research has characterized several types of distinctive pathways, especially those arising from maltreatment; they are marked by normal developmental complexity but distinctive affective-cognitive organization. In one study sexually abused depressed adolescent girls admitted for treatment in a mental hospital described themselves-in-relationships with age-appropriate, complex developmental levels equal to those of both nonabused depressed girls and other adolescents. At the same time, they showed a powerful negativity bias contrasting with the positivity biases of other girls. Many of them produced dramatic switches in affective-cognitive organization across assessments contrasting with the similar organization showed by other girls. In another study toddlers from maltreating families showed a consistent negativity bias in play and representations of interactions. We show how to portray these distinctive developmental pathways through the example of Hidden Family Violence, in which people dissociate their private violent world from their public, good-citizen world.

Brain talk: power and negotiation in children's discourse about self, brain and behaviour.

This article examines children’s discourse about self, brain and behaviour, focusing on the dynamics of power, knowledge and responsibility articulated by children. The empirical data discussed in this article are drawn from the study of Voices on Identity, Childhood, Ethics and Stimulants, which included interviews with 151 US and UK children, a subset of whom had a diagnosis of attention deficit/hyperactivity disorder. Despite their contact with psychiatric explanations and psychotropic drugs for their behaviour, children’s discursive engagements with the brain show significant evidence of agency and negotiated responsibility. These engagements suggest the limitations of current concepts that describe a collapse of the self into the brain in an age of neurocentrism. Empirical investigation is needed in order to develop agent-centred conceptual and theoretical frameworks that describe and evaluate the harms and benefits of treating children with psychotropic drugs and other brain-based technologies.

Robust resilience and substantial interest: a survey of pharmacological cognitive enhancement among university students in the UK and Ireland.

Use of ‘smart drugs’ among UK students is described in frequent media reports as a rapidly increasing phenomenon. This article reports findings from the first large-scale survey of pharmacological cognitive enhancement (PCE) among students in the UK and Ireland. Conducted from February to September 2012, a survey of a convenience sample of 877 students measured PCE prevalence, attitudes, sources, purposes and ethics. Descriptive and logistic regression statistical methods were used to analyse the data. Lifetime prevalence of PCE using modafinil, methylphenidate or Adderall was under 10%, while past regular and current PCE users of these substances made up between 0.3%–4% of the survey population. A substantial majority of students was unaware of and/or uninterested in PCE; however about one third of students were interested in PCE. PCE users were more likely to be male, British and older students; predictors of PCE use included awareness of other students using PCEs, ADHD symptomatology, ethical concerns, and alcohol and cannabis use. The survey addresses the need for better evidence about PCE prevalence and practices among university students in the UK. We recommend PCE-related strategies for universities based on the survey findings.

Not robots: children's perspectives on authenticity, moral agency and stimulant drug treatments

In this article, I examine childrens reported experiences with stimulant drug treatments for attention deficit hyperactivity disorder in light of bioethical arguments about the potential threats of psychotropic drugs to authenticity and moral agency. Drawing on a study that involved over 150 families in the USA and the UK, I show that children are able to report threats to authenticity, but that the majority of children are not concerned with such threats. On balance, children report that stimulants improve their capacity for moral agency, and they associate this capacity with an ability to meet normative expectations. I argue that although under certain conditions stimulant drug treatment may increase the risk of a threat to authenticity, there are ways to minimise this risk and to maximise the benefits of stimulant drug treatment. Medical professionals in particular should help children to flourish with stimulant drug treatments, in good and in bad conditions.

A Framework for Understanding Trends in ADHD Diagnoses and Stimulant Drug Treatment: Schools and Schooling as a Case Study

This article offers a socio-historical account of the development of the Attention Deficit/Hyperactivity Disorder (ADHD) diagnosis and methylphenidate treatment in America, attending particularly to the institutional and professional contexts that have supported this development. These historical developments frame a socio-cultural analysis that views contemporary schools and schooling practices as mediating factors in ADHD diagnoses and methylphenidate treatment. Consideration of the school as a mediating socio-cultural context illuminates important questions about the validity of the ADHD diagnosis, and about inter- and intra-national variations in the perception and tolerance of young childrens behavior, educational and behavioral goals for children, and styles of treating problem behaviors in children. It is argued that both local and cross-national research on schools and schooling are important means of increasing understanding of the complex socio-cultural factors inherent in the global growth of ADHD diagnoses and methylphenidate treatment.