View of How Do We Understand Children’s Restlessness? A Critique of the Biopsychosocial Model and ADHD as the Dominating Perspective in Current Understanding and Treatment

[Research Voices: Theoretical Studies]

How Do We Understand Children’s Restlessness? A Critique of the Biopsychosocial Model and ADHD as the Dominating Perspective in Current Understanding and Treatment

By Anna Helle-Valle

Abstract

How is children’s restlessness understood and handled by surrounding adults? Two approaches are outlined in this article: one is the biomedical and later the biopsychosocial model, the other is a tradition that can be traced back to Foucault’s concept of historical ontology. The biopsychosocial model and ADHD is currently the dominating perspective when it comes to describing, understanding and treating restlessness in children. In this tradition, a focus on pathology and biology places the root of the problem within the child and positions the surrounding adults as neutral observers and helpers. By contrast, historical ontology opens up to questions about the neutrality and validity of a biopsychosocial approach by pointing to our active role as subjects in creating ideas of truth about children, in judging their behaviour and in “helping” them. Rather than claiming that one approach is better than the other, it can be useful to regard the two traditions as providing different levels of analysis and be aware of the possibilities and limitations pertaining to these.



 

What is a “normal” child? Who has the right to decide what is normal? Why? What are the consequences of our adult expert conceptualisations of normality for the child? These broad and basic questions seem almost impossible to answer. At the same time, they reflect an attitude of fundamental curiosity that has a central position in my research approach to children’s restlessness.

I am rather new to the field of music therapy. My background is in psychology, but I am currently doing a Ph.D. on music therapy in a kindergarten in Bergen, Norway. The transition from psychology to music therapy has provided me with an inspiring distance to my own profession and clinical tradition, and simultaneously challenged me to adapt to a different, but related tradition of theory and practice. In my Ph.D. project I am investigating restlessness as a concept from normality to pathology. I am not sure when or how this topic became a research interest for me. In one way, restlessness has always been a part of what I consider normal. Growing up with a doctor/comedian/musician father and a feminist mother, I was allowed great freedom in exploring, expressing and discussing different aspects of normality. To me, restlessness represents a drive, a pulse and a way of being. Looking back, especially after writing this article, I see that I have really struggled with my own process of becoming a clinical or research "expert." For instance, acquiring and using the language that entails so-called objective descriptions of human behaviour has at times been an emotional and intellectual struggle. Doing an interdisciplinary Ph.D. on restlessness has allowed me to challenge this categorical language and way of thinking.

To be concrete, the Ph.D. project consists of two parts that are carried out in parallel in the same kindergarten: a semi-structured improvisation based song writing project about restlessness with the five year old children, and a group for practice improvement informed by action research (Reason & Bradbury, 2006). The second group consists of adults that are involved in the kindergarten as parents or professionals, including three parents, two educational supervisors, the head of kindergarten, two music therapists, a clinical social worker from the youth and children¹s mental health services, a clinical psychologist from the educational-psychological service and a general practitioner. The practice improvement group will discuss how we understand and handle restlessness in kindergarten, and they will watch a performance by the five year olds as part of that process.

ADHD is currently the most prevalent childhood mental health diagnosis, and is thus a central factor in how we view and rate children in our society. The perspectives on ideals regarding child personality or behaviour, disease and health are closely connected to a biomedical or biopsychosocial model of pathology, and the diagnostic culture involved in giving a child an ADHD diagnosis has roots back to the early 1900’s. This makes ADHD not only a mental health diagnosis, but also a historical and cultural phenomenon and an idea of truth through which the adult authorities can describe and act upon children. Neufeld and Foy (Neufeld & Foy, 2006) has used Ian Hacking’s conceptual analysis as a means of discovering and discussing the historicity of ADHD. I will use Hacking’s (Hacking, 2002) concept of historicity in a similar way to Neufeld and Foy, but relate it to a Norwegian context. My analysis includes an email correspondence with representatives from the National Centre for ADHD, Tourette’s syndrome and Narcolepsy (Nasjonalt kompetansesenter for ADHD, Tourette’s syndrome og Narkolepsi) that I will refer to as NK-ADHD. In this essay, the correspondence with NK-ADHD serves as a concrete example of how ADHD has established itself as a powerful frame of understanding and treatment in a Norwegian clinical context and as a political health issue. The question discussed in this essay is: How do we understand children's restlessness?

A Short Contextualisation

How we understand and handle the restlessness displayed by children is a question that can be investigated in many contexts and from different theoretical and practical angles. In this text I write from a position that is interdisciplinary, but at the same time quite specific and concrete. Apart from the fact that I am a psychologist doing a Ph.D. on music therapy, the interdisciplinary aspect of this text is reflected in the desire to pose some questions and outline some answers that are relevant to all adults working with children in a kindergarten, school or health care setting. The essay questions a tradition of understanding and practice related to children’s restlessness that has developed alongside the emergence of a biopsychosocial model. The definition of the biopsychosocial model used in this text is based on a renowned article by Engel (Engel, 1977) where he introduced the biopsychosocial model as both an expansion and critique of the biomedical model. According to his view, an understanding and practice based on a biomedical model was to blame for the lack of coherence between medical expertise and good patient care, representing a crisis in medicine and psychiatry. Engel’s argument was that descriptions of disease must also include descriptions of illness on a social, psychological and behaviour level (Engel, 1977). In this sense, the biopsychosocial model represents a break from the biomedical model. However, both focus on pathology, and although the biopsychosocial approach entails subjective descriptions of illness on various levels, these descriptions are still tied to the patient. A patient can be understood as a person that is subjected to expert descriptions and that is the focus of treatment and change. In this sense, Engel’s article both criticises and reinforces the power relations and process of objectification that comes with being a patient. Using the word client instead of patient can be an example of breaking with, but relating to a biomedical/biopsychosocial model of health.

Definitions of ADHD

Attention-deficit/hyperactivity disorder (ADHD) is currently the most prevalent childhood mental health diagnosis (Ullebø, 2010). The disorder is described by a set of symptoms relating to behaviour, divided into three main groups: problems with concentration/attention, hyperactivity and impulsivity. Examples of symptoms listed in the DSM-5 under the different categories are as follows.

The child should have at least six symptoms that have persisted in the last six months, and the symptoms should be maladaptive and not match the child’s developmental level (American Psychatric Association, 2013).

The diagnostic process is normally initiated by a GP or someone within the educational-psychological service, based on concerns presented by the school or parents. Subjective reports made by teachers and parents play a central role in this process. Health personnel that are qualified to diagnose mental and neurological disorders are responsible for how the condition is treated and followed up (Sosial- og helsedirektoratet, 2005).

The ADHD diagnosis was first included in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association in 1980 (Neufeld & Foy, 2006). WHO’s International Statistical Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organization, 1992) has been used in Norwegian psychiatric clinical contexts since 1997. The corresponding diagnosis to ADHD in the ICD-10 manual is F90 Hyperkinetic Disorder (HKD). This diagnosis is classified as an early onset behavioural and emotional disorder, and is associated with impairment of cognitive function and specific delays in motor and language development. HKD can broadly be seen as an extreme version of ADHD, and has thus lower prevalence (Neufeld & Foy, 2006).

ADHD in Norway

t-shirt with a print based on the logo of AC/DC, which reads AD/HD
Figure 1. T-shirt with a print based on the logo of AC/DC, which reads AD/HD. Photo: Anna Helle-Valle.

How common the disorder is relies on the diagnostic criteria used. ADHD can more easily be applied as a pathological label for unwanted child behaviour than HKD. ADHD is also the term that is most often used, both in professional and lay settings, as well as in popular culture. One example is a popular t-shirt with a print based on the logo of AC/DC, which reads AD/HD (figure 1).

In spite of ICD-10 (HKD) being the official standard for diagnostic practice in Norwegian child psychiatry, several examples exist where the DSM-IV (ADHD) has been used as the communicative term for diagnosing mental disorders in children. One example is the National Centre for ADHD, Tourette’s syndrome and Narcolepsy (NK-ADHD). The centre is organised as a part of Oslo University Hospital, and is fully financed by the Ministry for Health and Care Services. Their mandate, as regulated by law, entails building and spreading competency and knowledge about treatment to professionals and users, and to help implement knowledge based practice (Helse og omsorgsdepartementet, 2010).

In spite of operating in a Norwegian clinical context, NK-ADHD has integrated the DSM-IV term ADHD in their title. ADHD is also used as a headline in the column frequently asked questions (FAQ) that can be found on their web page (www.nasjkomp.no). The FAQ column acts directly as a means of spreading information about updated knowledge, and indirectly as an illustration or mediation of the perspective of the centre. One of the questions reads as follows: “Can the brain take damage from the use of ADHD medication?” The leader of the centre, who has a background in teaching and special education, answers the question with the following response. “Very many people have since the fifties used these medications, often for many years. There is nothing that indicates that brain tissue or the chemical processes in the brain have taken damage from the treatment.”

Whether such an answer reflects the format of the column, or a serious effort to sum up a complicated research field, is unclear. With this lack of clarity in mind, I formulated an email to the leader, with a copy to the head physician and the centre’s psychologist with experience from neurology. In the email I stated my background as a psychologist and current position as a Ph.D. student (Personal communication with NK-ADHD, 2011). In the email I repeated the FAQ-answer above, and asked why known side-effects and uncertainty about long term effects, as described by the Norwegian Medicines Agency (Statens legemiddelverk, 2009), were not mentioned. The email also referred to a comment made by the UN’s Commission for Children in 2010 (Barne- likestillings- og inkluderingsdepartementet, 2010), that expressed concern about the wide spread use of ADHD medications in Norway.

Based on the hypothesis that ADHD is caused by hypoactivation of dopamine systems in the brain, a powerful central stimulant is tested on the patient. The drug is “tested” because there are no objective measures that can clarify whether the child really has a dopamine deficiency. Symptoms of restlessness as perceived by adults and teachers, along with the observations of the clinician, are the only evidence available. If the symptoms as listed in the diagnosis are reduced, than the test is considered a success. Methylphenidate is most commonly used, and is sold under the names Ritalin, Concerta or Equacym. The drug acts by reducing restlessness, impulsive actions and improving ability to concentrate. Known side effects are disturbance of sleep, loss of appetite, depression, suicidal thoughts or behaviour, psychosis and manic episodes (European Medicines Agency, 2009). It is also recommended that blood pressure is measured and followed up throughout the treatment, and that the child stops using medication once a year to see if it is still necessary (ibid.). Treatment of ADHD with medication has been shown to treat the core symptoms of the condition as listed in the diagnosis, but has been less effective in improving function (Brown et al., 2005). In my email to the NK-ADHD I suggested that routinely stopping the medication could be interpreted as preventive measures with a focus on long-term effects on the cardiovascular system. Methylphenidate can be described as sympathomimetic drug, as is the more well known methamphetamine. A sympathomimetic drug means that the drug mimics the effect of the neurotransmitters of the sympathetic nervous system, like epinephrine (adrenaline) and dopamine. These compounds have a potent stimulant effect on the cardiovascular and central nervous systems (Nissen, 2006).

A month after sending the email, I received an answer from the head physician with a copy to the leader of the centre and two other colleagues. Her answers regarding my questions on medication of ADHD were divided into three points. In the first point, she agreed that “some” had raised concern about the side effects of central nervous stimulants. She continued to say that most side effects are either mild, transient or can be easily handled by dose adjustment or change of medication. In addition, she informed me about a new study in the field of sudden death, sudden cardiac arrest or stroke, related to ADHD medications. No significantly increased risk appeared in the group of children that were under current treatment with ADHD mediations. She also referred to an article titled “European guidelines on managing adverse side effects of medication for ADHD”, published in European Child and Adolescent Psychiatry (Graham et al., 2011).

In the second point she commented on my interpretation of the yearly medication break as being preventive regarding overmedication and severe long-term effects. This was incorrect, she stated, as this was only a recommendation meant to assess the child’s medical needs. She also underlined that it was the task of the Norwegian Medicines Agency to evaluate and if necessary change the routines regarding medication of ADHD.

In the third point she underlined that the curve showing use of ADHD medication was flattening out, and that fewer than expected used these medications, based on estimates of prevalence. Attached was a memo from the Directory of Health, referring a discussion about the use of ADHD medications in Norway during Prime Minister’s Questions, PMQ [Stortingets spørretime] (Helsedirektoratet, 2010). This memo connected the increased use of medications in Norway with the goal in the National Health Plan (Opptrappingsplanen for psykisk helsevern) that children and adolescents should have better accessible assessment and treatment regarding mental illness. It referred to the lack of knowledge of aetiology, and the existing conflict about ADHD as a diagnosis and the use of medications. The memo ended with a recommendation to focus on the persons that benefit from medication.

Based on this correspondence, the official stance of Norwegian clinical-political authorities can be interpreted as perceiving ADHD as a widespread problem pertaining to pathology as located within the individual. There also seems to be a strong belief that central nervous stimulants are efficient, not harmful, and considered a right for children fitting the ADHD diagnosis. By using the term ADHD and not HKD, NK-ADHD mediates the official Norwegian stance as having a wide pathological definition regarding restlessness in children.

Two Traditions

Through which mechanisms has the ADHD diagnosis become the most prevalent childhood mental health diagnosis? Paul Neufeld and Michael Foy (2006) have used historical ontology, in the form of a historicized conceptual analysis, to explain the growth of ADHD as a mental health diagnosis for children in North America. A definition or explanation of historical ontology is that everything that is in our society has emerged in history, and that this process can be studied. Hacking’s reflexions on the reality of transient mental illnesses constitute the philosophical backdrop: “(…) transient mental illnesses lurch into our consciousness and fade away, creating new ways to express uncontrollable distress, ways to absent ourselves from intolerable responsibility, and legitimating exercises in both constraint and liberation” (Hacking 1998 in Hacking 2002, page 4).

Ian Hacking (2002) derived his concept of historical ontology from Michel Foucault’s idea for a study of “the historical ontology of ourselves”, mentioned in the essay “What is Enlightenment” (Foucault, 1984). Foucault suggests that in such a study one could be concerned with "truth through which we constitute ourselves as objects of knowledge", with "power through which we constitute ourselves as subjects acting on others", and with "ethics through which we constitute ourselves as moral agents." I suggest that this way of thinking of ourselves and others as active agents that act upon each other through certain axes of knowledge, power and ethics, serves as a contrast to a biomedical - and later biopsychosocial – model. Despite the fact that I am using them in opposition, they could equally represent parallel perspectives that provide a commentary on each other and enable mutual development. I use them to contrast one another to underline that a biomedical perspective largely promotes an epistemology where objectivity of the researcher and neutrality of knowledge is assumed. In the other tradition, the force of the subject is discussed and can be used to challenge the neutrality of the researcher, her ideas and institutions, and as a consequence, the objectivity of her knowledge.

The Historicity of ADHD

Neufeld and Foy (2006) draw on Hacking’s (2002) metaphor of the ecological niche in their discussion of the life and history of ADHD in the USA. The ecological niche is the specific historical and cultural environment where ADHD as an explanation for children’s troublesome behaviours can and does thrive. The elements that make up the ecological niche are referred to as vectors, describing forces acting in a certain direction. In relation to ADHD, there are four central vectors: a) Conceptions of Disability and Self, b) Observability, c) Cultural Polarity, and d) Release (Neufeld & Foy, 2006, page 452). Observability will not be the focus of this text, but runs as a premise throughout the essay; ADHD as a concept is indisputably observable in both professional and popular contexts. I will summarize the authors’ analysis of recent and present conditions in North America and discuss the relevance of their perspectives for the Norwegian context.

Concepts of Disability and Self. In 1890, early American psychologist William James described a normal type of character he called the explosive will. Impulsivity, risk taking, and high levels of physical and verbal activity were central. In 1902, English physician George Still, described what is considered to be the first modern description of ADHD in children, referring to their deficit as “a morbid defect of moral control.” In North America, the encephalitis epidemic of 1917-1918 led to an increased focus on the connection between central neurological damage and a rise in “a severe behaviour disorder with over-activity and impulsivity.” This was later described as brain injured child syndrome by Strauss and Lethinen in 1947. This concept would later develop into minimal brain damage and minimal brain dysfunction (MBD). ADHD was first included in the DSM-IV in 1980, and was by 1994 the most commonly diagnosed childhood mental disorder in the USA.

Still’s notion of defective moral control, together with the encephalitis epidemics, marked the introduction of two central premises in ADHD: rule-related behaviour and neurological dysfunction. When making the diagnosis, however, one has only observations of behaviour to rely on. In spite of widespread research, no laboratory test can reliably predict ADHD (Rowland, Lesesne, & Abramowitz, 2002). This means that in the clinical process, there is no objective evidence that the child in question has a neurological dysfunction, but this lack of evidence is not a hinder for being medicated for neurological dysfunction.

By locating the source of pathology within the child, the emergent field of ADHD has been in keeping with the perspectives of disability that have been historically dominant within the fields of medicine, psychology and education. Through this similarity, ADHD could easily be assimilated into a larger public understanding of disability that was already in place (Neufeld & Foy, 2006). Although HKD should be the preferred diagnosis in European clinical settings, ADHD is clearly the most influential diagnostic concept also here.

Why is this? An explanation might be the central role of teacher reports in the diagnostic process. In the Norwegian context, the educational-psychological service is often involved in early assessment, and an ADHD diagnosis can give the school access to resources that would otherwise not be available. In this sense, a widespread use of the diagnosis can be argued to be beneficial for the child, his/her family and the school. One serious disadvantage of such use is that pathology is one-sidedly described as residing within the child. Additional functions of such placement of pathology will be described below.

Cultural Polarity. How is the ADHD diagnosis located within our culture? Neufeld and Foy suggest that ADHD is situated between two cultural polarities: one romantic-virtuous and the other frightening-vicious. Similarly to other mental illness diagnoses, being labelled as “ADHD”, or at least displaying behaviour compatible with the diagnosis, can afford the individual benefits in society, as long as the timing and context is right. This can be illustrated in the performances of comedians, actors, reality show participants and other celebrities being praised or rewarded for their impulsive, excessively talkative, over-the-top behaviour. The other end of the spectrum relates to research that ties the ADHD diagnosis to a conduct disorder (Rowland et al., 2002), and to emotional and motivational problems (Høvik & Plessen, 2010).

Referring indirectly to the frightening-vicious pole can be a method for promoting ADHD and medications. In the PMQ-attachment from the NK-ADHD, such an indirect referral was made as a part of a concluding consensus with recommendations for future focus (my translation from Norwegian to English):

The question here is what should be the consensus? There are strong opposing poles here – for and against ADHD as a diagnosis, and for and against the use of medication. In this case it should be most important to think about the patients that actually have an improved life as a result of treatment. The EU note in their comments in Article 31 of Directive 2001/83/EC that the treatment of children with ADHD with medications in addition to other treatment, can reduce the symptoms of hyperactivity so that they are given an improved quality of life, and hinder social problems, unemployment, criminality and substance abuse (Helsedirektoratet 2010, page 3)

Reading this concluding remark, it seems difficult to image a responsible stance against the use of medications for children with ADHD. Questions arise, however, about the validity and relevance of such a perspective. To focus on those who benefit from being diagnosed and treated with medication, in contrast to seeing the whole picture including those who benefit from not being diagnosed and treated with medication, can be seen either as naiveté, or as a way of intentionally neglecting parts of the truth. Would such a recommendation be likely in the case of a patient group that was not indirectly linked with frightening consequences for society? Would it be possible to use these arguments to promote similar interventions for patient groups that, unlike children, have formal power and resources?

Release. This vector depends on whether the diagnosis offers some form of release for the patient and his or her surroundings. The first type of release given by the ADHD diagnosis is that it offers the person in question an explanation about the patterns in life that cause pain or are deemed as deviating from normality. A second form of release involves discharging parents, teachers and other persons involved from responsibility for causing or facilitating troublesome behaviour. Indirectly, and in practice, the responsibility is thus transferred to the child and positions the adults and the system as “helpers.” This relates to the third form of release, which is the possibility of medical or behavioural interventions that suppress bothersome behaviour to the benefit of others in the child’s everyday life (Neufeld & Foy, 2006). The importance of this release may be indirectly found in the recommendation for medication to be started at the age of six (European Medicines Agency, 2009), corresponding to the year in which children normally start school. An expansion of this perspective, based on the note from PMQ passed on by the NK-ADHD, is the release from a potential future threat to society; the expectation that children with behaviour corresponding to symptoms of ADHD have an increased possibility of ending up as criminals, unemployed or substance abusers (Helsedirektoratet, 2010). If it is true that ADHD is involved in causing crime, unemployment and substance abuse, early treatment is an important economical incentive for politicians and health authorities. Medical treatment could be seen as resource saving, in that it is cheap and less time consuming compared with other interventions or changes that might require time, effort and collaboration.

Levels of Analysis

Arguments presented by Foucault, Hacking, Neufeld and Foy, could be used to interpret the biopsychosocial model as a continuation of the positions of the patient and the physician/expert/clinician. The biopsychosocial model represents an introduction of additional levels of analysis, but not a paradigmatic change. The expansion of the biomedical model to a biopsychosocial model can be seen as a widening of the ecological niche in which diagnosis may thrive. By including psychological and social aspects of a person’s life in the diagnostic process, these aspects are also included in the concept of pathology. If the biomedical model limited the physician/expert/clinician to define a head injury as a physical lesion that needed treatment, the biopsychosocial model introduces emotional reactions and social habits as an indication of brain disease, as in ADHD. It also suggests that a particular way of feeling, coping and expressing oneself is an illness that must be understood and treated by the physician/expert/clinician. In some cases this change of model is important and has resulted in more help being provided from within the system than previously. On the other hand it has strengthened the physician/expert/clinician’s position as an active agent in defining, controlling and judging the truth about health.

The strengthening of the position of the biopsychosocial expert also allows selected parts of the truth to be shown and believed by society at large. In the case of ADHD the truth that is communicated is a biomedical one: “ADHD children” deviate from others in brain structure and physiological functioning; and a biopsychosocial one: “ADHD children” have an unhealthy way of being with others. Both these conditions are focused on the pathology of the individual. This pathology is seen as unwanted by the clinical-political authorities and possible to treat with medication or interventions aimed at the psychological or social aspects of the child.

The tradition represented by Foucault, Hacking and Neufeld and Foy is concerned with the subject, the historical coming into existence of ideas and institutions, and with how we constitute ourselves through axes of power, truth and ethics. In the case of ADHD it could be formulated like this: ADHD has come into existence as an extension of an already existing concept of disability and self. This might mean that rather than discovering pathology, the adult subjects have been active in shaping and creating the ideals regarding child personality and behaviour. We have made the rules that underlie the measurements of rule related behaviour. We are the ones who formulate, publish and understand the scientific articles that describe brain structure as abnormal, or normal but delayed. A child’s developing brain, even a child that can fit the ADHD description, can also be described as miraculous, mysterious and uniquely perfect. Through our empowered position as adults we have been active in shaping the truth about children, maybe too often looking at them as imperfect grown ups. By focusing on parts of observed reality, in this case by largely operationalizing pathology as behaviour unwanted by teachers and parents in a classroom setting, the truth about restlessness and children in the clinical-political setting has largely become that of ADHD. We as adults, clinicians and experts (subjects with power) act as moral agents on a quest to “help” and “repair” children that the clinical-political authorities regard as unhealthy or problematic.

Through writing this text I have discovered that I am not criticising the biomedical or biopsychosocial model as such. When applied correctly and within its limits, it provides an excellent platform from which natural phenomena can be described and understood. Through advances in technology we can now observe and measure natural forces inside the human being. This creates new dilemmas regarding the division of nature as object and humans as subjects. We can measure neural activity and dopamine levels, but are we closer to understanding why children are restless? It is relevant and interesting that the development of some brain structures seem to follow a different trail in several children that fit the ADHD description. But what does it tell us? By using the biomedical/biopsychosocial model as a framework, we are in the danger of isolating aspects of the child, and reducing the truth to what is the shared understanding of certain authorities. This reduction enables us as adults and as a society to reduce our confusion, our shame and our responsibility. In my opinion describing these invisible forces should be a central part of the research that is conducted within the health field in general, and in the field of ADHD in particular. Donald Winnicott (1964) stated half a century ago: “ I once risked the remark, ‘There is no such thing as a baby’– meaning that if you set out to describe a baby, you will find you are describing a baby and someone. A baby cannot exist alone, but is essentially part of a relationship” (p. 88). If this is true, measuring "the baby" and presenting it as something true that pertains to the baby as an individual might not be the way to go about it. Yet, in the case of the restless child, this practice is mainstream. If I could wish for a different starting point when it comes to understanding and handling children’s restlessness, it would be this: there is no such thing as a child with ADHD.

Implications for Research and Practice

In this essay, I have tried to outline two approaches to understanding and handling children’s restlessness. As mentioned in the beginning of the essay, my aim has not been to judge one as better than the other. If anything, I have tried to show how the two approaches can provide us with different knowledge about the same phenomenon. How to best understand and handle children’s restlessness has been, and still is, the object of heated discussion. I think a central problem is that a biomedical finding is taken as evidence against restlessness being a cultural and historical phenomenon, and that critical approaches to ADHD is seen as an effort to undermine biomedical research. If we could regard findings provided by the two traditions outlined in this text as findings on different levels of analysis and use them to comment and compliment each other, I think research on children’s restlessness would be richer and perhaps more truthful than it is today.

Current mainstream research on this topic can best be described as research on ADHD. This research has provided us with a lot of knowledge on behaviour as observed and judged by adults close to the child. Research on medications, brain structure and activity, risk regarding criminal behaviour and drug abuse all depart from and relate to these subjective measurements. Still, the research literature on ADHD is written and read as objective measurements of the child. This discrepancy between a research goal (a true understanding of children’s restlessness) and research method (invested adults’ subjective observations and judgements about the child’s ambiguous and emotionally laden behaviour) and the lack of reflections about this discrepancy is what led me to write this text. Future research should explore this discrepancy and relate to it throughout the research process, from study design to description of findings.

Music therapists and others working with a child that is described as having an emotional or behavioural disorder should investigate whether there is a discrepancy between goal and method. Is the goal to bring children closer to who or where they want to be? Is the goal to help or force the child to fit in? These two goals imply two different approaches and two different ways of being with the child. The ethics of treating the child if the problem can be described as a relational, family based, or rooted in the institution and/or political system surrounding the child, should be taken into consideration.

The fact that different levels of analysis can provide us with different knowledge has enormous implications. If clinicians, researchers, political authorities, parents and kindergarten personnel all apply the same perspective on children’s restlessness, the truth that is constructed is in danger of becoming one-dimensional. Knowledge provided by other levels of analysis, in this text exemplified as a tradition pertaining to historical ontology, can be perceived as threatening and might be left unrecognised, marginalised or suppressed.

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