SummaryADHD and reificationThis thesis starts with a quote from eleven-year-old Sylvia, who thinks ADHD “is like a cancer (...) but you’re not going to die from it”. ADHD is no disease like cancer, but a con- cept from the Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in its fifth edition. The DSM-5 defines ADHD with -partly overlapping- behavioral criteria such as “often has trouble waiting his/her turn” and “often interrupts or intrudes on others”. Thinking that the definitions in the DSM are concrete illnesses, such as Sylvia does, is acknowledged as a problematic phenomenon called reification. The most well- known mechanism of reification is called the “nominal fallacy”: naming behaviors carries the risk of thinking we have thereby explained them. In fact, constructs like ADHD only name these behaviors. However, confusing naming and explaining is just one of the mechanisms of reification. This thesis aims to answer the questions: how is ADHD reified in written discourse, and how often do these identified mechanisms of reification occur?Generalization and other mechanisms of reificationBesides confusing naming and explaining, generalizations can also lead to reification; particularly group-to-individual generalization. For instance, the authors of a large meta-analysis of brain-anatomy compared groups classified with ADHD with groups of “normal” individuals. They stated in their paper in 2017: “We confirm, with high-pow- ered analysis, that patients with ADHD have altered brains; therefore ADHD is a disorder of the brain. This message is clear for clinicians to convey to parents and patients”. The find- ings were in fact mere averages, and the case and control groups largely overlap. The authors wrongly suggest that all those classified with ADHD have different (smaller) brain parts. In fact, many with an ADHD classification have larger than average brain parts while many without an ADHD classification have brain parts that are smaller than average.There are many other reifying mechanisms. For instance, when reporting about case-control studies of neurophysiology and neurochemistry, researchers often select brain-images of the extremes from both samples. These images are then often pre- sented as allegedly representative of the brain activity and neurochemistry of a whole population of those classified with ADHD. In reality, case and control groups again show much overlap. Furthermore, brain activity differs strongly across people, regardless of an ADHD classification. Also within persons neurochemistry and physiology are not consistent through time.Medical jargon, for instance words like “symptom”, can also reify ADHD as the term implies that behaviors like interrupting others are the result of a disease or disorder. Speaking of criteria for ADHD is a more appropriate term, as this word refers to a stand- ard on which a decision may be based, and the word does not suggest the behaviors are caused by an innate problem.Similarly, by using metaphors, such as comparing ADHD to a meat-cleaver that splits the brains of those with ADHD, agency is ascribed to the ADHD-concept as a real entity that does damage to the human brain. This reifies ADHD and such a metaphor may also create fear and stigma. Another reifying mechanism is the suggestion of causality when only correlation is empirically proven. It is often suggested that ADHD can cause academic failure and maladaptation to the point of delinquency. However, as for instance child maltreatment can cause problems of inattention and restless behaviors –for which the ADHD-con- cept merely provides a name- both ADHD and delinquency can be confounded by adverse circumstances.ADHD can also be reified by “textual silence”: omitting important information that shows the construct does not represent a steady and reliable disorder. For instance: birth-month studies reveal that normal, age-related behaviors tend to be “diagnosed” with ADHD and medically treated. Not mentioning this important information can leave the perception of ADHD as a concrete entity intact.How often do these reifying mechanisms occur?Using a sample of 43 academic textbooks used at universities in the Netherlands, this thesis aims to quantify the occurrence of reifying mechanisms such as textual silence in relation to genetics. For instance, roughly half of the textbooks mention 60-80% heritability estimates of twin/family and adoption studies that compare behaviors of relatives to estimate the influence of genetics. At the same time, these textbooks omit that the more precise molecular genetic studies reveal a low direct influence of genes of about 5%. Only a quarter of the textbooks mention the contrasting findings, which reveal that twin/family and adoption studies cannot separate genetic from environ- mental influences very well. A quarter of the textbooks do contrast the high outcome of twin/family/adoption studies and the limited effects according to molecular studies. This “missing heritability problem”, as it is known, is not mentioned explicitly as such.Generalizations are also a common mechanism of reification. Of 36 textbooks that discuss brain anatomy in relation to ADHD, 21 (58%) do not mention that empirical outcomes are mere average findings that have little bearing on individuals classified as having ADHD. Fifteen chapters on ADHD did place such findings in perspective, by referring, for instance, to the fact that such findings are mere group outcomes. Only 3 of those, however, clearly mentioned that those with ADHD do not necessarily have different brains, or that “normal” controls can also have different/smaller brains. Only one chapter on ADHD mentioned both: no single deficit is necessary or sufficient to explain all cases of ADHD. Additionally, none of the chapters mentioned sampling bias due to the use of “supernormal” controls on the one hand and “refined phenotypes”, rigorously screened ADHD cases, on the other.Background of reificationReification is a concept from scholars filed under the sociological school of “Conflict Theory” that sees the quest for power as a foundation of social relationships. Framing ADHD as a hardwired genetic and brain-based illness can privilege medical profes- sionals. When described by the catch-all concept that ADHD is at risk of becoming, everyday behaviors like interrupting others are framed as medical problems and not as a normal part of socialization. As a result, non-medical professionals, like teachers, may feel inept.Conflict Theory also addresses the monetary basis at the heart of the production of knowledge. Differences in the availability of monetary resources (e.g. from pharma- ceutical companies) might further tilt the power balance, such as by financing dedicated companies that help to prepare presentations, write scientific papers (ghost writing) and recruit opinion leaders. However, a conflict theoretical perspective seems limited to explain the passion of some of those who believe strongly in the biological approach. Financial incentives might not necessarily have preceded this enthusiasm, and many researchers do not receive industry funding.Philosophers such as Trudy Dehue and Charles Taylor bring an additional, more “functional” perspective to explain our contemporary eagerness to reify concepts such as ADHD. Dehue, for instance, states that as biological explanations of behavior, concepts like ADHD are functional by providing an excuse for the person one is, par- ticularly if one fails to meet the neo-liberal norm of being self-reliant and successful. Taylor traced one of the roots of this neo-liberal ideology, which he calls “disengaged reason” all the way back to the likes of Plato and Descartes. Disengaged reason means that humans can find true beliefs about the world when being disengaged from it and being disengaged from one’s emotions. This ideal is represented well by Descartes’ “I think therefore I am”.The success of science, partly founded on this notion of disengaged reason, eroded the influence of the church. The influence of the normative framework that the church provided eroded as well and created a void that, from a functional perspective, needed to be filled. Psychiatry rose to the occasion to help fill this void with its’ own psychiatric bible –as the DSM is often called. Perhaps unsurprisingly, psychiatry, as the new sci- ence-based norm-setting institution, is engrained with this ideal of disengaged reason.ADHD and the ideal of disengaged reasonI argue that the rationalistic norms strongly surface in the ADHD-concept. We expect children to control their impulses, be silent in their play and await their turn. Also in the way we study human behavior and “diagnose” children as having a neurodevelopmental disorder - based on splicing their behaviors and counting “symptoms”, we lean towards disengaged reason. A diagnosis does not require asking for a child’s motives for his/ her behavior. So, both the norms we bestow upon children via the ADHD-concept, and the norms we bestow upon ourselves by the way we try to classify them without the need to involve children themselves to give meaning to their behaviour, reflect the dominance of this disengaged reason in my view.ImplicationsSo, possibly we reify and fail to be objective to the disappointing outcomes of empirical studies with the ADHD construct due to our own narrow (institutional) interests. Or, possibly we have historically embedded high hopes for the success of psychiatry’s nor- mative framework. Either way, such interests or high hopes do not necessarily overlap with the interests of the child, which should be our primary concern. So finally, some political and practical implications are offered to safeguard the child’s best interest.Future studies based on this thesis could estimate the prevalence of reifying mech- anisms and could also include different domains of discourse besides textbooks. Ad- ditionally, institutional dependency on constructs from the DSM should be examined critically. For instance, scientific funding agencies should consider the pros and many limitations of the study into the highly reified classifications and consider alternative classifications, such as using Research Domain Criteria. Another possible approach to research and providing care is using a more tentative, back-and fourth, normalizing approach such as stepped diagnosis and stepped care. From a political point of view the high interdependence of science and commercially vested interest calls for reconsider- ation of how we can use financial resources. One longstanding idea is to concentrate these resources in a fund with representatives from different branches of industry, science and government.Finally, medically framing children’s restlessness that is associated with a plethora of problems -such as the contemporary schooling system, divorce, poverty, trauma and loss- makes it easy to forget such larger issues. To avoid this, we should seek refuge in the institute that aims to protect the child’s autonomy, agency and safety in the face of the many individual and collective challenges that our children are confronted with: The Convention on the Rights of the Child. This institution should also safeguard that our current healthcare system with its classifications is part of the solution and not part of the problem.
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Studies of brain size of children classified with ADHD appear to reveal smaller brains when compared to ‘normal’ children. Yet, what does this mean? Even with the use of rigorously screened case and control groups, these studies show only small, average group differences between children with and without an ADHD classification. However, academic textbooks used in the Netherlands often portray individual children with an ADHD classification as having a different, malfunctioning brain that necessitates medical intervention. This conceptualisation of ADHD might serve professional interests, but not necessarily the interests of children.
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Despite the consequences for women’s health, a repeat cesarean section (CS) birth after a previous CS is common in Western countries. Vaginal Birth After Cesarean (VBAC) is recommended for most women, yet VBAC rates are decreasing and vary across maternity organizations and countries. We investigated women’s views on factors of importance for improving the rate of VBAC in countries where VBAC rates are high. We interviewed 22 women who had experienced VBAC in Finland, the Netherlands, and Sweden. We used content analysis, which revealed five categories: receiving information from supportive clinicians, receiving professional support from a calm and confident midwife/obstetrician during childbirth, knowing the advantages of VBAC, letting go of the previous childbirth in preparation for the new birth, and viewing VBAC as the first alternative for all involved when no complications are present. These findings reflect not only women’s needs but also sociocultural factors influencing their views on VBAC.
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At the beginning of the twenty first century obesity entered Dutch maternity care as a ‘new illness’ challenging maternity care professionals in providing optimal care for women with higher BMI’s. International research revealed that obese women had more perinatal problems than normal weight women. However, the effect of higher BMIs on perinatal outcomes had never been studied in women eligible for midwife-led primary care at the outset of their pregnancy. In the context of the Dutch maternity care system, it was not clear if obesity should be treated as a high-risk situation always requiring obstetrician-led care or as a condition that may lead to problems that could be detected in a timely manner in midwife-led care using the usual risk assessment tools. With the increased attention on obesity in maternity care there was also increased interest in GWG. Regarding GWG in the Netherlands, the effect of insufficient or excessive GWG on perinatal outcomes had never been studied and there were no validated guidelines for GWG. A midwife’s care for the individual woman in the context of the Dutch maternity care system - characterised by ‘midwife-led care if possible, obstetrician-led care if needed’ - is hampered by the lack of national multidisciplinary consensus regarding obesity and weight gain. Obesity has not yet been included in the OIL and local protocols contain varying recommendations. To enable sound clinical decisions and to offer optimal individual care for pregnant women in the Netherlands more insights in weight and weight gain in relation to perinatal outcomes are required. With this thesis the author intends to contribute to the body of knowledge on weight and weight gain to enhance optimal midwife-led primary care for the individual woman and to guide midwives’ clinical decision-making.
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Nieuwe wetgeving voor jeugdzorg in Nederland heeft geleid tot de implementatie van teams, die geïntegreerde eerstelijns jeugdzorg bieden. Belangrijke doelen van de nieuwe Jeugdwet waren meer geïntegreerde, tijdige zorg en minder gebruik van intensieve vormen van zorg. Het doel van dit onderzoek was het bestuderen van veranderingen in het gebruik van jeugdzorg in de tijd en de rol van nieuw ingevoerde wijkgerichte ondersteuningsteams hierin. Patronen van jeugdzorggebruik veranderden naar meer lokaal geleverde primaire jeugdzorg, iets minder gespecialiseerde en iets meer residentiële jeugdzorg. Bovendien nam het jeugdzorggebruik onder jongere kinderen toe in de tijd. Deze trends komen deels overeen met de trends die de Jeugdwet beoogt. Er is weinig bewijs gevonden voor de rol van specifieke teamkenmerken op veranderingen in jeugdzorggebruik in de tijd.
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The professional growth of midwives, essential for optimizing midwifery leadership globally, can be enhanced through twinning collaborations. How twinning promotes growth is unclear. This case study explores how professional growth is affected by cultural differences between twins. We used a longitudinal qualitative design including data from open-ended questionnaires and focus groups. These data were analyzed using a content analysis. Our findings show that cultural differences were capable of both hindering and facilitating professional growth. Within the complex dynamics of twinning, professional growth was facilitated by twins’ preparedness to bridge cultural differences. Common goals positively influenced this process. Friction was more likely, and professional growth was hindered, when midwives were unprepared to bridge cultural differences. To optimize professional growth through twinning, we recommend a clear focus on common goals and consideration of the interaction between the length of a project and the extent of the cultural differences between twins.
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Objective To synthesise qualitative studies on women’s psychological experiences of physiological childbirth. Design Meta-synthesis. Methods Studies exploring women’s psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases: MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. We contacted the key authors searched reference lists of the collected articles. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography. Results Eight studies involving 94 women were included. Three third order interpretations were identified: ‘maintaining self-confidence in early labour’, ‘withdrawing within as labour intensifies’ and ‘the uniqueness of the birth experience’. Using the first, second and third order interpretations, a line of argument developed that demonstrated ‘the empowering journey of giving birth’ encompassing the various emotions, thoughts and behaviours that women experience during birth. Conclusion Giving birth physiologically is an intense and transformative psychological experience that generates a sense of empowerment. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary. Healthcare professionals need to take cognisance of the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary.
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Aim: Participation of adolescents with autism spectrum disorder hardly occurs in settings outside of home and school. Little is known about how their participation is influenced by environmental factors. This study explored how and why adolescents with autism spectrum disorder perceive aspects of their environment as facilitators or barriers to their participation outside of home and school. Method: This explanatory case study explored the participation experiences of adolescents with autism spectrum disorder (15–21 years) from Zurich and surroundings with in-depth interviews and photo-elicitation, using photos made by the participants during activities outside of home and school. Data was analysed with a 7-step procedure. Result: The presence of two main themes seemed necessary to facilitate participation outside of home and school: “environmental prerequisites to attend activities”, which consists of five subthemes, such as “the company of trusted persons” and “the provision of knowledge and information”, and “social interchange and engagement”, which consists of three subthemes and describes how actual involvement can be supported. Conclusion: Our findings highlight the influence of trusted persons on adolescents with autism spectrum disorder, and the need to extend the support network for these adolescents to other individuals, services and society so that their participation in activities can be encouraged.
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Aim: Participation of adolescents with autism spectrum disorder hardly occurs in settings outside of home and school. Little is known about how their participation is influenced by environmental factors. This study explored how and why adolescents with autism spectrum disorder perceive aspects of their environment as facilitators or barriers to their participation outside of home and school. Method: This explanatory case study explored the participation experiences of adolescents with autism spectrum disorder (15–21 years) from Zurich and surroundings with in-depth interviews and photo-elicitation, using photos made by the participants during activities outside of home and school. Data was analysed with a 7-step procedure. Result: The presence of two main themes seemed necessary to facilitate participation outside of home and school: “environmental prerequisites to attend activities”, which consists of five subthemes, such as “the company of trusted persons” and “the provision of knowledge and information”, and “social interchange and engagement”, which consists of three subthemes and describes how actual involvement can be supported. Conclusion: Our findings highlight the influence of trusted persons on adolescents with autism spectrum disorder, and the need to extend the support network for these adolescents to other individuals, services and society so that their participation in activities can be encouraged.
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