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In 2010, ­ under the headline “Hiperatividade é a Perturbação Mais Diagnosticada ” (“Hyperactivity is the Most Diagnosed Disorder”), the president of the Portuguese association of child psychiatry said in an interview that attention deficit–­ hyperactivity disorder (ADHD) is, in his experience, the most common diagnosis made in school-­ age ­ children and adolescents (Carreira 2010). However , he also noted that ­ there are no exact or reliable prevalence data on this complex, variable diagnosis in Portugal; this caveat has been underlined by other clinicians as well (e.g., Rodrigues and Nuno Antunes 2014; for a debate, see Filipe 2015). This discrepancy is but one vis­ i­ ble aspect of the shaping of this diagnosis in Portugal, where it is undergoing an ambiguous pro­ cess of definition and validation in which ADHD is recognized as a prevalent yet uncharted diagnosis. In this chapter, I examine how ADHD emerged and is currently being defined in this country, and I highlight some of the challenges that ­ those dealing with this diagnosis ­ will face in the near ­ future, including soaring levels of psychostimulant drug prescription and consumption. In so ­ doing, I throw fresh light on the dynamics, contingencies, and ambiguities that characterize the case of ADHD in the Portuguese context seen as both a relevant case study, on its own terms, and a case in point for a shifting configuration of the diagnosis in the Eu­ ro­ pean and global contexts. 7 The Emergence and Shaping of ADHD in Portugal Ambiguities of a Diagnosis “in the Making” Angela M. Filipe The Emergence and Shaping of ADHD in Portugal   119 Inspired by the social studies of diagnosis and medicine (Blaxter 1978; Mol 2002; Rosenberg 2006; for a recent overview, see Jutel and Nettleton 2011), I look at the diagnosis of ADHD not as a static medical category but as a dynamic and socially situated pro­ cess that varies in time and across contexts (Filipe 2016) and whose contours are, in the case of Portugal, distinctively intermediate. The term “intermediate” can be applied ­here to emphasize the ongoing configuration of diagnosis (i.e., a pro­ cess “in the making”) and the par­ tic­ u­ lar economic and po­liti­cal position that this country has historically occupied in Eu­rope and in the global system, as proposed by the Portuguese sociologist Boaventura de Sousa Santos (1985). From this perspective, I draw attention to the ways in which the diagnosis of ADHD in Portugal intersects and is ­ shaped by global data and diagnostic standards, local practices and contingencies, public debates and available models of care, and a unique social and po­ liti­ cal history. Empirically, I draw on a mix of documentary analy­ sis of the medical lit­ er­ a­ ture and public statements on ADHD in Portugal, archival research on the history of child ­ mental health (see Filipe 2014), and an ethnographic case study of a developmental clinic specializing in this diagnosis that I conducted as part of my doctoral research. This study included observing medical consultations and interviewing the developmental clinicians who ­ were involved in the assessment and treatment of ADHD. In order to update this study, which involved fieldwork mainly between 2011 and 2013, I have included documentary analy­ sis of more recent publications on ADHD (2013–16) and personal communication with the founder of the main ADHD advocacy group in the country.1 First, I look briefly at the history of child ­ mental health and the emergence of the ADHD diagnosis in the 1970s and 1980s expert lit­ er­ a­ ture, and at the translation and popularization of the term hiperactividade (hyperactivity) in the Portuguese context. Second, I draw attention to the establishment of ADHD as a clinically relevant and treatable condition in the late 1990s, which was accompanied by some contention and the creation of an advocacy group. Third, I look at what I term ­ here the two main models of care in the case of ADHD—­ the “medical-­ pharmacological” and the “psychopedagogic” models—­ which may provide complementary responses to the diagnosis, even though they are faced with institutional constraints as well as ethical and social challenges. ­ These challenges include, but are not limited to, the overdiagnosis of ADHD and the overprescription of psychostimulants. Fourth, I show how the diagnosis of ADHD has been managed and framed in the past de­ cade, despite the lack of epidemiological data and clinical guidelines. I explore how the diagnosis brought together vari­ ous 120   Global Perspectives on ADHD forms of assessment protocols, medical expertise, and emerging approaches and...


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