Social construct theory of ADHD

ADHD as a social construct

Psychiatrists Peter Breggin and Sami Timimi oppose pathologizing the symptoms of ADHD. Sami Timimi, who is an NHS child and adolescent psychiatrist, argues that ADHD is not an objective 'disorder' but that western society creates stress on families which in turn suggests environmental causes for children expressing the symptoms of ADHD. They also believe that parents who feel they have failed in their parenting responsibilities can use the ADHD label to absolve guilt and self-blame.

A common argument against the medical model of ADHD asserts that while the traits that define ADHD exist and may be measurable, they lie within the spectrum of normal healthy human behaviour and are not dysfunctional. However, by definition, in order to diagnose with a mental disorder, symptoms must be interpreted as causing a person distress / espec. maladaptive. In America, the Diagnostic and Statistical Manual (DSM-IV) requires that "some impairment from the symptoms is present in two or more settings" and that "there must be clear evidence of significant impairment in social, school, or work functioning" for a diagnosis of ADHD to be made.

In this view, in societies where passivity and order are highly valued, those on the active end of the active-passive spectrum may be seen as 'problems'. Medically defining their behaviour (by giving labels such as ADHD and ADD) serves the purpose of removing blame from those 'causing the problem'. Controversy over the social constructionist view comes from a number of studies that cite significant psychological and social differences between those diagnosed with the disorder, and those who are not. However, the specific reasons for these differences are not certain, and this does not suggest anything other than a difference in behavior. Studies have also shown neurological differences, but whether this signifies an effect rather than a cause is unknown. Such differences could also be attributed the drugs commonly prescribed to people with this disorder. Studies have also been able to differentiate ADHD from other psychiatric disorders in its symptoms, associated features, life course, and comorbidity.

Gerald Coles, an educational psychologist and formerly an associate professor of clinical psychiatry at Robert Wood Johnson Medical School and the University of Rochester who has written extensively on literacy and learning disabilities, asserts that there are partisan agendas behind the educational policy-makers and that the scientific research that they use to support their arguments regarding the teaching of literacy are flawed. These include the idea that there are neurological explanations for learning disabilities. Gerald Coles argues that school failure must be viewed and treated in the context of both the learning environment and the child's individual abilities, behavior, family life, and social relationships. He then presents a new model of learning problems, in which family and school environments are the major determinants of academic success. In this "interactive" paradigm, the attitudes and methods of education are more important than inherent strengths or deficits of the individual child.

Questioning the pathophysiological and genetic basis of ADHD

Some social constructionist theories of ADHD reject the dominant medical opinion that ADHD has a distinct pathophysiology and genetic components. The 'symptoms' of ADHD also happen to be morally questionable attributes, this is why the symptoms are described as 'inappropriate'. Many social constructionists trenchantly question deterministic views of behaviour, such as those views sometimes put forth within behavioural/abnormal psychology and the biological sciences.

Currently, the pathophysiology of ADHD is unclear; although research has found evidence of differences in the brain between ADHD and non-ADHD patients. Critics, such as Jonathan Leo and David Cohen who reject the characterization of ADHD as a disorder, contend that the controls for stimulant medication usage were inadequate in some lobar volumetric studies which makes it impossible to determine whether ADHD itself or psychotropic medication used to treat ADHD is responsible for decreased thickness observed in certain brain regions. They believe many neuroimaging studies are oversimplified in both popular and scientific discourse and given undue weight despite deficiencies in experimental methodology.

From a biological/genetic point of view, ADHD is said to be highly heritable and twin studies suggest genetics are a factor in about 75% of ADHD cases,. However, the genetic connection is questionable. Dr. Joseph Glenmullen states, "no claim of a gene for a psychiatric condition has stood the test of time, in spite of popular misinformation. Although many theories exist, there is no definitive biological, neurological, or genetic etiology for 'mental illness'." His critics argue that ADHD is a heterogeneous disorder caused by a complex interaction of genetic and environmental factors and thus cannot be modeled accurately using the single gene theory. Authors of a review of ADHD etiology have noted: "Although several genome-wide searches have identified chromosomal regions that are predicted to contain genes that contribute to ADHD susceptibility, to date no single gene with a major contribution to ADHD has been identified."

Alternatives to medication

Social critics question if environmental changes should be the main line of treatment for those with a diagnosis of ADHD, instead of the medical model which predominantly uses medication and to a lesser extent, behavior modification. Critics believe schools and the health system force children to conform to a narrow, predefined standard of child development. These critics believe that these institutions are propagating the dangerous viewpoint that children with ADHD are maladaptive and disabled simply because they do not conform to a socially constructed norm. Moreover, the argument against ADHD asserts that changing the child through medication regimes may cheat them of certain unique and positive personal characteristics that in turn may limit our collective future.

Sudbury model of democratic education schools' alternative

Some critics of the concept of learning disabilities and of special education take the position that every child has a different learning style and pace and that each child is unique, not only capable of learning but also capable of succeeding. These critics assert that applying the medical model of problem-solving to individual children who are pupils in the school system, and labeling these children as disabled, systematically prevents the improvement of the current educational system.

Describing current instructional methods as homogenization and lockstep standardization, alternative approaches are proposed, such as the Sudbury schools' democratic education approach in which children, by enjoying personal freedom thus encouraged to exercise personal responsibility for their actions, learn at their own pace rather than following a chronologically-based curriculum. Proponents of unschooling have also claimed that children raised in this method do not suffer from learning disabilities.

Criticism

Critics of the social constructionist view contend that it presents no hard evidence in support of its own position. Proponents of this view disagree that criteria for falsifiability are lacking. One way, for example, is to show that there exists an objective characteristic possessed by virtually all diagnosed individuals which does not exist in any non-diagnosed individual. However, because diagnosis of psychiatric disorders is based on opinion, this would be difficult to prove. Also, whether this would demonstrate any actual abnormality as opposed to the labeling of certain behaviors is unknown. Current candidates for falsifiability include PET scans, genes, neuroanatomical differences, and life outcomes. However, none of these have been shown to be precise predictors of a diagnosis or lack thereof. Also, as previously stated, neurological differences do not indicate a cause, nor do genes indicate a direct impact. Such criteria are generally fulfilled by well-understood medical diseases.

Critics of this view also assert that it is not consistent with known findings. For instance, they claim that ADHD is as frequent in Japan and China as in the US, yet in such societies (which supposedly favor child obedience and passivity) one would expect higher rates of ADHD if this theory were correct. However, this is also disputed on the grounds that more aggressively obedient societies may suppress 'symptoms' of rebellion or 'ADHD'. The style in which individuals of these nationalities interact in their home countries, which is typically much more reserved and serious than in the United States, seems to suggest this. However, there is no solid proof of this assertion. Additionally, rates of medical diagnoses in China cannot be a reliable indicator of ADHD prevalence, especially for such non-life-threatening disorders as ADHD, due to the large peasant population in that country who cannot easily seek the services of a trained child psychologist. Timimi's view has been seriously criticized by Russell Barkley and numerous experts in Child and Family Psychology Review (2005). In any case, it has been shown that Chinese and Indonesian clinicians give significantly higher scores for hyperactive-disruptive behaviors than did their Japanese and American colleagues when evaluating the same group of children. Significant differences in the prevalence of ADHD across different countries have been reported, however. Timimi himself cites a range of prevalence that goes from 0.5% to 26% as support for his theory.