Neurobiological accounts
The underlying causes of ADHD are not fully understood. However, scientific research continues to seek biological and genetic explanations (Remschmidt, 2005). Cooper (2001, 2008) suggests that research has typically concentrated on three areas of theoretical exploration: cognitive, neurobiological and genetic. In relation to cognitive factors, research which has focused on the impulsivity
‘characteristic’ of ADHD, has identified problems in four major areas of ‘executive functions’ (Bradley, 1997, cited in Cooper, 2001). These executive functions affect cognitive performance in areas relating to working memory, internalised speech, motivational appraisal (a system which regulates decision making based on the association of emotion and behavioural outcomes) and behavioural synthesis, an
ability to modify future behaviour based on assessment of previous behaviour outcomes (Cooper, 2001). These cognitive dysfunctions are understood to have an underlying neurobiological basis. Neurobiological explanations of ADHD include a malfunction of the central nervous system (Kean, 2005) and a dysfunction in the dopamine transmitter system, which interferes with
concentration and attention (Singh, 2008a). Recent interest in neuroimaging, has implicated the involvement of frontostrictal abnormalities in the manifestation of ADHD type behaviour. Arguments that support a genetic basis for ADHD are grounded in research findings that claim there is a greater incidence of ADHD in identical twins than in non-identical twins, and among children and parents who are biologically related, than between children and parents who are not biologically related (Cooper, 2001, 2008; Remschmidt, 2005). Genetic explanations regularly appear within media representations of ADHD (Horton-Salway, 2011, 2012; Schmitz, Filippone and Edelman, 2003). Within the UK media, it is fathers, in particular, who are implicated in the genetic explanation for ADHD, which, as Horton-Salway (2012:7) suggests, ‘has the effect of re-producing ADHD as a male phenomenon by implication, foregrounding boys as the natural recipients of
inherited ADHD and fathers as passing it on.’
Biomedical versus social: A polarised debate
Biological and genetic explanations for ADHD have been subject to much scrutiny and criticism. Singh (2002b) and Cooper (2001) describe the influence of the anti- psychiatry movement in critiquing the validity of such categories as ADHD. In particular, they single out the work of Thomas Szasz, who suggested that mental illness is a metaphor (because there is no demonstrable biological pathology) for culturally disapproved thoughts, feelings and behaviours’ (Singh, 2002b:362). Certainly, ADHD as a medical category remains controversial while there continues to be an absence of a valid clinical test for the condition, and ADHD
symptoms, it is argued, remain barely distinguishable from normal childhood behaviours (Singh, 2008a, Timimi and Taylor, 2004).
Singh suggests the anti-psychiatry movement was pivotal in informing intellectual and theoretical positions that aligned state mechanisms of social control with the medicalization of deviant behaviour and, in turn, hyperactivity (see Conrad, 2006). As Conrad (2006:4) states, ‘medicine always functioned as an agent of social control, especially in attempting to normalise illness and return people to a functioning capacity in society’. This view is endorsed by child and adolescent psychiatrist Professor Sami Timimi, who suggests that increasing rates of
diagnosis of ADHD reflect changes in society’s tolerance for behaviour that does not conform to social or developmental norms (Timimi and Taylor, 2004). Timimi, in dialogue with Taylor, another child psychiatrist, who holds different views, queries whether ADHD is a cultural construct rather than a medical reality (Timimi and Taylor, 2004). He cites the absence of a medical test for ADHD, cultural differences in prevalence rates, high levels of co-morbidity of the disorder, and the relatively small sample sizes used in neuroimaging studies as reasons to doubt the veracity of ADHD as a biomedical entity. Rather, he considers external factors such as family breakdown, frenetic family life, school pressure, the breakdown of moral authority within the family, and even the competitive nature of the market economy as being detrimental to children’s mental health (Timimi and Taylor, 2004).
As mentioned earlier, since the 1940s and 1950s there has been scepticism towards the neurological approach to ADHD. As well as the social factors
considered by Timimi, other social explanations offered as a way of understanding the causes of ADHD include the over stimulation of modern life and the
information through television and gaming (Rafalovich, 2008; DeGrandpre, 2000). Since the 1970s, literature linking behaviour and diet has received popular
attention. In particular, reactions to artificial food additives (Rafalovich, 2008; Feingold, 1974) are said to produce hyperactivity in children. As Horton-Salway (2011:544) identifies, the ‘toxic generation’ is a common media representation of children and young people with an ADHD diagnosis.
In critiquing the biomedical model, it can be tempting to enter into a polarised debate about whether ADHD is a mythical or real category, and to take up the extreme relativist position that all medical categories, including ADHD, have no medical truth but are wholly socially created. Whilst expressing some reservations about the limitations of the biomedical focus on internal cognitive structures and its exclusion of individual and social context, Singh (2002b) and Cooper (2001, 2008) caution against dismissing biomedical explanations. Indeed, they argue that the existence of so much neurobiological evidence supports, at least, a partial, biomedical understanding of ADHD.
However, despite significant scientific interest and activity taking place to identify biological and genetic causes of ADHD, a solely biomedical approach to this highly complex disorder is also considered over simplistic. Increasingly, evidence
suggests that genetic and environmental factors are both implicated in the production of mental health disorders such as ADHD (Singh, 2008a; Sonuga- Barke, 2005).
The biopsychosocial approach
Many ADHD researchers (Cooper, 2001, 2008; Gray, 2008; Sonuga-Barke, 2005; Singh, 2002b) call for a biopsychosocial approach, which integrates biological and socio-cultural aspects. Cooper’s (2008) call for such an approach is premised on research that implicates a child’s environment. In particular, he cites studies (e.g.
Nigg and Hinshaw, 1998) that suggest biological predispositions to ADHD are mediated by social and environmental factors such as parenting skills, disorderly home environments, marital or relationship discord maternal health and paternal personality factors. In positing a biopsychosocial approach, Cooper (2001, 2008) and Singh (2002b) call for a multimodal approach to treatment which incorporates medication with other forms of intervention, intervention that explicitly deals with environmental factors (although Singh is more reserved in her endorsement of treatment with stimulant medication). As Gray outlines in her thesis (2008), the biopsychosocial approach to ADHD is one that has been taken up by current health policy frameworks. NICE (2009) advocates a multimodal approach to treatment incorporating both pharmaceutical and psychological treatments.
However, despite increasing calls for a multimodal approach, medication remains a significant method in the treatment of ADHD and contributes greatly to the controversy surrounding it.