Attention Deficit Hyperactivity Disorder (ADHD) has been one of the most debated medical categories affecting children in different parts of the globe. Increasingly this is recognised as a lifelong disorder that can continue into adulthood, a diagnosis that has been reflected by the incorporation of adult criteria into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders , DSM 5 (APA 2013). The diagnosis and medical treatment of ADHD for both children and adults is rising and this is based on the view that ADHD has a biological, neurodevelopmental, genetic basis and, in the UK, it is typically identified by educational and health practitioners who refer to guidelines from the National Institute of Clinical Excellence on three areas of behavioural functioning: impulsivity, hyperactivity and inattention (NICE 2009).
Despite the classification of ADHD as a mental health category, there has been no absolute consensus historically and even currently about its status as a health condition, its meaning and causes which continue to be discussed, researched and debated by scientists and health practitioners, educationalists, multi-media and by members of the public. There have been claims, counterclaims and contributions to knowledge that have spanned over a century, ranging across perspectives of genetics and the biological sciences, to the psychological, social, educational and health sciences. Perspectives on ADHD and its previous labels have been followed up, summarised and debated in the media and further discussed by the public, families and individuals who are personally affected. This has given rise to a range of discourses about ADHD, constructed and contested through a long and chequered history that informs current understanding.
Science, Fact Construction and ‘Ships in Bottles’
To give this a wider context, allow us to unpack one of the theoretical principles informing the analysis in this book. The meaning of any medical category is as much a product of social activity and culture as it is a scientific discovery. According to sociologists who study the production of scientific knowledge , any scientific fact (even an apparently uncontroversial one) can be understood as the product of social constructive practices. This process of fact construction has been demonstrated in studies of the discourse and practices of scientists. For example, Woolgar (1988) described how science came to be regarded as a superior form of knowledge that is set apart from other forms of knowledge and distinguished as a means of discovering objective truths. In the natural sciences essentialists assumed that ‘scientific knowledge is determined by the actual nature of the physical world’ which is out there waiting to be identified (Woolgar 1988: 27). The scientific method of discovery was developed to define science as a neutral and objective process and a superior and reliable form of positivist enquiry. This, they argued, resulted in scientists being able to describe and represent the nature of the real world of objects, events and phenomena. However, a new wave of relativist philosophers and sociologists of scientific knowledge (SSK) challenged these realist and essentialist views of the world and argued that representations of reality are underpinned by culture and produced through social practices. The task that SSK set for itself was to study and describe how scientific facts were constructed in the discourse and practices of scientists. This approach has queried positivist views of science that treat scientific discovery as a process of describing a reality that exists prior to scientists’ representations.
In his seminal work, Science the Very Idea, Woolgar (1988: 32) pointed out that for any phenomenon it is ‘always possible to nominate an alternative to any specific proposed meaning’. Elaborations of meaning will always refer back to some other meaning that cannot be fully explained without resorting to a further representation and so on. Woolgar contended that where science is concerned, we accept the status of its facts and representations because science has itself convinced us that its models and practices are reliable. As he put this; ‘the perception of reliability is a consequence of its claimed superiority, not a cause’ (Woolgar 1988: 32). Phenomenologist Merleau-Ponty also regarded classical science as ‘a form of perception which loses sight of its origins and believes itself complete’ (Merleau-Ponty 1945/1962). In a circular manner, the idea of science as an objective activity is itself dependent on perceptions that are derived from an ideological framework that supports the idea of positivist science and objective facts (Woolgar 1988). Where error or anomalies might arise in scientific activity and findings, these can be put down to ‘technical difficulties’ or to problems in the work of individual scientists so that these contingencies do not threaten the robustness of science as a whole (Gilbert and Mulkay 1984).
Woolgar’s argument rests on the relativist philosophy criticising the underlying idea that any form of representation could be a reflection of a prior existing reality or an objective truth. Social constructionism is a way to explain the social processes that are involved in the construction of science facts and also the process of scientific change, such as the paradigm changes described by Thomas Kuhn (1962/1970). For example, Woolgar described the process of scientific change in the representation of ‘unusual rapidly pulsating radio sources’ that later became known as ‘pulsars’. He describes how this ‘discovery’ was published in 1968 in Nature by Bell and colleagues at Cambridge University in the UK and, at the time of writing his thesis, Woolgar (1988: 64–65) traced the development of this discovery through its ‘five separate incarnations’, including ‘unusual trace’, ‘interference’ extra-terrestrial activity ‘little green men’, and a ‘pulsating radio source’. Since naming the discovery as a ‘pulsar’, this was then defined as a ‘white dwarf star’, and became re-defined as a ‘a rotating neutra star’, a ‘neutron star with a satellite’, and ‘the plasmic interaction between binary neutron stars’ and so on. Woolgar went on to describe how the existence and character of the discovery had depended, not only on a social network of scientists, but also the culture of science for its meaning. The term ‘discovery’ implied that something was there and had now been found and named, but Woolgar contends that it was not possible to demonstrate this without representations that depend on other representations, and so on, for their meaning. In other words, to be represented in the first place, an object or phenomenon relies on a range of prior ‘discoveries’ and the current state of scientific knowledge that is treated as fact. Collins (1985) had earlier described such facts as appearing ‘like a ship in a bottle’. It is difficult to unpack the processes of construction that built such a ship because it looks as if it has always been there. The existence of pulsars as a named phenomenon (a ‘ship in a bottle’ ) came into being through processes of construction that included observation, theorising, representation, re-presentation and fact construction within the framework and assumptions of positivist science. Woolgar’s approach to understanding this process was to turn to the discourse and rhetoric of science to describe in detail how scientific discourse ‘constitutes the nature of the object it claims to be merely reporting’ (Woolgar 1988: 81).
The Context of Health and Illness
In a health context, a social constructionist analysis can help us to deconstruct the ‘ships in bottles’ of medically recognised categories. For example, coronary heart disease did not appear in official statistics as a cause of death until the 1920s and, as Alan Radley (1994) has observed, the discovery of degeneration in coronary arteries did not by itself make for a medical explanation. Degeneration was attributed to causes that were partly cumulative dietary, physical and lifestyle risk factors and these were theorised as factors having a specific link to congestion of the coronary arteries. Such theories about the part played by lifestyle risks have been further backed up by statistical epidemiological research and the significance of those findings for heart disease are continually being amended, updated, contested and argued about to this day. However, Radley pointed out how the discovery of degeneration in the coronary arteries had to be combined with explanatory theories about lifestyle risk factors to provide the specific diagnosis of coronary heart disease and a warrant for medical interventions. These interventions were pharmaceutical and increasingly social and psychological as discoveries were made about the relationship of lifestyles, diet and environment. How people experience and manage heart disease is dependent on these ideas and facts for its meaning. Congestive heart...