In July, 2012, I attended a talk by the distinguished Chilean biologist, philosopher, and constructivist thinker, Humberto Maturana. He was the keynote speaker at a conference in Monterey, California. I had heard of Maturana's work for many years, and was thrilled at the opportunity to hear him speak in person.
Maturana is best known for his theory of autopoiesis. Simply put, autopoiesis (which literally means self-creation) is the view that the world we inhabit is a world that we as individual biological beings create.
According to Maturana, all reality, including the reality that scientific theories claim to illuminate, is ultimately self-referential, and must therefore take into account the scientists who are doing the illuminating. Our theories of reality always reflect ourselves. We view nature, as it were, through a mirror.
And, according to Maturana, it is more honest to be aware of the self-reflexivity of our theories than not to be. He is, in a sense, a modern incarnation of the ancient sophist Protagoras, who famously said: “man is the measure of all things.”
Of course, many people have accused Maturana of solipsism, which is the view that we can only know what is in our own mind. I think this criticism misses the point. The importance of Maturana’s ideas can be best grasped if we understand his philosophy as an antidote to dogmatism. Maturana’s point of view is humbling--just as he himself comes across as a more humble person than one would expect, considering his fame and importance as a biologist and philosopher. His ideas lead us to question pronouncements of reality that do not take into account the agenda or motives of the people who are doing the pronouncing.
As a therapist, I found Maturana’s radical constructivist point of view very much in keeping with the way I view my work. When a child or young person enters my office, often he bears one or more diagnostic labels. A parent will tell me, “My son’s teacher thinks he has ADHD or ODD” or “my daughter’s pediatrician says she has ADHD.”
However, when you think carefully about it, ADHD is a construction by a panel of psychiatrists who authored a diagnostic manual called the DSM-IV. Like other theoretical constructs, the term "ADHD" attempts to capture the biological reality of the child. Previously, in the second edition of the DSM, the term "Hyperkinetic Reaction to Childhood" attempted to capture childhood behaviors for which we would use the term "ADHD" today. This diagnosis is characterized by restlessness, distractability, overactivity and short attention span. Does Hyperkinetic Reaction to Childhood still exist, even though it is not in the latest edition of the DSM?
But these theoretical constructs are attempts to understand the biological reality--the restlessness, distractability, overactivity, and short attention span. The theories are not the reality itself. The difference between the two diagnostic categories is that hyperkinesis was viewed as the child's reaction to dysfunctional circumstances in his life. It was not viewed as an unchanging aspect of the child's temperament or personality--something with which he was born and which he will have for his lifetime. In fact, many of the diagnoses in the first and second editions of the DSM were normal reactions to abnormal circumstances.
As a diagnosis, ADHD did not appear in the diagnostic manual until fairly recently. And many of the panelists that worked on constructing the diagnosis accepted significant amounts of money and other perks from pharmaceutical companies during the time they were working on the manual. Here’s an important example of how the reflexive quality of theoretical constructions has to be taken into account to fully understand them. The diagnosis of ADHD reflects the motives and mind view of the psychiatrists who authored the DSM-4.
So the answer to the question “Does ADHD exist” really depends on the persepective of the therapist. Personally, I find it more helpful to uncover the underlying social causes of a child’s fidgetiness or distractedness and make targeted changes in the child’s social environment to remove the stressors.
Does the child hear his parents fighting or arguing all the time? Is the child being abused? Does the child have a teacher who is not able to give him the extra attention he needs because she must deal with an overcrowded classroom? Does the child have food allergies or food sensitivities (to additives or colorings, for example) that might be affecting his behavior? Does the child behave and perform better at school when he does not eat sugary foods for breakfast? Does the child have enough physical exercise? Is the child among the youngest in her classroom, and simply less mature than her peers?
I don’t need to adopt a diagnosis of ADHD to help a child. In fact, constructing a diagnosis of ADHD is not especially helpful and it can do harm. The predominent way to treat a child with a diagnosis of ADHD is by stimulant medications, which may, in the long term, be harmful to a child’s brain development. Stimulants may also predispose the child to rely on drugs to solve life’s problems and he may more likely to become a drug addict as a young adult. A recent alarming article in the New York Times chronicles this growing problem among teenagers and young adults.
Moreover, constructing the diagnosis tends to obscure the underlying cause of the child’s distress. The diagnosis doesn’t help me to figure out what I need to do to get kids over their problems. In this respect, "Hyperkinetic Reaction to Childhood" is a much more useful diagnosis for solving the real problems in the child's life.
Constructing a diagnosis of ADHD, however, is very helpful to pharmaceutical companies who want to sell drugs. It is also helpful to DSM panelists who depend on drug companies to fund their research and provide them with other financial perks.
From this we can see the power of Maturana’s constructivist theory as an antidote to dogmatic pronouncements of reality—in particular, the constructions of Big Pharma and Big Psychiatry. If we adopt Maturana’s constructivist point of view, we discover that ADHD is not an objective reality in nature. It is a subective construction that reflects the person or persons who construct it. The ADHD diagnosis expands and contracts, according to the fads of the times. With the upcoming DSM-5, the diagnosis will cast its nets even wider so that even more people will be labeled with ADHD.
It is therefore up to the individual therapist or doctor to decide whether she finds it helpful to frame a child’s problematic behavior as ADHD or whether she can be more helpful to the child if she looks for the stressors in the child's life that lead to inattentiveness, distractability, overactivity and restlessness.
Copyright © Marilyn Wedge, Ph.D.
Read Marilyn Wedge's new book about ADHD in the United States and abroad: A Disease called Childhood.