Two Narratives of ADHD

Is it a brain defect or a response to environmental factors?

Posted Mar 14, 2019

“With our thoughts we make the world.” –Buddha

Presently, there are two co-existing narratives about ADHD as well as other mental disorders. The first is the psychiatric-neurobiological narrative that says ADHD behaviors are caused by a brain defect that must be corrected with medication.

The second narrative says that behaviors called ADHD are caused by environmental stress factors like trauma or adverse childhood experiences (ACE’s), inconsistent parenting, poverty, over-exposure to electronic screens, diet, incorrect classroom placement for the child’s level of maturity, etc.

The adherents of each of the two narratives cling to their points of view tenaciously. Each narrative is based on a fairly rigid belief system, according to the adherent’s education, training, research, and clinical or personal experience. 

A recent article in the latest issue of the journal Behavioral and Brain Sciences lends credence to the second narrative. Several prominent researchers in the Netherlands refute the notion that mental health concerns are brain disorders. In response to the main article, various influential researchers write commentaries, some supporting the premise, and others arguing against it.

The prominent Stanford scientist John Ioannidis wrote one of the commentaries on the article. Ioannidis argues that the neurobiological research agenda is a “dead end.” Instead, says Ioannidis, research should focus on the context of the person’s life.

Ioannidis suggests that mental health interventions should focus on environmental changes, rather than the neurobiological correlates of mental health. That is, the context of a person’s life has much more impact on their mental health than does their neurobiology. According to Ioannidis: “Our societies may need to consider more seriously the potential impact on mental health outcomes when making labor, education, financial and other social/political decisions at the workplace, state, country, and global levels.”

The authors of the main article refute the neurobiological narrative, calling it reductionism: “In the current scheme of things, explanatory reductionism is a remote possibility, not a realistic research target. We do not have biomarkers that are sufficiently reliable and predictive for diagnostic use. We have not identified genes that are specific to disorders and explain an appreciable amount of variance. We have not obtained insight into pathogenic pathways in the brain that are sufficiently secure to inform treatment. If anything, we should wonder why the massive investments in research, that should have uncovered these factors, have not pushed back the prevalence of common mental disorders by a single percentage point.”

Finally, the authors argue that reductionist biological explanations of mental health problems “should not be understood as science but as science fiction.”  This “position on mental disorders as brain disorders does not represent a scientifically justified conclusion, as is often supposed in the popular and scientific literature, but instead is a hypothesis.”

The article and commentaries are not about ADHD in particular, but a similar battle rages as to whether ADHD is a neurobiological disorder (the reigning popular view at present) or the result of environmental factors. Perhaps it is helpful to see the two narratives not as proven facts but as hypotheses or even belief systems that guide the adherent's research. 

Which view will prevail in the end depends on the direction of future research and (hopefully) the empirical results of clinical experience. Current research focuses primarily on the neurobiological narrative, giving short shrift to non-biological explanations of mental health problems. The article and commentaries suggest that it is time to shift the direction of research to the social context narrative. 

References

Borsboom, D., Cramer, A. O. J., Kalis, A. (2019) Brain disorders? Not really: Why network structures block reductionism in psychopathology research. Behavioral and Brain Sciences, 42(e2), 1–11. 

Ioannidis, J. P. A. (2019). Therapy and prevention for mental health: What if mental diseases are mostly not brain disorders? Behavioral and Brain Sciences, 42(e13), 23-24.