CHILDREN & SOCIETY VOLUME 16 (2002) pp. 368–371Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/CHI.747

Response from PaulCooper

Ifind I agree with much of the substance of this responseto my earlier article. In fact I find in the paper some usefuldevelopments of lines of argument that I established. The

fact that these lines were not more fully developed in theoriginal paper is a consequence of the limitations imposed bythe need to produce a paper of less than 3,500 words. I will saymore about this below with particular reference to the‘biopsychosocial’ perspective. Before doing this, however, Imust respond to the two criticisms of my original paper.

1. The prevalence of AD/HD

The UK prevalence rate of between 3 and 5 per cent is quotedby the National Institute of Clinical Excellence (NICE, 2000).This is identical to the figure quoted by the AmericanPsychiatric Association (APA, 1994, p. 82). In both countriesthere are other sources that could be drawn upon which wouldsuggest different prevalence rates, however, these are, I wouldargue, the most widely accepted figures because they are themost widely quoted and the ones accepted by key authorities(for example the APA in the US, and the National HealthService as represented by the NICE). Departures from theserates are often associated with idiosyncracies in data gatheringtechniques, such as the tendency of some researchers to relyexclusively on teachers’ perceptions of children’s behaviour(see Hinshaw, 1994; Robin, 1999).

2. An increasing consensus among clinicians about thenature of AD/HD

The growing international use of the APA AD/HD diagnosticcriteria would suggest a growing consensus among clinicians(as opposed to researchers) that of the available alternatives itis the APA version that is increasingly preferred. This isreflected in the British context in the recently published NICEguidelines, which locate the World Health Organisationdiagnosis of hyperkinetic disorder as a sub-set of the APAdiagnosis, rather than as an alternative. This is also reflected inthe shift among certain eminent UK experts in this area whohave tended in the past to refer to ‘hyperkinesis’ in their workwho now use the term AD/HD. This phenomenon is also

Copyright # 2002 John Wiley & Sons, Ltd.

Research

Review

Paul CooperSchool of Education,University of Leicester

Correspondence to: Paul Cooper,

School of Education, University of

Leicester, 21 University Road, Lei-

cester LE1 7RF.

evident in the UK in the publications of the British Psychological Society, which sponsoreda publication that challenged the validity of the diagnosis (BPS, 1996), and then followedthis four years later with a publication which appeared to be founded on an acceptance ofthe APA diagnosis as a valid construct (BPS, 2000). This is not to say that there is anabsolute consensus. However, there does seem to be an international convergence inrelation to this issue, albeit one that is accompanied by controversy. It may well be the casethat this shift is an effect of a biomedical hegemony, but the fact remains that the reasonwhy AD/HD is such a source of concern is that more and more clinicians appear to bediagnosing it.

The biopsychosocial perspective

I wholeheartedly agree with the biopsychosocial approach, having outlined it in my paperand earlier publications (for example Cooper and Ideus, 1996; Cooper, 1997; Cooper,1998). In discussing the dynamic interaction that takes place between biological andpsychosocial factors I indicate that they are thoroughly intertwined. I am not advocating aseparation of biological and cultural factors so much as a heightened awareness of theways in which these factors may interact, and how such an understanding can give way toeffective intervention.

One of the ways of understanding how these factors interact is to examine extreme caseswhere one or other of these factors appears prominent. Some of the biologically orientedresearch on AD/HD (see Tannock, 1998; Levy and Hay, 2001) helps us to understand therole that neurological differences might play in the development of certain behaviourpatterns. This is not to say that any particular behaviour is determined by particularneurological features, but it may be the case that particular neurological patterns interactwith certain ubiquitous environmental features to produce common behavioural outcomes.Take, for example, the drift towards individualism, which seems to be a common feature ofadvanced industrial and post-industrial societies, and may well provide a range ofenvironmental stressors which exploit, in a negative way, certain biologically basedindividual differences. In such a cultural environment, it may be argued, children withcertain frontal lobe dysfunctions, associated with problems of impulse control, will tend tohave difficulty in conforming in school settings which place a high value on behaviouralself-regulation. These behavioural difficulties can, in many cases apparently, be all buteradicated (in the school setting) through manipulation of the instructional environmentand the application of particular pedagogical, behavioural and cognitive interventionstrategies (see Cooper and Whitebread, unpublished report submitted to the NuffieldFoundation, 2002). Innovative educational methods are necessary in these circumstancesbecause features in the wider environment (for example extended family, cohesivecommunities, common values structure), which promoted and reinforced the conformityrequirements of mass schooling, are less evident in contemporary society.

This is not to say that biology and environment operate in a linear manner, with onenecessarily preceding the other. Neither should this argument be taken as support for asingle factor explanation for the causes of AD/HD. However, it is sometimes useful to beable to conceptualise the manner in which biological and environmental factors mayinteract. Without such a conceptualisation the biopsychosocial approach is itselfmeaningless.

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Copyright # 2002 John Wiley & Sons, Ltd. CHILDREN & SOCIETY Vol. 16, 368–371 (2002)

Conclusion

In my original paper, my aim was to provide a dispassionate account of the thinking thatcommonly underpins the application of the AD/HD diagnosis. Given that AD/HD is adiagnosis of the APA it seemed to me reasonable to begin the article by expressing what itmight mean to see AD/HD as a biomedical construct. I then went on to outline somelimitations of the construct before proposing a biopsychosocial perspective. My centralcontention, however, remains that social scientists, if they are to be of any use to thosepractitioners whose work they often seek to influence (for example teachers, socialworkers), must pay careful attention to the insights claimed by scientists working in thebiomedical sphere. We must of course realise that biological explanations for thebehavioural phenomena associated with AD/HD are alone insufficient. On the otherhand, the biological evidence would suggest that psychosocial explanations alone are alsounlikely to provide a sufficient explanation.

There is an unfortunate and counter-productive tendency, as Singh points out, forbiological and psychosocial explanations to be pitted against one another, rather thanthere being a concerted attempt to reconcile and synthesise these sources of evidence.

As Carl Degler (1991) has noted, social scientists in the mid-twentieth century often tookagainst biological approaches largely because of the misuses of biological arguments asjustification for repressive and discriminatory practices (for example eugenics, racialsegregation). The work of Thomas Szasz is a prime example of an ideologically drivenapproach to social science that brought important insights to bear on the ways in whichapparently biologically based disorders can be socially constructed. As Singh acknowl-edges, however, abhorrence for the misuses of one form of science may lead to blind-spotsin the eyes of the social-scientific beholder.

Singh outlines in the closing sections of the paper, a research programme which it isclaimed ‘could include biologically and socio-culturally oriented researchers’. It is truethat the proposed programme would provide scope for both groups of researchers, but notin the integrated way that is necessary to reflect a genuinely biopsychosocial perspective.My preferred vision of a biopsychosocial approach would not only require thecollaboration of biologically oriented and social researchers, but would also involvecollaboration at the clinical/service delivery level. For example, within the educationalsphere an appropriate research and development programme would involve the design ofinterventions based on a synthesis of biomedical and social scientific understandings (forexample through the identification of educational environments and pedagogicaltechniques that were calculated to achieve the positive educational exploitation of specificsocial, emotional, neurological and cognitive characteristics). Clearly, such studies, to bemost effective, would have to be located within an exploration of the broader biologicaland social-ecological world inhabited by the research participants. These interventionswould form the basis for experimental and quasi-experimental studies that wouldgenerate data of enormous practical value. Such studies will only happen when there isgreater cooperation and understanding between social researchers/practitioners andbiomedical researchers/practitioners.

No scientific endeavour can be free of ideology, and what I have argued for here is for anideology of pragmatism. By this I mean an holistic and multidisciplinary approach to

370 Paul Cooper

Copyright # 2002 John Wiley & Sons, Ltd. CHILDREN & SOCIETY Vol. 16, 368–371 (2002)

understanding complex phenomena which links research to practice. From thisperspective, research and practice (in the area under consideration) are renderedworthwhile only when they are directed towards the immediate and ongoing benefit ofpotentially marginalised groups and individuals (for example people deemed toexperience social, emotional and behavioural disorders). Put simply, this requires bio-medics to learn more about psychosocial and cultural processes, and social-scientists toresist the temptation to always ‘go beyond biology’ and learn more about the ways inwhich biology might interact with psychosocial and cultural processes. This will provide abasis for constructive dialogue and action. AD/HD provides an excellent basis for such abiosychosocial approach.

References

APA. 1994. Diagnostic and Statistical Manual of Mental Disorders Ed IV. APA: Washington, DC.BPS. 1996. AD/HD: A Psychological Response to an Evolving Concept. BPS: Leicester.BPS. 2000. AD/HD: Guidelines and Principles for Inter-Disciplinary Cooperation. BPS: Leicester.Cooper P. 1997. Biology, Behaviour and Education: AD/HD and the bio-psycho-social perspective.Educational and Child Psychology 14(1): 51–58.

Cooper P. 1998. The reality and hyper-reality of AD/HD: an educational and cultural analysis. InAD/HD: Educational, Medical and Cultural Issues (2nd ed.), Cooper P, Ideus K (eds). The Associationof Workers for Children with Emotional and Behavioural Difficulties: East Sutton.

Cooper P, Ideus K. 1996. AD/HD: A Practical Guide for Teachers. Fulton: London.Cooper P, Whitebread D. 2002. The Effectiveness of Nature Groups. Unpublished report submitted to

the Nuffield Foundation.Degler C. 1991. In Search of Human Nature. Oxford University Press: Oxford.Hinshaw S. 1994. Attention Deficits and Hyperactivity in Children. Sage: London.Levy F, Hay D. 2001. Attention, Genes and ADHD. Brunner-Routledge: London.NICE. 2000. Guidance on the Use of Methylphenidate for AD/HD. NICE: London.Robin A. 1999. ADHD in Adolescents: Diagnosis and Treatment. Guilford: New York.Tannock R. 1998. AD/HD: advances in cognitive, neurobiological and genetic research. Journal ofChild Psychology and Psychiatry 39(1): 69–99.

Contributor’s details

Paul Cooper is Professor of Education at the University of Leicester and Editor of the journalEmotional and Behavioural Difficulties.

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Copyright # 2002 John Wiley & Sons, Ltd. CHILDREN & SOCIETY Vol. 16, 368–371 (2002)