According to the American Psychiatric Association, about 5 percent of American children suffer from Attention Deficit Hyperactivity Disorder (ADHD), yet the diagnosis is given to some 15 percent of American children, many of whom are placed on powerful drugs with lifelong consequences. This is the central fact of the journalist Alan Schwarz’s new book, ADHD Nation. Explaining this fact—how it is that perhaps two thirds of the children diagnosed with ADHD do not actually suffer from the disorder—is the book’s central mystery. The result is a damning indictment of the pharmaceutical industry, and an alarming portrait of what is being done to children in the name of mental health.
He spoke with Mind Matters editor Gareth Cook.
What prompted you to write this book?
In 2011, having spent four years exposing the dangers of concussions in the National Football League and youth sports for The New York Times, I wanted another project. I had heard that high school students in my native Westchester County (just north of New York City) were snorting Adderall before the S.A.T.'s to focus during the test. I was horrified and wanted to learn more. I saw it not as a "child psychiatry" story, and not as a "drug abuse" story, but one about academic pressure and the demands our children feel they're under.
When I looked deeper, it was obvious that our nationwide system of ADHD treatment was completely scattershot—basically, many doctors were merely prescribing with little thought into whether a kid really had ADHD or not, and then the pills would be bought and sold among students who had no idea what they were messing with. I asked the ADHD and child-psychiatry establishment about this, and they denied it was happening. They denied that there were many false diagnoses. They denied that teenagers were buying and selling pills. They denied that the national diagnosis rates reported by the C.D.C.—then 9.5 percent of children aged 4-17, now 11 percent and still growing—were valid. They basically denied that anything about their world was malfunctioning at all. In the end, they doth protest too much. I wrote about 10 front-page stories for The New York Times on the subject from 2012-2014.
In what sense is ADHD an "epidemic," and how was it "made"?
ADHD itself is not an epidemic—ADHD misdiagnosis is an epidemic. If the system functioned in such a way as to stay anywhere near the 5percent diagnosis rate that the American Psychiatric Association's official definition suggests, we wouldn't be in this mess. But the system doesn't function properly, not by a long shot. About 15 percent of American children turn 18 having been diagnosed with ADHD, 20 percent of boys, and 30 percent of boys in much of the South. It's completely indefensible. It's time to figure out how not to necessarily "fix" it, because the genie long left the bottle, but do a far better job in diagnosing the kids who really fit the construct and help the other kids in other ways. Many kids have problems and need help—but those problems in many cases will derive from trauma, anxiety, family discord, poor sleep or diet, bullying at school and more. We must not abandon them. We must help. But we must also be more judicious in how we do that, rather than reflexively giving them a diagnosis of what is generally described as a serious, lifelong brain disorder.
As for "made," it's clear that whatever ADHD is, wherever it comes from and however it manifests itself in different people, it has been built up into something well beyond reasonable proportions. The disorder can exist and be respected without being misdiagnosed in millions of additional children. It's not the disorder's fault that the grownups in charge have mucked it up. We, the adults, have made it into something it didn't need to be.
What role have the pharmaceutical companies played?
A completely predictable one. We are a very capitalistic country, particularly when it comes to medicine, and the pharmaceutical industry has massive financial incentive to produce drugs that address medical needs. We all benefit from this – whether it was the Advil I took last night for a headache, or the chemotherapy my brother underwent for Hodgkin’s Disease 30 years ago. So there’s nothing wrong with their making a product people want. The problem, in the ADHD world and others—particularly psychiatric—is that the companies hijacked the entire field. It corralled all the top researchers and doctors in the field and paid them five, six, even seven-figures apiece to conduct studies all written in the same key: ADHD is more widespread and dangerous than anyone knows, the drugs work wonderfully and with almost no side effects, and that if you don't diagnose and medicate a child, he or she will be doomed to academic and social failure, crash their car, get venereal disease and more.
All these study findings were founded in small pieces of truth, yes, but they were unconscionably exaggerated specifically to scare doctors and parents into diagnosing and medicating children without much regard to how their problems might not derive from ADHD, but something else, something more complicated, and something worthy of a hell of a lot more attention and treatment than daily amphetamine pills. This was all orchestrated behind the sheen of academic institutions—it's easy to get away with it when the doctors performing the studies have affiliations at Harvard, Johns Hopkins and Cal, with only tiny print indicating that their work was subsidized by the drug makers and rewarded with consulting and speaking contracts.
Then, making things worse, the pharmaceutical companies took these studies to compose ads, ultimately to parents themselves, that misrepresented what their product was, what it treated, and what it did. Disgustingly so. ADHD drugs do not give a child “grades that match his intelligence,” which is what one Adderall XR ad told parents in People magazine. (The United States is almost unique in the developed world for allowing direct-to-consumer advertising of controlled substances, which ADHD meds are.) Another ad had a mother telling her kid that, thanks to the ADHD drugs, “I’m proud of you.” It’s sick. But there are really no repercussions for companies that do this. Every ADHD drug – Adderall XR, Concerta, Vyvanse, Metadate, you name it – has received a formal reprimand from the F.D.A. for false and misleading advertising. Every one.
Dr. Keith Conners is such an interesting figure. What do you find so compelling about his story?
He is ADHD's Oppenheimer. It was Conners, in the early 1960s at Johns Hopkins, who conducted the first formal trials on the use of Ritalin in obstreperous children. (The studies were subsidized by Ritalin's manufacturer, CIBA.) The results were incredibly compelling—this drug helped some children who might not have gotten a reasonable education, or lived a decent home life, to follow instructions and pay attention in ways that transformed their lives. These findings helped spur research into what was then called Minimal Brain Dysfunction or Hyperkinetic Reaction of Childhood, and other drugs emerged as effective treatments for what we essentially now call ADHD Conners became a champion of the diagnosis and medications, treated children in his own university-affiliated clinics, developed a symptom rating scale to help other clinicians identify and treat the condition, and worked for just about every pharmaceutical company conducting trials on new and better medications. This was all done in good faith for the benefit of children. But through the 1980s, 1990s and 2000s, he was so focused on these honest aims that he didn't pay attention to how the field was going completely off the tracks. He didn't realize what he had become a part of. He now does, and calls ADHD misdiagnoses "a national disaster of dangerous proportions."
You describe this problem as a genie that’s left the bottle. What is the way forward?
There is no way to rein in ADHD diagnoses to anything near the 5 percent that the American Psychiatric Association says is appropriate, and maybe even the 7 or 8 percent that most people could live with. (No system involving a subjective diagnosis, such as psychiatric disorders, will ever work perfectly, and we shouldn't expect it to.) But eleven percent of children currently aged 6 to 17 already have been told they have ADHD by a medical provider, and by the time they hit college age, 15 percent will have. It has entered the medical and cultural zeitgeist, in part because newly diagnosed kids are in such wide company, and in part because the medications do, in general, help them behave better in home and school. That's very seductive to parents, doctors, teachers and anyone troubled by the child's behavior.
Believe it or not, I would argue that any sort of sudden shift in the handling of ADHD, any significant aversion to allow a diagnosis, would hurt the children who really do fit the construct and benefit from treatments -- we can't overreact. What we must do is simply be more judicious in making the diagnosis. Parents and doctors must be taught that just because a child has a difficult time paying attention or sitting still in school does not, ipso facto, have a potentially lifetime brain disorder. It's complicated. It takes time to figure out what might be best for this individual child.
We, the grownups, must slow down. Be less impulsive. Pay careful attention. What we want from our children we must first expect from ourselves.