By the time they reach high school, nearly 20 percent of all American boys will be diagnosed with ADHD. Millions of those boys will be prescribed a powerful stimulant to “normalize” them. A great many of those boys will suffer serious side effects from those drugs. The shocking truth is that many of those diagnoses are wrong, and that most of those boys are being drugged for no good reason—simply for being boys. It’s time we recognize this as a crisis.
If you have a son, you have a one-in-seven chance that he has been diagnosed with ADHD. If you have a son who has been diagnosed, it’s more than likely that he has been prescribed a stimulant—the most famous brand names are Ritalin and Adderall; newer ones include Vyvanse and Concerta—to deal with the symptoms of that psychiatric condition.
The Drug Enforcement Administration classifies stimulants as Schedule II drugs, defined as having a “high potential for abuse” and “with use potentially leading to severe psychological or physical dependence.” (According to a University of Michigan study, Adderall is the most abused brand-name drug among high school seniors.) In addition to stimulants like Ritalin, Adderall, Vyvanse, and Concerta, Schedule II drugs include cocaine, methamphetamine, Demerol, and OxyContin.
According to manufacturers of ADHD stimulants, they are associated with sudden death in children who have heart problems, whether those heart problems have been previously detected or not. They can bring on a bipolar condition in a child who didn’t exhibit any symptoms of such a disorder before taking stimulants. They are associated with “new or worse aggressive behavior or hostility.” They can cause “new psychotic symptoms (such as hearing voices and believing things that are not true) or new manic symptoms.” They commonly cause noticeable weight loss and trouble sleeping. In some children, some stimulants can cause the paranoid feeling that bugs are crawling on them. Facial tics. They can cause children’s eyes to glaze over, their spirits to dampen. One study reported fears of being harmed by other children and thoughts of suicide.
Imagine you have a six-year-old son. A little boy for whom you are responsible. A little boy you would take a bullet for, a little boy in whom you search for glimpses of yourself, and hope every day that he will turn out just like you, only better. A little boy who would do anything to make you happy. Now imagine that little boy—your little boy—alone in his bed in the night, eyes wide with fear, afraid to move, a frightening and unfamiliar voice echoing in his head, afraid to call for you. Imagine him shivering because he hasn’t eaten all day because he isn’t hungry. His head is pounding. He doesn’t know why any of this is happening.
Now imagine that he is suffering like this because of a mistake. Because a doctor examined him for twelve minutes, looked at a questionnaire on which you had checked some boxes, listened to your brief and vague report that he seemed to have trouble sitting still in kindergarten, made a diagnosis for a disorder the boy doesn’t have, and wrote a prescription for a powerful drug he doesn’t need.
If you have a son in America, there is an alarming probability that this has happened or will happen to you.
6.4 MILLION CHILDREN BETWEEN THE AGES OF FOUR AND SEVENTEEN HAVE BEEN DIAGNOSED WITH ADHD. BY HIGH SCHOOL, NEARLY 20% OF ALL BOYS WILL HAVE BEEN DIAGNOSED WITH ADHD—A 37% INCREASE SINCE 2003.
On this everyone agrees: The numbers are big. The number of children who have been diagnosed with attention-deficit/hyperactivity disorder—overwhelmingly boys—in the United States has climbed at an astonishing rate over a relatively short period of time. The Centers for Disease Control first attempted to tally ADHD cases in 1997 and found that about 3 percent of American schoolchildren had received the diagnosis, a number that seemed roughly in line with past estimates. But after that year, the number of diagnosed cases began to increase by at least 3 percent every year. Then, between 2003 and 2007, cases increased at a rate of 5.5 percent each year. In 2013, the CDC released data revealing that 11 percent of American schoolchildren had been diagnosed with ADHD, which amounts to 6.4 million children between the ages of four and seventeen—a 16 percent increase since 2007 and a 42 percent increase since 2003. Boys are more than twice as likely to be diagnosed as girls—15.1 percent to 6.7 percent. By high school, even more boys are diagnosed—nearly one in five.
Almost 20 percent.
And overall, of the children in this country who are told they suffer from attention deficit/hyperactivity disorder, two thirds are on prescription drugs.
And on this, too, everyone agrees: That among those millions of diagnoses, there are false ones. That there are high-energy kids—normal boys, most likely—who had the misfortune of seeing a doctor who had scant (if any) training in psychiatric disorders during his long-ago residency but had heard about all these new cases and determined that a hyper kid whose teacher said he has trouble sitting still in class must have ADHD. That among the 6.4 million are a significant percentage of boys who are swallowing pills every day for a disorder they don’t have.
On this, too, everyone with standing in this fight seems to agree.
But on the subject of attention-deficit/hyperactivity disorder, that is where the agreement ends.
For example: Doctors, parents, and therapists give a lot of different explanations for the sharp rise. Increased awareness—that’s a big one. We know more now. Other possibilities put forth: Too many video games. Too much refined sugar. Pharmaceutical companies pushing ADHD drugs. Lack of gym classes at schools. All of these factors are cited. And people have a lot of different ideas about what to do for the children who receive these diagnoses. Many believe that medicine should be the first treatment, either combined with behavioral therapy or not. Others feel that drugs should be a last resort after making every other alleviative effort you can find or think of, from hypnosis to herbal treatments to neurofeedback.
Given today’s prevailing pharmaceutical culture, clinicians who believe that drugs should never be used to treat ADHD in children are very much in the minority. Marketing is powerful, and blockbuster drugs like Ritalin are big business. Business booms, market share grows when scripts are written, and countercultural doctors and therapists who advocate caution and who believe that diagnoses are made too easily—doctors and therapists who preach alternatives to drugs—are finding themselves the butt of jokes. But more about them shortly.
The United States government first collected information on mental disorders in 1840, when the national census listed two generally accepted conditions: idiocy and insanity. A century later, psychiatrists knew more. They had options when making diagnoses, and by the 1940s difficult kids were classified as “hyperkinetic.” Other terms would follow, like minimal brain dysfunction. In 1955, there came a pill doctors could prescribe for these children to temper their hyperactivity and make them behave more like “normal” children. It was a stimulant, so called because it heightened the brain’s utilization of dopamine, which can improve attention and concentration. The active ingredient was a highly addictive compound called methylphenidate. The drug was called Ritalin.
By 1987, the American Psychiatric Association (APA) had settled on a more refined name for a disorder among children who exhibited the same set of symptoms, including trouble concentrating and impulsive behavior: attention-deficit/hyperactivity disorder. ADHD. At the time, in American schools, it was still considered unusual for a child to take Ritalin. It was, frankly, considered weird.
Today, it has simply become a default method for dealing with a “difficult” child.
“We are pathologizing boyhood,” says Ned Hallo-well, a psychiatrist who has been diagnosed with ADHD himself and has cowritten two books about it, Driven to Distraction and Delivered from Distraction. “God bless the women’s movement—we needed it—but what’s happened is, particularly in schools where most of the teachers are women, there’s been a general girlification of elementary school, where any kind of disruptive behavior is sinful. What I call the ‘moral diagnosis’ gets made: You’re bad. Now go get a doctor and get on medication so you’ll be good. And that’s a real perversion of what ought to happen. Most boys are naturally more restless than most girls, and I would say that’s good. But schools want these little goody-goodies who sit still and do what they’re told—these robots—and that’s just not who boys are.”
Especially when they’re young. One of the most shocking studies of the rise in ADHD diagnoses was published in 2012 in the Canadian Medical Association Journal. It was called “Influence of Relative Age on Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children.” Nearly one million children between the ages of six and twelve took part, making it the largest study of its kind ever. The researchers found that “boys who were born in December”—typically the youngest students in their class—”were 30 percent more likely to receive a diagnosis of ADHD than boys born in January,” who were a full year older. And “boys were 41 percent more likely to be given a prescription for a medication to treat ADHD if they were born in December than if they were born in January.” These findings suggest, of course, that an errant diagnosis can sometimes result from a developmental period that a boy can grow out of.
And there are other underlying reasons for the recent explosion in diagnoses. Stephen Hinshaw, a professor of psychology at the University of California, Berkeley and the editor of Psychological Bulletin, the research publication of the American Psychological Association, presents evidence in a new book that ADHD diagnoses can vary widely according to demographics and even education policy, which could account for why some states see a rate of 4 percent of schoolchildren with ADHD while others see a rate of almost 15 percent. Most shocking is Hinshaw’s examination of the implications of the No Child Left Behind Act of 2001, which gave incentives to states whose students scored well on standardized tests. The result: “Such laws provide real incentive to have children diagnosed and treated.” Children with ADHD often get more time to take tests, and in some school districts, tests taken by ADHD kids do not even have to be included in the overall average. “That is, an ADHD diagnosis might exempt a low-achieving youth from lowering the district’s overall achievement ranking”—thus ensuring that the district not incur federal sanctions for low scores.
In a study of the years between 2003 and 2007, the years in which the policy was rolled out, the authors looked at children between ages eight and thirteen. They found that among children in many low-income areas (the districts most “targeted” by the bill), ADHD diagnoses increased from 10 percent to 15.3 percent—”a huge rise of 53 percent” in just four years.
48% OF SUBJECTS OF ONE STUDY WHO TOOK ADHD MEDICATIONS EXPERIENCED SIDE EFFECTS LIKE SLEEP PROBLEMS AND “MOOD DISTURBANCES.” IN ANOTHER, 6% OF CHILDREN SUFFERED PSYCHOTIC SYMPTOMS, INCLUDING THOUGHTS OF SUICIDE.
Source: Psychiatry, April 2010; The Canadian Journal of Psychiatry, October 1999.
And yet among many of the people interviewed for this story, the most common explanation for the staggering increase in diagnoses is that doctors know more now. Great strides have been made. “I don’t think there’s an epidemic of new cases,” says Mario Saltarelli, a neurologist and the senior vice-president of clinical development at Shire, which manufactures Adderall and Vyvanse. (Since our interview, he has left the company.) “It’s always been there. It’s now more appropriately understood and recognized.” Instead of lumping together all the kids with high energy and bad behavior and calling them hyper, many experts say, doctors can identify the children who exhibit the symptoms specific to ADHD and treat them accordingly. “We were paying attention,” says Jeffrey Lieberman, the president of the American Psychiatric Association and chairman of psychiatry at Columbia University Medical Center. “We [now] have reliable descriptions and the means of diagnosing.”
Every fifteen years or so, the APA publishes a book called the Diagnostic and Statistical Manual of Mental Disorders, which doctors around the world use as a guide for diagnosing mental disorders in their patients. Known as the DSM, it has been published seven times, first in 1952 and most recently in 2013. For each revision, a new task force of psychiatrists tweaks, refines, and often expands the descriptions, definitions, and symptoms of hundreds of psychiatric disorders. It’s not uncommon for definitions to be written more broadly, thus broadening the universe of people who might be diagnosed with a given disorder.
In the DSM-5, the 916-page version that came out last year, there was one important change made to the section on ADHD. The age at which a child can be diagnosed with ADHD was raised from seven to twelve. In the previous edition of the DSM, in order to meet the criteria for diagnosis, several symptoms of ADHD had to be present by age seven. Citing “substantial research published since 1994,” the authors increased the window for diagnosis by five years, meaning that twenty million more children are now eligible to be told they have ADHD.
And so if a child is deemed to meet the criteria for ADHD as defined in the DSM, even by a rushed pediatrician after a cursory twelve-minute examination, the clinical-practice guidelines strongly recommend medication as part of the first step in treating kids starting at age six. (Behavior therapy is recommended as a first step for four- and five-year-olds, followed by methylphenidate, or stimulants, if the behavior therapies “do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function.”)
A cynical person might wonder whether the task forces who write the DSM are influenced by pharmaceutical companies, seeing that with each new disorder they add and each new symptom they deem valid, more people can get expensive prescriptions. ADHD drugs alone were a $10.4 billion business in 2012, a 13 percent increase over the year before.
“I think it happens in an indirect but nonetheless powerful way,” says Lisa Cosgrove, a clinical psychologist who is an associate professor at the University of Massachusetts, Boston and a fellow at the Center for Ethics at Harvard. In a study of the DSM-5, she found that 69 percent of the task force acknowledged ties to the pharmaceutical industry. Many of these were likely indirect affiliations, but Cosgrove says that doesn’t matter. “It’s not that I think there’s this quid pro quo kind of corruption going on. But when the individuals who are charged with the responsibility of developing criteria or with changing the symptom criteria—I don’t think they are consciously aware of the way in which industry affiliations create pro-industry habits of thought.” Cosgrove points to what she calls a “major gap” in the APA’s disclosure policy for doctors who worked on the DSM-5: It allows unrestricted research grants from drug companies. “Now, ‘unrestricted’ means that the pharmaceutical company cannot in-house analyze the data…but there’s a wealth of social-psych research that shows that when you are paid even small amounts—and there’s the potential for future payment—it affects your behavior. If I get an unrestricted research grant from Pfizer for $500,000, and I’m hoping to get a $2 million grant, at some level I’m going to be aware of how I talk about the results.”
The journal Accountability in Research chose Cosgrove’s paper “Commentary: The Public Health Consequences of an Industry-Influenced Psychiatric Taxonomy” for publication in 2010, when a first draft of the DSM-5 was made public. In the paper, Cosgrove and her coauthors lambasted the psychiatric community for supporting a manual that largely ignores side effects and promotes diagnosis by constantly adding symptoms and disorders. “A psychiatric taxonomy [i.e., the DSM] which touts indication for medications, but is effectively silent about their associated risks, is evidently unbalanced and raises questions about undue influence,” they wrote. “The time has come to seriously reconsider whether the heavily pharmaceutically funded APA should continue to be entrusted with the revision of the DSM.”
Dr. Allen Frances, professor emeritus at Duke University School of Medicine, the former chairman of its psychiatry department, and the chairman of the DSM-IV (1994) task force, feels the problem is not corruption but the slow creep of misinformation. “I know the people. They’re not doing it for the drug companies—they really believe what they’re doing is right. They really believe ADHD is underdiagnosed, and they want to help people who should be getting medication. I just think they’re dead wrong.”
“It’s a disease called childhood.”
Frances points to the fact that in August 1997—the same year the CDC first started tallying ADHD cases in the United States—the Food and Drug Administration made it easier for pharmaceutical companies to advertise their drugs to consumers. Spending on direct-to-consumer drug advertising increased from $220 million in 1997 to more than $2.8 billion by 2002.
It’s not that Frances believes ADHD is not a real and valid diagnosis; he just believes that these days it’s made so frequently it has been rendered meaningless. “It’s been watered down so much in the way it’s applied that it now includes many kids who are just developmentally different or are immature,” he says. “It’s a disease called childhood.”