ADHD Nation is one of the latest of many books devoted to the topic of ADHD. It is unique in that it brings into the discussion the current views of Dr. Conners (an early pioneer in the area) while at the same time introducing the reader to some interesting and informative facts.
While stating that ADHD is real and exists and must be taken very seriously Schwarz puts aside the question as to whether or not it exists, states categorically that it does and then moves on to the issues of overdiagnosis and the rampant abuse of stimulant medications - or as he puts it “The Making of an American Epidemic”. At first blush, this appears to be a safer argument to embark upon. However, implicit in the information and arguments that he presents appear the very reasons why many question the legitimacy of the entire enterprise; any account of the rise and discovery of ADHD cannot be made without giving full credit to the pharmaceutical companies' role in the simultaneous promotion of an affliction together with its proposed cures. The underwriting, promotion and relaxing of the symptoms necessary to qualify for diagnosis are inexorably interwoven with the promotion of medications and the driving force behind the enterprise is unabashedly that of profit. What Swartz clearly identifies is that with the billions of dollars now involved in the identification, therapies and medications of ADHD, few who are involved can free themselves from some degree of complicity in what has become a profitable industry. As such, one is led to conclude that money and self- interest are compelling engines driving the phenomenon independently of genuine concern for the afflicted.
Interestingly enough, even the term ‘ADHD’ required some packaging. Early attempts to describe the general condition included ‘Hyperkinetic Impulse Disorder’ and ‘Minimal Brain Damage’ among others. Attention Deficit emerged as a satisfactory and acceptable description in terms of its messaging by striking a balance between what might be incomprehensible verbiage or an embarrassing personal flaw. ‘Attention’ was after all a term that everyone knew and having difficulty paying attention was something that everyone experienced to some degree. In a similar manner, the medications themselves needed names that would not ring alarms. And so Ritalin was named by a research chemist after his girlfriend named Rita who benefited from the medication both by encouraging her weight loss and invigorating her tennis game. Other medications provided similar soothing or non-threatening names. Having packaged the product both in terms of the problem and the cure, the next step was to identify the market. However, unlike the common cold, the diagnostic process itself needed to be tailored and also marketed.
Schwarz maintains that according to the American Psychiatric Association’s determination, the condition of ADHD affects about 5% of children and most of this number are male. However, Schwartz states that the current U.S. nationwide rate is 20% with some states topping 30% and some counties approaching 50%. Early pioneers in ADHD research and development believed that no more than 3-5 % of the population would be affected. Dr. Conners, who became famous and personally quite rich through his introduction of the Conner’s diagnostic test, very widely used for the diagnosis of ADHD, was distraught when interviewed for the book. Having originally been sure that no more than 3-5 % of children would be afflicted, the current inflated numbers could only be accounted for by virtue of misdiagnosis. Thus Schwarz concludes that given this huge gap ADHD has become the most misdiagnosed condition in American medicine. Therefore, the thesis promoted by this book is that the numbers can be rolled back by making the conditions for diagnosis stricter. However, it would seem that Schwartz’s solution amounts to no more than bell curving undergraduate exam marks to ensure that 5% of the class fails. In short, the admission that the definition and setting of the necessary and sufficient conditions of being diagnosed with ADHD are directly responsible for determining the number of people who can be legitimately identified as such infers that the diagnosis is determined by the definition. The fact that Conners believed that the condition could only afflict a limited range of no more than 5% of the population is a belief and could not qualify as a scientific observation since there would be no way of knowing this before the fact. How could one know therefore that no more than 5% of the population was afflicted? Perhaps the statement is more of the form that no more than 5% of the population ‘should’ be afflicted. The argument that the sufficient and necessary conditions should be made more restrictive in order to reduce the percentage that would qualify for a diagnosis to a preconceived range infers an arbitrary character to the entire enterprise.
What therefore becomes apparent is that whatever current test is used to determine ADHD, all reduce ultimately to subjectivity as it is only a thing insofar as it is defined as being such. As the sufficient and necessary condition is made more or less restrictive, more or less instances of the thing come or go out of existence. No growth, virus, bacteria or physical dysfunction can be identified with it. Despite attempts to argue that some physiological characteristics can be identified with ADHD through brain scans and computer colour enhancements, no credibility has been provided for this by the American Medical Association. Instead, a cluster of diverse behaviours is made unique not by their existence but by their subjectively determined degree and effect on normal functioning. Indeed, all of these behaviours can be ignored if there is no effect upon normal functioning and so there is an ad hoc character to the causal relationship insofar that the assumption exists that these behaviours could all exist to the same degree and either affect or not affect normal behavior. In short, the behaviours associated with determining the existence of ADHD are necessary characteristics only after it is determined that there is a dysfunction within a specific environment. In a real sense, the dysfunction comes first and the explanation follows later.
Looking at the actual diagnostic tools is a help to bring the discussion down from the abstract to the concrete. For example one of the first commercially marketed rating scales developed by Dr. Conners described 28 behaviours:
- Restless in the “squirmy” sense
- Makes inappropriate noises when he/she shouldn’t
- Demands must be met immediately
- Acts “smart” (impudent or sassy)
- Temper outbursts and unpredictable behaviour
- Overly sensitive to criticism
- Distractibility or attention span a problem
- Disturbs other children
- Pouts and sulks
- Mood changes quickly and drastically
- Submissive attitude towards authority
- Restless, always up and on the go
- Excitable, impulsive
- Excessive demands for teacher’s attention
- Appears to be unaccepted by group
- Appears to be easily led by other children
- No sense of fair play
- Appears to lack leadership
- Fails to finish things that he/she starts
- Childish and immature
- Denies mistakes or blames others
- Does not get along with other children
- Uncooperative with classmates
- Easily frustrated in efforts
- Uncooperative with teacher
- Difficulty in learning
Each of these behaviours is then rated 0 through 3 with 0 signifying never, 1 just a little, 2 pretty much and 3 very much. The score would then be tabulated with a minimum score being selected to qualify as borderline ADHD and so on.
As of 1980 and the publication of the DSM or Diagnostic and Statistical Manual, Attention Deficit Disorder details as to how doctor’s should diagnosis the syndrome were provided as follows:
Inattention. At least three of the following:
- often fails to finish things he or she starts
- often doesn’t seem to listen
- easily distracted
- has difficulty concentrating on schoolwork or other tasks requiring sustained attention
- has difficulty sticking to a play activity
B. Impulsivity. At least three of the following:
- often acts before thinking
- shifts excessively from one activity to another
- has difficulty organizing work(this is not due to cognitive impairment)
- needs a lot of supervision
- frequently calls out in class
- has difficulty awaiting a turn in games or group situations
C. Hyperactivity. At least two of the following:
- runs about or climbs on things excessively
- has difficulty sitting still or fidgets excessively
- has difficulty staying seated
- moves about excessively during sleep
- is always “on the go” or acts as if “driven by a motor”
Each edition of the DSM has relaxed the sufficient and necessary conditions so as to increase exponentially the number of people who could qualify to be diagnosed. As the DSM is not the only basis for diagnosis and professional interpretations as to what does and does not qualify someone to be diagnosed with ADHD further complicates the issue. However, the fact that relaxing a definition or changing it can either increase or decrease a condition can lead to speculation as to whether or not the definition chases the condition or the condition chases the definition.
Ultimately, however, it would also seem that who and what qualifies may be less important than the issue of the millions who apparently benefit from the variety of medications now prescribed. This brings up the issue of performance enhancing drugs in general. Schwarz mentions that during WWII Winston Churchill approved the production of 72 million Benzedrine tablets for distribution to troops to improve performance. Widespread use and abuse of Benzedrine followed the war with people commonly taking it in the morning with coffee and with the Rolling Stones referring to it in song as “Mother’s Little Helper”. Available without a prescription and over the counter, there were no curbs to consumption. As an energizer and as a weight loss pill, it gained popularity to the point where it was recognized as a threat to public health and placed on a restricted substance list. Another stimulant medication called Dexadrine was marketed as a substitute for the by then maligned Benzedrine. However, by early 1970, some 4 billion Dexedrine tablets were being dispensed in the U.S. each year and some 7% of all Vietnam forces became abusers or addicts.
It becomes apparent therefore that a steady market for stimulant medications existed prior to the advent of ADHD or other learning challenges. Whereas there is no doubt that such medications enhance performance, the fact that they address symptoms in this process does not logically infer the existence of an ailment that they are supposed to address. It remains to discuss ADHD medications, not as one would discuss an antibiotic that fights an infection and would have no beneficial effects unless you were sick as opposed to stimulant medications that enhance performance generally.
To take the argument one step further, if stimulant medications increase most people's ability to focus and stay on task why not allow anyone to use them? This is a question that has been taken up at universities and colleges across the USA and Canada where thousands of students are accessing these performance-enhancing drugs to assist them in studying and writing exams. In these contexts, the medications are valued because of their ability to enhance abilities in students whose abilities were strong enough to get them into top universities and competitive programmes. In short, there is no argument that medications to address ADHD issues are effective in many cases. It is equally true that these medications have similar effects in enhancing performance even where there is no dysfunction. It could be therefore argued that in the athletic realm we should issue medications to athletes whose performance is substandard but not allow them to better athletes as a means of levelling the playing field.
It has always been recognized that school is not an environment suited to everyone and traditionally a number of students left school and entered the trades or the workforce. It is also the case that school was viewed as a privilege rather than an affliction and was therefore valued. As school has become an imposed obligation upon youth by the state, the academic component has strayed further away from learning along traditional lines to a form of socialization and enculturation designed to ensure that its products share common values, ideas and attitudes. Despite universal claims from educators that government funded schools do a better job than ever, there is no empirical evidence to prove the claim that modern schools have advanced beyond the successes of the one-room schoolhouse. They are certainly more complex, expensive and inclusive. Much of this misdirection is as a result of being all things to all people. Failure at school is not a failure at life and those who are not suited by nature, temperament or timing to be successful in that particular environment may have many strengths in other directions that are better being capitalized upon than suppressed.
Part of the problems with much of current education is that students feel that they are being forced to attend and that what they are being taught has no value or interest to them. It is interesting that in the third world education is regarded by most students as a privilege and a way to advance themselves whereas in the West many young people regard education as an affliction developed by adults to destroy their adolescence. Just as all people are not destined to be athletes, it is equally true that not all people are destined to be scholars. It would seem then that in keeping with principles of consistency that athletics should be considered for medications as well in order that poor performers might perform better. However, it might be also argued in both academic and athletic environments that if any portion is receiving artificial assistance to enhance performance then perhaps everyone should enjoy the same benefit.
In conclusion, ADHD Nation is a book worth reading in terms of the new information and updates taking place as part of the crisis of overdiagnosis. It is however also of value insofar as it provokes discussion around the central issues concerning the birth and evolution of the ADHD phenomenon.