The new book titled ADHD Does Not Exist gets my hackles up and got me thinking about attention deficit in the news.
by Edward Hallowell, M.D.
Twenty years ago, reporters who asked me about what was then called ADD almost always opened with the question: “Is this just an excuse people make up for being irresponsible and careless?”
Since then genetic studies and epidemiologic research have reinforced the biological basis for what’s now called ADHD, so that question is not asked nearly as much. Yet the diagnosis and treatment of ADHD remain in the news and still stir strong feelings.
I call myself a “radical moderate.” I believe strongly in resisting the distortions inherent in polarization. I try to do all I can to preserve a balanced viewpoint informed by science, not rhetoric and misinformation.
Yet balance is not an easy feat in today’s polarizing world. For example, two years ago psychologist Alan Sroufe lobbed a polemic in an opinion piece in the New York Times (January 29, 2012) titled “Ritalin Gone Wrong.” He caricaturized using stimulants to treat ADHD, with conclusions like, “There will never be a single solution for all children with learning and behavior problems,” “The large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill,” and “The illusion that children’s behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary. Drugs get everyone — politicians, scientists, teachers and parents — off the hook. Everyone except the children, that is.”
Sroufe created a straw man he could easily attack: a group of brainless politicians, scientists, teachers, parents, and the manufacturers of drugs bent on finding the most simplistic, superficial means of understanding children and offering them “help,” which, of course, was doomed to worsen their plight.
The article was pure polemic that ignored reality. As a child psychiatrist who’s been in practice for 30 years, I have never met a parent, teacher, scientist, or anyone else who a) believed there is or ever could be a single solution; b) thought all of life’s problems could be solved with a pill; or c) rejected the need to pursue complex solutions to complex problems.
Sroufe’s article inflamed the debate instead of informing it; he promoted polarization, not understanding.
On the other hand, over the past year Alan Schwarz, the New York Times reporter who was nominated for the Pulitzer Prize in Public Service for uncovering the seriousness of sports concussions, has published a series of articles on the over-diagnosis of ADHD and the over-use of stimulant medication, especially Adderall. The articles have rocked part of the ADHD world. Various responsible experts with whom I spoke were angry, even outraged, at the reporting, which they thought was biased. Rather than joining the fray, I decided to reach out to Schwarz and see what he was up to.
Since then we’ve met several times, have exchanged phone calls and emails, and have learned from each other. He is an excellent reporter working to call attention to the times when ADHD is over-diagnosed and medication too easily dispensed, sometimes with disastrous consequences. I’ve concluded that he is, in fact, doing the world in general, and the ADHD world in particular, a favor. He urges us to educate doctors and other professionals who diagnose ADHD and prescribe medication, so that we can achieve the best standards of care.
I do wince at the articles, though, because I fear people will be scared away from getting the help that they might need. When I asked Schwarz about this, he replied, “When you write an article about a plane crash, you do not also report on the number of planes that land safely.” He’s been reporting on the plane crash of over-diagnosis and treatment, and straining to provide balance to the arguments. It’s up to us to learn the important lessons from what he’s uncovered, and it’s up to us, not Schwarz, to let people know about the planes that land safely.
Another man who is taking the world of ADHD to task is Dr. Richard Saul. Not a reporter but a clinician, he’s written a book called ADHD Does Not Exist: The Truth About Attention Deficit Hyperactivity Disorder, which will come out next month.
My problem with the book is its title. It’s what publishers call a “selling title,” designed to get people to buy books. It is ironic, though, that a book that purports to tell the “the truth” (always a suspect promise) has, as its title, a blatant falsehood.
ADHD is a shorthand term for a collection of symptoms that most assuredly do exist. One may quarrel with the shorthand term, as I certainly do, but no one with eyes to see and ears to hear would contend that there are no children or adults who meet the diagnostic criteria for ADHD as laid out in the DSM-V. In fact, there are millions of children and adults who meet the definition of ADHD. To say, then, that it does not exist is like saying that the nose on your face does not exist. You may not want to call it a nose, but whatever you call it, it’s there.
So it is with ADHD. Dr. Saul does make a valid and important point in his book, a point that the title unfortunately buries: Different causes may lead to many of the symptoms summarized in the diagnostic shorthand term, ADHD:
> Some of the symptoms may be the result of poor vision, poor hearing, or a hyperactive or hypoactive thyroid gland.
> Some may result from child neglect or abuse.
> Symptoms may result from too much time spent on electronics and not enough time spent at family dinner.
> They may be caused by spousal abuse, drug abuse, caffeine abuse, or Internet abuse.
> They may be caused by a lack of human connection, or by toxic human connections.
> They may be caused by genetics, head injury, lead poisoning, or lack of oxygen at birth.
> The may be caused by depression, an anxiety disorder, or the heartache of romance.
In other words, people may show many of the symptoms associated with ADHD for many different reasons. That’s why a careful diagnostic workup is so important. I commend Dr. Saul for pointing this out in his book. A more accurate title, though not nearly as sensational, might have been, ADHD Is Not Always What It Seems to Be.
I have ADHD, and I have treated thousands of adults and children who have the condition over the past three decades. To say that every case of ADHD has some cause other than the genetic wiring associated with the condition, to say that every case diagnosed is the result of the diagnostician’s overlooking some other underlying cause and condition, strikes me as hyperbole in the service of a selling title. It’s regrettable that Dr. Saul could not let “the truth” sell itself.
Years ago I got into a debate on public radio with a man who’d written a book that claimed that every case of ADHD was caused by poor parenting. When I pressed him, he remained adamant. “Every case,” he said pounding the table. “It’s all about bad parenting.”
Some day, when we’ve sorted out the complexities that combine to create the fascinating condition so misleadingly named ADHD, we may be able to talk about what causes every case, and we may be able to define more precisely what ADHD is, and what it is not. But we are not there yet.
We must, as Alan Schwarz reminds us, do all we can to take care when we make this diagnosis and offer treatment. But we must not do what Alan Sroufe did and inflame the debate through reductive rhetoric, or do what Dr. Saul’s title suggests and walk away from the condition as if it were not there.