The growth of ADHD diagnoses and drugs in America raises a question: Is anyone out there paying attention?
Since 1980, the year attention-deficit/hyperactivity disorder was first listed in psychiatry’s diagnostic manual, its has become the most prevalent mental disorder among children, exceeding depression and anxiety combined.
Eleven percent of American children have been diagnosed with ADHD. Among boys, the number approaches 1 in 5. The average age of diagnosis is 7, according to the Centers for Disease Control and Prevention.
Although the American Academy of Pediatricians says the first course of treatment should be talk therapy, 70 percent of children diagnosed with ADHD take drugs, and half don’t see a therapist at all. In 1990, 600,000 children in the U.S. took ADHD drugs. By 2013, 3.5 million did.
This provides fodder for skeptics who say ADHD is a profit-driven scam foist on Americans by the pharmaceutical industry. They note the lack of measurable factors in ADHD diagnoses, and a markedly uneven distribution in cases worldwide. Seventy percent of ADHD drugs, primarily stimulants, are prescribed in the U.S.
California child psychologist Marilyn Wedge refuses to call inattention and hyperactivity a disorder, saying what doctors call ADHD is “typical childhood conduct, or a normal childhood reaction to stress in the child's life."
Others say the symptoms indicate a malfunctioning brain and that the right medication is life-changing. “Can it ruin your life? Yes, it can; it can be a devastating disorder. But it also has many positives, depending on how you manage it,” said Dr. Edward Hallowell, who runs ADHD treatment centers in Boston, New York, San Francisco and Seattle, and has been treating it for 30 years.
But even those who prescribe and take ADHD medication concede the drugs are abused and can be dangerous for those who don’t have the condition. An accurate diagnosis is important, yet unlike strep throat or diabetes, there is nothing to test or measure: "The closest thing to test for it is history," Hallowell said.
The Adult Attention Deficit Disorder Center of Maryland offers an online screening test for ADHD. The questions include: “How often do you have difficulty keeping your attention when you are doing boring or repetitive work?” and “When you have a task that requires a lot of thought, how often do you avoid or delay getting started?” – things that lots of neurologically typical people do.
Similarly, the hallmark symptoms of ADHD — inattention, hyperactivity and impulsivity — are symptoms of childhood itself, argues Wedge, author of “A Disease Called Childhood, Why ADHD Became an American Epidemic.”
“Before it became a quote-unquote disorder in 1980, the kind of behaviors we call ADHD were called hyperkinetic reaction of childhood, and they were thought to be a reaction to a stressful situation in the child’s life, or an actual brain disease. If a child was subjected to trauma at home, or saw their parents fighting frequently, or had a brain tumor, then hyperactivity or inattention were seen as normal responses to these kinds of trauma and stress," Wedge said.
“Of course, for a boy, stress can be having to sit in a classroom for five hours at a stretch and not being able to run around and play. Yes, boys get fidgety. They want to get up from their chairs," she added.
At first, an ADHD diagnosis required an onset of symptoms at age 7 or younger. In 2013, that was changed to age 12. Recent studies have concluded that it can begin at any age.
“That’s due to drug industry pressure,” Wedge says. “What they’re doing, in my view, is taking a set a set of personality traits and treating them with performance enhancers.”
Some adults have admitted as much publicly. In personal essays in magazines such as Slate and The Atlantic, writers have confessed to experimenting with ADHD drugs in order to improve their focus and output. Teens and young adults use them to perform better on the SAT, GRE and MCAT. The New York Times has termed them "the good-grade pill." It's estimated that 44 percent of ADHD drugs in the U.S. will be taken by people over the age of 19 this year.
Unless an adult has a biological problem like meningitis or a brain tumor that affects mental performance, there’s no reason to take them, and ADHD drugs give people who use them an unfair edge over people who don't, Wedge says.
"They're mental steroids, which is ironic, because as a society, we’re opposed to steroids in sports, but not opposed to steroids to have us write better or take the bar or a medical exam," she said.
The Ritalin generation
Tyler Page was a Ritalin kid. Diagnosed at 8, he took Ritalin for eight years before he took himself off it at 16 without telling his parents. He’s now 39 and married, the father of two, and he's written and illustrated a graphic novel called "Raised on Ritalin" that he financed with a Kickstarter campaign.
Research for the book included his childhood medical records that he found when his parents divorced six years ago and he helped to clean out the house. When his oldest child, a daughter, started showing signs of ADHD, he was inspired to learn more about the medication he took and how it affected his life. He spent five years researching and writing the book, which he plans to self-publish in September.
"Raised on Ritalin" is an honest examination of what it's like to take more than 5,000 pharmacological stimulants in your formative years. It raises an eyebrow at the rate of diagnoses, but is ultimately sympathetic to his parents’ decision to medicate their son.
“If I look at where my parents were when I was a kid, they made the best possible choices that they could,” Page said.
Page says he doesn’t regret taking Ritalin, but notes that he has no Ritalin-free alternative life to which he can compare outcomes. He takes no medication now and says he occasionally still struggles with an inability to focus.
“As an adult, I come across as a quiet, responsible, goal-driven person. But there are days that if you ran through a diagnosis checklist, I might qualify," he said.
He notes that his parents saw a doctor for 18 months before putting him on medication.
“I don’t think that’s what happens in every case today. We have reached a point, especially in America, where many kids are prescribed drugs after a 25- or 30-minute visit with a primary care doctor. There are pills for everything today, and it’s the easiest thing to reach for," he said.
Among children ages 12 to 19, ADHD drugs are the most commonly prescribed drugs (trailed by asthma medication and antidepressants), according to the CDC. Although ADHD is classified as a mental disorder, half of ADHD children are diagnosed by their primary care physicians.
The drugs are not without side effects. FDA warnings for Ritalin include risk of sudden death and cardiac problems in children and adults; hypertension, mania, aggression and long-term growth suppression. (Page said he grew four to five inches in 18 months after going off Ritalin.)
Some children taking ADHD drugs develop tics, and loss of appetite and insomnia are common side effects.
The Vermont test
Hallowell, the Boston psychiatrist who runs ADHD clinics in four cities and has written a dozen books on the topic, said he's known for decades that the condition can come on in adulthood. But he says that it is easily misdiagnosed by what he calls modern-life disease, or "CrazyBusy" (the name of one of Hallowell's books).
There may not be a clinical test for ADHD, but there's one he calls "the Vermont test." Put someone on a farm in Vermont for a week, he says. If, afterward, she is relaxed and plowing the field, she has a severe case of modern life. If she turned the farm into an amusement park, she has ADHD.
“The point is, one is completely created by your environment. The other is part environment, part genetics."
The right medication, Hallowell says, transforms lives. He recently diagnosed a 50-year-old woman, an Ivy League graduate who has struggled with underachievement but was told by other doctors that she had depression and anxiety.
“When I explained it to her, she started to cry and said, ‘I’m 50 years old, why has no one ever explained this to me before?' It’s an incredibly life-changing diagnosis," Hallowell said.
Whether symptoms of ADHD are caused by modern life or faulty brain wiring, some people find relief with therapies don't involve medication. Recent studies on exercise and ADHD show improvement after a single session of vigorous exercise, and one 2014 study found that morning exercise, in particular, can help children.
Some people advocate meditation; others, high-protein, low-sugar diets. (The Feingold Diet, named after the pediatric allergist who developed it, leads the pack.) Vitamins that are said to improve ADHD symptoms include magnesium, B3, zinc and omega-3 fatty acids.
Parents of ADHD children should also explore nonmedical interventions, such as asking teachers for accommodations, such as letting the child sit at the front of the class so he won't be distracted by classmates.
Most importantly, Page stresses that an ADHD diagnosis and treatment with drugs should not be done quickly — for children or adults.
"The whole issue of adults getting diagnoses, without having had a diagnosis as a child — I don’t want to call phony on that outright — but maybe they’re taking the easy way out,” he said.