Dangerous Distraction

Jason Sholl from the May 2000 issue

(Page 2 of 2)

Several comparisons point in that di-rection. For one thing, ADHD rates vary dramatically with socioeconomic background and sex. ADHD-diagnosed children overwhelmingly tend to be middle or upper-middle class and white. They also tend to be male--by a ratio of four or five to one. And yet Jacobson reports that "the girls in my sample were just as `ADHD' as the boys, even though they almost never get labeled as such." ADHD rates also vary dramatically between countries. In the United Kingdom, for instance, fewer than 1 percent of elementary school students are diagnosed with ADHD--less than a third of the U.S. rate. Even the name of the disorder, according to psychiatrist Thomas Armstrong, has changed more than 25 times during the last century. (Earlier names for ADHD-like behavior include "Oppositional Defiance Disorder," "Conduct Disorder," and even garden-variety "Hyperactivity.") While many, including Walker and DeGrandpre, would like to frame the ADHD debate as one of biological disease vs. cultural artifact, it may simply be that hyperactivity lies in the eye of the beholder.

Even Walker--who believes that hyperactivity usually has an underlying biological cause, even if it isn't always "ADHD"--points out that there are few behavioral differences between ADHD-diagnosed children and gifted children. Both demonstrate boredom or resort to daydreaming in the classroom; both question rules, customs, and traditions; and both typically abandon tasks that seem irrelevant to them. While no one believes that ADHD and giftedness are the same thing, the comparison does highlight the importance of labeling in this debate--and not only in this debate.

During the past few decades, unpleasant aspects of human experience--everything from grief to shyness to anxiety--have increasingly fallen under the heading of medical illness. This trend was reflected in psychiatrist Peter D. Kramer's 1993 bestseller Listening to Prozac, which popularized the idea of "cosmetic pharmacology." Hyperactivity may be yet another example of a disagreeable personality trait that has been medicalized.

While Listening to Prozac raises poignant ethical questions about the medical construction of normality, the fact remains that drugs like Prozac and Ritalin do, to some extent, correct undesirable behaviors. Ritalin helps most children do at least a little better in school. Why should this advantage be limited to those with an ADHD diagnosis? But if it's not, what meaning does "Attention Deficit Disorder" really have? Does the target of treatment become the report card?

The Hyperactivity Hoax is written for concerned parents, and Walker is therefore careful to avoid incriminating them in the national ADHD epidemic. But in an uncharacteristic passage, he wonders why some parents are so "determined to have their children classified as handicapped by hyperactivity or attention deficit disorder." The answer isn't much of a mystery: An ADHD label can open the door to a variety of benefits. For poor families, the label can mean money--up to an additional $484 a month in Supplemental Security Income benefits. For students, an ADHD diagnosis can mean untimed SATs, MCATs, and LSATs as well as extra time to complete routine assignments in high school and college. Given ADHD's demographics, some even argue that the label effectively functions as "affirmative action for affluent white people," as health pundit Mary Eberstadt puts it.

Walker briefly touches on these perverse incentives, but he still argues that almost all ADHD-diagnosed children are victims of haphazard medical care. DeGrandpre, citing Ritalin's history as a street drug and cases of Ritalin-related deaths, seems to agree about whom this disorder puts at risk. But improperly diagnosed children aren't the only victims here.

Questions about ADHD have much to do with the distribution of scarce educational resources. By one estimate the U.S. educational system spends close to $9 billion each year on learning-disabled students (this figure does not include the $3 billion spent on related medical visits and prescription drugs). This is four times what was spent last year on federal Head Start programs. Such disparities are hard to defend when there is no clear evidence that ADHD is a legitimate disability. Is it right to selectively label students as "disabled" for exhibiting what may simply be the normal behaviors of childhood? And what is the justification for helping certain students conform to a school's behavioral standards while denying aid to others? These are difficult questions that popular books such as The Hyperactivity Hoax and Ritalin Nation fail to address.

In the end, what has made DeGrandpre's "Ritalin Nation" not only possible but inevitable is the framing of the ADHD debate itself--a debate that pits nature against nurture while ignoring the distinction between normal and diseased. As science gains the ability to adjust not only our bodies but our personalities, we have responded by labeling as psychiatric illnesses many patterns of behavior that were previously considered perfectly normal. If medicine can fix it, we reason, then there must have been something wrong. In the case of ADHD, we've become obsessed with trying to determine what that something is.

The 4 million American children being drugged with a chemical virtually identical to cocaine are victims of this obsession. So are the children denied the educational luxuries given to their ADHD-diagnosed peers. Over the course of a decade, our search for the roots of ADHD has revealed remarkably little. It's time we stopped looking for invisible causes and started asking about the very real costs that the idea of ADHD imposes on our children--those who are diagnosed with the disorder as well as those who are not.

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