The Hyperactivity Hoax: How to Stop Drugging Your Child and Find Real Medical Help, by Sydney Walker III, New York: St. Martin's Press, 260 pages, $23.95/$6.99 paper
Ritalin Nation: Rapid-Fire Culture and the Transformation of Human Consciousness, by Richard DeGrandpre, New York: W.W. Norton, 284 pages, $23.95
A 1998 conference on Attention Deficit/Hyperactivity Disorder (ADHD) sponsored by the National Institutes of Health concluded that "after years of clinical research and experience with ADHD, our knowledge about the cause or causes of the disorder re-mains speculative." The uncertainty hasn't stopped any number of researchers, journalists, and pundits from commenting on everything from the tricky ethics of diagnosing the disorder to the dangers of treating it with Ritalin. The debate over ADHD --biological reality or social construction, legitimate learning disability or cultural artifact--is one of the most heated in science and education today. And while the appearance of two new books on the subject doesn't promise answers to any of these thorny controversies, it does mark an opportune moment to sift through a decade's worth of information on ADHD and ask what, if anything, we have learned from the national experiment that has made this term a household word.
In The Hyperactivity Hoax: How to Stop Drugging Your Child and Find Real Medical Help, neuropsychiatrist Sydney Walker calls attention disorders "symptoms of modern life, rather than symptoms of modern disease." In Ritalin Nation: Rapid-Fire Culture and the Transformation of Human Consciousness, psychologist Richard DeGrandpre argues that attention disorders are the inevitable byproducts of a culture-wide addiction to speed--to cellular phones, to faxes and e-mail, to hard-driving rock music and seven-second sound bites on TV. Both believe that the tendency to portray ADHD as a purely "biological" condition, with Ritalin as its "cure," has more to do with culture and politics than with science. In fact, if these two books can be considered representative, then current thought about ADHD is so firmly on the side of nurture that one is left wondering what evidence, if any, was ever advanced on behalf of nature.
People undoubtedly felt differently 10 years ago, when newspaper headlines blithely announced genes "responsible" for everything from homosexuality to migraine headaches. One seminal experiment on ADHD from around this time seemed to demonstrate differences in brain metabolism between normal and ADHD individuals. Its results were never reproduced. Another early study found that a peculiar gene was overwhelmingly present in families with a history of ADHD. But as Walker notes in The Hyperactivity Hoax, this "doesn't mean that hyperactivity is a genetic disease. It means that many genetic diseases can cause hyperactivity." In fact, about the only thing that a decade of research on the disorder has established beyond doubt is that Ritalin does help children concentrate. Given that Ritalin helps just about anybody concentrate (as do amphetamines, its pharmaceutical cousins), one can see how the biomedical model of ADHD has become the subject of such fierce attack.
It was never the strength of the science, however, that carried the day for the biomedical view. All of a sudden there was a legitimate medical diagnosis that explained away uncooperative children, eased parental guilt, relieved teachers' anxiety, and lined the pockets of pharmaceutical companies and HMOs. Is it any wonder that this diagnosis caught on? As the opening sentence of an early book on the subject, Edward Hallowell and John Ratey's Driven to Distraction, prophetically (though unironically) observed, "Once you catch on to what this syndrome is all about, you'll see it everywhere."
Both Walker and DeGrandpre spend a good deal of time trying to explain this national fixation, which is responsible for roughly 9 million Ritalin prescriptions written in the past year alone. Walker's explanation centers on hurried doctors who treat symptoms without identifying underlying causes and overworked educators who force the ADHD label on any child who is difficult in class. Managed health care is indicted for pressuring physicians into making hasty diagnoses, and even the Western biomedical model itself is not above blame for its reductionist "disease-ification" of everyday life. "Hyperactivity is not a disease," writes Walker. "It's a hoax."
Long the director of the Southern California Neuropsychiatric Institute and a practicing child psychiatrist, Walker has spent years crusading against the misdiagnosis of physical ailments as psychiatric disorders. His 1994 bestseller, A Dose of Sanity: Mind, Medicine and Misdiagnosis, was his first foray into the cultural construction of mental disease, and his experience in the field is obvious from his writing, which is filled with anecdotes and case studies. Some of The Hyperactivity Hoax's most memorable passages are Walker's detailed clinical accounts of hyperactive children diagnosed with ADHD but in fact suffering from diabetes, brain tumors, lead poisoning, or other potentially fatal illnesses. Most of these maladies, Walker claims, would have been revealed by more careful diagnostic sleuthing.
But The Hyperactivity Hoax is a considerably more ambitious project than A Dose of Sanity. According to Walker, "Three to five percent of U.S. schoolchildren, and more than ten percent of elementary school-aged boys, currently take Ritalin or other drugs for hyper behavior, attention deficits, and impulsiveness." If the cultural production of disease was once problematic, it has since become epidemic.
So epidemic, in fact, that some, like DeGrandpre, are tempted to see attention disorders as woven into the very fabric of contemporary society. "Ritalin Nation is the story of the fastest culture on earth--American culture," writes DeGrandpre, "and how this culture of speed has transformed human consciousness and, in doing so, created a nation hooked on speed and the stimulant drugs that simulate speed's mind-altering effects." For DeGrandpre, hyperactivity can ultimately be reduced to boredom--the impatience of those used to the rapid-fire pace of MTV, Nintendo, and rollerblading.
While DeGrandpre's theory may seem intuitive, especially to those who lament the acceleration of modern life for other reasons, it is unsupported by any original research. DeGrandpre's dependence on generalized observation is as odd as it is unsatisfying. As both a professor of psychology at St. Michael's College and a fellow at the National Institute on Drug Abuse, he is in an excellent position to understand the full complexity of the ADHD phenomenon--its psychological as well as pharmacological aspects. Unfortunately, his long, subjective account of our society's "great misadventures in time" doesn't fully address either.
Moreover, as DeGrandpre himself admits, he is hardly the first to decry the hectic pace of modern life. There has been a long tradition in Western culture, from George Eliot to Søren Kierkegaard to Milan Kundera, of searching out broad cultural meanings from the perceived collapse of time. But before we start asking what ADHD means, don't we have to know what it is?
According to the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a child has ADHD if, for a period of six months, he or she exhibits at least six symptoms from a list of 14. Among them: "often has difficulty organizing tasks and activities," "is often easily distracted by extraneous stimuli," "often fidgets with hands or feet or squirms in seat," and "often blurts out answers before questions have been completed." As Walker and DeGrandpre both note, parents are frequently surprised to learn that the clinical observation of these symptoms, over the span of a 10-minute doctor's consultation, is the sole basis of an ADHD diagnosis. After all, aren't all kids "easily distracted" some of the time? Isn't a certain amount of hyperactivity a natural part of childhood?
While such questions seem obvious, for years researchers have been reluctant to take them seriously, not least because so many in the field are already heavily invested in a biomedical view of the disorder. In a rare exception last November, University of Massachusetts anthropologist Ken Jacobson completed the first behavioral study of ADHD involving a population of "normal" children. He observed two groups of English schoolchildren, one diagnosed with ADHD and the other not. Noting actions such as "giggling," "squirming," and "blurting out" on a 35-category behavioral checklist, he found no significant behavioral differences. "In both groups you'd have kids exhibiting concentration, alertness, and control at certain moments, and restlessness, inattention and defiance at others," Jacobson said. In a December interview with Lingua Franca magazine, he argued: "If you're predisposed to label any child as ADHD, the distracted troublemaker or the model student, you'll find a way to observe these behaviors. And if you're predisposed not to find it, then you'll find ways of overlooking these behaviors."
While much recent writing about ADHD, including The Hyperactivity Hoax and Ritalin Nation, has attempted to defend a view of the disorder as culturally shaped against claims of biological reality, research like Jacobson's suggests this distinction may be putting the cart before the horse. Regardless of where critics locate the blame for our country's ADHD epidemic--managed health care for Walker, the hurried pace of modern life for DeGrandpre, and miswired brains for many others--almost everyone agrees that ADHD is either a genuine disorder in its own right or a sign of some other, undiagnosed problem. But is it possible that the 700 percent increase in Ritalin prescriptions since 1990 has had nothing to do with nature or nurture?
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.