According to new CDC data, one in 10 American kids, including nearly a fifth of boys in high school, have been diagnosed with attention deficit hyperactivity disorder (ADHD). The New York Times worries that "the A.D.H.D. diagnosis and its medication are overused in American children." That sounds plausible, especially since ADHD diagnoses have increased by 41 percent in the last decade. But since ADHD is a malleable concept based on subjective impressions, it is hard to know what it means to say that someone who has received that diagnosis does not really have it.
New York Times reporters Alan Schwarz and Sarah Cohen say stimulants such as Adderall, Ritalin, or Vyvanse "can drastically improve the lives of those with A.D.H.D. but can also lead to addiction." What do they meant by "addiction"? Presumably something other than relying on a daily dose of a drug to function normally, since that describes what they consider to be the appropriate use of prescription stimulants. Similarly, although Schwarz and Cohen warn that ADHD medication can be "abused," the line between use and abuse seems pretty fuzzy. "While some doctors and patient advocates have welcomed rising diagnosis rates as evidence that the disorder is being better recognized and accepted," they write, "others said the new rates suggest that millions of children may be taking medication merely to calm behavior or to do better in school." But isn't that exactly what you would expect from a drug aimed at reducing hyperactivity and boosting attention?
Maybe abuse is what happens when someone is misdiagnosed and starts taking Adderall or another stimulant to treat a nonexistent disease. Schwarz and Cohen explain that "A.D.H.D. is described by most experts as resulting from abnormal chemical levels in the brain that impair a person's impulse control and attention skills." So determining whether a kid has been properly diagnosed should be straightforward: If he has "abnormal chemical levels," he has ADHD; if not, he doesn't. But it turns out that all the talk about chemical levels is mere supposition. As Schwarz and Cohen concede, "the disorder has no definitive test and is determined only by speaking extensively with patients, parents and teachers, and ruling out other possible causes—a subjective process that is often skipped under time constraints and pressure from parents."
In other words, it is impossible to say for sure whether someone diagnosed with ADHD actually has it. A subjective assessment of whether he meets the criteria laid out by the American Psychiatric Association (APA) is the best we can do. Furthermore, those criteria will change next month, when the fifth edition of the APA's Diagnostic and Statistical Manual of Mental Disorders is scheduled to be published. Under DSM-V, ADHD symptoms must appear by age 12 rather than the current 7, and they need only "impact" daily activities, rather than causing "impairment." Those changes, Schwarz and Cohen say, are expected to result in "higher rates of diagnosis." If someone who is diagnosed with ADHD under the new, looser criteria would not have qualified under the old definition, does that mean he has been misdiagnosed? Since ADHD, like other mental disorders, is whatever the APA says it is, I'm not even sure that's an intelligible question.
Judging from Schwarz's previous reporting on the "Risky Rise of the Good-Grade Pill," I gather that he believes something like this: When a below-average student takes Adderall to improve his academic performance, that is legitimate treatment of a bona fide disease. When an above-average student does exactly the same thing, that is drug abuse. This seems like moralizing masquerading as medicine.