Is ADHD a Pretext for Selling Speed?

New York Times reporter Alan Schwarz, who for the last year or two has been wondering what's up with all the speed kids are taking these days, has a long article in Sunday's paper on "The Selling of Attention Deficit Disorder." Unfortunately, Schwarz barely mentions the American Psychiatric Association (APA), the organization that identified ADD, later relabeled "attention deficit hyperactivity disorder" (ADHD), as a disease that can be treated with prescription stimulants such as Adderall, Ritalin, and Vyvanse. Instead he focuses on the companies that make those stimulants, which he accuses of encouraging "overdiagnosis" to maximize sales.

Schwarz surely is right that companies such as Shire, which sells Adderall, and Ciba-Geigy, which makes Ritalin, have a financial interest in pushing as broad a definition of ADHD as possible. But none of this would be possible without the APA's blessing, and Schwarz pays scant attention to the problem of saying whether someone does or does not have a disease for which there is no objective test. Here is the sole reference to the APA in his 5,300-word story:

Like most psychiatric conditions, A.D.H.D. has no definitive test, and most experts in the field agree that its symptoms are open to interpretation by patients, parents and doctors. The American Psychiatric Association, which receives significant financing from drug companies, has gradually loosened the official criteria for the disorder to include common childhood behavior like "makes careless mistakes" or "often has difficulty waiting his or her turn."

ADHD, like every other condition listed in the APA's Diagnostic and Statistical Manual of Mental Disorders, is whatever the current edition of the DSM says it is. Since the official definition is broad and "open to interpretation," it is hard to know what Schwarz means by "overdiagnosis." Here is his best stab at explaining:

Few dispute that classic A.D.H.D., historically estimated to affect 5 percent of children, is a legitimate disability that impedes success at school, work and personal life. Medication often assuages the severe impulsiveness and inability to concentrate, allowing a person's underlying drive and intelligence to emerge.

But even some of the field's longtime advocates say the zeal to find and treat every A.D.H.D. child has led to too many people with scant symptoms receiving the diagnosis and medication. 

Evidently Schwarz accepts the legitimacy of Classic ADHD while turning up his nose at New ADHD. But since neither purported disease can be objectively verified, it is not clear on what basis Schwarz prefers the narrower definition. It seems to me that Schwarz, who started his career as a sports reporter, is making a moral judgment about when it is acceptable to use performance-enhancing drugs: If you have a "legitimate disability," it's OK, but not if you are merely trying to turn a B+ into an A. He dresses up this moral judgment in the language of medical science, but it remains a moral judgment, and a questionable one at that.

As Schwarz concedes, stimulants help many people, adults as well as children, pay attention and perform better in school and at work. The relevant question is not, as Schwarz seems to think, whether all of these people "really" have ADHD (whatever that means) but whether the benefits of stimulants outweigh their risks. Schwarz tries mightily to magnify those risks:

Psychiatric breakdown and suicidal thoughts are the most rare and extreme results of stimulant addiction, but those horror stories are far outnumbered by people who, seeking to study or work longer hours, cannot sleep for days, lose their appetite or hallucinate. More can simply become habituated to the pills and feel they cannot cope without them.

Notice how Schwarz mixes "rare and extreme…horror stories" with a common, often welcome effect of stimulants, implying that users experience suicidal thoughts, insomnia lasting for days, and hallucinations (presumably due to the aforementioned sleep deprivation) about as often as appetite suppression. His final warning—that people may "become habituated to the pills and feel they cannot cope without them"—is little more than negative spin on a situation he elsewhere describes as taking a "medication" to compensate for a "disability." Schwarz's most laughable attempt to scare people away from stimulants is his grave warning that "these drugs are classified by the government among the most abusable substances in medicine." Yes, and according to the government, marijuana is even more dangerous.

I don't mean to imply that prescription stimulants—or their illegal counterparts, many of which, impurities aside, are chemically very similar or identical (e.g., Desoxyn vs. black-market meth)—carry no hazards at all. But the risks are the same whether or not consumption of the drug has been blessed by a doctor's prescripton, and whether or not Alan Schwarz thinks that prescription should have been written. People should be free to weigh the risks for themselves, without having to obtain the magical piece of paper that transforms crime into medicine.