Viewpoint: ADHD Isn’t A Metaphor

With all the alarmist reports about a rise in rates, we'd be wise to remember that it's a developmental disorder, not a symptom of societal ills

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Let’s say that rates of ADHD diagnoses among kids in America are continually rising. Let’s say that stimulant medication use — both prescribed by doctors, and as the result of illegal trade with friends —  is on the rise, too. What do we make of that information? What do we do with it? In particular, how do we use it to improve children’s and teenagers’ lives?

The answers speak volumes about where we are as a society and where we ought to be headed.

The default response, every time we get news about any sort of uptick in the diagnosis and treatment of children’s mental disorders, is to issue condemnations of bad parents, bad doctors, bad teachers, and bad schools. (Not to mention big bad pharma, of course, which, it seems, will never rise from the bed of nails it has built for itself  over the years.)

A more thoughtful response would be to ask what the rise means. Are more children with the disorder who previously went unnoticed — girls, African Americans, Latinos, notably — now being identified and counted? We know that’s true, and it accounts for some of the rise. Does the increased social acceptability of the ADHD diagnosis mean that it’s the “label” doctors are most likely to stick on kids who, in addition to distractibility, have a whole host of more scary-sounding problems, in the hope of getting reluctant parents to sign on for some sort of treatment? Does the decreased stigma surrounding ADHD (the commonly-heard, “everyone has it, so it’s no big deal” view) mean that parents who’ve been told their kids have “attention issues” in addition to, say, a learning disability or a mood disorder, will cling to — and report to survey-wielding researchers — just the banal-sounding ADHD label?

(MORE: The Myth of the Overmedicated American Teen)

And, much more troublingly, are children who don’t have the disorder now being diagnosed and treated for it? And, if so, where is this happening, how is it happening, and why?

The raw, unanalyzed, not-yet-peer-reviewed numbers that the New York Times, bizarrely, led the paper with last week don’t answer any of those questions. And since the CDC won’t verify their accuracy (precisely because they haven’t yet finished processing their own numbers), I’m not going to repeat them here. And I don’t need to. Previous surveys have shown a steady rise in the rate of ADHD diagnoses over the years. Previous research has also raised disturbing questions about the possibility that some children without actual ADHD are now being diagnosed and medicated for it.

But again, that research, for now, hasn’t provided any clear indication of what’s happening with those kids. Another recent CDC study — one of the largest, community-based, epidemiological studies ever conducted on ADHD prevalence — found last fall that that only about one-third of the children taking medication for ADHD met stringent criteria for the disorder . Exactly what that troubling finding means remains a mystery, Susanna Visser, the lead epidemiologist for the Child Development Studies team in the National Center on Birth Defects and Developmental Disabilities at the CDC, and one of the study’s co-authors, told me last week. It may, she said, mean that the medicated children who didn’t meet the study’s ADHD criteria did, in fact, have the disorder, and were having their symptoms controlled so well by meds that they were no longer discernible. Or it could mean that they were just misdiagnosed. “One group may have been appropriately treated and no longer met criteria and one group may have been inappropriately treated,” Visser said. The medicated children, over all, she added, “had a higher symptom count than those who were not medicated and didn’t meet criteria.” Visser’s CDC team is investigating those possibilities right now, and expects answers in the not-too-distant future.

(MORE: Is There Really A “Boy Crisis”?)

In the meantime, given the paucity of truly meaningful information, we might pause a moment to consider the effect — the actual, lived effect — of our current cultural obsession with ADHD and the stimulants used to treat it. Let’s take, for example, Alan Schwarz’s comment in the New York Times last Monday that “an A.D.H.D. diagnosis often results in a family’s paying for a child’s repeated visits to doctors for assessments or prescription renewals. Taxpayers assume this cost for children covered by Medicaid, who, according to the C.D.C. data, have among the highest rates of A.D.H.D. diagnoses.” Will this lead to a new round of Congressional hearings on the Medicated Child? Will those hearings comprise any real discussion of the toxic stressors of poverty — conditions long-known to contribute to mental health disorders, including ADHD — or, even more unlikely, to policy solutions that could reduce stress for impoverished families? Or will the focus on the pill-popping young poor simply lead to more roadblocks to treatment for a particularly vulnerable group of children — and parents — already deprived of access to good mental health care?

I wonder, too, what will happen to the children who don’t exhibit the most extreme forms of disruptive, socially and academically debilitating, ADHD: the big temper outbursts, the potentially dangerous, running-into-traffic hyperactivity, the bully-bait social cluelessness. I wonder, if, soon, insurers will decide they’re not entitled to treatment (especially the more expensive, non-drug treatments). I wonder if school districts will decide they don’t qualify for accommodations.

Many of us, myself included, worry deeply about the culture in which our children are growing up. We worry about the pressures, the competition and the class sizes, the lack of free time, the cloistered indoor time, the screen time, the stress. And we worry about the extreme measures some kids are using to cope with that stress: whether it’s cutting, or binge-drinking, or abusing stimulant meds. But ADHD isn’t about all that. It’s a developmental disorder — and while it’s true that its precise definition is linked to all sorts of values and understandings unique to our time, it is not a symptom of social pathology. It is a medical condition, not a metaphor.

If we truly care about kids — all kids — we’d do well to keep our stories straight.

MORE: The Denial of Mental Illness Is Alive and Well