The media tends to fixate on a ‘problem’ even when there has been no noticeable change. They sensationalize even the most minuet evidences that show a problematic area of society growing worse. The summer of 2001 was known as “The Summer of the Shark”, prominently due to increased media coverage of shark attacks. An 8 year old named Jessie Arbogast was attacked by a shark in early July of that year, and somehow this singular event spawned a massive media outpouring. Sharks attacks became a national epidemic overnight. The outcry even had legislative consequences, as a law was passed in Florida that banned people from feeding sharks. Sharks made it to the cover of Time magazine, headlined using big bold letters that screamed “SUMMER OF THE SHARK”(we’ll tell you how to survive if you buy an issue today!). Beach-goers began to fear for their lives, families canceled vacations nationwide, travel agencies lost money, videos of large packs of sharks made it to nearly every nightly news broadcast, and then it all ended. One day sharks were a terror, and the next they were a mere afterthought, lost in the chaos that followed the horrible tragedy of the September 11th terrorist attacks.
The ‘Summer of the Shark’ taught us a profound lesson: don’t always believe the hype. At the very least, we all must be skeptical when the media purports an epidemic based on flimsy evidences, especially when they spawn from anecdotal accounts. According to the International Shark attack File, (http://www.flmnh.ufl.edu/fish/Sharks/Statistics/2001attacksummary.htm) 2001 actually saw a substantial decrease in shark attacks as compared with the previous year, and the total number of deaths dropped from 12 to 5. Almost as many people die every year from a vending machines tipping over as they do from shark related attacks, so while they’re something people who frequent beaches need to be aware of, it’s not really a problem that should have taken control of our nations subconscious. So what does this have to do with the ADHD epidemic? Simply put, the ‘ADHD epidemic’ is more due methodological changes than it is based on an increasing number of troubled individuals. According to a study in 2009 (www.ncbi.nlm.nih.gov/books/NBK83978/#background.s2) the “underlying prevalence of the disorder in children appears to have been relatively stable since the 1980s, to the extent that is has been measured using identical methods.” The ‘epidemic’ can be seen as the result of changes to the criteria in which someone is diagnosed as having ADHD, and not due to increases in the rate of ADHD related behavior. But just like with “The Summer of the Shark”, you would never guess this by watching the national media. Unlike with the previous shark example, the rate of diagnosis does look, on the surface at least, to be growing in numbers. So while the national media may have more of a solid foundation from which to push their claims of a ‘growing epidemic’, what they fail to do is present the case within necessary context. This misidentification of the problem, the liberalization of ADHD criteria as opposed to increased rates of ADHD related behavior, is dangerously misleading the national public. This misidentification has spawned a litany of articles that mistake the underlying issues, for example, a quick google search brought up this article, “Do Video Games Cause ADHD? 3 Ways to Keep Your Kids Safe”. (WE MUST PROTECT THE CHILDREN!) http://health.usnews.com/health-news/blogs/on-parenting/2010/07/06/do-video-games-cause-adhd-3-ways-to-keep-your-kids-safe. Now without analyzing the study they cite in-depth, I cannot say for certain if there is not a real cause and effect correlation. While I think it may be more likely that children who play more video games already have greater ADHD tendencies (causing this to be a spurious correlation), I will not discount idea altogether. ADHD certainly may be associated with some of the cultural changes made in the last 20-30 years, but as noted earlier, this gets away from the real issue which is how we define who has ADHD in the first place. This is significant because who we really need to question aren’t the gaming companies, movie companies, or popular websites that seem to be taking more and more of our children’s attention, and instead we need to question the people who are telling us what constitutes ADHD to begin with. Unfortunately, these people are more than happy to remain relatively anonymous and outside of the national spotlight.
People who suffer from ADHD have most likely been around since the birth of man. But a peculiar thing happens when deviant types of behaviors go from being labeled ‘odd’ to a full blown diagnosed illness, suddenly we see it everywhere. So to say that ADHD first came into existence when its ancestral diagnosis of “Hyperkinetic Reaction of Childhood” was included in the DS-II in 1968 would be completely missing the point. Simply attaching an “illness” label to a behavior doesn’t mean it wasn’t common or as widespread as it was post-labeling, it is just much more noticeable and easier to identify common behaviors in afflicted individuals. As it was, pre 1968 the idea of people suffering from hyperactive tendencies wasn’t exactly unknown. In 1902 Dr. Still wrote about a disorder he called “Defect of Moral Control”, which he associated with a medical illness. Even as far back as the 1700’s, authors such as Sir Alexander Crichton wrote about people suffering from “mental restlessness”. So as we can see, behaviors now associated with ADHD have been on the radar of scientists and doctors for quite some time. Between 1902 and 1968, what is now seen as ADHD went through a number of semantic changes. It was known as “Minimal Brain Dysfunction” for a long period, and with the advent of Ritalin in 1956, people with the condition began receiving treatment to relieve their hyperactive tendencies. Once the third DSM volume came out in 1980, Hyperkentic Reaction of Childhood received yet another revision, this time it was to be referred as ADD (Attention Deficit Disorder). A revision of DSM-III (known as DSM-III-R) was released in 1987, and this was the volume that gave birth to the conditions current label of ADHD, otherwise known as Attention Deficit Hyperactivity Disorder. Terminology certainly wasn’t the only thing that changed, as it was, the criteria in which someone was labeled having MBD, HRC, ADD, or ADHD changed as well. For a long period of time the condition was believed to be purely psychological in nature, but was later revised to include environmental causes as well.
Currently ADHD is comprised of three different subtypes: hyperactive/impulsive (HI), predominantly inattentive, and both inattentive and hyperactive (http://www.additudemag.com/addnews/70/6914.html) . In the upcoming DSM revision, set to come out in 2012, these subtypes may be either eliminated and or separated into completely different conditions. One reason for the potential change is that a lot of kids, who are not hyperactive, rather are simply inattentive, are being diagnosed with ADHD. This can be problematic when doctors and physicians attempt to treat the condition. The guidelines of what constitutes ADHD are difficult to pinpoint, as a council member of an ADHD forum in the movie Generation Rx aptly proved. Despite the fact he had diagnosed hundreds of children with ADHD, he was unable to provide a clear definition for the disorder, how then are doctors less experienced with diagnosis expected to do so?
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With the social stigmatization of being labeled ‘ill’ you wouldn’t expect so many parents to want their children diagnosed with ADHD, yet this is what often happens. In a BBC article (http://www.bbc.co.uk/news/health-12359070) parents in the UK will "exaggerate what exactly is happening at home, particularly in terms of aggressive behavior, violent behavior, breaking furniture and so on, in order to get a health care allowance." While monetary gain could easily be seen as a sufficient incentive for most parents, they may not only be influenced to seek out a diagnosis for their child simply because of the health care benefits. Diagnosis may also be used to explain away their child’s deviancy. “People who commit a deviant act tend to excuse it in order to get away with it. In effect they are saying that ‘it was wrong, but it wasn’t my fault” (Scott and Lyman, 1981). With the heightened competitive nature of the education system, parents are becoming increasingly fearful of a poor report card. An ADHD diagnosis may help parents come to grips with their child’s poor performance, and by disassociating their inability to motivate their child, they pass on blame to an unavoidable psychological disorder. In essence, their child may be failing, but it wasn’t their fault. And as a bonus, these drugs are the magic bullet to fix the problem.
Even students are trying to game the system, as has been pointed out in a Daily Beast article (http://www.thedailybeast.com/articles/2012/01/25/faking-adhd-gets-you-into-harvard.html). Why would a student want to cheat the system when being labeled ill can make people perceive you as deviant? According to George DuPaul, a professor at Lehigh University’s School of Education in Bethlehem, Pa., “These students get accommodations in the school: extra time on tests, someone taking notes for you, alternative assignments, oral exams vs. written exams.” He goes on further to explain that the students may even use the medication recreationally and/or sell the medication for money. It is not hard to see what incentivizes students to seek out this disorder. Along with their parents, most students are aptly aware of the necessity to succeed in school. When the only barrier between receiving unlimited vs. limited time while taking the SAT is to get diagnosed, it is hard to see not why so many students are seeking diagnosis, but rather, why so many students are not. Gamming the system isn’t as hard as it seems, since after all, ADHD is determined by symptoms and not by testable differences in someone’s body chemistry. One problem is that ADHD-like symptoms are quite common, particularly with youth. Daydreaming, refusing to do homework, getting in fights; all are behaviors that can be easily tied in within the large umbrella of an ADHD diagnosis.
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The usage of ADHD related medication has increased substantially in the US in the past 20 years. From 1993 to 2000, total consumer spending on ADHD medication increased at roughly 17.3% per year. After 2000, spending has increased by 40% per year. By 2003 total spending was at $2.4 billion, marking a nine-fold increase from just 10 years earlier. (source: http://content.healthaffairs.org/content/26/2/450.full) The US makes up of about 92% of the total world expenditures for the drug. However, much of total spending has been associated with price increases, and not just total volume sales. While sales increased by 80% from 1994 to 2003; prices for ADHD medication increased by over 285%. According to consumer reports.org, ADHD drugs can cost as little as $16 a month to more than $1,000 per month, with most ranging in the $80-$150 dollar range.
I think it goes without saying that pharmaceutical companies have a lot to gain by expanding the definition of what constitutes an ADHD diagnosis. Pharmaceutical companies operate within the same economic constraints that other major US businesses do, and as it is with most businesses, they must prioritize financial gain above all other considerations. “The market forces of Adam Smith's “invisible hand” operate within the world of childhood mental health and illness. American psychiatry's infatuation with the brain coincides with a drug industry more than happy to contribute funds for research that only counts symptoms and pills.” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071175/). The ADHD ‘epidemic’ has been a godsend for big pharma, allowing them to rake in billions in profits in the last couple decades alone. The Pharmaceutical Research & Manufactures of America Lobbying group, big pharma’s main public policy tool, spent nearly 19 million in the last year alone. This is a dramatic rise over spending of less than 5 million in the early 1990’s. As you would expect, the explosion in spending has increased in lockstep with increased prescription rates. The more money that’s at stake, the more money needed to keep the gears of production moving along smoothly.
Realizing pharmaceutical companies are greatly biased in favor of increased prescriptions is not exactly earthshattering. What is a bit more sinister is the fact that people in the FDA and members of DSM councils, who define psychiatric disorders, also seem to have strong financial incentives for increasing prescription rates. According to a New York Times article (http://well.blogs.nytimes.com/2008/05/06/psychiatry-handbook-linked-to-drug-industry/) , “56 percent — of 170 experts who worked on the 1994 edition of the DSM manual had at least one monetary relationship with a drug maker in the years from 1989 to 2004.” These are the same people who must determine what constitutes proper and safe diagnosis, yet it goes without saying that strong financial ties between big pharma and DSM council members creates a serious conflict of interest. Even if the conflict of interest only led to perceived rather than tangible corruption, you can’t help but think how something which could so easily allow for unethical decision making by less scrupulous individuals, could be permitted in the first place. So far corruption has merely been hinted at due to large amounts of circumstantial evidence, as well as the basic understanding that financial incentives tend to affect most people’s decision making processes.
The parents, pharmaceutical companies, regulatory bodies, and yes, even sometimes the child themselves all have incentives to keep the ADHD epidemic chugging along. When everyone involved can potentially benefit from a diagnosis, it makes the explosion in ADHD diagnosed individuals a lot less surprising. But what we haven’t discussed are the serious social ramifications that can result from being diagnosed. Many people see mental illness as something that will never go away, “When you attach a feeling of permanence to this, then it justifies, in some ways, a person's sense of 'otherness' or 'less-than-humanness,'”( http://www.npr.org/blogs/health/2010/09/17/129937437/still-a-stigma-for-mental-illness). Being labeled mentally deficient can cause people to disassociate themselves from the afflicted individual. However, in the case of ADHD, the widespread nature of the illness can allow it to become deemed more socially acceptable. The OxyContin epidemic, described in Inciardi and Goode (2003), presents us with an analogous situation. As prescription of the drug became more prevalent, its use “has become normalized and integrated into the local culture”. An increased level of illness causes society to exempt much conduct previously stigmatized, and also quietly raises the “normal” level in behavior that was previously considered abnormal (Moynihand, 1993). But is increased acceptance of ADHD diagnosis really a good thing in the long run? Perhaps it will help relieve some of the negative stereotypes that are associated with a mental illness label, but it will also cause people to not take a diagnosis as seriously as needs be. ADHD drugs have been linked to brain atrophy, increased likelihood of suicide, and a litany of other side effects that would take too long to list out in its entirety. According to the movie Generation RX, one in thirty Americans aged 5-13, are now taking some form of prescription drugs, a large proportion of which are for ADHD. When so many lives are at stake, we must precede with caution.
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Inciardi, James A. and Goode, Jennifer L. (2003). “OxyContin and Prescription Drug Abuse,” Consumers’ Research Magazine, vol. 86, pp. 17-21
Moynihan, Daniel. (1993). “Defining Deviancy Down.” The American Scholar, vol. 62. No. 1
Scott, M.B., & Lyman S. M. (1981). “Accounts.” Pg 343-361 in G.P. Stone & H. A. Farberman (eds.) Social psychology through the symbolic interaction, 2d ed. New York: John Wiley.
