One of the lessons I’ve learned as I get older is that sometimes the most important things that affect us have incredibly obscure beginnings. One upcoming change that will impact all of us is the release of the Diagnostic and Statistical Manual of Mental Disorders (also known as DSM-5, for the version number). This book will published by the American Psychological Association this month and is the primary text used by psychologists to diagnose patients. In particular, the new manual redefines attention-deficit/hyperactivity disorder, or ADHD, by pushing back the time of onset from 7 to 12 and decreasing the number and severity of symptoms you need to have in order to be diagnosed, thus expanding the number of people who will be classified as affected and assigned prescription drugs.
This development is a disaster. Not only is it a harmful solution to a nonexistent problem, it perverts the use of medicine, encourages drug use, and undermines the fabric of our society.
First, the redefinition of ADHD fails to fix the problem we have. The APA thinks that we have too many kids with ADHD who are not getting the treatment they deserve, when in reality we are over-diagnosing it. This is especially true of boys who by high school are diagnosed at twice the rate of girls, at 20%, a number that has grown 50% in the last decade. Half of these children are eventually given a prescription.
This is a veritable flood in casework driven less by biology or any scientific revolution than by a change in perception. With the popularization of ADHD, far too many boys are no longer seen as simply energetic, rambunctious or quirky, but as being mentally diseased. For example, here are some symptoms:
- Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace.
- Often loses things needed for tasks and activities.
- Is often easily distracted by extraneous stimuli.
- Is often forgetful in daily activities.
- Often fidgets with hands or feet or squirms in seat.
- Often unable to play or engage in leisure activities quietly.
Is there any child or teenager who doesn’t meet these criteria? If not, then everybody has ADHD, especially since the APA invented a new sub-condition - “Inattentive Presentation (Restrictive)” – with fewer symptoms than any that existed in DSM-4. Moreover, DSM-5 also lowers the quality of evidence that doctors need to make a diagnosis, from the “clinically significant impairment” in DSM-4 to “symptoms interfere with or reduce the quality of social, academic, or occupational functioning.” With such loose standards like that, the psychiatrist doesn’t even need to see your child before prescribing them drugs. This is not how medicine is supposed to work.
A second problem is that loosening the restrictions surrounding ADHD diagnoses further encourages drug use. The flood of ADHD diagnoses in recent years has fueled an underground drug trade in too many of our schools, as students buy these attention-span-extending drugs to deal with exams. This is serious money in some places with people charging as much as $20 a pill, netting hundreds or thousands of dollars for each run to their local pharmacy. Even ignoring questions of the prevalence of ADHD, we should hardly increase the supply of these drugs when our current stock is already out of control.
Moreover, ADHD drugs – like Adderall, Ritalin, and Concerta - are addictive. The Drug Enforcement Agency (DEA) actually classifies Ritalin and Adderall as a class 2 controlled substance, on par with cocaine and morphine, for this very reason.
However, the real problem isn’t physical dependency but mental dependency. People who actually do have ADHD have not registered higher levels of substance abuse as a result of the drug. People who use the drug instrumentally however, have. They are drugs that make problems go away. Need to cram for a test? Take a drug. Need to work for the next 12 hours to finish a project? Take a drug.
Unfortunately, once you start relying on medications to make problems go away you begin to lack confidence that you can do anything without them, and that is where dependency begins. Moreover, what side-effects do exist with ADHD meds – depression and sleep deprivation – can lead to the abuse of other prescription drugs like antidepressants and sleep aids. We’ve all seen the commercials for these things – 30 seconds of ad followed by two minutes of the most horrific side-effects you’ve ever heard of. ADHD meds aren’t lethal, but they can push many users to take drug cocktails that are. After all, if there aren’t any side effects to taking this one medication, what could possibly go wrong if you mix it with others?
One father, Ted Gulp, testified to this a few weeks ago in the New York Times. His son David was diagnosed with ADHD in the first grade and was prescribed Ritalin and Adderall by a psychologist who never even saw him in person. Later, David started selling Adderall to his classmates and was eventually found dead in his apartment at the age of 21 after overdosing on a mixture of heroin and alcohol.
Unfortunately, Mr. Gulp is not alone. Some may know that American men have a low life expectancy compared to men in other wealthy industrial nations, mainly because we lose so many people under the age of 50. Few know, however, that the primary cause of death – 60% of the time – is not accidents, disease, or murder, but drug overdoses. And the APA thinks that we ought to put more than 20% of our boys on drugs? This is a tragedy waiting to happen.
Unfortunately, the new psychology manual is already at the printer and will soon be distributed to psychology practitioners everywhere. Given how we cannot trust the American Psychological Association to use common sense, a community response is needed to prevent our children from being hurt. Everyone needs to ask themselves serious questions before agreeing to drug their kids for psychological reasons. We need to warn our neighbors, friends, and extended family away from these medications except in dire circumstances. We ought to also resist any effort by the pharmaceutical industry to encourage the further use of ADHD drugs. As it stands, half of the APA committee members in charge of working on ADHD definitions have industry connections and are not forbidden from profiting from them later on (although one researcher who knows them insists that the problem is less one of money than bias for their pet ideas).
This is not to say that some people don’t need help. I have a friend of a friend who was so wound up as a teenager that he could hardly hold a conversation as he kept bouncing from topic to topic and room to room. He obviously needed medication, got help, and got better. But the upcoming standards are far too loose, and will entrap people needlessly.
This is a bit of an ominous picture I’ve painted, one of a society on the verge of drugging many of its men out of existence. Yet we also have a tradition in this country of learning from past mistakes. Some of the biggest problems of the past are mere phantoms today. If we all do our part in combating reckless medication then this problem won’t stand a ghost of a chance either.