Children, Doctors, Big Pharma, and the Making of an American Epidemic
By Alan Schwarz
In the late 1930s, Charles Bradley, the director of a home for “troublesome” children in Rhode Island, had a problem. The field of neuroscience was still in its infancy, and one of the few techniques available to allow psychiatrists like Bradley to ponder the role of the brain in emotional disorders was a procedure that required replacing a volume of cerebrospinal fluid in the patient’s skull with air. This painstaking process allowed any irregularities to stand out clearly in X-ray images, but many patients suffered excruciating headaches that lasted for weeks afterward.
Meanwhile, a pharmaceutical company called Smith, Kline & French was facing a different sort of problem. The firm had recently acquired the rights to sell a powerful stimulant then called “benzedrine sulfate” and was trying to create a market for it. Toward that end, the company made quantities of the drug available at no cost to doctors who volunteered to run studies on it. Bradley was a firm believer that struggling children needed more than a handful of pills to get better; they also needed psychosocial therapy and the calming and supportive environment that he provided at the home. But he took up the company’s offer, hoping that the drug might eliminate his patients’ headaches.
It did not. But the Benzedrine did have an effect that was right in line with Smith, Kline & French’s aspirations for its new product: The drug seemed to boost the children’s eagerness to learn in the classroom while making them more amenable to following the rules. The drug seemed to calm the children’s mood swings, allowing them to become, in the words of their therapists, more “attentive” and “serious,” able to complete their schoolwork and behave. Bradley was amazed that Benzedrine, a forerunner of Ritalin and Adderall, was such a great normalizer, turning typically hard-to-manage kids into models of complicity and decorum. But even after marveling at the effects of the drug, he maintained that medication should be considered for children only in addition to other forms of therapy.
Bradley’s research was ignored for a couple of decades as psychoanalysis became dominant in the United States. But his discoveries laid the foundation for one of the most aggressive marketing campaigns in history, which succeeded not only in helping to transform the nascent drug industry into the multinational juggernaut known as Big Pharma, but in convincing parents, physicians and public health officials that 15 percent of American schoolchildren are sick enough that they would require powerful medication just to get through the day.
This campaign (which would have horrified Bradley and his peers) is the subject of an important, humane and compellingly written new book called “ADHD Nation,” by Alan Schwarz, a reporter for The New York Times. The title of the book, of course, refers to attention deficit hyperactivity disorder: a constellation of behaviors and traits codified as a neurobiological illness in the bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders.
The boundaries of the A.D.H.D. diagnosis have been fluid and fraught since its inception, in part because its allegedly telltale signs (including “has trouble organizing tasks and activities,” “runs about or climbs in situations where it is not appropriate” and “fidgets with or taps hands or feet,” according to the current edition of the DSM) are exhibited by nearly every human being on earth at various points in their development. No blood test or CT scan can tell you if you have the condition — the diagnosis is made by subjective clinical evaluation and screening questionnaires. This lack of any bright line between pathology and eccentricity, Schwarz argues, has allowed Big Pharma to get away with relentless expansion of the franchise.
Numerous studies have shown, for example, that the youngest children in a classroom are more likely to be diagnosed with A.D.H.D. Children of color are also at higher risk of being misdiagnosed than their white peers. One clinician quoted in the book more or less admits defeat: “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”
Schwarz has no doubt that A.D.H.D. is a valid clinical entity that causes real suffering and deserves real treatment, as he makes clear in the first two sentences of the book: “Attention deficit hyperactivity is real. Don’t let anyone tell you otherwise.” But he believes that those who are disabled by the condition deserve a wider range of treatment options than an endless litany of stimulants with chirpy names like Vyvanse and Concerta.
Disorders of attention were once thought to be relatively rare by experts, affecting only an estimated 3 percent of preadolescent children. But kids and teenagers are now diagnosed so routinely that getting a prescription for Ritalin or Adderall has practically become a standard rite of passage, particularly in the United States. And the diagnosis isn’t just for children anymore: Its ever-expanding boundaries now encompass allegedly hyperkinetic infants and the distractible elderly. What’s really going on?
Influential patient-advocacy groups insist that only now is the true prevalence of A.D.H.D. finally being recognized after being drastically underestimated — akin to the spike in autism diagnoses once the narrowly defined condition was broadened into a spectrum in the 1990s. But Schwarz makes a convincing case that the radical expansion and promotion of A.D.H.D. has resulted in the label being applied in ways that are far beyond the needs of a historically underserved community, while nonpharmaceutical methods of treatment like cognitive behavioral therapy (which have been proved to complement the effectiveness of medication) are overlooked.
While other books have probed the historical roots of America’s love affair with amphetamines — notably Nicolas Rasmussen’s “On Speed,” published in 2008 — “ADHD Nation” focuses on an unholy alliance between drugmakers, academic psychiatrists, policy makers and celebrity shills like Glenn Beck that Schwarz brands the “A.D.H.D. industrial complex.” The insidious genius of this alliance, he points out, was selling the disorder rather than the drugs, in the guise of promoting A.D.H.D. “awareness.” By bankrolling studies, cultivating mutually beneficial relationships with psychopharmacologists at prestigious universities like Harvard and laundering its marketing messages through trusted agencies like the World Health Organization, the pharmaceutical industry created what Schwarz aptly terms “a self-affirming circle of science, one that quashed all dissent.”
In a narrative that unfolds with the momentum of a thriller, he depicts pediatricians’ waiting rooms snowed under with pharma-funded brochures, parents clamoring to turn their allegedly underachieving children into academic superstars and kids showered with pills whose long-term effects on the developing brain (particularly when taken in combination) are still barely understood. In one especially harrowing section of the book, Schwarz traces the Icarus-like trajectory of Richard Fee, an aspiring medical student who fakes the symptoms of A.D.H.D. to get access to drugs that will help him cope with academic pressure. When he eventually descends into amphetamine psychosis, his father tells his doctor that if he doesn’t stop furnishing his son with Adderall, he’ll die. Two weeks after burning through his supply, Fee hanged himself in a closet.
“ADHD Nation” should be required reading for those who seek to understand how a field that once aimed to ameliorate the behavioral problems of children in a broad therapeutic context abdicated its mission to the stockholders of corporations like Shire and Lilly. Schwarz is sounding an alarm for a fire that looks nowhere near abating.
Steve Silberman is the author of “NeuroTribes: The Legacy of Autism and the Future of Neurodiversity.”
A version of this review appears in print on August 28, 2016, on page BR10 of the Sunday Book Review with the headline: Attention Must Be Paid.