ADHD Nation

It was published by Scribner in 2016: ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic. The UK edition came out the same year from Little, Brown, with a shorter subtitle.

Alan Schwarz is a journalist. His long series of reports in The New York Times on concussions in sports was a finalist for the Pulitzer Prize in public service in 2011. He studied mathematics and has an award for statistical reporting from the American Statistical Association. Before this book he had done a series of reports in the same newspaper on ADHD diagnosis in children and stimulant medication use; the book is the expanded version of that series.

So what we have is an investigative journalism book. It has to be read by the standards of that genre: documents, witnesses, following the trail. While keeping the genre's known risk in mind: a good story can foreground an unrepresentative example.

I could not find a verified Turkish edition; I am writing it under its English name.

The reassurance on the first page

Schwarz opens the book by writing that ADHD is real and that those who say otherwise should not be listened to. This is a reassurance placed there to set the book apart from diagnosis deniers.

I felt relieved as I read. Then, through the book, I watched how much weight this reassurance could carry.

The book's basic numerical claim is this: real ADHD is seen in about 5 percent of children in the US, while the diagnosis rate has come close to 15 percent. In some states about a third of school-age boys have been diagnosed. Schwarz attributes the gap largely to wrong diagnoses produced by the system.

Keith Conners

The spine of the book is a person.

Keith Conners is the psychologist who developed the rating scales still known by his name in ADHD assessment. In the early 1960s at Johns Hopkins he was one of those who carried out the first studies on the effect of Ritalin in children, and these studies were funded by the maker of the drug. Schwarz positions him as the founding figure of the field.

The dramatic axis of the book is that, toward the end of his life, Conners looked back and was disturbed by what he saw. According to Schwarz, Conners realized that the field he had contributed to building with good intentions had gone off the rails, and described the widespread wrong diagnosis as a national disaster of dangerous proportions.

This structure is very effective; it reads like a confession. For exactly that reason it demands attention. One person's remorse does not carry the same weight as a testimony and systematic evidence about the state of a field. Schwarz at times uses the two in place of each other.

The trail of marketing

The strongest chapters of the book are those where he follows the trail of the pharmaceutical companies.

Among the things Schwarz documents are these: industry funding of research and educational activities that stress ADHD as more common and dangerous than assumed, and medications as almost free of side effects; direct-to-consumer advertising; warnings from the US Food and Drug Administration to the promotions of major ADHD drugs for misleading advertising. He also treats the examples in which parents were told that these drugs were safer than aspirin as misinformation.

These chapters rest on documents, and the book's care in citing sources was praised separately in reviews. I know of no better case study for seeing how marketing can shape the public perception of a diagnosis.

A note for readers from Turkey: direct advertising of prescription drugs to the public is not permitted here. The television ad and magazine ad part of the mechanism the book describes does not carry over here as it is. Promotion aimed at doctors is everywhere, and that part is more universal.

A new diagnosis for a side effect

The part that made me think most was not about marketing but about clinical practice.

Schwarz describes cases in which anxiety or insomnia caused by a stimulant was mistaken for a separate disorder and another drug was added for that too. There are also the stories of children whose real problem was trauma, anxiety, lack of sleep or bullying but who received an ADHD diagnosis without any of these being asked about.

This is a real risk, and one that good clinicians also voice. A diagnosis made without differential diagnosis and a prescription written without monitoring are two separate errors. In the article ADHD or anxiety I explained why this distinction is hard. The book shows what can happen when that difficulty is neglected.

The two places I objected

The first is the case stories. A significant portion of the young people Schwarz chose are people who misused stimulant medication, were drawn into addiction, whose lives fell apart. These stories are real and deserve to be told. But because they carry the book's dramatic weight, they leave the reader with the impression that this is the typical young person receiving treatment. Publishers Weekly also wrote in its review that in these stimulant stories sensationalism got ahead of analysis.

The evidence base does not support this impression. The 2003 meta-analysis by Wilens and colleagues showed that receiving stimulant treatment in childhood does not increase the risk of later substance use. The World Federation of ADHD consensus statement (Faraone et al., 2021) also sets out the safety profile of use under medical supervision together with the measurable harms of untreated ADHD. Stimulant misuse by students without a diagnosis is a separate and real problem; the book at times melts the two in the same pot. I covered the subject in detail in the article are ADHD medications addictive.

The second is its approach to the people in the field. Names such as Russell Barkley, Joseph Biederman and Edward Hallowell are drawn, though not stated outright, as spokespeople of the drug industry. A review written by a clinician found this stance unfair and superficial; I found it so too. Questioning financial ties with the industry is legitimate and necessary. But reading all of a researcher's findings through that relationship is avoiding discussing the findings themselves.

The contradiction with the opening sentence

Something caught in one review formed in me too. The book begins by saying ADHD is real. Then it describes in such detail how many times the diagnosis has changed its name over history and how the criteria have widened, that the impression left on the reader moves away from the opening sentence.

The historical change of a diagnosis does not show that the pattern underneath it is not real. The diagnostic criteria have changed many times in almost all psychiatric conditions. In the review by Faraone and Larsson (2019), the heritability based on twin studies is about 74 percent. However many times its name changes, we are talking about something measurable and traceable in families.

What lies between 5 percent and 15 percent

Prevalence meta-analyses done in community samples find a rate of around 5 percent in children (Polanczyk et al., 2007; Willcutt, 2012). The real rate Schwarz relies on is in this respect in line with the consensus of the field.

But the number "diagnosed" and the number "who have ADHD right now" are not the same measurement. The result changes depending on by what criteria, by asking whom, and whether lifetime or current is looked at. Part of the gap may be wrong diagnosis, part may be a difference in measurement. The book tends to attribute most of this gap to wrong diagnosis.

Because the book's question is overdiagnosis, the risk in the opposite direction, diagnoses that are never made, does not stand at the center of the narrative. The children of the inattentive type who stay quiet, the girls who were overlooked for a long time, those who are noticed in adulthood. Someone reading this book needs to complete this side from another source.

The pill in the school corridor

Another center of weight of the book is how stimulant medications circulate among adolescents. Schwarz describes young people using these drugs casually to study and prepare for exams, and institutions intervening very little.

I think this is the least disputed and most ignored part of the book. The drug a person with a diagnosis uses under a doctor's supervision and the drug a student without a diagnosis gets from a friend may be the same active ingredient, but they are two entirely different situations. In the first, the dose is adjusted, side effects are monitored, co-occurring conditions are assessed. In the second, none of these exist.

As a person with ADHD, I am bothered by the blurring of this distinction in public opinion, because the price is mostly paid by people with a diagnosis. What is referred to dismissively as "that pill" at the family table or at work feeds on the confusion of these two situations. Although the book does not always draw the distinction clearly, it shows that the problem is real.

A book by a statistics reporter

Schwarz's background explains the form of the book. He has spent most of his career reporting with numbers and has received an award for data-driven journalism. Throughout the book he thinks in rates, trends, figures that change over the years.

This is both the book's strength and its trap. The strength is that the claims do not hang in the air. The trap is that a rate can be read alone as a verdict. The figure of 15 percent hits the reader. But with which question, in which age group, in which period such a figure was measured is as important as the figure itself, and the reader has to ask these questions on their own.

When the book came out, The New York Times Book Review praised it as a well-researched guide, and The New Republic as an investigation that skillfully ties together the stories of the drug companies, Conners and the young people. These praises are deserved. Still, a well-written investigation does not make every detail of its conclusion correct.

Why I read it anyway

Despite all my objections, I am glad to have read this book.

One of the two sentences I constantly defend on this site, that careless diagnosis is a real risk, is shown most concretely by this book. A diagnosis made in a fifteen-minute appointment, a prescription that mistakes a side effect for a new illness, a pill a student gets from a friend. These are not made-up things.

The clinician who criticized the book also wrote that after reading it he began to talk about side effects with his patients in more detail. A book changing professional practice in this direction is no small thing.

What I took away is similar: better questions about treatment. Why the dose is what it is, what to do if side effects appear, how often it will be reviewed. The decision about medication is made with a doctor; going into that conversation prepared is our job.

For whom, and at what stage

For someone who has been diagnosed, whose treatment has settled, and who is curious about the American background of the ADHD debate. For someone who works in health or education and wants to see how marketing can seep into clinical practice.

For someone who is in the middle of deciding whether to start medication and is already anxious, this may not be the right time. The book's dramatic stories carry disproportionate weight at that stage, and the decision may be made more out of fear than evidence. I would say the same to a parent trying to make a decision for their child: first a balanced source, then this book.

How to read it: with a more measured book alongside. Hinshaw and Scheffler's The ADHD Explosion is a good companion. Reading Schwarz's anger and the other's restraint together, you see more clearly what one saw and what the other softened.