The ADHD Explosion

It came out in 2014 from Oxford University Press. Its full title is The ADHD Explosion: Myths, Medication, Money, and Today's Push for Performance. The four concepts in the subtitle work like the book's map: myths, medication, money and the pressure to perform.

Stephen P. Hinshaw is a clinical psychologist. He is a professor of psychology at UC Berkeley and of psychiatry at UCSF; he runs the largest longitudinal study of girls with ADHD. Richard M. Scheffler is a health economist, also at Berkeley.

This partnership sets the character of the book. One knows what a child goes through in the classroom, the other how that child turns into a line in a state budget.

I could not reach a verified Turkish edition; I am writing with the English title.

I got stuck on the word "explosion"

I opened the book on guard. The cover seemed to promise the kind of book I criticize on this site: one that says ADHD is inflated, one that sounds an alarm against medication.

It did not turn out that way. From the first chapters the book says two things at once. ADHD is real, with a strong biological basis and heavy consequences when untreated. And the rise in diagnosis and medication use in the US cannot seem to be explained by biology alone.

Holding these two sentences in the same book, without one smothering the other, is harder in this field than you would think. Most of the shelf picks only one of them.

The order of the ten chapters

The first half of the book lays the ground. The origins of ADHD and its cost to society; causes, as the place where biology meets culture; the price paid when diagnosis and treatment are done carelessly; the rise in medication use and its gray area between performance enhancement and misuse.

The fifth chapter is the spine of the book: diagnosis rates that vary from state to state and their link with education policy.

The second half widens. The economic cost of ADHD, how it is told and sold in the media, how the picture looks in other parts of the world, those who fall outside the white middle-class boy pattern, and stigma. The last chapter closes with predictions about the future.

In between there are case stories. They are kept short and are generally used to make a piece of data concrete. They do not carry the book on their backs, as they do in Driven to Distraction.

North Carolina and California

The most quoted part of the book, and rightly so.

In the data of the period the authors used, about 15-16 percent of school-age children in North Carolina had received an ADHD diagnosis. In California the figure was around 6 percent. Even after accounting for race and income differences, a child in North Carolina was almost twice as likely to be diagnosed. In some southern states, among boys past the age of nine, the rate approached one in three.

A genetic difference of this size between two states is not expected. The authors examine demographics, health policies and cultural attitudes one by one. The strongest explanation left standing is school accountability laws.

The logic is set up like this. Some states, before No Child Left Behind came into force federally in 2002, had set up systems that rewarded and punished schools by standardized test results. North Carolina was among the first. When a school's budget and reputation are tied to students' test scores, a strong incentive arises to refer a struggling child for evaluation.

The most striking finding is here too. When accountability pressure first arrived, diagnosis rates in children near the poverty line rose by close to 60 percent, while in children not in poverty the rise stayed at 5-6 percent. The pressure was felt most in schools with the fewest resources.

I stopped here

Reading this chapter I felt two separate discomforts and they did not cancel each other out.

The first was this: whether a child gets diagnosed depends partly on which state, which school they are in. This is not a finding that shakes everything we know about diagnosis. But it reminds us that a diagnosis is made in a room, inside a context, and that the context can push and pull the decision.

The second came from the opposite direction. The same data also carries the possibility that some of the children not diagnosed in California may truly have ADHD. The authors say this openly: a high rate may point to overdiagnosis, a low rate to missed cases. This data alone does not say which of the two states is closer to the truth.

Hinshaw stresses that this finding is a correlational, epidemiological finding. The causal claim is made carefully. A book stating the limit of its own most striking finding is one of the first things I look at when sorting books on this site.

The other side of performance pressure

The emphasis on performance in the subtitle is not only about school policy. The book also deals with stimulant medication being used for studying and exam preparation among students with no diagnosis, and takes this seriously as a misuse problem.

The tone stays the same here too: the medication itself is not declared bad. The problem begins when the diagnostic process is done carelessly and the medication turns into a performance tool. The authors' recommendation is careful assessment, treatment matched to the diagnosis, multicomponent intervention and regular follow-up.

This framework nearly matches the idea of two-way risk I defend in the article is ADHD diagnosis being exaggerated. Careless diagnosis is a real risk. So is a diagnosis never made.

The price of getting the diagnosis right

The title of the third chapter says that when diagnosis and treatment are not done right, a price is paid. The moral center of the book is here, I think.

At the time the book was written, about one in nine children in the US had been diagnosed with ADHD, and close to 70 percent of those diagnosed were prescribed medication. The authors do not present these figures as a scandal on their own. What they ask is how these diagnoses are made.

What the book advocates is careful assessment. Reading it I thought of the parts I describe on this site: childhood history, information from more than one setting, discussing loss of function with concrete examples, ruling out other conditions that could explain the picture. All of these take time, and time is one of the scarcest resources of the health system.

A careless assessment produces errors in both directions: sometimes it makes a diagnosis that is not there, sometimes it misses one that is. The book stays reliable because, while discussing overdiagnosis, it does not forget this second error.

Hinshaw's view of stigma

Hinshaw's coming to this field has a personal side. At eighteen he learned that his father, a philosopher, had lived with a severe psychotic illness all his life and that talking about it in the family was forbidden. Stigma in mental illness settled at the center of his research in the following years; he told this experience in a separate memoir, Another Kind of Madness, in 2017.

This background can be felt in the tone of the book. The chapter devoted to stigma and to those outside the white middle-class boy pattern does not look like an appendix. While criticizing overdiagnosis, the book is very careful not to belittle people who have been diagnosed.

As a reader living with an ADHD diagnosis, this care gave me confidence. In most books written on overdiagnosis, between the lines you sense a slight suspicion toward people who have been diagnosed. Here I looked for that suspicion and did not find it.

Scheffler's ledger

The economist's contribution shows most in the cost chapter. The book estimates the annual cost of ADHD in the US, for children alone, at over a hundred billion dollars; education, health care, the legal system and the labor lost by families are inside this calculation. The authors also add that firm figures are hard to find.

This chapter gave me the least emotional but most useful argument: untreated ADHD is not cheap. When talking to someone who complains that "everyone gets a diagnosis," a calculation showing that the cost runs both ways can be more convincing than a case story.

Criticism from outside

The book was well received but not without criticism. The pediatrician Lawrence Diller, in his review in Journal of Attention Disorders, called it the best book in the last fifteen years describing this social phenomenon. In the same review he also wrote that the authors underplay the financial incentives behind overdiagnosis, do not go deeply enough into the question of fairness created by diagnosis-linked accommodations in exams, and that the proposed solutions underestimate the financial barriers in the system.

I agree with part of this criticism. The book devotes a chapter to the media and marketing, but its tone is very measured compared with Alan Schwarz's anger in ADHD Nation. I prefer the measured one. Still, I think this book softens some of the things the angry book sees.

Where it has aged, where it has held

It was written twelve years ago and most of the figures are the figures of that period. Current diagnosis and prescription rates are different. The rise in adult diagnosis in recent years and its relationship with social media are not in the book.

The biological ground, on the other hand, has strengthened since the book. The review by Faraone and Larsson (2019), based on twin studies, gives heritability as about 74 percent. The World Federation of ADHD consensus statement (Faraone et al., 2021) brings together the validity of the diagnosis and the consequences of untreated ADHD with a broad evidence base. The book does not contradict these findings; the framework of biology meeting culture can still be defended today.

The book's basic distinction holds too. Prevalence measured in community samples and the number of diagnoses made in a country are not the same measurement. The worldwide review by Polanczyk and colleagues (2007) finds prevalence in children at around 5 percent and attributes most of the differences between countries to differences in method. The 16 percent in North Carolina is the figure of a diagnostic practice; it should not be read as a measure of prevalence.

On girls, the book is ahead of its period. Because it is Hinshaw's own field of research, there is a separate chapter that breaks the boy pattern. But the matter of late diagnosis in adult women had not yet gained its present weight in those years.

Reading from Türkiye

The strongest chapter of the book is the one that is hardest to carry over to Türkiye.

State-based accountability laws, the American insurance system and direct-to-consumer advertising of prescription drugs are specific to the US. In Türkiye advertising prescription drugs to the public is not allowed, and school funding is not tied to test scores in this way.

As a way of thinking, though, it does carry over. The question is: what makes a child's struggle visible and sends them to assessment? I do not know of a reliable study showing how Türkiye's exam-centered education system affects ADHD referrals. The book leaves this question here, unanswered but meaningful.

For whom, and how

If you are going to read only one book on the overdiagnosis debate, I think it should be this one. I recommend it especially to teachers, school counselors and those interested in education policy.

An adult who has just been diagnosed and is looking for what to do will not find it here. The book does not explain building systems, daily life, or the emotional side of diagnosis.

If you are already anxious about the legitimacy of your diagnosis, I suggest not reading the fifth chapter on its own. Torn from its context it can read like "see, diagnoses are made up," and that is not what the book says.

My suggestion for the reading order: the first four chapters will be familiar to a reader of this site and can be passed quickly. The fifth, sixth and seventh chapters are the book's original contribution; they should be read slowly. The world chapter is a good checkpoint for separating what is specific to the US from what is universal.

Under three hundred pages. Although it comes from an academic publisher, it is written for the general reader and its language is not heavy.