Book Review: ADHD Nation, by Alan Schwarz

“Attention deficit hyperactivity disorder is real. Don’t let anyone tell you otherwise.”

Thus begins ADHD Nation, a challenging, thought-provoking book, written by Alan Schwarz, an investigative reporter from The New York Times. Taken as a whole, this eminently readable book traces the development of the ADHD diagnosis, the discovery and growth of medications aimed at treating it, and the emergence of large pharmaceutical companies as omnipresent and irresistible forces as they aggressively marketed their products and, according to Mr. Schwarz, as they marketed the disorder itself.

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ADHD Nation could easily have been a very bad book. Mainstream critiques of ADHD tend to paint in very broad strokes. Typically, they make the case that ADHD is a myth created by big pharmaceutical companies and perpetuated by parents, teachers, and clinicians looking to respond to unruly, ill-behaved children by flinging pills at them rather than going through the more challenging, time consuming process of providing consistent and appropriate discipline. While ADHD Nation does present some withering critiques of the ADHD phenomenon and society’s response to it, many of Schwarz’s arguments are insightful, valid, measured and, most impressive of all for a book on this topic, balanced. While Schwarz writes sentences like “…the zeal for diagnosing and medicating children, and now adults, has distracted us from the abundantly obvious evidence that ADHD long ago jumped its tracks,” those criticisms are countered with statements like the one from the book’s opening sentence cited above. Indeed ADHD Nation is not a very bad book. It’s actually quite good.

ADHD Nation traces the life story of Dr. Keith Conners and uses it as a reference point in the story of ADHD. Dr. Conners is one of the pioneering researchers in the field of ADHD, most widely known for developing the Conners Scale, a ubiquitous assessment tool used to diagnose ADHD. For over 50 years, Conners was a reliable supporter/promoter of the diagnosis and the use of medication to treat it. Schwarz goes so far as to say that “If one person put ADHD on the medical map, it was Keith Conners.” In 2013, however, after a New York Times front page article reported on the CDC’s finding that as many as 15% of all children and 20% of all boys in the US would be diagnosed with ADHD, Conners started to believe he had created a monster. He began making the case for a more measured understanding of what constitutes ADHD.

As I was reading ADHD Nation,  the distinction between where I sit, as a clinician who is wrapped up in the world of ADHD, and the author who has the ability to take a more detached view of the diagnosis, became increasingly obvious. In some instances, Schwarz’s background served him well. He was able to question many aspects of ADHD’s status quo with a fresh set of eyes and cast doubt on conventional wisdom. In fact, since I finished reading the book, I’ve already found that it has informed some of the discussions I’ve had with parents at my practice concerning the evaluation and treatment of ADHD. I’ve been less likely to underplay the potential side effects that medication may have and I’m trying to be a little more specific about where I refer people for evaluations. Mr. Schwarz takes particular exception to the frequency with which pediatricians have been making the diagnosis. He writes “If it seems like many doctors don’t know enough about what ADHD actually is and how its medications work, that’s because they don’t…Painfully few physicians who diagnose and treat ADHD received any training in the area during medical school, or from any reliable source since.” As I read that passage, it occurred to me that “Hey – this guy might have a point here.” Filling out a questionnaire and talking to a pediatrician for 10 minutes really might not qualify as  due diligence before asking your child to take amphetamines.

Maybe it’s not a good idea for big pharmaceutical companies to make wild claims about stimulant medications in their advertising.

Maybe the fact that big pharma has funded so much of the research on ADHD treatments has slowed down further study of any treatments that don’t come in pill form.

On the other hand, I found that Mr. Schwarz’s role as a journalist limited his understanding in other areas. In particular, I found his treatment of some of the leading lights of ADHD research, treatment, and advocacy to be unfair and a bit superficial. He takes some pot shots at Ned Hallowell, author of Driven to Distraction, perhaps the most well known mass-market book on ADHD, Russell Barkley, author of Taking Charge of ADHD, probably the best book on the subject I’ve come across, and Joseph Biederman, one of the leading researchers on pharmacological treatment of ADHD in the world. While he never comes right out and says it, he strongly implies that all of them are little more than shills for drug companies. He refers to Biederman as being pompous (“Dr. Joseph Biederman spoke three languages, and was pompous in all of them.”), a judgment that, parenthetically, I’m much more inclined to cast on Russell Barkley if their public speaking styles are any indication. He casts Russell Barkley as being something of an alarmist about ADHD and belittles the research and writing he’s done. While he applauds a recent initiative undertaken by Ned Hallowell and others to educate pediatricians about ADHD, he savages him in other sections of the book. He takes particular exception to Hallowell’s claim that, in addition to the challenges presented by ADHD, there are “powerfully positive” aspects inherent in the disorder, particularly when it is effectively treated. Schwarz describes such characterizations as “pure bunk,” writing that “… at its core, Driven to Distraction was not science. It was marketing. It told current ADHD families what they wanted to hear, aroused the undecided, and left skeptics in the dust.”

As someone who has recommended Driven to Distraction to a lot of parents, I have to take exception to Schwarz’s assertions about it. I’ll concede that Hallowell’s own marketing efforts can be a bit Hallmark-esque at times. His marketing materials often include the blurb “I don’t treat disabilities. I help people unwrap their gifts.” Even though I understand the sentiment, it’s a bit syrupy for my taste. Be that as it may, sitting, as I do, in a clinician’s chair, I applaud Ned Hallowell for emphasizing to parents that their children’s ADHD diagnosis does not doom those kids to a life of crime, failure, and destitution. If you’re wrapped up in the world of ADHD everyday, you know that the negative messages that parents and kids hear on a daily basis outweigh the positive by many orders of magnitude. As much as these kids and families may benefit from medication, what they really need is resilience and Dr. Hallowell has spent his career trying to help them cultivate it.

If I were to level one overarching criticism at ADHD Nation, it would be around the tone and extent of the arguments it makes. ADHD Nation is a history book. It presents a series of facts about events, people, trends, and discoveries related to ADHD. Like most history books, the author does not stand neutral in the face of those facts. ADHD Nation has a slant. And that’s fine. Too often, however, when faced with the choice of presenting a topic with an air of cynicism or an air of trust or acceptance, Mr. Schwarz opts for cynicism. In some cases that cynicism is justified but the frequency and intensity with which Mr. Schwarz reaches for that lens can undermine the strength of his arguments. However, the exhaustive investigative reporting, the engrossing style of writing, and the overall argument, made in a commendably balanced manner, make ADHD Nation a worthy addition to any bookshelf.