Note: This post has been revised since its original publication.
My oldest daughter was diagnosed with ADD over 10 years ago, as the result of a comprehensive neuropsychological examination. It took several hours, over several days, and there was no doubt in anyone's mind about the conclusion. But like many parents, we were nervous about the prospect of medication, which was Ritalin. I distinctly remember what her psychiatrist said at the time, because it made me less anxious. He explained that stimulant medication only works if you have ADD/HD. Paradoxically, it provides a person with ADD/HD with enough stimulation to slow down, so she stops looking to the environment for more. He added that if I took Ritalin, far from quieting my brain, it would feel like an amphetamine and make me "miserable and crazy."
Good to know. Not that I was ever tempted, but this effectively eliminated any desire to try Lily's Ritalin.
About five years ago I noticed that doctors were no longer claiming that ADD medication worked only for those who had ADD. Not surprisingly, this coincided with the dawning recognition that both the diagnosis and medication of ADD/HD had increased so dramatically (from 1 in 20 in the '80s and '90s to 1 in 9 today) that it was highly unlikely that everyone prescribed ADD/HD medication actually had the disorder. Children, parents, adults, and doctors were using stimulant medication for "cognitive enhancement" -- the off-label use of these drugs for people who did not have ADD/HD -- but claiming benefits from the sustained alertness these medications provided. Simultaneously, drug companies were effectively marketing and advertising stimulant drugs to cover an increasingly broader and looser diagnosis of ADD/HD. It's now possible (though not recommended) to take a six-question quiz online, sponsored by the drug company Shire, to determine if you have adult ADD. In a nationwide poll of 1,106 adults conducted by the New York Times of 1,106 adults, about half scored in the "likely" or "possible" category.
The news now is filled with reports about the abuse and overuse of ADD/HD diagnoses and stimulant medication. Last year's startling New York Times piece featured several doctors and researchers who publicly questioned both the diagnosis rate and the resulting over prescription of medication for the disorder.
All of which has left me puzzled about what really happens when people who don't have ADD/HD take stimulant medication. Contrary to what Lily's first doctor told me, it must work. Otherwise, if it feels like an amphetamine and makes you miserable and crazy, why (aside from those who like the feeling of an amphetamine) are so many people without ADD/HD taking it?
This is a complicated question as the recent LA Times interview with Stephen Hinshaw and Richard Scheffler illustrates. Hinshaw and Scheffler have just published a book, The ADHD Explosion: Myths, Medication, Money and Today's Push for Performance (Oxford University Press), in which they discuss the economic pressures, government polices, and cultural differences that are behind the increase in diagnoses of this disorder. It's all fascinating, but what caught my attention was Hinshaw's discussion of a University of Pennsylvania study that came out in 2013.
So much so, that I went to the Neuropharmacology Journal to read it. The researchers began with 46 healthy young adults, ages 21-30, without ADD/HD. They administered 13 cognitive tests to establish a baseline reading of each subject's performance. Then they gave half of the participants a placebo and the other half 20mg of Adderall to evaluate whether their cognitive abilities improved as a result of the medication. The results found no enhancement with any of the 13 measures used. There was a significant interaction between baseline performance and cognitive enhancement in two measures. Cognitive performance improved more in those with below average baseline readings who received medication, but acted in the opposite direction for those with a higher baseline performance. In other words, in two instances, it appears that medication hurt the performance of the smarter young adults.
This, of course, begs the question of why anyone without ADD/HD would take stimulant medication. And to my mind, herein lies the most interesting finding of the study. On average, the participants believed that the medication had enhanced their performance. As the researchers point out, this perception stands in direct contrast to the reality: On average, there was no actual improvement.
As Hinshaw concludes, the findings from this study suggest that stimulant medication promotes a false sense of confidence in those who don't have ADD/HD. You feel more alert, and you think you aced the SAT. But unless you have the disorder, Adderall won't help, and might even hurt your performance. But you'll believe that it did.
And finally, there is the not insignificant issue of drug abuse. If you have ADD/HD, and take medication, it is extremely unlikely that you will become addicted to it. My daughter, for example, has no desire to take any more Adderall than she is prescribed. She doesn't really like the way it makes her feel, and her friends tell her that she is "less fun." But she knows she needs it. However, if you don't have ADD/HD, but take Adderall because you believe it helps you, you have up to a 15 percent chance of becoming addicted to the medication.
So it turns out that Lily's doctor was right all those years ago. ADD/HD medication won't help you if you don't have ADD/HD. Not exactly surprising. But what no one knew then is surprising, and has no doubt contributed to the current ADHD explosion; namely, there's a good chance you'll believe it does.
No wonder there is an ADD/HD epidemic.