Project and content management for Contemporary Authors volumes
WORK TITLE: ADHD Nation
WORK NOTES:
PSEUDONYM(S):
BIRTHDATE: 7/3/1968
WEBSITE: http://www.adhdnationbook.com/
CITY: New York
STATE: NY
COUNTRY:
NATIONALITY:
http://www.adhdnationbook.com/alan-schwarz-bio/ * http://www.simonandschuster.com/authors/Alan-Schwarz/488179735 * https://en.wikipedia.org/wiki/Alan_Schwarz
RESEARCHER NOTES:
LC control no.:
n 2016031134
LCCN Permalink:
https://lccn.loc.gov/n2016031134
HEADING:
Schwarz, Alan, 1968-
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PERSONAL
Born July 3, 1968, in Scarsdale, NY.
EDUCATION:University of Pennsylvania, B.A. (mathematics).
ADDRESS
CAREER
The New York Times, investigative reporter; writer for ESPN.com and Baseball America.
AWARDS:George Polk Award, Associated Press Sports Editors Award for Project Reporting (three times); American Statistical Association, Excellence in Statistical Reporting Award, 2013; Kirkus Reviews Best Nonfiction Book of the Year, 2016, for A.D.H.D. Nation.
WRITINGS
SIDELIGHTS
Alan Schwarz is a Pulitzer Prize–nominated investigative reporter for The New York Times whose has written more than a hundred articles exposing the seriousness of concussions in the National Football League. His articles have led to safety reforms for athletes nationwide and are credited with revolutionizing the treatment of head injuries in sports. He has also written about ADHD and other psychiatric disorders in children. With a degree in mathematics from University of Pennsylvania, Schwarz is an expert on the use of mathematics and probability in journalism and used statistical analyses of data in both his coverage of concussions and children’s mental health.
The Numbers Game
In 2004, Schwarz published The Numbers Game: Baseball’s Lifelong Fascination with Statistics, in which he presents the history of baseball statistics. Baseball was invented in 1845 and fans’ enthusiasm for statistics is nearly as old. Rather than focus on the statistics themselves, Schwarz highlights the people who are obsessed with those statistics. For example, nineteenth-century writer Henry Chadwick invented the first box score and explained which statistics mattered and which did not. Schwarz discusses other enthusiasts like Allan Roth, Earnshaw Cook, and John Dewan who each contributed to number crunching and statistics. With modern outlets like the Internet and fantasy leagues, fans now have more ways to become obsessed with the numbers.
Saying the book “is a thoroughly researched and intriguing history that goes beyond the numbers,” Stew Thornley added online at Nine: A Journal of Baseball History and Culture, “Statistics serve as the backdrop, but readers will learn much more about the changing way the game has been played and evaluated.” A writer in Publishers Weekly said: “Delivered in a delightfully breezy and confident style, this volume also serves as an excellent alternate or parallel history of the sport.” Library Journal reviewer Jim Burns declared: “Casual fans will almost certainly find something here to pique their interest, while raving statistics buffs will devour it.”
ADHD Nation
In 2016, Schwarz published ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic, named as a Kirkus Reviews Best Nonfiction Book of the Year. In the book, he explores the widespread misdiagnosis of attention deficit hyperactivity disorder, and how over the last half century, children are receiving powerful drugs for a psychiatric condition they likely don’t have. While some ADHD diagnoses are legitimate and the condition is a real problem, today one in seven children are diagnosed with ADHD and given daily doses of the stimulants Ritalin, Adderall, or Concerta. Experts say this number is three times more than is appropriate. While some people are decrying the lucrative industry drawn from this condition, drug companies and some experts see no problem, say the drugs are safer than aspirin, and expect the number of diagnoses to increase. However, Schwartz recounts cases of children and young adults becoming addicted to the drugs.
Schwarz reports on Dr. Keith Conners, the father of ADHD and how he calls the ADHD and drug epidemic a national disaster. Schwarz also explains how big pharmaceutical companies partner with scientists who become key opinion leaders who promote ADHD drugs. He says that fifty to eighty percent of academic papers in the ADHD field are written by doctors who are funded by the drug companies. In an interview with Emma Alberici of the Australian Broadcasting Corporation, Schwarz explained “Now that is unfortunately the situation we have allowed to develop here in the United States because the government, the National Institute of Mental Health, the National Institute of Health don’t provide that much funding for mental health research and it falls upon industry to do that.”
Schwartz has found that by the age of eighteen, twenty percent of American boys have been diagnosed with ADHD, and thirty percent in some southern states. According to the American Psychiatric Associations’ manual there should be only five percent of children diagnosed with ADHD. The difficulty for physicians and parents is to separate the legitimate diagnosis from the pharma-sponsored hype, the funded patient groups, and the selectively reported trials. “Part of the strength and accomplishment of ADHD Nation is that such separation is shown to be impossible. If the DSM and psychiatric establishment still referred to a phenomenon known half a century ago as ‘Minimal Brain Dysfunction’ Schwarz implies, the ADHD epidemic we are now enduring could never have happened,” said a reviewer in Psychology Today.
A Kirkus Reviews Online contributor declared: “The author pulls no punches in his in-depth portrayal of this falsehood and the prevalence of the drugs in schools and colleges across the nation.” Writing in Booklist, Karen Springen noted: “This eye-opening book should be a hit with drug-industry skeptics and worried parents.” According to Steve Silbermanaug in The New York Times, “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 … 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.”
BIOCRIT
PERIODICALS
Booklist, September 1, 2016, Karen Springen, review of ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic.
Library Journal, September 1, 2016, Lisa Jordan, review of ADHD Nation.
Publishers Weekly, May 31, 2004, review of The Numbers Game: Baseball’s Lifelong Fascination with Statistics; August 1, 2016, review of ADHD Nation.
Library Journal, June 1, 2004, Jim Burns, review of The Numbers Game.
ONLINE
Alan Schwarz Home Page, http://www.alanschwarz.net (May 1, 2017).
Australian Broadcasting Corporation, http://www.abc.net.au/ (July 9, 2016), Emma Alberici, author interview.
Kirkus Reviews Online, https://www.kirkusreviews.com/ (July 19, 2016), review of ADHD Nation.
New York Times, https://www.nytimes.com/ (August 22, 2016), Steve Silbermanaug, review of ADHD Nation.
Nine: A Journal of Baseball History and Culture, https://muse.jhu.edu/ (May 18, 2017), Stew Thornley, review of The Numbers Game.
NPR Diane Rehm Show, https://dianerehm.org/ (September 15, 2016), A. Martinez, “The Story Behind the Rise of ADHD in the United States.”
Psychology Today, https://www.psychologytoday.com/ (September 30, 2016), review of ADHD Nation.*
Alan Schwarz
Alan Schwarz is a former Pulitzer Prize–nominated investigative reporter for The New York Times whose acclaimed series of more than one hundred articles exposed the seriousness of concussions in the NFL and led to safety reforms for young athletes nationwide. His work was profiled in The New Yorker and honored with a George Polk Award, the Associated Press Sports Editors Award for Project Reporting (three times), and the 2013 Excellence in Statistical
At its core, A.D.H.D. Nation is a story – not just of the disorder itself, which has evolved over more than 50 (some would say 200) years, but of children, doctors and drug companies who have led us to the point where 15 percent of American youngsters get diagnosed with it. The main characters are Dr. Keith Conners, often considered the father of A.D.H.D., and two children, Jamison Monroe and Kristin Parber, who got caught up in the growing A.D.H.D. machine.
PART ONE
CHAPTER 1: FIDGETY PHIL’S ARITHMETIC PILLS
A look at the earliest days of concern about attention deficits in children, from the 1700s to today, with an emphasis on Charles Bradley’s discovery in the late 1930s that Benzedrine, an amphetamine for adults and ancestor of Adderall, calmed hyperactive children and made them more interested in schoolwork.
CHAPTER 2: DR. CONNERS
Meet Dr. Keith Conners, a Utah-born Rhodes Scholar turned young child psychologist, as he finds a new medication from Switzerland — Ritalin — improves children’s behavior. He publishes many high-profile scientific papers through the 1960s on how the pills treat hyperactivity — what was then called “Minimal Brain Dysfunction”.
CHAPTER 3: FROM M.B.D. TO A.D.D.
In 1970, the first national controversy over the use of Ritalin in children erupts when news that thousands of children in Omaha are being put on the drug leads to a fiery Congressional hearing. Dr. Conners ignores the debate and continues to diagnose and prescribe Ritalin for M.B.D., which in 1980 is rebranded “Attention Deficit Disorder.”
CHAPTER 4: COLLISION COURSE
As diagnoses of A.D.D. rise to 3 to 4 percent of American children, Ritalin explodes into an American phenomenon, featured on the covers of national magazines, debated on television talk shows, and subjected to high-profile lawsuits. The U.S. National Institute of Mental Health holds a summit on the matter and winds up only confusing parents more.
PART TWO
CHAPTER 5: KRISTIN
Meet Kristin Parber, a third-grader in suburban Philadelphia who is overactive and having trouble concentrating. Her parents and teachers, who through the 1990s have been bombarded by messaging that this means she has what is now called “Attention Deficit Hyperactivity Disorder,” get her put on Ritalin. The adults around Kristin believe it helps; she isn’t so sure.
CHAPTER 6: JAMISON
Meet Jamison Monroe, a freshman at a prestigious Houston-area prep school who sees his grades slip and wants to focus and study harder. He tries one of his friends’ Ritalin pills and likes them so much that he fakes A.D.H.D. to his parents and doctor to get a regular prescription.
CHAPTERS 7-18: Coming soonReporting Award from the American Statistical Association. He and his family live in New York City.
Alan Schwarz is a Pulitzer Prize-nominated journalist best known for his reportage of public health issues for The New York Times. His 130-article series on concussions in sports is roundly credited with revolutionizing the treatment of head injuries in professional and youth sports, and was a finalist for the 2011 Pulitzer Prize for Public Service. He followed that with a series on A.D.H.D. and other psychiatric disorders in children, which led to his writing A.D.H.D. NATION.
Mr. Schwarz is regarded as an expert on the use of mathematics and probability in journalism – his statistical analyses of data regarding both concussions and children’s mental health formed the backbone of both series. He has lectured at dozens of universities and professional conferences about these subjects, including keynotes at the 2015 SAS annual convention and this June at the Andrew Wiles Mathematical Institute at the University of Oxford.
Mr. Schwarz was honored by the American Statistical Association in 2013 with its Lifetime Excellence in Statistical Reporting Award. He holds a bachelor of arts degree in Mathematics from the University of Pennsylvania.
A native of Scarsdale, N.Y., Mr. Schwarz, 48, lives with his family in Manhattan.
Interview: Alan Schwarz, Author, 'ADHD Nation'
Print Email
Australian Broadcasting Corporation
Broadcast: 07/09/2016
Reporter: Emma Alberici
Emma Alberici speaks with Alan Schwarz who contends that ADHD is very real and it can be treated with medication, but also reveals the full story behind a billion dollar industry.
Transcript
EMMA ALBERICI, PRESENTER: It was once thought to affect only a small percentage of children and attention deficit hyperactivity disorder, or ADHD is now one of the most chronic conditions among children the world over.
In America more than one in seven children are diagnosed with ADHD, three times what some experts believe is the real figure and that number is rising.
So how is it that so many kids are being diagnosed for a psychiatric condition they don't have?
New York Times journalist Alan Schwarz attempts to answer that question in his book, ADHD Nation: Children, Doctors Big Pharma and the Making of an American Epidemic.
Alan Schwarz joins me now from New York.
Alan Schwarz, thank you for joining us.
ALAN SCHWARZ, AUTHOR, ADHD NATION: It's my pleasure.
EMMA ALBERICI: Can I start by asking you to tell us the story of Richard Fee, the teenager you credit as having made the writing of this book possible?
ALAN SCHWARZ: Well, Richard Fee was a college graduate in North Carolina here in the US, in I guess it was around 2011 or '12 and he wanted to go to medical school.
and he felt as if studying for medical school exams required some extra energy and focus and instead of coffee and instead of caffeine pills, he knew, because in colleges across the United States and even high schools, it's known that if you use and take the drug adderall or concerta or vyvanse or one of the other drugs prescribed for attention deficit hyperactivity disorder, he could presumably focus better and in fact, that is what happened.
He went to a doctor, faked ADHD symptoms which is not that hard to do, somebody was not paying attention, and got his prescription and unfortunately he became quite addicted to the medication, which can happen, particularly when it's abused because he took it and then he took more and then he liked it a lot, and he started, unfortunately, going down a psychiatric path that can happen when you abuse these medications.
And the problem, well, well beyond this one fellow's downfall, is that his experience in the ADHD system that exists here in the United States and increasingly elsewhere, is you have doctors who are diagnosing without paying attention, you had doctors who were refilling prescriptions without noticing the signs of abuse and addiction that were taking place in him, and all sorts of other situations that evidenced how poorly ADHD is sometimes handled here in the United States and I think that Australia is starting to have many of the same concerns.
EMMA ALBERICI: After all the research you've done for this book, is it inconceivable to you that as many as 15 per cent of American children have indeed got a serious enough health condition that requires them to be on these sorts of powerful, daily drugs?
ALAN SCHWARZ: Well, I don't think it's for me to say whether it's inconceivable or not. I understand the question, don't get me wrong.
I think what I'm trying to do is I'm trying to drop this information at America's feet and say I think it's time we discussed this. If this is what we want, if we want 15 per cent of children to be told that you have a potentially life-long, devastating brain disorder, then it's not for me to say don't do that.
That's something we're all going to decide.
Now, medication is not always taken. Only in about two thirds of diagnosis is medication taken, so I don't want to overstate that but we're telling an awful lot of kids that there is something wrong with your brain when the official definition of ADHD here in the United States which is quantified by the American Psychiatric Association says that ADHD affects about 5 per cent of children.
Now we can argue, oh it's real or it's medicalising childhood or it's all pharma derived. All these arguments are not really helping the situation at all.
We have three times as many kids as is appropriate being diagnosed with this disorder, which is characterised as being a really big deal.
Fine, but then why are we throwing around the label so willy-nilly. I don't understand it and I think it's time we figure out what in the world is going on here.
EMMA ALBERICI: Well one of the things that is going on that you explore is the relationship between drug companies and the people you call key opinion leaders, many of whom are highly respected scientists like Dr Joseph Biederman , a professor at Harvard Medical School.
Now did Harvard Medical School write papers on ADHD that were funded by big pharma?
ALAN SCHWARZ: Well, Harvard University doesn't do it, but sure, I mean there are almost, I would say 50 to 80 per cent of the influential papers in this field, and many others in psychopharma were written by doctors who were either were directly or indirectly funded by drug companies.
Now that is unfortunately is the situation we have allowed to develop here in the United States because the government, the National Institute of Mental Health, the National Institute of Health don't provide that much funding for mental health research and it falls upon industry to do that.
And now look, it has provided some good things, it's not inherently evil but what we have is so many doctors and researchers who are kind of co-opted emotionally, let alone financially, by industry that you see their work always coming out with a certain tone, which is hey, these drugs are great, we should prescribe them to anyone who shows any sign of issues.
And we've kind of been sold this bill of goods that these drugs, which really can help, they're not the devil's work, but do they really belong in the mouths of one in five American boys, which is basically what we are saying should happen. One in five American boys gets diagnosed with ADHD by the time he turns 18 and I've got to tell you, Australia's one of the few countries that is following the same path that the United States has.
EMMA ALBERICI: Has there been any legislative reform around marketing of these drugs, given some of the posters you've actually published in your book appeal directly to parents exhorting them to give their children these drugs to make them "normal"?
ALAN SCHWARZ: Well, the United States joined every other country in the world, basically, every other developed country in the free world in the early 1970s, at the United Nations saying we will not allow controlled substances, opoids, benzodiazepines like xanax and valium, and stimulants like at the time, desedrine but what we now call adderall and also ritalin. We will not allow these substances to be advertised to the general public because they simply won't understand the risks compared to the benefits and so it's only the doctors.
Well, in 2001 a British company that made a form of ritalin decided, you know what? This is just a United Nation's gentlemen's agreement, if you will. It's not against United States law so we're just going to put ads for our ADHD medication in women's magazines and they did.
And the FDA said this is wrong, this is bad, but they couldn't do anything about it because it wasn't against the law.
And so for the entire decade of the 2000s, you had women's magazines, basically flooded with ads for adderall, concerta, vyvance, strattera, metadate and all sorts of other ADHD medications promising mothers literally grades that match your kids' intelligence or things like hey, he will take out the garbage if you give him these drugs. I'm not kidding.
And things have calmed down a little bit, I think, for lots of reasons that are too complicated to get into here. But boy, did it fuel things and the United States right now is the only nation in the developed world that allows the advertising to the general public of these medications, except New Zealand. But that's a more complicated issue.
EMMA ALBERICI: And closer to home for us, indeed. Alan Schwarz, unfortunately we're out of time. Thank you so much for joining Lateline tonight.
ALAN SCHWARZ: My pleasure, any time.
Diane Rehm
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Thursday, Sep 15 2016 • 11 a.m. (ET)
The Story Behind The Rise Of ADHD In The United States
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The Story Behind The Rise Of ADHD In The United States
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GUEST HOST: A MARTINEZ
TONY WEBSTER, VIA FLICKR CREATIVE COMMONS
About 15 percent of children in the U.S. receive a diagnosis of Attention Deficit Hyperactivity Disorder, or ADHD. That is about three times the rate most experts agree is appropriate. This over-diagnosis means millions of kids may be taking powerful medications for a psychiatric disorder they do not have, or are not getting the support needed for the real challenges they do face. Investigative reporter Alan Schwarz tells the story of how we got here in a new book, “ADHD Nation: Children, Doctors, Big Pharma and the Making of an American Epidemic.”
Guests
Alan Schwarz investigatiove reporter, New York Times; author of "A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic"
Dr. Lawrence H. Diller behavioral developmental pediatrician, private practice and at University of California at San Francisco; author of "Running on Ritalin" and "Remembering Ritalin: A Doctor and Generation Rx Reflect on Life and Psychiatric Drugs"
Dr. Ned Hallowell psychiatrist; author of several books including "Driven to Distraction" and "Driven to Distraction at Work"
Featured Excerpt: ADHD Nation
Excerpted from ADHD NATION: Children, Doctors, Big Pharma, and the Making of an American Epidemic. Copyright © 2016 by Alan Schwarz. Excerpted with permission by Scribner, a Division of Simon & Schuster, Inc.
Transcript
11:06:54
MR. A. MARTINEZ
Thanks for joining us. I'm A. Martinez of Take Two on KPCC, Southern California Public Radio, sitting for Diane Rehm. Way back in 1970, Congress held a hearing about the possible overuse of a drug that treated minimal brain dysfunction, later called ADHD. Since then, rates of diagnosis have continued to tick up as have the number of prescriptions written for drugs such as Adderall and Concerta. Today, 15 percent of American children receive the diagnosis, a number significantly higher than most experts think it should be.
11:07:26
MR. A. MARTINEZ
Now, joining me to trace the rise of ADHD in America, from New York, Alan Schwartz, author of the new book "ADHD Nation." Also from New York, psychiatrist Ned Hallowell and from Berkeley, California, pediatrician, Larry Diller. Welcome to all three of you.
11:07:43
MR. ALAN SCHWARZ
Thank you. Nice to be here.
11:07:45
MARTINEZ
Alan, good to cross paths with you again. It seems like we're running into each other a lot lately. But good to talk to you again. Now, you've just written this book, "ADHD Nation." It lays out the history of the disorder and its treatment. And you start with some stats about just how many kids are getting diagnosed today. So can you give us the big picture of what's happening around the country right now?
11:08:06
SCHWARZ
Sure. The CDC has spent a lot of time and energy over the past 12 years trying to get a sense of how many kids have actually been diagnosed with ADHD, not how many kids have it necessarily, but how many kids have been diagnosed. And it's now 11 percent of kids aged 11 -- excuse me, 4 to 17 who have already been diagnosed. But by the time they turn 18, 15 percent of American children get diagnosed. 20 percent of all boys in the United States get diagnosed with ADHD and 30 percent of boys in some southern states.
11:08:48
SCHWARZ
This, obviously, is vastly higher than what most all experts suggest. The official definition of ADHD in the American Psychiatric Associations manual says that it affects about 5 percent of children. Well, we're obviously diagnosing more than twice that number and that's millions of children being told that they have a serious psychiatric condition when they probably don't.
11:09:18
MARTINEZ
The stat from Louisiana, that one really jumped out at me. Half of boys between 3rd and 5th grades are taking ADHD medications. Half.
11:09:29
SCHWARZ
Well, that's in some parishes, which is counties, essentially. So we, you know, we don't want to paint Louisiana with too broad a brush, however, they are one of those states where the number of boys overall is about 30 percent.
11:09:45
MARTINEZ
Dr. Hallowell, you wrote one of the most popular books on ADHD, also, in the 1990s. And your concern then was under-diagnosis. So how much consensus is there now that maybe the pendulum has swung the other way when we talk about diagnosing.
11:10:02
DR. NED HALLOWELL
Oh, it certainly has swung the other way and I, you know, as I've often said to Alan when I was writing "Drive To Distraction," came out in 1994, nobody had really heard of ADD and my goal was to bring it to the public's attention. Well, now they've heard of it, still most people don't know what it really is, including many doctors. So now, the big issue is educating the general public as to the finer points and particularly doctors so we don't diagnose it where it isn't.
11:10:36
DR. NED HALLOWELL
What I -- my career has been built on, helping people who do have it and Alan's excellent book is calling attention to the number of people who don't have it who are getting help they don't need.
11:10:51
MARTINEZ
Dr. Diller, you're a behavioral developmental pediatrician and you warned against over-diagnosis over 20 years ago in a book called "Running On Ritalin." How have times changed since you wrote that book?
11:11:02
DR. LAWRENCE H. DILLER
Well, I think everything I was talking about pretty much has come to pass and I think one line I had in the first chapter, "we may see a time when we find America running on Ritalin." We should change that to Adderall right now. And many, many social and economic and even political trends are involved in what I felt was an ominous possibility, most because while amphetamine works in everybody, it isn't the moral equivalent to addressing children's needs with nondrug strategies that engage the child, the family and the school.
11:11:45
MARTINEZ
Let's take a step back for a second, Alan. Take us back to the early days of ADHD, how it all evolved, how we kind of got to where we're at now.
11:11:54
SCHWARZ
Well, I think there has been concern for a very, very long time, more than two centuries and probably back into, you know, cavemen days that some children simply won't pay attention and won't sit still and have a hard time functioning. Now, it began being explored as a medical condition in the late 1700s.
11:12:15
MARTINEZ
1700s, wow.
11:12:15
SCHWARZ
And -- yeah, yeah. And but it was really in the early 19th century that people started, you know, as medicine evolved, they started thinking, look, is this -- is there something wrong inside these children's brains? Was it caused by encephalitis? Was it caused by other brain damage? And so it came to be known as minimal brain damage. And that was in the '50s and it's been trying to find a better name ever since.
11:12:44
HALLOWELL
Yeah, the term attention deficit hyperactivity is a terrible -- if I could just interrupt for one quick second, it's not kids who won't pay attention or sit still. It's kids who can't pay attention or can't sit still.
11:12:55
SCHWARZ
Yes, that's a very, very, very fair point.
11:12:57
DILLER
I would change that. I would change that to children who don't pay attention. The issue is whether it's won't or can't and I'd say mostly...
11:13:05
HALLOWELL
But Larry, the ones who have ADD can't pay attention in the...
11:13:08
DILLER
I would say it's harder for them to pay attention and saying can't...
11:13:10
HALLOWELL
All right, all right.
11:13:12
MARTINEZ
We're getting -- yeah, now we're...
11:13:12
DILLER
...already gets to a medical disease modality.
11:13:12
HALLOWELL
In any case, the important point is to get rid of the -- Larry, if I can just say it's important to get rid of the moral diagnosis. And that's what's plagued these children for centuries. You don't pay attention, therefore you're bad, lazy, willful and to help you, we will beat you with a stick and that's what's happened for thousands of years and that's what I'm in business to try to free children from, the moral diagnosis and the really getting broken in school because they can't pay attention and they're punished for what is really a neurological issue, not a moral infirmity.
11:13:48
MARTINEZ
And Alan, I...
11:13:49
DILLER
It's not an either/or. It's not an either/or.
11:13:51
MARTINEZ
Okay, we've established that. But -- and Alan, I want to get you into this, too, because that's -- I guess that's part of it, too. Aside from the science and the medicine and the prescription and all that, it's how we interpret this, right, and how different doctors and different parents and different groups kind of see this through their own lens.
11:14:08
SCHWARZ
Well, I think that, you know, this diagnosis, first of all, used to be called minimal brain dysfunction, throughout the late '60s and '70s and it was only in 1980 that it was renamed attention deficit disorder and it's sort of been fumbling around for a name ever since. But as it was originally conceived, it was supposed to be for severe hyperactivity, for severe impulsivity and severe inattention. And also, those symptoms, when they couldn't be explained by anything else, whether it be anxiety, trauma in the home, bad diet, bad exercise.
11:14:45
SCHWARZ
I'm not suggesting that any of those things can explain all ADHD, but they're supposed to be ruled out first. And so what we are left with is a mere measure of whether kids, and in this case, I think I'm using the right word, whether they do pay attention, whether they do what we frankly want them to do in this very structured educational system with no gym and no recess and no way for kids to blow off steam. And so what we've evolved into is -- I think what we're doing is we're not assessing and measuring children's symptoms.
11:15:29
SCHWARZ
We are measuring and assessing adult's tolerance for those symptoms and some kids, God bless them, fit the construct and when they take medication, things work out wonderfully. It's a great thing when it works properly. But an awful lot of dolphins are getting caught in our tuna nets and they shouldn't be labeled.
11:15:51
MARTINEZ
Now, you mentioned, Alan, you mentioned the word medication there. That's one thing that the pharmaceutical companies have. They have medication. They have it to sell. But to get that medication sold, they also have to kind of sell the reason why you should buy that medication. So how did they start to do that?
11:16:11
SCHWARZ
Well, the pharmaceutical companies, for a long time, have realized that you can't make money off of their product -- and by the way, there is no reason why big pharma shouldn't be successful in selling products. I mean, we've all bought big pharma stuff. The question is, is how do you do it? And unfortunately, in this case, as with some others, their main tactic is to scare parents with messaging, hey, if your child can't do this and can't do that, he probably has ADHD and you must give him this drug which will spare him from things like friendless school, school failure, dying in a car crash, venereal disease.
11:16:56
SCHWARZ
And these are risk factors for ADHD. I mean, these are things that you need to look at, but you're not going to spare that many kids those outcomes by using Adderall. It's a far more complicated situation or the kids who really do have it. And so my point, though, with big pharma is that they have really exploited the definition of what this thing really is and they have exploited parents' fears, what if I don't give my kid Concerta and it really leaves us in a bit of a mess.
11:17:35
MARTINEZ
Now, Doctors Diller and Hallowell, I want to get your thoughts on this coming up in just a second and your experience with parents on this as well. We'll also be taking your thoughts out there, 800-433-8850. That's 800-433-8850. And also, we'll take emails as well. We've got a lot already, ready to go, drshow@wamu.org. Coming up, more of our conversation. This is "The Diane Rehm Show," A. Martinez filling in.
11:20:02
MR. A. MARTINEZ
Welcome back. I'm A Martinez of Take Two, on KPCC, Southern California Public Radio, sitting in for Diane Rehm. Our guests today, Alan Schwarz, former New York Times investigative reporter and author of a new book, "A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic." Also Dr. Ned Hallowell, psychiatrist and author. His books include "Driven to Distraction." And also Dr. Larry Diller, behavioral developmental pediatrician and author of several books, including 1998's "Running on Ritalin." And we'll also take your thoughts too. 800-433-8850, that's 800-433-8850. And you can email drshow@wamu.org.
11:20:41
MR. A. MARTINEZ
Now, let's start with you, Dr. Hallowell. I've got a friend and we sit around watching TV a lot. And he does this all the time, especially when an ad for a pill comes on, he starts to say, yeah, yeah. I've got all that stuff. Maybe that pill will work for me. Instead of going to the doctor to realize maybe what he has and what can be done about it, he goes immediately to the pill. So I'm wondering, when it comes to be pharmaceutical companies -- if parents see an ad for something they think is affecting their kid, is it that much of a stretch to think that this kind of can get out of control sometimes?
11:21:18
HALLOWELL
Sure. And as Alan has pointed out in his book, in some places it has gotten out of control. But, please, let's not throw out the baby with the bath water. There are many, many children and adults, I might add, whose lives are changed dramatically for the better by proper diagnosis and treatment. And proper treatment is never just medication. It is always a comprehensive treatment plan that includes education, lifestyle modification, coaching. It's an ongoing process. You really -- you're managing this condition for the rest of your life.
11:21:53
HALLOWELL
You know, I tell kids and adults, it's like you've got a Ferrari engine for a brain but you have bicycle brakes. But, don't worry, I'm a brake specialist. And if we work together over the years, we will help you control the power of your brain, which is really what it's all about. These kids and adults are overflowing with energy, with ideas, with all sorts of mental activity and they can't channel it. And so in school, they're scattered, they're impulsive, they're disruptive, they're inattentive. And it's not a disciplinary moral problem whatsoever. It's a brain management problem.
11:22:28
HALLOWELL
And another analogy I use, it's like Niagara Falls, until you build a hydroelectric plant, you've just got a lot of noise and mist. But you build a hydroelectric plant and you light up the state of New York. Well, I'm in the hydroelectric plant business. So the success stories, the positives are tremendous. It just -- it's just, I wouldn't want listeners to think this is all a drug company conspiracy...
11:22:51
MARTINEZ
Mm-hmm.
11:22:52
HALLOWELL
...to medicate the nation. Has that happened? As Alan has pointed out, yes. There are people who overdo medication. You know, the fact of the matter is, most of the people who come to see me don't want to use medication. They say, I want a non-medication regimen. And I say, I'm happy to provide you with that. I think, however, you ought to consider, if used properly, the merits of medication, which are considerable.
11:23:16
MARTINEZ
Dr. Diller, you've argued that none of the ad campaigns would have mattered if there wasn't a receptive audience. What do you mean?
11:23:24
DILLER
Well, I've got to say, first of all, participating in this just makes me feel frustrated and sad.
11:23:28
MARTINEZ
Oh, no.
11:23:28
DILLER
I've been talking about things for...
11:23:29
MARTINEZ
We were hoping it would be a good experience for you, Dr. Diller.
11:23:31
DILLER
Well, you know, Ned is so articulate. Ned just says this so well. I'm not sure it's even worth reporting this because Ned's point of view is the point of view that is just culture media and gristen mill for the answer to your question. But I'm going to tell you again, I participate, but I wonder why. The -- when you consider an epidemic, you can't just consider the aspects of the virus. You have to consider aspects of the host, okay? So the virus might be, you know, doctors, drug companies, educational systems, insurance systems. But you've got to consider the families.
11:24:10
DILLER
And here, ironically, over a 50- or 60-year period, as feeling have become more important, we worry about children's self image and self esteem so much. And Ned's very articulate there. We're not trying to blame anybody here. But the reality winds up that parents are so worried about their children that there's an ironic increasing intolerance for minor differences in children's performance and behavior. No one is questioning, at this stage in the 21st century, that ADHD exists. The question is, are we talking about the ADHD of the 20th century or are we talking about Tom Sawyer, Pippi Longstocking ADHD of the 21st century?
11:24:51
MARTINEZ
But when it comes to parents -- parents that you've dealt with -- when it comes to what issues they bring up to you, I mean, are -- do they seem like they kind of are pushing toward that direction? That way it'll explain a lot of things, maybe take a lot of pressure off of them?
11:25:06
DILLER
I think the educational/indoctrination propaganda campaign of the academics, supported by big pharma, has been entirely successful. Parents are thinking in terms of neurotransmitters and brain disease. And I like to tell them, experience also affects neurotransmitters. And if the doctor, in pressed for time and money, only offers the parents medication or no treatment, the parents will opt for medication. "Better diagnosis," quote, unquote, often means going to a child psychiatrist. And in that case, 95 percent of the children will wind up on medicine. I'm sorry, Ned. That's what happens with better diagnosis these days, because of the structural aspects...
11:25:50
HALLOWELL
Well, Larry, I'm sorry, Larry, but my experience is...
11:25:53
DILLER
Yeah, okay.
11:25:53
HALLOWELL
...absolutely the opposite of yours.
11:25:55
DILLER
I know. This is hopeless.
11:25:55
HALLOWELL
Most of the people...
11:25:56
MARTINEZ
No, I know, I know. We've got a half an hour to go, so before we kind of go off the hills a little bit, let's kind of just stay on track here. Alan, let's go back to you for a second. Voice of reason, Alan Schwarz here. Now, when I, you know, I have a little three-year-old granddaughter. And she can get very hyper sometimes. She can kind of run around the house and kind of talk to herself and maybe, you know? And so I look at her and I wonder, like, sometimes, okay, when I'm describing her, I guess I could be describing any kid in America. And so I always worry about where my brain goes in terms of what I'm seeing in front of me.
11:26:31
MARTINEZ
So when it comes to definition, how much of the problem lies in definitions and how we define our terms, when it comes to ADHD?
11:26:39
SCHWARZ
Well, I think you've brought up, excuse me, a serious problem with how we have allowed this diagnosis to get so loose and diagnosing so many kids, that every kid at times can look like a kid who has been diagnosed. And so the parent or grandparent will think, gee, maybe, you know, this kid is ADHD as well, when it was supposed to be severe behaviors that impaired one's ability, at least in the case of children, to perform at school and to have anything reasonably approaching a healthy home life. That's the way it was supposed to be.
11:27:20
SCHWARZ
But unfortunately, the American Psychiatric Association and lots of other folks -- but they're the ones who write the definition of the disorder -- has spent 30 years loosening the definition and making it where it's no longer impairment, it's interfere -- these symptoms interfere with quality of life and abilities in school. And then you're talking about, you know, one whole standard deviation -- I mean, a one standard deviation instead of two.
11:27:50
MARTINEZ
Hmm.
11:27:50
SCHWARZ
And you have this diagnosis creep, where any kid who will display these behaviors will be a candidate for diagnosis. And it's our responsibility to have the parents slow down, more -- most importantly, the doctors to slow down and assess, is this normal variant of behavior or does it qualify for what is a serious psychiatric diagnosis?
11:28:20
MARTINEZ
Dr. Diller, how do you...
11:28:20
SCHWARZ
These things are -- these things are not irreconcilable. It's very easy to slow down.
11:28:26
MARTINEZ
Take us through the process, Dr. Diller, how you diagnose ADHD. Take -- walk us through that for a second.
11:28:32
DILLER
I was asked that earlier. So it turns out to take about three and a half to four hours. I'll meet with the parents by themselves.
11:28:38
MARTINEZ
Mm-hmm.
11:28:38
DILLER
I try to have the -- even the non-custodian fathers there. And generally they will show up for this, because they want -- or want to be involved in the decision of whether to medicate the child or not. Spend an hour with the parents. I do a conjoined family interview that's not done by most people, where I have the whole family in. Because I learn a great deal about family dynamics and parenting strategies. That's a 45 minute visit. I meet with the kid, depending on the age. At -- below age six, I used to not meet the child by themselves. But because of the increased academic demands on children, I will now do a developmental academic assessment of someone as young as four, in consideration of the demands on the child's development.
11:29:23
DILLER
Six and older, I meet with the child and talk to the child, play with the child a little bit. The older children will just spend time, the 45 minutes, talking.
11:29:32
MARTINEZ
Hmm.
11:29:33
DILLER
I talk to the teachers on the telephone, generally a 10- to 15-minute interview. If the pediatrician is involved, I'll talk to the pediatrician. And then I sit down with the parents for an hour, going over what's going on and what are the options here, both drug and non-drug. And importantly here, the recommendations say that drug and non-drug interventions are equal, first-line interventions. That's my beef. It's not that I'm against the medicine. I prescribed Ritalin in 1978. I prescribe it every day, all right? But I make a conscious effort first, for two or three months at least, in the mild to moderate ADHD cases, to work with family and school to see what we can do over a three-month period.
11:30:18
MARTINEZ
Dr. Hallowell, when it comes to medication for you, when you're doing this, is medication a last resort?
11:30:24
HALLOWELL
No. It's one tool in the toolbox. And I think the either/or mentality is a big mistake. Medication is one tool in the toolbox. We have many tools. And as I said earlier, medication should never be the only intervention. Education is always the starting point. It's really important that these kids -- and by the way adults have this too -- that they understand what it is and what it isn't. The racecar brain with bicycle brakes is the best analogy I have. And it stresses there are positives. But there is a big negative. You have no brakes. A Ferrari with no brakes is a dangerous machine. So how do we strengthen the brakes? And never, never, never do I just say, take this pill. Not at all.
11:31:04
HALLOWELL
Let's learn about it. And then in that context of education, what can we do to strengthen your brakes? Physical exercise is a tremendously powerful tool. Coaching, environmental modification. The fact that kids are held in for recess, it's not good for any kid, but it's terrible for kids with ADD. The last thing they need to do is be held in for recess. So we need to get them running around. We need to get them exercise. We need to pay attention to sleep. A lot of kids are staying up too late on their laptops. I often say the most difficult differential diagnosis is, how do you tell ADD from a severe case of modern life? People are over-stimulated electronically and under-stimulated in terms of family and human connections.
11:31:45
HALLOWELL
We're replacing the human moment with the electronic moment. So the treatment should always be an integrated, comprehensive treatment that may or may not include medication. Unfortunately, medication has become such a hot-button issue, people ask me, do you believe in Ritalin? And my answer is, it's not a religious principle. It's a medication. And if it's used properly, it can be very helpful. If it's used improperly, it can be very dangerous.
11:32:11
MARTINEZ
Alan, so...
11:32:11
HALLOWELL
Now that's true of most medications.
11:32:13
MARTINEZ
So both doctors go through a process, Alan. In the book, have you found that most children go through this kind of process to get a diagnosis, or any kind of process?
11:32:23
SCHWARZ
Well, there are of course no studies that will indicate, hey, how long did the doctor spend?
11:32:28
MARTINEZ
Okay.
11:32:29
SCHWARZ
You know, there are some Medicaid, frankly, data. But I think it's fair to say that, no. In a majority of cases, these things are handled rather haphazardly. We see more diagnoses made by pediatricians rather than child psychiatrists and psychiatrists, who in general will have some training in this area, although not much. And pediatricians are visited by the parents who are struggling. And they just -- they want to help. Most doctors are really very well meaning. Unfortunately -- and this is inexcusable -- some doctors, pediatrician or not, will say, well, we only have 30 minutes. Okay? So let's figure something out within these 30 minute. And you cannot make a responsible, let alone accurate ADHD diagnosis in 30 minute. Period.
11:33:28
SCHWARZ
And unfortunately, what you see at the end of those 30 minutes a lot of the time is the doctor or nurse practitioner or whoever it may be says, well, Johnny's having a tough time in school paying attention. Let's try this Concerta and see if it helps. Well, guess what? Concerta works in just about everybody. You might as well say, you know, give Johnny these platform shoes. See if he gets taller. Okay?
11:33:54
MARTINEZ
Hmm.
11:33:54
SCHWARZ
And so when the child improves on the medication, which in general they will, everybody takes that as confirmation that they have ADHD. And improvement on the medication is not a diagnostic tool. You're just sort of confirmed as human. Humans do better, in terms of attention, in terms of motivation, stick-to-itiveness. They typically are higher in those areas if they take an amphetamine, which is Adderall and Vyvanse, or methylphenidate, virtually the same thing, which is Concerta or Ritalin. And no one seems to be committed -- well, not enough people, excuse me...
11:34:38
MARTINEZ
Mm-hmm.
11:34:39
SCHWARZ
...are committed to slowing down and making sure that we diagnose correctly and not diagnose in the kids who don't, you know, shouldn't be diagnosed. It doesn't mean they're -- they don't have problems.
11:34:54
MARTINEZ
Mm-hmm.
11:34:55
SCHWARZ
These kids need to be helped. But giving them what is often described as a very serious, lifelong diagnosis, it changes their personal narrative. It changes their self image forever. Not always negatively, but I think that if we're going to tell a kid...
11:35:12
MARTINEZ
It certain -- yeah, it's certainly changes it a little bit, yeah.
11:35:13
SCHWARZ
...you have a serious psychiatric disorder, you'd better darn well be right.
11:35:17
MARTINEZ
I'm A Martinez. You're listening to "The Diane Rehm Show." If you'd like to join us, give us a call, 800-433-8850. That's 1-800-433-8850. Send an email to drshow@wamu.org. Or find us on Facebook or send us a tweet. You can tweet me @amartinezla. Let's go out to Lisa, Pittsburg, Pa. Lisa, you're on "The Diane Rehm Show."
11:35:42
LISA
Hi, thank you. I just really want to make a comment on one of the comments that someone on your panel said, where he felt that we were diagnosing a parent's tolerance for children like this. And I just wanted to share my experience. My son is now in his mid-thirties. But when he was born, back in the early '80s, he -- for many years, he was just uncontrollable. He could not sit still in school. He would talk out, just randomly, like the Tourette's, except it wasn't vulgar. He just would run around constantly. I -- he was -- I couldn't control him. He was really difficult, you know, get through those years. You know, the pediatrician was, well, maybe he has ADD. That's what it was called at that time. And I just didn't want to put him on meds.
11:36:27
LISA
We ended up doing an IQ test and found out that he's just really, really, really smart and the school he was in wasn't challenging enough. And so this is why he was running around and just whatever he was doing. Once we moved him into a more rigorous program -- they had some gifted programs here in Pittsburg -- once we moved him into that, most of those symptoms went away. And now he's a successful adult. So I just think that, had he born 10 years earlier, he might have been diagnosed and given medication. I'm not sure it would have done him much good. I mean it would have helped him, as you say, because any amphetamine would have.
11:37:04
LISA
But I think overall in the long run, it was difficult for me as a parent. I was a single parent. It was difficult as a parent to deal with him. But I think, in the long run, by not giving him medication, he's fine now. He's just really smart.
11:37:18
MARTINEZ
Coming up, more of your calls and questions. 1-800-433-8850. That's 1-800-433-8850. And as always, email us, drshow@wamu.org. A Martinez filling in on "The Diane Rehm Show."
11:40:01
MARTINEZ
Welcome back. I'm A. Martinez of Take Two on KPCC, Southern California Public Radio, sitting in for Diane Rehm. Our guest, Alan Schwarz, former New York Times investigative reporter and author of the new book "A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic." And Dr. Ned Hallowell, a psychiatrist and author. His books include "Driven to Distraction," and also Dr. Larry Diller, behavioral developmental pediatrician and also author of several books, including 1998's "Running on Ritalin."
11:40:27
MARTINEZ
Before we get back to you three, let me read this email from Ann. My son is a senior in high school. He believes he has ADD and wishes to be on medication. We do not believe he has ADD. I feel for my son because he is in a higher level of classes with many other students on drugs for ADD, and he wants the medication to help him focus. It's as if he's competing with students on steroids, and he isn't using. The competition is good grades and getting into college.
11:40:56
MARTINEZ
Now from that, let's go to Jameson in New York. Jameson, you're on the Diane Rehm Show.
11:41:03
JAMESON
Hey, thank you so much for having me on. I'm really enjoying the conversation. I'm -- Alan tells my story in the book "A.D.H.D. Nation," so I just wanted to call in and give some color to my personal story. And, you know, I'm one that believes that the medication does work and believes that ADHD does exist, but in my own story, I think I was a victim of the wide spectrum of attention issues that kids have and that in my personal experience and now in my professional experience, I'm seeing that a lot of times the first line of treatment is medication.
11:41:38
JAMESON
You know, and my own story as a 14-year-old, you know, I was very stressed, I had a lot on my plate, I had an extraordinary amount of pressure to perform. I had a poor diet, I had a poor sleeping schedule, you know, poor mental -- attention to my mental health. My parents were stressed out, putting pressure on me. I mean, this is kind of the American family these days. And I believe as a 14-year-old I wasn't designed to sit in a desk all day. I wasn't afforded any artistic or creative outlets through school, and, you know, I was definitely never given any mindfulness techniques to cope.
11:42:13
JAMESON
And so when I tried Ritalin for the first time at 14, as the doctors have said, it worked for me, and then I went and told my parents that I had ADHD, and being very concerned for me, of course they took me to the doctor, and I literally acted like I had attention problems, and sure enough at the end of the test I was prescribed Adderall at 14 and would go on to really just...
11:42:38
SCHWARZ
So Jameson, is it fair to say you faked your way to getting the medication?
11:42:41
JAMESON
Absolutely, yeah, totally. Now did I have attention problems? Absolutely. Was I given any other alternatives to try and combat these attention problems? No, definitely not, it was, you know, here's -- you have attention problems, here's the Adderall. And then what I've -- this is in the '90s, and then what I went on to do is I went on to try other drugs, other pharmaceutical drugs, whether they were uppers and downers, and then eventually my friends and I and even strangers would begin, you know, selling our Adderall or trading our Adderall, and I see that problem of the past 20 years just continuing to increase.
11:43:16
JAMESON
And so what I see as a huge problem is that with the over diagnosis or the overmedication of these issues that they -- the market, if you will, is flooded with an excess of prescription amphetamines, methamphetamine in a pill form, and I see teenagers widely abusing them and then trading them or selling them to their friends in high school, college and even in middle school sometimes, and that only contributes to, you know, what I believe is, you know, a huge national issue of a substance abuse problem that we have in this country, which I don't think anyone could deny.
11:43:50
MARTINEZ
Jameson, thank you very much for your phone call.
11:43:51
HALLOWELL
Could I just...
11:43:53
MARTINEZ
Go ahead.
11:43:53
HALLOWELL
Could I just interject real quick. You know, this show has talked a lot about over diagnosis, overmedication, which Alan has documented beautifully. I don't want listeners to leave the show without also realizing there's a wonderful positive story in here. People who receive proper diagnosis, proper treatment, which is never just medication, see their lives change dramatically for the better, and I could fill many ballrooms many times over with patients I've seen personally whose lives, be it age six or age 60, have done an absolute U-turn from failure to success, and it just would be a shame for listeners to think we're living in a sea of, you know, drug abuse and wrong prescribing and which it does occur, but there is a tremendously positive side to this story, which I know Alan acknowledges, as well, because we've talked.
11:44:48
HALLOWELL
And Alan's done a great job in calling attention to a problem of over diagnosis, misdiagnosis, overprescribing, but I think to balance it out we also need to acknowledge that proper diagnosis and treatment is -- can be a godsend to a person of any age. The biggest undiagnosed group are adults.
11:45:09
MARTINEZ
Dr. Diller, one thing that we haven't talked about yet is the safety of these drugs. What do we know about the safety of these drugs?
11:45:15
DILLER
Amphetamine was synthesized in the late 1920s. By the mid-'30s, it was clear that it was an addictive substance. That said, the experience in children suggests that it's pretty safe, meaning if someone's not dying or developing a severe allergy, doctors say the side effects are minor. So -- and the threat of future drug abuse, which is really frightening to parents to consider, just hasn't played out as a factor in the under-13 use of the medicine.
11:45:48
DILLER
The risk in terms of future drug abuse has to do with the misuse and abuse of prescription stimulants by people I'd say older than 14 or 15, and there Jameson is talking about an absolutely below-the-radar moment but just about to hit the media, serious crisis in prescription amphetamine abuse and addiction.
11:46:14
MARTINEZ
Dr. Hallowell, I guess any pill that's abused can be dangerous, but standing alone, the medications for ADHD, for the most part, are they safe? Can you say, can you make a sweeping, blanket statement like that, or do we have to kind of nuance it a little bit?
11:46:30
HALLOWELL
We have to nuance it. When used properly, they're safe. When used improperly, they're dangerous. The same could be said of penicillin or aspirin, by the way. If you use them improperly, they're dangerous. If you use them properly, they're safe. Now don't get me wrong, I'm not saying in any way that stimulants are analogous to aspirin. I'm just saying that all medications carry with them potential dangers and side effects, and the absolute clarion call that Alan has sounded is let us be careful in how we describe particularly controlled substance because they do carry with them a significant danger when used improperly.
11:47:12
HALLOWELL
I'm here to say used properly, they can be a godsend. I think we all agree that the need now is for education not only of the general public but of doctors so they won't hastily write a prescription, so they won't be conned, if you will, into giving a medication that a person does not need so that they won't be handed out as performance-enhancing drugs at, you know, high-pressure high schools and colleges where people are angling to get a better grade and that this condition, which is such a fascinating condition because it's such an admixture of positive and negative qualities, that the people who truly have it can get the help they actually need, as opposed to our being left with the people who are angling to get a prescription that they don't need. I just -- I just want to advocate for -- the positive story is a real story because I see it in my office every day of people who are struggling, and once they get the right help, which is never just medication, they go from struggling to soaring.
11:48:19
HALLOWELL
It's as if they go from driving on square wheels to driving on round wheels.
11:48:22
MARTINEZ
Alan, as you were putting this book together, talking to doctors and parents, in your experience doing that, how many times would you say that you maybe you ran into lazy doctors or undereducated doctors when it comes to dealing with this?
11:48:35
SCHWARZ
Well of course it's all anecdotal, okay? I mean, I can't take a survey of the United States to see how many bad doctors there are.
11:48:42
MARTINEZ
Right.
11:48:43
SCHWARZ
In the same way we can't find out how many bad journalists there are. But there are way too many stories of doctors just making the diagnosis in 10 minutes, particularly in adults. I mean, the joke in and around New York and Houston is that if you wear a suit, you'll walk out of there in 10 minutes because you couldn't be somebody angling for drugs. And, I mean, I've seen journalists go under cover, now I never did that at the New York Times, it was against New York Times guidelines to do anything remotely approaching that, but, I mean, I've listened to the actual meetings with the doctors, and they -- and too many of them, it's not a majority by any means, but way too many of them are not trained, they have chosen not to train themselves, which is terrible.
11:49:38
SCHWARZ
Dr. Hallowell actually, with Dr. Peter Jensen, has started an education program that isn't going to change everything, but at least it's trying to help, but yeah, way too many doctors, or medical providers, it's not all doctors, are just not performing the role -- you know, these doctors, these folks have signed a covenant with the people of their state to, in exchange for the monopoly on the controlled substances distribution business, okay, you need a controlled substance, you've got to go to the doctor.
11:50:13
SCHWARZ
In exchange for that monopoly, which is a very large financial benefit, they have promised the people of their state to behave responsibly, and too many of them are breaking that covenant.
11:50:27
MARTINEZ
Dr. Diller, how much is under-education an issue from your experience?
11:50:32
DILLER
I'm afraid, looking at history, that education of doctors rarely have changed their behavior. Given the standard of care is so broad at this point, to include, you know, eight psychiatric drugs being prescribed to a single child, the past has shown that only the threat of suit, loss of license and high negative publicity -- doctors are human beings, okay, they're affected by economic factors just as much as anybody else, and when the doctor makes twice as much money doing four med checks in an hour versus doing one 45- to 50-minute consultation with the family, that's a tremendous influence on the doctor's behavior.
11:51:15
DILLER
So I wish I could support Ned's belief that education of the doctors -- and even Alan's notion that education of the doctors will make a difference, but the historical record shows until things get really, really bad, and the doctors' licenses and malpractice suits are going, that doctors' behaviors doesn't change.
11:51:34
MARTINEZ
I'm A. Martinez. You're listening to the Diane Rehm Show. And as always, you can call us, 1-800-433-8850. That's 1-800-433-8850. Or email us, drshow@wamu.org. Let's go out to Edie in Fort Wayne, Indiana. Edie, you're on the Diane Rehm Show.
11:51:53
EDIE
Yes, hi there, thank you very much. Just a quick scenario here. I agree with both speakers there. My little grandson, who went into the elementary school system, he was -- he just could not sit still. He was not combative, not mean by any means. But like the speakers were saying, he was condemned. He was taken out of gym class. He would sit in front of -- outside in the hallway, or he would be taken to the principal's office.
11:52:17
EDIE
The teacher had 25, 26 kids. She didn't have time to control this child. So the notes went out to my daughter, do something, do something. She goes to her pediatrician, again no proper diagnosis, not that half-hour or hour or four hours were spent. Based on those standard protocols for ADHD, at the age of eight, nine, 10, he was put on one medication, and it's a trial-and-error basis on these meds.
11:52:43
EDIE
This little boy didn't react, you know, whatever, whatever. Again, the teacher would send notes, my daughter went to the pediatrician, and by the time he was 10 years of age, he was on three kinds of medication, and one particular to the point you'd up and down, you just didn't know what that little boy was doing.
11:53:00
EDIE
And inside, as a grandmother, I saw Laura take him off of these medications, stop this, to the point that one day his eyes were dilated, his lips were swollen, he had a tremendous rash over him. We went to the ER, and he was given Narcan, prednisone and Benadryl. Now -- but I also agree when we switched pediatricians, totally different. And I went along, and I said, Laura, we need to ask this doctor to take his time, proper diagnose this little boy.
11:53:28
EDIE
And after all of this and nearly his throat swelling in the ER because of the -- you know, 11 years old that he was finally give (unintelligible) and he's doing very well.
11:53:38
MARTINEZ
Edie, thank you very much for the phone call. This is for both doctors, and Edie mentioned that at the start of her call, and we haven't really brought this up yet. When it comes to the people that spend as much or sometimes even more time with our kids, it's teachers. So I'm wondering how much or how little do teachers know about this to be able to maybe be part of this solution. Dr. Hallowell or Dr. Diller on this.
11:53:59
HALLOWELL
Well, I think teachers are the single most reliable source of information. It is certainly not up to them to make a diagnosis. But whenever I see someone, I say please bring teacher comments with you, not checklists but narrative teacher comments. What is Joey like in the classroom? What is Nancy like in the classroom? It's a wonderful source of information because teachers have a cohort of peers, whereas parents only have, you know, a few kids. Teachers can really help me separate out, you know, what is true ADHD from what is, you know, a case of modern life.
11:54:29
MARTINEZ
Dr. Diller?
11:54:31
DILLER
I sympathize with the teachers. They have an often impossible job. I sympathize with the parents who are raising often difficult children. And I sympathize with the children themselves. However, education systems, medical systems, insurance systems prioritize efficiency and cost. The pill is fast. Parents, and many teachers individually, prioritize engagement with the child. And in mild to moderate ADHD, there are non-drug interventions that work.
11:55:01
DILLER
If you give a kid a pill right away, it'll, quote, take care of everything, all right, and the motivation to address other issues decreases tremendously. A pill and working with the child, family and school are not the same thing.
11:55:15
MARTINEZ
Alan, what do you hope people will take away from this book?
11:55:18
SCHWARZ
What -- I guess what I said before, which is just to slow down, okay. We can have ADHD exist in its current construct, as defined by the American Psychiatric Association. Now we can argue whether it's real, whether the symptoms are this or the symptoms are that, but let's just take that for now because it is the only practical way of going about this and simply demand that the symptom function far closer to what it is supposed to be than the wild west we have allowed it to be.
11:55:50
SCHWARZ
Right now 11 percent of children in the United States are currently diagnosed with ADHD. Let's just say we got that down to 10, still have almost all the kids who really deserve the diagnosis get it, which they need, okay. But let's just say we get one percent down. That's 600,000 children who will either not be labeled -- will not receive this diagnosis with its treatments but may get more targeted interventions.
11:56:24
SCHWARZ
They may do a lot better. You know, the last thing a kid with anxiety or trauma needs is amphetamine. These kids deserve -- this is the grownups' fault, it's not the kids' fault. And we need for the grownups to slow down and behave responsibly, even when it's harder and even when it costs more money. Tough.
11:56:49
MARTINEZ
Alan Schwarz, former New York Times investigative reporter and author of the new book "A.D.H.D. Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic." Dr. Ned Hallowell, psychiatrist, author. His books include "Driven to Distraction." And also Dr. Lawrence Diller, behavioral developmental pediatrician and author of several books, including 1998's "Running on Ritalin." My thanks to all three of you.
11:57:11
DILLER
Thank you.
11:57:13
HALLOWELL
Thank you.
11:57:13
MARTINEZ
I'm A. Martinez of Take Two on KPCC, Southern California Public Radio, sitting in for Diane Rehm. Thank you very much for listening.
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ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic
Karen Springen
Booklist.
113.1 (Sept. 1, 2016): p21. From Book Review Index Plus.
COPYRIGHT 2016 American Library Association http://www.ala.org/ala/aboutala/offices/publishing/booklist_publications/booklist/booklist.cfm
Full Text:
ADHD Illation: Children, Doctors, Big Pharma, and the Making of an American Epidemic. By Alan Schwarz. Sept. 2016.352p. illus. Scribner, $28 (9781501105913); e-book, $14.99 (9781501105937). 618.92.
Schwarz, a Pulitzer Prize-nominated investigative reporter for the New York Times who wrote more than 100 articles about concussions in the NFL, leaves no stone unturned as he documents the overdiagnosis of attention deficit/hyperactivity disorder. In fact, he interviews more than 1,000 doctors, parents, students, and researchers. Kids get pseudonyms to protect family relationships and sometimes for legal reasons. Schwarz tries to have fun when appropriate: one chapter title is "Fidgety Phil's Arithmetic Pills," another is "ADD for All." But good guys are few and far between. Students get diagnosed and are given Adderall to help them perform better, and then they become hooked. Pharmaceutical companies advertise heavily. "ADHD medications were hawked like any other consumer product when the companies knew they were anything but," writes Schwarz. And teachers wildly overestimate how many students have ADHD. One questionnaire found that they support an ADHD diagnosis in more than one in five boys. This eye- opening book should be a hit with drug-industry skeptics and worried parents who want to read a well-reported, definitive guide to this misunderstood and overly medicated disorder.--Karen Springen
Springen, Karen
Source Citation (MLA 8th Edition)
Springen, Karen. "ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic."
Booklist, 1 Sept. 2016, p. 21. PowerSearch, go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA463754990&it=r&asid=de5c2df23312b5d317f6b79e6c4aa81f. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A463754990
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Schwarz, Alan. ADHD Nation: Children,
Doctors, Big Pharma, and the Making of an
American Epidemic
Lisa Jordan
Library Journal.
141.14 (Sept. 1, 2016): p126. From Book Review Index Plus.
COPYRIGHT 2016 Library Journals, LLC. A wholly owned subsidiary of Media Source, Inc. No redistribution permitted.
http://www.libraryjournal.com/
Full Text:
Schwarz, Alan. ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic. Scribner. Sept. 2016. 352p. photos. notes. bibliog. index. ISBN 9781501105913. $28; ebk. ISBN 9781501105937. psych
New York Times investigative reporter Schwarz takes an in-depth look at the diagnosis of attention-deficit hyperactivity disorder (ADHD) through the eyes of doctor Keith Conners, who discovered that Ritalin could help children with the condition. Ritalin was so successful in treating ADHD that the pharmaceutical industry took notice. Schwarz reveals how big pharma has led the way to what could be considered an ADHD epidemic in the United States, with one in seven children receiving a diagnosis. This rate is three times what experts in the field would expect to see if diagnostic tools were being used appropriately and medications prescribed judiciously. Schwarz cautions that ADHD is real and that symptoms can be successfully ameliorated by the appropriate use of medication; however, with for-profit companies leading the charge in an effort to manage ADHD with medication, many are being misdiagnosed. Schwarz presents a well-researched and easy-to-read history of the condition and the pharmaceutical industry's influence. VERDICT A solid choice for anyone who interacts with those who may or may not have ADHD, such as teachers, clinicians, and parents; readers with a diagnosis themselves will also appreciate. Suitable for libraries with large psychology collections. [See Prepub Alert, 3/14/16.]--Lisa Jordan, Johnson Cty. Lib., Overland Park, KS
Jordan, Lisa
Source Citation (MLA 8th Edition)
Jordan, Lisa. "Schwarz, Alan. ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American
Epidemic." Library Journal, 1 Sept. 2016, p. 126. PowerSearch, go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA462044957&it=r&asid=e7c014a406944532b5acabdf59721476. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A462044957
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Attention Must Be Paid
Steve Silberman
The New York Times Book Review.
(Aug. 28, 2016): Arts and Entertainment: p10(L). From Book Review Index Plus.
Source Citation (MLA 8th Edition)
Silberman, Steve. "Attention Must Be Paid." The New York Times Book Review, 28 Aug. 2016, p. 10(L). PowerSearch,
go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA461753603&it=r&asid=34b6731d087819d38002f5cc62219468. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A461753603
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ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic
Publishers Weekly.
263.31 (Aug. 1, 2016): p64. From Book Review Index Plus. COPYRIGHT 2016 PWxyz, LLC http://www.publishersweekly.com/
Full Text:
ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic Alan Schwarz. Scribner, $28 (352p) ISBN 9781-5011-0591-3
New York Times reporter Schwarz (Once upon a Game) shifts from sports injury, about which he wrote a Pulitzer- nominated series, to attention deficit hyperactivity disorder (ADHD) in this sweeping critique. He finds that the use of stimulants for an initially small number of unmanageable children with "minimal brain dysfunction" was "commandeered by Big Pharma," leading to 11% of American children, and a growing number of adults, being diagnosed with ADHD. Schwartz primarily blames the marketing of medications direct to consumers, despite the associated side effects and risks of addiction. The calm, incisive side of Schwarz's investigative style dominates as he traces the development of drugs, treatment protocols, and public messages over the last 40 years, but sensationalism overwhelms the reader in the cautionary tales of Jamison Monroe, who faked ADHD to maintain his Adderall addiction before being "scared straight" into founding treatment center Newport Academy, and pseudonymous Kristin Parber, who went from reluctant Ritalin user to alcoholic and addict. Nevertheless, Schwarz's grounding in the viewpoint of Dr. Keith Connors, a pioneering ADHD researcher turned medication skeptic, makes it impossible to confuse Schwarz's interest--exposing the role of drug companies in shaping a society-wide issue--with a disbelief in the concept of ADHD overall. Agent: David Black, David Black Agency. (Sept.)
Source Citation (MLA 8th Edition)
"ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic." Publishers Weekly, 1
Aug. 2016, p. 64. PowerSearch, go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA460285738&it=r&asid=2cb17873c55c203be4f770114272b687 Accessed 12 Apr. 2017.
Gale Document Number: GALE|A460285738
.
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Hot Reads II
Sports Illustrated Kids.
19.6 (July 2007): p45. From Book Review Index Plus.
Source Citation (MLA 8th Edition)
"Hot Reads II." Sports Illustrated Kids, July 2007, p. 45. PowerSearch, go.galegroup.com/ps/i.do?
p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA165782318&it=r&asid=928824759963ec96b47b4b926c3308b2. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A165782318
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The Numbers Game: Baseball's Lifelong Fascination with Statistics
Publishers Weekly.
251.22 (May 31, 2004): p64. From Book Review Index Plus. COPYRIGHT 2004 PWxyz, LLC http://www.publishersweekly.com/
Full Text:
ALAN SCHWARZ. St. Martin's/Dunne, $24.95 (384p) ISBN 0-312-32222-4
Sports journalist Schwarz brings to the fore this intelligent, smartly researched and often hilarious look at the use of statistics in baseball, which Schwarz definitively shows to "date back to the game's earliest days in the 19th century." It will delight any fan who memorizes the numbers on the back of trading cards or pores over newspaper box scores. The book's success is rooted in its focus on the people "obsessed with baseball's statistics ever since the box score started it all in 1845," rather than being about the statistics themselves. The reader is presented with enthusiastic but unvarnished looks at such key figures as Henry Chadwick, whose love for numbers led to his inventing the box score grid that remains, Schwarz shows, "virtually unchanged to this day"; Allan Roth, the numbers man hired by the Brooklyn Dodgers who was as important to the team's success as its famed GM Branch Rickey; and the all-but-forgotten work of George Lindsey, one of the first people to apply statistical analysis to weigh various baseball strategies. Delivered in a delightfully breezy and confident style, this volume also serves as an excellent alternate or parallel history of the sport, as we see how the statistics influenced the game itself--such as the banning of the spitball--as much as they were used to detail individual games. Agent, Esther Newberg. (July)
Source Citation (MLA 8th Edition)
"The Numbers Game: Baseball's Lifelong Fascination with Statistics." Publishers Weekly, 31 May 2004, p. 64.
PowerSearch, go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA118446933&it=r&asid=e136da474e4824a3f95337bcef373900. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A118446933
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Schwarz, Alan. The Numbers Game: Baseball's Lifelong Fascination with Statistics
Jim Burns
Library Journal.
129.10 (June 1, 2004): p147. From Book Review Index Plus.
COPYRIGHT 2004 Library Journals, LLC. A wholly owned subsidiary of Media Source, Inc. No redistribution permitted.
http://www.libraryjournal.com/
Full Text:
SCHWARZ, ALAN. The Numbers Game. Thomas Dunne Bks: St. Martin's. Jul. 2004. c.384p. ISBN 0-312-32222-4. $24.95. SPORTS
Beyond even the pleasure of a big win for the home team, what baseball fans really enjoy is debating the relative merits of players, and that comes down to statistics. Schwarz, a writer for ESPN.com and Baseball America, gives us not statistics themselves but their historical progression to the center of the game. He shows their evolution from a time when about the only thing fans could find out about their favorite batters was how many times they appeared at the plate and how many runs they scored, to the computer-enhanced age when we can discuss a hitter's OPS (on-base plus slugging percentage) and a pitcher's "true" value based on his SNWL (Support Neutral Win-Loss). Along the way, the author introduces the men who steadily refined the state of the art of baseball statistics, the teams who first began using statistics other than mere ERA and batting average to make personnel decisions, and the controversies begat by the march of statistics (is on base percentage more important than batting average? Is clutch hitting merely a function of chance?). Casual fans will almost certainly find something here to pique their interest, while raving statistics buffs will devour it. Recommended for most medium to large public libraries.--Jim Burns, Jacksonville P.L., FL
Burns, Jim
Source Citation (MLA 8th Edition)
Burns, Jim. "Schwarz, Alan. The Numbers Game: Baseball's Lifelong Fascination with Statistics." Library Journal, 1
June 2004, p. 147. PowerSearch, go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA118343677&it=r&asid=0cc86aa2a9e3d679dd45301525a5858f. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A118343677
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Sacred stats
Ron Briley
American Book Review.
26.4 (May-June 2005): p28. From Book Review Index Plus.
Source Citation (MLA 8th Edition)
Briley, Ron. "Sacred stats." American Book Review, May-June 2005, p. 28. PowerSearch, go.galegroup.com/ps/i.do?
p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA133320134&it=r&asid=c5060baba25cd9545b59d290bb6a2af7. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A133320134
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Sports: of megabucks, athletes who commit crimes, and the clean-cut appeal of statistics
Bob Ivry
Book World.
34.34 (Aug. 22, 2004): p8. From Book Review Index Plus.
Source Citation (MLA 8th Edition)
Ivry, Bob. "Sports: of megabucks, athletes who commit crimes, and the clean-cut appeal of statistics." Book World, 22
Aug. 2004, p. 8+. PowerSearch, go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA122920461&it=r&asid=01422d2426bf3f24cb483386111ed638. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A122920461
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Sports: of megabucks, athletes who commit crimes, and the clean-cut appeal of statistics
Bob Ivry
Book World.
34.34 (Aug. 22, 2004): p8. From Book Review Index Plus.
Source Citation (MLA 8th Edition)
Ivry, Bob. "Sports: of megabucks, athletes who commit crimes, and the clean-cut appeal of statistics." Book World, 22
Aug. 2004, p. 8+. PowerSearch, go.galegroup.com/ps/i.do? p=GPS&sw=w&u=schlager&v=2.1&id=GALE%7CA122921726&it=r&asid=2758c1d25ef9e4b74d42a6c6bec517fe. Accessed 12 Apr. 2017.
Gale Document Number: GALE|A122921726
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Overselling A.D.H.D.: A New Book Exposes Big Pharma’s Role
By STEVE SILBERMANAUG. 22, 2016
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ADHD NATION
Children, Doctors, Big Pharma, and the Making of an American Epidemic
By Alan Schwarz
Illustrated. 338 pp. Scribner. $28.
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.
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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.
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Continue reading the main story
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.
ADHD NATION
Children, Doctors, Big Pharma, and the Making of an American Epidemic
by Alan Schwarz
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KIRKUS REVIEW
A troubling look at the systemic overdiagnosis of attention deficit hyperactivity disorder and a chilling analysis of the effect ADHD medications have on patients, especially children.
New York Times investigative reporter Schwarz (Once Upon a Game: Baseball's Greatest Memories, 2007, etc.) begins this hard-hitting book by making sure readers understand that, despite the prevalence of false diagnoses, ADHD is a legitimate condition that affects some children and adults; in these cases, appropriately prescribed medication may work wonders. However—a very significant however—in the 50 years since ADHD was clinically defined, it “has become, by far, the most misdiagnosed condition in American medicine.” Stunningly, in some states, 30 percent of school-age boys are diagnosed, the majority of whom are put on powerful stimulants such as Ritalin or Adderall. While the intentions of the prescribing doctors may have some merit, the fact remains that physicians and pharmaceutical companies alike assure parents that ADHD drugs are “safer than aspirin.” The author pulls no punches in his in-depth portrayal of this falsehood and the prevalence of the drugs in schools and colleges across the nation. Adolescents routinely and casually abuse stimulants to such an extent that school officials often shrug their shoulders at the problem rather than instituting rules to protect students. Worse, Schwarz describes how doctors misconstrue the dangerous side effects of stimulants as evidence of other maladies and prescribe additional drugs such as anti-anxiety medication. Tragically, many kids become quickly addicted and fall into a downward spiral they are helpless to prevent. The author, while vehement in his arguments, is no alarmist; his facts are meticulously sourced, and he relies on numerous first-person narratives from patients, parents, doctors, and pharma reps to make his argument. In no uncertain terms, he states that without immediate action to reassess the status quo, countless patients may face dire consequences.
In this powerful, necessary book, Schwarz exposes the dirty secrets of the growing ADHD epidemic.
Pub Date: Sept. 6th, 2016
ISBN: 978-1501105913
Page count: 352pp
Publisher: Scribner
Review Posted Online: July 19th, 2016
How We Became ADHD Nation
Alan Schwarz’s bracing book on the making of a distinctly American epidemic
Posted Sep 30, 2016
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Scribner
Source: Scribner
“ADD could replace oedipal anxiety as a new universal explanation; I urge restraint.” So warned Dr. Judith Rapoport of the NIMH to colleagues working on the 1980 Diagnostic and Statistical Manual of Mental Disorders about glaring overlaps among the proposed criteria for Attention Deficit Disorder. “Easily distracted” appeared right next to “has difficulty concentrating.” The obvious redundancy risked loosening an already vague definition, making diagnosis even easier. Not requiring signs of “hyperactivity” also meant girls would henceforth be diagnosed in much higher numbers.
In the end, as Alan Schwarz recounts compellingly in ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic (Scribner), the restraint that Rapoport counseled was ignored. Children who “fail to finish things” came to be listed in ADD’s formal symptoms alongside children who have “difficulty sticking” to tasks, and so on, in turn fulfilling still a third vague criterion—“shifts excessively from one activity to another.” Rapoport had been streamrolled. The loose, overlapping list of symptoms went to press and the rest is history: a distinctly American epidemic supported by the massive overprescribing of Ritalin, followed by Adderall, as well as multimillion-dollar marketing campaigns for each. By 2013, Schwarz reports, “ADHD diagnoses reached a staggering 15 percent of children nationwide, and 20 percent of boys."
The story of how more than one in seven American children and teens came to be diagnosed with ADHD is told with impressive detail and reporting. Schwarz, a Pulitzer Prize-nominated investigative reporter for the New York Times, draws on multiple sources, among them unpublished documents and interviews with “more than a thousand people, primarily doctors, parents, students, researchers, government officials, and other experts in ADHD.”
We learn how the disorder’s most ardent defender, Dr. C. Keith Conners at Duke University, now views its widespread diagnosis as “a national disaster of dangerous proportions.” How methylphenidate (brand name Ritalin) came to exist as but a “slightly tweaked formulation” of the highly addictive amphetamine Dexedrine, itself massively overprescribed in the 1960s and '70s, with symptoms in children not dissimilar from its parent form as speed. And how Adderall got its name from the very disorder its manufacturers hoped would become inseparable from it as a treatment:
All.
For ADD.
ADD for All.
Adderall.
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Just as incredible, Schwarz reproduces the commercially marketed “Conners Rating Scales” that the Duke professor agreed to sell in 1989. Thereafter, it was hauled in vast quantities to doctors’ offices nationwide and somehow became the industry standard for psychiatric diagnosis, though its formal criteria for telltale behaviors continued to list “pouts and sulks,” “daydreams,” “acts ‘smart’ (impudent or sassy),” and “restless in the ‘squirmy’ sense”—in short, a basic definition of childhood.
ADHD Nation points repeatedly to a dilemma among psychiatrists over how to name and properly identify the behavior they hoped to diagnose. First defined as “Hyperkinetic Impulse Disorder” in the 1950s, the disorder was subsequently renamed “Minimal Brain Dysfunction.” (“Hyperkinesis” appeared too restrictive and “Attentional Deviation Syndrome,” another name floated, didn’t catch the desired focus on hyperactivity.) Yet as Schwarz archly notes, “‘Minimal’ [also] didn’t exactly convey anything worthy of respect or governmental funding”—its very name limited the pool of potential patients and lacked the diagnostic ambition of psychiatrists wanting terminology with widespread applicability.
Newsweek, March 18, 1996
Source: Newsweek, March 18, 1996
The 1980 DSM went with “Attention Deficit Disorder,” which freed the term from its previously “ugly minimal brain dysfunction moniker,” but bore such resemblance to ordinary behavioral difficulties that the number of diagnoses increased rapidly, “with hundreds of thousands of new children identified each year.”
The sharp rise in Ritalin prescriptions follows an almost exact parallel, “doubling every six years since the early 1970s” and in the late 1990s increasing “a stupefying 400 percent in just five years,” with just a brief falling-off period between 1987 and 1990. That was due to several well-publicized lawsuits and media coverage warning of lax prescribing. “From just 1990 to 1993,” Schwarz continues, “annual diagnoses more than doubled from 900,000 to two million. They kept rising from there.”
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Supporting the massive increase in prescribing were all the usual suspects: Pharma-sponsored patient support groups such as CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder), which had accepted almost $1 million since 1989 in undisclosed funding “to attract parents and fuel its growth.” Key opinion leaders (KOLs) in psychiatry, mostly well-meaning but also massively ambitious for the disorder they had studied and redefined, who were willing to expand its diagnostic range at the drop of a hat. Psychiatrists and general practitioners only too glad to write a prescription for the crowds now swelling their previously empty waiting rooms. An enabling, often uncritical media, which at first represented the medications prescribed as wonder drugs with few side effects. And harried, often highly competitive parents willing to fill any prescription if it meant their child would maintain their GPA. Added to this, particularly in the case of Adderall, Schwarz notes: the many thousands of students at college and, increasingly, high school, who would become willing to fake symptoms of ADHD—hardly difficult, given their widespread applicability—to take prescription stimulants as study aids, with a well-documented spike in visits to the emergency room as a result. After all, “the drugs were still amphetamines. Eventually, that fact became all too clear.”
As one would expect of a seasoned reporter at the New York Times, Schwarz tells this complex story with flair and an eye for detail. The expansion here of articles previously published in the Times gives him the scope to bring in accounts of parents and students caught up in the drama of diagnosis, treatment, and recurring side effects. Yet it is in one sense the very precision of Schwarz’s account of the repeated renaming of ADHD, with its altered and greatly expanded list of everyday symptoms, that cuts against the opening to his book: “Attention deficit hyperactivity disorder is real. Don’t let anyone tell you otherwise.”
The somewhat perplexing issue here is that it is in fact Schwarz himself who rightly and repeatedly “tells us otherwise.” He doesn’t question, as some have, that ADHD is a medical phenomenon. But his precise rendering of the behavior’s vague definitions and complex history makes it almost impossible to reconcile “Minimal Brain Dysfunction” with the 1980 and later versions of “Attention Deficit Disorder,” since they define the problem in such different ways. For one thing, the latter term came to define a "lifelong condition"—something not even implied in the earlier literature.
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Our Kids First Foundation
Source: Our Kids First Foundation
That elasticity or diagnostic imprecision is clearly part of the story in the making of this American epidemic. Some might even view it as the story’s enabling condition. To minimize that from the start of the book is to suggest in part that there’s a bedrock to the diagnosis that we can separate from the pharma-sponsored hype, the funded patient groups, the selectively reported trials, and the KOLs who find personal checks left on their desks (“for further studies”) and scripts handed them if they’ll outright deny the medication’s side effects (“We’ll give you a thousand dollars if you say this for a half-hour”).
Part of the strength and accomplishment of ADHD Nation is that such separation is shown to be impossible. If the DSM and psychiatric establishment still referred to a phenomenon known half a century ago as “Minimal Brain Dysfunction,” Schwarz implies, the ADHD epidemic we are now enduring could never have happened.
The issue goes far beyond semantics. As Schwarz rightly observes of the consequences of such emphases, “Whether it’s just one child or today’s six million, if we’re going to tell a kid that he has a permanent, potentially devastating brain disorder, we’d better damn well be right.”
We’re Missing Something Big in the Way We Talk About ADHD
By Timothy Denevi
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Photo: Chris Gallagher/Getty Images/Science Source
After I finished Alan Schwarz’s ADHD Nation: Children, Doctors, Big Pharma and the Making of an American Epidemic, I kept thinking about another story — one that doesn’t appear in Schwarz’s book but that, in my opinion at least, gets at the heart of his subject matter: On a cold February morning in 1966, the journalist Hunter S. Thompson found himself facing down the most important deadline of his life. He needed to turn in a draft of his first book about the Hell’s Angels motorcycle gang or risk forfeiting his $1,500 advance — what amounted to a year’s worth of income.
Thompson knew what he needed to say. He’d already outlined the book’s structure and had long since finished his reporting. The problem now was the same one he always faced: sitting down to write. So during the last week of February, in a fit of panic over the looming deadline, he lighted on a tactic that might sound familiar: stimulants. Specifically, he began taking Dexedrine, an amphetamine mixed with salt and consumed in gelatin capsules. It had been prescribed to him by a friend, and he’d found that it helped him stay focused on necessary but boring tasks, without taking away the natural spontaneity that was his writing strength.
A stimulant like Dexedrine — similar to Adderall — has a way of mimicking sobriety. Reality becomes less blurry and more immediate, and as a result, the distance between you and what you want to accomplish feels smaller, which goes a long way to offsetting whatever motivation issues you might be facing. In this sense, staying on task — in his case, remaining seated in front of a typewriter for long stretches of time — can feel surprisingly natural, especially for someone who struggles with a task like that in the first place.
For the next four days, Thompson didn’t sleep. And after nearly a hundred hours of uninterrupted composition, he met his deadline with only moments to spare. Hell’s Angels: A Strange and Terrible Saga would go on to sell 500,000 copies in its first printing, launching Thompson’s literary career.
But in this instance and many others, Thompson’s use of Dexedrine went far beyond what today’s medical professionals have in mind when they prescribe stimulants to treat ADHD. Thompson did actually struggle with the harmful effects of hyperactivity, impulsivity, and distraction in his professional and personal life. There’s no question he benefited from the stimulants he was prescribed. There’s also no question that he blatantly abused them.
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Though this particular story took place in 1966, it’s a startling example of the bargain millions of people enter into today with drugs like Adderall: Whenever something is gained, something is also lost. And more than half a century later, Americans continue to replay the same sort of trade-off Hunter S. Thompson once made — and they’re doing it on a wider scale than ever before.
* * *
That’s the issue that Schwarz, a New York Times reporter, sets out to address — implicitly, at leas — in ADHD Nation. I say implicitly because, from the very beginning, Schwarz’s most pressing concern is to prove the extent of overdiagnosis and overmedication in America, rather than getting to the root causes.
His book, he writes in the introduction, is the story of how we “have allowed what could be a legitimate medical condition to become diluted beyond recognition, and beneficial medication to become a serious drug problem.”
Despite my criticisms — which I’ll get to in a bit — I think it’s important to come right out and say that ADHD Nation is a necessary book. Schwarz has done a fine job on a maddening topic, and everyone who’s interested in hyperactivity, attention spans, stimulants, and the current state of American health care should grab a copy. Schwarz goes to great lengths to explain that ADHD is a real disorder affecting the portion of the population for whom overactivity, inattention, and impulsivity cause extensive and significant harm (about 5 percent, give or take); that the diagnostic process is completely broken; that children and especially adults are receiving medication they shouldn’t; and that the doctors, organizations, and pharmaceutical companies who’ve all played a role in this systemic failure have at the same time made an enormous amount of money off it — and will fight tooth and nail to prevent significant changes.
The book begins with a historical overview of ADHD, going on to describe some of the people whose lives have been touched by the disorder in varying ways: There’s an attempt to dramatize the story of a young girl who was misdiagnosed with the disorder at age 7, as well as that of a teenage boy who faked symptoms to get medication. The most compelling of these profiles follows the long, fascinating career of C. Keith Conners, a child psychologist whose work, in the 1960s, would go on to play an outsize role in how we’ve come to conceptualize ADHD.
But perhaps the best way to understand ADHD Nation is through the context of a book that has nothing to do with attention and hyperactivity: Game of Shadows, by Mark Fainaru-Wada and Lance Williams — an exposé about steroid use and the baseball player Barry Bonds. At his best, Schwarz is channeling Fainaru-Wada and Williams’s careful reportage and moral urgency. But the problem with exposés is that they run the risk of reducing action and motivation to simple dichotomies: villain/hero; underdog/favorite, etc. And that’s my strongest criticism, in the end, of Alan Schwarz’s work on ADHD: he refuses to include or even consider examples from the real world that won’t fit neatly into the argument he’s created. In his view, there are people who have ADHD and are helped by medication. And then there are many more who, either through misdiagnosis or subterfuge, use stimulants in the way that baseball players use steroids: to gain an advantage. And if you don’t fall into these categories, then you don’t make it into his book.
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This is why, in retrospect, Hunter S. Thompson’s experience writing Hell’s Angels feels so striking to me: It refuses easy categorization. We can file Thompson in both silos.
* * *
Despite the similarities between Schwartz’s book and Fainaru-Wada and Williams’s, writing about stimulants and ADHD is an entirely different endeavor than writing about steroids and baseball. After all, the odds are slim that a great writer will also have a chance to play starting shortstop for the New York Yankees (and with few exceptions, vice versa). But there’s more overlap with ADHD — journalists of Schwarz’s caliber can be extremely hyperactive/inattentive and still excel in their field. There’s a whole generation of them coming up now, along with many others who, even if they don’t have ADHD, know from personal experience what it’s like to take Adderall and try to write.
Perhaps that’s why Schwarz’s book fell short in the way that it did: He hasn’t lived the phenomenon he’s writing about. Schwarz, through no fault of his own — and due to the simple reality that he’s over 35 years of age — will inherently fail to represent the perspective and experience of the very people he’s describing. But there are others who could succeed.
This isn’t to say that he shouldn’t have written his book. Or that he’s done a poor job. I’m simply trying to draw our attention to the direction we might be heading next — that moment when our discussion on ADHD will finally expand to include fresh perspectives. Specifically the voices of people who, on account of their personal and professional experience, hold the power to articulate the many things we don’t already know. I think it’s important to keep in mind that, even when we can point to larger forces at work in the widespread nature of ADHD diagnoses, the drama of the disorder will always play out on the personal level, in ways that broad sociology studies don’t necessarily articulate. ADHD manifests on a case-by-case basis. Stimulants work differently on everyone.
It’s time to hear from people with some skin in the game. What’s it like to work as a rookie reporter or go through college or enroll in a graduate program, today, in an era where you can acquire a drug like Adderall so easily — and without the moral opprobrium that was once attached to previous versions of amphetamine? How have the lives of your friends and family members who were diagnosed with ADHD at a young age played out? What happens when you reach the limits of your own ambition — and how do stimulants, in baffling ways, change the parameters of this equation altogether? When it comes to psychotropic drugs, where do the boundaries of personal agency end and begin? The goal is to speak honestly, and carefully, and without hesitation on the subject of stimulants and ADHD.
How ADHD Was Sold
A new book outlines an epidemic of over-diagnosis and addiction.
BY ADAM GAFFNEY
September 23, 2016
Rita was the wife of a chemist at the Swiss drug company CIBA who concocted a new stimulant by modifying amphetamine, and Rita enjoyed tennis. The chemist shared his invention with his wife, and—to their delight—the substance had a wonderful effect on her tennis game. He named the new drug in honor of his darling. He named the new drug Ritaline.
ADHD NATION: CHILDREN, DOCTORS, BIG PHARMA, AND THE MAKING OF AN AMERICAN EPIDEMIC by Alan SchwarzScribner, 352 pp., $28.00
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In 1956, CIBA began marketing this drug as Ritalin in the United States, for a wide range of adult psychiatric maladies. But soon, evidence emerged that it might benefit what were then called “disturbed children.” In a landmark randomized clinical trial conducted in Baltimore by the child psychiatrist Leon Eisenberg and the child psychologist Keith Conners (then at Johns Hopkins) that was published in 1963, the drug improved behavioral symptoms, from “demanding” and “disobedient” to “leads into trouble” and “lying.” The diagnostic label “attention deficit hyperactivity disorder” (ADHD) did not yet exist, but the pair had put the drug on the child psychiatry map.
This story of the origins of Ritalin is described in journalist Alan Schwarz’s hard-hitting new book, ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic. But Schwarz proceeds to show another side of the story, describing an episode that occurred in the aftermath of the trial. Some weeks after the publication of Conners and Eisenberg’s paper, the pair received a curious visitor: A man in a suit showed up at Eisenberg’s office and, with his protégé Conners looking on, gratefully glided a slip of paper across his desk, for what he referred to as “further studies.” The man, Schwarz notes, was a representative from CIBA (later to become a part of today’s drug giant Novartis), and the slip of paper was a check for $5,000. Eisenberg, Schwarz continues, tucked the check into a desk drawer, warned Conners to “watch out for these guys,” and never spoke of the day thereafter.
And thus was the study of ADHD therapy linked to Big Pharma’s silver from almost its very first day.
The addictive potential of amphetamines was well known by the time Conners and Eisenberg carried out their trial in the 1950s. “America’s First Amphetamine Crisis,” as the historian Nicolas Rasmussen describes it in a paper the American Journal of Public Health, began soon after the drugs’ discovery in 1929. The drug firm Smith, Kline and French began marketing them first as a decongestant (in inhaler form), he notes, and later as a treatment for depression and weight loss. During World War II, the US military provided amphetamines as a stimulant for soldiers, some of whom—Rasmussen describes—became addicted. In the following decades, production skyrocketed and addiction became a major public health problem.
Rasmussen gives sense of the truly massive amphetamine use, addiction, and resultant suffering that followed. By 1962, he notes, 80,000 kg of amphetamine was being produced annually in the US, translating into some 8 billion typical 10mg doses, or approximately 43 doses for every single person in the country each year. “The original amphetamine epidemic,” he asserts “was generated by the pharmaceutical industry and medical profession as a byproduct of routine commercial drug development and competition.” In other words, Big Pharma followed its usual approach to the mass-commercialization of a new prescription drug, and in so doing produced an epidemic of abuse.
The pharmaceutical industry learned nothing from the first amphetamine epidemic it caused.
Of course, simply because a medication has significant addictive potential—and here there is a strong parallel with today’s opioid pain-killer crisis—doesn’t mean that it doesn’t also have important therapeutic uses. Yet, as Schwarz’s book makes distressingly clear, the pharmaceutical industry apparently learned nothing from the first amphetamine epidemic it helped cause, when it began setting the research agenda for what was once called “minimal brain dysfunction” and later became ADHD. His book—a dazzling piece of journalism, based on extensive research and an enormous number of interviews—sheds some much needed light on what he calls a new “American epidemic.”
The epidemic is twofold. First, there are adults or adolescents who become addicted to stimulants, whether they first acquire them in clinical or recreational settings. Second, there are the enormous number of children who—it seems difficult to dispute—are being overdiagnosed with ADHD. Diagnosis rates, as Schwarz describes, are skyrocketing: Whereas expert groups (i.e. the American Psychiatric Association) contend that ADHD is a mental illness affecting 5 per cent of children, numbers from the Centers for Disease Control indicate that today, some 15 per cent of children in the United States will ultimately be diagnosed with the disorder by the end of their childhood. Indeed, he states, the drugs are even being given to thousands of toddlers as young as 2 and 3 years of age—despite a lack of good evidence for their use in such neuro-developmentally immature individuals.
ADHD, it seems, has become something of a runaway train. But who is its conductor?
It is not a judgment on the legitimacy of stimulant therapy for ADHD—much less on the diagnosis itself—to assert that the research agenda on ADHD has been appallingly contaminated from its very genesis. Since that $5,000 check from CIBA, Schwarz makes clear, pharmaceutical money has irrigated the channels running through every corner of the ADHD ecosystem, feeding researchers, patient advocacy groups, celebrity spokespeople, and advertisers. In particular, Schwarz paints many industry-funded ADHD “opinion leaders” in the academy in an unflattering light, and sees their influence as pernicious:
Psychiatry journals teemed with more than a thousand studies on ADHD conducted by … pharma-sponsored scientists. The Food and Drug Administration relied upon them when green-lighting medications as safe and effective. Their findings served as the backbone for the lectures that drug companies’ key opinion leaders delivered on world tours. The whirlwind created a self-affirming circle of science, one that quashed all dissent.
Money also flowed to one of the book’s central figures, Keith Conners: Over the years, he received high six-figure annual royalties for his diagnostic ADHD questionnaire, research support, and speaking fees from all the big companies. Schwarz traces Conners’s career from his early days running trials with Eisenberg in Baltimore, to the heights of his academic prominence, to his present-day misgivings about the direction his field has taken.
His story ultimately intersects with that of two other individuals Schwarz follows; both were misdiagnosed with ADHD as children and subsequently began to abuse stimulants and other substances. One of the pair faked the answers on an ADHD questionnaire when he was a child in the hope that stimulants would improve his sagging grades. He was prescribed not Ritalin, but what is perhaps the second most well-known ADHD drug, Adderall.
Why had this “new” drug—in reality, an old amphetamine—emerged? Essentially, CIBA’s patent on Ritalin had run out, and, as Schwarz notes, “fortune beckoned the company that could invent a new drug to treat ADHD, get it approved and patented, then unleash it on the awaiting market.” This is par for the course for Big Pharma: When a patent dies, a new brand drug must rise—even if the new one is not one iota better.
The curious story of Adderall starts with a decades-old weight-loss amphetamine called Obetrol.
The curious story of Adderall starts with a decades-old weight-loss amphetamine called Obetrol, which was being produced by a small company called Rexar. Bizarrely, it turns out that Rexar shouldn’t have been producing the drug at all: Approval of Obetrol had been “withdrawn by the [FDA] Commissioner’s order effective on October 5, 1973,” as the minutes of a January 1995 meeting with the FDA would describe. (The FDA documents regarding the affair are available online here.) About a decade later, the minutes note, there had been a single communication within the FDA that “the product was unapproved,” though “no further action was taken.” So Rexar kept on selling the amphetamine for weight loss into the 1990s.
Along comes Roger Griggs, a former high school football coach, who started a small pharmaceutical company named Richwood Pharmaceutical and became interested in scooping up Rexar. (Schwarz’s story of Adderall is in part based on interviews with Griggs). Rexar wasn’t selling much Obetrol at that point, but—interestingly—an oddly high number of prescriptions for Obetrol were being penned by a Utah pediatrician who was using it for ADHD, as Schwarz describes. Learning this, Griggs, asked himself: “Could the United States, with its notoriously short memory, be ready to try amphetamine again? Of course it would—with the right marketing.”
Thus Griggs bought Rexar, and in the summer of 1994 began advertising and selling Obetrol as Adderall (a name derived from “ADD for All”) even though it was unapproved, and indeed hadn’t even been tested for ADHD. The FDA quickly put a halt to the baldly outrageous undertaking, and Richmond responded by starting a trial and submitting a new drug application. But at least according to Schwarz, Griggs wasn’t sure whether the application would actually be approved or not until he received a call from a “well-connected Washington lobbyist,” who told him that a US Senator was furious with the fact that his son could no longer obtain Adderall. “You’re golden,” the lobbyist assured Griggs. And sure enough, the application was approved, ADHD became a blockbuster, and Griggs sold Richwood to Shire Pharmaceuticals for a cool $186 million.
“Regardless of the moral issue, dishonesty in advertising,” the advertising legend Leo Burnett is purported to have said, “has proven very unprofitable.” The quote, which could very well be apocryphal, happens to also be patently idiotic. Dishonest advertising with medical messaging has always made plenty of money, ranging from outrageous ads featuring physicians touting the health benefits of smoking to misleading ADHD drug advertisements in the twenty-first century. “The Food and Drug Administration,” Schwarz noted in an article in the New York Times in 2013, “has cited every major A.D.H.D. drug … for false and misleading advertising since 2000, some multiple times.” And this ongoing and often misleading advertisement blitz has, no doubt, played at least some role in soaring diagnostic rates, as Schwarz’s book makes clear.
The history of direct-to-consumer (DTC) drug advertising is rather fascinating. As Schwarz describes, the US was actually a signatory to the 1972 United Nations’ Convention on Psychotropic Substances, which proscribed advertising for psychiatric drugs. Although this did not actually make the practice illegal, pharmaceutical companies avoided it in the subsequent decades. ADHD drug-makers, however, helped sweep this tradition into the dustbin of history. In 2001, USA Today noted that the appearance of “brand-name ads for ADHD drugs…women’s magazines and on cable TV” was “the first break from a 30-year-old agreement between nations and the pharmaceutical industry not to market controlled drugs to consumers.”
The advertising quickly went beyond the pale, a decline Schwarz traces. Celltech pharmaceuticals (which made a patented extended-release version of Ritalin) created a new “cartoon superhero,” Metaman, who would presumably rescue children from their ADHD symptoms. The company then produced plastic action figures to distribute to doctors offices, where children could play with them “while parents discussed treatment options.” Ads also made various outrageous, scare-mongering claims not backed by the evidence. Schwarz distills the message of one campaigns: “Give your child Adderall or else he could become a car-crashing, felonious psychopath.”
In truth, “this is your brain on capitalism” could’ve been the title of Schwarz’s book.
As profitable as the children’s market for ADHD drugs might prove, it was also inherently limited. On the horizon, however, a much larger market for adults glimmered like gold. “But how should a doctor diagnose adult ADHD,” Schwarz notes, “when a few of DSM’s official criteria, like ‘runs about or climbs excessively’ and ‘has difficulty waiting turn,’ sounded so childish?” Schwarz describes how Eli Lilly sponsored the efforts of some academic ADHD specialists at Harvard and New York University to create a diagnostic ADHD questionnaire that could be used in adults. The team subsequently slimmed it down, and the World Health Organization endorsed it, “an imprimatur that forever obscured its Big Pharma roots,” Schwarz says.
Big Pharma then spent considerable resources promoting public awareness of the illness. Shire Pharmaceuticals partnered with TV personality Ty Pennington and later Maroon Five star Adam Levine to spread awareness of adult ADHD. Shire’s “stable of key opinion leaders” also helped to get a new diagnosis—“binge eating disorder”—into the latest Diagnostic and Statistical Manual of Mental Disorders (DSM), while paying “university-affiliated doctors to conduct studies to prove the obvious, that amphetamine would in fact make people eat less.” (Not just any amphetamine, of course, but Vyvanse.) Shwartz relates all this in a chapter titled “This is your brain on capitalism.” In truth, “this is your brain on capitalism” could’ve been the title of Schwarz’s book.
Yet none of this delegitimizes the diagnosis of ADHD and none of this precludes the fact that stimulants are useful for those with the illness. Indeed, the weight of the medical advance shows that stimulants do indeed reduce ADHD symptoms.
Nonetheless, the benefits of stimulants are probably often oversold. While many may be content with the fact that the drugs have a beneficial effect on ongoing symptoms, others have no doubt been led to believe that they can have a permanently life-altering effect, steering a child (or adult) off a ruinous path and onto a successful and happier life course. While this is conceivably possible, there is simply insufficient evidence to say so.
Consider, for instance, the Cochrane Collaboration’s 2015 synthesis of the existing body of evidence for Ritalin treatment for children diagnosed with ADHD. (This is not ground covered in Schwarz’s book). Many consider the scrupulous reviews and meta-analyses that the Collaboration carries out to be a gold-standard of bias-free evidence synthesis in clinical medicine. Ole Jakob Storebø and colleagues—the investigators behind this Cochrane review—used a highly systematic protocol to find, assess and combine the results of all relevant existing studies on Ritalin therapy in children with ADHD. They ultimately identified some 185 relevant randomized trials, and in their combined analysis, indeed found evidence that the drugs resulted in a “modest improvement in ADHD symptoms,” as reported by teachers and parents. The drugs, that is to say, worked.
However, the investigators made several other important observations. First, the studies all had issues that increased their individual risk of bias; indeed, for the main study outcome, the “quality of the evidence was judged to be ‘very low’.” For instance, as they described, the side effects of the drugs could practically result in study participants—and their parents and teachers—being effectively unblinded (that is to say, side effects of the drug would make them aware that they were not in the placebo group). As I described in a recent review of Peter Kramer’s new book on antidepressants, such “unblinding” can function to effectively enhance a placebo effect—this is what investigators call an “active placebo” effect—and give the false appearance of efficacy. Storebø and colleagues thus recommend future trials (beginning with adults) that compare the drug against an active placebo (a “nocebo,” or a drug with no therapeutic action but noticeable side effects) so as to better understand its real efficacy.
Additionally, there were non-serious but real side effects: They found that those on Ritalin were about 60 per cent more likely to have problems sleeping, and 266 per cent more likely to have a reduced appetite.
But most importantly of all, as they describe, the vast majority of these studies were short-term trials, with an average length of only two months. Thus, as they write, “little can be concluded about the benefits and harms of methylphenidate used for longer than six months”—nor for years on end (as they are sometimes used), much less a lifetime.
Compare these relatively modest conclusions with the enthusiasm frequently exuded by the ADHD commentariat. At an important and highly-publicized conference, convened by the National Institutes of Health in 1998, one of the participants, quoted by Schwarz, told the Philadelphia Inquirer: “Parents have to weigh the risk of not treating with stimulants,” and that “children with ADHD not treated go on to have serious consequences the rest of their lives.” It’s not clear that this is true: the clinical trial evidence we have is almost entirely for short-term symptomatic benefits, as noted above.
Or consider what ADHD guru and child psychiatrist Ned Hallowell stated to Ty Pennington on an episode of ABC’s The Revolution in 2012, an episode narrated in Schwarz’s book. (Pennington was a paid spokesperson for Shire, though didn’t bother to disclose this on the show). After Hallowell performs a breezy ADHD exam on an adult member of the audience, he concludes:
So you passed the test. Welcome to the illustrious club [of ADHD]! It’s a good-news diagnosis…there’s medication, which people are so afraid of, but they shouldn’t be. Medication works about 80 percent of the time. And when it works it works like eyeglasses! … You can suddenly see!
Such enthusiasm again goes well beyond the evidence. Again, here’s Hallowell in a recent interview with Gwyneth Paltrow’s lifestyle website GOOP:
If you are an adult reading this, and you feel you are underachieving, learn more about ADHD. It could be the answer you’ve been looking for—for years. Diagnosis and treatment could replace frustration and underachievement with success … The diagnosis of ADHD and the treatment that follows, if done properly, truly can change a life, at any age, from one of frustration and underachievement (if not worse), to one of triumph, fulfillment, and joy.
You do not speak about the diagnosis and treatment of a serious mental illness by promising a solution to all of life’s problems. That is of course how you effectively sell a product.
So where to from here? While Schwarz’s book is an outstanding exposé, he has only seven pages on solutions, which feels tacked on to the end of the book. It contains a handful of milquetoast if not unreasonable solutions, for instance that physicians should seek out more ADHD-specific education. Yet there is a nary a word about perhaps the most important issue, namely, pharmaceutical reform.
We are all patients, now or later, with lives more valuable than Big Pharma’s silver.
That said, I’ll admit that real “solutions” will not come easy, and they will not come cheap. It seems clear that new postmarket clinical trials (with no industry involvement) are needed to better understand the potential benefits of ADHD drugs, and to address the issues identified by the Cochrane investigators in their Ritalin study. This is to say, trials that perhaps compare drugs to “nocebos,” and even more importantly truly long-term randomized trials lasting many years in duration that examine not just how the drugs change ADHD scores on a questionnaire, but their effect on more meaningful and sustained life outcomes.
Additionally, as is the case with other mental illnesses, more emphasis should be placed on modifying the social factors contributing to the disease. Indeed, with all the media emphasis on stimulant use (or misuse) on college campuses, it could be forgotten that ADHD is associated not with wealth, but with deprivation. In a study published last year in the journal PLOS One, for instance, Abigail Russell and colleagues examined the socioeconomic predictors of ADHD in a cohort of more than 8,000 children who were followed from birth in the United Kingdom. Among a multitude of socioeconomic factors, the one that most potently predicted the development of ADHD at age 7 was the presence of family financial strain—essentially, when parents couldn’t afford basic necessities. In the US, such findings are especially important to consider in the context of the dismantling of the nation’s system of cash assistance for the poor by the administration of Bill Clinton, a “reform” that left in its place “a diminishing pool of money that guaranteed the poor precisely nothing,” as Slate’s Jordan Weissmann put it. Addressing such putative economic determinants of ADHD seems critical, even when we have enough reasons to eliminate poverty already.
Finally, if there is one overarching lesson here, it is that we need a sweeping reform of the way drugs are developed, studied, marketed, priced, and sold. Big Pharma has deeply corrupted the mission—and the methods—of medical research. It has squeezed families by pricing drugs at the maximum the market will tolerate (and then some). And it has been reckless and dishonest in its promotion of addictive drugs, with grave consequences for the public’s health. Those with ADHD deserve much better—indeed, as we all do. For we are all patients, now or later, with lives more valuable than Big Pharma’s silver.
Big Pharma and the ADHD Industrial Complex: A Review of ADHD Nation
Approximately 11% of children 4-17 years of age in America (6.4 million) have been diagnosed with ADHD as of 2011 and the number continues to increase every year. Many believe the US children are facing an unprecedented epidemic in regards to ADHD.
Alan Schwartz’s new book ADHD Nation: Children, Doctors, Big Pharma and the Making of an American Epidemic should be required reading for parents, teachers, and doctors everywhere. This book manages to be informative both historically and scientifically, while also being entertaining. Schwartz dismantles the ADHD “epidemic” by showing how the creation of a drug spurred a medical condition, not the other way around.
Anyone who has taken an ADHD survey for themselves or their children knows how tricky these assessments can be. With questions like “Does your child have difficulty listening?” and “Does your child misplace or lose items (i.e. homework or school supplies)?” absolutely every child (or adult!) will fall into that category.
While reputable doctors agree that ADHD is a legitimate condition in a small percentage of the population, Schwartz shows how more than 1 in 7 people will test “positive” for ADHD in their lifetime. Some estimates show that more than 50% of people who visit a psychiatrist will be prompted to take some form of medication to treat the symptoms of ADHD.
Schwartz’s book presents a detailed look at the “father of ADHD”, Dr. Keith Conners, a man who was at first thrilled to see such amazing results in his child patients who were treated with Ritalin. Many years later, however, Conners calls the overprescription “a national disaster of dangerous proportions”.
What’s great about ADHD Nation is that it sends up a red flag without being alarmist – Schwartz acknowledges how and when drugs like Ritalin can be beneficial. He shows case studies where the drug is extremely valuable. He’s not claiming that the US Government is trying to exercise mind control over the most vulnerable members of the American society. What he is saying is that overprescription of ADHD drugs is a serious problem indicative of larger societal issues with money, the medical community, and the American approaches to raising children. Even for readers without children, this book provides an excellent in-depth look at how prescription medications shape and change our society.
yogaesoteric
February 28, 2017
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ADHD: Redefining Childhood as a Mental Disorder for Profit
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“Children are not for-profit entities. The well-documented dangers associated with pharmaceutical ADHD ‘treatments’ are unacceptable and parents must be provided all the facts in order to make informed decisions—a public service CCHR has been providing for decades.”
By Kelly Patricia O’Meara
Published by CCHR International
The Mental Health Industry Watchdog
August 24, 2016
A new book has hit the shelves that is worthy of a nod. ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic, by Pulitzer Prize-nominated New York Times reporter, Alan Schwarz, explores many of the ADHD issues the Citizens Commission on Human Rights (CCHR) has been championing for more than three decades, eliciting the Human Rights Watchdog to renew its call for greater transparency about the adverse effects associated with ADHD drugs and that parents be fully informed of their rights to the facts surrounding the ADHD diagnosis.
adhd-nationA New York Times review of Schwarz’s book explains “ADHD Nation” focuses on an unholy alliance between drug makers, academic psychiatrists, policy makers and celebrity shills like Glenn Beck that Schwarz brands the “ADHD industrial complex.” The review continues: “The insidious genius of this alliance, he points out, was selling the disorder rather than the drugs, in the guise of promoting ADHD “awareness.”[1]
With more than ten million Americans taking ADHD drugs, one easily could argue that the pharmaceutical industry’s selling of the ADHD diagnosis, too often to the detriment of those taking the drugs, has far surpassed its wildest financial expectations.[2]
Despite having no conclusive medical evidence that ADHD drugs treat any known brain abnormality, the pharmaceutical industry sales job on ADHD has been stellar as evidenced by an ADHD drug market that is skyrocketing. According to a study in the Journal of the American Academy of Child and Adolescent Psychiatry, total spending on ADHD ranges from $143 billion to $266 billion per year,[3] and IMS Health, a health care information company, reports that prescription drugs for ADHD have nearly tripled from $4 billion in 2007 to $11.2 billion in 2015.[4]
One could easily argue, based on the fact that there is no data to support the ADHD diagnosis, that, while the selling of the diagnosis has been extraordinarily lucrative, the human element has been left out of the equation, beginning with the nearly 200,000 0-5 year olds who have been prescribed ADHD drugs. This number, of course, does not include the much more likely targeted age group of 6-17 year olds, which now accounts for nearly four-and-a-half million children taking ADHD drugs.[5] According to the Center for Disease Control and Prevention (CDC), one-in-five high school boys have received an ADHD diagnosis and two thirds of those diagnosed receive ADHD drugs like Ritalin or Adderall.[6]
adhd-drugs-not-proven-safe
There are more than ten million Americans taking ADHD drugs.
These data, while beyond alarming, do not provide the full ADHD picture. While the pharmaceutical industry’s ADHD profits continue to increase, the possible side effects of ADHD drugs do not promise such a lucrative outcome. ADHD drugs like Ritalin and Adderall (Methylphenidate and Amphetamine) may cause the following adverse reactions: nervousness, insomnia, nausea, dizziness, tachycardia, angina, cardiac arrhythmia, toxic psychosis, palpitations, abnormal liver function and weight loss, to name a few.[7]
In fact there have been 44 warnings from eight countries, including the U.S., United Kingdom, Canada, Japan, Australia, New Zealand, France and Singapore warning that ADHD drugs cause harmful, even deadly side effects including: 13 warnings on stimulants causing heart problems, 10 warnings on stimulants causing mania/psychosis, 9 warnings on stimulants causing cardiovascular problems and 8 warnings on stimulants causing death.
As Schwarz and others point out, the diagnosis is, of course, where the pharma payday begins, as there simply is no medical or scientific evidence that any brain abnormality exists that is ADHD—no blood test, no X-ray, CAT scan, or MRI. Even the National Institutes of Health Consensus Conference on ADHD states, “we do not have an independent, valid test for ADHD,” and “there are no data to indicate that ADHD is due to a brain malfunction.”[8]
This lack of evidence to support the ADHD brain abnormality is further reinforced by the pharmaceutical industry drug disclosures. For example, Novartis, the maker of Ritalin, explains in the Prescribing Information: “Ritalin is a mild central nervous system stimulant. The mode of action in man is not completely understood, but Ritalin presumably activates the brain stem arousal system and cortex to produce its stimulant effect. There is neither specific evidence which clearly establishes the mechanism whereby Ritalin produces its mental and behavioral effects in children, nor conclusive evidence regarding how these effects relate to the condition of the central nervous system.”[9]
“The mode of action…is not completely understood?” “Ritalin presumably activates?” “Neither specific evidence…nor conclusive evidence?” In other words, Novartis is unable to specifically explain how Ritalin treats ADHD or even what ADHD is.
CCHR has for decades provided the public with timely and accurate information about the ADHD diagnosis and alternatives to pharmaceutical drugs, including writing thousands of articles distributed world-wide, distributing more than one million publications (in 17 languages) on the labeling and drugging of kids, producing four award winning documentaries and making available parent-friendly websites, including Parents Know Your Rights, that have reached millions.
Children are not for-profit entities. The well-documented dangers associated with pharmaceutical ADHD “treatments” are unacceptable and parents must be provided all the facts in order to make informed decisions—a public service CCHR has been providing for decades.
CCHR is a non-profit, public benefit organization.
CCHR is a non-profit, public benefit organization.
Kelly Patricia O’Meara is an award-winning former investigative reporter for the Washington Times’ Insight Magazine, penning dozens of articles exposing the fraud of psychiatric diagnosis and the dangers of the psychiatric drugs—including her ground-breaking 1999 cover story, “Guns & Doses,” exposing the link between psychiatric drugs and acts of senseless violence. She is also the author of the highly acclaimed book, Psyched Out: How Psychiatry Sells Mental Illness and Pushes Pills that Kill. Prior to working as an investigative journalist, O’Meara spent sixteen years on Capitol Hill as a congressional staffer to four Members of Congress. She holds a B.S. in Political Science from the University of Maryland.
References:
[1] Steve Silberman, “Overselling A.D.H.D.: A New Book Exposes Big Pharma’s Role,” The New York Times, 22 Aug 2016, http://www.nytimes.com/2016/08/28/books/review/adhd-nation-alan-schwarz.html.
[2] IMS, Vector One: National (VONA) and Total Patient Tracker (TPT) Database, Year 2013, Extracted 2014.
[3] Blaire Briody, “The Shocking Cost of Your Child’s ADHD,” The Fiscal Times, 1 Apr 2013, http://www.thefiscaltimes.com/Articles/2013/04/01/The-Shocking-Cost-of-Your-Childs-ADHD.
[4] “Medicines Use and Spending in the U.S.,” IMS Institute for Healthcare Informatics, Apr 2016, http://www.imshealth.com/en/thought-leadership/ims-institute/reports/medicines-use-and-spending-in-the-us-a-review-of-2015-and-outlook-to-2020; “Top Therapeutic Classes by U.S. Spending,” IMS National Sales Perspectives, 23 Feb 2012, http://www.imshealth.com/files/web/Corporate/News/Top-Line%20Market%20Data/Top_Therapy_Classes_by_Sales.pdf.
[5] IMS, Vector One: National (VONA) and Total Patient Tracker (TPT) Database, Year 2013, Extracted 2014.
[6] Alan Schwarz and Sarah Cohen, “A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise,” The New York Times, 31 Mar 2013, http://www.nytimes.com/2013/04/01/health/more-diagnoses-of-hyperactivity-causing-concern.html?pagewanted=1&_r=0.
[7] Ritalin Side Effects Center, RxList, http://www.rxlist.com/ritalin-side-effects-drug-center.htm, accessed 24 Aug 2016; Adderall Side Effects Center, RxList, http://www.rxlist.com/adderall-side-effects-drug-center.htm, Accessed 24 Aug 2016.
[8] “NIH Consensus Report Highlights Controversy Surrounding ADHD Diagnosis and Stimulant Treatment,” Ethical Human Sciences and Services, Vol. 1, No.1, 1999, http://www.breggin.com/nihconsensus.pbreggin.1999.
[9] Ritalin, Prescribing Information, http://www.accessdata.fda.gov/spl/data/44555803-7377-4acd-a3f7-1d65d8660b2d/44555803-7377-4acd-a3f7-1d65d8660b2d.xml.
The Numbers Game: Baseball's Lifelong Fascination with Statistics (review)
Stew Thornley
From: NINE: A Journal of Baseball History and Culture
Volume 14, Number 1, Fall 2005
pp. 187-188 | 10.1353/nin.2005.0053
In lieu of an abstract, here is a brief excerpt of the content:
Reviewed by
Stew Thornley (bio)
Alan Schwartz. The Numbers Game: Baseball’s Lifelong Fascination with Statistics. New York: St. Martin’s, 2004. 270 pp. Cloth, $24.95.
Alan Schwarz's The Numbers Game is not a statistical book but a book about statistics that reads like a fast-paced novel. In it Schwarz demonstrates how statistics have evolved to reflect the changes in the game as well as at times influencing those changes and promoting baseball's popularity. It is a thoroughly researched and intriguing history that goes beyond the numbers. Much in the way that Bill James has proven to be an excellent historian beyond the numbers, so too is Schwarz in this book. Statistics serve as the backdrop, but readers will learn much more about the changing way the game has been played and evaluated.
The book delves into a number of interesting areas, profiling the early work of Henry Chadwick and the pioneers who followed: Ernie Lanigan, F. C. Lane (whose development of a percentage value of a run for different types of hits were, later, remarkably close to the values assigned by Pete Palmer in his Linear Weights method), the Eliases and the roots of the Elias Sports Bureau, Allan Roth, and Hy Turkin and the genesis of the first baseball encyclopedia.
This is followed up with the story of the first baseball encyclopedia from Macmillan Publishing Company and the use of the computer in compiling this tome. It points out the work of the editors in starting to straighten out long-held errors in recordkeeping. The latter topic becomes particularly intriguing with a description of the selective changing of statistics by Joseph Reichler in future editions of the encyclopedia along with the ongoing resistance of the baseball establishment to change records that were in error, no matter how compelling the evidence, and of the push for a statute of limitations on recording errors.
While noting that some teams have tried to avoid the stigma of being overrun by statheads in making personnel decisions, Schwarz is for the most part respectful of the work done in this area. However, his description of those present at a meeting of the Statistical Analysis Committee at the 2003 sabr convention may cause some consternation. His overall summary of the "motley crew," with many wearing "some sort of baseball-logoed T-shirt, cap, or jacket, many with all three," is essentially a correct description of the convention attendees in general. In addition, the relevance of his comment "There were lots of beards" is unclear, and the statement that "an odd number of men spoke with a lisp" goes beyond irrelevance to downright insensitivity.
The Numbers Game is packed with information and conclusions—such as whether clutch hitting exists (apparently not) or if Jack Morris's relatively high [End Page 187] lifetime earned run average was a result of his generally pitching well enough to win independent of the run support he received in a game (also apparently not)—without the square-root, sigma signs, and other mathematical hieroglyphics that scare some away. I found chapter 10, on the role of luck or random error, particularly enjoyable as Schwarz cogently examines the role of random chance in baseball along with the resistance of fans to acknowledge it.
The one essential missing from the book is a list of sources. There is a great deal of information, but it would be nice to know where it came from. The Numbers Game, which concludes with a look to the future, is the definitive baseball book of 2004 and a must-read follow-up to last year's best-selling Moneyball, by Michael Lewis.
Stew Thornley
Stew Thornley is the author of more than thirty-five books, including Land of the Giants: New York’s Polo Grounds and Six Feet Under: A Graveyard Guide to Minnesota. He has combined his love of baseball and cemeteries by visiting every grave of members of the Baseball Hall of Fame. He has been a member of the Society for American Baseball Research since 1979.
Copyright © 2005 the University of Nebraska Press
Book Review: The Numbers Game
The Numbers Game is a book that should appeal to many SABR members. Although the theme of the book is baseball statistics, the stories are really about the history, people, and organizations behind the numbers. There is actually very little mathematics in the book, so if you’re turned off by polynomials you should not let that deter you from reading this well-told story.
Schwarz tells the tale of baseball statistics, beginning with “Father” Henry Chadwick in the 1850s, through Bill James in the 1970s and ‘80s, and coming current with the likes of Billy Beane, Theo Epstein and Paul DePodesta in the 21st century. The histories of many of the statistics-oriented sports organizations are also told – the Elias Sports Bureau, STATS, Inc., Project Scoresheet, Retrosheet, MLB.com, and baseballprospectus.com, among others.
Of course, SABR is prominently featured in several of the chapters.
A theme that runs throughout the book is the battle for recognition faced by the statistics proponents. On one level, there’s the battle for acceptance of statistical analyses by “traditional” baseball men. But also, on another level, there’s the battle between those that “control” the official statistics and those that are challenging the meaning, and often-times the accuracy, of those statistics.
I found the book to be an easy, enjoyable read. This book would be especially useful for new SABR members to familiarize themselves with the statistical landscape of the sport.
Here’s the key statistics:
Book: The Numbers Game – Baseball’s Lifelong Fascination with Statistics
Author: Alan Schwarz
Author Credentials: Baseball America writer, ESPN.com columnist, contributor to New York Times, Wall Street Journal, and other national publications.
Published: 2004, St. Martin’s Press, ISBN 0-312-3222-4
Length: 254 pages; Foreword by Peter Gammons
Price: Retail list – $24.95; Online: new from $12.99 + ship; used from $4.25 + ship.
Darwins of the Diamond
Jul 8, 2004
Alan Schwarz
MLB
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Most fans, players and even team executives assume that baseball's infatuation with statistics is simply a byproduct of the information age, a phenomenon that blossomed only after the arrival of Bill James and computers in the 1980s. They couldn't be more wrong.
Alan Schwarz, the senior writer of Baseball America and a weekly contributor to ESPN.com, will forever change that misperception with his new book, "The Numbers Game," just published by St. Martin's Press. Schwarz provides the first-ever history of baseball statistics, showing how baseball and its numbers have been inseparable ever since the pastime's birth in 1845, and telling the story of this obsession through the characters who felt it most: Henry Chadwick, the 19th-century writer who invented the first box score and harped endlessly about which statistics mattered and which did not; George Lindsey, a Canadian military officer who spent hundreds of hours scoring games to figure out how often runners on second base score on a single; Hal Richman, who invented Strat-O-Matic baseball when he was 11 years old; and dozens more.
In this exclusive excerpt, Schwarz travels back to the early 1960s to profile the work of Earnshaw Cook, a kooky metallurgist (and consultant to the U.S. government's efforts to build the atom bomb), who retired to while away his days pursuing his theories about baseball statistics -- while Bill James was still in junior high. So you think baseball stats are just a modern fan fixation? Read on ...
Through the 1950s, college professors and graduate students began to pepper academic journals with sophisticated analyses of baseball. In 1952, Frederick Mosteller of Harvard University used binomial probability theory to prove that the best-of-seven World Series was a horribly unreliable way to determine baseball's champion. Four years later, an article in American Statistician discussed a method to adjust standings for the strength of each team's schedule. And in 1960, two Stanford grad students presented a paper to the American Statistical Association called "The Distribution of Runs in the Game of Baseball," which appears to be the first advanced attempt to combine the probabilities of hits, walks, outs, and more into a model of how runs score.
All these studies, however, were read only by tiny audiences, many of whom blanched at the idea of allowing so frivolous a subject as baseball into their otherwise important affairs. It would take a commercially published book to introduce statistical analysis of baseball beyond academia and to the more average fan. That book arrived in the summer of 1964: "Percentage Baseball," written by a bowtied Baltimore gentleman named Earnshaw Cook. More than a decade before Bill James' "Baseball Abstract" series began, Cook's "Percentage Baseball" became the first -- and perhaps most befuddling -- full-length book to be written on what we now call sabermetrics.
Cook was a most unlikely sort to devote four years to the study of baseball statistics. Gray-haired in his 60s, the stern and iron-faced Cook was an aristocrat at heart -- conservative to the core, constantly complaining about the "Japs" and inflation, and always, always wearing a smoking jacket, sport shirt, and tie (often a clip-on). He spoke with a faux English accent to lend an elitist aura, and his gruff bearing was so authoritative that his Chesapeake retriever would, on command, fetch the newspaper and then go to the closet and bring down his bedroom slippers. He signed all correspondence with his blueblood pedigree: "Princeton '21."
Cook had played varsity baseball at Old Nassau, and even was a distant cousin of George Earnshaw, the former big league pitcher, but went on to a distinguished career as a metallurgist, studying metals and their alloys down to the protons and electrons at their core, primarily for the American Brake Shoe Co. of Mahwah, N.J. He wrote "Engineering Properties of Heat Resistant Alloys" and other light classics. He served as a consultant on the Manhattan Project and for the Atomic Energy Commission before retiring in 1945 and ultimately nesting in a small estate in Baltimore. With little to occupy his time thereafter, other than training his dogs and playing golf at the nearby Elkridge Club, he decided to prove, once and for all, damn it, that Ty Cobb was better than Babe Ruth.
This Cobb-versus-Ruth, slapper-versus-slugger debate had raged for generations and became almost religious for each sect's most ardent followers. Cobb was the master of the single-and-speed game prevalent during his prime of 1907 to 1922, ringing up a .366 lifetime batting average (still the all-time major league record) and 892 stolen bases (a mark that lasted almost 50 years). Ruth's awesome power diverted focus from batting average to home runs, much to the chagrin of fans clinging to the game's original style. Cobb himself complained in a letter in 1952, "Now they have gone to the hit per distance game. They look as if they will be lucky to hit .340 or maybe less . . . The hit and run, stolen base, bunt, and sacrifice are deteriorating from unuse and they only hit for their amusement and pleasure for the home run." Everyone agreed that a home run was more valuable than a single, but by how much? To what extent did stolen bases and the venerable sacrifice aid in the scoring of runs? Come to think of it, what was the optimal lineup order? How should relief pitchers be used? Cook didn't want to go "by the book," blindly accepting the time-honored answers to these questions -- so he wrote a book of his own. In fits and starts over several years, Cook holed up in his study, overlooking the golf course, and pounded on baseball statistics. His slide rule and colored pencils stood at attention above his angled drafting table, piles of The Sporting News and its "Baseball Register" at the ready.
In his spare time, Cook used his research to teach math to his teenaged nephew, Bryson. Bryson returned the favor with one heck of a public relations coup. Bryson Cook's best friend was a kid named Gil Deford, whose big brother Frank had just, as luck would have it, graduated from college and begun writing for Sports Illustrated. Frank Deford learned of this quirky baseball scientist and mentioned him to his editor, who dispatched the young writer to interview Cook during the winter of 1964. The editor liked the piece so much he made it the lead feature story of the March 23 issue, with the headline "BASEBALL IS PLAYED ALL WRONG."
Deford breathlessly previewed Cook's discoveries: The sacrifice was generally worthless. Platooning was a waste of time. Sluggers should bat first. Games should be started by a "relief " pitcher who would leave for a pinch hitter at the first opportunity, followed by a "starting"-caliber pitcher who would then pitch four or five innings. All this, Cook claimed, would add a total of 250 runs and perhaps 25 wins to a team each season, numbers clearly absurd today but in 1964 as arresting as a Bob Gibson fastball at the noggin. "Right now," Deford gushed in his four-page article, "Earnshaw Cook knows more about baseball than anyone else in the world."
Cook asserted that by employing his theories, a .500 club could instantly become a pennant winner. Deford naturally presented baseball personnel as being alarmed, even humbled, by these findings. "If these figures are correct," Dodgers manager Walter Alston told SI, "Cook must have something
Maybe we've just been playing what we assumed was the proper way." Bill Veeck, the renegade owner of the White Sox, loved the idea of minimizing at-bats by weak-hitting pitchers. "By all means," Veeck raved, "get the pitcher out of there!" But privately most team personnel brushed Cook's theories aside. Pulitzer Prize-winning New York Times columnist Arthur Daley wrote, "It is highly unlikely that Cook, the iconoclast, will influence one manager to alter his pattern to the slightest degree
What was good enough for John McGraw is good enough for them."
The recalcitrance of baseball executives only hardened when Cook's full-length book, "Percentage Baseball," came out a few months later. It was barely intelligible to even educated readers; beyond sprinkling the text with haughty Latin phrases and quotations from the likes of Francis Bacon, Cook might as well have put a statistics textbook in a blender. Pages of graphs, equations, and probabilistic gibberish, such as:
Eqv. p.SHS.y = 1.1564 DX.y + 1.4370 DX.z + .1507 divided by 2.3225 DX.z + .2477
made much of his methodology hopelessly inaccessible. (This surely added to Cook's aura as a sort of baseball Merlin. His hometown Baltimore Sun would consult him for pennant-race predictions -- "projections," he insisted -- and use headlines such as "BIRDS TO FINISH 3D, STATISTICIAN DECLARES," and "COOK, BASEBALL'S SEER, IS PITCHING ORIOLES.") Cook loved the attention. While beguiling readers with a blizzard of figures and charts, "Percentage Baseball" represented the first comprehensive effort to model all aspects of baseball through applied probability theory, and was met with apprehensive awe.
Cook rooted his approach in a statistic he developed called the Scoring Index. He examined the relative chances of all offensive events -- single, double, sacrifice, steal, and so on -- and all the ways they can be strung together to score runs before three outs end an inning. (For example, a single can be followed by two straight outs, a steal, and a single. Or a batter can reach on an error and jog home on a later batter's home run, etc ) Cook concluded that the probability of scoring a run was proportional to the chances of reaching first base multiplied by the chances of advancing that runner. His final formula looked like this:
p.R = (K) × (p.H + p.BB + p.E.o + p.HB - 2p.SH - p.XBH) × (p.TB)
This equation, however disguised in ugly and cumbersome notation, was actually rooted in concepts some 20 to 30 years ahead of general acceptance. K was just a numerical constant. Each "p." merely denoted the probability of the event that followed it (for example, p.BB meant the probability of a base on balls, i.e., walks per plate appearance) so the entire equation can be seen as having plate appearances (PA) as its denominator. Ignoring errors and the subtraction of sacrifices and extra-base hits for the moment, the right-hand side's two terms reduce to:
(H + BB + HB) * (TB)
PA PA
This is far more recognizable to modern fans of statistics: It's effectively the product of on-base percentage and slugging percentage, and greatly resembles the approach Bill James took to developing his renowned Runs Created formula in the late 1970s.
Armed with his scoring index and other statistical tools, Cook examined dozens of baseball strategies and trends. Summarizing them here would require another entire book. But these were the most significant matters Cook analyzed, with his conclusions:
The best hitter ever: Lo and behold, Ty Cobb, with a scoring index of .2161, beat out Babe Ruth (.2109), Ted Williams (.1962), Lou Gehrig (.1828) and Mickey Mantle (.1743). Cobb's score was actually .1574, but Cook, citing how Cobb had performed mostly in the dead-ball era when home runs were very rare, adjusted his figure upward by comparing his performance to that of his contemporaries. Cobb and Ruth, at the time widely considered the best two hitters ever, had never before stood Nos. 1 and 2 in any statistic. Scoring index let them rise to the top.
The base-out matrix: How many runs score after any point in an inning? For example, Cook's probability equations figured that with one out and runners on first and second, an average of .92 runs were bound to score. Here are his figures for each of the 24 possible situations:
BASES OCCUPIED
0 1 2 3 1,2 1,3 2,3 Full
OUTS 0 | .34 .77 .94 1.04 1.36 1.46 1.63 2.06
OUTS 1 | .18 .47 .63 .72 .92 1.01 1.17 1.46
OUTS 2 | .07 .21 .32 .38 .46 .52 .64 .78
The stolen base: Cook determined that an average runner trying to swipe second base typically was a bad risk with none or one out, but a good risk with two. Then he assessed how the breakeven points fluctuated depending on the abilities of the runner on first and the hitter at the plate. For example, Minnie Minoso, the speedy outfielder for the White Sox, was successful in just 57 percent of his stolen-base attempts during 1960 and 1961; Cook claimed he should never run while any hitter with a .258 batting average or higher was up.
Alan Schwarz answered your questions about his new book in chat on Thursday.
The sacrifice bunt: Cook maintained that this was a bad play, except under certain conditions -- when a hitter was as poor as the typical pitcher, or when just one run was needed in the late innings of a close game. Outs were that precious. "There are two primary objects in baseball," Cook explained. "The first is to score runs. And the second is not to make outs." The latter concept didn't become understood by a majority of baseball executives for 35 years, and continues to baffle more than a few franchises.
The batting order: Most lineups put a speedster at the top, a bat-control artist second, and then the three best hitters third, fourth and fifth. But because roughly two-ninths of games end when the first or second batter makes the final out, the best hitters often miss a chance at another at-bat. Cook claimed that the lineup should always just put the best hitter first, followed by the second-best, and so on; even though sluggers such as Hank Aaron or Willie Mays might get fewer RBI because they would bat with fewer runners on base, that cost would be overcome by their getting roughly 40 more at-bats over the course of a season.
Platooning pitchers: Cook estimated that pitchers' horrible skills at the plate cost the average team 113 runs per season (of course there was yet no DH), and suggested that those hurlers virtually never be allowed to come to the plate at all. Given that complete games were becoming rarer in the early 1960s, Cook advocated starting a relief-caliber pitcher for two or three innings and pinch hitting for him at the first opportunity, and then using a starting-caliber pitcher to throw the next five innings or so, batting no more than once. Cook designed a 10-pitcher rotation to accomplish this.
Other assertions: Baseball's enlargement of the strike zone prior to the 1963 season had decreased offense up to 15 percent; a team's winning percentage should equal .484 times its ratio of runs scored to runs allowed; and the intentional walk is often a poor strategy, one that should be ordered, Cook wrote, "only if the actual 'DX.z' of the third batsman is less than his own equivalent 'DX.z' "
Cook's rigorous mathematics ultimately failed him on both ends of the reader spectrum. Baseball fans were spooked by the intercept coefficients, distribution curves, and bizarre graphical techniques that recalled too many failed algebra quizzes. Professional statisticians, meanwhile, accused "Percentage Baseball" of sloppy and amateurish use of probability theory. "The book is easier reading for a baseball fan than for a mathematician," Scientific American sniffed. The military science journal Operations Research cited "very inadequate numerical evidence," "no tests of significance, fit or correlation," and other crimes. "Some of the mathematical presentations which form the heart of the book are atrocious," the review sneered. "Aside from a number of outright mistakes in manipulating probabilities in a desperate attempt to relate [scoring index] to scoring the author is obliged to introduce a 'specific luck factor' that makes one's probability nerves twitch."
Cook did appeal, however, to a narrow band of audience: young, mathematically inclined fans who relished his application of probability to baseball, however flawed that application may have been. Several of them -- Carl Morris, Pete Palmer, Eric Walker, and more -- became noted academic and applied statisticians, and were heard from years later in the field of baseball analysis. It was Walker, in fact, who grew up to become Sandy Alderson's early statistics confidant in Oakland, and was the primary catalyst of baseball's modern on-base percentage craze.
Did major league executives pay attention to Cook at the time? Not really. Those who did were too young to have much influence in their traditionally stodgy industry. Tal Smith of the Houston Astros was a thirtysomething statistics buff who relished Cook's rigorous examination of accepted baseball opinion, but knew that altering that opinion was another matter altogether. "It was difficult to get anybody interested in any statistical information in the '60s -- they only wanted batting average and ERA and not to be bothered with it," recalled Smith, now president of the Astros. "Our general manager, Spec Richardson, was so statistically challenged that I'm not sure he knew what a batting average was. Managers in those days, most of them were old school. [Cook's approach] was nothing they were raised with. When I came across it there wasn't any way to put it into any practical effort."
Lou Gorman worked in the minor league department of the Baltimore Orioles in the late 1960s, knew of Cook's work from articles in the Sun, and after moving on to the expansion Kansas City Royals in 1969 kept a copy of "Percentage Baseball" on the shelf behind his desk. One day, the Royals' owner, Ewing Kauffman, noticed it.
"What is that?" he asked.
"It's a book a scientist wrote about baseball," Gorman said. "He analyzes lineups, strategies, and other things with hard-core math and statistics."
Kauffman, who made billions in the pharmaceutical industry, took the book in his hands and flipped through the pages. "I want you to have this guy call me collect," he told Gorman. "I want to meet him."
One month later, Kauffman sat down with Cook in the owner's suite at Kansas City's old Municipal Stadium. "Ewing loved the book and what Cook said in it," Gorman recalled, "but it never got to the point where he would use it to run the club. He stayed out of baseball decisions." Gorman, however, went on to a distinguished career with the Royals, Mariners, Mets, and Red Sox, always keeping "Percentage Baseball" in mind, and on his shelf.
At least one major league player took notice of "Percentage Baseball" and became an avid devotee. Davey Johnson, a young second baseman for the Orioles, just happened to also have a mathematics degree from Trinity University in Texas. Johnson read the book and noted that Cook lived in Baltimore, so he looked him up and visited his home. The two became friends, playing golf on occasion and always talking baseball. Johnson integrated some of Cook's ideas when he became a manager himself, leading the Mets to the 1986 World Series championship and later managing the Reds, Orioles and Dodgers. Johnson credits Cook with underscoring the importance of on-base percentage (rather than speed) at the top of batting orders and the inadvisability of intentional walks. "I'd played for a lot of managers who would just make out their lineup the old-fashioned way -- they didn't know what they were doing," Johnson remembered. "Cook showed how statistics could be used to run a ballclub better." In the end, the Times's Arthur Daley was proven wrong: Cook did influence a manager, a future one. Like most groundbreaking ideas, Cook's were appreciated most by people young enough not to feel threatened.
Cook himself did not witness the moderate influence he ultimately had. Eight years after the original publication of "Percentage Baseball" he followed up with a second volume, "Percentage Baseball and the Computer," in which he employed computer-simulation techniques to fine-tune, and usually validate, his theories. This book received considerably less attention than his first. In a 1975 letter Cook wrote, "At the age of 75, I do not expect to survive to witness any changes of attitude It is my opinion that the application of basic statistical analysis will eventually receive the attention of professional baseball -- as it has in so many other fields of endeavor with increasing use of the ubiquitous digital computer." He spent a few years applying his mathematics to golf -- he tried to prove that the great Bobby Jones was better than newcomer Jack Nicklaus -- but ultimately discarded the idea. He died in late 1987 of a heart attack.
Before that, however, Cook was asked by the Hall of Fame in Cooperstown to donate the slide rule on which he did some of his calculations for "Percentage Baseball." "I am more than content," he typed in a note of appreciation, "to present my last testament herewith to the Greatest Game of them all."
What Baseball Can Teach Us About Innovation
Scott Anthony
OCTOBER 06, 2009
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In a chat last week, Boston Red Sox General Manager Theo Epstein explained why he wasn’t bothered by J.D. Drew’s relatively low number of runs batted in (quotes from Joe Posnanski’s blog):
“When you’re putting together a winning team, that honestly doesn’t matter. When you have a player who takes a ton of walks, who doesn’t put the ball in play at an above average rate, and is a certain type of hitter, he’s not going to drive in a lot of runs. Runs scored, you couldn’t be more wrong. If you look at a rate basis, J.D. scores a ton of runs.
And the reason he scores a ton of runs is because he does the single most important thing you can do in baseball as an offensive player. And that’s NOT MAKE OUTS … Look at his runs scored on a rate basis with the Red Sox or throughout his career. It’s outstanding.
You guys can talk about RBIs if you want … we ignore them in the front office … and I think we’ve built some pretty good offensive clubs.”
Business managers can learn a lot from how baseball general managers build and manage their talent portfolio by drawing on the findings of baseball’s Sabermetrics revolution. And the same is true for business managers trying to balance their innovation portfolios: how can they focus on the metrics that really matter?
According to the old-fashioned metrics, the run-batted in is a vital statistic. But smart general managers like Epstein recognize that the RBI is not a valuable measure of performance (it actually correlates with the on-base percentage of the hitters earlier in the lineup).
Innovation managers, too, need to look beyond “obvious” but potentially misleading statistics like first-year revenue, first-mover advantage, and leveraging core competency to hidden drivers of success, such as targeting non-consumption and minimizing first year losses.
A key enabler of the statistical revolution in baseball was not just better statistics, but the widespread availability of those statistics. Even before the internet made possible utterly fantastic websites such as Baseball-Reference, Fangraphs, and Baseball Prospectus (which is also an annual book), the bible for statistics was Macmillan’s Baseball Encyclopedia, introduced to widespread acclaim in 1969. (Alan Schwarz, in The Numbers Game: Baseball’s Lifelong Fascination with Statistics, quotes from Christopher Lehmann-Haupt’s review in the New York Times: “I got lost in it for nearly two days…. It’s still the book I’d take with me to prison.”)
Companies should create an internal encyclopedia in which they highlight the year they started work on each innovation, what type it was, how projections about its market potential changed through time, its key characteristics, and its ultimate performance. The encyclopedia would facilitate statistical analysis to help the company increase its success rate.
Even better would be a cross-industry research effort to develop a deeper and broader reference work. A researcher who painstakingly created a like-for-like database of efforts across multiple companies (made anonymous, of course) would do the innovation movement a great service.
Key to the effort would need to be a robust categorization scheme for classifying the type of innovation (incremental line extension, disruptive, and so forth), the target customer (high-end, mainstream, low-end, nonconsumer) and the market circumstances (nascent, rapidly growing, mature, declining).
Better metrics give Theo Epstein a competitive advantage over his rivals. And better metrics can give you an advantage over yours — and create better innovations that benefit all of us. What else do you think would be in an ideal innovation encyclopedia? Is there an open source way to create a “good enough” starting point?
For a more in-depth argument about what you can learn from baseball about building and managing your talent portfolio, see my article in this month’s Harvard Business Review.
Scott Anthony (@ScottDAnthony) is the managing partner of the innovation and growth consulting firm Innosight. He is the author of The Little Black Book of Innovation and the HBR Single, Building a Growth Factory. His new book is The First Mile: A Launch Manual for Getting Great Ideas into the Market.
This article is about INNOVATION
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