Reviewed by: Lawrence Diller, Private Practice, Walnut Creek, CA, USA; and the University of California, San Francisco, USA. DOI: 10.1177/1087054714543370
The ADHD Explosion by Stephen Hinshaw and Richard Scheffler is simply the best book in the last 15 years to describe the social phenomenon we call ADHD. Hinshaw and Scheffler have taken a very broad view of the problems of children we diagnose as ADHD and properly relabel the condition a biopsychosocial disorder.
That they should be hailed for such insight is both justifi- able and ironic. Practitioners and the public alike for nearly 30 years have been presented with a deluge of information on ADHD which emphasized its neurological, genetic, and biochemical etiologies. Much of this information was based on drug industry–supported research and promoted by their advertising.
Hinshaw and Scheffler are now clearly stating that psy- chosocial factors play a major role in either the formation or presentation of what we are calling ADHD in America. This takes courage. The authors correctly say “Emphasizing the biological was as misleading as suggesting it (ADHD) is a social construct” (p. 11).
But it is also ironic because some of us over two decades have maintained a vigil for the importance of emotions, family, neighborhood, and culture (Diller, 1998).
The ADHD Explosion does not neglect the individual or the benefits of diagnosis and treatment of ADHD even as it addresses the very important broader associated societal issues. Each chapter opens with a short clinical vignette that then is connected with the larger themes the chapter addresses. They repeatedly acknowledge the pain, suffering, and real costs of an untreated or unrecognized disorder.
Chapter Five (“What a Difference a State Makes”) is pivotal and provocative. In it, Hinshaw and Scheffler take on the wide variations in diagnosis and treatment that exist within the United States. North Carolina is noted to have diagnosis rate of 15.5% for children (ages 4-17) whereas California’s is only 6%. (Note that boys in North Carolina have an ADHD diagnosis rate of 30%! [Visser et al., 2014]). Clearly there is something else going on with American ADHD diagnosis and treatment besides genes and syn- apses. It is to authors’ credit that they finally acknowledge, in a mainstream academic book, what has been obvious for years—psychosocial factors matter in ADHD.
Hinshaw and Scheffler look at four broad factors to account for this wide variation in diagnosis and treatment. The authors consider demographics, health care factors, cul- tural values, and teacher accountability laws. Looking at the United States, the pattern of ADHD diagnosis and treatment (except for Vermont and Massachusetts) seems to conform to a Red State/Blue State pattern (associated with political and social values) with the Red States having the highest rates of ADHD diagnosis and stimulant medication treatment.
The authors contend that their analysis leads them to believe the first three factors are not as important as teacher accountability laws (e.g., schools and teachers are assessed by the performance of their students in statewide exams). They believe the earlier the state adopted such accountabil- ity laws (before the “No Child Left Behind” law made teacher accountability a federal statute) the higher the rates of ADHD diagnosis and medication treatment.
It is too bad Hinshaw and Scheffler chose to present this intriguing theory in book form where there is no peer review. I, for one, was not dissuaded by their relatively brief discussion on the importance of cultural values. But I could understand their reluctance to conclude that decreased tol- erance for talent and temperamental diversity (especially in minority populations) might better explain why the American South and Midwest had much higher rates of stimulant use in children compared with those growing up in the Western and most of the Atlantic coast states.
Still, it is refreshing and encouraging to simply have a discussion of these questions finally raised by mainstream experts in the field. I do have some other questions or chal- lenges. The authors suggest that the national cost of ADHD is US$100 billion a year just for the care of children with the diagnosis. This figure assumes that the diagnosis is accurate. Given that ADHD rates approach 30% in boys in some states, one might conclude that the US$100 billion is the cost of addressing children’s externalizing problems in general in the United States.
Hinshaw and Scheffler are to be congratulated for includ- ing a good discussion of the ethics and values surrounding a correct and incorrect diagnosis of ADHD and its treat- ment. But the discussion left out the critical issue of “fairness” when it comes to potential enhancement versus treatment and the offers of accommodations and services based on diagnosis.
Increasingly, the public feels that students who may or may not have ADHD are receiving accommodations (extra time on tests) and medication (which improves short-term performance for anyone who takes stimulant medication) placing them at an advantage over undiagnosed students. Similarly, the use of medication (legal and illegal) at the high school and college level is creating a situation similar to one faced by athletes of “free will under pressure”—when one group is allowed to take performance enhancing drugs, it puts pressure on those not taking the drug to consider it.
In their chapter on Direct to Consumer (DTC) advertis- ing, the authors weigh the pros and cons of DTC advertising and decide to remain neutral overall. In their discussion, they do not mention that the United States is a signatory to the 1972 amendment to the Single Convention on Narcotic Drugs Treaty (United Nations, 1972) which prohibits adver- tising to end users of potentially abusable drugs. However, the Drug Enforcement Administration (DEA) decided in the late 1990s that the government would be unlikely to prevail in court against the drug companies in the current atmo- sphere of first amendment rights of free speech for corpora- tions. Therefore, the DEA never challenged the introduction of DTC advertising for prescription stimulants.
In their last chapter, Hinshaw and Scheffler make predic- tions about the current ADHD “epidemic” and suggestions for addressing the over- and mis-diagnosis problems. They predict on the short term that the incidence of reported diag- nosis of ADHD will continue to rise with a leveling off by 2020. They note with concern that rising rates of ADHD inherently delegitimize the potentially serious nature of the condition for those with more impacting symptoms.
Their suggestions for the future directions are excellent, thoughtful, and moral but do not sufficiently recognize the “money” factor stated in the title of the book. Hinshaw and Scheffler are to be applauded for their overall effort. But in the end their views and hopes reflect the best of the aca- demic/ivory tower perspective. Those of us on the front- lines of ADHD diagnosis and treatment are more cynical about change, as long as the overall structure and finances of mental health care delivery remain the same in this country.
References
Diller, L. (1998). Running on ritalin: A physician reflects on children, society and performance in a pill. New York, NY: Bantam Books.
United Nations. (1972). Single convention on narcotic drugs, 1961 (As amended by the 1972 Protocol amending the Single Convention on Narcotic Drugs, 1961). Retrieved from http:// www.unodc.org/pdf/convention_1961_en.pdf
Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M., . . .Blumberg, S. J. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 34-46.