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Comment by jordanlev | Hacker News Reader

This is a book review, not an article per se. I'd assume the book goes into much more detail.

Also, from the review:

> 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.

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But what does "real" mean, exactly? That it's a recognizable pattern of behavior? That doesn't necessarily mean it should be treated as a disease.

Why not? People are suffering and we have safe medications which improve their lives.

Not treating ADHD is far more dangerous. People with unmedicated ADHD are more likely to do poorly in school, abuse drugs/alcohol, suffer from depression etc.

I'm sure some people's school grades benefit from taking amphetamine-like drugs, but that still doesn't imply they are suffering from a disease in the first place.

It's far from clear why having the symptoms of ADHD should be considered a disease, in any objective sense. If kids are suffering because school is boring or society is restrictive, that doesn't mean there's something wrong with them.

>It's far from clear why having the symptoms of ADHD should be considered a disease, in any objective sense.

We have children facing social rejection, failing/dropping out of school, becoming dependent on drugs, suffering from depression/anxiety and other mental illnesses, committing suicide, etc.

In a perfect world we don't have to change our lives to fit into society at all! Unfortunately, the world isn't perfect. We have an obesity epidemic because people sit in an office working all day. One treatment I'm sure you'll approve of is going to the gym. Unfortunately gyms are pretty unnatural.

Why should obesity be considered a disease in any objective sense? People are suffering because modern life is sedentary. It doesn't mean there's something wrong with them.

—We change our behaviors to make up for the personal problems that come with society. We do unnatural things like go to gyms and take medication to help our bodies (which were made for a world where we live in caves and hunt wild animals) function properly in this society, because we agree its advantages vastly outweigh its disadvantages.

This analogy doesn't really work, because obesity is caused by living a modern sedentary lifestyle, whereas I'm suggesting ADHD is what we're labeling kids with for not living, or rebelling against, that sedentary lifestyle.

Obesity is a disease in an objective sense because it directly causes ill health. There's lots of studies to show that. The symptoms of what we call ADHD seem to simply be caused by unhappiness and boredom with the way we live today. We're demanding kids do something that makes them unhappy, and any reaction to it, is labeled a disease.

> take medication to help our bodies [...] function properly in this society, because we agree its advantages vastly outweigh its disadvantages.

This seems like a problematic kind of statement, because the implication is that people who don't fit into society should somehow be coercively medicated. What about their rights and bodily autonomy?

It's a perfectly fine analogy. They're both problems which are problems because of our society.

You're suggesting physical illness is more "real" than mental illness.

>We're demanding kids do something that makes them unhappy, and any reaction to it, is labeled a disease.

It's far more than kids not being able to pay attention in class. ADHD affects many aspects of a person's life—and adults too. Living independently with unmedicated ADHD can be incredibly difficult. Everything from social life, working, to driving, is harder/riskier.

The argument against treating ADHD is based on unfounded fears of psychiatry and medication. "What if this, what if that". Well this and that isn't happening, peoples lives are being improved, and people are suffering because of dangerous FUD like this.

> It's a perfectly fine analogy. They're both problems which are problems because of our society.

One is a disease caused by conforming with our sedentary society. The other is what we label those who refuse to go along with our expectations for school, work and conformity. Really, they are more like opposites of one another.

> You're suggesting physical illness is more "real" than mental illness.

That's right. It's pretty hard to rigorously define a mental illness outside of the context of a given society. Mental illnesses are not real in the same sense that, say, a broken leg is real. They are socially determined. Other societies outside the West don't have the same kind of mental illnesses we do.

> ADHD affects many aspects of a person's life—and adults too. Living independently with unmedicated ADHD can be incredibly difficult. Everything from social life, working, to driving, is harder/riskier.

Being ugly makes life hard, too. Does that mean being ugly is a disease? Should all of us ugly people get plastic surgery to treat our disease, as a matter of course?

Ultimately, none of this shows ADHD is an objective disease. In the anthropological view of mental illness, it is a disease - because our society claims that it is, and for no other reason. Psychiatrists are not that much different from witch doctors. (https://news.google.com/newspapers?nid=1755&dat=19710325&id=...)

I seem to find myself recommending Gatto's The Underground History of American Education on a reasonably regular basis, and indeed here I am doing it again. The Internet Archive has it in various formats at https://archive.org/details/TheUndergroundHistoryOfAmericanE.... While its conclusions are far from incontrovertible, the author does a good job of sourcing and supporting his argument, and I think you might find it worth your while.

I have no diagnosis of ADD/ADHD. I have recently, however, started to wonder. I'm an adult (39), and recently things that have just always been true for me are getting more rigid and interfering with my life. Things like: I need an exact amount of input: too little and I get bored/distracted, too much and I can't focus and get irritable. This has a huge impact on my ability to do work, to socialize with friends, or even have a serious conversation.

If someone could give me a pill to "fix" this, that sounds awesome. Now, real medication means balancing the side-effects, etc, so even if I were to get a diagnosis I'd have to do a lot of research and consideration. But I think outright saying "No, people should suffer without consideration" is not an full answer.

(And I'm allowing that I may be having completely different issues - getting a proper diagnosis/understanding is an important things that's not part of the above debate)

Shorn of all pretense you're essentially wondering if you'd benefit from or enjoy taking drugs. This is quite possible. People take drugs for all kinds of reasons. What I object to is calling this a disease.

Let's take that back a step.

If we're talking about "disease" in the sense of "a condition that interferes too much with normal life absent some intervention" and not "caused by bacteria or viruses", then we already have a bunch of subjective terms in there. And I don't think you can get a reasonable definition that DOESN'T have some subjective terms.

Given that we're talking subjective terms, you're stating something like "If you have a condition that makes you suffer more than most others in certain circumstances, and this condition can be treated with pharmaceuticals, I'm fine with that, but I don't want to call that condition a 'disease'." Others might say "drugs can make your life easier, but I don't believe that you actually suffer more than others in those circumstances, you just don't handle that suffering as well". With current technology we have no means to distinguish the two.

And I almost certainly agree with your statement regarding certain circumstances. There are people that have medical conditions that make them overweight - likely including some conditions we've not identified yet. There are also people (such as myself) that just value eating over losing weight. I know of no way to know which is which for most cases, but for situations such as mine I'd not call it a condition or a disease, I'd call it overeating. All of which is to say I think I know where you are coming from.

But I lack the basis to say when other people are suffering more than I do under the same stimuli. I have no way to know if something is a disease/condition unless I've experienced it. Any more than I know if Bill Cosby raped anyone, or if the convicted murderers sentenced this year actually killed anyone.

So I extend some trust in the collective people (while at the same time thinking some large collections of people are idiots, say, politically).

Honest, non-trolling question: On what basis do you have your confidence that this is not a disease/condition?

Whats a "disease" and whats not is not easy to define. If we could look at the living brain at a microscopic level, comparing individual dopamine receptors and the connectome of individual brains, it would be quite easy to give objective evidence for most mental diseases. But we can't. But we can see viruses and tumors and that leads to your idea that those are more "real" because it's more easy to see them. But is "visibility" really a valid criteria here?

For example look at a disease like fibromyalgia: For a very long time there was no objective evidence that this disease really existed, so people suffering from it where often seen as hypochondriacs. Today we know it's really a disease because modern medicine found ways to make it "visible" so it's accepted as a real disease now. But with your way of thinking you would've denied those people analgesics because a few years ago there was no objective way to tell if they really suffered the pain they reported.

OTOH depression is still an "invisible" disease: You can only look at the symptoms to diagnose it, there is no "objective" evidence for it. But still there are lots of people suffering and dying from it. And we know from lots of studies that it's possible to cure or at least manage this disease for a certain percentage of sufferers. So I would consider it unethical to let people suffer or even kill them self only because we can't see objective biological evidence that they have depression.

Now with ADHD it's not as clear as with depression because the symptoms aren't that severe. So you argue that it's just the society which wants "conforming" individuals and declares non-conforming ones as "ill". But if people are really disabled by something which prevents them doing certain things they want to do which the majority (> 90%) of people can do, while medication exists which let them do it, is it really ethical to not give them the medication? Those people are objectively suffering and there exists lots of evidence that their suffering can be reduced be giving them a certain medication. So it's unethically to let them suffer even if there exits a way to stop their suffering.

And yes, if there would be a medication which could lift the IQ of person with low IQ into the average range, I would also consider it unethically to not give this medication to people with low IQ. But such a medication don't exists today.

We simply don't know what the impact is of administering powerful amphetamines to children upon their development. Is there a population of children that would "age out" of the ADHD spectrum and develop coping mechanisms, if they were not given pills that prevent that? In such a case, the medication is actually hampering their development.

We have 80 years of data from giving children low doses of stimulants.

>In such a case, the medication is actually hampering their development.

Again, the actual data say otherwise. Medication tends to help children develop proper coping mechanisms. Not medicating is more likely to result in social rejection, drug abuse, depression, dropping out of school, and so on.

Most of this anti-medication sentiment is unscientific unfounded FUD.

You're conflating "not medicating" with "not treating", which is exactly the sort of thing that feeds the criticism that U.S. overdiagnosis rates are being driven by the pharmaceutical industry. Behavioral therapy is also effective, and avoids some of the negative impacts of medication. There are studies that compare medicated ADHD patients to untreated ADHD patients over the course of adolescence; but people who are skeptical over the over-prescription of ADHD drugs aren't actually advocating for non-treatment and non-intervention. Almost no one doubts that ADHD is a real problem for some children that requires medication. The question really is about the extent of overdiagnosis in the US, and the long-term use of medication for children, especially very young children. Stimulant drugs are not recommended for children under 6, and yet still something like 1% of US children under 6 are taking them. Both ADHD diagnoses and pharmaceutical treatment is far, far more prevalent in the US than other developed countries, and it is certainly a good question as to why. Parents naturally have a lot of anxiety about their children's schooling, and the marketing of ADHD plays upon and exacerbates that anxiety (to the extent that if you mention any hiccups in your child's adjustment to school, people immediately begin talking about ADHD). It is also true that kindergarten is the new first grade in terms of literacy expectations, which means more long, boring desk work for young children who are frequently seeing their exercise time reduced or eliminated. Those are problems also.

To which I'd add, the fact 'ADHD' symptoms are stereotypically behaviors of male children. I don't think it might be a total coincidence that we have a trend of drugged-up little boys for behavior deemed unacceptable, at the same time childrens' education is dominated by women.

Children's education has always been dominated by women. I think the problem is more that young children are suddenly being held to a standardized curriculum in which they are expected to learn to read in kindergarten (instead of 1st grade) while their recess time is curtailed or cut entirely. Then when the boys or the youngest quartile of 5-year-olds have trouble sitting still or focusing on desk work, it becomes pathologized.

Boys are more often diagnosed with ADHD (by a factor of 2 to 3) but that probably because boys simply have a higher base aggression level which is "added" to the ADHD symptoms which makes ADHD in boys easier noticeable than in girls. So girls are probably underdiagnosed because nobody notices their attention deficit symptoms and their hyperactivity is still not annoying enough to send them to a counselor.

Ugh. I hate this. My son has ADHD, and the public school just couldn't cope with him. He was bored so often, and had no release for his energy because they rarely gave them recess (it got taken away if the class was too noisy, because teachers are idiots). When he was diagnosed, we made the difficult decision to give him medication. It made a big difference to his behaviour in school, to the extent that if he ever forgot to take it, the teacher would call me and have me take it in for him.

Now we're coming to the end of the summer, more than two months where he hasn't taken his medication, and he's been completely within the limits of what we can cope with. But I guess we're not trying to control 30 of them. He's starting at a private (Waldorf) school in a couple of weeks.

Ironically, we can now barely afford it after I just got fired from my job as a software engineer, because my own problems with ADHD were hindering my ability to work quickly.

Now I have to decide whether to start him at his new school with or without his medication. I mean, did it really help him, or was it just helping his teacher? Should I let him be himself, or am I doing him a disservice by not giving it to him? He needs to do well in this school, and students there start with a month-long probationary period.

It's a really tough call.

You can make that argument for most if not all mental disorders (cf. Erving Goffman). The fact is that persons with ADHD face significant difficulties functioning in modern society and suffer as a result, which is our best criteria for treating a mental issue as a disease.

Like I said elsewhere - does that mean that being ugly/unattractive is a disease? Or having an awkward personality, or having a low IQ? Or for that matter, being a member of any discriminated-against minority?

It seems unjust and coercive to tell people they have a disease and should be medicated simply because society demands it.

Those certainly could result in some mental disorder. An awkward personality and to some degree low IQ could be symptomatic of a mental disorder as well. It's definatly possible to make a convincing case that all mental illness is a manufactured construct [1]. But I don't think you can reasonably say ADHD is not a disease and still believe, say, depression or anxiety disorders are diseases.

[1]https://en.wikipedia.org/wiki/The_Myth_of_Mental_Illness

Interesting link, thank you.

Before we talk about forcing people to go on drugs they don't want, let's get to a place where society lets everyone who could benefit from treatment at least have the option of receiving it.

The problem with this is that offering people the treatment can create the disease, in some sense.

So don't call it a disease. Call it a Snuffleupagus. Just don't stop treating patients affected by this particular Snuffleupagus because it doesn't meet your definition of a "disease".

We aren't morally obliged to treat people for things that aren't diseases.

You aren't morally obligated to do anything, you can go live in a hut in the plains of Montana if you want. But people with ADHD who seek treatment appreciate the efforts of the medical professionals who help them.

The fact it's about a book rather than a scientific article makes me suspicious. Finding people who are untreated and struggling is common. So what's the point of it being a book? Other than cashing in on the "it's all in your head" sentiment? Claiming it's real in a small aside just seems like ass covering.

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