Alumnus, Journalist, and Self-Described Math Geek Alan Schwarz Saw Something Rotten in the Number of Kids Diagnosed with ADHD and Treated with Amphetamines

PRESSURE (&) PROOF

Alumnus, journalist, and self-described math geek Alan Schwarz saw something rotten in the number of kids diagnosed with ADHD and treated with amphetamines. He responded with a powerful series in The New York Times—and an even more powerful book.

BY SAMUEL HUGHES

hen Alan Schwarz C’90 began his investigation into “High-school kids were not snorting Adderall or feeling Attention Deficit Hyperactivity Disorder and the like they had to pop Vyvanse to stay up until 2:00 or 3:00 and explosive growth in its diagnosis and treatment, he then be coherent for the exam at 9:30 because they wanted saw it as a story about academic pressure. to,” he adds. “They were doing it because the grownups made “It wasn’t about ADHD, and it wasn’t about Adderall, them feel as if they had to. And the grownups hadn’t taught though obviously it needed to discuss both,” he says them—not just how to succeed, but how to fail.” of his first New York Times article on the subject, That series served as the foundation for ADHD Nation: Wwhich was published in June 2012 and opened with a high-school Children, Doctors, Big Pharma, and the Making of an American boy snorting Adderall before taking the SATs. “But during the Epidemic, published last fall by Scribner. The book shines a extensive research for that article, it became extraordinarily thoroughly unflattering light on the symbiosis among phar- clear that the system through which the kids were getting these maceutical companies, psychiatrists, doctors, and researchers. medications—not just from their friends, but from their friends It’s also a crackling good read, not so much a Whodunnit as a who had gotten them from doctors—was extremely screwed up. Howthehelldidthishappen?

38 MARCH | APRIL 2017 THE PENNSYLVANIA GAZETTE PHOTOGRAPHY BY CANDACE DICARLO | ILLUSTRATION BY CHRIS GASH THE PENNSYLVANIA GAZETTE MARCH | APRIL 2017 39 According to Schwarz, the short answer phlet was funded and produced by Ciba- marily a sportswriter then, having been to that question is the steady loosening of Geigy, the Swiss pharmaceutical fi rm. senior writer for Baseball America from diagnostic criteria for the disorder, which 1991 till 2007, when he joined the Times’ he chronicles in deep and damning detail. Recognizing Concerta’s blockbuster staff after years of freelance contributions. “The process through which this diag- potential, Johnson & Johnson, the pharma- Over the next four years, he wrote more nosis was being made and the prescrip- ceutical behemoth, acquired ALZA in May than a hundred articles about sports-related tions written was extraordinarily hap- 2001 for $10.5 billion. Its subsequent mag- concussions and other brain trauma, as well hazard,” he says. “To anybody who could azine ads almost fl aunted drug compa- as the NFL’s cover-up of concussion-related A) listen to kids, and B) read scientific nies’ newfound freedom. One had a mother issues in retired players [“Alumni Profiles,” studies, it was clear as day that ADHD gazing proudly at her smiling son and Jul|Aug 2012]. His work in that unexplored was being wildly misdiagnosed and pre- saying: “Better test scores at school, more field was profiled by outfits ranging from scriptions written unjustifiably.” chores done at home, an independence The New Yorker to PBS’s “Frontline,” and its Yet when he would “bring those obvi- I try to encourage, a smile I can always impact went beyond mere awards—though ous situations to people in charge—psy- count on.” Every one of those promises any time you’re a finalist for a Pulitzer Prize chiatrists or professional organizations, was misleading or simply baseless. (as he was in 2011), you’re in pretty select pediatricians or school officials or even company. Schwarz’s articles led directly to drug companies—all the grownups said, One of Shire’s Adderall XR Web pages congressional hearings, major changes in ‘No, no, no, that doesn’t happen. That’s warned parents that ADHD kids were at the NFL’s approach to concussion-manage- just exaggerated,’” he says. “Or, ‘No, it’s “high risk for repeating a grade or dropping ment, and the league’s begrudging acknowl- not misdiagnosed. You can’t trust those out.” Another said that many children with edgement that those head injuries can, in numbers.’ Here we had something that ADHD can also have conduct disorder … fact, lead to serious long-term problems. was endangering the brains of children, Adderall XR had not only never been shown “The NFL has basically lost only one and the grownups didn’t seem to want to to address those behaviors, the company public-relations war in its existence, and know about it.” hadn’t even looked into them. Nonetheless, that was the issue of the effects of concus- parents got the message: Give your child sions in brain trauma in players,” he says. Adderall or else he could become a car- “I hate to sound so self-congratulatory, For the record, Schwarz is hardly an crashing, felonious psychopath. but to the extent that I am recognized anti-med absolutist, and in ADHD Nation as the guy who stuffed it down the NFL’s he writes that “only the cruelest of crit- throat, I won because I never deviated off ics would deny that many children were chwarz hadn’t planned on becoming center. I stayed right down the middle. benefitting” from both the diagnosis and an investigative journalist. A self- They never had anything where they could the medication. described “math geek” from a fami- say ‘That’s unreasonable, that’s wrong.’” “I’m not saying that ADHD isn’t real, ly of math geeks, his real dream was By 2011, having “gone through the or that the drugs are the devil’s work,” to be a high-school math teacher. wringer” with the concussion stories he explains in our interview. “I’m say- We’ll get back to that dream later, (which prompted some death threats, ing that, given their existence and the but for now we’ll just note that at he says), Schwarz was ready to move on inevitability of their use, how can we Penn,S along with all the sportswriting he from sports and into in an area that he handle that more responsibly? did for The Daily Pennsylvanian, he not already cared deeply about: education. “I don’t advocate for any particular only majored in math but credits his math “I had heard that some kids in high reform,” he adds. “I try to give people professors for teaching him how to write. schools like the one I went to in Scarsdale, the tools through which to consider it “Proofs are narratives,” he says, “and New York, were under so much academ- on their own.” narratives are proofs.” Press him a bit ic pressure to perform that they were One tool is the not-so-hidden camera of and he’ll describe his craft in terms of abusing and even snorting Adderall,” he his reporting, through which the reader “establishing facts, deriving conclu- says. “Now, I knew that this was possible can observe what was going on behind sions, merging those conclusions with because there was a Family Ties episode the scenes for all those years. other facts, getting from A to B to C to D on it in 1983. But it resonated with me A few tidbits: to E to F to G, and making sure you only more as an adult.” use facts that [have been] proven.” Skip The school psychologist handed Mrs. a step, “and the whole thing falls apart.” Parry a pamphlet called “ADHD—Attention His talent for infusing human interest The 2013 Statistical Reporting Award, Defi cit-Hyperactivity Disorder and Learn- into math-related subjects was evident in his a kind of lifetime achievement award from ing Disabilities—Booklet for Parents.” It first book, The Numbers Game: Baseball’s the American Statistical Association, is was written by Larry B. Silver, MD. The Lifelong Fascination with Statistics (2004, not something most journalists dream passage on medication read: Parents St. Martin’s) [“Arts,” Sep|Oct 2004], which of winning, but it must have given great should be aware that these medicines do brought some fascinating and forgotten satisfaction to Schwarz. His examination not “drug” or “alter” the brain of the child. characters to life and was ESPN’s 2004 (with a Times colleague) of raw data from They make the child “normal.” The pam- Baseball Book of the Year. He was still pri- the Centers for Disease Control is just

40 MARCH | APRIL 2017 THE PENNSYLVANIA GAZETTE one example; it showed that the number the retired professor of psychiatry and on. He came to a serious conclusion: he of children diagnosed with ADHD was behavioral sciences at Duke (among needed to open his own treatment cen- not 11 percent, as the CDC had concluded, other places), whose early diagnostic ter “for teenagers like I was when this but “15 percent of all American children scales laid the groundwork for assess- all started.” Thus was born Newport today.” (Among boys it’s 20 percent.) That’s ing and treating ADHD. Now 83, he was Academy, which now has three locations three times the number of kids that the a key force in the surge of diagnoses and around the country, “dedicated to helping American Psychiatric Association’s own treatment with stimulants. As Schwarz teenagers recover from substance-use population-assessment indicated should notes in ADHD Nation, he founded the disorders and other psychiatric troubles.” have the disorder. Journal of Attention Disorders in 1996, The other student—Kristin Parber “All I ask is that, ‘Hey, doctors, follow which “allowed dozens of ADHD studies (a pseudonym), from the Philadelphia the rules that you set up for yourselves,’” per year—many of them funded by Big suburbs—became one of Newport’s first he says. “You’ve told us what ADHD is. You Pharma, naturally—to be published and patients. Her ADHD diagnosis at age lay out how to diagnose it properly—what entered into the forever citable scientific 8—prompted by over-ambitious parents it is, what it isn’t. You told us that population studies suggest that ADHD occurs in about 5 percent of children. Fine, I’ll accept that, and I’ll even do it in good faith. Now, “The ADHD factions have grown if you would like to argue arithmetic with me and say that 15 is not 5 x 3, and that so polarized and unwilling to learn the difference between 15 percent of 56 million children and 5 percent of 56 million anything that they use the book children is not millions of children—bring it on, because I’ll bury you. as a sword, not a mirror.” “I can’t wait for somebody at the APA to say, ‘Well, you know, that 5 percent number is a little squishy,’ or ‘It really should literature.” But in recent years Conners and aided by a November 30, 1998 Time have been something else,’” he adds. “At came to believe that the system he helped magazine cover story easing parents’ which point I would reply, ‘Well, what create had become a “national disaster of concerns about Ritalin—led to a pre- else in the definition was half-assed? dangerous proportions.” scription that ratcheted up her anxiety What else did you mess up?’ I mean, The other two human storylines in levels. (Her psychiatrist responded not they’re screwed no matter what they do.” Schwarz’s narrative are of students. One by cutting off the Ritalin but by prescrib- “Part of the strength and accomplish- is Jamison Monroe, a fast-track kid from ing Xanax for anxiety and Lexapro for ment of ADHD Nation,” notes Christopher Houston who struggled with the workload depression.) Eventually she was abusing Lane in Psychology Today, is that it clear- at his new private school, prompting him enough Ritalin (and cocaine) to get herself ly shows how impossible it is to separate to fake the symptoms of ADHD for his pulled out of school, and hence to Newport the “elasticity or diagnostic imprecision” easily duped psychiatrist. (“Only an idiot Academy, where she is now a co-director. from the “pharma-sponsored hype, the couldn’t fake something called ‘attention Needless to say, each child is unique, funded patient groups, the selectively deficit disorder,’ he told himself. Stare out and the way Jamison and Kristin respond- reported trials, and the KOLs [Key Opinion the window. Act distracted, say ‘what?’ ed is by no means a predictor for others. Leaders] who find personal checks left a few times. Say your schoolwork is But their stories were both very real and on their desks (‘for further studies’) and slipping—that’ll clinch it.”) He got a pre- relevant for Schwarz’s larger story. scripts handed them [to read] if they’ll out- scription for Adderall in 1995, just after “I realized that Jamison and Kristin right deny the medication’s side effects.” it became the first amphetamine to be could or did fit the theme that I was try- Schwarz’s indefatigable reporting—more approved by the FDA. (Ritalin, the brand ing to portray—without any massaging than a thousand interviews as well as seri- name of methylphenidate, is a “slightly of facts,” he says. “Part of me was reluc- ous archival digging—led to a trove of his- tweaked formulation” of Dexedrine, an tant to follow them because it’s kind of torical and scientific detail, which he sprin- amphetamine notoriously overprescribed old—you know, mid-’90s, 2000s. But you kles throughout. (What’s now called ADHD in the 1960s and ’70s.) After taking ever- can’t profile a kid going through it right was once called Minimal Brain Disorder, larger doses, Jamison spiraled out of con- now. So when I realized, ‘Wait a minute, for example, while Adderall is a contraction trol and ended up in a drug-rehab center those could be the three strands I could of ADD for all, which is a bit more appealing that—incredibly—let him keep taking his braid,’ I started to see how the book could to parents than its previous name: Obetrol, daily Adderall, because his doctor said he be structured and the material could be a contraction of Obesity-control.) had ADHD. (“‘A way to get high in rehab!’ delivered in a narrative form.” To put a human face on the numbers Jamison said to himself.”) Unsurprisingly, The narrative takes on a meta quality when and history, Schwarz weaves the stories of that stint didn’t help, and he ended up at Keith Conners reads a front-page article in real, emblematic characters into the fab- another rehab center, where he finally the February 2, 2013 Times titled “Drowned ric of his narrative. One is Keith Conners, faced his amphetamine addiction head- in a Stream of Prescriptions.” That article

THE PENNSYLVANIA GAZETTE MARCH | APRIL 2017 41 chronicled the tragic fate of a young man Despite the warts-and-all portrait, or books. He’s not even a doctor! What could named Richard Fee (see excerpt on p. 44), who perhaps because of it, Conners was deeply he possibly know?’ The ADHD factions committed suicide after becoming addicted impressed. In an email, he told Schwarz have grown so polarized and unwilling to Adderall through a series of distressingly that ADHD Nation was a “masterpiece to learn anything that they use the book casual diagnoses of ADHD. of investigation, storytelling, and docu- as a sword, not a mirror. Having written that Times article—in mented history,” and that he was proud “Intractability is an indulgence,” he which the elderly psychiatrist acknowl- to have contributed to “one of the most adds. And those who refuse to listen to edges that scales like the one he created important medical stories of our genera- the other side “need to go back and look “have reinforced this tendency for quick tion that needed to be told.” The book, he at who you were actually serving—your and dirty practice”—Schwarz wrestled added, “is one I wish I had written.” own belief in right and wrong, or if you with how to present Conners’ reaction in were actually trying to help kids.” the book. Journalistic modesty advised What frustrates Schwarz is the dearth him to keep himself out of his narrative, Though ADHD Nation has received of studies that could assess the repercus- but it didn’t make sense not to mention very good reviews (Kirkus Reviews called it sions of misdiagnosis. “What is the cost the article, since Conners had assured “powerful” and “necessary”; New Republic when we get it wrong? What is the cost him that it was the key factor in his deci- hailed it as a “dazzling piece of journal- of telling a kid there’s something wrong sion to take a stand against the pharmaco- ism”), the reaction in the communities with your brain when in fact there is not?” logical tidal wave he had helped unleash. most affected was “dishearteningly pre- And because researchers can’t, for ethical “As Conners kept reading the sprawl- dictable from both sides,” says Schwarz. reasons, carry out scientific studies on ing, operatic tragedy, each paragraph “Some people who decry child psychiatry the effects of misdiagnosis—Group B is more horrifying than the one before, it as a construct say: ‘See! I told you ADHD going to be 100 eight-year-olds who were shook his soul unlike any other reader’s,” was a pharma-constructed conspiracy put on Adderall without justification, and Schwarz writes in ADHD Nation. “He felt to mind-control children!’—which the told they have ADHD when we know they almost ashamed. He felt … complicit … book doesn’t come anywhere near argu- don’t—there will “never be formal evidence Did I help pharma cover up the dangers ing. Those on the other side, who think of the cost or long-term effects,” he notes. of these drugs? … Conners didn’t feel as if everything in the ADHD world is per- As a result, psychiatrists and research- he had killed Richard Fee. But the system fectly hunky-dory, say: ‘Schwarz is just ers and pediatricians “don’t understand he had helped build sure did.” a muckraking alarmist trying to sell what I’m talking about because they

A BRIEF & INCOMPLETE 1937 1956 1962 1969 1970 1971-80 Charles Bradley publishes Ritalin (methylphenidate, Keith Conners presents his Child psychiatrist Virginia Douglas TIMELINE a study of the effects of named for Rita Panizzon, the 39-question Teacher Rating defines the disorder as one of OF ADHD Benzedrine on 30 schoolchildren tennis-playing wife of the CIBA Scale, which would “quite insufficient attention. In the 1980 with significant behavioral issues chemist who formulated it in precisely measure a kid’s Diagnostic Manual of Mental Disorders (All quoted passages in the American Journal of the mid-1940s) is released in behavioral symptoms before (DSM) the term is called Attention are by Schwarz unless otherwise indicated.) Psychiatry. The children the US for adults. and after a trial of Dexedrine Deficit Disorder. Conners’ 39-item “immediately showed more or Ritalin,” in the American checklist of symptoms has been cut to interest in school … Their Journal of Psychiatry. 16, with some overlapping. (As Schwarz comprehension, speed, and accuracy improved, too … notes: “Any child ‘easily distracted’ Moreover, the pills calmed the otherwise uncalmable.” But would have ‘difficulty concentrating,’ Leon Eisenberg and Keith Conners there were “several cases of nausea, insomnia, and too.”) The DSM states that in the US, conduct a study, funded by the heightened anxiety”; the “benefits lasted only as long as ADD “may occur in as many as 3 NIMH, in which Ritalin is given to 39 the pills did”; and the children’s “underlying physical and percent of prepubertal children.” An “disturbed children” and a placebo mental problems still needed careful psychosocial therapy NIMH researcher warns: “ADD could to 39 more. Most of the Ritalin kids from trained professionals.” replace oedipal anxiety as a new improved dramatically, becoming less universal explanation; I urge restraint.” Later that year, Time magazine reports that “students at impulsive and more alert. But many several Midwestern universities are taking the ‘new, powerful “lost their appetites, others struggled The Washington Post reports that 5 to 10 percent of but poisonous brain stimulant’ to stay up nights on end to to sleep, and a few became more children in the Omaha elementary-school system, mostly study.” Two years later, when a Purdue student died soon after anxious than usual.” black, are taking Ritalin, Dexedrine, or other drugs to taking the pills, “the tragedy was reported widely enough that control their hyperactivity and other disruptive antics, all Benzedrine’s dangers became too conspicuous for Smith, part of a ‘behavior modification program.’” That year the Kline & French to sell it as a tool to control children’s mental Controlled Substances Act places “unprecedented states”—which did not yet have a name. (Soon it would: first restrictions on the handling of addictive pharmaceuticals like “minimal brain damage,” then “minimal brain dysfunction,” Dexedrine and Ritalin … US production of amphetamines then “minimal brain disorder.”) plummeted an astonishing 90 percent in only a few years.”

42 MARCH | APRIL 2017 THE PENNSYLVANIA GAZETTE haven’t read it in [the Journal of Child than before,” and that they will “consider an unpaid volunteer, which means that he and Adolescent Psychopharmacology]. all possible explanations and treatments doesn’t have to deal with parents or school It defies all common sense—and what’s for the behavior, rather than jumping to a politics, or even grade papers. “So it’s clearly staring us right in the face.” diagnosis and medication in 20 minutes. not the true experience,” he admits. But still: As for the companies that produce the “Even small, incremental reforms can “I’m in heaven—so much so that I now come stimulants in question, he says: “I’m make a huge difference,” he adds. “If in all day Monday to Friday.” confident it will have no effect on Big current diagnoses decrease from 11 per- Journalism, after all, “deals primarily Pharma’s behavior—its playbook of paying cent to merely 10—which is still nowhere with the irreconcilable—politics, poverty, off researchers and exploiting advertising near appropriate—that’s half a million and, for me, football safety and child psy- has proven too effective, and too condoned children not being misdiagnosed with a chiatry,” he says. “The arguments never by lawmakers, to be adjusted by something lifelong brain disorder. And it’s so easy end. There are no right answers; at best, as quaint as a book. I’m only slightly if people just wake the hell up.” there are only those less wrong. But math? more hopeful that the American Medical There’s one right answer. You either get Association and the American Academy of the ripening age of 48, Schwarz it or you don’t. No specious agendas. No Pediatrics might learn something about has had a journalistic career disingenuousness. Its incontrovertibility what they have allowed to develop, and step that many would envy. But the is very attractive.” up efforts to make sure practitioners who dreams of a math geek don’t fade He hasn’t given up on writing alto- diagnose ADHD know more about what the in the daylight. gether, though. disorder is and isn’t, and what the medica- At“I always treated journalism as teach- “I do expect to write more books—but tions are and are not. My guess is that the ing—just teaching at a different black- books on math, and relatively lightheart- only way such organizations will [respond] board,” he says. Though that “detour into ed ones,” he says. “I might also do some- is through Congressional hearings—after journalism” lasted 25 years, he finally thing on mathematics in journalism, some Senator’s child dies.” left the Times last August, and has been using my experiences—if I can figure out He does hope that some parents and back on the Highway of Proof since then, how to avoid the inherent narcissism. educators will “learn how to approach with the help of the paper’s buyout. “Let’s face it—I’ve always said that writ- a typical situation—a child is struggling “I’m teaching Algebra 2 and geometry at ing was mathematical, so it’s hard to deny in school, and is suspected of perhaps the Dalton School, an elite private school that math mimics writing,” he concludes. having ADHD—with far more information in Manhattan,” he says. He’s doing it as “They’re my double helix.”◆

1987 1994 1995 1999 In the revised DSM, the APA renames PBS broadcasts “ADD: A Dubious NIMH researchers—the “vast majority” of whom “owed at least some of their ADD Attention Deficit Hyperactivity Diagnosis?” which reveals that professional or financial well-being to pharmaceutical companies”—conduct the Disorder (ADHD); later, a sub-diagnosis Ciba-Geigy had quietly given Multimodal Treatment of Children with ADHD (MTA) study. The most effective treatment is called “attention deficit hyperactivity CHADD “close to $1 million since medication plus therapy (68 percent), followed by medication alone (Ritalin or Concerta, 56 disorder without hyperactivity” will be 1989 to attract parents and fuel percent) and therapy alone (34 percent). “Neither” came in at 25 percent. The NIMH’s head added. (Today, says Schwarz, “most its growth.” researcher declares medication the “hands-down winner” compared to behavioral therapy. people skip the hassle, just say ‘ADD,’ “Study Says Drugs Best Help for Attention Deficit,” reports ABC World News Tonight, while and leave it at that.”) A group of parents Clinical Psychiatry News proclaims “Psychosocial Interventions of No Benefit.” in Florida forms CHADD, a support group Though the NIMH sound bites did hold some truth, writes Schwarz, they were “delivered of parents with ADD children, which soon with such tone deafness [and] disregard for how the statements would be interpreted by lay persuades Congress to classify ADHD as audiences, that they became misleading and occasionally downright wrong. Medication did a learning disability. not win ‘hands down.’ Therapy provided far more than ‘no benefit.’

Edward Hallowell and John Ratey “First, almost half of the kids did not significantly benefit from just medication, a publish Driven to Distraction, which remarkable finding for a study that was trumpeting the benefits of Ritalin,” he adds. argues that ADHD, when treated “Second, kids in the ‘neither’ group were not getting nothing—they were getting whatever properly, is not only “powerfully treatments their own doctors were already providing, which was usually Ritalin. Therefore, positive” but probably what made Ritalin, as used in the real world, was doing a pretty rotten job three-quarters of the time … people like Mozart, Albert Einstein, Behavioral therapy’s success rate was close enough to Ritalin’s that it should still have been George Bernard Shaw, and Salvador presented as viable for families who preferred at least to attempt non-medication Dali so special. approaches first.”

On July 18, Time magazine’s cover In the end, “the MTA wrote the ultimate prescription for prescriptions,” he concludes. story on ADHD proclaims: “It’s not just “Schools, already under severe financial pressure, could justify cutting aides and other staff kids who suffer from it,” helping to who had been brought in to help ADHD kids; after all, the study showed that one-on-one open up the market for adult ADHD. attention didn’t work better than a pill.” —S.H.

THE PENNSYLVANIA GAZETTE MARCH | APRIL 2017 43 “YOU KEEP GIVING ADDERALL TO MY SON, When Richard’s parents convinced him to see a different psychiatrist, Dr. Charles Parker, they specifically instructed the new YOU’RE GOING TO KILL HIM!” doctor not to prescribe Adderall; the doctor understood this so well that he wrote in his chart “no meds” with a box around it, as well as noting Richard’s anxiety and suicidal thoughts. And yet, August 2009, Richard Fee walked into the office of the Triad not long afterward, Dr. Parker gave Richard a prescription for Psychiatric & Counseling Center in Greensboro, North Adderall, and eventually a huge dose of 80 milligrams a day. The In Carolina, the just-down-the-street clinic for students at doctor later recalled that Richard had seemed so sincere about Greensboro College who wanted prescriptions for Adderall. At his needing the drug for ADHD—an aspiring medical-school the time Richard had everything going for him—academic schol- student wouldn’t lie about something like this, would he?—and arship, first baseman on the college baseball team, handsome didn’t exhibit any outward signs of abuse during their occa- and charismatic enough to have been elected president of his sional appointments. Richard’s delusions returned so severely sophomore class. He wanted to go to medical school. Having that he spent a week in a psychiatric hospital. When he got out, bummed Adderall pills off friends for a while, he and needing his amphetamine fix, Richard returned decided to get his own supply by faking ADHD to to Dr. Ellison. After only six minutes in the office, a gullible Triad nurse. She wrote down his com- Richard left with not one, but three thirty-day pre- plaints: “poor organization, memory, attention to scriptions for Adderall: one for that day, and one detail.” She gave him an airy eighteen-question each for the next two months, so that he didn’t have survey—not the official Conners Scale, but a descen- to schlep to the office for more. When Richard’s dant of it—and totaled up the zero-to-three scores. father returned to Dr. Ellison to ask what in God’s Twenty-nine? Yep, ADHD. She arranged for a pre- name he was thinking, it was too late— Richard had scription. The drug worked so well that, a few weeks his three-month supply. By the time those pills ran later, Richard returned to ask that the dose be out, Richard became so violent that his rages forced increased to 50 milligrams. She complied. He soon calls to the police. He moved into his own apartment asked for 60. She green-lighted three months’ worth and became despondent, withdrawn, and suicidal of medication in forty-three days. anew. He didn’t recover. His life and psyche in tat- When Richard graduated and moved back home to ters, he hanged himself in a closet. The Fees held a Virginia Beach, Virginia, to study for medical school gathering in Richard’s memory afterward. His old col- entrance exams, he visited a local psychiatrist to get Excerpt lege friends recalled how they, too, had used Adderall his Adderall prescriptions refilled. Dr. Waldo Ellison in college—to cram, just like Richard did—and realized listened to the young man’s complaints, assumed that his Richard’s fate could have easily been theirs. A baseball teammate original ADHD diagnosis back in Greensboro had been correct, later recalled: “It’s so prevalent and widely used, people had no and began writing Richard regular scripts. Because they met idea it could be abused to the point of no return.” Still grieving only for five-minute “med checks” once a month the doctor as the anniversary of Richard’s death approached, Mr. and Mrs. did not notice that Richard was abusing the pills from the Fee noticed in the local paper that a new documentary called start. He would blow through his monthly supply in a few “ADD and Loving It?!” was being screened at a nearby auditorium, weeks, staying up all night reading and scribbling in note- followed by a panel discussion among experts. They decided to books. As amphetamine psychosis took hold, he would climb go. It was being hosted by CHADD, whose emcee opened by thank- out his bedroom window onto the roof to talk with the moon ing their sponsor for the event: Shire pharmaceuticals. The and stars. Another side effect of amphetamine abuse is ele- hour-long movie was of the Ned Hallowell genre, casting ADHD vated body temperature; Richard would get so overheated that as a humorous, and often positive, condition; afflicted spouses he walked around the house with ice packs around his neck— giggled about misplaced keys and forgotten appointments, while and, in frigid weather, cooled off by jumping into his parents’ doctors recalled the “enthusiasm and excitement” their patients fifty-two-degree backyard pool. Richard’s father, Rick, con- had felt upon diagnosis. It closed by examining several “myths” fronted him about his bizarre behavior and whether it had about stimulant medications, with doctors praising their effi- anything to do with Adderall; his son replied, “The doctor cacy and safety, mentioning no risks. Hallowell himself said the wouldn’t give me anything that’s bad for me, Dad—I’m not pills were “safer than aspirin,” while another clinician was even buying it on the street corner.” When Rick watched Richard more reassuring. “It’s okay,” he said. “There’s nothing that’s going grow increasingly violent and heard him complain that his to happen.” Rick Fee seethed silently. After the movie ended, computer camera was spying on him, Rick went to Dr. Ellison’s during the expert panel Q&A, he rose from his fourth-row seat office to discuss the prescriptions. The doctor refused to talk to ask a question. The panel was moderated by a local clinical about Richard, citing patient privacy laws. Rick got so frus- psychologist named Jeffrey Katz, who also happened to be chair- trated that he yelled at Dr. Ellison, “You keep giving Adderall man of CHADD’s public policy committee. “What are some of the to my son, you’re going to kill him!” Dr. Ellison did leave Mr. drawbacks or some of the dangers of a misdiagnosis in somebody,” Fee with some reassurance, though: This doctor had tremen- Rick Fee asked, “and then the subsequent medication that goes dous experience in this area, he explained, because, “I prescribe along with that?” Dr. Katz took the question. “Not much—the more Adderall than anyone in the state.” medication itself is pretty innocuous,” he replied. He explained

44 MARCH | APRIL 2017 THE PENNSYLVANIA GAZETTE from the Child Mind Institute, a New York clinic devoted to diagnosing and treating children with ADHD—and whose president, Dr. Harold Koplewicz, had been involved with NYU’s “Your Kid Will Pay” ransom-ad marketing campaign—took the standard route of claiming that the Richard Fee story only “verges on the kind of fear-mongering that is unhelpful to parents trying to provide the best support and care to struggling children.” The most befuddling response came in a Times Letter to the Editor from Martin J. Drell, the president of the American Academy of Child and Adolescent Psychiatry, whose journal had long survived on glowing reviews of ADHD medications and pharmaceutical advertising. Dr. Drell empha- sized that the millions of Americans with ADHD were at risk for “accidents, injury and substance abuse,” but that “fortunate- ly, effective treatment is available.” One doctor, though, read the story of Richard Fee and had a reaction all his own. The events didn’t take place in his office, and he had never met or spoken with the patient or doctors involved. He didn’t write the prescriptions—and, in fact, still deeply believed in the benefits of ADHD medication. But as he put down the newspaper, having soaked the ghastly story in, he felt a unique sensation. He didn’t feel particu- larly sad. He wasn’t angry either. No. It was something different, more personal. He felt embarrassed. That Sunday morning, Dr. C. Keith Conners decided that ADHD, whose Manhattan Project he had so enthu- siastically helped lead, had clearly melted down. Not just on college campuses, but everywhere. His questionnaire, for which he was now annually getting $600,000 in royalties, and others were making false diagnoses for lazy doctors nationwide. The medications he had championed were that people without ADHD would see no benefit from Adderall being as overprescribed as antibiotics. As he recalled all his work and stop on their own. Dr. Katz concluded, as if puzzled by the for pharmaceutical companies—from CIBA to Abbott to Shire to question: “If you misdiagnose it, and you give somebody medica- ALZA to Lilly and more—he feared that his career had strayed tion, it’s not going to do anything for them. Why would they from medicine to marketing. After disregarding four decades of continue to take it?” gathering clouds, Conners decided to get up and see just how bad Reaction to the Times’s profile of Richard Fee was as polarized the situation had become. He quickly found it worse than he even as ever, with critics of the ADHD explosion being generally feared. Drug companies had grown unsatisfied with the popula- drowned out by those most invested in the disorder’s continued tion of children that he himself had discovered. Those kids were popularity. CHADD’s president blogged that Richard’s death now growing into adults—and as they did, Big Pharma wanted to was clearly tragic, but “stimulant medications that are taken keep their business. as prescribed are highly unlikely to lead to addiction”—avoiding Excerpted from ADHD NATION: Children, Doctors, Big Pharma, and the Making the issue at hand, which was the not uncommon circumstance of an American Epidemic. Copyright © 2016 by Alan Schwarz. Excerpted with when they are prescribed, and taken, improperly. An official permission by Scribner, a Division of Simon & Schuster, Inc.

THE PENNSYLVANIA GAZETTE MARCH | APRIL 2017 45