On Time and a Half, Learning Disabilities, Secondary Gain, and the Business of Mental Health
Though I have a medical degree and practiced general medicine for a brief period in Spain, I left clinical practice many years ago and have been involved in research and teaching in institutions of higher education in the United States for fifteen years. Soon after I started, I noticed some of my students came with letters explaining they had a learning disability and therefore the right to special accommodations. The most common accommodation is to have time and a half, or twice the usual time, for written assignments and exams. I was surprised when I noticed that the presence of these students was relatively common, and apparently rising, and I tried to learn more about these “learning disabilities.” I found that they are part of a large epidemic of “disorders” that supposedly require special attention and treatment for children and young adults in the United States.
Millions of children and young adults in the United States are diagnosed as having a mental or behavioral “disorder” or learning disability. On August 4, 2016, an advertisement was published covering a full page in the New York Times claiming that “1 in 5 kids” have a “learning and attention issue.” The advertisement was sponsored by an organization called understood.org that claims to be a “free online resource designed to help you to help your child thrive in school and in life.” I was intrigued by the ad, so I went online to the website and spent some time exploring it. You find there abundant “information” about “dyslexia,” “dysgraphia,” “acalculia,” etc. There is specific information about the difference between attention-deficit disorder (ADD) and attention-deficit hyperactivity disorder (ADHD). The experts in understood.org explain to the public that ADD and ADHD “are both brain-based conditions that affect people’s ability to stay focused on things like schoolwork, social interactions and everyday activities like brushing teeth and getting dressed.” The use of the term “brain-based conditions” is interesting, as it tells parents—specifically mothers—that these behaviors, which are “brain-based,” are not their fault. Of course, unless you believe that behavior is determined by a soul, or that thought occurs in the heart or in the liver, any behavior is “brain-based.” In using the term, the anonymous authors of understood.org are trying to imply that these conditions are grounded in the biology of the brain—which of course sets the stage for their pharmacologic treatment.
Allen Frances is a psychiatrist and author of Saving Normal, a book subtitled “An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.” Frances was the Chair of the Task Force that wrote the 4th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, that is, the DSM-4. According to Frances, in 1997 the drug companies launched new and costly medicines for attention deficit disorders into the market “and were simultaneously set free to advertise them directly to parents and teachers. Soon the selling of ADHD as a diagnosis was ubiquitous in magazines, on your TV screen, and in pediatrician’s offices—an unexpected epidemics was born, and the rates of ADHD tripled” (p. 26). The evidence of diagnostic inflation for mental disorders in children and adults is everywhere. Dr. Frances says that during a period of about 15 years, childhood bipolar disorder increased fortyfold, autism twentyfold, and the diagnosis of attention/hyperactivity disorders tripled (p. 104). Under the epidemics of diagnosis of ADHD about 10% of all children qualify for that diagnosis and “at least one or two kids are on medication in every classroom.” Thomas Insel, the former Director of the National Institute of Mental Health, has noted that what physicians once called ADHD is now often diagnosed as a “childhood bipolar disorder,” which has had “a 40-fold increase in prevalence from 1994 – 1995 to 2002 – 2003.”
Now, what is the reason explaining the explosion of psychiatric diagnoses in children and adolescents? Here the explanations of experts diverge. Dr. Frances mentions six circumstances that in his view contributed to the explosion of ADHD diagnosis, specifically “wording changes in [the diagnosis criteria] in DSM-4; heavy drug company marketing to doctors and advertising to the general public; extensive media coverage; pressure for harried parents and teachers to control unruly children; extra time given on tests and extra school services for those with an ADHD diagnosis; and finally, the widespread misuse of prescription stimulants for general performance enhancement and recreation” (p. 141). This vision is strikingly different to the view of Thomas Insel, who asserts that psychiatrists, parents, schools, or drug companies are not to be blamed for the explosion of psychiatric diagnosis in young people. Contrarily, Dr. Insel suggests that the increased use of medication may be not the problem, but a symptom. “What if more children were struggling with severe psychiatric problems and actually the problem was not over-treatment but increased need?” Perhaps the increased use of medication “reflected more children with severe developmental problems and more families in crisis? What if the bigger problem is not over-medication but under-treatment?”
Insel is reported to have left the National Institute of Mental Health in 2015 to join Alphabet Life Sciences, a tech conglomerate formed in the restructuring of Google that is exploring applications of high tech to diagnosis and treatment. The note in the MIT Technology Review reporting the move of Insel to Alphabet explains that wealthy tech companies have realized that health care, about a fifth of the U.S. GDP, is a bigger business than software and gadgets, and so it’s one business into which they should move.
An important fact to be considered is that U.S. adolescents are treated with drugs for psychological disorders that often are categorized as learning disabilities much more frequently than in other countries. This undoubtedly has to do with the fact that the diagnosis of the so-called attention deficit disorders are much more frequent using the American diagnostic criteria than using criteria of the World Health Organization. A study published by the journal Child and Adolescent Psychiatry and Mental Health found that among youth aged 0 – 19 with medical insurance the proportion using psychotropic medication was 6.7% in the U.S. compared with 2.9% in the Netherlands and 2.0% in Germany. Similarly, the prevalence of treatments with antidepressant or stimulant medication was 3 or more times greater in the U.S. than in the Netherlands and Germany.
Of course, reports like this have raised concerns that too many children and teenagers are diagnosed as “having a problem” and receiving powerful psychoactive drugs—as well as being entitled to special educational accommodations. But Thomas Insel himself assures us that most concerns about overmedication of children are unjustified, because “most of the prescriptions for stimulant drugs and antidepressants are not from psychiatrists” and furthermore, “drug companies, while frequently maligned, have reduced, not increased, their marketing budgets in the U.S.”
But let’s go back to understood.org. This is obviously a serious website that is just committed to ensuring total objectivity of the information that is offered there for the free use of the public. On the website we read that “understood is not—and never will be—affiliated with any pharmaceutical company.” When reading this the Spanish proverb came to my mind, dime de lo que presumes y te diré de lo que careces: “tell me what you brag about and I’ll tell you what you lack.” The understood website has many links to institutions that are referred to as “Founding Partners.” These are “15 founding nonprofit organizations” that are “diverse in their specialties, but united by a common desire to help parents help children.” For example, one link leads to “The Child Mind Institute” which is “dedicated to transforming mental health care for children everywhere […] committed to finding more effective treatments for childhood psychiatric and learning disorders, building the science of healthy brain development and empowering children and their families with help, hope and answers.” One of the links on the website of The Child Mind Institute is titled “ADHD Meds Cut Risk of Drug Abuse, STDs.” The link leads to a text authored by Harry Kimball and dated August 2, 2016, which explains that researchers at Princeton and Clemson University have found that young people with ADHD that take stimulant medication have fewer of the risky behaviors associated with the disorder. According to Kimball an analysis of data from 150,000 young individuals “with ADHD finds that those who took medication were 3.6% less likely to get an STD, 7.3% less likely to develop a substance-abuse disorder and 2.3% less likely to be injured than their peers who didn’t take medication.” These rates of effectiveness are remarkably small and suspect, especially in the context of an ADHD diagnosis, which is ambiguous as it is always made on the basis of subjective criteria. Kimball says that this investigation “probably won’t put to rest the continual debate over the effects of ADHD medication,” though he immediately asserts “that for children with ADHD as a whole, the medication can help them steer clear of common risks that affect them more than other kids.”
The well-established notion of “secondary gain” is used to indicate situations where a perceived disorder, ailment, or disease, no matter if it is real or nor, allows a person to enjoy specific advantages. Even a diagnosis of a lethal disease may generate a major secondary gain, for example in the form of compassion or increased attention derived from the diagnosis, and may be particularly valuable for the patient. Obtaining financial compensation, avoiding military duty under conscription, getting specific drugs or extra time for exams, and avoiding a jail sentence are typical examples of tangible secondary gain. One of the reasons that may explain why the unemployment rate has declined in recent years in the United States while the employment-to-population ratio has remained almost flat is the significant enlargement of the numbers excluded from the labor force because of a disability diagnosis. Thus the estimated number of persons aged 21 to 64 who reported a work limitation declined in the years before the Great Recession from 14.4 million in 2006 to 13.9 million in 2007 and 13.8 million in 2008, but when the crisis hit the labor market it climbed to 14.8 million in 2009 and continued rising to reach 16.0 million in 2014. When finding a decent job or even any job, is difficult for mid-age adults, the incentive to look for a disability diagnosis is very strong and thus the secondary-gain mechanism seems very likely to play a role in this phenomenon. Similarly, the secondary gain that allows kids with diagnosis of ADHD or other psychological conditions to have specific privileges in education is likely to be one of the factors promoting the diagnostic explosion of learning disabilities.
Disseminating the notion that the disorders or disabilities requiring treatment are very common is key to rendering socially acceptable the fact that millions of children and adolescents are chronically treated with powerful drugs that could have important adverse effects. Thus we are told by understood.org that among children and adolescents of the United States about one out of five requires specific care because of attention or learning disorders. According to the U.S. census there were 105 million males and females aged 25 or under in 2015. Therefore if the claim of understood.org is correct, 21 million children and young adults are the potential market for “shrinks” and for psychoactive prescription drugs. The very existence of entities like understood.org, generously providing information leading to treatment, itself suggests that “the mental-health industrial complex” is a key factor explaining the explosion of psychiatric diagnoses.
Marcia Angell was a former editor of the New England Journal of Medicine, the most prestigious periodical in the medical field. As she once explained, the pharmaceutical industry frequently masquerades marketing as education. Since the first step to selling a drug is to find people who are potential users, and the bigger the market the more promising the expectations of big sales, direct “educational” messages are just a hidden form of advertising. You just need to sit in front of a TV for a few minutes to get such “education” and learn that taking drug X or Y or using the device Z would make your life much happier. With declining TV watching in all segments of the population, “education” through Internet-based resources becomes increasingly important for pharmaceutical companies.
Recent years have seen alarming news on rising rates of suicide, increasing number of deaths because of overdoses of prescription drugs, medical errors as the third leading cause of death in the U.S. population, and skyrocketing public and private spending on health care. All that is evidence that American society is suffering an extreme form of medicalization. In that context, should we agree with Dr. Insel that probably more treatment is needed for individuals, or should we agree with the critics who claim that individuals actually need less treatment and that society needs to defend itself from these powerful business interests?
Today millions of children and teenagers in America are diagnosed as “needing help” and many more are the targets of marketing by the mental health psycho-industrial complex. These children and adolescents and their families become the “clients” of a powerful business that makes millions on supposedly “brain based” behavioral characteristics that in other countries are considered perfectly normal. Those supposedly suffering from mental disorders and learning disabilities, enthused by trivial secondary gains, are often treated with powerful psychoactive drugs that by themselves can lead to depression, addiction, and many other major side effects. In this, as in the availability of guns, America is certainly exceptional.
- Angell, Marcia. The Truth About the Drug Companies: How They Deceive Us and What to Do About It. (New York: Random House, 2004). Chapter 8: Marketing masquerading as education.
- Bound, J., & Waidmann, T. Accounting for recent declines in employment rates among working-aged men and women with disabilities. Journal of Human Resources 37;2: 231-50, 2002.
- Cornell University, U.S. Disability Statistics. www.disabilitystatistics.org/reports
- Frances, Allen, Saving Normal. (New York: William Morrow, 2013).
- Insel. Thomas. National Institute of Mental Health (NIMH) Director’s Blog: “Are children overmedicated?” June 6, 2014, www.nimh.nih.gov
- Kimbal, Harry. ADHD Meds Cut Risk of Drug Abuse, STDs. August 2, 2016. http://childmind.org/blog/adhd-meds-cut-risk-of-drug-abuse-stds/
- Makary, Martin; Daniel, Michael. 2016. “Medical error—The third leading cause of death in the US.” BMJ [British Medical Journal] 353:i2139.
- Regalado, Antonio. “Why America’s Top Mental Health Researcher Joined Alphabet: Tom Insel explains why he’s ready to give Silicon Valley a try.” MIT Technology Review. September 21, 2015.
- understood.org. About Our Founding Partners. https://www.understood.org
- U.S. Census. http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_14_1YR_B18120&prodType=table
- Zito, Julie M et al. 2008. “A three-country comparison of psychotropic medication prevalence in youth.” Child and Adolescent Psychiatry and Mental Health 2:26.
ContributorJose A. Tapia
JOSE A. TAPIA is an Associate Professor of Politics at Drexel University, Philadelphia. His research has been published in Journal of Health Economics, the American Journal of Epidemiology, Social Science & Medicine, PNAS, and other journals.