Several readers have taken issue with my use of the term “ADHD.”  To be honest, I’m not comfortable with it either, but my reason is the opposite of my critics.  Like the late great Thomas Szasz, my objection is that labels like ADHD medicalize people’s choices – partly to stigmatize, but mostly to excuse.  In his words, “The business of psychiatry is to provide society with excuses
disguised as diagnoses, and with coercions justified as treatments.”  I realize this is an unwelcome view, but I do have a whole paper defending it, and I stand by it.

My general claim:

[A] large
fraction of what is called mental illness is nothing other than unusual
preferences – fully compatible with basic consumer theory. Alcoholism
is the most transparent example: in economic terms, it amounts
to an unusually strong preference for alcohol over other goods. But
the same holds in numerous other cases. To take a more recent addition
to the list of mental disorders, it is natural to conceptualize
Attention Deficit Hyperactivity Disorder (ADHD) as an exceptionally
high disutility of labor, combined with a strong taste for
variety.

Consider how economists would respond if anyone other than a
mental health professional described a person’s preferences as
‘sick’ or ‘irrational’. Intransitivity aside, the stereotypical economist
would quickly point out that these negative adjectives are thinly disguised
normative judgments, not scientific or medical claims. Why should mental health professionals be exempt from economists’
standard critique?

This is essentially the question asked by psychiatry’s most vocal
internal critic, Thomas Szasz. In his voluminous writings, Szasz
has spent over 40 years arguing that mental illness is a ‘myth’ –
not in the sense that abnormal behavior does not exist, but rather
that ‘diagnosing’ it is an ethical judgment, not a medical one. In
a characteristic passage, Szasz (1990: 115) writes that:

Psychiatric diagnoses are stigmatizing labels phrased to resemble medical diagnoses,
applied to persons whose behavior annoys or offends others. Those who
suffer from and complain of their own behavior are usually classified as ‘neurotic’;
those whose behavior makes others suffer, and about whom others complain, are
usually classified as ‘psychotic’.

The American Psychiatric Association’s (APA) 1973 vote to take
homosexuality off the list of mental illnesses is a microcosm of the
overall field (Bayer 1981). The medical science of homosexuality
had not changed; there were no new empirical tests that falsified
the standard view. Instead, what changed was psychiatrists’ moral
judgment of it – or at least their willingness to express negative
moral judgments in the face of intensifying gay rights activism.
Robert Spitzer, then head of the Nomenclature Committee of the
American Psychiatric Association, was especially open about the
priority of social acceptance over empirical science. When publicly
asked whether he would consider removing fetishism and voyeurism
from the psychiatric nomenclature, he responded, ‘I haven’t given
much thought to [these problems] and perhaps that is because the
voyeurs and the fetishists have not yet organized themselves and
forced us to do that’ (Bayer 1981: 190). Even if the consensus view
of homosexuality had remained constant, of course, the ‘disease’
label would have remained a covert moral judgment, not a valuefree
medical diagnosis.

Although Szasz does not use economic language to make his
point, this article argues that most of his objections to official
notions of mental illness fit comfortably inside the standard economic
framework. Indeed, at several points he comes close to
reinventing the wheel of consumer choice theory:

We may be dissatisfied with television for two quite different reasons: because the
set does not work, or because we dislike the program we are receiving. Similarly,
we may be dissatisfied with ourselves for two quite different reasons: because our body does not work (bodily illness), or because we dislike our conduct (mental
illness). (Szasz 1990: 127)

My analysis of ADHD specifically:

4.2. Attention-Deficit Hyperactivity Disorder

Substance abuse is a particularly straightforward case for economists
to analyze, since it involves the trade-off between (1) one’s
consumption level of a commodity and (2) the effects of this consumption
on other areas of life. But numerous mental disorders
have the same structure. One way to be diagnosed with ADHD, for example, is to have six or more of the symptoms of inattention
shown in Table 2.

szasz.jpg

Overall, the most natural way to formalize
ADHD in economic terms is as a high disutility of work combined
with a strong taste for variety. Undoubtedly, a person who dislikes
working will be more likely to fail to ‘finish school work, chores or
duties in the workplace’ and be ‘reluctant to engage in tasks that
require sustained mental effort’. Similarly, a person with a strong taste for variety will be ‘easily distracted by extraneous stimuli’ and
fail to ‘listen when spoken to directly’, especially since the ignored
voices demand attention out of proportion to their entertainment
value.

A few of the symptoms of inattention – especially (2), (5) and (9),
are worded to sound more like constraints. However, each of these is
still probably best interpreted as descriptions of preferences. As the
DSM uses the term, a person who ‘has difficulty’ ‘sustaining attention
in tasks or play activities’ could just as easily be described as
‘disliking’ sustaining attention. Similarly, while ‘is often forgetful
in daily activities’ could be interpreted literally as impaired
memory, in context it refers primarily to conveniently forgetting
to do things you would rather avoid. No one accuses a boy diagnosed
with ADHD of forgetting to play videogames.

What about all the contrary scientific evidence?  It’s not really contrary.  The best empirics in the world can’t resolve fundamental questions of philosophy of mind.

Another misconception about Szasz is that he denies the connection
between physical and mental activity. Critics often cite findings
of ‘chemical imbalances’ in the mentally ill. The problem with these
claims, from a Szaszian point of view, is not that they find a connection
between brain chemistry and behavior. The problem is that
‘imbalance’ is a moral judgment masquerading as a medical one.
Supposed we found that nuns had a brain chemistry verifiably different
from non-nuns. Would we infer that being a nun is a mental
illness?

A closely related misconception is that Szasz ignores medical evidence
that many mental illnesses can be effectively treated. Once
again, though, the ability of drugs to change brain chemistry and
thereby behavior does nothing to show that the initial behavior
was ‘sick’. If alcohol makes people less shy, is that evidence that shyness
is a disease? An analogous point holds for evidence from behavioral
genetics. If homosexuality turns out to be largely or entirely
genetic, does that make it a disease?

Bottom line: My use of the term “ADHD” was indeed problematic because the concept itself is problematic.  Then why use it?  Because you can grasp my original point without sharing my broader perspective – and if I started with my broader perspective, it would drown out my original point.