ADHD Reconsidered By Bryan Caplan

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] largefraction of what is called mental illness is nothing other than unusualpreferences – fully compatible with basic consumer theory. Alcoholismis the most transparent example: in economic terms, it amountsto an unusually strong preference for alcohol over other goods. Butthe same holds in numerous other cases. To take a more recent additionto the list of mental disorders, it is natural to conceptualizeAttention Deficit Hyperactivity Disorder (ADHD) as an exceptionallyhigh disutility of labor, combined with a strong taste forvariety.

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.

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 connectionbetween physical and mental activity. Critics often cite findingsof ‘chemical imbalances’ in the mentally ill. The problem with theseclaims, from a Szaszian point of view, is not that they find a connectionbetween 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 differentfrom non-nuns. Would we infer that being a nun is a mentalillness?

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.