What Is ADHD - And Why Are So Many Major League Baseball Players Getting This Diagnosis?

How Do You Spell D-R-U-G-S?
Baseball Is Asking For Trouble Again

In December, 2009, the New York Times reported that the number of major league baseball players permitted to take otherwise-banned stimulants rose for the third year in a row, to 108 players (Michael S. Schmidt, New York Times, 12/1/09). The report was released by the testing administrator, Dr. Bryan Smith. Players can use these stimulants by virtue of having been diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) (Attention Deficit Disorder - or ADD - is an older term and is now subsumed under ADHD). In 2008, 106 players were granted therapeutic use exemptions, representing 7.86% of all major league baseball players. In 2007, 103 players were exempted, and, in 2006, 28 players.

Thus, the data look like this:
2006 = 28 players given therapeutic exemptions
2007 = 103 players given therapeutic exemptions
2008 = 106 players given therapeutic exemptions
2009 = 108 players given therapeutic exemptions

Baseball says that this represents a leveling off and that few new exemptions are being given. That sounds good, but can we still be a bit skeptical?

Data from epidemiologic studies indicate that the prevalence of ADHD in children worldwide may be as high as 8-12%; however, existing data show that in adulthood the prevalence of ADHD decreases to 3-5% (1-3). So how can it be that major leagues baseball players have approximately twice the usual rate of ADHD? How do you spell D-R-U-G-S?

What Is ADHD?
ADHD is a neuropsychiatric condition characterized by problems with organization, sustaining attention, procrastination, daydreaming, hyperactivity, restlessness, and impulsivity (4). The causation of this symptom complex is not clear. It is most likely multi-faceted, involving a combination of biological and psychological factors. There are probably subgroups, within which either the biological or the psychological is more dominant.

This is a very complex and controversial problem (5-8). Are people born with brains which develop or are vulnerable to developing ADHD? Do early parenting problems and trauma cause or contribute to biological changes and susceptibility to developing ADHD? The jury is still out on these questions - the answers are simply not there yet.

What is the Treatment for ADHD?
The treatment for ADHD includes medications, psychotherapy (e.g., talking therapy, psychodynamic psychotherapy, cognitive behavioral therapy, etc.) and educational assistance (studying and organizational skills, tutoring, and the like). Medications tend to be the predominant form of treatment, but this is where things get complicated: those who work intensely with children report that talking therapy can be very effective with some children who have been diagnosed with ADHD.

So what medications are used for ADHD? Some of the commonest are Ritalin (methylphenidate), Concerta (methylphenidate), Focalin (methylphenidate), Dexedrine (dextroamphetamine), Adderall (dextroamphetamine plus amphetamine), Strattera (atomoxetine), and Provigil (modafinil).

And what are these medications? They are amphetamines or amphetamine-like drugs! They are performance enhancers! They are among the most abused drugs in the world. Perhaps most importantly, these medications are routinely sold and bought by children and adolescents in school. They are addictive. Some recent studies have shown them to be associated with sudden death (9, 10). And we do not yet know the long-term effects of sustained use of these medications.

Baseball and ADHD
Now - back to baseball. No doubt some major league ballplayers are legitimately diagnosed with and treated for ADHD... but 2-3 times the usual adult rate of ADHD?

In response to the steroid scandal, baseball instituted an increasingly effective drug-testing program. However, it is hard not to be skeptical about the high incidence of ADHD diagnoses among major league baseball players. It is hard to escape the conclusion that many players are being diagnosed ADHD as a way to obtain amphetamines and amphetamine-like drugs.

The following questions emerge: What professionals are diagnosing these players? What kind of physicians are treating and prescribing medication for them? Are Board-Certified psychiatrists with experience in ADHD involved in any part of the process? How much are the professionals involved in the diagnostic and prescribing process being paid?

It would appear baseball once again is asking for trouble in the drug arena. The solution is readily available: oversight by the appropriate physicians. But first things first: baseball must acknowledge and investigate yet another problem of potential drug abuse.

1. Faraone SV, Sergeant J, Gillberg C, Biederman J (2003). The worldwide prevalence of ADHD: Is it an American condition? World Psychiatry 2:104-113.
2. Kessler RC, Adler L, Barkley R, et al (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Am J Psychiatry 163:716-723.
3. Faraone SV, Biederman J (2005). What is the prevalence of adult ADHD? Results of a population screen of 966 adults. J Atten Disord 9:384-391.
4. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM IV-TR. 4th ed. Washington, DC: American Psychiatric Association.
5. Faraone SV, Biederman J (2009). Attention-deficit/hyperactivity disorder research: Current status and future directions. J ADHD Relat Disord 1:7-13.
6. Sugarman A (2006). Attention deficit hyperactivity disorder and trauma. Int J Psychonal 87:237-241.
7. Salomonsson B (2004). Some psychoanalytic viewpoints on neuropsychiatric disorders in children. Int J Psychoanal 85:117-136.
8. Salomonsson B (2006). The impact of words on children with ADHD and DAMP. Int J Psychoanal 87:1029-1047.
9. Vitiello B, Towbin K (2009). Stimulant treatment of ADHD and risk of sudden death in children. Am J Psychiatry 166: 955-957.
10. Gould MS et al (2009). Sudden death and use of stimulant medications in youths. Am J Psychiatry 166: 992-1001.

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