Would you like to take performance-enhancing drugs to boost your pro sports career? Are the drugs banned as a form of cheating? No problem. Just find a doctor willing to certify that you have a "deficit" of the performance factor in question.
That's what seems to be happening in Major League Baseball. Three years ago, the league belatedly banned stimulants on the grounds that they unfairly aided players' performance. At the time, 28 players had "therapeutic use exemptions" allowing them to take drugs such as Ritalin or Adderall. "Therapeutic use" means you can justifiably use the drug because you need it for a medical condition. If you didn't have the condition, you'd just be a normal pro baseball player, and the attention-focusing benefits of Ritalin would be a form of "enhancement," i.e., cheating.
When the league banned these drugs, an amazing thing happened. The number of players claiming and obtaining "therapeutic use" exemptions for stimulants nearly quadrupled from 28 to 103. The basis of their claims? They all had attention "deficit" disorder. Accordingly, they were entitled to attention-boosting drugs.
Among children, the prevalence of ADHD is estimated at 3 percent to 5 percent. Among adults, the rate of diagnosis is between 1 percent and 3.5 percent. But among pro baseball players, the disease seems epidemic. The league has just announced that the number of "therapeutic use" exemptions based on ADHD increased again last year from 103 to 106. That means 8 percent of major-league players have ADHD—twice the rate among children and three to eight times the rate among adults.
How can ADHD multiply fourfold in a sport in a single year? How can it become three times as prevalent in that sport as in the adult population? Is it contagious? Of course not. ADHD is a psychological diagnosis. Like post-traumatic stress disorder, which we talked about Friday, it's open to interpretation in any given patient. Three doctors may say you don't have it. A fourth may say you do.
In the case of PTSD, critics object that such a fuzzy diagnosis shouldn't entitle a combat veteran to a Purple Heart. In baseball, the objection is similar: A fuzzy diagnosis of ADHD shouldn't entitle a player to drugs that will improve his performance, and presumably his livelihood, relative to players who don't claim a deficit and don't take drugs.
Rob Manfred, MLB's executive vice president, spins the latest increase in therapeutic use exemptions as a crackdown on ADHD. "We made progress this year; we granted fewer new T.U.E.'s than the prior year," he says. That's pretty funny. The number of exemptions increased, and it's now three to eight times the rate in the adult population. But because the increase is smaller than it was in the previous year, with fewer "new" approvals, we're supposed to applaud the league's vigilance.
Manfred says it's unfair to compare the rate of ADHD claims in baseball with the rate of diagnosis among adults generally. "We are far younger than the general population, and we have far better access to medical care," he argues. But baseball players aren't far younger than children, who are half as likely to obtain ADHD diagnoses. And even the rate of diagnosis among children is widely regarded as inflated.
The crucial factor, as Manfred notes, is that pro baseball players have "far better access to medical care." Charitably, you could say this means that ADHD is underdiagnosed in children and adults and that if the rest of us had access to as many doctors as pro baseball players have, they'd discover our hidden ADHD. Uncharitably, you could say that ADHD is accurately diagnosed in adults and overdiagnosed in children so we can put them on Ritalin. And if the rest of us had access to as many doctors as pro baseball players have, we could shop around, as they do, until more of us found a doctor willing to give the diagnosis and write a prescription for attention-enhancing drugs.
If you've ever listened to Garrison Keillor's Prairie Home Companion, you're probably familiar with his fictional Lake Wobegon, Minn., where all the women are strong, all the men are good-looking, and all the children are above average. But that was before the age of performance-enhancing drugs. Now it's the other way around: In order to get the drugs that will help your child become above average, you need him to be diagnosed as below average. You need the certificate of a "deficit" disorder.