No, Baseball Doesn't Have a Fake ADHD Epidemic

Many diagnoses in pro baseball players may be valid after all
Carlos Ruiz Photograph by Brad Mangin/MLB Photos/Getty Images; Leonard Lessin/Photo Researchers/Getty Images

At the start of the Major League Baseball season last year, Philadelphia Phillies catcher Carlos Ruiz was suspended for 25 games for using Adderall, a prescription stimulant commonly taken by children and adults with attention-deficit hyperactivity disorder. Ruiz had tested positive for the drug twice, and didn’t have the exemption granted to players with a league-certified ADHD diagnosis. When the new baseball season starts later this month, Ruiz will take the field using Adderall once again—this time with medical certification and the league’s blessing. He’s now one of 119 players, or about 10 percent of active roster personnel, with clearance to use prescription stimulants to treat ADHD.

In the press, this 10 percent figure is invariably compared next with the 4.4 percent rate of ADHD in the U.S. adult population. The favored explanation for the high incidence of the disorder is that players are using flimsy diagnoses as a backdoor to use amphetamines. “Need performance enhancing drugs?” Slate asked readers in 2009. “Claim ADHD.”

The suspicion is understandable. Baseball players have been known over the decades to ingest just about anything they think will help them on the field, and more recently to find and exploit any loophole in the league’s drug policy. Before the league added stimulants to its banned-substances list at the end of 2005 season, amphetamine use was routine. In a 2003 interview with the New York Times, San Diego Padres legend Tony Gywnn estimated that half of the league’s hitters took stimulants commonly known as “greenies.” Taking the field without them was known as “playing naked.”

It didn’t help that from the first year of drug testing in 2006 to 2007, the number of players with a so-called therapeutic use exemption for stimulant use jumped nearly fourfold, from 28 to 103. At the time, players who failed a test could seek exemptions retroactively. It looked as if dozens of players who’d been caught popping greenies had found a friendly doctor to say they had ADHD, an explanation that fit with widespread skepticism about the diagnosis in the U.S. population at large.

Baseball’s epidemic of malingering sluggers feigning ADHD symptoms makes for a good story, but it may not be true.

To begin with, 4.4 percent is not a useful number for comparison. The 2006 study that it comes from shows that the prevalence of ADHD among adult males is 5.4 percent. Even that number, according to the study’s lead author, Ronald Kessler, an epidemiologist at Harvard Medical School, is probably too low. The criteria for identifying the disorder in adults, Kessler says, still need work. Until the late 1970s, when researchers began to find that ADHD persisted into adulthood, the disorder was considered a kids-only problem. “You can’t say to a 40-year-old, ‘Do you disobey your mother?’ ‘Do you speak out in class?’” says Kessler. As clinicians hone their diagnostic tools, the adult rates may rise.

Baseball also probably draws its players from populations particularly prone to ADHD. In his current work studying suicide in the U.S. military, Kessler has found ADHD rates not far from those in baseball. The two demographics, he notes, are roughly similar. “This 10 percent is not out of whack with young, athletic, blue-collar men,” he says. “It’s probably 7.5 percent or something like that.”

And few cases of ADHD in baseball are likely to go untreated, since the game is basically an ADHD laboratory. Adults with the disorder have trouble keeping track of several things at once. “It’s that [lack of] ability to screen out distractions and prioritize what you’re seeing,” says Thomas Brown, a clinical psychologist and the author of A New Understanding of ADHD in Children and Adults. Ballplayers have to follow balls, strikes, outs, base runners, pitch sequences, positioning, and coded hand signals in an atmosphere of screaming fans, flashing screens, mascots, and loud music.

For Michael Lardon, a sports psychiatrist in San Diego who sometimes seeks stimulant exemptions for MLB players with ADHD, the exemption process has become too difficult. “We had a guy that had it in spades, with two well-respected doctors giving him identical 10-page reports,” he says, “and they turned it down.” The player, an eight-year veteran with no history of drug problems, eventually went to the players’ union for help getting an exemption. “The pendulum swings the other way quickly,” Lardon says.

After the jump in stimulant exemptions in 2007 and the attention that came with it, MLB did away with retroactive applications. “We’re on it,” Rob Manfred, now the league’s chief operating officer and then its head of labor relations, said at a congressional hearing in 2008. According to the league, a memo sent before the 2007 season encouraged players to get applications in before they failed a test. And many did.

Since then the number of exemptions has risen slowly to 119, with little turnover from year to year. An average 23 percent of applications have been rejected over the last four years, according to a person familiar with the process.

The league added a panel of three psychiatrists to the screening process in 2011. Its current members—Lenard Adler of NYU Langone Medical Center, Timothy Wilens of Massachusetts General Hospital, and Frances Levin of Columbia University Medical Center—serve as advisers to Jeffrey Anderson, the independent program administrator for MLB’s drug prevention program. The league has also certified 58 psychiatrists in adult ADHD diagnosis. While Anderson can approve an exemption application from a certified clinician on his own, all others automatically go to the panel.

The stable rate of ADHD throughout these changes suggests the league, within a reasonable margin of error and abuse, has properly identified the disorder among its players. “We are comfortable,” says Daniel Halem, MLB’s executive vice president of labor relations. “We’ve put in a process that is medically sound and stringent.” The panel, he notes, also monitors dosage. “If a player presents with ADD for the first time at age 27 and he is prescribed a short-acting Adderall, they are going to ask questions,” he says.

None of this is likely to satisfy those who see ADHD as a trumped-up label for knuckleheads who lack willpower during a four-hour ballgame. Kessler, the Harvard epidemiologist, has little patience for these critics. “It’s a nontrivial thing,” he says. “We know that people with ADHD, for example, have rates of automobile accidents four or five times as high as other people.”

But even if some of baseball’s Adderall users are not bona fide ADHD cases, Kessler isn’t convinced that should count as cheating. He’s one of several authors of a 2008 essay in Nature, titled “Toward Responsible Use of Cognitive Enhancing Drugs by the Healthy”, in which he advocates abandoning “the idea that ‘enhancement’ is a dirty word.”

Baseball classifies stimulants separately from full-on “performance-enhancing substances” such as steroids, and stimulants carry lesser penalties. But the league, like most of society, treats off-label use of prescription pills such as Adderall as an artificial shortcut to success. If you have trouble keeping your head in the game, the dominant message is: try harder. Yet some chemical enhancers are perfectly fine. “We certainly don’t say you are not allowed to drink coffee before a baseball game,” says Kessler. And how natural are eyeglasses or hearing aids?

A 162-game baseball season is a grind. Why not treat baseball players the way we do fighter pilots and the way many of us treat ourselves when fatigue is a problem at work? Ruiz, anyway, is just happy to be back on the field at full strength and with a new three-year, $26 million contract. After a career year in 2012, his hitting numbers were down dramatically during his suspension-shortened season. “I don’t want to talk about that,” he told reporters at spring training about his condition and its treatment. “I’m fine, and I feel great.”

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