Baseball Therapy: Someone’s Not Paying Attention

Something is very wrong with the Joint Drug Agreement in Major League Baseball.

Last week, ESPN’s Buster Olney reported on a conversation that he had with Dodgers first baseman Adrian Gonzalez on the subject of therapeutic use exemptions (TUEs), which is basically a doctor’s note saying that a player has permission to take a substance that would otherwise be banned under the JDA. Olney stated that it wasn’t the first conversation he’d had on the subject. Actually, it was the latest of several, but Gonzalez was the first to go on the record with his concerns. According to Olney, it’s the talk of camp that a lot of guys have TUEs, though some of them may not actually need them.

Olney cited widely published numbers from MLB that showed that there were 113 TUEs given out in 2015 and 112 in 2014. All but three of them were to cover stimulant use, such as Adderall, Concerta, and Ritalin, related to the treatment of ADHD. Use of these drugs is banned under the Joint Drug Agreement, although if a player can prove that he needs these medications for a legitimate medical condition (in addition to treating ADHD, these medications can also be used to treat narcolepsy), he can apply for a TUE. This is obviously meant as a humanitarian workaround. Players who are under the care of a physician and have a sincere need for treatment shouldn’t be denied meds. Completely rational.

Gonzalez’s solution was that he wanted the data on TUEs to be open to everyone. Perhaps a list of all players who have one and what it’s for could be passed around. That’s unlikely to happen, given that federal law prohibits the disclosure of personal medical information to anyone whom a patient doesn’t authorize as a recipient. If you’ve ever been to a doctor’s office, you’ve perhaps signed the HIPAA form. That’s what that form is all about.

Aggregate numbers are fair game, since they don’t reveal the names of individual players, but the aggregate numbers are enough to reveal that something fishy is going on. There were 1,252 players who appeared in the majors in 2015. If 113 of them had a TUE, and almost uniformly for stimulant medication to treat ADHD, then that means that 9 percent of players in MLB had a TUE. The problem is that the National Institute for Mental Health estimates that 4.4 percent of adults and 5.4 percent of adult males in the United States have ADHD. It is commonly assumed—falsely—that ADHD is a disorder that affects only children and adolescents and that one eventually “outgrows” it. We now know that this isn’t the case. People who have ADHD continue to have the disorder into adulthood. They generally just get better at managing its symptoms and they tend to pick jobs that don’t require a lot of sustained attention and that allow for a lot of movement. There aren’t a lot of desk workers out there with ADHD.

Maybe there is something to the thought that as kids are growing up, baseball provides an incentive for them to be properly screened, so that any cases of ADHD that really are present are properly treated. If a kid has a sweet swing or can throw gas, but has trouble paying attention, someone might suggest a trip to the clinic. But that doesn’t explain why baseball would draw more kids who already have ADHD than we might expect to the game.

Somehow, the rate of ADHD diagnosis in the majors is around twice the United States average. How did this happen? Prevalence estimates in other countries are usually comparable or lower than the U.S. average, so it’s not likely that players from other countries are skewing things. The chances that baseball players are just as likely (5.4 percent) to have ADHD as the rest of the population, but that by random happenstance, 113 out of 1,252 players have it are very remote. That leaves the theory that there is something about MLB that draws in more people who have ADHD than we might otherwise expect.

Now would be a good time to point out that I have a particular super power that most baseball writers don’t have. I’ve actually diagnosed someone as having ADHD. In fact, I’ve done it a lot. I hold a Ph.D. in child and adolescent clinical psychology. I no longer provide direct patient care, but in a previous life, I would routinely do assessments, both clinical and neurological, for people who had a wide range of mental health concerns, including ADHD. And like Adrian Gonzalez (and apparently a few other players), I’m scratching my head on this one. There’s something happening here, and what it is ain’t exactly clear.

I don’t doubt that there are guys in the majors who were thoroughly evaluated and diagnosed as having ADHD when they were 9, who honestly have it, and who have been taking medication for the last 20 years and it works for them. Great! But what explains the mismatch between the general population and the majors?

If there is something that’s important to understand about ADHD, it’s that it’s often assumed to be a disorder where someone has too much energy. That’s not quite right. ADHD is actually a problem with “the brakes.” People who have ADHD have a hard time regulating their attention not because they are hyper, but because the part of the brain that says, “We need to stop and take a closer look at this thing over here if we’re going to understand it” isn’t working optimally. Similarly, the reason that children who have ADHD are seen as hyperactive isn’t because the disorder gives them some sort of extra fountain of energy. Kids in general have an excessive amount of energy. In ADHD, the part of the brain that says “Let’s take a little time to rest” isn’t firing as much as it does for most kids. It’s not that people who have ADHD can’t pay attention, but they might take a little extra time to get to the point where the brain says “Stop!” The good news is that the medications which are available for ADHD are pretty effective. They help to promote attention in kids (and adults) by stimulating “the brakes” and bringing the system back into its proper balance.

If I were to design a game that would absolutely torture someone who had untreated ADHD, it would be baseball, and for all the same reasons that we often hear that baseball has a “pace of play problem.” Baseball is a game where you have to pay close attention, even though not a lot actually happens. But when the ball is hit, you have to react quickly. That sort of sustained attention in the absence of stimulus is hard. It’s a sport that will test the outer limits of someone who doesn’t have ADHD. And that’s why there’s a lot of incentive to go get stimulant medication, whether one actually has ADHD or not. The stimulant medication will increase the activity of the area that controls concentration and that will have some short-term benefit, whether the root cause is actual ADHD or fatigue. (The problem is that if the person doesn’t have ADHD, there are long-term negative neurological consequences.) It would help someone to focus on the task at hand, like hitting that ball coming at me at 95 mph.

There’s a lot of incentive to game the system. Now the question is how game-able the system is. To look into that, I read the Joint Drug Agreement and specifically, the section on therapeutic use exemptions. There’s a specific section on exemptions for stimulants. First off, the JDA establishes a three-person panel specifically to review cases related to ADHD. However, the expert panel isn’t always used. In fact, the expert panel can be side-stepped if the player is “diagnosed with ADD/ADHD by an MLB-Certified Clinician through the use of the Conners’ Adult ADHD Diagnostic Interview for DSM-IV (“CAADID”), or is diagnosed by an MLB Certified Clinician for another neurobehavioral or psychological condition requiring treatment with a Stimulant.”

In this particular case, “Conners” is a reference to Keith Conners, a very well-known researcher on the topic of ADHD diagnosis and assessment. The DSM-IV is the fourth edition (IV) of the Diagnostic and Statistical Manual (DSM) for Mental Health Disorders. It is the most widely used standardized set of criteria by which mental health problems are defined. (Although recently, the fifth edition of the DSM—creatively entitled DSM-5—has been published.) On its surface, that sounds like a good standard, but the clinician in me read this and said “That’s it? That’s all?”

The CAADID does pretty much what you might expect. It takes each of the criteria for establishing a diagnosis of ADHD and turns them into a series of questions. To get a diagnosis, a patient needs to show that he experiences five of the listed symptoms on a consistent basis. Who answers those questions? That would be the player himself. And frankly, it isn’t all that hard to figure out how to game the questions. Now, a good clinician who is doing a quality assessment would hopefully be able to probe for and spot inconsistencies in a fake story, but really, it just takes one person who does a sloppy job (and whose name gets out) before there’s a nice loophole in the system.

A good, solid assessment for ADHD should include more than just one way of assessing symptoms. Just ask the official webpage for the CAADID. There is no blood test for ADHD, but we are not without our tools. (The CAADID page helpfully suggests the Conners’ Continuous Performance Test and the Conners’ Adult ADHD Rating Scale.) There are performance-based measures of attention and impulsivity that can be administered. Despite my snark, the Continuous Performance Test, which makes a patient sit for 15 minutes and respond by hitting the space bar when a letter appears on the screen (except for the letter ‘X’) is actually a very good one. ADHD also often results in deficits in what are known as executive functioning skills, and there are tests that measure those skills. If someone reports having symptoms of ADHD on the interview and has difficulties in performing on attention and impulsivity assessing tasks, then it makes the diagnosis a little more bulletproof. There are several widely respected tests out there that would do the job. It’s a little strange that this additional info isn’t called out in the JDA as a requirement for obtaining an exemption.

Ideally—and this is harder to come by—there should also be some corroborating evidence from someone who knew the player well when he was young and could vouch that these symptoms have been present from childhood (a hallmark of actual ADHD; according to the DSM-5, symptoms need to have been obvious before the age of 12). ADHD does not suddenly appear out of nowhere in adulthood.

It’s possible that some of the assessments that are done are more comprehensive than just the CAADID interview. That would be the clinically responsible thing to do. I have no information to go on other than what’s in the Joint Drug Agreement, but I have my concerns that the JDA sets a very low standard for someone to receive a Therapeutic Use Exemption, one that has a lot of potential for abuse. I will leave aside the moral arguments around PEDs and simply say that if the purpose of the JDA is to ensure that only the people who have a formal diagnosis of ADHD are given exemptions, the policy as written is lacking. A simple interview is not the same thing as a proper ADHD assessment.

So, if Adrian Gonzalez and other players are suspicious that some players in the majors have gotten their TUEs through not-quite-savory means, I can’t offer proof that this is the case. What I can say is that, based on my experience in diagnosing people as having ADHD, I certainly see how it might happen, given how the system is currently set up.