Baseball Therapy: Starlin Castro and ADHD

Last week, Cubs beat reporter Gordon Wittenmyer of the Chicago Sun-Times wrote an article in which he discussed Cubs (former?) starting shortstop Starlin Castro and the possibility that Castro has Attention Deficit/Hyperactivity Disorder (ADHD; Wittenmyer used the older name—ADD—which was retired in 1994). It caused a bit of a tizzy on Twitter, but just about everything causes a tizzy on Twitter. It was a strange tizzy though, because no one quite knew what to make of it. Castro stated that he knew what the disorder was but preferred not to be tested. Was Wittenmyer right to ask Castro about the potential diagnosis? Is Castro right to ignore a potential issue like this and not seek out treatment?

I have never met nor spoken to Castro. It's entirely possible that he really does have ADHD in the sense that he is a human being and some human beings have ADHD, but I would have no way to know that. I can, however, speak to the question from the perspective of someone who has worked with a lot of people who have ADHD. In my real life, I hold a Ph.D. in clinical psychology, with a focus on children and adolescents. I am no longer involved in direct patient care, but back when I was, I saw a person or twenty who had ADHD.

So, let's break this down. Was Wittenmyer right to ask the question? Castro would hardly be alone if he does have ADHD. The National Institutes for Mental Health (NIMH) estimates that about 4.4 percent of adults in the United States meet the diagnostic criteria for ADHD. That's not everyone, but on a team of 25 people, chances are that one of them would have the disorder. He would hardly be the only major leaguer known to have battled mental-health concerns.

One left-handed commentator pointed out:

If we thought someone was playing through an undiagnosed shoulder thing, we'd speculate, ask him about it repeatedly and make a Mets joke.
— Zachary Levine (@zacharylevine) August 6, 2015

And since baseball fans seem to believe that they have some sort of holy right to know everything about a player's shoulder, I guess that kinda makes sense that it's fair game to ask about his pre-frontal cortex too. Asking the question brings up a very strange duality in our culture. It would be very strange for me to walk up to someone on the street and ask them to reveal their medical history to me. In fact, we have laws that specifically forbid doctors from revealing information about patients in public. The message there is pretty clear: Your medical concerns are your own business. Except if your job is to play baseball.

But such is as it is. We live in a world where I might know more about Castro's health than I do about my best friend's. So why would we ask about the theoretical shoulder injury, but not ADHD? A good chunk of the answer is that if Castro came out and said that he had a shoulder injury that he was playing through, no one would bat an eye. Shoulder injuries happen. If Castro said that he has ADHD, there would be laughter. After all, Castro would be "mentally ill." And, apparently, it's hilarious when people are mentally ill. Because … people suffering is good for a laugh. I guess. Stranger still, if I said that Castro had developed cancer and then made a joke about he was now a "cancer in the clubhouse," the comments section below would be filled with people (correctly) pointing out that I was a jerk (among other words) and demanding that I be fired.

If I can get one thing across in this column, it's that laughing at someone for having a mental-health problem is like laughing at someone for having a tumor. Mental-health problems have a physical cause, symptoms, and treatments. Some mental illnesses we understand better than others, but they do not happen because people "bring it on themselves" or are flawed in some way. ADHD, in particular, we know has to do with a problem in the rate of activity in the pre-frontal cortex, which is the very front part of the brain. ADHD does require work on the part of the person who has it and it's with you for a long time. You don't cure it. You manage it. In that way, it's actually comparable to diabetes. I wouldn't wish either one on anyone, but sometimes things happen.

I'd love to believe that I live in a culture where mental health issues are treated as what they are: problems that most certainly need to be taken care of, but nothing more than that. In that sense, Wittenmyer was right to ask the question and normalize mental-health concerns as being like anything else, although I don't know if America is ready to handle the answer yet.

Now, is it possible that Castro really does have ADHD? The evidence that Wittenmyer lays out is a little scant. From the article:

Throughout Castro's career, mental lapses, moments of lost focus and inexplicable errors on routine plays have raised speculation among fans, scouts and even some in his organization – including the clubhouse — that he has a form of the common disorder.

I get what Wittenmyer is laying out here. And to the untrained reader, that may be enough to diagnose someone as having ADHD. Loss of focus can be a sign of ADHD, although it's important to note that not everyone who has trouble paying attention has ADHD. Anxiety, depression, lack of sleep, and even certain endocrine problems can cause trouble with attention. ADHD is marked more by how consistently inconsistent one's attention is rather than whether someone is occasionally off in in their own world. It's not that they are never on the ball, it's just that they are less so than most. In fact, one of the telltale signs of ADHD is that while most people without ADHD take about the same amount of time to react to some prompt each time (some are overall faster, some are overall slower, but within one person, the results are consistent), those with ADHD show a lot of variability in reaction time from moment to moment.

In an odd intersection of baseball data and mental health, Statcast might actually provide us with some answers. We might look at Castro's "first step" times, reacting to balls hit in his general direction. Again, he might be generally faster or slower (and he may also be using an impulsive style to compensate for what he might know to be trouble paying attention), and we might see some pattern there. A trained eye might pick up on those patterns.

But the real test for ADHD should be done by a properly trained neuropsychological assessor. There are tests that can help to diagnose ADHD (and to differentiate the things that look like ADHD, but are not) and there is effective treatment out there. From the sounds of it, Castro is not interested, and that might be the most controversial piece of the article. Why would someone not take advantage of treatment that's right there?

In the same article, Wittenmyer quoted Cubs manager Joe Maddon saying that he didn't like the idea of "over-medicating" kids in general and was not a fan of ADHD medications. It's a common refrain that I heard during my clinic days. People commonly said that they didn't want their kids to be "like zombies;" some just didn't like the idea of taking pills in general. On the first issue, if a child (or adult) is behaving like a zombie while on ADHD medication, it means that they are on either the wrong medication or the wrong dose. (Please do contact the prescribing physician.) But on the second issue, Castro does have the right to decide whether he wants to pursue medication (or any treatment at all). We actually have direct evidence that ADHD does affect baseball-playing skills, but it's not like untreated ADHD is fatal.

In the clinic, I would often hear people say that they were fine with therapy either for themselves or their child, but that they were skeptical about (or sometimes completely opposed to) medication. In those circumstances, I wouldn't even bring it up or make a referral to a psychiatrist. (As a clinician, I did not have the power to prescribe medication.) The reason is that even if they went to the appointment and filled the prescription, they're the ones who need to actually ingest the pills. If they aren't convinced, then the pills will simply sit in the bottle, or be diverted to someone else. If I were advising Cubs management, I'd say that if he's not interested, it's pointless to push the issue.

Maybe Castro believes that taking ADHD medication would be a way of cheating. There are MLB players who use Adderall and other ADHD medications as performance-enhancers, despite not having a diagnosis of ADHD. MLB allows those who have the disorder to receive a therapeutic-use exemption. Adderall is a banned substance under the Joint Drug Agreement, but it seems cruel to withhold medication that someone legitimately needs, so the workaround was created. In general, ADHD medications have a very good record for safety and effectiveness for those who actually have the disorder. For those who do not really have ADHD, taking those medications is a really bad idea. They work by speeding up an area of the brain that isn't working as fast as it should. If it's already in balance and the person does not have ADHD, that area of the brain (nor any area of the brain) shouldn't be stimulated that much. I suppose that whether or not someone considers it cheating to take medication for a medical condition is one of those late-night philosophical questions, but if Castro was evaluated and was diagnosed as having ADHD, he would be entitled to use medication for it and would face no disciplinary action for doing so.

Perhaps Castro is aware of how medication might help him in baseball, but for reasons that have nothing to do with baseball, he's not interested. We have to allow that it is his choice to make, and whether or not it would make you a happier Cubs fan is not a reason that he should consider in either direction.

The next paragraph in this piece could start with "If I were Starlin Castro …" but I'm not Starlin Castro. I certainly hope that he's aware of the facts around ADHD and is making an informed decision. I hope that fans in Chicago would be adults and see ADHD for what it is, a medical condition that can be treated, and not some sort of character flaw. And yes, I think it's weird that we have a culture in which professional athletes aren't accorded the same courtesy about their medical status that the rest of us are, but at the same time, I get why this whole tizzy was actually a positive thing. ADHD shouldn't be a taboo. Nor should depression or bipolar disorder or anxiety or anything else in the DSM-5 (the handbook that defines mental-health disorders, published by the American Psychiatric Association). People have mental-health problems sometimes. That's not a wonderful thing that they have problems, but it does happen and it is not a weakness. And if someone has problems, then s/he should be able to access the treatment that is out there with the same level of fanfare that I receive when I get an antibiotic for an ear infection: none.

So, Mr. Castro, if you're reading this, feel free to make your decision. For everyone who isn't Starlin Castro: a little perspective please.