Fresh Air: Are Kids With ADHD Being Treated Effectively? Hosted by NPR's Fresh Air Release Date: April 24, 2025 Guest: Paul Tough, Contributing Writer for The New York Times Magazine

Introduction: The ADHD Epidemic in America

In the April 24, 2025 episode of Fresh Air, hosted by Dave Davies, Paul Tough delves deep into the rising prevalence of Attention Deficit Hyperactivity Disorder (ADHD) diagnoses among American children. Highlighting data from the Centers for Disease Control, Tough notes that over 11% of American children were diagnosed with ADHD last year, with 21% of 14-year-old boys affected—a record high. This surge has sparked debates about the efficacy and safety of commonly prescribed stimulants like Ritalin and Adderall.

Dave Davies [00:32]: "If you live in the United States, chances are good that you either are or know a parent whose child is being treated for ADHD."

The Multimodal Treatment of ADHD (MTA) Study

Tough discusses the landmark Multimodal Treatment of ADHD (MTA) study, a randomized, controlled trial initiated in the early 1990s across six U.S. sites. The study aimed to evaluate the effectiveness of various ADHD treatments, including stimulant medications and behavioral interventions.

Paul Tough [02:49]: "So they created this randomized, controlled study. ... some got behavioral training, some got Ritalin, and some were just left on their own to figure out their own treatment."

The results, released in 1999, initially favored Ritalin as the most effective treatment for reducing ADHD symptoms after 14 months. However, follow-up studies revealed that these benefits diminished over time, with no significant differences in symptoms among the groups after 36 months.

Paul Tough [03:42]: "By 36 months, there was no difference in the symptoms of any of the groups."

Concerns from Researchers: James Swanson's Perspective

James Swanson, a key figure in the MTA study from the University of California, Irvine, expressed growing unease with the escalating ADHD diagnoses and the long-term efficacy of stimulant medications. Swanson highlighted two main issues: the continued rise in ADHD diagnosis rates and the waning effectiveness of Ritalin over extended periods.

Paul Tough [04:12]: "The advantage that the kids in the Ritalin group had ... started to really fade."

Swanson's frustration stems from the initial positive messaging about Ritalin's effectiveness, overshadowing later findings that challenge its long-term benefits.

The Elusive Biology of ADHD

Tough explores the scientific quest to understand ADHD's biological underpinnings. Contrary to expectations, neuroscientists report that the biological understanding of ADHD has regressed rather than advanced over the past two decades. Early hopes for clear biomarkers—specific genes or brain structures—have not been substantiated.

Paul Tough [06:13]: "20 years ago, there was this belief that there were clear biomarkers... that belief has slowly been undermined."

The Enigma Study, a large-scale international research effort, found minimal differences between the brains of individuals with ADHD and those without, challenging the notion of ADHD as a distinct brain disorder.

ADHD Beyond Childhood: Rising Adult Diagnoses

While ADHD is often associated with children, Tough highlights a significant increase in adult diagnoses, particularly among individuals in their 20s, 30s, and beyond. This trend underscores the evolving understanding of ADHD as a condition that spans across different life stages.

Paul Tough [17:24]: "The fastest growing groups for the diagnosis are people, adults in their 20s and 30s, but even adults in their 40s, 50s, 60s."

Treatment Modalities: Medication vs. Behavioral Interventions

The podcast contrasts pharmaceutical treatments with non-drug approaches. While stimulant medications like Ritalin can temporarily alleviate ADHD symptoms, their long-term impact on academic performance remains questionable. Behavioral interventions, though lacking extensive scientific backing, offer alternative strategies such as organizational tools and environmental modifications tailored to individual needs.

Paul Tough [11:51]: "Things as basic as, you know, post-it notes and calendars and just ways of helping you organize your thoughts, organize your schoolwork."

Personal Experiences with ADHD Treatments

Paul Tough shares anecdotal evidence illustrating the diverse experiences of individuals with ADHD. He recounts stories of young people who find stimulants both beneficial and burdensome, noting that while medications can enhance focus, they may also dampen personality traits and emotional responses.

Paul Tough [29:29]: "They saw that there were benefits to it. They saw that it was going to help them in some significant way... but they didn't actually like the experience of taking them."

Challenging the ADHD Diagnosis: Controversies and Criticisms

The episode addresses the contentious debate surrounding ADHD diagnoses and treatments. Paul Tough responds to criticism from publications like Additude, which accuse his reporting of misrepresentation and bias. He defends his stance by emphasizing the variability in treatment effectiveness and advocating for personalized approaches rather than blanket medication strategies.

Paul Tough [37:05]: "There is no one size fits all solution."

Future Directions: Rethinking ADHD as an Experience

Tough introduces progressive perspectives on ADHD, particularly the work of British researcher Edmund Sanuga Bark. Bark proposes viewing ADHD not as a binary disorder but as a spectrum of experiences influenced by both biological and environmental factors. This paradigm shift suggests that interventions could focus more on aligning environments with individual neurological profiles rather than solely relying on medication.

Paul Tough [32:12]: "Their problems may have more to do with a misalignment between their own unique brain and the situation that they're in."

Conclusion: Balancing Biological and Environmental Approaches

The episode concludes with an optimistic outlook on future ADHD research. Paul Tough envisions a dual-focused approach that identifies specific ADHD subtypes for targeted treatments and emphasizes intentional environmental modifications to support individuals with ADHD. This comprehensive strategy aims to enhance both scientific understanding and practical interventions, ultimately improving the lives of those affected by ADHD.

Paul Tough [39:09]: "My hope is that those two strands of research together will make a real difference."

Key Takeaways

• Rising ADHD Rates: The prevalence of ADHD diagnoses in children, particularly among boys, has reached unprecedented levels, prompting scrutiny of current treatment practices.

• MTA Study Findings: Initial support for stimulant medications like Ritalin is tempered by long-term studies indicating diminishing benefits over time.

• Biological Uncertainty: Advances in understanding ADHD's biological basis have fallen short, with no definitive biomarkers identified to date.

• Adult ADHD: Increasing recognition of ADHD in adults highlights the need for broader diagnostic and treatment frameworks.

• Diverse Treatment Experiences: Individuals with ADHD report varied responses to medications, underscoring the necessity for personalized treatment plans.

• Controversial Debates: The discourse around ADHD diagnoses and treatments is polarized, with significant pushback from advocacy groups.

• Future Research: Emphasizing both biological subtypes and environmental factors offers a promising path forward for more effective ADHD interventions.

Notable Quotes with Timestamps

• Dave Davies [00:32]: "If you live in the United States, chances are good that you either are or know a parent whose child is being treated for ADHD."

• Paul Tough [02:49]: "So they created this randomized, controlled study. ... some got behavioral training, some got Ritalin, and some were just left on their own to figure out their own treatment."

• Paul Tough [03:42]: "By 36 months, there was no difference in the symptoms of any of the groups."

• Paul Tough [06:13]: "20 years ago, there was this belief that there were clear biomarkers... that belief has slowly been undermined."

• Paul Tough [11:51]: "Things as basic as, you know, post-it notes and calendars and just ways of helping you organize your thoughts, organize your schoolwork."

• Paul Tough [29:29]: "They saw that there were benefits to it. They saw that it was going to help them in some significant way... but they didn't actually like the experience of taking them."

• Paul Tough [32:12]: "Their problems may have more to do with a misalignment between their own unique brain and the situation that they're in."

• Paul Tough [39:09]: "My hope is that those two strands of research together will make a real difference."

Conclusion

This Fresh Air episode by Paul Tough provides a critical examination of ADHD treatment practices in the United States, highlighting the complexities and controversies surrounding diagnoses and interventions. By juxtaposing scientific studies with personal narratives, Tough underscores the need for a more nuanced and individualized approach to managing ADHD, moving beyond one-size-fits-all solutions toward more effective and empathetic treatments.