Paul Tough (7:49)

Thanks so much. Great to be here.

Derek Thompson (7:52)

So the article is have we been thinking about ADHD? All wrong. Let's start big. Why did you write this and what's the thesis?

Paul Tough (8:02)

Well, I wrote it because a few years ago I noticed that everyone around me, including me, myself and my family, my boys, we were all struggling with attention to some degree. And so I've got two boys, 110 and 1 15. And so in the families that I was talking to, other parents, ADHD just kept coming up. We were talking about technology, we were talking about the pandemic, but a lot of it was talking about this particular diagnosis. Your kid's just been diagnosed. We're thinking about getting a diagnosis. You took the medication and you love it. You took the medication and you don't love it. It was just in the air and I felt like I didn't understand why it was suddenly everywhere and I didn't understand what science was behind it. So that's what I set out to do, to talk to the scientists who are actually investigating this condition and have been for the last few decades in some cases, and to understand how they were thinking about adhd.

Derek Thompson (8:59)

And what would you say is the biggest takeaway? We're going to have a lot of time to dig into the nitty gritty, but this is an 8,000, 9,000 word piece. You talk to doctors, you talk to advocates of stimulants, you talk to skeptics. It's really, really wide ranging. I'm curious what you consider the signature overall takeaway of this essay to be.

Paul Tough (9:22)

Well, I think it's a slightly esoteric one, which is that so the headline is have we been thinking about ADHD wrong. And so sometimes that is an opportunity to say we're doing something wrong, we're over diagnosing, we're over prescribing, et cetera. And I think those are useful conversations to be a part. But part of what I'm trying to get at in this article is that literally the way we think about it and the way we talk about it, like within our family, to a doctor, to friends, that that actually matters. That when kids are struggling or when adults are struggling with attention or impulse control, how we talk about what's going on in our brains and in our children's brains, it actually matters. And that the way that in our culture, and I think in a lot of the medical culture that we talk about ADHD are researchers who are now saying that that model, that sort of conceptual model is itself hurting kids and hurting families.

Derek Thompson (10:24)

I have all these questions about ADHD and the pills we prescribe and the effect that these pills have in our bodies, but there's a way in which what you just said is almost more interesting than the next questions that I have set up for you. So I want to respond to it directly. I am personally obsessed with this idea that the language that we use to describe our inner lives shapes our inner lives. To have a word or a term like Generalized Anxiety Disorder or ADHD structures the way that people experience something like anxiety or an inability to pay attention. And sometimes I think that our words help us. They help us to clarify what we've been experiencing that we couldn't previously clarify, and thus gives us not only a roadmap, both clinically and pharmacologically, to fix those problems, but also provides us a sense of what our problems actually are. And then sometimes the words that we use can trap us. How do you think the concept of ADHD either illuminates or mystifies our experience of attention and attention disorder?

Paul Tough (11:43)

Great question. That's what I spend a lot of time thinking about. And it's hard to put into words, it's hard to write about. So I'm really glad to be able to talk about it. So, yeah, I'm going to talk about two thinkers who influenced me in this. One who doesn't write about adhd? Rachel Aviv, New Yorker writer and author who wrote a great book a couple of years ago called Strangers to Ourselves about mental disorders of all kinds. And her thesis, as I understand it, is exactly what you're saying. That the way that we talk to people experiencing psychological distress about their distress matters a lot. So if a kid stops eating. Like if a girl stops eating and we say, oh, what's going on? How are you feeling? Maybe we get one set of answers. And if we say you have anorexia, you are an anorexic, there are all these other anorexics that creates a different model in her mind and it often affects the course of her illness or of her distress. And so that's one thinker who I was really influenced by because I think something similar is going on with adhd. And the person who helped put that into words for me is this British psychiatrist named Edmund Sanuka Bark, who has been studying ADHD sort of as a frontline researcher for 35 years. Years. And in the last few years has really changed his thinking about what the goal is for studying and treating adhd. And he has turned away from what he calls the medical model of adhd where ADHD is a deficit in the brain, it's a disorder, it's neurobiological, neurodevelopmental, it's based in genes, it is just a physical thing that is happening in certain kids brains and not in other, other kids brains. And instead he is saying, actually when you look at ADHD symptoms, they are on a continuum. We're all on this continuum somewhere. There's certainly people, kids who are having a much worse time with these symptoms than others and we need to take seriously their distress. But that just telling them you've got ADHD and you don't have ADHD is not always particularly helpful. And that, that it tends to be limiting rather than liberating. That it tends to tell them there's something wrong with you, there's something wrong with you that really can't be fixed. It's just deep within you. And the best that we can do is just give you this medication that is going to somehow fix it or somehow deal with this problem. Instead, he is saying that ADHD is better thought of as a mismatch, as a disconnect between the way your particular brain works and the circumstances that you're in, the environment that you're in, and that our goal is to try to solve that mismatch. So medication can be useful. You know, if your environment is a third grade classroom and you are having a real hard time sitting still and functioning and controlling your impulses and getting your homework done in that third grade classroom, sometimes stimulant medication is exactly the thing that is going to make that environment more tolerable. But in other situations, maybe changing the environment can work better. Changing home, life, changing School life for older kids and for adults, changing work life, that when you make those changes, things change in your symptoms as well. And that that's not only more effective, it's not only going to help more people, but it also changes the way that kids and families think about it. So that rather than thinking there's something sort of inescapably wrong with my brain, instead they can think, this is not a great time for me and the experience I'm having, but things might change in the future.

Derek Thompson (15:43)

What you said made me think of this idea that I suppose I just made up. And there might be a better, more official academic term for it, but I thought of it as the homesickness to schizophrenia spectrum. For psychiatric disorders, homesickness is entirely situational. You don't feel homesick at home. By definition, you only feel homesick when you're away from home. So here we have a disorder, a feeling that is entirely about environment. On the other hand, schizophrenia exists, as far as I understand it. There is no psychiatrist or geneticist who does not believe that schizophrenia isn't real. It isn't chemical, it isn't even in many ways genetic. So schizophrenia is a very clearly real disease that is not environmentally, is not purely environmentally situational, homesickness purely environmentally situational. And most disorders, I would think, exist along some spectrum between homesickness and schizophrenia. And one of the hard and fascinating and to me just utterly interesting things about psychology is understanding how to think about what exists in the middle between homesickness and schizophrenia. I want to quote from your article right now and then have you begin to walk us through some of the really smart thinking that you did here. Quote, the total number of prescriptions for stimulants has grown by 60% between 2012 and 2022. That ever expanding mountain of pills rests on certain assumptions that ADHD is a medical disorder that demands a medical solution, that it is caused by inherent deficits in children's brains and that the medications we give them repair those deficits. End quote. Paul, I think we should go through these one by one. First. You talked, to, read, heard from so many doctors in the process reporting this article. Do you believe that ADHD is a real medical disorder?

Paul Tough (17:48)

Well, I absolutely believe that ADHD is real. It's a real phenomenon. It's a real condition that is affecting certain children and certain adults. The word that I'm not sure is the ideal one in that sentence is medical, right? Which is not to say that it's not worth having doctors treat it, that that medicine doesn't have a lot to offer. It is just to say that thinking of it primarily as a medical disorder, thinking about this in the same category as, say, diabetes, a condition to which some ADHD doctors compare. It might not be the most helpful metaphor. Right. That there might be other ways to talk about it that would be more positive. So that might seem like I'm weaseling out of your question a little bit.

Joe House (18:44)

Bit.

Paul Tough (18:44)

But mostly I'm just trying to complicate it. I think it's very much a real disorder. There's no question about it. This is not just kids who are lazy or not well disciplined. This is kids who are really suffering with real problems. But defining it as primarily a medical disorder I think is not always helpful.

Derek Thompson (19:03)

You take pains throughout this piece to point out the role of a child's environment in the progression of his or her symptoms. Let's get specific here. Are we talking about home, school, social factors? What is the environmental piece of ADHD that you think is most important?

Paul Tough (19:22)

Well, I think it's different for different kids. I mean, I say at one point that most of the researchers who I've talked to or read think that ADHD is somehow caused by a combination of environmental factors and biological factors, including genetic factors, but that there's real disagreement on exactly what the right balance of those two causes is. And the reality is it's probably different for different people. There are absolutely people who have a genetic predisposition to ADHD symptoms, sometimes very intense ones, sometimes ones that are co occurring with other mental health problems. But then there are others who are developing these same symptoms from very different causes. So one of the complications of ADHD that I think makes it hard, challenging for clinicians to diagnose, diagnose accurately is that some of the symptoms are exactly the same symptoms of lots of other mental disorders, some of them environmental. So early trauma can make it hard to sit still, hard to focus, hard to pay attention when you're in a classroom. Fetal alcohol syndrome in kids, head injuries, all of these things create similar symptoms in kids. And at the same time, there are are other psychological disorders, from autism to depression to anxiety, that can also make it hard to focus and sit still and control your impulses. And according to the Diagnostic and Statistical Manual of Mental Disorders, this handbook that clinicians use when they're trying to diagnose adhd, if these symptoms can be better explained by another condition, you are, you are not supposed to diagnose adhd. You're supposed to diagnose that other condition. So all of this is a Long way of answering your question. Just to say that environmental causes are clearly part of, for some people are part of the development of these symptoms. But it's really hard to say how much and the reality is it's probably pretty different for different kits.

Derek Thompson (21:34)

There's something in that answer that I think is so important just to hang on for one more beat. I think there's a bit of a toy model of ADHD skepticism that says boys will be boys. Boys were honed by millions of years of evolution to not sit still, to be the hunters of their tribe. They're not meant to just sit in chairs and learn math tables for seven hours a day. Of course they're going to act up. And while I do think that that sort of evolutionary psychology story has a bit of truth to it, what I think is so important about your answer is that you put a lot of extra food on the so called environmental plate here. You said ADHD could also be indicative of anxiety or depression or problems with parents at home, or autism or head injuries or fetal alcohol syndrome or trauma. There are a lot of different tributaries into the delta that is ADHD that need to be thought about. Rather than this being a simplistic mismatch between the overactive, evolutionarily honed energy of 11 year old boys and the fact that they have to sit in public school all day. Is that a fair restatement of your point or would you like to react? Fine, it.

Paul Tough (22:56)

No, I think it absolutely is a fair restatement. I mean, the one thing that I will say that I think these scientists would want to clarify is that they are not necessarily saying that these other conditions are leading to adhd, like fetal Alcohol syndrome or anything else. They would say that it's leading to ADHD symptoms. And that might seem like a distinction without a difference, but I think it's really important because these symptoms are things that you can just observe. There are things that, that kids do or don't do. But ADHD is an actual syndrome, an actual disorder. You know, I think in reality, like that's why, that's part of why the definition of who has it and who doesn't is so porous, because it's something we define by the symptoms, but the symptoms are common to lots of other things. But I do think that that distinction, at least for, for some in the ADHD world is really important. This guy, Edmund Sanuga Bark, this British researcher, spent a lot of time talking to and wrote about and find his ideas really compelling. One of the things that I like that he says is. He says, I don't believe that the medical model is the most helpful one to think about. I don't think that this search for what researchers call biomarkers, like, clear biological indicators that this kid has ADHD and this kid does not. He spent decades trying to find biomarkers like. Like everyone else in the field and has now said that was a red herring. It's not worth looking for biomarkers. But he's saying that. Not because he's saying that it's not biological or, you know, biology doesn't play a role. He's just saying that's not what we should be talking about, what we should be thinking about. What we should be thinking about instead is what is going on in the life of this kid. And in some ways, maybe it doesn't matter whether it is adhd, like symptoms caused by fetal alcohol syndrome or by early trauma or whether it's caused by something else. These symptoms still matter. The underlying distress still matters. And we need to find the best way to help that child deal with it. And that might be a very individualized approach. It might be environmental, it might be pharmaceutical. It might be a combination of those things. But simply saying, that kid's got ADHD and that's. And we know what the treatment is for that kid, that. That is often gonna lead to some real mistakes.

Derek Thompson (25:17)

You're offering a preview of the section we're about to get to on prescriptions on drugs. I want to just hang out on diagnosis for one more beat here. One thing we can say objectively is that diagnoses have exploded in the last few years. And it really has to be said here, and you make this plain in your piece, it hasn't just exploded for kids. The fastest growth in ADHD diagnoses over the last decade has been for adults, especially people in their 30s. And we can describe this objective reality. We can layer it with one of, I think, three interpretations. Interpretation number one is that diagnoses are catching up to the underlying reality. There have for decades been a certain need for ADHD medication, let's say 10% of the population. And if you start at a low base, well, naturally you need to grow and grow and grow to actually meet the underlying disease or disorder with the sufficient number of diagnoses and prescriptions. So option number one is that diagnoses are catching up to underlying reality. Option number two is that underlying reality is skyrocketing. ADHD is actually skyrocketing, whether it's due to screens or other mismatches in the environment. And then option three is, ADHD isn't rising, but the diagnostic net is growing. We are finding more, say, false positives, more examples of kids that we're giving medications to that don't necessarily need it. So I want to make this question simple, even though I think that there's ways in which it sort of has to be a little bit complicated. Between these three interpretations, diagnoses are catching up to reality. Number one, actual ADHD is skyrocketing. Number two. And number three, ADHD diagnoses arising in the absence of any change in the sort of underlying reality. What do you think is really happening here?

Paul Tough (27:05)

Well, I'm going to give you a frustrating answer, which is I don't know. And I think there are moments where all three of those make sense to me. And I would really distinguish too, when you're asking this question question between childhood ADHD and adult adhd. So just to stay on that question for one second or on that distinction for one second. So childhood ADHD has absolutely been growing as a diagnosis. The current percentages as reported by the CDC are the highest they've ever been. I think it's like 11.5% of children, higher percentages of adolescents and, and much higher percentages of male adolescents. But that rise is not, it's not really an explosion. It is this constant increase. Like, there have been small fluctuations, but it's amazing. Like, I was reading, you know, Newsweek stories from the 1990s about Ritalin, and it was the same thing. It was like, oh, my God, numbers have gone up from, you know, 1 million to 2 million in just a few years. Numbers of diagnoses, now they're at 7 million, right? But it's been this constant increase for decades. So meanwhile, though, what has really changed just over the last six or seven years, since I think just before the pandemic, is the rise in adult adhd. And I didn't write much about adult ADHD in part because I had a lot to say about childhood adhd. I've written about kids and educational before, so it seemed like the natural place to go. It's the place where we actually do have better research, where people have been researching, doing randomized, controlled studies over the years, which is not true for adult adhd. But also, to be honest, it was sort of a cop out because adult ADHD is just. It's even more mysterious, I think, than childhood ADHD because it really is exploding. Like, the numbers of prescriptions and the numbers of, of diagnoses has been going up really quickly. And there's this very, very basic difference, which is that if you're a kid, you cannot walk into a therapist's office and say, I think I have adhd. It's always going to be your parents or your teachers who are identifying this in you. And then it's a family decision whether you should be diagnosed or medicated or treated in any other way. With adults, it is something you can do sometimes very easily on an online prescriber, and it's something where you have a lot more agency. So I think I tend to feel like there is some kind of social contagion that is part of the growth in adult adhd. I think there's lots of evidence that people learn about adult ADHD online. There's evidence from previous eras of the way that psychological diagnoses can catch on and can spread. And I think that social media is a great way for the idea of a diagnosis to spread. I don't think that's everybody who knows how big a part of the story it is, but my guess is that it's certainly part of it. But there are also lots of advocates who point out that the biggest growth is among women, not among men. I think I have this number right, that I think among every age group, except for children and teenagers, every adult age group, the numbers of women who are diagnosed now is higher than the number of men, which is the opposite of what's true in teenagers and certainly the opposite of what's always been true among children. It was always thought of as a male disorder. And so a lot of people make the case that these are girls who were not treated, wasn't understood what was going on with them. There's evidence that women, girls are more likely to have the variety of ADHD known as inattentive rather than hyperactive and impulsive, and that inattentive adhd, adhd, might be harder to detect. You just think, oh, that's just a quiet girl, right? But actually she's really suffering and experiencing mind wandering in a way that's hurting her in school and in life. And that as these girls grow up, suddenly they realize that their ADHD that they've had their whole lives, wasn't being properly treated. I don't know how much that is the case for everybody. I think it's. It's certainly the case for some girls and women, but it's really hard to disentangle. And I haven't seen any evidence that makes me feel confident that I can say how much of it belongs to which of your categories.

Derek Thompson (32:09)

This episode is brought to you by Indeed. Hiring someone new for your business can be a big move, and I understand you probably want to take your time to make sure you found the right person. But playing the waiting game could do more harm than good because that's extra work and extra stress you're putting on you and your team. It's not a healthy work environment. When it comes to hiring the right people fast, Indeed is all you need. Their Sponsored Jobs Move your job posts to the top of the page, letting you stand out first to relevant candidates. It makes a massive difference. According to INDEED data, sponsored jobs have 45% more applications than non sponsored jobs. Another great thing about Sponsored Jobs is that you're only paying for results. You don't have to worry about monthly subscriptions or long term contracts. There's no need to wait any longer. Speed up your hiring right now with Indeed. Listeners of this show will get a $75 sponsored job credit to get your jobs more visibility@inn Indeed.com plane that's Indeed.com plane right now and support our show by saying you heard about Indeed on this podcast. Indeed.com plane terms and conditions apply. Hiring Indeed is all you need. Paul, as I'm listening to you, I'm getting flashbacks of previous conversations we've had in the show about rising anxiety in America, particularly among young people, because there's this open question of what is happening. Is there rising anxiety because of the phones? Is there a sort of ghost of anxiety that seems to be rising because of social contagion? Young people who are generally normal or going online, seeing that celebrities have identified themselves as having anxiety disorders and then going to their parents and telling them I have an anxiety disorder. And then how much of this is just a little bit of loosened diagnostic criteria? We've made it easier and more acceptable for people to go to their doctors and say, I'm depressed, I'm anxious, I'm worried about my inattention, and as a result we're having more diagnoses of gad, Generalized Anxiety Disorder, or adhd. Do you see that the beats of the story as you've articulated them scale to other social phenomena like anxiety?

Paul Tough (34:33)

I think there are definitely parallels and connections, and I think it's not clear certainly to me exactly how much a role each part of that story plays. So I do think that one overlap between the growth in anxiety and the growth in ADHD is phones. So I've read the Anxious Generation and am pretty persuaded by that case. And it is clearly my own experience that when, when I've Got my phone around. My own ability to focus and concentrate gets worse. And so it makes a whole lot of sense that for a generation of young people who are constantly exposed to their phones and to social media, that their ability to focus, to control their impulses, to sit still and get work done, would be compromised. How much a role that plays, I don't know, but I think it makes sense. The other thing, though, that I would say is that I think that. That it's certainly possible that social contagion plays some role in the increased diagnosis. But I also feel like the suffering of young people, including children, including teenagers, including young adults, is very real. I mean, I think there's a spectrum, and I think there are some people whose situation is worse than others. But I just feel like I. In my own personal life, I just keep encountering stories of young people, especially teenagers, especially teenage boys, who are having a really, really hard time. And so, you know, it's not always clear to me what the root cause of that hard time is and what the best way to treat it is. And I think that for those families, that's when a diagnosis of ADHD or of something else can be really sort of of a relief, right? That when you're just dealing with a kid who is suffering, it's very painful for a parent. And to have someone say, well, I've got the solution. This is the disorder, this is the treatment is really reassuring. I don't think it's easy in many of the cases that I know personally to say, here's the problem and here's the solution. But that does not mean that it's not a real problem. It's a very real problem, I think, for lots of kids. And I don't entirely know why it's happening.

Derek Thompson (36:58)

I am so glad you said that, because I love talking about the philosophy of this stuff. The way that the words we use shape our inner experience, the way that it's difficult sometimes to pin down a diagnosis when we don't truly understand the thing it is that we're diagnosing. But ultimately, this is a question of pain. This is a question of families and children and even some adults who are sometimes just really profoundly struggling, not only to keep up with work, but just to live life as they want to live life. And if we have at our disposal medical technologies that can bring peace to that suffering, I do think that in many, many cases, there is just an overwhelming duty to use that technology to reduce that pain. So let's talk about the technology. Adderall, Ritalin, if these drugs had practically no negative symptoms or long term risks, the cost of their overprescription would be quite low. If they were helping young people live easier lives and we couldn't point to some clear way that it might hurt them, then there wouldn't necessarily need to be a whole moral or scientific panic over prescription. What do you see as the negative symptoms and long term risks of these drugs that might make us concerned about prescribing them where they don't need to be prescribed?

Paul Tough (38:28)

Well, before I answer that part of the question, can I just address part of your premise? Because I think it's really important and it's something that I heard from a lot of the scientists, the researchers who I spoke to. One of the ways that they framed it, it was to say that one of the frustrations in this field is that our best treatments, or what are considered our best treatments, are basically the same thing that we were using to treat ADHD before It was called ADHD 90 years ago. It's amphetamines. It's medications that are based in amphetamines. And the first experiment that showed that amphetamines could control these symptoms was bad in the 1930s. And you know, like we understand what amphetamines can do. Like there are upsides and downsides to amphetamines. And at different times in American life, amphetamines have been very popular and very much demonized. You know, so they have upsides and downsides. The way that these, these researchers put it is that we have a pretty good medication, we have a pretty good solution for adhd. It's like compared to other psychological medications, it works much more effectively than antidepressants. It works faster. You can get off it more easily certainly than antipsychotics or anti anxiety medications. Like the success rate for pharmaceuticals for psychological problems is not great. And compared to those, this, these are relatively effective. But they're saying that the fact that this is a pretty good medication has distracted us from. Yeah, some real downsides. So I'll talk about three. So one is that the largest study of stimulant medications, the Multimodal Treatment of ADHD, or MTA study, found that over the first 14 months, when they did a careful randomized controlled study of, of Ritalin versus non pharmaceutical interventions versus just leaving kids alone and seeing how they did Ritalin was the best one. Over 14 months it absolutely diminished symptoms most effectively. But then when they continued to follow these kids at 36 months, the relative advantage had disappeared. And in fact, all three groups were doing basically just as well as each other. So that's one. There seems to be some kind of fade out, effectively. The second is that this one researcher at nyu, Xavier Castellano, said this to me. It's like we can see that these medications are getting kids to sit in their seats and look like grade students and to focus much more than they were able to. But we don't see an effect on their academic results, on their test scores, on their cognitive ability. And it seems like it should be there, but there's this frustrating gap. You can see that in lots of different studies over the years. So that's number two. And then number three, different people would put this one at different levels of seriousness. There seems to be, for people, for kids who stay on stimulant medications for a long period of time, a reduction in height by about an inch, which is not nothing, but it's a definite trade off. So I'd say those are the three big, big, big downsides to the medication. In some ways. I think the biggest one is that it's stopping us from thinking more, being more curious about what else we might be able to do, whether pharmaceutical or environmental, to treat this condition better.

Derek Thompson (42:13)

I want to underscore the very last thing that you said before I circle back and interrogate. The first thing that you said, the last thing that you said, I think that is so important, is that maybe the downside of prescribing a pill isn't the commission, what the pill does, the side effects of the pill, it's the omission, it's what we don't observe about this child. Maybe the kid doesn't have what we think of as ADHD at all. Maybe what they have is anxiety, in which case what they need is a therapist, or depending on the age, an ssri. Maybe there are home problems that we should focus on. Maybe the emotional issues would be better treated with a counselor from the school suggesting that parents get couples therapy or family therapy. And so the availability of the pill can obfuscate other prescriptions or ideas that would better remedy the underlying suffering. The point that I want to push you on is you mentioned this fade out effect, this long term NIH study of stimulant use that notably found the benefits severely waned after three years. What did this study really find? Did it find that the stimulants biomedical effect was waning after a few years, or did it show something more complicated, that like some people stopped taking the drugs, some parents leaned so much on the drugs that maybe they felt like the problem was solved and they didn't follow up to manage the child's other conditions. Right. The mechanism here is so important because one interpretation says the drugs just don't work longer than 36 months. And the other interpretation says, no, the drugs are like eyeglasses. Eyeglasses don't work if you stop using them. And it turns out that because adherence to drugs is not very good over the long term for many people, especially maybe for teenagers, we're just looking at a pure adherence effect rather than a biochemical effect. What did this study actually find?

Paul Tough (44:13)

Yeah, so those are great questions and it is a complicated study. My main source, I talked to a few different people who had worked on MTA over the years, but my main source was a guy named James Swanson who was there at the beginning in the 1990s helping to found and to start conducting the study and is still working on it today at age 80. And so he helped me through some of those complications and, and some of the answer is that we don't entirely know. So it's definitely true that after those 14 months, the rigor of the randomized controlled study loosened and it became, I think it's called a natural study, where they just continued to follow these different groups as they made their own treatment decisions. But as good scientists can do, they were able to use statistical tools to first of all find out if kids were continuing to take medication or not, but also just to calculate how much of the effect was the medication and how much was the effect of their own decisions. I think it does make those later results somewhat less clear than the 14 month results. But Jim Swanson is quite clear that the 36 month results are because the medication grew less effective. And he sees that, and I think I heard that from young people that I spoke to as well, that over time the medication becomes, it loses some of its effect, but it also becomes more bothersome. And so you're right, sometimes that means that kids just stop using it. Sometimes it means that they continue to use it and feel less effect. Sometimes they have to increase their dosage. So I do think that it's a real effect. I do think there's a real fade out effect. But I think you're right, it is complicated by the fact that some kids, lots of kids, just stop using the medication because it feels less effective and the downsides feel worse to them.

Derek Thompson (46:17)

I love the sophistication of that point, that adherence and effectiveness aren't trains on parallel tracks. Right. If people feel like a medication is waning Then they're much less likely to continue to adhere to it. So maybe some adherence is downstream of the fact that the medical. That the pills affect his winning. I think that's a very interesting point. The reaction to your essay was just enormous. I mean, I saw it everywhere. It got reactions from parents, from doctors, from social critics and cultural critics. I want you to respond to two categories of response. The first is strongly critical, and the second is actually very strongly positive. And both categories of response you might find wrong for various reasons, but that's why I want to throw it back at you. So first, the negative. As you truly know, your article generated a lot of controversy among ADHD researchers and clinicians, and some accused it of cherry picking data or overstating the case against medication. They said, look, we have decades of evidence that ADHD is something that's real, it's genetic. The disease shows up in some neuroimaging of the prefrontal cortex, or it's indicated by neurotransmitter behavior because it has to do with sort of the inability to regulate dopamine secretion. And these stimulants have helped millions of people to deal with a real problem. And that means there's real risk in problematizing a medical remedy that's working for them. How do you respond to this vein of criticism that you're downplaying the degree to which ADHD exists and can be seen in neuroimaging and neurotransmitter research, and that there's a risk to saying there's a problem with using effective pills in the short term to remedy this real problem?

Paul Tough (48:06)

Good question. And I want to try and divide it into its different points and do my best to answer each one of them. So the first one is I'll take a very narrow point, which is this idea that ADHD does show up in neurological scans. And that is something that you hear in a lot of places. And it's based on this one study from 2017, a really careful study done by this group called the Enigma Consortium that looked at thousands of scans of people with and without ADHD and found that there was a tiny difference in the cortical volume of certain parts of the brain in children with ADHD and without, but no effect in no difference among adolescents and adults. And that conclusion, that there was some difference among kids, I think was pretty powerful for a few years, and I think was overblown by some advocates. And what I was really surprised by when I talked to the scientist, a woman named Martine Hugman, from the Netherlands who conducted that study and who, when she published it in 2017, said, this is evidence that this is a brain based disorder, is now saying, that's not a fitting conclusion from what I found. And I wish that I could have phrased that differently, that the neurobiology is much more complex and nuanced than I said it was in 2017. So I do think that's an important distinction. I don't think think that answers the question of are medications the right thing to use or not? And so then to talk about that broader point, I mean, one thing that I will say about the article that I don't want to get or sound defensive is to say, like I am not saying, and neither are most of the researchers who I spoke to saying, don't take these pills or that these pills are bad or that they're not helpful. I mean, there are lots of places in this article where I and others say the benefits of these medications outweigh the downsides. Where various researchers, even some who are skeptical about the way this is diagnosed and treated, are saying, I've seen how this helps kids. I've seen in my own family how this helps kids. Some of them are saying, and this is a very effective treatment for lots of people. The question that I feel is the most important one is what you said, that it's not a good idea to problematize this treatment. And I think there is a certain, in some of these reactions, there is a certain kind of paternalism even. And another researcher mentioned this to me, but it really stuck with me that it has some parallels in the way that sort of establishment science talked about COVID right when that was first happening, the way we talked about masks, the way that it seems like some scientists were saying they can't quite handle the truth. Right. Our job as scientists who are talking to the public is to make things simple is to just say, okay, don't use masks, or a few months later, always use masks no matter where you are. You know, that there are various ways. I think that this idea that you should not problematize, you should not complicate what you tell the public about a medical solution, about medication is really powerful. And I just disagree. I think that this is, you know, that people are smart and that parents are smart and that they can handle ambiguity and nuance and complications and complexity. And this is absolutely a condition that is full of nuance and complication and complexity. And this is a treatment that is full of nuance and complexity. And so not only am I saying that just out of a sort of anti paternalistic point of view. But also I believe that for parents to be encouraged to take that more complicated, more sort of reality based, data based approach and understanding of ADHD will actually help, help the way that their family deals with ADHD in their children. That if you're a kid and you are told this is a very simple thing, you've got a deficit, you've got a disorder, there's something malfunctioning in your brain, this pill is going to help fix that and you don't need to know anything more. That that is really disempowering, that it makes you feel as a kid that there's something broken in you. And that instead when you can tell kids this is, you know, this is like a situation that you are in right now, you're having trouble adapting to the place where you are, that has something to do with the disconnect between your brain and the environment that you're in. And there are things that we need to do in order to address this. And maybe that is a daily pill, maybe that is, you know, a color coded calendar, maybe that is more exercise or, you know, meditation or therapy or something else. It not only, I think can lead to better solutions, it also gives the child and the family the sense that this is something temporary, this is something we're going to work through, this is something that might change. And I think that that's a more realistic and a more helpful vision of what it means to be a kid. It's complicated, it's confusing, your psychology is all over, over the place. But that if you are not trained to think of this as a simple medical problem, but instead you're trained to think of it as something more complex, you are going to get better faster. That for more kids there's going to be a positive outcome.

Derek Thompson (54:02)

One thing I'm pulling out of that answer is that ADHD is highly uncertain. But the effect of these pills is in many cases deeply certain. And the fact that we can solve uncertainty with certainty is going to feel like a magical remedy for many parents and many patients. And in many cases I think it is a magical remedy. But in some cases a convenient remedy can also serve as a blinder. Because when we give a child with behavioral issues a pill that moderates their behavior, transforms their entire personality, it can be easy to say, oh, job is done, behavior changed. But maybe they're really suffering from something else entirely. Anxiety or trauma or some unarticulated fear or need some other learning disability. And then the Pill's effect on the child, while it seems like a success, is actually obfuscating something else entirely that really needs our attention.

Paul Tough (55:03)

It is certainly true that this medication has lots of powerful effects, but it's also true that, like, there's a whole separate way that some researchers look at this phenomenon, which is not through the lens of the disorder, but through the lens of the medication. Right. Which is a derivative of amphetamine. In some cases. It's kind of literally amphetamines. Right. And there's a history of how we in this country have used and thought about amphetamines over time. And traditionally we use it, the people who use it, the groups, the social or cultural groups, or sometimes in one case, like a bunch of soldiers in World War II. The reason that we use it is when people are doing a job that is kind of boring, they start. We start giving it to them because it does make boring stuff less boring. And so there's this, you know, and so there have been lots of periods in American life where, like, we really felt great about amphetamines. You know, there were lots of women in post war suburbia who were prescribed amphetamines in order to just handle the, the tedium of being a suburban housewife. And for a while we thought that was a great thing and it was in a short term way for that individual woman. Yeah, taking amphetamines does make it easier to get through the day. And then culturally, there are moments where we are like, maybe this is not the right solution, where we know that there are downsides to these pills and where the, the sort of counter movement takes over. And so it's not quite the same. These are medically prescribed. The pills that a lot of kids are taking are extended release. So they're not as intense as, say, taking a Benzedrine pill in the 1930s. But there are lots of ways that it's the same thing. And so looking at it through that lens, I think gives us another way to think about what's happening.

Derek Thompson (57:00)

So let's take an aggressive interpretation of that lens because there was a positive genre of feedback to your article that may have overstepped exactly what you meant, or maybe didn't overstep. So the conservative commentator Ben Davis said, quote, new York Times finally gets around to admitting that ADHD diagnoses were a scam to justify the wholesale drugging of multiple generations of energetic boys. End quote. Mike Solana, another conservative tech commentator. One of the classic symptoms of ADHD is the ability to focus, but only on what you find interesting. That isn't a pathology, that's a personality. And Adderall isn't a medicine. It's a drug we use to turn young, thoughtful men into robots. Now, those were conservatives, but here's ABC's Terry Morgan. Quote, we medicalized childhood for millions of Americans for generations. Big Pharma benefited. So these reactions clearly take the thesis of your piece to be that a large number of, if not that almost all of ADHD diagnoses are a scam, that ADHD shouldn't be thought of as actually existing at all, that we've prescribed drugs that have turned young men into polite zombies, and that it's all basically been for Big Pharma's benefit. How do you feel about that interpretation of your article?

Paul Tough (58:20)

Yeah, not great. I think that it's nice to have people say nice things about your article, but I absolutely feel like most, if not all of those reactions are oversimplifications of what I'm writing and what I've found. And it is a lot of what I was trying to do. We've had 30 years of back and forth in the media coverage of ADHD and stimulant medication where we sort of trade exaggerated stories where one side talks about how bad the condition is and how wonderful the treatment is and the other side talks about how imaginary the condition is and how harmful the treatment is. And I don't think that that back and forth is serving anybody. I think that it is paralleled by all sorts of other sort of social media era fights and oversimplifications that we have. And I think it's doing real harm to families and to kids who are struggling with these symptoms and need help. And so what I'm trying to do in this article, perhaps a quixotic quest, is to look for some middle ground that's based in real science. And I think it's there. I mean, that's why I feel like what some of these scientists are saying is so powerful to me that they're saying, absolutely, this is a real condition. Absolutely there is real suffering going on. But looking at it through the narrow lens that we have had to do for so long has really diminished our ability to offer good solutions to families and to kids. And I think some of the negative reaction among ADHD advocates is because they feel very defensive. And I understand why they feel defensive because for decades there have been people who are attacking them and who are saying, you don't deserve this medication, you shouldn't have this medication. You're not treating your kids Right. You're not treating yourself right by taking these medications. And that is, you know, that's a really hard thing to hear when you are doing your best in often a very difficult situation. And in some cases, absolutely, the medication is the right thing to do, both for adults and for kids. And so I am hoping that by, I hope, complicating this conversation a little bit by, I hope doing it with some empathy rather than critique, we, all of us, or some of us anyway, the ones who aren't interested in that sort of narrow back and forth can get to a more realistic and a more helpful place in considering this condition that is affecting millions and millions of employees, American families. And yeah, there are lots of people who think this is not a time when you can have nuance or complication in conversations, that it has to be all black or all white. I don't think that's the case for this condition, for this problem, and I hope it's not the case more broadly.

Derek Thompson (61:26)

I appreciate and respect your attempts to complicate and add nuance to this discussion. However, for my final question, I am going to ask you to uncomplicate and denuance it at least marginally.

Paul Tough (61:38)

Great. Great.

Derek Thompson (61:40)

What do you hope will be the result of this article? For parents with children who face a potential ADHD diagnosis? For someone listening who either has ADHD or has a child with ADHD or has a child that's being tested for adhd, what do you want them to take away from your essay and this discussion?

Paul Tough (62:06)

I want them to take away that they are probably hearing two different messages, right? They're hearing from one side that this is a simple medical condition, that this is a problem in your kid's brain, and that we know the solution, that medicine is going to make a huge difference for them and that. That that really is the big solution for them. And then they're hearing from other people that this is made up, that you're a bad parent if you're thinking about medicating your kid, that this is part of a social trend, that you're just looking for an easy way out. And that is a rotten position for a parent to be in when you're trying to help a kid who is in real distress. And so what I hope is that the ideas of these researchers that I'm trying to bring to light and the evidence that they've found that kind of complicates our understanding of the medication can help parents feel like there are other ways to think about this, that it's not just a simple Condition that has a simple solution, that it's a complex condition, that these symptoms might be caused by other things, that symptoms fluctuate a whole lot. One study we didn't talk about showed that only 11% of kids who are diagnosed with ADHD in childhood have symptoms consistently throughout childhood and adolescence. And that's really important information to know that this is not a life sentence necessarily. This is quite likely something that is going to change. Not necessarily just go away, maybe go away and come back, but that it is responsive to the environment, that it is somewhat mysterious, it's going to come and go in ways that you can't always predict, but that we're starting to get some evidence of ways that changes in the environment can help kids. Medications can as well. And medications can be part of that solution. But they're not the end of the conversation. They are sometimes the beginning. I just want to say one other thing, which is that one of the things that this British researcher, Edmund Sanuga Bark, said that I liked so much is that he thinks of the medications as a way within a family. He doesn't think of them as like the cure that's just going to end things, end the problems of this child. He thinks they are often a way to open up a window within a family for better conversations about what's going on. That often families, when these symptoms are getting really bad, are just in a huge crisis where every night is just a fight over lost lunchboxes and homework that's overdue. And I've had those moments in my household, and it just drives everybody crazy, right? And it creates new problems, new psychological problems for everyone. And so if medication can just kind of put those big problems on hold for a little while and allow you a chance to just have more empathetic conversations with your kid and say, like, what can we do about this together? That's great. And I think if you can think about medication that way as like a. A potentially temporary solution to a temporary problem, I think it's a more realistic, but also much more helpful. And it's only when I think your parents are given the message that this is the solution, you've got to take it for the rest of your life. This is a chronic condition that there is no cure for, but this treatment is going to be the closest thing that we've got that that is really disempowering as well as scientifically misleading and can lead to further problems for a family rather than solutions.

Derek Thompson (65:40)

Paul Tuff, thank you very much.

Paul Tough (65:43)

Thank you.

Derek Thompson (65:45)

Many thanks to Paul Tuff. I want to pull out two quick themes here. The first is becoming a mini theme of plain English. In the last few weeks, it's the theme of uncertainty. I mean, just as earlier this week we had an astrophysicist talk about the incredible amounts of uncertainty that exists and the exoplanet atmospherical science that she does to figure out the possibility of alien life hundreds of light years away here, zero light years away, science is still a struggle against uncertainty. Our minds are extraordinary black boxes. And ADHD is complicated. Human behavior is complicated. And I just so really appreciate researchers and journalists who are comfortable saying I don't know when the truth is we don't really know. The second thing that I want to pull out, which I'm just sort of mulling on right now, sitting with this interview, is that we've done shows on GLP1 drugs. Now we've done shows on these amphetamine drugs and amphetamine chemical compounds based on old amphetamines like Adderall and Ritalin. These are drugs that just profoundly change our behavior. I've said before that GLP1 drugs are not really diabetes drugs, weight loss drugs, so much as in many cases, they're brain drugs. They change behavior profoundly. Adderall, Ritalin, these change of behavior just as profoundly. It really does raise some interesting questions, some merely fascinating and maybe somewhat troubling about the idea that we can dose ourselves to be different kinds of people. What does that say about personality? What does it say about Persona? What does it say about free will that these decisions and behaviors that sometimes seem so profoundly human, so profoundly originating from us, is so easily moderated by a chemical compound? I don't know. Maybe something for a future episode. We'll talk to you next week.

Paul Tough (68:10)

La.