Have We Been Thinking About A.D.H.D. All Wrong?

Summary

Summary of "Have We Been Thinking About A.D.H.D. All Wrong?"

The Daily
Host/Author: The New York Times
Episode Title: Have We Been Thinking About A.D.H.D. All Wrong?
Release Date: June 17, 2025
Hosts: Michael Barbaro, Rachel Abrams, Natalie Kitroeff
Contributor: Paul Tough

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Introduction

In the June 17th episode of The Daily, titled "Have We Been Thinking About A.D.H.D. All Wrong?", host Rachel Abrams delves into the escalating diagnoses of Attention Deficit Hyperactivity Disorder (ADHD) in the United States. Over the past thirty years, ADHD diagnoses and the prescriptions for managing its symptoms have surged. However, this growth has sparked debates among seasoned researchers who question the foundational approaches to identifying and treating the disorder. Paul Tough, a contributor to The Daily, explores these contentious perspectives, highlighting potential flaws in the current understanding of ADHD.

Personal Connection and Motivation

Paul Tough opens the discussion by sharing his personal motivations for investigating ADHD. As a father of two sons aged 10 and 15—both within the predominant ADHD demographic—Tough observed ADHD pervasive in his conversations with parents and educators. He noted the ambiguity surrounding ADHD diagnoses, where the boundaries between having ADHD or not appeared "fluid and porous."

Paul Tough [01:27]: "It felt like there were a lot of puzzles in this diagnosis that on the one hand, it seemed like something that was very clear and straightforward."

This personal stake led him to engage deeply with ADHD researchers to uncover the underlying issues in its diagnosis and treatment.

The Complexity of ADHD Diagnosis

The episode highlights the intricate nature of diagnosing ADHD, which relies on a checklist of symptoms outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Diagnosing ADHD entails identifying a specific number of symptoms across various settings over several months, accompanied by a significant level of impairment.

Paul Tough [07:25]: "There is this checklist of symptoms that doctors look at when they want to diagnose ADHD."

ADHD symptoms bifurcate into two main categories: hyperactivity and impulsiveness, and inattentiveness. This duality means that two individuals diagnosed with ADHD can exhibit markedly different behaviors, complicating a straightforward diagnosis.

Paul Tough [07:50]: "They can have two kids who are diagnosed with ADHD who might, from appearances, seem very different."

Additionally, many ADHD symptoms overlap with other conditions like anxiety or trauma, further muddling the diagnostic process. This complexity has driven the scientific community to seek a definitive biomarker—a biological indicator—that could unequivocally diagnose ADHD, thereby reducing subjectivity and legitimizing the disorder.

The Search for Biomarkers

Efforts to identify a biomarker for ADHD began with optimism in the early 2000s, fueled by advancements in genetics and neuroimaging. Initial studies suggested potential brainwave differences and specific genetic markers associated with ADHD. However, subsequent, more rigorous studies failed to replicate these findings.

Paul Tough [12:44]: "Edmund said, 'Basically, what we thought was there isn't really there.'"

The Enigma Consortium, an international network of neuroscientists and psychiatrists, analyzed 4,000 brain scans to find consistent differences between individuals with and without ADHD. Their results were underwhelming, revealing negligible differences in brain structures, especially in adults and adolescents. Only a slight variation was noted in children, but it was too minor to serve as a reliable diagnostic tool.

Paul Tough [12:51]: "It means we haven't found one yet, but it also means we probably won't find one that is as simple and clear as we'd hoped."

This setback has caused many researchers, including Edmund Sanuga Bark, to reconsider the biological-centric approach to understanding ADHD.

ADHD Medication: Efficacy and Concerns

The mainstay of ADHD treatment has been stimulant medications like Ritalin and Adderall, derivatives of amphetamines. Their usage skyrocketed from 1 million diagnoses in the early 1990s to 7 million by 2025. Initial studies, reminiscent of Charles Bradley's 1930s experiments, showcased remarkable short-term behavioral improvements in children administered these drugs.

Paul Tough [15:21]: "When you gave them to kids, their symptoms improved, often almost overnight. But they wanted to be more scientific about it."

A significant randomized controlled study compared the long-term effects of Ritalin against behavioral treatments and no specific treatment. Initially, Ritalin-treated children showed substantial symptom reduction at 14 months. However, by the 36-month mark, these benefits had dissipated, showing no significant advantage over other treatment groups.

Paul Tough [19:35]: "The relative benefits of Ritalin faded. By the end of those three years, the children in each of these treatment groups were doing exactly the same."

Moreover, despite improved classroom behaviors, these medications did not translate into enhanced academic performance. Cognitive tests revealed no improvement in learning outcomes, although students reported feeling more motivated and connected to their work.

Paul Tough [20:33]: "The main impact of stimulant medication is on our emotions more than on our cognition."

Significant concerns also emerged regarding side effects. The most notable was a consistent reduction in height among children who took stimulant medications over extended periods.

Paul Tough [22:59]: "The ones who had taken stimulant medication consistently were about an inch shorter than the ones who hadn't taken the medication at all."

While addictive potential was a concern, data indicated that prescribed stimulant use did not significantly increase addictive behaviors. Many teenagers expressed a desire to discontinue usage, associating it with discomfort rather than dependence.

Rethinking ADHD: Environmental Mismatch

Edmund Sanuga Bark, a British researcher diagnosed with ADHD in his childhood, embodies the challenges and reevaluations within the field. Reflecting on his past, Edmund suggests that ADHD might be better understood as a mismatch between an individual's unique cognitive profile and their environmental context rather than a fixed medical condition.

Edmund Sanuga Bark [27:11]: "I think the best way to think about ADHD is as this mismatch, this misalignment between the specific brain of a young person and the environment in which they're living."

Edmund's academic success in a university setting, contrasting his struggles in a conventional school environment, underscores this perspective. He argues that instead of solely focusing on pharmaceutical interventions, there should be an emphasis on adapting environments and building resilience and coping strategies in individuals with ADHD.

Edmund Sanuga Bark [29:26]: "It's not a silver bullet. It never will be."

Medication, in this view, serves as a temporary aid that can provide families with the space to implement more sustainable, environment-centric strategies.

Conclusions and Future Directions

The episode concludes with a call to shift the narrative around ADHD. Instead of viewing it as a rigid medical disorder necessitating pharmaceutical intervention, there is a growing advocacy for understanding the lived experiences of those diagnosed and tailoring environments to better suit their unique cognitive landscapes.

Edmund Sanuga Bark [31:11]: "Because your mates, your school, this kind of sense of shame when you fail. Those are the things I think are crucial in terms of the long-term well-being."

Paul Tough emphasizes that redefining ADHD could lead to more holistic and effective support systems, ultimately fostering environments where individuals with ADHD can thrive without solely relying on medication.

Paul Tough [35:32]: "Instead of telling kids that there is this absolute, essential, inherent thing in you that is disordered, that you have this deficit, that that is not actually a helpful message to give to kids."

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This episode of The Daily challenges conventional perceptions of ADHD, urging a paradigm shift towards a more nuanced and empathetic understanding that prioritizes individual experiences and environmental adaptations over a strictly medical model.

Transcript

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[Paul Tough]

Not.

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[Rachel Abrams]

From the New York Times, I'm Rachel Abrams, and this is the Daily. Over the past three decades, ADHD diagnoses in the United States have been climbing steadily, and so have prescriptions for the medication to manage the symptoms. But as the field booms, some longtime researchers are starting to question whether much of the fundamental thinking around how we identify and treat the disorder is wrong. Today magazine contributor Paul Tough explains. It's Tuesday, June 17th. Paul, welcome back to THE Daily.

[Paul Tough]

Thank you. Great to be here.

[Rachel Abrams]

Paul, you recently wrote a story about ADHD that got a lot of people's attention, including here on the Daily. And it might be because ADHD and the medications to treat it are something that, frankly, I think a lot of people seem to have kind of a personal experience with either themselves or people that they know. And so my first question to you is just how did you personally come to this story?

[Paul Tough]

So, yeah, it's a lot like what you're describing. I have two boys, one who's 10 and one who's 15. So they are both in the key ADHD demographic. And I think a few years ago, I just started to have this sense that, like, ADHD was all around me, that every conversation I was having with parents and with teachers, that this was a big part of what they were concerned with and what they were trying to figure out. But it felt like there were a lot of puzzles in this diagnosis that on the one hand, it seemed like something that was very clear and straightforward. Like a friend would say, yeah, we didn't know what was wrong, but then we found out it's adhd. But at the same time, it felt like the boundaries between what was ADHD and what was was not ADHD were kind of fluid and porous. And so I wanted to try to understand this disconnect. And I figured the place to start was to talk to the scientists who study adhd.

[Rachel Abrams]

So when you started diving into this field that it sounds like seemed both everywhere but also a little bit hard to pin down. What did you find? Like, what did these researchers tell you about the landscape of our understanding of this condition?

[Paul Tough]

Well, I found that they were a little confused as well.

[Edmund Sanuga Bark]

Hi.

[Paul Tough]

Hey. Is that Edmund?

[Edmund Sanuga Bark]

It's Edmund, yeah.

[Paul Tough]

How are you One whose work and whose thinking I found most interesting was this British researcher named Edmund Sanuga Bark.

[Edmund Sanuga Bark]

I've always had an inquiring mind about everything in life. I tend to be on the side of the questioner rather than the conformist. For sure.

[Paul Tough]

He was always a really fascinating guy to talk to and I think partly because he, he's kind of an iconoclast, really hardcore punk. And I like, when he was a teenager, he was in one of the first English punk rock bands and he still is really someone who just questions the conventional wisdom.

[Edmund Sanuga Bark]

I was at the pub last night.

[Paul Tough]

Our conversations would sometimes go off on these long tangents.

[Edmund Sanuga Bark]

Our cricket team plays, we went to the pub. I like to smoke cigars. I was smoking my cigar and the lady from the bar, who I know very well, came out and she said, we can't smoke here. I said, why not? She said, there's a big sign, it says no smoking. And I said to her, the bigger the sign, the more likely I am to ignore it. And I'm afraid that's the way it's been in my career.

[Paul Tough]

Edmund has spent his whole life trying to understand adhd. And part of that is professional, but part of it is personal. He was diagnosed with ADHD back before they were even calling it that. They called it hyperkinesis.

[Edmund Sanuga Bark]

There was no real treatment for that in them days, not in the UK anyway. People weren't taking medication for hyperkinetic disorder.

[Paul Tough]

This is around 1970. He was living in this working class town in the English Midlands. He's eight years old, misbehaving young kid, couldn't really sit still. And at that clinic anyway, they just sort of told him, you've got this. But they didn't do anything to help him.

[Edmund Sanuga Bark]

And so I just went to school and they put me in the remedial.

[Rachel Abrams]

Class.

[Edmund Sanuga Bark]

And I've got this memory, I've got this image, this memory of them giving me shapes to draw around, like squares and triangles. Because I, I couldn't, you know, I couldn't really write, so they just gave me things to draw around.

[Paul Tough]

He just had a kind of miserable.

[Edmund Sanuga Bark]

Time in school, looking back, I was always in trouble. I was quite a naughty boy and, and a naughty adolescent. And I think that was a mask, that was a camouflage. I found the setting where I could hide, you know, my weaknesses.

[Paul Tough]

Edmund says it was a miracle that he ever made it through high school. But then after high school, because of a few lucky breaks, he gets into a university, to Bangor University in Wales. And from there, eventually he devotes his life to studying adhd, to trying to figure out exactly how it works.

[Edmund Sanuga Bark]

I mean, I've invested 35 years of my life trying to identify the causes of adhd. And what we've found is that somehow we seem to be further away from our goal than we were when we started the journey.

[Paul Tough]

But in recent years, he has really begun to rethink a lot of the work that he's done and rethink the way that we think and talk about adhd. And what I also found out was that he's not alone. There are other researchers who are also rethinking the research that led us here.

[Rachel Abrams]

This sounds like some pretty profound and personal soul searching from Edmund and his peers in the field, potentially with broad implications for how we're thinking about adhd. So I'm curious, what are they actually rethinking?

[Paul Tough]

Well, I would say they fit into two big categories. Some of them are rethinking some of the basic questions of what the definition of ADHD is. Is it something that is a categorical biological condition where we can clearly say, like, this person has ADHD and this person does not, or is it something that's more like a continuum where the lines between a person with ADHD and a person without are not so clear and distinct? And then the other group is thinking about our treatment and specifically the treatment stimulant medications like Ritalin and Aderall.

[Rachel Abrams]

Okay, so it sounds like treatment and diagnosis, so kind of the whole thing. Let's start with how they're thinking about diagnosis. First of all, can you just walk me through how do we diagnose adhd?

[Paul Tough]

Sure. So there is this checklist of symptoms that doctors look at when they want to diagnose adhd. And. And these symptoms are laid out in the Diagnostic and Statistical Manual of Mental Disorders. And in order to diagnose adhd, a clinician has to count a certain number of symptoms in a certain number of settings over a certain number of months with a certain level of impairment.

[Rachel Abrams]

Can you give us a little flavor of what's on that checklist?

[Paul Tough]

Well, one of the things that is complicated about the ADHD diagnosis is that there are two large categories of symptoms, and they often seem pretty different. So there is one category that's about hyperactivity and impulsiveness, things like not being able to wait your turn, not being able to sit in your seat, interrupting people. And then the other category is inattentive adhd. And those often look very different than the hyperactive and impulsive kids. Those are often like they don't say anything when you speak to them. They're sort of dreamy, they are losing things, they're not able to sustain their attention. And so you can often have two kids who are diagnosed with ADHD who might, from appearances, seem very different. And to me, what that does is it highlights this conflict within the field, which is that on the one hand, these are supposed to be really clear, empirical, objective definitions of a certain disorder, something that you either have or you don't. But on the other, there's a lot of subjectivity involved.

[Rachel Abrams]

So put it another way, it sounds like this is actually not a simple diagnosis to make because these children can have the same condition but exhibit very different behaviors.

[Paul Tough]

That's right. And there are other reasons I think, that it is difficult to diagnose, including the fact that some of these symptoms are actually also symptoms of other things. They can be symptoms of, of anxiety, they can be symptoms of early trauma. And I think that makes for a really challenging diagnosis. And that challenge is part of why the field has been looking for what they call a biomarker, a biological indicator of whether a child has ADHD or does not. And I think there were a couple of motivations behind this search for an ADHD biomarker in part, like, as a diagnostic tool. Right. If you could just put a kid in an MRI or something to measure their brain waves and say, this child has adhd, that would be really helpful. It would eliminate a lot of the subjectivity that we've been talking about. But the other reason, I think, was to shore up the legitimacy of the diagnosis. There always have been skeptics who just say, like, ADHD is not even a thing, like it's just a made up diagnosis. These are just rambunctious kids. There is no such thing. And that's very frustrating, I think, for researchers who can see the great problems that a lot of kids have and see the medications are really helping them and so tough find a biomarker to find something where they could say, look, it's real. It's something very specific that you can see in this brain. This is a brain disorder. And it's something with clear boundaries. I think that was very appealing to the field as well.

[Rachel Abrams]

Like, this is a brain disorder. This is not just kids behaving badly. This is not just bad parenting.

[Paul Tough]

Exactly. It is something deep in the brain that we can track, we can measure, and we can diagnose.

[Rachel Abrams]

So tell me about the search for that biomarker and how it has contributed to the soul searching in the field.

[Paul Tough]

So in the very early 2000s was the period, I think, of the greatest optimism about this. This was an era in a lot of breakthroughs in genetics especially, and in lots of different conditions. There was this belief that we were going to find the one gene that predicted each of these disorders, and certainly including adhd. There were early signs that there were these electrical signals that seemed like they predicted adhd signs from MRIs as. But then, as the 2000s went on, a lot of those early experiments didn't hold up when larger, better studies were done with more sophisticated technology. And one by one, each of those early indications of a potential biomarker sort of fell apart. So the brainwave studies, when we got better equipment, no, there were no real brainwave differences between kids with the diagnosis and kids without genetics, as happened with lots of other psychiatric conditions. It was clear that there was no single gene that predicted adhd. And then there was this really ambitious attempt to confirm those early MRI studies. It was done by this big international network of neuroscientists and psychiatrists called the Enigma Consortium. They had this database of 4,000 brain scans that they were able to look at and they were able to, in this really detailed way, compare the brains of people with ADHD diagnoses and people without. But when they finished looking at all of the data from all of those scans, they found that actually they weren't seeing much of anything in adults and in adolescents, they didn't see any difference in the brains of people with and without the diagnosis, and in children, there was a small difference, but a really, really small difference.

[Rachel Abrams]

And just to be clear, though, what you have just described, does that mean that there is. Is no biomarker, or does it mean that we just haven't found one yet?

[Paul Tough]

It means we haven't found one yet, but it also means we probably won't find one that is as simple and clear as we'd hoped.

[Edmund Sanuga Bark]

Basically, what we thought was there isn't really there.

[Paul Tough]

And this is frustrating for the researchers involved, including Edmund. He devoted many years to looking for biomarkers and he basically thinks now that it was all a mistake.

[Edmund Sanuga Bark]

Chasing this biomarker has been such a red herring for the field that it's taken us in totally wrong direction.

[Paul Tough]

And now he's really, I think, turned away from just focusing narrowly on the biology of adhd.

[Edmund Sanuga Bark]

I'm not saying it's not biological, I'm just saying I don't think that's a proper target, really, to be honest.

[Rachel Abrams]

So, basically, we're no closer to understanding what ADHD is now than we were back when we first started searching for a biomarker.

[Paul Tough]

That's right. And the other place I think that started to have an effect is in our thinking about treatment. I mean, if this is not a clear, you know, black and white medical condition, is a medical treatment, a pharmaceutical the best way to treat it?

[Rachel Abrams]

We'll be right back.

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[Rachel Abrams]

So Paul, before the break, you mentioned that researchers were just starting to re examine the role of medication in treating adhd. I'm very curious about the medication itself, though. Can you talk a little bit about what medication we're talking about and how we even came to it?

[Paul Tough]

Sure. So the main medications that are used to treat ADHD are stimulants, Ritalin and Adderall and other similar medications. And there are some chemical differences, but basically they are all derived from amphetamines. And the way that scientists first got the idea that these might be useful as a way to treat ADHD, like symptoms came way back in the 1930s before anyone had thought of the initials ADHD. And there was this doctor who ran his own home in Rhode island for misbehaving kids. And he was trying to figure out what he could do to help them behave better. And amphetamines at the time were this kind of recreational drug. Benzedrine was the popular version. And so he just started giving daily doses of benzedrine to 30 or so kids who were in his home. And he noticed immediately this kind of miraculous change in these kids that overnight their behaviors improved, their mood improved, they followed the rules better, and it just felt like this kind of miracle cure.

[Rachel Abrams]

But what Bradley was doing sounds a bit informal. Right. Like he's giving amphetamines to kids in this home, essentially, which sounds pretty small scale, especially when you compare it to the amount of prescriptions that we see out in the world today. So I. I'm just sort of curious how we go from what he was doing in the 30s to this explosion that we see in the year 2025.

[Paul Tough]

So we do know a lot more about these stimulant medications than we did back then. And there have been some much more sophisticated stud. The one that I think is the most significant one started out in the early 1990s. Between 1990 and 1993, we went from having 1 million kids diagnosed with ADHD to 2 million. A huge rise. We're now up to 7 million. So things are a lot bigger than they were then. But this is like doubling in just a few years. And Ritalin was the big stimulant medication, and so it was what was being used to treat kids. But scientists didn't really know how effective it was. They were seeing the same sort of thing that Charles Bradley saw, that it looked like when you gave this to kids, that their symptoms improved, often almost overnight. But they wanted to be more scientific about it, so they devised this giant randomized, controlled study in which they divided hundreds of kids up into different treatment groups. Some would get a daily dose of Ritalin, some would get different sorts of behavioral treatments. Some would get a combination. And then there was a fourth group where they didn't give them any particular treatments. They could just figure out their treatment on their own.

[Rachel Abrams]

So you have a stimulant group, a therapy group, and a kind of control group that was not prescribed any specific treatment at all. Right, exactly.

[Paul Tough]

And so they studied it over 14 months. And at the end of the 14 months, the kids who had taken Ritalin every day were clearly doing better. Their symptoms were more reduced than children in any of the other groups. And so that was interpreted as this very clear message that Ritalin worked. It's the first. First thing that we should go to. And that message, I think, went out to doctors offices and clinics all over the country and all over the world.

[Rachel Abrams]

And it certainly seems that that message was well received just based on the number of prescriptions alone.

[Paul Tough]

Yeah. So during that era, this is now sort of the early 2000s, diagnoses continue to rise, and prescriptions continue to rise as well. But those scientists who had been carefully studying Ritalin compared to these different other treatments, they actually continued to follow these treatments, children in this study for many years. And what they found was that after three years, the relative benefits of Ritalin faded. And by the end of those three years, the children in each of these treatment groups were doing exactly the same. So the kids with Ritalin didn't have any advantage in terms of their symptoms over the children who had had the behavioral treatment. They didn't have any real advantage over the ones who had just been left alone to figure out their own treatment. All of the clear benefits that were there at 14 months had disappeared by 36 months.

[Rachel Abrams]

That really seems pretty stunning. This idea that this medication that has seen an explosion in prescriptions seems to have no discernible impact.

[Paul Tough]

Yeah, I mean, it clearly does have an impact in the short term, but over the long term, this most reliable study found no relative benefit to Ritalin. And there were other things that scientists were discovering at the same time. So one researcher described to me that the really sort of puzzling and discouraging thing is that even when we see the effect on symptoms like that, you can sit still in class, that you can, like, pay attention in class, that when you look at academic results, that when we look at sort of cognitive ability, there doesn't seem to be any corresponding impact, that the kids who take stimulant medications seem to be learning more, but that when you measure their results, they haven't actually learned any more than the kids who didn't take any medication.

[Rachel Abrams]

But can I just ask, I'm curious, like, if the medication is getting kids to do more work, Like, I don't know, for example, just filling out worksheets or multiplication tables or whatever. I mean, isn't part of learning, like repeating something over and over again? Like, I'm just sort of curious how the exercise of just doing more work that is intended to get you to absorb and learn stuff doesn't actually have that effect?

[Paul Tough]

Yeah, I think to a lot of researchers, it is a real puzzle. The research that helped make sense of this for me was another series of studies where gave simulant medication to a bunch of college students, had them do a bunch of cognitive tests, their scores were no better if they had taken the medication or not. But then when they asked them, how did you feel about the work that you just did? The ones who had taken the medication said that they did better, they felt better about themselves, they felt better about the answers that they had given. And that connects with other research that shows that the main impact of stimulant medication is on our emotions more than on our Cognition, it makes us feel more motivated, feel more connected with the work that we're doing.

[Rachel Abrams]

Even if it's boring.

[Paul Tough]

Yeah, especially if it's boring. But I think what this indicates is that even if it. If we think of these sometimes as smart pills, as things that are affecting our cognition, in reality, what it's affecting is our emotional state.

[Rachel Abrams]

I mean, it sounds like what you're telling me is that there's no long term, measurable benefit from these drugs and that even in the short term, they don't really work to improve academic performance in the way that we thought they did.

[Paul Tough]

Yeah, I mean, when you put it that way, it does sound kind of bad. But one of the things that strikes me when I talk to these psychiatrists is that they say that compared to other psychiatric medications, these are so good, right? Like, they do a pretty good job, at least in the short term, of helping kids manage their symptoms, remain calm in class. And they're so much more effective than, you know, antidepressants or a lot of anti anxiety or antipsychotic medications. They have fewer side effects. And most importantly, I think they're easy to stop. So a lot of psychiatric medications, when you take them, it takes a while for them to start working in your brain, and then if you want to stop, it takes a while to wean off them. But if Ritalin or Adderall isn't working for you, you can just stop and it leaves your system almost right away.

[Rachel Abrams]

So from their point of view, low risk, high reward.

[Paul Tough]

Yeah, exactly.

[Rachel Abrams]

But there must be some side effects, right? Like, every medication has side effects. So did these researchers find any downsides?

[Paul Tough]

Yeah. So in this big, randomized, controlled study, they did find some significant downsides. And the main one was about the effect of stimulant medications on height, on growth. So this was something they weren't expecting. But in that first study, when they looked at the different groups, after 36 months, the ones who had taken stimulant medication consistently were about an inch shorter than the ones who had either started and stopped or hadn't taken the medication at all. Oh, wow. And now, you know, the same scientists have continued to follow this group for decades, and that height disparity hasn't gone away.

[Rachel Abrams]

I feel like most people would want that inch. And I have to say, Paul, that's actually not what I thought you were gonna say. The downside was like, I thought you were gonna talk about these drugs being addictive, because, frankly, I just feel like I know people who, maybe in college or law school or Whenever they became really dependent on these medications and they did have a hard time getting off of them. And I know that that's just very anecdotal and not data, but is that an issue here? Do researchers think that these medications have addictive properties at all?

[Paul Tough]

I think we're not sure. So I think, you know, absolutely, for certain people, for certain personalities, certainly recreational amphetamines can be addictive. And I think for some kids and teenagers, even prescribed Ritalin or Adderall can be habit forming. When you look at the data as a whole, these medications don't lead to more addictive behaviors. And in fact, one of the things that I really heard when I talked to teenagers who had been taking Ritalin or Adderall for a while is that it was kind of the opposite. It wasn't that it was habit forming. They didn't really like it. They just didn't like the way that it made them feel. They would take it because they saw benefits more because, you know, their parents or their teachers were telling them that they should. But most of them just couldn't wait to get off it. When they had an opportunity, they would.

[Rachel Abrams]

So, Paul, where does the research and the work go from here? Like, how are the people who are studying this condition right now thinking about ADHD and how to treat it, given everything that you've just laid out?

[Paul Tough]

But one of the things that's interesting to me is that they're often not saying that we need to diagnose ADHD any differently or treat it any differently. They're just saying we should think about it differently. And a lot of that starts with thinking about the world surrounding kids more than just thinking about what's going on in their brains. And that gets me back to Edmund. So he is the scientist who I think is thinking about this stuff in the most interesting ways. And for him, this idea links back to his own childhood.

[Edmund Sanuga Bark]

I always remember thinking, why don't people think like me when I was at school? Why don't people think like that?

[Paul Tough]

Like I mentioned at the beginning, he was a terrible high school student. Terrible at the kind of, you know, sitting still, switching from one topic to another, doing exactly what you're told. But it turns out he's actually kind of a great university student.

[Edmund Sanuga Bark]

So it was like day and night compared to what I was like, four.

[Paul Tough]

He had this thing that. That he now calls hyperfocus, that to his teachers back in Darby, just looked like, you know, mind wandering. But that actually when you're trying to get deep on a subject, the way you do in university, it was really functional.

[Edmund Sanuga Bark]

And I did nine to five every day. So I'd go to the library, you know, even half eight in the morning, I'd sit in the library, I get all the books out, all the journals out, and I work through to five o' clock.

[Paul Tough]

And so he would just start going to the library and studying hard and suddenly found his identity as. As a scholar. So instead of feeling like the failure, the bad kid, the kid who was always in trouble, he suddenly was. Was getting positive reinforcement and good feedback and like, oh, this, this thing that happens in my brain turns out to be really useful in this particular setting. He thinks that maybe the best way to think about ADHD is as this mismatch, this misalignment between the specific brain of a young person and the environment in which they're living.

[Rachel Abrams]

The idea of ADHD that you are describing sounds kind of situationally dependent. Like something that works for you in one context could work against you in another context.

[Paul Tough]

Yeah, that's right. Not this kind of fixed idea of a condition you just have or don't have, but something more transitory or mutable. And looking back on this experience now, even including being really miserable in school when he was a kid, he thinks that if he had received medication as a kid, his life might not have turned out this way. This must be a question for you, like, how would life be different if you were in a different. Had grown up in a different era or in a different town and had been diagnosed and prescribed Adderall or.

[Edmund Sanuga Bark]

I think it's a very.

[Paul Tough]

What would be lost?

[Edmund Sanuga Bark]

I think I couldn't have gained anything.

[Paul Tough]

Wow.

[Edmund Sanuga Bark]

I might have gained peace of mind. I'm a worry, you know. You know, I got all these. I have a lot of. My mind is constantly. I mean that. The thing is exhausting. I'm constantly churning away thinking of things and, you know, I never relax. So I suppose that's the thing. I'd like to be able to relax. The only time I relax is when I'm dancing.

[Paul Tough]

Wow.

[Edmund Sanuga Bark]

I love dancing. I'm a big dancer. I still like dancing. So I would have liked to be able to relax a bit more. Maybe that would have done that. Maybe it wouldn't have done that.

[Paul Tough]

What do you think you would have lost?

[Edmund Sanuga Bark]

I don't know. But in my particular case, there's a lot of characteristics that have helped. I do believe the speed at which I think about things, the amount of things I think about my ability, and we didn't mention it last time, but.

[Paul Tough]

What he says is that he thinks that he learned some skills, some different ways of coping that have turned out to be really helpful for him.

[Rachel Abrams]

I am curious though, how Edmund feels about medication. Given all of this, does he think that there is a role for medication?

[Paul Tough]

Yeah, he absolutely does.

[Edmund Sanuga Bark]

All the people I know whose kids have taken their medication for adhd, it was appropriate and it's helped improve outcomes.

[Paul Tough]

He thinks that the problem is seeing ADHD as a medical problem with a medical cure. And that cure is stimulant medication.

[Edmund Sanuga Bark]

It's not. It's not a silver bullet. It never will be.

[Paul Tough]

One of the things that he says is that for young people, for kids and for teenagers, one of the best things that medication can do is it can give a family a kind of a break.

[Edmund Sanuga Bark]

The way I see medication really, I suppose, is a window for parents then to re engage with their kids or to teach it, to re engage with the child and to do the important work from there rather than as a medical solution to a medical disorder.

[Paul Tough]

That when you're in a family that is in a crisis, when a kid just is constantly losing lunchboxes and forgetting homework and that's all you talk about, all you're doing is just yelling at each other about these things. That medication, because it for most kids have this powerful effect, at least in the short term, on symptoms, it can give you a break from those quarrels and it can allow you a little bit more space to say, like, how do we want to deal with this?

[Edmund Sanuga Bark]

It kind of just creates a space where people can reconnect, redevelop relationships, so forth and so on.

[Paul Tough]

And I think what he would say is that the problem is that a lot of families stop their conversations there, that they look at the medication as the cure, as the end point. And he wants us to think of it as the beginning of a conversation, to think about what is going on with the misalignment between this young person's brain and the environment that they're in and to figure out what the path forward is. And maybe that continues to be medication. Maybe medication is the answer for the long term, but maybe not. Maybe there are other changes that you can make now that things are a little calmer that will help better in the long term.

[Rachel Abrams]

Like what?

[Paul Tough]

What he says is that what matters is the actual experience that people with ADHD symptoms are having.

[Edmund Sanuga Bark]

See, I think the biggest thing, and this is heartfelt, is self hatred and low self esteem.

[Paul Tough]

He doesn't deny at all that kids are in all sorts of distress, that they're having a really hard time. But he thinks that's where our focus should be. Rather than trying to figure out a very precise biomarker, let's look at the experience these kids are having and figure out how to help them.

[Edmund Sanuga Bark]

Because your mates, you know, your school, you know, this kind of sense of shame when you fail. Those are the things I think are crucial in terms of the long term well being of not necessarily success in life, getting a good job or anything, just being happy with in yourself.

[Paul Tough]

And instead of just trying to fix them by fixing the chemistry of their brain, we can think about how to make their environments more amenable to them and also how to help them deal better with the parts of their environments that are not, not a good fit.

[Edmund Sanuga Bark]

The goal is to add skills and resilience rather than to reduce adhd. Do you see what I mean? So it's the goal that changes. So methylphenidate.

[Rachel Abrams]

I can totally see the case for changing a kid's environment rather than their brain chemistry in theory. But in practice, you know, if you're busy and your kid is struggling and there's a prescription available to you, I can also just see why that is the option that you'd want to choose. And so I guess I'm having trouble envisioning, practically speaking, what does a change to a child's environment look like? Like, how would that actually play out in somebody's life?

[Paul Tough]

Well, I think that's something that he and a lot of researchers are still trying to work out. There's this one study that I found really affecting. It's actually with the same kids who were in that original Ritalin study back in the 1990s. When they reached young adulthood for the first time, they were able to make decisions about their lives and what their environment was. And a lot of them had put themselves in places where they fit better. And what they were finding was that their problems with ADHD were going away. So there was one young person who was in film school, another who had started cutting hair, another who was working on cars. And they all described that when I'm doing something I'm interested in, it's so much different than it was when I was in high school. This is stuff that I actually like, that I actually care about. And one of the things that I loved about that study was that it helped me understand Edmond Sanuga Barkley experience as well. Because he was a kid who in high school, he was just in the wrong fit in the wrong place for his particular brain. And he was miserable and Then he gets to university, this very academic environment where suddenly his ability to think deeply about things for a long period of time was perfectly well suited. And suddenly he's in an environment where his brain fits.

[Rachel Abrams]

I mean, it's not like these kids are doing something similar to what Edmund did, right? Like finding environments where they could focus. So I wonder, Paul, how much of the way that Edmund is reconsidering all of this understanding about adhd, how much of that reconsideration has broken through to the mainstream?

[Paul Tough]

I think it's kind of hard to measure. I mean, one of the things that is complicated about what he's doing is that he's not really saying, you know, we should stop using stimulant medications or stop diagnosing as much as we are. He is talking about changing the way that we think and talk about adhd. But I do think that that really makes a difference. And I think what a lot of people are coming to believe is that telling kids that there is this absolute, essential, inherent thing in you that is disordered, that you have this deficit, that that is not actually a helpful message to give to kids, that that can often make them feel like they are stuck in this thing that is just broken in their brain. And that if instead you can say to kids, you know, right now you have got this problem, and maybe medication is the right thing to do to help with that, but maybe there's something that can change in your behavior or something that can change in the environment that can help you, and next year, this symptom might not be there at all. I mean, in some ways, I think it's harder for a family to not have this sort of clear, sharp definition of what the problem is. But instead, I think it gives the family a place to build on.

[Rachel Abrams]

Paul, thank you so much.

[Paul Tough]

Thank you.

[Rachel Abrams]

We'll be right back.

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[Rachel Abrams]

Here's what else you need to know today. Israel continued to strike targets in Iran on Monday, including the headquarters of the state television broadcaster while an anchor live on the air. While she spoke, an explosion shook the building, followed by the sound of breaking glass and screams. And elsewhere throughout Tehran, residents weighed whether to take shelter or flee as gas stations ran short of fuel, Internet and phone services were disrupted and traffic snarled along a major highway leading out of the city. And a federal judge on Monday declared some of the Trump administration's cuts to the National Institutes of Health grants, quote, void and illegal, accusing the government of racial discrimination and prejudice against LGBTQ people. Ruling from the bench, Judge William G. Young of the Federal District Court for the District of Massachusetts ordered the government to restore much of that funding for now, pending an appeal. Today's episode was produced by Alex Stern and Nina Feldman, with help from Ricky Nabetky. It was edited by Brendan Klinkenberg and Michael Benoit, with help from Liz o' Ballin, research help by Susan Lee. It contains original music by Marianne Lozano, Sophia Landman, Rowan Ni Misto, Alicia Beitup and Dan Powell, and was engineered by Cross Chris Wood. Our theme music is by Jim Brunberg and Ben Landsberg of Wonderly. That's it for the Daily I'm Rachel Abrams. See you tomorrow.

[Heinz Advertisement]

Support for the Perfect Breakfast comes reminds Breakfast had rules. It was sweet, it was savory, it was safe. Then someone brought out the ketchup. Not your usual breakfast move. And that's the point. Suddenly, suddenly, hash browns found their soulmate. Aches got bold. Turns out ketchup is for breakfast. It has to be Heinz.