DAVE DAVIES, HOST:
This is FRESH AIR. I'm Dave Davies. If you live in the United States, chances are good that you either are or know a parent whose child is being treated for ADHD - attention deficit hyperactivity disorder. Last year, the Centers for Disease Control reported that more than 11% of American children had been diagnosed with ADHD - a record high. For 14-year-old boys, the figure was 21%. In a recent article for The New York Times magazine, journalist Paul Tough examines how ADHD is diagnosed and treated, often with commonly prescribed stimulants, such as ritalin and adderoll. Though they're regarded as highly effective and thus very popular, he finds three decades of scientific studies have raised questions about their efficacy and safety and about the nature of ADHD itself. Some researchers think the notion that ADHD is a distinct, identifiable brain disorder may be wrong or at least oversimplified, and that treatments other than medication should be considered. Paul Tough is a contributing writer to The New York Times magazine and the author of four books - most recently, "The Inequality Machine: How College Divides Us." Paul Tough, welcome to FRESH AIR.
PAUL TOUGH: Thank you. Great to be here.
DAVIES: You write that in the early '90s, there were rising rates of ADHD diagnoses - about 2 million American kids in 1993, roughly two-thirds of them taking Ritalin. This provoked protests from some, particularly the Church of Scientology, you know, arguing that you're drugging our kids. You write that you didn't have to be a Scientologist to acknowledge there were legitimate questions about ADHD. What were they?
TOUGH: At that point, the questions were pretty basic. We didn't exactly understand what this condition was and what treatments were the right ones to use. So Ritalin - doctors could see, families could see that when kids took Ritalin, there was this - in many of them, this overnight change in their behavior. But we weren't sure why that was happening, and the diagnoses were expanding at such a great rate. There was also a question of why that was, why suddenly it had doubled in just a few years.
DAVIES: So a massive study was organized by a number of researchers. Tell us how this was put together.
TOUGH: Yes. So this was the Multimodal Treatment of ADHD Study, or MTA, and a number of researchers at six sites around the United States and Canada decided that they wanted to test different treatments of ADHD. So there were stimulant medications. Specifically, at that point, it was Ritalin. But there were also behavioral interventions, so coaching, parent training. And they wanted to see, scientifically, which would work best. So they did what scientists do, which is they created this randomized controlled study. And at each site in the United States and Canada, they divided the children who were between 7 and 9, who had been diagnosed with ADHD, into different treatment groups. So some got behavioral training. Some got Ritalin, and some were just left on their own to figure out their own treatment.
DAVIES: Right. The results were released in 1999. What did they show?
TOUGH: That was after 14 months of treatment, and what they showed was that the most effective treatment for behavior, for symptoms, was Ritalin - that the kids who had taken Ritalin were doing significantly better than the other groups.
DAVIES: Over time, of course, more and more kids were diagnosed with ADHD. And you write about a guy named James Swanson who was at the University of California, Irvine, who, among others, grew uneasy about these trends in diagnosis and treatment. What was troubling them?
TOUGH: So there were two things that were really troubling James Swanson. And one was that that initial expansion of diagnoses from about a million kids to about 2 million kids - that made sense to him because scientists thought that about 3% was the most accurate guess of what percentage of children sort of naturally had ADHD, and 2 million was pretty close to 3%. But then it kept going up. So as the study was going on, it went up to 5%, to 6%, and he couldn't see a reason why that was happening.
The other thing that he found disturbing was that he and the other scientists that were running the MTA study continued after those 14 months to carefully study the children who were in the original group. And what they noticed was that the advantage that the kids in the Ritalin group had had after 14 months - it started to really fade. And by 36 months, there was no difference in the symptoms of any of the groups. The kids who had taken Ritalin weren't doing better in terms of their symptoms than the children who had been assigned to the behavioral group, and they weren't even doing better than the kids who had not been given any treatment at all.
DAVIES: You write that Swanson is now 80 years old and is troubled by the way ADHD research and treatment is going. Is there a kind of fundamental theme to his concern?
TOUGH: Yeah. I think mostly what he's concerned by is that that original study of the 14 months got a lot of attention, and the message really went out that Ritalin works, that it's the right treatment for most kids, but that the second study - the one that found that over time, those effects fade - that it did not get the same type of attention and that it's not reflected in the way that a lot of practitioners are now treating ADHD.
DAVIES: And there's been a lot of research into what it actually is biologically, and has that guided treatment at all? I mean, I guess that's the question. Is there a real connection between the understanding of the biological origins of this and the way it's treated?
TOUGH: One of the things that's so striking in talking to scientists, including neuroscientists, who've studied this is that they say that they actually understand the biology of ADHD less than they did 20 years ago. So normally, the course of science is that as time goes on, they get a better and better understanding of what's really going on in the brains of children with a particular diagnosis. And in this case, that's just not true.
So 20 years ago, there was this belief that there were clear biomarkers, clear indications in the brain in terms of electrical signals or a particular gene that would predict ADHD or differences in the size and shape of certain parts of the brain that you could say, this kid has that biomarker. He does have ADHD, and this one does not. And as the last couple of decades have gone on, that belief has slowly been undermined so that now there is no clear biomarker for ADHD. And I think most neuroscientists accept that that's the case.
DAVIES: This is such a big deal for parents. Nothing is more troubling than to see your child in pain or struggling. You have kids yourself, right? You have two sons?
TOUGH: I do, yeah.
DAVIES: Yeah. So you know the stakes here.
TOUGH: Absolutely.
DAVIES: What are the - some of the things that they observe that make them so desperate for help?
TOUGH: ADHD can be incredibly disruptive in a child's life, in a family's life, in a classroom. When kids are having trouble sitting still, focusing, getting work done, keeping themselves organized, controlling their impulses, it makes life really difficult. And it especially makes life difficult when you are going to school. A lot of the school day, you've got to sit still. You've got to focus. There's a lot of homework. I know as a parent. And when you are struggling with impulse control, when you're struggling with attention, those things are really difficult. And I think within families, that often leads to real conflict. And so what originally starts as just a problem in one child's life turns into a problem for a whole family.
DAVIES: And I guess one of the other things that's tricky about it as a diagnosis is that a lot of the things that you observe are also symptoms from other causes, such as, you know, injury to the head or other psychological conditions, anxiety and depression, right?
TOUGH: Yeah. So it is a very tricky disorder to diagnose for a lot of reasons. I mean, the first one is that the only way to do it is by using a symptom checklist that is in the Diagnostic and Statistical Manual. So there's this list of symptoms. If you have six symptoms, you officially have ADHD. If you have five, you don't. There are other criteria. It has to last for a certain amount of time. It has to exist in at least two different settings. But what makes it even more tricky is exactly what you're talking about, that there is great overlap between these symptoms and the symptoms of lots of other things, of early trauma, for instance, of anxiety, of depression. And to make it even more complicated, what the CDC has found is that there is a lot of overlap among children who are diagnosed with ADHD with other psychological problems. So about three-quarters of kids who have received an ADHD diagnosis have also received a diagnosis for another psychological disorder or a learning problem. And according to the DSM, if the symptoms of a child are better explained by another diagnosis, they shouldn't be diagnosed with ADHD. So that makes it really tricky, that there is sometimes overlap between two things, but you're only supposed to diagnose ADHD if it is the one that is causing these symptoms.
DAVIES: The DSM you mentioned, that's the Diagnostic and Statistical Manual of Mental Disorders, which guides treatment for a lot of practitioners. I guess one of the other things that's a little hard to understand about this is that two kinds of symptoms for ADHD are pretty different, right? I mean, there's inattention, not paying attention. And then there's hyperactivity and impulsivity. And they seem like pretty different behaviors. Why is it assumed that they arise from the same condition?
TOUGH: Yeah, I think that's another part of the complication of this diagnosis. There are some doctors who think these are two entirely separate conditions, that each should have its own listing in the DSM. And, you know, in fact, over the years, there have been lots of different sort of envelopes around ADHD. Its name has changed. The symptoms that predict it have changed. There's clearly something going on in a lot of kids who are having trouble focusing, having trouble sitting still and paying attention. But in individual children, that expresses itself in lots of different ways. And that's another real struggle, I think, for clinicians, for families who are trying to figure out, you know, there's something going on with my kid - what is it? And ADHD, I think, has become this sort of catchall diagnosis that we use to just put together a lot of kids who may in fact be quite different.
DAVIES: You know, it seems kind of counterintuitive that stimulants would help with hyperactivity and impulse control, right? I mean, it seems like you're pushing it in the same direction that's the problem. What's the medical explanation for that?
TOUGH: Well, I don't think we know exactly what's going on. But what studies of amphetamines, the drug at the root of the two most popular medications for ADHD, what amphetamines do is they help make whatever you're focused on seem more interesting. And so I think that then makes sense, right? If you're having impulse control, if you're distracted by everything else that's going on in the room, when you take this medication that makes whatever you're supposed to be looking at seem more interesting, it makes it easier to focus, easier to sit still.
DAVIES: So what are some of the nondrug treatments that are helpful in treating ADHD that people are discovering?
TOUGH: Scientifically, there is not yet any real data showing that there's any particular sort of parent training or behavioral techniques that makes things better, which I think is really frustrating for a lot of clinicians and a lot of parents, and I think, as a result, tends to make medication seem like a more attractive alternative. But lots of clinicians have found their own ways of working kids and with families that are just about, like, helping to create a calmer atmosphere in the classroom, a calmer atmosphere at home, you know, things as basic as, you know, Post-it notes and calendars and just ways of helping you organize your thoughts, organize your schoolwork if you're a kid in school. You know, none of those are a perfect cure, but a lot of them seem to help. And I think they're really individualistic. And, you know, a good clinician can help a family figure out the solutions or the tools, the interventions that are most helpful for that child.
DAVIES: You read about Russell Barkley, a prominent ADHD researcher. And he has a lecture that has been viewed more than 4 million times on YouTube, right? What is his perspective of the disorder?
TOUGH: Yeah, so he's written a lot about it, probably the most well-known, the most prominent doctor, scientist when it comes to popularizing our ideas about ADHD. And what he talks about in this speech is that ADHD is basically diabetes of the brain, so it's a chronic condition that you're going to have to treat for your whole life. And he tends to focus on the downsides of ADHD. He takes very seriously the real problems that can occur for kids and adults who have ADHD, including higher rates of, you know, traffic accidents, of early death, of drug addiction. And the way that he looks at ADHD is to look at it as this very much sort of black-and-white, yes or no diagnosis, like diabetes. If you've got it, you've got it. If you don't, you don't.
DAVIES: And you have to treat it because there'll be, you know, downstream effects that you really want to avoid.
TOUGH: Yes, exactly.
DAVIES: We need to take a break here. Let me reintroduce you. We are speaking with Paul Tough. He is a contributing writer for The New York Times Magazine. His recent cover story is titled "Have We Been Thinking About ADHD All Wrong?" We'll be back to talk more after a short break. This is FRESH AIR.
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DAVIES: This is FRESH AIR, and we're speaking with New York Times contributing writer Paul Tough. He has a new cover story about attention-deficit/hyperactivity disorder and its diagnosis. It's titled "Have We Been Thinking About ADHD All Wrong?"
I want to talk a bit about some of the research into the nature of this disorder. In 2002, you write, there was an international consensus statement signed by 85 researchers defending the validity of the diagnosis of ADHD because there had been questions about it. What was the thrust of their letter?
TOUGH: Well, the main point of that consensus statement was exactly to defend the diagnosis against critics. And so a lot of that statement is just about the basic fact that this is a real diagnosis that has real consequences. What I was drawn to in that statement was the focus on biomarkers, on particular biological signatures that could let us identify ADHD and in the process say, this is clearly a biological condition, not just a psychological one.
And it focused on three particular biomarkers. One was certain electrical signals in the brain that seemed different in kids with ADHD than without. The other was on genetics. There were early indications in the early 2000s that there was a specific, single gene that predicted ADHD. And the third was about the kind of physical signatures you could see in the brain on MRIs, that there were differences in the volumes and sizes of particular parts of the brain in kids who had been diagnosed with ADHD.
DAVIES: And has that held up to further study?
TOUGH: No, that part has not really held up to further study. It's become much more complicated - this search for the biomarker. And there are many scientists now who say that the search for a biomarker was just a red herring, that that's not what any scientists should be focused on. Instead, we should be focusing on the experience of kids with ADHD. So each of those three biomarkers that I mentioned have been undermined in one way or another. The study of these electrical signals, repeated studies to try to replicate that, turned up to have no result. Genetics is more complicated. There are still indications that certain combinations of genetic qualities are predictive of ADHD. But the very sort of simple and straightforward, you've got this gene, you've got ADHD, that scientists were hoping was the case 20, 25 years ago, that has proven not to be true.
And then the third is this idea that there are differences in the volume - the cortical volume, scientists say, in certain parts of the brain. And that was studied in this giant global study called the enigma study done by this consortium of neuroscientists and psychiatrists. And that similarly showed almost no difference between people with ADHD and people without. Among adults and adolescents, no difference at all. Among children, just a tiny difference in the cortical volume of certain parts of the brain.
DAVIES: You write that you found a consensus of sorts among most scientists that you spoke to about this question of whether it's a biological condition. What's the consensus?
TOUGH: Well, the consensus is that there are clearly both biological and environmental causes somehow combining to create these symptoms in kids. But beyond that, there's not much consensus. There's not a clear agreement on the relative role that environment plays and that biology plays.
DAVIES: You know, so much of the discussion here focuses on kids because obviously, parents are really concerned about helping their kids and helping them grow and flourish. To what extent is this a growing diagnosis among adults?
TOUGH: To a huge extent. So in this article, I focused on kids for a variety of reasons. Partly because the science is more clear because scientists have been studying ADHD in kids for much longer. But as a phenomenon, as a diagnosis in the United States, it is among adults that all of the growth is happening. So the fastest growing groups for the diagnosis are people - adults in their 20s and 30s. But even adults in their 40s, 50s, 60s, all of those diagnosis rates are going up really quickly, and prescription rates are going up by a huge degree, as well.
DAVIES: You know, it's interesting 'cause you mentioned this multimodal study earlier found that there were clear benefits to ritalin and, you know, stimulants, but that they tended to disappear after about 36 months. Do we know if that's also true of adults who take these medications?
TOUGH: We don't. It just hasn't been studied to the same degree. I don't think there's reason to think that there's a different result that we would see among adults, but there hasn't been a similarly rigorous study like MTA for adults.
DAVIES: This is such a common issue that we all know people in - that are dealing with this. And just over the past two days, just among the producers here at FRESH AIR, I've had one producer who has a son who struggles with some of this and finds the medication very helpful. And then I had another producer whose brother, when he was in second grade, had real trouble focusing and his teachers were struggling with him 'cause he was just all over the place. And they told his mom, look, you're going to have to put him on ritalin or one of these drugs, or otherwise, he can't come to school here. And the mom said, nope, I'm not doing that. And I know it's a public school, so you have to deal with him. He ended up in front of a school psychologist who taught him chess, and they began playing chess once a week. And, at least as my friend told the story, that was a real breakthrough. I mean, he really changed his behavior, and he's gone on. He's never taken medication. He's had a productive career as an artist, an animator and lives a happy life. So, I mean, an anecdote doesn't - isn't the same thing as research, but it just seems like there are a lot of ways this can go.
TOUGH: Absolutely. Those are great stories. And, yes, so I - and I've heard lots of stories as well, not only in my reporting, but just from friends before the article came out, and then in great numbers since the article came out. And I think what's hard for us is that when we hear two different stories like that, it's hard for us not to think, well, just one of them has to be true. But the reality is they are both absolutely true, and that different people have different experiences of this condition and of its treatment. There is no one-size-fits-all solution. And so, to me, that is what is reassuring and even exciting about this new research. By giving young people and families the message that this is not just a sort of singular biological condition that you have or you don't have. That, in fact, symptoms often fluctuate over time. That there are different sorts of treatments that work for different sorts of kids. That that gives them maybe less certainty, which can sometimes be scary. But also more of a sense of possibility that this is something that can - like the young person you're talking to, who was sort of cured by chess - that there may be ways that life can change that will really change these symptoms, as well.
DAVIES: We're going to take another break here. Let me reintroduce you. We are speaking with Paul Tough. He is a contributing writer for The New York Times magazine. His recent cover story is titled "Have We Been Thinking About ADHD All Wrong?" He'll be back to talk more after this short break. I'm Dave Davies, and this is FRESH AIR.
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DAVIES: This is FRESH AIR. I'm Dave Davies. We are speaking with New York Times magazine contributing writer Paul Tough. His recent cover story reported on the continued growth of diagnosis of ADHD - attention-deficit/hyperactivity disorder - in the United States and on research that raises questions about the common treatment for ADHD - stimulants such as Ritalin and Adderall. He writes that some researchers are thinking of ADHD in a new way and considering new approaches to treatment. His article is titled "Have We Been Thinking About A.D.H.D. All Wrong?"
You know, it's interesting. You write that the roots of treatment for this disorder go way back to an experiment, I guess, in the 1930s by a Harvard-trained psychologist in Rhode Island, right? Tell us about this.
TOUGH: Yeah. So this is a psychiatrist named Charles Bradley who ran a home for children with psychological problems in Rhode Island. And at the time - this was in the 1930s - Benzedrine, which is a kind of amphetamine, had become this really popular drug among jazz musicians, actually, and among college students who felt like it helped them focus. It sort of amped them up in various ways. And he thought, maybe I should try this on these kids. There was nothing that was seeming to help them. So he did a very small but rigorous experiment, where he gave 30 kids a daily dose of Benzedrine. And he noticed this - in about half of them, this vast change in their behavior. So they were more placid. They were more easygoing. They could get things done. They felt better about their work. And it felt to him like this kind of miracle cure.
DAVIES: And later, researchers followed up on this and did similar experiments. What did they find?
TOUGH: Yeah, so I spoke to this NYU researcher named Xavier Castellanos who actually told me about the Charles Bradley paper and said that he sees the same things now when he first prescribes Ritalin or Adderall to kids - that overnight, there's this kind of miraculous transformation for a lot of them, that their behaviors really change. What he said was frustrating, though, was that when you look at the sort of academic results for kids, even though they are able to sit and focus more and get more seat work done, their test scores don't go up. And that, I think, has been this puzzle that doctors have been wrestling with for the past couple of decades, that at least in the short term, these medications seem to have a powerful effect for some kids on their symptoms. But over time, they don't seem to have an effect on academic achievement, at least in - measured in test scores.
DAVIES: Yeah. There's another test that you described involving putting stuff in knapsacks. Explain this.
TOUGH: Yeah.
DAVIES: Yeah.
TOUGH: So I'd never heard of this test before. It's called the knapsack test. But apparently, it's pretty common in psychology and computer science. You give a kid a backpack. In this case, it's a virtual backpack. And it's just this kind of game. You give them a bunch of different things of different weights and prices, and you say, what's the best way to pack this backpack to get the most value of stuff into it? So it's a little sort of logical puzzle.
And these researchers in Australia gave this test to a bunch of young adults, and they tested how well they did when they were on stimulant medication and how well they did when they were not. And what they found was that when they were on stimulant medication, they, from the outside, looked to be doing much better. They were working more quickly. They were more diligent. They were more focused. But when they looked at the results of how well they were doing on this knapsack test, they weren't doing any better. And what they saw was that that was because they weren't actually making better decisions. They were just sort of randomly pulling things in and out of their backpack instead of focusing on it. So what I think some researchers believe is that this is a clue to why sometimes behavior in the classroom can improve on stimulant medication, but academic results don't. It's possible that these stimulants make you sit still and behave better, but they're not actually helping your brain process information better.
DAVIES: You mentioned some other things that were troubling about continued use of these stimulants. What were some of the other issues that came up?
TOUGH: Yeah. So James Swanson - the researcher who helped lead the MTA study - one data point that he really focuses on in thinking about this as a long-term treatment rather than a short term-one is that in the original MTA study, when young people took stimulant medication over the course of years, it had an effect on their growth, on their physical growth, on their height - that the kids who had consistently taken Ritalin were about an inch shorter than the kids who had not. And so Swanson and the other MTA researchers have continued to study this group through adolescence and even into adulthood. And the most recent study looked at them when they were 25 and continued to see this height differential. That the ones who had consistently taken stimulant medication all the way through childhood and even young adulthood - they continued to be about an inch shorter than the ones who had stopped taking it or who had never started at all.
DAVIES: Is there an explanation for that biologically that we know of?
TOUGH: There isn't a definite explanation, no. We don't exactly know why that is. The most sort of logical one is that these medications affect appetite in a big way. So when I would talk to young people who were taking these medications, that was the thing that they talked about the most, that it - you just don't want to eat. And if you're an adolescent and you don't want to eat, you're very different than other adolescents. This is a time when kids are eating a ton, and that's helping their growth. So that would make sense as part of the reason for this, but there haven't been enough careful studies to say that that's the real reason.
DAVIES: I mean, these are amphetamines, right? I mean, can they be addictive?
TOUGH: Amphetamines, as a whole, can be addictive. The way that the medications are formulated, especially the ones that release the medication over an extended time, over the course of a day - those are certain safeguards that make them less likely to be addicted. The young people I talked to who took these medications did not feel that they were addicting at all. They found them very easy to stop. So yes, they can be addictive. There's certainly anecdotal stories about people who become dependent or even addicted to these medications, but that doesn't seem like a very big problem for most kids.
DAVIES: We are speaking with Paul Tough. He is a contributing writer for The New York Times magazine. His recent cover story is titled "Have We Been Thinking About A.D.H.D. All Wrong?" We'll continue our conversation in just a moment. This is FRESH AIR.
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DAVIES: This is FRESH AIR, and we're speaking with Paul Tough. He's a contributing writer for The New York Times magazine. He has a recent cover story about the continued growth of diagnosis of ADHD - attention-deficit/hyperactivity disorder - in the U.S. and on research that raises questions about the most common treatments. His article is titled "Have We Been Thinking About A.D.H.D. All Wrong?"
Paul Tough, you spoke to students across the country about this - with ADHD diagnosis - who'd been taking these stimulants. What did you hear?
TOUGH: Well, I heard a variety of things. So I think every young person's experience is unique. But mostly, I felt like they had a pretty complex relationship to these drugs. So I think the way that these medications and the diagnosis in general is portrayed in the public is that this is, you know, a medical condition that has a medical solution. And in fact, the young people I talked to saw this as much more of a kind of constant negotiation between them and their medication.
A couple of the young people I talked to talked about - used the word sacrifice when they talked about their stimulant medication. They saw that there were benefits to it. They saw that it was going to help them in some significant way going forward in life. But they didn't actually like the experience of taking them, often not at all. I mean, one of them said, I just hate taking it. You know, you, first of all, get this real rush. You feel like you're on top of the world, but then there's a real crash. And so he didn't love it, but he saw, like, that in certain circumstances, it was the right thing to do. And that's what I heard from a lot of kids, that they had gotten to the point where they knew what this medication would make them feel like. And rather than think of it as, say, diabetes medication - something you've got to take every day in order to survive - it was much more situational. It was something that they would take at certain times and certain moments, and then other times not take.
DAVIES: Yeah. There was this one guy that - who you called Cap, who used it when he was preparing for his SAT exams and for baseball and baseball practice 'cause he could really focus on pitches, and he thought it made him a better hitter. But he didn't like it. And I guess people felt that it changed their personalities in some ways.
TOUGH: Yeah. That was something that I heard from a lot of people, that their sort of love of life, their sense of humor - that a lot of that would change when they were on this medication, that they were - you know, at lunch, they were not the happy, social person that they had been. One of them said, you know, it's not like I'm unhappy. It's just like I'm kind of flat.
There was one girl who I spoke to, who I didn't include in the article, who talked about how it did sort of suppress her emotions. And she said that she had been having this day a couple of days before I spoke to her when her friends were going off to college, and she wanted to say goodbye to them all. And she decided that day not to take her medication because she wanted feel. She wanted to have this emotional connection, and she knew that if she was on the medication, she just would feel more flat.
DAVIES: You wrote that there are some people who believe that ADHD is a clear, you know, identifiable biological disease and therefore best treated with medication, but that increasingly, people think that it may be thought of not as a condition that you have but as something that you experience. What exactly does that mean? What are the implications of that idea?
TOUGH: Well, I think this is where this question gets really interesting to me. And the person who I think is sort of leading the way - the researcher who's leading the way on this is a British researcher named Edmund Sonuga-Barke who has been studying ADHD for 35 years. And in the last few years, he has really started to change his approach, and I think that's been influential in the field.
So he talks about ADHD as not having any kind of natural cutting point where you can say this person has it and this person does not have it, but instead that ADHD symptoms exist on a continuum, where almost everyone has some of these symptoms, and that there are some who - for whom it is really an extreme problem, but there's not a natural cutting point. And to him, this distinction is important not only scientifically, but also kind of, like, psychologically and emotionally, that it enables us to tell young people that this is not just a case of them having a deficit of a certain skill and that that's a disorder that has to be treated medically, but instead that their problems may have more to do with a misalignment between their own unique brain and the situation that they're in. And if that's the case, sometimes medication can still help make that environment more tolerable. But there also might be things that we could change in their environment, that they could change in their habits and patterns that would have the same kind of positive result that medication would have.
DAVIES: Right. I mean, school is sometimes just going to be boring, and if your particular brain has a hard time focusing on boring stuff, I guess it's harder. What are the implications of that for treatment?
TOUGH: You know, it's interesting. It might not have implications for treatment, but it changes, I think, the way you think about your treatment and the way you think about yourself, the way you think about your own brain. I think when we give kids the message that this is a brain-based problem, that it's a disorder in the brain, that's something that they take in as a sort of identity, as a message about who they are and what they can accomplish. And if instead it is portrayed, I think, more accurately as a mismatch between where you are and how your brain works, that says something very different to kids. It says maybe medication is the right thing right now, but it's also possible that in the future, this is going to change, that you're going to find your way to another kind of situation that's not like high school English class, where your brain is actually going to be really powerful and really well suited.
DAVIES: There was one thing that you mentioned in the research - that some children with ADHD symptoms are at greater risk of more serious issues, and those are kids whose symptoms are accompanied by intense angers. I mean, what are the different risks there?
TOUGH: Yeah. So this is the research of a researcher in Oregon named Joel Nigg. And I think this is really important. I think that one of the downsides of us having perceived this condition as this sort of yes or no, black or white disorder is that it has obscured the fact that there are really lots of different degrees of intensity of ADHD. So, you know, the young guy I talked to who, you know, was using it for baseball as much as he was using it for school - he almost certainly does not have a really intense case of ADHD. But there are lots of kids who do.
And what Joel Nigg has found is that between 30 and 40% of young people diagnosed with ADHD also have symptoms of intense anger as children and that that is often the beginning of real psychological problems. When you have both hyperactivity in impulse control and intense emotional dysregulation, that's a real warning sign, and that those kids - it's not just about changing their environment. They really do need treatment, which might include stimulant medication, but it also might include other things. That those young people have - are more likely to have coexisting other disorders, oppositional defiant disorder, depression, anxiety. And so they need a more careful set of treatments.
DAVIES: You know, I'm sure we're going to get a lot of reaction to this interview because it affects so many people, and people's experiences are all unique, and there is disagreement about this. You know, I happened to look at this magazine called ADDitude - that's A-D-D-itude - you're familiar with this - which describes itself as the nation's leading source of important news, expert advice and judgment-free understanding for families and adults living with attention deficit disorder. I just went to the website and right away was struck by a story attacking your article, calls it misrepresentative, biased and dangerous. Have you looked at this stuff?
TOUGH: I have, yeah.
DAVIES: Yeah. I mean, it specifically says that, in some cases, you quoted people who you didn't interview. Wes Crenshaw says he told a Times fact-checker before the article was published that the reporter's information was incorrect and asked for an interview to set the record straight, none was granted. Generally, what do you say about?
TOUGH: Well, I'll say first that that particular claim that Wes Crenshaw asked for an interview is not true. So the reason that ADDitude is responding so intensely, I think, is because I wrote about this magazine, about ADDitude, in my article. And one of the things that I noticed in ADDitude was that there were a number of articles aimed at parents of children who were resisting the diagnosis and resisting medication treatment. And I'd talked to a lot of these kids - right? - who were themselves being treated and who had really mixed feelings about it.
And so the idea that parents need a strategy to persuade their kids to take medication felt really out of keeping with the research that I was reading - that medication works for some kids but it doesn't work for all kids, that on the whole, the benefits of stimulant medication outweigh the deficits for most people, but for individual kids, sometimes it is not the right choice. And I don't think that it's the job of parents to try to persuade their kids to keep taking this medication when they don't want to. You know, the research shows that lots of them don't want to, and lots of them stop.
And so these articles from ADDitude magazine that I mentioned, that they're responding to, were all in one way or another trying to give parents arguments and approaches to try to convince their kids to take this medication. And so that's what I wrote about. It's true I didn't go follow up and interview these people because I was just quoting accurately the articles that they wrote in this magazine. And I think that the magazine felt wounded by the fact that I identified these articles as being a part of that movement.
DAVIES: You know, the human mind is an awfully complicated thing, to say the least. And there are, you know, many circumstances in treatment in which medications are effective for reasons that just aren't clear, right? I think that is true of a lot of antidepressants - right? - for a long time. I don't know if it still is. And I'm just wondering, as you looked at this research on ADHD, are there people who are optimistic that they will get to a clearer understanding of its origin?
TOUGH: I think so, yeah. I mean, I think there's a mix of feelings about it. I think there are hopes that that sort of, you know, intense scientific research will help us. But I think there are more people, and this is including some of the researchers who I wrote about, who say that that's not where our research focus is going to be most useful, that there may be two directions that seem most useful. One is what Joel Nigg is doing and trying to figure out if there are subtypes within this group that is diagnosed with ADHD who have different problems, different maybe genetic signatures and different needs for treatment. And instead of saying you've got ADHD or you don't, if we can be more precise in what intensity of ADHD, what type of ADHD you have, we can give you more helpful treatment suggestions.
And then I think the other angle that I find really reassuring is to think about environments. So instead of to think of this as just a biological problem that has a biological solution, think about the environmental side of it. And a lot of the research suggests that as environments change for young people, their symptoms change as well. But mostly what we see is that just kind of happens as you go through life.
There is not a big push and I think there hasn't been a lot of study of, if we are actually intentional about how we change young people's environments, can we predictably make a difference in their symptoms? My hope is that those two strands of research together will make a real difference, that we not only will be able to say, well, this is the particular signature of ADHD that you have, but we'll also be able to say, and this is the kind of intervention, whether environmental or pharmaceutical, that might help your symptoms the most.
DAVIES: Well, Paul Tough, thank you so much for speaking with us.
TOUGH: Thank you.
DAVIES: Paul Tough is a contributing writer for The New York Times Magazine. His recent cover story is titled "Have We Been Thinking About ADHD All Wrong?" Coming up, Martin Johnson reviews a new tribute to Anthony Braxton, who Johnson says is one of the most polarizing figures in jazz. This is FRESH AIR.
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