ADHD has been considered a medical disorder, treatable with drugs like Ritalin, but New York Times Magazine writer Paul Tough says recent studies question that assumption and treatment options.Also, Martin Johnson reviews a new tribute to Anthony Braxton, who Johnson says is one of the most polarizing figures in jazz.Learn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy
Chapter 1: What is ADHD and how prevalent is it among children?
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%.
Chapter 2: How has ADHD been traditionally diagnosed and treated?
In a recent article for the New York Times Magazine, journalist Paul Tuff examines how ADHD is diagnosed and treated, often with commonly prescribed stimulants such as Ritalin and Adderall. 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 Tuff 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 Tuff, welcome to Fresh Air.
Thank you. Great to be here.
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?
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.
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Chapter 3: What were the findings of the Multimodal Treatment of ADHD Study (MTA)?
So a massive study was organized by a number of researchers. Tell us how this was put together.
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
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 seven and nine 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.
Right. Results were released in 1999. What did they show?
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.
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?
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.
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Chapter 4: What concerns exist regarding the long-term efficacy of ADHD medications?
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.
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?
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.
And there's been a lot of research into what it actually is biologically. And has that guided treatment at all? 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?
One of the things that's so striking in talking to scientists, including neuroscientists who have 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.
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?
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Chapter 5: Why is diagnosing ADHD complicated and what symptoms are involved?
And ADHD, I think, has become this sort of catch-all diagnosis that we use to just put together a lot of kids who may, in fact, be quite different.
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?
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.
So what are some of the non-drug treatments that are helpful in treating ADHD that people are discovering?
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 with 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.
You read about Russell Barkley, a prominent ADHD researcher, and he has a lecture that has been viewed more than four million times on YouTube, right? What is his perspective of the disorder?
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Chapter 6: How do stimulants like Ritalin work to help manage ADHD symptoms?
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 and 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.
And has that held up to further study?
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 scientist should be focused on. Instead, we should be focusing on The experience of kids with ADHD.
Chapter 7: What non-drug treatments are available for ADHD and how effective are they?
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.
You're right 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?
But 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.
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?
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.
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Chapter 8: What does current scientific research say about the biological basis of ADHD?
You know, it's interesting because you mentioned this multimodal study earlier found that there were clear benefits to Ritalin and 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?
We don't. It just hasn't been studied to the same degree. I don't think there's reason to think there's a different result that we would see among adults, but there hasn't been a similarly rigorous study like MTA for adults.
This is such a common issue that we all know people 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 because 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 and 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.
Absolutely. Those are great stories. And yes, 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.
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