This morning, my colleagues at The Times Magazine published a remarkable cover story by Paul Tough about a surge of A.D.H.D. cases in the United States — and the way we treat them. Today, 23 percent of 17-year-old boys have received a diagnosis of attention deficit hyperactivity disorder. The number of prescriptions rose nearly 60 percent in a decade. You almost certainly know people who take these stimulants.
Why is this happening? One thing I love about Paul’s story is that it’s partly a tale about how science is made and changed. Researchers in the 1930s saw immediate benefits when they treated jumpy kids with amphetamines. Eventually, doctors crafted a diagnosis that could explain distracted and excitable personalities, and a consensus formed about how to treat them. Paul’s story describes how a few scientists have come to challenge that consensus — and some of the fundamental ideas behind A.D.H.D.
For today’s newsletter, I spoke to Paul about his reporting.
What got you interested in this story?
I’ve been writing for decades about education and children, and I now have two boys of my own. A few years ago, I began to notice how many families I met were struggling with their kids’ attention issues. Attention was something I worried about in my own children — and in myself, too. But I didn’t know much about the science behind attention. So I started talking to scientists. When I did, I discovered they had a lot of big unresolved questions.
What is A.D.H.D., and why is it so tricky to define?
There is no biological test for A.D.H.D. So it has to be diagnosed by its symptoms, and those symptoms are sometimes hard to pin down. One patient’s behavior can look quite different from another’s, and certain A.D.H.D. symptoms can also be signs of other things — depression or childhood trauma or autism. Take a child who is constantly distracted by her anxiety. Does she have A.D.H.D., an anxiety disorder or both?
So A.D.H.D. may not be a clear, distinct medical disorder with defined boundaries — something you either have or don’t have?
Increasingly, the science shows that the condition exists on a continuum, and there is no clear dividing line between people who have A.D.H.D. and people who don’t. For many kids, A.D.H.D. symptoms fluctuate over time — worse one year, better the next — and those fluctuations may depend on their external environment as much as their internal wiring.
Traditionally A.D.H.D. is treated with stimulants like Adderall and Ritalin. Now a few researchers are raising questions about them. Why?
Most researchers I spoke with believe that stimulant medications are, on the whole, a positive thing for children with A.D.H.D. But some feel that their benefits have been oversold. One big study found that stimulants were more effective than other interventions only for the first 14 months of treatment. By 36 months, their relative benefit had disappeared. And even when these medications improve children’s behavior in the short term, they don’t seem to boost their learning or academic achievement. As a result, some scientists — and some families — are looking for other approaches.
What other approaches work?
That’s another challenge for the field: At this point, there isn’t much solid evidence for any treatment other than stimulant medication. What I found encouraging, though, was research suggesting that changes in children’s environments — a more stimulating classroom, a calmer home life, or, as they get older, an interesting job — can often have a positive effect on their symptoms. My guess is that a lot of the field is heading in that direction.
It’s tough because parents can’t always pick their kids’ classroom or work fewer hours. Do you think the way we diagnose and treat A.D.H.D. in this country is likely to change?
I hope so! For many families, stimulant medication has been, and will continue to be, a lifesaver. But there are plenty of other children who would benefit from a new and different approach. My hope is that the research I’ve written about will lead to a new way to treat A.D.H.D. and a new way to think about it.
I recommend you read Paul’s story here.