Is It Time to Rethink Pediatric ADHD?
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From KQED in San Francisco, I'm Nina Kim. Coming up on Forum is a time to rethink how we diagnose and treat ADHD in kids. Journalist Paul Tuff spent a year talking to researchers of attention deficit hyperactivity disorder and found many expressing concern over the disconnect between the science on ADHD and standard treatments for it, like Ritalin and Adderall.

Meantime, the number of children receiving an ADHD diagnosis in the U.S. has reached record highs. We talked to Tuff about his findings and why he says we may be thinking about ADHD all wrong. Join us.

Welcome to Forum. I'm Mina Kim. More than 11 percent, or some 7 million U.S. children, have received an ADHD diagnosis, the Center for Disease Control and Prevention reported last year, a record high. That figure also includes 23 percent of 17-year-old boys. And yet, according to Paul Tuff, in many ways, we now understand attention deficit hyperactivity disorder less well than we thought we did a couple of decades ago.

After spending the last year talking with ADHD scientists, Tuff has learned that new data are challenging previous assumptions about the disorder. His New York Times Magazine cover story is called, Have We Been Thinking About ADHD All Wrong? Listeners, what have been your experiences with ADHD? Paul Tuff covers education and child development and is the author of four books, including most recently, The Inequality Machine, How College Divides Us. Paul, welcome to Forum.

Thank you. Great to be here. So based on those figures I cited at the top, I can understand why you have felt like ADHD is sort of all around you. But tell our listeners what you mean by that. Well, I think in my case specifically, I'm the father of two boys, one age 10 and one age 15, and they are in the sort of key demographic for ADHD diagnoses. And so a few years ago, it just started to feel to me especially that, you know,

Every family I was talking to was trying to figure out what was going on with their kids' attention. And some were choosing to get diagnosed. Some were trying to find other solutions. But it was just really in the air. And these numbers from the CDC suggest that it's not just me and the parents that I'm talking to. This is something that is growing for lots of families all over the country.

So how? I mean, what is commonly understood as the way ADHD presents itself? What are sort of the classic symptoms of the disorder that are leading so many families to think that maybe their kids have it? Well, the official way that you come up with an ADHD diagnosis is laid out in the DSM, the Diagnostic and Statistical Manual of Mental Disorders. And it explains that there are two categories of ADHD,

one about distraction and one about hyperactivity and impulsivity. And for each of those categories, there are nine specific symptoms you can look for. And if a clinician finds that a child has six

of either of those categories. They have to be of sufficient duration. They have to be of sufficient impairment. There's a lot of judgment used in diagnosing this, but there is this checklist and that's where it starts. If you meet enough of these symptoms, you can be diagnosed. One of the most prominent ADHD researchers, I think his name is Russell Barkley, has labeled it diabetes of the brain. So a disease that you either have or don't have, I guess.

Yeah, that's right. So his approach is, you know, he's someone who feels that ADHD is a real crisis and that it is...

The symptoms are really making life worse for lots of children and adults as well. And he tends to portray it as something that is a lifelong medical condition. And so that's, I think, why he gave this analogy to diabetes, that it's something that will always be with you, that you have to manage like any other chronic condition.

And so as such, as a medical condition, that's also why he and many believe strongly that it can be treated with medication. Can you walk us through the standard treatment for pediatric ADHD? Sure. So I think he and lots of others would say that medication is not the only treatment.

treatment that a parent should look to or the clinician should look to. But I think that he thinks it's the most effective, the most reliable one. But I think clinicians tend to look for two different types of interventions. So one is medications, and there are the two main categories of medications. One is amphetamine salts, and Adderall is the most popular version of that.

The other is methylphenidate and Ritalin is the most popular version of that. They're pretty similar. They're both stimulant medications. But then there are a variety of different therapies, some very much like psychotherapy, working with families, working with kids on trying to control their impulses or their hyperactivity, but also potentially changing a kid's environment. So figuring out what in your home or in your classroom you can adjust.

to make it harder to be distracted and easier to pay attention. You noted in your piece that the medications that you talked about, Ritalin and Adderall, can show dramatic improvement in kids very quickly, right? How so? Yeah, so I think one of the things that lots of families experience, and this has been true, scientists have noted this for almost 100 years, is that this is unlike, say, antidepressants or some other psychiatric medications, this is not a drug

medication that takes a long time to work. When a child takes it for the first time, you can see overnight a change in their behavior. Doesn't happen for everybody, but for lots of kids, you see an immediate shift away from so much impulsivity and hyperactivity and towards better behavior by all the measures, all the symptoms that you see in the DSM.

I want to invite listeners to join the conversation. Listeners, what are your questions about the diagnosis and treatment of ADHD in kids? And have you or your child or a member of your family been diagnosed with ADHD? And what has that experience been like? You can tell us by calling 866-733-6786. Again, that's 866-733-6786.

You can email forum at kqed.org, find us on our social channels, Blue Sky, Facebook, Instagram, or threads at kqedforum. So Paul, so, you know, we have this very clear cut way of diagnosing it according to the DSM, for example, right? ADHD. We have this medication that has shown to be quite effective potentially and very quickly for kids. So what...

is wrong with that? Or what are some of the things that have led you to question if we've been thinking about it all wrong?

So what I found is once I started talking to scientists who had been studying this sometimes for 20 or 30 years or even longer, they were the ones who were expressing to me that they were starting to feel like there was something wrong in the way that we were thinking about this disorder. As one of them put it, there's this increasing disconnect between the way that we're thinking and talking about ADHD in a clinical setting and the way that we're –

that our science is developing and what we're learning in the lab. And I think those concerns, the concerns that they expressed to me fell into two categories. So one had to do with the medication. And there are a couple of concerns about the medication, one having to do with how much its effectiveness is just on behavior rather than on cognition and sort of the academic achievement.

The other is on the longevity of the treatment. So there is one important study that started back in the 1990s that has been used by advocates of medication to demonstrate how effective Ritalin in this case was after 14 months. And that is what that long-term study found. But the scientists continued to follow the children in this study after the 14-month

randomized controlled study was over. And they found that the advantage that the ones who had been prescribed medication had started to dissipate, started to go away. And that by three years, there was no real difference between the symptoms of the kids who were taking Ritalin and the kids who were not. So that's one set of concerns. The other set of concerns has to do with

more sort of the way we think and talk about ADHD. So I think like that diabetes analogy that Russell Barkley used, it is part of, I think, a tendency on the part of lots of people to think of ADHD as a very clear-cut medical disorder where just like with diabetes, you can tell for sure whether one person has it or one person doesn't. There's a test you can use. We know what it is. We know how it works.

And some of these scientists are saying that's just not the case with ADHD, that ADHD symptoms exist much more on a continuum, a continuum that lots of us find ourselves on, and that trying to find an exact cut point for this person has ADHD and this person does not is kind of impossible. There's a lot of subjectivity involved in the diagnosis.

Now that does not mean that ADHD is not real. It does not mean the distress of people with ADHD is not serious, but it does change the way that these scientists are saying it does change the way we should be thinking and talking about ADHD and potentially the way we're diagnosing it as well. Yeah. One of the things that I was struck by was you talk about that scientists have been trying to find out where, you know, what is the biological basis or where in our biology can you find ADHD, for example,

a distinct biomarker or gene. And they have been unable to, is that right? That's right. And, you know, so one of the scientists I talked to says that this search for a biomarker has just been kind of a red herring. And, you know, there are lots of psychiatric disorders that do not have a biomarker. There's no biological test for depression. There's no biological test for anxiety.

But I think what happened with ADHD starting 20 years or so ago, in the early years of the 21st century, was that because I think there's always been a certain skepticism about ADHD, that a lot of scientists were really intent on trying to find this biological marker. You mean skepticism of whether or not it was something real? Yeah. I think there's always been – I think because some of the symptoms –

uh, symptoms that lots of kids have. Um, I think there are some parents, some teachers, uh, even some scientists who just say, this is not really a real distinct disorder. And I think for families who are struggling with ADHD, that is incredibly frustrating to hear, right? Because they know that their kids are having a really hard time. Uh, and they often know that these medications are helping them. And so to have somebody, um, undermine that, uh,

that experience, I think, can be really hard. And so I think the scientists at that moment, 20, 25 years ago, felt like if we can identify specific biomarkers, specific biological signatures of ADHD in the brains of kids who have it, that will

first of all, be a better diagnostic tool. It'll help us figure out who's got it and who doesn't. But second, it will actually just change the public perception of this condition to be clearly a biological yes or no kind of disorder, much like diabetes. So we're about to go into a break, but can I ask you quickly, this figure of 11% of

U.S. children, 7 million of them. How different is that? It's a record high from what, as people were developing in this understanding of ADHD, to cold. What, how has the number of kids with it changed? Well, it's actually been growing pretty much constantly. So back in the early 1990s, there was a big concern because the numbers had gone up from about a million kids with ADHD to about 2 million.

But what's remarkable about the numbers is that they've continued steadily to rise through those decades. And so it's now 7 million kids who have been diagnosed. Yeah. We're talking about ADHD and new studies and understandings that are challenging the way we diagnose and treat it. As a record high, as Paul Tuff says, 7 million children in the U.S. have an ADHD diagnosis. More with him and with you after the break, listeners. This is Forum. I'm Mina Kim.

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Learn more about how you can get involved and become a supporter at earthjustice.org. You're listening to Forum. I'm Mina Kim. We're talking this hour with journalist Paul Tuff, who spent a year talking to leading ADHD researchers and says we need to reconceptualize the diagnosis and treatment of ADHD, that new studies and understandings are necessary.

suggesting that we may understand ADHD less than we thought we did a couple of decades ago and why it's important to keep that in mind. His cover piece for New York Times Magazine is called Have We Been Thinking About ADHD All Wrong? And listeners, what are your questions about the diagnosis and treatment of ADHD in kids? Have you or your child been diagnosed with ADHD? What has that experience been like?

Have you had any of the experiences that Paul Tuff is talking about with regard to diagnosis and treatment? Let me go to caller Janice in Petaluma. Hi, Janice, you're on. Hi, can you hear me okay? I can. Great. I really just wanted to share about my own experience. I wasn't diagnosed with ADHD until I was 43, and it was during COVID, and I had gone back to school.

And I all of a sudden was dysregulated and didn't understand why I couldn't function just on, you know, keeping doing normal tasks. And that was when I went and did some testing and through the school I was in and found out that, you know, yes, I do have ADHD, which kind of shed light on a whole lot of aspects of my life, even as a kid, because, you

I was masking really, really well my entire life. And the gym closed and I did not have access to the grocery store like I normally did. I wasn't in my classroom and going to school every day. I was now online. And so...

I didn't realize that I had been coping with it by establishing my own routines and habits and paying attention to how my body felt about food. And when that all went away, I was a mess. I'm trying to do school and trying to be a mom. And, you know, then I realized, okay, so as a mom, I'm great at this because I have all the reasons to focus, hyper focus on another person, my child. And so I was great at that.

but school was hard. And then, you know, I looked back at being a kid and how nobody knew because what and what I learned in my own research now about ADHD is that I was a people-pleasing perfectionist. And so that's when I kind of went, oh, okay, so now I have to really pay attention to my environment and really be honest with myself about what works for me and what doesn't.

and to stop people pleasing and to know that perfection isn't something that I need to attain. And that was hard and it was humbling, but it was also empowering in so many ways, having no idea that this is what had been going on my whole life. Janice, thanks so much for sharing that and for the role that a diagnosis of ADHD played for you.

Paul Janis, the story is making me think of a couple things. One is, well, first of all, we've seen a lot of growth in adult diagnoses too, right, of ADHD? Yeah, absolutely. That really, so as we were talking about, there's been this consistent, steady increase in childhood diagnoses.

But over the last 10 years, there's been, and especially relevant to what Janice is saying, since the beginning of the pandemic, there has been a really sharp increase among adults, especially those in their 30s and 40s, and for women much more so than men. That is really the big growth area. So Janice is not alone by any means. I think COVID was really hard on everybody, and especially hard on people in school, children and adults both.

And I think one of the things that a lot of these scientists talk about is that ADHD is maybe best thought of as this mismatch between your particular brain chemistry and the environment that you are in. And I think for so many people, often the environment is not conducive.

to paying attention, to focusing, to controlling impulses. But during COVID, it just got so much worse for so many people. So I think there are lots of people in Janice's boat who experienced the same thing and got a diagnosis for the first time. Yeah. The other thing that Janice is making me think about is how you spoke to a lot of students about their experiences with ADHD diagnosis and medication. And they actually painted a pretty complex picture

picture for you. Can you talk about what some of the kids shared with you, especially with regard to, you know, the way that it would improve certain things for them, but also would make them feel like other areas of their life were not improving?

Yeah. So I mostly talked to, well, I only spoke to high school students. So it was a slightly different situation from Janice's. But what really struck me in talking to these students is that, yeah, I think everyone acknowledged that the medication was useful in helping with some specific things. So there were a couple I talked to who were doing SAT prep regularly.

really boring stuff. And their stimulant medications made it much easier for them to focus on the stuff that was boring. Some of them used it in baseball practice too. They felt like they could see the ball better. They could avoid the distractions on the field better. But what a lot of them described is that it really, they felt like it changed and changes their personality on days when they took it. That they felt like

Less themselves, they said, less funny, less social, more they would describe just sort of this tunnel vision. And their friends would really notice it. At lunch, one of them put it, you know, it's not like I'm sad. I'm just not really that happy. I'm just sort of flat.

And I think lots of people have different experiences of these medications, but it was something I heard from a few different folks. And one of the things that really struck me was that a lot of these young people, especially, they just didn't like the medication very much. Like they saw it as a sacrifice that they had to make in order to get through the environments they were in, specifically high school. But it did feel like a sacrifice. It didn't feel like it was what they wanted to be doing. It felt like what they had to be doing.

And you mentioned something interesting earlier where you said that there are studies that are finding the medication may help kids behave better, but not necessarily learn better. Explain that.

Yeah, it's a really interesting and kind of puzzling collection of research studies. And I think a lot of the scientists I talked to said, like, this feels important and it feels frustrating, but we're not exactly sure what's going on. But so, yeah, as we discussed, you see this in many, many children. You see this immediate shift in their behavior. They change.

seem to be better students, they're sitting still, they're focusing class, they're not acting up. But then when scientists give kids or sometimes young adults sort of academic tests or cognitive tests both on and off medication, what they find is that the kids who are on medication don't do any better at these academic tests. They don't do better on academic assessments.

And one study that I found really interesting showed that when they gave some kids, some young adults stimulant medication, they were working at these puzzles much more quickly and they were busier. They seemed to be busier, but the choices they were making in solving this particular puzzle were less effective. They were just kind of, you know, doing busy work, just sort of throwing every possible solution they could at the wall rather than thinking rationally about it.

And that might be a clue as to what's going on, that the medication seems like it controls behavior much more effectively than it sort of improves the mind or improves our concentration or our cognition. A listener, Martina on Discord, writes, as we were having our son assessed in first grade for ADHD, I noticed that many of the questions applied to me. I tried three different stimulant meds over the course of a year and a half.

All of them made me feel so weird, fuzzy, slow brain, fatigue, sleep disruption, that I didn't want my son to try any of them. He's someone who already has trouble expressing and recognizing what his body is feeling. Instead, we put supports in place for him and changed his school to one designed for neurodivergent kids. However, I'm grateful for our diagnosis, which has allowed us to access therapies and explain our brains to our family members who don't struggle with distractibility and forgetfulness. What do you think about that, Hal?

Yeah, that's fascinating. And I think, you know, that's exactly, I think, the kind of

that parents and families should have. You know, I think Martine in this case was sort of, you know, the guinea pig for her family, which seems like it was a bit of a sacrifice. But I think it was really effective. And I think when parents experience the medications that way, I think they often have exactly the experience that Martine did, which is that they understand the pros and the cons, the way that medication really can change the experience of a child in a way that sometimes is hard to express for a child.

And so I think coming to the kind of conclusions that Martina did seem really ideal. It's not possible for every family to make the sort of

environmental changes that she did. But when I think it is possible, it's great. If you can change, if a kid is having a hard time fitting in a particular type of classroom setting and you can adjust that setting either by choosing another school or making adjustments in the classroom, that's a privilege not everybody has, but it can be really effective. And I think for many families, more effective than medication.

Well, the sister asks, and I'm not sure if you can explain this science potentially, but they said, why do stimulants, why are stimulants given to adolescents with ADHD? If someone has a hyperactive disorder, how does a stimulant help with hyperactivity? Yeah, I think lots of people ask about that apparent disconnect. But it's clear from, again, like 90 years of science that stimulants do work to help

push aside distractions and focus the brain. So, you know, one of the odd things about these stimulant medications is that they are all either amphetamines or based on amphetamines. And we have decades of experience as a country of people taking amphetamines. And the thing that both scientists and recreational amphetamine users will say is that it helps

you pay attention when things are boring. And so it was, you know, back in World War II, the Defense Department was giving amphetamine pills to soldiers or like to Navy soldiers

to Navy pilots who had to fly for a long time and just not get bored, not get distracted. You know, long haul truck drivers have, have for a long time taken the same kind of stimulant medication. And in each case, it's not, it's not just about hyperactivity. It's about dealing with boredom. It's about getting through, feeling connected to feeling able to concentrate on stuff that might be really boring. And I think that,

That's a real clue as to how it's working for a lot of kids and a lot of students, because, you know, high school can be kind of boring. And I think for certain personalities, for certain kids, especially so. And so that may be a big part of how these medications are working, that they're enabling kids to put up with stuff that in another context would be really boring.

Sarita writes, my kids were alleged to have ADD. The schools and doctors pressured us to give our sons Ritalin, but being immigrants from India and England, we couldn't quite get accustomed to the idea of ADD being a disease. And the side effects like growth stunting daunted us. This was in the 90s. I recently read the New York Times article by your guest, and it confirmed my doubts about the treatment. So in terms of side effects, you did say that it can impact growth in children, their height, right? Yeah.

Yeah. So this one study, it's called the MTA study that I wrote about that started back in the 1990s. It's the one that found that the effectiveness of Ritalin dissipates over time after those first 14 months.

But it also has the scientists behind the MTA study have found some other really interesting stuff. And one of them is this effect on height. And so in that first study, they found that after the first three years, the kids who had consistently taken Ritalin were about an inch shorter than the kids who had not.

And they thought that that was going to dissipate as kids got into adolescence, but it didn't. And as they continued to follow these children into adolescence and then even into adulthood, they found that this height disparity remained and that among adults, young adults, the ones who've consistently taken Ritalin were about an inch shorter than the ones who had not.

And I think that's, you know, it's another thing that's hard to figure out exactly what that means. I mean, that definitely for a lot of families does not mean just don't take these medications. But I think it is important information because I think it's important for families to weigh the pros and cons exactly like Sarita did decades ago. Yeah. Can these medications be addictive? Well, no.

I think they can be. I mean, there are certainly people who have abused Adderall and Ritalin over the years. Amphetamines certainly can be addictive. There are ways that the particular...

medications when they're in medication form are formulated that make them resistant to addiction or to misuse. And I think the science says that on the whole, receiving a prescription for stimulant medication as a child does not make you more likely to become addicted to anything, to substance abuse over the long haul.

In fact, you know, ADHD symptomology and substance abuse do tend to go hand in hand. So there are some studies that suggest that getting diagnosed and getting medication might actually diminish your long-term likelihood of substance abuse. You also said that most of the scientists you spoke with still felt the positives of the medication outweighed the negatives, especially if people were really struggling in everyday life.

Yeah. And I think, I think, you know, that's absolutely what they said. And I think that this, that the scientists are like, as they're rethinking a lot of these questions, I think a lot of them are really struggling with that fact. Um, because it is, I think for a lot of them are very nuanced decision. I mean, it's exactly what, what, you know, Sarita describes, what Martina describes, what a lot of your listeners are describing. It's, it's not just a, um, you know, you've, you're diagnosed with this medic, with this, uh,

You know exactly what the medication is. You take it. Everything's fine. There are real pros and cons. And I think...

On the whole, these scientists said the pros outweighed the cons, though they took the cons pretty seriously. But I think for any individual family, for any individual child, it's an individual decision. And I think for some kids, the experience is less positive. For some kids, it's really positive. And for some kids, I think it's positive. For some adults, it's positive over the long term. But one thing that one number that really struck me was that most kids,

adolescents stopped taking it. So most kids don't actually take it for over the long term. They mostly take it for a year or less. And I think for a lot of families, that's not bad news. I mean, I think for some of them, it might just be they had a terrible experience.

But I think for lots of them, it may just be that they needed it to get through a particularly rough period and that the control of symptoms was important and effective for a brief time. And that allowed the family or the individual to kind of get control of their lives in a certain way, to look for other things.

more environmental solutions, things that they could change in their school or in their home or in their job that made it easier to manage these symptoms. So I think thinking about it as potentially a short-term fix rather than a long-term one can be really positive for a lot of families.

I love this comment we just got from Michelle. Michelle writes, I'm a 13-year-old girl who was diagnosed this week with inattentive ADHD and started taking methylphenidate. My questions are, what disorders often get mixed up with ADHD, and can music help a neurodivergent person focus? I often listen to music to regulate my emotions as well as focus.

Wow, how great to hear from Michelle. So I'll take each of those parts separately. So her first question was, are there other disorders or conditions that often get mixed up? Yeah, to me, it's a real...

of the diagnosis because there's lots of overlap between an ADHD diagnosis and other psychiatric or psychological diagnoses including autism spectrum disorder, oppositional defiant disorder, learning disorders, anxiety, depression. And one of the real tricks about diagnosing this is if the symptoms of a child can be better explained by a

another condition, you're not supposed to diagnose ADHD. But in fact, 75, about three quarters, 75% of kids who are diagnosed with ADHD do have some other kind of psychological or psychiatric condition. So there's lots of overlap. And I think it makes the situation for someone like Michelle difficult.

I think if she's experiencing, she's not saying that she is, so I'm just assuming this. If she's saying that there are other things going on in her mental health or in her life that feel like maybe they're ADHD or maybe they're something else, I think that's a good instinct to follow. And it's very difficult to always understand what's going on in our minds. But to try to separate those different conditions and figure out which is bothering me right now and how should I think about that, that's really effective. Yeah.

Yeah. Well, we'll have more after the break. Thanks, Michelle. And thanks, Paul Tuff. Stay with us.

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You're listening to Forum. We're talking about ADHD this hour and new studies and understandings that are challenging assumptions about the way we diagnose and treat ADHD. As a record, 7 million children in the U.S. have an ADHD diagnosis. We're talking about it with Paul Tuff, an author and contributing writer to New York Times Magazine, who covers education and child development. The title of his Times Magazine cover story is, Have We Been Thinking About ADHD All Wrong?

You, our listeners, are joining the conversation with your questions about ADHD, your experiences as someone who has been diagnosed with it or has a child who has been as well. And if some of the experiences that Paul Tuff is describing are also your own. Let me go to caller Savannah in San Francisco. Hi, Savannah. Hi, Savannah.

Go ahead. Hi there. Hi. I'm a teacher in San Francisco, a middle school English teacher, and my question is actually two parts. A, what are some of the obvious impacts

but more negative impacts of blended classrooms, technology-infused classrooms, and just technology in general for kids struggling with ADHD. And also as a teacher, I've had some instances of parents who perhaps refuse medication for their children, and I was wondering what are some methodologies that you can recommend

for meeting the educational needs for these kinds of kids and situations. Savannah, thanks. Paul? Thanks, Savannah. So those are two great questions. And I think there's a lot of middle school English teachers who are experiencing ADHD specifically through classroom disruptions. It can be, I think, especially hard for teachers. So

To talk about parents, to take the second part of your question first, talk about parents who are resistant to choosing medication for their children. You know, we had a parent on just a little bit ago who was saying that that was her experience, that she had a clinician who was recommending Ritalin. And then after she had her own experience with it, she decided not to do that for her kid. And I think that should absolutely be up to the parents. You know, I think I think it can be fair.

challenging to work that out between a child and a parent and a teacher. But I really do feel like parents should be able to make that decision, ideally with some input from their kids. To talk about technology, so I don't know any research specifically about blended classrooms or technology in classrooms and how it affects ADHD symptoms in kids. But there is clear evidence that the increasing...

of technology in the lives of kids has something to do with this rise of ADHD. You know, some of that, some of those, the causality is still not entirely clear, but I don't think that it's a coincidence that we're seeing so much, so many, you know,

especially during this period of increased technology. You know, Jonathan Haidt's book, The Anxious Generation, it doesn't spend a lot of time talking about ADHD, but I think his thesis that increased smartphone technology and social media has just been changing the mental health of lots of young people and especially adolescents, it rings true for me, and I think the science behind it is pretty powerful.

Ami writes, I've always thought that some of the ways we talk about ADHD reveals an artificial construct that all children and many adults are expected to sit for an unnatural amount of our days. It's more natural to be physically active. Another listener writes, I guess I'm part of a trend. I was diagnosed in my 50s after my eight-year-old son was diagnosed. He began taking extended-release methylphenidate. It changed his ability to function in the classroom overnight.

His medication primarily helped with emotional regulation. That meant his confidence began to build. I began taking Adderall. For me, it enabled me to shift from repetitive thoughts into productive action in the present. Like my son, that has enabled me to begin to build confidence and a more positive, hopeful view of my daily life.

On the other end, Noel writes on Discord, are the drugs a shortcut in our society, which doesn't have the resources for behavioral training? In Europe, are rates of ADHD drug prescriptions a lot lower than the U.S.? If so, why is that?

Do you know, Paul? Great. Those are all great comments. They really run the spectrum of public opinion on this stuff. And I think it's really reflective on how complicated this question is. So, yes, in other countries, including European countries, the rates of ADHD diagnosis and

prescriptions of stimulant medication are lower, but they're rising quickly. So the kind of American paradigm is spreading to a lot of European countries as well. I will say, you know, in some ways, I think those three comments you just read seem a little bit contradictory. But I think there's something there that kind of connects them all. I mean, so the parent who was talking about her own diagnosis and her child's diagnosis

What I found so important about that was that she wasn't saying that it helped her son think better or even focus better, but it helped him feel better. And I think that that is really important. I think the experience of having ADHD when you're a kid and feeling like this classroom is just driving me nuts and the teacher's mad at me and everyone thinks I'm dumb and can't focus and it just feels bad. It just always feels bad.

And so I do think that it's one of the most important impacts of medication when it works well, if even in the short term, it can help you manage your your

impulses, manage your emotions, just like sit still for a while in class. That in itself, I think, can be positive because you get out of this cycle of fighting with teachers, fighting with parents, just always feeling like you're the failure. And so even though I think some of the long term data shows that these benefits might dissipate over time for a lot of kids,

That short-term fix can be really important. And if a family can then build on that to figure out, like, okay, what else can we do differently? How can we talk about this differently? How can we think about this differently? That itself, I think, can be really effective. So then what do you think we should do with these new things that we are learning, these deeper understandings that we are getting about ADHD? Yeah.

How should we apply this? You know, because as you say, it is also just a very complicated thing to diagnose and treat.

Yeah. And so I think this is not always what parents want to hear or what anyone wants to hear. But I think we should kind of embrace that complexity. Right. And I think that there is this tendency both in the in the clinical world, but also, I think, among a lot of individuals to want ADHD to be a really clear black and white medical condition. You've got it or you don't have it. If you've got it, you're going to have it forever. Right.

And in fact, it's much more complicated than that, as your listeners' experiences are really demonstrating. So for some people, these medications are working great. For others, they're not. For some people, they are getting diagnosed in childhood. For some, it's not really kicking in until adulthood. And I think...

Being able to think about it as something where there is not only one solution, where there's not only one diagnosis, I think is really important. One of the studies that I read about that I found really significant was that for a lot of kids, their symptoms just naturally come and go throughout adulthood. Only about 10% of kids who are diagnosed at 7, 8, or 9 have those symptoms consistently throughout childhood.

And so that, I think, tells us that if we can think about this as an experience that a child is having at a particular time, and often a really serious and bad one, but not sort of an identity, not the thing that is just going to define you for the rest of your life, you can make decisions as a family about that condition that I think can be much better. And you can have conversations about it between children and parents and teachers that are much more productive.

This is a problem we've got right now. How do we deal with it? Rather than this is who you are and who you will always be, and so here's the medication that you're going to have to take the rest of your life. Yeah. The other studies that I thought were fascinating was the ones that you cited that showed that for some, a medical diagnosis of ADHD or a biological explanation that can be medicated felt very empowering, was sort of life-changing, helped them to feel like

what they were going through was legitimate, right? And then for others to be told that, that it almost felt disempowering, like a facet of who they were that they could never escape. Yeah, I found that that is a study that I found really fascinating as well. And it is, it kind of feels like it exists in a very different realm than these, you know, randomized controlled studies where someone takes a pill and someone doesn't, we know exactly what the results are.

This is much more psychological. So it's much more about how a diagnosis makes you feel. And I think there are a lot of people for whom getting the diagnosis, especially I think in adulthood, is really clarifying. So one of your listeners was saying that when they got this diagnosis in adulthood, everything made sense. And I think that's something you hear from adults a lot when they receive the diagnosis in adulthood.

But I think for kids, it often, it's more beneficial to hear about ADHD, not as the thing that solves, that answers your question and defines you, but as something that like you're dealing with right now, and there are some different ways you might want to deal with it. But, you know, a couple of years from now, it might not actually be a part of your life. For kids who are still, you know, psychologically being formed, that is such a

positive way, I think, to hear something that like things change, you might change. And this is not something that's going to define you forever. And so that, you know, having that be my recommendation of how of sort of where I come out after all of this research, it might feel a little bit mushy, you know, because it's mostly just about let's talk about it. And let's think about it differently, rather than saying, these medications are

perfect or these medications are terrible. But I think actually that that is genuinely where the research should push us. And that as that study you were mentioning discovered that just receiving a diagnosis, how you receive a diagnosis makes a big difference in terms of how kids feel. But why are you saying it's so important to do that? I guess I'm asking because are you worried that we are

not moving in the direction that we should be with regard to complicating what ADHD is, and as a result, searching for treatments that could, you know, be better for a broader spectrum of kids. I mean, for me, I guess this question is like,

You were talking about how, you know, the science and these understandings are relatively new. I think you used the term emerging, and that means that it can take a long time to be widely adopted or to adjust people's thinking who are in the field and so on. But are you concerned that that's not the direction that we're headed in? And is that why you felt the need to write this?

Yeah, I mean, I think those rising numbers are concerning, you know, and I don't think we know why those are rising. There are some people who say that they're a symptom of or a sign of overdiagnosis, other people who say they're just a sign of the increasing prevalence of this disorder in society, but

Those rising numbers are concerning no matter what. And I do think that we don't have a good enough solution, even though we do have a medication that for a lot of kids is quite effective, at least in the short term. I don't think we have enough of a solution for families who are struggling with this. And so I do think that...

So giving families a different way to think about this and a different way to talk about this can itself be really effective because simply getting a diagnosis, I think if if a child hears this, that this diagnosis is just a black or white thing, this is now who you are. You're an ADHD kid and you're always going to be an ADHD kid. That has a big effect on them. You know, someone like Michelle, our 13 year old caller who just was diagnosed this week

how she hears about it, how she thinks about it in the years ahead may be just as important as the medication she takes and the environmental changes that she experiences.

Ruby writes, I'm a mental health provider who has worked with children and a mom whose child was diagnosed with ADHD in elementary school. It concerns me that we continue to use medication so much with children before looking at the environment, sleep, and considering side effects. Catherine writes, my son has ADHD wrapped up in an autism spectrum diagnosis. It includes anxiety and sensory processing. We tried Adderall, but he had bad side effects and didn't help at all.

We have learned that if he manages his anxiety well, the other symptoms are minimized. Also, it helps him a lot when he is working on school assignments that interest him. Are increasing ADHD diagnoses connected to the increase in autism diagnoses, and how do the other issues such as anxiety relate to ADHD? Your thoughts on Catherine's comment, Paul?

I mean, my thoughts on her comment is that that's just, it's great. I mean, I think the fact that she is working with her child and her family to try to figure out like, well, what can we change? You know, how, first of all, I think when you have these comorbid, is the word that psychologists use, these co-occurring disorders like autism spectrum disorder and ADHD, it's really tough, you know, because it's hard to figure out exactly what symptom belongs to what. Right.

And I think the solution is exactly what she's doing, is trying to figure out, like, for this individual child, what can we change? How can we think differently about what's going on in your life? And I think it is exactly the solution that they came up with, which is to do more interesting stuff to find out, I think, very...

both people on the autism spectrum, but also kids with ADHD, kind of all of us, when we're actually able to do stuff that's more interesting, we focus better, we are happier, we can pay attention longer.

And, you know, there's a lot that often happens in school that isn't particularly interesting. And as you mentioned, I'm someone who's reported on education for a long time. And I don't think it has to be that way, right? I think that there is a lot that we can do to help kids find more inherent interest in their education. And when that happens, it can have a real effect even on these disorders. So I think that's really an inspiring solution. Is the growth connected to autism, as Catherine's wondering, too?

I don't think it's connected in sort of like a biological way. I think it is connected. So there was just a really interesting op-ed in the New York Times this week by a doctor giving his theory for why autism spectrum diagnosis, disorder diagnoses have gone up so much. And he says it's because of the changing awareness and the changing definition that as the umbrella of ASD increased, we got more diagnoses.

And more of those diagnoses that any time that a diagnosis expands, the new people are going to probably have less intense symptoms. And I think something may be happening like that with ADHD, that some of this expansion is to kids who maybe would benefit from an ADHD diagnosis and might not.

But that shouldn't obscure in either of those disorders the fact that there are kids and adults who have much more extreme and serious symptoms and who really need lots of help, whether that's medication or something else.

else. And so there's something to be gained from from sort of widening the boundaries of a spectrum disorder like either of these. But there's complications that come along with it that if we just say, well, if you've got it, everyone's exactly the same. That's just not true. And so trying to to to have both of those ideas in our head at the same time that there is this category that's important, but it's also on a continuum. I think that that is challenging, but I think I think it's it's significant both for both of those disorders.

Let me quickly remind listeners, this is Forum. I'm Nina Kim.

When she says that her brain is getting noisier again, it's time to talk to her medical team about how to help her. We use her telling us how she is doing as well as her outward behaviors. I really want to squeeze in another listener, but unfortunately, I think we're almost out of time. But they do bring up something that you do bring up in your piece, which is that often ADHD can be misdiagnosed as fetal alcohol spectrum disorder. Can you just say that really quick as well so that people understand?

Yeah, so there are a variety of environmental problems from fetal alcohol syndrome to head injury that can produce symptoms that are really similar to ADHD.

When I was writing about that in the article, I was using it to sort of complicate this idea that it's simply this biological disorder the way that I think a lot of people thought 10 and 20 years ago. But, you know, symptoms are symptoms. And so if you are experiencing these symptoms, whatever the cause was, it's still serious. It's still a problem. But thinking about those symptoms as something to alleviate rather than trying to think of like this as a category where you need to say this person's got it and this person doesn't.

I think that can be a really positive way for all of us to think about ADHD. Paul Tuff, his piece on ADHD is how we've been thinking about ADHD all wrong for the New York Times Magazine. Thanks so much for talking with us. My thanks as well to Mark Nieto and Susie Britton for producing today's segment. And my thanks as always to listeners for sharing their stories, which add a mean so much to us at Forum. You've been listening to Forum. I'm Mina Kim.

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